Ethical Issues of Human Reproduction

1. Ethical Issues of Human Reproduction Dr. Yulia Peeva, DDS, MSc, PhD Chief Assistant Professor Department of Social Medicine and Public Health Medical University of Plovdiv

2. Background • 1. Moral aspects of human reproduction • 2. HRTs • Genetic counseling • Cloning for reproduction • Stem Cell Research • Sex Selection: Ethical or Unethical? • 7. Marriage of Homosexuals • 8. Conclusions

3. Moral aspects of human reproduction • Human reproduction is a complex and controversial field of ethics • Reproductive freedom - the freedom to decide whether or not to have children. Denying this liberty denies or imposes a crucial self-defining experience and thus denies persons respect and dignity • A negative right - must be free from interference • A deeply held moral and legal value

4. Moral aspects of human reproduction Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. It implies that: - People are able to have a satisfying and safe sex life - They have the capability to reproduce and the freedom to decide if, when and how often to do so.

5. Moral aspects of human reproduction • Definition • Reproduction = process by which living beings transmit their genes and give birth to a new generation of living beings (processus par lequel les êtresvivantstransmettentleursgènes en donnant naissance à uneautregénérationd’êtresvivants).

6. Moral aspects of human reproduction • The act or process of reproducing is specifically the process by which humans give rise to offspring and which fundamentally consists of the segregation of a portion of the parental body by a sexual or an asexual process and its subsequent growth and differentiation into a new individual. • Synonyms: duplicate, copy, replica

7. Moral aspects of human reproduction Men and women have the right to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice. They have the right to access to other methods of their choice for regulation of fertility which are not against the law. They have the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.

8. Moral aspects of human reproduction • Contraception Term birth control was introduced by Margaret Sanger in 1914 The deliberate use of artificial methods or other techniques to prevent pregnancy as a consequence of sexual intercourse. Contraception prevents pregnancy by interfering with the normal process of ovulation, fertilization, and implantation

9. Moral aspects of human reproduction • Contraception • Major forms of contraception are: • •barrier methods (condom or sheath); • •hormonal contraceptive pills; • •intrauterine devices (coil); • •male or female sterilization.

10. Moral aspects of human reproduction • Contraception Arguments against contraception: •Contraception artificially interrupts the natural process of conception. •Contraception encourage illicit sexual activity

11. Moral aspects of human reproduction • Contraception Arguments in favor of contraception: •Women have the right to control their fertility as a part of their body functioning (right to self-determination) •Contraception reduces potential harm for maternal and child health by preventing unwanted pregnancies and pregnancies that are too closely spaced as well as adverse effects on mental health and social wellbeing of women due to these events.

12. Moral aspects of human reproduction • Sterilization Sterilization is an irreversible medical procedure that renders an individual incapable of sexual reproduction and with profound physical and psychological effects

13. Moral aspects of human reproduction • Sterilization Types of sterilization: •Voluntary sterilization –a form of birth control wanted by a person •Forced sterilization -a person is sterilized after expressly refusing the procedure, without his/her knowledge or is not given an opportunity to provide consent. •Coerced sterilization -when financial or other incentives, misinformation, or intimidation tactics are used to compel an individual to undergo the procedure.

14. Moral aspects of human reproduction • Abortion Abortion continues to raise a number of ethical issues related to the rights of the women versus the rights of the fœtus, which, in addition to the risk of Sexually Transmitted Diseases (STD) including the Human Immunodeficiency Virus (HIV), emphasize the need for adequate family planning and sexual education. The key question: when does human personhood start, and how do we proceed when there is no consensus?

15. Moral aspects of human reproduction • Ethical aspects of abortion • The ethical problem: when, if ever, is an abortion the right alternative (comparative rights)? • Beliefs of religious groups: • Roman Catholic Church beliefs: • Evolution of Roman Catholic positions on abortion • Current Catholic Church teaching (sanctity of human life) • Exceptions to the Roman Catholic ban on abortion

16. Moral aspects of human reproduction • Ethical aspects of abortion In 1982, the late Pope John Paul II said, in a speech pertaining to embryonic experimentation: « I condemn in the most explicit and formal way, experimental manipulation of the human embryo, since the human being, from conception to death, cannot be exploited for any purpose whatsoever ».

