One of the great achievements of science has been the process in knowledge of human reproduction, especially in regard to the possibility of alleviating the problems of sterility and infertility. There is no doubt that the achievement of fertilization of a different medium to the human body with gametes from a partner or donated by third parties, the transfer of embryos to the woman where the product will be concealed, the freezing of embryos and the possibilities of experimenting on them have shaken the moral foundations of the entire world.
It is foreseeable that the applications of new knowledge in the field of medicine are accompanied by deep philosophical, psychological, legal, sociological and economic reflections. Like other scientific advances, they are characterized by a certain degree of ambiguity related to the use that can be made of them, especially those of genetic and reproductive change.
At the same time, it would seem utopian, in such a plural society, the various positions that conflict with issues that deeply affect social sensitivity without legal support to discern those values that need to be legally protected, serving the good of society in general..
Faced with a panorama of almost unlimited scientific possibilities, growing expectations, and limited resources, doctors warn that they are facing problems that far exceed their responsibilities and that concern the entire society.
Assisted reproduction
Scientific and technological development has allowed man to transform his environment and living conditions; These are verified from the early explorations of new horizons and geography, to the discovery of the arcana of nature and mysteries of the universe.
Currently, infectious, degenerative, metabolic diseases are effectively fought and prevented; and recently, satisfactory achievements have been made in modifying genetic transmission. All this has resulted in both levels and life expectancy increasing.
On the other hand, studies of fertility and human reproduction have made spectacular advances and discoveries in the last three decades, this branch of science since its inception, has grown exponentially with the knowledge generated.
The biology of reproduction, allows man, not only to be the only species that consciously has control of his own reproduction, but can directly and effectively intervene in the reproductive process, even resources have been created to influence the genetic inheritance itself, modifying it and making it possible to generate alternatives to the sterility and infertility of some couples, these resources are generally known as assisted reproduction techniques.
Patrick Steptoe and Robert Edwards in 1978, carried out the first pregnancy with IVF techniques and embryo transfer to the uterus, making the possibilities to solve the infertility problems of many couples who until then were unable to have a child. In this sense, these procedures were considered as a real path towards fatherhood, putting at the service of humanity the scientific advances through which people would have access to the biological processes with which their material existence was set in motion.
Assisted reproductive techniques
Assisted reproductive techniques can be classified into three main groups9: 1) Artificial insemination; 2) in vitro fertilization with transfer of the embryos to the uterus (IVF / TE) and 3) the transfer of gametes to the tube (GIFT), whose difference lies in the place where fertilization occurs. In the second fertilization it takes place in a culture medium that simulates the tubal fluid and the resulting embryos are transferred to the uterus. In the third, one of the tubes, the ovules and sperm are transferred, ensuring that fertilization takes place there. The stages of pregnancy with GIFT are greater than with IVF / TE because the magnitude and complexity of the diseases faced by these couples is less.
The latter are called invasive because they require the direct capture of the eggs present in the ovarian follicles, which implies a direct manipulation of the same. In this sense, it is essential that the centers where these techniques are practiced have a gamete laboratory that provide the eggs first and the embryos later, environmental conditions that are as similar to those existing within the woman's body, in order to that the results obtained are effective.
Fertilization procedures can be performed with partner or donor gametes, whose techniques are called homologous and heterologous, respectively. The homologous techniques do not present any legal problem for their application, all of which, being an arrangement of tissue components for artificial insemination, complies with the provisions of the fourteenth title of the General Health Law, which refers to transplants and donations..
Faced with the fact of these scientific advances, especially in the application of assisted reproductive techniques and the new paradigms of the science of reproductive biology, legislators are obliged to propose the rules and regulations to regulate this science and its technologies, which in the last case involves an attempt to control and order new professional behavior.
It is essential to regulate assisted reproduction in the spirit of protecting the rights of the actors involved in the process, such as doctors, patients, born and unborn children, donors. This is one of the most important challenges for our legislators, since it involves the ethical and legal rethinking of our standards since with the advances in science they are incomplete and do not adapt to the reality in which the entire world faces and from which our country does not escape.
