Ethical Dilemmas in BSE101

• Ethical dilemmas (BSE101) is presented by Dr. Lamis Nader, Assistant Professor, on March 8, 2025.

Objectives of Presentation

• Define abortion, list its types, and discuss it as an ethical dilemma.
• Identify ethical concerns related to AIDS/Covid-19 patients.
• Explain ethical conflicts associated with assisted reproductive techniques (ARTs).
• Describe the process of organ donation and its ethical concerns.
• Discuss dilemmas of stem cell transplantation, sterilization, wrongful conception, birth, and life.
• Recognize the laws and regulations in UAE governing those dilemmas.

Abortion

• Abortion, from the legal point of view, is defined as the termination of pregnancy before full term, either spontaneously or intentionally.
• The procedure is a pregnancy termination prior to 20 weeks' gestation or less than 500-g birth weight.
• Varying definitions are according to state laws for reporting abortions, fetal deaths, and neonatal deaths.

Types of Abortion:

• Spontaneous abortions happen spontaneously.
• Induced abortions may be Lawful (Legal or medical / therapeutic) or Illegal (Criminal).

Spontaneous Abortion (SAB)/Miscarriage

• Miscarriage is the spontaneous end of a pregnancy at a stage where the embryo or fetus is incapable of surviving.
• Called early pregnancy loss or chemical pregnancy, miscarriages that occur before the sixth week of gestation.
• Miscarriages that occur after the sixth week LMP are medically termed clinical spontaneous abortion.
• Between 10-25% of all clinically recognized pregnancies will end in miscarriage.
• Most miscarriages occur during the first 13 weeks of pregnancy.

Types of Induced Abortion

• Legal or Therapeutic Abortion involves inducing abortion on medical grounds to save the mother's life.
• Maternal causes, such as chronic diseases like advanced heart, renal, pulmonary diseases, or malignancy, especially hormone-dependent states are the indications.
• Gestational causes affecting the mother's life as eclampsia or hyperemesis gravid arum can also be indications.
• Illegal or Criminal Abortion, defined as the induction of abortion for any reason other than saving the mother's life, constitutes birth control or illegal pregnancy, i.e., “abortion on demand."

The Legal Role of the Physician in Abortion

• The right to life to the fetus exists from the moment of fertilization and protected by legal coverage.
• To avoid potential charges, physicians should have a written consent signed from the patient and husband in order to commit a therapeutic abortion.
• Consultation of two specialists for the reason of abortion with documentation is needed.
• Abortion operation is done in a licensed, well-equipped hospital.
• In an emergency case to save the mother's life or to prevent grave permanent harm to the mother, abortion is carried out on the certification of only one medical practitioner and without the need for a consent
• Cases, where illegal abortion is proved to be done by a doctor, are considered a professional offense, even with the presence of the woman's consent.

The Stages of Fetal Development

• Conception, or the moment of fertilization, is a logical point following the "pro-life" stance to be chosen as the beginning of human life.
• It is one of the few points that are objective, or difficult to judge, as an egg is either fertilized or not, and the fertilized egg has begun to develop into a separate and unique human being.
• The fertilized egg contains the full genetic code of a human being, but so do all the cells of the body.
• It is the beginning of a process of development and maturation and marks the beginning of biological life.
• Implantation is the moment when the fertilized egg is implanted in the womb, about a week after conception.
• Quickening is when the fetus first moves in the womb, about 16 to 17 weeks after fertilization.
• Quickening does not seem to be a starting point for human rights and is influenced by factors such as the number of previous pregnancies that the mother has had.
• Some believe that life begins at the first sign of brain activity.
• Viability of the fetus is the stage when the fetus could survive outside the womb
• Birth is a clear and objective date, but there is disagreement on the point at which a baby is actually born.

Moral Arguments

• Here is the main argument that is usually advanced against abortion:
  • P1: The fetus is an innocent person.
  • P2: It is morally wrong to end the life of an innocent person.
  • C: Therefore, it is morally wrong to end the life of a fetus.

The Moral Status of the Fetus:

• The abortion debate centers around whether the fetus is a person or not.
• If the fetus is a person, then it has the rights that belong to persons, including the right to life.
• The concept of personhood is the bridge that connects the fetus with the right to life.

Criteria of Personhood

• Possible criteria can be conceived by humans, have a genetic structure, possess a physical resemblance, harbor the presence of a soul, exhibit viability, and offer A future like ours.

The Rights of The Pregnant Woman

What right does a woman possess that would entitle her to choose an abortion?

