"IN VITRO FERTILISATION AND RELATIONAL ETHICS", par Luc Roegiers (colloque Santorin, 1999)

Medical aid for procreation has entered into our habits. This is one of the most salient observations issuing from my daily practice as a paedopsychiatrist associated with an in vitro fertilisation unit. Moreover, we have passed from "ethos" to ethics: couples requesting IVF, as well as the practitioners hardly ever question themselves anymore on the legitimacy of what has become just another medical technique. The benefits observed seem to have largely compensated the price to be paid. But are we able to analyse at the present time all the aspects of this price? The presence of a medical team in the marital bed poses multiple questions.

The two parts of my exposÈ will consist of the following : first of all, based on my clinical experience in IVF and with the help of some clinical observations I shall define a triple crisis: that of gynaecology in reproductive medicine, that of the infertile couple and that of the psychotherapist associated with this field. Then, after having specified the ethical stakes of these crises, I shall describe some aspects of the relational ethics of Boszormenyi-Nagy. It is a particularly enlightening model, not only in the field of medically assisted procreation, but in the broader framework of all perinatality.

Crisis in IVF

1 - What responsibility for the gynaecologist?

As for gynaecologists of assisted reproduction technology, can we really speak of a crisis? Not in the measure that the majority of them master their technique better and better, which has become a routine; and for the rest, that is to say the ethical guideposts, they are based on traditional criteria which are the beneficence, the respect of the patient's self-determination and the principles of justice. However, practitioners who analyse their functioning in a more pointed and critical way are often confronted with difficult and at times undecidable situations. These situations place them face to face with dissonances in relation to the principles of medical ethics which are familiar to them. Here are several examples :

* Beneficence

Mrs A associates two medical problems : multiple sclerosis with moderate manifestations at present and an anomaly of the uterine cavity due to the D.E.S. taken by her mother during pregnancy. Previously - and painfully - she and her husband had grieved over a pregnancy project. Then her gynaecologist proposed to her the IVF programme. After seven attempts she was pregnant with triplets. Her pregnancy was reduced to twins which she brutally lost at 24 weeks. She begged and succeeded in rapidly recommencing IVF attempts. But this time without result. Mrs A becomes depressed. Her husband became angry and cried out during a consultation "You think that I'm going to continue to live with an impotent and sterile woman?". One cannot say that reproduction medicine really helped this couple. In talking to the IVF patient, the gynaecologist deemed his position doubly defendable by medical indication and by the total commitment of the two spouses to this project. Obviously, the principle of beneficence envisioned in this way can become a trap. Numerous other less caricatured situations than this one daily confirm how hazardous it can be for a doctor to advance along the delicate terrain of the desire for a child with a compass as unwieldy as the wish for beneficence.

*Self-determination

In the course of the preliminary consultation for the couple in the IVF programme, the gynaecologist is troubled by the attitude of his patient, a bit distant from her partner. Although she had requested IVF, she appears by her body language to mean the opposite of what she is saying. Called at a later date to a private consultation by the gynaecologist, she confirms to him her refusal of any attempt at procreation. She is afraid of this violent man who has constrained her to participate in the IVF programme. The only way to escape, she says, is to obtain a false diagnosis counter-indicating IVF or to out and out sabotage the attempt. Faced with this couple dynamic, how is one to respect the principle of self-determination? In imagining the interests of each one : those of the woman, the man and their future child, one cannot but observe conflicts among them. How to clear them up?

How many couples in a generally more discreet fashion have their procreative divergences arbitrated by a medical team?

Hesitations or tensions sometimes show themselves in a non verbal fashion. A woman arrived one morning inebriated for her oocyte ponction. What of self-determination in this type of situation?

*Justice ?

Finally, the gynaecologist wishes to offer access to his technique to all couples without discrimination. He desires to avoid all paternalist selections and to appear fair. When it is a question of treating a patient, the Hippocratic oath forbids him to take into consideration certain particularities regarding the patient. Thus, a cancer of the cervix must always be treated in the same way; the fact that the woman might have psychological, sexual, financial or marital problems...this cannot change anything.

