Made, Not Begotten: IVF and the Right to Life Under Conditions

Abstract

In a society in which the decoupling of sexuality and human reproduction has become normal, In vitro fertilization (IVF) has mutated into a kind of standard procedure. There is little awareness of the ethical ruptures that the mechanization of human reproduction causes. The basic ethical problem with extracorporeal fertilization in a test tube is that a child is not conceived through the personal union of a man and a woman, but is “produced” in a laboratory. In the context of human creation, this entails a series of ethical problems. The technique does not merely offer another possible option for action, but it leads to a fundamental change in the attitude towards human life as such. A look at the history of assisted reproductive technology (ART) since the 1970s reveals that ethical problems, eugenic visions as well as medical experiments on humans have been inherent to the method from the very beginning. Considering that eugenic thinking has been a driving force from the very beginning it astonishes that this delicate point has hardly been recognized and highlighted so far. Robert Edwards' (1925–2013) vision went far beyond the mere treatment of infertility through the use of IVF, which he saw as enabling the selection of so-called “unhealthy life.” The article considers the risks of IVF and includes recent studies by physicians involved in reproductive medicine who are increasingly critical of their industry. Furthermore it emphasizes the core ethical question on human reproductive technology, contrasting the “ethics of procreation” with the “ethics of production.”

Summary

The article highlights historical aspects, considers the risks as well as the ethical questions on assisted reproductive technology.

Introduction

Loving the Imperfect—The Salutary Paradox of Christianity

The God of Christianity surprises. The rich, powerful and healthy are not his first interest. In the Gospel we see that Jesus, the Christ, explicitly turns first to the sick and the weak, the poor, the simple, the sinners—all who are needy and vulnerable. He chooses them and calls them to a perfection that goes beyond purely earthly standards. His kingdom is about a new, seemingly paradoxical perfection—that of loving acceptance of the imperfect, of caring for the vulnerable and fragile creatures that God entrusts to man. We are entrusted to each other in our fragility. Each one takes care of the weakness of the other, it is said (cf. Rom 15:1), and each one bears the burden of the other (cf. Gal 6:2). This is apparently the paradoxical way to exhaust the fullness of being.

These are strong gestures by which the Creator invites man, His creation, to act according to His example of unconditional love: Thus, He kneels before His creature and washes his feet (cf. Jn, 13:5). God serves His creature and thus bridges the infinite boundary between the perfection of his divine being and the imperfection of the human being—through love (cf. Jn 13:1).

Jesus does not proclaim an earthly utopia, a kingdom in which everything is perfect. He does not act with the hubris of a controlling man who wants to erase suffering, pain and death forever in the inner world. Achieving perfection of human life, in which all cracks will be healed, is not feasible or technically producible here on earth. The ultimate, actual and essential things in life cannot be made by man. There is a gap in our being that we cannot close by ourselves. At the same time, this gap opens up a salutary space of hope and relief: Namely, that what you can become will eventually come to you if you keep yourself open—not by right, but as a gift.

Tension exists in shaping life and at the same time accepting it as a given. Modernity sees itself as an age of feasibility. Its path leads—according to Odo Marquard—first of all “from fatum to factum” (Marquard, 1997, 67). “We live in a society that does not tolerate fate, in a society in which apparently nothing has to be the way it is,” Giovanni Maio (Maio, 2013a, 53) states. Where trust and the experience of being unconditionally accepted fall away and the time horizon shrinks to this world, the only thing left for human beings is to understand life as the ultimate last opportunity: What perfection is not produced and exhausted here and now cannot be made up for. There is pressure to optimize.

Under these auspices, the passivity of suffering no longer has a place in an active society dominated by doing. In it, suffering and pain are interpreted as signs of weakness (Han, 2020: 8–10). Byung-Chul Han puts it this way, “There are no longer any references to meaning that would give us support and orientation in the face of pain. The art of suffering pain is completely lost to us. Pain is reduced to a meaningless evil to be fought with analgesics.” (Han, 2020, 29). And Han continues, “Pain is the negativity par excellence. Pain now only has a place in a performance logic, in order to form a permanently happy performance subject out of man who is as insensitive to pain as possible.” (Han, 2020, 29).

The ideal of the healthy, strong, useful service provider shouts for a cost–benefit calculation and demands that everything be erased that reminds us of illness, decay and transience, because it unnecessarily holds us back.

