Theological and Biblical Precepts

The list of precepts examined below is not exhaustive, but they have been selected as examples for how ethical arguments based upon religious beliefs and convictions might be formulated. The first general precept may be characterized as the procreative mandate. As reported in Genesis 1.28, God commands humans to be “fruitful and multiply.” Theologians have drawn upon this passage in arguing that humans are in general commanded by God to procreate, and that offspring is the premier good of marriage (e.g., [4, 5]). Fecundity is thereby held in high regard as a necessary means of fulfilling this religious obligation. It is in light of this procreative mandate that infertility is often portrayed in the Bible, especially in the Hebrew Scriptures or Old Testament, as a particularly severe curse or tragic circumstance [6].

Although there is a long history of valuing fertility within the Christian tradition, there is no contemporary consensus regarding the ethics of ART in general and fertility preservation in particular. On the one hand, it can be argued that, despite the high esteem afforded to fertility, preserving the biological nature (sexual intercourse) of transmitting life and inviolable structure of monogamous marriage precludes any artificial or technological interventions to either treat infertility or preserve fertility. Specifically, artificial insemination by donor (AID) or by husband (AIH), in vitro fertilization (IVF), embryo or gamete storage, pre-implantation genetic diagnosis (PGD) and surrogacy would all be prohibited as violating the biological or marital integrity of procreation. Consequently, this predominantly Catholic teaching forbids any recourse to ART, which in turn also prohibits virtually all of the medical treatments associated with fertility preservation, with the possible exception of ovarian tissue transplants [7]. On the other hand, it can be countered that the so-called biological and marital integrity of procreation is not sacrosanct. The natural and legitimate desire for offspring should not be frustrated by a biological essentialism and highly restricted view of marriage which effectively constrains the freedom to reproduce. This largely liberal Protestant stance contends that using ART to treat infertility is thereby morally permissible in treating infertility and, by extension, so too fertility preservation.

Closely related to the procreative mandate is the second general precept of stewardship. Following God’s command to be fruitful and multiply, humans are enjoined to exercise a stewardship of the earth’s resources (see Genesis 1.28–30). Asserting such dominion or rule, however, is limited for ultimately the earth belongs to God; humans are the caretakers and not the owners of creation. Consequently, such human governance should accord with divinely inspired concepts of what constitutes the larger or general good of creation.

Subsequent theological reflection on the precept of stewardship has developed, among other things, the idea of the common good. Since material goods are finite, the pursuit of the common good may require that the desires of some individuals remain unfulfilled in order to promote a just distribution of scarce goods and services. For example, the desire to be rich is not necessarily wrong, but the desire should remain unfulfilled if its fulfillment results in impoverishing other individuals which in turn diminishes the common good.¹ Likewise, assisting reproduction and preserving fertility might very well be good desires, but whether or not they should be fulfilled needs to be determined within a larger set of social, economic, and political considerations. Consequently, the ethics of fertility preservation should not be evaluated solely in terms of personal preferences and therapeutic safety and efficacy, but also in respect to healthcare priorities, costs, and accessibility. Given the general healthcare needs of civil community, does preserving the fertility of relatively few individuals justify the allocation of scarce medical funding and personnel in achieving this goal?

The third precept is derived from the doctrine of the incarnation. The Gospel according to St John asserts that the Word became flesh, a reference to Jesus Christ (see John 1.1–18). The central tenet of this doctrinal teaching is that in Christ, as the second person of the Trinity, God became a human being. This act in turn affirms the embodied nature of human beings and consequently the finitude of the human condition. Bodily health is therefore not a matter of indifference. Subsequent theological reflection has affirmed the goodness of the body despite frequent heretical attempts to disregard or malign the body as a mere vessel, or worse, a prison of the soul. In Beth Felker Jones’ evocative words, “In the Christian tradition, the temptation to denigrate the body has been continually reasserted and consistently rejected.” [8]

The doctrine of the incarnation inspires a Christian affirmation of the human body, but no obvious ethical stance is forthcoming regarding modern healthcare in general, or assisted reproduction and fertility preservation in particular. Although the life of embodied human beings is highly valued and respected, efforts to preserve or reproduce life are relative rather than absolute [9]. For example, there is no corresponding moral duty to use every means possible to extend the life of dying individuals for as long as possible should such efforts prove unduly onerous or futile, though euthanasia and assisted suicide are generally proscribed [10, 11]. Similarly, the biological means of reproducing human life is held in high esteem, but it is again a relative rather than absolute good to be pursued. An infertile couple, for instance, incurs no moral obligation to employ every available medical treatment. As noted above, a Catholic couple would be prohibited from utilizing ART and could fulfill their natural parental desires through such alternatives as foster care or adoption [12, 13]. Many Protestant couples, however, believe they are free to utilize or refrain from utilizing ART in treating their infertility, which would presumably extend to attempting to preserve or not preserve fertility as well. This expansive range of options is derived from the theological teaching of the incarnation which while affirming embodiment, and derivatively reproduction, also indicates that with the birth of Jesus the urgency of the procreative mandate has been effectively diminished [14].