17. Moral aspects of human reproduction • Ethical aspects of abortion • Other religious and ethical matters : • Jewish beliefs on abortion • Muslim beliefson abortion • If the pregnant woman’s life is at risk, then, arguably, abortion could be viewed as the lesser of two evils. The Principle of Double Effect could thus be applied, as the intent of the abortion would be to preserve the life of the woman, and the death of the fœtus would be a secondary consequence of this attempt.

18. Moral aspects of human reproduction • Ethical aspects of abortion Ethical consideration on abortion include variety of questions with controversial answers, such as: Is a fetus a person with rights? Has the unborn child the right to life? Does the woman have ethical obligations to the fetus? Does the woman have the right to decide for termination of the pregnancy? Is it ethical to force a woman to carry a pregnancy to term? Is sexual activity ethical if it can lead to an abortion? Does the woman have ethical obligations to the father?

19. Moral aspects of human reproduction • Ethical aspects of abortion The codes of conduct and various declarations are opposed to the termination of pregnancy. •The World Medical Association Declaration of Geneva (1948): “I will maintain the utmost respect for human life, from the time of conception”. •The Hippocratic Oath: “I will not give to a woman a pessary to cause abortion….”

20. Human Reproductive Technologies (HRTs) Human reproductive technology(HRTs) is a medical intervention developed to improve an ‘infertile’ couple’s chance of pregnancy. ‘Infertility’ is clinically accepted as the inability to conceive after 12 (24) months of actively trying to conceive. It also refers to an inability to sustain a pregnancy, which is demonstrated by repeat miscarriages.

21. HRTs. Artificial insemination. Ethical issues Is it acceptable to provide AI to postmenopausal women, to single women or lesbian couples? What are ethically acceptable criteria for choosing a donor? Is it ethically acceptable to use the donated sperm after the death of the donor? (most of the countries prohibit this). Danger of inbreeding – limitation of the number of AI, e.g. in Bulgaria –three effective inseminations are allowed with one donor’s sperm

22. Human Reproductive Technologies (HRTs) • Contraception: sex without procreation • HRTs: procreation without sex

23. Types of HRTs • Artificial insemination by husband (AIH) • Artificial insemination by donor (AID) • In vitro fertilization (IVF) • Egg donation • Embryo Donation • Surrogacy • New Genetics • Human Cloning • Stem Cell Research • Sex selection

24. Arguments for and against surrogacy

25. Surrogate motherhood Surrogate mother is a woman who agrees to bear a child for another woman with the intention of handing over the child to someone else after the birth (intended parents). IVF is used to create embryoswith the wife's eggs and husband's sperm. The embryos are transferred to the uterus of the surrogatemother. If the procedure succeeds, the baby will be the biological child of both husband and wife.

26. Contrary Argument for Commercial Surrogacy • People have the right to procreation and to have a family. • Gestation can be regard as a service close to baby sitting or rearing a child for some else. No buying or selling baby is involved. • Anyone with a sound mind should be allowed, with his/her informed consent, to enter freely into a contractual agreement.

27. Family-based Argument for Non-commercial Surrogacy • If the baby has no genetic ties with the commissioning parents, why not adoption? • Gestation is the defining criteria of mother-child relationship. The woman who gives birth to a baby is its mother even in the absence of genetic ties. This can protect the best interests of the child. Some feminist maintains that the pregnant woman is the first person who has an intimate relation with the child and so she deserves to have the baby. • Commercial surrogacy involves the buying and selling of baby. It should therefore be prohibited!

28. Family-based Argument • With due respect to the parental right of the surrogate mother, contracts of surrogacy, commercial or non-commercial, should be unenforceable. • The commissioning parents should follow a procedure similar to the adoption of baby. The surrogate mother should be given a grace period for changing her mind. • Surrogacy should be permissible only if the baby has genetic ties with both commissioning parents and they are married.The result is better than adoption.

29. Best-interests Argument Against Surrogacy • The arrangement based on the family argument does not serve to protect the interests of all the parties involved, including the baby, because the arrangement is unenforceable. • What will happen if the commissioning parents change their minds after the baby is conceived? The surrogate mother is the true mother and has the responsibility to rear the baby even if she does not want to.

30. Best-interests Argument Against Surrogacy • What will happen if neither the surrogate mother nor the commissioning parents wants to keep the baby? • The surrogate mother may have developed an emotional tie with the baby during pregnancy. Should she be allowed to visit the baby? Will it undermine the integrity of the new family if she does that?

