New Reproductive Biotechnology, Values and Society
- Siti Nurani Mohd Nor, Ph.D.
Department of Science and Technology Studies, Faculty of Science, Universiti Malaya, 50603 Kuala Lumpur, Malaysia
Email: j10siti@umcsd.um.edu.my
Eubios Journal of Asian and International Bioethics 9 (1999), 166-9.
Einstein once said, "We should be on our guard not to overestimate science and scientific methods when it is a question of human problems; and we should not assume that the experts are the only ones who have a right to express themselves on questions affecting the organization of society." Recent advances in the biomedical sciences have allowed scientists "to be in control" of the processes of life and death. Not only can life be prolonged by machines, doctors and scientists can now also initiate the process of life: cloning, recombination of DNA, embryo transfer (ET) and in vitro fertilization (IVF) are but well-known examples. All these advancements bring us to the stark realization of Francis Bacon's (1561-1626) precocious directive to science. The call to aim at power over nature for the sake of raising humankind's material comforts have become working truth beyond expectations. This inevitably lead us to the question of whether all works of science are beneficial or otherwise for the human society. It is not simply the question of good or bad science but of good or ill effects of science. New discoveries in the field of biology which affects humans makes it all the more important for the common society to reflect and ponder.
In the Western world, many difficult ethical, legal, social and economic questions have been deliberated on the subject of IVF (in vitro fertilization). Likewise, as is often the case with dramatic advances in scientific technology, the Malaysian community is taken unawares by the announcement of the development of IVF and its successes. On the assumption that the media presents an objective indication of the Malaysian public's reception of IVF, this study suggests that the science of human reproduction has made a significant impact on the inherent values of the Malaysian society \ a unique multicultural society where Islam is the official religion. How unprepared the society was in coping with the wonders of technology is highlighted by the local scenario that took place through 1980s to early 1992.
In the 1970s, following worldwide resurgence of the Islamic faith, Islamic values have been actively assimilated in the shaping of various public policies within the Malaysian society (1). One good example has been the establishment of Islamic banks in Malaysia, which is in line with the Islamic prohibition of usury or the charging of interest.
The moral code of conduct of the Malaysian-Muslim's (2) daily affairs and his or her spiritual observance of the faith is defined by the Islamic value system or more aptly, the Shariah. The main sources of the Shariah are the Quran and the Sunnah or teachings of the Prophet preserved in a collection of prophetic sayings, known as the Hadith. One of the four Sunni schools of law (3), notably that of the Shafii sect have been adopted since the sixteenth century. Within the Shafii tradition, there is provision for the use of analogy by reasoning or ijtihad (4) and for community consensus in matters not directly stated in the Quran or Hadith. Community consensus is held to be both the "general will of the nation" and the "common interest" or "al-maslaha" which is the legal speculation of matters absent in the text but considered and related back to the sacred texts (5). The ulamas or religious authorities are usually consulted to produce a fatwa or legal ruling on matters of vital importance for Muslims.
New scientific advancements often pose difficult issues and rightly, needs to be addressed and deliberated. Moreso, on a revolutionary technology in human reproduction such as in vitro fertilization. IVF is concerned with the actualisation of a potential human being outside the womb. As such, it presents an interesting phenomenon when compared to the understanding of human creation as written in the sacred Muslim text. A verse in the Quran addresses God's creation of a human being inside the womb (6).
Man We did create from a quintessence (of clay). Then We placed him as (a drop of) sperm in a place of rest, firmly fixed. Then We made the sperm into a clot of congealed blood; then of that clot We made a (foetus) lump; then We made out of that lump bones and clothed the bones with flesh; then We developed out of it another creature. So blessed be God, the Best to create!
At the outset it can be said that the new technique of IVF is morally unproblematic because it does not entail creation out of nothing (ex nihilo) which essentially is the work of God (7).
He bestows (Children) male or female according to His Will (and Plan), or He bestows both males and females, and He leaves barren whom He will: For He is full of knowledge and power.
Doctors can initiate fertilization and assist in reproduction but God determines the eventual development and survival of the embryo. With this philosophical background, it is easy not to acknowledge physicians as co-creators of children even though there may be major medical intervention in conception. As one of several medical techniques in artificial human reproduction, the Shariah holds that it is both appropriate and legal when performed using gametes of married couples (8).