The fourth precept entails healing and love of neighbor. The Gospels report that Jesus performed many miraculous healings. Given the doctrine of the incarnation these acts are not surprising, for in affirming the embodied nature of human life ameliorating the pain and suffering that is inherent to the life of finite and mortal creatures is also an act of love and compassion. Moreover, Jesus commands his followers to love and care for their neighbors in need (see Matthew 22.34–40), especially those suffering from illness, disability or injury (see, e.g., Luke 10.25–37). In addition, Jesus is portrayed as keeping company with the sick and infirmed, especially those whose conditions have made them outcasts from the larger community.

The complementary images of Jesus as both healer and suffering servant have informed the subsequent theological and moral tradition, which affirms the importance of medicine and healthcare [15]. Christians have been instrumental in establishing hospitals and were early proponents of medical research. This religious commitment to relieving the human condition is exhibited not only in treating those suffering illness and injury [16], but is extended, by many theologians and official church teachings, to include treating infertility and prenatal screening and monitoring in order to prevent suffering [17, 18]. Presumably this expansive support of ART could easily embrace fertility preservation. Moreover, modern medicine exhibits in a highly visible manner the love for neighbor in the contemporary world, embodying Jesus’s roles as healer and suffering servant. In treating or preventing disease and injury the suffering of the neighbor is alleviated, and, more importantly, medicine represents a moral commitment that the ill and infirmed will not be abandoned by the civil community [19]. Arguably a case can be made that preserving fertility is consonant with the precept of healing and love of neighbor.

The preceding brief summaries of the theological and biblical precepts of the procreative mandate, stewardship, incarnation and healing, and love of neighbor provide some useful starting points for examining how Christians might assess the ethics of fertility preservation. As these summaries suggest, however, these precepts do not lead to a common moral position or stance. Although most Christians would affirm, in varying ways, these precepts, subsequent ethical reflection and discernment can lead to highly disparate assessments of fertility preservation. The next section examines the range of these ethical assessments and how they might be formulated.

Moral Stances

The following four moral stances are derived from the theological and biblical precepts summarized in the preceding section. Each stance demonstrates how religious beliefs and convictions might inform particular ethical assessments of fertility preservation. These stances do not reflect arguments promulgated by a specific church or theologian. Rather, they serve as heuristic devices that demonstrate varying and often conflicting assessments. Furthermore, these stances disclose how theological and biblical precepts may be interpreted and applied in a variety of imaginative ways in constructing a moral argument. As will be seen, there is no given correspondence between a particular precept and a particular stance regarding the ethics of fertility preservation. It should also be noted that these stances do not exhaust the possible options that could be formulated, but rather serve as examples along a spectrum ranging from prohibition to encouragement.

In each instance I make the following assumptions: An individual is facing the prospect of a therapeutic application that may result in the loss of fertility. The various treatments that could be applied in attempting to preserve fertility are accessible, relatively safe and potentially efficacious and adequate funding is readily available. All legal safeguards and recognized ethical practices and procedures are followed such as informed consent, protection of minors, and proper authorization and oversight of established protocols. In addition, I make no attempt to assess the adequacy of the various moral stances, especially in regard to their respective interpretations and applications of theological and biblical precepts and coherency of argument, nor do I offer any counter interpretations or arguments. Rather, I allow each stance to stand in its own right in order to identify various points along a spectrum of options concerning the ethics of fertility preservation that are based upon selected religious beliefs and convictions. Furthermore, it should be noted that in some instances these arguments do not accept medical designations of embryonic development, for example, the difference between “pre-embryos” and “embryos,” as implying any inherent normative content. It is important for medical practitioners to keep these potential discrepancies in mind when dealing with some patients who may exhibit reluctance in pursuing fertility preservation. In short, when doctors and patients refer to an “embryo,” they may not, in some instances, be referring to a shared perception. Although the religious reservations of these patients need to be honored, they do not necessarily call into the question either the morality of the procedures or humane intentions motivating their development and deployment.

