Sunday, October 22, 2017

The Imposter Syndrome: Fear and Loathing at the Annual American Society for Bioethics and the Humanities Meeting in Kansas City

This last Thursday I arrived at the American Society for Bioethics and the Humanities annual meeting in Kansas City. This is my not my first bioethics conference rodeo, not by a long shot. I have been active in the field for twelve years and working as a professor of bioethics for ten years and still, a doctoral degree, a master’s in public health and a master’s in bioethics later…I feel like an imposter. 

I always arrive at these gatherings with a strange knot in my stomach and fear that this is the year…this is the year that I am going to be exposed for the idiot that I am…the idiot who has been play acting at this job for the last decade. I go to the affinity groups (mixers for people who have similar research interests) and look around the room at the name tags that show institutional affiliation. An inferiority complex develops when you see people who have published way more than you and who appear way more successful than you and surely collect way bigger paychecks than you, mingling with one another. No one else is laughing or smiling, just speaking a language known as Academese, where jokes are not allowed and everything is a potential micro-aggression so words are chosen with scalpel-like precision. Ten years in and I still don’t know how to act. Do I start cracking jokes and referencing Will Ferrell movies to lighten things up or adopt the serious head tilt and nod everyone else is exhibiting? Or are the serious faces and monotone conversations just evidence that everyone’s nerves are on edge too?

I got my answer this morning in the elevator on the way up to my room following the breakfast session. A confident-looking woman got on the elevator with me. I glanced down to see that she had the most impressive name badge a human could realistically have. Without naming names, she had an educational and professional pedigree that would intimidate most people to the point of stuttering and stammering and of course I immediately felt inferior. To make matters worse her immediate words to me were, “Oh let me help you!” as she reached around and tucked the tag of my shirt back into my collar (a perpetual problem for me) and then as she stepped back she whispered, “You might want to brush those out.” I looked down to see my long unbrushed hair was full of croissant flakes from breakfast. Great. I felt like a real pro.

I started to pick the croissant flakes out of my mane and apologized for my appearance, saying, “Sorry, I really am not mature enough to be allowed to be out of the house on my own. At least I remembered to wear pants. So, there’s that.” She chuckled and said, “You’re fine, it’s just nice to look out for each other. I went to your presentation by the way, and you seemed like an easy-going person who wouldn’t mind me saying something.”

“Do I have spinach in my teeth too?” I asked. She laughed and shook her head and I assured her I didn’t mind her personal grooming assistance at all. In a lovely turn of events she told me she had enjoyed the talk I had given earlier and found it very informative and thoughtful. I thanked her and said, “It was an honor to present but if I’m honest I always feel like an imposter, like somehow I snuck into the party and everyone is just indulging me because they are too polite to call the bouncer to tell me to leave.”

The woman chuckled knowingly and said, “Me too! I’ve been coming to these things for twenty-five years and I still feel like an imposter. I am just trying to enjoy all the free cheese and croissants I can before they find out and revoke my membership.” I smiled but was actually in a significant amount of shock. This woman, this pillar of the bioethics community, this peer-reviewed publishing powerhouse, this credentialed crown jewel of medical academia still feels like an imposter?

Okay, if she feels like an imposter, how many other people do too? The thought occurred to me: Is everyone just pretending to feel like they belong so as not to arouse suspicion? And where did this concept of imposter syndrome come from? Thanks to Google I quickly found out that two American psychologists, Pauline Clance and Suzanne Imes, coined the phrase in 1978. They described it as a feeling of “phoniness in people who believe that they are not intelligent, capable or creative despite evidence of high achievement.” While these people “are highly motivated to achieve,” they also “live in fear of being ‘found out’ or exposed as frauds.”

The elevator ride and the conference now long over I was back in my room before the disturbing thought settled in that maybe this feeling never goes away. If after twenty-five years and myriad accolades my esteemed elevator companion still felt an angst upon entering professional conference sessions what hope do I have of ever feeling good enough?

I flopped in the chair to watch the NASCAR race at the Kansas Speedway (appropriately enough) and texted a friend who is also a fellow bioethicist and NASCAR fan about my perpetual inferiority complex in my professional life and frustration that Dale Earnhardt Jr. hasn’t won a race yet this season. I wasn’t sure which I was more upset about.

She texted back, “Well maybe that is a good thing, it means you are smart enough to know you aren’t really that smart and aware enough to know just how much you don’t really know. If it keeps you hungry and trying to be better and learn more then why would you want to change that? Obviously, it’s been workin’ for the rock star you met in the elevator. Remember the line from Talladega Nights? “You gotta drive with the fear…”
Truer words have never been spoken...

Tuesday, December 22, 2015

What Do Blood Transfusions and Christmas Trees Have in Common?

Four years ago, Claudia, a woman I occasionally hired to clean my house, revealed to me that she and her three daughters were living in a homeless shelter after she had fled her abusive husband in the night.  Horrified by this turn of events in her life I offered to let her and her daughters move into my guest bedroom until she could save up enough money to put a deposit down on an apartment.  

About a month after Claudia and her daughters had moved in it was time to put up the Christmas tree.  The little girls were gleefully placing glass baubles on the branches of the Douglas Fir and singing along to Top 40 Christmas covers when the seven-year-old said that this was the first time they had ever decorated for the holidays.  It took me aback and I thought perhaps economic hardship had prevented them from enjoying the Christmas season in the past.  However, I had completely misread the situation.  I had stereotyped and assumed that as a Mexican-American family they were Roman Catholics and if not practicing members of the faith they surely celebrated Christmas as a secular holiday. 

As it turned out Claudia was a practicing member of the Jehovah’s Witness faith and for those who are not familiar, Jehovah’s Witnesses do not celebrate Christmas or birthdays.  When Claudia got home later that day I talked to her about her level of comfort with me baking angel cookies with the girls and decorating the house for the holidays.  She assured me she was comfortable with tree trimming and setting up the nativity scene because she knew that interfaith relationships, whether romantic, platonic or professional were a part of life and she wanted the girls to learn respect for my love of Christmas.  However, this was not the feel-good end of the conversation you might be expecting.  There were bigger and less pleasant issue still to address.

Because I am a bioethicist by profession another more uncomfortable conversation immediately formulated in my head.  In my professional experience I have been no stranger to the belief espoused by the Jehovah’s Witness faith that blood transfusions are to be avoided. Actually the Jehovah’s Witness refusal of blood transfusions is one of the text book examples of religious refusals of healthcare that you learn about in your professional training. There are several passages in the Bible, ranging from Leviticus 17:10,14 in the Old Testament to Acts 15:28,29 in the New Testament that Jehovah’s Witnesses interpret as directives to avoid blood transfusions.  This practice can prove ethically problematic when in the course of the the delivery of healthcare a person requires blood to save their life.  Thus, there are countless cases of individuals who have been brought to the emergency room, bleeding to death following a traumatic injury and the only way to save their life is through a blood transfusion…but because of their religious belief the patient has refused the life-saving measure and bled to death.  This is particularly problematic for women who hemmorhage during labor and delivery, victims of any blunt force trauma and of course hemmophiliacs.

