Issues

Birth Control History Context Technology Problems Ethical Framework

and Culture

Ethics in Reproductive Medicine

Pablo Rodríguez del Pozo, MD, JD, PhD

Associate Professor
Division of Medical Ethics
Weill Cornell Medical College in Qatar

Doha, January 7, 2020

 Issues

– Sexual abuse
– Virginity tests
– Human embryonic stem cell research, cloning
– Fertility / infertility / assisted reproduction
– Pre-implantation screening
– Early pre-natal diagnosis
– Sex selection
– Eugenics
– Abortion
– Feticide
– Mental health and pregnancy
– Cancer and pregnancy
– Drug abuse
– HIV infection
– Paternity determination
– Patient-requested c-section
– Patients refusals of care
– Refusal of emergency delivery
– Sexual misconduct
 Reproduction and culture

• Human beings go through the inevitable cycle of life:

– Birth, growth, reproduction and death

• Human reproduction is today predominantly

voluntary: A personal option, a choice

A recent phenomenon
Reproduction and culture
 Reproduction and culture

© The History of Contraception Museum

 Reproduction and culture

The Peninsula, Doha, January 14, 2007

 Reproduction and culture

• The way we understand reproduction and all its

connected concepts (dating, mating, sexuality,
parenthood, etc.) is heavily influenced / determined
by culture (social patterns, religion, etc.)

• Culture pervades our values, feelings, and moral

perceptions about these issues

• Total control of reproduction is today medically

possible
 Birth Control

• People voluntarily limit family size

• Total fertility rate (TFW)

– Qatar: 1986 = 4.45 ààààà 2016 = 1.91 (estimated)
– Spain: 1975 = 2.79 ààààà 2016 = 1.33 (estimated)
– USA: 1960 = 3.65 ààààà 2016 = 1.80 (estimated)

• If a woman marries at 20, without artificially limiting

fertility, she would carry to term 10 children (Potts M,
Campbell M, 2002)

• Birth control:
– (a) Is technically feasible
– (b) In the current social and cultural context, is considered a
rational option
 History

• Medical contraceptive methods (documented)

– Genesis 38, 7-10 ... Onan "spilled his seed on the ground"
– Code of Hammurabi (Babylon, 2200 BC): Penalizes non-
consented abortion
– Petri papyrus (Egypt, 1850 BC): Pessary made of sodium
carbonate and honey
– Kahun papyrus (Egypt 1825 BC): Pessaries made of
crocodile dung, honey and sour milk
– Ebers papyrus (Egypt, 1550 BC): Honey
 History

– Hippocrates (V Century BC):

• Oath forbids to give an abortive pessary
• Diseases of Women (Gynikéōn Prōton): Formulas to "purge"
the uterus; and
• "Aid for preventing pregnancy, if a woman does not wish to
conceive: after soaking a bean-sized truffle in water, give it to
her to drink, and for a year, practically, she will not conceive" (I-
76)
– Ancient Greek (6 to 3 Century BC): Silphion (an herb), oral
contraceptive and/or abortifacient
– Desert camel drivers (Early BC): Stones inside the uterus of
their camels to avoid their impregnation in long trips
(frequently cited, but not well documented)
 History

– Pliny the Elder (Rome, 23 - 70 AD): Pessary from mice

dung
– Ancient Greece and Rome: Animal membranes as barrier
contraceptives (ill documented)
– Dioscofides (Greece, 58-64 AD): De Materia Medica,
Pessary made of pepper
– Soranus (Greece, 100 AD: Gynecology, Pessaries made of
alum potassium aluminum sulfate [KAl(SO4)2·12H2O]
– Imperial Rome (100 AD): Condom is used (Himes N.E. -
1932)
– Al-Razi (Rhazes) (Persia, 860 A.D.- 923): Mentioned in
Quintaessence of Experience
– Avicenna (Ibn Sina) (Persia 973-1037): Mentioned in Canon
of Medicine
– G. Fallopius (De Morbo Gallico, 1563): Publication about
condoms, clinical experiment as prophylactic
 History

