Kuka on potilas? : Suomalaisen sikiöseulontakäytännön sosiaalieettistä tarkastelua

Who is the patient? A social-ethical study of the Finnish practice of prenatal screening. The aim of this study is to examine the Finnish practice of prenatal screening from a social-ethical perspective. Analyzing ethical problems in medicine and medical practice only on a general scale may conceal relevant ethical dilemmas. Previous studies have suggested that many pregnant women view the prenatal screening practices customary in the Finnish maternal care system as intimidating and oppressive. This study analyzes the ethical questions of prenatal screening by focusing on the experiences and decision-making of a pregnant woman. Finnish women s experiences of and decision-making on the most common prenatal screening methods are reflected in the basic principles of biomedical ethics described by Tom L. Beauchamp and James F. Childress in Principles of Biomedical Ethics. To concretize women s experiences I refer to studies of Finnish women s experiences of prenatal screenings. This study shows that the principles of autonomy, non-maleficence and beneficence seem to materialize rather poorly in the Finnish practice of prenatal screening. The main ethical problem with prenatal screening is that the likelihood of a foetal cure is very limited and, upon detection of an affected foetus, the choice is usually whether to continue with the pregnancy or to undergo an abortion. Although informed consent should be required, women s participation in prenatal testing is, in many cases at least, not based on their active decision. Many women experience severe anxiety when they receive a positive screening result and must wait for the final results. Medical studies indicate that long- term anxiety may negatively influence the foetus and the mother-child relationship. This study shows that the practice of prenatal screening as such may cause more harm than benefit to many pregnant women and their foetuses. This study examines the decision-making process of a pregnant woman by using the theory of medical casuistry described in Jonsen, Siegler and Winslade s Clinical Ethics. This study focuses on each of the four points of view recommended by the theory. The main problem seems to be the question of whom the patient of prenatal screening is and whom the practice is intended to benefit: the mother, the foetus, the family or society? This study shows that the concepts of health in Finnish maternal care in general, and of the prenatal screening system in particular, differ considerably. It also demonstrates that the purpose and the aims of prenatal screening, aside from the woman s right to choose, has been expressed neither in Finnish public health programmes nor in the public recommendations of prenatal screening. This study suggests that the practice of prenatal screening is a statement, though unexpressed, of public health policy and as such comprises part of the policy of disability. This study further demonstrates that through a single explicit aim (the woman s right to choose) society actually evades its obligation to women by saddling pregnant women with the entire moral responsibility as well as the possible negative consequences of her choice, such as sorrow, regrets and moral balancing. The study reveals several ethical problems in the Finnish practice of prenatal screening. Such problems should be dealt with as the Finnish practice of prenatal screening advances.

Technological-forecasting and research inputs in area of birth-control technology

Technological forecasting, defined as quantified probabilistic prediction of timings and degree of change in the technological parameters, capabilities desirability or needs at different times in the future, is applied to birth control technology (BCT) as a means of revealing the paths of most promising research through identifying the necessary points for breakthroughs. The present status of BCT in the areas of pills and the IUD, male contraceptives, immumological approaches, post-coital pills, abortion, sterilization, luteolytic agents, laser technologies, and control of the sex of the child, are each summarized and evaluated in turn. Fine mapping is done to identify the most potentially promising areas of BCT. These include efforts to make oral contraception easier, improvement of the design of the IUD, clinical evaluation of the male contraceptive danazol, the effecting of biochemical changes in the seminal fluid, and researching of immunological approaches and the effects of other new drugs such as prostaglandins. The areas that require immediate and large research inputs are oral contraception and the IUD. On the basis of population and technological forecasts, it is deduced that research efforts could most effectively aid countries like India through the immediate production of an oral contraceptive pill or IUD with long-lasting effects. Development of a pill for males or an immunization against pre gnancy would also have a significant impact. However, the major impediment to birth control programs to date is attitudes, which must be changed through education.

