The Practice of Artificial Reproduction Technologies: Its Effects on the Goals and Duties of Medicine (Professionalism)

Gonzalo Herranz, department de Humanities Biomedical, University of Navarra
discussion paper at the Tenth Assembly of the Pontifical Academy for Life
Vatican City, February 20-22, 2004.
Published in Vial Correa J, Sgreccia E., eds. The Dignity of Human Procreation and Reproductive Technologies: Anthropological and ethical aspects. Proceedings of the Tenth Assembly of the Pontifical Academy for Life, Vatican City, 20-22 February 2004. Vatican City: Libreria Editrice Vaticana; 2005:82-92.
conference proceedings available here

Index

Introduction

The goals and duties of medicine

The surrender of professional morality to ideologies

Primum non nocere: the disregarded first professional mandate

Disdain for early human life

The extinction of the respect due to the human embryo

The human embryo: a thing, not a child of his/her parents

An arbitrary discrimination among siblings

ARTS: an unprofessional commercialization

Conclusion

Introduction

The transfer of the new artificial reproductive technologies (ARTs) from veterinary medicine to the medical practice is counted as one of the most outstanding social and scientific events of the twentieth century. In the average it is repeated once and again that ARTs have enabled countless subfertile couples to achieve their long-awaited dreams of having a child. In the medical journals, in-vitro fertilisation and the techniques and procedures associated with it (gamete and embryo freezing, pre-implantation genetic diagnosis, gamete and embryo donation, and surrogate motherhood), are presented both as the result of bold research and as the driving force for breaking fresh scientific ground.

By contrast, much less it is spoken about the unsightly aspects of ARTs. It is not easy to find in the medical literature data on the failures -biological, psychological or familial- that ARTs bring about. Only occasional reports are published on the emotional hurt and financial distress to couples that ARTs convey. Practically never it is spoken on the loss of meaning suffered by so basic institutions such as family or parenthood, or on the way human embryos have been diminished from the condition of beloved sons or daughters to that of dispensable things.

Regrettably, the disturbing effects of ARTs are not confined to the field of reproductive medicine. ARTs exert a disquieting influence on the whole of medicine, and are changing the general goals and duties of doctors. Some of the most considerable professional values and traditions of medicine are being eroded by the erratic demands of clients and the obsequious subservience of doctors. The practice of ARTs is blurring the professional limits between altruism and commercialism, healthy emulation and aggressive rivalry, due competence and arrogant virtuosity, public needs and individual fancies.

In this paper, I will try to offer a provisional and annotated inventory of the impact ARTs are making on the goals of medicine and the duties of doctors. I think it is more consonant with the introductory character of this contribution to follow a descriptive and enumerative approach, than a systematic one. The reason is simple: professional criticism on ARTs is still at an early stage of development. Some years have to pass until we can realise the extent and diversity of deviations and untoward consequences the instrumentalist use of ARTs can entail.

In conformity with its emphasis on the professional and ethical aspects of the problem, this essay will pay attention almost exclusively to the medical bibliography. The topics considered correspond to real situations, not to imagined scenarios.

The goals and duties of medicine

It is not an easy task to summarise in a few lines the standard wisdom about the goals and duties of medicine. The difficulties increase today, when almost all aspects of human life tend are medicalised, and the dividing line between health and disease seems effaced under the pressures of consumerism and the dialectics of patient's power. Already 20 years ago, Kass¹ could affirm that "all kinds of problems now roll to the doctor's door, from sagging anatomies to suicides, from unwanted childlessness to unwanted pregnancies, from marital difficulties to learning difficulties, from genetic counseling to drug addiction, from laziness to crime".

Such a weird situation must be confronted, so that we try to identify the main elements of the medical calling. To that end, different paths can be followed. First, many of the goals and duties of doctors have been determined by medical law and, particularly, by the codes of medical ethics of the national medical associations. In almost every code of medical ethics a description of the main features of the doctor's calling is offered as one devoted to cure illness, relieve pain and suffering, promote and maintain health, and preserve life. All of these elements are cemented by the respect of the dignity of every human being, without discrimination, in time of peace as well as in time of war.².

Second, the ends and duties of physicians have been defined as the result of the exercise of autonomy and self-regulation based on the notion of professionalism. In recent years and especially in the field of internal medicine, a decided effort is being made to restore the old and permanent values of medicine and to adapt them to the time ahead. It is impressive the effort made by a number of independent groups in their intent to recover the sense and spirit of medical professionalism.³.

