Eubios Journal of Asian andInternational Bioethics
EJAIB Vol. 33 (1) January 2023
www.eubios.info

ISSN 1173-2571 (Print) ISSN 2350-3106 (Online)

Official Journal of the Asian Bioethics Association (ABA)

Copyright ©2023 Eubios Ethics Institute(All rights reserved, for commercial reproductions).

Contents
page
Editorial - Darryl Macer
Reconstructing the meaning of life among
Japanese bereaved spouses: A qualitative
study of three peer support groups
2- Yuko Yokoseki and Michio Miyasaka
Shared decision-making and relational
identity in a pregnant woman with
Eisenmenger syndrome7-Endah Rahmawati, Agung Dewanto, Irwan
Tau iqur Rachman, Wika Hartanti
Heritable human genome editing in Japan:
status and continuity
11-Silvia Croydon
Why inhumane? An ethical issue on medical
negligence from health professionals
15-Zahira Amir Ali
The ethical aspects of unwanted pregnancy:
Cases of rape reported in the media with legal
restrictions on abortion in Turkey
19- Sukran Sevimli
Cloning prospects in 21st century humanity:
An ethico-theological discourse
26-Peter O. Ottuh
EJAIB Editorial Board
32
Ordering information
33

Editorial: Bioethics and themeaning of lifeff

One of the common threads of the six papers
in this issue of EJAIB is a critical one for all of us,
and one of responses we could make when we
ask what is “the question”? The question I refer
to is what is the meaning of life? Each of us
through our life journey will ask this question atleast once, and although the mundane that
constructs most of most people’s lives canignore that question, a bioethical life that is one
where the love of life demands us to ask
questions, will bring us back to that question.
Yuko Yokoseki and Michio Miyasaka attempt
to reconstruct the meaning of life among
Japanese bereaved spouses through a qualitative
study of three peer support groups.
This
research study is one that does not explore an
abstract theoretical topic, but an event andfeeling that half the people in the world will
experience. One of the joys and pains of life isthat we live a life together with our loved ones
but for most of that life we will not know who
will be bereaved and who will end their life
earlier, There are lessons for all relationshipsthat we humans hold to be dear.
Endah Rahmawati et al. explore a related
dilemma, but one with the hope of a new life intheir paper on shared decision-making andrelational identity in a pregnant woman with
Eisenmenger syndrome.
Silvia Croydon provides an ethical andregulatory analysis of one of the most hopefulinterventions for future life, namely heritable
human genome editing. Given the long awaited
success in somatic cell gene therapies, we as a
species will need to continue to re lect on thecorrect timing to allow those persons who
would like to attempt heritable genomic editing.
Peter Ottuh discusses the ethics of humancloning.
From West Asia, Zahira Amir Ali describes
some Pakistan cases of medical negligence byhealth professionals. Sukran Sevimli explores
the ethics of unwanted pregnancy in some casesof rape reported in the media with legal
restrictions on abortion in Turkey.
- Darryl Macer (Email: darryl@eubios.info)

2Eubios Journal of Asian and International Bioethics 33(1) (January 2023)

Reconstructing the meaning of life
among Japanese bereaved
spouses: A qualitative study ofthree peer support groups
Yuko Yokoseki and Michio Miyasaka*
Graduate School of Health Sciences, Niigata University,
Niigata City, Japan* Corresponding author
Email: miyasaka@clg.niigata-u.ac.jp

Abstract
This study aims to reveal how people who have lost a
spouse reconstruct the meaning of life in threedifferent peer support groups for the bereaved inJapan. We interviewed 20 study participants andconducted a qualitative analysis. Most study
participants had a negative experience of their
bereavement; however, by listening to others’
bereavement experiences, they gained a feeling of
fellowship, pieced together the fragments of thechaotic experience of bereavement, and reconstructed their experiences and sense of values ina coherent way from past to present. The study
results reveal that commensurability could beachieved in the peer support groups and that theopportunity to re-encounter the deceased
encouraged the meaning of reconstruction.

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Introduction
The population of Japan is in rapid decline and has
continued to age. The annual number of deaths
reached approximately 1.44 million (Ministry of
Health, Labour and Welfare, 2022), the greatest on
record. As elderly people pass away in large
numbers, Japanese society is moving from being an
aging society to the next phase, a “mass-dying
society” or “tashi shakai” which brings about avariety of unprecedented issues. One of these is grief
support for people who have lost family members.
In contemporary Japanese society, whererelationships in local communities are thinning,people may suffer more from the physical andemotional impacts of the death of a loved one,particularly the death of a spouse. According to one
meta-analysis, a statistically signi icant correlation
exists between spousal bereavement and mortality
risk, with greater risk of death in one to six months
following the death of one’s spouse (Moon, 2011). It
has been reported that spousal bereavement canin luence in lammatory and prothrombotic changes
associated with cardiovascular risks (Buckley et al.,2012). Spousal bereavement also aggravates mental
illness. People who have lost a spouse have a higher
rate of psychotropic drug prescriptions, see generalpractitioners at a higher rate, and are more likely touse various pharmaceuticals (antidepressants, sleep
medications, psychotropic drugs) (King et al., 2013).
They experience depressive syndromes at a rate of

42%, 1 month after bereavement and a rate of 16%,
13 months after bereavement (Clayton, 1990).
In Japan (2019) survey, the rate of suicide among
married people aged 60 and above was 19.3 per
100,000 people for men and 9.0 for women, whereas
the rate among those who had lost a spouse was 46.7
and 12.4, respectively (Ministry of Health, Labourand Welfare, 2021, p.30). In a review of older people
living alone in Japan after the loss of a spouse, morethan half of the men did not have anyone to talk toabout their problems, raising concern about thesocial isolation of men following bereavement(Kotani, 2017).
Social change and groups for the bereaved inJapan: Before the modernization of Japan, relativesby blood and marriage and local residents would
join the bereaved person and support them in theirgrief through funerals, burials, and Buddhist
memorial services. However, in recent years, due tothe trend toward nuclear families, and societal
changes such as the dilution of collective systems inlocal communities and the simpli ication of funerals,
burials, and memorial services, it has become
increasingly dif icult to provide grief support (Itou,
2016).
In this context, peer support groups have been
gaining particular attention in the recent years. In
the United States, after trials of early programs suchas widow-to-widow (Silverman, 1970) mutual aid for
widows, many groups for the bereaved have beencreated in various places.
In Japan, a German Catholic priest Alfons Deeken
conducted death education at Sophia University. In
1982, he held a seminar on death and grief for thegeneral public, encouraging participants to talkabout grief after bereavement, which was notcommonly discussed in Japanese society up to thatpoint. This was the impetus for creating peer
support groups for the bereaved throughout Japan(Yokoseki, 2015). The main activity content of thesepeer support groups includes sharing experiences of
bereavement, namely, listening to the sorrow of the
bereaved and allowing the bereaved to talk about
their sorrow.
Reconstructing the meaning of life: In peer support
groups for the bereaved, talking about theexperience of bereavement is the central activity.
Recently, the central challenges of the grief process
are thought to be giving meaning to loss and reconstructing the meaning of life and reason for living(Neimeyer, 2006). In peer support groups by the
bereaved, the act of talking to others is thought toencourage the reconstruction of the meaning of life
and the meaning of living, but how this happens is
not fully understood.
This study aims to reveal how people who havelost a spouse reconstruct the meaning of life in threedifferent peer support groups for the bereaved inJapan.

Eubios Journal of Asian and International Bioethics 33(1) (January 2023)
Methods
Participants: This study involved 20 participants
who belonged to groups for the bereaved (Group X,
Group Y and Group Z) in Japan. All participants had
lost their spouses at least three years prior, wereconsidered physically and mentally soundcandidates based on past interactions with groupleaders and had agreed to participate in the study.
Data collection: The irst author explained the study
plan to the leaders of each group, and obtained theirwritten approval for cooperation, including theselection of candidates for participation. The leadersthen contacted the candidates by telephone,
explained the outline of the study, and mailed or
hand-delivered the explanatory documents to them.
Approximately one week later, the leaders called thecandidates to ask about their willingness toparticipate. For those who were willing toparticipate in the study, the leaders arranged ameeting with the researcher. The irst author thenmet with the candidates at the designated date andplace, explained the aims, methods, the anticipatedbene its and potential risks, the discomfort the study
may entail, and the plan to protect participants’privacy and maintain con identiality of data.
Candidates signed a consent form agreeing to beinterviewed, recorded, and to allow discussion
content to be used for presentation and publication
purposes.
We conducted one interview for each participant,with an average interview time of 1 hour and 31
minutes. The interview format was semi-structured,and participants were asked to talk freely about
seven items: (1) Relationship with spouse, (2)Reaction after their death, (3) Motive for joining the
bereavement group, (4) Emotions when listening topeople talk about bereavement, (5) Changes after
talking about bereavement, (6) Changes in view oflife and death, and (7) What new things they did.
Interview content was recorded with permission,and notes were taken. We created verbatim
transcripts from the recorded audio data andanonymized them. The anonymized text data was
the target of analysis. The data collection period was
July to August 2019. Ethical approval was gained
from the Ethics Committee of Niigata University(2019-0036).

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Data analysis: We conducted a qualitative analysis
using the procedure below to ind thematic
categories across individuals: (a) We closely read the
textual data for each participant and summarized
their content, (b) We entered summarized data for
all respondents into a spreadsheet for abovementioned seven items, (c) We compared the data
for each question, grouped similar items, andconcisely summarized the content into subthemes,(d) We grouped together similar subthemes andreformulated their content in abstract terms to turnthem into themes.

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Results
Table 1 shows a summary of the participantscharacteristics. There were 20 study participants (10men, 10 women) in their 60s to 80s (average age72.7). Of these, 5 participants had a bereavement
period of under 10 years, 11 had a period of 10–19
years, and 4 had a period of 20 years or more
(average period 14.2 years). We divided theinterview items into three topics, with (1) and (2) on“post-bereavement reactions”; (3), (4), and (5) on“experience of listening and speaking”; and (6) and(7) on “changes in view of life and death.” Examplesof speci ic themes are given here for two topics:
listening and speaking experiences and changing
views of life and death (Table 2).
Topic 1: Post-bereavement reactions
Psychological reactions included feelings of loss,
apathy, regret/remorse, relief. Their postbereavement reactions often included the pain oflosing someone who had always been there for themas well as the sense of loss in missing theircon idant. By contrast, some people exhibited
positive psychological reactions, such as relief.
Physical reactions included insomnia, lack ofappetite, and poor physical condition. Of the 20
study participants, 9 complained of insomnia. There
were also some who had lost weight due to lack ofappetite, including some who had lost their appetite
not only after the death of their spouse but also
before the death. Some had lost the will to makemeals just for themselves while their spouse was in
the hospital, and others had lost their appetite andlost weight from the burden of caregiving.
Social reactions included isolation and social
withdrawal, distrust in personal relationships, andthe burdens of childcare and work. Afterbereavement, as mentioned above, some hadreactions of isolation and withdrawal, not wanting togo out due to apathy or losing touch with personal
relations because they no longer wanted to meetwith people they had previously been seeing. The
reaction of distrust in personal relationships wasfrom people who were hurt when their friends said
things to console them, and they felt that the friends
did not really understand their feelings.
Spiritual reactions: Some people felt that they had
lost their reason to live. However, some of the study
participants, believed in a transcendent presence.
Invisible connection to their spouses was
experienced by some participants who felt that theirdeceased spouse was near them.

Eubios Journal of Asian and International Bioethics 33(1) (January 2023)

Topic 2: Listening and speaking
Re a l i z i n g t h e d i v e r s i t y o f b e re a v e m e n texperiences and the signi icance of verbalizing:
Participants joined the group, listened directly topeople’s bereavement experiences in their own
words, and realized that the circumstances ofighting illness or being at someone’s deathbed andhow people felt after bereavement were diverse foreach person. Furthermore, as they participated andbegan to verbalize their own feelings and talk about
their experience of bereavement, their previously
chaotic emotions were put in order, and they began
to see their own circumstances and future pathforward.
Feeling of fellowship: Many of the study participants
stated that their family and friends did notunderstand when they spoke about their feelings
and that they could not talk about bereavement withco-workers or neighbors. Furthermore, the words ofpeople who had not experienced bereavement,
though with the intention of consolation, often
added to the painful experience of the bereaved. In
the midst of this, by attending groups for the
bereaved and listening to others talk about theirex p e r i e n c e s o f b e re ave m e n t , p a r t i c i p a n t s
empathized with others’ feelings and found that they
were not alone, giving rise to a sense of mutual
understanding and fellowship.
The three bereavement groups surveyed in thisstudy were not just for people who had lost theirspouses but also people who had experienced abereavement of any kind, so participants also
listened to the bereavement experiences of people
who had lost children, siblings, or parents. The study
participants learned about various bereavement
experiences from different standpoints and realizedthat grieving for people other than their spouses was
also painful.

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Next steps: When the study participants listened toand spoke about bereavement experiences, theyexpressed their sadness and pain and showed theirown vulnerability to the other bereaved people
there. In discussing their grief with others,
participants became aware of their ongoing lives andthought about how to live and interact with people
moving forward, uninhibited by sadness.
Feeling of connection with the deceased: Throughve r b a l i z i n g a n d t a l k i n g a b o u t t h e i r o w nbereavement experiences, the study participants had
a deeper sense of the presence of their deceased
spouses and were aware of their connection with
them.
Topic 3: Changes in view of life and death
Changes in sense of values that cannot be
achieved alone: On their own, the study participantsremained entrenched in circular thoughts that did
not progress, and they were stuck in their own wayof thinking; however, their sense of values changed
through listening to various people’s bereavement
experiences and talking about their own in thegroups. They also felt the importance of listening tomany bereavement experiences and of verbalizing
and communicating to others what they had learned
about death as well as the events and feelings that
had arisen within them.

Eubios Journal of Asian and International Bioethics 33(1) (January 2023)

5

Table2. Results of qualitative analysis
Topics

ThemesInterview quotes
The most painful thing was not being able to talk to her or see her face. I realized how much my wife had helped me. (Participant C)

Psychological reactions

I felt apathetic, I didn’t want to do anything. Somehow I lived through it. It was hard and I was down until about the second year.
(Participant D)
I thought it was me, I was the one who killed him. I mean, I didn’t notice. That he might have been sick. That he was sluggish, that
his blood pressure was high. I didn’t notice at all. I thought I was a murderer. (Participant L)
After all, she was facing death and didn’t have much time to live. I wasn’t fully there for he. I tried to face away as much as possible,
or I ran away. This was my greatest regret, I felt like a horrible person. (Participant E)
I think I felt relieved. Caregiving is hard too, you know. (Participant T)
I used to sleep six hours when my wife was here, but since she passed away, I sleep three to four hours. (Participant K)

Topic 1
Post-bereavement reactions

Physical reactions

I felt like I wouldn’t mind if I lost my life, so I only picked at things I wanted to eat while at home. ... I wasn’t eating, so I lost seven
kilograms. (Participant I)
When my husband was in hospital, I didn't have much energy to cook meals for myself, and I lost about 5 kg in twomonths.(Participant O)
I was tired from caring for my wife and lost weight. I was at my lowest weight when my wife died. (Participant B)

Social reactions

Very few people lose their husbands at the age I did, so even when I talked to my friends about my feelings, they didn’t understand.
They tried to console me. But of course, it didn’t quite work. More often they ended up hurting me instead. (Participant O)[The children] were quite a handful. I didn’t have anyone to talk to about how to raise three children (one in junior high, one inelementary school, and one in kindergarten). (Participant E)
Everything was meaningless. I thought there was no point in living. (Participant L)

Spiritual reactions

For about two days [after he passed away], I felt so strongly that he was near me. ... I felt so clearly that he was still here, that’s
what it felt like. (Participant R)
There were all kinds of lives, and different ways of feeling after a death.(Participant P)

Realizing the diversity of
bereavement experiences and thesignificance of verbalizing

With each repetition, I felt like things were being digested within me and organized into words. As I spoke, I sometimes noticed what I
had been thinking for the first time. I felt like that must be the purpose of speaking. (Participant R)
Talking with others about the experience of bereavement, you figure out what kind of path you’re on. (Participant A)

Feeling of fellowship

My siblings and friends didn’t understand when I talked to them; they tried to be encouraging but ended up hurting me. But here, we
had something in common, and that was comforting. I realized that I wasn’t alone, that everyone feels the same way, and that was arelief. (Participant O)
I am glad that I could come to a place like this to talk about bereavement, because it is a subject that I can never get through to myneighbors.(Participant P)
I could not talk about my wife’s bereavement at work. (Participant S)

Topic 2
Listening and speaking[I lost my husband, but] the stories of those who had lost a son or daughter were painful. (Participant R)
Relativizing one’s own sadness