Keskeytyksiä elämässä : Naisten toimijuudet aborttikertomuksissa

The present study focuses on the question of agency in the narratives of women who have experienced an abortion. The study scrutinizes agency by analyzing narratives and their context, that is, how narratives are entwined with cultural discourses and societal practices. The study thus addresses also the wider framework within which experiences and actions can be constructed in abortion narratives in the contemporary Finnish society. The women who wrote their stories or were interviewed were of different ages and had different social and religious backgrounds. Many variations of agency were found when abortion experiences were analyzed through the women s embodied and historically specific accounts. Independent and rational choices are entwined with emotions and choices made together with other people. Intimate relationships with family and friends have an important role in the choices regarding abortion. These relationships do not, however, simply belong in the private sphere but reflect the wider socio-cultural meanings of social bonds and family ties. Women s agency with regard to abortion is also constructed in encounters with the medical profession and within the wider framework of abortion legislation. The Finnish legislation grants women an abortion within certain parameters but not solely on the basis of a woman s wish to have an abortion. The data consists primarily of written narratives and interviews. All together 39 women shared their experiences with the researcher. The analysis focuses on decision-making regarding abortion, depictions of freedom and responsibility, emotions around abortion and expressions of values and religious views. The links between the women's experiences and the wider socio-cultural norms and institutions are analyzed through materials consisting of public debate on abortion in the media, ethical statements as well as literature and legislation on abortion. The analysis sheds light on the tensions apparent in the women's narratives between the legal status of abortion and more traditional views on abortion. The study demonstrates that the freedom linked to abortion is not solely to do with the right to have an abortion but also how abortion can be experienced, understood and where one can talk about the experience afterwards. The analysis reveals that Christian values shape women's experiences but that there are also new religious ways to deal with the ethical considerations brought about by abortion. Annually over 10 000 Finnish women experience an abortion, which is a situation involving ethical considerations. The study provides a nuanced account of the ways in which one can think and act when going through an abortion.

