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Presentation
at a training program ‘Applying the Principles of Ethics to Clinical
Practice:’ held at Aramco Dhahran April 6, 2015 by Professor Omar Hasan
Kasule Sr. MB ChB (MUK). MPH (Harvard), DrPH (Harvard) Chairman of the Ethics
Committee King Fahad Medical City.
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 procedures 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 scenario #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 scenario #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 scenario #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 scenario #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 scenario #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 scenario #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.
Ethical issues in human fertility
In vivo insemination
In vitro fertilization
Disputes about parenthood