Internal morality of motherhood and integrity of physicians in the era of assisted reproductive technologies (ARTs).

Assisted reproductive technologies (ARTs) (1) have posed significant new ethical challenges about the characteristics, meaning and values of creation of human life and human person, parenthood, medicine, and society. By increasing reliance on ARTs, (2) human procreation may become a technological manufacturing project reflecting the interests of the parents-to-be guided by the physician.

This essay is a variation on the theme of my recent article (3) in the Southern Medical Journal's Spirituality/Medicine Interface Project on the challenges physicians face, given their responsibilities as healers-teachers-leaders, regarding the dangers of commercial and technological dehumanization of procreation. I emphasize the creation of human persons who have cognitive, emotional, relational and spiritual attributes, and thus have the capacity of being moral agents. I use the term "procreation" with a humanistic connotation instead of "reproduction" with a biologic connotation. The spiritual dimensions of creating human persons help to appreciate the personal and professional moralities and integrity involved. I see the ethical challenges not in the reproductive right to use ARTs, but in the case-by-case procreative decisions about their application.

Please note the following caveats. When I refer to the mother-to-be, or mother, I consider her in the contexts of her husband and/or others who are involved in her life, influencing and supporting her in her decisions. And, when I refer to the physician, I consider him/her as the leader or representative of the healthcare team who helps making and carrying out the decisions of the mother-to-be or mother. Nevertheless, the ultimate ethical responsibilities are with the individual woman and physician. (4)

Conceptual Frameworks

I propose two conceptual frameworks representing my pragmatic views. These views have evolved over decades of clinical practice, research and teaching in the field of infant-child-adolescent-adult psychiatry and have been enriched by consideration of individual, social and professional moralities. Accordingly, my primary focus is on moral agents, not on moral status--that is, on human persons, not merely on human lives. For me, the essence of human procreation is the creation of the next generation of persons who are able to assume moral responsibilities for the wellbeing of themselves, families, societies, and our species. In terms of motherhood, I am concerned with the functions and responsibilities of the person who is instrumental in the birth of a newborn and in the development of the latter into a flourishing person.

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1. Human Procreation

I stipulate that human procreation has three components: (a) biologic creation of human life, the ex utero embryo, by natural or artificial means; (b) acceptance of the embryo in the uterus, ie, pregnancy, for its development into the newborn; (c) psychological commitment to a relationship with the young human being for the development of the human person. The three components may be separated unintentionally or intentionally, or by necessity or neglect, or, in the context of ARTs, by design.

The first two components represent the biologic phase that may or may not entail genetic linkage between the progenitor (the source of gametes) and the offspring, but it does entail the biologic linkage through pregnancy between the birth mother and offspring. The third component is the psychological phase in which the psychological mother (eg, the adoptive mother), who may be different from the birth mother, creates the new person.

The essence of this conceptualization is that human procreation is not about conception and pregnancy, but about the creation of persons. Indeed, the facts of normal biology are that there is a high rate of spontaneous de-selection of embryos (about 50% do not implant, and only about 30% make it from conception to birth). In vitro fertilization (IVF) has not improved on these statistics. (2) Even some newborns have limited viability, such as the anencephalic that can never become a person. Therefore, in my view, there is no justification for anthropomorphizing the embryo. Unless it is capable of implanting, and is accepted for implantation by a willing mother-to-be, its moral status is predicated on its stem cells with therapeutic potentials.

2. Internal Morality of Motherhood

This conceptual framework covers the full spectrum of motherhood from preconception planning to the point when the offspring is a mature person ready to assume adult responsibilities. However, to the extent that the birth mother and psychological mother may be different individuals, the framework implies moral expectations and responsibilities for both of them.