Now Claudia’s personal religious beliefs and healthcare choices were certainly none of my business and I would never step beyond taking an intellectual curiosity in them.  What she did with her body was her prerogative and I respected that.  However, what her expectations were regarding what I would do with her children when they were in my care definitely required further conversation.

I started what I was concerned would be an uncomfortable conversation by asking her if she would approve of her children having blood transfusions if it was medically necessary to save their lives.  She gave me an unequivocal no as her response.  I approached the next stage of the conversation delicately.  Claudia would frequently leave the girls in my care while she was at work.  If something had happened with the girls along the lines of a freak accident while playing in the driveway, a slip of the kitchen knife while slicing through cookie dough, a high fall out of the big tree in the backyard or anything that might cause major blood loss for that matter, and the girls needed to be rushed to the emergency room then I would need to act as the agent for their medical care.  In an emergency situation I may be asked to give consent to medical professionals to move forward with a blood transfusion to save the girl’s lives.  If this horrible scenario ever were to manifest itself as reality I would feel ethically compelled to say yes to a blood transfusion. 

I explained to Claudia that I was happy to continue watching the girls.  However, if she left them in my care, then she needed to know that should something happen to them and I had to act as their guardian in an emergency situation, I would have to honor my personal ethical beliefs and always opt for the blood transfusion.  She did not feel comfortable with this owing to her belief that receiving the blood of another was a sin, and so we agreed that the girls and I could continue to decorate, but that going forward she would not leave the girls alone with me where I could possibly be placed in a situation where I may have to make a decision regarding the girls’ healthcare.

In our increasingly diverse society there is a strong possibility that the person caring for your child may not be of the same ethical or theological tradition as you and there are a lot of questions we simply don’t ask. Had it not been for the relatively innocuous activity of decorating a Christmas tree I don’t know how much time may have passed before I learned of Claudia’s religious beliefs. I had thought to ask about all of the girls’ food allergies and whether or not she wanted the girls to stick to vegetarian, gluten-free, sugar-free pescatarian or paleo diets but not to delve into Claudia’s theology.  Thankfully nothing ever happened with the girls.  But it stayed in my mind all these years that while we are comfortable asking people about every aspect of their parenting ideology and whether or not we can give their kids candy that may have trace elements of peanut in the nougat we aren’t always mindful of the fact that there are profound issues of faith that it is not only OK, but meaningful and essential to discuss. 

Saturday, February 14, 2015

I'm taking my lectures online...let's learn about Assisted Reproductive Technology today!


For centuries Western Civilization’s definition of parenthood, family and the purpose of marriage has been relatively straightforward.  A man and a women join together in marriage for the purpose of procreation.  When their children reach adulthood they do the same, and one generation begets another generation begets another.  For the faithful the Bible gives direction, “27God created man in his own image, in the image of God created he him; male and female created he them.  28And God blessed them, and God said unto them, ‘Be fruitful, and multiply, and replenish the earth, and subdue it: and have dominion over the fish of the sea, and over the fowl of the air, and over every living thing that moveth upon the earth’ (Genesis 1:26-28, NIV).”  The second chapter of Genesis goes on to further define the role of man and woman, “24Therefore shall a man leave his father and his mother, and shall cleave unto his wife: and they shall be one flesh (Genesis 2:24, NIV).”  This last passage has led many theologians and jurists over the millennia to interpret the purpose of marriage as that of procreation.  So if we accept that the purpose of marriage is procreation, then what happens when a couple cannot produce offspring?
            The Biblical patriarch Abraham and his wife Sarah faced this difficulty.  After years of struggling for a child they resorted to having their maidservant Hagar carry Abraham’s child in order to give the child over to Sarah to raise, resulting in one of history’s first recorded incidents of surrogacy.  Hagar’s pregnancy and subsequent delivery of Ishmael was followed shortly by Sarah’s pregnancy and delivery of Isaac, creating a schism in the family that has echoed down the centuries, as Ishmael became the father of the Arab people and Isaac the father of the Jews. 
            The Bible’s discussion of struggles regarding roles and relationships within the nuclear family are not limited to the story of Abraham, Sarah and Hagar.  Moses’ adoption by the Pharo’s daughter illustrates the emotional and ethical conflict between loyalty to one’s biological family and to the family and society one has learned to love.  Further, the story found in 1 Kings 3:16-28 of the two women presenting King Solomon with their quarrel over the baby they each claimed to be their own gives us perhaps one of history’s earliest examples of a custody battle. 
            The aforementioned stories have for thousands of years well illustrated the emotional and legal complexities that arise out of a deviation from the traditional nuclear family, however in the last quarter century, developments in assisted reproductive technology (ART) have made the ethical arguments over traditional surrogacy, adoption and custody found in the Bible seem comically antiquated.  From the fifth century BCE until the 1980s the story of Abraham, Sarah and Hagar could be transposed on almost any case of surrogacy.  The same could be said for the story of Moses and adoption and the case of the two women lobbying King Solomon for custody.  However, there is no Biblical precedent for familial relationships being created today by modern science.

