Moral Decisions 4

Article #48 MORAL DECISIONS -- In the Name of Love by Reverend Monsignor James J. Mulligan All sorts of things have been done in the name of love. Some of them magnificently heroic. But horrors have been committed as well. Lovers have carried out suicide pacts. Mercy killings have occurred. In the case of Jimmy Jones some years back, hundreds of people committed suicide all in the name of love. Sex in marriage should be an act of love and so it should be both unitive and procreative. It should express the bond of unity between husband and wife and it should also help to strengthen that bond. Love should be mutually creative and in marriage the sexual expression of love should be open to the mutual creation of a new life. The two elements are inseparable and neither of them should be wilfully destroyed or set aside. The sexual relationship of husband and wife is the physical dimension of their much deeper love and self-giving. Our bodies are not just objects that we can manipulate in whatever way we choose. In the early days of the Church there was a heretical group called the Gnostics. They saw the body as worthless. It was no more than a thing to be used. It was, for some of them, a sort of prison in which the real person, the soul, was trapped. The Scriptures and the Church have always seen the value and the sacredness of the whole person, body and soul. The wholeness of the person is also the source of the wholeness of the sex act in marriage. It is in and from this act that children should be conceived and born. Our physical acts are not separated from the spiritual in such a way that the spiritual has one moral meaning and the physical another. Although it is clear that our loves and relationships belong to the order of the spirit, it is in and through the bodily and physical that they come into being. To attempt to divorce one from the other is as foolish as trying to explain our appreciation of good music as a spiritual reality without reference to our ears. What I am getting at is this: Even when a couple undergo the pain of infertility, their efforts to seek a solution must still remain within the context of the sex act itself. They can seek a variety of helps in trying to make that act fertile, but it is wrong to use methods that simply bypass it normal sexual activity. A child is certainly the most concrete expression of the unitive and procreative love of marriage. A child should come into existence in and through the act of that love and should never be viewed simply as the product of purely physical components. The child should be the result of an act in which father and mother express their loving union with each other and should not be the product of a technician. The couple who so desperately want a child may say that their desire springs from their love for each other and their desire to share that love. And if a couple were to tell me that, I would have no reason to disbelieve it. But the real temptation, of course, is that they may then begin to talk themselves into thinking that they can therefore make use of any method at all to have a child. It's a strong temptation and they are led gradually to give in to one thing and then another. It may be hard to realize it, but love does not justify reducing their hopes to purely technical methods. Too many things done "in the name of love" are actually destructive of love. Depth of feeling, depth of desire and depth of love may be very real, but even they cannot serve as a basis for a poor moral judgment. They can lead a couple away from the loving act of procreation through sexual union and push them instead to the point where they find themselves merely supplying the raw materials from which someone else will try to "make a child." There are, of course, morally acceptable things that can be done and I will begin looking at them in the next article. Article #49 Moral Decisions Where Do We Begin? by Reverend Monsignor James J. Mulligan The solution to problems with fertility is sometimes as easy and simple as telling a couple when the woman's fertile time occurs each month. But for many couples the problem is far more complex than that. There is no one solution that fits all cases, since the possible causes are so many. If we are to get a grasp of the problem or find any solution at all, then where do we begin? One way to start finding some answers is to look at the simple fact that the natural process of procreation has a few basic stages to it and to know that problems may occur at any of them. The first stage, of course, is the act of intercourse itself. There may be ejaculatory problems or even impotence. There may be difficulty with vaginal pH balance. These and other problems can often be treated so as to make possible the first step in the process of procreation. It may even be that no more need be done. The second stage in the conception of a child is the meeting of egg and sperm. Unless that meeting occurs at the right place and time conception will not be possible. The proper meeting place is in the upper third of the fallopian tube. That allows the fertilized egg time to continue to grow so that when it reaches the uterus it will be ready to implant. In fact, the egg only remains fertile for a day or so after it leaves the ovary, so that if the sperm meets it toward the lower end of the tube it is, by then, no longer capable of being fertilized. At this second stage also a number of things way contribute to infertility. The tube may be blocked perhaps by scars from endometriosis and so egg and sperm never meet. The sperm may lack motility and not be able to reach the upper part of the tube. Some chemical imbalance may create a hostile environment, causing damage to egg or sperm. It may even happen that ovulation does not occur. In many of these situations it may be possible, once a cause has been diagnosed, to do something to assist the natural process or to correct some deficiency. The third stage is the actual fertilization of the egg by the sperm at the moment of conception. The sperm, once they arrive at the egg, begin to try to penetrate its outer layer. A small enzyme cap on the tip of each sperm is able to dissolve the covering. One will break through, and when it does something quite amazing happens. The chemical composition of the egg itself will immediately change, so that no other sperm can enter. The nucleus of the egg and that one single sperm will fuse together and a new human being begins to exist. At this stage, too, problems can arise which cause infertility. Chemical barriers or enzyme difficulties can prevent fertilization from happening. In those cases also there may be treatments which will allow natural fertilization to occur. Even after fertilization has occurred, the risks are not over. Excess prostaglandins may move the embryo too quickly, causing it to arrive in the uterus before it has developed enough to be able to implant. Tubal blockages or other defects may lead to tubal pregnancy. Surgical or medical procedures may be able to correct or head off these problems. Each case must be looked at from a moral as well as a medical perspective. In general, however, we might say that a procedure which assists the natural process will most likely be morally acceptable. A procedure which simply replaces the natural act or process will not. The fact that something is technically possible does not mean that it will therefore be morally acceptable. There is no one procedure which always works and, even in quite similar cases, there may be no procedure guaranteed to work in every case even when it works in some. It might be worth pointing out that even procedures designed to assist do not always work, but they also do no moral harm. Procedures which replace the natural functions likewise do not always work (for example, in vitro does not work 90% of the time), but they do always cause moral harm. Article #50 Moral Decisions A Little Learning by Reverend Monsignor James J. Mulligan In 1711 Alexander Pope published his poem, An Essay on Criticism, in which he said: A little learning is a dangerous thing; Drink deep, or taste not the Pierian spring: There shallow draughts intoxicate the brain, And drinking largely sobers us again. That sentiment expressed by Pope did not originate with him, in spite of the originality of his way of saying it. As early as a century before the birth of Jesus a Roman writer, Publius Syrus, had written as one of his Maxims: "Better be ignorant of a matter as half know it." The lesson is clear and most of us have probably learned it by experience somewhere along the line perhaps even more than once. You act on partial knowledge and you are lucky if the only bad effect is embarrassment. It is a lesson that we all need and it is a piece of practical wisdom that science and medicine need to learn over and over again. We look back into the past and are sometimes shocked at the sorts of treatment that were dispensed by doctors. The medical practitioners of the Nineteenth Century looked at their predecessors and were convinced that their own time was the pinnacle of all medical achievement. We, in turn, look back to that century and marvel at just how much they did not know. Then we promptly act on what we know, forgetting that the next century will probably be astounded at the way in which we placed full confidence in such primitive medical practices! I am not implying that we should be mistrustful of medicine until all of Doctor McCoy's Star Trek diagnostic methods become available. What I do want to point out, however, is that we have to be honest about admitting and accepting the real limits of our present state of knowledge. In fact, the more important our area of concern, the more we should be aware of our need for caution. Nowhere, perhaps, is this more true than in the area of problems related to infertility. There we deal with human life itself and it deserves to be treated as most sacred and most serious. Medical knowledge in the area of infertility has made some considerable progress in the past decade. At the same time, however, there remains much that is not known. This is true even at the level of diagnosis. In fact, in about 10% of the cases our present methods of diagnosis reveal no apparent cause at all. Even when the cause is discovered, there is no guarantee that anything can be done to correct the condition. One cause of infertility, for example, is a condition known as endometriosis. I will look at this in more detail in a later article. For now, however, I would like to point out simply that this disease sometimes causes damage which clearly leads to infertility. In other instances, however, the damage may be very slight and yet the woman remains infertile and no one knows just why that is so. Present statistics would indicate that in any given year in the United States there are about 5,000,000 infertile couples. Only about 50% will find that their infertility can be corrected. What is, perhaps, most unusual about this is that, even when couples have apparently identical problems, treatments which work for one couple simply do not work for another. And no one can really say why! There is a great deal that we simply do not know. A goodly amount of what can be done at present remains more experimental than proven. The procedures and treatments may have been proven to be safe, but they have not been proven to work consistently. Even fertility experts are often reduced to a sort of trial and error method, proceeding from one drug to another and finding in the end that none have worked. Much yet remains to be learned abut causes, diagnosis, treatments, drug side-effects and even why some treatments actually seem to work. Anyone contemplating infertility therapy should think of this and proceed carefully. There is in many cases room for optimism, but in others (perhaps a majority) the optimism should be cautious. Article #51 Moral Decisions A Question of Timing by Reverend Monsignor James J. Mulligan Sometimes, even when a problem seems serious, help is still easy to come by. It may be just a question of learning something. There are times when this is true even with problems of infertility. The solution may amount to no more than a simple question of timing. What I am going to be saying today may seem, to some, to be almost too elementary. In fact, it isn't and in many cases consultation with a doctor or even a fertility expert may begin with some basic instruction and in some cases that may be enough. In the normal course of events, a woman, from puberty to menopause, will have a menstrual period each month. That period signals the end of one cycle and the beginning of the next. Ideally, it occurs every 28 days. Hardly anything in this life, however, conforms to the ideal and menstruation is no exception. Any woman's cycle may vary. For one the normal range may be 23 days, while for another it may be 34 or it may vary from one month to the next. There is, however, one factor that remains rather constant. When the menstrual period begins, you can count on the fact that ovulation took place 14 days earlier. Of course, accurate as that may be, it does not tell you the day on which ovulation will occur next month -- unless the woman's cycle is always exactly 28 days, and that would be rather rare. It would be possible for a women to study her cycle over a period of some months and come up with a good estimate of when the next ovulation would occur. But it would still be just an estimate. This was actually the basis for the old "calendar method" of natural family planning. A better way would be to look for some visible and easily detectable signs which always accompany ovulation then you would know for sure. And there are such signs. There is a slight but easily readable rise in basal temperature (i.e., body temperature first thing in the morning before eating, drinking or any activity). There is a clearly visible change in cervical mucus and a woman can see this by simple observation. Some women even feel a twinge of pain when ovulation occurs. These and a few other possible signs are the basis of the family planning method called the Sympto-thermal method. It is quite accurate and can tell a woman just when she is ovulating. It is also one of the first things a fertility expert may suggest to an infertile couple, whose problem may be no more than timing. A woman is fertile for only 12 to 24 hours in each monthly cycle. During those few hours the egg is in the upper end of the tube and is ready for conception. If egg and sperm are both in the right place at the right time, conception will occur in about 1 out of 5 cases. The fact is that if a couple are having intercourse during this fertile period of the cycle, and if they are not using contraceptives, and if they continue to do this each month, then chances are excellent that the woman will be pregnant within a year. Indeed, the chances of this happening are about 85%. However, a woman who has been taking oral contraceptives may find that even after she stops she may not ovulate for some time afterwards. One more example of the internal environmental pollution that people can inflict upon themselves. As I said, when a couple go to a doctor about infertility, and when there seem to be no other evident problems, he may very well suggest that they learn what I have described above. He will make sure that they know when and how to have intercourse. He will probably tell them to try for a year without any sort of contraception. This may seem almost too simple a solution to a serious problem, yet that is frequently all that it takes. Society places so much emphasis on sex that people are sometimes under the impression that they know all