Weathering the storm: the critical view in gynaecology
Gonzalo Herranz, Unit of Humanities and Medical Ethics, University of Navarra
Departmental session at the department of Gynaecology and Obstetrics, Clínica Universidad de Navarra
Pamplona, Wednesday, 2 May 2018
I am grateful for Luis Chiva's invitation to participate in this meeting. Logically, I was reluctant at first, as I think my age made it advisable. Then he convinced me, but not before I asked him to give me a specific date for this talk, topic . And he sent me a message in which he said: "In addition to talking about whatever you want in relation to the title (which I have changed to "Weathering the storm: the critical vision in gynaecology"), I would like you to talk about five points". I will say something about them later.
So first I will talk about holding on to subject in the midst of the storm. The idea comes from the time when I was a member of the National Commission on Assisted Human Reproduction. The Commission was made up of several of the country's leading specialists in assisted reproduction. On some occasions I was asked: Gonzalo, how is it possible that you do not carry out in vitro fertilisation in Pamplona? How is it that, being a cutting-edge institution, you refuse to be at the forefront of gynaecology?
In reality, they were telling us that we had been relegated to the second division. This was the temptation at the time and continues to be the case today. For four decades, assisted reproduction has been regarded as the mark of excellence in gynaecology, as the most humane and scientific of its sub-specialties. The media continue to echo the "miraculous" and often extravagant achievements of the new technical variants, they continue to talk about the happiness that IVF has brought to countless infertile couples, they take it for granted that assisted reproduction is a right of adult people, whatever their condition. Bioethics information services send us their news bulletins every week, fortnight or month. They seek to amaze us. I keep reading them. These days: A study published in RBMonline predicts that in 2100 there will be nearly 400 million people born as a result of assisted reproductive techniques result . IVF is increasingly effective, says the HFEA, with a success rate of 30% in women under 35, and 21% in those over 35. The New Scientist reports that it is possible to create human embryos without eggs or sperm; and, on its cover proclaims: "No eggs, no sperm, no wombs. Are we ready to create [human] life from scratch?" The weak flank of IVF, the emotional flank, the flank of its failures and its complications, is being strengthened. The public (or advertising) image of ART is charming, fascinating: it is the comfort and hope of childless couples, who willingly accept the sufferings and anguish linked to assisted reproduction as something worthwhile in order to become parents. Why go on?
The natural reaction to such disdain is to ride out the storm, to put one's head in the sand. The DRAE says that these expressions mean to hold on without retreating more than is inevitable when the wind is harsh and contrary, and to be on the lookout, to act when necessary. It means, therefore, not to stand still, but to hold on and, as far as possible, to act and move forward.
But there are two sides to weathering the storm. One is to remain faithful to one's convictions, to one's ethical creed. The other is to work, even to explore new paths, using as tool of work the scientific programs of study . We start from a principle that inspires us and gives us security: there is no possible contradiction between the truth of faith and the truth of science: God does not contradict himself. If there is disagreement between science and faith, it is because we have misinterpreted faith, or because we scientists, although we appear to possess a knowledge goal , have erred somewhere in our work. This obliges us to discern our right faith and to critically refine our science.
Rather than digressing, an example might be useful here. Even if it is staff, I find it clarifying. The dominant professional opinion is very much in favour of artificial reproduction (IVF, ICSI and all the satellite techniques, from pre-implantation genetic diagnosis and embryo selection to embryo genome editing). This professional opinion is result of much work and an object of legitimate pride. To say that these techniques, because they do not respect nascent human life and the dignity of procreation, should not be practised is considered offensive: scientific orthodoxy affirms that whoever says this is living outside reality, is a fanatic who deserves only contempt.
Suppose these orthodox subscribe to the minimal medical ethics of the Declaration of Geneva, which the association World Medical Association, the universal senate of the ethics of medicine, offers to all who enter the medical profession. In its latest version (Chicago, October 2017), it characterises the physician's attitude to human life as follows: I will maintain the highest respect for human life. (In 1948, it said: I will maintain the highest respect for human life from the moment of conception). ) It does not matter, in our argument, that very serious difference. It is enough to accept that the medical vocation is a vocation to care for and respect human life.
But ART does not respect human life. issue They are always linked to the loss of embryos: a competent internship is not conceivable today unless as many oocytes as possible are fertilised and a sufficient number of embryos are produced issue to select the most promising ones. The others are discarded either directly, or by cryopreservation, donation or withdrawal; or by use in experimentation.
Such loss and destruction is justified by saying that these embryos are not human beings worthy of respect, because, among other reasons, their individuation is not yet determined: in their first two weeks of development every embryo can divide to give rise to monozygotic twins, or two dizygotic embryos can fuse to give rise to tetragametic chimeras. This is what everyone says, what books and articles on embryology, Genetics, obstetrics and assisted reproduction techniques repeat in unison.
Back to speech: to weather the storm is to hear that and not to stand still, it is to behave like a rebel, non-conformist but rational, and to be constructively critical.
