reading articles and answer all the questions in the assignment description.

Ethics and reproductive health: a principled approach Ruth Macklina

When we learn that an estimated 500 000 women, at least, die annually from pregnancy-related causes (1) and that the vast majority of these deaths occur in the developing world (2), the ethical problem is self-evident. When we hear that in many developing countries, complications of pregnancy and child- birth are among the main causes of death in 15-19 year-old women and that in Jamaica and Nigeria, girls younger than 15 years of age are 4 times more likely to die during pregnancy and childbirth than 15-19 year-olds (3), the conclusion is inescapable.

As a public health imperative, both govern- ments and health-related nongovernmental orga- nizations have an obligation to take all necessary steps to reduce this staggering rate of maternal mortality. The same ethical obligation exists for the individual physician caring for patients, the obligation to strive to prevent the most common causes of maternal mortality: deaths resulting from obstructed labour and ruptured uterus, postpar- tum haemorrhage, pregnancy-induced hyperten- sion, postpartum infection, or septic abortion (2). For the individual clinician, this obligation means both helping women to take proper preventive health measures and also administering appropri- ate therapy to patients. When we learn that be- tween 100 000 and 200 000 of the annual deaths from pregnancy-related causes are estimated to be d u e to improperly performed and usually illegal abortions (1), the ethical problem is again self- evident, but more controversial.

When all the figures are considered, not just the maternal deaths from preventable causes, but the staggering figures for maternal morbidity from un- safe abortions, a very grim picture of women's over- all health and reproductive health begins to appear.

One way of addressing ethical issues in repro- ductive health is to look at the consequences of current laws, policies and practices and see whether the existing situation gives rise to a pre- ponderance of good or bad consequences. If the bad consequences outweigh the good ones, there is an ethical obligation to seek to change the laws, policies or practices. The data on maternal mortal- ity and morbidity in developing countries make it uncontroversial to state that the harmful conse-

quences for women of inadequate family planning programmes and of laws prohibiting abortion far outweigh the beneficial consequences.

Furthermore, these harmful consequences not only affect women, but also the children they bear. For example, it has been shown that the death of a mother increases significantly both the morbidity and mortality rates of her surviving children, par- ticularly those u n d e r age 5 (1). And it is well known that prematurity and low birth weight in infants are frequent consequences of births too closely spaced, as well as of pregnancies occurring when women are too young or of advanced age for child- bearing.

It is always easier to point to ethical problems than it is to devise solutions. Some solutions to poor reproductive health in developing countries require money those countries do not have, trained medical or paramedical personnel current- ly in short supply, and medical equipment of vari- ous kinds that is expensive or hard to maintain. There is no ethical principle that can dictate a solution to problems that stem from genuinely scarce or expensive resources. However, there are ethical principles that point to solutions to mater- nal mortality and morbidity from preventable causes. The barriers to these solutions are not lack of money but lack of political will, the indifference of men in power to death and disease among un- empowered women, and traditional customs that should be made to change for ethical reasons. Indi- viduals and groups can work towards a solution by using euiical principles to justify placing a high priority on reducing maternal mortality and mor- bidity from preventable causes.

Universal agreement on ethical matters is a goal unlikely to be reached. This is not only because of the cultural and religious differences that exist in our world, but also because some issues are deeply problematic from an ethical point of view. This creates dilemmas for decision makers, be they cli- nicians or policy makers. Even people who share a common religious and cultural background often disagree about particular matters. But despite such disagreements about particulars, universal ethical principles do exist. Problems in applying these principles lie not with the principles themselves, but with the various ways in which they can be interpreted. Let us begin with the principle of be- neficence, which obligates people to try to produce more good than harm.

148 Rapp. trimest. statist, sanit. mond., 49 (1996)

Beneficence In t h e field of m e d i c i n e , this principle obligates b o t h individual clinicians a n d policy makers to strive to b r i n g a b o u t m o r e beneficial consequences t h a n harmful o n e s . In clinical practice, the princi- ple takes t h e form of m a k i n g risk-benefit assess- m e n t s , on which physicians base t r e a t m e n t recom- m e n d a t i o n s having t h e most favourable benefit- risk ratio for the individual p a t i e n t .