To Create Perfection—To Eradicate the Frail

With modernity, man has detached himself from the overarching context of divine salvation. In a state of metaphysical homelessness, he is left only with “his wretched little life between birth and death.” (Gronemeyer, 2013, 87) Beyond life, heaven is no longer open, but a concrete ceiling seems to have been drawn in. To live means to have a few years of life at one’s disposal. Whoever wants to draw from abundance in the here and now must ensure that abundance is also available in the here and now without annoying renunciation or brittleness. The modern paradigm of mastering nature relates to the perfection of man (Gronemeyer, 2013, 99): Extending life and making life easier.

Advanced techniques and technologies, interventions such as genetic manipulation and hormone therapy are being used to advance the project of human enhancement, including anti-aging and eugenics. Today, it is the transhumanists who are working on targeted technical and genetic interventions to halt the aging process, eliminate degenerative diseases, enhance mental performance, and improve and prolong life overall (Schuster, 2019, 131–140). The declared goal is to expand the physical and mental possibilities of human beings and thus increase their chances of a fulfilled life by increasing to the greatest possible extent intelligence, lifespan, and sense of well–being.

The Chosen Child: The Emergence of a Dystopia

To be able to improve the patrimony of humanity through positive or negative eugenics is one of the archaic dreams of humanity. The care of the frail, the old and the sick is time-consuming, financially and existentially costly, the “sick person is a parasite of society” (Friedrich Nietzsche). ¹ In the realm of the healthy and optimized, there is no place for “inferiors” who have “lost the right to live.”

The field of Assisted Reproductive Technology (ART) shows that there, too, eugenic thinking has been a driving force from the very beginning. It is astonishing that this delicate point has hardly been recognized and highlighted so far. A critical look at ART shows that the image of the two doctors and “inventors” of the in vitro fertilization (hereafter, IVF) procedure as selfless helpers for involuntary childless women is only half the truth. Today’s worldwide established, million-fold, applied and controversial methods such as preimplantation genetic diagnosis were intellectually prepared and welcomed by the British physiologist Robert Edwards (1925–2013) and the gynecologist Patrick Steptoe (1913–1988). Edwards' vision went far beyond the mere treatment of infertility through the use of IVF, which he saw as enabling the selection of so-called “unhealthy life” (negative eugenics).

IVF: The Dark Side of a Child-Producing Industry

Reproductive Medicine: From an Individual Case to an Industrial Sector

When Louise Brown was born on July 25, 1978 as the first child produced as a result of IVF, it was celebrated as a medical sensation. In the USA, the first child was born after IVF in 1981, in Austria and Germany in 1982. In Germany alone, 296,747 IVF children were born between 1997 and 2017. In 2018, they accounted for three percent of all live births in both Germany and Austria. This means that in a school class of 30 children in those countries, there is, on average, one child who was born after IVF (cfr. Deutsches IVF-Register, 2019). It is estimated that there are now eight million people worldwide who have been born after extracorporeal fertilization (European Society of Human Reproduction and Embryology, 2018).

In public, the prevailing image of reproductive medicine is that it is a wish-fulfilling medicine that can do everything; it neither disappoints nor harms, and certainly never fails. If you browse the websites of Fertility clinics, you will mainly come across smiling babies and happy parents, including slogans such as “Relax. Get pregnant,” or “Finally, be pregnant!”

More than 40 years after the birth of the first IVF child, however, the number of critical voices are also increasing. The number of IVF attempts is increasing enormously worldwide, while the success rate is stagnating. At the same time, an aggressive global market of a veritable reproduction industry has emerged, fueling hopes. But for 80% of all couples who undertake one or more IVF attempts, the dream of having a child ends in trauma: they remain childless despite numerous promises. According to the German IVF-Register 2018, the so-called Take-Home Baby Rate—calculated per treatment—is only between 18 and 20% (European Society of Human Reproduction and Embryology, 2018, 8).

When IVF research was still in its infancy in 1971, the renowned British Medical Research Council was unwilling to fund the research projects of reproductive physicians. Their reasoning was that research and application of IVF technology on and with humans would not meet the necessary clinical and ethical standards. 50 years later, internationally prominent reproductive physicians are speaking out, and still criticize the IVF industry for relying on too few scientific studies, raising false hopes with risky methods, and seldom informing childless couples that want children about equally helpful alternatives (ElMokhallalati, 2019). Among the reasons cited by critical physicians for these problems are government reimbursement systems that provide financial support for IVF and the pressure from the fertility industry to promote their business, even at the expense of patients.

