ARTICLE

Today's Christian Doctor - Fall 2002

The debate over the status of pre-born humans has become clouded due to the redefinition of certain terms over the past few decades. Biological advances, including the destruction of embryos to obtain embryonic stem cells have also heightened the ethical dilemma.  However, human life remains worthy of protection from the moment of its individual uniqueness-fertilization.

• A woman in Houston drowned her children one-by-one. The nation was shocked. She was convicted of a crime.
• A teenage couple delivered their child in a public toilet, discarding it to die. Again, most of us were shocked. The couple were convicted of a crime.
• A woman decided to terminate her 30-week pregnancy because the anticipated stress of raising another child was too great. Her New Jersey doctor suctioned the contents of the cranium through the base of the skull just prior to delivering the infant in breech position. No law was broken. Well over a million abortions are performed each year in this country.
• Bill and Karen have five live-born children from three pregnancies. The first pregnancy was accomplished via in vitro fertilization. The next two pregnancies that followed within two years were total surprises. Bill and Karen also have ten other children-frozen embryos awaiting the chance to be implanted and born…a promise their parents plan to keep, even though discarding embryos is legal.
• Sam, my seat partner on a recent flight, told me that he supports any research on human embryos and clones if it holds even the slightest chance of curing his diabetes. He is not concerned about the loss of human life, because it is "too early to give it consideration."

Life, "lif'.

1. the quality that distinguishes a vital and functional being from a dead body
2. an organismic state characterized by capacity for metabolism, growth, reaction to stimuli, and reproduction

per son, "per-son".

1. human
2. individual

Merriam-Webster On-line (http://www.m-w.com)

What is the common thread to these stories? Each involves early human life, most within a few months of fertilization. And except for the story of Bill and Karen, these accounts also involve death. Some legal-some not. Some shocking to our culture…and some not.

For nearly 30 years our culture has permitted the taking of unborn human life. In recent years we have raced up a hyperbolic curve of advances in knowledge and technology that have expanded our ability to manipulate the course of early human life.

Despite the significant moral and ethical implications of these activities and capacities, there remains no societal consensus on when life begins-hence, no consensus on when respect for and protection of human life should begin. At the root of this dilemma is our failure to define the early boundaries of life and personhood. I approach this dilemma by asking the question, "When do you become you?"

Remembering George Orwell's warning that those who control the language control the debate, we should begin by understanding certain terms used (often wrongly used) in the scientific and public debate of this issue. An example of the confusion was found in a personal poll I conducted of my colleagues. Nearly all were unaware of the distinction between fertilization and conception.

Nor were most aware of changes to scientific terms used to describe early life- changes that have occurred since many of us learned them in medical and dental schools.

So what is the relevance of this new vocabulary? Using these definitions, medical writers make claims that certain interventions do not affect "embryos," nor do they cause abortion (e.g., literature used in the promotion of post-coital hormonal contraception). If such distinctions escape the notice of physicians, even more so, our patients are unaware. Many are left with the impression that certain contraceptive products have no effects on early development after fertilization.  He net effect is deception, even if not intentional.

While not admitting that "pregnancy" is affected, scientific studies continue to cite that many contraceptive technologies affect post-fertilization, pre-implantation embryos. Recent review articles on post-coital hormonal contraception and intrauterine devices (both used as "emergency contraceptives") document that these modalities have post-fertilization effects (i.e., they affect pre-implantation embryos).^1,2 Moreover, the practice of in-vitro fertilization has resulted in the production, even over-production, of pre-implantation embryos.³ Unused embryos are commonly frozen for potential later use. Conservative estimates place the number of frozen embryos in the United States at 100,000.⁴ As these frozen embryos are deemed unnecessary, most clinics destroy them by allowing them to thaw.

More recent biological advances like the destruction of embryos to obtain embryonic stem cells have heightened the ethical dilemma about how we manipulate early human life.⁵

Are pre-implantation embryos less important than embryos? Are they less important than fetuses? Than children? Are they less sacred? Are they less deserving of protection? Are they without personhood? Less valued by God? Is there not some demarcation on the continuum between fertilization and birth that might convincingly define the beginning of human life so that we might grant it the legal and moral status of a person?

Unfortunately, I am not smart enough to know. And I am not sure how anyone, through intellect or intuition, can know.

At a medical conference I attended, a well-known obstetrician/gynecologist diverted from his topic to show a series of slides. He began with the sperm and the egg, and then showed the zygote, morula, blastocyst and stages of development up to the third week. Of course, none of these early stages had the appearance of a human form. After each slide, he paused and rhetorically asked, "Is this a person?" While he did not verbalize an opinion, his obvious implication was that these early stages of human development have no claim to personhood. As he transitioned back into his lecture topic, I interrupted him with this question, "Doctor, would you please start with a newborn baby, work backward in its development, asking the same question?" His awkward response was that we did not have time.

But we must make the time!

Science, the courts and culture have attempted to draw rather arbitrary lines on the spectrum of human development to mark when "life" and "personhood" begin. Sadly, the lines have changed over time as we find self-serving reasons to do so. And because early cellular stages of life are abstract in form, they are easily disregarded as persons. Humans have a history of discriminating against those who look different from us.

