MLI: Ch. 12 Ethical Issues Related to Life

Assisted or Artificial Conception p. 294

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Child Abuse Prevention and Treatment Act of 1987 p. 307

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Negligence Suits Related to Sterilization p. 301

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Unborn Victims of Violence Act p. 306

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Describe the Baby M case.

Baby M was the result of a surrogate parenting contract between the surrogate mother, Mary Beth Whitehead, and Mr. and Mrs. Stern. The baby was conceived from Mr. Stern's sperm and Mrs. Whitehead's egg. The baby was turned over to the Sterns after birth, but a few months later, Mrs. Whitehead and her husband escaped to Florida with the baby. The baby was returned to the Sterns. A court ruled that the natural mother should have parental rights to see the child, but the Sterns were granted custody.

Discuss the ethical considerations relating to artificial insemination.

Could include: a. The confidentiality of AID records b. The method for handling the sperm donation c. The husband's acceptance of a child conceived in this manner d. The child's wish to know the identity of the father

Ethical Considerations with Surrogate Motherhood p. 297

Ethical dilemmas include: • Potential course battles over custody of a child conceived outside of marriage • Potential embarrassment for the surrogate mother, whose actions may be criticized • Potential harm to the surrogate's own children if they learn that their mother gave a child away (and received money in return) • Emotional distress when the child learns it was taken from the birth mother • Reducing birth to a legal and financial arrangement There are opposing views regarding surrogacy. • Some people equate it with selling a baby because compensation above the medical costs is paid to the surrogate • Other people believe surrogacy is a viable alternative for infertile people

Synopsis

Ethical issues relating to birth and life are especially difficult because they carry the extra burden of the students' and the instructor's own personal values. Nevertheless, all healthcare professionals must be willing to understand the topics and issues discussed by patients, physicians, and the federal court system. This chapter includes a discussion of fetal development, contraception, sterilization, abortion, assisted or artificial conception, conscience clauses, genetic counseling and testing, wrongful-life suits, the human genome project, genetic engineering, gene therapy, and stem cell research.

Explain the importance of Roe v. Wade.

In Roe v. Wade, the Supreme Court declared a Texas criminal abortion law that prohibited all abortions not necessary to save the life of the mother to be a violation of the woman's right to privacy under the Fourteenth Amendment of the Constitution. It gave strength to the argument that a woman should be allowed the right to have privacy over matters related to her own body.

Historical Progression of Cases Affecting Abortion p. 304

It is not the duty of anyone, except the physician, to advice the patient concerning such topics as sterilization and abortion.

Ethical Questions Regarding Genetic Testing p. 311

List of Seven on page 312

Sterilization p. 299

Sterilization may be incidental, therapeutic, or involuntary.

Ethical Issues & Questions Surrounding Abortion p. 307

Table 12. 1 on page 307

When Does Life Begin? p. 293

There are may beliefs abaout when life begins: • Many people believe that life begins at the moment of conception • One argument to support this is that this is the moment when the zygote receives its genetic code • People who believe this, therefore believe that any interference after this point is murder (abortion, morning after pill) • Others believe that life begins 14 days after fertilization, during the embryo stage • Others believe life begins when the embryo becomes a fetus at about the third month of development (around 9 weeks) because this is when the brain and beating heart of the fetus can be identified. • Others believe that life does not begin until birth (at about 40 weeks) Medical professionals whose religious or personal beliefs lead them to oppose abortion cannot counsel about or assist women in terminating a pregnancy in any way.

Fertility Drugs p. 298

These are drugs that increase female hormones and the production of ova in order to increase the chance of pregnancy. These drugs also increase the woman's chance of having a multiple pregnancy. • Multiple pregnancies (over twins) are high risk of spontaneous abortion or produce premature infants that require long term medical care. • Selective reduction is sometimes preformed to "cull" some of the developing embryos so the others have a better chance of survival

Funding for Abortion p. 306

Under the Hyde Amendment, the U.S. Congress limited the types of medially necessary abortions for which Medicaid monies may be spent.