The History of Assisted Reproductive Technology
            The earliest examples we have of what would constitute ART in the modern era would be attempts at artificial insemination.  Crudely put, physicians attempted to help bareen couple’s fulfill their spiritual duty to propagate by using some sort of artificial phallus to introduce semen to a woman’s vagina.
            Between 1845 and 1849, physician J. Marion Sims started on the road to becoming arguably the most famous American surgeon of the 19th century and acknowledged as the founder of modern surgical gynecology by experimenting on enslaved African American women in Montgomery, Alabama.[1]  Sims artificially inseminated 55 infertile slave women.  He produced one pregnancy, though the woman eventually miscarried.  Despite the groundbreaking work he was doing he was forced to stop his research because of moral condemnation of his methods.[2]   Though it is interesting to note that he was able to research on enslaved women in the first place because they were deemed sub-human.  However, when it became apparent that his research has applications in the white population it was deemed “un-Christian”.
            In 1884 Dr. William Pancoast, a professor at Jefferson Medical College in Philadelpha consulted with a Quaker couple who were struggling with infertility.  The husband was forty-one years of age, of sound body, had a good family history, and had never suffered from any serious illness in his life, save for a bout with gonorrhea in his youth, while sowing the proverbial “wild oats.”  His wife was ten years younger than him and was the picture of health.  Dr. Pancoast suspected that the source of the infertility was not the young wife but the husband, however it was blasphemy at that time to suggest that a man and not the woman was the source of the problem.  In order to test his hypothesis Dr. Pancoast took a sample of the husband’s sperm and when placed under the microscope he could see no spermatozoa.  Dr. Pancoast attributed this to the man’s history of gonnorhea but in order to be sure he developed an experiment.  His theory was that if the wife could be impregnated with the sperm of another man then the infertility didn’t lie with her. 
To test this hypothesis Dr. Pancoast gathered six of his medical students and collected a sperm sample from the most handsome among them.  Then, with the young Quaker woman anethetized with chloroform he used a large galvanized rubber syringe to introduce the sperm into her cervix.  The young woman became pregnant and gave birth to a baby boy.  Dr. Pancoast felt quite guilty about what he had done and eventually confessed to the husband.  The husband did not seem to mind as he was happy to have a child and felt no need to tell his wife.[3]
Scientists in the United States and Europe continued to experiment with artificial insemination but it remained a relatively taboo topic because of religious concerns that allowing a third party to facilitate the introduction of sperm to the cervix crossed the line into adultery.  This belief played out in court in 1954 when the Superior Court of Cook County, Illinois granted a husband a divorce because, regardless of the husband's consent, the woman's donor insemination constituted adultery, and that donor insemination was "contrary to public policy and good morals, and considered adultery on the mother's part." The ruling went on to say that, "A child so conceived, was born out of wedlock and therefore illegitimate. As such, it is the child of the mother, and the father has no rights or interest in said child."[4]

In Vitro Fertlization
            The next great stride in the field of assisted reproductive technology came in 1934 when Gregory Pincus, the man who would later gain fame for being the scientist who synthesized Enovid[5], claimed that he had achieved in-vitro fertilization of rabbits in Harvard laboratory. Pincus was instantly vilified in the national press for tampering with life and playing God. Due to the backlash Harvard did not grant Pincus tenure.[6] 
            Starting in the 1950s, Robert Edwards, a physiologist at Cambridge University was working on isolating hormones in mice.  One night in 1965 Edwards successfully created a human by adding his own semen to human ovum in a Petri dish.  It was a Frankensteinesque moment.  Edwards realized one of the greatest fears of those critical of scientific research into fertlization: a lone scientist, late at night, creating life in a lab.[7]   It is possible that Edwards feared the potential  criticism, ostracism and religious condemnation he would receive if he went public with his finding so he destroyed the evidence and kept his research a secret until he found a research partner in one Patrick Steptoe who could help him take his work to the next level.
            Patrick Steptoe was a small time gynecologic surgeon practicing in a small hospital outside of Manchester, England.  Steptoe had access to something Edwards did not:  human ova.  The two joined forced and over the next decade the duo set about created the first human pregnancy through in vitro fertilization.  They needed a woman and her husband who suffered from infertility would allow them to join sperm and egg in the lab and then insert the resulting embryo into uterus of the woman.  Enter John and Leslie Brown.
            John and Lesley Brown’s story sounds like the plot of an independent BBC funded film highlighting the quiet desperation of the British working class.  The couple had been trying to have a baby for the better part of a decade. John worked as a bartender in Bristol and found part time work for the railroad.  Leslie weighed and packaged cheese in a factory. Their relationship was strained by their failed attempts to have a child. Lesley’s fallopian tubes were blocked from uterine scarring.   Lesley reportedly told John, “I’ve nothing to give our marriage now that I can’t have a child.” But John, who had a daughter from a previous marriage, stuck by her, and their physician referred them to Dr. Steptoe, who was doing something that seemed like science fiction to them.
When they met with Dr. Steptoe they were confused by his language and terms like fertilization and re-implantation.  It may have all gone over their heads but they understood enough to know that Dr. Steptoe was offering them the possibility of a baby. Lesley reportedly told him that whatever he was offering she was willing to try.  She said that at night she would pray, “Dear God, I wouldn’t moan about being kept awake at night and washing dirty [diapers] if you’d let me have a child.”
            All parties went ahead with the procedure.  A healthy egg was harvested from Louise, and a sperm sample was taken from John.  Steptoe and Edwards introduced the two gametes in a Petri dish and then transferred the fertilized embryo into Lesley’s uterus.  The embryo implanted Lesley she was pregnant. 
            Dr. Patrick Steptoe performed a cesarian on Lesley Brown on July 25th, 1978 and the world’s first test tube baby, Louise Joy Brown, was born weighing in at 5 lbs 12 ounces.  News of the test tube baby had gotten out to the media during the last month of the pregnancy and reporters swarmed the tiny Oldham, England hospital.  It was the dawn of a Brave New World where children could be created outside of the marriage bed.[8] 
            It wasn’t long before IVF technology crossed the pond.  The first IVF baby born in the United States was Elizabeth Carr in 1981 and since that time fertility clinics and cryobanks across the country have been creating and storing embryos. 

Frozen Embryos
            Unlike the United Kingdom the United States, as general legal rule and political policy, does not destroy embryos.[9]  Thus, it is difficult to know just how many human embryos exist in cryo-stasis nationwide.  The Office of Populations Affairs, a division of the Department of Health and Human Services, estimates that there are more than 600,000 cryo-preserved embryos in the United States.[10]  Perhaps it is due to the strong Christian theological undercurrents of American politics that the federal government has opted to pursue a different political policy than the United Kingdom and rather than destroying frozen embryos after they have been in existence for five years the United States federal government takes a different tactic: adoption.     
The Office of Population Affairs has been authorized by Congress under Section 301 of the Public Health Service Act to publicize the existence of these embryos and promote adoption.  And this is not an inexpensive endeavor. In fiscal years 2002, and 2004 - 2010 Congress earmarked funding in the HHS annual appropriations act for an embryo adoption public awareness campaign. The purpose is to educate Americans about the existence of frozen embryos (resulting from in-vitro fertilization), which may be available for donation/adoption for family building.  Below is a record of the funds appropriated by Congress for this campaign:
·      FY 2002 - $996,000
·      FY 2004 - $994,100
·      FY 2005 - $992,000
·      FY 2006 - $1,979,000
·      FY 2007 - $1,980,000
·      FY 2008 - $3,930,000
·      FY 2009 - $4,200,000
·      FY 2010 - $4,200,000
·      FY 2011 - $2,000,000
·      FY 2012 - $2,000,000
·      FY 2013 - $980,000

But federal monies are not the only funds used to spread the word about embryo adoption.  The largest contributors to the embryo adoption are Christian organizations that have a vested theological interest in promoting embryo adoption,  a vested financial interest or in the case of Nightlight Christian Adoptions, the nation’s leading embryo adoption agency, both.
            Since 2006 the largest private donors to the federal embryo adoption program have been Nightlight Christian Services, Bethany Christian Services and the Baptist Health System Foundation who have all donated in the millions.[11]
            But what exactly are they donating millions for?  It is for a process known as heterologous embryo transfer that may represent the most theologically, ethically and morally troubling dilemmas of our time.