Next steps

Until then, it was like I thought I was the only one in pain. But actually, his parents must have been sad, and our children must havebeen sad. I was able to learn that through sharing. (Participant L)
We were crying and talking together, so it’s like those of us who came could become one and share. Maybe we would be able to take a
step forward. (Participant P)
I think it was a question of how to live with the time I had left. As we shared our sadness together and empathized, I faced myself.
After that, I found a way to interact with others going forward. (Participant M)
Talking made me feel even more connected to [my husband]. (Participant R)

Feeling of connection with thedeceased

People who have just lost someone may not know this, but the deceased person is watching over you, so I think it’s important for you
to have an enjoyable life. (Participant Q)
The body may perish, but when we talk and verbalize, [our deceased spouse’s] depth as a spiritual being increases. (Participant A)

Changes in sense of values thatcannot be achieved alone

I think there’s no way it would have turned out like this if I’d been on my own. I was going around in circles in my own mind,
but in truth, maybe it’s this other way or that other way, and I guess this is how, um, my sense of values changed. In a way, it was anawakening. (Participant M)
Death comes for everyone, without exception, and that’s not just something I know. I have listened to lots of experiences of
bereavement. ... Learning on my own and learning from others. Properly verbalizing my own experience for other people as best as I
could. (Participant A)
Death was something I feared and dreaded, but it’s something that will inevitably come, and it’s not so scary anymore. (Participant B)

Acceptance of death and preparation
for death
Topic 3
Changes in view of life and death

Before, death was something I hated, but now I think it has dignity. I’m not afraid of death. (Participant L)
You have to think regularly about your own thoughts and actions in terms of how to deal with death. (Participant A)
If I collapse, I absolutely do not want life-prolonging treatments. (Participant P)

Living to cherish the present
momentReception of spiritual feelings

Human beings can die at any time. This is why I think we have to properly live each day. But we forget this in our day-to-day lives.
(Participant J)
I don’t know what life will be like in a year, so I’ve decided to do my best right now with what I can. (Participant S)
When she was alive, my wife hated that I drank, so on the monthly anniversary of her death, I made sure not to drink; but one day, afriend came over, and I thoughtlessly ended up drinking on the anniversary. There was a white cloth covering the box that held mywife’s bones, and it was bunched up and was not hanging properly. I apologized, saying “I’m sorry, I drank,” and the white cloth fell
down to its proper place. Seeing that, I felt my wife’s presence, and I knew that she was watching over me. (Participant B)
I don’t know if there’s an afterlife or not, but I thought believing in an afterlife would ease my worries about death. (Participant E)

6Eubios Journal of Asian and International Bioethics 33(1) (January 2023)

Acceptance of death and preparation for death:Some participants previously had fear or dread ofdeath; however, through group discussion, death
became something that happens as a matter ofcourse, something no longer frightening, andsomething with dignity. Furthermore, by joining
groups and listening to various other people’s
bereavement experiences, more than a few
participants came to think about preparations fortheir own death, such as the kind of medical carethey wanted to have in the inal stages of life.
Living to cherish the present moment: By newly
recognizing the reality of death, participants
re lected on what they can do and cherish in thepresent. Some participants began volunteering insuicide prevention, helping young people who aresocially withdrawn (hikikomori), and visiting withthe elderly.
While some of the study participants had faith to
begin with, others were led by transcendent
experiences or group discussions to a new desire toconnect to the deceased. Some people who werepreviously afraid of or anxious about death came tothink that believing in an afterlife would diminish
the fear of death in their lives.
Discussion
Gaining a feeling of fellowship by listening toothers’ bereavement experiences: Yalom (1995),
who studied and practiced group therapy, reported
that patients who join therapy can hear othermembers disclose concerns similar to them and feel
more in touch with the world. He called this a type of“welcome to the human race” experience. The
participants of the present study attended groups forthe bereaved. By irst listening to others talk about
their experiences of bereavement, they empathizedwith others’ feelings and realized that they were notalone in their sadness and pain. This feeling of
empathy, of not being alone, may have beenconnected with being welcomed by their peers, andthis may have given rise to a sense of being
connected to others through grief and loss.
Furthermore, based on the notes of the bereavement
groups they attended, listening to others talk about
their pain is also a way for the listener to talk about
their own pain (Yamato Seitoshiwo Kangaerukai,2008). It seems that even without the bereaved
person speaking about themselves, their own
suffering and pain are being spoken for, and they arebeing empathized with.
Regarding negative experiences at bereavement
groups, it has been reported that some people felt
additional stress from listening to the stories ofothers and being overwhelmed by others’ situations(Dyregrov et al., 2014); however, none of theparticipants of the present study said that they felt
additional stress from listening to stories of loss.

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Reconstructing the meaning of life and living
through telling peers about bereavement:
Takahashi (2010), who is involved in bereavement

care in Japan, states that it is important to getbereaved families themselves to tell their stories andrecount the past as an event of loss. However, it is
dif icult to talk about the experience of bereavement
alone, and one needs an audience. An important roleis played by the presence of someone who will
reliably listen to one’s story (Noguchi, 2003).
However, not just anyone makes a good audience.
Morrigan et al. (2020) conducted an interview
survey of the bereaved and found that among people
with similar experiences, there was a comforting
common theme, and they spoke of being able to talkfrankly about what they thought and how they felt.
The participants in the present study stated thatthey hesitated to talk about bereavement with coworkers or neighbors and that they felt hurt when
their friends tried to console them. When it is
dif icult to talk about bereavement in one’s social
life, it seems that peer support groups provide anenvironment with equal footing due to having thesame experience of bereavement, and people caneasily put their inner thoughts into words andexpress their emotions.
Some people experienced the process ofverbalizing the situation they found themselves inand its meaning; as one study participant said, “Itfeels like talking organizes things into words.” Bytalking about their bereavement experiences withpeers, the study participants may have connected
the fragments of various experiences related to theirloss, which had until then been scattered in chaos,and built them into a whole, consistent experiencefrom past to present. As Riessman (2008) stated,“One can’t be a ‘self’ by oneself; rather, identities areconstructed in ‘shows’ that persuade.” Perhaps, thebereaved built a new self by talking about theirexperience of bereavement with peers. Gilbert(2002) stated that people recreate their own
experience in narratives and establish both orderand social connections through the sharing ofstories. The participants in this study adjusted theirperception of the experience of bereavement, which
had been chaotic within them, into somethingordered and gained a desire to connect with otherbereaved people and others in general.
Funding
This work was supported by JSPS KAKENHI Grant
Number JP17H02261 and by Research Grant from
Niigata University Graduate School of Health
Sciences.
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Mental Hygiene, 54(4), 540–547.
Ta k a h a s h i , K . ( 2 0 1 0 ) . G u r ī f u ( h i t a n ) k e a n ioite monogataru koto no imi: Supirichuaru na shiten
kara no enjo [The meaning of narrative in grief care:
Support from a spiritual perspective], Hirayama, M.
(Ed.): Sibestu no kanashimi kara tachinaoru tame ni, (pp.
193–224). Rinshō shisei gaku kenkyū sōsho 2, Seigakuin
Daigaku Shuppankai.
Yalom, I. D., (1995). The theory and practice of grouppsychotherapy: Fourth edition. Basic Books.
Yamato Seitoshiwo Kangaerukai (2008). Monogataru kotokataritsumugu mono [Narrating and putting into words].
Mokuseisha.
Yokoseki, Y. (2015). Alfons Deeken no desu ejukēshon:
Nihon niokeru juyō to sonogo no tennkai [Alfons
Deeken’s death education: Acceptance and developmentof death education in Japan]. Nihon University GSSC
Journal: The Bulletin of the Graduate School of Social and7

Cultural Studies Nihon University, 16, 208–219. https://
gssc.dld.nihon-u.ac.jp/wp-content/uploads/journal/
pdf16/16-208-219-Yokoseki.pdf

Shared decision-making andrelational identity in a pregnant
woman with Eisenmenger
syndrome-Endah Rahmawati, Agung Dewanto, Irwan Tau iqur
Rachman, 1, Wika Hartanti, MIH2
1Department of Obstetrics and Gynecology, Faculty of
Medicine, Public Health and Nursing, Universitas Gadjah
Mada
2Center for Bioethics and Medical Humanities, Faculty of
Medicine, Public Health and Nursing, Universitas GadjahMada

Abstract
Pregnancy should ideally be avoided in a woman
with Eisenmenger syndrome concerning the highmaternal mortality rate and probable poor prognosisof the baby. However, the decision making ofconceiving prevention and medical termination inpatients with Eisenmenger syndrome is still
dilemmatic. A 29-year-old, with non-corrective atrial
septal defect P1A0 passed away three days after
caesarean section due to pulmonary hypertensivecrisis. She was diagnosed with Eisenmenger
syndrome and had been educated related
contraindication to pregnancy but she refused toterminate her pregnancy due to encouragementfrom her husband, family and peer group. Based on
the four box methods, there are four approaches tomake decision for pregnancy termination. First,
medical indication; patient with Eisenmenger
syndrome, non-corrective atrial septal defect.
Second, patient preference; as a woman and wife thepatient believes that she must be a mother. Third,
quality of life; physically extremely poor for a patientwith NYHA class functional II (high maternalmortality rate), however psychologically might feelbetter from patient’s perspective to become amother. The last, contextual feature; various external
in luence advocating for continuation of pregnancy
despite the risk for mother, i.e. from her spouse,social construction of gender, religious values andmisinformation/ low literacy of medical informationin general society. In this case, medical indicationand quality of life (from clinicians’ perspective) werein con lict with patient’s preference, patient’s
perceived quality of life, and contextual features,
which caused clinicians to be in dilemma when
advocating for pregnancy termination. Increasing
the clinician capacity in ethical deliberation;
empowering patient’s capacity and educate society
are needed to prevent from decisions which lead tothe harm of patient. Further studies are needed tofocus on how to understand and bridge the gap

8Eubios Journal of Asian and International Bioethics 33(1) (January 2023)

between medical values (focused on prioritizing
patient's safety and autonomy) and society’s
expectation or perception on women especiallyregarding maternal role.
Introduction
Eisenmenger syndrome is a syndrome with acongenital heart defect and results in large anatomic
shunts which develop into severe pulmonary arterial
hypertension and elevated vascular resistance (1).
Maternal mortality in the presence of Eisenmenger
syndrome is reported as 30-50% (2). Pregnancy
should ideally be avoided in a woman with
Eisenmenger syndrome concerning the highmaternal mortality rate and probable poor prognosisof the baby (3). Termination of pregnancy is
generally recommended for those who present earlyin the pregnancy (3). However, the decision makingof conceiving prevention and medical termination inpatients with Eisenmenger syndrome is still
dilemmatic. Patients with Eisenmenger Syndrome
must face various issues that greatly determine theirdecision regarding their pregnancy. In this paper, we
discuss a case related to the decision-making
process of a patient with Eisenmenger syndrome
who continued her pregnancy even though thepatient was recommended to terminate her
pregnancy.

was it to continue her pregnancy or not. A
Multidisciplinary team of obstetrics and gynecology,
cardiology, anesthesia departments and the hospital
ethics committee discussed together to ind the bestsolution for the patient. With many clinicalconsiderations, the patient was advised to terminate
h e r p r e g n a n c y, b u t s h e r e f u s e d d u e t oencouragement from her husband, family and peergroup. At 27 weeks of gestation, the patient and herbaby experienced worsening so a caesarean section
was performed, and the patient passed away 3 days
later. The baby also died one week later.
Discussion
The case illustrates an ethical dilemma where theclinician has a moral duty to educate and prioritizematernal health or safety but at the same time has tomeet with the social norm or value or expectationand peer group in luence (Figure 2).

Figure 2. Ethical Dilemma Highlight

Figure 1. Case analysis decision making process of theEisenmenger Patient. A female patient, 29 years old,
suffered from Eisenmenger syndrome, had been
educated to use contraception but refused and got
pregnant; the patient was advised to end her
pregnancy. ASD= Atrial Septal Defect; TR= Tricuspid
Regurgitation; MR= Mitral Regurgitation; PR=
Pulmonary regurgitation; NYHA= New York Heart
Association; CF= Class Functional; mWHO
classi ication= modi ied World Health Organization
classi ication; PH= Pulmonary hypertension; PPROM=
Preterm Premature Rupture of Membrane.

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Case
A 29-year-old, Eisenmenger syndrome patient with
non-corrective atrial septal defect P1A0 passed away
three days after caesarean section due to pulmonary
hypertensive crisis (Figure 1). She was diagnosed
with Eisenmenger syndrome and had been educatedabout contraindication to pregnancy but the patientdecided to conceive and inally, she was pregnant.
Due to her clinical condition, a clinical conference
was conducted to determine whether this patient

Our attempts to comprehend and systematicallyanalyze the ethical dilemma in this case, were guided
by the Four-box paradigm/method by Jonsen, Siegler
and Winslade, in order to facilitate our clinicaldecision making ethically. Based on the four-box
method, there are four main aspects to consider inmaking the decision for pregnancy termination(Figure 3). First, medical indication; patient had been
diagnosed with Eisenmenger syndrome, noncorrective atrial septal defect and this condition wasa contraindication for pregnancy. Second, patient
preference; patient expressed her wish to keep the
pregnancy, as she believed that as a woman and wife,
becoming a mother is a noble dream, without thatsome women may feel useless. As a wife, shebelieved her husband’s request and opinion tocontinue pregnancy must be obeyed. Third, quality oflife; from clinical perspective, patient’s quality of life,
physically, would be extremely poor, as patient with
NYHA class functional II, would have limitations in
performing strenuous activities, as well as a highmaternal mortality risk. However, psychologically,
quality of life might be considered better from thepatient’s perspective, as she believed that keeping
the pregnancy is part of her duty as a woman andwife, hence she felt compelled to pursue carrying
and delivering a child despite the risk of losing herlife in the process. The last is contextual feature; theEubios Journal of Asian and International Bioethics 33(1) (January 2023)
in luential external factors for patient’s decision tokeep the pregnancy were her spouse’s request andopinions. Additionally, she was exposed to a peergroup of women and mothers who had theexperience of successful delivery. In broader context,
the social construction of gender, and religion values
were the factors that became the basis of patientreference in making decision to continue her
pregnancy. Concluding the 4-box analysis we foundthat the aspects of medical indication andassessment of patient’s quality of life in physicalaspects suggested the ethical clinical decision wasfor pregnancy termination. However, this con lictedwith the aspects of patient’s preference, patient’s
perceived quality of life psychologically, andcontextual features, which led her to continue
pregnancy. We were inclined to consider thiscon licting situation might have stemmed frompatient’s spouse and related peer group’s low
medical-health literacy, especially on Eisenmenger
Syndrome, and complicated with the society’s
construct on gender and religious values.
Although the clinical conference by themultidisciplinary teams (obstetrics and gynecology,
cardiology, anesthesiology, and ethical committee)
advised to terminate her pregnancy, she and his
family refused. Observing the patient's decisionmaking process is certainly an interesting thing inthis case. In shared decision making the clinician
should provide information to patients in order toenable them to decide autonomously and freely
about treatment together with the doctor, without
interference, force or coercion by others. However,the desired goal in this case (termination ofpregnancy) had not been achieved, resulting inmaternal death.

Figure 3. Four box method, an approach to makedecision to pregnancy termination in the patient with
Eisenmenger syndrome. The four-box method is anapproach that is used as a basis for making clinicaldecisions regarding ethical dilemmas. This method
consists of four boxes, namely: medical indications,patient preference, quality of life, contextual features.

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We can learn a lesson in this case concerning t thedecision-making process, as it is not only about the
informed consent of the patient and her family, butmore than that, a shared decision making together
with the patient and her family was needed.

9

Informed consent and shared decision making arevery different processes. Informed consent is more
focused on the process of conveying information
related to the nature of treatment, risks, bene its,
alternatives, and there is an opportunity for thepatient to ask questions and then decide to refuse or
agree to treatment (4-6). One level above is what iscalled informed choice where the process is thesame as informed consent but there is an additional
process of assessing patient understanding,
discussing risks and bene its as well as alternatives
and asking about patient choices. The most ideal
process in making a clinical decision is shareddecision making where we must identify patientneeds, values, preferences, goals and discussing
uncertainties of treatment, experience of providers,costs and two-way conversations with patients/
family having a role in decision (4-6).
Shareddecision making is not a simple process, as it has
several steps including reviewing the problem ofpatient, involving patient through the process, giving
information about the risks and bene its of each
option, discussing about patient concerns andexpectation, developing decision and arranging offollow up (7).
To reach the best decision for the patient,counseling and education are a must. Patient
education is part of management planning (8).
Counselling and education should be done clearly,
involving related parties (husband, family). Changing
the patient’s decision is not easy, it takes a complex
long process. The essential steps of shared decision
making are patient’s participation and capability toassess patient’s value and preferences and inallyreach the best decision for patient’s health (9).
Declining medical termination in this case can beaffected by culpability and responsibility, ideologies
and religions, mistrust, and hope (10). Role of peergroup in decision making cannot be ruled out since
they can be as source of information, in luence,pressure, support system and their moral values
could affect each other (Figure 4). The decision
making of patient in this case has been affected byher identity as a woman and wife and her
dependency on others’ (spouse, family, peer group,society) values, opinions, and experiences.