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Used by couples or singles who have viable productive organs but cannot achieve pregnancy.

Discuss the ethical considerations relating to surrogate motherhood and contraception.

You might discuss the following questions: Is it right to ask the surrogate mother to give up all rights to the baby she has carried for nine months? Does, or should, the child have an emotional or physical link to the surrogate mother? Will the relationship between the husband and wife be altered if the husband's sperm is implanted into another woman? What is the sibling relationship toward the surrogate baby? Can the contract between the surrogate mother and the couple be enforced?

Artificial insemination donor (AID) p. 294

a procedure in which a donor's sperm is used.

Artificial insemination husband (AIH) p. 294

a procedure in which sperm from the woman's husband or partner is used.

Amniocentesis p. 310

a test for the presence of genetic defects in which a needle is used to withdraw a small amount of amniotic fluid that surrounds the fetus in the uterus.

Surrogate mother p. 296

a woman who agrees to bear a child for another couple. The husband's sperm is implanted into this woman's uterus. The wife's ovum may be used, but often a donor ovum is used.

List several ethical issues surrounding sterilization and contraception.

a. Eugenic sterilization is abhorrent to many people. It carries the stigma of determining who shall live and who shall die. b. Many people question the ethics of public schools, which receive federal and state funding, dispensing contraceptive devices such as condoms and birth control pills. c. Many people question the ethics of suggesting that violent sex offenders be ordered to undergo sterilization. d. Some people believe that women who receive public funds such as Medicaid should not continue to have children by unknown fathers because, by so doing, they increase the welfare rolls. e. Some hospitals refuse to allow sterilization procedures on their premises. This is a consideration if they are the only hospital in the area. f. Some people believe mentally incompetent women should be sterilized to prevent a pregnancy from occurring if a man takes advantage of them. g. There is a concern that children are being treated as property. h. Is human life being destroyed (harvesting of embryos) to the achieve the birth of healthy children. i. Some people believe that issues of contraception can interfere with the relationship between husband and wife.

Induced abortion p. 303

an abortion caused by artificial means such as medications or surgical procedures.

Contraception p. 299

birth control.

Preimplantation genetic diagnosis (P.G.D.) p. 298

genetic testing on embryos for genes that cause untreatable or severe diseases.

Viable p. 302

in the case of a fetus, ability to survive outside of the uterus.

Anencephaly p. 308

missing a brain and spinal cord.

Eugenic (involuntary) sterilization p. 301

sterilization of certain categories of persons, such as the insane and mentally retarded (cognitively disabled), in order to prevent them from passing on defective genes to their children.

Therapeutic sterilization p. 300

sterilization undertaken to save the mother's life or protect her health.

Spontaneous abortion p. 303

termination of pregnancy that occurs naturally before the fetus is viable.

Artificial insemination p. 294

the injection of seminal fluid that contains male sperm into the female's vagina from her husband, partner, or donor by some means other than sexual intercourse.

In-vitro fertilization (IVF) p. 295

the process of combining ovum and sperm outside of a woman's body.

Sterilization p. 299

the process of medically altering reproductive organs so as to terminate the ability to produce offspring.

Eugenics p. 302

the science that studies methods for controlling certain characteristics in offspring.

Gestational period p. 293

time before birth during which the fetus is developing; usually nine months.

Embryo p. 293

unborn child between the second and twelfth week after conception.

Fetus p. 293

unborn child from the third month after conception until birth.

Abortion p. 302

• 1.2 million legal induced abortions are performed each year in the U.S. • An abortion may be spontaneous or induced. • The AMA adopted an anti-abortion position in 1959. • This influenced many states to pass laws making abortion illegal (unless performed to save the mother's life) • In the 60s and 70s, amendemetns to laws permitted induced abortion only if the mother was at risk, the child had serious congenital defects, or when the pregnancy was the result of incest or rape.