However, the ethical ramifications surrounding a typical IVF procedure are far too many to simply classify the technology as merely halal (permissible) or haram (prohibited). An IVF programme involves many steps and procedures and each one has been the subject of ethical concern. For instance, superovulation and the use of fertility drugs are required (9) to increase the number of fertilized eggs. Physicians claim that superovulation not only induces the production of oocytes in women who cannot naturally ovulate but that the time of egg maturation in the ovary can be predicted with greater accuracy. This is helpful in enhancing a better organization of an IVF programme and increasing the probability of its success (10). In addition, scientists also demonstrate that excess fertilized eggs could be frozen and stored for a limited period of time and this process would omit the invasive procedure of having to extract eggs from the mother during subsequent IVF attempts (11).
While doctors and scientists justify the need for this step, ethicists have objected to methods involved in superovulation as dangerous and unethical to women. Corea described in detail the methods applied which highlighted the researchers concern for their own status rather than minimalizing the risks to women (12). Cases of ovarian enlargement, neural tube defects and congenital malformations have also been reported in connection to the use of fertility drugs (13). These then are just a few of the ethical objections raised in the Western world against IVF. For Muslims in Malaysia, the dangers of superovulation may have the tendency of being overlooked as a factor of lesser concern than that regarding the use of donor eggs and donor sperm (14).
In Malaysia, the technique of IVF was first conducted by a group of researchers and physicians in 1984. This was followed by a live birth in 1987 (15) and up to 1990 seven cases of successful IVF births have been reported (16). What these events illustrate is keen public demand and support for a technology that has successfully presented itself as facilitator of human creation.
In February 1986, the first instance of government support for problems of infertility management began with the establishment of the MAC Project (Medically Assisted Conception) in Kuala Lumpur (17). This project was undertaken by a team of reproduction specialists and researchers from the National Population and Family Development Board (NPFDB). It was found that financial support was being received from the United Nations Fund for Population Activities (UNFPA) and the World Health Organization (WHO) (18).
National interest in IVF can be likened to the reception of family planning which came to the scene about three decades earlier. In the 1960s, the NPFDB was entrusted to develop and educate the public on various methods of contraception. The setting up of the Board faced much disapproval from Muslim ulamas and the Muslim community at large (19). Family planning and contraception was seen as "interfering" with human creation. The fact that the original name of the Board (then known as the National Family Planning Board) had to be modified illustrates the degree of controversy surrounding the incident.
Conduct of the family planning programme was tailored according to Islamic values. On this matter, the viewpoint of Imam Abdul Hamid Muhamad Al-Ghazali was referred and authorities reflected that maintaining a small family is encouraged because having smaller families is believed "to bear fewer hardships'. Encountering fewer hardships is believed to be a legitimate reason for an action and also regarded as "an aid to [facillitate the development of] religion' (20).
In this light, family planning and the use of contraception came to be accepted by most Muslim authorities. Of prime importance then was the country's main objective in population control - population growth had to be in equilibrium with the country's economy and resources (21). What can be quickly observed here, is how Muslims came to accommodate scientific technology for its practicality but not before formal assessment and deliberation.
In the case of IVF, the picture is not as simple. In March to July 1992, IVF, as a new scientific advancement made a significant impact on public morality. Media reports relayed wide public reception of the technology, in the form of ready sperm-donors coming out in numbers, though perhaps only ostensibly, in support of the technology (22). Some members of the public questioned the development of "sperm-banks' and the motives of scientists behind the controversial project. Identification of particular sites for sperm-storage as well as financial support from the World Bank was also reported to have been established (23). Some doctors bravely claimed that the sperm-banks were necessary "to help husbands of childless women to produce [and store] active sperms'. Interestingly however, the media also disclosed that an elite group donors were chosen among those who "had the brains and could produce good progeny'. It also established that a sufficient sum of money was rewarded for their "contribution' (24).
The above revelations by the media showed rapid development and reception of the biotechnology but clearly it also had every appearance of a form of eugenics in the midst of the Malaysian culture. This is quite reminiscent of proposals made by a Singaporean politician from the same motive in 1983 (25). In Singapore, higher educated women were encouraged to have more children while lesser educated ones were offered rewards to keep a small family.
The development of the sperm-banks was annulled due to the sensitivity of the subject (26) but it is worth to note that for a period of time within the Malaysian culture, scientific research had made a definite tax on the moral attitude of the society. A Muslim man actually donated sperms to a childless couple because he felt sympathy for them and wanted to help. A university undergraduate spoke that she was willing to be a surrogate mother for her own sister or a close friend if such a situation arose. While most women generally agreed that "taking money in exchange" for the deed [surrogacy] is immoral, they would however, do it for altruistic reasons.
