Eubios Journal of Asian andInternational Bioethics
EJAIB Vol. 27 (6) November 2017www.eubios.info
ISSN 1173-2571 (Print) ISSN 2350-3106 (Online)
Official Journal of the Asian Bioethics Association (ABA)

Copyright ©2017 Eubios Ethics Institute(All rights reserved, for commercial reproductions).

Contents

Editorial - Darryl Macer

Editorial:

page
173

Anguish and distress in recipients of cadaveric kidneytransplants in Japan: a study of four cases
174- Tomoko Miyajima, Jun Kikunaga, Megumi Taguchi,
Mio Tanaka, Mayumi Nishikata, Harumi Hayashi, andMichio Miyasaka
The influence of Islamic religious rulings (Fatwa) on
medical practice in Pakistan, the case of pregnancy
with fetus having birth defects
178- Sumaira Khowaja-Punjwani
A study on the knowledge of bioethics amongprospective biology teachers
183- Atok Miftachul Hudha, Mohamad Amin Sutiman,
Bambang Sumitro Sa’dun Akbar
Bioethical issues in dental practice and prevention: Is
dentistry paternalistic?
186- Nusrat Fatema Chowdhury
Born from the ashes: Ethics and law of posthumous
reproduction
190- R. R. Kishore
Palatal rugae pattern identification to determinefamily lineage in Minangkabau, West Sumatera,
Indonesia
201- Nila Kasuma, Dewi Elianora, Aida Fitriana, Fildzah
Nurul Fajrin
ABA Renewal and EJAIB Subscription

205

Editorial address, and all correspondence to:Prof. Darryl Macer, Ph.D., Hon.D.
President, American University of Sovereign
Nations (AUSN), Arizona, USA
Email: darryl@eubios.info
EJAIB adopts and complies with the Committee on
Publication Ethics (COPE) Publication ethics andmalpractice policy. All potential authors should haveread these guidelines and by submission of an article forpublication you acknowledge that you have compliedwith this policy. Violations will be handled in proportion
to the intention and seriousness of the violation.

Registered address of EJAIB: P.O. Box 16 329,
Hornby, Christchurch 8441, New Zealand

The first paper in this issue of EJAIB documents theexperiences of four kidney recipients in Japan,
exploring the impacts of receiving a life saving
operation which has been considered one of themiracles of modern medicine. Michio Miyasaka andcolleagues explore how people felt after receving
kidneys.
The second paper by Sumaira Khowaja-Punjwani
takes up a controversial topic for any religion, that ofabortion. There are various fatwa’s that serve as
guidance for persons faced with the bioethicaldilemma of consideringabortion of a fetus withgenetic and physical problems.
Atok Miftachul Hudha et al. examine how teacher
trainees in Indonesia are aware of bioethics, andwhere they receive their information about it.
Although bioethics is mandated to be included in alllevels of education, unless teachers are aware ofbioethics it is not going to be well taught, if taught at
all. Bioethics is moral reflection, not simply liketeaching algebra.
Nusrat Fatema Chowdhury describes how
paternalism is common in dentistry, and calls for achange from paternalistic practices to informed
consent in dental practice. Dental ethics is a crticial
issue that everyone faces in maintaining oral health.
Nila Kasuma et al explore hos palatal rugae patterns
can be used to determine familial lineage. This raises
further issues of privacy when tracing genetic
relationships.
This theme of familial relations is explored further
in a legal context by R.R. Kishore for posthumous
reproduction. This issue then presents some of thebasic bioethics issues that global society has discussed
over the past few decades. EJAIB hopes that thesecases and explorations from different cultures will
provide inspiration to generate more research toenhance our understanding of corss-cultural andglobal bioethics.
- Darryl Macer174

Eubios Journal of Asian and International Bioethics 27 (November 2017)

Anguish and distress in recipientsof cadaveric kidney transplants inJapan: a study of four cases- Tomoko Miyajima1, Jun Kikunaga2, Megumi
Taguchi2, Mio Tanaka2, Mayumi Nishikata2, Harumi
Hayashi2, and Michio Miyasaka2
1 Niigata University Hospital, Niigata, Japan
2 School of Health Sciences, Niigata University,
Asahimachi-dori, Chuo-ku 2-746, Niigata 951-8518,
Niigata, Japan
Corresponding author: Michio Miyasaka
Email: miyasaka@clg.niigata-u.ac.jp

Abstract

In this study, we reveal the anguish and distressexperienced by four recipients of cadaveric kidneytransplantation (CKT) at Niigata University
Hospital in the context of their life histories. The
study participants had experienced the following
life histories: 1) regret over worsening kidneydisease and dissatisfaction with the information
provided by medical staff, 2) long-term sufferingfrom dialysis, 3) hopelessness of receiving a living
kidney donation, 4) habituation to a life of dialysis
and anxiety about transplantation, 5) a positive or
negative impression of transplantation, and 6)
consideration of the donor with constraints
imposed by the anonymous transplant system. Our
analysis suggests that recipients who underwent
CKT experienced distress as follows: 1) waiting for
CKT while undergoing dialysis was the only optionthat patients had not having close relatives donors;2) their autonomy in making a choice of treatment
was too limited, partly due to long-term suffering
associated with dialysis. It was limited to adapting
to dialysis over their entire lifetime or undergoing
CKT to fully recover; and 3) CKT recipients
experienced distress over concern for others and as
a recipient of a precious gift that they should notwaste, regardless of their postoperative condition.
Moreover, the current system prohibits any contact
between donors and recipients; thus, recipients are
only able to express their gratitude to a namelessdonor.

Introduction
The number of patients with end-stage renal
disease is increasing worldwide. In 2010, an
estimated 2.62 million patients received renal
replacement therapy, and the number is estimatedto increase to 5.44 million by 20301. Renal
replacement therapy includes dialysis and kidneytransplantation. Kidney transplantation comprises
both cadaveric kidney transplantation (CKT) andliving kidney transplantation (LKT). CKT and LKT
have been performed in Japan since 1956 and 1964,

respectively. Since the 1980s, kidney transplant
outcomes have dramatically improved as potent
immunosuppressants have been developed andmeasures against postoperative infection haveadvanced.
In North America, Western Europe, Turkey, Iran,South Korea, and several other countries, 35 ormore cases of kidney transplantation per million
population were performed in 20132. The ratio
between CKT and LKT markedly varies among
countries. CKT is predominant in countries such as
the United States, Spain, Norway, and the United
Kingdom, whereas LKT accounts for more than halfof kidney transplantations in other countries
including the Netherlands, Turkey, Iran, and South
Korea. In Japan, 1,586 kidney transplants (12.5
cases per million) were performed in 2013; ofthese, 1,431 cases were LKT and 155 were CKT3.
After the Japanese Act on Organ Transplantation
was amended in 2009, CKT cases involving brain
dead donors increased, while those involving
cardiac arrest donors decreased. Although thenumber of LKT cases has continued to steadily
increase, the overall number of CKT cases appears
to have plateaued. According to a report publishedby the Japanese Organ Transplant Network, only
155 (1.2%) of 12,000 patients on the waiting list
were able to undergo CKT in 20134.
Although dialysis can be performed as long as thenecessary facilities are available, it has
disadvantages including higher cost, and patients
being restrained for a long time and being
restricted in their food and water intake. In
contrast, kidney transplants provide a better
prognosis with longer survival 5 at a lower cost6;
thus, a transplant is usually considered a better
option than dialysis. However, no clear evidence
exists on whether kidney transplants provide a
better quality of life to patients compared withdialysis7, 8, because the evaluation of the quality oflife in recipients must take psychological and social
impacts into account. In Japan, while there has beena social debate whether brain death is the same as
human death or not since the 1980s, the negative
effects of organ transplantation have also been
discussed in the context of life and death,traditional religious views, and ethical views among
the Japanese. Because the number of kidneytransplants has not increased in line with thenumber of end-stage renal disease patients, itappears that the suffering of patients with endstage renal disease has been compounded in Japan.
LKT is more likely to be performed but poses aphysical risk to healthy relatives. Additionally, as
CKT remains an extremely difficult option, theduration of dialysis is markedly prolonged. CKT
recipients include those who had received longterm dialysis without the possibility of LKT from aEubios Journal of Asian and International Bioethics 27 (November 2017)
close relative and those who had previously
received CKT of low feasibility. Therefore, thepatients’ suffering should be assessed throughout
the life span. However, no previous studies havebeen conducted from such a standpoint. In thepresent study, we aimed to examine the anguishand distress experienced by CKT recipients in thecontext of their life histories.

Methods

Our study participants were adult recipients of CKTat Niigata University Hospital from donors who
were not the recipient’s close relative, performed
after January 2012. Data were collected thropugh
approximately 60-min semi-structured interviews
held at Niigata University Hospital between April
and June 2014. Verbatim reports were created fromthe participants’ recorded conversations, andportions describing the evaluation and emotional
expression about events were extracted, which was
encoded using abstract representations. Codes
extracted from the verbatim reports of allparticipants were then compared and integrated,
and those similar in content were renamed. This
study was approved by the Niigata University
School of Health Sciences Research Ethics
Committee (No. 108).

Results

A- Background of participants:
Of the four participants, only A was a woman. D wasin his 40s; A and C were in their 60s, and B was inhis 70s (Table 1). The dialysis period ranged from13 to 20 years. D applied for CKT approximately
two years after hemodialysis was initiated, while
the other participants applied at the time of dialysis
initiation. Other than B’s household, which was athree-generation extended family, the householdsof the three other subjects included two members,
the participant and their husband or a parent. The
participants’ occupation statuses were as follows: A
left her job when she started dialysis, C retired at
the maximum age limit, and both B and D continued
to be self-employed. (See Table 1)
B-Pooled
analysis;Sharedanddiversified
experiences:
The codes extracted from the life histories of thefour participants were categorized into thefollowing six categories:
1) Regret over worsening kidney disease anddissatisfaction with the information provided by
medical staff.
The participants discussed the regret they felt on
having kidney disease. They rarely had any
subjective symptoms during the early stages ofkidney disease and came to know about thedeteriorated function of their kidneys only after

175

seeing the test results and being informed byphysicians. While experiencing regret about living athoughtless life with no sense of crisis, someparticipants were dissatisfied with the lack of
information provided by medical institutions.
Table 1: Participants’ background
Particip A
B
C
ant
Sex
Female
Male
Male
Age
60s
70s
60s
Period20 years
13 years
17 yearson
dialysis
Time of Upon
Upon
Upon
registrat dialysis
dialysis
dialysision asinitiation initiation
initiation
kidneytransplant
candidate
FamilyHusband Wife,
Adoptive
memberoldest son fathers living
and histogether
wife,
three
grandchildren
Occupat Unemplo SelfUnemploionyed (left
employed yed
job upon(retired
dialysisat the age
initiation
limit)
)

D
Male
40s
19 years
Approxima
tely twoyears after
dialysis
initiation

MotherSelfemployed2) Long-term suffering from dialysis.
Once dialysis was initiated, painful days began
without a precise endpoint. The participants shared
physical suffering such as fatigue and tiredness, andsuffered from restrictions in daily life, including
restricted water intake and long periods of timespent on dialysis.
3) Hopelessness of receiving a living kidney donation.
Three of participants (A, B, and D) received offers ofa living kidney donation from family members, but
LKT was not performed. Although the specificsituation of each participant was different, they all
revealed mixed feelings about LKT. For A, her son
offered to donate a living kidney, but A’s physician
did not agree to receiving LKT from a young family
member. C had given up on LKT from his family
because he was an adopted son.
4) Habituation to a life of dialysis and anxiety abouttransplantation.
When the participants received the notice forkidney transplantation, they became anxious about
the surgery itself and life after the procedure and176

Eubios Journal of Asian and International Bioethics 27 (November 2017)wondered if they should undergo CKT to end the
dialysis lifestyle they had endured for many years.
5) A positive or negative impression oftransplantation.
Once the transplantation was complete, theparticipant’s lives changed drastically. While threeparticipants (A, B, and D) were in a good
postoperative
condition,
thepostoperative
condition of the remaining participant (C) was not
as good as imagined. The participants who were ingood postoperative condition noticed the recoveryof health status with the resumption of urination,
which did not happen while on dialysis. In addition,
while they felt anxious about taking a large numberof medications, they gradually realized that they
were on their way to recovery because they had no
particular subjective symptoms.
6) Consideration of the donor with constraints
imposed by the anonynous transplantation system.
All participants had been concerned over the
feelings of the donor and his/her family andexperienced complex emotions because of these
considerations. These emotions included respect tothe donor and compassion toward the donor’sfamily. The transplant recipients wanted to telltheir donor’s family how thankful they were, butthey were not allowed to directly contact themunder the current system in Japan. Feelings fordonors and their families were often described aspressure. This was because if the received kidney
did not function, the recipient might feel as if it was
his/her fault.