there is to know before they have learned the basics. Article: #52 MORAL DECISIONS -- Gentlemen First by Reverend Monsignor James J. Mulligan In the days of chivalry and even well into our own less chivalrous age the order of etiquette was usually ladies before gentlemen. In spite of whatever courtliness remains, however, that may well not be the preferred order when it comes to testing for problems related to infertility. When a couple begin to undertake the process of diagnosis and therapy for infertility, there may well be a barrage of tests to be done. The cause of the problem may be in the husband, in the wife or in both. It may be a "mechanical" problem such as a blockage somewhere in the genital tract. It may be a hormone problem in either man or woman. In the wife it could be a disease such as endometriosis. The man might have a deficiency in his sperm. It could be an immune response in which the woman's body treats the sperm as invaders and kills then. It might even be a cause that no test can identify and that could be the most frustrating of all, and possibly the hardest to accept. Whatever the problem, if it resides in the man it may be easier to diagnose and easier to treat. If treatment is not possible, this also may be discovered more easily in the man than in the woman. And so, in fertility analysis, it is usually gentlemen first. The range of male problems is more limited and so are the recognized treatments. At present, however, it appears that in about 35% of cases of infertility the reason resides in the man. In about 20% it is a male problem combined with what might otherwise be a relatively minor problem in the woman. One problem area may be in the production and maturation of sperm. Sperm cells grow in the tissue of the testes and are constantly being produced. They take more than two months to come to maturity and be fertile. A number of things can interfere with this process. One such problem is called a varicocele. It is somewhat like a varicose vein and occurs in the veins which lead away from the testicles. More often than not it affects the left testicle. It can often be corrected by surgery. After a few months the sperm production then increases. About 50% of the time the surgery is successful and sperm production is enough to ensure fertility. Sperm production can also be affected by hormone deficiencies or imbalances, since it depends on a complex relationship of glands and hormones. We have various sorts of glands. Some, like sweat glands or salivary glands, release various substances through small ducts. Others are ductless and release what they produce directly into the blood stream. They are called endocrine glands and they produce hormones, which are chemical substances which affect various bodily functions. In sperm production three glands in particular are involved: The hypothalamus, the pituitary and the testicles. A hormone from the hypothalamus causes the pituitary gland to release two hormones of its own. These are FSH (follicle stimulating hormone) and LH (luteinizing hormone). Both of those were first discovered in women and so have been given names related to the female cycle, but they are actually male hormones as well. FSH acts on certain cells in the testicles to produce sperm. LH acts on other cells in the testicles to produce testosterone (a male hormone). When the testosterone reaches a certain level, it signals the pituitary to slow down its production of FSH and LH. Clearly for all of this to work properly, the balance has to be quite accurate. Hormone levels should be going up and down in the kind of smooth curves that keeps the whole process in balance. Sometimes this does not happen and then there will be problems that can affect fertility. Often enough something can be done to correct this -- as we shall see in the next article. Article #53 Moral Decisions What to Do? by Reverend Monsignor James J. Mulligan In the last article I spoke about some causes of infertility in men and particularly about hormone problems. However, once that diagnosis is made or, at least, seems most likely - the question is what to do. Can it be corrected? The answer is a qualified yes. If the sperm producing cells in the testicles are otherwise normal, then there are some treatments which may help. One possible treatment involves the use of a drug called clomiphene citrate (sold under such trade names as Clomid or Serophene). Exactly how it works is not fully understood. It appears, however, that it stops the hypothalamus from detecting rising levels of testosterone (the male hormone) in the man's system. This allows the pituitary to keep on producing more FSH (follicle stimulating hormone) and LH (luteinizing hormone). As long as they are present, sperm production continues. It takes about two and a half months for sperm to mature, so the clomiphene will be given in small doses over a few months. There are some undesirable side effects to which the doctor must be alert. Some studies indicate improved fertility. Other studies remain a bit indefinite. The clomiphene comes in the form of a pill and studies indicate that it is relatively safe. The therapy is not cheap, but it does cost less than other therapies. There is also another drug called Pergonal. It is composed of gonadotropin (a type of hormone) extracted from the urine of postmenopausal women. It is very potent and can cause serious side effects. It must be used quite carefully. It is used together with another hormone, HCG (human chorionic gonadotropic hormone), sold under the name of Profasi. This therapy is not as frequently used. It seems to help only in those cases where there is some deficiency in the hypothalamus, and those cases are rather rare. It should be used only by doctors who are experts in treating infertility. It is given by injection and is rather expensive. There are also fertility problems related to the testicles rather than to hormone problems. These involve damage from mumps, accidents, drug or alcohol abuse, or lack of sperm producing cells. For these there may be some treatment, but in some cases nothing can be done. Almost always diagnosis will probably begin with a sperm count. This checks on the number of sperm per cubic centimeter of seminal fluid, the ability of sperm to move, and the percentage of irregular or malformed sperm. In conjunction with the sperm count there is one moral problem that has to do with the way in which the semen specimen is obtained. Masturbation is not morally acceptable as a method. There is, however, a method which is both morally acceptable and clinically desirable. This is the use of a type of condom called a "silastic sheath." This sheath is perforated but self-sealing. It allows ejaculation into the vagina and then seals itself to contain the remainder of the semen, which can then be used for analysis. Some people tend to look at the use of something like the silastic sheath as just one more of those "silly Catholic things." Not so! Articles in Fertility and Sterility by doctors indicate that this method is medically superior to semen gathered by masturbation. This makes it better as a method for examining for fertility. The sheath is chemically neutral and therefore does less harm to sperm than either a glass jar or an ordinary latex condom. Furthermore, the ejaculate is different. It is improved by the stimulation of the female in intercourse and is therefore a better and more accurate sample than can be obtained by masturbation. The treatments described above do not in themselves create a moral problem. The collection of semen can be done in a morally acceptable manner one more example of good moral practice and good medical practice coinciding. We must remember, however, that, while the treatments offer hope, none of them is guaranteed to be successful. Article #54 Moral Decisions Moral Choices; Medical Problems by Reverend Monsignor James J. Mulligan In the last few articles I spoke of male problems with infertility. Today we begin to look at some problems that women can have. In many ways the female reproductive system is more complex than is the male. That should come as no surprise, because it is the female system which plays a part not only in conception but in the whole amazing process of pregnancy. There are varieties of problems, structural and hormonal. Some may be congenital, others due to various sorts of damage caused externally, still others from disease. In previous articles I referred to the fact that some male problems may be due to such things as alcohol and drug abuse. These are, in many instances, the result of earlier choices that were wrong both medically and morally. The same is true of some female problems as well. I do not mean to imply that all or even most problems with infertility are due to bad moral decisions. But it would be thoroughly unrealistic to ignore the fact that some are. Things that are immoral are so because they are destructive, and sometimes that destruction is physical, too. Many people do not wish to face this fact, but, in my opinion, that is ostrich morality. They prefer to stick their heads in the sand and hope that reality will go away. I am not saying this because I think that some problems are a divine punishment, nor do I think that those with such problems should be punished. Far from it. They deserve help and compassion. But I do hope that others will see how real the damage is and begin to realize that it is within their power to make choices which can help them avoid real pain later. Abortion is one of the causes of infertility, especially when the mother is a teenager. The uterus or cervix may be so damaged that successful pregnancy is later impossible. The abortionists may be guilty of sticking their heads in the sand; but I'm sure they are stuck in their account books as well. There are types of physical blockages or other damage caused by earlier activity. Pelvic inflammatory disease (PID) in almost every instance can be traced back to diseases transmitted by sexual intercourse or infections from such things as an IUD (intrauterine device). Sexual activity with multiple partners is a perfect way to end up with PID and so end up being infertile. The increased promiscuity of recent years has caused an enormous rise in the incidence of PID, with its resultant damage to the female reproductive system. About 20 years ago blockages due to this sort of damage were responsible for about 25% of cases of infertility in women. At present they account for 50%. Bacterial infections (e.g., gonorrhea or chlamydia -- which is now the most common venereal disease) are recurrent, damaging and sometimes fatal. They damage the soft tissue of uterus and fallopian tubes, sometimes irreversibly. Each flare up causes more harm. Of those who have one episode, about 15% are left infertile. After three episodes about 75% will be infertile. Chlamydia is also more common among women who use contraceptive pills. Whether that is connected to the pills or to the fact that so many pill users are promiscuous, I do not know. In any case, it seems to me that our society hesitates to point this out, especially to the young who will most likely be affected by the consequent suffering. After all, no one wants to be a party pooper. It seems such a shame the people would prefer to let our children suffer or even die rather than risk offending them by telling the truth. Venereal disease and PID are prevalent causes of infertility and can well prove impossible to correct. The sad thing is that they are preventible not by "safe" sex but by good moral decisions. Article #55 Moral Decisions Belaboring the Obvious by Reverend Monsignor James J. Mulligan At the risk of seeming to belabor the obvious, I would like to point out that there are differences between men and women. You may be amazed at the astuteness of my powers of observation. More likely, however, you have already noted some of those differences yourself, and do not find my opening statement too startling. As you might expect, those differences can be considerable when it comes to diagnosis and treatment of infertility. Since the woman's reproductive system is designed not only for intercourse, but for the whole physical process of pregnancy, it is, in many ways, more complex than the male system. That added complexity also allows for more points at which the system can go wrong. Even in the production of eggs and sperm there are considerable differences. The male begins producing sperm at the time of puberty and they are produced by the millions. The process takes place in the tissue of the testicles and is going on constantly. Each sperm takes about two and a half months to reach the point of maturity, so at any given time from puberty onward the testicles contain hundreds of millions of sperm at all stages of development. They are susceptible to damage from changes in body temperature, alcohol consumption, drugs and all sorts of infections. Even in the normal course of events some will be defective or deformed. But there are so many and they are produced at such a rate that in spite of considerable damage to many of them the man may still remain fertile. The production of eggs in the woman is quite different. While a female fetus is still in the uterus, eggs begin to develop in her ovaries. They are not, of course, mature eggs. They are follicles which will later mature into eggs. Many do not develop at all, but by the time she is born there is a set number of follicles present more, however, than one may use in a lifetime. At puberty they will begin to mature. Normally only one egg will mature each month until menopause so that in a whole lifetime she may produce only about 400 to 500 eggs. Deficiencies in this maturation process, therefore, may be more of a problem for a woman. There may be physical abnormalities which allow conception to occur and then interfere with pregnancy itself. For example, the uterus may be divided by a septum of tissue which would make normal uterine expansion impossible, so that a pregnancy could not come to term. The uterus may contain scar tissue from surgery or some other cause. This could interfere with expansion or even with implantation. The same may be said about certain kinds of benign fibroid tumors which sometimes occur in the thick muscle tissue of the uterus. The fallopian tubes are also susceptible to damage. The lumen (opening) of the tube is small and its walls are filled with delicate convolutions whose movement draws the ovum down into the uterus. It is also through these tubes that the sperm pass in order to fertilize the egg. If the tubes are blocked, then both processes will be impeded. Even small scars from flare ups of infection or from endometriosis may be sufficient to create blockages. There was a time, of course, when damage to the uterus or tubes could not have been repaired. Even benign tumors could have led to hysterectomy. Attempts to repair the delicate lumen of the tubes would have been practically impossible. Now, however, the situation is not always as bad. Surgery is far more refined and modern techniques of microsurgery and laser surgery frequently hold out high hope of success. Ultrasound, laparoscopy and fiber optical instruments all help to make possible more conservative and less drastically invasive procedures. In spite of the technical progress, it should still be noted that not every condition can be repaired. Each case has to be considered individually. Depending on the cause and seriousness of each individual situation, treatment may range from relatively easy all the way to impossible. Article #56 MORAL DECISION - The Mystery Disease by Reverend Monsignor James J. Mulligan One common cause of infertility is a disease