Risk-benefit assessments c a n also be used to evaluate family p l a n n i n g p r o g r a m m e s a n d o t h e r r e p r o d u c t i v e h e a l t h services. A p p l i e d to m e t h o d s o f family p l a n n i n g , t h e g o o d a n d b a d consequen- ces of e a c h m e t h o d m u s t be e x a m i n e d , looking at those c o n s e q u e n c e s b o t h for t h e user a n d h e r sexual p a r t n e r . H e r e , as elsewhere, g o o d ethics will b e g i n with g o o d facts. In m a k i n g risk-benefit assess- m e n t s , accurate, up-to-date information must be e m p l o y e d . Care m u s t be t a k e n to use a p propriate d a t a for t h e locale in which t h e m e t h o d is to be used. This is b e c a u s e d a t a g a t h e r e d a b o u t risks a n d benefits for w o m e n in d e v e l o p e d countries or in some r e g i o n s of t h e d e v e l o p i n g world may n o t be strictly applicable to w o m e n in o t h e r developing c o u n t r i e s . For this r e a s o n , characteristics of the users of c o n t r a c e p t i v e m e t h o d s m u s t be factored into t h e risk-benefit assessment. For example, tak- ing a daily pill in a society in which pill-taking is otherwise r a r e is unlikely to gain c o m p l i a n c e . T h e n a t u r a l family p l a n n i n g m e t h o d that relies on w o m e n accurately m o n i t o r i n g t h e i r cervical secre- tions is no d o u b t an alien c o n c e p t to women in m a n y c u l t u r e s . A n d reliance on c o n d o m s in societies in which m e n steadfastly refuse to use t h e m c a n n o t p r o t e c t w o m e n against unwanted p r e g n a n c i e s or sexually t ra n sm i t t e d diseases.

This last p o i n t d e m o n s t r a t e s t h a t t h e r e is an inevitable relativity in m a k i n g risk-benefit assess- m e n t s . D e p e n d i n g on t h e features of t h e service delivery system, t h e cultural aspects of a country or r e g i o n , a n d t h e beliefs a n d attitudes of t h e p e o p l e , some family p l a n n i n g m e t h o d s will have a m o r e favourable benefit-risk ratio t h a n o t h e r s . T h e risks i n c l u d e n o t only the m e d i c a l a n d psychological risks to t h e users of a family p l a n n i n g m e t h o d , b u t also t h e risk of not having effective family p l a n n i n g m e t h o d s available a n d n o t having a b a c k u p for failed c o n t r a c e p t i o n . This u n d e r s c o r e s t h e p o i n t that risk-benefit assessments are likely to yield dif- ferent results at different times a n d in different places.

This relativity in t h e application of ethical prin- ciples to different situations m u s t be distinguished from t h e very different n o t i o n of ethical relativism, t h e view t h a t ethics c a n be relative to time, place a n d c i r c u m s t a n c e . A l t h o u g h it is t r u e t h a t different c u l t u r e s have different n o r m s a n d customs, i t d o e s n o t follow t h a t whatever cultural or national prac- tices exist a r e ethically justified. I will r e t u r n to this p o i n t by way of c o n c l u s i o n .

T h e principle of beneficence, like o t h e r ethical principles, is objective. To say it is objective m e a n s t h a t its p r o p e r application requires obtaining accu- rate data. With regard to reproductive health, t h e d a t a must take into a c c o u n t the actual experiences of women. To do so necessarily relies on subjective reports given by women. But that does n o t under- m i n e the objectivity of t h e process. Information a b o u t subjective experiences can be g a t h e r e d in an objective way, that is, a way that is scientifically valid a n d uses established m e t h o d s of data-gathering. Social a n d behavioral research reveals a wealth of information a b o u t how women r e s p o n d to differ- e n t m e t h o d s of family planning, which m e t h o d s they find acceptable or unacceptable, the reasons for n o n c o m p l i a n c e with some m e t h o d s , the role female literacy plays in reproductive health, a n d why women resort to unsafe abortions in countries where safe, legal abortions are n o t accessible to t h e m . A failure to take into a c c o u n t w o m e n ' s ac- tual experiences a n d attitudes is likely to result in flaws in risk-benefit assessments m a d e from the perspective of medical scientists.

For example, evidence can be cited to show that w o m e n ' s values have b e e n either neglected or u n - d e r r a t e d in formulating risk-benefit assessments. W o m e n ' s health advocates t e n d to define the "safety" of contraceptive m e t h o d s in t e r m s differ- e n t from those typically employed by biomedical scientists. According to o n e report:

Scientists' c o n c e r n is to establish safety of meth- ods according to specific measurable parame- ters. They assess toxicity, first in animals a n d then in carefully controlled studies in h u m a n volunteers. Subsequent studies address efficacy and short- to medium-term safety. ... W o m e n ' s health advocates ... give m o r e priority to meth- ods that have fewer side effects a n d that protect against sexually transmitted diseases a n d their consequences such as infertility. While scien- tists have t e n d e d to give priority to m e t h o d s which minimize users' control, w o m e n ' s health advocates prefer m e t h o d s controlled by the user (4). T h e same mix of objective a n d subjective ele-

m e n t s e n t e r s into balancing risks a n d benefits. T h a t , too, is partly a scientific matter, based on available evidence regarding the probability a n d m a g n i t u d e of anticipated risks a n d benefits; b u t it is also a subjective matter. Different people - be they medi- cal scientists, patients or healthy laypersons - may evaluate the risks a n d benefits differently. They may consider some risks worth taking in relation to expected benefits while o t h e r risks may be viewed as unacceptably high in relation to e x p e c t e d benefits. A point m a d e by o n e participant in a meeting between w o m e n ' s health advocates a n d scientists is worth r e p e a t i n g , "On the question of side effects, t h e r e is always a tendency to over-emphasize the benefits a n d underplay the risks... Most of the time

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i t i s w e w o m e n w h o u n d e r g o t h e risks a n d t h e b e n e f i t s a r e t a k e n b y t h e p h a r m a c e u t i c a l c o m p a n i e s o r b y p o p u l a t i o n c o n t r o l e x p e r t s o r g o v e r n m e n t s o f T h i r d W o r l d c o u n t r i e s " (4).

An e x a m p l e of t h e way w o m e n ' s assessments of t h e risks a n d benefits of contraceptives may diverge from t h a t of clinicians, medical scientists or gov- e r n m e n t a l a g e n c i e s c o m e s from Mexico. O n e par- t i c i p a n t at a c o n f e r e n c e o n ethics a n d r e p r o d u c t i v e h e a l t h b s u g g e s t e d tiiat if allowed a c h o i c e , w o m e n m a y c h o o s e a h i g h e r risk m e t h o d of c o n t r a c e p t i o n t h a t h a s fewer side effects r a t h e r t h a n a m o r e effec- tive m e t h o d w i t h u n d e s i r a b l e side effects. W o m e n w o u l d r a t h e r take t h e risk o f b e c o m i n g p r e g n a n t t h a n use a c o n t r a c e p t i v e m e t h o d with u n a c c e p t - a b l e side effects. It was n o t e d t h a t the p o p u l a t i o n in M e x i c o d o e s n o t w a n t h o r m o n a l m e t h o d s o r IUDs, b u t t h e s e a r e t h e m e t h o d s p r o m o t e d b y t h e family p l a n n i n g agency. A c o n f e r e n c e p a r t i c i p a n t n o t e d t h a t t h e t h r e e c o n t r a c e p t i v e m e t h o d s m o s t p r e - f e r r e d by t h e p o p u l a t i o n are sterilization, t h e r h y t h m m e t h o d a n d t h e c o n d o m . However, a s t h e g o v e r n m e n t a l system in Mexico is c u r r e n t l y m a n - a g e d , i f c o u p l e s a c c e p t t h e c o n d o m they d o n o t officially c o u n t a s " a c c e p t o r s . "

T h e r e is a l o n g - s t a n d i n g tradition in m e d i c a l p r a c t i c e everywhere of paternalism, t h e view t h a t d o c t o r s a n d m e d i c a l scientists k n o w w h a t is best for p a t i e n t s . N o t only a r e they s u p p o s e d t o know w h a t is best, b u t t h e i r k n o w l e d g e a n d authority h a s tradi- tionally b e e n u s e d to justify decision-making by d o c t o r s o n behalf o f patients, a n d even c o e r c i o n o f p a t i e n t s "for t h e i r own g o o d . " As an illustration of this p a t e r n a l i s t i c a t t i t u d e a n d disregard for w o m e n ' s own values, a m a r k e t e r for o n e m e t h o d was q u o t e d at the c o n f e r e n c e in Mexico as saying, "This is a f e m i n i s t m e t h o d : w h a t d o e s it m a t t e r if it h a s side effects?"

Risk-benefit assessments play a c e n t r a l r o l e in t h e m e d i c a l c o n t e x t , even t h o u g h t h e risks a n d benefits have traditionally b e e n defined a n d w e i g h e d m o r e by physicians than by t h e patients w h o suffer t h e risks a n d enjoy t h e benefits of t r e a t m e n t s . However, analysis t h a t focuses o n benefit a n d h a r m h a s t o o often b e e n i g n o r e d a m o n g scholars in t h e field of b i o e t h i c s , w h o have t e n d e d t o focus m o r e o n t h e r i g h t s o f p a d e n t s a n d r e s p e c t for t h e i r a u t o n o m y .