Figure 4. Role of peer group in decision making

In share decision making, patients can decide
independently and freely about treatment with
doctors, without interference, or coercion by others.
In some circumstances, relatives (spouse and family)
may be seen as obstructing or hindering the10

Eubios Journal of Asian and International Bioethics 33(1) (January 2023)

patient's own decisions. Relatives may not act as
third parties beside the doctor and patient, but aspart of the patient's identity and thus be present in
the decision-making process since beginning (11).
Beside the medical professional support, thepresence and support of the spouse and family are
the main strength of the patient without expecting
systemic support (12).
The fundamental lesson that we can take fromthis case is related to the process of a woman in
making a decision. There are two basic factors thatin luence them in making decisions: identity anddependency (Figure 5). Identity includes their value
as a woman, wife and daughter, personal
characteristics, religion/belief and their healthcondition. Meanwhile, the dependency factors
include values, opinions, decisions, and experiencesby other people (spouse, family, peer group).
Changing the identity and dependencies attached toeach woman is not an easy thing because it requires
a complex and long process.

Figure 5. Factors that in luence a woman to makedecision.

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Conclusion
Based on the case discussed above, we learned thatpatient’s expression of preference and decision
making, especially with certain identity and roleassigned to women, was in luenced by far more
complex components such as spousal and peer
support/ encouragement, as well as the broader
issues of gender construct, religious values andmedical-health literacy in the society. Several points
need to improve in to how a clinician is able to deal
with ethical dilemmas and identify patient values
and preferences: improve counseling services to bem o r e c l e a r, i n f o r m a t i v e , p e r s o n a l i z e d ,multidisciplinary, and empowering patient capacity;society education on women's health andreproductive rights literacy and fostering dialogues
on understanding social construction of genderroles/expectations, increasing healthcare and peergroup partnerships to foster aligned healthmessages/information (reduce misconceptions andmisleading in luence). Further studies are needed on
how to understand and bridge the gap between
medical values (focused on prioritizing patient's
safety and autonomy) and society's expectation/
perception on women especially regarding maternalrole.

Figure 6. Future recommendation

References
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Syndrome. StatPearls. Treasure Island (FL)2023.
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PL, Bellotti G, et al. Maternal and fetal outcome inpregnant women with Eisenmenger's syndrome. Eur
Heart J. 1995;16(4):460-4.
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Cardiovasc Surg. 2016;31(4):325-9.
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Obstetrics and Gynecology: ACOG Committee Opinion,
Number 819. Obstet Gynecol. 2021;137(2):e34-e41.
5. Loeff DS, Shakhsheer BA. The ethics of informed
consent and shared decision-making in pediatricsurgery. Semin Pediatr Surg. 2021;30(5):151101.
6. Whitney SN, McGuire AL, McCullough LB. A typology ofshared decision making, informed consent, and simple
consent. Ann Intern Med. 2004;140(1):54-9.
7. Rosca A, Krones T, Biller-Andorno N. Shared decision
making: patients have a right to be informed about
possible treatment options and their risks andbene its. Swiss Med Wkly. 2020;150:w20268.
8. Greutmann M, Pieper PG. Pregnancy in women withcongenital heart disease. Eur Heart J.
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9. Lindley KJ, Bairey Merz CN, Davis MB, Madden T, ParkK, Bello NA, et al. Contraception and Reproductive
Planning for Women With Cardiovascular Disease:
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10. Abi Tayeh G, Jouannic JM, Mansour F, Kesrouani A,
Attieh E. Complexity of consenting for medical
termination of pregnancy: prospective andlongitudinal study in Paris. BMC Med Ethics.
2018;19(1):33.
11. van Nistelrooij I, Visse M, Spekkink A, de Lange J. How
shared is shared decision-making? A care-ethical viewon the role of partner and family. J Med Ethics.
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12. Zareba K, Makara-Studzinska M, Ciebiera M, Gierus J,
Jakiel G. Role of Social and Informational Support
while Deciding on Pregnancy Termination for Medical
Reasons. Int J Environ Res Public Health. 2018;15(12).

Heritable human genome editingin Japan: status and continuity-Silvia Croydon, D.Phil.
Graduate School of Human Sciences, Osaka University
Osaka, Japan
Email: croydon@hus.osaka-u.ac.jp
Every year an estimated 7.9 million children, 6% of
total births worldwide, are born with a serious birthdefect of genetic or partially genetic origin. Had
sexual reproduction been invented by scientists
rather than resulting from our evolved biology, it
would never have been licensed—far too dangerous!
John Harris, Professor Emeritus, University ofManchester

Introduction
At the 30th annual conference of the Japanese
Association for Bioethics held on 8th-9th December
2018 at Kyoto Prefectural University, at the end of asession on genome editing, one of the prominent
bioethicists in presence—a professor at a top
national university who is heavily involved in
shaping the regulation of bioscienti ic research andapplications—stood up to express condemnation of
the Chinese biophysicist He Jiankui. The professor
had personally witnessed He’s announcement a few
days earlier at the 2nd International Summit on
Human Genome Editing in Hong Kong regarding thebirth of a set of twins following genome alterations
with the clustered regularly interspaced shortpalindromic repeats (CRISPR)-Cas9 tool. This
technology, he explained, was not yet ready for
application in the clinic, nor was there social
consensus in place about the moral permissibility ofutilizing it in this way. The global scienti ic
community, he expounded, had made it abundantly
clear that this CRISPR-Cas9 is not to be employed inhuman reproduction at the current stage. Manynational academies of science and medicine, henoted, had issued calls for moratorium, and there
was even a multinational statement from the 1st
International Summit on Human Genome Editing inWashington, D.C., in 2015 stating that, for the time
being, it would be irresponsible to proceed withclinical use of CRISPR-Cas9. By ignoring these calls,
He had breached a code of conduct in science, theprofessor argued, and to prevent the occurrence ofmore cases such as this, the establishment of aninternational monitoring body for clinical use ofhuman germline genome editing was necessary—aproject for whose pursuit he has now joined forces
with his counterparts in other countries.
The legitimacy of condemning He’s experiment11

notwithstanding, what subsequently transpired at
the above-mentioned Japanese gathering amounted
to the participants throwing the baby out with thebathwater. A stream of ill-founded objections ensued
with regards to the modi ication of the genome ofembryos, and at no point until the end of that session
did anybody stand up in defense of the principle that
one day, when we have acquired technicalcompetency in altering the genome of such tissue,
there might be a compelling reason to do so. Indeed,
attendee after attendee rose to express what
appeared to be a dogmatically held view withregards to human germline genome editing.
Changing the human germline, one gentlemanargued with discontent, would result in a cascade of
unforeseen and irreversible repercussions for the
future generations. This line should never becrossed, claimed another, for, above all, there was no
way of obtaining the consent of those who would
stand affected – our descendants. We are at the
beginning of a slippery slope with this CRISPR/Cas9
technology, a third participant asserted, because, if
we allow its use for controlling diseases, we arebound to ind ourselves next permitting it for all
kinds of enhancements too. There is a potential withhuman germline genome editing, a fourth person
joined the bandwagon, for mistakes to occur withhorrendous consequences that are unimaginablefrom our current position.
The condemnation at this gathering of heritable
human genome editing (HHGE) altogether was not
an isolated occurring in Japan in the aftermath of therevelations surrounding He. On the contrary, thelevel of engagement with the question of HHGE by
the attendees of this event could be said to re lectthat which was sustained broadly in Japanese society
at the time. Corroborating this statement is theinding of Daiki Watanabe et al. that theoverwhelmingly negative coverage of the He affair
here brought about a dramatic fall in public
acceptance of the genome editing technology, notjust in the ield of human reproduction but also
across agriculture and ishery breeding1. There was,indeed, a lack of proper engagement on the topic inthis jurisdiction, with the only reaction seen in the
media and other public arenas, such as the academia,
being a re lex one, whereby commentators widely
rushed to decry the whole concept of HHGE. No one
could be seen to take the challenge of pointing out
the laws that underpin the common objections tothis notion and highlighting the responsibility
towards those currently without a therapeutic
reproductive option to continue pursuing mastery of
the technique. Even today, the difference is striking
between the record of irm af irmations made in theaftermath of the He announcement by scientists andbioethicists in other countries of the prospective

1 To be more speci ic, Watanabe et al.’s sequence of surveys revealed that the share of interview respondents saying that

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they ind the genome editing technology “most impressionable” dropped from 269, or 39.4%, in 2016 to merely 83.4, or
3.03%, in 2018 and 78.7%, or 2.97%, in 2019, with, simultaneously, the number of those being “concerned about[associated] ethical issues” jumping from 0 in 2016 to 71.8 in 2018 and 79.6 in 2019.

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Eubios Journal of Asian and International Bioethics 33(1) (January 2023)

12

Eubios Journal of Asian and International Bioethics 33(1) (January 2023)

value of prudently implemented HHGE (with ive
examples from two other biotech powerhouses, theUnited States and the United Kingdom, being: Daley2018; Harris 2018a, 2018b; Daley, Lovell-Badge &Steffann 2019; Greely 2021), and the silence, on theother hand, that remains in Japan with respect tothis subject.
The present article draws attention to thisstagnancy in the Japanese debate on HHGE. Putting
the question of HHGE in Japan in focus is importantbecause of the signi icant loss that could occur forthe community of people with heritable conditions
by having this country, which has been able tocontribute enormously to the so-called Human
Genome Project (Cook-Deegan 1994; Sasaki 2019)
and which boasts enviable bioscience capabilities,
remain a passive observer in the evolution of the
HHGE technology. Although Japan has recently
invested heavily in the development of somatictherapies based on the induced pluripotent stem cell
technology, this is but only one of the possible
approaches to controlling disease. Furthermore,insofar as this approach has not yet been realized,
consideration of HHGE as a reasonable alternative iswarranted. With it being the case that technologies
do not develop in a moral vacuum and that more
often than not the public debate leads the way whenit comes to their development, it seems importantthat the inaction on the part of Japan with regards to
HHGE is highlighted and an insight is sought as towhat the factors behind it might be. The present
article can be considered as a thrust in this direction.
In what follows, the article irst considers thestate of HHGE science in Japan, utilizing in thediscussion Japanese bioethicists’ views, as expressedin a conversation with the author, on why thiscountry diverges in this respect from its
counterparts in the developed world. This is thenfollowed by a more comprehensive overview ofexisting survey results with respect to the Japanese
population’s stance on the acceptability of HHGE.
Both these parts of the article are to serve as further
contextualization for the observation ultimately
presented that there is a continuity in how dif icult
issues of bioethical nature are handled by theJapanese academe, and bioethicists more speci ically.
Japan’s lack of scienti ic output on HHGE: The
disengagement in terms of the debate on HHGE in
Japan is borne out by the fact that, as Hokkaido
University bioethicist Tetsuo Ishii recently
highlighted (Ishii 2020), there exist literally zero
papers published by Japanese scientists reporting on
experimental work in this ield. Although this inding
might not seem of signi icance when it is consideredthat the research on HHGE is still in a nascent stateinternationally, Japan is but a global leader inbioscience and a most heavy utilizer of in vitro
fertilization (Croydon 2021a, 2021b, forthcoming),and so the absence of any scienti ic output in thisregard could be said to be at least conspicuous.
In relation to this lack of HHGE research activity,
the reaction of some might be that the existence of adiversity of approaches, or a global division of labor,
if you will, towards the goal of developing
therapeutics and eliminating disease, is a good thing:what could be so wrong, they might say, with Japan
putting, as it has since 2012, the majority of its
efforts and resources towards developing technology
for somatic treatments based on reprogramming
adult cells, and other scienti ic powerhouses, such as
the United States and the United Kingdom, forexample, focusing more on obliteration of disease in
the gametes or through the more traditional meansof embryonic stem cell therapies?
The lack of scienti ic output in HHGE on the partof Japan would not have been so noteworthy if it
re p re s e n te d a by p ro d u c t o f a d e l i b e ra tearrangement. Indeed, had it been the case of aninternational coordination and a conscious effort
being in place to let each jurisdiction play to its
strengths, Japan’s lagging in the ield of HHGE would
not have been particularly notable. However, to theextent that there is no such arrangement, and in lightof the above-described silence by bioethicists, one is
led to hypothesize that perhaps existing hostile
trends in the public perception of HHGE might bewhat is standing in the way of this science.
In relation to this hypothesis, it is pertinent tomention a remark made by a group of Japanese
bioethicists in December 2018, just after theunfolding of the He iasco. According to them:Japanese scientists are extremely mindful of
unspoken social norms (kihan no ishiki ga takai).
Whilst in other countries, scientists would
venture into HHGE even if there is a law or otherregulation explicitly prohibiting it, in Japan, bycontrast, even in the presence of a legal green
light for HHGE, the scientists would not dare go
into it. They would be too fearful that they would
be breaching a tacit social consensus thattampering with the human germline genome isoff limits2.
Although this is merely an of hand comment, inthe absence of any other explanation of the reticenceof Japanese scientists to work on HHGE, it appears
worthwhile paying heed to it. Is it not more likely,
indeed, that rather than resulting from the Japanesescientists’ divergent view on the feasibility, or utility,of delivering therapeutics through HHGE, theabsence of scienti ic output in this area here is afunction of the latter being fearful of breaking asocial taboo?
Survey results on HHGE’s acceptance in Japan: Acomprehensive overview: The fears of Japanesescientists put aside, is it really the case that there is a

2 Author’s translation from Japanese. Private conversation, 15 December 2018. Names of participants withheld for

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resolutely established domestic public view on
HHGE in Japan, which is what one might conclude
from the above-mentioned survey results of
Watanabe et al.? On this question, it would constitutea grave omission to fail to mention the existence of
two other recent surveys on the level of domestic
public acceptance of the use of the genome editing
invention on human germline tissue—Uchiyama etal. 2018 and Hibino et al. 2019. Taken aggregately,
these papers present a more nuanced portrait of theextent to which the Japanese public supports HHGE.
To explain concretely with regards to thesesurveys, the irst one investigates the attitudes tohuman germline genome editing in two groups inJapan: one comprising 10,881 general adults (GAs),and another—937 patients (Pts) diagnosed with orat risk of developing a genetic condition, with thebasis for bringing into an independent focus thelatter being that, as stakeholders in the technology(i.e. as in being prospective clinical trials
participants and bene iciaries of heritable genome
editing, or, reversely, being candidate eugenic
targets), they might hold divergent views from thoseof the general population. In con irmation of thishypothesis, the researchers reported that Pts were,
to begin with, more aware of this technology thanGAs, and that people with higher awareness of HHGE
in both groups were more supportive of it, with over
50% of these more knowledgeable respondents
agreeing that it may be used for diseases thatshorten a baby’s life or require long term care
(Uchiyama et al. 2018). However, when asked if they
had concerns about changing the genes of otherhumans, about the unexpected effects on the human
body, and about the effects on future generations, inboth groups and across all levels of understanding of
HHGE, respondents predominantly indicated thatthey do, with this percentage being often in thehigher 80s. To cite the researchers’ summary of theirindings, “despite low awareness and inadequate
understanding about genome editing before
responding to the survey, [the] respondents were
accepting of its use in targeting of disease-related
genes, albeit with substantial concerns about risks”(Ibid.: 748).
As for the second survey, it presents acomplementary picture, in that it highlights thatwhen given the option to select between more thanjust the binary answers of “I agree” or “I disagree” toquestions about the acceptability of use of synthetic
biology and genome editing, including with respect
to human germline tissue, as much as around 80% of
respondents in Japan, choose to give an equivocal,
indecisive, judgement-postponing, reserved
response (Hibino et al. 2019). To cite theresearchers’ own words with regards to what thisoutcome means:
This indecision was found to be related to the
cognitive image of the self and future generations.
Our survey analysis demonstrated that those with anarrow cognitive self-concept tend to postpone
judgement on emerging biotechnologies. Those withff

Eubios Journal of Asian and International Bioethics 33(1) (January 2023)