Wrongful Life p. 312

• A baby born with severe defect may greatly affect the quality of life for the child • A wrongful-birth claim or lawsuit is often brought against the physician or laboratory by the parents. • They may claim they were denied the right to decide whether to continue the pregnancy or not because they were not given warning about the condition early enough. • Lawsuits are also brought when sterilization has failed. • Wrongful-birth damages may be awarded, but rarely are wrongful-life damages paid • It is important for healthcare workers to alert their employer if they contract a contagious disease.

Surrogate Motherhood p. 296

• A contract is established between the couple and the surrogate mother, who must give up the child at birth. • The couple may pat $20,000 to $25,000 to the surrogate for medical expenses. The baby itself cannot be sold/bought. • It is legal in most states, but there are few laws to regulate it. • Cases end up in court when either the surrogate or parents change their minds. This often occurs when the baby is born with health problems. • In the Baby M case the surrogate wanted to keep the baby (her ovum was used).

Ethical Considerations in Artificial Conception p. 295

• AID records which indicate the identity of the sperm donor, are considered confidential and are not public record • There have been cases where physicians participated in unethical artificial insemination procedures (like using his own sperm) • Problems may arise between the parents if the father resents his wife for conceiving with another man's sperm. Children may question their parentage. • Record keeping of donor-assisted conceptions is often incomplete or inaccurate. • If the information is available, it is important to note on a child's health record if they were conceived by artificial insemination so that medical history of the donor can be added. The topic should never be discussed in front of the child my medical professionals.

Baby Doe Regulations p. 307

• Baby Doe's parents denied treatment that would make feeding possible because the baby had severe impairments • It was considered a case of withholding treatment rather than of mercy killing • Resulted in Congress enacting legislation called the Child Abuse Prevention and Treatment Act of 1987 that prevented the withholding of medical treatment solely because the infant was disabled. • Legislation prevented healthcare providers from receiving federal financial aid if they discriminated against handicapped infants. • The law was altered slightly so that parents have some say about their handicapped infant's medical treatment because some women who were carrying handicapped fetuses were opting for late-term abortions. • Many ethical questions arise (page 308)

In the Matter of Baby K p. 308 p. 307

• Baby K was anencephalic and the mother insisted that a mechanical ventilator be used to assist the baby with breathing even though the baby had no brain or spinal cord • The hospital and the baby's father (who were footing the expense for keeping the baby alive) joined in a lawsuit against the baby's mother • She invoked the Emergency Medical Treatment and Active Labor Act (prevents patient dumping) • The court sided with the mother because the law had to be upheld even though keeping the tiny body breathing was considered morally and ethically incorrect

Involuntary or Eugenic Sterilization p. 301

• Considered unethical by most people • Some states still authorize the involuntary sterilization of wards of the state who are genetically impaired. The procedure must be proven in court to be to the persons best advantage. It is losing favor, as research shows that most forms of cognitive impairment are not hereditary. • Some states also allow involuntary sterilization of sexual deviates and habitual criminals, but this practice is losing favor. This is done after notification of the person's guardian or nearest relative, undergoing a hearing, and an opportunity for appeal has been offered. • Assault and battery charges fall upon anyone who castrates or sterilized another person without following procedures.

Contraception p. 299

• Contraception means (contra) against, (conception) union of male sperm and female ovum. So, contraception is any action taken to prevent pregnancy from occurring. • The Catholic Church condemns contraception and sterilization. • Many people do not consider contraception and sterilization moral issues. Ethicists and moral philosophers only address the issue in regards to coerced sterilization. • Terminology changes. E.g., "mentally retarded" is no longer acceptable, but cognitively challenged or impaired and developmentally delayed are acceptable depending on the environment.

In-Vitro Fertilization p. 295

• Ethical issues arise in regard to unused cells/embryos as they are often destroyed. • Sometime frozen embryos are frozen and custody issues develop. • Even if the couple plans ahead and completes a written, notarized plan for the embryos should they dispute in the future, there are few laws to enforce their agreement if one or both changes their mind.