Nevertheless, w e c a n n o t e l i m i n a t e t h e l a n g u a g e of rights w h e n a d d r e s s i n g ethical issues in r e p r o - ductive h e a l t h . T h a t is b e c a u s e we c a n n o t i g n o r e t h e r o l e of r e p r o d u c t i v e rights within a larger framework o f h u m a n rights. I n t e r n a t i o n a l a t t e n - tion t o h u m a n r i g h t s h a s focused o n violations o f h u m a n r i g h t s i n a r e a s s u c h a s t o r t u r e , t h e treat- m e n t o f political p r i s o n e r s , a n d d e n i a l o f t h e fun- d a m e n t a l f r e e d o m s o f citizens u n d e r a u t h o r i t a r i a n

political r e g i m e s . It is n o w widely believed t h a t at least s o m e r e p r o d u c t i v e rights s h o u l d b e i n c l u d e d a m o n g t h e f u n d a m e n t a l h u m a n rights n o w ac- k n o w l e d g e d t h r o u g h o u t t h e world.

Respect for persons T h e universal ethical p r i n c i p l e from which t h e c o n c e p t of h u m a n rights is d e r i v e d is k n o w n as "respect for p e r s o n s " . As a universal e t h i c a l p r i n c i - p l e , it p r e s u m e s t h a t all h u m a n b e i n g s have dignity a n d a r e worthy of respect. In today's world, virtual- ly every society pays lip service to h u m a n rights. Sadly, however, violations of h u m a n rights c o n t i n - u e i n s o m e n a t i o n s a n d r e g i o n s . B u t even i n t h o s e societies t h a t a c k n o w l e d g e r e s p e c t for p e r s o n s , it is often the case t h a t e q u a l r e s p e c t is n o t shown to w o m e n a s p e r s o n s . O n l y w h e n w o m e n a r e g r a n t e d a status of r e s p e c t as p e r s o n s e q u a l to t h a t tradition- ally given to m e n can ethical issues in r e p r o d u c t i v e h e a l t h b e p r o p e r l y a d d r e s s e d .

For e x a m p l e , c o u n t r i e s that have laws or c u s t o m s r e q u i r i n g a h u s b a n d ' s a u t h o r i z a t i o n b e f o r e a wom- a n can b e sterilized, receive c o n t r a c e p t i o n o r u n d e r - go an a b o r t i o n , fail to show e q u a l r e s p e c t for w o m e n as p e r s o n s (5). Similarly, l o n g - s t a n d i n g c u s t o m s t h a t sanction h u s b a n d s ' p o w e r t o d e t e r m i n e which m e a n s of b i r t h c o n t r o l , if any, t h e i r wives may u s e quite clearly g r a n t u n e q u a l r e s p e c t t o m e n ' s deci- sion-making a u t h o r i t y over tiiat of w o m e n . Yet it c a n n o t be d e n i e d that t h e effects of s u c h decisions o n w o m e n a r e m o r e p r o f o u n d a n d potentially m o r e devastating t h a n o n t h e m e n w h o m a k e t h e m . I t i s n o t m e n w h o a r e dying from c o m p l i c a t i o n s o f p r e g - n a n c y a n d c h i l d b i r t h o r septic a b o r t i o n . I t i s n o t m a l e a d o l e s c e n t s w h o suffer m o r b i d i t y a n d m o r t a l - ity from c h i l d b i r t h . A n d i t i s n o t m e n w h o b e c o m e infertile as a r e s u l t of t h e s e practices.

T h e ethical p r i n c i p l e t h a t serves as a f o u n d a t i o n t o g r a n t i n g w o m e n r e p r o d u c t i v e rights i s t h e p r i n - ciple o f individual f r e e d o m o r liberty. T h e m a n - d a t e t o p r o m o t e r e p r o d u c t i v e f r e e d o m h a s b e e n r e c o g n i z e d , at least as a m a t t e r of p r i n c i p l e , t h r o u g h o u t t h e world. Since t h e first W o r l d P o p u - lation C o n f e r e n c e , h e l d in B u c h a r e s t in 1974, m o r e t h a n 130 c o u n t r i e s have s i g n e d t h e following s t a t e m e n t r e g a r d i n g r e p r o d u c t i v e r i g h t s : "All c o u - ples a n d individuals have t h e basic r i g h t t o d e c i d e freely a n d responsibly t h e n u m b e r a n d spacing o f t h e i r c h i l d r e n a n d t o have t h e i n f o r m a t i o n , educa- tion a n d m e a n s to do so." (6) T h a t s t a t e m e n t was r e i t e r a t e d 10 years l a t e r at t h e Mexico City W o r l d P o p u l a t i o n C o n f e r e n c e , a n d s t r e n g t h e n e d even f u r t h e r i n 1994 a t t h e I n t e r n a t i o n a l C o n f e r e n c e o n P o p u l a t i o n a n d D e v e l o p m e n t i n C a i r o . c , d