The internal morality of motherhood implies the adherence to the following ideals: (1) Creation of human life and human persons require appropriate ethical and psychological reflections; (2) Once she accepts the implanted embryo, the mother-to-be is committed to its development into a viable newborn; (3) Newborns and minors are not for sale or donation because they have inalienable human rights to dignity and identity; (4) Newborns and minors may be offered and accepted for rearing (as in adoption), but this must not involve compensatory exchange of material goods; (5) Newborns have the basic need to be wanted and the right to have at least one committed adult (5) to develop into flourishing persons; (6) Being the birth mother or progenitor does not guarantee psychological commitment to the newborn; (7) Psychological commitment entails that, through empathic tuning into and discernment of the affect states (ie, needs and communications) of the young human being, the mother is experienced as reliably available and responsive with whom a unique trusting relationship (called attachment) could develop, (6) within which the fledgling individual may gradually acquire the attributes of personhood; (8) The psychological mother is the person who provides unconditional loving care and respect for the unique individual thereby fostering the development of the physical, emotional, mental, moral, social and spiritual potentials of the person-to-be.

The essence of this conceptualization is that every procreative decision needs to be filtered through the tenets of morality of motherhood. In other words, psychological and ethical issues should be considered, identified and analyzed by the mother-to-be and the physician before making plans for conception and pregnancy.

Ethics of Procreation

Motherhood

Thurer (7) offers a perceptive account of the rich and conflicted history of motherhood. The prehistoric Great Mother enjoyed sexual equality, but the Greek (Athenian) Classical Mom was utterly devalued in a society where female infanticide was rampant. The Medieval Mother was idealized, like the Virgin Mary, but her sexuality suppressed. During the Renaissance, in the male-owned nuclear family, the Early-Modem Obedient Mom's role was simply to produce children. The Industrial Revolution shattered the structure of the family, as father had to work outside the household, and the 18th to 19th century mom became the "angel of the house," that is, the Victorian mother. Her "maternal instinct," as a biologic attribute, was recognized but was used in part pejoratively, since "from a Victorian perspective women wanted babies" and the father was considered to be the source of the child. Nevertheless, because of this unique ability of women, motherhood became highly esteemed, which, in turn, became part of the claim for equality by the early feminists in the mid-19th century. During the recent reign of the Empathic Mom (1940-1980), she became seen as the primary determinant of her child's development that proved to be a dangerous double-edged sword. By the end of the 20th century, a confusing array of maternal types has emerged: the working moms, super moms, single moms, lesbian moms, as well as foster moms, adoptive moms and surrogate moms, with mixed or no genetic links to the children they raise.

I do not question that historically women's function and esteem has been socially determined, and that in particular social contexts women's view of themselves as mothers has varied markedly. However, it does not follow necessarily that motherhood itself has become heterogeneous. In my view, the internal essence of motherhood represents distinct, definable, biology-based practical functions and psychological features to which specific moral attributes and expectations may be attached.

The current technological and commercialized era of ARTs does represent a crisis of and confusion about motherhood, making it necessary to clarify its critical role in procreation. The quality of mothering functions is vulnerable to all sorts of external and internal circumstances, and it can be socially shaped. What I emphasize here is that ultimately not the biologic but the psychological tie is the critical determinant of the quality of personhood of the next generation. Since the psychological capacities for mothering functions may be present in men as well, both women and men may use these proclivities to develop high quality emotional ties with children to whom they have no biologic ties-in other words, either of them may adequately step into the role of the psychological mother when the birth mother is not available for that. Finally, it is society's responsibility to accord the necessary special recognition and support to ethically authentic motherhood.

Procreative Liberty

Procreative liberty is an important negative right against undue interference with procreative choices, including the use of ARTs. (8) It is not an absolute right, as it may be trumped by the identifiable risks of unnecessary human suffering of the offspring. One may argue, however, for a positive right to the preventive or curative uses of reproductive technologies because they represent, as do healthcare services, important social utility. Thus, the ethical justification for procreative liberty is that it promotes human flourishing by maximizing the possibility of having healthy newborns.