But when the so called "therapeutic" intervention is supposed to permit the gestation and arrival into the world of a child, is the same attitude still applicable? Certain gynaecologists believe that their role is limited to placing a tool at the disposition of their patients without distinction. Thus, according to them, donor insemination could be applied to the single woman or a homosexual couple; intraconjugal insemination would be a medical option for the couple devoid of any sexual life, the schizophrenic background of a woman requesting IVF or her dependence on psychotropes would not have to interfere with her integration in the programme; the fact that a spouse spent ten years in prison for serious paedophilic practices would be a strictly personal anecdote in the couple's history; the same when four children have been placed in foster care by the juvenile court and their mother with a tubal ligature requests a new opportunity with IVF. Are these serious situations marginal? In my experience they are far from exceptional. The fact of refusing to envision in these cases the consequences of medical assistance for reproduction, in particular for the child conceived, appears to me a destructive attitude. Legal regulations appear to be only little adapted to the diversity of these cases. There remains then the gynaecologist's reponsibility. But if he begins to refuse certain couples,where will he place the limit? Is he not proceeding to a de facto selection of his patients? And what is his actual competence to decide that this or that person is apt for parenthood?

2 - IVF : a trap for couples?

The point of view of the patients is just as problematical.

Access to IVF is an opportunity, without doubt. But several types of situations attest that couples requesting IVF are at times in crisis because they are submitted to certain constraints which restrict their autonomy. These can take several forms.

*Pregnancy as "treatment"

A pathology such as endometriosis is a cause of a growing proportion of infertility cases, in the order of 10%. There is no definitive cure which could impede the risk of relapse; so the lesions are symptomatically treated and the affected women are told that a pregnancy might be beneficial. This is not false; but an ambiguity then arises : Is IVF undertaken in these cases to treat the illness? And is the child expected as a medication? In certain endometrioses which have spread to the genital or intestinal sphere I have realised just how much the therapeutic stakes of a medically obtained pregnancy were a source of pressure and stress. It is even more true as the treatment itself which includes ovarian stimulation is unfavourable for the evolution of endometriosis. An extra risk is thus taken. This precise case of endometriosis is perhaps metaphorically exemplary of a much more general expectation in IVF : that of being cured of ones infertility by means of a pregnancy. This hope is not only uncertain but illusory in the measure that a process of mourning is necessary in order to accept this state.

*Multiple pregnancies

What to say of the paradoxical risk of multiple pregnancies? The majority of couples accepts this possibility if it is the price to pay in order to conceive at least one child. But numerous people desirous of IVF are overwhelmed by this perspective which has become more and more difficult to assume socially. A characteristic reflection which I regularly hear is this: "Will the gynaecologist ask our opinion about the number of embryos to be transferred?". This insecurity introduces very well the following point.

*Dispossession

IVF couples have no choice : they must trust the practitioners. They often ask me during preliminary consultations if a maximum of precautions will be taken for "their" embryos. They fear errors, distractions which would be catastrophic for them. One day, a couple asked me if they could spend the night next to their embryos. By all the evidence, a loss of control is experienced in IVF the moment the gametes are picked up. This experience is all the more painful in that it follows the loss of control already felt following the diagnosis of infertility.

*Secondary effects of treatment

Feminists pointed out more than ten years ago the sum of manipulations, pain and other inconveniences endured by the woman in IVF. The "thou shalt give birth in pain" has been duplicated by a "thou shalt conceive in pain". And one should add "in anguish as well". For incertitude still characterises IVF despite all its progresses. Today we hardly dwell at all any more on what was termed recently "the obstacle course". The commonplace nature of the technique has led to the commonplace nature of its inconveniences. And for the man? No movement of male defence has pointed out the degrading aspect for the man to have to masturbate on command practically in the presence of the medical staff. This exercise is all the same resented, particularly by men already destabilised by their infertility. They have no room for error and produce their sperm with more stress than libido. And as one might expect, the compatibility of inconveniences reflects on the climate of the couple in a link with the causes of the infertility: who is the most responsible and who suffers the most...

