Choosing to Conceive: Should IVF be Restricted in the Same Way We Restrict Unhealthy Food?

An article in today’s NYTimes online provocatively titled “The Gift of Life and It’s Price” discusses both the economic costs and emotional toll of the fertility industry. The issue of IVF is receiving renewed attention in light of the debate about healthcare and the significant costs that IVF children, particularly IVF-conceived twins who are frequently born premature with severe health problems, contribute to overall healthcare spending:

The hospitalization and doctor’s care for Ms. Hare and her son exceeded $1 million. Most of that, about $750,000 to $800,000, was for Carter. The bill was picked up by the self-funded health plan of the Trammell Crow Company, the Dallas real estate investment company where Ms. Hare worked.

“The following quarter during the earnings release, somebody asked why there was a sharp increase in medical costs,” Ms. Hare said. No one identified her, but Ms. Hare knew that her family had contributed heavily.

In Atlanta, the Centers for Disease Control and Prevention hired an economist to predict what would happen if single embryo transfer were used in a large number of IVF cases.

Dr. Macaluso, the C.D.C. reproductive health official, estimates the patients, businesses and insurance providers would save more than $500 million annually, even taking into consideration the cost of extra in-vitro rounds, by lowering neonatal intensive care, special education and other costs of premature babies.

In an effort to be competitive in today’s fertility industry, clinics grant the maximum autonomy possible to clients in choosing how many fertilized embryos to transfer, despite the fact that higher implantation success rates means that multiple transfers is significantly more likely to lead to multiple births. Potential parents know the risk, but since IVF procedures frequently come out of their own pocket, most are unable to afford multiple rounds, and multiple embryo transfers makes it much more likely that the first round of IVF will lead to conception. Twins are much more likely than single births to have complications at birth.

According to one federal study, about 30 percent of all twins end up in a neonatal intensive care unit, with twins eight times as likely as single babies to be born below 3 pounds, 4 ounces. These are the babies who often need the longest hospital care and face the most sever health problems. Dr. Macaluso, the doctor featured in the article, calls them “million-dollar babies.”

The story does a good job balancing between discussing the extreme financial costs of IVF and multiple births with the more emotional side of the story. The parents discussed (and many of the ones weighing in with comments at the end of the article) are couples who want ever-so-badly to have children and are willing to bear any costs to make this a reality. Moreover, they are providing their children the gift of life, a gift that outweighs any financial burden.

This article brings to the mind of the everydaythomist the morality of choice, and in particular, a distinction made by the renowned Servais Pinckaers between freedom of indifference and freedom for excellence. Pickaers argues that in the contemporary period, we are accustomed to thinking of choice as a matter of choosing between what he calls “freedom of indifference” and “freedom of excellence.” Much of Pinckaers discussion of these two freedoms is a rhetorically charged jab at a caricature of nominalism, and particularly William of Occam (I am more inclined to blame Scotus for the sins of nominalism), but in essence, freedom of indifference is a conception of human freedom that reduces the matter of choice completely to the will’s ability to choose between contraries.

Essentially, freedom of indifference for Pinckaers is the freedom to do whatever is within the realm of possibility for human beings. Human beings have the ability to implant one or two or ten embryos into a woman’s uterus, thus, a woman has the freedom to decide how many embryos will get transferred. Freedom of indifference is the freedom of choice, the choice to say “yes” or “no” to whatever is possible.

Freedom for excellence is, on the contrary, a more limited construal of freedom. This conception of freedom is not one that focuses on the will’s ability to choose “yes” or “no” to whatever possible, but rather the will and intellect’s ability to choose “yes” to whatever is good. Freedom for excellence is a freedom limited to the telos of human flourishing. Choosing what is conducive to flourishing, both for the individual and the community, is an exercise of such freedom; choosing what is not conducive to flourishing, despite the fact that it may look like an exercise of freedom, is actually a mere expression of the will and reason’s enslavement to the passions, or custom, or some other power that prevents the person from becoming the person that God intended.

