Introduction: Medical anthropology and science and technology studies 2004 Culture, Medicine and Psychiatry Testing Women, Testing the Fetus: The Social Impact of Amniocentesis in America 1999 Testing Women, Testing the Fetus Twice Dead: Organ Transplants and the Reinvention of Death 2002 2003a 1996 localizing 2000 1995 What Really Matters: Living a Moral Life amidst Uncertainty and Danger 2006 Reproducing Jews: A Cultural Account of Assisted Conception in Israel 2000 maschigots mamzer Ivf in the muslim middle east 2000 fatwa 1991 1992 Sunni Islam and IVF 2006a 1992 1994 1996 1992 1990 1991 1995 with the husband’s semen is not zina laqit If the marriage contract has come to an end because of divorce or death of the husband, medically assisted conception cannot be performed on the ex-wife even if the sperm comes from the former husband. An excess number of fertilized embryos can be preserved by cryopreservation. The frozen embryos are the property of the couple alone and may be transferred to the same wife in a successive cycle, but only during the duration of the marriage contract. Multifetal pregnancy reduction (or so-called selective abortion) is only allowed if the prospect of carrying a high-order pregnancy (i.e., twins, triplets, or more) to viability is very small. It is also allowed if the health or life of the mother is in jeopardy. All forms of surrogacy are forbidden. Establishment of sperm banks is strictly forbidden, for such a practice threatens the existence of the family and the “race” and should be prevented. The physician is the only qualified person to practice medically assisted conception in all its permitted varieties. If he performs any of the forbidden techniques, he is guilty, his earnings are forbidden, and he must be stopped from his morally illicit practice. 1997 1997 2003b Shi’a Islam and IVF For Shi’ite Muslims, attitudes toward gamete donation have changed considerably since the late 1990s. Shi’a is the minority branch of Islam found in Iran, parts of Iraq, Lebanon, Bahrain, Syria, and Saudi Arabia, as well as Afghanistan, Pakistan, and India. It has been much in the news lately because of the United States–led war in Iraq, the conflict between Lebanon and Israel, and the current tensions between the United States and Iran. Until recently, most Shi’ite religious authorities have supported the majority Sunni view: namely, they have agreed with Sunni clerics who say that third-party donation should be strictly prohibited. marja’ taqlid both With regard to sperm donation, Ayatollah Khamanei said in his original fatwa that the baby born of sperm donation will follow the name of the infertile father rather than the sperm donor. However, as with egg donation, the donor child can only inherit from his biological father, the sperm donor, since the infertile father is considered to be like an adoptive father. ijtihad mut c a ijtihad c aql ulama 2002 2004 within mut c a sigheh 1992 c 1989 c c c 1989 c c when a couple needs a donor, they should go to a Shi’ite religious court, where a decision can be made on a case-by-case basis; there should be a determination about which religious “reference” (i.e., source of spiritual emulation) the infertile couple follows; the decision should be made in the presence of witnesses, the IVF doctor, and with the agreement of both parties (the infertile couple and the donor); c c 1996 1992 whether sperm donation should be allowed at all; whether the child should follow the name of the infertile father or the sperm donor; whether the child should inherit from the infertile father or the sperm donor; 1 whether donation is permissible at all if the donors are anonymous; whether a financial transaction should be allowed between gamete donors and recipients; c c 2006 whether the wife of an infertile husband can temporarily divorce her infertile husband, remarrying him after accepting sperm from a donor (Tremayne, personal communication, 5/5/06). 2006 c 2006 2004 2004 2 majlis is hallal not both 2005 2006 2004 3 sayyid shari’a 2006 2006 Muslim patient opposition to donation Although donor law and practice are headed in interesting new directions in both Iran and Lebanon, it must be reiterated that the vast majority of Muslims, both Shi’ite and Sunni, do not accept the idea of third-party gamete donation. Why are they opposed to donation? haram 2006b With regard to marriage, Islam is a religion that can be said to privilege—even mandate—heterosexual marital relations. As is made clear in the original Al-Azhar fatwa, reproduction outside of marriage is considered zina, or adultery, which is strictly forbidden in Islam. Although third-party donation does not involve the sexual “body contact” of adulterous relations, or presumably the desire to engage in an extramarital affair, it is nonetheless considered by most Islamic religious scholars to be a form of adultery, by virtue of introducing a third party into the sacred dyad of husband and wife. It is the very fact that another man’s sperm or another woman’s eggs enter a place where they do not belong that makes donation of any kind inherently wrong and threatening to the marital bond. The other aspect of third-party donation that troubles marriage is the potential for incest among the offspring of unknown donors. Moral concerns have been raised about the potential for a single anonymous donor’s offspring to meet and marry each other, thereby undertaking an incestuous union of half-siblings. The final moral concern voiced by Muslim IVF patients is that third-party donation confuses issues of kinship, descent, and inheritance. As with marriage, Islam is a religion that can be said to privilege—even mandate—biological inheritance. Preserving the “origins” of each child—meaning its relationship to a known biological mother and father—is considered not only an ideal in Islam, but a moral imperative. The problem with third-party donation, therefore, is that it destroys a child’s lineage, which is immoral in addition to being psychologically devastating. 