Ethics

2 Ethics
Andreas A. Noll

Fertility treatment is closely tied to ethical issues. These extend from therapeutic assistance in itself to IVF (e. g., regarding surplus embryos) and are discussed extensively by society with regard to pre-implantation diagnosis or cloning. Given the almost worldwide “tourism” of numerous help-seeking patients, the practitioner here is also confronted with diverse moral and legal views.

Reproductive medicine has opened up new possibilities in the last few years to bring about the fertilization of ovums with techniques in vivo and in vitro, that is, inside and outside the human body. Previously beyond the reach of intentional human intervention (coincidental), this event has become plannable and thereby been delivered to the responsibility of humans themselves. This responsibility implicates the question of ethical standards to regulate how we deal with “failed attempts” or “surplus.”

The qualities of an embryo are now judged according to standards that are not left to science alone. They result from a societal consensus of right and wrong, good and bad.

Human Dignity

Human dignity is closely tied to the exact point in time when a human being is created. This raises the following question: At which moment in the connection of sperm and ovum is it considered that a human life is created? Scientific, religious, and philosophical perspectives diverge greatly from each other in their ideas.

Circumstances of Conception—Criteria

The first question that arises in this context concerns the beginning of human life: from which moment on are we no longer dealing with lifeless building blocks but with a living being?

“A living human being is endowed with a right to life and human dignity. However, we can only speak of a being’s right to life if this being has been granted ‘dignity.’ Being granted dignity can mean nothing else, as far as the legal realm is concerned, than that the bearer of this dignity is, to use Kant’s term, ‘Selbstzweck’ (an end in itself), or in other words, that any action implemented on him by other people must be justified to him. He has the status of a subject with rights, not of a tool for other people’s purposes; and also not of a mere object of care, as is prescribed in laws for the protection of animals.”4

Determining the beginning of human life thus means that from this point on, he or she can no longer be used for other purposes, that he or she is endowed with comprehensive liberties and rights, regardless of the possibilities to take advantage of them. Unborn life is therefore as much endowed with these rights as someone failing in physical and mental capabilities due to old age. As Thomas Jefferson writes in 1776 in his declaration of independence for the United States:

“All men are created equal … and are endowed … with certain unalienable Rights, that among these are Life, Liberty … and the pursuit of Happiness.” (Virginia Bill of Rights, United States 1776)

Criteria for the beginning of life are constructed by:

the natural sciences
religions
philosophies

Scientific Criteria

These arise from the stages of conception, which can certainly serve as the basis for a graduated protection of life: accordingly, law and morality are universally binding even if they are not embedded in the context of a specific view of the world and of humanity. If we follow these secular standards, given the fact that we live in an ideologically pluralistic society, we have to accept the concept of a graduated protection of life for pre-personal human life.1

Germany’s Embryo Protection Law determines in Article 1 Section 8 that the fertilized viable human ovum from the time of cell union as well as any totipotent cell that has been removed from an embryo must be considered an embryo. Article 4.1 in the American Convention on Human Rights from 1978 states, “Every person has the right to have his life respected. This right shall be protected by law and, in general, from the moment of conception” (Table 2.1).

Religious Ideas

These most commonly begin from the infusion of the soul, which happens at different stages in the formation of human life. The origin of the soul is seen in God, in the parents, but also in the seed of the father (Table 2.2).

**Table 2.1** Developmental stages of the embryo
Point of Time	Event	Significance
Fertilization	Fusion of ovum and sperm cell	Individual potential is created
4th– 5th day	Nidation	Implantation in the uterus, fusion with the mother
13th– 14th day	Embryo can no longer divide	Hereafter, formation of twins is no longer possible Complete individuality
3 weeks	Heartbeat	Cardiac circulation as mechanistic criterion for life
15th– 42nd day	Nervous system	Precondition for psychological facilities
16th week	Movements of the child	Mother can feel the new life
20th week	Extra-uterine viability	Viability independent of the mother’s body
Birth	Own digestion, breathing	Extra-uterine life