*Affirmation of the desire for a child

Much more insidious is the necessity for those requesting IVF to have to present their desire for a child without any ambivalence. Psychoanalysts such as Monique Bydlowski have shown the complexity of the desire for a child, which, besides, is to a great extent unconscious. Discontinuing contraception is far from involving the couple in the same measure as participation in an IVF programme. In the latter case, the couple must clearly formulate a request which in natural conditions often remains imprecise and in all cases progressive. We say "we'll see when it happens". In IVF it is not known either when the child will come. But it is known in principle, if one renounces the programme, one renounces the child. The desire for a child is continually and consciously in question. The motivation necessary to surmount the obstacles of the technique hinders one from sheltering comfortably in ones ambivalence. And what of outside opinion? Everyone knows that reproductive technologies exist. Infertility is no longer an excuse for the absence of progeniture. He who desires the end desires the means, this is the message which at times assails the spouses, the families and in-laws, friends, the professional world or the neighbourhood. In a certain way, reproductive technologies impose themselves on infertile couples. They permit no hesitation.

*The responsibility of a "normal healthy" child

Finally, and it is not the least of all the enumerated tensions, the child expected with such difficulty must be a success. People have often spoken in a pejorative manner of what has been called a desire for an ideal child. In fact, everyone carries inside, generally unconsciously, such a desire. The infertile couple does not seem to me to expect a more ideal and perfect child than any other couple. But they want a child without problems, a a normal healthy child. Perhaps a child who can repair the suffering, at times their childhood wounds reactivated by infertility and by all the frustrations related to the treatment.

It is necessary here to insist on the fact that at the heart of technology and medical mastery, couples imagine, erroneously moreover, that at least their efforts will have served to enable them to select a normal healthy child. For many of them, it would be very hard luck, that after so many quality controls that they would be given a bad embryo. And more subtlety, they feel, much more than other couples, responsible for the integrity of this child because they have truly wanted and asked for it. That begins at the embryo transfer. They are told : "here, your embryos are there" and sometimes even "Madam, you are pregnant". Between the lines : "we doctors have done our work, it's now your turn". And at that moment develops the at times overwhelming feeling of responsibility. How to behave, what to think of to give the embryos the best chance, and to assure them a normal development? The perspective of a handicap is for infertile couples particularly unbearable and guilt inducing. If the pre implantation diagnosis were accessible to them, they would most likely ask with insistence to see it, even in the absence of risk factors.

The crisis of IVF seekers and the pressure which weighs on them are thus not only related to infertility. The specificity of the treatment is also in question. How could these infertile persons avoid in IVF an alienating experience damaging to their mental health, to the equilibrium of their couple, perhaps to the building of their family, and to their child exspected as a "repairer" ? Here is an ethical question which to me seems too neglected in IVF.

3 - What reference model for the psychotherapist?

Ten years ago I proposed my collaboration as a psychotherapist paedopsychiatrist with the IVF unit of the St Luc clinics of the UniversitÈ Catholique de Louvain. I inaugurated a systematic preliminary consultation for couples seeking IVF. In effect, it is the occasion for them to step back, reinvest their project for a child, to list their expectations. Consequently, couples wishing to be accompanied or a deeper reflection recontact me at their own initiative.

This formula, which has been well accepted by my colleagues, has proved conclusive. But it poses multiple questions concerning my positioning as a psychotherapist.

In fact, the psychotherapist is integrated in procreation medicine because his somatician colleagues realise very well the affective and relational dimensions of this treatment. These dimensions are obviously determinant in most of the crisis situations which I have enumerated. The psychotherapist is supposed to solve them. But there also appears a trap: it would be perverse for the psychotherapist to assume as a subcontractor the human aspects of a process of which the gynaecologist would only be in charge of the technical aspects.

Moreover, by his training and specificity, the psychotherapist brings to procreation medicine another interpretation, a critical reflection. But his own position is subject to caution: what is his theoretical model? If he is a behaviourist, he will have a tendency to decondition the IVF seekers from their anxiety. If he is a psychoanalyst, he will question the deep sense of skirting by medicine the "infertility" symptom. If he is systemician, he will be tempted by a strategic intervention when faced with certain conjugal dysfunctioning.

Personally, I have thought that without renouncing one's basic identity, one should as a psychotherapist seek a model which meets the complexity of clinical situations. Furthermore, the crisis contexts which I have enumerated are often broadly irreducible. No psychotherapist can pretend to resolve problems in the place of those confronted with them. But in order to aid doctors as well as couples to forge a path through the procreative project, he must be able to refer to a framework which at the same time allows the prevention of possible damage but also the appearance of relational resources. In this way, the path followed by IVF seekers pay become less painful, less obscure and at times less absurd. The issues belong to mental health but also to ethics.