Particular ethical conflicts may relate to getting over-focused on procreative rights, ie, on the narcissistic interests and wishes of the mother-to-be, possibly encouraged by the physician, about being the creator-in-charge in designing both her motherhood and her creation, the child. Indeed, Robertson (8) argues for giving maximum freedom to the mother-to-be in using ARTs. When justifying the nonmedical selection of gender, he emphasizes that if the parents very much insist on it (ie, seem very determined about it), then it must be ethically acceptable. I argue exactly the opposite: the stronger the parents insist, the greater is the likelihood that the motivation is unethical, because it seems that the parents' own agenda is imposed on the child with the risk of harmful consequences for the child's emotional development. Robertson's legal perspective seems to disregard the importance of medical professional judgment and guidance. I side with Gorovitz (9) who emphasizes the medical applications of ARTs as tools of preventing or correcting abnormalities related to procreation. I also agree with Ryan (10) who argues that individual reproductive rights have to be framed in social terms with special attention to the need of the children created.

Who Is the Birth Mother?

I use birth mother and biologic mother interchangeably because she operates in the biologic phase of procreation. Some use gestational mother instead, but that connotes a passive container concept, rather than an active procreative one. There is no genetic mother, only female progenitor. Clarifying the fixed versus changeable elements of procreation is necessary for the sake of appropriate ethical perspectives. The fixed cornerstone is the birth mother, all others are changeable.

It may seem paradoxical that I put special emphasis on the creation of the person from the newborn, that is, on the role of the psychological mother, when in actuality the major ethical decisions have to be made before that by the biologic mother. Let us sketch out some scenarios.

The natural coital procreation is a blind process, if the only elements of some predictive value are the phenotypic characteristics and family histories of the parents-to-be. The birth mother is left with the task to accept and adapt to what she is dealt with by the natural lottery, and the physician's role is relatively minor. In the new era of the ARTs, even within the realm of coital procreation, the physician's presence and responsibilities are greatly magnified. (4)

a. Preconception genetic testing and noncoital procreation. The availability of preconception genetic testing to screen the parents-to-be for known diseases or disabilities and of specific birth control methods to prevent unwanted pregnancies has enhanced both the self-determination and ethical responsibilities of the mother-to-be. If she decided not to risk transmitting pathologic genes, the motivation would seem to be to benefit the wellbeing of the offspring. But is it really? There may be several permutations to consider depending on whose gamete is to be replaced by gamete donation: hers or the father's-to-be? If the latter, artificial insemination (AI) or in vitro fertilization (IVF), while if the former, IVF with donated oocyte and embryo transfer (ET) to her uterus may be the solution. Replacement of both gametes can be accomplished by embryo donation. Before attempting to implant any of these embryos, preimplantation genetic diagnosis (PGD) could screen them for abnormalities. Upon implantation, she would become the birth mother-to-be, but either she and/or the father-to-be will not be progenitors of the offspring. How could this affect their commitments to each other and to the offspring? The latter would be the key to the appropriate ethical decision as to how to proceed. May the adoption of an infant be a better alternative? If so, she sidesteps being the birth mother, gives up on both the genetic and biologic ties with the offspring, and focuses on being the psychological mother of an unrelated person-to-be. Presumably, but not necessarily, her primary motivation is to benefit the adopted person-to-be.

A variation on using ARTs for prevention of disease transmission is the recently publicized case of an HIV positive woman. (11) Through unprotected intercourse at age 18, she became infected by HIV. Since then, she has been on retroviral treatment regimen while living a healthy lifestyle. Consistent with having practiced safe sex throughout nine years of marriage, to avoid the risk of transmitting the HIV to her husband, they opted to procreate via IVF using their own gametes. She has successfully become pregnant. The risk of transmitting HIV to her child is negligible.