**Table 2.2** Criteria for the beginning of life
Development of the Idea	Term/Source	Formation of Human Life
St. Thomas Aquinas	Creationism	Soul is lowered into the embryo by God: in men on the 40th day in women on the 80th day
Catholic Christianity	Simultaneous animation	Only one soul “forma unica” since conception
Protestant Christianity	Image of God	Embryo is an image of God and worthy of protection
Judaism	Halacha	Life only from implantation in the uterus onwards
	Jewish-orthodox philosophy	Divine breath on the 49th day
Islam	Koran, Central Council of Muslims	40 days drop of seed 40 days blood clot 40 days piece of flesh Breathing in the life spirit: either 40 or 120 days until the formation of human life
Buddhism	Ngawang	The process of becoming human begins with conception, from that point on worthy of protection

Different Concepts

Culture, religion, and philosophy therefore have different ideas about the point in time when life begins and must be protected:

Absolute positions—integrity from conception onwards—advocated by the Christian churches and, for example, also by the philosopher R. Spaemann quoted above.
Graduated ideas deduce the right to protection from a specific developmental stage. They differentiate between human dignity (not qualifiable) and right to life (limitations, e. g., in self-defense, are possible). Considerations are also informed, for example, by the individuation of the embryo, brain function (life and death), or birth.
A modified protection of the embryo is advocated, for example by the philosopher J. Habermas, quoted below, who distinguishes between the “dignity of human life” and “human dignity.” “Dignity” is shown and awarded like “reverence” and “respect,” while “human dignity” is an inalienable right and exists in and of itself, independent of allocation.

Instrumentalization—Intervention in Fertility Treatment

The second question that can confront the practitioner is the basic consideration of the extent to which he or she should intervene in the creation of new life at all. Where are the limits of personal responsibility and ethics? Are there limits to therapeutic action?

We can see the relevance of this question in the case of pre-implantation diagnosis (PID)—prohibited in Germany and objected to by many social and religious conservatives in the rest of the world. This procedure means that fertilized egg cells can be selected by their genetic quality. Habermas outlines the potential consequences:

“Let us suppose that parents will some day be able to select genetic designs to pre-natally determine certain traits, dispositions, or abilities for their planned child. The adolescent who later learns of such programming then might encounter genetically fixed intentions that he does not want to adopt as part of his own identity. The musically gifted person who would rather become a professional athlete can blame his parents for not having provided him with athletic skills.”

And further on:

“Nobody can justify decisions that irrevocably affect the social fate of another person. Nobody can predict whether something will turn out to be a curse or blessing in the context of another person’s life history—even if it concerns ‘basic genetic assets’ like memory or intelligence. In some contexts, a mild physical impairment may even yield an advantage for a child. The results cannot be calculated because the allocation of genetic resources affects realms in which another person will some day make use of her ethical liberty to shape her life in her own direction. In cases of conflict, a programmed person would no longer be able to see herself as the complete author of her own life.”1

These questions regarding the possibilities of intervening in the quality of the future person arise in every IVF procedure. Even limiting the selection criteria to eugenics, which covers genetic disposition to diseases, is questionable at the least, if we consider the immense range of variability for defining “disease”:

“To the extent that this development opens up promising chances to treat previously incurable diseases, it probably also offers the questionable options of an improved eugenics. Within the structure of liberal societies, such practices of changing genetic traits would through the market fall into the hands of parents’ personal choices. Shopping in the genetic supermarket is a scenario of the future that relevant bioethical discussions in the United States have been addressing for a long time already. If we have any doubts about whether we really want this individualized variety of eugenics, we should pay attention to the contributions of today’s practices to this development.”¹

But even if we leave aside for the moment the possibilities of IVF and the availability of surplus embryos resulting from this method, and the drive to research in biomedicine and genetic engineering, other options of medical intervention cause some fundamental problems: what does the naturalness, the God-given origin, the sacredness of life mean for us? Doesn’t Chinese medical philosophy also understand the term ming men, which is based on a mandate from heaven that humans are supposed to fulfill? Or the wu wei of philosophical Daoism, which actually postulates non-intervention? These notions collide with the development of medicine, and the reader of this book can indeed ask about the extent to which they play a role in fertility treatment.

