"Be fertile…": On Catholic Health Care's Distinctive Social Responsibility to Treat Infertility
A response to an article by Sr. Patricia Talone, RSM, published in a previous issue of HCEUSA.
Elliott Louis Bedford, Ph.D.
Director, Ethics Integration
St. Vincent
Indianapolis
Introduction
In her recent article, "First, Do No Harm: Ethical Questions about Ova Donation and Surrogacy" in Health Care Ethics USA, Sr. Patricia Talone, RSM, Ph.D., speaks powerfully to areas of vulnerability arising from infertility.1 She highlights how current circumstances place young women — especially those with economic disadvantages — in compromised positions, for instance, donating gametes and even their bodies despite not having pertinent information about the potential risks and harm. She also does well to shine light on the dehumanization and commodification that such practices reinforce. Sr. Talone is clear: while Catholic healthcare does not offer such interventions, it still maintains certain obligations on the issue, as a matter of respect for human life. These include pragmatically minimizing the commodification of human beings, especially women and children, and advocating for public policies and regulation that protects women and children against extortion.
I concur with Sr. Talone. Catholic health care can and should do what it can to help protect these vulnerable populations of women and children. For instance, working with our local Catholic conferences to address state level public policy is one excellent opportunity to bring this voice to bear.2 At the same time, I would add to her proposal: Catholic healthcare can and should take a leadership role in addressing infertility itself — the root cause of these problematic behaviors. This should be done consistent with our Catholic moral tradition. Our Christian anthropology and moral tradition require us be distinctively focused on and recognized for our infertility treatment. But why has this not been the case?
A Recognized Public Health Concern
In June 2014, the Centers for Disease Control (CDC) published a National Public Health Action Plan for the Detection, Prevention, and Management of Infertility which outlines infertility as a public health concern. This Action Plan was developed in light of nationally representative data from the CDC which showed "that 6%, or an estimated 1.5 million U.S. couples, were infertile, meaning they were unable to conceive after 12 months of trying. Additionally, 12% of reproductive-aged women had impaired fecundity, meaning they had experienced difficulty conceiving or carrying a pregnancy to term during their lifetime."3 According to one analysis, a $3-4 billion industry that in large part centers on interventions such as IVF has developed to meet these needs.4 Yet, the need continues to grow.
To better address this need, the CDC Action Plan outlines three priorities:
- Promoting healthy behaviors that can help maintain and preserve fertility.
- Promoting prevention, early detection, and treatment of medical conditions that can threaten fertility.
- Reducing exposures to environmental, occupational, infectious, and iatrogenic agents that can threaten fertility.
These priorities are very broad but the message is clear: the secular world recognizes infertility as a social ill — a "crisis" even — just as much as it is an individual matter. However, in my experience, when discussion of infertility, and associated with matters pertaining to sexual activity like contraception, it usually takes place in terms of "act analysis" of individuals: determining whether a specific action is licit or illicit under the principles of the Catholic moral tradition.
While Catholic healthcare should find nothing objectionable about these CDC priorities in themselves, there would, of course, be a divergence regarding some of the methods proposed for remediation. The Ethical and Religious Directives for Catholic Health Care Services (ERDs) outline these.5 There is a distinctly Catholic approach to addressing the issue of infertility but it is usually understood in terms of proscribed individual actions to the neglect of social considerations. Why does our tradition (appear to) focus predominately on infertility in this way?
Theological Foundations
Sexuality is an intrinsically social reality. It is an inherent dimension of human life and is defined, primarily, through its relationship to the other sex,6 that is, sex is defined best by the telos towards which it is per se ordered: unitive procreation. Thus, the sexes, male and female, are always defined — and only fully intelligible — through their relationship with each other. The creation stories in scripture attest to the fundamental and pivotal the nature of this interdependent relationship — in the relationship of Adam and Eve, creation reaches its culmination, for together they are to exercise dominion over it. The fall led first to a broken relationship with the Creator, then to fracture is the relationship between man and woman. Whereas in truth each is "bone of my bone, flesh of my flesh (Gen 2:23)," their relationship is now characterized by self-assertion and dominating the other, instead of the harmony of original justice. This fractured relationship then spills out into the whole of human society.
