Presentation
at the 1st Ethics Scientific Day, King Fahad Medical City organized
by the Ethics Committee on 27th May 2014 by Professor Omar Hasan
Kasule Sr MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Chairman of the KFMC
Ethics Committee
INTRODUCTION OF BASIC CONCEPTS
·
Infertility:
·
Assisted reproduction:
·
Contraception:
·
Reproductive cloning:
·
Abortion or pregnancy termination
·
Gender selection:
·
Gender change:
·
Menopause:
ASSISTED REPRODUCTION
·
In vivo
insemination / invitro fertilization permissible between husband and wife
·
Ova/sperm from
a dead spouse cannot be used
·
Paternity for
illegal peocedures determined on genetic basis
·
Use of excess
embryos: donation, research, stem cell production
·
Gender
selection before implantation
·
Fetal reduction
in multiple pregnancy
CONTRACEPTION
·
Contraception
is permissible based on the method of coitus interruptus by the prophet.
·
Contraception by
mutual consent between the husband and wife unless wife’s life is in danger.
·
Irreversible
sterilization is generally forbidden but there is no consensus among legal
experts on sterilization.
·
Immoral and
demographic consequences of widely available contraception
THE PERMISSIBLE REVERSIBLE CONTRACEPTIVE METHODS FOR MALES
·
Condom
·
Coitus
saxonicus (consisting in squeezing the urethra
at the base of the penis immediately prior to ejaculation),
·
Coitus reservatus (deliberate delaying or avoidance of orgasm during intercourse)
·
Coitus interruptus (sexual intercourse deliberately interrupted by withdrawal of the penis
from the vagina prior to ejaculation).
PERMISSIBLE REVERSIBLE CONTRACEPTIVE METHODS FOR FEMALES
·
Mechanical: the
diaphragm, the cervical cap, or the vaginal sponge
·
Chemical/hormonal:
spermicides and oral contraceptive pills
·
IUD:some forms
of IUD are not permitted because they cause early abortion.
·
The safest and
perhaps the least effective is the rhythm method.
ABORTION
·
Induction of
pregnancy termination either medically or surgically can be carried out for
medical or social reasons.
·
Medical reasons
for pregnancy termination usually relate to a grave risk to the mother’s life
and health if the pregnancy continues.
·
Social reasons
usually are associated with ‘unwanted pregnancy’. ‘Unwanted pregnancy’ is
associated with general social determinants (hedonistic life styles, sexual
transgression, addiction to drugs, fear of poverty and low female status) and
specific antecedent causes (sexual crimes, egoistic greed, maternal/fetal
disease and gender discrimination).
ABORTION
·
Termination due
to medical reasons has few associated ethical issues. Abortion is the lesser of
two evils in cases of serious maternal disease because one life is lost instead
of two.
·
Termination due
to social reasons creates several ethical dilemmas because it is destruction of
life without a compelling necessity, dharurat (ضرورات).
Legal experts differ in their interpretation of dharurat while some will
allow termination for congenital anomalies and pregnancy from rape, others
consider all termination as prohibited.
·
Some Legal
experts prohibit termination for social reasons on the basis that it will
encourage immorality in society by removing the fear of unwanted child birth
among those engaging in illegal sexual intercourse.
TIME OF TERMINATION
·
Legal experts
also differ in terms of when termination is allowed for social reasons.
·
Some consider
fertilization as the start of life making any termination unlawful.
·
Others consider
ensoulment (ensoulment is a philosophical or religious concept referring to the
moment at which a human being gains a soul), nafakh al ruh (نفخ الروح), at gestation age 120 days as the
start of life and are more liberal in permitting termination before 120 days.
GENDER SELECTION
·
It is a human
desire to get children of the desired gender and parents make efforts towards
this end. It is the methods used that give rise to ethical problems.
·
Natural methods
with no ethical implications are generally not effective and include: selecting
days of copulation before and after ovulation & changing upper vaginal
chemistry artificially.
·
There is no
consensus on use of artificial methods that include: separation of male sperms
by centrifuging and in vitro insemination, gender pre-selection and implanting
only zygotes of desired gender with in vitro fertilization, or gender
change by genetic engineering, exposure of fetuses to specific hormones to
produce the desired phenotype and gender reassignment operations.
GENDER CORRECTION / CHANGE OPERATIONS 1
·
Changes can be
made to the external appearance of a person to be made male or female using
surgery and hormones. These may be gender correction procedures or gender
change procedures.
·
Gender
correction procedures are allowed for those with an indeterminate gender, for
example when someone has both male and female anatomical and physiological
characteristics.
·
The decision to
make this person male or female is based on the underlying genotype or the
predominant gender as assessed anatomically, functionally, or as a result of
socialization.
GENDER CORRECTION / CHANGE OPERATIONS 2
·
Some procedures
may be carried out for the sole purpose of correcting anatomical anomalies to
enable copulation and reproduction.
·
Gender change
procedures carried out on persons with normal anatomical features but who
psychologically desire to be the opposite gender are generally frowned upon by
Legal experts. Victims of such gender identity conflict should be counseled to
accept their anatomical gender.
MENOPAUSE
·
Women coming to
the end of their reproductive life experience many health problems as a result
of hormonal changes and imbalances.
·
Hormonal
replacement therapy (HRT) can help many of the problems of menopause but there
is also a risk of breast and other types of cancer.
·
The ethical dilemma
is how to balance the benefits of HRT with its risks. In the final analysis the
decision is made on a case by case basis. In case of the decision to use HRT,
close monitoring is ethically required for early signs and symptoms of cancer.
ONCO-FERTILITY
·
Cancer
treatment by radiotherapy and chemotherapy may adversely affect reproductive
function.
·
It is therefore
recommended that ova and semen be withdrawn and stored in cold storage before
treatment.
·
They can be
retrieved after treatment and used in IVF procedures to ensure child bearing
for cancer victims.
CASE #1 An infertile couple was in the midst of an IVF procedure
when the husband died soon after his semen was frozen. The wife wanted to
obtain the semen and have a baby by a surrogate mother. A former wife also
wanted the semen because she had a girl with leukemia who needed a compatible
bone marrow donor, preferably a sister.
CASE #2 A recently married woman continued taking oral
contraceptives prescribed for menstrual irregularities. Her husband wanted his
wife to discontinue her contraception because he wanted to start a family
immediately, but the wife refused.
CASE #3 A 14
year-old girl was admitted to the hospital for an abortion. She was two months
pregnant from what she claimed was rape. The family was distraught and wanted
the doctors to carry out the abortion immediately. The physicians were
reluctant because there was no medical reason.
CASE #4 A couple who had eight girls in successive pregnancies
desperately wished a boy. They decided to try IVF with selection of male
gametes. The obstetricians refused because there was no medical indication
since the couple had no problem in conceiving.
CASE #5 A child whose external appearance was female and had been
brought up as a girl was taken to the hospital at 14 years of age because of
delayed menstruation. The internal gonads and chromosomal patterns were male.
The parents wanted a gender reassignment operation to conform to the genetic
profile. The child refused to change from her familiar female identity.
CASE #6 A middle-aged woman without any medical condition asked her
physician for hormonal treatment to appear younger. The physician refused
because he judged the risk of cardiovascular and cancer complications to be
more than the benefits.
CASE #7 A 14 year-old girl with cancer requiring chemotherapy was
advised to have her ova removed and put in cold storage for the duration of the
treatment. Her parents refused the procedure because they did not believe in
IVF and she was not yet married.