I, some years ago, asked myself: is this true, is it proven beyond doubt that monozygotic twins are formed by partition of one into two, and tetragametic chimeras by fusion of two into one? If you study the bibliography critically, you will see that everyone affirms this as a fact. Hundreds of papers tell us that monozygotic twinning occurs in the first two weeks of development by cleavage of a single embryo into two, or that two initially separate dizygotic embryos fuse into a new single entity: into a tetragametic chimera. But where are the demonstrations, where are the collections of histological sections, where are the photomicrographs, where are the microcinematography films? Nowhere. After many hundreds of hours of searching, one concludes that what is described as facts is a mere hypothesis. This is soon said. And, once that was clear, it took many more hours to trace the history of what I called the dominant view of monozygotic twinning: to find its origin in a forgotten article , published in 1923, and to trace the additions and explanations until the idea was firmly established in 1955. It has been an adventure that has fascinated me for years.
I recount it in The Fictitious Embryo (and before that in a article published in Zygote), where, apart from its history, I analyse the weaknesses that discredit the dominant view. And so as not to remain in the negative, I proposed replacing this untenable hypothesis with another, just as hypothetical as the previous one, but for the moment stronger, and I think more in line with reality, and compatible with what faith tells us. I propose that twinning and the training of tetragametic chimeras are phenomena linked to fertilisation, not subsequent to it: twins and tetragametic chimeras exist ab initio. There is no time when the embryos are half-baked, when they are not properly individuals. They are from the beginning, from the moment fertilisation ends.
I cannot say that The Fictional Embryo (the book and the theory) has succeeded. Some leading figures in embryology and Genetics have been very appreciative of the work historical critique of conventional wisdom and have published papers in which my hypothesis is put on a par with others. I have had a lively email exchange with some leading lights. But no one, so to speak, has stood up for the new ideas. On the contrary: the establishment has anathematicised them. In RBMonline, Richard Gardner has published a very harsh critique of my article in Zygote, realised its importance, and tried to discredit it by accusing it of being Vaticanist, pro-life; but his scientific assessments seem rather improvised. I refuted them in a Commentary of the same length as his criticism. They did not publish it. After much wrangling, they accepted a simple letter to publisher, more testimonial than probative. For its part, the journal Zygote commissioned Hans Denker to write a review of my article. I have the impression that he wrote it simply to get out of the way. But publisher refused to publish my counter-critique. It was not enough to invoke the rules of fair play. He stopped replying to my complaints. Patience, swallow your breath and move on.
My purpose in recounting this is to highlight two ideas. One: that weathering the storm requires first of all to be very active, vigilant, hard-working; but above all, it requires reflection, asking questions, including difficult ones, and not letting them go, holding on to them like gold, trying to answer them, and sharing them with others to join forces. Ask questions when listening to a lecture, when reading a article: Are the conclusions presented scientifically acceptable or are they exaggerated? Are the method and the patients well selected? Has the bibliography been consulted and fairly evaluated? Where is the evidence for the conclusion proposal?
The second thing is that it is not easy to make yourself heard by those in the establishment. And if they do hear, they do not respond: they have a very effective instrument at their disposal, more of annulment than torture: silence, silence for an answer. Neither whistles nor applause, but the hard and difficult to bear silence. We must be prepared to bear it. The prolonged storm will pass and a time will come when tongues will be untied.
So much for weathering the storm. Now it's time for the five questions Luis Chiva asked me to address.
I. How to be true to one's convictions despite the difficulties, using scientific evidence as test .
I think the question has already been answered when speaking of the principle: There is no possible contradiction between the truth of faith and the truth of science: God does not contradict himself.
We are not afraid of the truth, we love to investigate it and cooperate in the ongoing work to free science from pseudoscience. Because science is not infallible, it is provisional, it is very human. Peter Medawar, award Nobel 1960, in his little book Advice to a Young Scientist, said that half of good biomedical research was aimed at eliminating the errors that have crept into the preceding research . It is a mental and public health activity. It requires courageous honesty, a hunger and thirst for scientific truth. And it requires serious work. We must despise communications for showcasing or abusing science in favour of ideologies. Going against the grain is very scientific and very honourable if one handles science with rectitude and skill. Aspire to be a person of whom one says "I am going to read this article of yours, because it says interesting things and has never misled me".
II. How to have a superiority complex on this status. Do not give in. Don't block in the face of a hostile environment
A superiority complex cannot come from arrogance. Haughtiness is more than enough in science, in research, in teaching, which have to stand on their own, they do not need decorations or media reinforcements. A good superiority complex comes from humility. It treats people with kindly respect, but treats error with intransigence, albeit gently.
With that complex, we don't have to pick fights with colleagues. We are not afraid of them. On the contrary, we are sincerely interested in their friendship, in trying to identify those things on which we agree agreement, in order to start from them together in search of the truth, or, more modestly, in search of errors that need to be identified and eliminated. It is very important to determine with colleagues that minimum common ground that is at the core of the genuine medical vocation, that which gives us a superiority complex, without despising anyone, however mistaken they may be: respect for the dignity of people, respect for human life, the scientific nature of medicine, the human values of the medical internship .