Perinatal mortality and maternal health in rural China

Background and context Since the economic reforms of 1978, China has been acclaimed as a remarkable economy, achieving 9% annual growth per head for more than 25 years. However, China's health sector has not fared well. The population health gains slowed down and health disparities increased. In the field of health and health care, significant progress in maternal care has been achieved. However, there still remain important disparities between the urban and rural areas and among the rural areas in terms of economic development. The excess female infant deaths and the rapidly increasing sex ratio at birth in the last decade aroused serious concerns among policy makers and scholars. Decentralization of the government administration and health sector reform impacts maternal care. Many studies using census data have been conducted to explore the determinants of a high sex ratio at birth, but no agreement has been so far reached on the possible contributing factors. No study using family planning system data has been conducted to explore perinatal mortality and sex ratio at birth and only few studies have examined the impact of the decentralization of government and health sector reforms on the provision and organization of maternal care in rural China. Objectives The general objective of this study was to investigate the state of perinatal health and maternal care and their determinants in rural China under the historic context of major socioeconomic reforms and the one child family planning policy. The specific objectives of the study included: 1) to study pregnancy outcomes and perinatal health and their correlates in a rural Chinese county; 2) to examine the issue of sex ratio at birth and its determinants in a rural Chinese county; 3) to explore the patterns of provision, utilization, and content of maternal care in a rural Chinese county; 4) to investigate the changes in the use of maternal care in China from 1991 to 2003. Materials and Methods This study is based on a project for evaluating the prenatal care programme in Dingyuan county in 1999-2003, Anhui province, China and a nationwide household health survey to describe the changes in maternal care utilization. The approaches used included a retrospective cohort study, cross sectional interview surveys, informant interviews, observations and the use of statistical data. The data sources included the following: 1) A cohort of pregnant women followed from pregnancy up to 7 days after birth in 20 townships in the study county, collecting information on pregnancy outcomes using family planning records; 2) A questionnaire interview survey given to women who gave birth between 2001 and 2003; 3) Various statistical and informant surveys data collected from the study county; 4) Three national household health interview survey data sets (1993-2003) were utilized, and reanalyzed to described the changes in maternity care utilization. Relative risks (RR) and their confidence intervals (CI) were calculated for comparison between parity, approval status, infant sex and township groups. The chi-square test was used to analyse the disparity of use of maternal care between and within urban and rural areas and its trend across the years in China. Logistic regression was used to analyse the factors associated with hospital delivery in rural areas. Results There were 3697 pregnancies in the study cohort, resulting in 3092 live births in a total population of 299463 in the 20 study townships during 1999-2000. The average age at pregnancy in the cohort was 25.9 years. Of the women, 61% were childless, 38% already had one child and 0.3% had two children before the current pregnancy. About 90% of approved pregnancies ended in a live birth while 73% of the unapproved ones were aborted. The perinatal mortality rate was 69 per thousand births. If the 30 induced abortions in which the gestational age was more than 28 weeks had been counted as perinatal deaths, the perinatal mortality rate would have been as high as 78 per thousand. The perinatal mortality rate was negatively associated with the wealth of the township. Approximately two thirds of the perinatal deaths occurred in the early neonatal period. Both the still birth rate and the early neonatal death rate increased with parity. The risk of a stillbirth in a second pregnancy was almost four times that for a first pregnancy, while the risk of early neonatal deaths doubled. The early neonatal mortality rate was twice as high for female as for male infants. The sex difference in the early neonatal mortality rate was mainly attributable to mortality in second births. The male early neonatal mortality rate was not affected by parity, while the female early neonatal mortality rate increased dramatically with parity: it was about six times higher for second births than for first births. About 82% early neonatal deaths happened within 24 hours after birth, and during that time, girls were almost three times more likely to die than boys. The death rate of females on the day of birth increased much more sharply with parity than that of males. The total sex ratio at birth of 3697 registered pregnancies was 152 males to 100 females, with 118 and 287 in first and second pregnancies, respectively. Among unapproved pregnancies, there were almost 5 live-born boys for each girl. Most prenatal and delivery care was to be taken care of in township hospitals. At the village level, there were small private clinics. There was no limitation period for the provision of prenatal and postnatal care by private practitioners. They were not permitted to provide delivery care by the county health bureau, but as some 12% of all births occurred either at home or at private clinics; some village health workers might have been involved. The county level hospitals served as the referral centers for the township hospitals in the county. However, there was no formal regulation or guideline on how the referral system should work. Whether or not a woman was referred to a higher level hospital depended on the individual midwife's professional judgment and on the clients' compliance. The county health bureau had little power over township hospitals, because township hospitals had in the decentralization process become directly accountable to the township government. In the township and county hospitals only 10-20% of the recurrent costs were funded by local government (the township hospital was funded by the township government and the county hospital was funded by the county government) and the hospitals collected user fees to balance their budgets. Also the staff salaries depended on fee incomes by the hospital. The hospitals could define the user charges themselves. Prenatal care consultations were however free in most township hospitals. None of the midwives made postnatal home visits, because of low profit of these services. The three national household health survey data showed that the proportion of women receiving their first prenatal visit within 12 weeks increased greatly from the early to middle 1990s in all areas except for large cities. The increase was much larger in the rural areas, reducing the urban-rural difference from more than 4 times to about 1.4 times. The proportion of women that received antenatal care visits meeting the Ministry of Health s standard (at least 5 times) in the rural areas increased sharply from 12% in 1991-1993 to 36% in 2001-2003. In rural areas, the proportion increase was much faster in less developed areas than in developed areas. The hospital delivery rate increased slightly from 90% to 94% in urban areas while the proportion increased from 27% to 69% in rural areas. The fastest change was found to be in type 4 rural areas, where the utilization even quadrupled. The overall difference between rural and urban areas was substantially narrowed over the period. Multiple logistic regression analysis shows that time periods, residency in rural or urban areas, income levels, age group, education levels, delivery history, occupation, health insurance and distance from the nearest health care facilities were significantly associated with hospital delivery rates. Conclusions 1. Perinatal mortality in this study was much higher than that for urban areas as well as any reported rate from specific studies in rural areas of China. Previous studies in which calculations of infant mortality were not based on epidemiological surveys have been shown to underestimate the rates by more than 50%. 2. Routine statistics collected by the Chinese family planning system proved to be a reliable data source for studying perinatal health, including still births, neonatal deaths, sex ratio at birth and among newborns. National Household Health Survey data proved to be a useful and reliable data source for studying population health and health services. Prior to this research there were few studies in these areas available to international audiences. 3.Though perinatal mortality rate was negatively associated with the level of township economic development, the excess female early neonatal mortality rate contributed much more to high perinatal mortality rate than economic factors. This was likely a result of the role of the family planning policy and the traditional preferences for sons, which leads to lethal neglect of female newborns and high perinatal mortality. 4. The selective abortions of female foetuses were likely to contribute most to the high sex ratio at birth. The underreporting of female births seemed to have played a secondary role. The higher early neonatal mortality rate in second-born as compared to first-born children, particularly in females, may indicate that neglect or poorer care of female newborn infants also contributes to the high sex ratio at birth or among newborns. Existing family planning policy proved not to effectively control the steadily increased birth sex ratio. 5. The rural-urban gap in service utilization was on average significantly narrowed in terms of maternal healthcare in China from 1991 to 2003. This demonstrates that significant achievements in reducing inequities can be made through a combination of socio-economic development and targeted investments in improving health services, including infrastructure, staff capacities, and subsidies to reduce the costs of service utilization for the poorest. However, the huge gap which persisted among cities of different size and within different types of rural areas indicated the need for further efforts to support the poorest areas. 6. Hospital delivery care in the study county was better accepted by women because most of women think delivery care was very important while prenatal and postnatal care were not. Hospital delivery care was more systematically provided and promoted than prenatal and postnatal care by township hospital in the study area. The reliance of hospital staff income on user fees gave the hospitals an incentive to put more emphasis on revenue generating activities such as delivery care instead of prenatal and postnatal care, since delivery care generated much profits than prenatal and postnatal care . Recommendations 1. It is essential for the central government to re-assess and modify existing family planning policies. In order to keep national sex balance, the existing practice of one couple one child in urban areas and at-least-one-son a couple in rural areas should be gradually changed to a two-children-a-couple policy throughout the country. The government should establish a favourable social security policy for couples, especially for rural couples who have only daughters, with particular emphasis on their pension and medical care insurance, combined with an educational campaign for equal rights for boys and girls in society. 2. There is currently no routine vital-statistics registration system in rural China. Using the findings of this study, the central government could set up a routine vital-statistics registration system using family planning routine work records, which could be used by policy makers and researchers. 3. It is possible for the central and provincial government to invest more in the less developed and poor rural areas to increase the access of pregnant women in these areas to maternal care services. Central government together with local government should gradually provide free maternal care including prenatal and postnatal as well as delivery care to the women in poor and less developed rural areas. 4. Future research could be done to explore if county and the township level health care sector and the family planning system could be merged to increase the effectiveness and efficiency of maternal and child care. 5. Future research could be done to explore the relative contribution of maternal care, economic development and family planning policy on perinatal and child health using prospective cohort studies and community based randomized trials. Key words: perinatal health, perinatal mortality, stillbirth, neonatal death, sex selective abortion, sex ratio at birth, family planning, son preference, maternal care, prenatal care, postnatal care, equity, China

