CHAPTER X Biomedical Ethics Lear ing Outcomes | sees dann me aareae Ee — es sDapaimtipy sy eet misiegene | HE introduction Jean Vanier, the founder of L'Arche ( community that Jusive of people with mental disabilities), reported in 2008 book Living Gently in a Violent World that a few |) years hence, poople with Down syndrome might not be born because they would have been aborted. Chorionic villus sampling late flilled Vanier’ prediction. National health | services of European nations such as France, Denmark, end the United Kingdom recommend CVS as a form of prenatal testing done aroul 10 to 12 weeks of pregnancy. It is a sampling of placental tissue, chorion sills, that allows the dktection of birth defects, genetic diseases, and other disorders in the fetus. In 2014, 698 abortions (roughly 90 percent of | those who tested positively in CVS) was carried out in the United Kingom." John, a member of LArche with Down in the medical | ist w2 CHAPTER X: BIOMEDICAL ETHICS syndrome puts it, “That doesn’t make us feel very welcome, dos i?” ties can hardly keep up with the fast and confusing advancement in the fields of genetics, medicine, and pharmacology. An introductory book of ethies for college students cannot cover all the nuanced epplications of the theories and available perspectives. The limitations can only mit learners an introductory but sound guide to navigate ‘through these current and emerging developments. For such ‘purposes “personalist biomedical ethics” Is suggested. Personalist Biomedical Care ‘At the tum of the 20th century, personalist theories emerged as a reaction to perceived depersonalization ‘caused by the advent of science, technology, and totaistic systems in philosopiy. Though different key thinkers give their own versions of pertonalism, « common affirmation is the centrality of the human person for philosophical thought, It posts the valte of personhood as a center of life, experience, decisions, and actions. Biomedical ethics has ‘stable grounding if it holds the inviolable, inherent, and Intrinsic value of the person, a well as his/her relational and comaunitarian realities. To better guide the Introduction to such Personalist Biomedical Ethics, the birth, well-being, ‘ad death suitable for the man person aze covered. Ethics of “Prenatal Personhood” Hreated discussion among ethicists always begins with the ‘question: “When does human personhood begitt?” Locally, the discussion is grounded on the Philippine constitution that upholds the protection of life of both the mother and the unborn child. The Philippine Medical Association 193Pant I: SPECIAL TOPICS IN ETHICS also released a document signed by Dr. Bu C. Castro and Dr. Oscar Tinio clearly assuming that the human person ‘exists atthe point of fertilization/conception. Even the culture supports such serious valuation of the unborn in that a pregnant (buntis) woman is also said to be nagdadalangtao for childbearing (literally humanbearing). Given such bedrock of certainties, the debate persists. For instance, if conception is considered as a process, there hes to be 8 point of readiness for the body to be able to support the lity of the self as a person. Cliven that the body is not sccidental to the integrality of the human being, does i not need this particular stago of readiness to be able to support personhood? Such questions, however, are not enough to disprove the claim that human personhood does not begin at the point of conception. At best, these considerations remain simply as questions for discussion; they are not proofs ‘A more nuanced postion which holds that since it cannot be proved or disproved as factual that the human being begins to exist at the very point of human conception, nevertheless “the fertilized ovum or fetus ought to be treated as a human person” This nuanced position passes on the burden of proof to those who raise such questions as to the personhood of fetuses. If one thinks about it more, a pragmatic support is also found in the fact that each one of the participants in the “ethical discussion of the start of personhood” all went through the same process of conception or fertilization in the womb of his/her mother. The issue cannot be miade light of simply because itis a matter of philosophical discussion (CHAPTER X: BIOMEDICAL ETHICS Pregnancy and the Principle of Double Effect James Keenan reported a discussion on the question of ectopic pregnancy as early as 1893." An interesting point ‘was raised in the discussion ofthe theologian. named Aloysius Sabbetti (1889-1898). If the fetus is said to be where it should not be in the ease of ectopie pregaaney (Le, outside ‘the womb) and fs threatening the life of the mother, can it be treated as an unjust aggressor? A