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Sunnī and Shia Perspectives on Assisted Reproductive Technologies

By:
Marcia C. Inhorn, Soraya Tremayne
Source:
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Sunnī and Shia Perspectives on Assisted Reproductive Technologies

Introduction

The world’s first “test-tube baby,” Louise Brown, was born in England in 1978. Less than ten years later the Muslim world’s first test-tube baby, a little girl named Heba (meaning “gift” in Arabic), was born in Egypt in 1987 (Inhorn, 2003). In vitro fertilization (IVF)—the form of assisted reproductive technology (ART) used to conceive both of these children—rapidly globalized in the 1990s, subsequently spreading to many parts of the Muslim world by the end of the twentieth century. Today the Muslim Middle East boasts one of the strongest IVF sectors in the world, with more than fifty IVF clinics in Egypt, more than sixty in Iran, and more than one hundred in Turkey (Inhorn and Patrizio, 2015).

This eager acceptance of IVF has been due in large part to the permissive attitudes of Islamic religious authorities, who have viewed ARTs as biomedical tools to overcome human suffering. Given that both male and female infertility lead to the social problem of involuntary childlessness, Islamic authorities have tended to condone the use of ARTs among Muslim physicians and their patients, providing interesting and insightful Islamic bioethical justifications to do so (Tremayne, 2006). Furthermore, this acceptance of ARTs must be viewed from the standpoint of Islam’s inherent pronatalism. Numerous passages in the Qurʾān and ḥadīth refer to the rewards of motherhood, the joys of having children, and the desired growth of an Islamic “multitude.” Thus, childbearing, in and of itself, receives support in the religion (Inhorn, 1996).

Before examining Islamic bioethical standpoints on the ARTs, it is important to define what these technologies encompass. IVF was the first ART, becoming the platform technology for many other innovations (Franklin, 2013). In IVF a woman’s ovaries are hormonally stimulated to produce excess eggs. These eggs are then “harvested” from a woman’s ovaries and placed in a petri dish in an IVF laboratory. Spermatozoa retrieved from the male partner (usually through masturbation) are then placed with the eggs in a petri dish with the goal of an in vitro (i.e., outside of the body) conception. Successfully fertilized embryos are then transferred into the woman’s uterus, in the hope that one or more will implant to create a viable pregnancy.

Since the development of IVF numerous variants have emerged. These include: (1) intracytoplasmic sperm injection (ICSI) to overcome male infertility; (2) third-party reproductive assistance (with donor eggs, sperm, and embryos) to overcome problems of poor egg and sperm quality; (3) gestational surrogacy to help women who are unable to carry a pregnancy in their own uterus; (4) cryopreservation (freezing) and storage of unused sperm, embryos, eggs, and ovarian tissue; (5) mitochondrial transfer from a healthy human egg to the diseased egg of another woman; (6) preimplantation genetic diagnosis (PGD) to determine if embryos have genetic defects; (7) preimplantation genetic selection (PGS) to select embryos of a specific sex, or to select embryos that can grow into “savior siblings” through the donation of their umbilical cord blood; (8) human embryonic stem cell (hESC) research on unused embryos for the purposes of therapeutic intervention; and (9) the future possibility of human reproductive cloning, or asexual, autonomous reproduction, which has already occurred in other mammals (e.g., Dolly the sheep).

Sunnī Islam and ARTs

IVF was first practiced in 1986 in the Sunnī Muslim majority countries of Egypt, Saudi Arabia, and Jordan. Egypt’s early entrance into assisted reproduction was especially important from an Islamic standpoint (Serour, 1996). The Grand Shaykh of Egypt’s renowned religious university al-Azhar issued the first widely authoritative fatwā on assisted reproduction on 23 March 1980, only two years after the birth of Louise Brown in England, but a full six years before the opening of Egypt’s first IVF center. Over the ensuing decades this original al-Azhar fatwā, although not legally binding, has proved authoritative and enduring. It has been reissued many times in Egypt, and subsequently reaffirmed by fatwā-granting institutions and authorities in other parts of the Sunnī Muslim world, from Morocco to Saudi Arabia to Indonesia. (For a fully translated English version of this fatwā, see Inhorn 2003 and 2005).

In general, Sunnī authorities have permitted IVF as a solution to infertility among married couples as long as the fertilization of a wife’s egg occurs with the sperm of her husband (Serour, 2008). Furthermore, many variations of the basic IVF procedure have been considered ḥalāl (religiously permissible) and subsequently condoned for clinical use. These permitted practices include:

  • (1) Intrauterine insemination (IUI) using a husband’s sperm;
  • (2) Intracytoplasmic sperm injection (ICSI), in which the sperm of a husband is injected directly into the egg of his wife;
  • (3) Cryopreservation, or freezing, of any excess embryos, as well as sperm and eggs to be used later by a married couple, or by patients prior to cancer treatment;
  • (4) Post-menopausal pregnancy using a wife’s own cryopreserved (frozen) embryos or oocytes, in combination with the sperm of her husband;
  • (5) Preimplantation genetic diagnosis (PGD) for couples at high risk of genetic disorders in their offspring, or for the purposes of “family balancing” among couples with only sons or daughters, who would like offspring of the other sex;
  • (6) Embryo research on excess embryos that are donated with a couple’s permission for the advancement of scientific knowledge; and
  • (7) Most recently, uterine transplantation, in which a healthy uterus is transplanted from a willing donor to another woman who is lacking a competent uterus, so that an IVF pregnancy can take place in the transplanted uterus. (The first such attempt at uterine transplant was carried out in Saudi Arabia).