• Right to privacy
• Right to ownership of one's own body.
• Right to equal treatment.
• Right to self-determination.
• Women have the right to decide about their own futures.
• It is morally repellent to force a woman to bear a child against her will.

Rights of the Father

• To what extent do the father's preferences count in making this decision? Mothers actually give birth, fathers don't.
• Society usually places primary responsibility on the mother.
• Fathers don't even always know they are fathers; mothers always do.

General Areas of Abortion Legislation Worldwide

• Parental Consent and Parental Notice: The consent of both parents is a must unless otherwise specified.
• States may require a minor seeking an abortion to obtain the consent of a parent or guardian of twenty-four-hour with an adequate judicial bypass procedure.
• Informed Consent. A state may require a physician to provide parents with information such as alternatives to abortion, sources of financial aid, development of the child, and the gestational age of the child.
• Waiting Period. A twenty-four hour waiting period does not constitute an undue burden on a woman's decision to abort and, therefore, is constitutional.
• Fetal Remains. States may not require that the remains of the unborn child are disposed of in a "humane and sanitary" manner.

Abortion of a Malformed Fetus

• Congenital anomalies contribute a significant proportion of infant morbidity and mortality, as well as fetal mortality.
• A debate regarding aborting a malformed fetus still exists.
• The severity of structural anomalies directly correlated with abortion rates of anomalous fetuses.
• The prenatal ultrasound at 18-20 weeks can detect major structural anomalies in approximately 60% of such cases.

UAE Law Regarding Abortion

• A physician may not perform an abortion or prescribe anything that may induce an abortion except in the following two cases:

1. If a continuing pregnancy poses a risk to a pregnant woman's life, and under the following conditions:

   • Abortion is performed by a specialist gynecologist/obstetrician with the approval of the physician who is attending the medical condition, giving rise to abortion.
   • A report shall be written by the concerned physicians indicating the reason for abortion.
   • It is signed by the pregnant woman, her husband, or guardian (if her consent cannot be obtained) and acts as proof of consent to the abortion procedure.
   • Each of the concerned parties shall keep a copy of the report.
   • Approval by the husband is not stipulated in the case of emergencies requiring immediate surgical intervention.

2. If it is proven that the fetus is mutilated, and under the following conditions:

   • Abortion is performed at the request of the parents.
   • The length of pregnancy is shorter than one hundred and twenty days.
   • The mutilation is proven by a report of a medical board comprising consultants in gynecology, obstetrics, pediatrics, and radiology.
   • The board's report is based on medical examinations and the use of scientifically acceptable technologies.
   • The fetus suffers from a serious untreatable mutilation and will have his life be bad and painful for him and his family if born alive.

Confidentiality of AIDS/COVID-19 Patients

• All medical information generally is considered confidential and protected under the law.
• Because of the sensitivity of HIV-related information, many states in U.S. have adopted laws that provide additional protection to HIV-related medical records.
• However, Exceptions to the legal and ethical obligation to maintain the confidentiality of HIV-related information exist.
• Healthcare providers have a duty to report HIV infections and AIDS cases to public health authorities.
• U.S. government policy has recommended that HIV-infected healthcare workers who perform exposure-prone invasive procedures have their cases reviewed by an expert panel.
• Urge the patient to sit with the partner and inform them about the HIV/AIDS condition.

Consent

• The majority of states require specific informed consent to HIV testing, and many of these require that consent be written for specifications.
• Some states permit HIV testing without informed consent under specified circumstances.
• Some states permit the testing of prisoners and persons accused of sex crimes, and also require mandatory HIV testing of newborns, which indirectly reveals maternal HIV status.

Assisted Reproductive Technology (ART)

• ART refers to treatments and procedures that aim to achieve pregnancy.
• It is an option for people who have already gone through various infertility treatment options but who still have not achieved pregnancy.
• ART techniques involve the manipulation of eggs, sperm, or embryos to increase the likelihood of a successful pregnancy.

Artificial Insemination

• It's the instillation of semen into the genital tract of the female.
  1. Intravaginal Insemination (IVI):, involves the injection of semen into the vagina.
     • Intrauterine Insemination (IUI) is the injection of sperm into the uterus by means of a catheter introduced through the cervix.