Divvying up an incubator: How parasitic and mutualistic fig wasps use space within their nursery microcosm

Differential occupancy of space can lead to species coexistence. The fig-fig wasp pollination system hosts species-specific pollinating and parasitic wasps that develop within galls in a nursery comprising a closed inflorescence, the syconium. This microcosm affords excellent opportunities for investigating spatial partitioning since it harbours a closed community in which all wasp species are dependent on securing safe sites inside the syconium for their developing offspring while differing in life history, egg deposition strategies and oviposition times relative to nursery development. We determined ontogenetic changes in oviposition sites available to the seven-member fig wasp community of Ficus racemosa comprising pollinators, gallers and parasitoids. We used species distribution models (SDMs) for the first time at a microcosm scale to predict patterns of spatial occurrence of nursery occupants. SDMs gave high true-positive and low false-positive site occupancy rates for most occupants indicating species specificity in oviposition sites. The nursery microcosm itself changed with syconium development and sequential egg-laying by different wasp species. The number of sites occupied by offspring of the different wasp species was negatively related to the risk of syconium abortion by the plant host following oviposition. Since unpollinated syconia are usually aborted, parasitic wasps ovipositing into nurseries at the same time as the pollinator targeted many sites, suggesting response to lower risk of syconium abortion owing to reduced risk of pollination failure compared to those species ovipositing before pollination. Wasp life history and oviposition time relative to nursery development contributed to the co-existence of nursery occupants.