Left without a moral paradigm for making these important decisions, we have shifted the definition of life and personhood to suit the prevailing opinions or goals of those making the decision. Some argue the line should be drawn at fertilization, some at implantation, some much later. These shifting sands have allowed legal protections to wither to the point that fetuses capable of life outside the womb can now be killed just inches away from birth. Some have even used consumer rights arguments to suggest that if a baby happens to be born before a partial birth abortion is completed, the consumer should not be denied her right to the desired outcome for which she bargained (death)! Further, one Princeton professor advocates allowing parents to decide weeks after birth whether they will allow their baby legal and moral status-i.e., life!⁶ In essence, this becomes a "satisfaction guaranteed, 30-day return policy!"

But back to the question, "When do you become you?" Can we leave the answer for a parent to decide a month or more after giving birth? Can we trust ourselves to be wise about such decisions months earlier? Robert Spitzer, President of Gonzaga University, has offered a simple proposition: "…err on the side of assuming and according personhood to every being of human origin."⁷ From this perspective it seems reasonable to conclude that personhood begins at the very moment of individual uniqueness-fertilization. This event marks the appearance of a new living cell having a separate genetic identity. Even with the risks of miscarriage, the natural destiny of this cell is to become a newborn baby-a child-an adult. Should immaturity disqualify an embryo from respect and legal protection?

Our senses are rightly shocked when we hear that a mother has killed her children. Why should we be less concerned when that life is a few months younger? And why should location matter? Should being in a fallopian tube, a petri dish or a mother's womb result in loss of moral status? On what moral justification can "the line" be drawn at a point later than fertilization? Can we be certain beyond a reasonable doubt that God would find that argument acceptable? Should not the standard of "reasonable doubt" also be applied to this life and death decision? The question is not about innocence, it is about existence.

No doubt the world would be less complicated if we could be sure that life and  personhood begin sometime after fertilization-perhaps after conception-or even later. We would not have to worry about IUDs, hormonal contraception, harvesting embryonic stem cells, making "therapeutic" clones, or maybe even performing early abortions.

As I said, I am not smart enough to know that you "became you" or that I "became me" at some time after fertilization. As long as it is possible that God cares about pre-implantation embryos, I am deter-mined to do the same. Did He not care for you and me when we were that age?

Notes:
¹ Spinnato JA. Mechanism of action of intrauterine contraceptive devices and its relation to informed consent. Am J Obstet Gynecol 1997;176:503-6.
² Trussell J, Raymond EG. Statistical evidence about the mechanism of action of the Yuzpe regimen of emergency contraception. Obstet Gynecol 1999;93:872-6.
³ Foubister, Vida. "Extra embryos: What is their future?" AMNews. 13 Nov. 01. http://www.ama-assn.org/sci-pubs/amnews/pick_00/prsa1113.htm.
⁴ http://www.nationalpost.com/home/story.html?f=/stories/20010.
⁵ Albert, Tanya. "Stem-cell research divides doctors along with country."  AMNews. 6 Aug 01.
http://www.ama-assn.org/scipubs/amnews/pick_01/prl10806.htm#rbar_add.
⁶ Singer, Peter. "Taking Lives: Human." Practical Ethics, 2nd Edition, Cambridge, 1993. http://www.petersingerlinks.com/taking.htm
⁷ Spitzer, Robert J. Healing the Culture. San Francisco: Ignatius Press, 2000: 54.

Terms in Current Use:

Fertilization is the union of the egg and the sperm, normally occurring in the outer third of the fallopian tube. Conception is a bit more confusing. While some medical dictionaries and references define it as either fertilization or implantation,^1,2 most define it as "successful implantation of the blastocyst into the lining of the uterus."³ While fertilization may occur within an hour after sexual intercourse, implantation takes place days later. The fertilized ovum is called a zygote. While still in the fallopian tube, it begins dividing into the morula (up to 16 cells) and then the blastocyst (a sphere of cells at approximately day four or five). Transport through the tube into the endometrial cavity takes three to five days. During these stages, we can call the conceptus a pre-implantation embryo. While short-lived, this pre-implantation phase is significant to our view of when life begins.

Contraception is defined as the "prevention of conception" (note that there is no mention of fertilization).⁴While contraception is commonly thought of in terms of products that reduce the chance of fertilization, by definition and practice, it includes products that prevent the development of pre-implantation embryos. This distinction is significant for those who believe life begins at fertilization. Said another way, contraceptives may act on sperm, ovum, their ability to unite and / or on pre-implantation embryos.

The term embryo is defined by the American College of Obstetrics and Gynecology as beginning "about two weeks" after fertilization and continuing through the eighth week after fertilization.⁵ ACOG uses the term "pre-embryo" (not to be confused with my use of the term pre-implantation embryo) to refer to the first two weeks after fertilization. Adding to the confusion (deception?), the current literature typically does not include the pre-embryo phase as being part of pregnancy.^4,6 By the ACOG definition, the two-week "pre-embryo" phase continues until nine to eleven days after implantation (conception)-but is still not considered a pregnancy.

¹ Merriam-Webster Medical Dictionary, http://www.intelihealth.com?IH/ihtIH/WSIHW000/9276/9276.html?k=tnavx408x9276.
² On-line Medical Dictionary, http://www.graylab.ac.uk/cgi-bin/omd?action=Home&query=.
³ Stedman's Medical Dictionary, 27th Edition.
⁴ Merriam-Webster Medical Dictionary, http://www.m-w.com/cgi-bin/dictionary.
⁵ ACOG Clinical Opinion #136, April 1994.
⁶ "Is emergency contraception the same as RU-486, the 'abortion pill'?" The Emergency Contraception Center. 1998 Gynetics, Inc., http://www.preven.com/emerg/01-03.html.