Early pregnancy wastage: ethical considerations

Early pregnancy wastage: ethical considerations

Reproductive BioMedicine Online (2011) 22, 692– 700 www.sciencedirect.com www.rbmonline.com ARTICLE Early pregnancy wastage: ethical considerations...

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Reproductive BioMedicine Online (2011) 22, 692– 700

www.sciencedirect.com www.rbmonline.com


Early pregnancy wastage: ethical considerations Giuseppe Benagiano


, Maurizio Mori b, Norman Ford c, Gedis Grudzinskas


a Department of Obstetrics, Gynaecology and Urology, Sapienza, University of Rome, Policlinico Umberto I, 00161 Rome, Italy; b Department of Philosophy, University of Turin, via sant’Ottavio 20, 10124 Turin, Italy; c Catholic Theological College, East Melbourne, Vic 8002, Australia; d 92, Harley Street, London W1G 7HU, UK

* Corresponding author. E-mail address: [email protected] (G Benagiano). G. Benagiano is Professor Emeritus of Gynaecology and Obstetrics at ‘la Sapienza’ University of Rome (Italy) and former Director general of the Italian National Institute of Health; M. Mori is Professor of Bioethics at the University of Turin (Italy) and President of ‘Consulta di Bioetica’ a national association promoting bioethics in a pluralistic attitude; Norman Ford, is Lecturer in Bioethics and Healthcare Ethics at the Catholic Theological College (Melbourne College of Divinity) and an Adjunct Research Associate in the School of Philosophy and Bioethics, Faculty of Arts, Monash University, Melbourne (Australia); G. Grudzinskas, formerly Emeritus Professor of Obstetrics and Gynaecology at St Bartholomew’s and the Royal London Hospitals School of Medicine and Dentistry, London, UK, is in independent clinical practice.

Abstract Information on early embryo wastage is relevant for debating the status of human embryos. Two main points of view con-

front each other. Theists hold that human embryos should be treated as human persons from the moment of conception because, even accepting that human beings are the fruit of evolution, they are part of a divine project. Without a developmental event prior to which the human embryo could not be considered a human being, embryos should be regarded as if they were human subjects. After all, if one believes in the resurrection of the dead, it makes no difference at what stage one’s life ends. Secularists oppose the idea of granting absolute value to human life from its beginning because early human embryos lack individuality and sentience. Personifying embryos is morally absurd because it would mean that countless human beings never had even the slightest chance to express their potential and, in the light of this catastrophic loss, one would expect early pregnancy wastage to have become an important research priority; this is not the case. In practical terms, most Western countries have legalized first-trimester abortion, de facto giving embryos a lower status than that of full person. RBMOnline ª 2011, Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved. KEYWORDS: embryonic loss, individuality, personhood, sentience

Introduction This paper stems from the collaboration between biologists and philosophers and represents an attempt at explaining how early wastage may or may not have an influence on the moral status of the human embryo. We hold very different personal convictions on the matter, but decided it was important to provide a dialectic response to the issue. We have recently reviewed the evi-

dence accumulated over the last 50 years or so, documenting the existence in the human species of a massive loss of fertilized ova and early embryos that, overall, may reach 50% (Benagiano et al., 2010). We believe that updated information on precisely what happens after fertilization, based on a comprehensive review of the most recent epidemiological, biochemical and morphological data, can go a long way in providing the foundation for an in-depth bioethical analysis and debate. Specifically, this information

1472-6483/$ - see front matter ª 2011, Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.rbmo.2011.03.008

