© Springer International Publishing AG 2017P. Anne Scott (ed.)Key Concepts and Issues in Nursing Ethics10.1007/978-3-319-49250-6_9
9. Ethical Issues at the Beginning of Life
School of Healthcare, University of Leeds, Baines Wing, Leeds, LS2 9JT, UK
This chapter explores the ethical and legal issues faced when caring for pregnant women. A case study involving four women who have used or are contemplating using reproductive technologies forms the basis of the chapter to illustrate and discuss the issues raised. The issue at the heart of the debate is the question of when life begins and what sort of status we should afford to the entity that develops from a fertilised ovum through various stages to be a fully formed baby. Beginning with an exploration of this concept of when life begins and begins to matter, assisted conception, surrogacy and prenatal diagnosis are discussed. This is followed by a consideration of the notion of choosing children including the creation of saviour siblings. The final section of the chapter considers the complex ethical issue of abortion particularly on the grounds of fetal abnormality. Differing views on the moral status of the embryo are explored along with common reasons for justifying abortion. The chapter concludes with a glimpse into the future, with an examination of new and emerging technologies.
KeywordsAssisted conceptionAbortionPrenatal diagnosisSaviour siblings
Introduction (Including Case Study)
Over the last 50 years technological advances and new treatments have been developed in the care of pregnant women. There have also been changes in the law to allow abortion under some circumstances, and sophisticated treatments for infertility, all of which give rise to ethical questions focusing on the very essence of human life. Beginning with a discussion of when life begins, this chapter will explore some of the ethical issues in contemporary healthcare including assisted conception, surrogacy, prenatal diagnosis, the creation of saviour siblings, and the controversial subject of abortion. A case study involving four women in different stages of their reproductive lives will be used to illustrate and inform the debate. The chapter concludes with a consideration of new and potentially controversial techniques emerging in reproductive medicine.
Clare, Saadia, Ruth and Liz are friends who were at secondary school together over ten years ago. They now live in different parts of the country, but meet up for a reunion every year. At their most recent meeting, two of the friends are pregnant, Clare with her first child and Saadia with her second. Saadia knows that the baby is a boy who they are going to name Amir. Saadia’s first child, Yusuf, now 4 years old, was born with beta thalassaemia, an inherited condition which means that he has to have regular blood transfusions. Saadia explains that she had undergone IVF in this pregnancy to ensure that her baby would be a tissue match for Yusuf. Immediately after birth some blood will be taken from the umbilical cord and the cells in it used to treat Yusuf and hopefully cure his condition.
Clare is in the early stages of her pregnancy, and tells her friends that she is worried about the tests she has recently had to exclude fetal abnormality. Clare has a brother with Down’s syndrome and knows how difficult her parents found caring for a disabled child. But she is very uncomfortable with the idea of termination and says she doesn’t know what she would do if she was told there was something wrong with her baby. Liz, who has had four children in six years, is adamant that she wouldn’t want another child and says that she just couldn’t cope. While she understands Clare’s views, she says she wouldn’t be concerned at all about having a termination and thinks that it is her right as a woman to have this choice.
Ruth tells her friends that she hadn’t planned to have any more children, feeling that her family is complete with the two she has. But recently her sister has undergone treatment for breast cancer, and has been advised to freeze some of her eggs as the treatment is likely to affect her fertility. Ruth asks her friends what they think about surrogacy and wonders if she should offer to have a child for her sister.
The women in this scenario face a number of challenges concerning the way in which they view the moral status of the fetus, the use of assisted conception and prenatal diagnosis, the creation of saviour siblings, and the ethical dilemma of abortion. Central to all of these and other ethical problems in reproductive technology is the fundamental question of when life begins; this is where we will begin this exploration.
When Does Life Begin?
There are several different claims about when human life comes into existence. These claims are important as they are relevant to the question of what status should be afforded to the human embryo and ultimately what can be done to it. For some people, life begins at conception, that is, when the sperm fuses with a mature ovum to form the early embryo. In many respect this is the most obvious point to identify as the beginning of life, as the fertilisation of the ovum by the sperm, each containing 23 chromosomes, causes the creation of a new life. For some people this means that the embryo, from the moment of conception, should have the same degree of protection as any other human being.
