Friday, September 15, 2017

Why is IVF wrong? (Major Premise)

Img credit: Mr. J Conaghan, Wikimedia Cmns
Recently a very articulate medical student, with the mind of faith, asked about the Catholic doctrine oHumana Vitae's prohibition of contraceptives. Why can't infertile couples have the procreative aspect of sex using a medical procedure? Isn't this being open to the procreative aspect? The difference in time (if having the procreation through IVF) is not willed by the couple. Isn't this the same or better than leaving one component entirely missing through a failing of nature?
f conception, asking why the Church does not permit artificial reproductive technologies or techniques (ARTs). The student accepted that sex is unitive and procreative and meant for marriage; moreover, the student agreed with

I really love hearing from medical students who are seeking understanding in the mind of faith. As the student pointed out, an infertile or subfertile couple does not disobey God's law by having sex, even though there is a disorder inhibiting the fruits of the procreative aspect. But the reason why the Church teaches that IVF is wrong is that sex is the only act which is legitimately procreative, the only way we are meant to conceive. We can syllogize to this conclusion with two premises. The major premise is that ARTs are not sex.*

Img credit: Cancer Research UK, Wikimedia Commons
Let's establish an analogy between sex and eating. Eating has two aspects, the gustatory (analogous to unitive) and nutritive (analogous to procreative). One is the enjoyment of food that only a rational creature can have, while the other is an important but more biological motivation. Just like infertile or subfertile couples, some people can't taste very well or can't taste at all, but that doesn't make eating wrong for them. I propose an imaginary neck cancer patient who physically has trouble eating and has a tube placed through his skin and into his stomach (a PEG-tube or G-tube). He tastes nothing, but he stops losing weight and he's receiving appropriate nutrition through tube feeds.

I thought it was interesting that the student called ARTs (e.g. IUI or embryo transfer) "procreative acts" in the original question. This is exactly right! These things can lead to babies, so they're procreative acts. But they are not sexual acts: they are professional, medical acts without foreplay, climax, orgasm, etc. Our G-tube patient gets liquids pushed through his tube (a nutritive act), but he's not eating. Medical parlance and common sense reflects this: we won't say "he's eating" until he's using his mouth. G-tube feedings aren't eating; ARTs aren't sex or sexual acts.

Moreover, ARTs cannot be aspects of sexual acts. When our G-tube patient starts a tube feed, he's nourishing himself, but he's not doing "the nutritive aspect of eating." He's not eating at all, and he can't complete aspects of one action while doing a related but separate action. Similarly, if an infertile or subfertile woman has an IUI, she may be procreating, but she's not doing "the procreative aspect of sex." They are separate acts and one's intention to view the acts together do not knit them together. ARTs cannot be viewed as aspects of sexual acts.

The minor premise, "All conceptions must occur through sex," is defended in the next part.

*By "sex," I mean heterosexual sex using reproductive organs, not oral or anal intercourse.

Wednesday, August 30, 2017

Quaeritur: Postpartum LARCs and mental illness

I was recently asked:
I recently looked up your article about encouraging a LARC for a drug addicted patient and your subsequent examination of conscience. I have a 27yo G2P1 bipolar patient with current benzo/meth/etc addiction who's 32 weeks and planning on getting a tubal ligation. I did not disagree with her decision, and was considering the morality of this. Did you ever find a conclusion to this "absurd state" of using contraception for those in addiction or mentally impaired patients (mental retardation, schizophrenia, etc)? Did you find any Catholic discussion regarding this? Humane Vitae and the discussion in Catholic Health Care Ethics book all are geared towards a typical person.
 Okay, let's take this apart. I want to say first that I did not encourage that patient in my blog post down any particular path. I never discussed postpartum family planning with her because we were always trying to ground her in the reality of her pregnancy and in circumstances surrounding her safety. It was only after my attending made a comment about contraception and I went to a St. Louis CMA guild event on LARCs in the mentally handicapped that I started to think about HV's possible limitations. (There's a post about that one, too, which you've probably seen.)