Early pregnancy wastage is of relevance when trying to address the question ‘When does the life of a human individual begin?’ because if it is postulated that a new human person exists at syngamy, then the inescapable consequence is that, over the life span of genus Homo, an endless number of human beings have come into existence for only hours or a few days, without any chance of expressing their nature in any conceivable way. Biological facts, however, per se cannot offer an answer to an ontological or categorical question; this can only come by confronting and even contrasting interpretations given by philosophers, bioethicists, theologians and political and juridical experts. Each of them can help in trying to reach a consensus for an agreed answer. The matter is complicated by the abundance of terms used to define the nature of human life’s early stages (spermatozoa, ova, zygote, preor pro-embryo, early embryo, being, individual, person, etc.), which are usually interpreted in a different manner by biologists, ethicists, lawmakers, lawyers or the public at large. Many will argue that the task of elaborating and defining the concept of a ‘new individual’ belongs to philosophers and moralists. This may be so, but it is equally true that ethicists, philosophers and theologians cannot proceed without taking into account new information and new realities continuously being produced by progress in biology and embryology. Indeed, today, what used to be a theoretical discussion has taken a very practical turn thanks to advances in assisted reproduction technology and over the past 20 years several governments have been induced to formulate legislation regulating such techniques. In doing so, an attempt inevitably had to be made to define when the beginning of a human individual occurs. Not surprisingly, the ‘legal’ definition varies from country to country and often reflects the prevailing philosophical and religious beliefs of a specific group or nation. In some instances legislators have turned to science as the basis of human knowledge, considering it as generally impartial and often above national and religious boundaries. This, however, has resulted in more, rather than less, controversy, because many consider defining life in its broader and complex meanings to be beyond the reach of science: they argue that science alone cannot define terms like ‘person’, ‘being’, ‘soul’, ‘individual’, terms that have ethical, legal, philosophical and religious meanings. Debates on ‘When does life begin?’ preceded IVF, the technology with the potential of providing a much more precise picture of the events leading to embryo formation and development. For instance, one of the most widely read Italian weekly magazines, Panorama, more than 30 years ago published a debate opposing biologists and theologians (Vecchi et al., 1976). In that debate, the position was brought forward that ‘life’ can be considered a continuous cyclical process with gametes bridging the gap between adult stages. In this sense, ‘human life’ began hundreds of thousands years ago when the present human genome developed more or less to its present nucleotide sequence. To most people however, the question of when life begins requires a very different answer and a much more personal one. During the debate, participants presented concepts such as: ‘life started 3 billion years ago and therefore nowadays it never begins’ or ‘human life

693 began when the DNA specific to our species was first assembled; from that day life simply continues’. Theologians replied: ‘A beautiful but irrelevant theory, since it does not concern the life of an individual. Generically speaking, life may have occurred for 3 billion years, but each individual has a beginning and an end’. In fact, scientists and clinicians on the one hand, and philosophers, bioethicists and legal scholars on the other, concur that we do not study or treat the continuum, only individual variations. In debating the beginning of ‘human life’ it is therefore necessary to focus on when the life of a single individual begins; in other words, what needs to be established is when a new individual detaches itself from the continuum of the human lineage and begins its autonomous existence. It has been argued by biologists that there is no special reason why such a ‘birth’ of a new individual is defined by fertilization and, indeed, although fertilization is a unique and fundamental phenomenon, a milestone in the creation of a new human being, it is neither the only nor its sole determinant. This, however, per se does not help reaching an agreement on the ‘moment life begins’, for the simple reason that philosophers, theologians, legislators, bioethicists and even the public at large utilize different and often irreconcilable starting points. In addition, the definition of what constitutes a new human ‘life’, as much as that of when ‘death’ occurs has undergone a considerable evolution during the second part of the 20th century. For some, the beginning of human life coincides with the time of the formation of a diploid body in which male and female sets of human chromosomes are mixed and are capable of reproducing (Congregation for the Doctrine of the Faith, 1987, 2008). For others, true human life only occurs after implantation of the embryo in the decidualized uterine mucosa (Eberl, 2000). Many others believe that a new individual only initiates its ‘real’ human life when early differentiation leads to neural development (Gertler, 1986). Finally, some believe that a living being is only a person (and thus has moral status) when it has the capability to live outside the uterus; indeed, some would argue that one is only a person after developing self-awareness (Bortolotti and Harris, 2005). Interestingly, the ethical dimension of pregnancy wastage was addressed 25 years ago by Murphy (1985) when he claimed that, although spontaneous abortion has no moral relevance for strict pro-abortion positions, their high incidence is not (as some claim) eo ipso any sort of justification for voluntarily induced abortion. At the same time, he argued that if the strict anti-abortionist position is to be taken seriously in its insistence that prenatal life has a right to be protected by virtue of its being conceived, then it seems necessary to take measures to prevent spontaneous abortion and its presumptive causes and that this is a matter of moral obligation. Today, two main opposite points of view confront each other. On the one hand, the official position of the Roman Catholic Church, Christian Orthodox Churches and several conservative Protestant denominations (e.g. evangelical churches) is that a human embryo ‘must be treated as a human person from the moment of conception’. It is not the same as stating positively that a fertilized ovum is already a person. Rather, it means that, leaving aside the