Cuestiones en juego en los proyectos de legalización del aborto

Resumen: Se procura identificar los más importantes tópicos bioéticos en tratamiento ante el Congreso de la Nación en relación con el inicio de la vida: proyectos sobre el delito de aborto, con diversas derivaciones como la píldora del día después; sobre técnicas de procreación humana; sobre clonación y otras situaciones de bioingeniería aplicada a la vida humana. Se formula un análisis contextualizado de los proyectos y una valoración crítica a la luz de los principios de la Bioética personalista ontológicamente fundada.

Reflexiones sobre la argumentación en los debates en torno a la vida

Resumen: En el debate público acerca del aborto hay muchos buenos argumentos en su contra. Sin embargo, no todos tienen la misma relevancia práctica, a la hora de incidir en las decisiones colectivas en la materia. Diversas clases de motivos hacen que algunas de esas buenas razones no tengan hoy en día suficiente fuerza persuasiva para generar convicciones sociales relevantes sobre el punto. En consecuencia, la argumentación debe estar a la altura de la cultura de nuestro tiempo, si se quiere defender eficazmente los buenos principios. Debemos escoger cuidadosamente solo los mejores argumentos, conforme lo sugieren las reglas de la ciencia pragmática. Indagar cuáles serían los argumentos más convenientes en esta materia, constituye el propósito de este trabajo.

Aborto : dolor prohibido

Resumen: En este trabajo se hace una aproximación a la experiencia del aborto, a las consecuencias emocionales y psicológicas que acarrea y a cómo cada mujer lo vive, ya sea en silencio o acompañada de su entorno. Para las mujeres que abortaron es evidente la necesidad de evitar y negar esa experiencia, considerando el intenso dolor, pena y confusión que sintieron después de esta intervención que se supone haría mejores sus vidas. Nuestra cultura, lamentablemente no está preparada para manifestar, aceptar o incluso respetar el dolor post-aborto, ocasionando que su sanación se haga aún más difícil de lo que debería ser. La autora presenta varios testimonios en los cuales se manifiesta la gravedad de esta experiencia. Si, como sociedad, queremos contribuir a la salud mental de mujeres y hombres, debemos tener una mirada más crítica sobre las muchas maneras en que el aborto puede afectar sus vidas.

Mi colaboración con John Finnis

Advertí por primera vez la existencia de John Finnis cuando me envió una nota de felicitación en ocasión de la publicación de mi libro de 1970, Abortion: The Myths, the Realities, and the Arguments. Uno de los capítulos del libro fue el fruto de una extensa investigación en bibliotecas jurídicas, y me sentí tremendamente satisfecho al recibir la aprobación de un catedrático de Oxford y profesor de Derecho. John y yo trabajamos juntos por primera vez desde el 25 de abril al 1º de marzo de 1974, en un hotel de Roma, en cuatro capítulos sobre ética cristiana para el libro The Teaching of Christ: A Catholic Catechism for Adults, el cual fue editado por Ronald Lawler, Donald Wuerl y Thomas Comerford Lawler –un libro que fue traducido en trece idiomas y ha atravesado cinco ediciones, al igual que algunas versiones simplificadas para gente joven...

Sobre el embrión humano y la cuestión de la personeidad : un argumento de Luigi Ferrajoli y su discusión

Resumen: El texto analiza las afirmaciones defendidas sobre el estatuto entitativo del embrión y de la solución ética a la cuestión de la legitimidad del aborto provocado, en un trabajo del jurista y pensador italiano, Luigi Ferrajoli, defensor de lo que puede denominarse el bioderecho “liberal”, con una posición decisivamente tomada en favor de la eticidad del aborto. Se advierte que cada uno de sus argumentos parte de una premisa: considerar las afirmaciones de la Iglesia Católica como inexorablemente erróneas, especialmente en lo atinente a la relación entre moral y derecho. La consecuencia más grave de este tipo de argumentación es la deriva anti-humanista del pensamiento contemporáneo con la consiguiente pérdida de toda racionalidad lógica.

