Fertility, Ethical and Theological Reflections

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    INTRODUCTION

    26 Then God said, "Let us make humankind in our image,according to our likeness...

    27

    So God created humankind in his image,in the image of God he created them;male and female he created them.

    28 God blessed them and God said to them, "Be fruitful andmultiply, and fill the earth... (Genesis 1:26-28a, NRSV).

    Jerry and Sally came to the platform and before the church I led them

    through a dedication of their new born child to the Lord. This was their third child

    and it was a day for them to celebrate with their family and friends this precious

    new life. As I led them through the presentation of their child, I was keenly aware

    of another couple, Barbara and John, who two days earlier buried their

    prematurely born twins. Before going to the reception at Jerry and Sallys, I sat

    and wept with Barbara and John. Barbaras and Johns pain was all the more

    deeply felt because they, unlike Jerry and Sally, had been unable to conceive

    without medical intervention, the twins that they finally did conceive were the

    result of extensive fertility treatments.

    This story makes the discussion of fertility and infertility more than an

    academic exercise. Instead, this discussion is important at this time because of

    rapid developments in the field of reproductive medicine and treatments. Andrew

    Kimbrell, in an article highly critical of the current practice of the commodification

    of human parts, seeks to bring into perspective the usual statistics that

    surround the reporting of infertility. According to Kimbrell, instead of the

    popularly reported 10 million couples, infertility affects 2.3 million couples in the

    US. Therefore, slightly less than one in 12 couples are infertile instead of the

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    commonly reported one in six (Kimbrell, The Body Enclosed, 127). For a

    pastor, this means that if a churchs active membership is representative of the

    general population and it includes 12 couples in the child bearing years then

    chances are, one of these couples will face issues that the other 11 couples will

    not. As their pastor, I must be able to walk with them and so this issue becomes

    one that I cannot ignore since it will be impossible for those who are infertile to

    ignore it when their friends begin to have children.

    My purpose in this paper is to explore the issues surrounding the wonder

    of procreation and the beginning of life, fertility/contraception,

    conception/infertility and options that currant beginning of life technologies

    provide. I will seek to examine these issues in light of what seem to me to be the

    theological, philosophical, and ethical issues that arise as a result of modern

    medical technology. This discussion will then become the basis for some

    reflections on a pastoral response to couples who are living through the child

    bearing years. Couples facing these issues will not come to their pastor for an

    answer concerning the physiology of their condition. There are other and more

    appropriate sources for that information. Instead, they will come to their pastor

    for help in answering the question of why God has allowed and/or caused this to

    happen to us.

    And because the LORD had closed [Hannas] womb... she wept andwould not eat. Elkanah... would say to her, "Hannah, why are you weeping? Whydon't you eat? Why are you downhearted? Don't I mean more to you than tensons?"

    Once... in Shiloh... In bitterness of soul Hannah wept much and prayed tothe LORD.... [she] was praying in her heart, and her lips were moving but hervoice was not heard. Eli thought she was drunk and said to her, "...Get rid of yourwine."

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    "Not so, my lord," Hannah replied, "I am a woman who is deeply troubled.I have not been drinking wine or beer; I was pouring out my soul to the LORD.Do not take your servant for a wicked woman; I have been praying here out ofmy great anguish and grief." (1 Samuel 1:6-16 NIV)

    When this time comes in our pastoral ministry, will we be able respond

    with Eli, Go in peace, and may the God of Israel grant you what you have asked

    of him."

    SOMETHEOLOGICAL REFLECTIONSON THEHUMANDESIREFORPROCREATION

    There are a number of passages and Scriptural narratives that are helpful

    in this discussion. Two in particular that seem especially helpful in this

    discussion as a starting point for a theological basis of a discussion on infertility

    and a pastoral response are Genesis 1:28 and Ephesians 3:14,15.