Types of Artificial Insemination and Ethical Concerns

1. Artificial Insemination Homologous (AIH):
   1. The semen is obtained from the spouse. It is a legal procedure. It must be done in front of the husband to be sure from using his semen; and so preventing suspicion.
2. Artificial Insemination by Donor (AID)

• This procedure is used in case of infertile husband. The semen is obtained from a donor, so it violates good morals and ethics. It may also result in serious social problems, as the possibility of incest may occur from possible future marriage between offspring of the same donor.

In Vitro Fertilization (IVF)

• It is a laboratory medical procedure in which fertilization of the ovum is induced outside the body of the individuals (husband, in vitro), then the fertilized ovum is embedded in the uterus.
• It is usually resorted to in cases of failure of normal fertilization of the ovum (husband) due to female sterility of any cause rather than an ovulation.
• When the semen is obtained from the husband and the ovum is that of his wife, it is considered a legal procedure; otherwise, it is illegal and against religions.

Pre-implantation Genetic Diagnosis and Ethical Issues

• Pre-implantation Genetic Diagnosis (PGD) is a laboratory procedure used in conjunction with in vitro fertilization (IVF) to reduce the risk of passing on inherited conditions.
• Common reasons for PGD are specific single-gene conditions (such as cystic fibrosis or sickle cell anemia) and structural changes of a parent's chromosomes.
• PGD is ethically acceptable when done for good reasons, such as preventing offspring with serious genetic diseases and may prevent selective abortions for those diseases.

IVF Pros and IVF Cons

• Supporters of PGD argue that it can ensure a couple undergoing IVF get a healthy baby rather than one with a genetic disorder.
• Opponents of PGD argue that it can be used for less ethical means as sex selection and designer babies.

Ethical Issues Related to IVF

• Fertilization must take place inside the woman's body within the origin of the human being and follows from a procreation that is linked to the union, spiritual unity, and the "bond of marriage".
• 'Spare' embryos must not be discarded, frozen, or experimented upon, and procedures such as “selective abortion" must not be used.
• Those embryos which are not transferred into the body of the mother and are called 'spare' are exposed to an absurd fate, with less of their being offered safe means of survival which can be licitly pursued.

Ethical Issues Concerning IVF

• The quality and validity of consent must be obtained from those involved.
• Examine the motivation and suitability of the parents.
• Consider the uses and implications of pre-implantation genetic diagnosis, which can screen for genetic diseases or traits.
• Examine the permissibility and consequences of sex-selection or other forms of embryo selection.
• Consider storage and fate of surplus embryos, which may be discarded, donated, or used for research.
• Calculate the cost, coverage, access, and resource allocation of IVF, which may create inequalities or exploitation.
• Account for the use of sperm, eggs, or wombs from third parties, which may raise issues of identity, rights, and responsibilities.

Surrogate Parenting (Third Party)

• Another woman (a third party or surrogate) bears a child for an infertile couple.

1. Classic surrogacy:

• A classic surrogate is inseminated with sperm from the child's father. Her own egg is fertilized, and she carries the baby to term on behalf of the patient.

2. Gestational surrogacy (or "IVF surrogacy"):

• The baby may be conceived entirely by the intended parents; the biological mother's egg is fertilized with the biological father's sperm, or by one or more donors. The embryo is then placed in the surrogate's uterus and carried to term.

Ethical Issues Regarding Surrogacy

• Both types create great medico-legal dilemma.
• Who is the mother to be considered and are they the biological mother or the surrogate?
• Is it considered baby selling?
• Is it forbidden by religion and law in UAE making it illegal.
• Potential child trafficking,
• Could the body of a woman be equated to an incubator?
• What happens if there is a way to cash in on the grief of others?
• Must there be the violation of the genetic connection between the child and biological parents?
• Could there be a negative impact on the mental health of parents, surrogate mother and the child? Autonomy and informed consent are needed. Is there a welfare of the future child born from surrogacy? Legal and ethical issues around international surrogacy.
• Payment.

Concept of Ova Bank

• An ova bank, cryobank, or egg cell bank is a facility that collects and stores human ova, mainly from ova donors, primarily for achieving pregnancies.
• It may occur in the donor, at a later time (to overcome issues of infertility), or through third-party reproduction, notably artificial insemination.
• Ova donated this way are known as donor ova.
• The demand for donor oocytes for third-party assisted reproduction is continuously growing due to delayed parenthood, treatment indications, and societal acceptance of alternative family structures.
• Many people will seek treatment with donor oocytes across borders because of national legislation or donor shortages.