This clearly represents a substantial list of permissions, allowing for a wide range of ART practices to be performed. However, Sunnī religious authorities have also agreed that some ART practices are ḥarām (religiously forbidden). These include:

  • (1) Third-party donation of sperm, eggs, or embryos to other persons or couples;
  • (2) All forms of gestational surrogacy, in which an embryo is implanted in another woman’s womb;
  • (3) Posthumous (or post-divorce) usage of frozen eggs, sperm, or embryos by a now single spouse;
  • (4) Preimplantation genetic selection (PGS) or sperm sorting techniques for the purposes of sex selection (against daughters);
  • (5) Genetic alteration of embryos for the creation of genetically modified offspring; and
  • (6) Human reproductive cloning for the creation of a cloned child (who would be the genetic twin of the cloning parent) (Eich, 2006; Moosa, 2003).

The first prohibition on this list—namely, the clinical ban on any form of third-party reproductive assistance, including surrogacy—is perhaps the most important (Gurtin, 2016; Inhorn, 2003; Shabana, 2015). It stems from the fact that transmission of reproductive material between persons who are not legally married is considered a major violation of Islamic law. This sense of reproductive violation is justified on three important Islamic bioethical grounds (Inhorn, 2003, 2012).

First, Islam mandates the creation of offspring within marriage. As is made clear in the original al-Azhar fatwā, reproduction outside of marriage is considered zinah (i.e., illegal intercourse, or adultery), which is strictly forbidden in Islam. Although third-party reproductive assistance does not involve the body contact (“touch or gaze”) of adulterous sexual relations, it is nonetheless considered by most Islamic religious scholars to be a form of adultery, by virtue of introducing a third party into the marital union of husband and wife. As such, it is inherently threatening to the marital bond.

Second, third-party reproductive donation introduces the potential for incest among the offspring of anonymous donors. If an anonymous sperm donor “fathers” multiple children, these children could grow up and unwittingly marry their biological half-siblings. The same could be true for the children of anonymous egg donors.

Third and perhaps most important, third-party reproductive assistance confuses kinship, descent, and inheritance. Preserving the nasab, or known genealogical origins of each child, is considered a moral imperative within Sunnī Islam. The problem with third-party donation of eggs, sperm, and embryos, therefore, is that it destroys a child’s nasab and violates the child’s legal right to known parentage, which is considered cruel and unjust. A donor (or surrogate) child conceived through any illegitimate form of ART cannot be made legitimate (e.g., through legal adoption). Thus, the rights of the child underlie these concerns, as well as the prohibitions on sex selection (against girl children), genetic alternations of the embryo (to create “designer” babies), and cloning (to create genetic replicas of a parent).

Shia Islam and ARTs

These Sunnī Islamic positions on ART have held powerful sway since the 1980s, meaning that third-party reproductive assistance (including surrogacy) is not practiced in most Muslim-majority countries. However, since the late 1980s Shia Muslim jurists have diverged in their thinking on this subject (Tremayne and Akhondi, 2016). Because Shia jurisprudence places a high priority on ijtihād, or independent legal reasoning, various Shia religious authorities have engaged in discussion and debate on the permissibility of third-party reproductive assistance. Despite diverging views among the leading Shia jurists, who are sources of emulation for their followers, third-party reproductive assistance has been allowed in all its forms (Abbasi-Shavazi et al., 2008). Eventually, at the turn of the century, the Supreme Leader of the Islamic Republic of Iran, Ayatollah ʿAlī al-Husseini al-Khameneʾi, also gave his endorsement to third-party reproductive assistance by issuing an authoritative fatwā (Clarke, 2009). He justified this permission by arguing that, in the absence of “touch and gaze,” third-party reproductive assistance could be practiced, as it will ensure the continuity of family and prevent the “marital and psychological disputes” that would otherwise arise from a couple’s ongoing involuntary childlessness. (For a fully translated English version of this fatwā, see Inhorn, 2005).

With regard to egg donation specifically, Ayatollah Khameneʾi agreed with those jurists who were in favor of third-party donation by arguing that egg donation “is not in and of itself legally forbidden.” But he stated that both the egg donor and the infertile mother must abide by the religious codes regarding parenting. Thus, the child of the egg donor has the right to inherit from her, as the infertile woman who received the eggs is considered to be like an adoptive mother. With regard to sperm donation, Ayatollah Khameneʾi stated that the baby born of sperm donation belongs to the biological father (i.e., the sperm donor) and thus can only inherit from him. But the infertile father is considered to be like an adoptive father, and thus the child takes its name from him. The question of lineage has thus been resolved by Ayatollah Khameneʾi and other Shia jurists’ fatwās (Tremayne, 2009). They have recast the definition of lineal descent by replacing it with the consent/agreement of the donor, who transfers his right to the child to the recipient of the donor sperm. The question of inheritance, however, remains unresolved.