But fertilisation does not always produce an embryo and on rare occasions (approximately 1 in 700–800 pregnancies per year), the fertilised ovum does not develop normally and while there is a mass of rapidly growing cells called a hydatidiform mole, no embryo develops. As a molar pregnancy is likely to develop into a choriocarcinoma,1 it is usually removed as soon as a diagnosis has been made. To suggest that the mole should not be removed would be a difficult argument to sustain, firstly because there is no embryo, and secondly, because of the potential dangers of not removing it. We cannot even describe a fertilised ovum as being the beginning of a unique new life, as there is still a possibility of twins being formed from the single fertilised ovum as late as 2 weeks following conception. Nevertheless people holding what are described as Pro-life views, such as members of the Society for the Protection of Unborn Children (SPUC), unequivocally state that life begins at conception because at that point “a person is genetically complete, unquestionably human, distinct from mother and father, and alive – with the capacity to grow and develop to maturity” (SPUC 2016).
Before the advent of ultrasound, much significance was placed on the first time a woman felt the fetus move, usually around 16 to 20 weeks. Reference to fetal movements can be found in the Gospel of Luke in the Bible. Luke describes a meeting between Mary, pregnant with Jesus, and Elizabeth who was pregnant with John the Baptist. On hearing Mary’s voice, Elizabeth says that “the babe leaped within her womb” (Luke 1:41). It is not surprising that this was associated with the beginning of life as a moving fetus clearly indicated a “live” fetus. In traditional Roman Catholic theology, the first fetal movements had even more significance, in that they indicated the moment when the soul is created in the embryo. Aristotle believed that a male body was formed at 40 days, but that of a female took 90 days to be formed. Thomas Aquinas, a thirteen century theologian developed Aristotle’s theory further by proposing that God creates the soul within the embryo at 40 days for males and 90 days for females (Gillon 2001). From this we can conclude that for Aquinas, male fetuses were valuable at an earlier stage than female ones. While a moving fetus is undeniably a “live” fetus, modern ultrasound techniques show fetal movements are present much earlier in pregnancy than when the woman begins to feel them, or than suggested in historical accounts.
In 1984 an influential committee chaired by Dame Mary Warnock debated the ethical and social implications of infertility treatment and embryo research following the birth of the first ‘test tube baby’ (DHSS 1984). An important point to emerge was the significance of the primitive streak, that is, the beginning of the individual biological development of the embryo and the last point at which twinning can occur. The primitive streak represents early development of cells that will develop into neural tissue, the very first stages of the nervous system and hence the root of consciousness. As the primitive streak develops on day 15, one of the Committee’s recommendations was that embryo research should only be allowed up to 14 days after fertilisation. While ensuring experimentation would only be carried out on embryos before the appearance of any neural tissue, this could be interpreted as meaning that embryos up to this point are seen to be less valuable than those over 14 days.
Even if it is not possible to argue that life definitely begins at conception, and that a new individual is created at that point, it does still seem plausible to recognise the importance of conception. Following this line of argument, we might say that while there is a continuum of human development, the embryo even in the earliest stages has the genetic material of a human and, given the right conditions, will develop into a human being. Therefore, the embryo should be afforded the same rights and protection as any human being. This is called the potentiality argument.
John Harris (1985) points to two problems with this argument. Firstly, the fact that something will become X is not a good reason for treating it now as if it were X. For example, an acorn, given the correct conditions has the potential to grow into an oak tree, but does this mean that should we treat an acorn the same as an oak tree? Or to put it another way, do you think that squashing an acorn is the same as cutting down an oak tree that is a 100 years old? Even using acorns and oak trees as the example still has a moral nuance. We may have more reservations about cutting down an ancient tree without due cause than standing on the acorn accidentally or otherwise. The second problem relates to the ova and sperm individually, as clearly they too have the potential to become human beings. Generally speaking we do not take much care over the fate of “unwanted” ova or sperm. However, following the potentiality argument methods of contraception that destroy ova and/or sperm could be deemed morally wrong, and Roman Catholics have teaching forbidding the use of contraception based upon this argument.