13

a broad cognitive self-concept tend to have a twosided attitude and are more short-sighted but makejudgements based on the impact of their decisions
on the current and future generations (Ibid: 4).
To recap, the picture that emerges when theinformation from these surveys is taken holisticallyis one of a lack of a resolutely established domestic
public view on HHGE and of the existence
simultaneously of serious considerations regarding
passing pathogenic gene mutations on to future
offspring and anxieties about risks.
Background: The precedent of human embryonicstem cell research (hESR): Taking stock of thematerial presented hitherto, how do we make senseof the seemingly con licting evidence that, on the one
hand, Japanese scientists refrain from HHGE
research, arguably due to their fear of breaching asocial taboo, and, on the other hand, an urge being
detectable here of the public to endorse thistechnology’s use to alleviate pain and suffering? An
insight regarding this, it is the contention of thisarticle, can be found in earlier episodes of Japan’s
biomedical history. More speci ically, a striking
amount of parallels could be found between this caseand that of hESR, with the quiet of the academics
regarding the ethical aspects of the subject being theroot cause of the stagnation of both the debate andthe research.
To elaborate on the hESR case, in the late 2000s,
the anthropologist Margaret Sleeboom-Faulkner
attributed the stagnation in this area in Japan
precisely to the disengagement of the academics, inaddition to the policy-making elite, with the public
on the issue of the moral status of the humanembryo (Sleeboom-Faulkner 2008, 2010). Japanese
bioethicists, she observed, avoided making
uncomfortable comments in public. At a time when
Christian groups had brought a moratorium on
public funding for hESR in the United States to theembarrassment of the science community there, theJapanese science and policymaking elite, she argued,
adopted the hackneyed view, arguably in a bid toposit Japan’s superiority, that the local religious andcultural canons allowed for a moral void to exist
surrounding the human embryo, meaning that there
is no obstacle domestically to such research. Thisview, expressed by experts in the media and other
outlets, that the embryo is of no moral concern to thepeople of Japan stymied the emergence of a publicdebate, with everyone becoming hesitant to share
their real opinions in the open. As for how theseexperts corroborated their claim, SleeboomFaulkner noted their referring to the long-standing
extensive practice of induced pregnancy termination
here—if the embryo held a special place for Japanesepeople, we would not have been witnessing such asizable abortion practice, the argument appears tohave gone.
Furthermore, as a way of demonstration that it is,indeed, the state of the public debate that makes adifference as to whether a morally controversial
biomedical practice picks up or not in Japan,

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Eubios Journal of Asian and International Bioethics 33(1) (January 2023)

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Sleeboom-Faulkner pointed to the process throughwhich the 31-year Japanese moratorium on tissue
donation at the other end of life—or more precisely,
following brain death—was broken here. As had
been elaborated by Masahiro Morioka, amongst
others before her (Morioka 2012; also, Lock 2001),
the promulgation in 1997 of the Brain Death andOrgan Transplantation Law, which legalized organ
procurement from brain death donors as long asconsent exists from either the bereaved or theirfamily, was precipitated by both: a declaration by aministerial ad hoc committee that “medical criteria
for brain death” is different from “the concept ofhuman death”, with the latter being dependent upon“the consensus of the Japanese people”, and an
ensuing publishing lurry of popular books on thesubject. With regards to hESR, Sleebom-Faulkner
subtly suggested, Prime Minister Junichiro Koizumi
might well have made Japan one of the irst
countries, short of a full law, to permit it, but without
the public’s uneasiness about the use of embryos asa means to therapies being acknowledged in thesame fashion as the anxiety about cadaveric organ
donation was recognized, and re lected in aparliamentary draft bill, in the 1990s, the outcome ofembryo donation and public funding stagnating waspredictable.
Juxtaposing these two cases, the continuity
between the Japanese situation with regards to hESR
in the 2000s, as described by Sleeboom-Faulkner,and the current state of affairs here in relation to
HHGE is striking. The discovery in the intervening
years by Shinya Yamanaka of how to induce
pluripotency in adult cells made it seem as if the
obstacle to developing regenerative medicine here,
and perhaps elsewhere, has been overcome.
However, the fact that his discovery was endorsed isa vindication of Sleeboom-Faulkner—it is because
the public had moral concerns about the embryothat they endorsed the narrative of Yamanaka.
To spell out what the parallels are between thesetwo cases, similarly to their low-key approach to thethorny bioethical issues related to the humanembryo in the 2000s, the Japanese elite—theacademia and policy-makers—are now quiet about
HHGE, reluctant to calm agitation that emerges fromthe mentioning of the term “germline” in the context
of human genome engineering. Discussions with
scientists reveal that they are keen on sustaining theillusion that debate about how the human embryo
might be treated in the scienti ic laboratory is
academic and redundant in the Japanese context.
The simplistic old assertions documented by
Sleeboom-Faulkner continue to be made withdogged persistence. In his attempt to posit aJapanese moral vacuum with regards to the humanembryo, one younger bioethicist, for example,
remarks that “most Japanese do not have a religion,and the roughly 30% who do af iliate with Buddhism
are not taught anything about reproduction throughthis tradition” (Personal email communication, 30
June 2021). The Christian community is very small

in Japan, comments another established Japanesescientist, and as far as Buddhism is concerned, heasserts, it focuses more on what happens after death(Interview, Kyoto, 28 October 2019). In short, no
acknowledgement is sought of any unease that might
exist in the public with regards to the manipulationin the laboratory of the human embryo—ethicalvacuity continues to be projected onto it.
Conclusion
In the absence of an existing alternative method forovercoming certain reproductive problems andheritable conditions, it seems imperative that thebattle for overcoming moral scruples with regards to
HHGE within the public of a country such as Japan isfought in earnest. Whatever one might make of thenumber of people for whom there is a plausible
useful function for HHGE in therapeutic-treatment
terms—and indeed, this number varies wildly
depending on whether only couples are consideredthat do not possess a non-disease promoting genetic
variation to pass, or whether other cases are counted
as well, such as where pre-implantation genetic
testing has failed to produce a suitable embryo fortransfer, or where changing a letter in the genome
can mean the concerned person would not have toworry about developing a serious condition—thedebate about it needs to take place. Whilst it iscertainly not for the scientists/academics alone to
make the decision as to whether performing HHGE is
permissible, it is one of their responsibilities to place
the debate about it in the broader public on the rightfooting. Insofar that simple truths about HHGE (suchas that, as Stanford University Law Professor Henry
Greely eloquently and repeatedly explains, there isno single entity that can be called “human germline
genome” and which constitutes the holy essence ofhumanity, and that our genomes have changed fromtime immemorial and will continue to change not
only ad hoc, but also as a result of our own actions(Greely 2017; 2019 & 2021)), remain an esotericknowledge in Japan, the country’s bioethicalcommunity could be found culpable of laziness. As
the case of cadaveric organ donation in Japandemonstrated, there is no substitute for an open
public debate on a contentious bioethical issue. It isonly by creating an atmosphere where plethora ofperspectives can be voiced, with an
acknowledgement of any anxieties and concerns thathave surfaced, as opposed to maintaining silence orengaging in dismissal, that the HHGE science in thiscountry can commence, for the bene it of all those inneed.
References
Cook-Deegan, R. (1994). “Japan: A Special Case”, in The
Gene Wars: Science, Politics, and the Human Genome.
New York: W.W. Norton & Company.
Croydon, S. (2021a). “Assisted Reproduction and theJapanese Paradox”. Eubios Journal of Asian andInternational Bioethics Vol. 31(3): 158-61.
Croydon, S. (2021b). “Outsourcing Reproductive Care: TheEubios Journal of Asian and International Bioethics 33(1) (January 2023)

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Restrictive Regime of the Japan Society of Obstetrics
and Gynecology”. Journal of African and Asian Studies
56(7): 1692–707.
Croydon, S. (forthcoming). “Reluctant Rulers: Policy,
Politics and Assisted Reproduction Technology inJapan”. Cambridge Quarterly of Healthcare Ethics.
Daley, G. (2018). “Genome editing: Pathways totranslation”. Second international summit on humangenome editing diyhpl.us/wiki/transcripts/humangenome-editing-summit/2018-hong-kong/georgedaley-genome-editing-pathways-to-translation/(accessed June 15, 2021).
Daley, G., Lovell-Badge, R., and Steffann, J. (2019). “Afterthe Storm–A Responsible Path for Genome Editing”.
New England Journal of Medicine 380(10): 897-9.
Greely, H. T. (2017). “Why the Panic Over ‘Designer Babies’
Is the Wrong Worry”, LeapsMag leapsmag.com/muchado-about-nothing-much-crispr-for-human-embryoediting (accessed Oct. 2, 2020).
Greely, H. T. (2019). “CRISPR’d babies: human germline
genome editing in the ‘He Jiankui affair’”. Journal of
Law and the Biosciences 6(1): 111–83. doi:10.1093/
jlb/lsz010.
Greely, H. T. (2021). CRISPR People: The Science andEthics of Editing Humans. Massachusetts:
Massachusetts Institute of Technology Press.
Harris, J. (2018a). “Pro and Con: Should Gene Editing Be
Performed on Human Embryos?” National Geographic,
www.nationalgeographic.com/magazine/article/
human-gene-editing-pro-con-opinions (accessed 5
June 2021).
Harris, J. (2018b). “Genome editing in humans could
become both ethical and prudent if properly
regulated”. BioNews 978, www.bionews.org.uk/
page_140192 (accessed 21 June 2021).
Hibino, A., Yoshizawa, G., and Minari, J. (2019). “Meaningof ambiguity: A Japanese survey on synthetic biology
and genome editing”. Frontiers in Sociology 4(81): 1–6.
doi:10.3389/fsoc.2019.0008115.
Ishii, T. (2020). “The Regulation of Human Germline
Genome Modi ication in Japan”, 441—68. In Boggio, A.,
Romano, C. R., Almqvist, J. (eds.), Human Germline
Genome Modi ication and the Right to Science: A
Comparative Study of National Laws and Policies.
Cambridge: Cambridge University Press.
Lock. M. 2001. Twice Dead: Organ Transplants and theReinvention of Death. Oakland: University of California
Press.
Morioka, M. 2001. “Reconsidering Brain Death: A Lesson
from Japan’s Fifteen Years of Experience”. Hastings
Center Report 31(4): 41-6.
Sasaki, Y. (2019). “A Japanese history of the Human
Genome Project”. Proceedings of the Japan Academy,
Series 95(8): 441-58. DOI.org/10.2183/pjab.95.031.
Sleeboom-Faulkner, M. 2008. “Debates on Human
Embryonic Stem Cell Research in Japan: Minority
Voices and their Political Ampli iers”. Science as
Culture17(1):
85-97.
doi:
10.1080/09505430801915455.
Sleeboom-Faulkner, M. 2010. “Contested Embryonic
Culture in Japan—Public Discussion, and Human
Embryonic Stem Cell Research in an Aging Welfare

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Society”. Medical Anthropology 29(1): 44-70. doi:
10.1080/01459740903304256.
Uchiyama, M., Nagai, A., and Muto, K. (2018). “Survey on
the perception of germline genome editing among thegeneral public in Japan”. Journal of Human Genetics
63:745–74. doi.org/10.1038/s10038-018-0430-2
Watanabe, D., Saito, Y., Tsuda, M. Ohsawa, R. (2020).
“Increased awareness and decreased acceptance ofgenome-editing technology: The impact of the Chinese
twin babies”. PLoS ONE 15(9): 1-13. doi: 10.1371/
journal.pone.0238128.

Why inhumane? An ethical issue
on medical negligence from healthprofessionals-Zahira Amir Ali,
Aga Khan University- School of Nursing and Midwifery
Pakistan, Aga Khan University Hospital Pakistan
Email: zahira.amirali@aku.edu
zahirakhalfan@gmail.com
Abstract
Medical negligence in healthcare settings is anin idelity to the profession, and a sin towards human
lives. Often used as a matter of excuse, blame game,irrational mistake, and frustration with stressfulenvironments, it is overlooked and swept under the
carpet. However, acknowledging the ethical values ofthe profession, sensitizing healthcare professionals
to implement best practices, and reporting events toprevent harm in future, is certainly imperative. This
paper shares an overview of medical negligence
under an analysis of different biomedical ethicaltheories and shares relatable recommendations for
future implications in healthcare practice.
Introduction
Medical negligence is a long-standing ethical issue.
Negligence is the act of omission or commission
from a health professional that speculates due care
(Burkhardt and Nathaniel, 2013). This breach of
duty results in harm to the patient (Raja, 2017).
According to Waraich (2018), there are various
reasons for intentional or unintentional negligence.
It includes a lack of awareness or experience of the
problem, a culture of silence, system constraints likeinadequate patient-provider ratio, sleep deprivation,
poor communication skills, improper documentationand illegible writing, lack of professional ethics andfaulty health policies. The paper aims to re lect on acase of negligence under ethical theories and ind
ethically sound justi ications to deal with this issue.
A heart failure patient with hemoglobin level of
5.1mg/dl presented in the emergency room at one of
the tertiary care hospitals of Pakistan. The patient’s
history revealed multiple transfusions; therefore,
blood products were arranged in the blood bank.
The doctor ordered to start transfusion after theEubios Journal of Asian and International Bioethics 33(1) (January 2023)

transfer of the patient to special care for closemonitoring. However, after shifting, the bloodtransfusion was delayed for 2 hours due to thenurse’s workload. Meanwhile, the patient’s vitals
deteriorated requiring inotropic support due tocardiogenic shock. The case was reported to thehospital’s clinical affairs resulting in verbal
disciplinary action against the doctor and nurse. Thiscase presents diverse questions to be considered
under the light of ethics:
1- How responsible do health professionals feel for
their duty of care?
2- Is punitive action the only solution for workloadassociated negligence?
3- Is equity in care more important than equality?
This article presents the overview of medical
negligence, through a case description, under thelight of various ethical perspectives, and shares
recommendations for future implications inhealthcare practice.

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Multidimensional analysis
The culture of a healthcare setting is based on the
power of knowledge to treat. It is understood andsocially accepted that health professionals, by
default, may hold prime power and responsibility totreat patients. Consequently, patients develop trust
towards health professionals. When suchpreventable negligence transpires, it directly harms
the patient’s quality of life.
In reference to the Islamic perspective of
biomedical ethics, ethical decisions are based on
revealed texts from Quran, Hadith and Sunnah rather
than personalized intuitions. Since humans areintellectual beings, they are capable of correlating(mulazama) moral judgments with divine
commandments. According to Sachedina (2009),
Muslim jurisprudence is based on istihsan(prioritization of two judgments using juristic
practice) and istislah (promoting bene it andpreventing harm for the public) to achieve maslaha(public good). Harm is called “darar”, which is anintentional or unintentional act committed by one
person against another. Islamic bioethical judiciary
preliminary focuses on the principle of nonmale icence as “No Harm, No Harassment”. This isevident by the holy quote “In Islam there shall be noharm in licted or reciprocated” (la darar wa la dirari al-islam) (Sachedina, 2009, p.47) and hadith“There shall be no [adopting of a course of actionthat leads to] harming of one man to another”(Sachedina, 2009, pg. 68). Thus, the principle of “No
Harm, No Harassment” depends on ive rules thatare, “action depends upon intention, hardshipnecessitates relief, one needs certainty, harm must
be rejected, and custom determines course of action”(Sachedina, 2009, pg.67). Muslims strongly believethat God does not harm his creatures. Pakistan beingan Islamic state functions upon the above-mentioned
Islamic guidelines.
From a legal perspective, the disciplinarycommittee of the Pakistan Medical and Dental

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Council, have the authority to terminate the practicelicense of doctors who are found guilty of medical
negligence (Raja, 2017). Additionally, the patient andfamily (victims) have a right to ile a First
Information Report (FIR) under Section 318 ofPakistan Penal Code 1860 which af irms that any
intentional or unintentional act causing harm ordeath is sentenced as Qatl-i-khata, therefore, suchindividuals shall be punished with 2 years of
imprisonment or monetary ine or both as per
Section 304-A PPC 1860 (Raja, 2017). Furthermore,according to the Tort Law for misdemeanor, civil
court sanctions victims to obtain compensation from
hospitals under Fatal Accidents Act 1855 (Raja,2017). Despite such stringent religious and national
legislation, it is crucial to understand the issue ofnegligence and ways of prevention from an ethicalparadigm.
My position: Health professionals should use thevirtue of ethics, critical thinking and prioritization
setting strategy to prevent medical negligence. They
must implement the core concepts from ethicaltheories which are duty to care, protection fromharm, provision of justice and acknowledging therights of patients while making patient-caredecisions. Since the patient had heart failure withsevere anemia, blood transfusion should have been
initiated from the emergency room or directly after
transportation to special care as an acute lifesaving
measure.
Ka n t i a n t h e o r y ve r s u s r i g h t s o f h e a l t hprofessionals: Deontology also known as Formalism
and Kantianism infer a rationalist view. An act isconsidered right or wrong based on the nature ofthat act rather than consequentialism (Burkhardt
and Nathaniel, 2013). These ethical acts become
universal, and humans utilize reasoning to imply it invarious situations. The rightness of an action
depends upon the maximum that is a categoricalimperative (universal acceptance) and practicalimperative (performing duties owned to others). The
two imperatives of duty go hand in hand to
determine a professional code of ethics. Totten(2013) af irms that health professionals have theright to access tools that are necessary for themwhile performing their duty. This could be in theform of help from co-workers, personal time forrelaxation and hydration and safety from harm or
injury. In the above case scenario, although the nurse
might have intended to care for the patient as a duty
the workload resulted in negligence for which
disciplinary action was taken. The dilemma arises
whether disciplinary action against workloadassociated negligence is justi iable or not.
Consequence of my position: If health professionals
are forgiven for their negligence with no disciplinary
action, this could be a wrong role model for others.
Such an action would promote carefree culture
amongst health professionals. They would not bebothered over their accountabilities.
Counterargument for justi ication: The duty tocare for patients is the prime responsibility of healthEubios Journal of Asian and International Bioethics 33(1) (January 2023)
professionals as per the International Council for
Nurses Code of Ethics (Burkhardt and Nathaniel,2013). Disciplinary action for unintentional
negligence may result in demotivation, fear ofreporting, mental and moral distress, and a highprobability of future mistakes. Thus, if a conducive
workplace environment is not created where
subordinates reach out to help in managing busy
shifts; it would lead to medical negligence.

