Orthodoxy and Pastoral Issues: Beginning of Life

1. Orthodoxy and Pastoral Issues: Beginning of Life Gayle E. Woloschak, PhD DMin Northwestern University School of Medicine Zygon Center for Religion and Science, Chicago

2. Technology Issues

3. Surveys about Scientists • Views of children: speak foreign language that no one can understand, live underground, wear white coats even when they sleep, wear glasses, don’t require food • Views of adults: speak language no one can understand, are anti-social, have cured diseases but only the rich people can get the cures

4. Science Impacts Humanity: • Understanding the world—education • Medicine—diagnosis, treatment, quality of life, end of life • Ecology—recombinant foods, environmental issues • Genome science—genetic counseling, gene editing • Stem cells—new therapies, cloning

5. Example: Science drives the Ethics for HIV • Early considerations: quarantine, restrictions for interactions (including aid to those infected) • Science demonstrated route of viral transmission Result: Informed decisions • Knowledge gained from science impacted decisions so they could be made ethically. • Inclusion of scientists in discussions was important, made decisions timely and informed. • Facts shaped the understanding of the disease…and therefore the ethical treatment of patients.

6. “…science is a way of knowing, but it is not the only way. Knowledge also derives from other sources, such as common sense, artistic and religious experience, and philosophical reflection.” Francisco Ayala (population geneticist, NAS member) in Theology and Science, 2003, 2:9-32

7. How Far is too Far? (or: Should we Limit Technology?) • New technologies are providing us with tools to manipulate the environment, nature, energy, etc. • Rapid movement from technology to discovery—makes it hard to limit the technology • Most limitation is done at the level of the application of the technology • Safety issues associated with technology take second-place • Long term effects rarely considered or conceptualized • Positive and negative aspects to application of technology

8. Concerns about Technology and our Society • Conviction among general population that technology can cure all things afflicting humanity • Belief in technology over a belief in God • Little pause for reflection in culture about whether a technology should be used • Little testing of whether a technology is safe • Result: Attitude of entitlement, disappointment, high costs for medical intervention

9. Technology that is Available • Science and engineering are technology-driven. • Those that can use new technologies are the “can-dos” and ultimately become the “haves” • Those that don’t explore new technologies rapidly become obsolete. • Examples: cell phones, computers, earthquake-safe buildings, etc.

10. On Medical Knowledge as a Gift from God “Medicine is a gift from God even if some people do not make the right use of it. Granted, it would be stupid to put all hope of a cure in the hands of doctors, yet there are people who stubbornly refuse their help altogether.” “All the different sciences and techniques have been given us by God to make up for the deficiencies of nature…Not by chance does the earth produce plants that have healing properties. It is clearly evident that the Creator wants to give them to use to use.” -St. Basil, The Greater Rules, 55

11. On the Source of Knowledge “For it is he (God) who gave me unerring knowledge of what exists, to know the structure of the world and the activity of the elements; the beginning and end and middle of times, the alternations of the solstices and the changes of the seasons, the cycles of the year and the constellations of the start, the natures of animals and the tempers of wild animals, the powers of spirits and the thoughts of human beings, the varieties of plants and the virtues of roots; I learned both what is secret and what is manifest, for wisdom, the fashioner of all things, taught me.” -Wisdom of Solomon 7:17-22

12. Orthodox Perspectives on Technology • Technology can be good or bad depending on how it is used—ex/radiation • Wisdom and creativity are gifts from God • Medicine and medical intervention are appropriate for humanity because they are gifts from God • Knowledge should not be blinded by self-importance or be bent on self-perpetuation • Must know how to act when needed and abstain when appropriate—when to act, when to “let it be”

13. Human Responsibility • Technology comes with a responsibility: to oversee it properly, to protect those who might be harmed by it (including the earth and animals) • Must exert proper stewardship over technology • Must try to be humble – it is not possible to imagine all consequences of a technology – being watchful and willing to accept truth is necessary • Must use discernment: eliminating technology means the elimination of cures; accepting all technologies will leave ethical concerns

14. Beginning of Life and IVF

16. Newly fertilized egg 3rd day embryo in mouse: 16 cells, beginning of implantation FIGURE 12.3 During preimplantation, the embryo consists of a limited number of cells. A: Newly fertilized mouse egg. B: By the 3rd day, the mouse embryo consists of only 16 cells. About 5 days after conception in the mouse, which corresponds to about 9 or 10 days in the human, the embryo becomes embedded in the wall of the uterus, and at about this time, cells begin to differentiate to form specific tissues and organs. (Courtesy of Dr. Pedersen, University of California at San Francisco.)