When Does Life Begin to Matter?
The development of the fertilized ovum into an embryo, fetus, and ultimately a baby, can be thought of as a continuum with stages that merge into each other. Therefore, rather than trying to answer the question ‘when does life begin’ a different approach is to ask ‘when does life begin to matter’. We have already seen that the emergence of the primitive streak is a biological event which marks the development of neurological tissues, and the emergence of the sentient being2 is linked to this concept. Peter Singer (2012) argues that if a sentient being, human or non-human, can feel pain or distress then it’s interests should be given the same consideration as any other human being. So if hurting or destroying sentient beings is considered to be wrong, then sentient beings should not be harmed. However, non-sentient beings cannot be harmed by their destruction as they do not have the capacity to feel pleasure or pain and thus cannot be harmed. Based on sentience, abortion and embryo research are legitimate as long as the embryo cannot feel any pain; as the argument from sentience only prohibits hurting the sentient entity but does not offer absolute protection.
Leaving biological definitions and sentience to one side, a far more complex issue, and one of the most influential philosophical arguments about when life begins to matter, is that of the recognition of self or personhood. The precise meaning is hard to define, but personhood is essentially the things that make us human, or the combination of beliefs, desires, and aspects of personality that make us who we are. From as early as the seventieth century this has been described as a combination of rationality and self-consciousness (Locke 1997). More recently and directly related to abortion and infanticide, Michael Tooley defined the criterion for personhood as an organism that “possesses the concept of a self as a continuing subject of experiences and other mental states, and believes that it is itself such a continuing entity” (Tooley 1972, p. 29). So for Tooley, in order to have a claim to a right to life, the person must be able to recognise themselves as the same being over time. Therefore, killing a person is wrong as it removes from the individual something they are able to value, but using this distinction, individuals who cannot value their own existence cannot be wronged by killing as they are not deprived of something they are capable of valuing. While this may be a persuasive argument, a key problem with defining personhood as a combination of rationality and self-consciousness is that fetuses, babies, some adults with learning disabilities, those in a permanent vegetative state, and even some with dementia cannot be classified as persons.3
Having explored some of the differing views on when life begins and begins to matter, we will now turn to some of the contemporary uses of reproductive technologies and the ethical questions that face Clare, Saadia, Ruth and Liz. To ensure a tissue match for her son with beta thalassaemia, Saadia has become pregnant using IVF, while Ruth is considering being a surrogate for her sister’s baby.
Since the birth of Louise Brown, the first ‘test tube’ baby, in 1978, increasingly sophisticated techniques to assist conception have been developed. Some forms of treatment, such as those that solely use medication, are not usually considered controversial. However other techniques, such as the use of donor sperm and/or ova, IVF, and surrogacy, do raise ethical problems. Opinions on the morality of assisted conception rest on an individual’s view of the moral status of the embryo. The idea of creating a life in vitro is considered to be unnatural and, unsurprisingly, those who hold pro-life views are generally opposed to IVF. What lies at the heart of this debate is whether infertility is considered a disease to be treated the same as any other condition. At the very least, infertility is a malfunction of part of the body much in the way that diabetes is. Treatment of diabetes with insulin, like many other medications, may also be considered unnatural; yet we would not consider this to be a sufficient reason to deny someone having insulin. But while infertility might be thought of as a malfunction of the body, unlike diabetes, the treatment is not life-saving. Although infertility is a cause of suffering and misery to those unable to have much wanted children. There is also the added problem that the treatment is concerned with creating embryos, not all of which will be used. Those that are not may be discarded or used in research. Despite some moral objections to the assisted conception process it is widely utilised. The latest figures show that in 2013 49,636 women were treated and 2.2% of all the babies born in the UK in 2012 were as a result of IVF (HFEA 2014a).