PHHE 435/535 Ethical Decision Making for Health Professionals Module 10A

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In this week’s readings and lecture, there is mention of certain ‘behaviors’ that are only morally acceptable if justified by adequate reasons. Discuss what is meant by this. As in previous Discussion Board topics, you are asked to incorporate an ‘Ethics of the Good’ when responding to this topic. Provide an example of a behavior that is only morally acceptable if justified by adequate reasons. Describe in detail what those adequate reasons might be.

PHHE 435/535 Ethical Decision Making for Health Professionals Module 10A Reproductive Issues Master of Public Health Program – Copyright © 2017. Board of Trustees of Northern Illinois University. All Rights Reserved. Objectives • Describe the techniques and technologies affecting reproduction • List medical interventions to prevent/promote pregnancy Photo Credit: Bobby • Identify the ethical issues prevalent in this area Reproductive Techniques & Technologies • Examine techniques and technologies affecting reproduction: 1 Reproductive Techniques & Technologies • Examine techniques and technologies affecting reproduction: – Contraception/sterilization Reproductive Techniques & Technologies • Examine techniques and technologies affecting reproduction: Photo Credit: Sarah Mirk – Contraception/sterilization – Facilitate pregnancy Life • When does life begin? 2 Life • When does a woman become pregnant? • Fertilization? Photo Credit: AndreaLaurel • When fertilized ovum implants? Pregnancy Occurs… • …when the female body grasps the fertilized ovum Pregnancy Occurs… • …becomes ‘one of us’ some time after fertilization and implantation 3 Pregnancy Occurs… • Destroying an embryo before implantation ≠ abortion • Why is that? • Because pregnancy has not occurred • Still morally significant action Contraception & Sterilization • Three reasons to engage in moral reflection: Contraception & Sterilization 1. Up until recently, Christianity condemned contraceptive practice Immoral 4 Contraception & Sterilization • Nothing about contraceptive practices in the Bible Photo Credit: changeable focus Contraception & Sterilization Photo Credit: gt8073a 2. Thought of as a criminal act (many state laws against use and distribution) Contraception & Sterilization 3. Pose some risk (risk damage to life) Photo Credit: Tommaso Meli 5 Contraception & Sterilization Contraception & Sterilization • Only ethical if there is adequate/proportionate moral reasons to balance the risks 6 History of Contraception Contraception & Sterilization • Population pressures valued having more children to increase likelihood of survival • Contraception seen as immoral, undermined social good Romans Photo Credit: Wayne Noffsinger • Had laws against taking substance that would prevent conception/cause miscarriage 7 Early Hebrews • Contraception not explicitly condemned Photo Credit: Lawrie Cate Early Hebrews • Many times, biblical stories interpreted in a way to support a position/agenda – Story of Onan, son of Judah Photo Credit: Lawrie Cate Early Christians • Not mentioned in the Christian scriptures as either condemning or condoning Photo Credit: Live Action Hero 8 Stoicism (350 B.C.E. – 300 C.E.) Stoicism (350 B.C.E. – 300 C.E.) • Powerful moral philosophy in Greek and Roman traditions Stoicism (350 B.C.E. – 300 C.E.) Fundamental tenets that advocated a negative moral judgment about contraception 1. Emphasized nature as the norm of morality (living morally) 9 Stoicism (350 B.C.E. – 300 C.E.) Fundamental tenets that advocated a negative moral judgment about contraception 1. Emphasized nature as the norm of morality (living morally) 2. Nature was imbued with reason (LOGOS) so behavior should not be motivated by emotion/passion Stoicism (350 B.C.E. – 300 C.E.) • Sex moral when undertaken: Stoicism (350 B.C.E. – 300 C.E.) • Sex moral when undertaken: – According to natural design 10 Stoicism (350 B.C.E. – 300 C.E.) • Sex moral when undertaken: – According to natural design – In accord with reason, not passion (reproduction) Stoicism (350 B.C.E. – 300 C.E.) • Powerful influence on Christianity Stoicism (350 B.C.E. – 300 C.E.) • Powerful influence on Christianity • St. Jerome (340-420) Photo Credit: POP • Christian theologian 11 Stoicism (350 B.C.E. – 300 C.E.) • Powerful influence on Christianity • Augustine (354-431) • Christian theologian Augustine • Condemned contraception, sex for reproduction only Augustine – The Good of Marriage • Sex without pregnancy as goal is morally defective • Unmarried woman having intercourse in order to have a child sins less than a married woman having intercourse with the hope of avoiding pregnancy 12 Augustine • Saw women’s role only as in reproduction / justifies her existence • Without pregnancy, species will die out Stoic-Christian Position Against Contraception • Influence until 16th century • Challenged • Still, came out with official catechism equating contraception with homicide • Stiff penalties 20th Century • Positions of some Christian churches were altered • 1930 – Anglicans noted that artificial birth control is ethical if practiced for morally sound reasons and not motivated by selfishness 13 20th Century • 1959 – World Council of Churches – once a responsible decision was made not to have a child, any appropriate method could be used Catholic Church Natural Family Planning • 1930 – Position of Roman Catholic Church somewhat altered • For a good reason, could deliberately choose to have sexual intercourse only during the infertile periods for purpose of preventing pregnancy Catholic Church • Still, traditional prohibitions against artificial birth control in effect • 1968 – Despite recommendations from papal commission findings, maintained position about immorality of artificial contraception 14 Invoking Natural Law Photo Credit: Bureau of Land Management • Natural Law forbids contraception, Pope was saying immoral for ALL human beings Invoking Natural Law Photo Credit: Bureau of Land Management • Implied that need Church authorities to interpret Natural Law, at odds with original intent, i.e., knowable by Natural Reason Invoking Natural Law • In some cases, (contraception), has to be interpreted by the Pope Photo Credit: Steven Polunsky 15 Invoking Natural Law Photo Credit: Bureau of Land Management • Interpretation binding for ALL humans Invoking Natural Law Photo Credit: Bureau of Land Management • Interfering with normal reproductive process is not a morally neutral activity Underlies Position • Attempt to dignify human sexuality – linked with having a family • Bad features associated with contraception – unwanted side effects, cause health problems 16 Morality Photo Credit: Kathy Kimpel • Avoid disorders in human behavior unless Morality Photo Credit: Kathy Kimpel • Avoid disorders in human behavior unless we have an appropriate reason to justify them 17 Morality • Avoid disorders in human behavior unless we have an appropriate reason to justify them • Think about the impact of contraception on our lives Morality • Will action truly contribute to individual and social human goods? • Will it undermine them? • Moral or immoral Law Photo Credit: Chad Kainz • Up until recently, many state laws prohibit use and distribution of contraceptive devices 18 Law Photo Credit: Phil Roeder • 1961 – U.S. Supreme Court heard Poe v Ullman pharmacist challenged Connecticut state law Law • Although case was dismissed, two judges dissented, on grounds it was an invasion of privacy Photo Credit: Phil Roeder • 1965 – Griswold v. Connecticut – U.S. Supreme Court struck down the state law – on basis of invasion of privacy Law • Although still felt using contraceptives was wrong, invading bedroom to enforce the law is a greater wrong Photo Credit: Phil Roeder • Violate couple’s right to privacy during sexual intercourse 19 Law • 1972 – U.S. Supreme Court struck down Massachusetts law prohibiting distribution, use of contraceptives by unmarried couples Photo Credit: Phil Roeder • 1977 – states cannot restrict distribution of contraceptives to minors Law • Did not address issue of whether use of contraceptives was moral or immoral. Indeed… Photo Credit: Phil Roeder • Invalidated laws because they violated people’s privacy Continue Photo Credit: Tracy Sorensen 20 PHHE 435/535 Ethical Decision Making for Health Professionals Module 10B Reproductive Issues Master of Public Health Program – Copyright © 2017. Board of Trustees of Northern Illinois University. All Rights Reserved. Contraception and Ethics • Raise set of ethical concerns because they are intended to cause dysfunction • Only morally acceptable if justified by adequate reasons Contraception and Ethics • Moral differences exist between IUD and