Everyday Bioethics

Reflections on Bioethical Choices in Daily Life

Giovanni Berlinguer

• Publisher: Routledge
• Year: 2020
• eBook ISBN: 9781351868518
• Topic: History
• Subtopic: Italian History
• Index: History

"Everyday Bioethics" suggests a new perspective on the relationships between science, ethics and society. It is based upon the distinction and integration of two fields: the frontier bioethics, which examines the new development of biomedicine; and the bioethics of everyday life, which concerns all people around the world. Indeed, moral reflection on birth, human bodies, jobs, the gender and class relations, diseases and the treatment of the sick, death, the interdependence of human beings and other living creatures, has a long history, as long as that of mankind itself. The ideas and values that daily permeate the minds and behaviors of all human beings in these fields deserve the greatest attention, and are increasingly influenced by the progress of science and technology.

CHAPTER 1

Procreation and Birth

PROCREATION AS FREE CHOICE

Although the expression “epoch-making” has been abundantly used and abused, especially during the transition from the second to the third millennium, it appropriately defines the changes in the field of human reproduction that began in the twentieth century. The advent of reproductive technology is one aspect of the changes in this field, changes that, indeed, moved the frontiers of science. These changes have a bearing on the daily life of a large number of human beings, affording the possibility of consciously regulating births and thus modifying the demographic situation: the demographic transition that began in the developed countries is now widespread and has begun to affect both birth and death rates.

So far, the use of reproductive technology has remained comparatively limited, and there is thus still no strong and widespread connection at a practical level between the technology and the demographic changes. On the other hand, ethical considerations have begun to present themselves. Although the moral issues emerging from the many changes vary, taken together they have given rise to a need to reflect on the beginning of human life. The depth of these changes has shaken many certainties and led to heated debate. This is only to be expected, because recognizing procreation as a free choice was a major component of the revolution in the relations between men and women, perhaps the most profound and longest lasting of the revolutionary changes that occurred in the twentieth century.

The freedom to procreate and, together with this, the freedom for children to thrive after birth are historical constructions typical of our times. In the past, unremitting procreation from puberty to menopause (which women rarely reached, owing to the incidence of early death) had been one of the major obstacles to women’s full attainment of the status of multidimensional human beings.

In his History of Women’s Bodies, Edward Shorter emphasizes that, in the past, women were “victims of nature,” that is, of serious female-specific diseases, of sexual relations subordinated to male desire, and of the obligation of looking after at least half a dozen children (1). Only in the twentieth century were these difficulties reduced. This reduction made a substantial contribution, together with the civil and social struggles of their gender, to breaking what John Stuart Mill called the “subjection of women,” which he compared to a widespread form of slavery (2). Furthermore, until the twentieth century, infant mortality had always been high (for the Italian poet Giacomo Leopardi this was the first sign of human destiny: “man struggles to be born / and his birth is a risk of dying”), and half of newborns died before the age of five. This was the price paid in terms of longevity, quality of life, and substantial freedom when the demographic dynamics were characterized by high birth rate and high mortality. These images from the past can be used to measure the progress made and to evaluate the limits to the spread of that progress in places, in classes, in ethnic groups, and in individuals living on the planet today.

FREEDOM, DUTIES, AND RIGHTS OF PROCREATION

Freedom to procreate has increasingly implied both the theoretical and the practical rejection of ideas based on the conception of procreation as an obligation deriving from natural laws, political coercions, or religious precepts. The Catholic Church in particular has considerably changed its views on sexuality. Sexual intercourse between husband and wife, which in canon law had only two acknowledged purposes—procreatio and remedium concupiscentiae—after John XXIII and Vatican Council II was viewed not only as the duty to procreate but also as the expression of bonum coniugium deriving from the natural desire of man and woman. What has not changed is the criticism of birth control. The encyclicals Casti connubi and (later) Humanae vitae condemned in sexual intercourse “any act that… is aimed at or is a means for rendering procreation impossible” (3). Any act; yet couples may refrain from sexual intercourse during the woman’s fertile periods by employing what is known as the “natural method” of birth control.

I shall not dwell on the theological justifications for this distinction (in this connection, see 4) but rather on the consequences of the directives it attempted to impose. The most obvious is that most Catholics almost always ignore these rules, often with the approval or tolerance of their ministers. Implicit sanction thus gave rise to a double moral standard: one preached and the other practiced. According to a survey conducted by the Italian Episcopal Conference in 1995, 70 percent of practicing Catholics do not accept the distinction between “natural” and “artificial” contraception, and only 15 percent obey the Church’s rules on this matter.