694 so-called issue of animation (ensoulment), a fertilized ovum – if undisturbed – has the potential of becoming a human person and as such must be fully protected (Benagiano and Mori, 2006). In absolute contrast to this position, many secular philosophers oppose the idea of granting ‘absolute value’ to human life from its very beginning and have objected that the fertilized ovum cannot be considered a person because it lacks individuality (in the earliest stages all its cells have the potential to evolve into a human being); that if a fertilized ovum is already a human person, then aneuploid or polyploid embryos, ‘blighted ova’ and embryonic vesicular moles are all human persons, even when no embryo at all is formed. For this reason, ‘personifying’ early human embryos means – for secular bioethicists – accepting that countless human beings never had even the slightest chance to express their potential, which is hardly plausible and looks like an absurdity. In this line of thinking, Green (2008) argued that if human embryos are the moral equivalent of children and adults, then, based on the calculations summarized in Benagiano et al. (2010), as well as on current estimates of world population growth, each year ‘this amounts to the catastrophic loss of perhaps a 100 million ‘human’ lives worldwide’. This, for secularists, would certainly be a real tragedy, perhaps the greatest one among those deserving emergency help (Mori, 2008). Given the variety and diversity of ethical positions existing vis-a `-vis the high early pregnancy wastage, the authors of this paper believe that it is useful to enter the debate and try to draw some – hopefully shared – conclusions. We wish to point out that, as individuals, we hold almost opposite views on how to answer the question ‘When does life begin?’ At the same time, we strongly believe that engaging in dialogue is the only way to make progress. To achieve this we have summarized below what we consider the two very opposite viewpoints. However, it is important to remember that a number of bioethicists hold intermediate positions on the issue of when the life of a human individual begins and, as a consequence, when it begins to matter morally; indeed, some of these bioethicists would argue that human life doesn’t matter morally just because it is human life.

The theistic position Theistic philosophers believe that, even if human beings are the fruit of evolution, this is part of a divine project and that immaterial souls are directly created by God. Therefore they support respect for the human embryo and its formative process because, in their view, reason can work out that God, as Creator, is the architect responsible for the natural processes of human procreation and embryonic development. In this respect, the words of Albert Einstein (Einstein, 1950) come to mind: ‘The highest principles for our aspirations and judgments are given to us in the Jewish-Christian religions tradition;’ adding that ‘science can only be created by those who are thoroughly imbued with the aspiration towards truth and understanding. This source of feeling, however, springs from the sphere of religion. To this there also belongs the faith in the possibility that the regulations valid for the world of existence are rational,

G Benagiano et al. that is, comprehensible to reason. I cannot conceive of a genuine scientist without that profound faith. The situation may be expressed by an image: Science without religion is lame, religion without science is blind.’ With Norman Ford (Ford, 2002, p. 68), theistic philosophers argue that: ‘The moral necessity to show respect for human embryos is a profoundly human insight and reflects the respect due to human life naturally resulting from a couple’s mutual self-giving and our shared humanity, apart from religious considerations. There is no justification for the reductionism that sees human embryos as no more than genetic products, devoid of moral significance and value. From a theistic perspective, the fruit of human generation in the early embryo has moral significance and a claim to unconditioned moral respect.’ In this view, the deliberate destruction of a human embryo is a serious moral offence against the basic good of human life. Others argue in favour of respect for human embryos without reference to belief in God or any particular religion. This approach is found in a minority expression of dissent opposing the UK Warnock Report’s recommendation for permitting destructive research on early human embryos: ‘the embryo has a special status because of its potential for development to a stage at which everyone would accord it the status of a person. It is in our view wrong to create something with the potential for becoming a human person and then to deliberately destroy it. . . . It must therefore be given special protection so that this potential can normally be fulfilled’ (Department of Health and Social Security (United Kingdom), 1984, pp. 90–91). A similar line was adopted by an Australian Senate Select Committee when it gave the following reasons as its grounds for the moral inviolability of the human embryo: ‘It is in its orientation to the future that the Committee finds the feature of the embryo which commands such a degree of respect as to prohibit destructive non-therapeutic experimentation.’ Without a developmental event prior to which the embryo could not be considered to be a human subject, the Select Committee concluded: ‘prudence dictates that until the contrary is demonstrated ‘‘beyond reasonable doubt’’ . . . the embryo of the human species should be regarded as if it were a human subject for the purposes of biomedical ethics’ (Australian Senate Select Committee on the Human Embryo Experimentation, 1986, 25, 3–6, 28, 3–18). It is fair to say that a majority of theistic philosophers make reference to biblical texts and many believers in God who are neither Jewish nor Christian appreciate the moral precepts of the Bible because they appeal to their reason as an expression of authentic humanity. At the same time, theistic philosophers do not need to have recourse to divine revelation to justify respect for human embryos. They believe that the Creator’s design is inherent in the formative process from the start, culminating in the expression of a human being’s ability to perform rationally self-conscious acts of knowledge, of free choice and of a moral life. This position is clearly found in the early Christian tradition. Taken as a whole, this tradition shows God as actively present throughout the human formative process, and especially for the creation of each human being’s spiritual soul. In biblical times it was simply taken for granted that any assault upon life in the womb was an offence against God