This leads us not to give in, not to betray the core of non-negotiables. What is negotiable, we are happy to negotiate.
III. mission statement The need for fertility research from our respectful perspective
It will be increasingly difficult, in the path set by laws, judges and, unfortunately, professional and scientific organisations, to oppose conscientious objection, even under the guise of scientific objection, to abortion, contraception and assisted reproduction techniques. It is therefore necessary to discover a new way of acceptable ART from a perspective faithful to Catholic doctrine.
It is not enough to highlight the ethical failures of the internship (some speak of the industry) of assisted reproduction: its declared auris sacra fames; its laziness internship in applying ICSI as a panacea and forgetting the fine diagnosis of sterility; its disinterest (or its concealment) of cases of spontaneous fertilisation on waiting lists or of double fertilisation (natural and artificial) in some cases, its negligence in accepting and treating failure after repeated IVF attempts; etc., etc.
Effective and acceptable solutions must be found. That is your challenge.
I declare myself incompetent to go into details. I think this is a very difficult issue. Firstly, because it is a very long and complex process of refund , i.e. defining the different types of infertility and finding a cure for each of them by addressing the specific cause. Secondly, because it is not easy to find alternative variants of artificial reproduction techniques that are respectful of nascent life and the dignity of human procreation.
But we must insist. Natural methods can be improved. Endocrinological and psychological factors of aetiology and therapeutics should be further refined. We must insist on the prevention of the causes of acquired infertility and temper the couple's concept of infertility, recommending patience. And it is always advisable to make a kind suggestion of adoption. Married couples sometimes need time to internalise it before accepting it.
On summary: many hours of study, reflection and conversation are needed. You have to keep up to date with progress and make the best of it. It takes a lot of tenacity, because business is long. A lot of hope is needed, because business is hard. Working together will be the main value of the group
IV. Need to articulate an international network in order to have scientific impact
All the efforts and expenses of this meeting would be justified if you were able to weave this network. Nothing could be more recommendable. You have to form a living group to exchange ideas, organise a simple market of ideas, I like to call it. It has a multiplier effect. But it has no unifying effect: freedom is a treasure, also in research. Within the framework of Catholic doctrine and morals, we are interested in divergences: inspiration can come from them. We share ideas, but we do not impose them.
Weaving this network does not require much organisational work : free as life itself. It would be enough for everyone to leave here with everyone else's e-mail address and, logically, to tell everyone at home what has been said in this meeting . And when one comes up with a well thought-out idea, or reads a really interesting article , send a message to the others: just the article or the idea with a short comment that acts as a hook. And everyone receives the idea, considers it, comments on it, and this enriches them and brings them closer together. No answers subject OK, or how interesting! refund ideas for worthwhile ideas. Don't overload that network with trivia: load it with big fish, or things that can become big fish: things that make you think, that provoke, that light the fire.
Trust. In Shakespeare's Henry V, when the King, before the battle of Agincourt, harangues his soldiers, few and very worn out after a long campaign, who are about to face a large and fresh French army (more or less the panorama of today's gynaecology), he tells them: "We few, we happy few, we band of brothers". That is what is good for us: fraternity, which has nothing to do with group closed or with a single school of thought.
V. Overflowing optimism for the future, avoiding pessimism
Rather than overflowing optimism, I would prefer a wear-resistant optimism, because I think it is not about having an unconditionally rosy view of the future and thinking that everything will work out in the end. Anton Wurster, a Croatian professor from the early years of high school of journalism at this University, used to say that "Nothing fixes itself; everything is fixed by someone else".
Optimism means rolling up one's sleeves and setting to work with the conviction that even the smallest contribution anyone can make to science can make a difference: optimism is rooted in the awareness of freedom and in the certainty of the power of grace, as St Josemaría used to say. It is not good to go through life defeated, but neither is it good to go through life triumphant. We must go with our eyes wide open, like little children, who never stop asking questions.
Optimism is to keep asking questions, the good questions, and to hope that sometime we will come up with the answers, the good answers. Whenever something catches our attention, like a reflex, to ask ourselves, why is it like this? Why such a black prognosis? Why should the only solution be abortion? Isn't it more noble and dignified, even biologically, to keep the pregnancy to term? Why is it more noble? Why more dignified? Do not despise these sparks. Take them seriously. At the very least, write them down in a notebook or on your mobile phone and then consider them slowly. And, if they deserve it, share them with others and ask them: Can you think of anything on this subject? Sometimes, a good idea will spark. Rarely, a "eureka!
Avoid pessimism. It is fatalistic and paralysing. Something is always better than nothing. It is better to light a match than to curse the darkness, says a German proverb that Benedict XVI liked to repeat. I hope that this group will light many matches.
Thank you.