Discussion
1. LKT as an intersubjective choice.
At the time of initiating dialysis, kidney disease
patients in Japan face the option of LKT from close
relatives. It has been reported that people whohave successfully undergone LKT from family
members experience a sense of guilt that they
imposed a risk to their loved ones9. However, ourparticipants did not undergo LKT from close
relatives. For them, it was not a simple personal
choice but rather a complex decision based oninterpersonal considerations with close relatives, as
illustrated by A’s story. She initially accepted theoffer from her son but later gave up this possibility
by accepting the opposing opinion of her physician.
Moreover, she made no attempt to discuss LKT withher husband. If the power structure in the family
was more patriarchal, she might not be able to even
expect a live organ transplantation from a man inher family. In addition, C’s story illustrates that thelack of equality in receiving organ transplantationfrom a living donor was greatly influenced by thepatient’s family relationships. C had given up the

possibility of organ transplantation from a living
donor because he was an adopted child.
However, even if the power structure in thefamily is completely equal, LKT still depends on thedonor’s willingness, the recipient’s intentions, anassessment of the potential risks to the donor, areview of medical problems that can affect therecipient, and several other factors. Moreover, it
has been reported that decisions regarding LKT can
affect the relationship between the recipient andhis or her close relatives. On the other hand, thechoice of waiting for CKT while undergoing dialysis
is independent from the family power structure anddoes not create expectations or guilt toward thefamily, thereby becoming the only option that thepatient can choose autonomously. In Japan, theoverwhelming majority of kidney disease patientschoose this option although fewer patients are
eligible to undergo CKT compared with LKT. This isbecause organ transplantation is a form oftreatment made possible by resourcifying organs10.
However, compared with Western countries, a few
number of people in Japan are willing to donate
their organs to non-relatives, reflecting the feelingof resistance toward resourcification. As a result,
CKT, as an autonomous option for kidney disease
patients which is not under the influence of familyrelated factors, remains relatively unrealistic.
2. Insufficient autonomy and suffering associatedwith dialysis.
Kidney disease deteriorates over a long period oftime during which patients fail to control thedisease progression and eventually reach a stage
that requires dialysis or transplantation. Ourparticipants felt their autonomy was incomplete in
two ways: 1) they could not comprehend thedisease onset in the early stages because there
were virtually no symptoms associated with thedisease; 2) Doctors did not always provide
sufficient information on effective ways to preventor decelerate kidney deterioration. In particular,
patients often received ambiguous advice about
their salt and protein intake during early stages. In
some cases, even physicians may not be confident
whether kidney deterioration can be stopped if
patients follow such advice. Our participants rarely
discussed the medical causes of their illness anddescribed feeling regret that they were responsible
for the deterioration of their kidney anddissatisfaction with their physicians.
Such feelings appear to be related to the longterm dialysis-associated suffering that theparticipants experienced. Although some could
predict that the initiation of dialysis was inevitable,
those who were informed of the need for dialysis byphysicians with virtually no subjective symptoms
were significantly shocked. A study investigating
psychological pain among dialysis patients in JapanEubios Journal of Asian and International Bioethics 27 (November 2017)has reported a high incidence of subsequent
depression in patients (and their families)11. Unlike
conditions that involve few symptoms, patients
who begin dialysis perceive the suffering to thebody, as well as that associated with constraints intheir social life. From this experience, patients forthe first time understand that their disease severely
affects all aspects of their life and realize that they
have no option but to adapt by changing theirintended life plans. However, patients eventually
become accustomed to life on dialysis and accept
that the condition may remain unchanged overtheir remaining lifetime. Researchers who analyzed
the life histories of chronic disease patients
describe this as biographical disruption12 due to achronic disease. However, patients may keep on
hoping that they will undergo CKT someday andthereby may be able to discontinue the painful
dialysis. Therefore, patients simultaneously
consider the situation of life-long dialysis as well as
the potential of undergoing CKT and recovering.
Two participants (B and C) shared the experienceof receiving a notice of CKT that was neverperformed. The possibility of such an event makes
their future situation increasingly uncertain.
3. Consideration for others and the recipient’s
dilemma.
Patients who could undergo CKT understandably
perceive transplantation in different ways
depending on their postoperative condition. C,
whose postoperative condition was not as good as
expected, told a story that was very different fromthe other three participants. Unlike what he hadenvisioned before transplantation, C could not evenfreely venture out. However, he continued toconvince himself to think that it was nice to haveundergone the surgery out of his concern for thedonor. Recipients feel responsible for the sacrificemade by donors, and it is said that a recipient feels
guilty for the donor when organ rejection occurs
and the recipient cannot return to normal life.
However, guilt toward the donor is reduced if the
postoperative course is favorable. Therefore,
recipients in Japan have a psychological tendency of
regarding a failed transplantation as their
responsibility. This seemingly excessive tendencyof remorse may be related to the feeling of regret
for failing to prevent kidney deterioration during
the early phase of their life history.
The other three participants who experienced
significant improvement from the dialysisrequiring conditions also had complex feelings
toward the donors and their families. Any form oforgan transplantation other than living organtransplantation occurs only when a potential donor
dies. Therefore, a large number of transplantation
candidates are morally conflicted with the situationof waiting for someone to die. Griva et al. reported

177

that people suffering from guilt are fewer among
CKT patients than among LKT patients13. However,
the results of the present study suggest that CKT
recipients may also feel responsible and guilt
toward the donors. Sato et al. described that theviews of life and death, religious beliefs, and ethicalstandpoints among the Japanese prevent the donor
kidney and the recipient’s body image from being
integrated14. Moreover, some people cannot accept
the presence of a part of someone’s dead body intheir own body or feel that there may be a curse of
the dead.
One may argue that many of such conflicts
experienced by the recipients are caused out ofconcern for others (i.e., the deceased donors andtheir families). In Japan, organ transplants may be
performed when there is a strong relationship witha relative or if there is an anonymous non-relative
donor. The former causes a dilemma to therecipient (or recipient candidates) because of theclose relationships in the form of wanting to receive
a gift, but not wanting to impose a risk to the donor.
The latter results in a dilemma to the recipient who
receives a gift from a non-relative and they areconcerned that the person providing the gift isdead. Both are interpersonal dilemmas. In the caseof CKT, a “Thank You Letter” is available as a means
to mitigate this dilemma. Under the current system,
no contact between the donor (or the donor’sfamily) and the recipient are permitted, and therecipients can only express their appreciation to anameless donor. However, the donors’ role to therecipient is not simply a supplier of a resource, butrather an individual whose name they are notallowed to know. The stories of our participantsrevealed that to the recipients, the kidney provided
by an anonymous donor is not a resourcified organthat is anonymous and abandoned, but is instead agift from a specific individual that they must
continue to cherish, regardless of whether thetransplantation was successful or not.

Acknowledgments

We thank the study participants, as well as Ms.
Mayumi Tanabe, who is a recipient coordinator at
Niigata University Medical and Dental Hospital, andthe staff of Niigata University Medical and Dental
Hospital. This work was supported in part by aresearch grant from Niigata University Graduate
School of Health Sciences, which is based on a fiscal
2014 Niigata University GP Support Project.

178

Eubios Journal of Asian and International Bioethics 27 (November 2017)

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Cabrita, A. (2012). Cost analysis of renal
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L., Cochat, P., Oberbauer, R., Haller M.C., Van Biesen,
W. (2015). Does pre-emptive transplantation
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Tamekuni, T., & Gondo, A. (2010). The General
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The influence of Islamic religious
rulings(Fatwa)on
medicalpractice in Pakistan, the case of
pregnancy with fetus having birthdefects- Sumaira Khowaja-Punjwani, Pediatric Bioethics
Certificate, MBeth, BScN
Founding Principal & Assistant Professor
Saifee Burhani School of Nursing
Saifee Hospital Trust, ST-1, Block F, North
Nazimabad, Karachi-74700, Pakistan
Email: sumaira.khowaja@yahoo.com
skpunjwani@saifeehospital.com.pk

Abstract
Termination of pregnancy is a debated anddisputed topic in almost all major religions of theworld. In Pakistan, the topic is disputed because
Islam is the major religion and most of the
population residing in Pakistan is Muslim. This
article highlights the case of a 22 year old woman,
24 weeks pregnant, admitted for termination ofpregnancy because of fetal anomaly. The father wasagainst the decision of termination of pregnancy
and his verdict was grounded on the fatwa by
religious expert mentioning that pregnancy should
be continued regardless of the outcome withreference to the Quranic Verse in Sura Nisa. Thesetypes of clinical situations are very prevalent in
hospitals of a developing country like Pakistan andillustrate a conflict between religious and moral
values and beliefs. Autonomy of vulnerable groups
and decision-making capacity is controversial even
if the decision is being made by weighing benefits
verses risks associated with a particular treatment
modality. The power deferential and autonomy of
women over their life and body living in adeveloping country in diverse perspective can also
be perceived in such cases. The paper addresses
sensitive issues that raise questions about the
impact of religious rulings on ethical/medical
decision making.

Eubios Journal of Asian and International Bioethics 27 (November 2017)
Introduction
Human life is both irreplaceable and unique, andsince the fetus is a formative stage of human life,
rights and protection are conferred upon fetal life(1). Many questions arise when referring to fetal
life and fate; the first and foremost question is who
has the right to decide about the fate of the fetus incases where a fetal anomaly is detected orrevealed? Is this right if the mother takes thedecision or it should be the father or both? Orshould the healthcare personnel decide as they
have the knowledge that can act as a guiding lightfor taking the right decision or this right should beof the religious scholars as their advice is in thebest interest of a person with their vast experienceand knowledge about religion? The neutral
approach on this issue can also be that they all
share a mutual right on the fetus but then thequestion arises that whose decision should be
respected if there are conflicting decisions and on
what basis or grounds action should be taken?
This paper presents the ethical dilemma thatexists between the medical science and religious
scholars in terms of deciding the fetal fate in case of
fatal abnormality identified during pregnancy. This
paper also addresses the question: does religious
fatwa made by religious experts guide medical
practice or do they blur the path in making ethicalmedical decisions.
The term therapeutic abortion is defined as“those recommended by the healthcare provider toprotect the mother’s physical or mental health” (2).
The debate over therapeutic abortion is still
controversial as ever and is a politicized andcontested topic in many countries. Although, it hascommonly been practiced throughout most of theworld even before the beginning of recorded
history, it is still a subject in controversy and israising questions about human existence. The
controversies are pertinent to the question thatwhen life begins and what makes us human, theright of women to control their own bodies andexercising autonomy versus the decision of fatherof the fetus. Thus, a strong tension is seen between
secular and religious views of human life and theindividual and society, the rights of spouses andparents to be involved in the abortion decision, andthe conflicting rights of the mother and the fetus (3)The newly emerging argument of a westernethicist in medical ethics is “quality of life” which isa relative and subjective term. The term is relativeand subjective because people with different
background and culture will have a diverging rangeof understanding of the term “quality of life”. This
argument affirms that life is worth living only if itmaintains a certain level of happiness and only
when the living person does not harm the society or
surrounding people. If in the case of human fetus

179

these conditions are not met, than the fetus may
have a “right not to be born,” and it should bepossible to abort the human fetus (4). Terminationof a desired pregnancy due to diagnosis of fetal
anomaly is distressful for the women and these
women find themselves stuck in the middle of adebate framed as “pro-life” vs. “pro-choice” aswomen have a sense of love and responsibility
toward the fetus and yet they have to make thechoice to terminate the pregnancy when fetal
anomaly is diagnosed (5). The experience of making
this decision becomes extremely distressful for the
women when there is a diverging range of opinions
pertaining to termination of pregnancy amongst thepartners, society and especially religion.
This article presents a case study that addresses
a predominantly qualitative exploration of how
women make decisions about pregnancy affectedby fetal anomaly, with a consideration of husband’s
and religious viewpoints. This also explores theconcept of autonomy of vulnerable groups and theirdecision-making capacity where religious andmoral values are contradictory.
The Case
A 22 year old, pale, weak, malnourished lady wasadmitted to the obstetrics and gynecology inpatient
department of one of the secondary care hospitalsof Karachi. Her Weight was 50kg and vital signs
were BP 120/80mm of Hg, pulse 125/min,temperature 98 oF. On per abdominal examination
her HOF was 24cm, FHS positive and FM negative.
Her history reveals that she is 24 weeks plus 3 days
pregnant, gravida 2, para 1+0 admitted via OPD for
termination of pregnancy. At 22 weeks of gestation
her ultrasound revealed a fetus having anencephaly
and spina bifida. At the time of admission her planof care was to admit and start tablet cytotec q6 hrly
per vaginal plus arrangement of one pack cellblood. During interview with client it was reported
that she was married by the age of 19. She hadlastly delivered a baby boy about 1 year 4 month
ago by SVD at home assisted by traditional birthattendant. Baby birth weight was not known. No
antenatal visit, screening or immunization was
done during previous pregnancy. She was notaware of family planning methods. 40 days after
her delivery her husband administered her birthcontrol injection IM himself once and this was the
only dose administered to her. She belongs to lowsocioeconomic status, having an extended family.
Husband was the only earning member of thatfamily and his source of income was job at medical
store. Educational level was primary. She also hadinterfamily conflicts for TOP (Termination ofPregnancy) i.e. her husband was not in favor of TOP
resulting in separation. Psychologically she wasvery disturbed because of TOP, separation and180

Eubios Journal of Asian and International Bioethics 27 (November 2017)conflict with husband. She also had a history ofdomestic violence due to conflict with her motherin law. As her socioeconomic status was low so dietwas not according to requirement and she was also
not taking any supplements.
As patient admission for Termination ofPregnancy was not in the knowledge of her
husband, the team contacted her husband in orderto take his consent and to settle conflict between
them to an extent. Her husband arrived at hospitalvery anxiously and was very angry as he was not infavor of termination of pregnancy for which heprovided three ultrasounds from different labs but
mentioning the same findings and also fatwa in
which it was suggested that this pregnancy should
be continued regardless of the ultrasound findings.
The statement written in Fatwa was supported by a
Quranic verse of Surah Isra, chapter 17, verse 31“And do not kill your children for fear of poverty.
We provide for them and for you. Indeed, their
Killing is ever a great sin.” The team counseled
patient and husband regarding the reason for TOP
and to understand the context in which it is written.
Although, he understood but was in conflict
between religious, medical and moral values andbeliefs. Finally, two questions were suggested by
the team to be asked by those fatwa makers i.e.
what if fetus is abnormal, and what should be done
if mother’s life is in danger. Later on, individual andcouple counseling was also done that was focusedon need and reason for TOP, family harmony,
importance of being together for their child,
avoiding miscommunication, ignorance, acceptance,
diet to avoid these anomalies in future pregnancies,
anemic diet and alarming conditions in which
immediate action is to be reported to hospital.
As for termination of pregnancy the consent
must be obtained from both parents and in thiscase, the father was not in favor of termination ofpregnancy therefore, Patient was discharged
without TOP and family conflict was settled to acertain extent. The team tried to contact the couple
for follow up but was not able to do so.

Discussion

A- Religious Ethics: Debate of Termination ofPregnancy in Islam.
If all the major religions of the world are consulted
on the issue of termination of pregnancy depicted
here, they may unanimously consider life as sacredthat is initiated with conception and ends withdeath. The Catholic Church does not allow abortion
under any circumstances; Buddhists also oppose
abortion; Judaism allows abortion when the life of
the mother is threatened but otherwise considers it
to be forbidden and Islam is no exception in thismatter (6).