Freedom for excellence is not something that is simply given, but is rather something that humans need to develop through the exercise of virtuous external activities, and particularly through the development of the virtues. When I resist gorging myself on Halloween candy because I know it will make me feel sick and sluggish afterwards, I am exercising my freedom for excellence. When my husband and I choose not to buy a TV because we know that our default evening activity will be to veg out in front of the tube rather than engaging in more productive and life-giving activities, we are developing our freedom for excellence, despite the fact that we are limiting our ability to “choose” what to do each night.

Pinckaers distinction between the two freedoms is overly-simplistic, and my summary is even more so, but I think this distinction can illuminate an element of this debate about the cost, both financial and human, about fertility treatment. We think of the ability to choose whether or not to engage in fertility treatment as a foregone conclusion. After all, the technology is available, and much that is good is resultant of the use of this technology, namely the freedom for infertile couples to have their own children. Couples previously denied a choice concerning whether or not to have children now have their freedom to choose restored. This article discusses the cost of couples choosing whether or not to utilize this technology, but does not discuss the choice itself.

I am not so convinced that IVF and other fertility treatments are an authentic and moral exercise of human freedom. Consider this comment from one reader:

I’m sure I share many readers’ thoughts and feelings. Although I acknowledge people’s primal and mindless urges to procreate, in the world we share, “want” doesn’t equal “should have”. Our country and planet are places of finite resources of every kind. To squander them on IVF and its incredibly resource-intensive consequences is simply an outrage. There is no tenable argument in favor of IVF.

Many of the comments reflect this sentiment, and criticize the article for never mentioning adoption. The logic behind these comments is that it is more moral to choose adoption than to choose IVF.

Why wasn’t adoption ever mentioned in this article? Why do these women put themselves and their families through such risky procedures when there are so many children who could need loving, supportive families?

And another.

There are always options for adoption (although it is my understanding that this process can be equally time consuming, emotionally draining, and financially burdensome.

I think there is a case to be made for limiting the freedom to choose IVF, which is a restriction of one conception of freedom, in order to expand another conception of freedom. I think we need to bring the debate about IVF back down to the morality of the choice itself. Our society is limiting the ability to “choose” in all sorts of ways in order to make people “more free” in another way. We are taking coke and snack machines out of primary schools, for example, which is limiting the freedom our children have to choose between healthy and unhealthy dining options in order to make them more free by making them less disposed to obesity and diabetes as adults. In many cities across the US, including my own, it is illegal to smoke inside public buildings in order to make people more free to enjoy a meal or a drink without exposure to second-hand smoke.

We choose to limit our ability to choose in order to make us more free to make choices that are conducive to health, flourishing, and excellence. Why do we not do the same for IVF. Yes, in one sense, it is wonderful for parents who cannot conceive naturally to be able to conceive artificially, and there are many beautiful IVF success stories that serve as a testimony to its advantages. But are fertility procedures like IVF allowing individuals and society to make choices that are really conducive to excellence and flourishing?

This article points to one way in which IVF may be detracting from individual and societal flourishing by causing a huge burden to the health care system which is already over-stretched and under-accomplished. The comments about adoption point to another way in which the ability to choose IVF is not conducive to flourishing—it makes people more likely to choose IVF and less likely to choose adoption, leaving millions of kids unwanted in under-resourced foster care system. By restricting the freedom to choose IVF, we increase the freedom to choose adoption, in the same way that restricting the freedom to choose a treat from the snack machine increases the freedom to choose a healthy snack of veggies or whole grains.

Deep down, most of us are libertarians in some way. We want to maximize our choices as a way of maximizing our freedom. But most of us also recognize that on a society-wide scale, maximizing choices is not usually conducive to either making us more free or making us more happy. If given the choice to eat unhealthy snacks or a balanced lunch, most people are going to choose the latter. And we may say that it is a good in itself that they can make this choice, but when we get a society where over 30% of the population is obese, and we can’t provide adequate healthcare to all because the healthcare industry is already over-taxed in treating preventable illnesses like heart disease and obesity, we have to step back and ask whether the inherent ability to choose an unhealthy lifestyle is so good after all.