17. In Vitro Fertilization (IVF) • Used primarily to treat fertility “disorders”: help infertile couple bear children • Originally called “test-tube babies” • Approach: isolate eggs from mother, sperm from father, mix in the test tube, let the embryo develop for several days and then implant into the mother • Left over fertilized eggs in test tube can then be used for embryonic stem cells

18. How are IVF-embryonic stem cell lines established? • IVF-generated fertilized eggs are grown in culture using “feeder cells” from mice to provide growth factors. • The process is inefficient and not all cells established in culture will become an embryonic cells cell line. • Once a line is established it is tested for 2 features: absence of genetic abnormalities (hard to measure) and ability to grow without developing into any set (partially mature) cell type. • Cells are then harvested and frozen for future studies.

19. Standard Laboratory for Stem Cell Studies

20. Embryonic Stem Cell

21. Why IVF and not adoption? • Many question whether IVF is based in the need to pass “my genes” on to the next generation rather than care for a child to be raised. • High costs of adoption, difficulty of adoption, problems with enculturation are issues raised by those who choose IVF. • IVF is also expensive

22. Unique Aspects of IVF: Manipulation of the Embryo (PGD) • Pre-implantation Genetic Diagnosis • Selection against certain genetic defects • Selection for an embryo that produces certain proteins • 2009: Clinic in LA offers screening for gender and physical traits

23. Pre-implantation Genetic Screening

24. Nature445, 479-480 Reproductive medicine: The first cut

25. Religious Perspectives: Roman Catholic Two major issues: • Strong opposition to IVF: IVF eggs are embryos despite their not having been in the womb (based on Encyclical Letter of Pope John Paul II, 1995) • Opposition to separation of sexual and procreative act (Vatican, 1993)

26. Other Religious Perspectives • Supportive of IVF/stem cell research: Jewish, Anglican, some Lutheran, Presbyterian, others • Opposed: Southern Baptist, National Association of Evangelicals

27. Orthodox Christians and Sanctity of Life • Strong belief in the sanctity of life • Do not have same attitudes toward procreation as the Roman Catholic Church • Do have a general acceptance of technologies that preserve and protect life provided that it does not extend meaningless life • Major questions: (1) does the Orthodox Church accept IVF and (2) are the IVF-generated embryos human life?

28. Orthodox Attitudes Toward IVF Contradictory • Some bishops have given a blessing for a married couple who cannot have children to use IVF to assist them. • This is done on a case-by-case basis. • It is not clear what the bishops thought about the remaining IVF-generated embryos. • Other bishops have refused to give a blessing. The Church of Russia has not sanctioned IVF. The Church of Greece has been more ambiguous.

29. Stem Cell Research

30. What are Stem Cells? • Stem cells are immature cells that under the right conditions can be induced to give rise to mature (differentiated) cells. • Two types of stem cells: adult and embryo • Applications for adult stem cells: bone marrow transplants, blood transfusions; other applications have not proven successful • Applications for embryonic stem cells: currently banned in the US

31. What are Embryonic Stem Cells? • Currently being developed for use in human disease; difficult because of potential for graft rejection • Concept: Some diseases lead to loss of cell function. Can we replace lost cells with embryonic stem cells? • Possible applications: diabetes, Parkinson Disease, Alzheimer Disease, spinal cord injury, others

33. Lisa M Hoffman & Melissa K Carpenter . Characterization and culture of human embryonic stem cells. Nature Biotechnology  23, 699 - 708 (2005)

