Developmental Totipotency as a Normative Criterion for the Moral Status of the Human Embryo
Thomas HEINEMANN, Philosophisch-Theologische Hochschule Vallendar, Germany

The notion of human dignity is central to the German basic law. Article 1 of the German basic law declares that human dignity shall be inviolable, and the duty of all state authority shall be to respect and protect human dignity. While this implies the right to life and physical integrity of every person, as is laid down in Article 2, controversial debate revolves around the question of whether the notion of human dignity also applies to the human embryo in its earliest stages of development and therefore, whether the embryo must be protected. The German Embryo Protection Act from 1990 defines a human embryo as “[…] the human egg cell, fertilised and capable of developing, from the time of fusion of the nuclei, and further, each totipotent cell removed from an embryo that is assumed to be able to divide and to develop into an individual under the appropriate conditions for that” (§8,1). This definition implies both, embryos created by “natural” fertilization of a human egg cell as well as embryos created “artificially”, e.g. by embryo splitting. With regard to the latter, intensive discussion is continuing on the meaning of the criterion of totipotency of a cell. In a biological understanding totipotency defines a developmental capacity of a single cell to develop into a born individual. Since the criterion of totipotency differentiates an embryo from all other cells not capable to develop into a born individual, the criterion is necessary for defining a cell as an embryo. However, as there are currently no biological markers available to identify the totipotent state of a cell this criterion cannot be verified. In addition, while in “natural” embryos the knowledge of their development to term is based on common experience, totipotency remains just an assumption in “artificially” created embryos as they cannot be brought to term, by ethical reasons, just for research purposes. Moreover, biological totipotency cannot be simply used as a normative criterion since deducing a normative statement from the as-is state may represent a logical fallacy. Thus, although necessary, the criterion of totipotency is not sufficient to define an embryo. Since it is the aim of the Embryo Protection Act to protect the embryo rather than biological totipotency itself, the question rises which other criteria may implicitly define the moral status of an embryo.

The developmental capacity of totipotency corresponds to the well-known philosophical argument of potentiality which is used to constitute the moral status of the human embryo. In this view, the notion of human dignity – which is founded in the capability of a human being to be subject of and responsible for his acts and thus being conceivable as an end in itself – applies to the early embryo since right from the beginning the embryo has the potential to develop into a moral subject and the embryo and the moral subject are identical, i.e. the same human being. Acknowledging the moral status on this basis defines the embryo as a good in terms of a moral assessment which ought to be granted a high level of protection. In accordance with this reasoning the German Embryo Protection Act imposes a strict ban on any manipulation involving a human embryo if the manipulation does not aim exclusively at the preservation of the embryo. However, since the moral status of a human embryo is founded in the embryo being an end-in-itself, the question rises whether this applies to an artificially created totipotent cell as well, as this cell was created for the aims and by the will of its creator. Thus, the formation of a totipotent cell free from aims set, and manipulations performed, by others as well as genesis by “natural” fertilisation may be important criteria, in addition to the criterion of totipotency, for defining a human embryo.


The Death Problem
Stuart J. YOUNGNER, MD, Case Western Reserve University, USA

The reliable determination of death was a challenge for society until the early 19th Century when advancing medical knowledge—the invention of the stethoscope and a growing understanding of cardiorespiratory functioning—allowed physicians to declare death effectively.  Ironically, the advent of new technology in the middle of the 20th Century again made the reliable determination of death a problem.  Two factors were at work here.  First, the high tech intensive care unit allowed the acute dying process to be stretched out over days or weeks.  Some vital functions were lost and some remained.  Second, society’s need for viable organs for transplantation put pressure on physicians to declare death when much life remained.   The creation of the concept of brain death is one result of that pressure.

To restate the modern problem, technology has presented us with an excellent source of organs—i.e., patients whose status is “almost dead”, “good as dead”, or “dead enough” rather than dead in the traditional sense.  Yet, traditional values and the law insist that we declare them dead before we remove their organs—the so-called dead donor rule.  Academic bioethicists and others have almost uniformly rejected both the conceptual and clinical justifications for equating brain death with death and with declaring death after two minutes of asystole in donation after circulatory death (DCD) protocols.  Some have even questioned the necessity of the dead donor rule.  This scholarship threatens or appears to threaten society’s uneasy acceptance of the myth of brain death.  Some have even suggested that academic critics of brain death muzzle themselves to avoid “causing trouble.”

