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Veröffentlicht im Arbeitskreis Biotechnik - INTERNET FORUM Ethical and Social-Economical Issues of Gene Technology Ethische und sozio-ökonomische Aspekte zur Gentechnik der Berliner Wissenschaftlichen Gesellschaft http://www.bwg-berlin.de/start.html Ethical Implications of Genetic and Reproductive Technologies Reconsidering the Questions Nikola Biller-Andorno, Claudia Wiesemann Abteilung für Ethik und Geschichte der Medizin, Universität Göttingen Zusammenfassung Die medizinethische Diskussion um die Möglichkeiten der Gen- und Reproduktionstechnologien konzentriert sich zumeist auf den moralischen und juristischen Status des menschlichen Embryos, besonders des Embryos in vitro. Doch wenn die komplexen Fragestellungen aus dem Umfeld der assistierten Reproduktion nur unter dem Gesichtspunkt konfligierender Rechte (z.B. Lebensrecht des Embryos vs. Forschungsfreiheit) betrachtet werden, besteht nur wenig Aussicht auf einen Konsens. Außerdem besteht die Gefahr, dass andere wichtige Fragen nicht hinreichend gewürdigt werden. In der Ethik ist in letzter Zeit die Dominanz einer Sichtweise kritisiert worden, die sich auf die Bestimmung des Rechtsstatus abstrakter Entitäten konzentriert und Lösungen im Einzelfall mittels einer Anwendung allgemeingültiger, kontextunabhängiger Prinzipien finden möchte. Eine solche Sichtweise, so die Kritik, bedürfe zumindest der Ergänzung durch eine andere Perspektive, die die multiplen Verantwortlichkeiten der an einem Konflikt beteiligten, in einem Beziehungsgeflecht stehenden Personen in den Vordergrund rückt. Dies bedeutet keine inhaltliche Festlegung, denn sowohl "Rechts-" als auch "Verantwortungsperspektive" lassen unterschiedliche inhaltliche Standpunkte zu. Wohl aber ändert sich das Spektrum an Fragen und die Relevanz, die ihnen beigemessen wird. Reproductive Medicine and the Moral Status of the Human Embryo The discussion on assisted procreation has traditionally focused on the moral status of the human embryo in vitro. The recent debates about reproductive medicine in Germany are no exception in that respect. The priority that is accorded to the status question is illustrated by the fact that the German Federal Ministry of Health put this problem on top of a list of items that were discussed on a national symposion on reproductive medicine in Berlin in May this year. Approaching the complex field of ethical implications of genetic and reproductive technologies this way may seem the straightforward thing to do. It is certainly true that how we perceive the human embryo plays an important role in our moral judgments. However, there are considerable problems that come with a predominant focus on the determination of status. 1. The moral status of the human embryo has been the object of quite controversial ethical debates for many decades and a clear and simple solution is still not in sight. Sometimes, however, the determination of this status has been seen as the prerequisiste just to start an ethics debate. But there is no agreement, neither on the methodological nor on the content level, rendering a moral consensus extremely unlikely.1 Building a moral argumentation on one of the many possible status concepts does therefore not seem a very promising stategy. 2. In contrast to the situation in vivo the embryo in vitro is seen as a being without relationships exposed to a dangerous environment, and therefore in The spectrum of positions on the status of human embryos reaches from "a specific group of particularly vulnerable persons, whose life and integrity are endangered by greedy researchers" to "conglomerates of human cells with remarkable capacities the investigation of which might lead to very promising insights and new cures". 1 2 need of a particularly strict protection. Medical technology is indeed now able to manipulate and - at least for some time - maintain embryos "per se", that is without physically interfering with the body of a woman. This new relationship of the embryo and a gynecologist or researcher therefore requires particular consideration. But in many cases there are also caring parents, who feel a very strong bond to their developing embryo. There is a certain danger to reduce phenomenological description of "the" embryo in vitro to an abstract entity, forlorn and isolated in a Petri dish, disregarding the fact that there may indeed be many other forms of relationships than the bodily integration in a mother' s womb. 3. Whereas it is true that the way we regard the human embryo and its status is of great importance, it is rather to be seen as the result and not as the precondition of moral reflection. We certainly start with some kind of intuition or preconception of how to treat the human embryo in different situations. They may change over time, with exposition to concrete moral conflicts, with social or technological developments etc. It is helpful to try to make those assumptions explicit as well as the factors influencing it in order to allow a reflection one's own moral thinking. It is not necessary, however, to try to mold these ideas into a decision about a fixed moral status, which is then supposed to serve as the major guideline for concrete moral judgments. Such a strong general value judgment