There is no good answer that I can find on this issue. The best that we came to at the guild event was temporary sterilization with filshie clips, but the Church is clear that not even temporary sterilization is acceptable. There are a few sets of articles from the Linacre that touch on it (from most to least relevant):

The articles that overtly deal with contraception in the mentally disabled adult or adolescent:

  • Contraception for the Mentally Disabled: A Contraceptive Act? (Napier, 2013)This paper argues that in certain circumstances, a Catholic institution that cares for disabled persons can ensure that some of them conform to a temporary sterilizing intervention. The argument proceeds by observing that the Church permits temporary sterilizing interventions for rape victims, because such interventions are not contraceptive acts, but rather, acts of defense. For similar reasons, some mentally disabled persons cannot consent to sexual intercourse and since rape is defined as unconsensual intercourse, some mentally disabled persons are proper candidates of temporary sterilizing interventions. These interventions do not count as contraceptive acts either. This is the case even if the disabled person in question desires the intercourse. This is so because consent is an intellectual act and desire is a passion. Desire does not entail consent. Although the conclusion reached may look "liberal" or "heretical" the argument shows that it is consistent with firm Church teaching.
  • The demands of human dignity: Sexuality in the young person with intellectual disabilities (Fernandes, 2014)The topic of sexuality among the disabled is often ignored within Catholic seminaries; within pediatrics, it is treated as a “problem” where the best solution is contraception or sterilization. In this article, the authors argue for an approach to sexuality in disabled youth that is grounded in the inherent dignity of the person, borne out of Christ's own humanity. Because sexuality is a part of the human person in his or her totality, it cannot be ignored or obscured; on the other hand, it cannot also be the overriding “problem” which defines them. Rather, by friendship, love, and covenantal solidarity with the disabled person, we can begin to set an example for them and for society that there are goods to be strived for beyond the physical. The demands of dignity require practical changes in seminary and medical education and practice.
  • Contraceptives for Victims of Rape and for the Mentally Disabled: A Reply to Stephen Napier (Tollefson 2013)In this paper I argue for the following claims. First, contraceptive acts are intrinsically wrong, and not merely always wrong within the marital context. Second, in consequence, the defense of the administration of contraceptives in case of rape must be understood under the rubric of the principle of double effect. Third, the existence or threat of rape is therefore not a sufficient condition for the permissible administration of contraceptives; the intention must be upright. Fourth, in the case as described by Stephen Napier, the intention with which contraceptives would be administered is almost certainly contraceptive; thus this administration would be an instance of an intrinsically evil act. Recognition of why this is so is the key to understanding why, despite a prima facie agreement, as noted by Napier, between his own position and that of Germain Grisez, there is nevertheless a rather deep disagreement. I articulate that disagreement, and indicate why I believe the question has not been fully resolved by Napier's essay.

The use of hormones in sexually active patients

  • No Justification for Using IUD to Treat Menorrhagia (Raviele)
  • The Mirena® Levonorgestral-Releasing Intrauterine System and Its Application to the Treatment of Menorrhagia: A Moral Opinion (Mulligan)
  • Levonorgestrel in cases of rape: How does it work? (Raviele 2014)
  • Does levonorgestrel emergency contraceptive have a post-fertilization effect? A review of its mechanism of action (Peck et al, 2016)
  • Mechanism of action of levonorgestrel emergency contraception (Kahlenborn et al, 2014)
  • Appreciation for analysis of how levonorgestrel works and reservations with the use of meloxicam as emergency contraception (Schneider et al, 2016)

The HIV/condom debate

  • “Validity” and “liceity” in conjugal acts: A reply to Stephen Napier on the HIV-condom debate (Arias)
  • Condoms and HIV: The State of the Debate (Newton)
  • The Missing Premise in the HIV-Condom Debate (Napier)
  • Condoms and AIDS: Is the Pope Right or Just "Horrifically Ignorant"? (Wills)

Question used with permission.