As religious, cultural and philosophicalconceptions influence decision making of thepatient and also influence medical teaching andpractice (7), healthcare professionals in Pakistan
need to consider what religion has to say about theissue of termination of pregnancy in fetal anomaly.
Islam is the major religion in Pakistan and most of
the population is Muslim, therefore, Islamic standon this issue has a significant value.
In Islam there are various sources for derivationof any authentic ruling and jurisprudence that are
divided into primary and secondary sources. Quran,the Holy Scripture and Sunnah, religious actions
and quotations of Prophet Muhammad are primarysources that are binding and accepted unanimously
by all Muslims. According to Sunni school of law,secondary sources are Ijma, consensus; Qiyas,
analogical reason; Istihisan, pure reason; AlMaslahah, seeking public interest; juristic
discretion; ruling of first generation of Muslims;
and local customs. Secondary sources of Shia schoolof thought are Ijma, consenses; and Aql, intellect(8). Other than primary and secondary sources,
Muslims also refer to religious Fatwa which areformulated as legal opinions pronounced by wellknown religious jurists (mufti: scholar of Islamic
Law). Fatwa is an authoritative explanation or
clarification of an issue and often in a question
answer format. More than one mufti can be
consulted for fatwa on the same issue. These are
non-binding legal opinions; therefore, different andeven contradictory fatwas can appear on the same
issue at a specific period in time, in various
geographic locations or even in the same country.
Thus, a versatile range of opinions exists and we
may find disagreements and various opinions
regarding the same issue. In addition, even thesame mufti, when consulted twice about the same
matter, might change his mind, and accordingly
write a fatwa that differs from the first one (9).
Since it is a non-binding document, one does nothave to act according to the fatwa provided.
Islam recognizes, respects and protects humanlife in all its phases that also includes intrauterine
life, and therefore termination of pregnancy is not
permitted with an exception i.e. under the mostdirect medical indication (10). Abortion is totally
opposed by one school of thought based on thefollowing verse from the Quran, surah Al-An’am
chapter 6, verse 151: “Do not kill your children forfear of poverty, for it is we who shall provide
sustenance for you as well as for them”. Some other
Muslims believe that abortion is permitted only if
the mother’s health is endangered, and they derive
this from another verse of Quran Surah Al-Baqara,
chapter 2, verse 233, which states that “A mothershould not be made to suffer because of her child”,
therefore most of schools of thoughts of IslamEubios Journal of Asian and International Bioethics 27 (November 2017)
emphasize that abortion can only be permitted if
the reason for it is serious i.e. threat to mother’s lifeor the probability of giving birth to a deformed or
defective child (11). However, gestational age is asignificant factor in allowing abortion because a
Hadith of Prophet Muhammad categorizes fetal life
into different stages: “Each of you is constituted inyour mother’s womb for forty days as a ‘nutfa’(male and female semen drops), then it becomes an‘alaqa’ for an equal period, then a ‘mudgha’ (like achewed piece of meat) for another equal period,
then the angel is sent, and he breathes the soul into
it, and again when forty-two nights have passed
over the sperm drops, Allah sends an angel to itwith four instructions. The angel is ordered to write
the sustenance, life span, deeds and whether
eventually his lot is happiness or misery, then toblow the sprit into him” (12). It is interpreted fromthis Hadith that the fetus receives the soul after 120
days and thus enters into “personhood” and at thisstage, abortion becomes a crime. As every life has apurpose and the purpose is determined by God,
therefore an elective violent termination of life isviewed as a protest against God’s will and wisdom(13).
Quran and Hadith mark when it is permissible tohave Termination of Pregnancy and when it’s not.
Whereas, the role of Fatwa seems ambiguous andopen to interpretations. Referring back to the casestudy provided earlier it can be debated that thecontext was not properly understood therefore thereference citied in Fatwa was irrelevant to thesituation. Therefore, it is a point to ponder whether
these religious fatwas are guiding medical practiceor they lead to a blurred pathway.
B- Secular Ethics: Debate of Termination ofPregnancy in Medical Ethics.
Analyzing this scenario in the light of basic
principles helps one understand the underlying
conflicts in particular with its impact on decision
making in the context of developing countries. The
first and foremost ethical principle is autonomy
that is best expressed in terms of decision making
capacity, particularly in the form of informed
consent. This case poses a range of questions withregard to the principle of autonomy including but
not limited to: whose autonomy should takeprecedence for guiding decision and on what
grounds? Does autonomy of father over fetus
outweigh mother’s autonomy or vice versa? From
whom the informed consent should be obtained?
Autonomy in case of fetus is referred to a mutual
decision of both the parents and therefore,
obtaining consent from both parties is importantprior to taking any decision for fetus. However,Islam offers a varied viewpoint for autonomy incase of fetus, for example, according to Hanafi
scholars, a pregnant woman could have an abortion

181

without her husband’s permission, but she shouldhave ‘reasonable grounds’ for this act (14). Basedon this it can be said that religion places themother’s autonomy over father’s autonomy.
However, the society where these cases areprevalent is patriarchal and women’s decision
making are controlled and inclined by men at every
stage of life be it daughter, sister, wife or mother.
The autonomy of women is not assumed as equal tomen. The second principle to consider in this case isbeneficence and non-maleficence. Motivation of
TOP in fetal anomaly is to offer benefit to family
and preclude harm. The initiative for individual andcouple counseling was based on this principle andthe objective was to settle down conflict amongst
them for facilitation of mutual shared decision
making and relationship. The intensity of conflictdemanded multiple sessions of counseling but it
was not achieved because of loss to follow-up.
C- Conflict between Religious, Moral and Medical
Values.
Religious, moral and medical values may be inconflict. The moral value is to make sure of safe
motherhood
whereas,religious
value
iscontradictory, and medical value signifies that theprobability of putting wife’s and child life in danger
is great if the pregnancy is continued. Laszlo
mentioned in an article that “the rift between
science and religion needs to be assessed not
merely on pragmatic grounds, on the basis of theeffect of science versus religious beliefs on people’s
behavior”(15). Hence, religious values and beliefs
influence selection of treatment for medical
decision and client autonomy needs to be respected
as well. Similarly, healthcare professionals involvedin this scenario are also in moral conflict because asa health care professional, one could think that TOP
at this stage is much safer rather than continuing
pregnancy that may have adverse outcomes but
HCPs cannot take a paternalistic approach byimposing their opinion on patient as it will override
patient’s autonomy.

Conclusion

This culturally sensitive thought provoking casepresents clinical ethical dilemmas resulting fromconflict amongst religious, medical and moral value
beliefs. Autonomy and decision-making process forvulnerable groups is controversial even if thedecision is being made by weighing benefits verses
risks associated with a particular treatment
modality. Scenarios like this happen in almost every
hospital in a developing country the context of avulnerable population which in this case is about
pregnant women and fetus.
Fatwa provided in this case was imprecise andwas irrelevant. The Fatwa should have provided

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Eubios Journal of Asian and International Bioethics 27 (November 2017)

recommendation based on the guidelines provided
in authentic sources regarding action in case of
fetus having birth defects rather than the worry
over financial expenses. The better approach forgiving medical related fatwa should be either
consultation with medical professional before
issuing fatwa in order to have a complete
understanding of background of the situation or
involving medically expert fatwa makers.
The possible factors to consider dealing withsuch type of cases can be keeping societal norm
under consideration as they will be a guiding force
in resolving these types of ethical dilemmas. First ofall, clarification of own values and beliefs because
understanding professional and clarifying personalvalues are important in order to be free from bias,
being nonjudgmental and nondirective (16).
Religious, moral and medical value conflicts should
be resolved to enable one to address the situation
in better terms. In addition, awareness sessions andcomprehensive
researchforhealthcare
professionals will strengthen their power on
subject and will provide a guiding path while
counseling. Moreover, consent policies in suchcases should be reviewed and followed strictly sothat conflicts can be minimized. As peri-natal
mortality, morbidity and anomalies elicit complex
emotional and psychological issues, psychologicalsupport at this time is important and must be done.
The effect of religious convictions and culture on
the decision of family to terminate pregnancy andtheir experience of guilt and going against God’s
will are important issues to be considered by healthcare professionals. It can be concluded that Islamic
law is a disputed domain; there’s much debate on
almost every topic even among scholars that
produce fatwa therefore the question arises: ‘How
does religious fatwa influence medical practice?’

References

1- Kyriakides-Yeldham, A. (2005). Islamic Medical
Ethics and the Straight Path of God. Islam andChristian - Muslim relations, 16(3), 213-225.
2- Hedayat, K. M., Shooshtarizadeh, P., & Raza, M.
(2006).
Therapeutic
abortioninIslam:
Contemporary views of Muslim Shiite scholars andaffect of recent Iranian legislation. Journal of Medical
Ethics, 32, 652-657.
3- Asman, O. (2004). Abortion in Islamic countries Legal and religious aspects. Medicine and Law, 23,
73-89.
4- Forrester, M. G. (1999). The right not to be born:
Abortion of the disadvantaged fetus incontemporary Fatwas. The Muslim World, 89(2),130-143.
5- McCoyd, J. L. (2010). Women in no man's land: The
abortion debate in the USA and women terminating
desired pregnancies due to foetal anomaly. British
Journal of Social Work, 40, 133-153.

6-Hedayat, K. M., Shooshtarizadeh, P., & Raza, M.
(2006).
Therapeutic
abortioninIslam:
Contemporary views of Muslim Shiite scholars andaffect of recent Iranian legislation. Journal of Medical
Ethics, 32, 652-657.
7- Asman, O. (2004). Op. cit 3. note p.73-89.
8- Wikipedia. 2015. Sources of Sharia. Available at
http://en.wikipedia.org/wiki/Sources_of_sharia[Accessed May 25, 2015]
9- Forrester, M. G. (1999). Op. cit 4. note p.130-143;
Asman, O. (2004). Op. cit 3. note p.73-89
10- Fozwzan, S., Alkuraya, & Kilani, R. A. (2001).
Attitude of Saudi families affected withhemoglobinopathies towards prenatal screening
and abortion and the influence of religious ruling(fatwa). Prenatal Diagnosis, 21, 448-451.
11- Wiebe, E., Najafi, R., Soheil, N., & Kamani, A.
(2011). Muslim women having abortions in Canada:
Attitudes, beliefs, and experiences. Canadian Family
Physician, 57, 134-138.
12- Kyriakides-Yeldham, A. (2005). Op. cit 1. note
p.213-225; Fozwzan, S., Alkuraya, & Kilani, R. A.
(2001). Op. cit 8. Note p.448-451; Hedayat, K. M.,
Shooshtarizadeh, P., & Raza, M. (2006). Op. cit 6.
note p.652-657; Forrester, M. G. (1999). Op. cit 4.
note p.130-143; Asman, O. (2004). Op. cit 3. note
p.73-89; med, S., Green, J. M., & Hewison, J. (2006).
Attitudes towards prenatal diagnosis andtermination of pregnancy for thalassaemia in
pregnant Pakistani women in the North of England.
Prenatal Diagnosis, 26, 248-257.
13- Forrester, M. G. (1999). Op. cit 4. note p.130-143
14- Noble, R., & Iqbal, M. (2009). Islamic Identifty andthe Ethics of Assisted Reproduction. In E. Blyth, & R.
Landau, Faith and Fertility: Attitudes towards
reproductive practices in different religions fromancient to modern times (p. 96). London: Jessica
Kingsley Publishers; Akber, K. (n.d.). Familyplanning and Islam: A review. http://muslimcanada.org/family.htm [Accessed May 25, 2015]
15- Laszlo, E. (2005). Religion versus science: theconflict in reference to truth-value, not cash value.
Zygon, 40(1), 57-61.
16- Simmonds, K., & Likis, f. (2005). Providing options
counseling for women with unintended pregnancies.
Journal of Obstetrics, Gynecology and Neonatal
Nursing, 34(3), 373-379.

For forthcoming conferences see: www.eubios.info or
www.ausn.info
Email to Darryl@eubios.info for more information.
Twelfth Kumamoto University International Bioethics
Roundtable: Philosophy and practice of bioethics acrossand between cultures, 1-3 December 2018, Kumamoto
University, Japan
Nineteenth Asian Bioethics Conference (ABC19): Bioethics
for Smart Living in Asia and Beyond: Taiwan as a hub for
nurturing international partnerships and sustainable
practices, 13-16 November 2018, Kaohsung and Pingtung,Taiwan.

Eubios Journal of Asian and International Bioethics 27 (November 2017)

A study on the knowledge ofbioethics among prospective
biology teachers- Miftachul Hudha
State University of Malang, East Java, Indonesia &University of Muhammadiyah Malang Jalan Raya
Tlogomas, East Java, Indonesia
Email: atok1964@gmail.com- Mohamad Amin
State University of Malang, East Java, Indonesia- Sutiman Bambang Sumitro
Brawijaya University, East Java, Indonesia- Sa’dun Akbar
State University of Malang, East Java, Indonesia

Abstract

This research was conducted to examine theknowledge of bioethics among students of teachingbiology, the sources of their knowledge aboutbioethics and their response to various problems as
examples of bioethics study. This research isimportant because bioethics is becoming animportant part of the curriculum developed forstudents of teaching biology. Through survey
research results, 75% of responding students ofbiology knew bioethics in vocabulary but did nothave a deep understanding of it, and 25% of
respondents did not know bioethics either invocabulary or its understanding. From all
respondents, 79.68% stated that bioethics was very
important to be integrated in the biology coursethat already exists in the curriculum and 20.32%
stated that bioethics was important to be given andbecome the main subject in the curriculum.
Moreover, 75% of respondents who knew bioethics
in the context of vocabulary but did not have a deep
understanding of bioethics had learned about itfrom various sources, namely: articles 21% of
respondents, books 4% of respondents, internet
48% of respondents, senior students 16, 33% of
respondents, teachers and lecturers 10% of
respondents. Furthermore, most respondents
agreed and strongly agreed on various problems
presented as relevant to bioethics case studies,
namely: (1) environmental damage caused bypollution; 2) the low moral and ethical aspects oflife; 3) exploitation of animal life on land and sea.

Introduction

Bioethics is as an observation of the moral
dimensions of decision in relation to health and incontexts involving biological knowledge andbiological issues (Shannon, 1987). It is a new
discipline that bridges between fact and value
Apressyan et al. 2008), that combines biologicalinvestigation, scientific technology and ethical183

issues as well as a biology and humanisticknowledge (Burnham and Mitchell 1992), andstudies ethical issues and decision-making related
to the use of organisms (Macer, 2008). Bioethics
learning has not been part of the curriculum in theform of main subjects or materials that are
integrated or collaborated with the existing
subjects in the field of biology.
The importance of bioethics for students ofteaching biology is that the students are required tohave the thinking and learning skills, as called by
Moylan (2008) as 7-Cs, namely: 1) Critical thinking
and problem solving; 2) Creativity and innovation;3) Collaboration, teamwork, and leadership; 4)
Cross-cultural understanding; 5) Communicationand information fluency; 6) Computing andInformation &Communication Technology; 7)
Career and learning self-reliance. Maftuh (2016)
states, human resources in the 21st century must
behave ethically.
The competence of ethical behavior is formed
through the learning of bioethics, so the purpose ofbioethics learning becomes important forprospective teachers. In order to be able toimplement the learning of bioethics, it must becollaborated with various sources of otherdisciplines, even with experts from other scientificdisciplines. Helland (2002) says that thedevelopment of bioethics requires cooperative
effort from philosophers, doctors, scientists,
lawyers, theologians, sociologists and politicians,
since there is no one field that can be more precise
to study bioethics because it is interdisciplinary.
Attempts to establish ethical competence
through bioethics learning in biology students areimportant efforts, so it must be started by knowing
the students’ initial knowledge of bioethics, theexpectations of bioethics, as well as the ethicaldecisions related to the ethical dilemma of life's
problems. However, first, bioethics has not beendeveloped as a subject for biology teacher
candidates or in collaborative or integrated studies
with other subjects. Secondly, bioethics can be
expected to help solve ethical problems of life
involving moral and ethics, so that ethical problemof life related issues of life ethics can be a focus.
Third, teaching bioethics to biology students
increases the hope that in the future students will
gain knowledge about bioethics from their biology
teachers.
Moreover, studying bioethics must be serious;
Green and Wishart (2008) firmly state that
understanding bioethics is not easy, so students
must take part to understand bioethics by deep
thinking process. Through thinking deeply biology
teachers can improve thinking skills and learning
skills, so that bioethics as an interdisciplinary study

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Eubios Journal of Asian and International Bioethics 27 (November 2017)

can be mastered well by students. Macer (1999)
asserts that bioethics is love of life.
The priority of bioethics learning is to cope withthe development of science and technology and theemergence of various ethical dilemmas on science
products and human actions and behaviors that
impact on life. As Mustami (2009) asserts, theworld of education is currently facing a challenge
by rapid technological development, full of
uncertainty
anddilemmas.
TsekosandMatthopoulos (2014) state that uncertainty is acharacteristic of the environment, and biologicalphenomena raise matters of social life. According toRanjan (2000) education teaches respect to natureand environment, society and social values.
Therefore, a study on students who are prospective
biology teachers regarding bioethics knowledge
and bioethics problems is important for thedevelopment of bioethics learning so that in the endof a process occurs which is called by Takahashi(2016) as happiness in bioethics.