barrier method – Prevent implantation vs. prevent fertilization 1 Contraception and Ethics • Moral differences exist between sterilization and reversible method Contraception and Ethics • Key question is when do they contribute to the human good of the couple and of society, despite the disorder they introduce to reproductive physiology – Despite the risks/side effects Contraception and Ethics • Deliberating morality of various contraceptive interventions • Realization that role of sexuality in human love grows in importance • Less emphasis on traditional idea that every sexual act is morally acceptable only if it is open to pregnancy (love not as important, more the parent role) 2 Contraception and Ethics • Population control Contraception and Ethics • Population control – is natural family planning as efficacious as artificial methods of birth control Contraception and Ethics • Question is Photo Credit: Stefan Baudy 3 Contraception and Ethics • Question is between those that say contraception is always a moral evil and those who say it is always bad, but not a moral evil whenever there are sufficient reasons for introducing it into the interpersonal relationship Photo Credit: Stefan Baudy Contraception and Ethics • Contraception can be a moral evil (unethical) if it is used to enable one to be promiscuous and engage in sexual intercourse for the sake of lust and not caring Contraception and Ethics • Moral deliberation needs to consider how an unexpected pregnancy can compromise the economic freedom, opportunity to expand role of women beyond that of mother/wife 4 Other Issues • Dispensing contraceptives at public high schools – Condoms – Birth control pill – Implant Norplant capsules Photo Credit: Surija /”Sray” Other Issues • Court imposed forced sterilization for criminals (violent sex offenders) • Sterilization for welfare participants • Sterilization for mentally challenged women (can’t avoid) Photo Credit: ResolueSupportMedia Other Issues • Determined by whether or not the intervention is justified by moral reasons showing that alternatives… will do even more harm to the good life 5 Medically Assisted Pregnancy Treatment for infertility 1960’s popular Artificial Insemination (AI) • Eventually used by – – – – Heterosexual without a partner Lesbian woman with no desire for male partner Not treated for infertility Some clinics declined to provide under these circumstances Photo Credit: Katelyn Swelgart 6 Artificial Insemination • Man providing sperm is the ‘donor’ • Could be from husband • Could be business transaction at sperm bank – Remains anonymous Photo Credit: Katelyn Swelgart Artificial Insemination: > 30,000 pregnancies/year • Sperm banks supply AI clinics • Advertise in numerous publications – $35.00 per sample Photo Credit: Katelyn Swelgart Artificial Insemination • Originally, moral/ethical issues not considered • Now, the source of serious harm must be considered Photo Credit: Katelyn Swelgart 7 Artificial Insemination • The offspring might become distressed if/when they discover their origin of 1/2 genetic complement – Business transaction – Could marry a half-sibling, even sperm donor himself Photo Credit: Katelyn Swelgart Difference between Adoption & AI Adoption • Attempt to help a child born into a less than ideal situation AI • Deliberate attempt to produce a child with an unknown and disinterested genetic father Artificial Insemination – Other Challenges • Single mother – long term effects on the offspring • Stigma of not having a ‘traditional family support’ • Stigma from sexual orientation of mother Photo Credit: Katelyn Swelgart 8 Artificial Insemination – Other Challenges Artificial Insemination • Catholic Church prohibition against masturbation as a serious moral wrong, despite the intention • Not all Catholic theologians agree Photo Credit: Katelyn Swelgart 9 1978 In Vitro Fertilization (IVF) • Ovulation induction • Egg retrieval • Fertilization • Embryo transfer Photo Credit: Solis Invicti In Vitro Fertilization (IVF) – Ethical Concerns • Object to masturbation to obtain sperm • Beginning of human life outside body as degrading human dignity (right to be conceived naturally) Photo Credit: Solis Invicti 10 In Vitro Fertilization (IVF) – Ethical Concerns • Object to using fertility treatments for unmarried women – Not think appropriate because not using for infertility problem – Violation of traditional