Ethical Aspects of Oocyte Banking

• There are three components consisting of the intake, storage, and distribution of donor oocytes, and each is associated with multiple ethical challenges.
• The intake requires that the ethical aspects are related to the donor because there are psychosocial impacts of donation, motivations and risks, compensation in donor recruitment, and requirements for informed consent.
• Ethical aspects entail the potential child's welfare standards and selection of donors, secondly, anonymity and disclosure.
• Storing ethical aspects of donor oocytes, requires ART quality standards, confidentiality, the issues of ownership and control, and transport (International) of Donor.
• The distribution of donor oocytes requires recipients' needs to be considered and to be acceptable of treatment of 'non-traditional' and 'traditional' families in particular.
• The prioritization of recipients in case of scarcity, cross-border reproductive care, matching of recipients and donor oocytes, informed consent, and counselling for recipients requires ethical support.

New UAE Law on ARTS

• Federal Decree Law No. 17/2023 (the 'new law') introduces amendments to the Federal Law No. 7/2019 'On Medically Assisted Reproduction'.
• Non-Muslim couples may now access any of the lawful assisted conception and reproduction services after Article 8(2) and within the country, even if unmarried, including surrogacy, subject to the consent of the relevant regulator in the UAE with the given eggs and sperm were collected from the interested couple.
• Assisted reproductive technology (ARTs) may not be performed in a woman or an embryo planted in her womb except from the married couple and with their written consent, provided that this occur during the life of their awful marriage.

Organ Donation

• Life is gift to share through organ and tissue donation and transplantation
• Organ Donation is a process when organs or tissues are removed from a live, or recently dead, person to be used in another, via the donor, recipient gets the organ.
• Organs can also come from animals (xenotransplantation).

Types of Donors

• Dead Donors allow most organs donation, they must reach the recipient within a few hours of death.
• Brain death or donation after cardiac death (DCD) can happen.
• Live donors: related and unrelated.

Consent

• Donor: Relatives provide consent.
• The State law may allow other surrogate consent.
• Generally voluntary.
• In live donation:
• Donor is willing to consent.
• If a child, Parental figures provide the consent.

Organ Donor Criteria

• All criteria should be present.
• Individuals age less than 80; age is based on the patient's current medical history.
• Individuals who are "Brain Dead" by neurologic criteria
• Individuals who Died by cardio-pulmonary criteria.
• Those willing to give Consent (Live or dead).
• Must be Free of HIV, although that is an option also. -All serology samples are examined at time of death and HIV to HIV is possible.

Stem Cell Transplantation as a Dilemma:

• 'Stem cells' are primitive cells with the capacity to divide and give rise to more identical stem cells or to specialize and form specific cells of somatic tissues. -Two Types: Embryonic Stem (ES) Cells and Adult Stem Cells. -Embryonic Stem (ES) Cells derived from pre-implantation embryos and have a proven ability to form cells of all tissues of the adult organism (termed 'pluripotent') -Adult Stem Cells are found in a variety of tissues in the fetus and after birth and are, under normal conditions, more specialized ('multipotent') with an important function in tissue replacement and repair.

Sterilization

• It comprises processes that renders an individual incapable of sexual reproduction.
• Forced sterilization occurs when a person is sterilized after expressly refusing the procedure, without her knowledge or opportunity to provide consent.
• Coerced sterilization occurs when financial or other incentives, misinformation, or intimidation tactics are used to compel an individual.

Recommendations

• Free and informed consent of the is a must before sterilization. Only women with physical disabilities themselves can give consent legally and ethically, with Family and Medical consent is not valid unless mental incompetence is diagnosed.
• In June 2011, FIGO (The International Federation of Gynecology and Obstetrics) issued new guidelines on contraceptive sterilization and informed consent.

UAE Law Regarding Sterilization

• Actions or procedures may be taken for the purpose of regulating reproduction when requested and or a married couple grants an approval. No action or procedure may be for sterilizing a woman with the advice of a medical specialty.
• The board includes at least three physicians and determines that pregnancy and labor pose a danger the mother's life.
• The Wife's written approval and knowledge must be obtained unless mental incompetence is diagnosed.

Wrongful Conception:

• A claim for damages the parent of the unexpected child sustains due to in effectives sterilization or device.

Wrongful Birth:

• Congenital defect leads to negligence and deprived the termination or prevention option. Wrongful Life: a congenital defect that was caused by negligence that may have prevented, for example, prenatal testing or misdiagnosis.

Wrongful Life

• A claim brought on the child's behalf when a congenital defect could have been avoided if negligence would not have occurred, thus suffering could have been avoided.