concerning the embryo alreadly establishes a strong hierarchy among possible arguments even before the moral discourse has begun. It also risks that a decision against the continuation of an embryo's development is interpreted as considering it "not worth living", even if this decision may have an entirely different background. Talking about the moral status of the embryo implies talking in a language of rights and justice. This perspective makes it hard to include situational and contextual arguments of care and relationship which, however, would be important in order to underline that reproduction is an essential feature of familiarity and human relationship.2 A pure rights discourse may thus distort our perception of what is at stake in reproductive medicine. C. Gilligan, whose studies in moral psychology had drawn attention to a "care perspective" as opposed to a "justice perspective", had made a similar observation in the context of the US debate on abortion in the 1970s, which she perceived as dominated by a language of rights (cf. C. Gilligan in Nunner-Winkler, Gertrud (ed.): Weibliche Moral. Die Kontroverse um eine geschlechtsspezifische Ethik. München: dtv, 1995, p. 85-86.). The current abortion law in Germany, on the other hand, can be considered a very much 2 3 Rights and Responsibilities, Care and Justice Every ethical discussion profoundly relies on an adequate description of the persons or situations involved. How we describe them is how we perceive them as moral actors or morally relevant facts. Kant for example put emphasis on reason as the highest principle of morality. But from his texts we can learn that he did not attribute full capacity of reason to women. His thinking therefore necessarily focused on white European men and their moral problems. As women's rational capacity was considered to be of objectively minor value, their perspectives and needs were not equally included in Kant's moral theory. Although until now serious attempts have been made to include women's perspectives into moral consideration, we should not ignore the problem that who in different times and spaces is considered a moral actor and what is thought to be a morally relevant fact depends on cultural attitudes and beliefs that cannot easily be transcended. For example, in Germany, ethical problems in reproductive medicine are usually classified as problems at "the beginning of life". However, they could equally be called problems "in the middle of life" or "in the age of fertility". Talking about it as we do, we imply that the embryo's problems are of main interest, not the mother's or the father's. Ethicists should be aware of this and similar problems. Ethics has also the duty to question the given "facts" that could be of moral relevance should it not solely function as legitimation of the present situation. In biomedical ethics, this is a very common phenomenon. It has been one of the discipline's main achievements to show that scientific descriptions of seemingly purely objective "facts" indeed include cultural beliefs and moral judgments. Ethics was one of the means of criticising the pretention of the life sciences to act with desinterested objectivity, thus reducing the epistemic gap between natural science and humanities. But consequently medical ethics itself got critized for focusing too exclusively and uncritically on universal principles and general statements about rights, neglecting a perspective that concentrates on the concrete other in his or her specific situational and relational context: "From a care perspective, the relationship becomes the figure, contextual solution which is not based on a right to life (or to abortion) but on (bodily) relationship and the idea that the state should abstain from imposing unreasonable demands on that relationship. 4 defining self and others. Within the context of relationship, the self as a moral agent perceives and responds to the perception of need. The shift in moral perspective is manifest in a change in the moral question from "What is just?" to "How to respond?" 3 This "care perspective" has been claimed to be more frequently associated with women. However, the gender association is controversial as well as its causal explanation. It is also possible, for instance, that being more intimately familiar with a conflict produces a switch from a predominant interest in the generalizable aspects of a case to its particularities.4 The consequence of this "discovery" of the existence of multiple perspectives of a moral conflict should not be to start playing out "justice", "rights" and "equality" against "care", "responsibilites" and "particular relationships". Rather, it can serve as a reminder that there is more than one vision, not just regarding the answers to a given problem, but also regarding the definition of the underlying conflict and the questions deemed appropriate to address it. Assisted Procreation - More than One Central Question For those familiar with the development of assisted reproductive technologies (abbreviated "ARTS") it comes as no surprise that the spectrum of applications of invitro fertilization is widening from the treatment of infertility to preventive or selective purposes. The question if and to what degree such an expansion can be