Many methods used in IVF are touted as promising and are costly, but their clinical benefits have not been proven. The increasing commercialization of non-clinically proven IVF methods also correlates with a currently declining success rate. Japan was recently cited as a particularly glaring example of this. There, widespread introduction of non-clinically proven methods to increase Take-Home Baby Rate, such as selection of embryos after preimplantation genetic diagnosis, single embryo transfer, or blastocyst transfer leads to a dramatic decline in the IVF live birth rate from 15% in 2004 to 5% in 2013. As a result, during the same time period there was a tripling in the total number of IVF attempts. Similar results have emerged from Australia and New Zealand. The outcome, critics say, is that now the measure of success of IVF is no longer the birth of a child, but the increase in the number of IVF attempts and the concomitant flow of money (Gleicher et al., 2019).

ART have become the basis for a profit-making industry with many players cashing in. Late childbearing, lifestyle changes, and fertility disorders, and other factors, are cited as the main factors behind the rising demand. It is estimated that the global IVF market will grow from $13.7 billion in 2019 to $25.6 billion by 2026 (Pandey and Sumant, 2019).

Originally, untreatable tubal occlusion was considered the only indication for IVF and was limited to married women, then male fertility disorders were added. Within a very short time, however, the spectrum of indications for reproductive medical interventions expanded to include life plans without any pathological background. Depending on national legislation, married couples who wish to have children, cohabiting couples, singles, post-menopausal women, single women, widows, lesbian couples (with sperm donation), homosexual couples (with egg donation and surrogate mother), or even couples who are fertile but want to have embryos genetically tested beforehand are entitled to IVF.

The Child as a Therapeutic Agent? The Medicalization of Reproduction

The prerequisite for the use of ART is that involuntary childlessness has been defined as a disease. On its own reproductive disorders can indeed have pathological causes, but is childlessness in itself a disease that requires therapy?

Suffering from an unfulfilled desire to have children is an existential crisis for many couples, which is often accompanied by considerable restrictions on self-esteem and can become a heavy psychological burden (crf. Rauprich, 2008, 44). Reproductive medicine is not about curing infertility. The woman is not healed from being infertile. ART is a means of circumventing it so as to fulfill the desire for a child of one’s own, or as Petra Gehring puts it “Reproductive medicine doesn’t make you healthy, it produces offspring” (Gehring, 2007, 57). In a certain sense, the production of the child becomes a curative treatment for a primal human need, namely that for one’s own reproduction (Eichinger, 2013, 79). In this way, however, the child itself becomes an object, an approach that entails ethical problems.

According to Tobias Eichinger, the medicalization character in the case of children’s wishes is clearly shown in the increase of “unconventional family constellations, the fulfillment of which an increasingly becoming the everyday business of reproductive medicine” (Eichinger, 2013, 79). In Great Britain, for example, the number of single women giving birth through the use of sperm banks tripled between 2005 and 2015 (Starza-Allen, 2015). In California, fertile couples, who already have children, undergo IVF to enable the sex of the child to be selected (cfr. Reddy, 2015). In light of the growing number of women over 40 or post-menopausal women who still want to fulfill their desire to have children, ART is now also being considered in so-called “geriatric obstetrics.” In 2016, a WHO working group took the logic behind this one step further: people should also be considered infertile if they simply have not found a suitable sexual partner, that is, singles or homosexual men with a desire to have children (Bodkin, 2016). Involuntary childlessness is a serious affliction for couples. But being single or homosexual is not a handicap. Should medicine now strive to realize life’s desires, fulfill longings and solve social problems? Here, the child is increasingly becoming a kind of therapeutic agent for unfulfilled self-realization and life planning—even in physically healthy people.

Even if the desire for a child is legitimate, however, no individual “right to a child” can be derived from this. It is true that no one should be prevented from founding a family; this is enshrined in international human rights law. However, this “right of defense” conversely/by implication does not give rise to a “right of claim,” neither against the partner nor against the child.

The Technicization of Human Reproduction: Visions and Conflicts

In a society in which the decoupling of sexuality and human reproduction has become normal, IVF has also mutated into a kind of standard procedure. There is little awareness of the ethical ruptures that the mechanization of human reproduction causes.