called endometriosis. Just how it originates or why is unknown. What it does is very well known. The endometrium is the tissue which lines in the uterus. Each month it grows and thickens into a blood rich layer. If a woman does not become pregnant, then the endometrium breaks down and is the source of the menstrual flow during a woman's period. When a woman has endometriosis, this tissue is found at other places in her body. It may appear within the fallopian tubes, on the ovaries, on the bladder, in the peritoneal cavity and even elsewhere. Each month when a woman with endometriosis has her period, all of this tissue also breaks down. In its abnormal sites it may then cause scar tissue and resultant blockages. It can be exceedingly painful, it can cause severe cramps and can even result in making intercourse quite painful. Symptoms of the disease may indicate its presence, but full diagnosis will usually involve the use of a laparoscope to find just where the affected tissue is located. The scar tissue that it forms can cause blockages in the very complex and fragile reproductive system. This can easily lead to infertility when the tubes become blocked and thus make it impossible for sperm and egg to meet. Tubal blockage can be determined by the use of a dye put into the uterus and a laparoscope to see if the dye passes through the tube. Endometriosis can also damage the ovaries. It causes scar tissue on the surface, creating spots at which the ovary can no longer release the eggs. It can become extended enough to make the ovary seriously or even completely nonfunctional. Some of these effects may be relieved by surgery or laser. In some cases it may be possible to help with hormone therapy rather than surgery. It has been observed that in some cases pregnancy seems to cure endometriosis. This is, perhaps, because the monthly cycle does not then occur and the affected sites have time to heal. Some doctors, therefore, have used a synthetic male hormone called Danazol. It acts on the pituitary gland to suppress the signals which cause the normal production of estrogen and progesterone. This results in "pseudo-menopause." The theory is that ovulation and menstruation are stopped for a while and the affected areas will have a chance to heal. In mild cases this may help, but even then its success is not guaranteed. Danazol can also have serious side effects, so its use must be carefully monitored. One of the mysteries of endometriosis is that it seems to cause infertility even in women with mild cases and no apparent blockage or damage. Why? No one knows. This makes it even more frustrating since there seems to be no reason why conception should not occur, and yet it doesn't. There are, of course, theories. Dyspareunia (painful intercourse) may cause less frequent intercourse, or prevent full penetration, or cause muscle spasms which affect the fallopian tubes. The misplaced bits of endometrial tissue produce prostaglandins (another type of hormone). These can have a variety of effects. They may slow down the movement of the sperm. They may increase or decrease muscular contractions in the uterus or fallopian tubes. This might lead to failure of the egg and sperm to meet or even cause the embryo to move too quickly and thus arrive in the uterus before being sufficiently developed to implant. They may even cause uterine contractions which interfere with implantation. It is even possible that the misplaced endometrial tissue causes some sort of immune reaction, leading to the formation of antibodies which attack the endometrium or the sperm. All of these, however, are conjectures. The fact is that no one really knows the cause and no one really knows the solution either. It is , perhaps, one of the most frustrating causes of infertility. It remains a mystery. Article #57 MORAL DECISIONS - More Hormones by Reverend Monsignor James J. Mulligan Earlier I wrote about the use of hormones to treat infertility in men. There is a need for a regular pattern of rise and fall of various hormones in order for fertile sperm to be produced. The interrelationship of glands is essential. The hypothalamus, the pituitary and the testicles all produce hormones and they must all be in proper balance in order to work well. In a woman there is a similar pattern and the need for a similar balance. If it is disturbed, there will be a problem with the maturation of eggs and, therefore, a problem with fertility. Just as in the man, both FSH (follicle stimulating hormone) and LH (luteinizing hormone) play an essential role. In fact, about half of female infertility problems can be traced to difficulties in ovulation or the endocrine system. Some problems with ovulation are, of course, due to other than endocrine difficulties. Sometimes there is no active ovaian tissue. This can happen, for example, as a result of chromosomal abnormalities or premature ovarian failure in early adulthood. In these instances hormonal therapy is of no help, nor is there anything else that can be done. Anovulation (failure to ovulate) is permanent. There is also such a thing as irregular anovulation. In that case, the necessary ovarian tissue is present, but the ovaries, for some reason, do not produce an ovum in every cycle. Situations like this are far more likely to be the result of hormonal problems. The function of the endocrine glands or the balance between them may be at fault, and there may well be some useful form of treatment available. Somewhere in the early stages of diagnosis the doctor will probably want to determine if ovulation is occurring and, if so, how regular it is. One cause of irregular ovulation is sometimes easy to determine. That is the use of birth control pills. It is not very unusual for women who have been using oral contraceptives to find that ovulation does not occur even after they stop using them. They may, in fact, need treatment in order for regular ovulation to resume. It is worth pointing out, I think, that hormone therapy always should be done with care and cannot usually be done at great length without some attendant risks some of them serious. Contraceptive pills are hormone therapy and inevitably involve varying degrees of risk sometimes considerable risks. Yet they are used so casually and anyone who points to their danger runs the risk of being ridiculed. A woman may have a menstrual period every month and still not be ovulating. How can she tell if ovulation is occurring? One simple way to find out is simply to check her basal body temperature as is recommended in the Sympto-thermal method of family planning. This is done in the morning before eating or drinking anything and before any sort of activity. This gives an accurate reading of the base temperature. A special thermometer is used special only in the sense that it is made so as to be easier to read. If she ovulates, she will see the characteristic slight rise in basal temperature which always accompanies ovulation. There are also other ways to see if ovulation occurs. With little difficulty a doctor can check the level of progesterone in the blood. It is possible also to see the developed ovum with ultrasound. If ovulation is not occurring, then there are therapies which may help. The therapy will probably go in stages each stage involving a slightly more potent drug. A usual starting point might be treatment with clomiphene citrate (Clomid or Serophene). This therapy should be started only after careful diagnostic evaluation by a physician skilled in this area. (This may not mean a general practitioner, but a gynecologist or even a fertility expert.) If ovulation has not been reestablished after treatment in three of the woman's cycles, then the use of this drug should be discontinued and the case reevaluated. The drug is not recommended in cases where the ovaries already seem to be functioning properly. Article #58 MORAL DECISION Stronger Stuff by Reverend Monsignor James J. Mulligan When infertility is due to failure to ovulate, a variety of treatments are available. Earlier I wrote about the use of clomiphene citrate as one such therapy. Like most hormonal therapies it is quite strong and must be used carefully. However, if it does not work there are other drugs which are stronger still. There is no direct moral problem about their use, but one must consider the seriousness of side effects which may emerge and some of the potential problems created by multiple ovulation. Their use should be preceded by a very careful physical examination. One of the possible drugs is called Pergonal. It is given by injection and contains both FSH (follicle stimulating hormone) and LH (luteinizing hormone), so it causes egg follicles to come to maturity. In fact it will almost always cause a number of eggs to come to maturity at about the same time. Since there is more than one ovum, the chances of pregnancy are correspondingly increased. The progress of the maturing follicles is monitored by the use of ultrasound. The follicles, by the way, appear as swellings (quite minute, of course) on the surface of the ovary. They are filled with a liquid, within which is the developing egg. When they mature, they burst. The egg is expelled onto the surface of the and swept into the open end of the fallopian tube. Once the follicles are ripe, an injection of HCG (human chorionic gonadotropic hormone) is given to cause the follicles to burst at a predictable time. The couple seeking help to achieve fertility will be able to know exactly when conception is most likely. As you move up the line from clomiphene citrate to the more potent drugs, you also run added risks which may even include ovarian damage. The stronger drugs can cause enlargement of the ovaries or ovarian cysts, so they should be used with great caution and only in the hands of experts and patients should be clearly informed of the risks, if they are to be able to give proper consent to treatment. If Clomid and Pergonal both fail to produce results, the next step may be a drug called Metrodin. Pergonal has about equal amounts of FSH and LH. Metrodin has more FSH and a smaller amount of LH. It, too is given by injection to stimulate the follicles and HC6 is used to make the eggs emerge. Because Metrodin is so potent, the doctor should examine his patient at least every other day during therapy and for two weeks afterwards. The purpose of such careful monitoring is to detect as early as possible any excessive enlargement of the ovaries. I have referred to multiple ovulation and this can happen with all three drugs Clomid, Pergonal and Metrodin. This means, of course, that there is the possibility of multiple pregnancy as well. Statistics indicate that the use of Colmid results in multiple pregnancies about 10% of the time. With either Pergonal or Metrodin, the frequency rises to about 20% . This can create a situation which requires careful moral decision making. Multiple pregnancies have additional problems. There is a limit to how many children can be carried at the same time. Of course, the fact that there are multiple eggs does not mean that all of them will be fertilized -- especially since we are dealing specifically with people who have heretofore been unable to become pregnant at all. Yet, as the physician monitors the formation of the eggs, he should warn the couple not to have intercourse in the fertile period when the number of eggs is excessive. Otherwise they may be forced to make impossible moral decisions. What happens if six or seven or even more eggs are all fertilized at the same time? One solution offered by some physicians is that of "selective reduction of fetuses." That is an antiseptic way of saying "random abortion." It is an immoral solution to a problem which has been created by therapy and has left no good moral decision available. That has to be understood by both physician and patient and not allowed to happen. Article #59 MORAL DECISIONS The Bottom Line by Reverend Monsignor James J. Mulligan The bottom line... What does that mean? It is the line on an account where it all comes together. It is the total, the profit or loss, the real cost. For some weeks now I have been writing about all sorts of therapies for infertility surgical and pharmaceutical procedures, with most of the latter being hormone therapy. What does it all cost in the end? The financial cost is, perhaps, easiest to assess. Each level of therapy demands more expensive drugs and places increased demands on the time invested in each patient by the physician and his staff. Medical costs, like all costs, seem never to drop. Whatever the old saying, "What goes up must come down," refers to, it does not seem to be prices. One cost survey in 1988 gave the relative prices of therapy as follows: (1) Clomid $30 - $250 per cycle; (2) Pergonal, $150 - $900 per cycle; (3) Metrodin, $225 - $1350 per cycle. At that time, therefore, if a couple went through all three levels, with treatments for three cycles at each level, the financial cost would range from $1215 to $7500. The cost is clearly not based on drugs alone, or there would not be such wide disparity. It is based, no doubt, also on staff, equipment, local prices and, equally without doubt, on the decision by some to go as high as the market will bear. There is no doubt that these therapies can be costly. The specialist must invest a great deal. Expensive equipment is required for diagnosis, laboratory work and monitoring. In view of this the physician should be especially careful to avoid the unnecessary prolonging of treatments. Honest and sincere medical motivation can also be influenced by financial concerns. Doctors, no less than any of us, can be influenced by mixtures of motives. It is also easy for doctors to be truly concerned about patients and, in this area especially about their pain and frustration so that it becomes hard to admit defeat. Real care, may have to admit defeat, thus allowing people the chance to face reality and begin to grow from there, rather than being subject to the frustration of a constantly offered but false hope. Another cost to be considered is the emotional one. Hormone treatments especially the longer extended ones that a woman may have to undergo have effects on emotional life. Those effects are not imaginary. They are real and have a physical cause stemming from the chemistry of the hormones themselves. In the course of therapy for infertility there are bound to be pronounced undulations of hope and disappointment. These roller coaster emotions are amplified by the drugs themselves. The effect of all of this on the marriage should not be overlooked. There does come a time to say, "Enough!" Another moral concern to be faced is one that arises from the gradual elevation of therapies to the point where the only methods that seem to be left are going to be immoral. Long extended therapy can easily begin to make such things as in vitro fertilization or even surrogate motherhood look attractive. The couple should try from the beginning to be clear about moral lines and be sure not to cross them. Medicine knows a great deal about infertility, but there is, in truth, even more that remains unknown. The fact that treatments work only 50% or 30% or 10% of the time is in itself a clear indication of just how much is not known. There is a vast amount of knowledge combined with an enormous amount of very well educated guesswork. We are dealing with a complex and obscure mechanism in the area of hormone therapy. Some therapies are used with the frank admission that no one knows how they work and no one can predict if they will work except to give a percentage of their overall chance of success. We must admit all of this and then be respectfully cautious in what we do. And we must