more precise nuanced Js even arrived at by presenting it 8 a "materially unjust aggressor” that is, even without intention simply because it Js in the wrong place, the immature fetus is a grave threat to the life of the mother. It is likened to someone under the influence of drugs or alcohol who may be so drunk that clear Intentions are no longer present but nonetheless severely threatens to kill A better analogy is even presented in a case ‘when the soldier who belongs to an invading army is detected by a sniper who Is defending a particular territory. While unseen, the sniper is not intentionally threatened by the soldier but simply because he i in the place where he should not be, self-defense demands action (not excluding fatal shooting) on the part ofthe sniper. Given such logic of “self. defense” against a “materially unjust aggressor”, is abortion of the fetus acceptable? Ethicists who belong to the Catholic communion were ssiven an instruction clearly defining that it is @ matter of faith for this particular Church that itis not allowed to vuse the cabogory of unjust aggressor, formal or material in ‘questions involving fetal life." Abortion is also defined as| ‘an intrinsic evil act thot is unacceptable in any direct and tan rena Bre Mh ttf, ae » Beane”PART Il SPECIAL TOPICS IN ExHics Intended form as @ human action.” The case then of ectopic rognancy occasions the principle of double effet. ‘This principle is applied in the case of an action that is soon to have two results: one it known as good and hence ‘that which we eau only intend another simultaneous effect is bad, however, but since we do not intentionally doit for that purpose, this can be considered as a mere by-product of the action. The bad effect is willed to not have occurred at all ‘only if such an instance is possible, ‘The originating act ought to be deemed good or at the very least morally neutral. Applying this to the ease of ectopic pregnancy, itis unacceptable that the medical professional directly aborts the fetus; hence, his/her action of surgically cutting the fallopian tube that is clogged is 8 more tolerable option. Such a surgical intervention saves the mother but sadly also results in the indirect removal of the misplaced fetus If personalist ethics is aplied to biomedical issues, in this {instance the option that upholds the value of the fetus as that ‘ho “ought to be treated as a person" should be maintsined. Te may be considered that imputing aggression albeit materially (without intention) to a fetus is indicative of an objectification of one who is desorving of better consideration Emmanuel Lovinas, in his ertque of just war, once sald that reservation regarding justiieation of wars is that in being Justified one loses his/her conscience or conscientiousness. ‘Tho same can be said here; a justified seli-defense may push ‘one to ervingly shun that “the fetus ought to be tested as a person.” 196 CHAPTER x: SloMEOICAL ETHICS Child-Bearing Enhancements, Self-Improvement, and General Well-being “The applications in the Bel of meine have put forward wonders in the area of enhancement of human bla. Those tthe hd dieuty in having eilren, for Instance, ce ow {tren option to better improve thar chances of coreling& ChILL. "The Human Genome Project has promised personally designed drugs that can better Improve one's health oF recovery from sickness. Given the advancement of human fenetie mapping, predispositions to particular eknesos thd syndromes can be detected the ealest (at diocesed above even during the first 10 to 12 weeks of pregnancy). While thee bealthroughs and applications are not ell hn Uhemcles personals etic provide ws wi larger vew in nsiderng the ratloal and communitarian dimensions ef the san pera The cost of childbearing techniques util now te cexorbitanty high. While this may not be an isu for those Sho can afford them, the mune oF adoptees and children Born in poor familes deserve to also be considered In the dlechion In the coat of ellbearing tht benefits fom the Interventions avallable in igh-end bonptls “acceptable in Justice” for 8 country that stil indeate 40% self reported Poverty! Perhape the tredonal consideration of “common fle ls in place inthis nstance If there ae o many thildren who are orphans, don't they deserve poly Over ‘such costly means especially if the cost of having gle Child can in ello! suppart 2c 3 cident Une Fearing to Stour ‘Ancter issue to be considered in the present state of ctuldbearing entancemente has to do wih the so-called “pare Present tecniguc of cit oncving enhancementsPar Il: SPECIAL TOPICS IN ETHICS involve the harvesting of egg cells from the mother. Since it Js impossible or costly to store these without fertilizing