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T h e e t h i c a l p r i n c i p l e o f "equal r e s p e c t for per- sons" can be u n d e r s t o o d at an individual level a n d as an i n g r e d i e n t in social j u s t i c e . At t h e individual level, showing e q u a l r e s p e c t for w o m e n as p e r s o n s m e a n s recognizing their a u t o n o m y a n d treating t h e m as capable decision-makers a n d full partici- p a n t s i n medical decisions. O n e e x a m p l e would b e h o n o u r i n g w o m e n ' s feelings a n d p r e f e r e n c e s i n m o d e s o f c o n t r a c e p t i o n a n d m e t h o d s o f abortion, even if it is m o r e cost-effective to i m p o s e m e t h o d s p r e f e r r e d by providers or f u n d e r s . A n o t h e r exam- ple is t r e a t i n g p r e g n a n t w o m e n with dignity a n d r e s p e c t i n s t e a d of merely as "fetal c o n t a i n e r s . "

T h e p r i n c i p l e of "respect for p e r s o n s " is viol- a t e d w h e n w o m e n w h o seek a b o r t i o n s or ask for m e d i c a l h e l p following c o m p l i c a t i o n s of an in- d u c e d a b o r t i o n are t r e a t e d punitively by physi- cians or o t h e r health-care workers. Even worse t h a n b e i n g t r e a t e d punitively or in a d e g r a d i n g m a n n e r a r e situations in which physicians refuse to r e n d e r m e d i c a l assistance to w o m e n following a self-induced a b o r t i o n . A m e m b e r of t h e a u d i e n c e at the a u t h o r ' s lecture in Santiago, Chile in 1993 r e p o r t e d t h e following case. A p a t i e n t was b r o u g h t t h e hospital after a self-induced a b o r t i o n , dying a n d i n n e e d o f m e d i c a l a t t e n t i o n . T h e physician refused to h e l p t h e p a t i e n t , saying t h a t if a d o c t o r tried to h e a l a p a t i e n t w h o h a d c o m m i t t e d a sin, t h e physician would also be complicit in that sinful b e h a v i o u r . T h e d o c t o r refused to assist t h e pa- t i e n t . T h e physician i n t h a t case h a d u n q u e s t i o n - ably violated his obligation to care for sick a n d dying p a t i e n t s . A physician w h o is o p p o s e d to a b o r t i o n s o n m o r a l o r religious g r o u n d s should n o t be forced to perform t h e p r o c e d u r e . However, this case did n o t involve a physician p e r f o r m i n g or assisting in an a b o r t i o n b u t r a t h e r , t r e a t i n g a pa- t i e n t w h o h a d m a d e t h e a t t e m p t herself. S o the physician c o u l d in no way be viewed as complicit in t h e p a t i e n t ' s earlier act.

T h r o u g h o u t history, w o m e n have always s o u g h t a n d will c o n t i n u e to seek an e n d to u n w a n t e d p r e g n a n c i e s . W o m e n will c o n t i n u e t o resort to a b o r t i o n as a b a c k u p for failed c o n t r a c e p t i o n . A first step in seeking to r e d u c e t h e n u m b e r of abor- tions, be t h e y safe or unsafe, legal or illegal, is the r e c o g n i t i o n of w o m e n ' s right to be adequately in- f o r m e d a b o u t available family p l a n n i n g m e t h o d s . This i n c l u d e s i n f o r m a t i o n a b o u t what p r o c e d u r e s are involved in p r o p e r use of t h e m e t h o d , a n d a b o u t t h e risks a n d benefits of various available m e t h o d s . T h e p r i n c i p l e of r e s p e c t for p e r s o n s m a n d a t e s t h a t w o m e n ' s use of a particular m e t h o d must be voluntary, t h a t is, free c o e r c i o n or u n d u e i n d u c e m e n t s of any sort.

I n t h e a b o r t i o n d e b a t e , t h e rights o f the fetus are typically p i t t e d against t h e rights of t h e preg- n a n t w o m a n . I n t h e political d e b a t e carried o n i n the U n i t e d States o f A m e r i c a a n d i n o t h e r coun- tries, feminists have a d o p t e d t h e p h r a s e " a

w o m a n ' s right to control h e r own body", thus iden- tifying a right that could presumably override the r i g h t to life of t h e fetus. "The right to control o n e ' s own body" is a n o t h e r way of describing the right to self-determination. T h e underlying basis for this reproductive right is the right to liberty. T h e principle of liberty dictates that individuals have a right to freedom of decision a n d action, to the e x t e n t t h a t their actions do n o t interfere with t h e rights of others. O p p o n e n t s of a woman's right to a b o r t i o n do n o t disagree on the soundness of that fundamental ethical principle itself. Yet they disagree profoundly over its application: o p p o - n e n t s of a b o r t i o n claim that the act of terminating a pregnancy d o e s interfere with t h e rights of a n o t h e r (the fetus), while advocates of a w o m a n ' s right to p r o c u r e an abortion deny that killing a fetus is a violation of rights.