Undoubtedly, assisted reproduction techniques have opened expectations and hope for the treatment of infertility and sterility to thousands of couples who afflict them. Particularly when other procedures or treatments have not given satisfactory results.
Society has become aware of these surprising scientific advances, above all because it is aware that they may be the way to invade the most intimate world of the origins of human life, which gives them reasonable and reasonable insight into the possible transgression of human rights and the dignity of the person, in such a way that the actors involved in this activity must ensure that the use and application of assisted reproduction techniques have absolute respect and observance of the rights and fundamental freedoms of men and women of this service.
Artificial insemination consists of artificially introducing human semen into the woman's vaginal canal or uterine cervix, the seminal material can be fresh (obtained by masturbation) or previously frozen.
In 1776 Spallanzani studied the effect of freezing on sperm, in 1799 Hunter obtained the first pregnancy of a woman with semen inoculated from her husband and this served as the basis for the first publication of this case by Sims in the US, in 1886 Montegazza proposes the creation of "frozen semen banks", in 1899 Dickinson practiced artificial insemination with donor semen in the US, opening the spread of this technique worldwide and in 1953 successful artificial inseminations were announced to know successful inseminations with frozen semen.
The technique consists of carrying out studies in couples to try to establish the cause of infertility, ovulation is monitored, in order to establish the optimal time when insemination should be performed and fertilization in the fallopian tube is possible; the male's semen is collected, by masturbation, epididymal percutaneous puncture or during sexual intercourse (coitus interruptus), in some cases the semen is not adequate and must be prepared or trained so that there are good results, liquids are removed or factors that may lead to rejection or disability and the semen is then (washed) with substances such as albumin and the sample is filtered to contain only the most mobile sperm and prepared in the laboratory for introduction.
The insemination procedure itself, consists of depositing the semen already prepared in the endocervical canal or in the inner third of the vagina and the patient at rest for about six hours, it is also possible with a catheter to introduce the seminal material up to the uterine body; anesthesia is not required and there are no problems for women.
The main indications for conjugal (homologous) artificial insemination, that is, of the couple, are: 1) due to the impossibility of naturally depositing the semen at the bottom of the vagina or in any part of it, due to impotence of the male when he does not reach the erection or ejaculation; 2) due to congenital malformations of the female or male genital apparatus; 3) when there is ejaculation but the semen is scarce, scarce in sperm, or these are incapable of penetration and can be trained in the laboratory; 4) due to an immunological rejection of the sperm at the level of the vagina or the uterine cervix; 5) local alterations, whether it is dryness, scarcity or infection of vaginal or cervical mucus and 6) in idiopathic sterility, when studies do not reveal any abnormality and pregnancy does not occur.
In donor semen insemination (heterology), the main indications are: 1) male sterility due to irreversible or unsolvable factors, such as azoospermia or severe oligospermia; 2) in infertility due to chromosomal or genetic alterations or abnormalities of the male, that even though the female may be fertilized, this is the cause of repeated abortions, during the first trimester of pregnancy; 3) in severe genetic or chromosomal diseases of the male, which can be transmitted to offspring; 4) in infertility due to male impotence, and 5) in infections transmitted by semen from the partner's male, such as AIDS or hepatitis C, etc.
In vitro fertilization and embryo transfer. In vitro fertilization and embryo transfer (FIVTE), as its name implies, consists of two important phases: the fertilization of an artificial medium, not inside the fallopian tube and the embryo treaty, rather from the embryos, to the maternal uterus. Unlike fertilization (in vivo), this is done in the laboratory, where under the microscope the process and development of the embryo or embryos originated can be followed.
FIVTE is carried out as follows:
a) Collection of ovules from the mother: the woman is hyperstimulated with ovulation stimulants (chorionic gonadotrophin, cloniphene parlodel) and follicular growth is monitored by ultrasonography and daily dosing of estradiol and LH, to diagnose exactly the day of the ovulation, you are hospitalized a day or two before this to prepare for egg collection thirty or thirty-six hours after a LH hormone spike, is performed in the operating room, a laparoscopy reaching the ovaries and puncturing the developed follicles, obtaining by aspiration of the follicular fluid, the ovules that will be fertilized at present also in some places the follicular aspiration is done by transvaginal route) guided by ultrasound.