These findings pertain essentially to the relationship between believers and their faith. Others also may be troubled, at the practical and moral level, by the insistent campaign carried out against the so-called “artificial” method, insofar as it increases the number of unwanted pregnancies and thus unwittingly encourages the practice of abortion. And it is of interest to everyone that, in the face of the danger of sexually transmitted diseases such as AIDS, the Church intervened, in Italy but even more vigorously in Argentina and several African countries, in order to prevent the state from promoting the use of condoms as a way of avoiding contagion. The cost in terms of human lives of the delays and obstacles deriving therefrom is difficult to quantify; what is certain, however, is that the cost was paid by both believers and nonbelievers.

What is clear, in any case, is that freedom in sexual relations and procreation (which includes also freedom not to procreate) also implies duties. The latter are to be viewed as responsibilities to one’s dignity, to one’s system of interpersonal relations, and, above all, to the as yet unborn. However, one controversial issue is whether there exists a right to procreation in addition to a freedom. Many (particularly women) doubt that the language of rights is the most appropriate language for dealing with matters such as procreation and birth, in which the predominant dimension is the relationship (both legal and, more importantly, affective) between the subjects, whose autonomy could be distorted by legislation and by state intervention. Then again, on the juridical plane, to shape a fully enforceable right is not always easy. This becomes obvious whenever the obstacle to procreation consists of sterility due to biological causes, such as anomalies or disease, at a time when there are both the means for preventing or treating such causes and a legal recognition of the right to health, as in, for example, article 32 of the Italian Constitution. But the question may arise whether assisted procreation, which works to circumvent sterility without removing the cause, represents a right, and if so, for whom and under what conditions.

COMPULSORY AND INDUCED STERILIZATION

Despite the doubts about procreative rights, a broad consensus exists that to be arbitrarily deprived of such a right is unacceptable. Nevertheless, this has happened several times in history, even in the twentieth century, using medical means, for political or ideological reasons and even on humanitarian grounds—but mainly for selective purposes. Within the framework of policies to restrict the numbers of migrants from southern and eastern Europe to the United States, for example, by the late 1920s “two dozen states had approved as lawful the eugenic sterilization of mental patients. These laws were declared constitutional in 1927, in the Supreme Court decision in the Buck v. Bell case, which was explained by Judge Oliver Wendell Holmes on the grounds that ‘three generations of imbeciles are enough’” (5).

Even more sensational cases occurred simultaneously in Germany, even before the advent of Nazism, involving the sterilization of handicapped and mentally deficient persons, under pressure from the wave of eugenics theory based on Galton’s idea that it was useful to eliminate “undesirables” in order to improve the species. After Hitler came to power, sterilization was extended and became an integral part of Nazi racial programs. According to the ideologist H. W. Krantz, such programs had to be combined with the destiny of a “multitude of misfits, as many as one million, whose hereditary predisposition can be eradicated only through their elimination from the reproductive process” (6, cited in 7). After the fall of Nazism, the widespread indignation aroused by these practices appeared to have swept them away in all democratic countries. In actual fact, they continued silently in many parts of the world until, in 1997, the news was published that in Sweden (as well as in Austria, Norway, Denmark, the United States, and elsewhere even later), from 1946 to 1976, women who were carriers of disabilities or “the poor of mixed race” or the scholastically retarded continued to be sterilized.

Sometimes these practices were justified on the grounds of “their advantages”: to avoid burdening these women with procreative responsibilities. However, compulsory intervention—sometimes concealed behind an unlikely consent as well as being directed in a discriminatory fashion only towards women (cases of male sterilization without consent being extremely rare)—runs counter to two fundamental acquired rights. One of these is the right of all human beings to the integrity of their own bodies. The other is the right to employ alternative methods of birth control free of fear of permanent impairment, a right that, thanks to scientific progress, is now available for the very rare cases in which preventing procreation is necessary.

In Italy, the National Bioethics Committee (CNB) has expressed a strongly critical opinion on “nonvoluntary sterilization” (8), citing also article 2 of the European Bioethical Convention, according to which “the interest and welfare of the human being must take priority over the interest of society and science.” In addition to its negative opinion of eugenic sterilization, which it criticized for giving rise to “discrimination among the citizens, which is inadmissible in a state of law,” the CNB has also criticized two other practices.

