Dr Carl Djerassi, co-pioneer of the contraceptive Pill, has predicted that egg freezing will be the next reproductive revolution[1]. Initially developed to help women made infertile through cancer, egg freezing is now being requested by fertile women who want to try to guarantee a pregnancy in their mid to late thirties. ‘Social egg freezing’, as it has come to be known, has created excitement for career women and debate among ethicists.
Technological Advances
Technological developments have made this shift possible. Traditionally, eggs have been hard to freeze successfully due to their large size and high fluid content. New freezing methods mean that eggs are no longer damaged by the process. In 2000, the Human Fertilisation and Embryology Authority (HFEA) declared the technique safe enough to be used in infertility treatments. Its popularity has soared as a result, with a 2009 study showing that nearly 1000 babies had been born worldwide using the method[2]. The benefits of egg storage for fertile women have also been more widely promoted, with five clinics now offering the service in London alone[3].
To make sense of the ethical implications, it is important to outline how fertilisation is achieved from a frozen egg. It is first necessary for a woman to release more than a single egg in a cycle, so a process called superovulation is induced using hormonal injections. Once a number of eggs have been produced, they are extracted under general anaesthetic, dehydrated and frozen. When the woman is ready to conceive, months or years later, the eggs are thawed out and examined. The healthiest eggs are fertilised using the intracytoplasmic sperm injection (ICSI), which injects a single sperm into each harvested egg. Increasingly, the resulting embryos are then scanned and the healthiest selected for implantation. Excess embryos are either frozen for future implantation, used for research purposes or left to perish. A normal pregnancy is then hoped for.
To standardise egg freezing, in the manner Djerassi describes, raises significant ethical questions. I am going to proceed by using the Universal Declaration of Human Rights (UDHR) as a moral compass with which to scrutinise the technology and its applications. The following Articles will be cited for their relevance to the treatment of embryos, access to infertility treatments and to contraception.
Article 1: All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood.
Article 3: Everyone has the right to life, liberty and security of person.
Article 16: (1) Men and women of full age, without any limitation due to race, nationality or religion, have the right to marry and to found a family.
Article 25: (1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.
The ‘Proclamation of Tehran’, released as an update to the UDHR in 1968, contains the following relevant Paragraph:
Paragraph 16: Parents have the basic right to determine freely and responsibly the number and spacing of their children.
I will use these principles to deduce two outcomes. Firstly, whether I consider egg freezing to be morally acceptable in the case of infertility and, secondly, whether it is ethical for fertile women to request social egg freezing as a family planning choice. Despite promoting logical arguments in favour of both options, my conclusion will promote caution and careful regulation.
Religious Objections
I am going to judge that egg freezing can still be morally acceptable even if it is not justified on religious grounds. Nevertheless, all of the main religions offer valuable criticisms of reproductive technologies that warrant consideration. It must be stated from the outset that there is often as much disagreement within the religious denominations as there is between them. I have offered the views that are most standard.
The Role of Sex in Reproduction
Whether we should have sex to make babies is a main concern of the religious outlook. Fertilisation using the ICSI method is viewed by the Catholic Church as violating the stipulation that ‘the procreation of a human person be brought about as the fruit of the conjugal act specific to the love between spouses' [4]. This means that egg freezing is unacceptable for Catholics under any circumstance. Other religions adopt more liberal viewpoints. Judaism and Protestantism both view assistance in reproduction as a means of abiding by the commandment that man should ‘be fruitful and multiply.’[5] Islam also views assistance with fertility as following Allah’s blessing that men should ‘marry the loving, child-bearing women’ to have a large number of prophets on the day of Resurrection[6]. Dr. Djerassi offers strong arguments in favor of the separation of sex and reproduction in his paper ‘Sex and Reproduction: Ready for Divorce.’ His main point is that the separation has already taken place:
‘According to the World Health Organization (WHO), every 24 hours there occur over 100 million acts of sexual intercourse resulting in approximately one million conceptions, of which 50% are unplanned and 25% unwanted. It is this last estimate-250,000 unwanted conceptions a day-that is responsible for the occurrence every 24 hours of approximately 150,000 abortions, of which 50,000 are illegal, leading to the deaths each day of 500 women….. clearly a significant percentage of these 100 million daily coital acts has little to do with reproduction or any desire to perpetuate the species.’[7]
I do not consider it to be morally objectionable for fertilisation to take place without sex and so do not oppose egg freezing on these grounds.