    GENESIS 1:28

    In the beginning God created the heavens and the earth. In creating the

    sphere of the heavens and the earth, God created a space for life. Once

    created, God proceeded to fill that space with life. Intrinsic to that life, whether

    plant or animal, is the ability to reproduce itself within the space which God

    created to sustain it. The Genesis account of creation builds to the final creative

    act in which God created humanity in his own image thus making humans distinct

    from the rest of creation though sharing all that creation or creatureliness entails.

    Therefore, it cannot be said that the human capability to reproduce or

    procreate is distinctive since reproduction is intrinsic to all life on earth. The

    distinction made between humanity and the rest of creation is rather found in two

    things; our participation in the image of God and the second part of the

    imperative of Genesis 1:28 ...subdue [the earth]; and rule over the fish of the sea

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    and over the birds of the sky, and over every living thing that moves on the

    earth. Part of humanity's participation in the image of God has to do with our

    ability to subdue and rule. However, the subjugation of nature and ruler-ship

    over other animals is tied to the imperative to be fruitful, to multiply and to fill the

    earth.

    This discussion from the Creation Poem has implications for the present

    discussion. First, there is an imperative for humans to actively procreate.

    Someone once said regarding contraception and the 1960s population explosion

    rhetoric and with reference to Genesis 1:28, This is the only commandment we

    havent broken and now we are trying to break it. The wisdom or absurdity of

    such a statement is not important here, what is important is the idea that giving

    birth to children is at least a deep seated concern in human culture which uses

    something as powerful as fundamental religious beliefs to insure that it takes

    place or it is truly a fundamental concern of the Creator for us and the creation.

    In either case, we find a Scriptural basis for the concerns that are raised by our

    growing ability to control and manipulate the birth process.

    A second implication has to do with the control and manipulation just

    mentioned. Does our growing knowledge and the consequent development of

    technologies for the control and manipulation of conception fall within the second

    part of the Genesis imperative to subdue and rule? This question is intriguing for

    two reasons. First, the language of Genesis 1:28 implies that creation will not

    do mans (sic) bidding gladly or easily and that man (sic) must now bring creation

    into submission by main strength. It [nature] is not to rule man (sic) (Harris, et al,

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    Theological Wordbook of the Old Testament, 430). Since we and those things

    which adversely affect us physically are part of the realm of nature then is it fitting

    and proper for us to subdue those things which inhibit our ability to fulfill the

    imperative to conceive and give birth.

    The Genesis passage, however, brings into view another aspect of

    humanity, we are not animals only. Humans are created in the image of God.

    This alone must bring into question how far we can go and under what conditions

    we are to go about subjugating nature including subjugated human life. Even in

    a secular setting there is a basic understanding of human rights that modifies

    how we go about the business of handling technologies that directly affect human

    life at such a basic level as conception. For these two reasons then it is critical

    that we examine closely our progress in this area. I would not want to violate the

    imperative to subjugate and rule in regards to human reproduction and the

    treatment of infertility, but I want to make sure that this is carried out within a

    context and framework that respects human dignity and the idea of our being

    created in the image of God.

    EPHESIANS 3:14,15

    Before turning to a discussion of the beginning of life, it will be helpful to

    discuss briefly the idea of parenthood.

    For this reason I kneel before the Father (patera ), from whom everyfamily (patria) in heaven and on earth derives its name. (Ephesians3:14,15,)

    Although closely related to God as creator, the implication here is that the

    relationship between the creator and that which is created is more than simply

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    mechanical. The significance is that as with Gods relationship to his creatures

    as Father, so is the relationship between parents and their children. This idea

    further complicates and accentuates the heart cry of those who are unable to

    conceive a child. Procreation is not making babies. Humans do not bread. We

    create our future and extend our past. We have the capacity to transcend our

    own generation in that we can and do look to our parentage and consider lineage

    and posterity as important to who we are.

    The ideal of family relations, though greatly impaired and threatened by

    the immigrant and mobile culture characteristic of the U.S., still carries a great

    amount of weight as witnessed by The romanticization of the family in the media

    especially during the Christmas season. Here again, we witness more than a

    mere biological attempt at species preservation. The Creator himself confronts

    the breakdown of family relationships through the prophet Malachi,

    ...the LORD is acting as the witness between you and the wife of your youth,because you have broken faith with her, though she is your partner, the wife ofyour marriage covenant.