On the subject of eugenics, some couples affirmed that if the technique allowed them to screen embryos of any morphological or mental defects, they would welcome it since it enabled them to select the "perfect baby". That human beings have rejected defective babies is not a relatively new phenomenon. Plato once remarked in his Republic that babies who do not fit the prescribed standard should be hidden in dark, secret places (27). Again, during the time of pre-Islamic Arabia, there was prevalent practice of female infanticide because society preferred a male child who was looked upon as a source of strength while a female was associated with a symbol of weakness. A verse in the Quran which indicated disapproval of female infanticide states,
Kill not your children for fear of want: We shall provide sustenance for them as well as for you. Verily the killing of them is a great sin (28).
Growing public uncertainties about this particular biomedical technology eventually led by the Malaysian Fertility Society to organize a forum with the theme "Infertility and the pathway to parenthood" in August 1993. While the public was "technically" educated on the various services available for infertility treatment, it was also evident that the religious status of the technology to that day was still fuzzy (29). The forum alluded that "the Islamic point of view on such technology is flexible so long as it is done within marriage" but on matters concerning the disposal and freezing of embryos, no official fatwa" has been drawn up.
To a question on whether there was a law regulating the practice of assisted reproductive technology in the country, the Committee's answer was nil. It however admitted that guidelines for the conduct of the technology were adopted from the Royal College of Obstetricians and Gynaecologists of the United Kingdom and the Warnock report (30).
The recommendations of the Warnock Committee regarding human embryo manipulation have been subjected to many debates in the Western world. They have been widely perceived as being very liberal where virtually all professionals within the scientific and medical community supported them but on the other hand, opinions remained divided among people from all walks of life, conservatives, politicians, lawyers, philosophers and, ordinary men and women. Taking note of the background and the reception of the Warnock recommendations, necessary caution must be taken when accepting a Western code of ethics as part and parcel (or as the intuitive matrix) of a particular Western technology. Moreso, on technology that involves humans and, human entities, human beliefs and human values. The risks and benefits to mother and foetus must be evaluated and, of equal importance, there is need to ensure that the risks and benefits do not fall inequitably among economic, racial and social classes.
The necessity of having a specific code of ethics for Malaysian practitioners has been frequently expressed to safeguard the legal, religious, and social norms pertaining in the country (31). Questions relating to the disposal of surplus eggs and embryos and their storage will need to be addressed when practicing IVF, either for clinical or research purposes. Contemplating on the strength of "iddah' laws may present a picture of what would be an appropriate answer when it comes to the question of storing excess fertilized eggs. The period of iddah is important because it helps to determine the paternal lineage of the child of a woman whose husband is deceased. Since paternal lineage is important in Islam and is strongly entrenched by the drafting of the laws of iddah, this may enlighten the question of allowing or prohibiting a period for conservation of eggs in an IVF procedure for Muslims. In western ethics, regulations about the disposal of eggs are centralized upon the principle of the sanctity of human life because the embryo at 14-days after fertilization is said to "contain' life and ethical problems arise regarding its disposal. In Islam the matter does not relate to that principle as strongly as the matter of rightful family lineage and fetal right to inheritance. The Warnock recommendations did not to address this paradigm and may not be the most appropriate guideline for physicians to use when attending to Muslim clients.
The question of health-care priorities had been much earlier addressed by Robert McCoy from the Committee of the Council for the Obstetrical and Gynaecological Society of Malaysia. While he noted that resources were limited in a country like Malaysia, he felt that the matter "should not be an argument against the technique itself' (32). The current estimated cost of an IVF treatment is calculated to be between RM5000 to RM10000 per treatment cycle (33). The Society acknowledged that IVF was expensive high technology medical care and that it would only benefit a few, but it was prepared to defend the universal human right and freedom to have children and that doctors should be allowed to perform the technique in an effort to alleviate childlessness in their patients (34). Since the UN declarations of human rights have been subjected to many criticisms of late, it is probably irrelevant to refer to these declarations to justify a need for the technique as opposed to the high costs it entails especially for a country like Malaysia. Even though the country has decided to increase its population fivefold to seventy million, it may not be prepared to channel a high amount of its medical funds into the treatment of infertility when drafting a priority list of heath-care services, ranging from the most important to the least important, to serve its entire population.