always be open to learn. Article #60 MORAL DECISIONS - What Next? by Reverend Monsignor James J. Mulligan A couple, faced with the fact that they are infertile, will have to get past the initial temptation of guilt because "I am infertile" or anger because "you are infertile." The fact is "we are infertile." They may need help in overcoming such normal feelings and realizing that the solid base of their love for each other is still there. Things may be even more frustrating if the man has fertile sperm, the woman is ovulating and there are no apparent physical problems, and still pregnancy does not occur. Nothing so far has worked. They have already overcome a host of hurdles physical, emotional and financial. What next? Most of the infertility treatments considered up to this point are not morally problematic in themselves although some have moral implications in their side effects or methods of use. Many of them were hormonal problems. Once a couple is past that point, however, and the infertility remains, further procedures are more likely to have serious and central moral problems. Earlier stages of treatment tend to be ways of assisting the couple's sexual activity to achieve pregnancy. From that point on, however, suggested courses of action are more likely to replace marital sex and that will make it immoral. There will be a lot of technical jargon and catchy acronyms, but we have to look carefully to see the reality being proposed. The variety of methods is bewildering. Why so many? One reason is that the causes of infertility are many. But another is that the causes are not really understood. All sorts of things can be tried, some of them with a degree of success low enough to make you wonder if it was not merely by chance after all. Another reason for the variety of methods may be that the extent of infertility at present makes the operation of a fertility clinic a potentially booming business. Actually, are excellent sources of income even when they may never have produced a single pregnancy! The first in vitro baby in the United States was born in Norfolk, Virginia, in 1981 and fertility centers immediately sprang up. By 1988 there were about 100 of them, charging people $3000 to $7000 per couple, even though a third of them had not yet been able to report the birth of even a single baby! This whole area of technological production of babies should be looked at most thoughtfully. Some methods are so obviously immoral that they should never be used at all. Even morally acceptable methods should be studied closely before being used. Claims to success rates demand careful scrutiny. Suppose, for example, that a success rate of 30% is claimed. What does that mean? If it means that 30 couples out of 100 had babies, that may sound encouraging. But is it? You need to ask how many cycles were included. Most methods do not work on the first try. If the average pregnancy took only 5 cycles to achieve, then for 100 women that means 500 cycles. If 30 of the women had babies, the real rate is 30 successes out of 500 attempts, which is only 6%. Is the success rate based on actual births or on pregnancies. Some methods result in a much higher rate of ectopic pregnancies. (An ectopic pregnancy is one that is "out of place." The embryo implants in the tube or on the ovary, instead of in the uterus.) Some may count these as pregnancies, even though there is no chance that they could be born. Even if statistics are based on live births, look carefully. How many were multiple births? If there were 9 births among 100 women, and they were three sets of triplets, then the apparent 9% success rate involved only 3 women and should be only 3%. Another very serious question to ask is: How many of those born did not long survive? Finally, you should ask what rates are being given. Are they the real ratio of this clinic? Are they just overall rates for the country? For only certain research centers? Are they for only one year? Or for a whole practice? Or just for a single month that happened to be good? Ask for raw data as well as rates. And remember that you will pay just as much for a failure as you will for a success! Article #61 MORAL DECISIONS Verbal Inflation by Reverend Monsignor James J. Mulligan We live in an era of inflation and it seems to have affected not only finances but language as well. Everybody likes to use a nice big $50.00 word, even though a little word might be easier, better and far more accurate. People love to say "utilize," when "use" would do as well. The army has people line up to receive "personnel entrenchment tools," and what they get is a shovel. Some fertility therapists like to speak of "surrogate embryo transfer," when the simple word for it is adultery. Some methods of fertility treatment involve sperm or eggs from someone other than husband or wife. No matter how we try to explain or rationalize this, it is and always will be wrong. it is in clear contradiction to both the unity and the fidelity that are at the heart of marriage. One such procedure is what is referred to as SET (surrogate embryo transfer). It has been taken over by some fertility experts after having been developed for cattle breeding. A number of eggs from a good breeding cow are fertilized and begin to develop. The embryos are then put into a number of other cows, where they implant and grow. In 1983 the first human use of this procedure was reported. The method depends on a woman who acts as "egg donor." It also involves both members of the infertile couple. It also requires some careful choreography. To keep the players straight, I will refer to them as husband, wife and egg donor. The SET procedure may be used when the wife is anovulatory (produces no eggs) or even in other cases in which there is infertility. The wife and the egg donor are both given hormone therapy to get their cycles synchronized. It is important that they be at the fertile period at the same time. Once that has been achieved, the egg donor is given additional therapy causing her to produce multiple eggs. It is then time for the husband to join in. He supplies sperm which is then used to artificially inseminate the egg donor. The egg donor is then monitored in order to see if the husband's sperm has successfully fertilized any or all of the eggs. If it has, then they are simply allowed to continue on their normal course through the fallopian tubes and on into the uterus. Before they have a chance to implant, they are removed. Next one or some or all of these embryos (new persons) are inserted into the wife's uterus in the hope that they will implant there. This is why it was so important to get both women synchronized in their cycles. It is only in the latter half of the cycle that the endometrium (inner lining of the uterus) is ready and able to receive implantation. Embryos not used can be frozen destroyed or used for experiment or, I suppose, given to other women, just as is done with the cows. The process involves adultery and considerable disregard for new human life. It should also be painfully evident that the whole procedure reduces a woman, the egg donor, to the level of breeding stock. The child, of course, will be genetically related to the husband and the eg donor, even though it is the wife who goes through the pregnancy. If we are to be realistic, however, we must admit that the child is not the child of the wife. She has done a highly technical form of baby sitting, but that is all she has done. There is a financial aspect too, just as you would expect. The egg donor may get about $250.00, while the husband and wife will pay about $3000.00 per cycle. As I said, SET was developed for cattle breeding. It is interesting to note that its commercial aspects were carried over, too. An effort was made to patent the process and charge set fees for its use. In 1985 a group called Fertility and Genetics Research, Inc., began selling stock with the intention of franchising "ovum transfer centers" by which, of course, they meant fertilized ova, which are really embryos. It's a plan similar to the way in which such companies as Pizza Hut or Dunkin Donuts might set up operations. Article #62 MORAL DECISIONS Alphabet Soup by Reverend Monsignor James J. Mulligan In precious articles we have considered therapies which use FSH, LH and HCG. We have learned something about PID, IVF and SET. In articles yet to come there will be things to say about LTOT, TOTS, GIFT and ZIFT. Our topic for today, however, is AID. AID stands for "artificial insemination by donor." Like SET (surrogate embryo transfer) it is still another form of adultery. And, like SET, it is a carryover from cattle breeding. The sperm is "donated" by means of masturbation. In fact, some years ago I remember reading of sperm being collected from medical students who were paid for this "service." Sperm which is collected can then be frozen and stored for some period of time. Of course, since the sperm are living cells and are easily susceptible of damage, the freezing process is not what we would think of in freezing vegetables or meat. In that process it doesn't matter if the cells crystallize. That would make a difference in the freezing of sperm, since crystallizing would kill them. Rather the freezing process here would be similar to what is done in the freezing of embryos. The purpose of the freezing is to lower the temperature in such a way as to slow down all molecular movement almost to a standstill. The lowering of the temperature, therefore, causes what we might see as a slowing down of time as well. The cells are kept in what might be described as a kind of suspended animation. They are alive, but their vital activity goes on at such a slow pace that the life span is considerable extended. This, too, is carried over from animal breeding. The process is called cryopresevation. AID has, of course, its commercial side as well. It has led to the development of "sperm banks" where a collection of sperm from various donors is kept on hand until purchased by some potential user. The most obvious use would be the sale of sperm to couples in which the wife is fertile, but the husband is not. It lends itself also, of course, to "mix and match" shopping. You can get sperm from a donor who had characteristics of the husband. Or you might find some other qualities that you liked better. In any case, the child is not the husband's child. There have even been efforts to popularize the idea of collecting sperm from especially talented or famous people, so that buyers could try to produce their own little Einsteins or movie stars or rock idols. That idea, fortunately, seems never to have quite gotten off the ground. AID has also been used to impregnate single women who wanted a child without the bother of a husband. For the sperm banks, of course, that may not matter, since they get the same fee whether the woman is married or not. In the end, it will matter to the child thus produced, who will be deprived of any chance at life in a normal family. It also says something quite bothersome about the attitude of the mother. She will, of course, be doing this in order to have a child to love or to stave off her own aloneness. In either case, the child is already doomed to being produced as a means to an end not for his own inherent worth. The whole process is rather sad. It is born, in so many instances, out of the desperate desire of a couple to have children. Yet it makes the child a commercial product and it purposely separates that child from its own real father. As I have said before, AID is simply contrary to the unity and fidelity of marriage. It produces a child by undermining the relationship of husband and wife a relationship which should have been the foundation of the child's life. It is depersonalizing to the "donors," who are usually anonymous and create new life with the fervent hope of all concerned that they will disappear into the woodwork and never be heard from again. Article #63 MORAL DECISIONS Comforting Words by Reverend Monsignor James J. Mulligan A friend once told me of an incident when he was with the Peace Corps. His fellow worker in a remote African village broke out in a rash, that would not go away. The local doctor's diagnosis was, "You have a rash, but I don't know what it is." Finding this no comfort, he undertook a motorcycle journey of a few days to a city hospital. He came back a week later still with the rash much comforted. The city doctor had diagnosed his illness as unspecified dermatitis. It had not occurred to him that in plain English that means, "You have a rash, but I don't know what it is." Just as important sounding words can give an aura of wisdom to ignorance, so also they can give an aura of approval to what is absolutely wrong. "Liquidation" sounds so much nicer than murder. "Termination of pregnancy" so much better than abortion. Even "surrogate motherhood" has a rather scientific or even altruistic ring to it, when, in fact, it is a thoroughly dehumanizing and depersonaling reality to all who become involved in it. A surrogate is a person who takes the place of someone else, who acts on behalf of another. A surrogate mother is one who takes the place of or acts on behalf of another mother. To many people it sounds somehow noble or at least rather altruistic. A woman heroically bears a child for someone else who is unable to have one of her own. The facts of the matter, however, involve far more than that. The reality of surrogate motherhood is this: A woman is hired to become pregnant and then hand over her baby to those who hired her. Of course, as soon as you get into the area of hiring and selling, you are almost bound to find entrepreneurs ready to set up a business. And so it has happened. There are actually businesses which have been set up to bring together potential buyers and potential surrogates. They make a tidy profit by preying on the monetary needs of the one and the sad infertility of the other. They may claim to be high minded public servants, looking out for those in need. Their rates, however, may pay the surrogate a fee of up to $10,000. The actual selling of a person is, in most places, illegal. Therefore, the money given to the surrogate is defined as a "fee for her services." Sanitized language strikes again! The process, of course, is a depersonalized form of adultery. The husband who, together with his wife, is buying the baby, provides the semen which is used to impregnate the surrogate. The egg is usually hers. Of course, the semen may also come from a donor in which case the child is not even physically related to the couple who eventually purchase him. In fact, even the egg could be donated, in which case the child is not in any way the genetic offspring of the woman who bears him. He is not related to the couple who buy him and his real parents are excluded from it all completely. It becomes an utter distortion of parenthood and reduces the child to a merchandisable property. In August of 1990 there was a case of two women hired as surrogates (for the usual $10,000). The couples who hired them had used their own sperm and eggs, fertilized in vitro. Both women had babies in fact, one had triplets. One of the women spoke of her deep sorrow at having to give up the child even knowing that it was not hers, although she had given birth to it. It is a sad thing to live in a society willing to ignore the reality of feelings and the values of marriage, unable to see the painfully evident wrongness of what is being done. It is content, instead, to treat babies as a commodity, to turn persons into merchandise and men and women into breeding stock and to consider all of this as acceptable because it has found nice words to describe it. Article #64