    Has not the LORD made them one? In flesh and spirit they are his. Andwhy one? Because he was seeking godly offspring. So guard yourself in yourspirit, and do not break faith with the wife of your youth. (Malachi 2:14-15 NIV)

    Thus it becomes clear that the desire for procreation and parenthood is a

    real one and that such a desire is not just the result of societal, biological, or

    family pressures, all of which are present and real, but is in some way intrinsic to

    our very being as creatures created in the image of God. It also seems that one

    can make a case for the pursuit of a cure for the problem of infertility in light of

    at least the Genesis passage and perhaps the Ephesians passage. However,

    before turning to a discussion of the technology that has developed for this

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    purpose, in my mind, one more question must be addressed- When does human

    life begin?

    THEBEGINNINGOF LIFE

    In our post-Enlightenment, Post-Christian, scientific secular age we cannot

    assume that society at large any longer holds to or even understands the

    theological/Christian concerns in this issue. Neither can it be assumed that those

    who come to us are less influenced by the now dominate secular philosophies of

    a modern or "post-modern" society. Nevertheless, in order for us to provide

    sound pastoral care to those who come to us in the setting of pastoral care, it is

    necessary for us to give serious thought to the debate of when human life

    beginnings. Indeed, such a discussion will impact our counsel and ability to

    provide a loving presence to the person or persons who approach us not only

    for help in coping with infertility, but also for those who, being fertile, are

    considering various ways of controlling or preventing conception (contraception).

    As a beginning point, the Evangelical Covenant Church has no official

    statement that either defines or that provides guidelines to help in this area. At

    best, we can look to the resolution on abortion that was adopted in its current

    form by the 1994 Annual Meeting for some insight on how we can proceed. In its

    discussion on abortion, the Annual Meeting uses ambigous language in

    reference to the unborn. However, even though no attempt at defining when

    personhood begins is made in any of the resolutions presented and adopted

    between 1984 and 1987, and again in 1994, there is a recognition of the unborn

    as human life. The 1994 revision leaves intact the original language of the 1987

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    resolution which hints at the idea that human life begins at conception: We are

    responsible to God, to ourselves, to each other, and to the new lives we are

    capable ofbringing into existence. We recognize that every sexual act could

    result in conception... (italics mine, 1994 Covenant Yearbook, 320).1

    It is not possible to make a definitive statement from this language.

    However, it affirms the Covenants basic recognition of and commitment to the

    sanctity of human life in its early formative and developmental stages. While a

    hard line cannot be drawn on when human life begins, there are some

    philosophical considerations that can help in coming to a conclusion. From the

    outset, it is commonly recognized that our understanding of the process of

    conception, development and formation of the pre-born passes through a number

    of complex and delicate stages. The question being debated is when exactly in

    this process does the pre-born become human.

    The options are: 1) at birth; 2) at that point in fetal development when the

    nervous system is fully viable; 3) at that point in embryonic development when

    the appearance of the primitive streak and implantation precludes twinning; or 4)

    at conception. The language of the abortion resolution by the Annual Meeting

    indicates that the first option is unacceptable for most if not all Covenanters and

    would probably be unacceptable to most Covenant pastors.

    In deciding when the pre-born is to be considered human is often tied up

    philosophically in the idea of personhood. If one understands personhood as

    1It must be recognized that such a resolution is not binding in any sense on the local churchesnor on individual members of the Covenant. However, since this resolution was adopted by the

    Annual Meeting it is as close as one will get to an official position on such an issue as what weare discussing here.