Third, the goals of medicine and the duties of the doctor can be deduced from the internal morality of medicine, grounded in the clinical encounter between physician and patient.⁴. From the structure of this encounter, Pellegrino thinks that it is possible to derive an understanding of the core professional obligations, free of external adhesions. Although some have criticized this approach, it is able to offer and develop an ethics to inform and fortify the duties, virtues and obligations of physicians qua physicians. In medicine, the primum principium primum of all ethics (do good and avoid evil) applies fully. According to Pellegrino, in due consideration to the elements present at the clinical encounter, it is found that the good of the patient consists in "a quadripartite good, a complex inter-relationship between medical, staff, human, and spiritual goods, hierarchically arranged".

In my view, with the help of the basic elements derived from the internal morality of medicine it becomes possible to attempt a critical analysis of our problem.

The surrender of professional morality to ideologies

The normative documents on professional ethics, the classical codes of conduct or the lately composed manifestos on medical professionalism, behave very differently in the face of ARTs. Overall, they do not seem suitable objects for our analysis. Such shortcomings do not come only from the extremely differing way in which they treat the matter (from silence to discordant precepts contained in one and the same document). Their main inadequacy lies rather in their submission to the more fashionable social opinion or to the dominant political viewpoint. Substantive ethical considerations in those norms are very scant or absent. The reason of such ethical void resides, perhaps, in the circumstance that those norms are the result of the impoverishing controversy needed to reach at a consensus, where robust ethical convictions must be sacrificed to the views of the majority.

Under the imperative of scientist ideology, market demands and financial gain, permissive and loosely regulated ARTs have received a warm approval from many medical institutions. ARTs have been frequently declared an important medical service for the alleviation of the pain of infertile couples, as well as an efficient instrument for the prevention of genetic disorders. Particularly worrying, by virtue of its authoritative and wide influence, is the statement on ARTs of the World Medical Association⁵. In some countries, professional ethics regulation on ARTs has bowed as an obedient servant to the general law of the state⁶. In others, as is the case of Italy, during the many years of absence of legal regulation, the code of medical ethics represented the only moral signpost for the practice of ARTs⁷.

Only a few medical organisations have expressed ethical criticisms on ARTs and limited their use to very restricted situations⁸. I did not find ethical norms congruent with the doctrine expressed by the Instruction Donum vitae of the Congregation for the Doctrine of the Faith in any of the national or supranational codes or regulations I could gather.

A disconcerting finding in many of these documents is the incoherence between the principle of respect for human life and the dignity of persons they proclaim in their introductory lines, and the biased way in which they approve, in carefully chosen and politically correct language, the entire gamut of ARTs. The timeless imperative of medicine -cure disease and relieve suffering in the respect of human life and dignity, with no discrimination- has been denatured with the purpose of putting it to the service of the strong and powerful and to the scorn of the weak.

Three factors have been responsible of such regression. First, the major role played by national law or international professional guidelines on the production of national or local rules on ARTs. Second, the influence exerted by ideological and sentimental pressures conveyed by the average, which changed the mind and the heart of society and, unfortunately, of many doctors. And third, the frequently biased membership of committees, advisory or legislative, charged with the drafting of ethical guidelines or legal proposals.⁹.

As a result, from the mid nineteen eighties onwards, a number of professional guidelines on ART have relinquished the ethics intrinsic to medicine, to slavishly conform themselves to utilitarian views. The crucial issues of the utmost respect due to the living human embryo and to the basic values of family and marriage have been the victims of such unprecedented ethical surrender.

Primum non nocere: the disregarded first professional mandate

It is said that the mandate "Do no harm", included in the principle of nonmaleficence, is the most basic of the principles of bioethics when applied to medicine. It is for the physician the oldest and first deontological precept. It enforces on the doctor the duty of not inflicting deliberate harm to the patient and of preventing harm to others. In the Hippocratic Oath, the duty of keeping the sick from harm and injustice is closely linked to the duty of applying medical measures for their benefit, of always doing good to them. This general duty of nonmaleficence towards the ill is resolved in more specific and immediate rules, among which it is easy to identify those of not killing, not causing pain, not maiming, not injuring, not depriving others of the goods and joys of life. And, by no means the least of these mandates, not expropriate the weak and abandoned of their inherent human dignity.

