versão impressa ISSN 0102-311X
Cad. Saúde Pública v.14 supl.1 Rio de Janeiro 1998
| Ruth Macklin || |
Debate sobre o artigo de Fernando Zegers-Hochschild
Debate on the paper by Fernando Zegers-Hochschild
Department of Epidemiology and Social Medicine Albert Einstein, College of Medicine, New York, EUA.
What is a dilemma for some people may not constitute a genuine dilemma for others. This point is probably best illustrated by the case of embryo cryopreservation. Freezing embryos creates a serious dilemma only for people who believe that embryos have a moral status equivalent to that of persons. The same beliefs about the status of prenatal life that drive the abortion debate create controversies over the freezing (and subsequent thawing) of embryos.
Fernando Zegers correctly notes the difficulty of specifying a precise time at which personhood begins. As he observes, different religions and secular accounts have come up with very different answers to that question. In a pluralistic society like the United States, a distinct minority of the population adheres to the Roman Catholic position that a human "person" exists from the moment of fertilization. Instead of trying to identify the exact moment when a "person" begins to exist, Dr. Zegers adopts a developmental view. This is a very good strategy to avoid the pitfall of having to specify exactly when a developing fertilized ovum becomes a person.
Nevertheless, a developmental viewpoint of the sort Fernando Zegers proposes does not succeed in determining the moral status of an embryo or a fetus. One can claim that the development from zygote to birth is a process along a continuum, and still decline to grant moral status to the developing entity at any point along that continuum. Usually, however, the farther along the developmental stage, the higher the moral status of the prenatal entity. Embryos at the stage at which they are cryopreserved are at a very early point along that developmental continuum. That is a compelling reason for holding that embryos do not have a "right to life," and so excess embryos may be discarded.
The dilemmas of cryopreservation arise only when one considers an embryo an entity that may not intentionally be destroyed. Thus the situation Fernando Zegers discusses whether freezing and thawing embryos destroys only those that would not survive anyway, or destroys normal embryos that would otherwise survive will not even be a dilemma for some people. Tens of thousands of embryos remain frozen throughout the world. Most of those will never be implanted, either in the women from whom the ova were harvested or in other women intended to be their mothers. This gives comfort to those who hold that embryos should not intentionally be destroyed, but it is a self-delusion. An embryo that is frozen forever is no different from an embryo that is intentionally destroyed. Neither will be given the opportunity to become a human being.
Many countries have no laws that prohibit the destruction of unimplanted embryos. Whether it is ethically permissible to destroy them fresh, frozen, or thawed depends entirely on the moral status one accords the embryo. Although people's ethical views about embryos usually conform to their position on abortion, this is not always the case. One intermediate position maintains that implantation marks the beginning of "personhood," and so an unimplanted embryo lacks moral status while an embryo that has successfully implanted in a woman possesses moral status.
The second dilemma Fernando Zegers discusses is research on preimplantation embryos. Here again, the ambiguous status accorded the conceptus is what gives rise to the dilemma. If a conceptus is not considered the moral equivalent of a minor child, the consent of the progenitors would be sufficient to authorize the research. This dilemma, like the first, can easily be resolved if the conceptus is not considered to be the moral equivalent of a minor child.
Current laws in the United States permit research on embryos that have been created for the purpose of treating infertility, but do not permit the creation of embryos solely for research purposes. Preimplantation diagnosis is not strictly considered a research maneuver, since the purpose is to make a diagnosis of genetic defects and then implant only those embryos found to be free of such defects. Since there are no laws that prohibit discarding unused embryos, the ethical debate in the United States regarding preimplantation diagnosis is whether it is ethically permissible not to implant embryos discovered to have only a very minor genetic defect, or one that results in a late-onset genetic disorder. Some members of the disability community argue that preimplantation diagnosis, like prenatal diagnosis generally, devalues people with disabilities, since the point of using these techniques is to avoid having a child with a genetic disorder or birth defect. This group argues that the quest for a "perfect child" can only lead to further discrimination against individuals living with disabilities or handicaps, and society should not promote these practices.
The third dilemma, related to donation and adoption of gametes, goes to the heart of psychosocial conceptions of the family. The conception of a family as consisting only of genetically related individuals is very narrow and, as Dr. Zegers demonstrates, inappropriate in consideration of the many families resulting from adoption of children already born. Sperm donation has been carried out for many decades, and egg donation is now widespread in places where assisted reproduction has become common. The ethical dilemma, therefore, is not whether such donations somehow undermine the conception of "family," but involves a quite different set of questions: Does payment to gamete donors "commodify" the human body? Might problems arise when the gamete donor is a relative - the brother of the man who will be the father of the child, the sister of the woman who will be the mother of the child? Is there an ethical problem with a daughter donating eggs to her own mother, who has now remarried and wants to start a family with her new husband? What should the children of these arrangements be told, and at what point in their lives? These are practical ethical questions, important because they affect the lives of a number of people who may be affected by these new reproductive practices.
It is time to focus more on these practical ethical matters affecting living human beings, and leave behind the continuing obsession with the human embryo. Individuals whose religious beliefs ordain or prohibit certain maneuvers with embryos should, of course, be free to follow the teachings of their religion. But a free, democratic society should not transform the dictates of any specific religion into public policy that governs an entire population. Numerous ethical dilemmas surrounding assisted reproduction remain to be resolved once we set aside the traditional concerns related to embryos. Dr. Zegers is correct in calling for multidisciplinary reflection on how the technologies of assisted reproduction should be regulated.