ETHICO-LEGAL ISSUES IN NURSING ADMINISTRATION:

REPRODUCTIVE DECISION MAKING

REPRODUCTIVE DECISION MAKING

REPRODUCTIVE DECISION MAKING

“But for the Bible we could not know right from wrong.”

– Abraham Lincoln

DISCUSSION OBJECTIVES

1. Define reproductive decision making;2. Describe the foundation of reproductive

decision making in the Philippines;3. Compare the Philippines’ and

International views and conditions in reproductive decision making;

4. Outline the issues concerning reproductive decision making in general; and

5. Identify the role of nursing administrators in reproductive decision making.

DISCUSSION OUTLINE

I. Definition of Reproductive Decision-MakingII. Reproductive Decision-Making Issues in the

PhilippinesA. ContraceptionB. AbortionC. Assisted Reproductive Technologies

III. International View of Reproductive Decision-MakingA. Reproductive AutonomyB. Right of the Unborn Child

I. Definition of Reproductive Decision Making

Reproductive decision making – is the decision to become a parent (Perrin, 2002)

HUMAN GENETICS COMMISSION (HGC)- An advisory body set up by the UK

Government at the end of 1999- Role: To advise UK Government on the

ethical and social aspects of developments in human genetics as well as their effects on health and healthcare

Human Genetics Commission in UKReproductive Decision Making is an area where society holds a range of

deep-rooted views and this was reflected across the Commission.

Decisions are personal and can be based on or influenced by all or none of the following:

- The desire to have genetically related offspring

- Belief or value systems- The opting to start a family later in life- The increased risk of multiple pregnancies and

births associated with assisted conception

- The welfare of the child who may be born

- The welfare state, support, educational structures; and

- The effect that decisions made how might have on future generations

II. Reproductive Decision Making in the Philippines

A. DEMOGRAPHIC PROFILE

Philippines – 39th most densely populated country in the world (Source: CIA World Factbook)

- with a density of 335 per squared kilometre- Population Growth Rate: 1.9% (NSO’s 2010

Census)

- Total Fertility Rate (TFR): 3.20 births per woman (2013) from the rate of 7 in 1960

- TFR for women with college education: 2.3 children per woman

- TFR for women only with elementary education: 4.5 children per woman

Source: Pia Lee Brago of Philippine Star

B. REPRODUCTIVE HEALTH LAW

Republic Act 10354 - The Responsible Parenthood and

Reproductive Health Act of 2012- Also known as the Reproductive

Health Law or RH Law

What the RH Bill does is reduce the cost of access to (a) information about reproductive health and (b) devices and technology that allow people to promote their reproductive health, manage family size, and have greater control over their lives.

Section 4 (s) Definition of Terms:Reproductive Health Rights – refers to

the rights of individuals and couples to decide freely and responsibly whether to or not to have children

- The number , spacing and timing of their children

- To make other decisions concerning reproduction, free of discrimination, coercion and violence;

- To have the information and means to do so;

- And to attain the highest standard of sexual health and reproductive health

- Provided, however, That reproductive health rights do not include abortion and access to abortifacients.

The bill mandates the government to “promote, without bias, all effective natural and modern methods of family planning that are medically safe and legal.”

(Lira Dalangin-Fernandez, Philippine Daily Inquirer)

RH Law Support:Free choice regarding reproductive health

enables people, especially the poor, to have the number of children they want and can feasibly care and provide for.

There are several studies cited by those who support the bill:

University of the Philippines School of Economics and Asian Development Bank

- Rapid population growth and high fertility rates, especially among the poor, exacerbate poverty and make it harder for the government to address it.

- Poverty incidence is higher among big families.

- Smaller families and wider birth intervals could allow families to invest more in each child’s education, health, nutrition and eventually reduce poverty and hunger at the household level.

(Population and Poverty: The Real Score by UP School of Economics; 2010 Presidentiables; Senate of the Philippines )

- 44% of the pregnancies in the poorest quintile are unanticipated.

