The purpose of reproduction is the generation of new individuals. An extremely current issue is the characterization of the moment when the new human being starts to be recognized as such. Currently, nineteen different criteria can be used to establish the beginning of a human being's life.
Attempts to carry out medically assisted reproduction procedures began in the late 18th century. In 1978 these procedures gained notoriety with the birth of Louise Brown, in England, who was the first baby generated in vitro.
The British Government, in 1981, established the Committee of Inquiry into Human Fertilization and Embriology, which studied the subject for three years. Their findings were published in 1984 in the Warnock Report. That same year, another baby was born in Australia, called Baby Zoe, who was the first human being to develop from a cryopreserved embryo.
In 1987 the Catholic Church published a document - Instruction on Respect for Human Life and the Dignity of Procreation - establishing its position on these matters.
Starting in 1990, numerous medical societies and countries established ethical guidelines and legislation, respectively, for reproductive technologies. England, for example, established the legal limits for assisted reproduction in 1991, based on the propositions of the Warnock Report.
In Brazil, the Federal Council of Medicine, through Resolution CFM 1358/92, instituted the Ethical Norms for the Use of Assisted Reproduction Techniques, in 1992.
The most important ethical aspects involving issues of human reproduction are those related to the use of informed consent; sex selection; the donation of sperm, eggs, pre-embryos and embryos; selection of embryos based on evidence of associated diseases or problems; surrogate motherhood; embryonic reduction; cloning; research and cryopreservation (freezing) of embryos.
An important issue, of increasing ethical, moral and legal discussion is abortion. Regardless of the legal issue, in this situation there is a conflict between the autonomy, beneficence, non-maleficence and justice of the mother, fetus and physician. Moral judgments about the justification of abortion depend more on beliefs about the nature and development of the human being than on rules and principles.
Another very complex area is that involving homosexual couples and reproduction. Female homosexual couples can request that an assisted reproduction service enable the generation of a child, in one of the partners, using donor semen. Should the doctor perform this procedure, equating this request with that of a heterosexual couple? Or should an entirely different approach be taken? The issue of adoption of children by homosexual couples has been admitted in several countries. Can medically assisted reproduction be equated with legally assisted (adoption) reproduction?
Ethical Aspects of Medical Technology
Prof. Carlos F. Francisconi
Advances in technology have enabled the development of progressively more developed equipment that has mostly brought unequivocal benefits to patients. On the other hand, technological advances often bring with it ethical problems. This is easily detected in various fields of medicine and I mention in-vitro fertilization techniques, manipulation alternatives. genetics and advances in the area of transplants as examples of areas that are causing great ethical discussions nowadays. The advancement of technology does not only bring ethical problems at the individual level. As we are most of the time dealing with complex procedures, it is inevitable that they become expensive. In this sense, these advances lead us to a discussion that is also relevant from the collective point of view: the principle of justice and its application in the allocation of scarce resources in the health area.
We must differentiate medical practice from medical research. The first represents planned interventions aimed only at the well-being of the individual patient or client and which has a reasonable expectation of success. These are our day-to-day actions: we make decisions regarding the best medical action strategy based on our experience, which in turn is based on acquired knowledge through reading scientific material or what we capture in our continuing education by attending congresses, seminars, courses and conferences with specialists of greater knowledge and experience. Most of the time we use validated medical practices, that is, practices that are based on previous empirical procedures.
When these procedures are not performed, we will be referring to non-validated practices, which should be avoided as much as possible, if not rejected ab start a not be when we are forced to improvise an innovative solution for an unusual case that most often represents just a variation of an already established. On the other hand, medical research can be defined as any planned activity aimed at testing a hypothesis that allows conclusions to be drawn and in this way contributes to a more widespread. For a medical research to be characterized as such, it must follow a certain ritual that includes the preparation of a project of research, which must be approved by a Research Ethics Committee and must follow Brazilian and international standards for research in human beings. humans. Therefore, we are prohibited from employing new technologies in our patients that were not previously and formally researched and therefore cannot be labeled as medical practices. validated.
Then, new techniques are tested in other centers and are offered to us to be incorporated in our professional activity. At this point we should ask if:
a) is the new procedure safe?
b) is it effective?
c) does it represent a real improvement over the “traditional”?
d) what is its usefulness (cost/benefit ratio)?
e) what is the social impact of the new procedure?
Safety
Safety should be reviewed by examining original research projects published in scientifically serious journals. What is the number of patients examined, how were they selected, were those results already reproduced by another group of researchers, how long were the patients followed to learn about the long-term effects of the new technique (if applicable)? These are some of the questions we should ask before introducing and accepting a new procedure as a routine.
In the situation of taking the initiative to test a new technique, how should we proceed? First, prepare a good quality research project. If there is no previous experience with the proposed method, a project that tests the effect of the new intervention on animals is first needed; only after defining the safety standards for the use of the new procedure can a project of research that tests its effectiveness in humans to be referred for evaluation by an ethics committee in research.