b. Preimplantation genetic diagnosis, and de-selection or enhancement. IVF creates multiple embryos to be selected or de-selected before an attempt at implantation to increase the likelihood of having healthy newborn(s). The de-selected embryos are not necessarily known to be defective, and may either be frozen for later use, donated to a mother-to-be, or used for research. Using PGD for medical information is ethically neutral, in the sense that the results may help prepare the mother-to-be for the conditions with which the newborn may present. Ethical dilemmas may result from selective discarding of embryos found to carry defective genes or considering germ-line gene therapy. If either of these option are chosen for medical reasons, ie, in the realm of prevention or treatment, I find them ethically justifiable. However, people with disabilities, like Asch, (12) voice concerns about being devalued by not being allowed to be born. She points out that living with disability may be meaningful and humanly rich, and urges physicians not to imply to mothers-to-be upon problematic PGD results that the creative process should be abandoned. Instead, the physician should respect and promote the self-determination of the mother-to-be, while helping her to discern her own and her future child's foreseeable best interests, and then support her in whichever direction she decides to go. I find this an ethically appropriate clinical approach whereby the mother-to-be and the physician exercise their individual and social responsibilities.

The therapeutic purposes of having healthy newborn(s) may become overshadowed by the selection of gamete donors of particular qualities (physical attractiveness, athletic or intellectual prowess, etc). Thus, the diagnostic information may be used for genetic enhancement. Answering Botkin's question, (13) I find it ethically objectionable to use medical knowledge and techniques for nonmedical enhancements or selections. I see the physician's ethical responsibilities in the area of procreative decisions within the purview of what is medically relevant.

c. Prenatal genetic testing, bonding and abortion. Returning to coital procreation, suppose that preconception genetic tests are negative, and the mother-to-be decides to become pregnant. In the fist half of the pregnancy, the fetus may be screened for genetic and anatomic abnormalities. Upon positive findings, she faces the dilemma of whether to continue or terminate the pregnancy. Such a decision may hinge not only on the projected health, disability, quality of life and viability of the offspring, but on how she may be affected and capable of providing for the special needs of the offspring. Alternatively, even if the fetus is well, the health of the birth mother may become compromised by the pregnancy itself, representing an explicit risk of harm to her. Even if her pathologies and/or that of her fetus remain in medically manageable realm, and she proceeds with the pregnancy, she will have to reflect on whether she would be able to maintain her commitment to the relationship with the offspring. If not, her ethical responsibility is to consider alternative arrangement for the psychological phase of procreation.

Ideally, and most often, the birth mother and psychological mother is the same individual. While commitment has ethical importance, it is closely related to the psychological phenomenon of attachment which is called bonding when referring to the mother's attachment to her newborn. In this context, one needs to consider that the birth mother-to-be faces two fundamental psychological tasks during pregnancy: first, to accept the fetus as part of herself, and then, to negotiate a unique relationship with a developing individual. (14) In this process, she may need to rework her relationship with her own mother. If her mother is not available, her husband's ability to fulfill her need to be mothered and validated may be a critical determinant her bonding and commitment. (15) If the pregnancy is unplanned, bonding typically develops with the acceptance of it. The commitment (ethical), then, runs parallel with bonding (psychological). However, bonding and commitment may also take separate courses. First, the mother-to-be may develop some bonding but cannot commit to the creative process. Second, she may feel compelled to continue the pregnancy even when she experiences quite negative feelings toward the (intruding) fetus. I argue that without commitment, the crucial part of an ethically authentic procreation is missing because of the risk of unnecessary suffering or harm in the future.

Little (16) states that the process of creating a person "brings with it an emotional intertwinement that can reshape one's entire life." She argues that the moral issue is not so much the value of human life but rather the meanings of creation and responsibility and kinship, as well as the integrity of the mother-to-be. Therefore, "it is a sign of respect not to continue creating" when the appropriate conditions are not in place. In other words, a woman may make morally sound decisions in either direction (ie, to continue or terminate the pregnancy) by responsibly considering her current circumstances.

d. Infertility. ARTs have most frequently been used for the treatment of infertility. If various attempts by using own gametes had failed, gamete or embryo donations would be considered. The possible complexity of these has been touched upon in an earlier section above. Donation of gametes or embryos can be likened to organ or tissue donations or to adoption. The donor has no inherent ethical responsibility or right.