- At least 41% among the poorest women who would like to avoid pregnancy, do not use any contraceptive method because of:lack of information or access.

- 22% (among the poorest families) of married women of reproductive age express a desire to avoid pregnancies but are still not using any family planning method.

• Use of contraception, which the World Health Organization has listed as essential medicines, will lower the rate of abortions as it has done in other parts of the world, according to the Guttmacher Institute

• An SWS survey of 2008 showed that 71% of the respondents are in favour of the bill

C. Abortion

- Although abortion is recognized as illegal and punishable by law, the bill states that “the government shall ensure that all women needing care for post-abortion complications shall be treated and counselled in a humane, non-judgmental and compassionate manner”.

R.A. 10354 Section 2 (d)The State shall also promote openness

to life; Provided, That parents bring forth to the world only those children whom they can raise in a truly humane way.

WILL THE PASSAGE OF A REPRODUCTIVE HEALTH LAW ENCOURAGE ABORTION BY

LEGITIMIZING CONTRACEPTIVES?

In the first place, contraceptives are legal, hence, the passage of a reproductive health law will not legitimize what is already legal. What remains illegal is abortion, which is different from contraception.

According to Section 12, Article II, 1987 Constitution, the law protects the “life of the unborn from conception,” whereas the use of contraceptives will not give rise to any unborn because contraceptives “prevent” pregnancies.

DOES A REPRODUCTIVE HEALTH LAW HAVE THE EFFECT OF LEGALIZING

ABORTION IF IT INCLUDES MANAGEMENT OF ABORTION

COMPLICATIONS?

Management of abortion complications refers to the duty of medical professional to give medical care to women who have undergone abortion. Although abortion is criminalized in the Philippines, this does not mean that a person who has had an induced abortion is not entitled to receive humane medical treatment for post-abortion complications.

To withhold medical care as a way of punishing the woman is tantamount to violating her rights to life and health.

DOES THE RH BILL CONFLICT WITH THE STATE POLICY TO “EQUALLY PROTECT

THE LIFE OF THE MOTHER AND THE LIFE OF THE UNBORN FROM CONCEPTION”?

In conclusion, Reproductive Decision Making in the Philippines is concerned with Poverty and Family Planning

III. Scope of Reproductive Decision Making

A. Reproductive Autonomy

Reproductive Autonomy – the right of a person in controlling their own body and their choice of trying to have (or not to have)children.

Issues:- Treating other people (babies and adults) as

subjects in themselves rather than merely being instruments

- Traditionally, reproductive autonomy simply means the freedom to decide whether to try to reproduce, with whom, when and where.

Questions whether reproductive autonomy should extend to include:

- Social Sex Selection- Buying and selling eggs, sperm, and embryos- Selection of characteristics of possible future

children or to having one child to save another

B. Rights of the Born and Unborn Child

Child Born Alive – have the full protection of the civil and criminal law

Unborn Child – have very limited legal recognition and protection (Abortion Act of 1967)

- Neither UK nor European Law recognise the fetus as an independent legal person with equal rights

- It is clear in the Law that the legally competent pregnant woman has an unfettered right to make medical treatment decisions, even if her decision endangers the life of the unborn child

IV. REPRODUCTIVE DECISION-MAKING: WESTERN WORLD VIEW

AND CONDITION

A.MAJOR CONCERNS FACED BY CONTEMPORARY EUROPE

• Very low Fertility Rates• Inevitable Future Population Decline

Dilemmas:• Women and men across Europe wish to have

more children than they actually achieve by the end of their reproductive lives

• This ‘gap’ between intentions and actual behaviour leaves plenty of scope for effective policy action

European Commission (2005:5) – points out that the fertility rate in Europe is “insufficient to replace population”

Pre-Project Determinants of Low Fertility:The result of Private Choices:• Late access to employment• Job instability• Expensive housing• Lack of incentives (Family benefits, Parental

leave, Child care, Equal Pay)