Efficiency and improvement over the "traditional"
The efficiency of the new method should be evaluated by clinical studies in which this hypothesis has been tested. Often in the first place case reports are published which evidently cannot be accepted as evidence that the new technique is efficient. We should evaluate controlled studies that can be randomized open or closed. The first ones are justified in the initial phases, when we want to evaluate security and already have an idea of the method's efficiency. In order to know its real efficiency, well-done controlled studies are essential when the new technique will be compared with the one already available. For a new procedure to be incorporated, it is not enough for “statistically significant” differences to be the reference standards for its incorporation into our medical routine. Does your direct and indirect cost represent an acceptable value in relation to the traditional one? Sometimes a high initial cost technology becomes “cheap” when we analyze the costs involved with that disease without using the innovative technology.
As an example of this situation, one can mention kidney and liver transplants. There is evidence in other countries that both long-term dialysis treatment and the care of severe hepatopathy with multiple hospitalizations due to clinical complications that are inherent to it, are more expensive for the health system than the transplant. Studies that assess the medical and economic impacts of new technologies should be a priority in our postgraduate courses so that we have consistent Brazilian data regarding their incorporation into our practice doctor.
These days also bring another type of problem that generates high costs in the exercise of the profession: the so-called defensive medicine, sometimes is pressuring doctors to use technologically complex procedures, which in a normal clinical situation would not necessarily be employees. Several emergency services in the United States were closed because they could not afford the enormous costs of defensive medicine taken, perhaps, to its most dramatic example.
Utility
Our first concern must always be the patient's good. In bioethical literature this concern is incorporated into the so-called principle of beneficence. Of course, in seeking the good we sometimes unintentionally cause harm to our patients. The term utility refers to the risk or harm/benefit ratio inherent to the medical act.
Factors related to the numerator of the relationship can be method or operator dependent. Animal experiments and controlled studies will already give us an idea of the risks related to the procedure itself. The human variable of the relationship concerns us greatly at the moment. We observe that complex techniques are being performed by some professionals, who have not invested their time in formal training that enables them to use the new technique with competence. On the other hand, there is very strong pressure from the medical equipment industry for new instruments, not yet sufficiently tested, are incorporated into the routine of diagnostic centers and treatment.
We are equally concerned at this moment with what is happening with videoendoscopic therapeutic methods. Videolaparoscopic cholecystectomy by tortuous routes, as it was incorporated into medical practice without further controlled studies in serious university scientific centers, has become the procedure of choice for gallbladder removal biliary. Can we give the same vote of confidence to other videolaparoscopic techniques as for hernia repair or for oncologic surgeries, to cite two examples. In the United States, studies show that the laparoscopic method for the correction of inguinal hernias represents an increase of 40 to 60% in cost compared to traditional treatment. It is not known, on the other hand, whether an earlier return to work would make this increase in direct costs irrelevant, nor are the its long-term results: how does the recurrence of hernias or the organism's tolerance to the foreign body placed in the region compare? inguinal? Again, we do not have Brazilian information regarding these variables.
social repercussions
When introducing a new medical procedure another type of consideration must also be made. What are the social repercussions of the new method? We can examine this question in light of the principle of justice. Will it be the good that comes from the new technique used equally across the population or will it be used a market strategy in which only the wealthiest, who can afford it, will have access to the new good. It is, in my view, ethically incorrect to use the poor population to acquire the skill with a new technique, distributing within this universe a greater added value of risks and damages within the learning curve of a new technology, from the moment of acquired competence to offer it only to those who can afford it pay. We must also bear in mind that the resources for managing the health of any nation are finite. This should clearly signal that the practice of medicine based on solid clinical knowledge and valuing correct history and physical examination findings are irreplaceable for professional practice performed in a cost-efficient.
I believe that the preparation of competent professionals, with time to care for their patients in a adequate and more decently remunerated represents the nation's best investment to reduce costs. of health. In this context, an efficient primary care network, with a high degree of resolution, would only allow it to reach the most advanced medical centers more complex cases in which the use of medical technology, both traditional and modern, is indicated to solve them in the most efficient way possible.
The future also holds some concerns about the impact of information technology in practice. The use of a database and the routine of identifying the patient on endoscopic and radiological images pathological aspects of your exams creates potential risks with respect to the confidentiality and privacy of the medical information. We should be concerned about creating passwords that control access to this type of privileged information and also to the we use our iconographic material, as scientific illustration, not allow our patients to be identified.
In conclusion, it is important to emphasize that the new times we live in are already demanding that medical professionals be competent not only in scientific and technological areas. Ethical competence is a current necessity and will likely become progressively more necessary as new scientific and technological knowledge evolves. Our corporate societies cannot ignore this reality. They should be concerned both with the quality of the graduates of the Faculties of Medicine, as well as with the enhancement of the title of specialist, maintaining a high principle of qualification professional of the same as with the offering of qualified training centers and continuing education that contemplate the scientific, technological and ethical advancement of the practice doctor.
Beginning of Human Life
Below are some of the criteria used to establish the beginning of a human being's life.
Beginning of Life Criterion
Cell Fertilization
Cardiac Onset of heartbeat (3 to 4 weeks)
Brainstem Activity (8 weeks)
Neocortical Onset of neocortical activity (12 weeks)
Respiratory Respiratory Movements (20 weeks)
Neocortical sleep-wake rhythm (28 weeks)
"Moral" Communication (18 to 24 months postpartum)
The criterion based on the possibility of “moral behavior” is extremely controversial, but defended by some authors in the field of Bioethics.
Source: Brazil School - https://brasilescola.uol.com.br/biologia/bioetica-reproducao-humana.htm
