Reproductive medicine, politics and religion in Italy:  Reflections on the 2005 referendum

In June 2005, Italy held a referendum on repealing the law on medically assisted fertilization (Law 40, February 19, 2004), which limits access to artificial reproduction to infertile couples, prohibits the donation of gametes or their use, and forbids the cryopreservation of embryos, preimplantation genetic diagnosis (PDG), and research on human embryos. The referendum was invalidated because turnout was only 25%, well below the 51% quorum required by the Italian constitution. Thus the law remains unchanged.

The Italian scientific community took an active part in the political and cultural debate over the referendum. As with the Swiss referenda concerning research on embryonic stem cells (2004) and GMOs (2005), and the California vote on Proposition 71 (2005), Italian scientists found themselves at the center of a heated controversy over whether reproductive biotechnology threatens humankind or whether it just can be abused.  They had to face the challenges of communicating rationally and pragmatically with each other and with society on ethically controversial issues, on the aims of scientific research, and on its reliability.

The Italian scientific community proved to be neither influential nor effective. It was divided over empirical questions such as whether adult stem cells have the same potential as embryonic stem cells. In fact, only a few scientists who spoke defended the law and said that there is no need of embryonic stem cells for the new regenerative therapies. But this minority viewpoint was amplified by the media and the Catholic Church to transmit to the public the idea that Italian scientists were split into two equivalent halves. What happened confirms that when scientific data are still uncertain they can be used in the political arena as any other kind of logical-rhetorical argument to uphold a thesis or its opposite. Consequently, what happened in Italy should encourage all scientific communities to reflect on and foresee what effective role science might play in similar types of political and cultural debates.

To better understand the present situation, it is necessary to recall the recent history of science policy in Italy.  In the 1960’s a few science managers such as Adriano Buzzati-Traverso and Felice Ippolito tried to introduce a merit-based system and results assessment to replace patronage when evaluating scientists who apply for a university position or a grant. But their actions were unsuccessful and research funding, as well as scientific and academic careers, became more and more dependent on political affiliations.  Consequently Italian governments started to support scientists mainly on the basis of political-cultural conveniences or of their academic power, rather than on the basis of their specific competency and abilities.

The context of the referendum is a good representation of the political climate in today’s Italy. For many years Italy was one of the few countries in the world without a law on medically assisted fertilization because, on the one hand the Catholic Church wanted it outlawed, and on the other lay politicians wanted it regulated. The situation stalled until the majority of representatives in the Italian Parliament were observant Catholics, and realized that one of the two positions could prevail.

The politicians who rely on the Catholic Church’s guidance on ethical and regulatory issues, together with liberal right-wing politicians who sought an instrumental alliance with the Church, drafted a law that included all of the Vatican’s objections to assisted fertilization.  They sought the advice of various experts, physicians and researchers, but the final bill ignored the opinion of those doctors and researchers who denounced the standards which were being proposed as contrary to the prevailing medical opinion on the subject of reproductive medicine.

After the law was passed, some parties and associations sought a referendum to repeal the law.  The Italian constitutional court rejected the application for a referendum to repeal the law, but granted four referenda aiming at modifying the main prohibitions.

Having understood that the “yeses “ would prevail since polls showed a majority of Italians thought most of the prohibitions were wrong, the Catholic Church cleverly adopted the strategy of persuading people who would have otherwise voted “no” to not vote at all so that the necessary 51% quorum would not be reached.

Another strategy adopted by the Catholic political hierarchy was the creation of a committee called “Science and Life”, which maintained that the law’s prohibitions were scientifically and medically justified. Bruno Dallapiccola, an eminent Italian geneticist and professor of medical genetics at the University of Rome “La Sapienza” who is also the head of the Mendel Institute, and the physician Paola Binetti were appointed to chair the committee. The latter was then joined by mostly Catholic jurists and gynecologists. Others involved in the abstention campaign included Angelo Vescovi, a professor at Milan’s San Raffaele University and author of well-known if controversial studies on the subject, who distinguished himself for the aggressiveness with which he has publicly maintained that research on embryonic stem cells is pointless.