MethodThis study was conducted on respondents who
were prospective biology teachers who had taken
the courses of zoology and ecology. The study was
designed with a qualitative descriptive approachwith observation, questionnaires and in-depth
interviews to collect data on bioethics knowledge,
the source of bioethics knowledge, decisions on
problems related to bioethics and perceived impact
to ethical dilemma on respondents. The data that
had been obtained were processed with frequency
distribution in percentage form.
The responses of respondents are stated basedon scores in four categories: strongly agree (4),agree (3), disagree (2), and disagree (1). Classcategories with intervals of 0.75 are used asfollows: Strongly Disagree (1.0-1.75), Disagree(1.75-2.5), Agree (2.5-3.25), and Strongly Agree(3.25-4.00). This research was conducted on
students who have not received bioethics learningin campus, and the expectation of this research is to
produce data to recommend bioethics as animportant study included in the curriculum ofprospective Biology teacher.

Resultsa. Knowledge and resources of bioethics
Based on data conducted on 123 students, theknowledge of students of teaching biology is low;
75% of respondents have knowledge of bioethics inthe context of knowing the word bioethics and havenot known yet the meaning of bioethics and 25% of
respondents are not familiar with bioethics, both asa word and a term or a definition, so bioethics isknown as a new designation. The information usedby 75% of respondents in knowing the wordbioethics comes from various sources, 48.33% fromthe internet, 20.67% from articles, 16.33% fromsenior students, 10.30% from teachers andlecturers, and 4.37% from reference books.
Similarly, the response of respondents to bioethics,
78.50% of respondents stated that bioethics is very
important to be given to student prospective
Biology teacher although it must be integrated in
Biology subject which already exist and 21.50% of
respondents said bioethics is very important and is
expected to be the main subject for prospective
Biology teacher.
b. Respondents’ response to ethical dilemmas
Various life problems that cause ethical dilemmas
were presented to the respondents throughquestionnaires. There were three basic problems:
1) Problems related to the environment, 2)
Problems of moral and ethical awareness, and 3)
Problems in animal welfare. Most respondents
agreed and strongly agreed that the problems had
an impact as ethical dilemma and were worthy of
study in bioethics learning, as seen in table 1.
Table 1: The response of students (prospective biology
teachers) in the assessment of the bioethical problems inlife.
Bioethics Problems

Mean

Category

A. Environmental Damage:Land Pollution
Water Pollution
Air Pollution
Sound Pollution
Beach Damage
Coral Reefs Damage
Deforestation

3.39
3.40
3.25
2.20
2.75
2.75
3.01

Strong agree
Strong agree
Strong agree
Agree
Agree
Agree
Agree

3.35
3.55

Strong agree
Strong agree

3.35

Strong agree

3.55

Strong agree

3.67

Strong agree

3.40
3.39
3.55

Strong agree
Strong agree
Strong agree

3.55

Strong agree

3.55

Strong agree

Beef Damage
Exploiting Natural Resources of
Mining
Exploiting Natural Resources of
Sea
Having low awareness ofenvironmental conservation
B. Having Low Morale andEthical Life Sustainability:
C. Animal Treatments:
Fishing at sea with bombing
Fishing at sea with poison
Exploiting sharks’ fin andthrowing sharks back without
fins in the sea
Exploiting manta ray gills withsadistic hunting
Serving frog soup a liveEubios Journal of Asian and International Bioethics 27 (November 2017)
The desire of students to have bioethics in theexisting curriculum as a main subject is evidence ofthe emergence of awareness of the importance of
bioethics. Making bioethics a part of an existing
curriculum will support reform in teaching, because
according to Yali (1997) the reforms are better thanthe old ones. Learning bioethics will certainly
encourage students to become humanists and havea good personality. Humanists according to Pelligro
in Nalini (2013) includes two components namely
cognitive and affective, as according to Haryadi andAripin (2015) cognitive and affective component
can be trained in learners.
Haryadi and Aripin (2015) also mention that thecognitive component is closely related to the mind,
memory, reason, intellectual, numeracy, logic, exact
science and academic. The affective component isclosely related to the psychic, which includes
attitudes (enjoyment, respect), rewards (reward,
punishment), values (moral, social), and emotion(happy, sad).
Students get information about bioethics
enormously from the internet; the internet is themost dominant source of information for students.
However, information about the bioethics fromteachers and lecturers has very low percentage, so
it can be interpreted that teachers and lecturers
have not been effective in discussing bioethics onteaching-learning activity. According to Arends(2007), the role of teachers is to help students
acquire new knowledge. The absence of bioethics
courses and bioethics studies that are integrated in
the course can be interpreted as many lecturers
never mention the issue of bioethics. It is
supportive to recommend the importance of
bioethics in the curriculum for students.
Although students are not familiar with bioethics
yet, their response to the exposure to various life
problems with ethical dilemmas were positive.
Most of the students strongly agree that the
problems related to environmental aspects, moral
and ethical awareness and animal welfare aspects(in zoological studies) deserve to be an important
study in bioethics. Moreover, a small proportion
agrees that pollution, coastal damage, coral reef
destruction and deforestation are related tobioethics.
The respondents strongly agree that the cause ofenvironmental problems is the low morale andethics of survival; according to respondents, any
human action is inseparable from morals andethics, so that environmental problems occur
because morality and ethics have a great role indecision making. If the decision is good, then people
will not exploit and destroy the environment for
personal gain or group. Moral norms as stated by
Magnis (1989) are the benchmarks used by society
to measure one’s goodness. As an example, the185environment Climate Action Network (CAN) (2007)
states that about 8 million to 16 million hectares oftropical forests were damaged annually between
the 1980s and 1990s. This destruction released 0.8
billion to 2.4 billion tons of carbon into theatmosphere and 20% of global warming is caused
by deforestation.
Based on various bioethics problems presented,
all students stated strongly agree that the low
morale and ethics of life sustainability is a serious
bioethics problem, as shown by a mean of 3.67 of
the class categories achieved from all items ofbioethical problems. These data indicate that theconcerns of students on moral and ethical issues
are very high. Macer (1999) asserts that bioethics islove of life.

Conclusions

The result of this research is that the knowledge of
biology teacher candidates is still low because there
is no subject matter in the curriculum. It can bestated that the interest of students is very high inbioethics. The expectations shown by students is tomake bioethics a part of the learning curriculum
even though it must be integrated in the existing
biology subject or become a major subject to befollowed up. This study can recommend an analysisof the need for the importance of bioethics forstudent of teaching biology.
Acknowledgement
I thank Dr. Eko Budi Minarno, M.Pd who gave me
the Bioethics book he wrote, so I have a bioethics
reference that is very exciting in studying bioethics.

References
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Untuk Belajar. Translator Helly Prajitno S dan Sri
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Apressyan, Ruben. at al. (2008). Bioethics Core
Curriculum. UNESCO.
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Boyd, Ann. (2016). Framing Assumptions in Teaching
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Bioethical issues in dental practiceand prevention: Is dentistrypaternalistic?
- Nusrat Fatema Chowdhury
Dhaka, Bangladesh; Ph.D. Student, American
University of Sovereign Nations
Email: dr.nusratchow@gmail.com

Abstract

Paternalism is not acceptable in dentistry today
because it eliminates the patients’ right to choose
the treatment they feel is right for them, even if
their choice is not what the doctor feels is best.
Paternalism violates the patient’s autonomy andself-determination. Dentists accept the ethicalprinciple of non-maleficence and in many countries,
are also recognizing the right to informed consent.
Most people trust health professionals who servethem. Dentists are among the trusted professionals,
and the paper will investigate the attitudes todentists in several different countries as examples.
When patients request inappropriate dental
treatment, the dentist must decide how to balance a
concern with patients' wellbeing with respect for
their choices. It is important for a dentist to keep
this in mind and to reflect of its implications,especially when dental practice seems to bechanging so much under the influence of themalpractice crises, the changing economic scene,
the changing regulatory environment, and so on. A
dentist must consider the patient’s values andpersonal preferences, and must involve the patientin the decision-making process. It is the dentist’s
responsibility to determine the decision-making
capacity of each patient with the help of
appropriate surrogates. For example, patients may
be given choices about which type of tooth repair
they will choose, given that there are often choices
between what an insurance will cover and what aninsurance will not cover. Are dental implants only
for the rich, and dentures for the poor? Is there aclass divide between a silver, gold or white smile?
Ethics affect virtually every decision made in adental office, encompassing activities of bothjudging and choosing, relationship with patients,
the public, office staff, and other professionals. This
paper gives an overview of bioethical issues indental practice and explains the fact that dental
ethics cannot support paternalism even inprevention.

Introduction

Medical paternalism is a set of attitudes andpractices in medicine in which a healthcare
professional determines that a patient’s wishes orchoices may not be honored. These practices wereEubios Journal of Asian and International Bioethics 27 (November 2017)
common up to the early to mid-20th century, andwere characterized by a paternalistic attitude,
surrogate decision-making and a lack of respect forpatient autonomy (1). They were undertaken with
the intention of benefiting the patient, although thisis not always the case. In the past, paternalism wasconsidered an absolute medical necessity, as there
was little to no public understanding of medical
procedures and practices (2). In the 18th century,
medical paternalism was considered necessary. It
was believed that only a doctor could properly
understand symptoms and draw useful conclusions.
During this period, the prevailing consensus wasthat disease was nothing more than symptoms. This
meant that the individual history of the patient
didn't matter in providing care, so the patient’sview was irrelevant in the medical encounter. Thus,
it was deemed necessary that physicians makedecisions for patients. This view of paternalism wasencouraged by the rise of hospitals in the later 18th
century. Because patients in hospitals were often
sick and disabled, the view of them as passive
recipients of medical care only became moreprevalent (3). However, paternalism in recent years
has become limited, and a blind faith in doctors'
decisions has come to be frowned upon (4).
Medical ethics is changing everywhere with thebalance between technology and humanism. The
evolution of the concept of patient autonomy isseen in a trend that is reflected in all cultures
moving from paternalistic compassion and love
toward informed decision making (5). Today, theprevalent presumption is that the patient has aright to know what the physician knows about her
condition. This right to know is explicitly related to
the right to make decisions about one’s own
welfare. Treatment should normally be given onlywith the patient’s informed consent, which is only
possible if she has access to information about her
condition (6). The clinician's first responsibility is
to try to improve the patient's understanding ofthese matters, but patient inattention, cognitive
limitations and clinging to false beliefs can limit thesuccess of these attempts. If a good-faith effort toimprove her understanding fails, the probability is
increased that paternalism is warranted (7).
The moral conflict that characterizes paternalism
is between the principle that requires one torespect others' autonomy and the principles thatforbid harm and promote benefit to others. But wemust also bear in mind that there are cogent moral
reasons for respecting patients' autonomy7,8.
Allowing people to exercise their autonomy as theysee fit often will have better consequences in thelong run than trying to make decisions for them.
Even when people's decisions are shortsighted, illmotivated or poorly reasoned, the obligation torespect autonomy remains9. Like most other moral

187

obligations, this sometimes can be overridden byother moral considerations. Others have suggested
that the obligation to respect autonomy may beoverridden by the dentist's obligation to promote
the patient's well-being.10,11

Ethical Issues in Dental PracticeThere are many ethical issues and challenges
surrounding the dental healthcare system, perhaps
the most important include:
Patient's life and general health: Recommendingor performing a treatment that places a patient's
life at risk would be unprofessional. A dentist who
pays no attention to the connections between apatient's oral condition and the other aspects of thepatient's health would be guilty of professional
failure. The patient's life and general health havecentral value.
Patient's oral health: Appropriate and pain-freeoral functioning is the next important value. A
dentist who leaves a patient with significant oral
impairment or painful oral functioning would be
unethical.
Patient's autonomy: A dentist must refuse torespect a patient's choice if the action chosen iscontrary to the patient's oral or general health. But
if a dentist fails to respect the patient's autonomouschoice among treatment alternatives in order tomaximize esthetic value or cost containment, thedentist would be acting unprofessionally.
Dentist's preferred pattern of practice: A dentist
has choices in terms of diagnostic, operative andother dental procedures, in consideration of patient
outcomes, patient comfort, efficiency, doctor's
comfort and trust in procedure. But the fact that adentist has a habit of practicing a certain way does
not outweigh a patient's autonomous choice, if
general and oral health is not compromised.
Esthetic values: Shaping a restoration to proper
form and function is part of general and oral healthas well as the capacity of the dentist to apply
his/her expertise for the patient's benefit. The
patient's judgment about esthetic values would
rank below the other values. Acting on patient's
judgments of appearance never justifies damaging
healthy teeth.
Efficiency in the use of resources: A dentist who
pays no attention to accepted professional
standards or to a patient's value of esthetics for
personal, financial or other reasons is acting
inappropriately12.