Early pregnancy wastage and a rejection of the divine gift of human life. Theistic philosophers argue that this cannot be explained away as mere cultural conditioning, because these ancient texts indicate a stand for a culture of prenatal life and provide strong theological grounds for saying human embryos belong to God their Creator and for claiming they have intrinsic value, worthy of absolute moral respect. Human beings have been created male and female; thus, new human lives are meant to originate as the result of loving spouses’ marital intercourse and the formation of the zygote following the fusion of spermatozoon and egg. Each newly formed zygote is endowed with its own unique genome which functions as a live blueprint. There are obvious indicators of purpose, finalism and direction in the interactions of cells, the formation of a human body plan and the orderly development of tissues and organs to achieve this end (Ford, 2008). Here again, Ford has argued that ‘respect for human embryos is based on the divinely conferred natural actual potential of their genome, given a suitable environment, to direct and organize continuous development and growth from conception to birth and to adulthood. The formative process of the developing human embryo is naturally linked to the terminus of the process, i.e. a human being with a rational nature, a subject of inestimable worth and personal dignity, made in the image of God’ (Ford, 2008). In this perspective, the duty of absolute respect for embryos stems from the fact that they exist and are integral to the formative process of human persons (Ford, 2002, p. 68). Interestingly, Wendler has proposed a similar argument to oppose abortion, basing his rejection of terminating a pregnancy on the moral significance of the natural process of foetal development (Wendler, 1999). The presence of such finalism argues that the human being must somehow be present in the zygote from the constitution of its unique genome. The ontological character of this ongoing teleological causal influence on the developing embryo generates solid reasonable grounds for holding that the human zygote is the same living being as the growing embryo, foetus, newborn child and adult human being. These considerations, coupled with the continuity of human development from the zygote stage with its inbuilt ontological relations, provide credible scientific and philosophical reasons in support of the zygote being deemed a human being, a natural person (Ford, 2002, p. 68, 2007, 2008). The topic of the formation of animals and human beings interested Aristotle throughout his life. In one of his last books, Generation of Animals, he wrote in some depth about the subject (Rist, 1989, pp. 25, 32, 35, 286–287), but already in his early work Aristotle admitted that the human embryo could be a human being: ‘the seed [human semen] is not yet potentially a man; for it must be deposited in something other than itself [a woman’s reproductive tract] and undergo a change. But when through its own motive principle it has already got such and such attributes, in this state it is potentially a man’ (Aristotle, Ross translation, 1966, p. 1049a). Aristotle’s metaphysical mind held that living beings ‘become so and so because they are so and so, for the process of Becoming or development attends upon Being and is for the sake of Being, not vice versa’ (Aristotle, Ross translation, 1965, p. 778b). Hence, in saying ‘man’ he would have to include a human soul to account for human rational nature, but not yet with the actual capacity

695 for the use of reason. So in Aristotle’s early view, when an embryo is formed, a man, a human being is also formed, who in due time becomes in actuality a grown child, i.e. what it already is in potency. Aristotle’s reasoning is valid: the human embryo already has the rational nature of a human being, but not the acquired ability to exercise reason until well after birth. Naturally this reasoning would also apply to human embryos that fail to implant until they died, including many other embryos that are lost due to their failure to develop to the foetal stage. This means that there ‘would also be good reasons to hold that the immaterial soul or life principle is created within the zygote to complete the formation of a person, but there could be no empirical evidence for this’ (Ford 2002, p. 68). In other words, there would already be the rational nature of a natural human person, but not the acquired ability to exercise reason until well after birth. Patrick Lee expresses his agreement with this position in this way: ‘From conception on, the unborn human being is a developing entity with the basic natural capacities to reason and make free choices. She right now is that type of thing that matters, not the condition that thing is in, which may or may not allow her immediately to exercise all of her basic capacities. Potentiality is important only because it is an indication of what kind of thing is already present’ (Lee, 2004). Francis Beckwith with acute Aristotelian insight concurs: ‘One can only develop certain functions because of the sort of being one is’ (Beckwith, 2005). Not everyone, even among those favouring protection for the early embryo, agrees. As an example, Michael Lockwood, believes that a week-old human embryo is a human organism but it would not be a person: ‘I came into existence only when the appropriate part or parts of my brain came into existence, or more precisely, reached the appropriate stage of development to sustain my identity as a human being, with the capacity for consciousness. When I came into existence is a matter of how far back the relevant neurophysiologic continuity can be traced’ (Lockwood, 1985, p. 23). He does, however, admit that it is in theory possible for an immaterial soul to supply the required substratum for a human being’s personal identity, but not believing there is any empirical evidence for a spiritual soul, he settles for the organized physical structures of the brain. We therefore have a situation in which, although the moment when a human soul is created within the embryo is not known precisely, Catholic theology holds that even ‘. . . supposing a later animation, there is still nothing less than a human life, preparing for and calling for a soul in which the nature received from parents is completed’ (Congregation for the Doctrine of the Faith, 1974). The developing human embryo is duly attributed human dignity and the moral inviolability of the adult human being who consciously relates to God and to others through acts of knowledge and of love. To clarify further this concept, the Catholic Church in 1987 issued the instruction Donum Vitae, to provide moral guidance on a great variety of moral issues on the use of assisted reproduction technology and to once again stress the respect due to human embryos (Congregation for the Doctrine of the Faith, 1987, p. 18). The instruction clearly states that ‘the fruit of human generation, from the first moment of its existence, that is to say from the moment the zygote has formed, demands the unconditional

