In The Sunday Times (3 May), Josie Muscat spoke again on the IVF controversy. I have often expressed my opinion in favour of IVF for infertile couples, grappling with myself to come to terms with the dilemma it poses vis-à-vis our faith’s institutions’ statements. Nevertheless I do feel that couples have a right to have children and that if medical science can help in this regard without crossing ethical boundaries, it should do so and couples should have a right to make the ethical decision whether to go forward or not. Many pastoral services indeed encourage them to do so. However I think that Dr Muscat’s article deserves some attention as it may help resolve some differences which exist in regard to this technology. I start with the premise that many of our differences are disputes – that they do not involve a difference in values. The latter would indeed amount to a conflict, rather than a dispute. We have to assess therefore whether our disagreements are about disputes or about a true conflict.

Indeed for those who object to IVF based on the Church’s document, Donum Vitae, the difference is a conflict. IVF should not be used, period. It is illicit as it involves the use of a third party to bring about a birth which should be brought about solely by the union of a man and a woman. But when many within the faith, including theologians, argue that this may be too stringent a punishment on the poor couples trying to conceive and that we should not be judgmental on those who seek these services as long as legislation does not threaten the family value or the principles of sanctity of life, then many still receive a conflicting message. It would seem therefore that, this conflict aside, there really exist disputes on who should receive IVF and whether we should freeze embryos. In reality, prima facie, these seem based on divergent ethical values and therefore one should call them conflicts. But I honestly believe that we inherently hold the same values and that these issues can be resolved.

Dr Muscat hints at the legitimacy of freezing embryos. He states that we lose patients because we do not offer this service. Many women go abroad because where they freeze embryos they stand a greater chance of success without having to go through the same procedure repeatedly. Now I have honoured Dr Muscat myself when I was president of the Malta College of Family Doctors. I do believe he is a true pioneer in Malta both in the political field (ironically) and in the medical field of primary and secondary care.

From a successful GP, he developed full fledged private services, group practices, under-water birth, and of course treatment of infertile couples. He is indeed a maverick in the good sense of the word. However, while accepting that his endeavours to change the face of services offered to infertile couples are indeed revolutionary for a conservative country as ours, I honestly also believe that perhaps, the ethical implications may be underestimated. While I do not intend to enter into any media debate and will surely invite those concerned when we study the issue academically in the newly created Bioethics Research Programme at the University, I hope that future debate will help us all arrive to compromises which are satisfactory not only to infertile couples and those offering the service, but to the ethical values of the general Maltese population as well.

Therefore I do not think that we should judge our limits by what other countries offer. If some Maltese couples can go to other countries because they freeze embryos, then this cannot be our measuring stick. Neither, in my humble opinion, can we state that since only those who have the money to do so can have access to these services, it makes it morally correct. The Hippocratic Oath, which Dr Muscat invoked, does not oblige us to do so. The rich will always have access to more services than others; moreover it is those who have money who usually have access to the more controversial things in life. This does not make them a moral feasibility for all.

Even if there were arguments about when the human embryo should have moral status (many try to invoke the time of the primitive streak, or the time when a primitive brain has developed), the fact is that we cannot, on our own, as an island, decide this issue. Of course we can legitimately participate in debates. But we cannot change the world view to accommodate our laws. It is perhaps true that in medieval times, the soul was considered to enter the body when the brain was formed.

One need only read Dante and his invocation of the ‘motor primo’ sending the soul when the brain has formed. It is also true that up till a couple of weeks the embryo can form twins and therefore this puts into question whether a soul splits up – not naturally, as this can be argued to have been planned in the genes, but in vitro, where we can split an early embryo into 10 or more, begging the question whether we are creating souls. This is epistemology however; the study of knowledge. From a phenomenological point of view – the study of the world we are ‘thrown’ in, being-in-the-world has it that morally we speak of the moral conferment on the embryo when fertilisation has occurred. This is also backed by epistemological thought, as all biologists would agree that any form of life begins at fertilisation.

So when we come to legislating for IVF, which I am all in favour of, we have to respect our socio-cultural position. Legislating in favour of giving IVF to stable couples and protecting the embryo is the least we can do. Even if we do not see the freezing of an embryo as an insult to this small being, we must concede the consequential issue that freezing embryos will result in many of them being unused. This happens simply because success does not always happen at the exhaustion of all these embryos. It can happen before and you are left with those you can spare. Now many theories have been thrown around by those who pontificate (to use Dr Muscat’s wording). Some say you can donate them; others say you can use them for research. The base line is that if we are to uphold our moral values and respect the embryo from conception, we cannot leave it in a state of frozen limbo. From this we can learn from the experience of other countries.

Last but not least there is the faith of the public in the profession. We offer services to assist people in need. If these are not offered by the state, we can do so privately. But should it be the fact that the state is more wary of moral implications than is the private sector. If this is not the case, the public will certainly get the impression that monetary ends justify any moral doubts. While I am not putting into question anybody’s motives, one cannot deny that where morality is concerned, we may disagree on some boundaries, but if we live in a democratic country, the goose and the gander must have the same fodder. It would be lame if government services are bound by moral rules which do not hold true for private lives and businesses.

I concede that not having space in the SCBU is not an excuse for not offering private services. One has to question however that we pay for our SCBU services from our taxes, which then are used by those who have had the money to get IVF services privately (even if at great sacrifices to their personal lives). The fact remains that many do not get IVF because they cannot afford it. Our SCBU is equipped to deal with the run of the day intensive care in the newborn. Should this include services to those who are opting for this expensive service? Of course, ethically we always have a duty to care and we cannot judge people or leave them without a service, saying that once they conceived privately, they should seek SCBU services privately. But discussion in biomedical ethics involves the principle of justice, which inevitably has to discuss allocation of resources. We cannot have people abuse these services, for abuse it may seem to some, if people have the money to start something only to finish it at the expense of the tax payer. This may be because the service is not offered privately. Even if it were, we cannot oblige people to seek SCBU services privately, even if they have had IVF in this sector. But it leaves an open question – at minimum food for thought. It has after all already given rise to much controversy in our media.

I sincerely hope that we can work together to arrive at a just solution to this problem – as problem it is for patient advocates – and work out together our disputes. If we turn these disputes into conflict, then we are facing more profound differences in values. This would be more serious than people think. Not only will this impede our progress in this area, it would endanger the whole process, as many moralists, including I dare say myself, are not willing to compromise on moral issues dictating when life begins. I have been known, in a spirit of dialogue, to discuss the status of the embryo from a purely academic point of view. One can view it as merely a template of DNA. But we all started off as one cell. That is a mere fact of life. Is it up to us when to put moral status of when that cell should have rights? I am quite sure that Dr Muscat’s values are in the right place as everyone else’s in this matter. In the end, if the law stalls, it would not be in the interest either of those who receive the service of IVF, or of those who offer it. Until we come up with a formula whereby freezing embryos would not leave them on the shelf indefinitely, perhaps we can look at the more legitimate freezing of ova. But this is still undergoing peer scrutiny. Perhaps our doctors can be involved in this avant-garde technology. As far as I know we are not, yet.

Pierre Mallia is Associate Professor in Family Medicine, Patients’ Rights and Bioethics at the University of Malta; he is also Ethics Advisor to the Medical Council of Malta.