Imagine for a moment having the capacity to create new life in a laboratory. Imagine being able to place an egg on a Petri dish, guide a microneedle into its cytoplasm, and release within it a healthy sperm. Imagine then incubating it, watching it as it divides and cultivating (literally) life, all the while being perfectly capable of genetically modifying the embryos and then implanting them into a uterus that you have also artificially prepared, so that this same life may flourish there, as a seed blossoms in fertile soil.
Isn’t this beautiful?
Now imagine that the person seeking assisted reproductive treatment is over 50 years old, and requires a donor, but not just anyone: the patient insists on a white, European, college-educated woman with blue eyes, in good health, and a male donor with similar requirements. Furthermore, the patient wants to choose the baby’s sex and make certain genetic and phenotypic ‘corrections’. Imagine that, despite their own physical condition, the patient wishes to repeat the treatment cycles relentlessly, to the point of exhaustion or illness.
In these cases —far more common than one might suppose— and in many others equally complex, the familiar forces reemerge: the private sector, big pharma, individual interests, and even scientific curiosity itself. This is precisely why assisted human reproduction remains so highly regulated, more in some countries than in others, as in all things.
The ethical dilemmas of assisted reproduction
For a little over a year now, I have been working at a clinic specialized in this field and I have witnessed a stream of people come and go, each with their own complexities. I have closely followed successful cases of couples who undergo fertility treatments for years until they finally achieve pregnancy. Yet, I have also supported others who never quite made it. Working so intimately with the creation of life, I am certain that science can achieve almost anything… and that is precisely why the need to regulate it becomes imperative.
A few months ago, one of our regular patients had her baby: a 57-year-old woman, a member of Opus Dei, who, after already having five children, negotiated her most recent pregnancy with our medical team. We’ve come to recognize those who belong to Opus Dei, particularly because of their belief in large families as an act of trust in God. For them, reproduction is a divine gift. Hence, reaching ‘advanced maternal age’, as defined medically, is a cornerstone of their financial planning, and I emphasize their financial prioritization because these procedures are available only to a privileged few; the prices are quite high, and the outcomes are uncertain.
According to the Spanish Code of Medical Ethics (Código de Deontología Médica), fertility treatments must respect a woman’s reproductive age. The consensus among gynecologists, obstetricians, and other professionals in the field—being benevolent toward the gestational desire and private clinics while pushing the boundaries of biological capacity—is to set this limit at 50 years of age. In the section of the code dedicated to this topic, the ethical (though not necessarily legal) recommendation is not to exceed the age of 45. To come to this conclusion, they likely considered several factors: women now menstruate at a later age and, if they choose to become mothers, do so significantly later in life than decades ago.
Moreover, evolution never pauses; bodies adjust to the system’s pace until, synchronized with late capitalism and its cult of productivity, science enables us to optimize our very existence, our so-called ‘useful’ years, to count our eggs one by one and freeze some for when we have the ideal formula: a suitable partner, a house, marriage, job security, a finished postdoc, and living wage. Fertility and assisted reproduction services are actively marketed—a practice explicitly condemned by binding ethical codes—and indeed, one of the infallible slogans is: ‘Freeze your eggs so you don’t have to freeze your life’.
Beyond the laws, the ethical dilemmas of assisted reproduction are infinite. How many eggs should be frozen? To what extent should they be genetically modified? What should be done with the surplus embryos? What happens if they are transferred to a foreign country? What will their nationality be? Do the parents have to be married? And if so, in countries where same-sex marriage is illegal, will these treatments not be available? How long should the confidentiality of donors be respected? What to do if, in the future, confidentiality has to be waived due to criminal matters? All this without yet addressing how repeated treatments eventually compromise a woman’s well-being, nor the significant role played by the commercial incentives of private clinics. The questions are overwhelming, the debate infinite. This happens with several topics in medical science; it happens with both the beginning and the end of life, with euthanasia. One might say it’s because it places us above or below God.
Reproductive Technologies: Ethics, Gender, and Biopower
The literature includes conservative stances, such as those presented in Leon R. Kass’s essay, The Wisdom of Repugnance. In this text, Kass refers to the moral repugnance that assisted reproduction, among other medical practices, generates, according to him. The author argues that this instinctive revulsion stems from the way these practices transgress core ethical limits: they dehumanize the reproductive process, sever the bond between couple’s love and the erotic pleasure of procreation, and transform life into manufactured products. By generating lives under conditions of experimentation and control, Kass warns, we violate the core principle of inherent human dignity—the idea that humans are ends in themselves, not means to be manipulated. He criticizes ‘genetic design choice’ as a eugenic and utilitarian distortion of parenthood that reduces children to products and thus directly attacks this principle.
Fortunately for all, there have been positions that have challenged Kass as the ethical frameworks of assisted reproduction shape its legislation. The most recognized is that of philosopher Martha C. Nussbaum, particularly in her article Danger to Human Dignity: the revival of disgust and shame in the law, in which she argues that moral emotions like disgust do not represent ethical foundations and have been used historically to justify misogyny, racism, homophobia, and exclusion. Thanks to disgust, “witches” have been burned, abortion prohibited, and legal union between people of the same sex vilified. She also challenges the view that assisted reproduction is morally questionable simply because it is ‘unnatural,’ arguing that this characteristic alone does not diminish its ethical standing.