696 respect that is morally due to the human being in his bodily and spiritual totality’. Since there were disputes over when in empirical terms the new embryo begins, in the definitive Latin text the Catholic Church decided it was not its role to resolve scientific debates on the precise moment of the beginning of the zygote and therefore made no reference to syngamy, simply stating Catholic doctrine in the following definitive Latin text: ‘zygotum est cellula orta a fusione duorum gametum [the zygote is the cell produced by the fusion of two gametes]’ (Congregation for the Doctrine of the Faith, 1988 80/1, p. 78). In the earlier provisional Italian version, the zygote was defined as ‘the cell produced when the nuclei of the two gametes have fused’. In other words: ‘The zygote is the subject of genetically human life from the beginning of its formation, when it is constituted into a single living cell. The fruit of human generation is present once its formation begins in the life of the cell that starts during fertilization’ (Ford, 1988). In the theistic perspective, God’s special creative involvement makes human life sacred and thereby absolutely morally inviolable: ‘Human life is sacred because from its beginning it involves ‘‘the creative action of God’’ and it remains forever in a special relationship with the Creator, who is its sole end. God alone is the Lord of life from its beginning until its end’ (John Paul II, 1995). This teaching has recently been formalized by the Catholic Church: ‘The reality of the human being for the entire span of life, both before and after birth, does not allow us to posit either a change in nature or a gradation in moral value, since it possesses full anthropological and ethical status. The human embryo has, therefore, from the very beginning, the dignity proper to a person’ (Congregation for the Doctrine of the Faith, 2008).

Theism and early embryo loss When asked whether the biological reality of an ‘enormous’ early, preclinical human embryo wastage somehow changes the nature of the teleology or finalism, manifested in the predetermined developmental process from the embryo to a newborn baby and eventual adult, theistic philosophers respond with a variety of arguments. They accept the existence of high embryonic and also foetal losses naturally occurring during normal gestation and they agree that, from conception, the loss rate may be high and has been put by some at 60–65% or higher (Benagiano et al., 2010). However such a high loss rate of human embryos before birth does not imply that human embryos are not human beings or persons. Modern theists would accept the following definition of a human embryo as ‘a totipotent cell or a group of contiguous cells or a multicellular organism, which, due to its genome, has the inherent actual potential to continue organized human development in a suitable environment’ (Ford, 2002, p. 68). What makes a group of these contiguous cells an embryo depends on what it is, not what it may or may not eventually become. A spermatozoon or an egg is not an embryo, but they have the potential to become an embryo once they fuse and form a zygote. In doing so, they become what they previously were not. Although the embryo depends on the mother for its continued life, it is independent of the mother in regard to the genetic informa-