In a similar fashion, we might think it inherently good that couples at one time debilitated by the disease of infertility can now choose to bear a child of their own to love and care for. But when we get a bloated foster care system, and another giant strain on the healthcare system from couples having IVF babies demanding millions of dollars of expensive lifesaving treatments, maybe we have to step back again and ask whether the inherent ability to choose the IVF procedure is so good after all as well.

The Pope’s Very Political Encyclical

Pope Benedict promulgated his third encyclical last week entitled “Caritas in Veritate” (Charity in Truth). It’s a lengthy encyclical but if you choose, you can read the full text here. Or you can just peruse this or this very useful summary.

The encyclical fits into the genre of “Catholic Social Teaching,” and in it, Benedict reemphasizes some prominent themes from that tradition: the protection of life, the protection of workers, the importance of the economy serving human beings and not the other way around, and the principle of subsidiarity for the organization of society.

There are lots of blog posts examining the encyclical, which I am not going to do here. My interest concerns rather a point made by Ross Douthat in the NYTimes op-ed column entitled “The Audacity of the Pope.” He writes:

Inevitably, liberal Catholics spent the past week touting its relevance to the Democratic Party’s policy positions. (A representative blast e-mail: “Pope’s Encyclical on Global Economy Supports the Principles of the Employee Free Choice Act.”) Just as inevitably, conservative Catholics hastened to explain that the encyclical “is not a political document” — to quote a statement co-authored by the House minority leader, John Boehner — and shouldn’t be read as “an endorsement of any political or economic agenda.”

Then, after acknowledging that the pope is neither a Republican or a Democrat, Douthat writes that “Benedict’s encyclical is nothing if not political. Caritas in Veritate promotes a vision of economic solidarity rooted in moral conservatism. It links the dignity of labor to the sanctity of marriage. It praises the redistribution of wealth while emphasizing the importance of decentralized governance. It connects the despoiling of the environment to the mass destruction of human embryos.”

What bothers me about the rest of the column is that Douthat tries to make the encyclical somehow “fit into” American conceptions of politics, recognizing that putting the pope’s recommendations into practice is challenging for Democrats and Republicans alike. “For liberals and conservatives alike, ‘Caritas in Veritate’ is an invitation to think anew about their alliances and litmus tests.”

Douthat is right that people want to take the encyclical as political when they agree with it, but when they don’t, the pope is just weighing in with his opinion. For the vast majority of people looking at the political implications of the encyclical, politics is a matter of debate, division, and voting. Politics is like a debate competition with winners and losers. Basically, politics is about what you do; morality is about what you believe. The pope can believe whatever he wants, but this has nothing to do with politics. Morality is a private issue; politics is public.

I think this understanding of politics stems from the idea that somehow morality is something separate from politics. I’m reminded of Al Gore’s speech at the Academy Awards where he said that climate change was “not a political issue, it’s a moral issue.” Gore’s comment makes it seem like politics is about power, or about making people do something. Morality on the other hand is about right and wrong.

Aristotle and Aquinas give us a very different understanding of politics. Politics is not about coercion and power, or even primarily about making laws and enforcing them. Politics for Aristotle and Aquinas is simply a branch of ethics. For Aristotle, “politics” is simply part two of his ethics. And Aquinas never even wrote a treatise on politics, though he did write about politics in his ethics found in the Secunda Pars of the Summa Theologica. In honor of Benedict’s very political encyclical, now is a good time to review what Aristotle and Aquinas take “political” to mean.

For Aristotle and Aquinas, human beings are political creatures, naturally inclined to live in society. Political society (civitas) emerges from the needs human nature and is in itself a purely natural and desirable. This is a stark contrast with a thinker like Thomas Hobbes who thought that political society was an artificial imposition established to curb the violence of human nature. For Hobbes, if human beings were virtuous, they would not need a political society; for Aquinas, political society is necessary for the full perfection of human existence. The political society is the social setting in which human beings find their fulfillment and flourishing.