MORAL DECISIONS Only the Names Have Been Changed...

By Reverend Monsignor James J. Mulligan

If you are about my age, you may recall the old police stories on the radio and even on early TV that ended with the dramatic, deep-voiced announcement: "The story you have just heard is true! Only the names have been changed to protect the innocent." In earlier articles I wrote about the process of in vitro fertilization (IVF) and the serious moral problems which are part of it. It replaces rather than assists the normal process of human reproduction. It bypasses sexual intercourse and substitutes a technical process instead. It separates conception from sexual union. It gives rise to the lives of a number of human beings and then snuffs out the vast majority of them by failure or purposeful destruction. As a medical procedure it offers only a slim chance of success and an overwhelming probability of severe disappointment. Morally, it is simply wrong. Would it make any real difference if we gave it a new name? Hardly. The reality would be exactly the same. But, in a sense, that has happened. There is a process called ZIFT which is offered as something new and different, when, in reality it simply gives the old IVF a new name. ZIFT is still another acronym, standing for Zygote IntraFallopian Transfer. The words may be unfamiliar, but they are easy to explain. A zygote is a fertilized egg before it begins the process of cell division. It is the very first stage of human life a new person. It is called a zygote only until cell division begins, and then it is referred to as an embryo. "Intrafallopian" means "within the fallopian tube" (which is the tube through which the egg moves toward the uterus and in which fertilization takes place). "Transfer" refers simply to the fact that a zygote will be transferred from one place to another. In ZIFT the process begins with using drugs to cause multiple ovulation. The ova (eggs) are then removed and are fertilized with sperm collected, usually, by masturbation. The fertilization takes place in a petri dish, just as it does in IVF. The resulting zygote or zygotes are then replaced in the upper end of the fallopian tube with the hope that they will continue to develop normally from that point on. In IVF the embryos are allowed to develop further toward the point at which they can implant and are then placed in the uterus. In effect, ZIFT is IVF with a new name. There is a difference in that the embryos are not allowed to develop as far as they are in IVF, since they are to be placed in the tube rather than in the uterus. Everything that was discussed earlier about the moral problems of IVF and equally true in the case of ZIFT. In fact, we might even point out that the name, ZIFT, is not truly accurate, since what is actually replaced in the tube is not the zygote, but the already developing embryo. It is simply a question of allowing the embryo to develop only to about the third stage of cell division before it is put back into the woman's body. The hope, of course, is that there will be a better chance of success since most of the process is allowed to take place inside the body which everyone agrees is the best place for it to occur. I am not aware, however, of any solid evidence which would indicate a greater success rate for ZIFT than there is for IVF. And both procedures have exactly the same moral problems. While it may be true that changing the names does sometimes protect the innocent, it is equally true that taking on an alias can also protect the criminal. ZIFT is not a name change which indicates that something wrong has become innocent. It is simply a case of an alias for the same old evil.