The Status of Embryos
When Article 1 states that ‘All human beings are born free and equal in dignity and rights.’, we need to assess whether this should include embryos. To consider whether the Article makes embryo disposal morally unacceptable, we need to assess what type of life we think an embryo is. It is certainly human, but it may not yet have the life force we equate with a human being. Religious stances vary. The Catholic Church prohibits the destruction of embryos, as human life is considered to start from the moment of conception. Orthodox Judaism permits them to die passively but not to be used for research and subsequently destroyed. Islam stipulates that embryos can either be frozen for future implantation or donated for medical research. Both agree that the embryo is not thought to become a human until the soul enters the body, approximately forty days after conception. The Anglican Church states that embryos must be respected, but that they do not have the moral status of a person. In 1967, the Board of Responsibility of the Church of England described the foetus as only a ‘potential human life.’[8] This led to the 1984 conclusion of the Warnock Report that the use of embryos up to 14 days old is acceptable.
My interpretation is that Article 1 refers to the ‘born’ human being. I do not view the loss of a small number of embryos as an unacceptable aspect of reproduction. A strong argument to support this view comes from research into the prevalence of very early miscarriages. In normal attempts at getting pregnant, 30 to 50 percent of fertilized eggs are lost before or during the process of implantation[9]. Excessive loss of embryos and keeping embryos alive for research purposes appear to pose a greater violation against this form of life.
The Virtue of Motherhood
There is clearly support for egg freezing among some religions, but could social egg freezing be justified from a religious perspective? It seems unlikely for two reasons. Firstly, religious justification for reproductive technology has been based solely on alleviating the burden of infertility. Secondly, a religious outlook views motherhood as one of the most important roles in society. Jonathan Gorsky, lecturer in Judaism at Heythrop College, comments that ‘Postponing childbirth for many years in order to give precedence to the pursuit of a career is to lose sight of the preciousness of the human person and affirm that greater value is to be given to purely economic consideration.’[10] This is seen to have psychological and relational implications, as well as to raise questions of ultimate human value.
I agree that the importance of motherhood is being marginalized in modern Western society. Many women have set high career aspirations that render motherhood an inconvenience to be avoided. When arguing in favour of egg freezing, Dr. Djerassi comments that women gain access to an ‘extraordinarily important’ period of five to ten years if they delay childbearing until 35 [11]. We need to ask whether women should be spending these prime years raising children or building a career. Ultimately, as the Proclamation of Tehran states, the time at which a woman chooses to bear children is her choice. For many, later motherhood represents the opportunity to provide a more secure and emotionally mature environment for their children. Others can very successfully balance motherhood with a career. Social egg freezing should not be viewed as necessarily degrading the role of motherhood in society.
The Right to a Child
When we assess a woman’s moral right to fertility treatment, we need to consider whether she has a human right to bear a child. The right to ‘found a family’, outlined in Article 16, is typically understood as justifying the right not to be forcefully prevented from conceiving. However, infertility sufferers have argued that it can also support a right to be treated for infertility. To assess the moral credibility of this claim, we need to discern what infertility is and whether the Article should be interpreted in this way. The concept of a right to a child is generally viewed as counter-intuitive. We all have some natural physical limits that cannot be overcome. I may admire climbers who can ascend Everest, but, if my fitness is weak, I do not have a right to join them. I agree with Warnock’s analysis of the issue in her book, Making Babies; children are a gift that we do not have a right to receive[12].