Another feminist philosopher, Donna Haraway, based some of her most renowned studies on the idea of the cyborg as a symbol of freedom: one that blurs bodily frontiers, rejects gender categories, and occupies an interstitial space between human and machine, nature and technology. This metaphor reimagines bodies and human connections, moving motherhood beyond naturalistic ethics and the notion of women’s ‘biological destiny’—that idea that they are born with ‘the gift of giving life’ and other phrases that have tormented us throughout history. For Haraway, it represents a technopolitical act: one that includes both in vitro and natural motherhood, as both are shaped by cultural norms, power structures, and medical technologies. And this is precisely why, with new technologies, what is at stake is: which bodies can mother, and under what economic, sociopolitical, legal, and affective conditions can they do so?
Feminism has also divided the bioethics behind new reproductive technologies. Yet, motherhood remains inaccessible to those who are not white, cisgender, heterosexual, and legally married. Needless to say, though it must be said, the experience of pregnancy is conditioned by birthplace and privilege: the realities of a marginalized migrant body cannot be compared to those of a privileged, middle-class European with private medical access.
We could well see it another way: where morality sets limits against deviation from the traditional model, there is space for creativity and repair.
I, surely due to professional bias, cannot see ethical positions that are not accompanied by scientific reasons. This is why, to legislate, a multidisciplinary team is necessary: one that, on such dynamic issues, must constantly modify sections and points of view. No two cases are alike. The reality of daily practice shows that the most abstract limits, those that cannot be contained in a law, are constantly violated for the benefit of capital. This is why public services must become the primary channel for shaping laws and research, despite being themselves underresourced and compromised, but that is another debate.
It is the universities, in collaboration with hospitals that practice public and free assisted reproduction, that define the frontiers of science, medicine, and biotechnology. For example, it has been demonstrated that embryos can be created under extreme conditions, even when the health of the egg, the sperm, or the body to be implanted is not optimal. A private company could (and does) violate these limits, even against regulatory recommendations. Likewise, multiple pregnancies must be prevented, something that has been debated as a moral restriction, but is in reality a clinical safety standard. The other clinical limits are clear: maternal age is fundamental because, even though gestation may be possible under adequate conditions up to age 60 or slightly beyond (I am not sure if there is a true biological limit), the risks to maternal health—including psychological well-being—and to the fetus and future infant are significant. Motherhood should be based not only on biological factors but also on realistic parenting expectations.
I had a patient, Gema, aged 49. After multiple fertility treatments at our clinic, she finally became pregnant on her third embryo transfer. Gema turned 50 while pregnant. She got married so that the procedure she was about to undergo would be not only legally easier but more “structured.” This information, which we did not need, was provided by herself in the initial interviews. Throughout her pregnancy, Gema struggled with intense irrational fear of everything: that a measurement would be off by a millimeter (literally) compared to the non-specialized readings she did on her own responsibility, of improbable results, of extremely rare pathologies. The day we scheduled her caesarean section, she was overwhelmed by panic, convinced she was not ready. But it was done, her beautiful girl was born healthy, full of life, and Gema is going through a deep depression that prevents her from many daily activities, even breastfeeding. Fortunately for all, she is not alone.
Prolonged and invasive assisted reproduction treatments are a fundamental cause of postpartum depression.
CRISPR: The Great Power and the Great Responsibility
Medical science boasts groundbreaking discoveries that have changed the course of human history: penicillin, ether, pasteurization, X-rays, among others. In this century so far, probably the most important discovery we have witnessed is the development of CRISPR-Cas9, the new tool for genome editing. Actually, it had been discussed since 1987 thanks to palindromic and repeated sequences discovered by chance in an Escherichia coli, but the latest related news was heard in 2020 when two women were awarded the Nobel Prize in Chemistry: Jennifer Doudna and Emmanuelle Charpentier; a rather controversial Nobel, by the way. CRISPR functions like magical scissors that cut out the defective DNA sequence, which is then repaired by specialized enzymes.
A watershed in the prevention, diagnosis, and treatment of diseases, even rare ones. You may remember the case of K. J., the boy cured using this tool, whose face we saw across all major newspapers. Researchers (those who still have a budget for it) are still trying to gauge its risks. With great power comes great responsibility, and with CRISPR, a world of hopes and possible catastrophes opens up. Editing DNA could well mean transforming the human being as we know it. The truth is that, at least to date, public opinion agrees not to use genetic editing for functions such as physically modifying a person or enhancing their intelligence, skills, or predispositions.
The case of the baby with carbamoyl phosphate synthetase deficiency was a positive development, but setbacks have occurred. In 2018, Chinese scientist He Jiankui genetically modified two embryos to protect them from HIV, violating protocols and without proper institutional approval. The modifications he made were entirely novel, so their consequences remain unknown. Jiankui not only used techniques that completely altered the twins’ DNA, but it is also unclear whether he shortened their life expectancy, whether the changes will be passed to their offspring, or even if the intended outcomes were achieved.
This is why a country with the resources and infrastructure for assisted human reproduction bears a set of responsibilities toward humanity, and no private clinic laboratory, regardless of its scale, is excluded from this duty. Highly specialized science may seem inaccessible, yet its hidden depths contain a wealth of creativity and theorizing about the true possibilities of human beings.
With AI now leading every endeavor, I wonder: What are the true boundaries of medical science? Is a state’s mere will sufficient to regulate and map the possibilities? How destructive can capitalism become? And what roads are genuinely open to humanity? These questions sound passionate, and they are—especially when asked amid the rubble of an old-world order where, in addition to dealing with foreign wars, there is barely any time or resources left to develop science beyond market-driven interests.
It might be for the best that groundbreaking discoveries decelerate within a sociopolitical framework incapable of managing their repercussions. However, the desire to create and nurture life persists. The dilemma lies in the responsibility of guaranteeing care, dignity, and a future, a task that embodies, perhaps, one of humanity’s most profound gestures.