Article #65

MORAL DECISIONS Hopes and Disappointments

By Reverend Monsignor James J. Mulligan

In 1980 and for a few years thereafter we read in the papers of a new procedure designed to help with problems of infertility. It offered hope of both medical help and moral acceptability. Unfortunately, the hope ended at first in disappointment, since the procedure did not produce the expected results. I refer to it now, because I want to explain it and then, in the next few articles, describe modifications which have indeed produced some success and which, perhaps, offer a moral solution in a very difficult matter. Doctors Kreitman and Hodgen of the National Institutes of Health, in 1980, did some experiments on monkeys which produced significant results. The fallopian tubes were tied and eggs were taken and placed back in the tubes below the blockage. After normal mating, 5 (16%) of the 30 monkeys used became pregnant. The procedure offered hope at least to those women whose tubes were blocked or otherwise damaged. In 1983, at St. Elizabeth Medical Center, a Catholic hospital in Cincinnati, Doctors McLaughlin, Troike and Tegenkemp researched the same procedure. One of their major concerns was to find something that would be morally acceptable. They called their procedure LTOT (lower tubal ovarian transfer). It was a method which did not involve bypassing intercourse; it did not fertilize ova outside the body of the mother. It did assist in offering a new way to help make normal intercourse fruitful. Couples were advised to have normal intercourse before the transfer of the egg and again on the day following. Fertilization, if it occurred, would take place in the woman's body and as a result of loving sexual relations. There was no manipulation of the embryos. Sex was not replaced by technology. The disappointment was that, although it had worked in monkeys, it did not seem to work for humans. It was tried in 65 cycles with about 40 women, and none of them became pregnant. The doctors then modified their procedures. First of all they tried to make sure that the ovum was placed as high in the tube as possible, on the supposition that the developing embryo needed more time to develop so that it could implant in the uterus. Still it was unsuccessful. Finally they added still one more factor, which also changed some other aspects of it all. Along with the ovum, they also inserted sperm into the tube. They now called the procedure TOTS (tubal ovarian transfer with sperm). The sperm was collected with the use of a silastic sheath in normal intercourse [see some of the earlier columns for an explanation of this]. It was "washed" (which means removing things such as prostaglandins, which could cause the embryo to move too quickly through the tube). Both ovum and sperm were placed in a catheter, separated by an air bubble. They came together only after being released in the upper part of the fallopian tube. Conception took place in vivo (inside the living body) rather than in in vitro (in a glass dish). This makes it more easily acceptable morally and also more desirable medically. There is no doubt that the mother's body is the best place for fertilization to occur in fact, no one is yet sure if harm is done to embryos produced in vitro, even when they come to successful birth. This procedure (TOTS) has had some medical success, although opinions are divided about its full moral acceptability. What success was there? What moral questions came up? How have they been handled? Much as I would like to explain, one of the necessary limitations on a newspaper column is that it must fit into a specific space, and mine has come to an end for now. Look for the answers in coming weeks.

Article #66

MORAL DECISIONS Variations on a Theme

By Reverend Monsignor James J. Mulligan

One of the fascinating aspects of music is that a composition can take a particular theme and then develop through variations of that theme without becoming simply repetitious. The listener hears the pattern and realizes that it is the same, while, at the same time, knowing equally well that the variations have made it quite different. In the last column, I spoke of TOTS, a procedure designed to help overcome certain problems in infertility. At the end of that column I indicated that I would take up the questions of the medical success of the method and its moral implications. But before we do that, we should take a look at still another infertility treatment called GIFT. GIFT is quite similar to TOTS (tubal ovarian transfer with sperm), and yet is different enough to be described as a variation on the same theme. But just as variations can so transform a theme as to make it new, so small changes in procedure can have significant effects on the judgements we must make about moral issues. GIFT means "gamete intrafallopian transfer." Earlier we had spoken of ZIFT (zygote intrafallopian transfer) and saw that it was no different than in vitro fertilization with a new name and that it is morally wrong. GIFT is something different. A "gamete" is what is referred to also as a "germ cell." This means a reproductive cell; in other words, a gamete is either a sperm or an ovum. GIFT was first publicized by Doctor Ricardo Asch in 1984. It is almost identical to TOTS. In both, an egg is taken and inserted, together with sperm, in the upper end of the fallopian where it is hoped that fertilization will take place. One significant difference, however, was that those working on GIFT obtained the sperm by means of masturbation thus creating a moral problem. If, instead, the sperm had been gathered by means of the silastic sheath used in TOTS, the procedures would have practically identical, and the same moral judgements would have applied to both. I have focused on these similarities and differences, since the two procedures have become confused with each other to some extent. There are now those who use the GIFT procedure, but do so with collection of sperm in a proper way. If you contemplate either procedure as a way of treating infertility, you should be clear about which process is being used. It should be noted, at the same time, that even if the sperm is gathered in a morally acceptable manner, there are still some disagreements among theologians about the morality of the whole procedure. That discussion is more than can be contained within the space allotted for this one article, so we will look at it in the next few articles. At this point, however, we can say something about the success rates of TOTS and GIFT. Success has been fairly good. The pregnancy rate is reported as about 30% as compared to the overall 10% for in vitro. The highest rates of success for GIFT/TOTS have been in cases of endometriosis (32%) and unexplained infertility (31%). Just why the rates should be better in these instances is really not known. It is another one of those observable facts for which we do not yet have an explanation. One final comment remains to be made. The success rate of 30% refers to the rate of pregnancy. About one third of those pregnancies, however, did not result in successful birth. The birth rate, therefore, is about 20%. The moral questions still remain to be considered.

Article #67

MORAL DECISIONS Consulting the Experts

By Reverend Monsignor James J. Mulligan

An obvious way to learn about something is to consult the experts which, of course, you can do by reading what they write, even if you cannot talk to them in person. This is as true in moral theology as it is in any other field. Yet even in theology you will find some questions on which the experts do not agree. This is the case when we look for help in making a moral judgement about tubal ovarian transfer with sperm (TOTS) and gamete intrafallopian transfer (GIFT), both of which have been explained and discussed in preceding articles. All may agree that it is wrong to use procedures that attempt to treat infertility by methods which simply bypass normal sexual relations. They may agree that it is wrong to use procedures which replace intercourse rather than assist it. They certainly agree that it is wrong to use methods (such as in vitro fertilization) which cause death in the effort to create life. But they may very well run into problems in the application of principles in some instances. TOTS/GIFT give rise to such an instance. The procedures of TOTS/GIFT allow fertilization to take place in the fallopian tube. They do not create life outside of the woman's body. If they gather the sperm in a morally acceptable manner, then this also is a point in their favor. But both procedures add another very important factor to the equation. Both of them remove the sperm from the vaginal tract and replace it in the upper part of the tube with the egg. That may seem like a small enough point to many, but it is important and must be considered. It is this particularly which causes disagreement among the experts when they attempt to arrive at a good moral judgement about the whole process. The question that they try to answer is this: Does TOTS/GIFT assist in the reproductive process or does it in some way begin to replace it? Some theologians view this as assistance to the normal process since the sperm is gathered from normal intercourse and is simply assisted in its journey to meet the egg in the upper tube. The process simply places the sperm in the place where it is intended to be. The egg is also moved into the tube, which is where it should go in the normal process. They contend that this assists rather than replaces the normal process, because for some reason, in a particular couple, either the sperm are not arriving alive at the right place or the egg is not properly entering the tube as it should. They would consider TOTS/GIFT morally acceptable. Others see it in another way. They view it as a form of artificial insemination, separated in time and place from the act of intercourse itself. For them, the procedure does not simply clear the way for the sperm and ovum to meet in the normal course of events. Rather, it intervenes in the process and in some way changes things. It replaces the normal process. I have, of course, simplified both arguments to some extent, but what I am presenting is the substance of what both say. For a more complete explanation you might consult a book such as Reproductive Technologies, Marriage and the Church, published by the Pope John Research Center, where excellent articles present both sides. This is clearly a case of honest disagreement among people who are experts in their field. But if the experts disagree, then how are we to arrive at a practical answer when it comes to making decisions? There is a way to resolve the question, but I will have to take it up the next time, since, as has happened before, we are out of space for now.

Article #68

MORAL DECISIONS Important Choices

By Reverend Monsignor James J. Mulligan

Every day of our lives we make choices. What to have for lunch, what to wear, what to watch on television one choice after another and very few of them world shaking. But often enough we are faced with choices whose consequences are far more significant. They deserve more thought and they demand more knowledge knowledge of the facts involved and knowledge of the principles which help us to interpret that knowledge. If you have been following these columns, then you know that we have been considering TOTS (tubal ovarian transfer with sperm) and GIFT (gamete intrafallopian transfer) both of which are procedures which may help some infertile couples. Moral theologians are divided in their opinions as to whether these procedures are morally acceptable or not. The reasons for their opinions I discussed earlier. What I would like to look at now is just how we can make good moral decisions when the Church has made no official statement and the experts are not in agreement. Many people thing that the Church makes it moral decisions on the basis of authority alone. That is simply not the case. Decisions do, indeed, involve authority in the final analysis, but it is an informed authority. Final decisions are never made without full and careful study and that frequently means discussion over a period of time and even disagreement during the learning process. That is, in fact, a clear sign that the teaching of the Church comes from a living Spirit and not from a dead letter. This explains why the Church has offered no official statement on TOTS/GIFT. Those who exercise the teaching authority in the Church have no desire to mislead and will not pronounce in a new matter which remains unclear or disputed among reputable theologians. Where does this leave couples who are trying to make the best moral decision in regard to possible use of TOTS/GIFT? Well, both sides have rational explanations for what they propose. Both opinions (that TOTS/GIFT seems morally acceptable or morally unacceptable) are held by good and reputable experts. There has been no final statement by Church authority. In fact, there has been no statement at all as of the date of this writing. In such a case it is perfectly allowable to examine the reasons on both sides and come to your own honest and informed conclusion. Of course, if the Church had offered a clear statement, then that becomes a part of your own process of making the judgement. You must, at this point, take whatever guidelines are available and arrive at a decision. Of course, it should be done lightly, just as not moral decision in a serious matter should be treated lightly. The point is that there is no authoritative statement to offer guidance, so our only source for the decision is the arguments offered by those who are in disagreement. I am not saying that in every case of disagreement among theologians everything is up for grabs. I am saying that (1) when reputable theologians disagree, and (2) both sides present arguments that seem strong and probable, and (3) the weight of official Church teaching does not clearly support one side or the other, then you may feel morally justified in choosing either alternative, dependent upon your understanding of the value of the arguments. This is good, clear common sense and that is a hallmark of the moral teaching of the Church.