A counter-committee was created called “Research and Health.” It was joined by hundreds of scientists and physicians who signed a petition in favor of the four referenda. The Research and Health Committee emphasized the law’s inadequacy from the viewpoint of good clinical practice, as well as the obvious manipulation of scientific information by those who defended it and who urged citizens not to vote.

The Accademia Nazionale dei Lincei expressed its belated opinion only on the issue of research on extra embryos, insisting that “the loss or elimination of already existing frozen embryos should be avoided” and that “parliament should rapidly pass a law allowing the donation of such embryos, under very strict conditions.”

The outcome of the referendum was a defeat for those seeking to repeal the law.  The percentage of Italians who went to vote was not much lower than that which allowed the Swiss to authorize research on stem cells (25.9% in Italy and 37% in Switzerland), and the percentage of those in favor of repealing the law was very similar (24.4% in Switzerland and 23.1% in Italy). Compared to the California vote on Proposition 71 last November, the Italian referendum campaign was all but unsuccessful: in California, 57% of registered voters went to the polls, and 31.7% of them voted in favor of the proposition. One observation that emerges from a comparison with the Swiss and California cases is the disinterest of the Italian business community. The Swiss and California committees that fought to allow research on embryonic stem cells were consistently and openly supported by corporations, entrepreneurs, and patients associations, but the Italian business community was not supportive of efforts to defend freedom of research and biomedical innovation.

Some possible explanations for the failure of the efforts to change the law come from the two most recent “Eurobarometers” (Special Eurobarometer 224 “Europeans, Science and Technology” and Special Europbarometer 225 “Social Values, Science and Technology”) focused on the public perception of science and the moral values that influence science policy.  These surveys indicate that the Italian referendum confirms the difficulties scientific research is meeting in European democracies. These Eurobarometers show that  in countries with a higher rate of scientific literacy, citizens who are more satisfied with the quality of their lives and who acknowledge the merits of science and technology tend to emphasize the risks of research and innovation including research on stem cells. Among the 25 members of future Europe, Italy remains one of the countries where people are more willing to accept the new applications of genetics and biotechnology (except for GMOs), and in particular stem cell engineering.

Of course, it may be mere chance but the percentage of Italians who went to the polls for the referendum corresponds to the percentage of people who understand how the scientific method works, i.e. about 25 per cent of the population, according to a 2001 Eurobatometer study. It is impossible to judge whether scientific illiteracy, which in Italy is slightly higher than in north European countries, played a role in abstention because people did not really understand what they were asked to vote for or against. Those who advocated a “yes” vote were unable to communicate effectively and to define correctly the terms of the debate, which in the end turned mostly around when life begins, the moral status of the embryo, the menacing nature of scientific research and, above all, the risk of eugenics.

The results of the referendum may be due to the apparent standstill of the process of secularization in Italy. Eurobarometer 225 shows that Italy is one of the most religious countries in Europe with a very low percentage of atheists (6%). This confirms a phenomenon sociologists have already observed: starting from the 1990s, there has been a halt in the process of secularization of the country and in some areas even a reversal of that process. It is true that the Italians are pragmatic people and in order to have healthy children they have always made, and are still making, use of reproductive medicine (mainly prenatal diagnosis and abortion), ignoring the moral precepts of the Church. However, they may have found it difficult to assess the consequences of the proposed legal changes to their personal freedoms as well as the results it can produce in some medical situations.

The consequences of law 40/2004 on reproductive medicine in Italy is becoming apparent. Until last year, Italian clinics and research centers specializing in reproductive medicine were on the cutting edge. Now their level of excellence is bound to collapse and our best gynecologists and geneticists will likely take their competence out of the country. Of course, the couples who can afford to will go abroad. In fact, they have already been doing so in larger numbers for the last two years – from 1,315 in the year before the law to 3,610 in the year after the law. Moreover, since the law went into effect pregnancies declined – from 4,922 in 2003 to 4,613 in 2004 – and early abortions increased by 2-5%, depending on the woman’s age.

The calculated aim of the Catholic Church was certainly to discourage the use of assisted fertilization. What is disputable is whether this was also the aim of the majority of Italian citizens, considering what they seem to expect from medicine.