Changing Concepts

Changing Concepts

I I r FERTILITY AND STERILITY Copyright ~ 1974 The American Fertility Society Val. 25, No.9, September 1974 Printed in U.S.A. CHANGING CONCEPTS T...

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FERTILITY AND STERILITY Copyright ~ 1974 The American Fertility Society

Val. 25, No.9, September 1974 Printed in U.S.A.

CHANGING CONCEPTS The Presidential Address* JOHN C. WEED, M.D. Department of Gynecology and Obstetrics, Ochsner Clinic and Alton Ochsner Medical Foundation, New Orleans, Louisiana 70121

It has been a great honor and roid era of reproductive physiology, privilege to serve you as president for begun more than a quarter of a centhe past year. Having been a mem- tury ago, has exposed many secrets ber of this group for more than 20 of reproduction whose revelation, years, I have observed the many though still incomplete today, has changes which have led to the great led to revision of theories of ovulaSociety that we now have. As presi- tion, for example. Much is yet to be dent, let me assure you that the learned, and it is certain that our Society has continued to grow and to present knowledge of physiologic prothrive. Its place in the field of re- cesses will be altered with newer disproductive medicine is now well recog- coveries and newer investigational nized at home and abroad, and its techniques. influence will continue to increase One simple medical conceptual in the years to come. change has been the attitude toward As has been noted by my many cesarean section as a method of dedistinguished predecessors, it is the Little more than a decade ago, livery. president's privilege to discuss a subthe accreditation of hospitals with ject of his choice, whether philosophical, historical, or medical, perhaps some- maternity divisions required justiwhat editorially. I shall take ad- fication of cesarean section rates, vantage of this opportunity to dis- and specific consultation was required cuss briefly the changes in the in each case. With improvement in various aspects of fertility, sterility, technology and with awareness of and reproduction in general which dangers to the fetus and the mother, I have observed during my years of abdominal section no longer requires membership. These involve moral, justification. Similarly, medical attimedical, technical, and ethical con- tudes toward surgical sterilization cepts which affect each and every have changed within a very few years. one of us as well as the patients With broadened education of the populace, increasing awareness of we treat. Perhaps the easiest and most population growth, and realization of readily acceptable changes in con- global problems such as extreme povcept involve those related to medical erty and famine, male and female and technologic advances. The ste- sterilization, permanent or temporary, has become increasingly ac*Presented at the Thirtieth Annual Meetcepted legally, medically, and moring of The American Fertility Society, April 4-6, ally. Only a relatively few years ago, 1974, Hollywood, Florida.

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you will recall, sterilization of either sex for other than strict medical indications was not performed without supportive consultation. Newer developments and discoveries have changed our basic concepts in other fields that involve not only the safety of medical practices or technologic improvement, but also the moral and ethical approaches to political and economic world problems. Many of these involve issues with which we, in The American Fertility Society, concern ourselves-namely, artificial insemination, sperm banks, abortion, family conception control, and egg transfers. Each has had an influence upon the other. The use of the artificial insemination donor (AID) has become increasingly accepted by physicians and patients, both male and female, in the last decade. Although education of the public has been slow, recent changes in abortion laws, coupled with fewer infants available for adoption, have helped overcome the moral and religious objections both of husband and donor to artificial insemina: tion. Moral and religious principles still interfere with its widespread clinical application, and the legality of AID has yet to be accepted. The law, justifiably awaiting popular opinion, has been slow to adopt a position on such medical advances as AID, organ transplantation, or ovum transfer. Sperm banking, another relatively recent development in reproduction techniques, has been demonstrated to be an effective adjunct to the armamentarium. Its usage in the cattle industry has improved breeds and resulted in economic gain. It has been proved to be effective and to be free of mutation of the offspring. However, moral and ethical problems do not arise in the bovine world.

September 1974

Although super cows, super bulls and, perhaps later, superior race horses are possible and desirable, the prospect of super races, super athletes, super brains, and super laborers has been considered, but discarded violently. The Aryan superiority which Hitler propagandized was discounted with his failure at world conquest, as were other racist cultures which preceded him. Emerging nations and civilizations different from ours indicate that the superiority of ethnic or racial background is relative, not absolute. Although Behrman and Ackerman 1 feel that "natural selection" in the survival of frozen sperm will eliminate the unfit, the Darwinian theory of survival may be circumvented in this area as it has been in others, in which many inadequate for survival are protected by the state. The views that few mutations and an average percentage of birth anomalies are found in sperm bank pregnancies do not fully satisfy criticism because of short follow-up and imperfect genetic analysis. Furthermore, the question of miscegenation has been neither raised nor discussed. A newer and perhaps more important area of moral and ethical decision seems imminent in genetic engineering with egg or zygote transplant. This field of experimental biology has shown tremendous growth and promise in the past few years with in vitro fertilization and implantation of zygotes into female animals prepared naturally or artificially to receive and accept the implant. The procedure has been carried out successfully in rodents and other mammals even to the production of chimeras. As a result of successful ovum transfer in animals, the ethical and moral principles of in vitro human fertilization and transfer