Article #69

MORAL DECISIONS Today's Wisdom; Tomorrow's Error

By Reverend Monsignor James J. Mulligan

Marcel Proust in Remembrance of Things Past said: "Medicine being a compendium of the successive and contradictory mistakes of medical practitioners, when we summon the wisest of them to our aid, the chances are that we may be relying on a scientific truth the error of which will be recognized in a few years' time." There is a certain degree of cynicism in that statement, but also a degree of truth. We should be aware of both. The medical practitioners of a little over a century ago used purging, bleeding and blistering to cure their patients. It was the height of medical knowledge, but the patients survived anyway, if they were lucky. The discovery of the possibility of prefrontal lobotomy was hailed only 50 years ago as a great advance and is recognized now as a disaster. Of course medicine has advanced over the centuries and we should be thankful for it. But we should also recognize its limits. For some time now I have been writing about problems with infertility and the treatments that are offered. There is no doubt that much has been learned, and for this we should be glad. But we should also recognize in this area, too, that more remains unknown than known. In the famous 1989 frozen embryo case in Tennessee, one of the most prominent witnesses was Doctor Jerome Lejeune, a world famous geneticist. He spoke about present knowledge and its limits when it comes to treating infertility. In what follows I am reflecting his testimony. A great deal of our effort in overcoming infertility has been put into the mechanical problem of bringing the egg and sperm together so as to produce conception. In some cases such as the problems which arise from damaged fallopian tubes that may be all that we can presently do. But there are many instances in which the whole problem of infertility remains shrouded in mystery. In the case of endometriosis, for example, the system seems to function but pregnancy does not occur. It is not enough to say that this is due to the endometriosis, since we still remain unable to say why that should be so. It remains impossible to say precisely why endometriosis occurs or why it should cause the problems that it does. Mere mechanical solutions are insufficient. Doctor Lejeune makes the significant point that our preoccupation with the mechanics may be taking us on a completely false and misleading course. He suggests that the real answers may be in the areas of tubal repair, antibiotics and chemical factors. Interestingly enough, the pursuit of further knowledge in those areas would lead to treatments which would not generally have the moral problems now attendant on present procedures. Discoveries in the areas suggested by Doctor Lejeune would almost always be aimed at correcting those things which interfere with the natural process. Correcting them could make normal intercourse both possible and fruitful. No one would object to that, and there is no doubt that it would be easier and more acceptable than much of what is currently being done. Present methods, such as in vitro fertilization, are still quite crude efforts to mimic nature and their highest success rates are still not comparable to their enormous failure rate. Perhaps our time and resources should be directed back to where they would ultimately do the most good, even though those efforts would not generate the enormous financial profits that are currently available through treatments that do little good. Moral theology may seem to some to be a kind of gadfly circling the heads and nipping the tender skin of present science. But in the end, its insistence may well be the source of great achievement both medically and morally.

Article #70

MORAL DECISIONS The Course of True Love

By Reverend Monsignor James J. Mulligan

It was Shakespeare who said it. in A Midsummer-Night's Dream Lysander says to Hermia:

Ay me! for aught that I could ever read, Could ever hear by tale or history, The course of true love never did run smooth...

Yet, in spite of its apparent inability to run smooth, the Roman poet Virgil, seventeen centuries before Shakespeare, had said, "Love conquers all things." And if it can conquer all, then why should there ever be a hill or a valley or even a bump in its path? If I may presume to intervene in an apparent disagreement between two such distinguished authors, I would say that in a sense both are right. For the span of many articles now I have been talking about problems with infertility and the methods used to overcome them. I have insisted that many of the methods currently suggested are morally wrong and that they should be avoided. But underlying the whole question and underlying the capacity to make good moral judgements, there is much more than law involved there is also love, and that is always at the heart of any good and proper moral decision. In this life all real love seems to involve pain of some sort. People love and are not loved in return, so their love becomes longing and longing means unfulfillment and so pain. Parents love their children and yearn to help them when they see them falling apart. But they may find themselves helpless and so love involves pain. Married couples start life together being "in love" and find that it is not enough. It is only the beginning. To learn to live in love together is to find that you and your beloved are both weak human beings, prone to faults and sin. There is room for considerable growth before "being in love" becomes the depth of real love. We all have rough edges and so there is almost always friction in the closeness of love. You know the old joke, "How do two porcupines make love? Very carefully!" We also have to learn not to let our rough edges damage the other's tender spots. We make mistakes and find that we need the humility and generosity both to repent and to forgive. In the movie, Love Story, one of the characters says, "Love means never having to say you're sorry." Nothing could be further from the truth. Without real repentance for our own foolish faults, love would hardly be possible at all. True love never does run smooth, because we are human. But if we choose to commit ourselves to love and live that commitment, then love does indeed conquer all things. It far surpasses any temporary emotion. It gently rubs away any rough edges. It grows and deepens and creates something new. The loving couple give life to each other and they begin to long also for their love to be so creative that it gives new life to a child. This is one of the characteristics of real married love. It seeks to extend itself, to give life, to create. It is a quality that we inherit from our Father in Heaven. The married couple who long for a child and find that they are unable to have one will almost always find this a test of their love. A test, not in the sense that it will necessarily cause their love to falter, but in the sense that their mutual pain may become a source of an even deeper care and tenderness for each other. And also in the sense that the temptation to fulfill so wonderful a desire may test their virtue in choosing to find fulfillment only in ways that are morally good for both of them. They may well learn that love, even when it does not run smooth, can still conquer all.

Article #71

MORAL DECISIONS Falling in Love

By Reverend Monsignor James J. Mulligan

The romantic novels of an earlier age had their own literary conventions for portraying love. The hero and heroine would meet. Love at first sight! Their hearts would beat wildly, their cheeks would flush, their eyes would open wide, their breath would come in gasps... Symptoms of being in love? Not necessarily. Actually they might be symptoms of high blood pressure or an overactive thyroid or just an extra spurt of adrenalin. The fact is that our own literature and drama are most often no better at portraying love. Perhaps, indeed, they are worse. In modern novels and drama love is all too often confused with lust. Physical desire all by itself is certainly nothing but a cheap substitute for love. Desires are satisfied or not and then soon forgotten, only to be replaced by some new fancy. But love lasts even while desire waxes and wanes, and the two even though they may accompany each other are never the same thing and should not be mistaken for each other. Desire and the feeling of "falling in love" seem to happen with a certain spontaneity even when unwanted or at least unbidden. The fact is that real love never just happens. It must be chosen and fostered and stand the test of time. People speak of falling in and out of love as though it were an accident and all beyond our control. On the soap operas the characters fall in and out of love as though their emotional lives were spent on a sheet of ice and all their actions were the result of unsteady footing. And every slip means the abandonment of one partner and the embracing of another as though life were a sort of square dance conducted in a skating rink. The fact is that spontaneous emotions and desires which are all temporary are, to some extent, out of our control. At least they are out of our control insofar as their initiation seems to be concerned. They are certainly not inevitably out of our control in terms of what we decide to do about them. We do not have to be ruled by them and, indeed, we should not be ruled by them. That reduces love to a series of unfortunate accidents and that is certainly not what it is. Real love is never an accident, it is always a choice. And when it is a lasting choice it becomes all that it was meant to be. We really know very little about love if we never learn that it is freely chosen. True love does not come about by chance. To love is to commit yourself and your life to another. It is to receive into your hands and heart the life of another person, and it is to do so willingly with all that this implies about a commitment made and kept even when its keeping is tested by the whimsical capriciousness of our wandering emotions. There is probably no better example of love than the commitment made in marriage. Even Saint Paul felt constrained to use it as his example for the bond between Christ and His Church. Marriage does not mean that you decide to live together because you happen to "be in love." To do that is to play a game with someone else's life. It is a way of using the other to satisfy one's own desire and has nothing of commitment in it. Marriage is a contract, a covenant, a freely chosen commitment. It is a permanent union entered into by the most solemn vows. It is a promise made before God and His people, the Church. For many this may sound like dry as dust language, but there is far more than dry dust involved in a commitment to love "for better or for worse, for richer or for poorer, in sickness and in health until death." It is not a thyroid condition, it is not lust, it is not passing desire, it is no accident. It is the deepest kind of love and the very reflection of the love that God has for us.

Article #72

MORAL DECISIONS Why Be a Parent?

By Reverend Monsignor James J. Mulligan

The Instruction on Procreation of the Congregation for the Doctrine of the faith says: "On the part of the spouses, the desire for a child is natural: It expresses the vocation to fatherhood and motherhood inscribed in conjugal love." This, of course, is rather a formal and stylistic way of stating an ideal; but we do not always do even good things in the best way or from ideal motives. There are abundant reasons for wanting to be a parent reasons which range from the best to the worst. I have even heard of what is perhaps the most dreadful reason of all a father who wanted to have girls so that he could sexually abuse them! Even when the reasons are nowhere near so perverse as that, they can still be far less than perfect and even quite self-centered. Some couples seem to have children for their own satisfaction wanting to love and be loved on demand and then pushing the children away or totally ignoring them when they are inconvenient. There are sad cases of single women purposely becoming pregnant by intercourse or artificial insemination in order to satisfy their own longing for a child, while depriving that same child of the fuller love that ought to come from having both mother and father. Often enough we hear of this in relation to someone famous a movie star, perhaps. Almost as though the child is one more thing on the agenda of self-fulfillment. "I have money, a career, fame and now I also want one of those children that everyone else has, before my 'biological clock' stops ticking." The child is a means to an end one more possession designed to make the owner happy. There are those for whom a child is a necessary proof of their own masculinity or femininity. Some want a child simply to have an heir. There are even those, I am sure, who, consciously or subconsciously, want to have the standard 2.6 children necessary for their own social status. Of course, noe of the reasons I have thus far mentioned is a good reason for having a child. In each instance the child is being used. It is not desired in and for itself, to be loved and cherished. Rather, it is intended to fulfill some self-centered need of its parents. There are even those who will go to great lengths to have one or two children and will then go to even greater lengths perhaps even to the point of abortion to avoid having any more. That bespeaks a deep and dreadful contradiction perhaps even a generous impulse overcome, in the end, by human selfishness. It bespeaks an attitude far removed from faith or love. It is an outlook so filled with a self-centered autonomy as to leave no room for God. It is the assumption of control even over life and death. The real reason for having children ought to be love. A mutual love of husband and wife willing to create in order to love even more. This love involves faith in each other and in God. And then there are those who do love and try to grow. They long for the fulfillment of their vocation to fatherhood and motherhood and nothing happens. They are, for whatever reason, infertile. They share a deep love with each other and long to share that mutual love with a child and find they cannot have a child of their own. There is great love and also great pain. and whenever you find that mixture of love and pain, you will find also the potential for growing in love (indeed, for holiness) as well as a potential for disappointment and rejection. In the next few articles I will look at the various aspects of both.