Historically, it is evident that the ethical conflicts of IVF have not been a consequence of later methodological improvements or emerging technologies, but have been inherent to the procedure from the beginning. This includes the fact that the vision of British physiologist Robert Edwards went far beyond simply treating infertility through the use of IVF technology.

Edwards had already begun working on methods of extracorporeal fertilization in the 1950s. After numerous failed attempts, he and gynecologist Patrick Steptoe succeeded in 1969 in fertilizing the first human egg in a test tube. In their application for funding for their research on IVF, which the two submitted to the Medical Research Council (MRC) in 1971, they discussed the importance of their project, as they saw it: The key outcome of their planned basic research would be a better understanding of the mechanisms underlying human reproduction. Thanks to this basic research, a threefold goal could be pursued: In some cases, infertility would be alleviated, the further development of contraceptive methods would be supported and, in the long term, technologies would be available to prevent the birth of children with certain hereditary diseases (cfr. Johnson Martin et al., 2010).

Edwards was initially very interested in developing new methods of contraception and population control (Johnson, 2011). This was very much in keeping with the trend at the time; this was also the priority for international reproductive research. The 1970s were a time when catastrophic scenarios were conjured up because of a supposedly imminent collapse due to human overpopulation. ² Correspondingly, worldwide funding for contraception research tripled between 1965 and 1972, from $31 million to $110 million.

It is clear that Edwards was not only interested in contraception and reproduction, but that eugenics were also to play a central role in justifying the development of his new technology. Significantly, if not surprisingly given his research interests, the early study and detection of genetic disease is afforded a heavy focus compared with the slight emphasis on infertility alleviation (Johnson, 2011). “Thanks to IVF it would be possible to prevent humanity from producing individuals with genetically predisposed genetic material and thus improve the genetic pool of mankind” (Johnson, 2011). ³ Edwards served on the Council, the leadership body of the British Eugenic Society, as a trustee; he considered genetic selection to be ethically justified. To this day, the Eugenic Society is considered a dark chapter in the history of eugenics in Britain and the United States (Obasogie, 2013). While eugenic ideologies and laws were frowned upon after the experiences of the Nazi regime of terror, the British Eugenic Society retained its name. It only renamed itself the Galton Institute (after its founder, Francis Galton) in 1989. Its quarterly journal, The Eugenics Review (1909–1968), which was an organ of eugenic propaganda, continued to be published until 1968 (Kurbegovic, 2013).

Edwards was heavily criticized within the scientific community at the beginning of his clinical trials, and met with massive opposition in the early years of his work. For example, James Watson, himself a Nobel laureate and discoverer of the DNA double helix, reproached Edwards for “only being able to carry on his work” if he accepted the “necessity of infanticides.” (Edwards and Patrick Steptoe, 1980). Edwards countered his opponent by saying that science should not be limited by ethics. In a 1969 interview for Living Marxism, he confessed that he “can’t do anything with these hyper-emotional things” according to which there are supposed to be “areas that [...] should not be touched.” (Furedi, 2013, 16–20)

In 1999, Edwards declared, “Soon it will be a sin for parents to have a child who carries the heavy burden of a genetic disease,” the time will come, Edwards said, when “we will have to examine the quality of our children.” (Obasogie, 2013) The moral imperative clearly rings through here: Once the technology is established, it will be culpably irresponsible, a “sin,” not to use it to spare the lives of those children who are a (genetic) burden to themselves and to society. In 2010, Edwards received the Nobel Prize, and in 2013 he passed away. He never distanced himself from institutions with eugenic ideas (Obasogie, 2013).

Treatments on Humans — Without Prior Evidence Review?

The Medical Research Council denied Edwards' and Steptoe’s application for research funding in 1971 (Johnson Martin et al., 2010). This was not because of a principled rejection of IVF, but because of the lack of ethical standards in their clinical research projects. For example, aspects of patient safety would be given secondary consideration; Edwards and Steptoe had not been willing to first develop the procedure in primates before moving into human clinical research, which the MRC considered, ‘premature’. In animal studies, IVF had shown far from only positive results; the procedure was thus deemed too risky to be used directly on humans.