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    self-consciousness then the earliest possible moment that the fetus could be

    identified as human is only at the second option. This is so because, whether or

    not the pre-born is actually self-conscious at that point it is only when the neural

    system is fully formed that the capacity for self-awareness is possible(Cahill,

    The Embryo and the Fetus, 136-137; Crosby, The Personhood of the Human

    Embryo, 399-400). The problem with this view is that it is not at all certain that

    self-consciousness is an adequate way to define personhood. Is someone who

    is in a dreamless sleep, dreamless coma, or who because of pathology is

    incapable of self actualization not therefore a person? When one ceases to be

    self-conscious does that ones personhood cease to exist (Crosby, The

    Personhood of the Human Embryo, 402-404)?

    Here again, it seems that the language of the abortion resolution indicates

    that there would be discomfort with the second option since conception and

    human life are used in such close proximity as being definitive of what makes

    abortion offensive. Those who argue for the third option, do so out of an attempt

    to take into account the current understanding of embryonic development that

    has become available only in our time. The question of being and personhood is

    tied to the stability of the embryo at this particular stage of development. The

    complex interaction between sperm and egg (syngamy) resulting in the formation

    of the zygote, the passage of the zygote through the fallopian tube and its

    development (morula stage) into the blastocyst which must then successfully

    implant in the uterine wall where it can continue to develop into the embryo

    proper is too delicate and unstable a period of development for this entity to be

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    recognized as possessing humanness or personhood (Shannon and Wolter,

    Bioethics, 39-41).

    It must be pointed out that there is approximately a 60% chance that the

    process will result in failure (Cahill, The Embryo and the Fetus, 127). In

    addition to this rate of failure there is a certain instability in the zygote during

    these early stages in that twinning and recombination can take place. Also,

    throughout this first 14-21 day period the zygote is dependent on several factors:

    the progressive actualization of its own genetically coded information, the

    actualization of pieces of information that originated

    e novo during the embryonic

    process, and exogenous information independent of the control of the zygote

    (Shannon and Wolter, Bioethics, 41). However, can it not be said that even the

    adult human is dependent on a number of factors both de novo (hormonal

    activity, white blood cell production) and exogenous (cultural and moral norms,

    food production) in order to continue the process of self-actualization, albeit at a

    higher order, and it must be noted, the survival rate of adults to full potential, as

    far as we know, is zero.

    That humanness exists at conception cannot be proven or empirically

    demonstrated. But, is humanness ever empirically demonstrable? If we

    understand the person to exist holistically, that is being and physical embodiment

    are one and the same, then whether or not the environment or process of

    development are more or less stable has little to do with the humanness or

    personhood of a human being at any given point of development he or she is in.

    John F. Crosby summarizes his sustained argument for life beginning at

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    conception with this statement, I am at present embodied in my body in such a

    way that I have to assume that I was present in it from its very beginning, even

    before I awoke to consciousness; for I know that there is more to myself as a

    person than my consciousness (The Personhood of the human Embryo, 415).

    This is a brief overview of the field of discussion of when life begins. It is a

    highly philosophical discussion of which the forgoing is admittedly an

    oversimplification. In a sense human life in its embryonic stages is teleological

    and it is certainly ambiguous. Nevertheless, this helps us as we turn to consider

    infertility treatment in that we must recognize that the treatment of infertility is not

    about curing a pathology that affects the health of or the physical wellbeing of an

    adult, female or male. What is being treated is the inability to procreate and

    while there is a physiological component, the issues that must be prayerfully

    worked through are as much, if not more so, emotional, psychological, and

    spiritual. A pastoral response will seek to address each of these areas.

    TREATING INFERTILITY:OPTIONSFORTHECHILDLESSCOUPLE

    Is an infertile couple without recourse? The answer to this question is

    obviously No. There are a number of ways in which a couple can become

    parents and fulfill their parental desires. A couple may not look to the pastor as a

    resource for what these options are, but it is needful for the pastor to be aware of

    what the options are if he or she is to be prepared to be a pastor to these

    families. I will briefly present several of the most common options that are

    currently available with some reflections on ethical and moral considerations.

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    This is not an exhaustive listing but will reflect the literature available to me at the

    time of writing.