It should therefore be no surprise that, in the redemption that Jesus won through his life, passion, death and resurrection, marriage is raised to the level of a sacrament.7 Here, God the creator and redeemer accepts the free invitation of the man and women to be a primary actor in the relationship precisely so that through his grace he is able to nurture a relationship of total self-gift, which moves it beyond original justice into Divine charity.8 Gaudium et Spes summarizes with these words: "The Lord, wishing to bestow special gifts of grace and divine love on [marriage], has restored, perfected and elevated it."9
It is only within this context that the logic of the Church's teaching regarding fertility becomes fully and manifestly evident. Here, I am speaking first of the Church's anthropological teachings and, secondarily the moral teachings which establishes that fertility is a gift given to an individual with a social purpose. Indeed, through this gift society comes into being. In short, the connections between the individual and the social whole are inborn and ineradicable precisely because of humanity's social nature. The Church summarizes this connectivity in its statement: the family is "the first and vital cell of society. [It] is a divine institution that stands at the foundation of life of the human person as the prototype of every social order."10
Reality-based Moral Guidance
With its established potency, the reproductive faculty lays out a track, what Karol Wojtyla calls a "vector of aspiration," that leads to human flourishing.11 Hence, we recognize the inclination and desire to find a spouse and have children as powerfully natural and dispositive.12 Given this innate desire and drive, infertility then is a source of great suffering for many married couples. The Catholic Church is deeply committed to help those who suffer in this way. It seeks to help in a manner that respects the dignity of all involved, including the nascent human being.13
Consequently, the Church distinguishes different kinds of interventions that are used to overcome infertility:14 those interventions that assist marital intercourse (e.g. corrective surgeries for endometriosis, hormonal medications to manage progesterone) and interventions that replace marital intercourse, which depersonalize and commodify human beings, treating them as raw material that can be stored, discarded, or destroyed.15
In other words, only interventions that address the reproductive health and function of the spouses, thereby assisting the husband and wife in marital intercourse, are consistent with their personal dignity, and the exclusivity and fidelity of their marriage. In contrast, interventions that substitute for sexual intercourse between a husband and wife, perhaps including third parties, would be not consistent with the moral identity of a Catholic health ministry.
Our understanding of human dignity holds that it is an injustice to violate the exclusivity and fidelity of marriage or to treat a human being as a mere object or a commodity. This is true for individual relationships as well as social relationships. As Sr. Talone suggests, practices like surrogacy and IVF represent an injustice on both the individual and social level. The surrogacy contracts that she describes clearly illustrate human commodification and the exploitation of vulnerable individuals. The social dimensions of this harmful practice are so clear that several countries recently banned the practice of surrogacy precisely for its exploitative nature.16 Given this, I argue that matters of sexuality provide one of the clearest examples for how the Church's moral teaching is indeed a 'seamless garment' — a social-life issue.
A Distinctive Calling
If reproductive matters are so clearly both individual and social, then what might explain a perception that the Church's teaching is exclusively focused on individual acts? One possibility might be perception and reaction to documents like Humanae Vitae.17 In this document, Pope Paul VI sets forth, from a natural law perspective, the Church's teaching on pursuing or avoiding pregnancy. This approach lends itself very easily to act analysis, i.e. making distinctions to apply moral principles amid varying concrete circumstances. Further, some felt that the teaching was too invasive into their personal, private lives. While the natural law approach is at the heart of our moral method, it can be seen as too "act centered," to the neglect of its social dimension. I believe that an exclusive focus on its 'act analysis' implications misses the bigger picture: Humanae Vitae is, fundamentally, Catholic Social Teaching (CST).
Most summaries of CST resources do not include Humanae Vitae among them.18 But I argue that they should. Indeed, documents that are unquestionably part of the CST canon, such as Gaudium et Spes, recount the same teaching.19 As mentioned, the subject matter itself is inherently and pivotally social. Further, Paul VI calls out the social ramifications that will result from the widespread adoption of contraceptive practices. In this regard paragraph 17 is particularly notable, as it speaks to the general tenor and character of relations between the sexes as well as the population control efforts of state governments that arise from the adoption of contraceptive practices.20 These claims are not just 'far-sighted'. They are simply spelling out the social dimensions of the teaching regarding fertility and what Pope John Paul II describes as a "contraceptive mentality,"21 which rends sex and procreation asunder, evacuating sex of meaning and reducing human beings — especially children — down to mere objects. This mentality, which does not recognize the inherent meaning and value of sexuality and fertility or the value of human beings, is a seedbed for further socially corrosive and harmful thought patterns, such as those that Pope Francis has denounced as a "throwaway culture" (in which human life, among other things, is not valued) and "ideology of gender" (which rejects the givenness and meaning of biological sex).22 Given manifest development of these socio-cultural ills, along with the concerns that Sr. Talone mentions, it is time for the Church and Catholic healthcare in particular to recognize Humanae Vitae (HV) for the value it poses as an element of CST and energetically promote it and the practices it inspires as such.