Artificial Insemination p. 294

• Few legal problems if the husband's sperm is used. • An exception is when a woman uses a deceased husband's sperm. Issues arise regarding the childs rights, like if the child can be entitled to receive Social Security benefits form the deceased father's account. Precedence was set at a federal level in 1995 that says children conceived like this are entitled to benefits if born more than 11 months after the father's death.

Genetic Counseling and Testing p. 309

• Genetics is the study of heredity and its variations. It describes the biological influence the parents have on their offspring. • Genetics should not be confused with eugenics (or selective breeding), is the science that studies methods for controlling certain characteristics in offspring. • Genetic counseling is usually performed by geneticists who have a master's or higher degree or my medical doctors with special training in genetics. • Over 2,000 diseases have been identified as having a genetic factor • In these recessive gene diseases, each parent must pass on a copy of the defective gene in order for the disease to be produced in the child. • People with the recessive gene can be tested so they have the most information for making a decision to remain childless • Table 12. 2 Hereditary Disorders

Employee's Right to Refuse to Participate in Abortions p. 306

• Hospital employees have the right to refuse to participate in performing an abortion and the hospital cannot dismiss the employee for insubordination. • In the healthcare profession, patient's viewpoints must be respected even when they differ from the employee's viewpoint.

Therapeutic Sterilization p. 300

• If sterilization occurs incidental to another procedure, it is not considered sterilization.

Partial Birth Abortion p. 305

• In a few cases, late-term abortions (after 24 weeks) resulted in live birth because the fetus was viable. • There are two type of partial birth abortions 1. This two day process starts with inserting absorbent filters into the mother's cervix to dilate it overnight. The next day digoxin is injected into the amniotic fluid to stop the fetus's heart. The next day, the fetus is removed by dilatation and evacuation (D&E) 2. The second type allows the fetus to enter the birth canal and then the skull is punctured and the brain contents sucked out. This is opposed by many states. Many women wait until the second trimester to seek an abortion because they do not have the money to pay for it earlier. They cannot use Medicaid because the Hyde amendment says Medicaid funds can only be used if the mother's life is in danger.

Incompetent Persons and Abortion p. 305

• Many people believe that if the incompetent person were ale to speak for herself, she would not wish to be pregnant as a result of incest or rape.

Opposition to Abortion p. 306

• Many people think that Roe vs. Wade protects the person that is the mother, but not the person that is the baby. They feel that under Roe vs. Wade in the 14th amendment the mother's rights are covered but the fetus' is not. • The Unborn Victims of Violence Act of 2004 provides legal penalties for harm done to an unborn child at federal facilities. This law treats all unborn life as a person. • Almost 40 states have statues that grant degrees of legal standing to a fetus. These relate to criminal matters like murder and homicide.

Consent to Sterilization p. 300

• No one, not even habitual criminals, can be sterilized without consent or it is considered battery. • Usually a patient's written consent is all that is necessary. Some hospitals encourage attainment of the spouse's consent as well, but not doing so presents little legal risk. • No federal law requires consent from the spouse. • Sterilization is usually permanent so consenting individuals must be 21 yeas of age.

Genetic Testing of Newborns p. 311

• Routine genetic screening on newborns has become standard • One common test screens for PKU, a disorder that can cause cognitive impairment or even death; it can be treated with dietary restrictions • Donors of semen are routinely screened to rule out genetic diseases

Selective Reduction or Harvesting Embryos p. 298

• Selective reduction or harvesting is the removal of extra embryos during a multiple pregnancy. • Some ethicists think that widespread use of fertility drugs could become reckless • Harvesting can be used to choose an embryo that is free of specific genetic traits for certain diseases for transplantation (PGD). • Diseases that can be detected with PGD are cystic fibrosis, sickle cell anemia, and Huntington's disease. It can also be used for less serious predispositions such as arthritis and obesity.