Article #73

MORAL DECISIONS Life: Blessing or Curse

By Reverend Monsignor James J. Mulligan

Do we look at life as a blessing or a curse? That may seem an odd question to ask, but it is far from unreal. We've all heard of the death doctor and his suicide machine. We have seen votes taken on whether doctors should be allowed to "assist" people who wish to kill themselves. Healers are encouraged to become killers and those whose vocation is to save life are asked to destroy it. How could a society even contemplate such a thing unless it had already begun to see life or, at least, the lives of some as a curse rather than a blessing? Suicide is wrong. It is a rejection of God's right over life and the assumption to oneself of a prerogative that is His. Yet the fear of pain may tempt a person to take life that we can easily enough understand while, at the same time, offering all the support and help in our power to aid a person in getting past the hurdle of such a temptation. What is, however, even more frightening is an attitude in our society which sees even the beginning of life undesirable. Our culture even treats children as a curse. There are couples who do all that they can short of abstinence, of course to avoid having children. Birth control is simply taken for granted and so is abortion if that "disaster" of new life should actually occur. Children interfere with freedom. They are an unwelcome burden. They cost money and get in the way of so many things that a couple may want. Now obviously I am not talking about couples who seek to exercise responsible parenthood and who go about it in a moral manner. I am talking about another attitude entirely. This self-centered attitude undermines love because it reinforces the rejection of generosity. The couple who view the birth of children as a distasteful burden as a curse are not likely to have a happy marriage. If they cannot be generous together, they will not likely be very generous even toward each other. In spite of all the "things" they may accumulate, inside they will shrivel up and die. In the midst of plenty they undergo the worst kind of starvation. They are to be pitied. They do not grasp the meaning of love. They are ignorant even of the great gift of their own sexuality. They are offered the gift of creating life and they turn it down. How different are the couples who generously open their love to the gift of life. Their eagerness to give the gift of life makes it all the more likely that they will want to give life to each other as well. Their growth in love will not be without struggle. They are, after all, human and it is an all too human quality to look out for ourselves first. But the choice to love begins to take us outside of ourselves. It gives us the courage to be open to another. To take that other into one's own life and to foster and nourish all that is best in both. Each moment of struggle, each little letting go of self, is another opportunity to change and to grow. And each step in that growth is an affirmation of the blessing of life, since it becomes increasingly clear that love and life are inseparable. Love is a gift. It is freely given and freely received. You are never the owner of the one you love, nor are you ever owned by the one who loves you. Instead, love sets you free and you choose, ever more freely, to deepen and live to its end that commitment which was made on the day of marriage. The right that each has over the other is not ownership, but a right that is a freely given gift a gift offered every day until death. That is a love which will see its power to create new life as the real blessing that it truly is.

Article #74

MORAL DECISIONS The Right to a Child

By Reverend Monsignor James J. Mulligan

"We have a right to have a child of our own. We can do whatever it takes to have one." I have heard that statement or one quite like it made by people who were struggling with the painful problem of infertility. The words came forth from their pain and their longing, and that I can and do understand. And yet what they are saying is wrong. But it takes gentleness and patience and tact to help them to see just what is wrong. When a couple discovers that they are infertile it is no surprise that they experience a whole range of powerful and disconcerting feelings. Among them are grief and anger, and both of these are expressions of deep pain. A good and holy desire has been thwarted and they are deeply hurt. They may feel renewed hope when they realize that help may be available and they set out to seek it. Yet this may produce an even deeper pain as time goes on. The help may go on month after month without result. One by one the available solutions are tried and each ends in failure. Each time hope springs up and then is met with even deeper disappointment. Is it any wonder that hope, before very long, becomes desperation and ideas that would once have been rejected soon become more and more attractive? Even starting with the highest ideals and the very best of intentions, they can find themselves drawn into a process which gradually leads them to methods of treatment which deal death more than life or violate the most sacred aspects of their married love and unity. It is hard for many to draw back and stop at that point. And, although it may not seem so to them at the time, their choice to do only what can morally be done and to go no further is a choice which can deepen their love for each other. That love, if it is to be all that God means it to be, must reach past their material welfare, past their strongest desires, and all the way to the depths of their spiritual welfare. If I truly love someone, then I would never desire that person to do something sinful no matter how strong might seem the desire or the provocation. That is not easy to do when the desire is so deep in both persons, and yet it is right. Real love will never wish to proceed to the point where the one who is loved could be hurt physically or spiritually. This is a side of married love that is all too often forgotten. The choice to love for life, to care for and to cherish, goes that deeply. It is the acceptance of the other's full welfare including their relationship to God. But what about the right to a child? What has become of that? Well, the fact is that there is no such right! We have rights only to what we can in some way possess and justly claim to have fully under our control. Just as a husband and wife can never own each other, so also they can never own a child. There is no right to a child in the way in which one might have a right to a piece of property. Of course, parents do have what we call "rights" in regard to their children, but those are actually obligations of parents. They have a right which prevents someone else from taking or raising their children apart from them. But the fact that this is an obligation rather than an absolute right is clearly seen in the fact that their failure to carry out that obligation justifies someone else in intervening to see that they change or even to remove the child from their care. "A true and proper right to a child would be contrary to the child's dignity and character. The child is not an object to which one has a right, nor can he be considered as an object of ownership: rather, a child is a gift, 'the supreme gift' and the most gratuitous gift of marriage, and is a living testimony of the mutual giving of his parents" (Instruction on Procreation).

Article #75

MORAL DECISIONS At What Cost?

By Reverend Monsignor James J. Mulligan

Infertility is a burden that is hard to bear. So hard, in fact, that the original generous and loving desire to give and nourish life may, through anger and frustration, be gradually led to the effort to have a child at almost any cost. Along with this there may very well coexist the honest and sincere desire to do nothing wrong. Much of the problem may be due to the fact that our own culture has so much changed in the last half century. Things once clearly and universally and rightly recognized as wrong are now grown fuzzy or simply accepted. What is morally wrong may be civilly legal and society says, "Do it!" The cost of what is proposed and accepted legally may be enormous. I am not thinking simply of the financial cost, although that is usually exorbitant as well. I am thinking of moral costs. The cost may be the creation of new lives, only to kill most and save only the one most likely to survive. It may be the purchase of a child by contract from its real mother. It may be infidelity to the marriage bond or the reduction of husband and wife to mere "manufacturers" of a child quite apart from their own loving act of intercourse. These are costs that early in the process might never have been considered, but the pain of frustration may result in an increasing blindness to the price to be paid. At the same time the teaching of the Church is treated as no more than a lot of rules and regulations. It is ridiculed in the press and denounced as old fashioned and outmoded by those who stand to profit from its rejection. Yet, what does the Church teach? It teaches that every human being has a God-given value that must never be denied or violated. Every human being, from conception to death, is a child of God created to live this life on the way to eternal life with the Father. Every human being is loved by God and must be loved by us. In all that it says about the creation of human life, the church is telling us that we must never lose sight of who and what we are. We must never claim that our goal is good and then violate the meaning of love in order to achieve it. Those who go through the pain of infertility must pray that the pain of it will not blind them to the truth. No matter how deep is the longing for a child, they must also realize that their value in themselves and for each other is not based on the capacity to have a child. There is even a sort of guilt that can accompany the realization of being infertile. It is really a regret that probably comes from the sense of loss in the fact that they cannot give to each other what both of them so much desire. It is really the sadness of not being able to do what you so much want to do for the one you love. The fact is that this is the sort of pain that can actually make love grow. They can, in word and action, begin to say to each other, "It is you I love and not just what you can do for me." They may feel anger at themselves and at each other, because frustration produces anger. Yet even that can, in the end, make love grow. They must realize that it is not "I" or "you" who cannot have a child. It is "we" who are unable. This can bring them to a deeper knowledge that they have come together in marriage to love each other and to share together whatever is painful to either or to both. As they sustain and support each other even in this trial, their love will be that much deeper. that is a price that is worth paying!

Article #76

MORAL DECISIONS Love and Holiness

By Reverend Monsignor James J. Mulligan

In a real Christian marriage, the bond between husband and wife carries with it an obligation about which too little is said. It is the enormous obligation to assist each other in becoming holy. If I truly love someone, then I want that persom to be happy not only here and now, but forever. I want the one I love to be all that he or she was ever meant to be. Husband and wife, if they really love, must each care about the moral goodness and immortal life of the other. Each must help and support the other in doing what is right and avoiding what is wrong, because whatever is wrong is destructive. No morally wrong answer to the problem of infertility can be accepted, because it means obtaining a goal at the expense of moral damage to yourself and to the one you love most of all -- the one who has become one with yourself in marriage. To accept this may seem painful, but it is the sort of pain which springs from and leads back to a deeper love. I certainly have no desire to leave you with the impression that I think pain is a good thing in itself. It isn't. Even though we may romanticize the pain of martyrs or great saints, pain is pain and it hurts. It's only romantic when it is someone else's pain.

The real point of what I am saying is this: Growth in love, like growth in anything, has its painful side. Much of that pain comes from the fact that growing in love takes us outside our own small selves. It begins to cut away at whatever is self-centered. Love demands that we give ourselves and that we face and accept reality. Not all of our desires -- not even the most cherished of them -- will necessarily be fulfilled in the way we may want them to be. We must face up to this. When we can do so with the loving support of someone who really loves us, then unfulfilled desires and honest reality can merge into loving acceptance. Acceptance of truth opens us to a new side of life. It helps us to turn the focus of our minds and hearts beyond what we cannot have, so that we can begin to see and rejoice in the gifts and love that we do have. What advice would I give to couples who want to have children but cannot? First of all, you should look deeply at each other and see beyond what you cannot do to see more clearly what you can do. Look at your love for each other and begin to do all that you can to help it to grow. Be gentle and kind to each other. See your life together in its fullness, including God's love which has brought you together in order to love each other. Pray together and for each other. Let your love reach outward to others and don't let your own pain blind you to the gifts you have to share. Don't focus on desire so completely that you end up missing reality. Even if having children is not possible, married love does not therefore lose its value. There still remains an abundance of ways in which love can be shared. Adoption is, of course, one of those ways. There is also the loving service of education, of helping other families, of caring for the poor and handicapped. All the love of husband and wife can still reach out beyond themselves even when they have no children. This may, at first, seem a poor substitute for that which they desie most of all. It can, in fact, be deeply fulfilling. The heart of my advice is this: Don't close in on yourselves. Let your love grow and allow it to be creative and productive. You will find yourselves not only loving but deeply loved as well. And you will find God's love and holiness in all that you do.

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