Heterologous Embryo Transfer (HET)
            Heterologous Embryo Transfer (HET) is the transfer of a genetically unrelated embryo into the uterus of a woman.  In its most basic form it raises few eyebrows, as surrogacy is relatively uncontroversial and common practice.  However, the introduction of the phenomenon of embryo adoption has complicated HET, a technology that has been in existence since 1983[12], to new levels that rival the plotlines of the most cutting edge science fiction novels.
Imagine this scenario:  A heterosexual couple wants to have a child, but the woman cannot conceive, or can conceive but is unable to carry the fetus to term.  Desperate for a child the couple seeks out assisted reproductive technology (ART).  The man’s sperm and the woman’s ovum are harvested and fertilized in a laboratory to create two embryos.  The physicians and fertility specialists perform Preimplantation Genetic Diagnosis (PGD) on the two embryos to determine which one is more viable or shows genetic traits that the parent’s consider preferable.  The more desirable embryo is implanted, the woman becomes pregnant and the couple is blessed with a child.  The couple is satisfied with their one child and so they choose not to pursue a second round of in vitro fertilization (IVF) with the surplus embryo they created.  Time passes and the fertility clinic where the couple’s less desirable surplus embryo has been frozen in liquid nitrogen is closing.  The couple is contacted by the fertility clinic and given four options as to what they can do with their excess embryo: 1) they can have it implanted in the woman and attempt to have a second biological child, 2) they can have the embryo destroyed, 3) they can donate the embryo to science for stem cell research, or 4) they can place the embryo up for adoption.
            The couple has already decided that they only want one child and rule out a second pregnancy as an option.  Because they believe that life begins at conception, at the moment an embryo is created, the idea of destroying “life”, their combined DNA, which could ultimately develop into a person is contradictory to their religious beliefs and so they decide against destroying the embryo.  Donating the embryo to science is at first appealing to the couple but upon learning of the legal regulations placed on the use of embryos in stem cell research in this country they chose not to pursue that avenue, further, the embryo would be destroyed if used for scientific research which contradicts their religious beliefs and defaults them back to the position they took for the second option.  Ultimately they decide to give their surplus embryo up for adoption.
            An adoption agency enters the picture at this point, taking custody of the frozen embryo.  The adoption agency begins interviewing potential parents for this embryo.  A second heterosexual couple approaches the adoption agency wanting to adopt the embryo that the first couple gave up for adoption.  The woman in the second couple wishes to be implanted with the surplus embryo of the first couple and the man pledges to support the woman, his partner, during the pregnancy and assuming the embryo successfully develops into an infant he pledges to raise the infant as his own adopted child.  However it is discovered that the woman in the adoptive couple has a medical condition that precludes her from carrying a fetus to full term.  The couple still wishes to proceed with the adoption so they hire a woman to serve as their surrogate.
            A third couple is introduced to the scenario, with the women in the third couple agreeing to serve as the surrogate in exchange for a cash payment.  The women in the third couple is implanted with the surplus embryo created by genetic material of the first couple and is being financially supported by the second couple.  The man and woman in the third couple experience the nine months of development of the embryo inside the woman’s womb.  The man feels the fetus kick as he cares for his partner who is the surrogate and they both find they are developing an emotional connection to the fetus.
            When the surplus embryo turned fetus is finally delivered and a baby boy is born, he is born into a world with three sets of parents.  The first couple are his genetic parents, without whose DNA he could not exist, and whose physical traits he will exhibit.  The second couple are his adoptive parents, who played just as great of a role in making his existence possible as his genetic parents in that their financial support and commitment to see his development from embryo to full human being has made his birth possible.  Finally, the third couple are his surrogate parents, without whose physical presence, particularly the woman’s womb, he would not exist beyond the embryo form.  So while there are arguably three sets of parents there is yet a fourth party integral to this process.  It was the embryo adoption agency that facilitated the transfer of the frozen embryo from cryobank to womb. 
            Now a beautiful baby boy is born, however he has a few health problems, such as poor vision, an enlarged heart and a metabolic disorder.  The adoptive parents love their new baby boy, however they are dismayed at his health problems and question whether or not their new son’s health problems are the result of genetic abnormalities, misconduct on the part of the surrogate parents, or the fact that their new son existed in embryo form, encased in liquid nitrogen in suspended animation for over a decade[13], before being implanted into the surrogate mother.
            Facing a litany of medical procedures for their new adopted son the adoptive parents track down the genetic parents.  Upon learning that their surplus embryo, is now their biological son and he being raised by another couple, they are so emotionally moved that they pursue legal action and sue for custody of their genetic child.  The adoptive parents have no intention of relinquishing custody of their adopted child.  To further complicate matters the surrogate parents have an emotional attachment and the woman has a biological attachment to the child and enter the custody battle to become the legal parents of what the woman claims is her biological albeit not genetic child. 
            Given the scenario just outlined, how would the legal system or the religious community ever begin to sort this matter out?  There are no court cases documented in the United States in which a scenario like this taken place, however, there is no legislation currently in place that would prevent such a hypothetical scenario from becoming reality.  The scientific technology currently exists that would make the birth of a child with three sets of parents with legal claim to him or her completely possible.  Further, embryo adoption is not the stuff of science fiction novels.  Embryo adoption is a thriving industry functioning within the legal framework of the United States constitution.[14] 
            Bringing a child into the world by traditional means is a process fraught with moral, ethical and emotional complications.  Bringing a child into the world by non-traditional means, such as heterologous embryo transfer (HET) increases the complications exponentially, begging questions such as what defines a parent (genes, love, pregnancy and delivery, etc…) and who does the child belong to?  But does an increase in complications translate into the process being morally or ethically wrong?  Bringing a child into the world and raising it to adulthood has never been an easy exercise but the human race has not ceased to procreate simply because the process is too difficult.  In fact, as the ethical ante has been raised it seems more people are having children through more scientifically diverse ways.  Getting past the fact that there will inevitably be emotional and legal conflicts between the multiple forms of parents created in the process of heterologous embryo transfer a larger question looms: is it ethical, both legally and theologically, to bring life into the world outside the normative standards of the ages?