The primary task of the political society, therefore, is to create good and virtuous citizens. Drawing on Aristotle, Aquinas says that a political society comes into being as a necessary component of human life, but it exists for the sake of living well (Commentary on the Politics, Book 1, Lesson 1).

So we see that ethics and politics has a similar end or purpose–the formation of good people. And in both ethics and politics, this process is a gradual process of development and progress over time. While political society might be completely natural, a good political society is not. In the same way that human beings must acquire moral virtue through education and habituation, even though they are naturally inclined to moral virtue in Aquinas’ system, so too must a political society be developed and fostered.

One of the ways this happens is through the natural law. The natural law, most basically, is the rational creature’s participation in the eternal law. The eternal law is the Divine Governance that is behind creation. For most of creation, the eternal law is pretty determinative. It is by God’s eternal law that the seasons change, the planets move, fire rises upward, and stones fall downward. It is by the eternal law that plants grow, and lions chase gazelles, and whales swim instead of fly. But rational creatures (i.e. humans), as Aquinas writes, are “subject to Divine Providence in the most excellent way, in so far as it partakes of a share of providence, by being provident both for itself, and for others” (ST I-II, Q. 91, art. 2).

Human beings are not determined to specific actions like other parts of creation. Humans do have natural inclinations that come from the eternal law, but human beings have freedom and choice regarding how those inclinations will be directed. Thus, the natural law is about directing natural human inclinations towards the ultimate human good, which is flourishing. These natural inclinations include those inclinations that we share with all created things, namely, to keep ourselves in existence. They also include the inclinations that we share with other animals, namely to reproduce and educate offspring. And those natural inclinations include those distinctively human inclinations to form societies and seek out knowledge of God.

So the formation and regulation of society is a subject of study both for ethics and for politics. Laws are the natural outgrowth of the rational creature discerning how to live in order to flourish. Laws are not primarily about coercion (although they can and do have coercive effects). Laws are the product and outgrowth of the natural law. They are the embodiment of a community’s morality.

Politics, therefore, like ethics, is about discerning right from wrong in order to best live a good and flourishing life. So the pope’s encyclical, in so far as it is about morals, is political. But that does not mean that is primarily concerned with legislation. Determining how such moral values offered in the encyclical are to be enacted in legislation will vary from community to community. Aquinas explains how the process of creating laws is like craftsman who uses the “general form of a house” to build a particular house. Laws, in the same ways, are built on moral values (derived from natural law) but their specific form will vary depending on the needs of a given community.

Thus, different societies will have different ways of enforcing the precepts of natural law like prohibitions against murder or theft or laws regulating the best way to raise a family, protect the environment, or educate citizens. And different societies are going to have different ways of enacting the moral values espoused in Caritas et Veritate. The pope’s encyclical talks about the foundations for this process–the sort of moral values that all people of good will should espouse and all societies should take seriously in working to promote the common good. This is very much a political endeavor, or as the pope writes in his encyclical, it is the fruit of the “political path of charity.” (7)

No matter what you might think of the pope’s ideas, you cannot write off the encyclical as moral, but not political. But it isn’t political because the pope is taking sides or affirming the platform of any given party, or playing a political game. It is not political because the pope is coercing individuals or nations to act in any given way. It is political because the pope is talking about ethics, about the moral values that we act on that either contribute to or detract from the good life. It is political because the pope is inquiring after what human beings need in our changing world to flourish. As we debate the merits of the encyclical, let us not debate about whether it is political or not, and let us definitely not assume that simply because the pope wrote something political, he is out of line. Rather, let us allow the political process the pope started to continue as we examine the encyclical and reflect on what our society needs for its people to live good lives.

Should Christians Want to Pay More Taxes?

Today, on Divine Mercy Sunday for Catholics and the first Sunday after Easter for Protestants, the Lectionary presents us with a challenging reading from the Acts of the Apostles.