In my experience, one consequence of an overly narrow interpretive lens of HV has been that Catholic healthcare has generally been passive when it comes to infertility. For instance, Richard Fehring notes, "The Catholic Church and in particular the popes from Pius XI through Benedict XIV and Francis have called upon and pleaded with Catholic health care providers and Catholic institutions of higher education to provide NFP [Natural Family Planning] services, education, and research in this area of family planning."23 But, given its appropriate emphasis as an element of CST, HV calls the Church and its health care ministry further. We should adopt a dynamic, active, missionary approach.
For Catholic healthcare, I suggest this specifically entails developing robust mechanisms and service lines for treating infertility in accord with Church teaching. As Fehring highlights, "Many morally sound standardized and evidence-based treatments exist for women's health problems. They include medical and surgical treatment of endometriosis, medical and lifestyle treatment of PCOS [polycystic ovarian syndrome], medical and surgical treat of infertility that does not involve in vitro fertilization, and surgical and medical treatments for dysfunctional uterine bleeding…"24 Moreover, these options can be less costly and more effective than practices like IVF (which are often several thousands of dollars, requiring multiple rounds and not necessarily covered by insurance). Do only the wealthy deserve the ability pursue having children? Catholic teaching clearly says no. We have the answers to address the root cause of these significant social ills; all that is needed a collective, institutional will to help these practices and services advance and grow.
We are called to go out and encounter the suffering that arises from infertility of individual couples as well as the dehumanizing practices that have developed to treat infertility. The anthropology at the heart of the Church's teaching on sexuality and fertility provide a roadmap for the Church to go out to the margins, to the suffering, and help them heal and be restored, to first heal their wounds, as Pope Francis has said. This is not simply a calling to provide a "Catholic alternative" to people who want to pursue (or avoid) pregnancy. This is galvanizing our internal resources to minister to the deepest generative aspirations of human beings. This can in turn heal elements of the social order that tend towards exploitation and dehumanizing practices.
Conclusion
Because of it our social understanding of the person, fertility can be seen in its fullness as a social-life issue. Catholic healthcare therefore has a unique obligation on a social level. This means we cannot just not be passive, receiving the culture where practices like IVF dominate. Rather our commitment to social justice imposes an obligation address social conditions that contribute to or reinforce practices that dehumanize, objectify or commodify people, especially those are socio-economically vulnerable. Sr. Talone calls for fighting these practices at the level of public policy. I agree, and add that our approach must be multipronged. There are many ways that Catholic healthcare institutions can act towards this goal on a social level. I have argued that the best way to address the social injustices Sr. Talone identifies is through developing robust infertility services in line with Church teaching.
This should be a task of the whole Church. Today, this would include collaborating with the medical and scientific professionals that are advancing techniques and services for infertility that are consistent with Church teaching. It would also include helping lead public health initiatives that address factors that lead to infertility, e.g. sexually transmitted infections. By becoming a dynamic leader in infertility services, the Church can, in some small way, begin to heal the wounds of the culture as she is called by Christ to do.
1 Sr Patricia Talone, "First, Do No Harm: Ethical Questions About Ova Donation and Surrogacy," Health Care Ethics USA 25, no. 4 (2017): 1-7.
2 Brigid Ayer, "Bill to Expand Ivf across State Lines Advances in House," The Criterion (2018), https://www.archindy.org/CRITERION/local/2018/02-16/icc.html. (accessed March 23, 2018)
3 Lee Warner, Denise J. Jamieson, and Wanda D. Barfield, "CDC Releases a National Public Health Action Plan for the Detection, Prevention, and Management of Infertility," Journal Of Women's Health (2002) 24, no. 7 (2015), http://dx.doi.org/10.1089/jwh.2015.5355.