them, ‘what are frozen in hospitals/linies that give are uman embryos or fetuses that are implantation. The 100% success of a not yet reached 90 & numberof fertilized eggs or embryos are frozen as “spares.” An important question that is occasioned by this procass has to do with the “spares” that are lft after a successful pregnancy up to the full verm is achieved, ‘Maintaining the principle that the fetus “ought to be ‘treated as a human person,” a careful monitoring of the “spares” is in order. The Philippines has boasted recently of local doctors’ ability to engage in stem cell therapy. While stom coll research has reached developments that ‘most no longer make use of human embryos, the history of ‘his research betrays the fact that it does not exclude such methods. The absence of laws defining “spares? as deserving of treatment as human persons simply mean that the “spares” are not out of the reach of unconscientious therapists. Embryos in the fist 4 days are known for ther totipotency (imuttipovency, that is, germane in the "spares" are the cells ‘that make up every organ in the human body including. ‘gray matter that is important for the brain. ‘This is hardly negligible especially given the presence of massive monetary support for researches that address debilitating diseases such as Parkinson's and Alzheimer’s that hit retired and financially influential fist-world citizens. The awareness ofthese ius is too low and the temptation to enter into it too strong that the victimization and objectification of these “spares” may slready be happening, in our country. Other selfenbancements and general well-being Improvements that are now available to those who can afford thom ought to be evaluated also along the lines of personalist ethics. While personal improvements such as the Intake of glotathione for aesthetic improvements can hardly 198 CHAPTER X: BIOMEDICAL EKies bbe branded a evil or bad, ethicists warn of the objectification that is peddled by such *self-actuslization” products, Most concerting are the products that purport to improve the woll-boing or intelligence of children. While these may truly bbe beneficial for them, the question should be raised: “Is it contributing to the view that children are like projects that should fellow the designs deemed relevant by parents?” This objectification affects personal regard betwoen them and leads to intolerance of personal differences betwoen family members. Other products or techniques (including surgery) that sll selfeuhancements should be countered or balanced with an appeal to personal growth that is not only physical. Bodily aesthetic or self actualizaton directions ought to be inclusive of interior values such as kindness, solidarity, and compassion. While a moneyed person may have access to such services ‘or products, justice and the traditional concept of common ‘good demand a mitigation (individual as well as communal evaluation) of these commercialized self-enhancements. Extraordinary Means, Euthanasia, and the Significance of a Living Will A biief examination of end of life ethical issues continues ‘the View that is consistently personalist in orientation. Euthanasia or mercy killing is the direct murder of another human being and is thus unacceptable at this point in the Philippines. ‘The value given to persons is inherent and inviolable for personalist ethics that it excludes the direct and intentional killing of a non-aggressor. End of life care ought to be improved to ensure the dignified dying that ie worthy of human persons, Pain management and hospice care, particularly for those who suffer, should be explained clearly, ‘made reachable and available, especially forthe poor in this country. 199PaRY Il: SPECIAL TOPICS IN ETHICS A distinction, however, should be made between euthanasia and the termination of “extraordinary means” that simply allow the process of dying to take its course. ‘The stoppage of extraordinary means, without which the sick person is simply allowed to have a dignified death, is not passive euthanasia. Extraordinary means are additional or artificial ways that extend the life of a person, 4. respirator. If the chances of recovering are deemed by doctors as slim and the family no longer has the means to continue the costly use of these means, taking away the respirator does not mean ‘the sick person who ean no longer breathe on his own. The process of death in this instance is permitted to follow its ‘cutee, and the person is simply allowed to go through the process ofa dignified death, ‘The writing ofa living will i, therefore, relevant to give szuidance to loved ones in the remote possibilty that an fccident of sickness renders someone “brain dead" comatose, or in a persistent