The complex ethical issues of assisted reproduction explored in reporter Liza Mundy’s new book, Everything Conceivable, (and reviewed earlier this week on this site) can make the abortion debate look outdated. ReligionWriter called up Mundy to discuss the new meanings of “reproductive choice,” the voice of religious leaders in answering these ethical questions, and what the U.S. can learn from the U.K. about encouraging public debate on reproductive technology.

ReligionWriter: What drew you to the topic of fertility medicine?

Liza Mundy: I came of age in the early 1980s, when reproductive rights was an almost defining ideological issue. The word “choice” really had one meaning: your position on what a woman could do with an unwanted pregnancy. I’ve written all my career about reproductive politics, including what turned out to be a controversial article about two deaf lesbian women seeking a deaf sperm donor, which introduced me to the field of bioethics. Then I wrote about how low-income people experience infertility in 2003 and learned how common infertility is and how hard people will work to have a child.

After that article I was having lunch with a reporter who was pregnant with IVF twins, and it was at that moment I realized the menu of reproductive choices had expanded enormously since I was in college. When you embark on infertility treatment, you face hard choices that scramble whatever preconceived notions you might had about the notion of choice.

RW: Do the questions raised by assisted reproduction make the abortion debate obsolete?

Mundy: I don’t think it will ever be obsolete in this country. In

England, people have managed to move past it. We don’t seem to be able to do that. As one reviewer of my book in England put it, the story has become “how the battle to achieve freedom to control conception gave way to a battle to conceive.”

RW: In your book, you suggest that some infertility doctors hide, in some sense, behind the mantle of “reproductive choice.”

Mundy: Of course there is a lot of variation among these doctors; some are very scrupulous, others less so. But yes, some have co-opted the concept of choice to justify making everything available, and leaving up to the patient important decisions like how many embryos to transfer [to the womb in an IVF cycle.]

RW: So what does the word “choice” mean now in the reproductive context?

Mundy: The concept is so widespread as to be meaningless. There was one moment during my reporting, when the director of a pro-life-oriented group called Snowflakes, which arranges embryo adoptions, talked about providing people with “as many choices as possible.” It was a beautiful example of how the pro-life and pro-choice positions become so intermingled on these issues.

RW: When you interviewed people who were facing hard choices — about whether to reduce a multiple pregnancy, for example, or a tell a child he or she was the result of gamete donation — did you find that many consulted with their religious traditions or leaders?

Mundy: I was at one fertility clinic, waiting to speak with a doctor, and I saw a woman, who was Catholic, cancel her appointment after talking with her priest, who advised her against being treated with fertility drugs. Of course the Catholic Church has more formal guidelines [on assisted reproduction technology] than most; they oppose IVF from the start as being unnatural and abrogating the realm of God.

I also talked to pastors who said in the course of their work people confide in them about the grief of experiencing lifelong infertility.

RW: In your book you talk with infertility doctors, patients, bioethicists and others who have thought deeply about the ethical issues of fertility medicine, but religious figures don’t appear much. Why is this? Are there no religious leaders up-to-date enough that they would have made an interesting interview?


Mundy: Yes, I would say so. I didn’t run across anyone who jumped out at me. A lot of official church bodies are being forced to grapple with reproductive technology now, most evidently in the area of stem cell research. They are trying to figure out how to think about the embryo, and some churches have weighed in.

RW: You describe how many couples are almost paralyzed by the question of what to do with their frozen embryos. If religious organizations all issued clear moral guidelines, would that help people make these tough decisions?

Mundy: People don’t always follow dictates of their church of course. The question is made more difficult because it’s so hard to donate embryos for research right now.

When patients go through this process, they become very attached to the embryos. It’s a very personal thing. So even if your church says it’s okay [to allow embryos to “lapse” or be donated for research or adoption,] that doesn’t necessarily mean it’s easy or it feels okay to you.

RW: Do you see a parallel here with descriptions of pro-life people who have, for whatever reason, found themselves seeking abortions? That personal experience can be so powerful as to override even religious belief?

Mundy: That’s right. What makes it so hard for people is that many if not all religions place a high value on family and family life. The Catholic Church might say IVF is wrong, but the church and the culture are simultaneously saying children are the greatest blessing. Those would be confusing messages to process.

I also talked to people who encountered religious prejudice. One woman used fertility drugs and conceived quadruplets, one of whom died and the other three of whom were disabled. She said sometimes when she went forth into her Texas community, people would say, “You got what you asked for in defying the will of God, because God intended you to be infertile.”

RW: Was there ever a moment in your reporting when you thought, “Maybe the Catholic Church is on to something in prohibiting IVF. Maybe we never should have let the genie out of the bottle?”

Mundy: No. What struck me most were the people who said, “No matter how hard it was, it was all worth it.” I don’t want to be Pollyanna-ish about it. There were certainly people, particularly with multiples, who said, “If I could go back and do it over again, I would do it differently.” But I do think it’s a good thing that three million children now exist who would not have existed if it were not for the science. I was trying to highlight the difficult choices, but I didn’t have the sensation that all of this is wrong or misguided.

RW: In one of your chapter titles, you call selective reduction the “best-kept secret” of reproductive technology. Why hasn’t the issue received more public attention?

Mundy: It’s not something people like to talk about it, if they’ve had a selective reduction. Unlike abortion, there are not strong advocacy groups mobilized on either side. The fertility industry really doesn’t want people knowing how often this occurs, and most of the doctors who perform it probably aren’t going to let a reporter spend time with them. But there is no shortage of medical literature about it. Just go onto Pub Med and type in “selective reduction” or “multi-fetal pregnancy reduction.”

