– Author: Rav Joel Kenigsberg
As technology advances at breakneck speed, new possibilities are emerging on an almost daily basis that just a few years ago could hardly be imagined. But along with hope and opportunity, these new procedures and technologies raise moral dilemmas as to if, how, and when they should be implemented. Medical science alone cannot answer these questions. Legal and ethical standards and indeed, halachic answers as well, need to be provided.
One of the areas of medicine that has seen the greatest advances in the past few decades has been the realm of assisted reproductive technology (ART). Through the procedures of IUI and IVF, many couples who would otherwise have remained childless have been able to have children and fulfill the Torah’s directive of pru u’rvu.[1] Although initially many poskim viewed such intervention with suspicion and there were those who forbade it entirely,[2] in recent years it has become standard medical practice,[3] and thus under the correct conditions has mostly developed a halachic consensus that it is permitted as well.[4]
PGD – A Background
Since the advent of IVF, beginning in the 1970s, medical science has taken another great leap forward with the development of PGD (Pre-implantation Genetic Diagnosis). Building on IVF, a technology whose sole purpose was to enable couples to have children who would otherwise have been unable to, PGD seeks to ensure that the children born will necessarily be healthy. Thus in cases where there is a risk of a child being born with a serious disease (as will be specified below), PGD is a technique that can be used to assist fertile and infertile couples alike to prevent the spread of genetic disorders in their offspring.
The procedure is as follows:
First, the standard IVF procedure is carried out, whereby fertilization of egg cells takes place in a lab setting. Initially, hormonal treatments are given to the mother in order to increase the number of egg cells to reach maturity and thus maximize the chances of success. When the egg cells reach the right stage of development they are extracted from the ovaries through a surgical procedure. The egg and sperm cells are then placed together in a lab in order for fertilization to take place in-vitro. After a few days the fertilized egg is implanted back in the mother’s womb and hopefully a successful pregnancy will develop.
However, when PGD is performed, an additional stage takes place before the embryo (or embryos)[5] is implanted back in the womb. Two to three days after fertilization occurs, the embryos are examined to determine whether they possess a genetic abnormality which would manifest in a disease. Those embryos found to be bearing disease will be discarded.[6] Only those which are found to be healthy will be selected for implantation – thus ensuring that the potential for disease has been eliminated.
What PGD has done is to give a new lease on life (literally) in situations where a married couple are found to both be carriers of a recessive genetic disorder.[7] Examples of such disorders with devastating and potentially life-threatening outcomes are Tay-Sachs and Cystic Fibrosis. When husband and wife are both carriers, there is a 25% chance that the child born to them will be affected by that disease. Historically, the easiest way to prevent such diseases was to perform genetic screening before marriage, and if the potential husband and wife were found to be carriers of the same disease – to cancel the marriage. This remains the case – prevention is still the best form of cure[8] and genetic screening prior to marriage is still highly recommended, if not obligated, by most poskim.[9] However, if such screening was not performed or its results were ignored, the possibility of bringing children into the world for such a couple was accompanied by a one in four chance of those children being born with a devastating, and perhaps life-threatening disease. Nowadays, this is no longer the case. A couple found to both be genetic carriers can (and according to most authorities should)[10] undergo the process of IVF and PGD and thus ensure that healthy children are born.
Expanding the Scope
However, as with many technologies, PGD can be utilized not just for the life-saving purposes for which it was created, but for other desires as well. Just as embryos can be examined to determine the presence or absence of a specific disease, almost any genetic feature of the embryo can be discerned, ranging from eye and hair color to the gender of the baby. The question must then be asked: While intuitively it makes sense to perform PGD in order to prevent life-threatening illnesses, could the same be said for other features? Could a healthy couple choose to do PGD in order to select the gender of their baby? Or perhaps other genetic characteristics? Conceivably, the age of designer babies may be upon us. Would this be halachically acceptable?
The answer can be divided into two – one focusing on a legalistic framework and one considering the wider implications of such an approach.
As mentioned previously, with the advent of IVF a number of poskim were somewhat hesitant about allowing the procedure. Ultimately the lenient view prevailed as IVF became a routine procedure, due to the weight of the mitzvah of pru u’rvu. However this is not to say that the process itself is without questions. Many of the issues raised by poskim still exist; nonetheless, they are overridden by the Torah’s command to have children and the fact that the couple is unable to do so in any other way. However, when it comes to a couple who is able to conceive without the need for ART, a number of the potential prohibitions need to be revisited:
- Some are concerned that the process may involve wasting of seed, especially if the end result is unsuccessful. Although the ultimate aim here is for the purpose of pru u’rvu and thus would not constitute the prohibition of wasting seed according to most authorities, some would opine that it is better to avoid the question where the couple are able to conceive naturally.
- The Risk factor – Any surgical procedure involves a certain risk factor. Although this factor is relatively minor in the case of the procedures done for IVF, it must be considered nonetheless. The poskim agree that this consideration is offset against the weight of the mitzvah of pru u’rvu, yet here again if the couple are able fulfil the mitzvah without any increased risk that may be far preferable.
- “The Slippery Slope” – Another concern mentioned against the use of IVF in general is the “slippery slope” argument and fear as to where this may lead in the future, due to the possibility of sperm samples being switched (inadvertently or deliberately). Clearly this procedure, if utilized incorrectly, could have major implications regarding lineage and the family structure. According to this approach, it would be instructive to limit the use of IVF wherever possible.
Yet more broadly speaking, a different question can be asked, namely how far should human intervention go in the natural process of creating life?