    ADOPTION: Adoption is a realistic option for the childless family. But is it the most

    desirable. This depends on several factors, some of which are: (1) what is it that

    the couple desires? If their desire is to rear children then this can be argued to

    be the best option since it does not require subjugation of the couple to medical

    treatment; (2) are there sufficient parentless children for those couples who wish

    to be parents by adoption; (3) is the couple willing to risk the unknowable's of the

    history of an adoptable child. This option is ethical from at least two points of

    view. In a consequential framework it can be said that the outcome of adoption

    is that both the couple and the parentless child are benefitted and the problem of

    childlessness and parentlessness are remedied. In addition, adoption provides a

    legal heir that for all intents and purposes is equal to a natural child and thus

    continues the history of the family. Further, society is benefitted since the

    community will no longer be burdened with the care of the child. Deontologically,

    the moral imperative of the love commandment is fulfilled by the couple and

    orphans are cared for.

    FOSTER PARENTING: This option is in many ways like that above and yet is

    distinctively different. It will perhaps be a better option for a couple with a very

    strong parental desire and a strong sense of calling. The built in

    "temporariness" of the foster care system creates unique issues for children and

    will put higher demands on the emotional and spiritual resources of the foster

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    parents, but it can also carry a great sense of fulfillment in making a significant

    difference for children in the foster care system.

    It seems to me that the same ethical evaluation applies to this option as to

    adoption. However, because of the stresses foster care places on these children

    and the foster parents, I would not recommend this option to a childless couple

    until or unless they have fully worked through the emotional and spiritual issues

    of their infertility. In addition to the ethical frameworks mentioned for adoption,

    perhaps an ethic of rights could also apply here. Do these children have a right

    to a safe, secure and loving home? If so, this must be weighed against the

    willingness of the perspective parents to give up certain rights to freedom of

    movement and having their home come under the scrutiny of the State.

    ARTIFICIAL INSEMINATION: This is a medical procedure that seeks to overcome

    male infertility. The procedure takes semen and by means of syringe, deposits it

    in or near the wifes cervix. There are generally two types of artificial

    insemination, by husband (A.I.H.) or by donor (A.I.D.). I agree with E.D.

    Schneider that A.I.H. presents few difficulties either socially or ethically

    (Schneider, 10-11). The benefits are possible pregnancy with a minimum of

    intervention or invasiveness medically. If it can be said that the wife has a right

    to become pregnant with her and her husband's child, then this right is fulfilled

    without violating the right of the husband to be the biological father of his wifes

    child. Deontologically, we could say that the Genesis imperative is fulfilled.

    However, one might raise the question of natural order in that the pregnancy did

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    not occur through "natural" sexual intercourse. However, I believe I could

    counsel a couple to consider this option.

    On the other hand, my initial reaction to A.I.D. is negative. Perhaps this

    reaction falls under an ethic of intuition. However, this raises a legitimate

    concern for me as a person who, if I am truly maturing as such, can expect to put

    some trust in intuition (Heb. 5:14). Schnieder raises several questions

    surrounding this form of infertility treatment. These range from legal issues to

    social and psychological considerations to concerns about eugenics and ethical

    questions. I would advise extreme caution for a couple considering this option

    (for a negative conclusion see Schneider, 11-29; for a positive conclusion see

    Bayles, 11-18).

    IN VITRO FERTILIZATION:2 Kimbrell points out that Although infertility did not

    increase during the 1980s, infertility treatment did. And although infertility is just

    as often a male as a female problem, it is women who are targeted by what are

    called the new reproductive technologies (Kimbrell, The Body Enclosed,137,

    sidebar). In vitro fertilization (IVF ) is developing into a common practice for

    treatment of female infertility which is the result of diseased or blocked fallopian

    tubes or when the reason for infertility is unknown or undetectable. It is also

    used in cases where the husbands sperm are abnormal and fail to respond to

    treatment (Paul Jersild, Questions About The Beginning of Life, 34). Jersild does

    not see the IVF procedure as particularly complicated, nor as being of any great

    2IVF treatment has led to the development of a number of artificial and invasive proceduresincluding GIFT (gamete intrafallopian transfer, ZIFT (zygote intrafallopian transfer), TET (tubalembryo transfer) PZD (partial zona dissection) and MESA (microsurgical epidiymal spermaspiration) (Kimbrell, 137, sidebar).

