Ethics and human reproductive medicine

1. Ethics and human reproductive medicine Yulia Peeva, PhD, Chief Assistant Professor at Public Health Department, Faculty of Public Health, Medical University - Plovdiv

2. PRESENTATION GOALS • Introduction • Moral aspects of human reproduction • Types of HRTs • Contraception • Sterilization • Abortion • Assisted reproduction • Surrogate motherhood • Conclusion

3. Introduction • Definition • Reproduction - process by which living beings transmit • their genes and give birth to a new generation of living • beings. • The act or process of reproducing is specifically the process • by which plants and animals 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

4. Introduction Life depends on the presence of DNA and its family of genes. The process of reproduction makes it possible for living beings to transmit their genes to the next generation of life. There are essentially two types of reproduction: asexual reproduction, which requires only one parent, and sexual reproduction, which requires two parents. As far as human reproduction is concerned, the act is sexual and naturally requires two parents from different sex (male and female).

5. Introduction However, the technological advancements achieved in the pass centuries in the area of reproductive health care have also led to the evolution of very important ethical issues that will have to be dealt with in the current and the coming centuries. In other words, there is nowadays a strong violation of the concept «reproduction» due to new technologies, which needs to be moderated.

6. 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.

7. MORAL ASPECTS OF HUMAN REPRODUCTION 1. Reproductive health 2. 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; • 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;

8. MORAL ASPECTS OF HUMAN REPRODUCTION • People 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.

9. MORAL ASPECTS OF HUMAN REPRODUCTION • 3. 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.

10. Types of HRTs • 1. Artificial insemination by husband (AIH) • 2. Artificial insemination by donor (AID) • 3. In virtro fertilization (IVF) • Egg donation • Embryo Donation • 4. Surrogacy • 5. New Genetics • 6. Human Cloning • 7 .Stem Cell Research • 8. Sex selection

11. 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. • Major forms of contraception are: • barrier methods(condom or sheath); • hormonal contraceptive pills; • Intrauterine devices(coil); • male or female sterilization.

12. CONTRACEPTION Arguments againstcontraception: •Contraception artificially interrupts the natural process of conception. •Contraception encourage illicit sexual activity.

13. CONTRACEPTION Arguments in favorof 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

14. STERILIZATION Sterilization is an irreversible medical procedure that renders an individual incapable of sexual reproduction and with profound physical and psychological effects. 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.

15. STERILIZATION Voluntary sterilization is an acceptable form of family planning. •An ethical requirement is that performance of sterilization be preceded by the patient's informed and freely given consent. Information for consent includes: •that sterilization should be considered irreversible; •that alternatives exist such as reversible forms of family planning; •that life circumstances may change, causing a person later to regret consenting to sterilization; •that procedures have a very low but significant failure rate.

16. ABORTION Abortion is the focus of some of the most intense social, cultural, political, religious, and ethical debates Termination of pregnancy brings out conflicts between the rights of three persons: 1. mother’s rights2. the fetus's rights 3. father’s rights 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?

17. 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….”

18. ABORTION Abortion laws differ between the countries from being very liberal and allowing abortion on request without any limitations to being very restrictive and allowing abortion only to save the life of the mother Up to 12-14 week or later Allowed only to save mother’s life or prohibited Abortion allowed in case of abuse, incapacity to care for the child or immaturity

19. SEX SELECTION The ethical debate on sex selection is focused on acceptability of applying medical diagnostic techniques to fulfill a desire based on personal preferences of the parents. Two positions exist on that issue: •Sex selection for non-medical reasons is not acceptable because it is extremely sexist and causes a skewed sex ratio •Sex selection is acceptable as a method for family balancing by which the parents choose a child of the other sex (family with an equal number of boys and girls is considered ideal in the general population)

20. ASSISTED REPRODUCTION Assisted reproductive technology(ART) 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. ASSISTED REPRODUCTION Two-party assisted reproduction – methods applied to the partners in heterosexual infertile couples that use only their own genetic and biological reproductive capacities Third-party assisted reproduction – • methods applied to those who cannot reproduce using only their own genetic and biological capacities (donor is included) • Heterosexual and same-sex couples and single women and men who seek to have biologically connected children, assisted by a “donor” who provides sperm, eggs, or gestational services, usually for a fee.

22. ARTIFICIAL INSEMINATION The procedure by which sperm are inserted directly into a woman'scervix, fallopian tubes, or uterusfor the purpose of impregnating her. This makes the trip shorter for the sperm and bypasses any possible obstructions. Intrauterine insemination (IUI), in which the sperm is placed in the uterus, is the most common form of artificial insemination.

23. 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

24. 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.

25. SURROGATE MOTHERHOOD ETHICAL CONSIDERATIONS • Diminishing the value of expecting a child to simply being pregnant, “human incubator” for someone else’s child • Commercialization–the surrogate mother is exploited because of her socio-economic status and her dignity is jeopardized • The effects on surrogate’s family members and family life • Should the husband of the surrogate mother give his informed consent as well? • Respect for autonomy of the surrogate mother – to what extend the parents can control the life stile of the surrogate mother?

26. SURROGATE MOTHERHOOD ETHICAL CONSIDERATIONS • Do the genetic parents have the right to ask for prenatal diagnosis and in case of detected abnormalities to require an abortion? • The surrogate mother has the right of bodily integration, but she has not the right to determine the destiny of the fetus • In case of abnormalities do the parents have the right to refuse taking the child? • Who is the real mother of the child? –the woman who contributes the egg-cell or the woman who bears the child.

27. IN VITRO FERTILIZATION • The first successful test tube baby -Louise Brown was born in 1978 in England

28. IN VITRO FERTILIZATION IVF poses a lot of clinical and ethical considerations •Hormone stimulationis needed to harvest sufficient number of oocytes for the procedure and is related to several risks–infection, ovarian hyperstimulation syndrome, multiple pregnancies and others •Preimplantation genetic diagnosis(PID) of genetic diseases is done to the embrios. Selective transfer of the embrio is morally justified by preventing the suffering related to genetic defects and disorders for the prospective children and for their parents •PID can endanger the reproductive autonomy; to set a precedent for positive eugenics; rises concern about cloning of human embrios; gives less value to life of disabled and discriminates them; selection of embrios with best tissue match for a very sick sibling

29. IN VITRO FERTILIZATION IVF poses a lot of clinical and ethical considerations •Selective reduction of the foetuses in utero can be requested by the family or suggested by the doctor in a case of multiple pregnancies •Number of IVF cycle •Financial burden •Depression in women after unsuccessful IVF cycle

30. IN VITRO FERTILIZATION IVF poses a lot of clinical and ethical considerations • What to do with extra embrios that were not used for implantation? •Criostorage of all embrios for next attempts of implantation. How good are the thawed embrios? •Informed consent of parents for storage or use of gametes or embrios –statutory limits of 10 yrs. for gametes and 5 yrs. for embrios; what to do with them if the person who consented dies or incapacitated; consent specifies if they can be used for treatment of a specified person, for the treatment of others, or for research

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