A stronger line of argument for the infertile comes from the right to medical care, outlined in Article 25. The World Health Organisation now classifies infertility as a disease, meaning that men and women have a right to be treated for it. As with all cases of healing disease, certain limitations come into force. Firstly, there is no right that a treatment should work. Some women have to accept the grievances of infertility just as many live with the suffering of any other disorder. Egg freezing is still not that effective, with the most successful centres achieving a live birth rate of 50%[13]. Secondly, many treatments must be regarded as morally unacceptable due to an excessive drain on resources. The annual budget of the NHS is approximately £100 billion, paid for by an annual taxation of approximately £2000 per person[14]. Egg freezing and implantation costs from £4000 - £8000, with approximately £200 per annum for storage. The cost of many medical treatments does run into thousands, with the NHS spending an average of £35,000 on each cancer sufferer[15]. Yet distinctions must be drawn as to the necessity of treatment. Women who are fertile should certainly not receive NHS-funded egg freezing. Limiting the number of attempts at artificial conception still appears to be the most plausible option for infertility sufferers.
The Right to Family Planning
The most effective way to make a moral case for social egg freezing is therefore through a family planning argument. The concept of a right to family planning was first brought into law through the Proclamation of 1968. The right for women to ‘determine freely and responsibly the number and spacing of their children’ was directed towards the use of the contraceptive Pill and access to abortions. The right to prevent pregnancy in this way was an enormous landmark in the emerging social status of women. The Pill has been free to all women in the UK since the 1970s as a result of this reproductive right. Social egg freezing is a very different form of family planning in the sense that it is a form of assisted reproduction and not a form of contraception. Women who wish to choose precisely when pregnancy will occur, perhaps even opting to artificially conceive after the menopause, are distinct from women at risk from forced conception. Martha Farah, author of Neuroethics, goes further by arguing that social egg freezing is not therapy but a form of enhancement[16]. Article 16 should not be interpreted as meaning that women have the right to bear children at a time of their exact choosing.
However, a crucial term in the Article is that family planning must be allowed to take place ‘responsibly.’ Could egg freezing be argued for as a more responsible family planning method than the Pill? There is some scope for this, due to the health risks that can result from a woman trying to conceive after decades of Pill use. At thirty-five, women have 95% fewer eggs than when they were born and of a reduced quality[17]. This affects the health of the embryo. The chance of conceiving a Down Syndrome child rises from 1 in 1250 at the age of 25 to 1 in 378[18]. The main advantage of egg freezing is the ability to use eggs stored while they are young. The Pill also has side effects for some women and may increase the likelihood of heart disease and stroke[19]. Yet this argument is made redundant by the health risks of the egg freezing process. Standard minor symptoms include bloating, breast tenderness, cramping, pelvic twinges, fatigue and headaches. In a small number of cases, there is risk of Ovarian Hyperstimulation Syndrome (OHSS). This is a potentially serious condition characterised by a dramatic increase in ovary size and a dangerously high accumulation of fluid. On balance, it seems that health benefits do not constitute a strong argument in favour of social egg freezing as a responsible family planning choice.
Ironically, perhaps the most responsible aspect of the egg freezing process could also be viewed as the most distasteful. Dr Djerassi has proposed that, in order to prevent unintended pregnancy, women will be sterilised once their eggs have been frozen. This could provoke moral outcry, especially among the religious, but it could also strengthen the responsibility argument. Despite prevalent use of the Pill, unwanted fertility remains a problem. In 2009, 189,100 abortions were carried out for women resident in England and Wales[20]. Family planning methods still fail, which leads to a great emotional strain on individuals and a great financial cost to the state. Those who support contraception are not likely to object ethically to sterilisation in this context, provided fertilisation after egg freezing has come to be at least as reliable as normal conception. This argument carries some weight, but a more straightforward option is for women to use contraception more effectively. The Pill has a failure rate of only 0.3% when used correctly[21]. This approach would also avoid the serious ethical questions that follow.