The community of believers was of one heart and mind, and no one claimed that any of his possessions was his own, but they had everything in common. With great power the apostles bore witness to the resurrection of the Lord Jesus, and great favor was accorded them all. There was no needy person among them, for those who owned property or houses would sell them, bring the proceeds of the sale, and put them at the feet of the apostles, and they were distributed to each according to need. (Acts 4:32-35)

This is a challenging reading because it smacks in the face of typical American economic sentiments that are based on the rights to private property and capitalism and a strong aversion to anything that smacks even remotely of communism. Moreover, this passage goes against sheer pragmatism. How could society function if this is the ideal?

The type of sermon you might hear on this passage depends heavily on what type of church you attend. Many choose not to preach on it, especially since the Doubting Thomas gospel passage offers an opportunity for a more irenic message from the pulpit. But this passage also presents the opportunity to give a heavy-handed political message, a message that is especially relevant in light of the dire state of the economy right now, and followed so closely on the heels of tax day. What I am referring to is an argument akin to the one Diana Butler Bass makes in this piece for Sojourners Magazine.

<blockquoteWednesday morning, at 9 a.m. sharp, I took my tax payment to the local post office. When I handed it to the clerk, she said, “I hate tax day.” I replied, “Not me. I don’t love parting with the money, but I kinda like it. That check is a bargain — roads, schools, medical care, social security, and the freedom of living in the greatest country in the world. It is patriotism by checkbook. Why should I hate it?” She replied, “Why, I’ve never heard anybody say that! It isn’t such a bad deal when you put it that way.”

No, taxes aren’t such a bad deal. Nor are they, as might have been heard at the ersatz “tea parties” around the country, at odds with Christianity. Indeed, tax day is a day that progressives should celebrate — as we participate in one of the greatest social reforms of the 20th century: the progressive income tax.

Her argument is essentially that a progressive tax is an expression of Christian love and a fulfillment of the economic demands of Jesus. Moreover, a progressive tax is a way of taking care of the poor, of providing relief to the suffering, of instituting reform that all Christians should be on board with, like universal health care, welfare reform, and education. What true Christian would not want to pay more taxes?

The problem with Bass’ argument on this point is that she has a view of the government which is thoroughly unscriptural. As I heard so aptly expressed today in church by someone who I am sure will not mind me borrowing his words, people like Bass want to “separate Jesus’ ethics from his apocalypticism.” Jesus’ ethics were beyond progressive. They were radical, even if for Christians they are so familiar as to be paradoxically comfortable.

• “Go, give everything you have to the poor.”
• “It is easier for a camel to pass through the eye of a needle than it is for a rich man to enter the Kingdom of Heaven.”
• “Blessed are you that are poor for yours is the kingdom of god, but woe to you who are rich for you have already received your comfort.”
• “Do not resist an evil person. If someone strikes you on the right cheek, turn to him the other also. And if someone wants to sue you and take your tunic, let him have your cloak as well.”

But Jesus’ apocalypticism is a little harder to swallow. Apocalypticism is a way of explaining the state of the world and why so much suffering seems to exist. According to the apocalyptic worldview, God had temporarily relinquished the world to the evil forces that opposed him, a situation which would in some future eschatological battle be reversed and God’s sovereignty restored. Apocalypticism is closely associated with dualism, with the division of the world into light and darkness, good and evil, the realm of Satan and the realm of God, the present age of wickedness and suffering and the age to come of glory. In this apocalyptic worldview, there is no middle ground, no neutral territory. People are either on the side of the Good, or they are opposed to it. If you are on the wrong side of things, you had best repent and turn your attention to walking in the light, or else be vanquished in the coming eschatological battle where God’s kingdom will be restored.