In contrast with such elementary and essential injunctions for the morality of the doctor-patient relationship, we find that the relations of doctors to human embryos show in many cases an almost complete lack of respect. The esteem for the individual human embryo is so low, that practically it is rejected as non-sense the thought of considering the death of the in-vitro human embryo as an ethical disgrace. Such is a blunt unprofessional conduct.

People practising ARTs act as if they had forgotten that a strong connection exists between the basic medical principle of not doing harm and the death, loss or damage of the embryos they produce and manipulate. Therefore, behaviours such as the intentional production of surplus embryos for mere technical proficiency, the drama of abandonment of embryos by their producers or progenitors, their destruction on more or less fashionable research, or the shocking annual immolation of out-of-date embryos ordered by law, are held as trifling, everyday matters.

Let us see some examples of that loss of concern for early human embryos. In recent years, a sincere solicitude for preventing avoidable harm to patients is growing everywhere in medicine. A co-ordinated effort is made in hospitals to reduce iatrogenic harm to patients. It has become evident by now that the conditions of in-vitro culture, and specifically deficiencies in the epigenetic regulation of development, can induce important damage to the embryo. Some data show that the loss of embryos and the intensity of epigenetic damage increase with the length of the in-vitro incubation period. No serious research is being done to identify the factors responsible for those developmental alterations dependent on the length of in vitro culture of human embryos. The damage induced is either held as an unavoidable event, or explained as the effect of a Darwinian selection-like process with its ineluctable loss of the weakest embryos and survival of the fittest ones. With Olympian calm it is said the all that loss and damage is compensated for by the higher implantation rate of the higher quality blastocysts resulting from long-culture procedures.

There is a need to take with serious professionalism the harms inflicted to human embryos caused by ARTs. The devastating physical, psychological, or social harm to the resulting children should be investigated more thoroughly than at present.¹⁰. A field of the utmost interest is that of the disorders of reprogramming of parental imprinting occurring during early embryonic development¹¹11 , when it can be interfered by abnormal in vitro conditions or by insufficient epigenetic regulation. A beginning alarm is being sounded by the increased prevalence of cases of Beckwith-Wiedemann syndrome¹² and Angelman's syndrome¹³13 observed in children conceived by in vitro fertilisation or intracytoplasmatic sperm injection.

Disdain for early human life

There is an enormous contrast between the love and joy for any new and singular human being expressed in the first page of the Encyclical Evangelium vitae, and the blasé attitude for human life so widely spread among those working in the ARTs industry. In ARTs, the formalised routines of inspecting, counting, scoring and selecting human embryos are the surrogate for unconditional love for every human being beginning her or his life. The application of quantitative standards for the measure of biological traits directed to the eventual rejection of defective early human embryos collides frontally with the idea of the incomparable worth and acceptance of every human being. The scoring according to scales of morphological or biochemical markers -more intuitive than scientifically grounded- is deemed sufficient to class human embryos in batches linked to appallingly differing fates of life or death.

The discarding of human beings is part of the daily routines of ARTs. With the pass of time, the selection and disposal of embryos became for doctors and technicians an uninteresting and predictable habit, a painless routine.

The extinction of the respect due to the human embryo

In the soul of many doctors practising ARTs no trace appears to remain of the medical commitment, pledged at the time of being admitted as a member of the medical profession, to maintain the utmost respect for human life¹⁴. So says the Geneva Declaration, the modern version of the Hippocratic Oath, adopted by the World Medical Association in the aftermath of the World War II. The medical profession holds the Declaration as its ethical cornerstone, to proclaim publicly that medicine is founded on the respect for human life and human patients. According to the Declaration, the human embryo is entitled to that same utmost respect from her or his very beginning.

The same affirmation that the human embryo must be respected as a person from the very beginning of his or her existence has been reiterated once and again in the documents of the Magisterium dealing with the embryo moral status and with the embryo/parents and embryo/doctor relationship¹⁵. But, regretfully, practically all ethical directives coming from governmental or scientific institutions have insisted in the idea that the human embryo is worth of only a relative or second-class respect.

The lessening in moral worth of the human embryo has not been the work of ARTs' proponents. In the early nineteen sixties a number of doctors and theologians of pragmatic mind feel the need to neutralise ethically the few days old human embryo in order to free interceptive contraception from any moral responsibility. Such pretension required the redefinition of conception as different from fertilisation, and the shift of the beginning of pregnancy from fertilisation to the ending of implantation. Years later, the supporters of ARTs and human embryo research took refuge with the notion of the lesser value of the embryo during the first two weeks of her or his life to justify the loss of countless human embryos in clinical or experimental procedures linked to ARTs.