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Aristotle’s virtue and rights theory: Virtue ethics,
also known as character ethics, are a set of innate
moral values that are socially acceptable and create amoralistic character which impact on an individual’s
judgment and actions (Burkhardt and Nathaniel,2013). Beauchamp and Childress (2013) proposedfour focal virtues for a moral character: compassion,
discernment, trustworthiness, and integrity. Goodcharacter is formed if these virtues are enrooted to
depict good nursing (Burkhardt and Nathaniel,2013). Simultaneously, Rights Theory supports theprovision of individual rights (right to safety, right tohealth care) that become an obligatory responsibilityo f s o c i e t y i n c l u d i n g h e a l t h p ro fe s s i o n a l s(Beauchamp & Childress, 2013). According to
Human Rights Convention Article 2 and 3, an
individual has a right to life and to prohibition of
torture, respectively (Gosney, 2013). In the
aforementioned case, virtues were important todevelop sensitive insight among healthprofessionals. Acute judgement for early transfusion
could have prevented life-threatening cardiogenic
shock. Also, it is important to understand patient’s
bill of rights to attain correct and prompt treatment.
Although blood products were arranged, they were
not transfused timely.
Consequence of my position: If these two theories
are not acknowledged and implemented by healthprofessionals, that may cause desensitization and alack of a professional attitude towards patients
leading to negligence. According to the institution’sStandard Operating Procedure (SOP), Blood andBlood Product Administration Module (2015), it ismandatory for doctors to write the reason fortransfusion. Since the patient was symptomaticallyanemic and clear written documentation for theurgency of transfusion was not documented, this led
to the act of negligence. If the doctor had
demonstrated professionalism and sensitivity
towards the patient, such delay in care would havebeen impeded.
Counterargument for justi ication: Nurses must
understand overt and covert values while working in
healthcare settings. The overt values are the explicit
institutional values in the form of policies; however,the covert are implicit personalized values. The
con lict between overt and covert values may end up
in moral distress. Moral distress is a state where anurse realizes the morally correct action but couldn’t
perform it due to institutional constraints.
(Burkhardt and Nathaniel, 2013). In the above case,the nurse followed the doctor’s order to transfuse
blood after reaching the special care unit which

17

wasn’t the correct decision for the patient but still
followed. Currently, nurses must understand thatthey belong to an autonomous profession, and have a
key obligation to their patients, not physicians. They
should not follow physician orders if it’s unethical,
incompetent, or illegal which keeps the patient at
risk of harm. Instead, nurses must advocate for theirpatients and communicate with doctors regarding
the high or low spectrum of urgency and feel
obligatory to rectify impending harm (Burkhardt
and Nathaniel, 2013).
Non-male icence versus Rawls’s theory of justice:Non-male icence, the irst ethical principle, is to
avoid harm to achieve bene icence (Burkhardt andNathaniel, 2013). Failure of due care results innegligence associated with male icence. If the risk ishigh, it can override bene icence. Concurrently,
justice is to protect basic liberties by guaranteeing
equality of opportunity (Bulletin of the World HealthOrganization, 2008).
Consequence of my position: If justice precedence isfair care to all irrespective of who needs the mostattention, equality would remain af irmed. However,equity that depends upon need-based care will becompromised. Nurses must understand situations
where harm outweighs bene it and should care forthose irst, who need the most (Burkhardt andNathaniel, 2013).
Counterargument for justi ication: Priority setting
is a skill that could promote non-male icence. It is a
critical thinking skill that plans nursing actions
based on the urgency of care. For example, a patientwith respiratory distress would be considered more
liable than a patient with pain due to a hairline
fracture. This urgency of action depends upon whichvital organ is involved and what is its acute state.
Poor implementation of priority-setting skills byhealth professionals leads to life-threatening
consequences for patients. Nurses’ experience andeducation, patient’s health status, scarcity ofresources, work dynamics, therapeutic nurse-patient
relationship and cognitive strategies in luence
nurses’ priority setting (Hendry and Walker, 2004).
Thus, priority setting does not mean neglecting any
patient from care rather, it is prioritization ofpatients for care.
Recommendations
Re lecting upon the case scenario and the associatedissue of medical negligence, a few recommendations
are proposed at individual, organizational andnational levels. At an individual level, physicians andnursing management must conduct debrie ing
sessions on sentinel events for root cause analysis sothat health professionals can have an opportunity for
self-awareness and self-re lection. Additionally,
supervisors should provide summative andformative ongoing clinical performance evaluations
and appraisals to appreciate their hard workthrough incentives and inform the need for
improvement. Moreover, continuous nursing andmedical professional education for skill development

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Eubios Journal of Asian and International Bioethics 33(1) (January 2023)

on patient assessment, reporting indings, planning
relevant interventions and reevaluations should be
conducted to enhance their knowledge and promote
evidence-based practice. This will reinforce healthprofessionals to learn priority setting, use criticalthinking and perform problem-solving skills
ef iciently. Biomedical ethics should be taught as aseparate refresher course to all health professionals
from all hierarchical levels (subordinates to leaders)to build sensitization. Moreover, medical and nursing
faculties should plan undergraduate courses that
could give an opportunity to students to understandreal-life biomedical ethical dilemmas. At theorganizational level, the Quality and Patient Safety
department should run frequent quality assurance
audits and promote a blame-free error reporting
culture by reinforcing a safe disclosure policy.
Moreover, keeping the principle of veracity andtrustworthiness robust, negligence disclosure andapology should be informed to the entrusted family
member of the patient after involving Hospital Ethics
Committee (HEC). This would give a gesture ofreconciliation and acknowledgement towards the
special duty of care. They must be apprised of Tort
system for either waiving of fee or monetarycompensation for inancial loss. To prevent future
negligence, clear policies and protocols on theconsequences of medical negligence should beformed to ensure professional liability. Human
Resource department and managers should assure
manageable duty hours and suf icient staf ing toprevent work overload and physical-psychologicalexhaustion. Health professionals’ competency
checklists should be reviewed annually to verify
credentials. Patient wellness programs and support
groups should be initiated for psychological, social,emotional, and inancial wellbeing. Research could
be conducted to prevent negligence in future. A risk
management strategy should be utilized to maintaineffective communication, expertise in conscientious
practice, autonomy, and empowerment among
health professionals. Moreover, suf icient investment
should be done in health systems to create
corruption-free health for all.
Humans are imperfect beings and certainly may
cause some errors (human error). Healthprofessionals are the fundamental assets of oursociety with greater responsibilities to deal withhuman lives. With this responsibility, healthprofessionals must ensure to follow core ethicalprinciples of providing holistic care and essentially
understand that there is no better service than theservice you render to others. Therefore, systems tocontrol negligence at individual, institutional andnational levels must be formed to ultimately prevent
future medical negligence.

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References
Beauchamp, T., & Childress, J. (2013). Principles ofbiomedical ethics, (7th Ed.). New York, NY: Oxford
University Press.

Blood and Blood Product Administration Module.
(2015). Nursing Education Services, Aga Khan
University Hospital Karachi
Bulletin of the World Health Organization. (2008) 86(6) 577-656
Burkhardt, M. A., & Nathaniel, A. (2013). Ethics andIssues in Contemporary Nursing, (4th ed.). Delmar,
Austrailia: Nelson Education.
Gosney, J. (2013). Legal Commentary: Human Rights
arguments in medical negligence cases. https://www.digbybrown.co.uk/news/legal-commentaryhuman-rights-arguments-in-medical-negligencecases
Hendry, C. and Walker, A. (2004). Priority setting inclinical nursing practice: literature review. Journal ofAdvance Nursing, 47(4), pp.427-436.
Raja, A. (2017). Medical negligence must not go
unchecked. https://www.pakistantoday.com.pk/
2017/05/04/medical-negligence-must-not-gounchecked/
Sachedina, A. (2009). In Search of Principles of
Healthcare Ethic in Islam In. Islamic Biomedical
Ethics Principles and Application. (1st Eds.),(pp.45-75). New York: Oxford University Press.
Totten, V. (2013). Viewpoint. Emergency Medicine News,35(11), p.3.
Waraich, R. (2018). Healthcare System and Medical
Malpractice Law in Pakistan. Policy Perspectives,
15(3), p.85.

The ethical aspects of unwanted
pregnancy: Cases of rape reported
in the media with legal restrictions
on abortion in Turkey- Sukran Sevimli, M.D.
Department of Medical History and Medical Ethics,
Dursun Odabas Research Hospital, Faculty of Medicine,
Van Yuzuncu Yıl University, Turkey
Email: sukransevimli@gmail.com

Abstract
This study examines the ethical and legal issues
faced by girls/women requesting abortions who
were victims of rape, aspects which have received
little attention to date. This is a retrospective study
using a case-based approach to analyze the ethicaland legal issues relating to incidents of unwanted
pregnancy resulting from rape as reported in
Turkish newspapers from 2010-2018. A total of 95
articles were discovered and categorized. These
were then evaluated for content and analyzed interms of the ethical issues related to the cases. Of
these articles, 14 involved rape-related pregnancy
cases. The six cases chosen for analysis in this study
were carefully selected from newspaper reports
between 2010-2018. The victims who requested
abortions were between 9 and 26 weeks pregnant
and aged 14-26 years old. Turkish courts approvedEubios Journal of Asian and International Bioethics 33(1) (January 2023)
only two of the victims' requests. The cases in thisstudy were evaluated by the authorities solely on
legal grounds. The stress experienced by victims ofrape is exacerbated by compulsory pregnancy; thefact that these victims were not allowed to terminate
their pregnancies resulted in their further
punishment. Requests for abortion should thus beassessed not only in terms of legality, but also on thebasis of medical and especially ethical issues.

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Introduction
The objective of this article is to examine cases inwhich victims of rape sought to terminate theunwanted pregnancies resulting from sexualassaults. As sexual violence occurs in all parts of theworld, unwanted/compulsory pregnancy istherefore a global issue, involving not only biological,
psychological, and social health problems but also
ethical and legal issues. A report by the World HealthOrganization has stated that every 2-3 minutes
somewhere in the world a woman is a victim ofsexual assault (Organization, 2013). Some victims
who become pregnant because of sexual assault
request abortions; when these requests are denied,the victims are then forced to endure further trauma(Gipson, Koenig, & Hindin, 2008; Holmes, Resnick,Kilpatrick, & Best, 1996; Satin, Hemsell, Stone,
Theriot, & Wendel, 1991).
Even governments that support reproductive
freedom as a human right may implement legislation
restricting the termination of a pregnancy, forreasons pertaining to dominant religious beliefs,
accepted morality, scienti ic conceptions regarding
the fetus, concerns about decreasing birth rates, or
simply as a continuation of traditional policies onabortion (Shaw, 2010). However, restrictive
legislation has not managed to eliminate thecontroversy surrounding abortion, whether on legal,
ethical, or religious grounds. In Turkey, abortion on
demand is allowed until the 10th week; however, if
the fetus is disabled or a heartbeat is not detected(Apendix1) the pregnancy may be terminated until
the 24th week with informed consent (Regulation,1983). A girl who has not reached majority canundergo an abortion with the written consent of herparents (Hall, 1990).
Unfortunately, outside of the legal limits placedon abortion, many feel that they have a right toinvolve themselves in women’s reproductive choices
by virtue of their claim to moral and religious values.
For this reason, the status of the fetus must be
clearly de ined. Firstly, the fetus is an entity thatcannot live independently of the mother and is notrecognized as having individual rights. Secondly, thebrain of a fetus has not undergone suf icientdevelopment to enable conscious thought. After
fertilization, the newly fertilized ovum develops intoa pre-embryo, then embryo, fetus, and inallyneonate, who only then has the potential to be a fullyautonomous individual to be granted all ethical andlegal rights (Gillon, Higgs, Boyd, Callaghan, &Hoffenberg, 2001).

19

Women may wish to terminate a pregnancy for
any number of reasons, including having been a
victim of rape or incest, health issues (of the motheror the fetus), family planning goals, economic
factors, etc. However, since rape and incest are actual
crimes, pregnancies resulting from such actions
should be evaluated on a separate basis. The
expectations of rape or incest victims with respect totheir (entirely unwanted) pregnancies should beseriously considered by the healthcare and justicesystems when reviewing such cases; any reason
provided by a woman for requesting an abortion
should be analyzed on its own merits. To date, there
has been little research regarding the issue of rape/incest victims requesting abortions in terms of thelegal and ethical issues involved. Due to the lack ofstatistical data available to analyze such cases indetail, no study has as yet been able to determine theprevalence of pregnancy resulting from rape orincest. The objective of the present study was toincorporate analysis of ethical issues into the legal
debate regarding abortion as it pertains to victims ofrape, using cases reported in the Turkish press.
What kinds of medical issues require ethicalanalysis? The availability of abortion often leads tothe state and/or society claiming a right to intervene
in women’s decisions affecting their bodies, as
contrary to the principles of bioethics, which grantprimacy to the concept of bodily autonomy.
The subject of abortion raises several scienti ic,
ethical, and religious questions pertaining to theconcept of the soul. Since every religion and/or
belief system has its own de inition of the concept of
the soul (NCo., 2016), there is no global consensus as
to the nature of the soul or the idea of life after
death.
The irst category of questions involves theembryo or fetus itself. If a fetus or embryo is
accepted as human, how does one determine at what
point life begins (Harris, 1985)? Is it immediately
after fertilization, upon implantation in the uterus, atsome point during development of the embryo or
fetus, or at birth? The second concerns whose rights
take precedence - those of the embryo/fetus or themother? The third concerns the act of abortion itself.
Should laws regarding abortion have de inite limits?
Who has the right to decide what these limits shouldbe (Harris, 1985)?
The answers to these questions are still being
debated, as there is little consensus regarding the
ethical-legal, biological, and psychological aspects ofabortion. This article addresses abortion in terms of
medical ethics, a subset of bioethics prioritizing
patient and human rights, and with respect tomedical ethical principles (e.g., do no harm,bene icence, autonomy, justice, truth-telling) whichhold that every human has a worth irrespective ofgender, age, religion, or nationality (Beauchamp &Childress, 1994.).
Ethical con licts related to abortion may result
from the involvement of various institutions, such associal service (especially child welfare) agencies,

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Eubios Journal of Asian and International Bioethics 33(1) (January 2023)