Finally, we should also give some thought to another group of arguments and considerations; reflecting on them illuminates the problem of therapeutic intervention beyond catchphrases. These are the arguments people advance against human interventions from the “principle of randomness in childbirth.” There is, for example, “naturalness,” “natural healing,” “natural birth”—whatever is natural is seen as good. However nature leads the way is well-ordered and “right.” This naturalistic ethics is rooted in the notion that the order of nature is the result of divine action and therefore provides the standard for moral judgments. Alteration of this God-given nature is therefore reprehensible and leads to misery.

Arguments that reject the actualization of the possibilities of therapeutic intervention are also often informed by notions of social Darwinism—humans are becoming older and older, which leads to overpopulation and cost explosion in health care. Humans therefore cause their own doom by intervening in “natural evolution.” Nevertheless, “human nature,” as the totality of our fundamental, original identity as beings belonging to the genus Homo is at the same time an important, if barely comprehensible orientation for our actions. We humans continue to see ourselves as the crown of creation. As such, our life is sacrosanct, whether in the Christian notion of the image of God or as a part of nature.

These reflections show that contemporary Western people have developed in flesh and blood, in the deepest layers of our culture-based identity an image of humanity and therefore also an image of life as sacred and worthy of protection that cannot make unconditional claims of general validity. Our Chinese, Korean, and Japanese colleagues view this problem with completely different eyes. When we consider the use of selective abortion, cloning, stem cell experiments, and positive and negative eugenics in the Far East, issues that cause profound moral apprehension about violating human dignity in our cultural context, it becomes obvious how deeply our ideas are rooted in our culture (see p. 8).

Love, Sex, and Reproduction

As described in detail in “Infertility and Sexual Disorders” (Chapter 18), the possibilities of biomedicine, as well as a general social tendency, are increasingly destroying the ideal of a unity of love, sex, and reproduction. As we explain there though, this unity never existed under culturalreligious premises. The Catholic theologian C. Breuer has elaborated on this topic:

“The physical act of procreation necessarily also includes a mental dimension. This mental act of love between man and woman and its expression in the ‘language of the body’ is tied to the conditions of the body because the body is the ‘carrier’ of mental acts. This separation of loving union and reproduction, which has taken place especially since the so-called ‘sexual’ revolution of the 1960s, has caused an instrumentalization of human sexuality (sex without having children). Under opposite auspices, this instrumentalization is now further intensified by the technology of reproductive medicine (having children without sex). Nevertheless, the oneness of loving union and reproduction is a fundamental condition of humanity because it not only facilitates the unity and integration of personal-mental life (in the act of love) and natural life (sexual act), but in addition prevents the creation of human life from becoming an act of ‘making’ and then ‘disposing’ of life, in which human life becomes primarily an object.”²

On the one hand, secularization has caused issues like reproduction that appear to be explainable by technology to indeed be treated as technological problems. They have thereby been freed from the constraints of this complex, with their solution being simply a question of time. In its social-communicative function, sexuality is reduced to sperm production. And love? It appears to continue to remain in the metaphysical realm.

Developments

The secularization of morality, the previously mentioned need for personal initiative by the practitioner in areas where religious norms used to provide clear moral guidelines, requires new thinking:

“Up to now, the development of biotechnology has been unfolding a dynamic that continues to overrun the time-consuming processes by which society forms a self-understanding of its moral goals. The shorter the range of time that we are considering, the greater will later be the power of the facts that have then already been created.”1

We cannot escape from this development, and whatever is doable will be done. Humanity has begun to construct and also to destruct itself. It will not lose the relevant knowledge.

In this book, we introduce the possibilities of Far Eastern medicine for the treatment of infertility—the possibilities of Chinese medicine. On the one hand, this refers to the regulation of the human energetic system. This includes efforts to incorporate physical, mental, and spiritual sensitivities and their changes, for the purpose of regulating the harmony and flow of the life force qi to such an extent that new life qi can be created. Nevertheless, these efforts are therapeutic interventions in a (natural?) state of non-function as well. The possibilities of Chinese medicine extend, however, also to a supplementary role in IVF, insemination, and other techniques of biomedicine. In the confrontation of Western-mechanistic ideas with Eastern-synthetic concepts that takes place in such cases, we can perhaps discover new paths.

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