31. The New Genetics

32. Gene Testing • Create unnecessary psychological distress. • Discrimination by employers and insurance companies. • Confidentiality and Privacy • Social stigmatization.

33. Prenatal Screening • Sex selection: Gender discrimination and imbalance of sex ratio unless it is done solely for therapeutic purpose • Discrimination: Lives of the disable are not worth living.

34. Genetic Engineering • Germ-line changes, unlike somatic modification, can pass onto the next generation and be with us forever. So germ-line changes could be very risky. • Genetic therapy *may* be alright (note that reproduction without sex or abortion is involved). • Is it a form of eugenics?Is genetic enhancement moral? • Dignity of a child: Parental love should not be based on the traits and the characters of a child. Children should not be treated as a means to please their parents.

35. Human Cloning

36. Two Techniques • Two techniques: • Embryo splitting • Nuclear substitution

37. Embryo splitting • The clone is usually used for tests of abnormality, and will be destroyed subsequently.

38. Nuclear Substitution • What is the relationship between the nuclear donor and the clone? • The same person? • (Technologically-aided and birth delayed) identical twins? • Siblings? • Parent-child? • Should a homosexual be allowed to use the technology to obtain his/her own child?

39. Nuclear Substitution • Is it moral alright for parents to clone their beloved children who die youngor provide organs for their siblings? • Should it be used as an infertility treatment or gene therapy if it is safe? • No third party is involved. • According to the parent-child ordinance in Bulgaria whoever gives birth to a baby is its mother, and the husband who goes through the infertility treatment with her is his father. • Yet, human cloning has been banned by the HRT Ordinance.

40. Stem Cell Research

41. Three Types of Stem Cell • Stem cells: undifferentiated, multi-potent, precursor cells, capable of developing into virtually any body tissue. • Three types of stem cells: • Embryonic stem cells (ESC) • Fetal stem cells • Adult stem cells

42. Three Main Sources • Adult bone marrow and other types of cells. • Miscarried or aborted embryos/fetus; extra embryos left over from IVF. • Embryos from therapeutic cloning.

43. Potential Treatments • Embryonic stem cells (ESC) is most promising for treatment, and therapeutic cloning can avoid the problem of immunological incompatibility. • Ethical issues: • Destroying an embryo to harvest ESC is equivalent to killing a child to obtain his organs. • Left-over from IVF are already there. • Therapeutic cloning: The embryo is not created for reproduction. • How about the wellbeing of many patients who may be cured by ESC research?

44. Sex Selection: Ethical or Unethical?

45. Scope of the Ethical Issues • A paradigm or type case in bioethics. • The moral controversies arising from sex selection covers most of the major ethical issues in regard to human reproductive technologies (HRT) because it is a form of genetic engineering and often involves the use of abortion, infertility treatment (such as artificial insemination and in vitro fertilization), human cloning and/or other HRT.

46. Arguments Against • Conservative arguments: • Abortion is morally wrong. • It is unnatural to separate sex from procreation. • Even early abortion is morally justified in some exceptional cases. The preference for children’s sex cannot serve as a justification for granting an exception. It does not meet the criteria for termination of pregnancy.

47. Arguments against • Biased sex ratio: • when the proportion of woman is lower, they “may be confined to traditional gender roles and excluded from high-status positions; • when their proportion is higher, misogyny increases, and women are likely to be exploited in sexual relationships and have difficulty in finding committed male partners.”* *Holmes, H. Q. “Choosing Children’s Sex: Challenges to Feminist Ethics’, in J. C. Callahan (ed.), Reproduction, Ethics, and the Law, Bloomington and Indianapolis: Indiana University Press, 1995, p. 149.

48. Arguments against • Sex discrimination: Children of different sexes should be treated equally. • Reinforces sexism and devalues women as a class

49. Arguments against • Dignity of a child: Parental love should not be based on the traits and the characters of a child. Children should not be treated as a means to please their parents (see arguments against genetic engineering).

50. Arguments for • Prevention of sex-linked diseases. • Parents have their rights to procreative choices and family planning. • The cultural condition or the individual situation may put a woman in a very difficult position if she cannot give birth to a child of the preferred sex (more dowry, getting a concubine, divorce, being abused, tortured or even killed…).