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religious councils, medical associations, nongovernmental organizations, etc. (Denbow, 2005;
Fromer, 1982; Patil BA, 2014). In addition to legal
restrictions that already limit access to abortion,some individuals and organizations consider it theirright to intervene in women’s decisions regarding
their pregnancies. Can pregnancy thus lead to thesuspension of the individual rights of women andgirls?
What happens to the victim? Limiting access toabortion punishes women and girls in four ways:
1. The trauma of rape can lead to long-term
psychological issues, including post-traumatic stressdisorder (PTSD), as well as various physical injuries,
such as sexual/pelvic loor dysfunction issues(Postma, Bicanic, van der Vaart, & Laan, 2013;
Samsioe & Abreg, 1996). Mutluer et al. (2017) foundthat children and adolescents who had been sexuallyassaulted experienced PTSD and had bilaterally
smaller amygdala, hippocampus, and anterior
cingulate, and a thinner prefrontal cortex (Mutluer etal., 2018), all of which play an important role in theformation and storage of memories and cognitive
behaviors. During rape, victims may be con licted as
to whether to surrender or try to escape, and after
the assault by negative feelings (e.g., feelings of being
objecti ied, de iled, and/or alienated from their ownbody) (Halvorsen, Nerum, Oian, & Sorlie, 2013).
2. Secondly, for rape victims forced to continue
their pregnancies, full recovery from the trauma of
sexual violation is highly unlikely (Halvorsen et al.,2013), resulting in their being doubly punished.
3. The trauma of rape may reach its pinnacle
when the victim gives birth (Howlett & Stein, 2016).
This increases the duration and intensity of theanguish caused by rape, causing the victim to feel
further traumatized at having been violated at themost intimate level and turned into merely a vessel,
rather than an autonomous person who possesses
inherent value in her own right.
4. After giving birth, the victim faces a new ordeal,
having to decide whether to accept or reject thebaby. The rapist may even claim parental rights.
Individuals in the victim’s community may continue
to speak of the incident long afterwards, creating an
unpleasant and possibly traumatic environment for
both the victim and her baby (DG., 2015).
What happens to the fetus? The fetus is a living
being that has the potential to be an autonomous
person with full moral status only after birth.
Unfortunately, as there is no empirical evidence
concerning souls, any discussion rests entirely on apriori arguments (Gillon et al., 2001). However, brain
development is a meaningful measure ofconsciousness, without which there can be noconcept of moral behavior. A recent study has
indicated that infants born at 22 or 23 weeks cansurvive independently of the mother withappropriate intensive postnatal care (Mehler et al.,2016). Fetuses do not acquire the ability to feel pain
until the beginning of the third trimester (Lee,Ralston, Drey, Partridge, & Rosen, 2005). Can

sentience be considered a reasonable criterion for
granting personhood?
Moral status, de ined as the ability of a conscious
being to make judgments regarding the morality ofan action, is another important consideration in the
ethical debate concerning abortion. According toWarren, the gradualist approach grants greater
moral/ethical status to the mother than to the fetus(M.A., 1997). Contemporary bioethics thus makes no
distinction between an embryo at 14 days and afetus at 24 weeks (Patil BA, 2014). Sentience isamong the criteria for autonomy, along withconsciousness, the ability to think independently,
responsibility for one’s own behavior, free will, andexperience. Gillon noted that other vertebrates also
possess sentience, while stressing that they lack
moral accountability (Gillon et al., 2001). Although
the fetus itself lacks self-awareness, it is at the centerof most arguments concerning abortion.
Materials and methods
This research was designed as a retrospective of
ethical-legal issues pertaining to cases ofcompulsory pregnancy resulting from rape asreported in the Turkish press. The approach taken
in analyzing the cases was based on human rights
and ethical concepts. Key words were used to search
Google and Turkish news organizations for the years
2010-2018. An exhaustive systematic review ofincidents of sexual assault resulting in compulsory
pregnancy was carried out by searching mass media,
from newspapers to internet news websites. In
determining the selection criteria, attention was
paid to such factors as whether the same case wasreported by other news agencies, whether a case
was followed to its legal conclusion, and how the
information was presented to and discussed by the
public.
In choosing which cases to analyze, there were
two main selection criteria. The irst wasdetermining the existence of barriers to the legalityof abortion, including:
1. Requests for abortion can only be approved forindividuals under the age of 18.
2. Pregnancies exceeding 10 weeks cannot beterminated.
3. Victims of rape/incest must make a formal
complaint to the proper legal authorities, of icers
must collect evidence to prove that a crime occurred,
and a medical report must be obtained (AppendixA).
Due to the amount of time involved to ful ill its
requirements, a frequent consequence of the third
condition, is the expirations of the legal period for an
abortion.
Secondly, attention was paid to such factors as
whether the same case was reported by other news
agencies, whether a case was followed to its legal
conclusion, and how the information was presented
to and discussed by the public (Appendix B). A
thorough legal analysis must take into account suchfactors as age, duration of pregnancy, and informed

Eubios Journal of Asian and International Bioethics 33(1) (January 2023)
consent, while ethical analysis incorporates abroader spectrum of factors by which to evaluate acase and according to which health care
professionals can better understand the needs of thevictim (before, during, and after pregnancy). The
selected cases therefore included those that
presented legal problems and in which one or morelegal barrier existed.
We located 95 news items, categorized andcounted these articles, evaluated the articles forcontent, and analyzed the ethical issues. Out of thosearticles, 14 concerned rape-related pregnancy cases(Appendix B). The six cases chosen for analysis in
this study were carefully selected from newspaper
reports dating from 2010-2018. When determining
the selection criteria, a number of common features
were identi ied that represent a large number ofexisting cases, including the age of the victim,
whether the rapist was a member of the family, andat what stage in the pregnancy the victim requested
an abortion, and requests for abortions resulting indifferent legal outcomes.
In addition, the author of this study also reviewed
statistical data collected by the Turkish government.
Two important reports were unearthed: (i) The
Turkish Statistical Institute (TUIK) reported that
accusations of sexual assault, including rape andharassment, have increased at all levels of Turkishsociety by 30 percent in the last ive years (28, 29),
and (ii) The Children's Rights Commission of the
Human Rights Association’s Istanbul bureau
reported that 440,000 children under the age of 18
gave birth in the last 16 years. It also stated that 46%
of sexual crimes were committed against children,and that the rate of child sexual abuse in Turkey was
the third highest in the world. Children were foundto have been abused in all settings, including in their
dormitories and in schools by their teachers andschool staff, as well as in their homes by close
relatives. However, in Turkey only 5% of rapists
were identi ied; the statistical reporting on this issue
is therefore incomplete. As is often reported in news
articles, many victims do not tell their family
members until their pregnancy becomes visible, nor
do they ile complaints with the proper legal
authorities. The cases selected for this study thus
represent only the tip of the iceberg.
Evaluation of the Data: News reports ofpregnancies resulting from rape were evaluated as
qualitative data. Analysis of qualitative data includes
organizing the data and categorizing it, researchingpatterns, identifying important points, and deciding
how to approach the data for purposes of discussion(Bogdan & Biklen, 1998).
Limitations: This study was restricted to six sample
cases due to space limitations. The cases arenonetheless varied enough in their details that they
may be viewed as being representative of a muchlarger number of similar cases.

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Results

21

This study is signi icant in that it analyzed the issueof abortion from a strictly ethical standpoint. Whenabortion is evaluated solely on the basis of legality,
the autonomy of rape victims is compromised, andjustice is not realized. The special circumstances
engendered by cases of rape should be assessedfrom an ethical standpoint. This discussion should
increase awareness of this issue and hopefully pushsocieties to take more effective measures to prevent
rape and incest, as well as to improve how their legal
systems treat the victims. Those who have not had
the misfortune to be a victim of rape or incest cannot
fully comprehend how traumatic these crimes canbe.
The cases analyzed in this study are as follows:
Incident 1: Ms. N.Y. was 26 years old and married
with two children. After being sexually assaulted bya male relative, men in her village began referring to
her as a "bad woman" or prostitute. To protect her
honor she then killed her rapist. However, by thattime she was approximately 20 weeks pregnant. She
stated that she did not want the child and desired an
abortion, even if it were to result in her death.
Nonetheless, she was not able to procure an abortionand gave birth in prison in November 2012, after
receiving a life sentence for murder (Arkan/Yalvac,
2016; H.N., 2016). The question of whether a 20week-old fetus can be aborted was evaluatedaccording to Article 99 of the Turkish constitution.
N.Y. lived in a small village and was not able to travel
to a city without her husband’s knowledge to havean abortion. She was ive months pregnant when she
killed her rapist. Article 99 of the Turkish Penal Code(6) states abortions can be performed for medical
reasons between 11-20 weeks (Birliği, 1984). It also(2) states that in the absence of medical necessity, aperson who induces a pregnant woman to miscarry afetus over 10 weeks old can be imprisoned for two tofour years, even with the consent of the pregnant
woman. Two rights are in con lict here: one is theright of the fetus to live, the other is right of themother to bodily autonomy.
Incident 2: A 16-year-old girl’s petition for an
abortion was denied by the magistrates’ court inJanuary 2014 on the grounds that "ending the
pregnancy is considered a violation of the fetus's
right to life" barring exigent circumstances(Newspaper, 2014). The girl was 16 weeks pregnant
at the time she submitted her petition, and likely was
not aware that she was pregnant much prior to that.
The court based its decision on Turkish law, which
does not allow abortions after 10 weeks except incases where the health of the pregnant woman is atserious risk or the fetus has severe disabilities ordeformities.
Incident 3: A 14-year-old girl taken to a hospitalwith complaints of abdominal pain was discovered
to be 2.5 months pregnant. The hospital authorities
informed the police because they suspected that she
was a victim of rape. The girl, accompanied by apsychologist, said that she had been raped several
times by her neighbor. The police then detained theEubios Journal of Asian and International Bioethics 33(1) (January 2023)

person that she identi ied. The court granted
permission for the pregnancy to be terminated(KAYA/ORTACA, 2016).
Incident 4: A 15-year-old girl was raped by her
brother. The family, fearful of legal sanctions, tried tocover up the rape, putting the girl’s life at risk by
having a maternal aunt induce an abortion when thegirl was 6.5 months pregnant. The aunt then buried
the fetus. The girl’s sister reported this to the police.
The mother and aunt were taken into custody andthe brother was sought by the police (KOCAER,
2009).
Incident 5: A 15-year-old girl was raped andrequested an abortion when she was 9 weeks
pregnant. Her request was rejected by themagistrates' court. The judge who examined her ile
stated that there was no regulation in place forchildren aged 15 and under in his jurisdiction andthus he could not issue a ruling regarding thetermination of her pregnancy (Cumhuriyet, 2014).
Incident 6: The request for an abortion made by
a 16-year-old girl who became pregnant as a resultof rape was rejected by a local court, which declaredthat "the right to life of the fetus is more important
than the mother's mental health". At the insistence ofthe girl’s family, the prosecutor's of ice sent the caseto a higher court. Citing the legal statute stating that"in the event that a woman is impregnated as aresult of a crime, on condition that the victim is not
more than 20 weeks pregnant and consents to an
abortion, termination of the pregnancy will not bepunished," the prosecutor requested that permission
for the abortion be granted. The higher court foundin favor of the girl. Had the family not persisted
however, the 16-year-old victim would not have beenable to receive an abortion (DEMİR, 2014).

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Discussion
Our research illuminates the need to recognize andunderstand issues facing victims of sexual assault.
Societies should aim to decrease prejudice against
and infra-humanization (Baldry, Pacilli, & Pagliaro,2015) of rape victims.
A report by the World Health Organization(WHO) stated that sexual assault may involve therisk of unwanted pregnancy; however, few studies
have examined the likelihood of pregnancy resulting
from rape (Organization., 2013). The National
Women’s Study in the U.S. found that 5.3% of therapes of adolescent girls aged 12–17 years resulted
in pregnancy and reported a similar rate for adultwomen, with 50% requesting to terminate theirpregnancies (Holmes et al., 1996).
This study was carried out in the hope that it may
lead to a more open discussion of relevant cases
involving sexual assault and compulsory pregnancy,
and also contribute to the literature on helping
victims. Unfortunately, in many societies rape is
explained away if not justi ied by certain
assumptions (e.g., rape is somehow encouraged by
the victim; it is merely an attempt to satisfy therapist’s sexual appetite or a misguided expression of

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love) (Ellsberg, Jansen, Heise, Watts, & GarciaMoreno, 2008; Keogh, 2007). In fact, tolerance ofrape only serves to protect the rapist and further
punish the victim; such punishment includes actions
to protect the fetus if the rape results in pregnancy.
In Turkey, there have been numerous reports of rape
victims forced to marry their rapists in order toprotect the honor of the victims and their families.
The World Health Organization considers sexual
violence to be a serious public health and humanrights problem. In particular, female rape victims
face not only the violence of the assault itself but
also the possibility of becoming pregnant and being
forced to carry the child to term. Although many
rape victims request abortions, the age of theembryo/fetus may present a signi icant legal
obstacle. The victims discussed in the current study
tried to hide their sexual assaults, preferring to keep
it secret, out of shame or simply in an attempt toforget such a traumatic experience (Machado,
Fernandes, Osis, & Makuch, 2015). The cases
selected for the present study all occurred within thepast 8 years, and the rape victims all faced thepossibility of compulsory pregnancy as a result of
the inadequacies of the legal system in this regard.
Three of the victims whose cases are reviewed
herein were not able to obtain a legal abortion
because of the legal limits placed on the procedure
with respect to the age of the fetus. These cases areworthy of special consideration as they call attention
to the ethical issues pertaining to compulsory
pregnancy. Examination of these ethical issues is theirst step in a process that will ideally lead tolegislation to address the injustices associated withcompulsory pregnancy.
Reproductive and abortion rights are closely
related to population policy. Evolving concepts ofhuman rights, women's rights, and children's rights
beginning in the second half of the nineteenth
century have resulted in challenges to current
population policies. The adoption of principles of
medical ethics and bioethics and the codi ication ofpatient rights have led to the emergence of new
perspectives regarding population control.
Rape is a serious offense whose negative effects,
which include psychological damage and asigni icantly diminished quality of life (Mehler et al.,2016), are compounded further when pregnancy
results. While rapists go free or, more rarely, receive
prison sentences, their victims must deal with thetrauma of rape and, sometimes, the problem of
unwanted pregnancy as well (Arkan/Yalvac, 2016;
Cumhuriyet, 2014; DEMİR, 2014; Kaya/Ortaca, 2016;
Kocaer, 2009; Newspaper, 2014). Victims of rape
who become pregnant as a result can request an
abortion to at least end the trauma of unwanted
pregnancy. This request should be assessed in termsof its medical, legal, and ethical dimensions, inaccordance with the nature of the case.
Article 28/1 of the Civil Code of the Constitutionof the Republic of Turkey states that the rights of theindividual begin with live birth and end with

Eubios Journal of Asian and International Bioethics 33(1) (January 2023)

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death(Meclisi, 1982). Civil Code 28/2 regulates thechild's right to exist in the mother’s womb. In otherwords, when a baby is born and takes his/her irst
breathe, he/she is granted full human rights inaddition to legal rights. The Universal Declaration of
Human Rights expresses the fundamental nature ofinalienability in Article 1 thusly: “All human beings
are born free (author’s emphasis) and equal indignity and rights.” The use of the word “born”
indicates that human rights do not apply to a fetus.
The European Commission on Human Rights (1967)
declared that “the life of the fetus is intimately
connected with, and cannot be regarded in isolationof, the life of the pregnant woman” (Gillon et al.,2001).
The medical de initions of the terms “fetus” and“neonate” are consistent with those of legal andethics regulations. However, doctors have an ethicalobligation to protect both the patient and her fetus
from harm (Lyerly, Little, & Faden, 2008); a con lict
may thus arise between the interests of the pregnant
woman and those of the fetus. In fact, the main basis
for legal and medical principles regarding the statusof the fetus is the fact that the fetus cannot survive
independently of the mother before approximately
22-23 weeks, after which it is only possible withintensive neonatal care (Ishii, Kono, Yonemoto,Kusuda, & Fujimura, 2013). A fetus also cannot
accept moral responsibility, because it has notundergone the brain development necessary forconscious thought. The ethical dimensions of fetal
development are critical to an ethical understandingof the abortion debate. Does society place more
importance on fetal rights than on the rights of thepregnant woman?
Doctors evaluate this issue within a legal-ethicalframework. Principles of medical ethics (do no harm,bene icence, autonomy, decision making, and justice)provide a framework in which to assess the rights ofthe pregnant woman/girl (Flagler, Baylis, & Rodgers,
1997), fetus, and the speci ics of a given case.
Pregnancy should not mean loss of bodily autonomy
for a pregnant woman, nor should society have theright to intervene in a pregnant woman’s decision
regarding her own body. The physician's priority
should be to treat the rape victim while respecting
her decisions. In order to prevent further harm torape victims, physicians and ethicists must proceedfrom an ethical standpoint when making theirevaluations.
In the irst incident, a 26-year-old married woman
killed her rapist. She was sentenced to life
imprisonment and was not allowed to undergo an
abortion because she was more than 20 weeks
pregnant.
The victim in the second incident was a 16-yearold girl who only realized she was pregnant at 16
weeks. The court did not grant her permission for
an abortion.
The third incident involved a 14-year-old girl who
was 2.5 months pregnant. The court approved her

23

abortion because she was less than 10 weeks
pregnant.
In the fourth incident, a 14-year-old girl who had
been raped by her brother tried to solve the problem
by herself instead of going to family court orrequesting medical assistance from a healthcare
professional. More comprehensive legislation isneeded to protect such victims and shouldincorporate ethical principles with a view to humanrights.
In the ifth incident, a 15-year-old girl was 9
weeks pregnant when she requested an abortion.
The court rejected her request because there was nolaw pertaining to children 15 and under in its
jurisdiction, and thus no regulation regarding thetermination of pregnancy for minors.
The sixth incident concerned a 16-year-old rape
victim who was 10 weeks pregnant at the time of her
request for an abortion. Her request was rejected by
the regional court on the grounds that a fetus’s rightto life was more important than the mental health ofthe mother. The family appealed the decision andpermission for an abortion was granted by a higher
court.
Although all the victims in the selected cases
requested to terminate their pregnancies, only
victim was initially granted permission for an
abortion by the legal system. The social-legal
community needs to understand that therelationship between a pregnant girl/woman who
has been raped and her fetus is not adversarial;rather, both are victims of rape. When discussing therights of the fetus, it should be kept in mind that a
fetus is not granted personhood and moral
responsibility, while the primary victim of the rape,
the pregnant girl/woman, does have personhoodand full human rights (Organization., 2013). The
woman and girls in cases 1, 2, and 4 were raped andtheir requests for abortion were assessed solely on
the basis of legality, whereas evaluations of theircases should have included ethical principles as well.
The outcome of these incidents was loss ofautonomy on the part of the rape victims, who werealso subjected to psychological trauma, while therapist either received either minimal or nopunishment (Daro, 2006.; Flagler et al., 1997;
Howlett & Stein, 2016).
Why is the importance of the victim's life nottaken into consideration? Why is a fetus consideredmore important than the mother? Why are special
medical and ethical evaluations not required forthese women and girls? Goodwin (2016) has
addressed these issues, stating that preventing
access to abortion is a form of punishment ofpregnant women. According to a report on humanembryo research by the Nuf ield Council on
Bioethics, the modern bioethical approach is basedon the concept of gradualism, which distinguishes
the moral status of the embryo/fetus from that of themother, and as such accords each a different worth
(8).