Fertilisation in the Laboratory
Significant ethical implications follow from the fact that fertilisation after egg freezing takes place in the laboratory. One of the consequences of this is far greater use of screening methods, such as preimplantation genetic diagnosis (PGD), to test for abnormalities in the embryo prior to implantation. This is carried out with the sound intention of promoting a good implantation and a healthy pregnancy. Yet if such a method became standard, how we deal with abnormality would be profoundly altered. The most extreme reaction is to argue that it would take us towards a eugenic system of reproduction. Systematically eliminating weaker or undesirable embryos would undermine the whole intention under which the UDHR was born. After the heinous atrocities of the Second World War, it sought to legitimise in law the ‘inherent dignity’ and the ‘equal and inalienable rights of all members of the human family.’ [22] When embryos are discarded on account of disability or disease, there is a clear intent to minimize suffering. Yet with this comes a sour victory for discrimination and social stigma. What is a perfect embryo? What we risk losing is the essence of ‘valuing human life in all its imperfection’, identified by the US Presidential Council as a key concern in the debates surrounding screening and selection[23]. Disability advocates have argued that they already experience an ‘organised assult on the integrity, dignity and worth’ of their lives[24].
In The Future of Human Nature: On the Way to a Liberal Eugenics? (2003), Jürgen Habermas outlines the profound implications PGD and genetic engineering could have on our notions of humanity, identity and moral autonomy. As a German thinker profoundly affected by World War II, Habermas demonstrates how this modern form of liberal eugenics is distinct from the authoritarian kind. It is the subtle acquiescence of the state and authority of parents that make it deceptively dangerous. If we start to genetically engineer children, he asks, then is the identity we create really the child’s own? What would happen to the sense of ‘Self’ for the ‘manufactured’ child? Even a child’s sense of moral responsibility could be undermined. Was it really ‘my’ reaction when I hit that man, if my character has been chosen for me? This then extends into implications for our notion of humanity. To engineer more perfect people would blur our distinction between the natural and the manufactured human. Habermas does support the genetic engineering of embryos for therapeutic measures, emphasising the distinction between therapy and enhancement. I deduce that artificial methods of reproduction should not be offered to fertile and healthy couples, in order to minimise the serious social implications that could arise from widespread use of PGD and genetic engineering techniques.
For those who are infertile and therefore allowed access to these methods, some clear lines need to be drawn. In their 2006 report, ‘Making Babies: Reproductive Decisions and Genetic Technologies,’ the Human Genetics Commission stated that ‘The anxiety that PGD lies at the top of a slippery slope leading to the possibility of a wide range of potential enhancements, such as intelligence or beauty, is misplaced.’[25] They support this by highlighting both the extreme difficulty of matching gene combinations with specific characteristics and the public opposition to doing so. At the moment, the HFEA stipulates that PGD must only be carried out under specific circumstances, such as when there is a history of chromosomal disease. This has included the use of PGD for genetic predisposition to aggressive cancers, but there is a strict prohibition on screening for superficial social characteristics. This emphasis on the most serious diseases must be maintained.
Conclusion
The fertilisation of eggs in the laboratory was a revolutionary development that has brought joy to many infertile couples. I continue to be in favour of egg freezing for those who are aggrieved by infertility. But the manufacturing of humans in this way should not be used simply for convenience. The process of artificial fertilisation contains too many ethical dilemmas to be undertaken for non-medical purposes. It should be with gratitude that fertile women embrace motherhood within their normal reproductive period. The fashion for egg freezing has started to whir in fashionable cities, but it should be quelled by the weight of ethical objections raised. Those who are healthy and fertile are not morally justified in seeking artificial assistance with reproduction.
Bibliography
Books
ed. Farah, M., Neuroethics (Massachusetts, 2010).
Schaler, J. (ed) Peter Singer Under Fire (Illinois, 2009).
Singer, P. and Wells, D. The Reproductive Revolution: New Ways of Making Babies (Oxford, 1984).