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have been discussed with differing equality of the sexes have given rise views. to a "new" morality which is not new. Population control The limitation of biologic manip- really ulation in man is obvious, and suc- through various contraceptive decess except in fortuitous circum- vices, abortion, and infanticide has stances would be unique. When the been known throughout the ages manipulation is limited to a husband and in all civilizations. Recent aborand an infertile wife with blocked tion law changes reflect the liberor absent tubes, there could be little alization of our views in keeping with criticism. However, when there are those of other nations. The present other circumstances, such as im- law allows abortion in the first triplantation into a "suitable female pa- mester with no other cause than a tient" from a "bank of fertilized hu- patient's request and the consent of man ova," the legal and moral prob- her physician; abortion is permitted lems of eugenics, maternity, foster in the second trimester after physimotherhood, paternity, and the in- cian consultation and hospital perherent rights of the progeny must mISSIOn. Medical reasons need not be dealt with. now be considered. Such abortion An apocryphal anecdote is told re- upon request has imposed a moral garding George Bernard Shaw who and ethical problem upon the medical was approached by a beautiful and profession, especially those in our glamorous stage star. "Mr. Shaw," Society whose aims and ideals are she said, "how great it would be for concerned with assisting the nonme to have your child-with my looks fertile to procreate and the fertile and figure and with your brain he to control this ability. would be an even greater genius There is no question that contracepthan you." Mr. Shaw replied, "Would tion is better than abortion-on-demand. not this be a greater tragedy if he had The rate of mortality in late abortion my looks and your brain?" approaches the rate of maternal morAt present, the methods of genetic tality due to deliver.2 In infant deaths, transfer are by no means clear, and it may approach the rate of infanticide the donor for artificial insemination as practiced in ancient civilizations. and for sperm banks may indeed have Abortion is an inefficient and dangerunknown genetic problems in his ous means of population control and background. Eugenic engineering the end does not justify the means. Alis in its infancy with many unsolved though acceptance of population control problems. Are we medically, morally, has been growing, the acceptance of aborand ethically ready for human eu- tion is being re-evaluated in various genic engineering? Perhaps we will geographical areas, especially those with be technically prepared before legal zero or minus population growth. The acceptance is universal. number of abortions has decreased in the most liberal states when more atAn even more serious problem in tention has been given to adequate exregard to medical, moral, and ethical decision has already been forced upon planation of reproductive processes and This involves the liberalized contraceptive measures. us. Modern medicine has concerned itabortion laws in the United States. A permissive society has developed in self with moral and ethical attitudes which sex education and increasing toward the quality of life itself. To-

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day more debate has concerned itself with the question, "When does death, the end of life, occur?" rather than, "When does life begin?" There is no clear-cut decision in the law as to when life begins-at fertilization, implantation, fetal movement, fetal heart or cerebral function, or fetal independence of the mother. There is also no legal decision as to when life departs, yet increasing pressure upon the law seems to indicate that cerebral function-the element which differentiates the human from other mammals-is the critical area. Euthanasia is not, and has not been, acceptable in modern civilizations. Yet euthanasia can be considered to be at either end of the life span (depending upon definition); therefore, abortion might be considered euthanasia at its earliest level. Medical, moral, and ethical values, the real problems of our Society, must be the responsibility of the Society generally and of the individual particularly when dealing with reproductive physiology, enhancing fertility, and conception and population control. Education of the populace, especially the young, regarding reproductive function, sexual activity, and parental obligations, is a foremost Such responsibility of our group. education provides the joy of overcoming infertility and prevents the dismay of an unwanted pregnancy. Competent widespread contraceptive advice would prevent abortions that haunt their victims and remain serious health hazards. Education would also avoid serious emotional, religious, or moral disturb-

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ances often associated with abortion, sterilization, or AID procedures. Moral, religious, and legal acceptance cannot keep pace with the scientific knowledge and technology that have progressed so rapidly during the past half century. Moral responsibilities vary with religion and with generations, but they will still remain an important factor for a large part of the population. Changing concepts in science and medicine are inescapable, since progress must be made to the millenium where there will be no facts unknown and when a perfectly balanced universe will exist. But until that time there will be numerous concepts which, by newer and better investigative procedures, will be replaced by newer theories proven in performance and in time, and perhaps accompanied by changes in the mores of mankind and in the ethical bases upon which we now operate. It is our duty as members of The American Fertility Society, to be aware of the problems of influencing human reproduction and to avoid the temptation to change the principles of Darwinian theory to accomplish our own dreams. I urge the members of The American Fertility Society to seriously, conscientiously, morally, and ethically consider their responsibilities to the next and future generations. REFERENCES 1. Behrman SJ, Ackerman DR: Freeze preser-

vation of human sperm. Am J Obstet Gynecol 103:654, 1969 2. Tietze C, Guttmacher AF: Deaths after legal abortion. Lancet 1:105, 1973