Ethics and assisted human reproduction

Pathways: The Novartis Journal 1 (2, October 2000), 40-43.

Author: Darryl R. J. Macer
Bioethics: The case for an individual informed approach to decision-making

As scientists continue to push the boundaries of what we can do, bioethicists strive to help determine whether we should do it. But with so many recent technological advances having colossal implications for humanity, can bioethics cope? Professor Darryl Macer argues that a universal approach to bioethical decision-making, based on empowerment of the individual, is needed

It is the year 2040. By now you have received your second replacement heart, and finished the first course of stem cell therapy to rejuvenate your liver. You are currently choosing the appearance and personality traits of your next set of children \ your third. The first child will definitely be a girl, but her race, characteristics and the identity of her surrogate mother are more difficult decisions. Still, you can take a quick break from it all on the Siberian beaches by switching to the virtual mode of the mind supplemental software recently installed in your cranial cavity. It is just as well the program has inbuilt presets to ensure that at some point you return to reality and your reproductive decision-making.

This prediction tells us more than simply what we could be doing in 40 years' time. It also generates different reactions in different people - some consider it a nightmare vision, others look forward to being able to utilize such technologies and abilities.

As we begin the new millennium, humanity must decide how best to use the astonishing power we are slowly but surely gaining - through major advances in such fields as genetic engineering, cloning, medicine and neuroscience - potentially to re-engineer our very existence. In many ways we are being called to rethink what it is to be human. Just how far should we go in modifying ourselves, and our children, in the quest for intelligence, health, beauty, strength and entrepreneurial ability?

The task of guiding us through such decisions falls to the discipline of ebioethicsf. It can be defined as the study of ethical issues arising from human involvement with life. But I argue that the simplest, most all-encompassing and most pragmatic definition of bioethics is the elove of lifef. If we as individuals and nations can understand this, then our decision-making becomes much easier and our future much more assured.

Bioethics as the love of life

The word bioethics itself is only 30 years old, yet as an idea and guiding principle it has been with us for thousands of years. Issues such as abortion and euthanasia, for example, have long been subjects of debate, in almost all cultures, philosophies and religions. It was only in the 1960s, with rapid advances in life sciences and growing concern about global environmental issues, that the academic field of bioethics began to emerge.

A set of four principles or ideals forms the recognized common ground for most bioethical decision-making. These include the autonomy of individuals to make choices, while at the same time respecting the choices of others \ justice. And in all things we do, the ideal is to avoid doing harm, and to try to do good.

I suggest these principles are all manifestations of love, and that applying self-love (autonomy), love of others (justice), loving life (do no harm) and loving good (beneficence) provides us with a vehicle to express our ethical values. Love is not only a widely accepted goal of ethical action, but also the foundation of normative principles of bioethics.

The major criticism of the use of love of life in the bioethics context is that it is not substantial or concrete enough. But if we consider it as an intelligent process of acting for the good of people, respecting individuals and avoiding harm, then such concerns are largely dispelled. And crucially a key advantage of love as a definition of bioethics is that it is such an understandable concept among all peoples of the world. This allows the development of both a responsible personal approach to decision-making, and also more of a universal approach - especially important because of the cross-cultural implications for humanity of the emerging bioethical issues.

These are not, as they might seem, mutually exclusive approaches. Diversity is part of what we call being human, and we should never presume that our neighbor will reason the same way as ourselves, even if we are both equally informed on the subject. Love and respect for others demands that we should give different societies and their peoples a chance to adapt themselves to the modern life, rather than just attempting to merge them into a global modern order, However, recognition of the universal implications of individual decisions is vital.

Therefore universalism in the sense that everyone thinks in the same way and balances ideals of action in the same way, is not possible. But universalism in the sense that decisions have much broader consequences beyond a single individual, nation or even continent, certainly is possible.