– Earl of Condom (1660–1685): Created a prophylactic and

contraceptive device and for King Charles II
– S.S. Lungren (1880): First tubal ligation
– C.Hasse (pseudonym: Wilhelm Mesinga) (Germany, 1882):
Diaphragm
– Walter Rendel (1885): Quinine as spermicide
– H. G. Lennander (Sweden, 1897): First vasectomy
– Hallwig (1902): Designed a pessary which stem extended
into the uterus (first modern IUD)
– Knauss (1928) - Kyusaku Ogino (1930): Calendar of fertile
and infertile days
– Pharmaceutical industry (1950's): Surfactant spermicides
 History

– Gregory Pincus (1959): Oral contraceptives "the pill"

– Jack Lippe (1962), Tatum (1968), Lerner (1970): "Lippe
loop", "Tatum-T", and "Dalkon Shield", amply prescribed
IUDs
– Albert Yuzpe (1974): 100 µg ethinyl-estradiol + 1.0 dl-
norgestrel (emergency contraception)
– Etienne-Emile Baulieu (1980): RU-486, a contragestive
(chemical abortion)
– France (1992): Female condom
– Milex (2004): Silicone Diaphragm
 History

• Home methods (documented)

– Stems (parsley stem)
– Knitting needle
– Catheter
– Coat hanger
– Silver wire
– Hypertonic solutions
– Coca-Cola
– Ergotamine
– Quinine
– Misoprostol (anti-ulcer anti-prostaglandines)
– Veterinarian medicines
– Methotrexate (antitumoral)
...why?
 Social context of birth control

• Social situation of women

– Penalization (legal or social) of single motherhood
– Family, social rejection, loss of status (pariah)
– Discrimination
– Practical difficulties (studies, job, career, marriage)
 Social context of birth control

• Eugenics (coined by Darwin's cousin, Francis Galton

- 1822-1911). From Greeek eu- "good" + genos
"birth")
– Improve the human race and society
– Positive eugenics (foster the desirables)
– Negative eugenics (get rid of the undesirables)
– Boosted after the rediscovery of Mendel's works in 1900
– Eugenics movements and laws in the US and Europe:
Forced sterilizations of mentally retarded, castration of
criminals, laws forbidding marriage among people of
different races, etc.
– Extended by the Nazis
– Prenatal diagnosis since the 60's: Option to abort fetuses
with genetic or chromosomal disorders
 Social context of birth control

• Family planning
– Decline of mortality
– Increased life expectancy
– Decline of child mortality (‰ of live births who die before 1
year old)
– Reduction of the replacement rate fertility (number of babies
that an average woman should have to replace her
generation, given prevailing levels of mortality)
• Ancient times replacement rate fertility was 5 or 6 children per
woman
• Today: from 2.07 (Netherlands) to 3.35 (Swaziland) or 3.21
(Sierra Leone)
• To have the same number of children around, you need to have
a lot fewer children (Espinshade, Guzman and Westoff, 2003)
 Social context of birth control

• Family planning…
– Birth of childhood: The changing social value of children
• Middle Ages: No concept of childhood - Children left home at
between 7 and 10 years old (Ph. Ariès)
• Children were neglected, brutalized, deprived of affection (H.
Hendrick)
• Good mothering is an invention of modernization (E. Shorter)
• XV or XVII Century: Children start staying with or close to their
families until late teens (Ph. Ariès)
• 1870 - 1930: Sacralization of children:
– From wage-earners / cheap laborers to mandatory schooling
• If children: (a) stay at home; (b) have to be schooled; (c) do not
earn a salary. And if: (d) parents care about children's welfare
and education…

Children become a big responsibility and a heavy burden

 Social context of birth control

• Family planning…
– Women enter the labor market
• 1900: 18.3% of the labor force were women
• 2005: 46.4%
• 99% of women will work for pay at some point in their lives (U.S.
Department of Labor - www.dol.gov)