vegetative state. Personal autonomy is given priority even in such instances that the living will (that is left behind) is significantly considered. Is the person open to forgan donation and to what extent of organ harvesting for ‘the life of other persons is permissible? Hospitals put up DNR (do not resuscitate) cards in accordance with a patents living will (lse the wishes of the next of kin is followed). Agnin, DNRs are different from euthanasia. It is the rescinding of CPR (cardiopulmonary resuscitation) or other means of resuseitations in The event of « fatal erash of the patient DNR allows for dignified death, The writing of living wills permits the resolution of confusion that may arise in families regarding such difficult decisions. Personalist ethics also stresses the communitarian dimension in the waiting of living will. Other persoas ean also be saved through the willingness of the brain-dead patient (expressed in the living will he/she left behind) to gift them with an extension of life through organ donation CHAPTER X: BIOMEDICAL Eruies Conclusion ‘The current breakthroughs and craze in pushing new researches in medicine and pharmacology may lead humanity to lose sight of what is of utmost importance, ic., the inherent, inviolable, and inalienable value of personhood. Bach and every human being is unique insofar as he/she is fan expression of « depth that is ever a source of creativity, willfulness, and decision, Man in his/her freedom is the ‘very height of his/her being. How he/she utes that freedom in biomedical issues is not only @ concern about the limits of how far he/she can go but is first and foremost a question ‘of who he/she is or what is he/she to become given his/her biomedical decisions. The questions of ethies applied in th field are not only about the treatment of patients and clients; they inquire first and foremost about humanity that involves us all, cluding, medieal practitioners themselves “Treating the embryo as a human person” not only ensures the dignity and value of the fetal life that is being studied; the priniple engages the medical practitioners and researchers themselves, Such an approach in biomedical ethics raises the question about the kind of humanity that is endorsed by the research and built up in the very study that Is conducted. Using the advancements in medicine to Improve the well-being of persons may be very attractive but also misleading if we treat physicality as an end in itselt ‘An integral personhood involves not anly external or bodily improvements. An actualized person includes his/her entirety that is saifsfaction not only regarding his/her exteriority or physicality but a deeper interior kind of happiness too, Sustaining respect for the person until death moves us away from euthanasia that may be marked by impatience towards the process of death. This does not mean that dignified dying and pain management are excluded in what we ought to secure in these end-of-life concerns. Autonomy of the‘human person is respected in hospitals that the living will is of utmost importance and “DNR” posts are ensured to be consistent with them. Death, being the very end of life for the Jnuman person, i included in the very realty of personhood that dignity ought to be maintained unt then Ea Study Questions ‘What is moral dilemma in the fisld of modical ethies? Provide examples of medical moral dilemmas. 2. How relevant is the personalist perspective in the consideration of biomedical ethics? 3. Explain the significance and muance of the mandate, “Embryos ought to be tread lke human persons” 4. What is ectopic pregnancy? Explain the principle of double effect in this case. 5. List and evaluate the availability of personal enhancements and general well-being improvements obtainable today ‘6. Why is the common good relevant in the consideration ‘and evaluation of techniques that improve childbearing of couples? 7. Explain the diference betwoen euthanasia, DNR, and the termination of other “extraordinary means? for 8 patient who fs terminally il 8, What isa living will and how important is it today? Exercise Research on particular ethical dilemma presented. in this section or choose one of your own research. Try to explain a possible response to the dilemma using any of the philosophical systems presented throughout this course. Explain why you chose this. References ‘Edmund Pellegrino, Edmund, and A. I, Faden, eds. Jewish ‘and Catholic Bioethics. Washington DC: Georgetown University Press, 1998, Cail, Lisa Sowle. Theological Bioethics: Participation, Justice and Change. Washington DC: Georgetown University Press, 2005. ‘Walter, James, and Thomas Shannon. Contemporary Issues ‘in Bioethics. New York: Rowman and Litlfield, 2005,