As the MRC understood it, Edwards and Steptoe were therefore conducting human experiments. The experience of medical experiments on humans from the Nazi regime had occurred only three decades previously, which also explains the caution of the MRC that had the risks of IVF research more in mind than its possible benefits. IVF research was subsequently funded entirely by private foundations, most notably the Ford and Rockefeller Foundations and the Population Council, from 1971 to 1978. For Rockefeller, the findings on possible new contraceptive methods were considered particularly relevant; to this day, the foundation is considered the main investor in research projects on contraception (Johnson Maryin et al., 2010).

Since the birth of the first test tube child in 1978, the variety and numbers of techniques involved in IVF have grown at an enormous pace. However, safety and efficacy in human use were not always taken too seriously. Ethics and the zeal of the IVF industry for applying untested technologies to humans are questioned by authors. Precisely because ART involves often emotionally vulnerable individuals—some methods are only offered after several failed IVF attempts—and economic interests play a role, British reproductive scientist Joyce Harper argues for special care: it must be ensured “that all new technologies are appropriate and tested for safety and efficacy before they are used clinically.” (Brown and Harper, 2012). But few of the procedures being used, she said, were tested to clinical standards before they came to market.

“The benefits of some technologies already established for routine use are currently dubious and there are clear ethical concerns with providing them to patients when their scientific basis is not clear” says Harper. IVF-Clinics would not be willing to put the safety of the women involved and the benefits of the applications first and modify the applications of the techniques despite new randomized trials, Harper criticizes, commercial considerations would play a role in promoting these techniques (Vergnac, 2016).

In 2018, British IVF pioneer Lord Robert Winston urged self-critical reflection in the industry, more transparency and seriousness (Connor, 2018). He complains that people are “sucked into IVF” without learning how low the success rates are. The IVF market has become a business, with private British wanted-baby clinics literally “skimming off the top,” said Winston, professor emeritus of fertility studies at Imperial College London. The desperation of couples who want a child, combined with the greed of private practices, makes for a “dangerous mix,” he added.

Of Effects and Undesirable Side Effects

Studies are gradually being published that address the increased health risk to mother and child after IVF (Kamphuis et al., 2014); a few recent papers will be cited here as examples.

Oocyte donation pregnancies are associated with a high risk of adverse maternal and fetal outcome, that is, hypertension in pregnancy, preterm delivery, Cesarean section as mode of delivery, and increased peripartum hemorrhage (Altmann et al., 2021). Women are up to five times more likely to experience serious health complications after pregnancy with egg donation than women after spontaneous pregnancy. An U.S. study published in 2019 found that in 11,703 pregnancies in which women carried a not genetically related child to term, serious health complications occurred in 30%: of 3500 women, 800 required intensive care unit admission, 1150 required blood transfusions, and in 465 cases there was an unplanned hysterectomy (Luke 2019). The same study shows that even with an IVF performed with the women’s own eggs, the health risks for the women increased significantly. For example, IVF increased the risk of serious complications such as severe perineal rupture at birth, unplanned hysterectomy, uterine rupture, or the need for blood transfusions by 1.3–2.5 times compared with spontaneous pregnancy. For their analysis, the authors had examined data between 2004 and 2013 from 1,346,118 fertile women, 11,298 subfertile women (i.e., in need of treatment) and 120,106 women who underwent IVF.

During the first few days after IVF, embryos are cultured in a nutrient solution in an incubator. Scientists have long suspected that this, non-standardized, chemical and hormonal mixture can cause epigenetic changes. Modification of the genetic makeup at the molecular level can lead subtly to long-term health problems—high blood pressure, late effects of lower fetal growth, lower birth weight, asthma, metabolic disorders. That the IVF procedure can be a risk factor for cardiovascular and metabolic disease in IVF infants as early as adolescence and young adulthood was shown in a 2018 Swiss study (Meister et al., 2018). Its authors considered the procedures and materials used in IVF to be the cause of premature vascular aging in adolescents, although it is still unclear which factors are negative determinants. Swiss cardiologist Urs Scherrer calls for IVF to be classified as a cardiovascular risk factor, such as smoking, inactivity, or obesity. Young people should therefore be told how they were conceived in vitro, how the pregnancy went. They have a right to know about their genesis, because it contains important information for the anamnesis. It is becoming increasingly apparent that this earliest phase in life has a decisive influence on later health.