This is what has led me to take into consideration the Boszormeyi-Nagy model which favours what he terms the "dimension of relational ethics".

Relational ethics : reference and resource framework

It is illusory and somewhat arduous to schematically present an approach such as Nagy's. I shall nevertheless try to sketch in several aspects and to specify their adequation in procreation medicine.

*A multidimensional approach

My analysis of the daily running of medical aid to procreation underlines first of all the complexity by its crisis peaks. The interest of Boszormenyi-Nagy's model is that it reminds us that no act, no human position - especially not when it concerns procreation - can be understood by the simplification of a sole approach dimension. Nagy's model envisions four dimensions :

The first dimension includes facts, that is to say the givens which are imposed on us unilaterally in our existence such as our biological equipment or the events and culture in which we are immersed and which determine us. I wish to recall here how important it is for every individual who suffers, in particular in the context of an infertility to be recognised for the burden which he bears : a burden he has not chosen and of which he must bear the consequences. This is not a question of feeling, such as compassion, but simply a portrait. No reliable relation can be built without this "partiality" offered to the interlocutor. Many psychotherapists and other carers have a tendency to forget it. Too often today we think "He asked for it, she wanted it that way, they should ask themselves about the cause of their troubles etc.".

The second dimension, that of psychology or psychoanalysis, recalls that beyond facts, there is also a world of affects, representations, and projections. To consider the desire for a child independently of its intrapsychic bases would be a simplistic and disrespectful attitude. Besides all desire related medicine goes astray when it limits itself by responding with its offer to the explicit demand of the patient. I remember for example a couple among the beneficiaries of the very first attempts at ICSI : after having brought to these people manifestly distraught by their history a miraculous pregnancy, the famous centre which had performed the intervention saw the patient return three months later with a request for a voluntary interruption of pregnancy. This request was accepted in just as "functional" a way as the assisted procreation.

The third dimension is that of the systemic understanding of the human being. It is a question of transactional patterns, relational equilibria, modes of communication, interactional strategies etc. Every symptom is envisaged, in this dimension, according to the function that it acquires in a certain system of relations. It is in the light of this point of view that one can understand among others the subtle contract which is formed between a gynaecologist, a woman and a man around procreation. This three way partnership or mÈnage ‡ trois constructs its rules, its alliances, its roles. In this dimension on can for example wonder what place the gynaecologist occupies : rival, confidant, arbiter or parent?

The last dimension, the fourth, is the most specific of this model. Nagy terms it "relational ethics". It corresponds to an aspect rarely taken into account in the study of the taking of positions which found human relationships. For Nagy and for every attentive therapist, what mobilises the human being in the crucial phases of his life is ethics as an intrinsic experience of the relation.

On the philosophical level, Nagy is inspired by several authors.

He often refers to Buber. A citation from him will make it easier to understand the contribution of relational ethics to medically assisted procreation : "The therapist must cast his glance again and again there where existing person relates to existing person, this person here, the "patient", to another living being who is not "given" to the doctor and who may be completely unknown to him".One sees the appearance of the necessary taking into account of the interests of the child to come not as an object of preoccupation, but indeed as a subject in the beginning of a relation described by Buber as "Ich und Du".

The asymmetrical reciprocity of this relation in the framework of the transmission of life is at the base of the ethical question, adds Nagy, not without evoking another philosopher, Emmanuel Levinas, who said "The intersubjective relation is a non symmetrical relation. In this sense I am responsible for another without expecting reciprocity..."..

With Hans Jonas and his ethics of the future, Nagy points out that responsibility concerns additionally and above all relations with future human beings, whose existence will depend on our preoccupation. If procreation today is in the midst of mutation, such guidelines could be valuable for doctors who are involved therein. Especially in the perspective of the possible development of pre implantion diagnosis indeed of cloning, whose objectivant consequences are to be feared. Nagy redefines in this framework the notion of responsibility.

*Destructive entitlement and procreation

If relational ethics is anchored in the asymmetry or in the non-reciprocity between what is given and received, what is the consequence in clinic?