Ethical principles for decision making ina dental clinic
The process of ethical decision making by dentists
may be simple or quite complex, ranging from “theGolden Rule” to decisions that contemplate theethical principles or considerations at stake. Ethical188

Eubios Journal of Asian and International Bioethics 27 (November 2017)

decision making involves both judging andchoosing. Emotional state, incompetence, physicaland mental disorders, and other conditions may
adversely affect a dentist’s decision-making
capacity. Decision principles, elements, and models
are summarized to broaden the dentist’s
understanding of the processes involved and toaccommodate individual needs or preferences.
Autonomy—Patients have the right to determine
what should be done with their own bodies.
Because patients are moral entities they arecapable of autonomous decision-making. Respect
for patient autonomy affirms this dynamic in the
doctor patient relationship and forms thefoundation for informed consent, for protecting
patient confidentiality, and for upholding veracity.
The patient’s right to self-determination is not,however, absolute. The dentist must also weighbenefits and harms and inform the patient ofcontemporary standards of oral healthcare.
Beneficence—Beneficence, often cited as afundamental principle of ethics, is the obligation tobenefit others or to seek their good. Whilebalancing harms and benefits, the dentist seeks tominimize harms and maximize benefits for thepatient. The dentist refrains from harming thepatient by referring to those with specialized
expertise when the dentist’s own skills are
insufficient.
Compassion—Compassion requires caring and theability to identify with the patient’s overall wellbeing. Relieving pain and suffering is a common
attribute of dental practice. Acts of kindness andsympathetic listening to the patient are all qualities
of a caring, compassionate dentist.
Competence—The competent dentist is able todiagnose and treat the patient’s oral health needs
and to refer when it is in the patient’s best interest.
Maintaining competence requires continual selfassessment about the outcome of patient care andinvolves a commitment to lifelong learning.
Competence is the just expectation of the patient.
Integrity—Integrity requires the dentist to behavewith honor and decency. The dentist who practices
with a sense of integrity affirms the core values andrecognizes when words, actions or intentions are in
conflict with one’s values and conscience.
Professional integrity commits the dentist to
upholding the profession’s Codes of Ethics and tosafeguarding, influencing and promoting thehighest professional standards.
Justice—Justice is often associated with fairness orgiving to each his or her own due. Issues of fairness
are pervasive in dental practice and range fromprocedural issues such as whom shall receive
treatment first, to complex questions of who shallreceive treatment at all. The just dentist must beaware of these complexities when balancing the
distribution of benefits and burdens in practiceTolerance—Dentists are challenged to practicewithin an increasingly complex cultural andethnically diverse community. Conventional
attitudes regarding pain, appropriate function, andesthetics may be confounded by these differences.
Tolerance to diversity requires dentists torecognize that these differences exist andchallenges dentists to understand how thesedifferences may affect patient choices andtreatment.
Veracity—Veracity, often known as honesty or
truth telling, is the bedrock of a trusting doctorpatient relationship. The dentist relies on thehonesty of the patient to gather the facts necessary
to form a proper diagnosis. The patient relies on thedentist to be truthful so that truly informed
decision-making can occur. Honesty in dealing withthe public, colleagues and self are equallyimportant13 .
Patient’s consent, paternalism and someexamples— Informed consent is necessary fortoday’s progressive medical and dental treatment.
This allows for patient autonomy, selfdetermination, and beneficence, thus avoiding
paternalism. Dental offices, like medical offices, areable to “provide patients a financial estimate forprostheses and other treatments,” and even have
patients sign a document acknowledging theirfinancial agreement. Informed consent requires
opening the lines of communication between
providers (dentist or hygienist) and patients. The
provider needs to make sure patients understandtheir options, and patients then acknowledge they
have all the information, benefits, and risks alongwith their financial obligation. Interestingly, many
providers do not take into account the pain people
will experience as an ethical problem — “for some,
pain still seems to be only a technical problem
solved by treatment.”14
Paternalism is the practice of acting as the“parent,” which is taking it upon oneself to makedecisions for the patient. Here is an example ofpaternalism. The patient is given a treatment planof extracting a painful tooth and fabricating a threeunit bridge for tooth replacement. Due to thepatient’s age, the dentist feels this is the easiest
approach so the tooth will not give the patient any
problems in the future. In this case, there is no
mention of possible endodontic treatment or
replacing the extracted tooth (if extraction isrequired) with an implant. In another case, a longterm periodontal patient is currently receiving
periodontal maintenance recalls every threemonths. He is a diabetic patient with normal A1C
values. After receiving root planing, periodontal
pocketing is still out of control, with depths ranging

Eubios Journal of Asian and International Bioethics 27 (November 2017)

189

from 4 mm to 9mm. The hygienist is frustrated andthe dentist does not think the patient will consider
a periodontal referral due to his age and advanced
periodontal condition; thus no referral is offered(paternalism, nonmaleficence). In this example,
nonmaleficence is the primary ethical principle atissue. Nonmaleficence is included in the ADA Codeof Professional Conduct description as doing noharm and “… knowing one’s limitations and whento refer to a specialist or another professional.”15
Paternalism violates patient’s autonomy and selfdetermination, affects non-maleficence for not
giving the patient the right to informed consent;
thus, paternalism is the opposite of informed
consent14.

cons of each option and its consequences discussed
in step three.
Step five, making the decision, must become
apparent by evaluating your pro and con
worksheet. One may assume that the option withthe most pros would be the correct decision, but
carefully evaluating the degree of severity
regarding the consequences in the con column may
have an affect on your decision.
In step six, you are now ready to implement thedecision. There is no sense in going through thesesix steps unless you’re serious about implementing
ethical decisions. Without following through andacting on the ethical dilemma, there will be no
resolution for the patient or party affected14.

Ethical approach for dental practice
Knowing the major principles of healthcare ethics
and how to use a model to solve an ethical conflictis the best way to solve a dilemma. Weighing all
outcomes is necessary to reach a fair resolution foreach party. Working through an ethical dilemma
does not come easily but takes practice and carefulconsideration16. Patients deserve to exercise theirself-determination, but not at the risk of theirdental health. Dental professionals must weighoptions that allow a patient’s autonomy while
exercising beneficence and avoiding maleficence.
Exercises or decision models can help workthrough each dilemma to reach an ethical decision.
The first step, identifying the ethical dilemma, is
to pinpoint the ethical problem. Do you have alegitimate ethical dilemma? Are principles inconflict? State the specific conflict, then evaluate
and apply the specific healthcare principles thatconflict with one another. Without a conflict ofprinciples, there is no ethical problem but merely aright or wrong type of predicament.
Step two, collecting specific information, is
critical to the case in question. The information canbe specific statements of fact and can come from avariety of sources pertaining to how the conflictbegan, how it proceeded, and what parties are
involved. Information collection is necessary to
make a balanced ethical decision.
Step three, state the options, is a step-by-stepprocess or analysis to judge each option and theconsequences related to each option. Troubleshootas many options and their full consequences before
proceeding to the next step.
In step four, apply the ethical principles to theoptions. Beemsterboer recommends, “State howeach alternative will affect the ethical principle orrule by developing a list of pros and cons.”17 .List
each principle violated while considering specificvalues such as supervised neglect, informed
consent, paternalism, and more. Show the pros andConclusion
The oral healthcare system should promote andrestore the oral health of the patient and treatment
could be administered in the best interest of thepatient. But every human being as well as patient
has a right to choose their own healthcare methods.
Everyone has a right to maintain their own oral
habits like smoking and chewing tobacco although
they can lead to oral pathologies. The dentist can
only suggest preventive measures and treatment
plan but cannot force the patient to adopt suchmethods. These leads to some serious dilemmas indentistry and only ethics can solve it. The Code of
Ethics provides a basis of shared values in thepractice of dentistry to avoid paternalism.
Therefore, paternalism cannot be supported
even for preventive purposes.

References

1. Brennan, Troyen (1991). Just Doctoring: Medical
Ethics in the Liberal State. University ofCalifornia Press. pp. 51–53.
2. MPS. "Theendofpaternalism"
http://www.medicalprotection.org.
Retrieved 2017-04-15.
3. http://en.wikipedia.org/wiki/Medical_paternalism, Updated: 2017-08-28T17:55Z
4. Prof. Darryl Macer, The traditions of informed
choice about a good death around the world.
5. Beauchamp TL, Childress JF. 2001. Principles ofbiomedical ethics [5th ed]. Oxford University
Press:80–8, 283–90.
6. Ralph Bargen, Carolyn Baergen. Paternalism,
Risk and Patient Choice.
7. Faden R, Beauchamp T. 1986. A history andtheory of informed consent. New York: Oxford
University Press.
8. Dworkin G. 1988. The theory and practice ofautonomy. Cambridge, Mass.: Cambridge
University Press.
9. Angell M. 1984. Respecfing the autonomy ofcompetent patients. N Eng J Med; 310(17):1115-

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10. Ozar DT, Schiedermayer DL, Siegler M. 1988.
Value categories in clinical dental ethics. JADA;
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11. Chiodo GT, Tolle SW. 1993. Requests fortreatment: ethical limits on cosmetic dentistry.
Gen Dent; 41: 16-20.
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Dental Learning and OSHA Training, LLC,
designates this activity for 3 continuing
education credits (3 CEs). Terrie Bruscino Health
Science Editor: Megan Wright
13. ETHICS HANDBOOK FOR DENTISTS
14. Hamel O et al. (2006). Ethical reflection in
dentistry: first steps at the faculty of dental
surgery of Toulouse. J Am Coll Dent., 73(3): 3639.
15. Solving ethical dilemmas in dental hygiene
practice By Marcy Ortiz, RDH, BA
16. Wentworth R. (2010). Ethical moment: what
ethical issues should general dentists consider
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regarding referral of patients to specialists. J Am
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17. Jenson L. (February 2005). Why our ethics
curricula do work. J Dent Educ., 69(2):225-8.
18. Beemsterboer P. (2010). Ethics and law indental hygiene (2nd Ed.). St Louis, MO: Saunders
Elsevier.

Born from the ashes: Ethics andlaw of posthumous reproduction- R. R. Kishore, MD, LLB
Advocate, Supreme Court of India
President, Indian Society for Health Laws and Ethics,
New Delhi
E.mail: rrkishore@vsnl.com

Abstract

Posthumous reproduction is a profound scientificachievement bestowing biological continuance onhuman life after death, fulfilling the wishes whichwere hitherto unattainable. The process hasbrought hope and joy to many but its
implementation is marred by ethical ambiguity andlegislative inadequacy. Many jurisdictions in theworld claiming to be a part of scientific social orderdisplay a highly restrictive and debilitating
approach by forbidding posthumous reproduction.
In this article I discover the fundamental ethicalquestions which remain unanswered, analyse thelaw and the judicial responses across the world anddiscuss the prevailing conflicts and controversies in

the regulation of posthumous reproduction. I
conclude that judicial decisions are no substitutefor legislative policies which need to be evolved onpriority in view of fast advancing biotechnology andgrowing affirmation of posthumous reproductive
rightsIntroduction“They are never going to let me leave this
hospital, Mum; the only way I will get out ofhere will be in a body bag. I want you to carry
my babies. I didn’t go through the IVF to savemy eggs for nothing. I want you and Dad tobring them up. They will be safe with you. I
couldn’t have wanted for better parents, I
couldn’t have done without you.”‘A’ to her mother

The above statement of a terminally ill daughter as
quoted in the 30th June 2016 decision of the UK’s
Court of Appeal in Mr and Mrs M. v. Human
Fertilisation and Embryology Authority enabling a
72-year-old woman to give birth to her own
grandchild by using her dead daughter’s frozen
eggs, reflects stark realities of life and has inspired
me to write this article. (1) Not long ago, death was
the ultimate exit. But, not now. After departure fromthis planet the dead may continue to live as gametes
to create their offspring. Assisted reproductive
technologies have made tremendous progress since1978 when Louise Brown, the world’s first “testtube baby” was born and 1980 when posthumous
sperm retrieval was first reported by Rothman. (2)One report shows that “human semen stored forapproximately 40 years (from 39 years, 10 months
to 40 years, 9 months) maintained its ability toresult in a live birth through ICSI-IVF” (3). Motile
sperms have been successfully obtained as late as
36 hours after death (4). The persons in persistentvegetative state (PVS) or the victims of sudden andunexpected death may become parents after they
are no more. Also, those who preserved their
gametes
beforesurgicalinterventionorchemotherapy because of malignancy may become
parents after death. “In the 1960s, freezing, or
cryopreservation, of sperm was made available to
the Apollo astronauts so that even if space travel
were to harm their reproductive systems, they
could still father healthy children using the stored
sperm. During the Vietnam War, soldiers sentfrozen sperm back to their wives in the UnitedStates so they would be fathers when they returnedhome” (5).
The process of conceiving children after death,
spectacular in its scientific promise, is equallychallenging in terms of morality, ethics and law. The
ethico-legal paradigms have failed to keep pacewith the scientific development and manyEubios Journal of Asian and International Bioethics 27 (November 2017)
fundamental questions remain unanswered. In
several jurisdictions there are no legislative
enactments in place and the emerging problems arebeing handled in an ad-hoc manner. Faced with noother option, people have knocked the doors of
Courts but the judicial responses have beenheterogeneous. On one extreme are the judicial
decisions like Parpaliax v. CECOS (1984) of theFrench Court describing the sperm as “the seed oflife ... tied to fundamental liberty of a human being”(6); re the Estate of the Late K (1996) of theSupreme court of Tasmania, Australia holding thatfrozen embryos are entitled to acquire inheritancerights (7) and Parrillo v. Italy ( 2015) of theEuropean Court of Human Rights, reaffirming thespecial status of human embryos, denying their
donation even for scientific research (8). On theother extreme are decisions like Davis v. Davis(1992) of the Tennessee Supreme Court (9); Hecht
v. Superior Court (2002) of the California Supreme
Court (10) and J.C.M. v. A.N.A. (2012) of theSupreme Court of British Columbia, Canada, (11)holding that the parties are entitled to exercise
ownership rights on the embryos and takedecisions with regard to their disposal as theirproperty. Posthumous reproduction thus suffersfrom moral ambiguity and legal uncertainty andseveral vital issues need to be addressed in order tomake the process meaningful. In this article I
discover the fundamental ethical questions which
remain unanswered, analyse the law and the
judicial responses across the world and discuss theprevailing conflicts and controversies in theregulation of posthumous reproduction. I conclude
that judicial decisions are no substitute forlegislative policies which need to be evolved onpriority in view of fast advancing bioetchnology andgrowing affirmation of posthumous reproductive
rights

Ethical Challenge

The moral status of the human embryo, the natureof the deceased’s rights in gamete or embryo,consent of the deceased, respectful treatment of thedead body, rights of the widow or widower,
offspring’s identity, parentage, consanguinity,
legitimacy, rearing, social security benefits,inheritance rights, and participant’s religion makethe process of posthumous reproduction
contentious. The process may include several
possibilities such as (i) sperms of the male partnerare preserved during his lifetime and the woman’s
ovum is fertilized and implanted after the malepartner’s death, (ii) ovum, preserved during the life
time of the woman, is fertilized after her death by
the sperms of her partner and is implanted in asurrogate, (iii) embryo is created and preserved
during the life time of the partners and is implanted

191

after death of the male partner in the woman whose
ovum contributed to the embryo or in the event ofher death in a surrogate and (iv) sperms and ova
are retrieved from the body of the male and female
partners after their death and after fertilization
they are implanted in a surrogate. In terms of
biological outcome these combinations produce thesame result i.e. the birth of a child but each scenario
leads to a different set of social relationships andlegal consequences. The resulting offspring may be
confronted with a host of challenges such as
multiple parentage, muddled sibling relationship,consanguineous distortions, family destructuring,emotional stress, deficient rearing, social rejection
and legal disputes including problems ofinheritance and social security benefits. Despite
tremendous progress in assisted reproductive
technologies, parental eligibility and obligations
remain inadequately defined. In the case of
posthumous reproduction, the child may be more
vulnerable because of the absence of one or bothbiological parents. There are primarily four
stakeholders in the process namely the deceased
partner, the living partner, the child and the State.
In view of their stakes, several fundamental
questions need to be answered in the context of
ethics and law of posthumous reproduction,
including the following:
1. Does a person possess a constitutional right toreproduce after death?
2. Does a person possess property rights in his/her
gametes or embryo?
3. Can the gametes be bequeathed and inherited
like other properties?
4. Can the gametes be retrieved from the body ofthe decedent on the basis of consent given by
his/her spouse/partner or other family member,in the absence of will or advance directive fromthe decedent?
5. What should be the criteria to determine theintent of the person dying intestate with regard tousing his/her gametes for reproduction?
6. Can an embryo be implanted and grown in asurrogate in the event of death of both thepartners on the basis of their will or intent?
7. Who will be parents of the child born out of
decedent’s embryo implanted in a surrogate?
8. Is the woman entitled to implant the embryo
created by her ovum and the sperm of thedivorced/diseased husband, even after her
remarriage? If she is entitled to do so is theconsent of the present husband necessary? Whowill be the father of the child born in this manner,
the deceased /divorced husband or the present
husband, or both?
9. Is a posthumously conceived child entitled toinherit the property of his/her genetic parents?