In many circles, it is held as axiomatic that the human embryo acquires humaneness and entitlement to ethical respect in a gradual way. The wide acceptance of such a deviant idea was facilitated by the introduction of the neologism "pre-embryo", a notion to be applied only the human embryo, not the embryo of any other species. This contrived term pretends to make known that during the pre-embryonic period of fourteen days the very young human embryo is entitled not to the utmost ethical respect, but to an indeterminate "profound respect".¹⁶or to an indistinct "measure of respect" 17¹⁷.

In countries where the national law condones the unrestricted production of embryos for clinical use or the destruction of surplus embryos for experimental purposes, many medical associations have accepted the ontological splitting of mankind into two categories. One formed by those worth of the utmost respect; the other constituted by those who can be respectfully killed. Such behavior has been considered as a paradigmatic case of profound self-deception.¹⁸18 and has been rejected by other medical associations. For example, the code of ethics of the Spanish medical organisation affirms that "The human embryo-foetal individual must be treated according to the same ethical guidelines that are applied to the other patients".¹⁹.

The abolition of the absolute respect due to the human embryo or its reduction to a vaguely profound or measurable respect constitute a severe blow discharged to the moral values of the medical profession. A great number of national medical associations, as a review of their codes of ethics shows, have abdicated their commitment to the utmost and unconditional respect for every human being. This shift, from absolute to relative, in the respect due to the embryo is playing a major, perverting role in the way human embryos are seen. The general public consider them more as objects than neighbors; the parents deem them more as things than as children. This is not a subtle, meaningless shift. It should remind us of that subtle change in the basic attitude of the physicians towards the worth of human life, that, according to Alexander, preceded the euthanasia movement in Germany.²⁰.

The human embryo: a thing, not a child of his/her parents

The professional hard core of Medicine, what defines the character and professionalism of physician, resides in the fact that doctors deal with men and women, not with things or animals. A peculiar feature of ARTs consultations is this: the initial encounter between parents and doctors is full of human tension. Never it does begin by saying the parents: Doctor, produce us some embryos, make us a lot of embryos! Instead, it begins practically always with a parents' plea to the physician. They say: Doctor, we want a child! Please, help us!

Such a vehement request should determine, in a true professional patient-physician relationship, the behavior of the doctor, and mark the ethical limits to his intervention. The doctor ought not to forget that each of the embryos produced in the practice of ARTs is a child of their parents, neither his own creature nor his possession. That each human embryo is a child is an illuminating and basic concept. It helps to understand that there is, in the context of ARTs, a humane way of practising responsible parenthood if, and only if, the decision on how many embryos are created and the responsibility for the human destiny of each one of these embryos do belong to the parents, not to the physician.²¹.

Too frequently, parents and doctors alike forget that every human embryo is a child to be received as a beloved and accepted son or daughter. Never must they be treated as shapeless reproductive material, as a valuable but amorphous and interchangeable precursor matter, or as something disposable and provisional that can be accepted or rejected in compliance with certain legal provisions. In the root of the superfluity of hundreds of thousands of surplus embryos is the stubborn denying by people in the reproduction business of the fact that each embryo is the progeny of a man and a woman, that human embryos are essentially filial. It must be clearly affirmed that it is ethically brutal and professionally irresponsible to bring to this world people whose destiny leads nowhere, whose existence is truncated from their very origin, who are deliberately disowned of the promise of a flourishing staff life of relationship with God and men. No area of medicine is plagued with so an overwhelming failure of professional accountability as the unbridled production of excess embryos. It is a cruel mockery to proclaim human embryos as worth of profound respect and, simultaneously, profess as reconcilable with professional ethics the frivolous decision to produce them in excess.

Doctors practicing ARTs never refer to in vitro embryos as sons or daughters. They look upon them as biological specimens of their property. Obstinately they conceal from the progenitors any direct parental relationship with their own embryos. Some mothers want to name the embryos as they are being transferred to their womb, but doctors, to prevent a too strong bond between mother and in vitro embryos, discourage so human an intimation.