Warnock, M., Making Babies (Oxford University Press, 2003).
Documents
BabyCentre Medical Advisory Board, ‘Understanding Miscarriage’ (2009). From http://www.babycenter.com/0_understanding-miscarriage_252.bc
BBC News, ‘First embryo screening birth’ (04.08.2003). From http://news.bbc.co.uk/1/hi/health/3123633.stm
BBC News: ‘NHS: what we give and what we get’ (11.04.2006). From http://news.bbc.co.uk/1/hi/programmes/breakfast/4898158.stm
Congregation for the Doctrine of the Faith, Dignitas Personae: On Certain Bioethical Questions (2008). From http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_20081208_dignitas-personae_en.html
Drake, S., ‘Not Dead Yet!’ ed. Schaler, J., Peter Singer Under Fire: The Moral Iconoclast Faces His Critics (2009).
Djerassi, C. ‘Sex and Reproduction: Ready for Divorce’. From http://www.djerassi.com/icsi2/index.html
Egg Freezing Centre, ‘Success Rates’ (2009). From http://www.eggfreezingcenter.com/about-us/success-rates.html
Gurevich, R. ‘Getting Pragnant After 35.’ From http://infertility.about.com/od/causesofinfertility/a/pregnantafter35.htm
Department of Health, ‘Statistical Bulletin: Abortion Statistics, England and Wales (2009)’. From
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_116336.pdf
Healthy Women, ‘Contraception (birth control options).’ From
http://www.healthywomen.org.uk/medical-directory/contraception/contraception.htm
Human Genetics Commission, ‘Making Babies: Reproductive Decisions and Genetic Technologies,’ (2006). From http://www.hgc.gov.uk/UploadDocs/DocPub/Document/Making%20Babies%20Report%20-%20final%20pdf.pdf
Ipas, For 40 years, family planning as a human right.’ From http://www.ipas.org/Library/News/News_Items/For_40_years_family_planning_as_a_human_right.aspx
Miryam, Z. and Wahrman, ‘Assisted Reproduction and Judaism.’ From http://www.jewishvirtuallibrary.org/jsource/Judaism/ivf.html
Newsweek, ‘Why I Froze My Eggs’(May,2009). From http://www.newsweek.com/2009/05/01/why-i-froze-my-eggs.html
NHS Choices, ‘About the NHS.’ From http://www.nhs.uk/NHSEngland/thenhs/about/Pages/overview.aspx
Peregin, C. ‘IVF practitioners disagree on prospects for egg freezing’, from http://www.timesofmalta.com/articles/view/20110204/local/ivf-practitioners-disagree-on-prospects-for-egg-freezing
President’s Council on Bioethics, ‘Beyond Therapy: Essential Source of Concern’, ed. Farah, M., Neuroethics (Massachusetts 2010).
Prusak, B. ‘Rethinking “Liberal Eugenics”: Reflections and Questions on Habermas on Bioethics, The Hastings Center Report Vol. 35, No. 6 (Nov. - Dec., 2005), p. 31-42.
Silber, S. ‘Judaism and Reproductive Technology’. From http://www.infertile.com/pdf_files/archive/2010_Judaism_Chapter.pdf
Sheikh Jamaal al-Din Zarabozo, Is Family Planning Allowed in Islam?’ Fromhttp://www.missionislam.com/family/familyplanning.htm
‘The Universal Declaration of Human Rights.’ From http://www.un.org/en/documents/udhr/index.shtml
This is London, ‘Convicts ‘should be allowed IVF treatment while in jail.’ From http://www.thisislondon.co.uk/news/article-23432216-convicts-should-be-allowed-ivf-treatment-while-in-jail.do
Online lecture
Djerassi, C., speaking at ‘Making Babies in the 21st Century,’ (04.11.2010). Available at http://www.guardian.co.uk/commentisfree/audio/2010/nov/04/reproductive-technologies-sex-21st-century
Correspondence
Jonathan Gorsky, Lecturer in Judaism at Heythrop College, in person.