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Eubios Journal of Asian and International Bioethics 27 (November 2017)

10. What is the role played by the religion in
posthumous reproduction?
11. What are the effects on the personality of thechild born through posthumous reproduction?
12. What is the level of social acceptance of thechild born through posthumous reproduction?
The above issues make the process controversial.
Consent of the deceased poses a serious challenge.
Incapacitation due to PVS, sudden and unexpected
death and the urgency involved in the post mortem
gamete retrieval may make the elicitation ofconsent impracticable. In such cases explicit
consent of the deceased may not be available andthe implied or presumed consent may be the only
option. However, even in jurisdictions where
explicit consent is not required, the evidence of
implied consent may not be found to be convincing
and the fertility clinic may refuse to extract thegametes. “For it seems that in most of these cases,
the deceased will not have contemplated the issueof posthumous reproduction or made their views
explicit. Consequently, the presumption against
consent
effectively
prohibits
posthumous
reproduction in the very situations where it is most
likely to be requested” (12).
Participant’s religion may further complicate theproblem. Major religions including Catholicism(13) and Judaism (14) do not approve posthumous
retrieval and use of gametes. ‘Islam also rejects thisprocedure because it takes place after the end of
the marital term” (15).
The only credible way to answer the above
questions is through consensus among all actors ofcivil society and evolution of suitable legislative
strategies. This is a difficult task owing to diverse
perspectives emerging out of religious beliefs,
cultural sensitivities, socio-economic imperatives
and varied value concepts. Furthermore, theindividual and common approaches vary because of
the accompanying circumstances. An issuelessperson, suffering from terminal illness or afflictedwith malignancy needing chemotherapy may be
genuinely interested in preserving his/her gametes
which may not be a relevant factor in case of others.
Legislative enactments therefore have to becomprehensive and in a holistic way capable ofaddressing multiple concerns and priorities. As wewill see in the later part of this paper, in view oflegislative inadequacy the courts of law haveattempted to answer some of the aforesaid
question through judicial pronouncements, while
several of them remain unanswered.

The Law

The laws on posthumous reproduction present aheterogeneous picture across the world. “Amongdeveloped nations, the U.S. assisted reproduction or

fertility industry is one of the least regulated” (16).
Posthumous reproduction is not prohibited by law
in the USA. In the context of posthumous
reproduction two uniform laws may come in tooperation: The Uniform Probate Code (UPC), 1969
and the Uniform Parentage Act (UPA), 2002. The
UPC governs inheritance and the decedents’ estatesin the United States. It has no specific provisions
with regard to children born out of posthumous
reproduction and as such it is not of much help in
addressing their inheritance rights, except ingeneral terms. The UPA, approved in 1973, last
amended or revised in 2002, provides a uniform
legal framework for establishing paternity of minor
children born to married and unmarried couples.
Section 707 of the UPA deals with the parental
status of deceased individuals. It lays down, “If an
individual who consented in a record to be a parent
by assisted reproduction dies before placement of
eggs, sperm, or embryos, the deceased individual is
not a parent of the resulting child unless thedeceased spouse consented in a record that if
assisted reproduction were to occur after death, thedeceased individual would be a parent of the child”
The Act leaves several vital dimensions of
posthumous reproduction unaddressed.
Assisted reproduction seems far better regulated
in Canada as compared to the USA and several
other countries. The process is regulated by theAssisted Human Reproduction Act which came into
force in 2007. The Act was last amended on
September 30, 2012. Section 8 (2) of the Act relates
to posthumous use of gametes and lays down, “No
person shall remove human reproductive material
from a donor’s body after the donor’s death for the
purpose of creating an embryo unless the donor of
the material has given written consent, in
accordance with the regulations, to its removal forthat purpose” (17). As regards the parentage, “The
Uniform Child Status Act (2010)2 provides that a
posthumously conceived child, or a person who
was "married to or in a common-law partnershipwith" the person who is alleged to be a parent ofthat child, may apply to court for an order declaringthat a deceased person is the child's parent.
However, the court may only grant the order if it issatisfied that the deceased's "human reproductive
material" was used, and that the deceased
consented in writing (and did not withdraw suchconsent) to be the parent of a child conceived
posthumously. Although not binding on any
particular province, this uniform act serves as asuggestion for the harmonization of laws between
provinces and can be expected to inform discussion
and drafting throughout Canada.” (18)
In the UK, Sections 39-41 of the Human
Fertilization and Embryology Act, 2008 (HFEA)
contain provisions with regard to insemination byEubios Journal of Asian and International Bioethics 27 (November 2017)
the sperms or the embryo created by the deceased’s
sperms. The law allows postmortem fecundation
but, along with other riders and restrictions. It
mandates that a man whose sperm has been used
after his death must be considered the father of thechild only if he has given written consent (and did
not withdraw the consent) to use his sperm after
death and the woman has elected in writing notlater than the end of the period of 42 days from theday on which the child was born for the man to betreated as the father of the child, subject to thecondition that no-one else is to be treated as thefather of the child by virtue of section 35 or 36 orby virtue of section 38(2) or (3), or (ii) as a parentof the child by virtue of section 42 or 43 or by
virtue of adoption.
Post mortem fecundation is forbidden in manystates of Europe such as Austria, Bulgaria, Croatia,
Cyprus, Czech Republic, Denmark, Estonia, Finland,
France, Germany, Hungary, Ireland, Italy, Latvia,
Lithuania, Luxembourg, Malta, Netherlands, Poland,
Portugal, Romania, Slovakia, Slovenia and Sweden.
It is allowed in Belgium, Greece and, Spain. There
are varied restrictions on the time after death bywhich fecundation must be started or completed. In
Belgium and Greece it is between 6 months to 2
years after the donor’s death while in Spain it is up
to 12 months after the donor’s death (19). The
European Society of Human Reproduction and
Endocrinology (ESHRE) provided guidelines in2006 suggesting that PMSR be offered only if thedeceased had provided written consent and that,furthermore, the sperm could only be used after
extensive counselling and at least 1year after thedeath (20).
Australia
In Australia, the legislative scenario isheterogeneous and “it is important to refer tothe law in each state/territory, and/or National
Health and Medical Research Council, Ethical
Guidelines on the Use of Assisted Reproductive
Technology in Clinical and Medical Practice andResearch (2017) (The NHMRC Ethical Guidelines) inorder to determine whether the removal and or use
of gametes after a person dies is permissible, and if
so the circumstances in which this may occur (21).
Assisted Reproductive Technology Act 2007 (NSW)
provides that use of gametes or embryos ispermitted after death if the gamete provider has
consented to the use of the gamete after his or her
death, the woman receiving the ART treatment has
been notified of the death or suspected death of thegamete provider and the date of death (if known),
and the woman receiving the ART treatment hasgiven written consent to the provision of the ART
treatment using the gamete despite the death orsuspected death of the gamete provider. (22)193

In Victoria, Section 46 of Assisted Reproductive
Treatment Act 2008 (Vic) provides that “Aregistered ART provider may use a person's
gametes, or an embryo created from the person's
gametes, in a treatment procedure after the
person's death only if- (a) the treatment procedure
is carried out-(i) on the deceased person's partner;or (ii) in the case of a deceased woman, by the
woman's male partner commissioning a surrogacy
arrangement in accordance with Part 4; and (b) the
deceased person provided written consent for thedeceased person's gametes or an embryo createdfrom the deceased person's gametes to be used in atreatment procedure of that kind; and (c) the
Patient Review Panel has approved the use of thegametes or embryo; and (d) the person who is toundergo the treatment procedure has received
counselling under section 48”. (23)In South Australia, Queensland, Australian
Capital Territory, Tasmania, Western Australia andNorthern Territory, there is no specific legislation
on ART. The use of ART for posthumous
reproduction may be subject to the Court orders
and may be facilitated by the NHMRC Ethical
Guidelines.
IsraelAt present there is no comprehensive legislation on
posthumous reproduction in Israel. The Bill in thisregard is about to be submitted to the Knesset(Israeli Parliament) for consideration. According to
the proposed bill, in the absence of provisions madein writing by the deceased, “his wife or steadypartner alone may become impregnated from thesperm of the deceased or inseminate her eggs withhis sperm…” As currently drafted, it also provides
that “relatives of the deceased, except his wife or
steady spouse, will not have any standing regarding
extraction or use of his sperm, except if thedeceased was not married or did not have a steadypartner at the time of his death, and only if heinstructed so in writing…” As of July 2017, it has yet
to be submitted to the Knesset for consideration(24).

Judicial Decisions

In 1984, prior to the enactment of legislations
forbidding posthumous reproduction, the French
Court, in Parpaliax v. CECOS, while determining thefate of deceased’s sperms, refused to treat them as
an ordinary moveable property. Instead, the Court
described the sperm as “the seed of life... tied tofundamental liberty of a human being to conceive
or not to conceive.” (25)In the USA, in Hecht v. Superior Court, theCalifornia Superior Court allowed a probate court
to assume jurisdiction over the sperm as propertyof the decedent. The Court observed: “Given the

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Eubios Journal of Asian and International Bioethics 27 (November 2017)

procedural posture of this case, and the fact that,for purposes of addressing real parties’ arguments,
we are assuming that decedent intended to allow
Hecht to use his sperm for posthumous artificial
insemination, it is premature for us to apply theDavis test. At this point, the only issue which we
address is whether artificial insemination with thesperm of a decedent violates public policy. There isnothing in Davis which indicates that such artificial
insemination violates public policy.” and held, “Forthe foregoing reasons we conclude that the trial
court abused its discretion in ordering decedent's
sperm destroyed” (26). As regard the inheritanceand social security benefits to posthumously
conceived children the judicial decisions in the
United States have been conflicting. In re estate of
Kolacy the Court decided the twins were thedeceased husband’s heirs and once paternity isestablished, a posthumously conceived child should
receive the legal status of heir so that they are able
to take property from their parents (27). In
Woodward v. Commissioner of Social Security, theMassachusetts Supreme Judicial Court held that a
posthumously conceived child must prove a“genetic relationship between the child and thedecedent” and the decedent must haveaffirmatively
consented
toposthumous
reproduction and support of any resulting child. In
this case, the court compared the succession rightsof the children conceived before and after the deathof the husband. In this context, the Court identified
three “powerful” state interests: “The best interestof children, the . . . orderly administration of estates,
and the reproductive rights of the genetic parent.”
The Court directed the state legislature to address
this subject through statute (28), the Court ofAppeals for the Ninth Circuit awarded Benefits to
the Twins of Rhonda Gillett and Robert Netting,holding that they were Netting’s children and met
the Act’s dependency requirements (29).
The United States Supreme Court case, Astrue v.
Capatoc, aptly reflects the negative legal
implications
arisingoutofposthumous
reproduction with regard to social security benefits
and inheritance rights. Shortly after marriage with
Karen Capato, in May 1999, Robert Capato wasdiagnosed with oesophageal cancer for which he
was administered chemotherapy. Robert deposited
his sperms in a sperm bank to be preserved andused for IVF. In march 2002 Robert died of cancer.
Using Robert’s preserved sperms Karen became
pregnant and delivered a pair of twins. Shortly
afterwards, Karen claimed survivorship benefits onbehalf of the twins under the Social Security Act.
Karen’s claim was rejected by the Social Security
Administration. Karen filed an appeal in the US
District Court of the District of New Jersey whichaffirmed the Administration’s denial of benefits totwins on the ground that Robert has not mentioned
any biological children born after his death as
inheritors of his property in his will and as such thetwins cannot be treated as his “child” in terms of
Section 416(h) of the Social Security Act. Karen
appealed to the Court of Appeals for the Third
Circuit which reversed the District Court’ decisionin her favour holding that “the undisputed,
biological child of a deceased wage earner and his
widow” qualify for survivorship benefits and thus
the biological child is considered a child under theAct; therefore, there is no need to apply Section
416(h) to determine whether the twins were
eligible under Florida’s intestacy statute (30) The
matter finally reached the US Supreme Court whichreversed the decision of the Court of Appeals
holding that the District Court’s decision wascorrect because for a biological posthumously bornchild to receive Social Security benefits under theAct, the state’s intestacy statute where the wage
earner was domiciled must provide that theapplicant meet the definition of “child.”, as definedin 416(h) of the Social Security Act (31).
It may be interesting to see how the legal statusof the offspring likely to be conceived after thedeath of biological father has been perceived inother jurisdictions. In Australia, the Supreme Court
Tasmania, In re Estate of the Late K, held thatfrozen embryo is entitled to acquire inheritancerights. Justice Slicer held that under the civil law thefetus has contingent legal interests which vest andbecome enforceable upon its live birth (32).
In Australia, in 2011, the Supreme Court of New
South Wales in Re the estate of the late Mark
Edwards, on application by wife for possession of
sperm extracted from body of late husband, heldthat “Ms Jocelyn Edwards is entitled to possessionof the sperm recovered from the body of her latehusband, Mr Mark Edwards” for intended use in
assisted reproductive treatment to conceive a childalthough there was no written consent by latehusband to such use (33).
In the U.K., Mrs. Diane Blood wanted to use herhusband’s sperms which were collected ‘shortly
before her husband was certified clinically dead’, inMarch 1995, so that she could have her husband’schild. The Human Fertilisation and Embryology
Authority did not allow Mrs. Blood to use thesperms on the plea that such use was incontravention of the Human Fertilisation andEmbryology Act 1990 because the sperms wereextracted and stored without the written consent of
Mr. Blood. Mrs. Blood’s request for going abroad
for using the sperms was also turned down. Mrs.
Blood sought judicial intervention wherein the
Court of Appeal ruled that extraction and storage ofher husband’s sperms was illegal because it wasdone without written consent of Mr. Blood. The