That human embryos are treated as things is paradigmatically shown by the comments made by a lawyer to a notorious case of switched embryos. Insensitive to de deeply human, professional and symbolic aspects of the case, the lawyer reduced it to a problem of merely economic nature, where negotiated solutions for childrearing were to be found, conflicts between gestational and genetic parents solved, and compensations granted²².

An arbitrary discrimination among siblings

One of the most ethically painful practices connected to ARTs is embryo reduction. It has been the rule in some ARTs centres, to obtain social recognition of efficiency, to transfer a high number of embryos so that the implantation of at means one embryo could be achieved. Such objectionable and egotistic behaviour, condemned today by many medical organisations, is unfortunately followed by a high order twin pregnancy with its well-known risks (high rates of foetal loss, intrauterine growth retardation, premature birth, congenital malformations, neonatal low-weight and respiratory and central nervous system morbidity).

To avoid the real dangers linked to multiembryo pregnancy, the nonselective embryo reduction has been recommended. This procedure is performed before the end of the first-trimester with the purpose of terminating the life of one or more embryos in order to increase the chances of survival of the remaining embryos and to protect the health of the mother.

A Declaration made public by the Pontifical Council for the Family in July 2000 stressed a very fundamental moral fact: that since every embryo must be considered as a human person and treated with respect for his eminent dignity, embryo reduction is in fact the killing of innocent human beings.

Next to that, embryo reduction performed for the welfare of the remaining embryos implies another ethical dimension of considerable psychological importance. When the physician performs a non-selective reduction, he is destroying human lives guided by such hints as the more favorable placement of embryos in the uterus for the continuation of pregnancy. Or by the fortuity of being the operator left- or right-handed, he can get more easy access to one or another of the siblings. Of two embryos, one is killed, the other spared. Based on very brittle reasons he is deciding arbitrarily who survives or who is sacrificed. That is certainly the exercise of a terrible power, a truly instance of playing God. This terrible performance is deemed irrelevant in the declarations on embryo reduction published by some professional associations.²³.

Multifoetal pregnancies should be declared the result of unprofessional behaviour. They are motivated by the me-too mania of high pregnancy rates per cycle, an idol to which highly esteemed professional values are sacrificed. The yearning to climb to a high place in the league table of competitors for public renown and financial gain is considered sufficient reason for such cruel a behavior.

Recently, a movement has emerged to promote the use of the natural cycle for the practice of ARTs, a procedure which could eliminate not only the insoluble problems of surplus embryos and embryo reduction, but also lessen the high cost of stimulated cycles.²⁴. This procedure avoids ovarian stimulation and its inherent risks (hyperstimulation syndrome, multiple pregnancy and premature birth). It has been demonstrated by different groups that natural cycle IVF shows an acceptable cumulative pregnancy and live birth rate, to such an extent that it results in an effective and potentially cost-effective treatment option for certain groups of infertile couples. Natural cycle IVF is less expensive than conventional treatment involving stimulation. The use of natural cycles may also help the move towards replacing fewer embryos. The present trend to replace two embryos as the best practice could herald a future of replacing only one embryo, which would bring IVF closer to a more reasonable medicine.

ARTS: an unprofessional commercialization

Disedifying examples of greed and financial abuse have been constantly present in the history of medicine. But it is typical of the medical ethos to reject the idea of medicine as a lucrative activity. Many Codes of Ethics of European and Latin-American Medical Associations establish clearly that medicine is a learned profession that cannot be practiced as a trade.

In recent years, many directives of medical associations have sounded a cautionary advise on the perils threatening the medical profession from a shift from the traditional ethos of moderate financial relations with patients to the competitive principles of the market place. Such a change would have disgraceful effects on the traditional practices protecting since Hippocrates the members of the profession from avarice or selfishness.

Regrettably, due to the particular emotional situation of couples asking for reproductive services and desiring a child at any cost, ARTs are seen as a profitable speciality by many of its practitioners. The prevalence of financial interests in the field of ARTs is revealed in the poor development everywhere of this type of services offered free or at cost price by public or private non-profit institutions. That contrasts with the thriving expansion of for-profit practices, the aggressive or alluring way ARTs are advertised, and the variety of techniques conceived to attract clients and to satisfy their whims.