In 2011, the Deutsche Ethikrat presented figures regarding malformations and health consequences in children born after IVF, specifically the increased risks to the health of IVF children associated with the particularly frequent multiple pregnancies or births after such intervention.

Risks include increases in premature birth (<37 weeks): about 10–fold; low birth weight (<2500 g): about 7– to 10–fold; cerebral palsy: 3– to 10–fold; respiratory distress syndrome of the newborn: 5– to 7–fold; sepsis: 3–fold; and permanent severe disability:1.5– to 2–fold. The risk of stroke, myocardial infarction, cardiac arrhythmia and type 2 diabetes mellitus increases significantly in newborns with low birth weight. However, the increase in risk does not only affect twins or multiples conceived by ART. According to the German Ethics Council, it also affects ART-singletons who have in comparison with naturally conceived singletons, a 1.3– to 4.3–fold risk of prematurity and therefore neurological and neurodevelopmental problems associated with low birth weight (Deutscher Ethikrat, 2011).

Ethical Considerations Regarding Reproductive Medicine

The basic ethical problem with extracorporeal fertilization in a test tube is that a child is not conceived through the personal union of a man and a woman, but is “produced” in a laboratory. In the context of human creation, this entails a series of ethical problems. In this case, the technique does not merely offer another possible option for action, but it leads to a fundamental change in the attitude towards human life as such. The child is no longer conceived in the mode of the gift, but in the mode of the possession. The logic of “making” leads to relativizing not only the subjectivity of the parents, but also that of the child. The embryo in the test tube is transformed more and more into an object, into a producible thing; it is no longer someone, but something. Not only its existence, but also its “quality” must correspond to desires and demands in the course of the logic of production.

In the womb, the coming into existence of the human being is withdrawn from external access in the course of natural procreation. In the course of extracorporeal fertilization, the creation of the human being falls under the interpretive sovereignty of product manufacturing. Technical actitude is not simply value-neutral, but entails a moral imperative in the laboratory, the embryo transforms into an object whose product quality must be ensured, but this undermines the unconditionality of human existence.

From the Logic of Procreation to the Logic of Generation

The technical approach to have a child through ART leads to a qualitatively new, sometimes fatal, relationship between parents and the desired child (Maio, 2017; Maio, 2013b, 14). A naturally conceived child is always more than merely a product of its parents' will and action; it may or may not be desired or “planned,” but even then conception, happens as an unavailable act. The child has never been merely produced by its parents. It is conceived, both its creation in the womb of the mother and its being remains beyond the direct grasp of the parents and others. The mode of producing life in the laboratory, on the other hand, changes this perspective from the ground up. There, doctors and the laboratory team take the front row, while the subjectivity of the parents recedes into the shadow of a technical process that they allow to take place over them. The couple provides only their genetic “raw material.”

The embryo in the test tube thus transforms into a producible thing; it is no longer someone, but something. In accordance with a production logic, the embryos are then also tested for their quality, like a commodity; frozen, stored in deep-freeze containers and, if necessary, selected or destroyed. An excerpt from Great Britain shows the extent of embryo loss during this process: from 1991 to 2012, 3.5 million embryos were created in the UK in the course of IVF procedures, of which 1.3 million were implanted in women. In only about 15% of cases did the procedure result in pregnancy. A few thousand were made available for research. Other embryos were of insufficient quality to be implanted in the uterus. Eventually, 1.7 million embryos remained, finding no further use, they were orphaned and discarded (cfr. Doughty, 2012).

Contradictions inherent in the IVF-process rise that can no longer be resolved in any meaningful ethical way: Bringing one child into the world means at the same time destroying embryos. Or, as one woman put it after the birth of her IVF child, “When my child cries, I hear all the other children crying along with it!” ⁴

Certified Procreation

Human life loses its unconditionality in the course of reproductive medicine, expressed in the sentence: “It is good that you exist because you exist.” In the logic of the product, conditions are now also placed on the suchness of human beings. Not only the existence, but also the “quality” must, in the course of the logic of production, correspond to the desires, and demands of the human being.

The future of reproductive medicine is that thousands of photos of the embryos cultivated in the test tube will be taken via a monitoring camera in the incubator, which will then evaluate morphological characteristics as a measure of survivability by means of an algorithm. In the future, artificial intelligence will determine the “quality classes” and thus the “quality” of the embryos and control the selection of the “product.”