It is my understanding that Japan has largely avoided this issue by marginalizing brain death as a source for organs.  How the death problem will play out in the West is uncertain.  In the United States, brain death was introduced in part to allow removal of life-sustaining treatment without a charge of murder.  However, after more than three decades of public debate and discussion, American society has defined the moral circumstances under which life support can be discontinued without any legal problem.  Perhaps, similar moral analyses will evolve about when it is acceptable to break the dead donor rule when patients who want to be organ donors are in conditions so severe and hopeless that they are beyond harm.  This seems a better solution than to increasingly support a determination of death for purposes of organ transplant in a manner relies more on propaganda than scholarship.


Euthanasia in the Netherlands: Medical Practice and Societal Control           JJM van DELDEN, MD. PhD., Julius Center, University Medical Center, Utrecht, The Netherlands

The debate about the acceptability of (medical) assistance in dying is worldwide. It is often a heated debate in which all sorts of assumptions about effects and developments are made. The Netherlands was the first country in the world to legislate euthanasia and assisted suicide, if performed by a physician according to certain criteria of due care. The Netherlands is also the only country with a wealth of data about end of life decision making. As such the Netherlands can be regarded as a societal laboratory from which the world can learn what to do and what not to do.

In this lecture I will discuss the euthanasia law that came into effect in 2002 and the way that societal control (eg by means of the euthanasia assessment committees) is shaped. I will present the results of five large nation-wide studies performed in the Netherlands between 1990 and 2010. I will show the trends in incidences of end of life decisions such as euthanasia, assisted suicide, palliative sedation and non-treatment decisions in medical practice in the Netherlands. The characteristics of the patients involved will be discussed. I will show in what way the results of these studies have influenced public debate and the process towards legislation. Also the question whether the Netherlands has been successful in creating an adequate system of societal control will be addressed.

The last part of this lecture will be devoted to the question whether the Netherlands have created a system that is ready for the future. From this it can be shown what positive and negative lessons can be learned from the Netherlands. This may help other countries to formulate their own answers, attuned to their own contexts, to pressing societal questions about the acceptability of assistance in dying.


Developing Clinical Ethics: Experiences and Reflection from One Asian Country and Certain Cultural Perspectives
Prof. Daniel Fu-Chang TSAI, MD, PhD.
Department and Graduate Institute of Medical Education and Bioethics,
National Taiwan University College of Medicine

Clinical ethics is concerned with the ethical issues arising from clinical practice and patient care. As a branch of modern Western bioethics whose principles and practices have widely spread and influenced Eastern countries through the introduction of the concepts of medical human rights and rapid globalization in the past four decades, and also as driven by the increased social expectation for better health care ethics, the practice of clinical ethics through institutional mechanism such as clinical ethics committee(CEC) and ethics consultation(EC) has become a growing interest and challenge to hospital practice in many Asian countries in the past one decade. However, discourses in cross-cultural bioethics often refer to that Asian values empathize more on communitarian values, family decision and relational personhood which are distinctive from Western bioethics which stress more on liberal individualism, personal autonomy and independent self, therefore the practice of clinical ethics should adopt different norms which will lead to different results.

In this presentation, the speaker will introduce the current practice of clinical ethics which includes the development of CECs and EC in the past 10 years in Taiwan. Arguments for and against the cross-cultural bioethical principles will be examined. Clinical cases concerning cultural variances in medical ethics and some Taiwanese empirical studies concerning “organ donation” and “genetic testing”, which reveal the dynamics and tension between “individual autonomy” and “family decision” will be presented and discussed. The speaker will then adopt theories on “the independent/dependent self” and “the Confucian social orientation” to elaborate the idea of cultural variances in clinical ethics, and then conclude with presenting the characteristics of Confucian ethics and their possible implication and application to “clinical ethics” in East Asian contexts.



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