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    risk to the woman (35). However, Kimbrell describes IVF as having a dismal

    failure rate (see attached chart) and as highly invasive procedures with multiple

    doses of powerful hormones, numerous artificial inseminations, embryo

    implantations, and fallopian transfers (The Body Enclosed, 137, sidebar).

    As with AID, a distinction can be made in this procedure between IVF that

    is performed using the sperm and eggs of the husband and wife and the resulting

    child (if successful) is genetically related to both parents. Or either the sperm or

    the eggs or both sperm and eggs are from donors and thus the child resulting

    from this procedure will be genetically related to only one or perhaps neither

    parent. This, then, begs the question of what is a parent. However, upon

    reflection is the end result of a successful AID procedure substantively different

    than an adoption - only in the AID case the child is adopted before conception

    especially if the eggs and sperm are from donors.

    One sustentative concern that is raised in IVF treatment is the need for

    multiple fertilized eggs in order to increase the effectiveness of the procedure to

    justify its use. What is to be done with the extra eggs that are now fertilized

    eggs. This is an especially critical question in light of our discussion of the

    beginning of human life.

    A consequential question is raised when the natural process of conception

    is bypassed. This is a question relating to eugenics. Are genes being passed on

    into the gene pool that would not normally be, thus creating unforeseen problems

    for future generations? I only raise this question here and would not bring it up

    with a couple who sought me out for pastoral counsel. Another consequential

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    concern is for those embryos that are either destroyed because they were not

    used or are destroyed in uterine in order to improve the chances of survival for

    the stronger embryos. I again am initially intuitively uncomfortable with this

    choice. But I would not make this the sole reason for questioning its ethicalness.

    HORMONAL TREATMENTS: In this case the woman receives a regimen of hormonal

    injections in an attempt to stimulate the maturation of eggs. This was the

    procedure used by Barbara and John. There can be sever side affects related to

    this treatment including extreme swelling of the ovaries and mood swings that

    can add stress to the marriage. This treatment also increases the possibility of

    multiple births which has further implications for the health and welfare of the

    mother and children.

    The concern that I would raise with this is that the couple closely monitor

    their relationship and the effects emotionally and personality wise that this

    treatment causes. As long as these do not become greater than the possible

    good of having a child then I believe this is an acceptable option.

    SURROGATE MOTHER: IVF does not require that the wife carry or give birth to the

    child so conceived. If the wife is unable to carry the child because of uterine or

    other problems it is possible to place the fertilized egg in the uterus of another

    woman who has contracted with the couple to carry the fetus to birth and then to

    relinquish the child to the genetic parents. This is one type of surrogate

    motherhood. Other types include a woman who agrees to be impregnated by

    artificial insemination with the husbands sperm and her egg or to carry a

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    combination of donor sperm or donor eggs and the eggs or sperm from one of

    the contracting couple.

    Surrogate motherhood was practiced historically as demonstrated by

    Abraham and Sarah with Hagar. This is one of several examples of surrogacy in

    the Bible, but in each case the results bring into question the advantages.

    Consider the rivalry to this day between the descendants of Isaac and Ishmael.

    Or consider the rivalry between Jacobs sons, many of whom were born through

    surrogacy. Here again, intuition tells me to avoid this option. However, there are

    other ethical considerations that must be considered including justice and

    perhaps the rights of the surrogate mother toward the child, especially if her egg

    is used (Shanley, 624-25).