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Eubios Journal of Asian and International Bioethics 33(1) (January 2023)

In conclusion, requests for abortions by victims ofrape and incest should be evaluated in terms of a
medico-ethical-legal framework, so that the victims,
rather than their rapists, are in a position todetermine their future. Evaluations made on thebasis of ethics will protect women’s autonomy,
prevent further harm, may improve the prospects forsome form of justice, and help the healing process.
Governments should consider ethics consultations
when victims of rape or incest request abortions andexpand legal regulations to that end.

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Appendix B. Legalized abortion in Turkey.
1. Is it a legal right? Yes, abortion is legal in
Turkey until the 10th week of pregnancy. Abortion
that is not medically necessary is available uponrequest with the informed consent of the pregnant
woman/girl.
2. If the mother is under 18 years of age, both she
and her guardian must consent to the procedure.
Girls under 15 years of age cannot be granted
permission for an abortion solely with the consent of
their guardians; they must irst make a report to the
judicial authorities.
3. Is a married woman required to receive
permission from her husband? Yes. If the husband
cannot accompany his wife to the procedure, then hemust provide signed authorization. He must also
provide documentation that he accepts full legal
responsibility for the procedure. Without thepermission of the husband, legal responsibility forthe abortion resides with the physician.
4. If a pregnancy exceeds 10 weeks, under what
conditions abortion is legal? Abortion after 10 weeks
is only allowed if the pregnancy threatens the life of
the mother, or in cases where the fetus is severely
deformed, or the baby would be severely disabled.
5. If a woman (or girl) becomes pregnant as aresult of being raped and wants to terminate her
pregnancy before 10 weeks, is her declaration
suf icient? A simple statement declaring “I was
raped” is not suf icient; the woman must prove that
she was raped. She must irst ile a complaint withthe public prosecutor or the police, then undergo a
medical check-up to furnish evidence of rape. Her
pregnancy cannot exceed 20 weeks. According to
Article 99 of the Turkish Penal Code (TCK) 5,
obtaining an illegal abortion is punishable byimprisonment for a period of ive to ten years.
If there is no medical necessity but the woman
has given her consent, the prison sentence is for two
to four years. If the woman is more than 10 weeks
pregnant, the abortion is not legal. In such situations,a woman consenting to an abortion shall besentenced to imprisonment for up to one year or be
imposed a judicial ine.
Competing interests: The authors declare they haveno competing interests.
Ethics approval: This study was approved by the
Ministry of Health, University Ethics Committee.

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Cloning prospects in 21st century
humanity: An ethico-theologicaldiscourse-Peter O. Ottuh,
Department of Religious Studies and Philosophy,
Delta State University, Abraka, Delta State, Nigeria
Email: pottuh@delsu.edu.ng

Abstract
Ethical and theological debates about human cloning
are getting hotter in recent times. Nowadays, cloning
research is more common than ever before becauseof developments in biotechnologies, public outrage,
and religious and ethical issues. Yet, despite
concerns about its effectiveness and safety and thepotential danger, studies demonstrate that humancloning does not produce a class structure. This
paper aims to contribute to the research and debate
on human cloning from the perspectives of ethics
and Christian theology. Using the descriptive andcritical analysis methodology, the paper reveals thatwhile it is unethical, human cloning still has theprospect of bene iting future humanity by appealing
to sick persons, infertile couples, those who want toavoid undesirable genetic traits, single and same-sex
couples, and parents who want to clone a dead child.
It concludes by calling on public authorities aroundthe world to exercise their statutory responsibilities
to maintain the unity, coherence, and organization of
new technologies in society along the dictates of theUnited Nations Universal Declaration of Human
Rights, which recognizes the dignity, rights, andfreedoms, and moral growth of humanity.
Introduction
Religion has been rattled by science, which has
called into question human conceptions of God'smight and the role that humankind plays in thecosmos. The popularity of cloning research is risingbecause of developments in biotechnology, publicdebate, and religious and ethical issues. Future
generations may bene it from the advancements that
result from these debates. Since the Industrial
Revolution (IR), there have been both cautionary andoptimistic expectations of technological and societal
transformation. Although it is important to support
the freedom of inquiry and discovery, opponents ofhuman cloning technology have advocated thatimmoral scienti ic adventurism has to be reined. The
moral limits of the United Nations (UN) declaration
concerning human cloning may be called into
question by biotechnological advances in the twentyirst century. For instance, the social teachings of the26

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Church re lect its dedication towards human salvi ic
warfare and care for the future of humankind. The
ethical and theological explanations of the practicesof the church teachings are intended to provide amethodical approach to human problem-solving sothat discernment, judgement, and choices will be inaccordance with reality, and collaboration and hope
will have more in luence on the state of the world
today. The truth about human beings, managing
diversity and plurality, and the start of a new periodthat is focused on humankind's future are the major
dif iculties that humanity is now facing in thetwenty- irst century.
Human cloning has been proposed as a means ofenhancing humanity's genetic potential, but there
are many insurmountable challenges anddisadvantages. The aim of this paper is to contributeto the research and debate on human cloning fromthe perspectives of ethics and Christian theology tooffer solutions to the issues affecting humanity as aresult of the current advancement of the technology.
The paper argues that despite its potential, humancloning may be challenged in the twenty- irst
century. Yet there is a need for more ethical,
theological, and religious debates to create moreawareness for the twenty- irst century humanity.
The paper is signi icant because it aids in ethical andtheological discernment, encourages positive
attitudes and moral behavior, and informs thefaithful of the church's social morality teachings.
Human cloning and its nature: Creating duplicatesof a biological thing, such as genes, a cell, or a humanbeing, is known as cloning. The concept of humancloning was initially proposed by J.B.S. Haldane, who
did so by using the phrases "clone" and "cloning,"
which have been employed in agriculture ever since
the early 20th century (Thomas, 2013). Therapeuticcloning and reproductive cloning are two often
discussed varieties of human cloning. In therapeuticcloning, human cells would be reproduced for use intreatments and organ transplants. Even though it is a
topic of ongoing study, as of 2023, it is not used inany medical settings worldwide. Somatic cell nuclear
transfer (SCNT) and induced pluripotency are two
popular techniques for therapeutic cloning that are
currently being studied (Trounson & DeWitt, 2013).
Instead of only replicating certain cells or organs,reproductive cloning would include creating ahuman being from scratch. A certain kind of cell may
be replicated in the laboratory through the processof cloning in order to study its characteristicfeatures. Identical twins naturally produce individual
humans, and Dolly was the irst animal to be cloned
from an adult cell (Daar, 2003). By extracting thegenetic material from the egg and inserting the cell
nucleus into the oocyte, which would be
subsequently induced to begin embryonicdevelopment, it is possible to clone an animal via
SCNT.
Some scientists think that it is not possible toclone a person because the technology is not there
yet. Mammals have been cloned successfully, but a

lot of pregnancies end up being miscarried on theirown, which has terrible economic, physical, andemotional effects. Ayala (2015) says that cloning has
caused animals to have serious health problems, likebeing overweight, dying young, having deformed
limbs, and having weak immune systems. Stem cells
from cloned human embryos could be used to ix
damaged nerve cells, transplant organs, and do othermedical treatments. Still, most concerned people andmany religions would still have ethical concerns
about cloning people. Moreover, because a person's
character, personality, and qualities other than theiranatomy and physiology make them up, it is
impossible to clone their deoxyribonucleic acid
(DNA).
Human cloning in theological and philosophicaltimelines: To understand how to evaluate genetic
research from a theological and philosophical pointof view, it is important to quickly look at how
religious practise and human cloning have caused
disagreements over the years. In this way, thephilosophers, theologians, and religious thinkers
who have talked about the ethical implications ofcloning humans can be put into four different time
periods that overlap. The irst debating period began
in the 1960s. This early debate was prompted by acontext of expanded options and control over
reproduction, such as the accessibility of birthcontrol pills, the potential for potential substitutes,
technologically assisted reproduction, such as invitro fertilization (IVF), and advocacy of cloning
preferred genotypes by eminent biologists andgeneticists to prevent overloading the human genepool with harmful genes and endangering thesurvival of the human species (Campbell, 2002).
Charles Curran, Bernard Haring, Richard McCormick,Karl Rahuer, Joseph Fletcher, and Paul Ramsey are
just a few of the notable theologians who
participated in these early talks regarding genetic
engineering and human cloning. Given the current
state of the debates, the latter two, Joseph Fletcher
and Paul Ramsey, staked out diametrically opposed
stances and contemplated a world of human cloningthat is perfectly relevant. Compared to thehereditary roulette of sexual reproduction, humancloning, in Fletcher's (Campbell's, 2002) opinion, is abetter method of reproduction. Laboratory
reproduction, according to him, is radically humansince it is intentional, planned, decided upon, andwilled. Ramsey (Fletcher, 1979; Ottuh, 2020a), on
the other hand, views cloning as a moral barrier forsociety and medicine that could only be crossed at
the risk of jeopardizing reproduction andhumankind. He notes three horizontal bordercrossings of cloning, irst from one person toanother, and two vertical border-crossings—from
person to God.
The irst IVF infant, called "Louise Brown," wasborn in 1978, marking the start of the second periodof theological as well as philosophical debates abouthuman cloning (Ramsey, 1970; Ottuh, 2020a).
Although Christian theologians focused on the moral

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questions raised by IVF, Jewish intellectuals like
Seymour Siegel and Fred Rosner focused on humancloning. They were not as critical of human cloning
as Ramsey or as supportive of it as Fletcher was(Rorvik, 1978; Ottuh, 2020a). The United Church of
Christ provided the irst recognized and of icial
protestant answer to the cloning debate in 1977.
This religious organization gave a broad summary of
the science and morality of human cloning.
According to Ottuh (2010d), during this time, otherreligious organizations, including some particulardenominations and the World Council of Churches in
1975, 1982, and 1989, as well as the National
Council of Churches of Christ in 1980, 1983, and1986, also released resolutions or positions t a t e m e n t s c a u t i o u s ly e n d o r s i n g g e n e t i cintervention strategies for therapeutic purposes(Lynn, 1973; Ottuh, 2010d). Campbell (2002) opinesthat when some religious leaders expressed theiropinions on genetic engineering in 1979, the thenUnited States President Jimmy Carter asked thePresident's Commission for the Study of Ethical
Problems in Medicine and Biomedical and
Behavioral Research to look into the scienti ic, moral,
and social implications of gene splicing.
The third period of the theological andphilosophical debates began in 1993, afterc o n l i c t i n g re s p o n s e s t o t h e b l a s t o m e r i cdifferentiation of embryonic cells at George
Washington University Campbell, 2002. Initially, theRoman Catholic Church vehemently objected,
branding the study as intrinsically wicked in a
Vatican editorial (McCormick, 1993). Moreover,according to the conservative Protestants, the study
went against their core beliefs in personhood andhumanity. Some Protestants, on the other hand,acknowledged the research's potential medicinal
advantages and preferred regulation over a ban(McCormick, 1993). With the unprecedented cloningof Dolly the Sheep, religious disputes entered theirfourth and most current phase. The Catholic andProtestant organizations reiterated their priorstances in this instance. On the other hand, several
other Protestant theologians have voiced cautious
approval for cloning studies and human cloning
considering the notion of human cooperation with
continuous divine creative activity.
In this renewed discussion of the ethics andmorality of cloning research and its applications forhuman cloning, the testimony given to the USA
National Bioethics Advisory Commission (NBAC) in
the public hearings on March 13 and 14, 1997, offers
the most carefully considered statements oftheological examination (Verhey, 1995). From thehistorical history of religion and human cloning
shown above, some general yet normative
generalizations may be made including extended
theological and philosophical discussion of thequestion of cloning that foreshadows and clari ies
much of the current debate; proof that there areseveral valid religious and philosophical viewpoints
on human cloning; proof that theological and27

philosophical positions re lect societal pluralism;that despite advancements in scienti ic knowledge
and technical prowess, the values that underlie
theological and philosophical objections to humancloning have proven resilient and persistent,
in luencing public debate on the issue; and that thereligious debate is no longer restricted totheologians with formal training; It has grown to
include other occupations, such as science, otherreligions, and the education of religious believers.
This indicates that theological and religious
positions have advanced to become knowledgeable
moral discourse groups on concerns relating to
reproductive and genetic technology.
Human cloning prospects: Although it had been amatter of discussion during the early modern period,
scientists and decision-makers have begun toinvestigate the technology seriously in terms of its
potential bene its. Cloning embryonic cells to
produce pluripotent or even other stem cells that
may be utilised for organ transplantation,
regenerative medicine, or to cure or prevent illness
is known as stem cell therapy (Ayala, 2015; Ottuh,
2010a). A common type of stem cell therapy is bonemarrow transplantation, and stem cells can beutilised to treat sickle cell anaemia. Growing organs
for transplantation using stem cells that include thegenome of the organ recipient is one of the mostpromising uses of therapeutic cloning. The
therapeutic development of nerve cells is aregenerative medical application that has thepotential to have signi icant negative health effects
on both society and those who have been injured(Ayala, 2015; Ottuh, 2010c). While it is possible,
mitochondrial replacement (MR) is a kind of genetherapy that modi ies the embryo and has a poor
success rate (Ayala, 2015). Whether the advantagesof MR may last into old age is uncertain anddisputed.
One of the merits of human cloning technology isthat it has enabled critical knowledge about humandevelopmental biology in modern times. Humans’pluripotent stem cells (iPSCs), on the other hand,produced in culture, are aiding in providing
information and insights into human embryogenesis.
Prospectively, several developmental illnesses andabnormalities may be resolved by researching signaltransmission and genetic modi ication in thedeveloping human embryo (Ayala, 2015).
Researchers studying the developmental trajectoryof humans have found greater support for the ideathat these pathways are conserved across species. In
addition to serving as model systems for thedevelopment of new drugs, induced pluripotent stem
cells (iPSCs) and cells produced via SCNT are
important for studying the origins of most humanand animal illnesses. Additionally, research is being
carried out to see whether stem cell treatment canbe used to cure cardiovascular disease, diabetes, andinjuries to the spinal cord in the future (Cartier &Aubourg, 2010). Thus, stem cell treatment can beused, as it involves the application of stem cells to28