• Repercussions
– Competition, pursuit of success and economic achievements
– Women's empowerment, freedom, rights
– Variety of interests (career, education, culture, personal
space, self)
– Limits on births
– Delayed motherhood

– Higher opportunity cost of unwanted pregnancy

… also: Children are scarce and more precious than ever

 Reproductive Technologies

• Reproductive technologies and newborn care

– Aristotle (384 / 322 BC): Generation of Animals, Principles
of generation (female transformed / male transformer)
(epigenesis)
– Hippocrates (460-377 BC): Particles (gemmules) from each
part of the parent's body entered seminal substances (male
and female) (pangenesis)
– Antonie van Leeuwenhoek (1632 - 1723): Describes animal
and human spermatozoa
– John Hunter (1776): Artificial insemination
– Girault (France, 1838): Publishes a paper reporting
successful artificial insemination
– Girault (France, 1868): Reports 12 cases of successful
artificial insemination
– J. Marion Sims (1860): Artificial insemination by husband
 Reproductive Technologies

– Paolo Mantegazza (Italy, 1887): First published report of

artificial insemination by donor
– Robert L. Dickinson and William Cary (1919): Artificial
insemination by donor
– Bunge and Sherman (1953): First births from cryopreseved
semen (1949: cryopreservation with glycerol by Polge et.al.)
– [1960: 70% of all calves born in the US are the product of
artificial insemination]
– Alan F. Guttmacher (1962): 5 to 7 thousand children per
year are conceived through donor insemination in the US
(although others estimate 15 to 20 thousand)
– Edwards et.al. (1970): First in-vitro human embryonic
development -16 cells
– Whittingham et.al. (1972): Cryopreserved mouse embryos
– Steptoe and Edwards (1978): First birth resulting from in-
vitro fertilization
 Reproductive Technologies

– 1998: 1504 clinics in 44 countries, 88,594 births of children

conceived by IVF worldwide = 390,000 cycles
• Cost: 390,000 x $12400* = $4.83 billion American Society of Reproductive
Medicine

– Today: Up to half million people have been conceived by

IVF worldwide
 Reproductive Technologies

– Many medical practices related to reproduction are

demanded by people

– Most of them can be technically performed

– However, many of them are ethically or religiously

controversial, or are forbidden by law
 Ethical Problems

• Cases:
– 1.- Person wants to be sterilized (salpingectomy,
vasectomy) without her/his spouse's knowledge
– 2.- Eight-week pregnant 22-y.o.-unmarried woman "wants to
terminate her pregnancy". No other reason is mentioned
– 3.- Same case, but she's now married. Doesn't want her
husband to know
– 4.- 18-week pregnant woman is diagnosed with cancer.
She'll not survive if she carries her pregnancy to term; if
pregnancy is terminated, her chances for 10-year survival
are 75%. She refuses to have an abortion
 Ethical Problems

• Cases:
– 5.- Same case. She now wants to terminate her pregnancy.
However, performing, facilitating or otherwise contributing
to produce an abortion is against your convictions.
– 6.- Woman 11-week pregnant with twins. She and her
husband ask to abort one.
– 7.- Parents want to produce a 2nd, disease-free child in
order to obtain bone marrow for an older sibling who suffers
from Fanconi's anemia
– 8.- Wife has congenital absence of uterus, and her ovocyte
is fecundated in vitro by husband's sperm. Now they want
the husband's mother to have the embryo implanted and
carry the pregnancy to term
 Ethical Problems

• Invariably these cases have to do with conflict of

interest
– Woman - Embryo or Fetus - Partner - Third parties

• Invariably these problems are rife with religious

considerations

• Invariably these problems are rife with cultural

perceptions and traditions

• Invariably these cases are dealt with by the law of

each country
 Ethical Theory

• Two competing traditions in medicine

– The beneficent tradition vs. the autonomist tradition

• The beneficent tradition

– Naturalistic / Hippocratic
• Aristotle: Good and bad are such in reference to the ordo
naturalis (order harmony of nature)
• The moral rightness or wrongness of human actions is judged
according to how they contradict, preserve or restore the
harmony of nature
• Hippocrates: Health is good; disease is bad
• Physician must have a deep understanding of nature (physis)
by means of reason (logos): Physiologo, i.e. physiologist
• Doctor knows best
 Ethical Theory

