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ICA Symposium - Cultural Diversity in Attitudes Towards Intervention in Reproduction

Dr. M.C. Orgebin-Crist (USA) opened the symposium by emphasizing how profoundly new developments in reproductive technologies have impacted on the fundamental cultural and religious beliefs of our society. The diverse societal attitudes and ethics governing reproductive behavior and practice are reflected in the contrasting ways in which different cultures have accommodated or rejected these advances in clinical andrology and reproductive medicine. She stressed that the aim of this special symposium was to highlight this cultural diversity and not to reach a universal consensus.

Dr. K.Z. Mahmoud (Egypt) discussed how reproductive practices in Muslim cultures are doctrinally based on the Islamic jurisprudence "Sharee", which safeguards the five primary sources: self (including life, health and procreation), mind, religion, honor (including marriage), and ownership. Sharee permits a degree of secondary intelligent reasoning "Ijtehad" which accommodates new developments while ensuring the preservation of the five primary sources. Thus all modes of assisted conception including cryopreservation are accepted provided that the husband and wife are the sole source of gametes/embryo while donation by a third party is regarded as adultery and, therefore, prohibited. Therapeutic abortion is permitted if the life of the mother is threatened or when serious fetal abnormalities are detected. Male and female contraception is permitted if reversible but sterilization is not. The overall impression is one of intelligent reasoning without much ambiguity with the exception of female circumcision which is not obligatory but "preferable."

Dr. T. Wagatsuma (Japan) described the unique but pragmatic approach to contraception in Japan which was historically dictated by the social and economic conditions after the World War II, the postwar surge in birth rate and the subsequent expansion of the Japanese economy. Condoms and spermicides have since remained overwhelmingly the dominant method of contraception forming 77.2% of current usage, while the rhythm method is practiced by 17% of couples. Twenty-six percent of married females have experienced one or more induced abortions. IUD used is very limited and Japan is the only country in the world in which the oral contraceptive pill is not approved by the government. Contraceptive research is virtually nonexistent because of the apparent lack of demand for new methods. Although assisted reproduction technologies, in contrast, have attracted much media and professional interest, the government has maintained the traditionally non-interventional stance towards these procedures. It is, therefore, left to the Japanese Society of Obstetrics and Gynecology (which has no legal authority) to approve procedures such as AID and IVF and formulate guidelines. Although AID has been practiced in Japan since 1949, the Japanese Society of Obstetrics and Gynecology did not officially approve this procedure until February 1997! IVF has not yet been approved. The cultural tendency to leave matters ambiguous rather than to establish clear rules in Japan is in sharp contrast to attitudes in Islamic societies.

Dr. R.Z. Qui (PR China) considered that the Chinese concept of sex and reproduction is overridingly molded by the dualistic theory of yin (female)-yang (male) forming the two complementary forms of the vital energy "qi", which underpins the existence of all beings and matters in the universe. Interaction between these two kinds of vital energy (including sexual intercourse between male and female) is the basis of all life. The ethics and attitudes to reproduction are dominated by Confucianism which sets out contextual principles in interpersonal relationships within the family and community. The Chinese believe that any intervention in natural reproduction is undesirable if sex is separated from reproduction. This will deprive a man or woman from enhancing their yang or yin through sex. However, if there is no alternative to natural sex and reproduction, then reproduction takes priority. AID and other forms of infertility treatment are, therefore, well accepted. Chinese men are reluctant to use condoms because they are prevented from assimilating yin from the vagina and will also lose jing (physical embodiment of yang) in the condom. Interestingly, "the fetus is not considered a person" because "birth is the beginning of a person" so that induced abortion and embryo research are permissible.

Dr. W. Wolbert (Austria) discussed the official Catholic position towards reproductive intervention. This is based on the key precept of Donum Vitae, the gift of life, set out in the Instruction on Respect for Human Life in its Origin and on the Dignity of Procreation, published in 1987. Dr. Wolbert highlighted the practical deficiencies, ambiguities and contradictions of these instructions formulated as a series of theological questions and answers which can sometimes be overinterpreted. For example, the first thesis "The human being must be respected - as a person - from the very first instant of his existence" does not define the beginning of personhood. This has led to a growing tendency of the antiabortion lobby to interpret the beginning of personhood as from the moment of conception, quoting as support an earlier Declaration on Procured Abortion 1974. The second thesis, "the fidelity" of the spouses in the unity of marriage, involves reciprocal respect of their right to become a father and a mother only through each other, does not permit the practice of AID, AIH, IVF or contraception because they dissociate the unitive and procreative meanings of the conjugal act and deprive procreation of its perfection. The question of the use of less perfect (artificial) means of procreation when natural measures have failed in infertile couples is not answered explicitly, but the answer would be negative. Dr. Wolbert concluded by suggesting that these instructions should be regarded as moral exhortations and not a treatise on normal practical ethics. In other words, the problem lies in how these instructions are being interpreted and perhaps a touch of Islamic intelligent reasoning "Ijtehad" would be helpful.

Dr. F. Zegers-Hochchild (Chile) surveyed attitude to and practice of reproductive interventions in Latin America, a continent markedly influenced by teachings of the Catholic Church (see above). Despite the Church1s specific instructions to legislators, health providers and the public, contraception is not widely accepted except in parts of Brazil. Abortion is illegal in Latin America but illicit abortion is common. Assisted reproduction is widely accepted as a medical treatment for infertile heterosexual couples irrespective of marital status and regarded as an alternative form of procreation when coitus has proved to be ineffective for reproduction. ICSI including the use of immature testicular germ is being performed on the principle that the responsibility towards the unborn resides in the potential parents and provided that the couple understands the risks, known or unknown. Gamete donation from a progenitor is acceptable if the father is willing to express paternal love and undertake the corresponding parental responsibilities.

The symposium certainly achieved the objective of comparing and contrasting the diverse ways different cultures and societies have assimilated or rejected reproductive interventions. Hopefully, cross-cultural and international interactions will allow us to learn from each other so that we will be better placed to exploit future scientific advances to the benefit of individuals seeking fertility regulation or enhancement within the boundaries of accepted ethical considerations.

Frederick C.W. Wu