To produce means to rule and to be able to dispose. It implies the determination of a result. Having children is then no longer an open process that gives space to life, but it is the other way around: the desired result “determines the entire process of making.” (Maio, 2013b, 19 ff.) In this context, the German social ethicist Manfred Spieker talks of “certified procreation” (Spieker, 2006): If the embryo does not meet the previously defined criteria of “quality control”—criteria that include not only survival, but also genetic predispositions, gender, or even whether the child is suitable as a donor for sick family members—so-called “rescue siblings”—it is discarded and has forfeited its right to life. This right is not unconditional, but is determined by third parties only under certain conditions. “The path from the certified quality management of the reproductive medical center to the quality management of its product is consistent. Preimplantation genetic diagnosis (PGD) is the logical consequence of in vitro fertilization, and genetic manipulation is the logical consequence of preimplantation genetic diagnosis.” (Spieker, 2006, 153). For Robert Edwards, inventor of IVF, this was a path clearly mapped out from the beginning, as we have already seen.

Desired, Not Wanted: The Slippery Slope of IVF

If the desired child demands such a high price on a financial, physical, and psychological level, then it must be a perfect, healthy child that meets one’s expectations. Otherwise, it does not fulfill its “purpose.” The desire to have children is, after all, coupled with the desire of adults to have their own definite life. “The child question is always also a parent question.” (Eichinger, 2013, 88). Wish-fulfilling children are subsequently accepted only under certain conditions (e.g., health, gender) while other children, who do not meet those wishes, are considered “undesirable” and would then be considered “superfluous and useless and therefore a burden.” (Maio, 2013b, 20). An example of an unwanted child that caused a media stir is the so-called Gammy case from 2014. In that instance an Australian couple had ordered their desired child from an agency. However, the Thai surrogate mother was expecting twins, and it turned out that one of the two children was disabled. The order parents demanded an abortion; the surrogate mother refused. However, because the Australians only wanted the healthy child, they left the child with Down syndrome in Thailand. ⁵

The Logic of Depersonalization: When Technology Replaces Relationship

The procreation of human life is not a purely biological or merely technical act, but a relational act that is normally the exclusive object of a familiar relationship between two people (Eichinger, 2013, 67). Maio therefore refers to the fact that procreation, which has been transferred to technology, strips the emergence of the human being of this relational structure, as it were, as a “logic of depersonalization.” The result is, as Eichinger analyzes, a “spatial-physical dissolution of the boundaries of reproduction” (Eichinger, 2013, 67): the intimate process of human procreation and the becoming of human life in the womb of the mother now takes place in the laboratory, under the microscope, in nutrient solutions, and, depending on the phase, in warming or freezing cabinets. The entire process of reproduction must be broken down into individual steps, for which a team of dozens of doctors, project managers, agencies and laboratory staff is responsible. Couples experience this as extremely stressful, but these physical and psychological burdens of reproductive medical treatment are significantly underestimated in advance (Rögener, 2018).

Reproduction is delegated to experts, who then also have to bear responsibility and liability in the event of damage. In 2016, for example, it became known that improper work had been carried out in the laboratory of the UMC University Hospital in Utrecht: Human eggs were fertilized with the wrong sperm. Twenty-six women had “false children,” nine had already given birth to their child, and four were pregnant. In the 13 other cases, the embryos were still frozen. It took a year and a half for the error to be discovered, and claims for damages for the “false children” are pending (Griffin, 2016).

The term “donation” is a pure euphemism in this context. A donation—money, clothes, even a blood or kidney donation—is alienated and made available to an already existing subject completely for its use or consumption. Donation is ultimately spoken of as something that one can “give away” without danger or personal constraint, and there is no further relationship nor responsibility to the thing given away. In the case of sperm or egg ”donation” the term is misleading. It is not a matter of something that is used or consumed, but rather of the endowment of an existence and thus of a lifelong relationship and responsibility toward one’s own, genetically related, child. The child created by the “given–away ovum” demands to be able to grow up not in the mode of being given away, but of being accepted by its genetic parents.

The De-limitation of Reproduction and the Welfare of the Child

Reproductive medicine forces human reproduction to be fragmented and split into individual components. These genetic “components”—egg cell, sperm cell, gametes from third parties, surrogate mother, etc.—are newly “combined” with each other. In so-called sperm donation, a woman’s egg is fertilized—heterologous fertilization—not with the sperm of her partner, but from an anonymous donor. The child thus has three parents: a genetic mother, a foster father and a genetic father, whom he will usually never know. This results in a deliberate splitting of genetic and social parenthood.