As is t r u e of any conflict of rights, this o n e m i g h t be resolved in favour of either party - the w o m a n or the fetus. If a right to life is ascribed to fetuses a n d a right to terminate a pregnancy is assigned to women, a h i g h e r priority could be giv- en to the rights of the woman. However, as impor- tant as t h e value of liberty is in philosophical and political t h o u g h t , only rarely is it held to outweigh t h e value of h u m a n life when the two values con- flict. T h e r e f o r e , the most reasonable way to resolve this a p p a r e n t conflict of rights in favour of the woman is to d e n y that t h e fetus can properly be considered an entity having rights. T h e view that a fetus is a "person" from the m o m e n t of fertiliza- tion, a n d therefore possesses a right to life j u s t like already-born individuals, is a p r e c e p t of some, but by no m e a n s all religious faiths.

O n e way of trying to think clearly about the r i g h t of p r e g n a n t women to control their own bod- ies is by c h a n g i n g the context of the abortion de- bate. A useful analogy to consider is that of organ or bone-marrow transplantation. Sometimes chil- d r e n are in n e e d of a life-saving or possibly curative p r o c e d u r e a n d the best tissue match is a parent. No o n e has ever convincingly argued t h a t an unwilling father should be compelled to u n d e r g o surgery for removal of a kidney or even a b o n e marrow extrac- tion for t h e benefit of his child. And no j u d g e has ever o r d e r e d such a p r o c e d u r e . For t h e govern- m e n t or, p e r h a p s , a h u s b a n d to insist that a woman r e m a i n p r e g n a n t against h e r will, for the sake of t h e fetal life within her, is thus to g r a n t a higher moral status to developing fetal life than to that of already-born children.

Justice This article has explored the ethical principles of beneficence a n d respect for p e r s o n s a n d their ap- plication to reproductive health. A third leading c o n c e r n of bioethics is justice. Questions of justice arise with respect to the distribution of family plan- n i n g m e t h o d s , including access to safe abortion in

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cases of c o n t r a c e p t i v e failure. A j u s t distribution of r e p r o d u c t i v e health services r e q u i r e s t h a t m e t h o d s be accessible to p o o r w o m e n as well as those w h o a r e b e t t e r off, to t h e less e d u c a t e d as well as t h o s e w h o a r e b e t t e r e d u c a t e d , to rural as well as u r b a n r e s i d e n t s .

T h e p r i n c i p l e o f j u s t i c e m a n d a t e s t h a t all indi- viduals w h o n e e d family p l a n n i n g a n d h e a l t h ser- vices s h o u l d have e q u i t a b l e access to t h e m . F r o m a n e t h i c a l p e r s p e c t i v e , " e q u i t a b l e access" m e a n s t h a t u s e o f t h e s e services s h o u l d n o t b e based o n a n ability to pay for t h e m . G u a r a n t e e i n g access by law h a s n o t p r o v e d sufficient for achieving social j u s - tice in societies t h a t do n o t recognize a r i g h t to h e a l t h c a r e . An a d d i t i o n a l p r e c o n d i t i o n for access i s i n f o r m a t i o n a b o u t t h e existence a n d n a t u r e o f t h e services. A m o r a l obligation exists to e n s u r e t h a t w o m e n have i n f o r m a t i o n , as well as t h e m e a n s to o b t a i n family p l a n n i n g services.

T h e s e c o n c l u s i o n s apply with even m o r e force t o w o m e n i n d e v e l o p i n g c o u n t r i e s t h a n they d o i n d e v e l o p e d c o u n t r i e s . P o o r w o m e n everywhere dis- p r o p o r t i o n a t e l y b e a r t h e b u r d e n o f restrictive a b o r t i o n laws a n d i n a d e q u a t e o r n o n e x i s t e n t fam- ily p l a n n i n g services. J u s t i c e dictates n o t only t h a t e q u a l r e s p e c t b e shown t o w o m e n , b u t also t h a t t h e n e e d s o f t h e least a d v a n t a g e d m e m b e r s o f society b e a d d r e s s e d .