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cure or eliminate a disease or condition. While
genetic engineering is not yet used in clinicalsettings, it is actively being studied. The promise of
iPSCs as a dependable source for producing humanneurons currently demonstrates the possibility forregenerative therapy in the brain and for neuralailments.
Most scholars have argued that human cloning
might be a safe and successful means of human andanimal reproduction, enabling couples who areresistant to current infertility therapy to havegenetically related children. Others have argued thathuman cloning can also be utilised to prevent thetransfer of detrimental genetic characteristics tochildren. According to DeWitt (2013), the Human
Genome Project (HGP) has uncovered the genetic
underpinnings of many illnesses and is now starting
to identify the speci ic location of genes considered
to be responsible for them. Thus, couples seeking toprevent harmful gene transfer may ind cloning
appealing since it does not require the intentional
eradication of defective embryos. In addition, Ottuh(2010a) posits that cloning could help single people
and same-sex couples who want to become pregnant
without the assistance and possible complications ofgamete donors. However, it is postulated that lesbian
couples who utilise donor arti icial insemination
may face concerns about parenthood if they use
donor gametes (Ayala, 2015). Cloning technology
may also be utilised to help parents who have lost achild and to remove gamete donors from thereproduction equation. Others, however, dispute
whether the bene its of conception in this way andunder these conditions would extend to the cloned
child. As a result of the above, cloning technology
would be acceptable to an uncompromisingutilitarian in this situation if the bene its were seen
to exceed the demerits.
One cannot talk about cloning potential without
talking about its potential risks or demerits. The
most signi icant information in most cloning
research and debates is the worry about theeffectiveness and safety of human cloning, thedanger to the clone's uniqueness, and the possibilityof lessening the number of distinctive genomes born
into the world. Cloning creates speci ic conditions
and experiences that mould the clone's life, yet it
shields them from the cell donor's formativeenvironment (Parvin, 2009). Human clones would
anticipate that a treatment for their speci ic
condition will be accessible when necessary, given
the expected exponential growth in genetic
diagnostics and gene therapy. Yet, the risk of humanclones becoming commodities is increased sinceparents would want a return on their cloning
investments and be intolerable of any laws in theircommodity. While eugenics is being advanced inhuman culture via the use of cloning, research has
proven that this does not result in a class structure.
History has shown that eugenics may be practised
without the use of cloning, as illustrated by the
Holocaust, cultural genocide, and laws requiring

forced sterilisation (Richardson, 1998). Cloning
humans does provide parents with the option of
selecting the phenotypes and genotypes that would
come together to create their children, albeit it isunlikely to give humans any more opportunities tomanipulate their progeny than they now have.
Ethico-theological response: According to Ottuh(2010a), cloning ethics refers to a range of ethicalperspectives on the use and potential of cloning,particularly human cloning. To treat patients whoare ineligible for transplant, prevent
immunosuppressive medications, and delay theconsequences of ageing, proponents advocate thedevelopment of therapeutic cloning. The position ofstem cells from embryos, which is related to theabortion discussion, is the main point of contention
for opponents of cloning technology. However,religious believers are split, with some believing thatthe technology usurps the divine's role in creation
while others perceive no con lict between Christianbeliefs and the good and possibly life-saving effectsof the technology. Since it is straightforward and may
be used to determine whether a human action ismorally proper or wrong, utilitarianism and otherethical models and theological principles are popularmoral theories that can be used to judge the morality
and humanity of human cloning (Ottuh, 2010a). Yet,these ethical and theological principles have two
signi icant laws that include exaggerating
advantages while ignoring disadvantages anddisagreeing on which values are most important.
Utilitarian principle: Ottuh and Idjakpo (2021b) saythat in utilitarianism, a decision is morally right if itmakes most people happier and morally wrong if itmakes most people sad or the opposite of happy.
This is true for everyone involved in the action, notjust the actor. Thus, if the balance of negative
repercussions exceeds the positive outcomes,
utilitarian ethics might support a ban on humancloning. This is due to the fact that reproductive
cloning might be advantageous for four different
groups: infertile couples, couples looking to ensurethat a harmful genetic feature is avoided, single andsame-sex couples who choose not to employ gamete
donors, and parents looking to clone a dead child.
But only after balancing the advantages anddisadvantages of cloning can its overall usefulness be
determined.
Principle of respect for human dignity: The mostsigni icant points in the ethical and theologicaldebates on cloning are that a fair society, in its
quests for advancement, must respect humandignity; therefore, all technological and scienti ic
a dva n c e m e n t s m u s t b e m o t iva t e d b y a n
understanding of the supremacy of the individual
over society and its quest. Therefore, it is argued thatevery technological and scienti ic advancement
under the control of public authorities must keep aclose watch to ensure that any limits set on freedom
or any responsibility located on favorite activities
are never going to be damaging to personal dignity.

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For Ottuh (2010b), human cloning violates humandignity by using humans as experimental objects(technically called "instrumentalization"). The
human person cannot be used as a tool for carryingout technological and scienti ic projects that are
imposed by some authorities.
Natural law theory: Natural laws guide universal
ideals. People are united by natural law, which
upholds universal ideals. It provides the moral
framework for establishing human society and isunchangeable and unaffected by human wickedness(Ottuh & Idjakpo, 2021b). People cannot establish ameaningful and enduring connection with others if
their understanding of the moral law's universality is
clouded. All humans can only become accountableand be able to defend public morality when they
have freedom that is founded in a common nature.
Those who believe they are the only source of reality
and truth are unable to coexist peacefully andcooperatively with other people in society. Humancloning is manipulative and unnatural; therefore it
negates the laws of nature.
Principles of freedom and human rights: Ottuh andErhabor (2022) argue that one of the mostimportant efforts to meet the unavoidable needs ofhuman dignity is the trend towards the recognitionand declaration of human rights. The Magisterium of
the Church has praised the Universal Declaration of
Human Rights for its positive contributions, which
Pope John Paul II (2006) referred to as a signi icant
turning point in humanity's moral development. The
foundation of human rights is the inherent dignity of
every person, which is irst and foremost recognized
and comprehended by reason. The supernatural
perspective of considering that human dignity was
assumed and restored by Jesus Christ, for instance, isin his incarnation, death, and resurrection, whichmakes the natural basis of rights look all the more
irm. For Ottuh and Erhabor (2022), human rights
ultimately come from humans and God rather thanfrom the will of other human beings. These rights
can be upheld collectively as well as individually
since they are universal, unalienable, and inviolable.
They include meeting humans' basic needs in thematerial and spiritual domains and must be
consistent with the requirements of human dignity.
The teachings of Pope John XXIII, the Second Vatican
Council, and Pope Paul VI have all provided
signi icant indications of the notion of human rights,
which is universality and indivisibility (cited in
Ayala, 2015). These include the right to life, the rightto a loving family, the right to a moral environmentthat fosters the development of the child's
individuality, and the right to one's own personal
progress. According to Ottuh (2020a) and Ottuh(2010b), human reproductive cloning violates
human rights, including women's reproductive
rights, the right to life, the right to a loving andchoice family, the right to a choice moral
environment, and the right to a child's individuality.
Principle of the common good: The common goodis everything in society that makes it easier andff

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more convenient for people to reach their own
happiness. It can't be split up, it belongs to everyone,
and the only way to get, keep, and get more of it is towork together. Ottuh (2021) asserts that a societythat prioritizes the common good is one that desires
and aims to stay in the service of people on all levels.
No manifestation of social activity can avoid the
problem related to its own common good since it is anecessary component of its importance and the realreason it exists (Thomas, 2013). The requirements ofthe collective good are linked to respect as well as
the integral advancement of the individual and his
basic rights, and they depend on the social
circumstances of each historical era. A good legal
system, environmental preservation, and thedelivery of basic services to everyone are included inthis list of requests, along with peace and thestructure of the state's authorities. For Ottuh, Ottuh,
and Aitufe (2014), everyone in society is involved inachieving and advancing the common good; no one
is immune from doing so in accordance with theirown capacities. He added that everyone has the rightto take advantage of the social circumstances thatthe pursuit of the common good results in. As
achieving the common good is the reason politicalpower exists, the state likewise has an obligation to
do so. In order for the common good to be achieved
with the assistance of each citizen, the state should
ensure the coherence, unity, and organisation of thecivil society of which it is a manifestation (Ayala,2015). Most religious, theological, and ethicaldebates on human cloning portray it as anti-society
and anti-human because of its unnaturalness andpotential risks. Anything that is anti-society and antihuman is a negation of the common good; hence,
public authorities in charge of protecting thecommon good have the responsibility to ban orcontrol cloning technology.
Principle of solidarity: The concept of solidarityrefers to the necessity of acknowledging theinterconnectedness of individuals and socialgroupings, the freedom granted to individuals fortheir own development, and the readiness tosacri ice oneself for the sake of others. It emphasizes
the social character of people inherently, theirequality before the law in terms of rights andrespect, and their shared journey towards closer
togetherness. Solidarity is a human value that
establishes the hierarchy of institutions. Through thedevelopment of laws, market rules, and judicial
systems, structures of solidarity must be cleansed(Pope John Paul II, 2006). It is a genuine moral
quality that serves the greater good and is shown by
a dedication to the welfare of one's neighbor and awillingness to sacri ice one's own interests on behalfof the other. Many people are aware of the close
relationship of interdependence between people andthe quick proliferation of real-time communication
methods. The domestic and global lives of manystates are negatively impacted by exploitation,tyranny, and corruption, and there are still glaring
disparities between industrialized and developing30

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nations. Ottuh (2010c) asserts that most opponentsof human cloning have labelled it an exploitative
enterprise. Cloners will exploit the poor, especiallywomen, by, for example, harvesting their embryoswith or without their consents. On the other hand,cloners carry out human cloning for economic gains
to the detriment of the public. Besides, only the richor wealthy in society can afford the technology since
it is very expensive. Thus, public authorities should
promote ethical-social solidarity, which is an
essential moral imperative ingrained in all humanconnections, in order to prevent the perilous effectsof committing injustices on a global scale.
Deontological principle: If a person must make adecision that will either satisfy one’s moral
responsibility while violating another, deontology
and the con lict of duties dilemma will occur. For
instance, if an only child were injured in a car
accident and developed kidney failure as aconsequence, the parents would decide to clone theailing child in order to conceive and raise a second
child who might one day donate their kidneys. As it
denies many people the chance to reproduce in a
way t h a t o p t i m i z e s t h e i r we l l - b e i n g a n dconsequently promotes the well-being of future
offspring, a prohibition on cloning certainly raises
important considerations about the moral duties
surrounding human or sexual reproduction. In thissense, cloning would be illegal if it were permitted
because doing so would violate the moral imperative
to ensure the freedom to reproduce. In a
deontological sense, it is dif icult to forbid humancloning because of the con licting and ambiguous
moral responsibilities that accompany both
reproductive technology and the growth of science.
On the other hand, human cloning may beconsidered intrinsically unethical by deontologists
because it denies many people the chance toreproduce in a way that optimizes their well-being
and, by extension, that of their offspring. But if
humanity has a moral duty to increase its knowledgeof how human life is created, then humanity may
ethically seek the most secure techniques for humancloning. However, that is not immediately obvious
since everyone brings their individual moral
conscience to the cloning discussions.
Creational principle and God's free will action:
According to Ottuh (2020b), the Christian Scripturespoint to the idea of creation and God's free will,
which is according to Israel's confession of faith: God
is the Creator and freely grants existence and vitality
to all things, including human beings. In the Gardenof Eden, where God positioned the irst humans as
the cultivators and keepers of the products ofcreation, they were likewise invited to be theoutward symbol and vehicle of divine gratuity. Thus,
cloning humans attacks the creational principle andGod's free will. This is because cloning humans is
unnatural.
Personalism as a principle: The dynamic image of
God is seen by the church in both males and females
and in each individual. The Bible declares thatpeople are God's creations and that the thing thatmakes them unique and distinctive is that they are
made in God's likeness and image (Ottuh, 2020b). In
this sense, human beings have the dignity of being
individuals, capable of self-knowledge and selfpossession, voluntarily offering themselves, andcoming into communion with other human beings.
According to Ottuh and Jemegbe (2020), God setshuman beings at the centre and apex of the createdorder, and through grace, human beings are required
to enter into a relationship with the Creator and toprovide humans with a faith- illed, love- illed answer
that no other creature can provide. The connection
between God and humans is one that already exists,
and it is expressed in the social and relational
aspects of human nature (Pope John Paul II, 2006).
Only human beings have the potential for God, andhuman existence is a journey and a search for God.
Therefore, human beings ind a mirror of God intheir neighbors, who represent their ultimate goodand ful illment. All of this is predicated on the ideathat a person is someone who actively participates in
his or her own development and that of the society
to which they belong.
Synthesizing the responses: The possibility ofhuman cloning in the future is very unknown due toits ethical, legal, and technological obstacles.
Scholars contemplate that the prospect of recreating
humans like once-in-a-generation sportsmen or
super-geniuses could be alluring if human cloning
were ever to be accomplished. Even if human cloning
were to ever take place, researchers assert that for
many qualities or characteristics, environment or
nurture would have a far greater effect than genetics
or nature. As a result, cloned humans would
probably vary greatly from the original in many
ways. Recent genetic data and evolutionists bothsupport the African origin of modern humans, whichstarted there and then spread to other parts of the
globe (Ayala, 2015). By matching their genetics,
proteins, and other substances, one can determine
how strongly linked human beings are to otherspecies of primates. Nevertheless, studying fossils
and tools will help people comprehend how humans’lineage evolved through time. Humans live in sociallystructured groupings, and culture is a de ining social
characteristic of humans. It encompasses all of the
products of the human mind in general, including
social and political structures, modes of operation,
moral and religious norms, language, common sense,and scienti ic knowledge. Due to cultural inheritance—a uniquely human method of accomplishingenvironmental adaptation—culture evolution has
taken over as the predominant process of human
evolution. Humans have two different types ofheredity: biological and cultural. Hence, humansexuality, not asexuality, is part of biological heredity.
This concurs with Ottuh and Onimhawo's (2006)
submission that sexuality is a divine heritage ofhumanity. Only hereditary qualities may be passed
on to the progeny under vertical heredity, which isthe case in biology.

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Lamarckian heredity is not the same as cultural
inheritance, because cultural inheritance is not only
vertical, but also horizontal and oblique. A person's
traits may be picked up from and passed on to otherpeople in their generations, regardless of whether
they are related, as well as from and to any otherpeople they come into contact with. According toOttuh and Idjakpo (2021a), cultural inheritanceenables cultural evolution, a fresh method ofenvironmental adaptability unavailable tononhuman animals. Humans have been adjusting
their surroundings to their genomes more often
during the past several millennia than their genes totheir environments. Even without anatomicaldevelopment of fur or hair, this has allowed them toexpand from the hot tropical and subtropical parts of
the Old World to the whole universe, with the
exception of the icy wastes of Antarctica. By creating
lying robots, they have also more effectively andadaptably conquered the air, and the space mission
has begun while waiting for mutations that would
enable people to breathe under low oxygenpressures or operate without gravity (Thomas,
2013). Since cultural adaptation is a more successful
kind of adaptation, it has outlasted biological
adaptation throughout the history of humans. The
Church has contended that the predominance of thehuman person does not correspond to anindividualized or mass perspective and that thehuman person is instead an organic, harmonious
reciprocal connection. The basis of human oneness isthe spiritual and eternal soul, which was formed
with the body in perfect harmony (Ottuh &Onimhawo, 2020). Because the resurrection of the
body has been promised, reason and free will areintertwined with all of the corporeal and sensory
capacities. Given that God created it and will bring it
to life on the inal day, it is reasonable to value
physical life rather than detest it. Humans have two
distinct qualities: they are metaphysical beings whoare capable of transcendence and who are open tolearning deeper truths. They are also material
creatures that are physically connected to thisphysical planet.
The Church argues that the union of soul andbody is so fundamental that one needs to regard thesoul as the shape of the body. Since God createdhumankind and intended it to be so, human nature isbuilt on relational subjectivity, and the humanperson is fundamentally a social creature (Pope John
Paul II, 2006). A society is a collection of people whoare connected by the universal concept of unity.
Therefore, humans’ ability to separate themselvesfrom other living things on earth is a natural trait.
Social interaction is a re lection of humans’ characterand part of what makes them humans. The humanbeing is compelled to live in society from the very
beginning and can only develop and ful ill his
purpose in relationship with other people. Yet
arrogance and sel ishness may result in antisocial
behavior. The social character of people varies, and ahealthy social plurality is necessary for the commonff

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31

bene it of all. It is necessary to support voluntaryorganizations and institutions in order to foster thebroadest possible involvement in a community. In
addition to fostering humans’ traits, particularly asense of initiative and responsibility, thissocialization also supports the protection of theirrights.
Conclusion
The philosophical and theological discussions
surrounding human cloning began in 1978. Today,
the prevalence of cloning research is rising due toadvancements in biotechnologies, public outcry, andethical concerns. From a theological perspective, thefoundation of human oneness is the spiritual, eternalsoul, and human being is an organic, harmonious
reciprocal interaction. Research shows that humancloning does not create a class structure, despite
worries about its ef icacy and security, the risk to theclone's identity, and the potential to reduce thediversity of genomes. According to theology, people
must be aware of their Creator and respond to him
in a way that shows love and faith. Although humanreproductive cloning is considered immoral, it is still
appealing to infertile couples, couples who arehoping to avoid negative genetic characteristics,
single and same-sex couples, and parents hoping toclone a deceased child. Rapid advancements inanimal cloning and rogue attempts to start thehuman cloning process have ensured the viability of
cl oning as a potential method of humanreproduction in the future.
The best approach to dealing with the issue ofcloning in the future is with reasonable legislation
rather than impenetrable obstacles. Humanity's job
in the twenty- irst century is to igure out how to use
cloning to its fullest potential, because the structures
we build now will shape the future. Even though it's
important to support the freedom of scienti ic
inquiry and discovery, scientists who do things thatare wrong need to be stopped. In order to sustain theoneness, coherence, and organization of newtechnologies in society in accordance with theprinciples of the United Nations Universal
Declaration of Human Rights, which af irms the
dignity, rights, and freedoms of all people, publicauthorities around the world are called upon to
uphold their legal obligations in this regard. While
human cloning technology may be challenged in thetwenty- irst century and beyond, there is a need formore ethical, theological, and religious discussions
to create more awareness about the potential risks
and bene its of human cloning for twenty- irst
century humanity.

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