G Benagiano et al. tion required for orderly development to birth and beyond. To be alive implies having actual potential to live on. A suitable environment like the uterus does not confer life, but enables a living embryo or foetus to continue to live. Death, in fact, is the loss of the actual potential to continue to live on. In this respect, it is important to note that every living or developing human embryo has the actual potential of an integrated and functioning human organism. A seed’s natural potential to become a tree is independent of the major wastage that occurs with all seeds; it is actualized once germination begins (Ford, 2005). Frozen embryos that survive the freeze–thaw process retain their natural potential to continue development, as proven by thousands of live births from thawed embryos. Embryos are not formed if fertilization arrests and development fails. The same applies to arrested development in cases of cloned embryos or of abnormal development in which disorganized embryonic tumours are formed. Obviously, theists accept that in all instances when no true embryo is formed as a result of abnormal fertilization (‘blighted ova’, ‘anembryonic vesicular moles’, etc.), or when an embryo has absolutely lost its potential for further human development (as in ‘aneuploidy’ or ‘polyploidy’), or when as a result of failed implantation there is no surviving living embryo, there would be no human embryo present to save or protect. At the same time, as long as these cases cannot be diagnosed in a non-invasive manner, all initial pregnancies must be protected. As to the specific question of early embryo losses, common experience proves to scholars and ordinary people alike that all human beings are conceived and born with a mortal nature. Death awaits every living human being, and death may, and does, occur before and after birth. There is no moral problem with people dying at any stage of life provided nobody has caused death deliberately either by lack of due care in the family context or in a professional medical situation. Fortunately, modern science and medicine enable more lives to be saved before and after birth – even many years after birth. At the same time, the reality is that believers in God (and more specifically Christian believers in God’s divine revelation in the historical Jesus Christ) do not accept that death is the end of the entire person. For them, the souls of all human beings, including embryos, are spiritual, i.e. immaterial and are not liable to corruption when human individuals die. In conclusion, Catholic teaching offers hope for all by holding that the souls of deceased persons do not cease to exist. Theists rationally think and hold that a spiritual and immortal soul is united with a human body to constitute a living human person. Christian theists believe that, on the final day of resurrection of the body, everyone will have a new, immortal body, irrespective of the stage of development at which death occurred. In short, theists believe that immaterial beings are real and that there is a Provident God, the Creator of all creatures, visible and invisible. They hold that it is naı¨ve to rule meta-empirical concepts or transcendent metaphysics as meaningless when one has gratuitously adopted an empirical principle of significance, thereby labelling as distorted any use of a concept that fails to make direct utilization of empirical criteria for its employment.

Early pregnancy wastage

The secular position In contradistinction and in opposition to the theist position, secular philosophy in its many interpretations does not accept that a new human being begins at fertilization, although, over the last few decades, secular philosophy within the Western culture has undergone a sort of paradigm shift, a general change of attitude and approach to the question of the nature of human embryos, creating new problems and perspectives (Harris, 1999). At the same time, before anyone can accept this new paradigm, it is important to stress that it involves a number of new considerations requiring a careful examination and a critical review. Traditionally, questions relating to early human embryos were not at all connected with human somatic or corporeal individuality as such. When – long before Christianity appeared – the Hippocratic paradigm reputed and felt human life as holy and sacred, the real issue was the absolute duty of respect due to the human reproductive process as such, not in its single parts (Hartshorne, 1985, pp. 27–44). To state whether there is genetic individuality, or the union of two objects or things (human gametes), or somatic individuality or sentience, was considered as a false and misleading issue. At the time, the only important question was: Is it licit or not to interfere with the human reproductive process? (Mori, 1996b, pp. 99–110). Instead of using the word ‘reproduction’ or some derivate adjectives, Christian tradition considered as appropriate the term ‘procreation’, which conveyed the idea that men and women were co-operating in the most exclusive divine enterprise: the creation from nothing (ex nihilo) of a new individual. The shift proposed today by secularists consists in getting away from a position held from the dawn of civilization, namely judging human actions in terms of whether they are respectful of the procreative process or are in some sense against it. For those holding this position, it made no sense at all to state the exact time of the beginning of human individuality or of personhood and this was for two reasons: first, because it was practically or technically impossible to do so; second and most important, even if it had been possible, it was morally irrelevant. Reproduction or procreation was to be respected as such, independently of possible individual outcomes. Procreation was a special realm devoted to the transmission of human life, and it deserved respect and awe for itself, because in it the shadow or the seal of God is hidden. For sure, procreation was to be respected not for consideration of the outcomes, i.e. of the person(s) coming out at the end of the process. In contrast to the traditional position, secular philosophy holds today that setting the focus on the forthcoming person, or on the beginning of individuality, is a sign of the victory of modern individualism over a more classical view. If what is crucial is to determine when the life of an individual begins, this implies that we have to do it because we care about the quality of life of such an individual. The point is that assuming this is already accepting a secularized view of the world where the individual human life is all that is morally relevant. In this sense, the most important duty is to preserve, or not to harm, human individuals. The reasoning goes that, following secular bioethical principles,