Further complications may result if the mother-to-be is unable to carry pregnancy and reaches out for a 'surrogate mother.' The surrogacy itself may have several permutations depending on the source of gametes. In my view, it is very important that everybody involved acknowledges that by accepting the implantation of the embryo(s) in her uterus, the surrogate mother becomes the birth mother. This is well illustrated in the Baby M case. (17) The contracted surrogate mother, Ms. W, developed bonding to the fetus, even though not intended. Mr. S, the sperm donor father, wanted a child for his own ends in relation to having lost his relatives in the Holocaust. Upon delivery, Ms. W was supposed to give away the infant she gestated and to whom she had bonded for money. Anderson (18) argues that the woman's labor is not a commodity and urges legal prohibition of surrogacy.

Infertility treatment of postmenopausal women is a questionable medical intervention, since the pregnancy at that age may directly compromise the woman's health with the added undue risks for the offspring both in utero and ex utero. It also illustrates the ethical conflict between procreative liberty of the woman and the concern over the potential harm to the offspring. Yet, a few years ago, it was heralded on national television broadcast (19) that a postmenopausal married woman in her mid-fifties, after many years of multiple failed attempts, still wanted to bear children. Embryos created by IVF using donor eggs of a young woman and her husband's sperm were successfully implanted in her uterus, resulting in healthy twin boys. More recently, the case of a 62 year old woman was publicized who got pregnant the same way as above and gave birth to a boy--apparently because she had a new husband. (20) Some argue that children are not harmed by being born, and that a child's interests should not prevent an older woman to use IVF to become pregnant. (21) My rejoinder is that despite fortunate initial outcomes, unnecessary psychological problems and suffering may still await such offspring in the future due to their parentage. In addition, an older woman, given her interest in children, may demonstrate greater moral and social responsibilities by becoming an adoptive mother. I personally know a woman in her mid-fifties who adopted two preschool children from foreign orphanages; she serves as an instructive counterexample and demonstrates some of the ingredients of the internal morality of motherhood.

e. The sine qua non of procreation. The unique functions of accepting and gestating the embryo into a newborn make the birth mother the sine qua non, and, as such, the primary moral agent, of procreation. Since the physician is her ally in making and carrying out her decisions, I consider the physician the secondary moral agent. Other secondary moral agents may be, when applicable, the psychological mother-to-be and others closely involved in the procreative process. Society is the tertiary moral agent, having the responsibility to support and protect ethically authentic motherhood and the new generation of developing persons.

Ethics of Meritocracy 

The often severe grief reactions to pregnancy loss show the significance of early bonding, but also that procreation signifies moral achievement. Thus, the ethics of meritocracy is recognizable when having a child counts as success, while losing a pregnancy means failure. (22) Likewise, when the newborn presents with disability or genetic disorder, the mother may feel devalued because of her 'failure' to create a healthy newborn. On the other hand, the mother may feel socially rewarded for having a high-functioning and attractive child. Motivation for socially successful procreation may make the use of ARTs attractive by promising more control over the outcome--in other words, the mother-to-be may feel more like an active creator than a passive nurturer. The powerful motivating force of maximizing success and minimizing failure also affects the physician. Thus, when I look upon the woman and the physician, as key moral agents, to guard the territory of procreative ethics, I also expect them to be psychologically aware and prepared regarding these issues.

Reflections

It would be a mistake to completely externalize the dangers of commercialization and dehumanization of medicine and procreation. Scientific knowledge and technical skills do make us powerful which, in turn, may incline us from the inside to act more in our interests than in that of others, that is, more in the interest of those who procreate with the use of ARTs than more in the interest of those who will be created. In addition, mothers inevitably tend to see their children as their 'product' and even with the best of intentions it is hard to decide for those who do not yet exist. There are many psychological hurdles upon which the mother-to-be-and the physician, may have to reflect to make appropriate ethical decisions about and in the course of procreation. If in doubt, it is wise to refrain from the biologic phase and to focus just on the psychological phase of procreation. There is plenty of work to do in creating more flourishing persons.