The technique of IVF is known to have afforded considerable insight into embryology and genetics. IVF research has potentially many benefits for the medical sciences, in particular for the understanding and the cure of hereditary diseases. For example, the advent of genetic probes have opened up a whole new horizon for the early detection of human disease and disease susceptibilities (35). Such technology could in future mean that single cell biopsy of early human embryos growing by in vitro fertilization techniques may be possible. The DNA material could be amplified and screened in order to detect the presence or absence of normal or mutated genes. It may be possible to detect at an early stage the presence of such disorders such as Huntington's chorea, cystic fibrosis, cleft lip and palate and spina bifida, to name a few.
Islam places a high value on the acquisition of knowledge and the alleviation of human suffering. Experimentation for the benefit and sustenance of mankind and to seek comforts in life is strongly recommended by the Quran:
"And seek of the bounty of Allah." (Sura 62:10)
But it must be remembered that new possibilities and potentials bring about new responsibilities. The prerequisite for responsibility is the ability to make reliable estimates of the consequences for the society. As IVF research presents numerous interesting features, it therefore demands an equally careful exercise of ethical considerations in the light of Islam and its objectives. IVF and its implications challenges the notion of how a nation can produce a society that has at its core a deep sense of religious consciousness, and is committed to the highest standards of ethical and moral values, and yet is also industrious, dynamic and devoted to advancement.
References
1.The world-wide Islamic resurgence has also influenced the observance of the Islamic faith in Malaysia and began shaping several policies, for example: the education and the banking system. See Z. Anwar, Islamic Revivalism in Malaysia: Dakwah Among the Students, Kuala Lumpur: Pelanduk Publications, 1987, p. 30 and, C. Muzaffar, Islamic Resurgence in Malaysia, Kuala Lumpur: Fajar Bakti, 1987, p. 5.
2. The Muslims are mainly from the Sunni faith, which is distinct from the Shi'ites of Iran. The word "Sunni'is derived from "Ahlul-Sunnah' which applies to orthodox Muslims, as opposed to the "Shi'ite', the partisans of Ali. See H.A.R. Gibb, Mohammedism, New York: New American Library, 1955, p. 61.
3. All Malays and most South-East Asian Muslim belongs to the Shafii sect. The majority of Muslims in Turkey, India, and Pakistan are Hanafis. West and North African Muslims are Malikis, while the Hanbali school is officially recognised in Saudia Arabia. All three schools, together with the Shafii, are recognized as equally orthodox and in agreement on all matters of vital importance. A. Ibrahim, Islamic Law in Malaya, S. Gordon (ed.), Singapore: Malaysian Sociological Research Institute, 1965, 2nd. Ed. 1975, p. 72. See also J. Nagata, Reflowering of Islam in Malaysia: Modern Religious Radicals and Their Roots, Vancouver: University of British Columbia Press, 1984, p. 21.
4. In the Malaysian Shariah system however, there is little preoccupation with ijtihad, the constant review and reinterpretation of Quranic and Prophetic injunctions. This is because of fear of deviation from the original meanings of the holy text, ibid. Nagata., Introduction, p. xix.
5. S. Ramadan, Islamic Law: Its Scope and Equity, London: Macmillan, , 1961, p. 98.
Sura 23: 12-14.
6. The Holy Quran, translation and commentary by A. Yusuf Ali, Maryland: Islamic Propagation Centre International, 1946.
7. The Holy Quran, Sura 42: 49-50
8. IVF is seen in the same light as artificial insemination. "Islam permits artificial insemination by husband to produce a child'(statement made by Dr Ishak Mas'ud, the President of the Islamic Medical Society) as reported in the national daily newspaper, Berita Harian, 6 March 1992. The same standing is also held elsewhere, see J.G.Schenker, "Jewish and Moslem aspects of in vitro fertilization and embryo transfer', Annals of New York Academy of Sciences, 1985, Vol. 442, pp. 601-607.
9. The use of the drug clomiphene citrate in combination with human menopausal gonadotrophin tended to induce multiple egg follicular growth, Trounson A.O., 'Manipulation of endocrine requirements for in vitro fertilization', Proceedings of The Endocrine Society of Australia, 1982, 25: Supplement (1), pp. 1-6).
10. Nine successful pregnancies have resulted with the help of superovulation techniques, Wood, C., A. Trounson, J. Leeton, J. Mc Talbot, B. Buttery, J. Webb, 'A clinical assessment of nine pregnancies obtained by in vitro fertilization and embryo transfer, Fertility and Sterility, 1981, 36, pp. 502-508).
11. Trounson, A.O., C. Wood, J.F. Leeton, "Freezing of human embryos: an ethical obligation', Medical Journal of Australia, 1980, 2, pp. 332-334.