Embryo vs. Person
            Is an embryo human life?  Biologically speaking an embryo is the fertilized genetic material of a man and a woman, the earliest recognized form of individual human life, the product of human conception up until the third month of pregnancy.[15]  However, it is tantamount to a parasite.  It cannot live on its own, it is entirely dependent on finding a host and if it finds a host (i.e. a uterus), it can potentially develop into human life but there is no guarantee of that.  As an embryo it exists only as potential personhood.  If an embryo does not find a host following sexual intercourse it is discarded from the body never to be considered a person with moral status.  However a new era in science has ushered in a new moral, legal and ethical status for the embryo, that of the potential person kept frozen in a state of suspended animation.  But the question is, for how long and to what end?
            Do frozen embryos have a right to life?  If the answer is yes, do they have a right to life that is lesser, equal to, or greater than the rights you or I have to life?  There is a feel-good saying that often gets thrown out during pep talks, “the first race you ever ran you won,” referring to the race of the spermatozoa to fertilize the egg.  Does the winning of that race earn you a right to life or does the right to life begin when you are physically able to exist separate from your mother?  And is it the luck of the draw who makes it to the independent viability, Darwinian adaptability, divine providence or is it the result of the careful strategic selection of traits by a scientist leaning over a Petri dish?
            One of the major concerns about heterologous embryo transfer is that regardless of whether you put stock in the luck of the draw theory, divine providence or Darwinism, all are violated by the process of human embryo selection.  But for those in the Darwinian camp heterologous embryo transfer is especially problematic.  This is due to the fact that the vast majority of surplus embryos implanted in adoptive mothers or surrogates were deemed surplus for a reason.  Frequently couples who undergo treatment for infertility are older and may have lower sperm counts, less viable eggs or other age-related conditions to contend with or they may have hereditary conditions which make embryos less likely to thrive.  Either way, in a natural environment such individuals would be, in Mendelian terms, less likely to produce viable, healthy offspring.  Thus, when these individuals seek out assisted reproductive technology scientists use artificial means such as preimplantation genetic diagnosis to select out the genetic material that is the most viable, creating an unnatural advantage for survival for the resulting embryo.  The weaker or less viable embryos are not implanted because they are deemed less likely to result in a normal baby.  These less viable embryos are considered surplus and placed in cold storage until a decision can ultimately be made about their fate.
            So allow yourself to imagine the realities and the possibilities.  Five, ten, twenty, a hundred years later an embryo adoption agency comes along and pulls an embryo out of the liquid nitrogen and implants it in a woman.  Not only is it likely that the embryo will have genetic traits and other characteristics that made it less suitable for implantation at the time of its creation, but it has been in deep freeze for a prolonged period of time and no scientific data currently exists to tell us what the effects of cryostasis are on the development of the embryo.[16]
            All factors considered is it ethical to bring a life into this world, with the knowledge that that it may be at an increased risk for disability?  This question is profoundly difficult to answer and to make the argument against bringing life into the world on the basis of potential disability is to run the risk of slipping into the ideology of the Third Reich with the concept of “life unworthy of life”.[17] 
            Finding a solution to this ethical dilemma requires a careful treatment of the theological concepts of family and human life.  These concepts then need to be contextualized in order to be serviceable in a twenty-first century context. 
The Christian is directed to imitate God in a variety of ways.  The Catholic doctrine of Imitatio Dei can be traced back to the origins of the Christian church.  Drawing from the scriptures it directs the believer to imitate the essence of God.  Matthew 5:48 says, “Therefore you are to be perfect, as your heavenly father is perfect.”  Luke 6:36 says, “Be merciful, just as your Father is merciful.”  Christians are also directed to imitate the actions of God based on emulating the life of Christ.  Paul says in 1 Corinthians 11:1 “Follow my example, as I follow the example of Christ.”
            Doing as Christ would do came to the forefront of theological thought at the end of the 19th century with the Social Gospel of Walter Rauschenbusch and the publication of Charles Sheldon’s 1896 book In His Steps: What Would Jesus Do?  A century later the motto What Would Jesus Do? was being printed on everything from bracelets to Bibles and being used as a battle cry for the Evangelical movement in the United States.  And while the concept of What Would Jesus Do? is helpful for solving most ethical problems the Christian faces in daily life it is woefully inadequate for dealing such a complex and nuanced issue at heterologous embryo transfer.  Imagine staring at your “WWJD” bracelet and asking, “Should I hire a surrogate and have the embryos of a third party couple implanted in her so that when the embryo has gestated I can raise it as my own adopted child?”  The scenario may seem comically absurd but the fact remains that for a Christian navigating the moral and ethical convolutions of heterologous embryo transfer there are no obvious answers to be found in the Bible or in most denominational teachings.
            Literal interpretation of scripture, personal interpretation of the accounts of Jesus’ life and two thousand years of ecclesiastical history have still left theologians and ethicists grasping for some sort of religious foundation upon which to build an argument for or against heterologous embryo transfer.  The situation has also left faithful Christians with surplus embryos wondering what the Christian thing to do is.