Egg donation in particular has found acceptance on the part of numerous leading Shia jurists, because its accords well with other accepted Shia principles and practices (Inhorn, 2006a; Tremayne, 2015). Namely, an infertile woman who receives a donated egg can gestate, give birth to, and breastfeed an egg-donor child, thereby creating the bonds of ridaʾ, or milk kinship, which is an established way of forging new kinship ties in Islam (Al-Torki, 1980; Khatib-Chahidi, 1992). Furthermore, husbands sympathetic to their wives’ infertility problems may engage in the practice of mutʿah, or temporary marriage, which is allowed (only) in Shia Islam and which means that egg donation can be undertaken within the remit of a husband’s temporary polygynous marriage to the egg donor. This use of temporary marriage as a way to make egg donation morally permissible is a creative solution to the moral challenges posed by third-party reproductive assistance within a Shia Islamic framework (Haeri, 1989).

Sperm donation, on the other hand, has proven more challenging on a Shia bioethical level (Inhorn, 2012; Tremayne, 2012). Outside of Iran, not a single Muslim jurist, either Shia or Sunnī, approves of this particular donor technology. However, because it has been permitted by some of the leading Iranian jurists’ authoritative fatwās, sperm donation is being practiced in private IVF clinics in Iran. Having said this, sperm donation defies deeply rooted patriarchal values in Iran, including patrilineal kinship reckoning, in which the father assumes priority and rights of ownership over the child. According to Twelver Shia Islam, the child takes his lineage from both parents (mother and father), but the father remains the sole “owner” of the child, with the mother’s role viewed primarily as that of “caretaker.” Sperm donation is thus tantamount to “owning” another’s man’s child. This why most infertile Muslim men, including most Shia men, refuse this particular ART practice, often noting that a sperm-donor child “won’t be my son” (Inhorn, “He Won’t Be,” 2006).

To grapple with this difficulty of lineage and inheritance, many infertile Shia Muslim men and women prefer to use their close relatives, especially brothers and sisters, as sperm and egg donors, thereby keeping gamete donation “within the family.” Brothers donate sperm to their infertile brothers, while sisters donate eggs or uteruses (via surrogacy) to their infertile sisters and sisters-in-law (Inhorn and Tremayne, 2016).

Yet, egg and sperm donation between brothers and sisters and their spouses may violate the rules of maḥramiat (closeness/privacy), which determines the boundaries of the interaction between men and women in society (Tremayne, 2015). To wit, men and women are divided into two groups—the maḥram and na-maḥram. The maharem (plural for maḥram) are relatives who are not potential marriage partners and with whom one may undertake free but not sexual interaction. The maḥram group includes one’s siblings, parents, grandparents, aunts and uncles, children and grandchildren. Any sexual relationship between the maharem therefore constitutes incest. Na-maḥram, on the other hand, are all those who are potential marriage partners and with whom neither sexual nor social contact is permitted. This latter category includes all non-family members, as well as those members of the kin group who are not part of the maḥram category. There also exists a third category, namely, those who are maḥram at some point, but who become na-maḥram due to changes in the individuals’ marital status.

When a sister donates an egg to her sister-in-law, for example, her egg will be fertilized with her brother’s sperm, which is a clear violation of the rules of maḥramiat. Similarly, if a brother donates his sperm to his sister-in-law, it is as if two brothers have taken the same wife in (polyandrous) marriage, which is illegal in both Shia and Sunnī Islam. Yet, infertile couples who recruit their own relatives as gamete donors typically do not see their actions in this light. Because there is no sexual contact occurring during the actual gamete-donation process, ARTs allow family members to bypass the rules of maḥramiat, as well as feelings of incest, adultery, or illicit polyandry. By using a relative’s gamete, lineage purity can at least be maintained, strengthening kinship relations.

Conclusion

Overall, the Muslim world has embraced ARTs with considerable enthusiasm while, at the same time, attempting to regulate them according to Islamic bioethical principles (Inhorn and Tremayne, 2012). In Sunnī Muslim countries the authoritative prohibition on third-party reproductive assistance has led to an entrenchment of deeply held religious beliefs about the importance of marriage, biological kinship, and child rights, none of which should be undermined through the practices of ART. Having said this, independent bioethical rulings emanating from Iran, the epicenter of Shia Islam, have fundamentally altered understandings of the ways in which families can be made and marriages can be saved through the use of ARTs. The permission of donor technologies in Shia-dominant Iran has led to, among other things, significant reproductive “tourism” of infertile couples from Sunnī- to Shia-dominant countries; the mixing of gametes across familial, ethnic, national, and religious lines; and the birth of thousands of donor children to infertile Muslim couples. How these practices of Sunnī and Shia assisted conception will continue to unfold in the twenty-first century is important to follow, especially given that new forms of ART continue to be invented. However, after forty years of ART experience, it is fair to say that IVF and its many variants have significantly shaped the reproduction of the Muslim ummah, bringing the birth of thousands of test-tube babies to the Muslim world.

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