The same applies to egg donation, where, however, it is also a medically insufficiently documented procedure that involves numerous risks for women, mothers and children (Luke et al., 2019; Meister et al., 2018; Storgaard et al., 2017; Tordy and Riegler, 2014). When one’s own eggs are donated to other women, additional ethically serious problems arise, such as “expense allowances” as hidden payment and potential exploitation. Eyes are gladly closed to the internationally increasing egg cell trade and the associated degradation of the woman’s body to a raw material supplier. The commercialization and thus the exploitation of women in precarious situations is increasing.

Particularly in the case of children created through the sperm of a third party or the egg of a third party, the problem of the dissolution of boundaries in the sense of a depersonalization and thus a lack of relationship applies: men make their sperm available in order to produce children in vitro for whom they will never assume parental responsibility. In view of the thousands of children who have been born after anonymous sperm donation, the question arises as to which father image is thus supported in an increasingly fatherless society.

What is problematic in these family constellations is that the question of how this life can be lived by children is not taken into account. Genes are not everything, but genes are also not simply nothing. Knowing our genesis, our bodily origin, is part of finding our identity. Knowing our genetic origins is also enshrined as a right in the UN Convention on the Rights of the Child. Instead, more and more “desired children” are born in a family no-man’s land. This deliberately imposes a foreign origin on the child, which will be a great challenge to overcome. ⁶ These include patchwork embryos conceived in vitro from sperm or eggs of third parties, or embryos subsequently carried to term in service contracts by surrogate mothers.

The temporal dissolution of reproduction is also playing an increasing role: women who still want to become mothers after menopause, or widows who still want to have the embryo created with their partner in vitro implanted posthumously in order to give birth to the “joint” child.

Outlook: Strengthening Alternative Coping Strategies for Childlessness

Given the current pull of feasibility, it seems that we have lost cultural competence in dealing with involuntary childlessness. The subtle pressure from doctors, relatives, and society resulting from the technological potential can no longer be denied. At the same time, there is little information about the high price and risks, about the ups and downs of treatment, in which euphoria alternates with deep disappointment, and where life and death decisions are required.

Studies show that the failure of IVF represents a personal failure. In order to quickly displace what they have experienced, they rush into new attempts. Grief over a miscarriage—typical in the context of IVF—has no place. It is a necessary part of the overall “Childproject,” for which sacrifices must be made. The termination of treatment due to lack of success is difficult for many couples to accept and often causes depressive reactions.

Thus, at the end of the treatment, into which they often slid without thinking, the couples are back at the starting point of their suffering: they have no child of their own, and they will not have one. The difference now is that childlessness after umpteen failed attempts at IVF also becomes a question of guilt and an indictment of personal failure, which may be reinforced by the many open ethical questions as to whether all the sacrifices, including the sacrifice of other embryos, were worth it.

It is time to purposefully break new ground: the medical and social treatment of couples with involuntary childlessness should say goodbye to its fixation on mechanized reproduction. Couples who are involuntarily childless are facing a crisis of meaning, so perspectives beyond technology must be developed. The goal of curative treatment must be the couple’s state of suffering—and not the technical induction of the birth of a child. (Maio 2013b, 31) Human resources must be strengthened in this process: Coping with childlessness needs grief work and the generation of alternative perspectives to the desire for a child. Erik H. Erikson understands generativity not only as procreation but also as the assumption of responsibility in areas other than parenthood (cfr. Erikson 1988). Hanna-Barbara Gerl-Falkovitz speaks of the possibility of a “vicarious maternity and paternity,” a “spiritual and mental parenthood” that “unfolds in the assumption of foreign, weaker life.” (Gerl-Falkovitz, 2017: 61–69) The limit imposed by the unfulfilled desire to have children can thus lead to a new, transboundary openness that becomes fruitful in a life task, a meaning of life also outside the bodily formation of a family.

Biographical Note

Susanne Kummer studied philosophy and german philology at the universities of Vienna and Graz. Since 2022 she is director of IMABE (Institut für medizinische Anthropologie und Bioethik) in Vienna, Austria.

ORCID iD

Susanne Kummer https://orcid.org/0000-0001-6479-0724