Why HET?
            Before one can make the argument for or against heterologous embryo transfer it is helpful to first discuss why this practice takes place.  Typically when a woman seeks to become pregnant via assisted reproductive technology (ART) several of her ova are harvested and then fertilized with the sperm of her husband, domestic partner or a sperm donor.  The physician selects a few of the fertilized ova, also known as embryos, to be implanted in the woman.  Assuming the woman becomes pregnant the physician stops fertility treatments and the leftover embryos get placed in cryo-stasis.
            One day, long after the woman has given birth to the child she conceived through in-vitro fertilization the fertility clinic goes bankrupt and has to figure out what to do with all of the surplus embryos it before it closes.  Workers at the clinic cannot locate the mother or perhaps they can locate the mother but she relinquishes her claim to the embryos.  The fertility clinic now has to decide what to do with these embryos.  The fertility clinic, having gone bankrupt is now facing the closure of their facility and the power being turned off.  No electricity means the embryos will thaw and be destroyed.  Hearing of the impending destruction of embryos a Christian group, who believe the embryos to have the same moral status as a fully gestated human being, agrees to take physical and financial responsibility for the embryos and find adoptive parents for them.  The fertility clinic relinquishes custody and turns the embryos over to the Christian group. 
            While this may seem to some like a far-fetched scenario be assured it is not.  On August 1, 1996, two hundred women in the small village of Massa, Italy who were members of a Catholic women’s association asked the British government if they could adopt 3,300 frozen embryos that were scheduled for destruction.[18]  Under British law frozen embryos that go unclaimed after five years are thawed and discarded.[19]   The women of Massa, most of who were married and already mothers, asked to adopt these embryos in order to stop what they saw as mass infanticide.  The British government did not grant their wish but this event was just the beginning of a series of movements led mostly by Christian groups in the United States, on a crusade to save embryos from destruction.
            Despite their intention to perform their Christian duty to save embryos, the proposal by the women of Massa was immediately criticized by the Vatican and many members the Roman Catholic academic community.  The Osservatore Romano, the Vatican daily newspaper, reported the remarks of theologian Gino Concetti: “These couples deserve all our admiration, but their choice is not provided for in the teachings of the Magisterium of the Church. If we accept it, it would make a breach and embryo production would become an endless chain.”[20]  Adriano Pessina, professor of moral philosophy at the Catholic University in Milan was even more explicit: “Stop the machines; let those frozen embryos die in the cold limbo of technological tyranny.  If we allow their implantation, we will be accepting that it is morally decent to divide the act of union and the act of procreation” (a reference to Vatican theology of sex in marriage as a singularity of union and procreation).[21]  However, this opinion about doing away with the embryos is not universally shared by the Catholic hierarchy.  Cardinal Ersilio Tonini agreed with efforts to adopt the embryos in order to prevent them from being destroyed.  He was joined in that position by the president of the Italian National Bioethics Committee, Francesco D’Agostino, who remarked, “The British position that envisions the suppression of the redundant embryos five years after their production, cannot be justified easily and rationally.  It is ‘embryocide,’ since there is no respect for embryos considered as human life.”[22]
            The Catholic Church has by far the most well developed theology to address the issue of heterologous embryo transfer and even with the countless volumes that have been written by Catholic scholars on the moral status of the embryo and the normative conditions of the family the Catholic church cannot come to a consensus on how to approach this issue.

Why Not HET?
            In 1987 the Congregation for the Doctrine of Faith of the Roman Catholic Church issued a statement that has left Catholics and many other Christian denominations who look to the Catholic church to lead the way in Christian bioethics in a moral and ethical quandary:
The freezing of embryos, even when carried out in order to preserve the life of an embryo constitutes an offense against the respect due to human beings by exposing them to grave risks of death or harm to their physical integrity and depriving them, at least temporarily, of maternal shelter and gestation, thus placing them in a situation in which further offenses and manipulation are possible.[23]
However, the document also goes on to say that while the existence of these frozen embryos is wrong they are indeed human beings and as such:
…have the right to be treated with the dignity due all human beings.  The human being is to be respected and treated as a person from the moment of conception; and therefore from that same moment his rights as a person must be recognized, among which in the first place is the inviolable right of every innocent human being to life.[24]
            Thus, the embryos should not exist, but once they do they should not be destroyed nor can they be used for experimentation.  Of course they cannot be left frozen either, because leaving them in cryostasis is depriving them of maternal shelter and exposing them to further indignity.  So if they cannot be kept frozen and they cannot be destroyed the only option left is to implant them in a woman.  However this is forbidden because it will result in, as Professor Adriano Pessina, put it, “accepting that it is morally decent to divide the act of union and the act of procreation”.  Is this not a theological Catch-22?
Procreation as the Purpose of Marriage
            Is procreation the purpose of marriage?  Most Judeo-Christian writings on the matter say yes.  Throughout the centuries Jewish rabbis have told the Jewish people that “one without children is considered as though dead” and an early Talmudic source said, “he who does not engage in procreation is as if he diminished the divine image.”[25]  The most often quoted verse in Christianisty regarding the purpose of marriage is Genesis 2:24 which says, “Therefore a man will leave his father and mother and cleave unto his wife: and they shall be one flesh”.  A third century BCE Stoic text reads, “We have intercourse not for pleasure but for the maintenance of the species.”[26]  Just in case there was any ambiguity left regarding the matter of whether procreation is the purpose of marriage Paul cleared it up in 1 Timothy 2:15, “Woman will be saved through bearing children.”  And lest one assume that procreation as the purpose of marriage is an antiquated notion no longer held in regard by anyone save for the deeply devout there is the case of Goodridge v. Department of Public Health.[27]  When Massachusetts state officials were faced with a lawsuit by same sex couples for the right to marry the state’s lawyer’s main argument was that, “making babies was the first purpose of marriage.”[28]
            Martin Luther saw the goal of marriage to be procreation.  He believed that God’s words in Genesis 1:28, “Be fruitful and multiply,” represent more than a command, they were, he said, “a divine ordinance which it is not our prerogative to hinder or ignore.”  This led him to reject celibacy as a special spiritual state and to encourage even priests, monks and nuns to marry and have children.  Luther wrote:
 We were all created to do as our parents have done, to beget and rear children.  This is a duty which God has lain upon us, commanded, and implanted in us, as is proved by our bodily members, out daily emotions and the examples of all mankind.[29]
            If Luther directed us to do as our parents did and beget children, and we interpret him literally, then heterologous embryo transfer would not be permissible for Protestants. Our parents did not have the technology available to them to even consider the possibilities of heterologous embryo transfer, nor perhaps could they imagine the possibility that one could beget an embryo that could be placed in suspended animation for five, ten, fifty or one hundred years, and then be thawed and brought to maturity.  Perhaps the question is not could our parents or grandparents have imagined their child being born long after their death but we should ask ourselves, can we imagine it?  And assuming we come to terms with the understanding that our progeny, our embryos, can be produced outside out bodies, frozen, thawed, implanted in other individuals, raised by other people long after we are dead and gone, can we understand the embryo as a person with all the equal rights we would accord a living, breathing human we can see and touch and who can live on his or her own?
            Returning to the concept of procreation as the purpose of marriage, if most denominations still hold that producing offspring is the Christian duty of the married couple, then what lengths should couples go to in order to beget the next generation?  What is more important, producing offspring as God commanded us at the cost of the production of several unwanted embryos or preventing the creation of surplus embryos through artificial means but not ever producing children?  The Catholic Church, when pressed, places the importance on procreation but admonishes those who use assisted reproductive technology, while most Protestant denominations are still undecided on the matter.  But for those Catholic couples who, despite the dictum against assisted reproductive technology, still receive fertility treatments and produce multiple embryos the Vatican’s position is that the couple commit to having all the embryos implanted and raising them to maturity [30] So if a couple has eight embryos created through the in-vitro fertilization then the woman is encouraged to have all eight embryos implanted whether she wants eight children or not.  For the Catholic faith the moment sperm and egg touch and fertilize a new human is created and ensouled by God and has a right to reach maturity and be born.