Policy Influences on Fertility Behavior:• Indirect Influence – By affecting people’s

childbearing norms, desires and intentions• Direct Influences: • Creating a structure incentives that would be

sizeable enough to increase fertility rates irrespective of people’s initial preferences (This is potentially problematic)

• Deliberately intervening into individual’s decisions, e.g. By restricting access to abortion (This is unacceptable in most democratic societies)

Questions Remain Unanswered:• What should be the socially desired or optimal

fertility?• Would these policies improve the quality of

life and well being of the citizens

According to Van de Kaa (2006), the most commonly considered ‘optimal’ level of fertility is POPULATION REPLACEMENT LEVEL (Around 2.07 children per woman in the most developed countries)

Lutz and Striessnig (2010) argued that ‘optimal fertility’ may be well below 2 children per woman considered that there is:

• A high share of university-educated population, and;

• A related rapid rise in productivity

B. REPRO PROJECT: (Reproductive Decision-Making in a Micro-Macro

Perspective)

According to the Synthesis and Policy Implications made by Tomas Sobotka (Researcher at the Vienna Institute of Demography, Austrian Academy of Sciences), this project studied:

1. Fertility Decisions (Reproductive Decisions)

2. Fertility Intentions and Behaviors in 3 levels:a. Aggregate (Macro) Level – social, cultural or

institutional conditions are related to aggregate level outcomes (fertility norms, intentions and fertility rates)

b. Individual (Micro) Level – decision making process, its determinants and outcomes at the level of individual men, women and couples

c. Macro-Micro Level – individual behaviour is conditioned by both individual level factors:

• Age• Number of children• Employment situation or education• Institutional conditions of a given country or

region

Research Instrument Used in the Qualitative Studies on the Reproductive Decision-Making Process:

• In-depth interviews conducted in cities in 7 European countries.

Post-Project Major Findings:Most important avenues for potential Policy

Intervention:• Job insecurity• Gender Equality• Reconciliation of work and family

Post-Project Indentified Issues:• Low Fertility in Europe• Differences in Family Policies across Europe• Policy Influences on Fertility Rates

Identified Results:1. In developed world, ‘Negative Intentions’

(Intentions not to have a child) are always realized with higher probability than the ‘Positive Intentions’

2. Intentions NOT to have a birth (or to use contraceptives) predict non-birth of a child better than childbirth intentions predict childbearing (Westoff and Rydern1977; Rindfuss et al. 1988; Philipov 2009)

United Kingdom – first country to pass legislation to regulate fertility treatment

Human Fertilisation and Embryology Authority (HFEA) – oversees 1990 HFE Act by a system of inspection and licensing of clinics that offered any treatment involving the handling of gametes (eggs and sperm) outside the body.

• Donor Insemination (DI)• In Vitro Fertilisation (IVF)• Intracytoplasmic Sperm Injection (ICSI)

Lord Robert Wilson – leading fertility specialist who argued that the HFEA should be abolished. He said that the HFEA should be replaced by “something a great deal less bureaucratic, which doesn’t inhibit research, which has a better consultation process with the public and which has a much more adequate inspection process.

According to the argument, HFEA claims incompetence over its decisions in those cases where new ethical dilemmas are faced, such as recent debates about sex selection of embryos and creation of tissue-matched embryos for sick siblings.

Suzi Leather – Chairperson of the HFEA. She defended the authority saying, “having a regulator has given the public confidence in the infertility sector and the system f regulation.

• She also believed that it is time for Parliament to revisit the 1990 Act, because technologies have advanced so much since it came onto the statute book that parts of it are out of date.

What factors bring new and seemingly irreconcilable dilemmas regularly into conflict with aging legislation and thus into the news headlines?

• Increase in medical and scientific knowledge, understanding and skill

• Powerful needs of involuntarily childless couples

QUESTION: What do you think is the ideal number of children for a family

to have?- George Gallup (1936)