The first stance may be characterized as preserving the natural reproductive process. This stance draws heavily upon the precepts of the incarnation and the procreative mandate. The divine affirmation of the embodied nature of human existence necessarily entails the need of human beings to perpetuate themselves from one generation to the next; hence God’s command to be fruitful and multiply. This affirmation and command, however, imposes constraints in exercising an accompanying stewardship. In affirming their embodiment and obeying the command to procreate, individuals are not free to do whatever they might want. The affirmation and mandate acknowledges and consents to the frailty and limitations of the human body, otherwise stewardship is distorted into a form of mastery that rightfully belongs only to God. Although this stance does not reject modern medicine in general, indeed it is seen as an important means of excising the stewardship of God’s creation and expressing the love of neighbor, it too is limited to restoring the natural health of the body.¹, ²

Given these religious presuppositions, the morality of fertility preservation is assessed largely, though not exclusively, in respect to whether or not it preserves or violates the natural reproductive process. Consequently, fertility preservation should not be used in many, if not most, instances because the treatments employed violate this natural integrity. Similar to the objections against ART, gamete and embryo storage are illicit because of the means required to procure the gametes and embryos. Although such medical treatments are motivated by the legitimate desire to treat infertility resulting from other therapeutic applications, this motive does not justify bypassing the natural method of procreation. The creation and storage of embryos is particularly objectionable since it might entail the destruction of unneeded and, in the case of PGD, unwanted embryos. The ensuing destruction of embryos fails to exhibit a proper love of weak and vulnerable beings.³ This stance, however, would presumably have no objections to repositioning ovaries when undergoing radiation treatment in the lower abdominal area. No attempt is being made to bypass the methods of natural reproduction such as extracting oocytes, nor are any embryos artificially created or willfully destroyed. Performing a radical trachelectomy in treating cervical cancer would presumably be illicit since artificial means of initiating pregnancy following treatment would be required. Similar objections could also be raised against ovarian tissue cryopreservation if IVF-created embryos are implanted. In short, these treatments, with the exception of ovary repositioning, are illicit not only because they violate the integrity of the natural reproductive process but also because they represent an improper stewardship of medicine as they seek to transcend rather than restore natural health, thereby failing to honor the limitations of embodiment which are affirmed in the incarnation and presumed in fulfilling the procreative mandate.

The principal strength of this first stance is its seriousness concerning the embodied nature of human beings. Since the incarnation affirms embodiment, the inherent finitude and mortality set integral and delimiting conditions that should be honored. To be embodied, therefore, entails a natural reproductive process which may be disabled by disease, dysfunction, or therapies treating a condition unrelated to fertility. Although one may sympathize with individuals who are infertile or may lose their fertility, this does not justify recourse to technologies which bypass the natural reproductive process. The principal weakness is its appeal to a biological essentialism that is not applied consistently in respect to other medical practices. Given their status as finite and mortal creatures, humans necessarily suffer the natural effects of disease, dysfunction, and degeneration, yet there are presumably few, if any, moral objections to treating these conditions. It is not clear why such rigid prohibitions are set regarding the reproductive process in comparison with other organic systems. The contention that ART, and thereby fertility preservation, attempt to bypass rather than restore natural fertility does not resolve this inconsistency. Using suppressants in conjunction with organ transplants, for instance, bypasses the natural immune system, yet few, if any, theologians would now argue against these procedures in terms of violating the so-called natural integrity of the immune system.⁴

A second stance entails assessing the ethics of fertility preservation in light of larger social priorities. The precept of stewardship carries the heaviest weight in formulating this moral perspective and evaluation. Humans do not exercise their stewardship of creation as autonomous individuals, but through cooperative social and political relationships. Technology in general and medicine in particular have undoubtedly assisted humans in fulfilling this responsibility, but their development and deployment should be determined in respect to larger social and political priorities rather than merely satisfying individual desires. The common good and the needs of the many should trump the interests of the few. This moral commitment to the common good affirms the precept of the incarnation by recognizing the finite character of human life within the finite constraints that are imposed by creation. This scarcity must be taken into account in ensuring that a just distribution of goods or services is pursued in a manner which proves most beneficial to the greatest number of people. This same principle holds true in the allocation of scarce medical resources. The relative urgency of the procreative mandate, therefore, should be determined in light of contemporary economic and political concerns related, for instance, to population growth, and how these concerns are addressed in healthcare policies.⁵