[1] Djerassi, C,. speaking at ‘Making Babies in the 21st Century,’ (4.11.2010). From http://www.guardian.co.uk/commentisfree/audio/2010/nov/04/reproductive-technologies-sex-21st-century
[2] Newsweek, ‘Why I Froze My Eggs’(05.09). From http://www.newsweek.com/2009/05/01/why-i-froze-my-eggs.html
[3] See http://guide.hfea.gov.uk/guide/SearchResults.aspx
[4] Congregation for the Doctrine of the Faith, Dignitas Personae: On Certain Bioethical Questions (2008). From http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_20081208_dignitas-personae_en.html
[5] Silber, S. ‘Judaism and Reproductive Technology,’ p. 467. From http://www.infertile.com/pdf_files/archive/2010_Judaism_Chapter.pdf
[6] Sheikh Jamaal al-Din Zarabozo, ‘Is Family Planning Allowed in Islam?’ From http://www.missionislam.com/family/familyplanning.htm
[7] Djerassi, C. ‘Sex and Reproduction: Ready for Divorce’. From http://www.djerassi.com/icsi2/index.html
[8] Sutton, A., ‘Three Christian Views on Assisted Conception and Marriage - The Roman Catholic Church, Church of England and Presbyterian Church of Scotland’ (1996). From http://www.eubios.info/EJ64/EJ64H.htm
[9] BabyCentre Medical Advisory Board, ‘Understanding Miscarriage’ (2009). From http://www.babycenter.com/0_understanding-miscarriage_252.bc
[10] Gorsky, J., Lecturer in Judaism at Heythrop College, in person.
[11] Djerassi, C,. speaking at ‘Making Babies in the 21st Century,’ (4.11.2010). From http://www.guardian.co.uk/commentisfree/audio/2010/nov/04/reproductive-technologies-sex-21st-century
[12] Warnock, M., Making Babies (Oxford University Press, 2003).
[13] This means that in one embryo transfer cycle, fifty percent of women will achieve a live birth. See Egg Freezing Centre, ‘Success Rates’ (2009). From http://www.eggfreezingcenter.com/about-us/success-rates.html
[14] NHS Choices, ‘About the NHS.’ From http://www.nhs.uk/NHSEngland/thenhs/about/Pages/overview.aspx
[15] BBC News: ‘NHS: what we give and what we get’ (11.04.2006). From http://news.bbc.co.uk/1/hi/programmes/breakfast/4898158.stm
[16] ed. Farah, M., Neuroethics (Massachusetts, 2010).
[17] Djerassi, C,. speaking at ‘Making Babies in the 21st Century,’ (4.11.2010). From http://www.guardian.co.uk/commentisfree/audio/2010/nov/04/reproductive-technologies-sex-21st-century
[18] Gurevich, R. ‘Getting Pragnant After 35.’ From http://infertility.about.com/od/causesofinfertility/a/pregnantafter35.htm
[19] Ibid.
[20] Department of Health, ‘Statistical Bulletin: Abortion Statistics, England and Wales (2009)’. From
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_116336.pdf
[21] Healthy Women, ‘Contraception (birth control options).’ From http://www.healthywomen.org.uk/medical-directory/contraception/contraception.htm
[22] ‘The Universal Declaration of Human Rights.’ From http://www.un.org/en/documents/udhr/index.shtml
[23] President’s Council on Bioethics, ‘Beyond Therapy: Essential Source of Concern’, ed. Farah, M., Neuroethics (Massachusetts 2010).
[24] Drake, S., ‘Not Dead Yet!’ ed. Schaler, J., Peter Singer Under Fire: The Moral Iconoclast Faces His Critics (2009).
[25] Human Genetics Commission, ‘Making Babies: Reproductive Decisions and Genetic Technologies,’ (2006), p. 15. From http://www.hgc.gov.uk/UploadDocs/DocPub/Document/Making%20Babies%20Report%20-%20final%20pdf.pdf