Jesus’ apocalypticism is a little hard to swallow because it makes him out to be a little less nice, a little less civilized, a little less progressive than we typically think of him:

• “Therefore everyone who confesses me before men, I will also confess him before My Father who is in heaven. But whoever denies me before men, I will also deny him before My Father who is in heaven.” Matt. 10:32-33
• “So it will be at the end of the age; the angels will come forth and take out the wicked from among the righteous” Matt. 13:49
• “If you were of the world, the world would love its own; but because you are not of the world, but I choose you out of the world, because of this the world hates you” John 15:19

Jesus thought the world was under the dominion of evil. His coming was not only to usher in the Kingdom of God, but also to set apart some who would be “children of the light.” Jesus’ ministry was not about changing the structure of the government or about initiating a political revolution. If anything, Jesus expected the governments to be a source of persecution for his followers, not a source of godly support. He says to his disciples in Matthew: “Behold, I am sending you like sheep in the midst of wolves; so be shrewd as serpents and simple as doves. But beware of people, for they will hand you over to courts and scourge you in their synagogues, and you will be led before governors and kings for my sake as a witness before them and the pagans. . . You will be hated by all because of my name.” (Matthew 10:16-22).

So let’s return to this passage in Acts and the question of a progressive tax. It does not say in Acts that the community of believers sold all they had and gave it to the emperor. It does not say in Acts that the community of believers put the welfare of the poor into the hands of the government. It says that the community of believers would sell their property or houses and bring the proceeds at the feet of the apostles. The community of believers was not clamoring for government reform. Rather, with “one heart and mind . . . [they] bore witness to the resurrection of the Lord Jesus.” The community of believers is at odds with the government, not collaborating with it. Earlier in this chapter of Acts, we read that they are citing Psalm 2 which in no way indicates that the apostles or their burgeoning community think that Christian reform either starts or ends with the government: “the kings of the earth took their stand and the princes gathered together against the Lord and against his anointed.”

So what about taxes? If the government is wicked, should Christians just stop paying taxes? Jesus seemed to think the question of taxes was secondary. “Render unto Caesar what belongs to Caesar, and to God what belongs to God.” (Matthew 22:21). The government uses our tax dollars in a lot of good ways that, of course, Christians can and should support. It is through tax dollars that our roads get built, our public schools get funded, our poor and homeless and handicapped get helped. But our tax dollars get put toward funding an awful lot of wickedness as well. The biggest chunk of the federal government’s budget goes to the military. We have bases all over the world, and two wars (maybe three) raging in the Middle East, wars which Christians have good arguments for thinking are unjust. President Obama’s administration has just bailed out the flailing General Motors with billions of dollars of loans that may never be paid back and a CEO making 1.3 million dollars. And earlier this year, Obama allotted 10 billion federal dollars to fund embryonic stem cell research, which he does not think of as a matter of ideology, even though millions of Americans do.

The point is, Christians have to come to terms with the fact that our tax dollars go to both good and evil things. There is no way to reconcile this fact by saying that your tax dollars go to support only the initiatives that you support—welfare reform, for example, but not the war. No, your tax dollars are sullied by all of the many unethical things that government gets involved in, financed by you, the American people. This does not mean that you should stop paying taxes, but only that you should realize that you do so with dirty hands.

“The community of believers was of one heart and mind . . . with great power the apostles bore witness to the resurrection of the Lord Jesus, and great favor was accorded them all. There was no needy person among them.” Christians cannot expect the government to provide for the poor, to cure the sick, to offer succor to the suffering. This is the task that has been given the Christian community, which, in a sinful world under the control of forces of evil (what Walter Wink called “the Powers that be”) can only be accomplished through the powerful grace of Christ. It is the power of Christ that heals, and the power of Christ that knocks down the sinful and oppressive structures of the world that cause innocent people to suffer. It is the power of Christ that enables sinful and selfish human beings to give all that they have to the poor because it is in doing so that we realize our freedom to follow our Lord.

The Christian should pay their taxes with a heavy heart, not because of money lost, but because of how that money is spent. And with new zeal, the Christian should offer everything else they have—their heart, mind, soul, and possessions to the Christian community, laying all this at the feet of the apostles, and “bearing witness to the resurrection of the Lord . . . [and] distributing to each according to their need.”