697 it is not any longer necessary, as it was in the past, to subordinate human individuals to the moral law, whose prescriptions could lead to pay little or even poor attention to individuals. In a theistic vision, a single individual has a supreme goal: to save her/his soul and therefore every individual should be ready to give up her/his life in order to obey the moral law, whatever the consequences. This assumption was peculiarly strong in issues concerning manipulation of the reproductive process, where also race considerations were involved. For this reason, to focus the attention on the issue of individual life and individuality is to make a paradigm shift towards individualism. Once such a step is made, several further consequences follow. The most prominent one is that sentience becomes the basic criterion for morality, not respect of the moral law as such. In the past, the task and goal of morality was to make sure the order of generations and obedience to the moral law guaranteed this aspect, which was peculiarly visible in the field of transmission of human life. Now for some secularists (e.g. consequentialists and utilitarians) the situation is reversed and everything is ordered to the human individual. But, if this revolution occurs and it is accepted, this implies that nature, as well as natural processes, is neither good nor bad. They are indifferent, and what makes a natural event good or bad is the perception of it, i.e. how it is felt by some sentient being. This means that secularists today sponsor for biomedical sciences a process analogous to the Copernican revolution: in the Ptolemaic paradigm celestial bodies had a given meaning and an intrinsic value. They could speak to humans and were morally significant. After the revolution stars and planets were nothing else but big stones running in the sky, deprived of any intrinsic meaning, whose movements could be explained and predicted through physical laws. Whether they have a value depends on the positive or negative relation (or perception) they have to some sentient being (Mori, 1998a, pp. 38–55, Mori, 2011). Something similar is now occurring in the biomedical world and in particular to the issue concerning pregnancy and reproduction. If the focus and centre of attention becomes the human individual and not any longer the transmission of human life as such, then at least two questions become crucial. First why such an emphasis on individuality, and second, why on human individuality? Secular philosophy holds that ‘individuality’ as ‘indivisibility’ and ‘difference from other things’ is a very problematic notion if referred to biological processes, because biological bodies are not ‘things’ as spatio-temporal entities limited by sharp borders and indivisibility. It further stipulates that, even if we could reach an agreement on an adequate notion of individuality concerning the beginning of human life, there is no reason why this should be morally significant. What is important is not individuality as such; rather it is something else, namely whether there is an individual human sentient being. But even this presupposition may not be true, since up to about 24 weeks of pregnancy there is no capacity for feeling pain or pleasure (Royal College of Obstetricians and Gynaecologists, 2010). After such still vague limits, for some time up to birth and even after it, some secular bioethicists discuss whether there is sentience or not. In this connection, secular reasoning holds that our position should be analogous to that held for other

698 statements made under uncertainty, i.e. when we are ignorant about a certain condition and have to evaluate whether it is likely or not. In other words, although in a different context, the same anti-probabilistic argument used by Catholic theology on abortion (Congregation for the Doctrine of the Faith, 1974) can be used here. Moreover the quality of prospective sensations must also be brought into the equation, because in some cases we can predict that, because of some sort of biological disorder, they will be only negative and this counts too, to the point to lead some to believe that, although it is impossible to predict the total amount of happiness and pain for a normal individual, in some specific cases we know that pain will overcome happiness, and therefore we have a responsibility for this outcome (Singer, 1993, 2002). In conclusion, utilitarian secularists believe that the real issue at stake is not individuality as such, but sentience. Following this line of thought, they point to individuality, because in the traditional settings only individuals, but not complexes (groups of people) or artefacts (institutions or machines), could feel pain or pleasure. In this sense, the search for individuality is a sort of stenographical abbreviation for the real goal: sentience. These secular philosophers therefore wish to reframe the traditional view and go straight to what they believe is really relevant from a moral point of view: the capacity of feeling, because only the presence of this property provides a meaning to the world and gives to it some colour and sense, taking it out of mere natural indifference.

Secularism and early embryo loss Strangely enough, both theists and secularists converge on the above-mentioned analysis, even if they diverge radically in the conclusions. For the theists the shift is the sign of the perversion of the new world, while for the secularists it is the stamp of a new beginning, because through control of human reproduction humans can hope to enhance human life and maybe increase the general happiness of all sentient beings. According to the secularist vision, as expressed above, the issue of early embryo wastage can be seen in two different ways. On the one hand, it becomes almost irrelevant, because the moral value of human life is not dependent on the presumed status of the embryo. Indeed, when looking at the many steps occurring during the human reproductive process, fertilization is simply one of them, and not even the morally crucial one. Therefore, from the secular moral point of view, ceteris paribus, early embryo wastage is not dissimilar from gamete wastage. Of course, even secular philosophers accept that the ceteris paribus clause never fully applies, because fertilization has a cost and it implies a parental investment. For this reason, it is recognized that this ‘extra factor’ may constitute an incentive to modify our attitude and could corroborate our thinking that fertilization is something special, extraordinary and in a sense magical. It is therefore accepted that there are several forces leading in this direction, starting from common sense that stresses the union of ‘things’ as the beginning of a new ‘thing’ and continuing with the strong cultural survival dependent on religious attitudes. At the