Only follicles larger than 18 mm are aspirated in order to obtain only mature or secondary oocytes. In more than 90% of attempts, at least one ovum is obtained; if the exact chronology is not acted upon, the ovules may be immature and not fertilizable, or it is late and they have fallen into the cavity or have entered the tube and are therefore recoverable.
b) Semen collection: semen is obtained from the husband by epidiminary percutaneous puncture or sexual intercourse, culture medium is added, washing is performed by gentle centrifugation, leaving a precipitate with the sperm, it can also be done with frozen semen; The adequate concentration of motile sperm is 500,000 per cc. In certain cases, training and selection of useful sperm should be carried out, especially in oligospermia.
c) Gamete contact and in vitro fertilization; each one of the obtained ova is united in different containers with the selected spermatozoa and they are kept in incubation for 15 to 20 hours, in the Petri dishes; the initiation of in vitro fertilization is verified, which generally occurs in two thirds of the ovules and it is observed how cell division begins; the zygotes in division are kept for another 12 to 24 hours, in the incubator, while they continue their division into blastometers.
d) Embryo transfer: in the cell division phase between 16 and 16 cells, the embryos are transferred to the mother's uterus transcervically and through a thin catheter and this must be performed in the operating room, this procedure is recommended It is practiced between 36 and 48 hours after fertilization, since it has been seen that its early contact with the endometrial mucosa reduces the percentage of micro-abortions due to implantation failure, hence at least three embryos must be transferred, as success will rely on multiple transfer with a higher probability of implantation of at least one of the embryos; Finally, the transfer catheter is carefully checked to avoid the loss of embryos that were not deposited in the endometrial cavity.
Bioethics, a historical approach.
Even though the term is of very recent coinage, since it was proposed in 1971 by an oncologist, dr. Van Renselaer Potter, various authors have correctly pointed out that ethics and social morality have always been present in the professional work of those who have dedicated themselves to medicine, and that this profession has been a quintessential humanistic activity.
In this sense, since time immemorial medicine has had norms and guidelines, both external and self-imposed, that have marked medical practice in its obligations, such is the case of the most widespread ethical code in medicine, the Hippocratic Oath, which in the fifth century before the Christian established the ethical and moral behavior of the doctor and gave a sacred character to these obligations.
Many codes and standards of professional conduct in ancient times have had similar provisions, such as the Hammurabi or Maimonides code, the provisions in the Old Testament and many more.
The evolution of medical practice and its deontological norms had a similar advance and evolution, as they incorporated into the professional work, the ethical laws and regulations that the State and society were imposing on the doctor.
In the 20th century, however, a series of situations appeared that caused a crisis to the social name and a paradigm shift in medicine, the most shocking of all was the clinical and pharmacological research that the doctors and researchers of Nazi Germany carried out with the prisoners of the death camps in Europe, as well as the practice of a eugenic policy in Germany, which as a whole cost millions of lives, and where man and his most elementary rights were not respected.
The discovery of the atrocities of scientists in the service of the Third Reich, caused the Catholic Church, at the end of World War II, to make a moral condemnation to whoever tried to appropriate the results (and use them) of the medical discoveries made in the violation of human rights, of prisoners of war and enemies of the Germans, who were made against the person and his dignity, this sentence, was what according to some authors, gives rise to modern medical ethics, later designated as Bioethics, a discipline that is based on the very crisis of medicine, regarding the new definition of its object, method and purpose, which required redefining medical, health care and research problems.
The crisis of reason in medicine does not occur only as a result of Nazi excesses, as scandals and atrocities begin to appear in many parts of the world, pushing states and society to rethink the social morality of the medical profession. and scientific research applied to health, such were the cases of eugenic policies against minorities in the former Soviet Union, the inoculation of cancer cells in terminally ill and mentally ill patients in the United States, in what is known as the Willowbrrok scandal.. Eugenic policies, human research on prisoners and the mentally ill, and many more cases.
Likewise, the appearance of new techniques and technologies and the discovery of new diseases and treatments, in situations that man had not even imagined, in new cultural, philosophical, social and economic settings, face users and providers of health services, to a form of professional work that requires ethical principles in the new social context.