La fundamentación eugenésica del artículo 86, inc. 2, del Código Penal y el fallo “F., A. L. s/medida autosatisfactiva” : convalidación de una teoría aberrante

Resumen: Este artículo analiza el fallo del 13 de marzo de 2012 de la Corte Suprema de Justicia de la Nación, en los autos “F., A. L. s/ medida autosatisfactiva”, en el cual el máximo tribunal argentino adoptó la interpretación amplia del Artículo 86, inciso 2, del Código Penal, a la luz de la “voluntad del legislador histórico”; teniendo en cuenta que la misma Corte la invoca en sus fundamentos para fallar a favor de la constitucionalidad del inciso referido. Se parte de entender el contexto histórico e ideológico de las primeras décadas del siglo XX, tanto a nivel nacional como internacional, del cual surge la influencia que tuvo la eugenesia en los ámbitos científicos, académicos y jurídicos. Teoría que tenía por objetivo la búsqueda del “perfeccionamiento” de la especie humana, lo que implicaba descartar a los seres humanos más débiles, imperfectos o defectuosos. Dentro de este contexto se impulsó la modificación del Código Penal, por lo que es central para entender la “voluntad del legislador histórico” el Informe de la Comisión de Códigos del Senado de la Nación, de 1920, que receptó claramente las ideas eugenésicas, siendo el Artículo 86, inc. 2, un claro ejemplo de ello. El mencionado informe demuestra que la verdadera motivación de los legisladores para incluir la no punibilidad del aborto en este inciso fue que no nacieran “seres anormales o degenerados”, no hay una sola mención a la situación de la mujer embarazada y de los perjuicios que un embarazo en estas condiciones le podrían acarrear.

El judaísmo frente al problema bioético del aborto : la vigencia del postulado frente a todo derecho

Resumen: El judaísmo, desde sus cánones y a través del análisis del conceptus, contribuye no solo a lidiar con la forma en la cual en el presente se intenta dirimir la problemática bioética del aborto, sino también a desarrollar un campo de acción y pensamiento aportando consideraciones, juicios y nociones diferentes que permiten mejorar la calidad de discusión y a su vez construir una sociedad más justa y por ende más libre.

Raíces ideológicas de la perspectiva de género

Resumen: El feminismo radical o de género tiene sus orígenes históricos, su matriz ideológica y su modo dialéctico de entender la relación varón-mujer, en el pensamiento marxista (Engels, de Beauvoir, Firestone). La “antítesis” de esta lucha de sexos es la revolución feminista radical, y su principal instrumento revolucionario y de penetración cultural es la ideología de género. La fase central de esta revolución es el apoderamiento, por parte de las mujeres, de los medios de reproducción. Los medios que han demostrado ser más aptos para lograr la victoria son el aborto por decisión privativa de la mujer, la fecundación artificial y el matrimonio entre personas del mismo sexo. La revolución se libra en el campo cultural y, luego, en el jurídico.

Diagnóstico prenatal en el marco de la bioética personalista ontológica : percepción del uso, actitudes y requerimientos de los pacientes en un centro privado de la ciudad de Buenos Aires

Resumen: Los estudios prenatales tienen la capacidad de realizar diagnósticos precoces de anomalías en el feto, ello facilita la posibilidad de implementar intervenciones tempranas, tanto médicas como no médicas, en el cuidado de la gestación y controles perinatales, pero también permite, en ciertas circunstancias, considerar como opción el aborto electivo del hijo en gestación. Surgen dos dilemas: por un lado, la forma en que esta información es comunicada a la familia y, por otro -y como consecuencia del anterior-, responder en qué circunstancias estos diagnósticos genéticos permitirán obtener más beneficio que daño.

El aborto en la ley europea : derechos humanos, derechos sociales y la nueva tendencia cultural

Resumen: Este artículo se propone analizar: 1) si existe un verdadero “derecho al aborto” en la Convención Europea de Derechos Humanos, 2) si el aborto es una violación a los Derechos Sociales, 3) si la reciente tendencia en Europa frente a la restricción del aborto muestra que éste es un problema social y no un derecho o una libertad individual. Legisladores y organizaciones esperando proteger mejor a los niños y a las mujeres, del aborto, encontrarán críticas a la idea de la existencia de un derecho humano al aborto, así como el marco legal en el cual elaborar leyes protectorias.