G Benagiano et al. same time, secular bioethics holds that these extra aspects concern our psychology and cannot modify the final judgment about the morality of the issue. On the other hand, for secularists the vast early embryo wastage is quite relevant as a piece of strong evidence in favour of the sentience thesis. They reason that, if fertilization had to be the crucial mark for the beginning of a human person, it would be at least quite odd, if not absurd, that so many young ‘persons’ had to be lost at the very beginning of their life. We have already mentioned the argument brought forward by Green (2008) that, under the circumstances, one would have expected that researching early pregnancy wastage in order to identify ways to prevent it should represent an important research priority, which is certainly not the case. Some have explained this ‘indifference’ by the scientific community with the fact that these losses are inevitable and are the result of a ‘natural’ process of elimination of major developmental errors; Green disagrees and further points out that a majority of pathological conditions (from cancer to malaria to AIDS) are also the result of natural processes and – in the vast majority of cases – these diseases are not intentionally caused. Yet, this ‘naturality’ does not reduce our moral commitment to fight them. Indeed, as stressed by Green (2008), to prevent their death or to save them would become the major issue of public health care. Furthermore, considering the fact that most of them are affected by major anomalies and genetic disorders, the prospect of launching such a programme appears totally unrealistic, if not clearly absurd. Secular philosophers unanimously hold that the idea is so counterintuitive that, via modus tollens, the conclusion must be that fertilization is almost irrelevant and it is high time to make a paradigm shift and to see reproduction in an entirely different way. There is another issue that should be mentioned in presenting the secularist case, namely the ethics of destructive embryo research. In an ample debate published in the Cambridge Quarterly of Healthcare Ethics, Harris (2004) has argued that the now well-proven fact that, in the human species, reproduction ‘inevitably involves the creation and destruction of embryos’ creates major problems for those who believe that the embryo is ‘one of us’. He believes that if, as mentioned above, the occurrence of a major natural embryo wastage is not problematic for theists, then ‘neither is the creation and destruction of embryos for a purpose of comparable moral seriousness – the development of lifesaving therapy, for example’. A fortiori, the same argument would then apply to the admissibility of assisted reproduction treatment with its inevitable loss of embryos. Savulescu and Harris (2004) have further argued in favour and against the concept that a commitment to the permissibility of natural reproduction (with its inevitable loss of embryos) entails the permissibility of destructive embryo research and, again, of assisted reproduction treatment. Clearly, secularists believe that matter and material energy alone exist in this world and they cannot accept that the spiritual soul of a deceased human individual could survive and eventually be united again with a renewed body to form the same living human person as one entity. And even if they might accept it, they would argue that in the event of early embryos or, a fortiori, in the event of aneuploid or

Early pregnancy wastage polyploid embryos, ‘blighted ova’ and anembryonic vesicular moles, there would be no person in the first place with which to be reunited. Therefore, most non-believers in God, in spiritual souls or in any immaterial beings find the theist discourse difficult or problematic to say the least. Some might find it out of touch with reality or even bordering on the ridiculous (Mori 1996a, pp. 151–63, Mori, 1998b, pp. 83–92, Mori, 2011).

Conclusions We hope to have shown that the debate on when exactly a new human life becomes a new human person provides multiple and opposed answers. We have tried to summarize the two best-known positions, arguing in favour and against each of these two positions. The starting point for our reflections has been the general rule in reproduction that gametes and embryos may be produced in abundance, with only a tiny proportion of these surviving to produce offspring; in the first paper (Benagiano et al., 2010) we have shown that humans are no exception to this rule and here we hope to have shown that the ethical relevance of this phenomenon has been fully understood by bioethicists for years, especially at a time when in some countries the number of cryopreserved embryos grows exponentially because there are no time limitations to their storage (Pfeffer-Merryl, 2009). In this connection, 25 years ago Leon Kass (1985) understood the importance of natural embryo wastage for an equitable solution to the problem. He stated that ‘it is estimated that over 50% of eggs successfully fertilized during unprotected sexual intercourse fail to implant’ and, with great intuition, he argued that ‘the demise of the un-implanted embryos would be analogous to the loss of numerous embryos wasted in the normal in-vivo attempts to generate a child’. Obviously, the analogy is only partially true: in the case of IVF we may end up discarding perfectly normal embryos that, if given a chance, may end up implanting and going to term. What we believe to be important is the fact that human reproduction cannot take place without embryo wastage and this now well-established fact must be taken into consideration in any ethical discussion. Whilst this debate continues, it could be argued that, in practical terms, most Western countries that have legalized first-trimester abortion for non-medical indications have de facto given embryos a lower status than that of a true person.

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