    ABIOETHICAL CONSIDERATION:

    Autonomy, nonmaleficence, beneficence, and justice are four concepts

    that are used in bioethical discussions. I will here attempt to examine the

    infertility treatments mentioned above in the light of these four concepts keeping

    in mind that in some ways this may not be an appropriate endeavor. My reason

    for questioning the applicability of these for traditional categories is because

    infertility is not a life threatening disease. Nor is It a pathology that requires

    treatment in order to alleviate physical pain. Infertility can be lived with without

    causing detriment or discomfort or disability to those who are infertile.

    The principle of justice applies appropriately to the treatments that require

    a high level of medical interventions (IVF, GIFT, ZIFT, Hormonal treatment).

    Non-comparative justice calls into question the just distribution of resources. The

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    cost of IVF is up to $10,000 per cycle (Science and Technology, 79). With a

    success rate of between 10 - 14 percent (Kimbrell, The Body Enclosed,, 137,

    sidebar) it seems hard to justify the treatment when resources for medical

    treatment in other areas where quality of life can be affected are already being

    stretched to the limit.

    Comparative justice calls into question the fairness of a procedure that

    excludes a group of people because they do not possess the resources to afford

    treatment. Is their burden of infertility any less than that of those who possess

    the resources? The same problem arises with surrogate mothering where it can

    cost $30,000 to $45,000 per child with the surrogate mother receiving $10,000 at

    the birth of a live child and as little as $1,000 if still born (Kimbrell, The Body

    Enclosed,, 139).

    REFLECTIONSONAPASTORALCARE

    In the first section of this presentation, I sought to place the experience of

    a couple experiencing infertility in the context of Gods creative activity and our

    place in that creation. In that context it becomes apparent that the desire to have

    children is more than a cultural or biological matter. Therefore, it is necessary for

    me as a pastor to affirm the validity of both the feelings that this couple is

    experiencing and to help guide/lead them into a healing exploration and

    discovery of who they are and into an experience of redemption, restoration and

    healing. By this I do not mean necessarily physical healing although prayer in

    this vein would be appropriate and has Biblical precedence. How would this

    pastoral care look? What can I do?

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    First, it seems that infertility is a type of death. As such it is a loss that

    must be processed, there needs to be a time of grieving. Helping the couple to

    recognize this and to give themselves permission to grieve can help them to

    begin the process of healing.

    As the couple comes to terms with their infertility, I would want to wait on

    them to initiate conversation about possible options. However, I would want to

    be careful to be intentional about keeping the lines of communication open.

    There will be questions that will arise about their self-worth, their adequacy as

    persons, their place in the larger community. It will be necessary for the pastor to

    keep the couple from being isolated and alone though the feeling of isolation is

    real in grief (Wolterstorff, quoted in Hauerwas, facing page vii).

    One way to help deal with these questions and the sense of isolation is to

    provide a group setting where couples of infertility can support each other. In this

    setting the couple becomes couples and the common resource and common

    experience can become a place where Gods grace can become manifest and

    real.

    Finally, prayer. Each of us must face loss with its accompanying sense of

    abandonment. The Scriptures are filled with stories of loss, beginning with the

    first couple. Contained within the Scriptures are words given by the Spirit of That

    give words for our own often unutterable pain. I believe a basic pastoral

    response would be to lead this couple to the laments of the Old Testament where

    they could find in Gods own words of lament (all Scripture is the breath of God) a

    way to pour out their heart until the song of lament becomes the prayer for

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    restoration as they begin to experience Gods healing, redeeming, restorative,

    power.

    Sing, O barren, thou thatdidst not bear; break forth into singing, and cry

    aloud, thou thatdidst not travail with child: for more are the children of thedesolate than the children of the married wife, saith the LORD. Enlargethe place of thy tent, and let them stretch forth the curtains of thinehabitations: spare not, lengthen thy cords, and strengthen thy stakes; Forthou shalt break forth on the right hand and on the left... (Isaiah 54:1-3a,NIV)

    The infertile couple does not need from me answersper se to their

    situation. They need in me a living, loving presence who will walk with them

    through this particular and poignant valley of the shadow of death.