Introduction to bioethics

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

2. 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. 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 êtres vivants transmettent leurs gènes
en donnant naissance à une autre génération
d’êtres vivants).

6. • 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
Moral aspects of human reproduction

7. 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.
Moral aspects of human reproduction

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

11. 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.
Moral aspects of human reproduction
• Contraception

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. 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.
Moral aspects of human reproduction
• Sterilization

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. 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 ».
Moral aspects of human reproduction
• Ethical aspects of abortion

17. Moral aspects of human reproduction
• Ethical aspects of abortion
Other religious and ethical matters :
• Jewish beliefs on abortion
• Muslim beliefs on 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. 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?
Moral aspects of human reproduction
• Ethical aspects of abortion

19. 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….”
Moral aspects of human reproduction
• Ethical aspects of 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. 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
HRTs. Artificial insemination.
Ethical issues

22.  Contraception: sex without procreation
 HRTs: procreation without sex

23.  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

25. 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 embryos with the wife's eggs
and husband's sperm. The embryos are transferred
to the uterus of the surrogate mother. If the
procedure succeeds, the baby will be the biological
child of both husband and wife.
Surrogate motherhood

26.  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.  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.  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.  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.  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?

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

33.  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.  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.

36.  Two techniques:
◦ Embryo splitting
◦ Nuclear substitution

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

38.  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.  Is it moral alright for parents to clone their
beloved children who die young or 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.

41.  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.  Adult bone marrow and other types of cells.
 Miscarried or aborted embryos/fetus; extra
embryos left over from IVF.
 Embryos from therapeutic cloning.

43.  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?

45.  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.  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.  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.  Sex discrimination: Children of different sexes
should be treated equally.
 Reinforces sexism and devalues women as a
class

49.  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.  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…).

51.  A feminist strategy for undermining patriarchy:
◦ Choose to have boys and raise them as non-sexists
◦ Choose to have girls so as to cut down the
proportion of men, dissociate from the ruling sex
class and establish all-female communities
 The impact on sex ratio is largely uncertain if sex
selection not for medical reason is legalized in
developed countries.

52.  Giving people incentives, e.g., tax deductibles,
for choosing daughters.
 Using a quota system to balance the sex ratio.

53.  The root of the problems is not technological.
Sex selection per se is not unethical. Sexism is the
source of the problem.
 Yet unregulated use of the technology may
reinforce the existing gender biases or make the
situation even worse.

54.  It is often difficult to enforce the legal
prohibition of sex selection not for therapeutic
purposes.
 The question of whether an all-or-nothing
approach should be adopted deserves a more
open discussion.

55. Conclusions

56. Thank you! If you have any
questions: julipeeva@abv.bg