RW: Does it strike you as odd how some fertility-related ethical issues — like partial-birth abortion for example — grab headlines, but other equally vexing issues — like selective reduction — don’t?

Mundy: It tends to come up when someone has, say, octuplets, or other high-order multiples, and it’s on the evening news. Sometimes the couple says, “We just couldn’t bring ourselves to do selective reduction.”

RW: Out of the many issues you discuss in the book, are there one or two you think are likely to become hot-button debates in the next few years?

Mundy: In this country, a lot of these debates are going to be carried out in state legislatures, because that’s where family law is made. Connecticut, for example, has voted for insurance coverage for IVF, and insurance companies can therefore limit the number of embryos transferred in IVF.

In the United Kingdom, there is a government agency to regulate assisted reproduction, and its decisions are often met with outcry and debate. You see assisted reproduction issues on the front pages of the newspapers there all the time. It’s just part of the public discourse. Whether or not people [in the U.K.] have been through fertility treatment themselves, everybody thinks they have a stake in these moral debates.

In the U.S. because [infertility treatment] is a private, profit-making branch of medicine, and it’s not regulated or funded in any high-profile way that would provoke an outcry, I don’t know whether the public discussion is ever going to crystallize. But something could always percolate up. Who knew that one of the first questions President Bush was going to have to deal with when he took office was federal funding for stem-cell research?

RW: So does the U.K. have it right?

Mundy: They have a more coherent policy than we do.

RW: Is that because they have a state-run health care system?

Mundy: After IVF first succeeded, in England, with the birth of Louise Brown, there were scientists who organized themselves and created charitable foundations to bring some coherence to the debate. They made a concerted effort to educate Members of Parliament, literally inviting them to look down microscopes at embryos. As one scientist told me, “That did a lot to persuade people that we weren’t making Frankensteins in the basement.” They made an effort to move the issue forward, and that doesn’t seem to have happened in this country.


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If you’re looking for a summer-reading book that will both keep you up late at night turning pages and give you a shopping-list-long set of often-heartbreaking moral questions to ponder, then run don’t walk to get Liza Mundy’s recent book, Everything Conceivable: How Assisted Reproduction is Changing Men, Women and the World.

While reporters have covered aspects of the ethical dilemmas posed by assisted reproduction technology, such as parents struggling to decide what to do with unneeded frozen embryos, or some people’s discomfort with gay men become parents through surrogacy, or, of course, the question of women delaying childbearing, Mundy appears to be the first to pull together these disparate social trends and scientific advances to give a big-picture look. And as she pulls the camera back for the wide-angle view, Mundy reveals a host of bedeviling questions, which she deftly illustrates with portraits of the real people who are wrestling with them. Here’s a sample:

Are parents who have children using sperm or egg donors obliged to tell these children the truth of their conception and genetic history? If you say no, consider this story Mundy relates: A D.C.-area single mom uses a sperm donor to conceive twins, then finds out the woman across the street from her is also pregnant with twins — from the same donor! These sets of twins, who are genetic half-siblings, could be in the same class at the same school: Do they have a right to know that their potential friends or even, at some point, mates are in fact related to them?

On the flip side, Mundy describes the situation in the UK, where sentiment favoring children’s right-to-know runs high; anonymous sperm and egg donation is now prohibited. This law, however, has had the effect of drying up gamete donations — meaning, as Mundy puts it, some children won’t be born as a result — and pushing UK parents to seek anonymous donors in Eastern Europe. (And the word “donors” here belies the fact that in many countries, including the U.S., women can earn thousands of dollars for donating eggs.)

Should there be a limit on how many embryos fertility doctors transfer to a mother’s womb in the case of in-vitro fertilization (IVF)? If you feel like you don’t know enough about the topic to make an informed decision — well, that’s how many IVF-treatment parents feel when their doctor gives them five minutes to make the decision to implant one, two, three or more embryos.

The risk involved? A multiple pregnancy can seriously endanger the lives of not only the fetuses but the mother herself. Because would-be parents usually have to pay for expensive IVF cycles out of pocket, however, the pressure to transfer multiple embryos is intense. The result? A skyrocketing number of multiple births and a relatively new procedure known as “selective reduction,” in which a doctor ends the life of one or more fetuses to protect the lives of the remaining fetuses.

Mundy’s chapter on this topic, “Deleting Fetuses: Selective Reduction, ART’s best-kept secret,” is perhaps the most disturbing, as she follows several couples forced to choose between keeping all three or four fetuses — and running the risk of losing them all — or eliminating one or two of them. (A condensed version of this chapter also appeared recently in the Washington Post Magazine.) Mundy describes how one doctor decides which fetuses’ hearts will stop beating on the basis of their genetic health, position in the womb, or — gulp — sex.

It is a Sophie’s Choice nightmare to contemplate, especially when we read one parent’s comment that selective reduction is harder to deal with after the surviving fetuses/children have been born. Said one mother who had reduced her triplet pregnancy to twins: “You think: I could have ended up with one of these being gone, and the one that is gone could have been one of these.”

These are just several of the many dilemmas Mundy’s book raises, and while she offers no easy answers, she says the first step is clear: There needs to be a louder, more public debate on these complex moral issues.  Her book is a perfect place to begin.

Coming Wednesday: ReligionWriter interviews Liza Mundy on whether the ethical questions of assisted reproduction technology make the abortion debate is obsolete, and how religious leaders are struggling to keep up.



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