4 Amelia Josephson, "The Economics of Infertility," accessed. https://smartasset.com/personal-finance/the-economics-of-fertility. (Accessed 3/1/2018)
5 For instance, Catholic healthcare does not treat infertility with those methods proscribed by directives 38-42. United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, 5th ed. (2009), Cf. No. 38-42.
6 Elliott Louis Bedford and Jason T. Eberl, "Actual Human Persons Are Sexed, Unified Beings," Ethics & Medics 42, no. 10 (2017): 1-4. As Karol Wojtyla clarifies, "The natural direction of the sexual urge is towards a human being of the other sex and not merely towards 'the other sex' as such. It just because it is directed towards a particular human being that the sexual urge can provide the framework within which, and the basis on which, the possibility of love arises." Karol Wojtyla, Love and Responsibility (Boston: Pauline Books & Media, 2013), 49. In other words, the highest end of our sexual nature is complimentary love that is a holistic expression of the person.
7 Catechism of the Catholic Church (Collegeville, MN: The Liturgical Press, 2008), No. 1601.
8 Ibid., No. 1661.
9 Second Vatican Council, Gaudium Et Spes (1973), no. 49.
10 Compendium of the Social Doctrine of the Church (Washington D.C.: United States Conference of Catholic Bishops, 2007), No. 211.
11 "The sexual urge…is a natural drive born in all human beings, a vector of aspiration along which their whole existence develops and perfects itself from within." Wojtyla, 46. (emphasis in the original).
12 "Sexual inclination is something that humans share in common with all living beings, but it exists in humans in a more perfect way. It comes to fulfillment in marriage, which unites a man and a woman for life. It is not solely biological, even though this component is a characteristic feature of it. It engages the entire personality through the bonds of affection. We commonly distinguish two ends of marriage: first there is generation — the gift of life and education of children, who ensure the growth and continuance of the human species and is cultural heritage. Second, there is the love and mutual support of the couple. The two finalities naturally aid each other. One cannot be fulfilled without the other, for the law of love is gift and fecundity." Servais Pinckaers, Morality : The Catholic View (South Bend, Ind.: St. Augustine's Press, 2001), 103-4.
13 Catechism of the Catholic Church, Nos. 2374-79.
14 Congregation for the Doctrine of the Faith, Instruction Dignitas Personae: On Certain Bioethical Questions (2008), No. 12.
15 See Pope Francis on 'throwaway culture. Francis X. Rocca, "Pope Says 'Throwaway Culture' Harms Environment and Human Life," accessed. http://www.catholicnews.com/services/englishnews/2013/pope-says-throwaway-culture-harms-environment-and-human-life.cfm. (accessed 2/20/2017). This devaluation of human life in assisted reproductive technologies is recounted by Paul Conner, "Ivf: Mayhem and Murder--Well Disguised," Nova et Vetera 14, no. 2 (2016).
16 "As Demand for Surrogacy Soars, More Countries Are Trying to Ban It," accessed. https://www.economist.com/news/international/21721926-many-feminists-and-religious-leaders-regard-it-exploitation-demand-surrogacy. (accessed 3/1/2018)
17 Pope Paul VI, Humanae Vitae: On the Regulation of Birth (Glen Rock, N.J.: Paulist Press, 1968).
18 See, David J. O'Brien and Thomas A. Shannon, Catholic Social Thought: The Documentary Heritage (Maryknoll, N.Y.: Orbis Books, 2010).
19 See Council, nos. 49-51. It is noteworthy that in 1965 Gaudium et Spes no 51 articulates the same teaching on regulating birth (e.g. citing Casti Connubi) that Humanae Vitae would later reaffirm in 1968. However, historically, the reception of the two documents has been very different: GS was lauded as the great piece of social teaching that it is, while HV was received with great controversy.
20 Paul VI, No. 17.
21 Pope John Paul II, Familiaris Consortio (1981), No. 6.
22 Pope Francis, Ladauto Si (2015), No. 56.
23 Richard Fehring, "Fertlity Care Services," in Catholic Witness in Health Care: Practicing Medicine in Truth and Love, ed. John M. Travaline and Louise A. Mitchell (2017), 202.
24 Ibid., 191.
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