Given these religious assumptions it can be argued that although fertility preservation need not be prohibited, the practice should nonetheless be discouraged.⁶ Although there is nothing necessarily objectionable to the various treatments employed in preserving fertility, it marks a costly expenditure of scarce medical resources that serves a relatively small segment of the population.⁷ These resources should instead be deployed in addressing basic healthcare needs of the broader population that is often deprived of such care due to costs and limited accessibility, thereby promoting the common good rather than serving the interest of a few individuals. Moreover, such a policy or strategy is more in line with Jesus’s role as healer and suffering servant, which were most often performed for the sake of the poor and destitute. In addition, given the array of social, economic, and political problems associated with overpopulation, it is hard to justify the allocation of funds, the time of healthcare personnel and technologies to meet the needs of relatively few individuals. The ethical issue at stake is not so much to preserve fertility (or treat infertility), but to ease the longing of childless couples or individuals which can be addressed through such options as foster care and adoption. This approach would have the additional benefit of providing parental care for orphans, abused and neglected children, thereby once again promoting the common good, and recognizing the need for tempering the urgency of the procreative mandate given the pressing need to control population growth and caring for needful children. In short, although one may be sympathetic with the desire of individuals to preserve their fertility, a faithful stewardship of creation requires that more pressing healthcare needs are given priority. Consequently, fertility preservation should be discouraged as an unwarranted consumption of scarce medical resources.

The principal strength of this second stance is the recognition that medicine and healthcare cannot be separated from larger economic and political considerations. A medical decision is never made in isolation from broader social contexts, as demonstrated by determining which treatments and procedures are and are not funded by public and private insurance carriers. Given limited economic resources, and other ethical concerns such as overpopulation, good stewardship requires limiting the provision of medical treatments that affect a relatively small segment of the population. Again, one may sympathize with individuals desiring to preserve their fertility, but it should not be granted much priority, or even discouraged, given more pressing and expansive healthcare needs. The principal weakness is its implicit paternalism. Invoking a greater common good often entails an appeal to abstract moral principles that are divorced from actual practice. This disjuncture in turn effectively masks the imposition of the emotive values and preferences of some over those of others; those in a relative position of power know what is best for everyone, thereby corrupting stewardship into an exercise of behavioral control [31]. Yet it is not clear why fertility preservation should be discouraged on the basis of utilizing scarce medical resources contributing to overpopulation when such a small segment of potential patients is at stake. Rather, discouraging fertility preservation by appealing to larger social priorities may effectively serve as a more troubling wedge argument. If the common good is promoted by limiting births in general and the births of individuals with potentially chronic conditions in particular since both place strains upon limited healthcare resources, then discouraging fertility must be seen within the context of social and political agendas of utilizing medical technologies to control both the quantitative and qualitative outcomes of reproduction (e.g., [32, 33]).

A possible third moral stance can be characterized as one of freedom of choice. The embodiment affirmed in the precept of the incarnation does not diminish the need for moral agency and the personal responsibility it entails. Constricting or denigrating the freedom to choose among various possible options effectively denies the human dignity which the incarnation affirms. Stewardship, therefore, should be directed toward enabling the concrete and varying goods of individuals rather than promoting an abstract common and collective good. In respect to medicine and healthcare, it should be noted that Jesus was not required to either heal or keep company with the ill and infirmed, but freely embraced his roles as healer and suffering servant. Likewise the Good Samaritan was not compelled to stop and render aid but chose to do so. Similarly, although the urgency of the procreative mandate may be muted in light of contemporary population concerns, it has not been rescinded and individuals should be free to make responsible reproductive choices. To portray individual freedom and personal responsibility as antithetical to the common good, particularly in respect to healthcare and procreation, is to effectively eviscerate the very meaning of ethics, especially Christian ethics, since the love of neighbor expresses moral action based upon liberty as opposed to compulsion.⁸

Given these basic religious convictions, this stance would permit fertility preservation while neither encouraging nor discouraging its use. Since the decision to either employ or forgo fertility preservation is a matter of personal discernment, a wide variability of choices are to be expected. On the one hand, for instance, if an individual does not believe that the various medical treatments and social circumstances are morally objectionable then presumably there would be no compelling ethical reason to refrain from attempting to preserve one’s fertility.⁹ So long as it is determined that, for ART and the potential destruction of unneeded embryos, these procedures are not jeopardizing basic healthcare provision or substantially contributing to problems associated with overpopulation, then an individual is free to pursue fertility preservation since it does not violate the theological and biblical precepts outlined above. On the other hand, if an individual believes that the medical treatments and social conditions are morally troubling then presumably there are strong ethical reasons to refrain from attempting to preserve one’s fertility. If it is discerned that ART, the potential destruction of unneeded embryos or that the provision of these treatments are unjust given the lack of basic healthcare provision or overpopulation concerns, then an individual would choose not to pursue fertility preservation since doing so would violate relevant theological and biblical precepts. It should be noted that, although Christians come to conflicting conclusions regarding the ethics of fertility preservation, the source of moral authority resides in the conscience of the individual believer rather than compliance with external sources. The act of moral discernment and action stems from the will of the individual rather than obedience to prohibitions imposed by the larger community.