Eubios Journal of Asian and International Bioethics 27 (November 2017)
Court, however, concluded that “Mrs Blood has theright to receive treatment in Belgium with her
husband’s sperm unless there are good public
policy reasons for not allowing this to happen.”(34) Mrs. Blood was, ultimately, inseminated withher husband’s sperms in Belgium and gave birth toa healthy child (35).
However, the 30th June 2016 decision of the
Court of Appeal in Mr and Mrs M v. Human
Fertilisation and Embryology Authority enabling a
72 year old woman to give birth to her own
grandchild by using her dead daughter’s frozen
eggs is a momentous pronouncement, reflecting adivergent approach. In this case the Human
Fertilisation and Embryology Authority (HFEA)
refused permission for posthumous fertilizationand implantation of the frozen eggs of a 21 year old
girl dying of cancer in 2011 in her 60 year oldmother on the ground of absence of valid consent of
the deceased, as contemplated under the Human
Fertilisation and Embryology Act. The High Courtof Justice, Queens Bench Division, endorsed the
HFEA decision. But, the Court of Appeal, London,
relying on the circumstantial evidence in thenature of conversation of the deceased with hermother and the fact that “she asked for her ovaries
to be transplanted in her mother” clearly showing
her intent and desire to have the baby created outof her eggs by using her mother as the surrogate,
allowed the mother’s appeal setting aside theHigh Court’s decision and directed the HFEA toreconsider their decision in accordance with thewishes if the dead girl.. The decision reflects theneed to read the deceased’s intentions and desires
in an objective and humane manner, keeping inview the real-life situations, rather than insisting on
the literal interpretation of the law (36).
The Israeli judicial system has moved towards
liberalization from their earlier position confining
the right of in vitro fertilization solely to the female
partner of the deceased. In several cases, on thebasis of presumed consent, the family court has
granted permission to the parents to use theirdeceased son’s sperms to impregnate the woman
who would be the legal and biological mother of the
expected child. In 2007, a court allowed the parentsof 19-year-old Staff Sergeant Keivan Cohen who
was mortally wounded in the Gaza Strip on August20, 2002 to produce a grandchild using their deadson’s sperm as a “sperm donation” to a single
woman who wanted a baby with a known father’s
identity (note that otherwise, in Israel there is no
option for a known sperm donation). The child who
was eventually born from this joint process is now
four years old, and lives with his biological mother.
The parents of the deceased enjoy limited status of
the child’s grandparents, having visitation rights
and also the right to provide financial support (37).

195

In 2009, a soldier suffering from cancer, donatedhis sperm while still alive. A woman was
impregnated with his sperm and a child was born(38). In another case the wife of a young man who
died in an accident in 2004 got his sperms
extracted and stored. Subsequently, the wife
adopted a new partner and gave birth to twochildren with him and was not inclined to use thestored sperms. The parents of the deceased son
wanted to inseminate another woman with his
sperms. The widow objected to their request. The
District Court ruled that half of the 19 tubes offrozen sperm belonged to the parents of thedeceased. The widow appealed against the decision
to the Israeli Supreme Court. The matter was hotly
contested by the parents but the Supreme Court
rejected their claim holding that Grandparents’rights do not extend to the right to demand thebirth of grandchildren (39).

Discussion
1. Right to posthumous Reproduction
It is only the person who dies, not the personhood.
The “deceased does not forfeit all of his or her
human status upon death” (40). The dead may
continue to live through his/her reproductive
material. Article 16 (1) of the Universal Declarationof Human Rights (UDHR), adopted by the United
Nations General Assembly on 10 December 1948
states “Men and women of full age, without any
limitation due to race, nationality or religion, havethe right to marry and to found a family”. Article 12of the European Convention on Human Rights(ECHR), entered into force on 3 September 1953,
asserts “Men and women of marriageable age havethe right to marry and to found a family, according
to the national laws governing the exercise of thisright” The similar right has been recognized under
Article 12 of the Human Rights Act, 1998, of theUnited Kingdom. Furthermore, Article 8 (1) of theEuropean Convention affirms “Everyone has theright to respect for his private and family life, hishome and his correspondence.” Article 23 (2) of theInternational Covenant on Civil and Political Rights(ICCPR) proclaims “The right of men and women of
marriageable age to marry and to found a family
shall be recognized.” As such, right to beget andbear children is an internationally recognizedhuman entitlement. The U.S. constitution does not
explicitly recognize a right to reproduce. However,the US Supreme Court has consistently
acknowledged a person’s fundamental right toprocreate, child rearing, contraception and family
relationship (41, 42, 43, 44, 45). “The philosophicaljustification for posthumous reproduction stems
from a belief that having biological children is ahuman right. The right to reproductive choice

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Eubios Journal of Asian and International Bioethics 27 (November 2017)derives from individual free will and consciousness
that transcends religious and government
authority. Denying the right to procreation is asentence, perhaps closest in nature, to involuntarysterilization or the death penalty” (46).
Any opposition to one’s right to posthumous
reproduction appears paradoxical per se. In a world
where right to receive organs and tissues from thedeceased by others has been recognized as anormative practice how can one argue that aperson cannot use his/her own gametes forfulfilling his/her desire. Resistance against
posthumous reproduction, it seems, is rooted inarchaic mindset reflecting taboo and unwarranted
moral paternalism. It is the inherent right of every
individual to exploit scientific promise to address
his/her problems and to pursue happiness as longas it does not affect the rights of others.
Posthumous reproduction in that context is a
blissful scientific advancement. As such, prohibitionon post mortem fecundation in most of the States ofEurope is not intelligible.
2. Property rights in gametes and embryo
Property rights in human body and its materials
has been a debatable issue since long. “No otherrule of law can claim as macabre a passage throughhistory as the common law rule that there is 'no
property in the human body'. Slavers, graverobbers, grieving widows, freak show exhibitors
and harvesters of body parts have featured
prominently. The rule is only now coming in fromobscurity and assuming growing importance. New
uses for the human body, driven by medical
advances in IVF, stem cell research, cloning, genetherapy and other like areas, require that we reexamine the efficacy of this rule in its application tomodern circumstances” (47). Although there areheterogeneous judicial approaches with regard to
moral status of the human gametes and embryo
ranging from “property” to “seed of life” the Courts
in several jurisdictions have held that the parties
are entitled to exercise ownership rights on thegametes and embryos and take decisions withregard to their disposal as their property. In the
U.S.A., in Davis v. Davis, the Tennessee Supreme
Court, the first state supreme court to deliberate on
the issue of embryo disposition, held, “[embryos]
are not, strictly speaking, either ‘persons’ or‘property,’ but occupy an interim category that
entitles them to special respect because of theirpotential for human life.” But, the Court held thatthe parties were entitled to exercise ownershiprights on the embryos and take decisions withregard to their disposal (48). In Hecht v. Superior
Court, the California Supreme Court ruled that a
decedent’s frozen sperm were a distinct category ofproperty in which “decedent had an interest, in thenature of ownership, to the extent that he had

decision making authority as to the sperm within
the scope of policy set by law.” The Court allowed aprobate court to assume jurisdiction over the
sperm as property of the decedent at the time of hisdeath (49). Supreme Court of British Columbia,
Canada, in J.C.M. v. A.N.A., in 2012, held that the
sperm “should be treated as property and divided
between the claimant and respondent as such.”(50) In C.C. v. A.W., in a dispute involving four
residual embryos after in vitro fertilization, theCanadian Court, in 2005, decided in favour of A.W.
holding that the “remaining fertilized embryos
remain her property. They are chattels that can beused as she sees fit.” (51) In Parpaliax v. CECOS,
the French Court while determining the fate ofdeceased’s sperms refused to treat them as an
ordinary moveable property describing them as“the seed of life” but impliedly recognized theproperty rights in the gametes by granting theircustody to the deceased husband’s wife (52).
The Court of Appeal of England and Wales inYearworth and others v North Bristol NHS Trust
while dealing with the loss of preserved and stored
sperms due to fall of liquid Nitrogen below therequired level unanimously held that the sperms
are property for the purposes of the law ofnegligence (53).
The Supreme Court of Queensland, Australia, in
2000, In the matter of Gray refused to recognize
property rights in human gametes. While rejecting
the application of the wife for post mortem
extraction of sperms of her husband who suddenly
died in his sleep the Court observed, “It appears
that the underlying principles of law are that thoseentitled to possession of a body have no right otherthan the mere right of possession for the purpose of
ensuring prompt and decent disposal. The
prohibition on interfering with a body sanctionedby the possibility of criminal prosecution indicatesthat to remove part of the body for whateverreason or motive is unlawful” (54). In a diverse
opinion, in 2011, while examining the property
rights in human gametes, the Supreme Court of
New South Wales, in Re the estate of the late Mark
Edwards, after a thorough analysis of various
judicial decisions across the world, observed,“Subject to a consideration of various discretionary
aspects to which I am next to turn, in my view Ms.
Edwards is the only person in whom an entitlement
to property in the deceased's sperm would lie. The
deceased was her husband. The sperm wasremoved on her behalf and for her purposes. Noone else in the world has any interest in them. My
conclusion is that, subject to what follows, it would
be open to the Court to conclude that Ms Edwards
is entitled to possession of the sperm” (55).
Perhaps the A’s mother provides the most candid
description of their status: “I have absolutely noEubios Journal of Asian and International Bioethics 27 (November 2017)
doubt in my mind that, as far as A was concerned,
her eggs held a life force and were living entities inlimbo waiting to be born (56).
3. Consent
The European Society of Human Reproduction and
Endocrinology (ESHRE) 2006 guidelines suggestthat PMSR should be offered only if written consent
has been given by the deceased person, thoroughcounselling has been received by the surviving
partner before taking the decision and a minimum
waiting period of 1 year has been imposed before atreatment
canbestarted(57).
These
recommendations, at times, may not be consistent
with the real-life situations and larger humaninterest. The purpose of consent is to promoteautonomy of the individual, not to obliterate
his/her biological expressions and desires. The
validity of consent needs to be determined in a
candid and realistic manner, under the prevailingcircumstances. Consensual paradigms in case of
sudden and unexpected death and the urgency
involved in the post mortem gamete retrieval haveto be pragmatic. For insemination of a remarried
woman by the sperms of her deceased husband or
implantation of the embryo created by her ova andsperms of her deceased husband the consent of her
deceased as well as the present husband seems
necessary. In the event of absence of the deceased
husband’s consent his intent must be determinedbytherelevant
circumstances
beforeinsemination/implantation. The Courts across theworld in this regard have adopted a pragmatic andrealistic approach by relying on the intent of thedeceased as reflected through accompanying
circumstances.
In this context, the French court’s verdict in
Parpaliax v. CECOS provides a positive andenlightening analysis. Alain Parpalaix who wasdiagnosed with testicular cancer, deposited his
sperms in a fertility centre in France without
specific instructions regarding their use, before
being subjected to chemotherapy. Alain could notsurvive but he married Corrine just two days before
his death. Corrine claimed access to Alain’s sperms
in order to conceive his child but the fertility centre
denied their access to her. Corrine sought judicial
intervention. The French court, in the absence of awritten contact, examined the associatedcircumstances. The fact that Alain deposited his
sperms and chose to marry Corrine just two days
before his death demonstrated his intention that
Corrine should carry his child. This was further
supported by Alain’s parents who testified that hewanted Corrine to be the mother of his child (58).
In Australia, in 2011, the Supreme Court of New
South Wales in Re the estate of the late Mark
Edwards on an application by his wife Ms Jocelyn
Edwards for possession of sperm extracted from197

the body of her late husband, despite the absence of
written consent by her late husband for such use,issued a declaration that she was entitled topossession of the sperm recovered from the body ofher late husband for intended use outside New
South Wales to conceive a child. In the absence of
written consent, the Court relied on the wishes of
Mr. Edwards conveyed to his wife in a conversationon the Valentine's Day in which he said, “Ifsomething happens to me I would want a part of me
to be here with you. Our baby will be a part of us our legacy even after we are both gone. She will be
the bond that unites our families. The bond
between [their two children]. If we find out I havecancer I want to make sure we have our baby
before I am unable to have one, before I do any
chemo. Please promise me you will still have ourbaby" (59).
Based on the parental wishes of becoming grandparents, in the absence of written consent, thephysicians in Israel have retrieved sperms from thebody of the deceased and the Courts have allowed
impregnation of the unrelated woman to produce
child although such a course is not supported byany legislative enactment. This reflects Israel’s
general pro-natalist sentiment founded in the
Jewish belief that procreation is a fundamental
commandment within the Jewish tradition, “befruitful and multiply.”
The 30th June 2016 decision of the UK’s Court ofAppeal in Mr and Mrs M v. Human Fertilisation andEmbryology Authority enabling a 72 old woman togive birth to her own grandchild by using her deaddaughter’s frozen eggs also reflects the need to readthe deceased’s intentions and desires in an
objective and humane manner keeping in view thereal life situations rather than insisting on theliteral interpretation of the law (60). I agree withthe author when she says: “I believe thatconditioning the posthumous use of gametes orembryos on the ability to prove that the deceased
wanted posthumous children gives the legal system
undue authority to determine a person’s genetic
legacy. I argue that biological continuity is a humanright that neither society nor the government has
the right to negate. A more logical assumption isthat an individual seeks genetic continuity unlesss/he says or acts to the contrary. I see carrying on a
person’s posthumous genetic legacy as the essenceof the sanctity of life and an act of dignity” (61).
4. Parentage and rights of the child
The question of parentage of the child borne out of
posthumous reproduction is a complex issue. Twomen, the genetic and the nurturing may be treatedas fathers and three women, genetic, gestationaland nurturing may be assigned the motherhood.
The time of harvesting the sperm or ovum i.e.,
before or after the death, is not as vital a