Acknowledgments

I thank Professor John D. Arras, PhD, for his helpful comments on an earlier version of this essay.

References

1. Society for Assisted Reproductive Technology. A Patient's Guide to Assisted Reproductive Technology, Available at: http://sart.org/ARTPatients.html. Accessed on 5/29/06.

2. Jones SL. The confluence of two clinical specialties: genetics and assisted reproductive technologies. Medsurg Nursing 2004;13:114-121.

3. Solyom AE. Educating physicians: are we doing enough? South Med J 2006;99:436-440.

4. Shanner L, Nisker J. Bioethics for clinicians: 26. Assisted reproductive technologies. CMAJ 2001;164:1589-1594.

5. Fraiberg S. Every Child's Birthright: In Defense of Mothering. New York, Basic Books, 1977.

6. Solyom AE. New research on affect regulation: Developmental, clinical, and theoretical considerations. Psychoanal Inquiry 1987;7:331-347.

7. Thurer SL. The Myths of Motherhood. Boston, New York, Houghton Mifflin Company, 1994.

8. Robertson JA. Children of Choice: Freedom and the New Reproductive Technologies. Princeton, Princeton University Press, 1994.

9. Gorovitz S. Doctors' Dilemmas: Moral Conflict and Medical Care. New York, Oxford University Press, 1985, pp 117-127.

10. Ryan MA. The Ethics and Economics of Assisted Reproduction: The Cost of Longing. Washington, Georgetown University Press, 2001.

11. CNN: American Morning on May 19, 2006.

12. Asch A. Prenatal diagnosis and selective abortion: a challenge to practice and policy. Am J Public Health 1999;89:1649-1657.

13. Botkin JR. Ethical issues and practical problems in preimplantation genetic diagnosis. J Law Med Ethics 1998;26:17-28.

14. Bibring GL, Dwyer T, Huntington D, et al. A study of the psychological process in pregnancy and of the earliest mother-child relationship. Psychoanal Study Child 1961;16:9-72.

15. Solyom AE, Ainslie RC, McManus ME. Early assessment of psychological risk factors: On the role of husband/father during pregnancy and in the early postnatal period. Infant Ment Health J 1981;2:23-32.

16. Little MO. The morality of abortion. In: Steinbock B, Arras JD, London AJ, eds. Ethical Issues in Modern Medicine, 6 ed. London, McGraw-Hill, 2003, pp 492-500.

17. Steinbock B. Surrogate motherhood as prenatal adoption. Law Med Health Care 1988;16:44-50.

18. Anderson E. Value in Ethics and Economics. Cambridge, Harvard University Press, 1993.

19. ABC Evening News, November 12, 2002.

20. ABC News: Great-Grandmother Gives Birth at 62. Available at: http://abcnews.go.com/GMA/Health/story?id=1637601&page=1. Accessed November 11, 2006.

21. Hope T, Lockwood G, Lockwood M. An ethical debate: should older women be offered in vitro fertilization? In: Kuhse H, Singer P, eds. Bioethics: An Antology Maiden, Blackwell Publishers, 1999;116-118.

22. Layne LL. True gifts from God: motherhood, sacrifice and enrichment in the case of pregnancy loss. In: Transformative Motherhood: On Giving and Getting in a Consumer Culture. New York, New York University Press, 1999, pp 167-214.

Antal E. Solyom, MD, PhD, MA

From the University of Virginia Health System, Charlottesville, VA.

Reprint requests to Antal E. Solyom, MD, PhD, MA, PO Box 3620, Lynchburg, VA 24503. Email: [e-mail]