One is penal sterilization, that is, sterilization of those guilty of sexual offenses. It has no scientific justification at the therapeutic level and is not effective in preventing relapses, because violence, even if one considers it innate or irrepressible, can always be channeled in other directions. On the ethical-juridical plane, “it can barely conceal the primitive logic of juridical retaliation that underlies it.” The absence of justification on theoretical or practical grounds is sufficient to refute the argument often advanced in the United States that, as capital punishment is appropriate for murder, so too are less serious corporal punishments such as sterilization appropriate for sexual violence. It may be added that, at this rate, the introduction of lex talionis, the law of retaliation, is only one step away.

The other practice is demographic sterilization, carried out in the name of population control. Compared with the pro-natalist coercion in vogue in Italy and Germany between the two World Wars, and later in several communist countries, demographic sterilization represents an opposite, anti-natalist coercion. The Italian CNB criticizes this procedure on moral grounds and adds a perspective based on experience: the facts have shown that “the declining birth rate is not the result of compulsory sterilization campaigns but of experiences of social modernization.”

While I share many of the opinions represented in the CNB’s remarks, which are common to many critical treatments of compulsory sterilization, I must express my disagreement with what the CNB considers the fundamental ethical principle on which to reject the various hypotheses: “the principle of the intangibility of the body, which should render illegitimate any intervention on it.” I believe that this principle has been amply superseded by many beneficial techniques, starting with grafts and prostheses, and that we should avoid confusing the protection of the body and its intangibility, as, in other cases, we should avoid confusing its availability and its use as a commodity. The confusion of protection and intangibility could be detrimental to personal autonomy, which is precisely the value degraded by compulsory sterilization.

Among the many categories of sterilization subjected to critical review, that of induced sterilization is often neglected—that is, sterilization that appears to be voluntary but is actually coerced, as in cases of women who must accept sterilization in order to gain admission to a workplace or to avoid being marginalized or stigmatized. There are many established (and other concealed) cases of companies that have made employment contingent upon the demonstrated sterility of the candidate. I shall return to this topic in Chapter 3 with reference to ethical problems in the workplace. Italy’s CNB has criticized the various cases of induced sterilization in the name of the substantive and not just the formal nature of autonomy: “Wherever pressure is exerted against essential aspects of a person’s dignity and autonomy, it is impossible to assume a generalized sufficient level of freedom, which would demand a structure of the personality and of the resources which cannot be taken for granted, not even in the case of statistical majorities” (8, p. 26). In other words, it is the procreative freedom of those who are least able to withstand unlawful pressure that is in most need of protection.

STERILITY:
BIOPATHOLOGICAL, SOCIAL, AND CULTURAL

All cases are not equal, but the pressures applied to induce or impose the acceptance of sterilization are to a certain extent connected with factors restricting procreative freedom in general. They have not been sufficiently analyzed or opposed, and so Italian statistics in this area may be particularly interesting. Italy shares with Spain the lowest fertility rate in the world. The average number of children per woman is 1.17 for Spain and 1.18 for Italy, while it fluctuates between 1.50 and 1.80 in central and northern Europe. These indexes are almost certainly the lowest ever recorded in the world, in the history of our species, in “normal” periods—that is, excluding times of war, famine, pandemics, and other catastrophic events.

I shall not say whether this is good or evil. It is difficult to demonstrate that a community is happier under conditions of higher or lower birth rate, or that children grow up better if they are an only child or have brothers and sisters. Nor do I wish to subscribe to critical arguments outside the field of procreative choice that are based on moral judgments or social evaluations and are as categorical as they are unwarranted. I shall merely mention two arguments. One refers to the risk of ethnic and cultural contamination due to the higher birth rate of immigrants. This ignores or diminishes immigrants’ rights and a society’s advantages deriving from integration. The other argument criticizes the low procreation rate as being detrimental to the future contributions to pension funds. It ignores the existence of unemployment, which involves 10 to 20 percent of young people in Italy and Spain. If there were no jobless youth, existing and future pensions would be less exposed to risk, young people would probably marry earlier, and married couples would give less anxious answers to the question: “A child? And what will he do when he grows up?”

I shall not dwell on these topics, which, although stimulating political and social reflection, may deviate from bioethical analysis. In this field, again starting f...

Table of contents

• Cover
• Title Page
• Copyright Page
• Preface
• Table of Contents
• 1 Procreation and Birth
• 2 Population, Ethics, and Equity
• 3 Work and Health: Foundations and Ethical Conflicts
• 4 The Human Body: From Slavery to the Biomarket
• 5 Global Health
• Afterword
• Index