Bioethics is born in this new world context, a discipline that deals with ethical norms in the biological sciences, specifically in medicine, and that resorts to the interpretation of the reality of philosophy, legal science and medicine.
Bioethics proposes a philosophical, plural and democratic methodology to find the truth about biological disciplines in its action on human health, considering four essential categories in health care; justice, autonomy, beneficence and maleficence.
Bioethics currently grows exponentially, both due to the appearance of new contradictions and dilemmas regarding the person, as well as the advent of new scientific knowledge and the appearance of new technologies applied to health.
Throughout the world, the development of bioethics has been surprising, a few years after its foundation in most universities, it has already been included in the professional curricula of students in the health professions, the main hospitals have integrated Bioethics committees, as well as the health institutions of each country and in global legislation, the norms and laws that guide scientific research in humans, health programs and the practice of the health professions are beginning to appear.
Mexico is not oblivious to the advancement of bioethics, nor the proposal of laws on the matter, not only that, but today we have a great advance on the matter of elaboration of ad hoc laws, even though these have not yet been published in the Official diary.
The lag in terms of bioethics legislation observed up to the year 2000 has now been overcome, since within the Health and Social Security Council, a comprehensive bioethics project has been drawn up, which in its beginning has already presented the more urgent laws to cover the most important existing bioethics and health gaps.
Mexican society was already urgently demanding the creation of a legal framework that would protect it, since in what some authors call the Knowledge Society, attacks on people in their dignity and beliefs were beginning to be observed, as well as a debate between the scientifically possible and the ethically acceptable.
Scientific and technological knowledge has been configured as the matrix of the society of the third millennium, this is a source of personal and social wealth, as well as generated by improvement and comfort, although ethical, belief and ideological considerations also arise from these..
The obligation of the legislators is to endorse the knowledge, technical elements and opinions of the society, incorporating social ethics into their respective works and projects, and without pretending to arrogate the right to impose their criteria on others, but taking care that the Technical and scientific achievements and advances effectively serve society, enabling justice, equity and the common good.
Origin and history of bioethics
Ethics is the critical reflection on the values and principles that guide our decisions and behaviors. The word bioethics is a neologism coined in 1971 by Van Rensselaer Potter (in his book Bioethics: bridge to the future), in which this author encompassed the "discipline that combines biological knowledge with that of human values". He defines bioethics as "the systematic study of human behavior in the area of life sciences and health care, insofar as such behavior is examined in the light of values and moral principles." Today it covers not only the traditional aspects of medical ethics, but also includes environmental ethics, with discussions on the rights of future generations, sustainable development, etc. (In fact,Potter's book addressed ethical issues in relation to the environment with evolutionary perspectives, but subsequently the term bioethics has been used mainly to refer to the new medical ethics and the ethics of new advances in biomedicine).
Bioethics Division
We can divide bioethics into a general or fundamental part and a special or applied part. General bioethics deals with the ethical foundations, the values and principles that must guide ethical judgment and the documentary sources of bioethics (medical codes, national and international law, deontological norms and other sources that enrich and illuminate the discussion, such as biographical, literary or religious). Special bioethics deals with specific dilemmas, both in the medical and biomedical field as well as in the political and social field: models of health care and resource distribution, the relationship between the health professional and the patient, prenatal medicine practices, the abortion, genetic engineering, eugenics, euthanasia, transplants, experiments on humans, etc.It is clear that the approach given to the foundation (general bioethics) will condition the possible solutions offered to the dilemmas (special bioethics). This is the case with the rejection of euthanasia in a bioethical model based on the search for truth about man and on the recognition and respect of his special dignity, or - on the contrary - the enthusiastic acceptance of euthanasia in relativistic models based on in the absolute autonomy of individual freedom. Sometimes there is talk of clinical bioethics or decision making. In it, dilemmas born in the medical practice of medicine are examined, analyzing the ethical values at stake and the concrete means available to resolve the conflict in the best way. Although the particular case presents nuances to consider and prioritize,behavior should not conflict with the values used in bioethics in general.