The Gemara[11] details a fascinating conversation that took place between Chizkiyahu and Yeshayahu:
בימים ההם חלה חזקיהו למות ויבא אליו ישעיהו בן אמוץ הנביא ויאמר אליו כה אמר ה׳ צבאות צו לביתך כי מת אתה ולא תחיה…אמר ליה מאי כולי האי אמר ליה משום דלא עסקת בפריה ורביה אמר ליה משום דחזאי לי ברוח הקדש דנפקי מינאי בנין דלא מעלו. אמר ליה בהדי כבשי דרחמנא למה לך מאי דמפקדת איבעי לך למעבד ומה דניחא קמיה קודשא בריך הוא לעביד.
“In those days Chizkiyahu became deathly ill, and Yeshayahu ben Amoz the prophet came and said to him: Thus says the Lord of Hosts: Set your house in order, for you will die and you will not live” (Yeshayahu 38:1)…
Chizkiyahu said to him: What is all of this? For what transgression am I being punished? Yeshayahu said to him: Because you did not marry and engage in procreation. Chizkiyahu apologized and said: I had no children because I envisaged through divine inspiration that the children that emerge from me will not be virtuous. Chizkiyahu meant that he had seen that his children were destined to be evil. In fact, his son Menashe sinned extensively, and he thought it preferable to have no children at all.
Yeshayahu said to him: Why do you involve yourself with the secrets of the Holy One, Blessed be He? That which you have been commanded, the mitzva of procreation, you are required to perform, and that which is acceptable in the eyes of the Holy One, Blessed be He, let Him perform, as He has so decided.
What emerges from this source is the natural tension that exists between bitachon and hishtadlut, specifically when it comes to the mitzvah of procreation. Is the outcome of this realm to be left entirely in the hands of Heaven? Or do human beings have a responsibility to intervene where we have the capability? While the topic of the Gemara concerns ruach hakodesh, modern medicine provides us with an ability to alter the course of action as well.
In a different context, the Gemara[12] quotes the pasuk of v’rapo yerapei and states:
מכאן שניתנה רשות לרופא לרפאות.
“From here, permission was given to doctors to heal.” Lest we might have thought that illness and health too are to be left in the hands of Heaven, the Gemara informs us otherwise. Thus, regarding the case of PGD, in order to prevent serious disease, the consensus among nearly all poskim (as mentioned above) is that the process is highly recommended, if not obligatory. But can this license be extended for other more wanton desires?
Poskim do provide a number of situations where one may utilise PGD in order to select the gender of the baby. Cases include preventing genetic diseases specifically linked to the Y chromosome, or cases where a couple already have many children of one gender exclusively and deeply desire a child of the opposite gender in order to fulfill pru u’rvu.[13] Yet it is clear to all that these cases are the exception rather than the rule and that extreme caution needs to be applied when expanding the use of PGD. Medically, PGD allows the choice of which embryos may be born and which will not. All can agree that a child’s future health is a valid consideration for such a choice, but regarding other factors the picture is far from clear. The slippery slope argument once again comes into play in full force. By allowing too much choice in which embryos to bring into the world, a situation may be created whereby potential lives are lost before they begin. There needs to be a limit as to where these considerations are applied. It is not yet entirely clear where that limit should be.
As with any new technology, the questions arising will only increase as time goes on. While medicine can provide the technologies, it cannot provide the answers. For this, we will need the ancient principles of Halacha to help us traverse these modern-day quandaries. Ultimately, it is the Torah’s eternal laws that can set the boundaries and help modern medicine utilize its breakthroughs for the purpose they were invented – to improve and perfect the world around us.
[1] Although there is some debate as to whether the mitzvah of pru u’rvu is fulfilled through IVF, the consensus of many contemporary poskim (including Rav Ovadya Yosef, Rav Vozner, and Rav Elyashiv) is that one does fulfill the mitzvah in this manner. See Sefer Puah, Vol. 2 p.337-338.
[2] See Tzitz Eliezer 15:45
[3] In Israel approximately 4.3% of births occur as a result of IVF. Worldwide, over 8 million babies have been born through IVF since 1978.
[4] Sefer Puah, Vol. 2, p.342
[5] Historically, several embryos were implanted in order to provide a greater chance of a successful pregnancy developing from one of them. With advances in the technology and higher success rates than previously occurred, current standard practice is to implant one embryo alone, barring exceptional cases.
[6] The consensus among most poskim is that embryos in a lab may be discarded where necessary and doing so constitutes no halachic prohibition (especially when they are not viable candidates for implantation). See, for example, Rav Mordechai Eliyahu’s responsum in Techumin Vol. 11, p.272. Rav J. David Bleich (Tradition 2002), however, disagrees.
[7] A recessive disorder will only express itself in clinical symptoms where the genes inherited from both parents are affected. Thus if only one parent is a carrier, the child will at most be a carrier but will not be affected by the disease. This is distinct from dominant disorders which can express themselves even if only one set of genes is affected. Recessive disorders have been mentioned specifically due to their relevance regarding genetic testing prior to marriage. However PGD can be used in the same way to prevent dominant disorders from occurring.
[8] As expressed by the Rambam and paraphrased in the Encyclopedia of Medical Halacha (Rav Prof. Avraham Steinberg): “Preventative medicine is the most important component in the entire medical profession.”
[9] See, for example, Igrot Moshe, Even HaEzer 4:10.
[10] See Shut Puah, Vol. 2., pp. 455-484.
[11] Berachot 10a
[12] Berachot 60a
[13] Some poskim note that while this latter case is not to be encouraged, there is no prohibition in doing so. See Rav Avraham Steinberg, “HaRefuah keHalacha.” On the other hand, the Sefer Puah (p.301, 344) cites a number of poskim who do not permit doing so when a couple has already given birth to other children.
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