34. Lisa M Hoffman & Melissa K Carpenter . Characterization and culture of human embryonic stem cells. Nature Biotechnology  23, 699 - 708 (2005)

35. Pros and Cons of Embryonic Stem Cells • Cons: Sacrifice of embryos cannot be justified; use of embryos for stem cells could be used to “justify” abortions or even increase abortion rates; embryonic stem cells can be rejected by the host • Pros: Stem cells may cure many diseases for which there is currently no treatment • Solution: Obtain stem cells from other sources—some of these have been successful and mitigate problems of graft rejection

36. Possible Sources of Embryonic Stem Cells • Embryo—obtain stem cells from therapeutic abortions • Cells remaining from IVF—fertilized eggs never implanted into a mother • Cloned cells—nucleus from adult cell transplanted into an egg cell • Oocytes that have been induced to have 2 nuclei

37. Adult vs. Embryonic Stem Cells ADULT STEM CELLS EMBRYONIC STEM CELLS Derived from other sources: fetal sources are NOT used; IVF is main sources IVF-embryo stem cells use not supported by Catholics and some Protestants (groups against birth control); supported by Judaism, Episcopalian, Presbyterian, etc.; Orthodox have not expressed a view Less limiting because embryonic stem cells develop into many cell types; more promising clinically Experimental: no applications now State limitation: transplantation • Used for decades: for example, bone marrow transplants • Orthodox Church has supported their use • Currently developed for additional therapies including cardiac diseases, with some limited successes • Reprogramming adult cells to be stem cells for different organs • Can match for compatibility from one person to another much like transplantation

39. Scheme for iPS Generation from Adult Cells Introduce virus to express stem cell genes Add in feeder cells that are “inactivated” Isolate donor cells Small subset of cells become iPS and generate ES-like colonies

40. Pros and Cons of induced Pluripotent Stem Cells (iPSCs) • Cons: Requires reprogramming of adult stem cells to be pluripotent: low efficiency, genomic insertion comes with risks, can go on to develop tumors, incomplete reprogramming sometimes occurs • Pros: does not need embryonic cells, do not need to worry about graft rejection • Some risks may be mitigated with newer technologies: gene editing is being improved, work with improved viruses as vectors may reduce cancer risks

41. Orthodox Perspectives • Opposed to use of embryos for stem cells • Perhaps opposed to the use of cells remaining from IVF—questionable • Questions about cloning- and oocyte-derived stem cells • Current discussions by several Orthodox groups • No opposition to use of stem cells that are NOT derived from stem cells (but this is not well-discussed)

42. Technologies and Pastoral Care • Biotechnologies increase the number of decisions and turning points in life. • Challenge for pastors is to be equipped with sufficient understanding and insight to help individuals, couples, families address these issues. • Examples: marriage/pregnancy when genetic issues arise; guilt or blame or denial in decisions when a genetic condition results; questions about new forms of contraception, conception, and beginning of life questions. • Requires more collaboration between pastors and health professionals.

43. Genetic Counseling and Pregnancy

44. Genetic Counseling During Pregnancy • Often use small amount of amniotic fluid to examine genetics of the child (15-20th week of pregnancy) • Purpose is not always for aborting the child—can be to prepare the family for a difficult birth, treat the child at birth for a disease or abnormality, etc. • Risk of amniocentesis is 0.06% or lower

45. Some diseases diagnosed by amniocentesis • Down Syndrome (Trisomy 21) • Trisomy 13, Trisomy 18 • Fragile X Syndrome • Neural tube defects (spina bifida, anencephaly) • Other rare inherited disorders • Prediction of fetal lung maturity

46. Site for amniocentesis

47. Amniotic fluid:

48. Perform amniocentesis under ultrasound guidance

49. Insertion of the needle

50. Orthodox Perspectives on Amniocentesis • Motivation is important • Appropriate motivations: to prepare the family for the coming child (particularly if a physical abnormality is predicted for birth), to help the child at the time of birth • Inappropriate motivations: abortion of a child • Motivations that involve selection of particular traits in children (male vs female) would not be considered acceptable