The primary strength of this third stance is that it places the weight of moral responsibility upon the individuals most directly affected by the treatments in question. Consequently, individuals should be free to make whatever choices they might prefer regarding fertility preservation, so long as they do not violate their own religious and moral convictions or that such decisions do not demonstrably harm others. In the absence of freedom of choice, how else can individuals affirm their embodiment, pursue procreation, and exercise their stewardship as the responsible beings they were created to be? The question of whether or not to pursue fertility preservation is best left to patients facing the prospect of undergoing therapies that may compromise their fertility in consultation with appropriate medical expertise. The primary weakness is a diminished understanding of freedom that is reduced to license. Freedom is not merely the absence of external constraints against the will of individuals pursuing their respective reproductive interests. Rather, freedom results from limitations necessarily imposed by various relationships [36]. Responsible choices regarding fertility preservation should not be made in isolation from the interests of partners, spouses, family members, medical personnel and healthcare institutions, religious communities, and the civil community. In the absence of these considerations, freedom is eviscerated into a fictional autonomy that potentially distorts the purported affirmation of embodiment, pursuit of procreation and stewardship into self-indulgence. Moreover, coupling freedom with such a diminished understanding of moral autonomy exacerbates the more troubling aspects of the so-called “procreative liberty” pervading contemporary society by adding fertility preservation to a growing list of reproductive options designed to bypass biological limitations and social inequalities [37].¹⁰

A final possible stance may be characterized as a technological affirmation of life. Although the procreative mandate has lost its urgency in the modern world, using medicine to preserve fertility may nonetheless serve as a witness to the goodness of life in a dominant “culture of death” [41].¹¹ If medical technologies are routinely used to prevent conception, destroy embryos, and abort fetuses, why can’t they also be used to assist the birth of children thereby promoting a culture of life? In this respect, fertility preservation serves as a powerful countervailing witness to the dominant culture. Such a witness upholds the incarnation’s affirmation of embodiment, while also enabling a stewardship of medical resources oriented toward securing the good gift of life. Moreover, using medicine to preserve fertility is consonant with Jesus’ ministry of healing and ameliorating suffering.

Based on this admittedly highly speculative interpretation of the theological and biblical precepts discussed previously, this stance would not only permit but would encourage fertility preservation; there is not only permission but an implicit imperative to preserve fertility.¹² There are, however, some moral constraints that should be honored in pursuing fertility preservation. Presumably the techniques of repositioning ovaries, performing a radical trachelectomy, ovarian tissue cryopreservation, artificially extracting and fertilizing gametes, storing and implanting embryos, and surrogacy are permissible. Yet if these treatments are being employed, in part, as a witness to enabling a culture of life, then provisions need to be in place for ensuring that unneeded embryos are not destroyed, a goal that could be accomplished through embryo donation or adoption (e.g., [44]). In addition, PGD would also be prohibited since it implies the possible destruction of embryos with genetic or chromosomal abnormalities.

The principal strength of this fourth stance is its embrace of human ingenuity accompanying the affirmation of embodiment. Technology is what makes Homo sapiens into human and humane beings; to a large extent humans are rightfully becoming Homo faber (e.g., [45]). Technology in general is a significant means for exercising stewardship, and medical technologies in particular, for pursuing healing and ameliorating suffering. Moreover, fertility preservation in conjunction with ART provides a refreshing and powerful witness to life in a culture of death in which all too often medicine is used to prevent or destroy life. Consequently, provided that the moral constraints of avoiding embryo destruction and PGD are honored, there are not only no compelling reason why fertility preservation should be either discouraged or greeted with indifference, but should instead be encouraged. The principal weakness of this stance is that it assumes that greater technological development is synonymous with moral, social, and political progress. It fails to recognize sufficiently the often unintended and unforeseen evil effects accompanying this so-called progress. This is not to simply parrot the simplistic slogan of technological neutrality in which tools and instruments can be used for good or evil purposes; a scalpel, for example, can be used for surgery or to commit a murder. Rather, it fails to acknowledge the extent to which modern technological development itself shapes or misshapes moral vision (e.g., [46–50]). In respect to medicine, for example, the patient becomes subtly transformed into an artifact of medical techniques, or in respect to ART, and by extension fertility preservation, distorts procreation into reproductive projects. In short, encouraging fertility preservation may in the long run prove to be one more little piece in forming a Homo faber that is not necessarily comprised of more humane individuals.