Case study - germ-line gene therapy

The case for universalism is based on several key factors, including:

Several of these factors, for example, are driving international efforts to regulate germ-linegene therapy - the process of inducing beneficial changes to an individual's genetic make-up (for example for health reasons) that can be inherited by subsequent children. The genome is shared by everyone - each of us alive today shares a common African ancestor who lived more than 100,000 years ago, often referred to as mitochondrial Eve - therefore we should all have a right to contribute to debates on regulation. The issue is certainly international, as anyone with an altered germ-line would be able to move across national borders.

Germ-line gene therapy has already been outlawed in some parts of the world, for example by the Council of Europe's Convention on Biomedicine and Human Rights. But there is still intense debate worldwide about whether it might be justified to alter the genes that children inherit. Would it, as many believe, inevitably lead to human genetic engineering for no medical reason? Would that be such a bad thing? Many people reach the conclusion that if we allow cosmetic surgery than some types of genetic enhancement without medical reason may also be ethical.

Case study - human reproductive cloning

Another major bioethical issue is human reproductive cloning. Within two years of the reports of the cloning of Dolly the sheep, all 180 member countries of UNESCO supported the inclusion, in the Universal Declaration on the Human Genome and Human Rights, of a clause which prohibits human reproductive cloning, as being contrary to human dignity. That repeated some individual governments' decisions to outlaw reproductive cloning, and the Council of Europe's Convention on Human Rights and Biomedicine: Additional Protocol, which outlawed reproductive human cloning.

But as a member of the UNESCO International Bioethics Committee between 1993 to 1998, I share with some other members doubts on whether human reproductive cloning would in every case be against human dignity, and whether it would be unethical. One of the features of humanity is diversity. It was claimed by those who sought to prohibit cloning that cloning violates human diversity. Anyone who has seen identical twins knows that identical genes do not mean identical people. Science would tell us clones are not identical.

No-one could ethically support making full size organ donor clones for spare parts, but as an extension of existing assisted reproductive technologies, I could not support a prohibition on a technique that could be used to bring about the birth of a child who would be loved by an otherwise childless couple. Bioethics should teach love and respect for the values of others, so that even if my values would not allow me to make use of a technology, I could tolerate others doing so.

Time to think

I do not believe that international law to prohibit development of technology will protect anyone, as history has shown that people reject stringent laws or legalistic religions. Education of mature and tolerant citizens is a more effective and longer term solution. What these declarations and laws may do is to give us, humanity, time to carefully consider which paths we will walk down.

It is not a bad thing to give society time to think, and in fact it also follows the ethical principle of loving life by avoiding harm, as we give science a chance to fully test and develop techniques. I believe that human reproductive cloning, for example, if proven safe and effective, will one day be routine as a technique for assisting infertile couples.

In order to have a sustainable future, we need to promote bioethical maturity. This can be defined as the ability of a society to balance the benefits and risks of applications or medical technology. It is also reflected in the extent to which the views of the public are incorporated into any policy-making. Awareness of concerns and risks should be maintained and debated, for it may lessen the possibility of misuse of these technologies. Indeed, one of the growing signs of bioethical maturity is a healthy questioning of new technology.

Education in bioethical decision-making at all levels in society has already been called for by global bodies such as UNESCO and the International Union of Biological Sciences, who consider that better choices should mean a better life and a better society. The logistics of providing any education is of course a massive task, but its form and content need not be complex in any way. I would argue that the four principles of bioethics expressed as love - self-love, love of others, love of life and love of good - provide the simplest and most understandable approach for everyone. This should be our starting point for all efforts at promoting universalism.

We as individuals, and also as societies, have obligations of justice to every person in the world. When we value the rights of all persons we have a sound basis for deciding how - or indeed whether - we utilize new technologies. At the same time we must respect those who make educated decisions that are different to our own educated decisions. Ultimately this provides the most satisfying scenario for the future of humanity.

Prof. Darryl Macer is director of the Eubios Ethics Institute and associate professor at the Institute of Biological Sciences, University of Tsukuba, Japan. He is also a board member of the International Association of Bioethics and the Human Genome Organisation Ethics Committee, and was a founding member of the UNESCO International Bioethics Committee

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