• "Perform all this calmly and adroitly, concealing most things

from the patient while you are attending him. Give necessary
orders with cheerfulness and serenity, turning his attention
away from what is being done to him; sometimes reprove
sharply and emphatically, and sometimes comfort with
solicitude and attention, revealing nothing of the patient's future
condition." (Hippocrates, Decorum, XVI)

• Everything for the patient, but without the patient

• Paternalism: "Reluctance to accept or consent to the wishes,

options and actions of another person, invoking the benefit of
that person" (James Childress)
 Ethical Theory

• John Gregory (1724 - 1773): Lectures on the Duties and

Qualifications of a Physician
• Benjamin Rush (1745 - 1813): Medical Inquiries and
Observations
• Thomas Percival (1740-1804): Doctors and Ethics
• American Medical Association (1847): Code of Medical Ethics
draws heavily on Percival's work
 Ethical Theory

– Religious ethics has some of these features

• Averroes (Ibn Rushd) (Córdoba, 1126 - 1198): The

Commentator of Aristoteles. Naturalism
• Maimonides (Córdoba 1135 - 1204): Influenced by Averroes,
introduces Aristotelian naturalism into the Jewish tradition
• Thomas Aquinas (1225-1274): Natural law is the reflection of
the eternal law in the sensitive world
 Ethical Theory

– Civil law reflects naturalist and religious principles

• Divorce, abortion, contraception have been -or still are- legally
banned in a number of countries
• Anthony Comstock (1844-1915): US Comstock Act "Comstock
Act," defined any information about birth control as
pornography, banned and penalized its distribution with hard
labor imprisonment
• The ban on prescribing birth control methods was declared
unconstitutional in 1936; the law was abolished in 1971 (U.S.)
 Ethical Theory

• The map of abortion

• Argentina: 35.3% of OB-GYN deaths in women between 15

and 40 are due to complications from illegal abortions
 Ethical Theory

• The autonomist tradition

– David Hume (1711-1776): A Treatise of Human Nature

– How we know: Impressions (sensitive world) and Ideas
(reason)
– Impressions precede reason
– Impressions tell us very little about the thing's properties
(color, odor, temperature...), but rather about our own
sensitive faculties and categories
– If impressions are unreliable for capturing the sensitive
world, ideas built upon impressions are unreliable as well
– George E. Moore (1873 -1958): "The naturalistic fallacy" (in
Principia Ethica of 1903)
 Ethical Theory

– Individual rights and limits of state power

• The American Independence (1789, June): Bill of rights
 Ethical Theory

• The French Revolution (1789, August): Declaration of the

Rights of Man and of the Citizen

– 1. Men are born and remain free and equal in rights. Social
distinctions may be founded only upon the general good.
– 4. Liberty consists in the freedom to do everything which
injures no one else; hence the exercise of the natural rights
of each man has no limits except those which assure to the
other members of the society the enjoyment of the same
rights. These limits can only be determined by law.
– 5. Law can only prohibit such actions as are hurtful to
society. Nothing may be prevented which is not forbidden by
law, and no one may be forced to do anything not provided
for by law.
– 6. Law is the expression of the general will (…)
 Ethical Theory

– Medical Jurisprudence and Patient's Rights

• Carpenter vs. Blake (turn of the century)

• Mohr vs. Williams (1905)
• Pratt vs. Davis (1906)
• Rolanter vs. Strain (1913)
• Scholendorff vs. Society of New York Hospitals (1914):
Doctrine consent
• Salgo vs. Leland Stanford Jr. (1957): Doctrine of informed
consent
• Canterbury vs. Spence (1972): Doctrine of self determination
as the goal of medical care

– Today's prevalent paradigm: Person knows best - Patient

knows best
– Do we still have a role as doctors?
Questions?

Comments?