family structure – confusion over parenthood Photo Credit: Solis Invicti In Vitro Fertilization (IVF) – Ethical Concerns • Discarding unused developing embryos (destruction of human life) • Question of what to do with frozen embryos – (1983) Mario & Elsa Rios – inheritance Photo Credit: Solis Invicti In Vitro Fertilization (IVF) – Ethical Concerns • Question of what to do with frozen embryos – (1989) – Mary Sue Davis and Junior Davis (IVF) • Marriage broke up • Who owns embryos • No longer exist? Photo Credit: Solis Invicti 11 In Vitro Fertilization (IVF) – Ethical Concerns • American Fertility Society – embryos first 14 days of development may be: – Frozen for future use – Discard if unneeded – Used for research with permission Photo Credit: Solis Invicti In Vitro Fertilization (IVF) – Ethical Concerns • Not all ethicists agree Respect human embryo – Feel only should fertilize the number of eggs to be immediately implanted – Although inconvenient, acknowledges the value of the human embryo In Vitro Fertilization – Moral Status – Extremes An unborn baby Human tissue 12 In Vitro Fertilization • Prudential position finds IVF reasonable for married couples of child-bearing age when all else has failed • The number of fertilized ova restricted to the number immediately returned to woman Photo Credit: Solis Invicti In Vitro Fertilization • Couples carriers of serious genetic disease, need to select only unaffected embryos for transfer • Might be able to justify use of frozen embryos after menopause Photo Credit: Solis Invicti In Vitro Fertilization • Since an ethics of prudence requires us to consider all relevant circumstances/consequences of action and we do not know it all in this area, all moral judgments are tentative • Need to be conservative Photo Credit: Solis Invicti 13 Other Interventions • Gamete Intrafallopian Transfer (GIFT) Gamete Intrafallopian Transfer GIFT is a procedure in which eggs and sperm are placed in the fallopian tube via laparoscopy. Fertilization may then take place in the fallopian tube. Other Interventions • Zygote Intrafallopian Transfer (ZIFT) • Ovum Transfer • Surrogate Motherhood 14 Surrogate Motherhood • By husband’s sperm Surrogate Motherhood • By husband’s sperm – Could be wife’s egg Surrogate Motherhood • By husband’s sperm – Could be wife’s egg – Married couple would be the genetic parents, surrogate the gestational mother 15 Surrogate Motherhood • By husband’s sperm – Could be wife’s egg – Married couple would be the genetic parents, surrogate the gestational mother – Biblical precedent – Sarah and Abraham (Hagar, Ismael) Surrogate Motherhood • By husband’s sperm – Could be wife’s egg – Married couple would be the genetic parents, surrogate the gestational mother – Biblical precedent – Sarah and Abraham (Hagar, Ismael) – Not really surrogate, the real mother Who is the Mother? • Genetic mother – eggs • Gestational mother – conceives, carries, labors, delivers, nurses • Social mother who raises the offspring 16 Who is the Mother? • Use of the term ‘surrogate’ has many complexities • If not considered the real mother, demeans the one who was pregnant and gave birth • May be difficult to understand gestational mothers’ change of heart Photo Credit: Paul J Everett Commercial Surrogacy • Works through agency • Contract services • AI • Medical bills paid • Final fee paid upon delivery of goods Family Surrogacy • Not a business transaction • Involves personal relationships • Family member is gestational mother • Egg from wife, sperm from husband 17 Family Surrogacy • Can get very confusing – Gestational mother of her grandchildren – Grandmother of her own children – Great-grandmother of her grandchildren Family Surrogacy • Although not as many ethical issues as with commercial surrogacy, also other issues Family Surrogacy • If family surrogacy places the women who do it in a position of exploitation, then the human good is undermined • Choice may actually be coerced 18 Ethicists • Problems with commercial surrogacy • Weak moral arguments – Reproductive freedom, right of people to have children – Describe how noble it is for one woman to help another The Case of Baby ‘M’ • 1984 Elizabeth Stern • Wife well educated, employed • No indication of infertility • Met Mary Beth Whitehead – Made a contract – Financially compromised 19 Conclusion 20

 

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