Consent for Artificial Insemination Donor (AID) p. 294

• Some AID legislation says both the husband and wife must sign consent to use sperm from a donor. This avoids issues with a husband denying responsibility for the child. • It is wise to require consent from both the husband and the wife even if there is no state statute

Conceiving Donor Siblings p. 311

• Sometime women will conceive a baby in the hopes that it will be able to donate tissue to a sibling in need. • Sometimes, they will abort the fetus if it is not a match • The Uniform Anatomical Gift Act implements legal safeguards to prevent women from becoming pregnant with the specific purpose of aborting the fetus to sell the fetal tissues or organs, or donate them to a relative.

Incidental Sterilization p. 299

• Sterilization is incidental when performed for another purpose (e.g., hysterectomy)

Roe vs Wade p. 303

• The Supreme Court refused to determine when life begins, but it did recognize that states would have an interest in protection the potential lives of their citizens. The court tried to clarify the extent to which states can regulate and even prohibit abortion. The court adopted a three-step process based the three trimesters of pregnancy. 1. First trimester - between the woman and her physician because the fetus is not viable 2. Second trimester - the fetus is viable so abortion so abortion should be limited to incidence where it would save the mothers life 3. Third trimester - abortion at this stage is limited as above

Prenatal Testing p. 310

• The most common form of genetic testing during a pregnancy is through amniocentesis. This invasive procedure requires consent. • Genetic testing is not always performed for the purpose of aborting a pregnancy. Parents may want to know so they can better prepare for the child in advance.

Legal Status of Offspring p. 295

• The most common legal/ethical concern relates to the legitimacy of the child and determining who is responsible for the child's support. • Several states say that if consent is signed by the husband, that he and not the donor are responsible for the child's support.

Conscience Clause in Contraception and Abortion p. 308

• There are no clear answers to the many dilemmas that arise in these situations. A patient's needs must come first, but the employees have the right to practice their religious beliefs. • Always clarify your own values and beliefs with your employer when you are hired.

Safe Haven Laws p. 313

• These laws create a safe alternative to leaving unwanted babies in dangerous places such as on doorsteps or in dumpsters. • They allow a parent to voluntarily give up custody of an infant 31 days or younger to a hospital Emergency Room or a police or fire station. • In CT, an ER nurse will ask about the child's medical history and give the parent information on how to contact the Department of Children and Families (DCF). DCF takes custody of the baby and contacts both parents if knows, if not they post a newspaper notice.The parents can change their minds and accept custody but they must act quickly and ask for a court attorney to represent them. The court schedules a hearing within 30 days of DCF's application. DCF will try to place that baby for adoption within 30 days. • These laws are ment to protect babies whose parents are unable to care for them • They do not provide protection to parents if abuse or neglect has already occurred. It does not allow for the abandonment of older children. • States vary on the administration of these laws so it is important to check with you state to find out.

Plan "B" or "The Morning After" Contraceptive Pill p. 305

• This pill contains a high dose of a contraceptive that if taken with 72 hours following intercourse will prevent pregnancy. • It works by releasing hormones that prevent ovulation and implantation of a fertilized egg. • Divided opinion on this pill leads to a variety of statutes • Catholic hospitals are opposed to giving it if the woman is carrying a fertilized egg or to a non ovulating woman. • In some states it is a law that all pharmacies must carry the drug • In other states there are laws protecting pharmacists who will not fill prescriptions for this pill for religious or moral reasons • Rape crisis counselors believe that it is morally indefensible to deny this pill to rape victims

Wrongful Conception/Wrongful Pregnancy p. 313

• Wrongful-birth lawsuits are increasingly awarding fiancial damages to parents. • Wrongful-life lawsuits in which the disabled children sue the physician, have generally been rejected by the courts. • The best method to avoid wrongful conception/life charges is for the physician to advice the parents in writing that a small percentage of sterilization procedures are unsuccessful.