Cultural and ethical relativism W e n o w r e t u r n t o t h e topic o f cultural a n d ethical relativism. P e r h a p s even m o r e than i n o t h e r a r e a s o f m e d i c i n e a n d h e a l t h c a r e , t h e i n t r o d u c t i o n o f t e c h n i q u e s a n d practices related t o h u m a n r e p r o - d u c t i o n gives rise to ethical controversy s t e m m i n g from social, c u l t u r a l a n d religious differences. A c u l t u r e may have a long-standing tradition prefer- r i n g or rejecting c e r t a i n m e t h o d s of family p l a n - n i n g . T h e r e may be a religious p r o h i b i t i o n against c o n t r a c e p t i o n or a b o r t i o n . In a c u l t u r e c h a r a c t e r - ized b y d o m i n a n c e o f m e n over t h e i r w o m e n part- n e r s , o r o n e i n w h i c h t h e rights o f w o m e n a r e n o t fully r e c o g n i z e d a n d g r a n t e d , some family plan- n i n g m e t h o d s m o r e desirable t o w o m e n m i g h t b e r e j e c t e d b y m e n , b e t h e y m e n w h o h o l d political p o w e r o r m e n w h o a r e t h e h u s b a n d s a n d sexual p a r t n e r s of w o m e n . By law or custom, t h e p r a c t i c e o f "spousal a u t h o r i z a t i o n " for sterilization o r c o n - t r a c e p t i o n r e m a i n s in force in a n u m b e r of devel- o p i n g c o u n t r i e s t o d a y (5).

It r e q u i r e s e n h a n c e d sensitivity a n d a c o m m i t - m e n t t o social p r o g r e s s t o recognize that c e n t u r i e s - o l d c u l t u r a l p a t t e r n s of b e h a v i o u r of m e n toward t h e i r wives, t h e i r sexual p a r t n e r s , a n d t h e i r d a u g h - ters a r e ethically u n a c c e p t a b l e . J u s t because t h e s e p a t t e r n s have existed for c e n t u r i e s d o e s n o t m a k e t h e m r i g h t . J u s t b e c a u s e they have b e e n wide- s p r e a d a n d largely t o l e r a t e d i n m a n y c u l t u r e s d o e s n o t m a k e t h e m r i g h t . T h e fact t h a t a majority o f p e o p l e in a society a c c e p t a n d subscribe to c e r t a i n

social o r c u l t u r a l practices d o e s n o t a m o u n t t o a n ethical justification of t h o s e practices.

For e x a m p l e , c o n s i d e r t h e p r a c t i c e o f g e n i t a l m u t i l a t i o n o f w o m e n , m o r e politely c a l l e d "fe- male circumcision." An e s t i m a t e d 120 million girls a n d w o m e n i n t h e w o r l d are genitally m u t i l a t e d (7). S h o u l d this be t h o u g h t of simply as a " c u l t u r a l rite" following t h e t r a d i t i o n a l c u s t o m w h e r e t h e ritual has b e e n practised for centuries? O r s h o u l d it m o r e p r o p e r l y be t h o u g h t of as m u t i l a t i o n of t h e body o f female p e r s o n s , m o r e akin t o t o r t u r e t h a n to a c u l t u r a l ritual t h a t causes t e m p o r a r y p a i n b u t is n o t overly harmful? Can any of t h e justifications offered for t h e p r a c t i c e of female g e n i t a l mutila- tion stand u p t o ethical scrutiny? I t w o u l d n o t b e sufficient t o show t h a t t h e practice o f g e n i t a l m u t i - lation of females is merely approved of by t h e cul- t u r e s t h a t p r a c t i c e it. A c c o r d i n g t o t h a t m e t h o d , slavery c o u l d be ethically justifiable if a majority of p e o p l e in t h e society ( t h a t is, t h e slaveholders) a p p r o v e d of slavery. Using t h e ethical p r i n c i p l e of b e n e f i c e n c e , o n e w o u l d have t o d e m o n s t r a t e t h a t this c u l t u r a l p r a c t i c e actually c r e a t e s m o r e g o o d t h a n h a r m , c o m p a r e d t o t h e alternative o f n o t e n g a g i n g i n t h e p r a c t i c e ; o r t h a t i t p r o d u c e s m o r e beneficial c o n s e q u e n c e s for t h e g r e a t e s t n u m b e r o f p e o p l e t h a n i t d o e s harmful c o n s e q u e n c e s . However, t h e m o r b i d i t y a n d mortality o f female infants, p u b e s c e n t girls, a n d w o m e n l a t e r i n t h e i r lives has b e e n w e l l - d o c u m e n t e d a n d is sufficient to c o n d e m n t h e p r a c t i c e o n g r o u n d s o f its h e a l t h c o n s e q u e n c e s for t h o s e w h o a r e subjected to it. T h e c o n s e q u e n c e s i n c l u d e p a i n , t r a u m a a n d se- vere physical c o m p l i c a t i o n s i n b o t h t h e s h o r t a n d l o n g t e r m .