The way in which ARTs are being promoted today by some practitioners and centres is an important pointer to the direction this speciality will follow in the future. There is ample conviction among medical ethicists that the type and style of advertising accepted by each profession determines the way the corresponding profession is perceived by the members of the wide society. Medicine can be viewed as a true profession or as a mere commerce. As a Position Statement of the Australian Medical Association on advertising puts it, "the promotion of a doctor's medical services as if the provision of such services were no more than a commercial product or activity is likely to undermine public confidence in the medical profession".

Aggressive advertisement is eroding the ethos of medicine, and changing a vocation devoted to the service of the ill to a commercial activity guided by the rules of the market, if not by the sacra auri fames. Advertising is not reduced today to the factual and verifiable information needed by patients to make an informed decision. It frequently shows a consumerist bent, includes declarations about the quality of the services offered, and induces in the public a feeling of urgency or need for the services promoted. The visiting of the pages of Internet dealing with in vitro-fertilisation is a display window of alluring and competitive marketing.

The way advertising and financial arrangements are used by some practitioners of ARTs throw doubts on their integrity and correctness.

Comparative advertising of ARTs is frequent because the great importance people grant to the choice of a doctor or a centre with credentials of high performance. Therefore, to be in the first places of the league tables made public by official or private organisations is a key to success, an aspiration that can cost a lot in professional and ethical values. To be able to present a high performance card, it is necessary to exclude from the services of ARTs the less than ideal candidates. Particularly unjust is the exclusion of patients with poor prognosis, which are neglected or set aside for the purpose of maintaining a high success index. It is also expedient to run the risk of high order twin pregnancies with subsequent embryo reduction, to go very close to the limit of ovarian stimulation, and to expand the concept of sterility to attract to ARTs young couples who would conceive without the help of ART.²⁵. There is a frequent dumping of cases with poor prognosis, although there are also ARTs centers specialized in the treatment of cases with very poor reproductive outlook.

A phenomenon that was of ordinary occurrence in the first years of ARTs was the publication of inflated rates of success or the use of parameters of scant value, but that were a bait for clients, particularly if those data came along with a self-satisfied declaration of excellence. This lack of professional honesty forced the publication of a calling to rectitude and integrity by the directors of the American Society of Reproductive Medicine²⁶.

Other widely accepted fault in professional integrity comes from the ethically deviant practices of guaranteeing outcomes, linked to contingent medical fees, Programs of sharing risks or the offer to refund money. All these practices are against the traditional ethics of medicine and reflect a grossly commercial attitude in those that promote and use them. What is worrying is the lukewarm response of the professional organisations in the face of those aberrant practices.²⁷.

Other practices as egg sharing, an arrangement in which a woman is offered free or reduced-cost assisted conception treatment in return for 'donating' oocytes for the treatment of another woman²⁸can be seen as a way to outmanoeuvre the legal prohibition of selling gametes. It is practised everywhere, but cannot resist the criticisms of being exploitative, misleading and contrary to the principle of non-commercialisation of the human body.

The entrepreneurial "geist" of some ARTs promoters does not recognise limits. Human gametes are sold to the best purchaser. "There is nothing wrong with bidding for human eggs," they say. The encroachment upon the traditional practice by both commercial enterprises and physician-led groups who have inflated the cost of donor compensation 500% in the past decade²⁹.

Conclusion

In the field of ARTs work many people, with many different sensibilities and attitudes. Nevertheless, practically all of them are dominated by an ethos of discrimination. They appear full of compassion towards the suffering of infertile couples, and at the same time show in the application of their techniques a cold and hardened stance before nascent human life.

Such disposition of mind makes practically impossible to achieve the goods peculiar to the calling of medicine. In diverse ways and despite the appearances on the contrary, they fall short of the professional, human and spiritual goods of medicine.

ARTs are a sad and interesting paradigm for the troubled destiny of medicine when doctors adopt as the rationale of their work technical refinement, marketing proficiency, relentless fight for recognition, and high financial rewards for their work. The deviation from the traditional mores embodied in the deep sense of genuine medical professionalism is leading ARTs practitioners to a progressive loss of ethical commitment and, inevitably, of patients' trust.

I am sure that doctors will react against the commercialising of services and the manipulation of feelings so deeply ingrained in the mind of many leading doctors devoted to ARTs. Perhaps the time is not afar when the wisdom of the doctrine of Donum vitae will be recognized, and its invitation to hope will be accepted: "to understand the incompatibility between recognition of the dignity of the human person and contempt for life and love, between faith in the living God and the claim to decide arbitrarily the origin and fate of a human being".