12. Corea,G., The Mother Machine: Reproductive Technologies from Artificial Insemination to Arftificial Wombs, New York: Harper & Row, 1985, pp.99-102.
13. Ford, W.D.A. and K.E.T. Little, "Fetal ovarian dysplasia possibly associated with clomiphene', Lancet, 14 November 1981, p.1107; Keiichi Kurachi et al., "Congenital malformation of newborn infants after clomiphene-induced ovulation', Fertility and Sterility, 40(2), 1983, pp. 187-9.
14. "Orthodox Islam forbids artificial insemination from donors", T.A. Sinnathuray, "Ethical review procedures in Malaysia'in: Human Experimentation and Medical Ethics: Proceedings of the XVth CIOMS Round Table Conferrence, Manila 13-16 September 1981, Z. Bankowski and N. Howard-Jones (eds), Geneva: Council for International Organizations of Medical Sciences, 1982, p. 237.
15. The scientist responsible was Dr John Yovich, who incidentally was also the director of the Pivet Medical Centre in Perth, Western Australia, as reported in the local newspaper Utusan Malaysia, 4 October 1986. It is interesting to note that the Centre at Perth receives patients from "mostly South East Asia - Singapore and Malaysia'. See In Vitro Fertilisation Centres in Australia: Their Observance of the National Health and Medical Research Council Guidelines, Canberra: Australian Government Publishing Service, 1987, p. 32.
16. The Annual Report of the National Population and Development Board of Malaysia 1990, Kuala Lumpur: Ministry of National Unity and Social Development of Malaysia, 1990, p. 65.
17. ibid.
18. E.W. Wilson, "Asia', in: Research in Human Reproduction: Biennial Report (1986-1987), E. Diczfalusy, P.D. Griffin, J. Khanna (eds), Geneva: WHO, 1988, p. 303.
19. pers. comm. Shafie Khatib Jali, an official from the Islamic Affairs Division of the National Population and Family Development Board, Kuala Lumpur, interviewed on the 15 March 1993.
20. Imam Abu Hamid Muhammad Al-Ghazali, Marriage and Sexuality in Islam, M. Farah (trans.), Salt Lake City: University of Utah Press, , 1984, p. 110.
21. Family planning is against Islamic injunctions and only accepted if the motives are reasonable, The Population and Family Development Act (Revised in 1988), cited in The Annual Report, op. cit., p. 34.
22. Articles appeared in various local newspapers, among which were The Malay Mail and The New Straits Times, 6 March 1992.
23. A minister from the National Unity and Social Development Ministry had acknowledged this. The project was supposed to receive funding from the World Bank and the United Nations Foundation for Population Activities, Berita Harian, 5 March 1992.
24. Ibid. University students were most sought after as donors.
25. Lee K.Y., National Day Speech (14 August 1983). Reprinted as "The education of women and patterns of procreation', in Regional Institute of Higher Education and Development Bulletin, 1984, Vol.10, p. 4.
26. According to literary sources, "the issue of the sperm-bank was shelved for the time being because of religious [Islamic] sensitivities about artificial insemination from donors', Sinnathuray, op.cit.
27. Plato, Republic, in: Platonis opera, Oxford:Clarendon Press, 1957, vol. IV, 460a \ c.
28. The Holy Quran, Sura 17:31.
29. The New Straits Times, The Malay Mail, Kuala Lumpur, 2 August 1993.
30. Report of The Committee of Inquiry into Human Fertilization and Embryology, Chairman Dame Mary Warnock DBE, London: Her Majesty's Stationery Office, 1984. Reproduced in M. Warnock, A Question of Life: The Warnock Report on Human Fertilization and Embryology, Oxford: Basil Blackwell, 1985.
31. H. Arshat, "Ethics in assisted human reproduction', Medical Journal of Malaysia, 1989, 44, pp. 1-2.
32. R.S. McCoy, "Ethical aspects of in vitro fertilization and embryo replacement', Bulletin of The Obstetrical and Gynaecological Society of Malaysia, 1989, 6, pp. 6-9.
33. Arshat, H., Public Forum: Test-tube Babies, 24 March 1996, Kuala Lumpur: Malaysian Fertility Society, 1996)
34. op. cit. McCoy. The United Nations Universal Declaration of Human Rights of 1948 recognizes the "right to found a family.'
35. Nossal, G.J.V., Reshaping Life \ Key Issues in Genetic Engineering, Carlton:Melbourne University Press, 1984.
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