Embryo vs. Person
            Is an embryo human life?  Scientifically speaking, yes, an embryo is the earliest identifiable stage of human development.  When sperm and egg join, it produces a genetically unique organism that has the potential to develop into a living, breathing, walking, talking, nascent human being.  But just because it represents the earliest identifiable point on the spectrum of human growth and development does that mean that is has a right to life, the same way a five-year old girl or a fifty-five year old man does?  Does the embryo have a fundamental right to life despite the fact that is cannot survive on its own?  The Catholic Church and many Protestant denominations say yes.  In fact, the state of Louisiana has ruled that the embryo has more of a right to life than a fetus in the womb.  Louisiana law recognizes a human embryo outside the womb as a “juridical person” and prohibits the destruction of a viable fertilized ovum.[31]  However, abortion is still legal until the third trimester.  So a frozen embryo, which is not nascent, has no organs, no qualities resembling a human being save for 46 chromosomes, has more right to life and protection under the law than a fetus, with a heartbeat, developing inside a mother’s womb.  It makes one wonder whether the lawmakers asked themselves what Jesus would do?

Theological Condonation or Condemnation of HET
            It has proven difficult enough for the Roman Catholic church to produce a definitive doctrinal statement on what should be done with the surplus embryos resulting from in-vitro fertilization, imagine the difficulty smaller Protestant denominations face in determining their theological position on the matter.  The Catholic Church has the academic and financial resources to employ panels of scientists, scholars and theologians to sift through the massive amounts of materials available on the matter and examine every possible extenuating circumstance.  The Roman Catholic Church also has a concrete starting point to work from: life begins at conception, life should never be taken by anyone but God, and life should be the product of the marriage bed without the involvement of artificial reproductive technology.  How does a denomination begin to wade through the mire of ethical dilemmas when it does not a concrete position on when life begins or whether assisted reproductive technology is morally wrong or not?

Seventh-day Adventism and HET
            In 1994 the Seventh-day Adventist General Conference issued the official guidelines on assisted reproductive technology to the members of the church.  Because the Seventh-day Adventist faith does not have an official position on when life begins the church guidelines for abortion, assisted reproductive technology, stem cell research and the moral status of the human embryo are much more flexible than in Catholocism.  However, the belief that reproducing is part of God’s plan remains the same, though it is important to note that in Seventh-day Adventism procreation is not considered the purpose of marriage, simply something that occurs in the natural course of marriage.
            Assisted reproductive technology is condoned provided it falls within the guidelines of the church, which are as follows:
Human reproduction is part of God's plan (Gen 1:28), and children are a blessing from the Lord (Ps 127:3; 113:9). Medical technologies that aid infertile couples, when practiced in harmony with biblical principles, may be accepted in good conscience.[32]
            While allowing assisted reproductive technology within the practice of the faith the Seventh-day Adventist church is hesitant to encourage it when it extends beyond the use of technology to assist a married couple in conceiving their own child.  The church’s guidelines go on to say:
                  God's ideal is for children to have the benefits of a stable family with active participation of both mother and father (Prov 22:6; Ps 128:1-3; Eph 6:4; Deut 6:4-7; 1 Tim 5:8). For this reason, Christians may seek medically assisted reproduction only within the bounds of the fidelity and permanence of marriage. The use of third parties, such as sperm donors, ovum donors, and surrogates, introduces a number of medical and moral problems that are best avoided. Moreover, family and genetic identity are significant to individual well-being. Decisions regarding assisted reproduction must take into consideration the impact on family heritage.[33]
Without ever committing to a specific point at which life begins the document does acknowledge that care and concern must be taken upon entering into the process of assisted reproductive technology so that the embryos and genetic material used in the process is handled in an ethical manner:
Human life should be treated with respect at all stages of development (Jer 1:5; Ps 139:13-16). Assisted reproduction calls for sensitivity to the value of human life. Procedures such as in vitro fertilization require prior decisions about the number of ova to be fertilized and the moral issues regarding the disposition of any remaining preembryos.[34]
It has been fifteen years since the General Conference of the Seventh-day Adventist church issued these guidelines and in those years the technological advances involving embryos have outstripped the imaginations of most of the members of the committee who drew up this document.  Notice the wording, “preembryos”, referring to the sperm and egg, does not address the status or disposal of an embryo.  This distinction in the wording leaves the Seventh-day Adventist church at present with no official statement on the status of the embryo.

The Ultimate Decision
            In order to make any headway in this discussion the Seventh-day Adventist Church needs to come to a consensus as to what the moral status of the human embryo is.  Perhaps the best way to determine how the church should view the embryo is to examine the church’s statement on the fetus.
            The Seventh-day Adventist Church’s “Guidelines on Abortion” state the following:
Prenatal human life is a magnificent gift of God. God's ideal for human beings affirms the sanctity of human life, in God's image, and requires respect for prenatal life. However, decisions about life must be made in the context of a fallen world. Abortion is never an action of little moral consequence. Thus prenatal life must not be thoughtlessly destroyed. Abortion should be performed only for the most serious reasons.
            Prenatal life must not be thoughtlessly destroyed but the destruction of an embryo, or thousands of embryos for the greater good should be permissible in the faith if it is done to prevent suffering.  The over 400,000 known embryos in suspended animation in liquid nitrogen across this country can potentially serve two purposes.  Their destruction for use in medical research could open new doors in regenerative medicine that could ease the suffering of millions.  At the same time the destruction of the embryos could be considered one of the greatest instance of genocide in history.  But what of leaving these embryos in cryostasis?  What does it mean theologically, morally, ethically and socially to know that an embryo that is genetically your uncle, your aunt, your son or your daughter is frozen in suspended animation and could potentially be implanted, gestated and raised to maturity at any time in the future based on the decisions of scientists in a laboratory.  What does this phenomena do to the idea held so dear in the Christian faith that God knows and chooses the time and the place of your birth?
            Decisions will have to be made.  Theologians will be divided.  Scholars of Ecotheology will see the injustice in harming the earth with the vats of liquid nitrogen necessary to keep these embryos frozen.  Christian leaders will see the injustice in the extermination of hundreds of thousands of humans in embryonic form as they are thawed.  Decisions will have to be made but perhaps not by us.  If we cannot come to a consensus then there is another option.  We can do nothing, leave the embryos just as they are and let the next generation decide.

[1] Wall, L.L. "The Medical Ethics of Dr. J Marion Sims: A Fresh Look at the Historical Record." Journal of Medical Ethics 32, no. 6 (2006): 346-50.

[2] Pence, Gregory E. Medical Ethics: Accounts of Ground-Breaking Cases.  New York: McGraw Hill, 2008. p. 99.