2006b ikhtilat in-nasab hadith Allah ibn haram 2006b actually 1996 1995 1992 2006b is 2004 2004 Nonetheless, Iran’s acceptance of adoption has clearly paved the way for gamete donation, with Ayatollah Khamanei’s initial fatwa deeming the infertile couple to be like adoptive parents. Indeed, Iran’s clearly adventurous path regarding both adoption and donation is leading to social transformations in other parts of the Shi’ite Middle East, in ways described in the following section. Marriage and gender relations In considering infertility and IVF in the Muslim world, it is important to ask: What happens to infertile Middle Eastern Muslim couples who are not allowed to adopt and who do not accept the use of donor gametes? In the absence of adoption and gamete donation, infertile Muslim couples have no choice but to turn to IVF and other assisted reproductive technologies to solve their infertility problems using their own gametes. 2004 1992 1996 1996 2003b 2004 The emergence of the revolutionary new IVF technology called intracytoplasmic sperm injection (ICSI), however, has ironically increased the potential for divorce in the Muslim Middle East. Namely, with ICSI, infertile men with very poor sperm profiles—even azoospermia, or lack of sperm in the ejaculate—are now able to produce “biological” children of their own. As long as a single viable spermatozoon can be retrieved from a man’s body, including through painful testicular aspirations and biopsies, this spermatozoon can be injected directly into the ovum under a high-powered microscope. What ICSI requires, then, is high-quality ova, despite low-quality sperm. However, the wives of many of these men, who have “stood by” their infertile husbands for years, even decades in some cases, may have grown too old to produce viable ova for the ICSI procedure. In the absence of adoption or of any kind of egg donation, infertile Muslim couples with a reproductively “elderly” wife face four difficult options: (1) to remain together permanently without children; (2) to legally foster an orphan, which is rarely viewed as an acceptable option; (3) to remain together in a polygynous marriage, which is rarely viewed as an acceptable option by women themselves; or (4) to divorce so that the husband can have children with a younger wife. are are 4 Laila before 5 c c 2004 2004 2004 I did not get the impression that people desperate to have a child thought very far about the issues of kinship and family relations. As far as I could see, the donation is considered more a financial transaction than a donation/gift, and once you have paid the couple to buy their embryo, or paid the temporary wife for her egg, they have no further claims on you and this is the end of the story. The forms filled by the donors leave it to them to decide whether they want to give their name or not. 6 2006 Conclusion 1996 can can For Shi’ite Muslims, in particular, the frankly adventurous attitude on the part of some Shi’ite religious leaders toward third-party donation has led to a potential transformation in gender relations among infertile Muslim couples. For example, in Lebanon, the recent Shi’ite fatwas allowing egg donation have been a great boon to marital relations. There, both fertile and infertile men with “reproductively elderly” wives are lining up at IVF clinics to accept the eggs of donor women. Furthermore, in multisectarian Lebanon, the recipients of donor gametes are not necessarily only Shi’ite Muslim couples, but include some Sunni Muslim and Christian couples as well. 2006b Nova 1994 Notes rida’ 2006 2004 In Iran, I want to thank Mohammad Jalal Abassi-Shavazi, Mohamad Mehdi Akhondi, and Pegah Ebadi for so generously inviting and hosting me at the Avesina Research Center and University of Tehran conference on embryo and gamete donation. In Lebanon, anonymous sperm donation—using frozen sperm from overseas sperm banks or fresh sperm samples from mostly medical and graduate students—is “quietly” practiced at IVF clinics. One of my azoospermic Lebanese male informants produced a donor child in this way, and several others, both Muslim and Christian, had also made the decision to use donor sperm. In Iran, women commonly bring their sisters as potential egg donors. But this is not allowed, as Islam is explicitly against the marriage of one man to two living sisters. Apparently, men also bring their brothers as potential sperm donors in Iran. According to Tremayne, she observed one case where the husband did so without his wife’s knowledge; the wife believed that she was receiving her husband’s sperm instead of that of her brother-in-law. Some leading members of the Lebanese medical community are pushing for a law that bans all forms of third-party donation in the country. However, this law has yet to be debated in the Lebanese parliament and is unlikely to pass, according to some sources.