justified is currently being hotly debated in Germany.5 We shall very roughly outline the major problem of a focus on the moral status of the human embryo and then sketch some examples for possible care arguments. Concerning in-vitro fertilization the Embryo Protection Law prohibits the production of more than three embryos. Therefore, in Germany it is not possible to further increase the birth rate and to reduce the chance of multiple pregnancies by producing more embryos than necessary and implanting only those who have developed best. Similarly, preimplantation diagnosis is currently not offered to couples who suffer from a genetic Gilligan, Carol: Moral Orientation and Moral Development. In: Kittay, Eva F., Meyers, Diana T. (eds.): Women and moral theory. Totowa, NJ: Rowman and Littlefield, 1987, p. 23. 4 "Particularities" need not necessarily refer to the individual or personal level, but can also include the sociocultural context, e.g. when the introduction of a new technology is being discussed. 5 Together with embryonic stem cell research preimplantation diagnosis was the "big issue" discussed at the Berlin meeting on reproductive medicine mentioned above. 3 5 disease and would like to use assisted reproduction in order to prevent the birth of an afflicted child instead of prenatal diagnosis and abortion.6 Both strategies would entail producing embryos that are not implanted and have to be stored or disposed of and are thus open to manipulation by researchers. To address this problem, a rights perspective could refer to a gradually increasing protection at the beginning of life. For several reasons, among others the particular history of Germany, this option is treated by some with suspicion. Or it could claim an absolute right to life for the embryo, which would then consequently lead to a renewed discussion of abortion and some sort of contraception.7 A care-oriented perspective, on the other hand, would focus on the relationships involved. One could, for example, underline that the main aim of producing more embryos than necessary is to help a desired child come into being and reduce the risks and discomfort for the mother. Another argument, which was also used to legitimate prenatal diagnosis with consequent abortion in Germany, would stress the relationship of mother and fetus and concede that the mother as the person who would be mainly responsible for the care may feel physically or psychologically unable to bear the consequences of a pregnancy. But still another care argument might point to the burden on the parents who would have to choose from their embryos or might feel pressured to let some one else do research with the ones that were not selected. Evidently a "care perspective"can work in different argumentative directions and would not automatically imply any decisions in terms of content. But it might change the usual priority of questions and arguments: From a "care perspective", the nature of relationship becomes a central concern. What do they look like under which circumstances, which responsibilities do the entail? Which relationships can be freely chosen resp. rejected, and for what reason? Another important aspect would be the suffering involved, on all sides of the conflict. What ways are there to prevent or minimize the suffering? How can compromises be justified? The care aspect would The legal status of Preimplantation Genetic Diagnosis in Germany is not clear. It hinges on the question if the cells used for diagnostic purposes are still totipotent or not. But all we can know about the totipotence of human embryonic cells we can find out only by doing research on the embryo. So in Germany we find ourselves in the paradox situation that the criterion to prohibit research on embryonic cells (or diagnosis with the consecutive death of the cell) can only be specified by doing what is prohibited. 6 6 finally try to identify vulnerable groups, whose concerns are easily marginalized and strive to help their voice to be heard. However, a "care perspective" should not strive to replace or superseed a rightsoriented argumentation. Both are in need of mutual correction. Also, they do have important common goals: a transparent dialogue, which does not instrumentalize arguments or groups, and the serious reflection, not instantaneous delegitimization of contrary positions. Whereas law may be in need of clear-cut solution, the participants in the preceeding debate in the public, academic and political arena can take the liberty to acknowledge the existence of various perspective and to gain by listening closely to the ideas of the other. In many respects, the recent conference of the Ministry of Health in Berlin has shown promising signs that such a discourse is in fact feasible in Germany. And it is going to be facilitated further if we do not insist on solving or determining the question of the moral status of the human embryo first and foremost, deducting all other moral consequences. Questioning that takes into account the intricate web of relationships and responsibilities in which we all find ourselves will perhaps be more cumbersome and less clear. But it will present a fuller, richer, and more satisfying debate. 7 Devices preventing the fertilized egg from implantation in the uterus. 7