T h e r e a s o n s given for this ritual surgery in- clude: (i) it is a g o o d t r a d i t i o n n e e d e d for g r o u p identity; (it) it is a religious r e q u i r e m e n t ; (Hi) it is necessary for cleanliness a n d h e a l t h ; a n d (iv) it is n e e d e d t o p r e s e r v e virginity a n d family h o n o u r , a n d to c o n t r o l immorality (8). It is b e y o n d t h e scope o f this p a p e r t o analyse a n d r e s p o n d t o e a c h of these r e a s o n s . However, a careful analysis w o u l d have t o a d d r e s s e a c h o f these r e a s o n s a n d q u e s t i o n f i r s t a n d f o r e m o s t , w h e t h e r they rest o n s o u n d empirical e v i d e n c e . F o r e x a m p l e , c o u l d this partic- u l a r c u l t u r a l p r a c t i c e b e a b a n d o n e d while still p r e - serving o t h e r t r a d i t i o n a l practices t h a t p r o m o t e g r o u p identity? Secondly, t h e claim t h a t it is a religious r e q u i r e m e n t also m u s t b e subjected t o ethical scrutiny. If s o m e religion r e q u i r e d t h e sacri- fice of t h e first-born child at age twelve, c o u l d t h a t practice be ethically justified simply b a s e d on t h e fact t h a t it is a feature of t h e t r a d i t i o n a l religion? F u n d a m e n t a l ethical p r i n c i p l e s c a n b e u s e d t o eval- u a t e specific practices r e q u i r e d o r c o n d o n e d b y any r e l i g i o n , h o w e v e r p r o m i n e n t , d o m i n a n t , o r w i d e s p r e a d t h e religion may b e . J u s t b e c a u s e a religion d i c t a t e s or c o n d o n e s a p a r t i c u l a r p r a c t i c e d o e s n o t m e a n t h a t t h e p r a c t i c e i s ethically right.

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T h e r e c o u l d be no religious reform if it were n o t possible to stand outside the dictates of a particular religion a n d j u d g e some of its features to be wrong.

U n l i k e some ethical c o n c e r n s , female genital m u t i l a t i o n is a practice in which all t h r e e leading b i o e t h i c a l principles are shown to be violated. T h e ethical p r i n c i p l e of "respect for p e r s o n s " is viol- a t e d in situations w h e r e w o m e n are c o n t r o l l e d by m e n for t h e express p u r p o s e of satisfying m e n ' s sexual p l e a s u r e at t h e e x p e n s e of their own, when w o m e n lose t h e capacity for sexual pleasure a n d expression of their sexual feelings, a n d w h e n they are u n m a r r i a g e a b l e if they are n o t genitally muti- lated in a c c o r d a n c e with t h e n o r m s of t h a t society. F u r t h e r m o r e , any society in which t h e r e a r e differ- e n t s t a n d a r d s of sexual morality for m e n a n d for w o m e n violates t h e p r i n c i p l e o f "equal r e s p e c t for p e r s o n s . " W o m e n are u n d e n i a b l y p e r s o n s . If geni- tal m u t i l a t i o n is a cultural practice held to be justi- fied b e c a u s e it serves to c o n t r o l immorality, it is the alleged sexual immorality of w o m e n b u t n o t of m e n t h a t it seeks to c o n t r o l . Failure to g r a n t equal r e s p e c t t o w o m e n a n d t o m e n , a n d p e r p e t u a t i o n o f practices t h a t constitute o p p r e s s i o n of w o m e n are violations of t h e p r i n c i p l e of j u s t i c e .

To resist ethically m a n d a t e d c h a n g e because of long-held beliefs or practices is a philosophical e r r o r . T h e e r r o r lies in c o n c l u d i n g t h a t because a state of affairs h a s existed in the past, it o u g h t to c o n t i n u e i n t o t h e p r e s e n t a n d future. T h e flaw i n t h a t r e a s o n i n g c a n easily be seen by reflecting on the fact t h a t manifestly unjust social institutions, such as slavery a n d colonialism, would still be with us if history a n d tradition served as an infallible m o r a l g u i d e . M o r a l progress r e q u i r e s a critical eval- u a t i o n of past practices a n d institutions. Of course, m a n y social practices a n d institutions will with- stand such critical evaluation, b u t o t h e r s will not. Subjugation of w o m e n , d e n i a l of their right to self- d e t e r m i n a t i o n i n c h o o s i n g a n acceptable m e t h o d of family p l a n n i n g , a n d p r e v e n t i n g t h e m from hav- ing access to safe, legal a b o r t i o n are practices t h a t c a n n o t withstand critical ethical evaluation.

Summary

Universal ethical principles can be used to analyse problems in reproductive health. The principle of benef- icence obligates people to strive to bring about more beneficial consequences than harmful ones. The princi-

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