[3] Dr. Pancoast kept the secret of this experiment for twenty-five years until he decided to write a letter to the editor of The Medical World which was published the letter in the April 1909 issue (pages 163-164).  The letter was later reprinted in:   Gregoire, A.T., and R.C. Mayer. "The Impregnators." Fertility & Sterility 16 (1964): 130-34.

[4] Doornbos v. Doornbos, 23 U.S.L.W. 2308 (Superior Court, Cook County, Ill., December 13, 1954)

[5] On May 11, 1960 the FDA approved Enovid, the first oral contraceptive pill on the market.  Pincus had synthesized the compound in his lab with funding from Margaret Sanger and Katherine McCormich.  See: Junod, Suzanne White. "The Pill at 40." FDA Consumer 34, no. 4 (2000): 36.

[6] Biggers, John D. "Ivf and Embryo Transfer: Historical Origin and Development." Reproductive BioMedicine Online 25, no. 2 (2012): 118-27.

[7] Pence, Gregory E. Medical Ethics: Accounts of Ground-Breaking Cases.  New York: McGraw Hill, 2008. P. 97.

[8] Pence, Gregory E. Medical Ethics: Accounts of Ground-Breaking Cases.  New York: McGraw Hill, 2008. p. 99.

[9] The United Kingdom has a five-year moratorium on frozen embryos so that those that are not used within five years of their creation are destroyed.

[10] OPA. "Embryo Adoption." Office of Populations Affairs,

[11] OPA. "Embryo Adoption." Office of Populations Affairs,

[12] Brakman, Sarah-Vaughan, and Darlene Fozard Weaver, eds. The Ethics of Embryo Adoption and the Catholic Tradition: Moral Arguments, Economic Reality and Social Analysis, Philosophy and Medicine / Catholic Studies in Bioethics. New York City: Springer Publications, 2007. p. 6.

[13] As of 2006 the longest an embryo has remained in cryostasis before being thawed for implantation was 13 years.  However, the current record is 20 years.  In May 2010 a 42-year-old woman gave birth to a baby boy that had been frozen at the embryonic stage since 1990. For more information see: Lopez-Teijon, M. "Case Report: Delivery of a Healthy Baby Following the Transfer of Embryos Cryopreserved for 13 Years." Reproductive BioMedicine Online 13, no. 6 (2006): 821-22.  AND  Dowling-Lacey, Donna, Jacob F. Mayer, Estella Jones, Silvina Bocca, Laurel Stadtmauer, and Sergio Oehninger. "Live Birth from a Frozen-Thawed Pronuclear Stage Embryo Almost 20 Years after Its Cryopreservation." Fertility & Sterility 95, no. 3 (2011): 1120.

[14] The most well known of the established embryo adoption agencies is Nightlight Christian Adoptions and their Snowflakes Program, named for their belief that each embryo is unique, like a snowflake.  The Snowflakes Program has over 600,000 embryos which they are currently looking to adopt out to families.  Nightlight Christian Adoptions boasts that 343 children have been born as a result of the Snowflakes Program. "Snowflakes Embryo Adoption and Donation." Nightlight Christian Adoptions,

[15] McGraw-Hill, Embryo, in McGraw-Hill's Access Science Encyclopedia of Science & Technology Online. 2009, McGraw-Hill.

[16] Brakman, Sarah-Vaughan, and Darlene Fozard Weaver, eds. The Ethics of Embryo Adoption and the Catholic Tradition: Moral Arguments, Economic Reality and Social Analysis, Philosophy and Medicine / Catholic Studies in Bioethics. New York City: Springer Publications, 2007. p. 8.

[17] Glass, James. Life Unworthy of Life: Racial Phobia and Mass Murder in Hitler's Germany.  New York Basic Books, 1997.

[18] Demartis, F. "Mass Pre-Embryo Adoption." Cambridge Quarterly of Healthcare Ethics 7, no. 1 (1998): 101-103.

[19] Boulton, Alison. "Britain Poised to Extend Storage of Frozen Embryos." British Medical Journal 312, no. 7022 (1996): 10.

[20] LaRocca, O. 1996. "Adotare no gli embrioni, รจ lite tra teologi e cardinali." La Republica, July 27, 1996, 22.

[21] Boulton, Alison. "Britain Poised to Extend Storage of Frozen Embryos." British Medical Journal 312, no. 7022 (1996): 10.

[22] Boulton, Alison. "Britain Poised to Extend Storage of Frozen Embryos." British Medical Journal 312, no. 7022 (1996): 10.

[23] Sacred Congregation for the Doctrine of Faith, Donum Vitae, 1987, part 1, no. 6.
[24] Sacred Congregation for the Doctrine of Faith, Donum Vitae, 1987, part 1, no. 1.

[25] Babylonian Talmud Nedarim 64b and 63b.  Cited in Lewis D. Solomon, The Jewish Tradition, Sexuality and Procreation. Lanham, MD: University Press of America, 2002.
[26] Harder, Richard, ed. Ocellus Lucanus: The Nature of the Universe. Berline: Weidman, 1926. Section 44.

[27] Goodridge v. Dept. of Public Health, 798 N.E.2d 941 (Mass. 2003)

[28] Carlson, Allan C. Conjugal America: On the Public Purposes of Marriage.  Piscataway, New Jersey: Transaction Publishers, 2006.

[29] Luther, Martin. "An Exhortation to the Knights of the Teutonic Order That They Lay Aside False Chastity and Assume True Chastity of Wedlock." In Luther's Works Vol. 45, 1523. P. 155.
[30] Brakman, Sarah-Vaughan, and Darlene Fozard Weaver, eds. The Ethics of Embryo Adoption and the Catholic Tradition: Moral Arguments, Economic Reality and Social Analysis, Philosophy and Medicine / Catholic Studies in Bioethics. New York City: Springer Publications, 2007.

[31] La. Rev. Stat. tit. 9, §§ 123, 129 (West 2000).
[32] This document was recommended by the Christian View of Human Life Committee at Pine Springs Ranch, California, April 10-12, 1994, and was voted by the General Conference of Seventh-day Adventists Administrative Committee (ADCOM), Silver Spring, Maryland, July 26, 1994.  See:      

[33] General Conference of the Seventh-day Adventist Church. "Official Statement: Considerations on Assisted Human Reproduction." Silver Springs, Maryland: General Conference of Seventh-day Adventists Administative Committee (ADCOM), 1994. Section 3.

[34]  General Conference of the Seventh-day Adventist Church. "Official Statement: Considerations on Assisted Human Reproduction." Silver Springs, Maryland: General Conference of Seventh-day Adventists Administative Committee (ADCOM), 1994. Section 4.