The examples which I have developed in my exposé evoke numerous crisis situations. It is evident : histories of infertility are lived out in suffering. And in my experience the destabilisation which accompanies this suffering indeed the treatment which by its uncertainties amplifies it, reactivates existing fragilities. An important concept of relational ethics is the link between experienced injustices and what Nagy terms destructive entitlement. The more one suffers from various burdens and the less one is recognised for the weight to bear and also the less one has the opportunity to give of oneself, then the more awakens in oneself the possibility of revenge. It is destructive entitlement : one will seek in other relations the repair required as a compensation for what one has lived through as an exploitation. The child at all costs often resembles this mender. He becomes then more and more parentified. Medical aid for procreation certainly does not create this situation but could accentuate it in the measure where doctor and patient could be caught in a reparatory dynamic. Both parties would ignore the gratuitous and non reciprocal character of all procreation, of the risk inherent in all transmission of life (one gives without knowing what one will get back) and of the chance that the child may reinvest as a trump in his autonomisation. Such considerations have a preventive scope in the long term. They must not make us forget the current rather reassuring observations of IVF children, but to qualify them.

*Creating the conditions for dialogue

To be more precise on the clinical plan here in conclusion are several concrete steps. In effect, the reference to relational ethics is not a simple theoretical horizon, it is a dimension to be approached in therapeutic practice. It helps the doctor and the patient to orient themselves through the more and more complex choices which are imposed on them. By opening a reflection on the relational consequences of medical acts, it creates a preventive perspective.

How to accede in reproduction medicine to the dimension of relational ethics? By the creation of an authentic dialogue. In the first place, at the moment of the request for the doctor's aid, the simple logic of supply and demand or even of medical indication are insufficient to respect the relational scope of the enterprise. To go beyond, a quality confrontation between the positions of each of the actors (man, woman, doctor etc.) must be rendered possible. That presupposes an awareness and a taking into account of the interests of each one, of the capacities of manifesting one's own independence; briefly, a process of differentiation : "Who wants what?". And above all, what proves to be necessary and valuable in a society where mistrust often structures relationships is reliability, trustworthiness rather than vaunting one's prestige or financial interests. Then other aspects must be envisaged such as the asymmetrical character of the relation; patients and doctors, sometimes man and woman, from all the evidence parents and children to be conceived, do not play with the same hand of cards. Lastly, this child must be privileged in a multilateral perspective. It is no longer a question here of a singular individualistic confab between a doctor and a patient defined by the beneficence of the one and the self-determination of the other. It is a project to be constructed through each relational link : conjugal relation, relations with the families of origin, doctor-patient relation and above all relation with the future child. Being able to care for its interests in spite of all the suffering undergone, the constraints of medical technology and claims of all types is the best way out. This evaluation of the interests of the child is above all else relational and necessitates on the part of the doctor or the psychotherapist a new competence. Such a process necessitates specific training and an increased availability on the part of the participants. And especially a particular state of mind open to the pluralistic confrontation of points of view and indeed to what Nagy has termed "multidirectional partiality".

The right to give more than the right to receive

Ethics of discussion, ethics of responsibility, ethics of consequences, many are the different paths today to replace the ethics of instituted dogmas, fallen into disuse. The relational ethics is the clinical contribution of such a movement. What is at stake is to avoid the misunderstanding of a purely technological response to a claim originating in suffering which is sometimes of very long date. The bereavements, parentifications, abandonments which the patients often testify to when one listens to them on the threshold of an IVF programme, create in them an experience of unbearable injustice when mixed with the uncertainty of being able to procreate. But the right to a child generated by this pressure risks leading to the psychological exploitation of this child. It would also be harmful to the parents to the extent that it would cut them off from the resource of truly being able to take care of their child. The succeeding generation would thus receive the "slate" revealed by the crisis of infertility. The model of relational ethics is not only applied to IVF. It can concern the whole process of reproduction and finds other concrete fields in voluntary interruption of pregnancy, in preimplantion or prenatal diagnosis and in the decisions to be taken in neonatology. With this question always in the foreground : how to allow our interlocutors to give of themselves what they want and can give rather than sticking them into the position of "receiving".

Briefly, all the crucial moments of the transmission of human life necessitate a new type of analysis from the moment they are defined by voluntary decisions, often linked to doctors; IVF and the crises it reveals can thus in my sense - optimistic - be considered as the crucible of a search for coresponsibility by associating the progress of technology to the progress of the decision process...for the benefit of future generations.