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Eubios Journal of Asian and International Bioethics 27 (November 2017)consideration as the genetic origin of the offspring.
Genetic linkage provides the surest way of
establishing parentage and the person’s biological
identity. In the UK, the Human Fertilization andEmbryology Act, 2008 (HFEA) mandates that a
man whose sperm has been used after his deathmust be considered the father of the child only if he
has given written consent (and did not withdraw
the consent) to use his sperm after death and thewoman “has elected in writing not later than theend of the period of 42 days from the day on which
the child was born for the man to be treated ...... as
the father of the child”. However, the laws in othercountries are not so explicit and declaration ofpaternity solely on the basis of sperms, in theabsence of such legislative provisions, may create
conflict of interest and disputes among various
stakeholders in the matter of inheritance and social
security benefits. In the event of successful
implantation and birth, the legal rights of the childand his/her mother, including the paternity of thechild and his/her right of inheritance and the rightto marry due to possibility of consanguinity may
lead to dispute. In the USA, Section 707 of the
Uniform Parentage Act deals with parental status of
deceased individual but the Act leaves several vitaldimensionsofposthumous
reproduction
unaddressed. In Canada, the Uniform Child Status
Act (2010)2 contains provisions regarding theparentage of posthumously conceived child andserves as a suggestion for the harmonization oflaws between provinces but the declaration ofparentage is subject to the orders of the Court
which may only be granted if the Court is satisfied
that the deceased's "human reproductive material"
was used and that the deceased consented inwriting (and did not withdraw such consent) to be
the parent of a child conceived posthumously.
“Although the proposition that after-born children
should be legally recognized as the children of theirdeceased parents is broadly supported, noconsensus has emerged concerning the rights ofsuch children to inherit or to claim support fromtheir deceased parents.” and “considerable
disparities remain in the approaches taken bydifferent jurisdictions to the rights of after-born
children (62).
The Supreme Court of Queensland, Australia, in
2000, In the matter of Gray while rejecting theapplication of the wife for post mortem extractionof sperms of her husband declined to exercise the
Court’s discretionary powers in favour of theapplicant, inter-alia on the ground that the“interests of any child born as a result of theprocedure must be of particular importance in theexercise of the discretion. I cannot see how it can besaid that the interests of such a child will beadvanced by inevitable fatherlessness. The very

nature of the conception may cause the childembarrassment or more serious emotional
problems as it grows up. More significant, because
the court can never know in what circumstances
the child may be born and brought up, it is
impossible to know what is in its best interests”(63).
Paternity “plays an important role in shaping thechild’s identity and in fashioning the familial
relationship between the child and her relatives,
including the husband’s parents, his siblings or hisother children” (64). Fairness and equity mandates
that the rights of the child borne out of husband’s
posthumous retrieval of sperms should not beaffected due to presence of the subsequent husband
as long as the child’s claim is confined to the assetsof his/her genetic father. “The interests of all theseparties — the deceased, the widow, the child — aswell as the broader social interest, must be weighed
if we are to decide on the ethics of posthumous
reproduction” (65). Scholars believe that “lack oflegislative activity is unfair to the innocent children
born into this circumstance. It is time for politicians
to step forward into this political hotbed and makeconscious, thoughtful decisions regarding the statusof these children” (66) and that “the posthumouschild and the rights and responsibilities relating tosuch a child, are directly related to the fundamental
right to procreate, thus statutes must support
rather than prohibit posthumous conception” (67).
As such, the law needs to be evolved to equitably
define the legal entitlements of the posthumously
conceived children and the children conceived
during the life time of the parents.
5. Way Forward
Contemporary world order is founded on humandignity, scientific promise and the rule of law.
Human dignity contemplates compassion andbeneficence; scientific promise envisages evolved
and awakened minds, free from bias and taboo; ruleof law mandates supremacy and sprit of law basedon reason, logic and equity. All human endeavours
need to be tested on the touchstone of these corevalues. Posthumous reproduction has been
available for almost thirty years but it continues tobe utterly unlegislated. Owing to legislative
inadequacy the aggrieved parties are constrained toseek judicial intervention. But, the Courts are no
substitute for legislature. “The possibilities of
posthumous reproduction pose fundamental
questions about the significance of reproductive
material, the meaning(s) of autonomy in thecontext of reproductive decision-making, and thebalancing of interests between the living and thedead” (68). “Practical, comprehensive, flexible, andstandard laws will need to be developed to provide
the necessary guidelines to give parents, doctors,
and fertility clinics/sperm banks a reasonableEubios Journal of Asian and International Bioethics 27 (November 2017)
opportunity to provide for posthumously conceived
children” (69). In the event of dispute between thepartners with regards to use of gametes or embryos
a balance-of-interests approach may, at times, be avalid option.
Ability to conceive children by those who aredead is a profound scientific achievement. Although
not explicitly recognized in law, and forbidden in
most of the European countries, the judicial
decisions reflect a positive attitude towards
continuance of the dead in the form of his/her
offspring. With advancing biotechnology rights ofthe dead have come to the fore and the law has tokeep pace with the emerging scientific promise.
Cultivators of law ought to appreciate that
posthumous reproduction is a highly personalized
expression of the emerging scientific promise andspecific provisions need to be made in the law toensure timely retrieval of gametes from the dead,without undue legal hurdle. “There is perhaps nogreater way that the living can honor the dead thanby safeguarding the pre-death intentions of those
who are now deceased, in a matter as fundamental
as procreation” (70). “In a society that values theindividual's rights of privacy and procreation sohighly, where questions on abortion have caused
severe internal strife, where single-parents abound,
and where so many millions of Americans facetrouble conceiving a child, it seems unthinkablethat we would unilaterally restrict the rights aperson has in his or her own reproductive material
and in the freedom to decide when and how to havechildren. Instead of being scarred for life, thesechildren could certainly grow-up better adjusted
than "the kid next door," embraced by the love of aparent who went to great lengths to have them andthe knowledge that they were unquestionably
wanted” (71).

Conclusion

Posthumous reproduction is a spectacular
expression of advancing biotechnology bringing
hope and joy to many but its concretization ismarred by ethical ambiguity and legislative
inadequacy. Several issues such as right toposthumous reproduction, moral status of thehuman embryo; nature of the deceased’s rights ingamete or embryo; consent of the deceased;
respectful treatment of the dead body; rights of thewidow or widower; offspring’s identity, parentage
consanguinity, legitimacy, rearing, social security
benefits, inheritance rights and a host of others
continue to be controversial. Many jurisdictions in
the world, claiming to be a part of scientific social
order, display a highly restrictive and anti-futuristic
approach as nearly half of the Europe forbids
posthumous reproduction. Incapacitation due to
PVS, sudden and unexpected death and the urgency

199

involved in the postmortem gamete retrieval callfor due consideration while dealing with the issueof consent of the deceased. Consensual paradigms
in such situation have to be pragmatic. Courts
across the world have ruled that a person continues
to have rights in his/her gametes and embryo after
death and these rights can be exercised either
through the deceased’s will or intention. The earlier
laws of inheritance based on the notion that aperson must be alive at the death of his or her
benefactor, or in the womb and later born alive, arenot consistent with the emerging scientific promiseand human aspirations. Specific laws based onequity and biological proximity need to be evolved
with regard to legal entitlements of theposthumously conceived children vis a vis thechildren conceived during the life time of theparents. Undoubtedly, the 30th June 2016 decisionof the UK’s Court of Appeal enabling a 72 oldwoman to use her dead daughter’s frozen eggs is anoasis in the desert of ethical and legal ambiguity.
However, the courts of law are no substitute forlegislative wisdom. The issue of posthumous
reproduction needs to be adequately legislated by
evolving comprehensive, pragmatic and humane
legislative policies in order to ensure spontaneousand meaningful application of this rewarding
reproductive technology.

References

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viable sperm in the postmortem state." Fertil. Steril.
34(5):512
3- Andras Z. Szell, Russell C. Bierbaum, W. Brent
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8- European Court of Human Rights, Parrillo v. Italy,
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11- J.C.M. v. A.N.A., 2012 BCSC 584 (CanLII)
12- Rebecca Collins. 2005. Posthumous Reproduction
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Medicine and Philosophy A Forum for Bioethics andPhilosophy of Medicine. 30(4): 431-442.
13- Instruction on respect for human life in its origin
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14- Grazi, R V; Wolowelsky J B. (1995) "The Use of
Cryopreserved Sperm and Pre-embryos. In
Contemporary Jewish Law and Ethics", Assisted
Reproductive Technology-Andrology, 8:53–61.
15- G. Pennings, G.de Wert, F. Shenfield, J. Cohen, P.
Devroey and B. Tarlatzis. ESHRE Task Force on
Ethics and Law 11: Posthumous assisted
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Thereof) of Assisted Reproductive Technologies in
the U.S. and Abroad’ Post. The Center for Bioethics &HumanDignityhttps://cbhd.org/content/
regulation-or-lack-thereof-assisted-reproductivetechnologies-us-and-abroad
17- Assisted Human Reproduction Act http://lawslois.justice.gc.ca/PDF/A-13.4.pdf.
18- Wendi P. Crowe and Tyson A. Wagner “Canada:
After-born Children: Succession Law And
Posthumous Conception” Last Updated: November
232015[http://www.mondaq.com/canada/x/445542/wills+intestacy+estate+planning/Afterborn+Children+Su
ccession+Law+and+Posthumous+Conception]
19- Francesco Paolo Busardò, Matteo Gulino, Simona
Napoletano, Simona Zaami, and Paola Frati1, The
Evolution of Legislation in the Field of Medically
Assisted Reproduction and Embryo Stem Cell
Research in European Union Members. BioMed
Research International Volume 2014 (2014), Article
ID 307160, https://www.hindawi.com/journals/
bmri/2014/307160/abs/
20- European Society for Human Reproduction andEmbryology (ESHRE) (2006). “ESHRE Task Force on
Ethics and Law 11: Posthumous assisted
reproduction”. Human Reproduction Volume 21,
No.12 pp. 3050–3053.
21- Health Law Central: Information, Education,
Research&
Policyhttp://www.healthlawcentral.com/assistedreprodu
ction/post-humous-use-gametes/
22- Section 23 of the Assisted Reproductive
Technology
Act
2007
(NSW)
http://www8.austlii.edu.au/cgi-bin/viewdoc/
au/legis/nsw/consol_act/arta2007367/s23.html
23- Assisted Reproductive Treatment Act 2008 (Vic)
http://www7.austlii.edu.au/cgibin/viewdoc/au/
legis/vic/num_act/arta200876o2008406/s46.html
24- Daphna Cohen-Stow and Victoria Gelfand, Israel:
Update on the Status of Posthumous Sperm
Retrieval for the Purpose of Later Insemination or
IVF
Under
Israeli
Law,
Jul
26,
2017
http://www.reproductivefacts.org/news-andpublications/news-and-research/legally-speaking/israel-update-on-the-status-of-posthumous-sperm-

retrieval-for-the-purpose-of-later-insemination-orivf-under-israeli-law/
25- Ibid 6
26- Ibid 10
27- In re estate of Kolacy 753 A.2d 1257 (N.J. Super.
Ct. Ch. Div. 2000).
28- Woodward v. Commissioner of Social Security,
760 N.E.2d 257 (Mass. 2002) In Gillett-Netting v.
Barnhart.
29- Gillett-Netting v. Barnhart 371 F.3d 593 (9th Cir.
2004).
30- Capato ex rel. BNC v. Com’r of Social Sec., 631 F.3d
626, 631 (3d Cir. 2011).
31 Astrue v. Capato, 132 S.Ct. 2021, 2025-26 (2012).
32- Ibid 7.
33- Re the estate of the late Mark Edwards [2011]
NSWSC 478.
34- R v Human Fertilisation and Embryology
Authority; Ex parte Blood [1997] 2 All ER 687 (CA)35- ‘Life Comes from Death’, The Sun-Herald(Sydney), 13 December 1998, 51.
36- Ibid 1
37- Ruth L Fischbach, John D Loike Postmortem
fatherhood: life after life. Lancet Vol 371 June 28,
2008, p2166-67 www.thelancet.com
38- Daphna Cohen-Stow and Victoria Gelfand, Israel:
Update on the Status of Posthumous Sperm
Retrieval for the Purpose of Later Insemination or
IVF
Under
Israeli
Law,
Jul
26,
2017
[http://www.reproductivefacts.org/news-andpublications/news-and-research/legallyspeaking/israel-update-on-the-status-ofposthumous-sperm-retrieval-for-the-purpose-oflater-insemination-or-ivf-under-israeli-law/]39- Ibid 38
40- Richard V. Grazi and Joel B. Wolowelsky
Parenthood from the Grave. The Jewish Spectator,
65:4,
Spring
2001,
Aviv
5761
[http://www.daat.ac.il/daat/english/ethic/grave_1.
htm]
41- Meyer v. Nebraska 262 US 390 (1923),
42- Skinner v. Oklahoma 316 U.S. 535 (1942),
43- Stanley v. Illinois 405 U.S. 645, 651 (1972),
44- Cleveland Bd. of Educ. V. LaFleur, 414U.S. 632,
639-40 (1973),
45- Eisenstadt v. Baird 405 U.S. 438 (1972)
46- Danya, The Biological Will - a New Paradigm in
ART?, Published: February 25, 2013[http://www.newfamily.org.il/en/4905/thebiological-will%E2%84%A2-%E2%80%93-a-newparadigm-in-art/]
47- Richard Taylor, Human Property: Threat or
Saviour? Murdoch University Electronic Journal of
Law Volume 9, Number 4 (December 2002)
http://www.murdoch.edu.au/elaw/issues/v9n4/ta
ylor94_text.html#t1
48- Ibid 9
49- Ibid 10
50- Ibid 11
51- C.C. v. A.W., 2005 ABQB 290 (CanLII). paras. 21
52- Ibid 6

Eubios Journal of Asian and International Bioethics 27 (November 2017)53- [2009] EWCA Civ 37; [2010] QB 1,
54- In the matter of Gray [2000] QSC 390, para 18
55- [2011] NSWSC 478, para 91
56- Ibid 1, para 14.
57- G Pennings, G.de Wert, F. Shenfield, J. Cohen, P.
Devroey and B. Tarlatzis. ESHRE Task Force on
Ethics and Law 11: Posthumous assisted
reproduction, Human Reproduction Vol.21, No.12
pp. 3050–3053, 2006.
58- Ibid 6.
59- Re the estate of the late Mark Edwards [2011]
NSWSC 478
60- Ibid 1.
61- Ibid 39 Danya, The Biological Will - a New
Paradigm in ART?, Published: February 25, 2013
http://www.newfamily.org.il/en/4905/thebiological-will%E2%84%A2-%E2%80%93-a-newparadigm-in-art/
62- Wendi P. Crowe and Tyson A. Wagner Canada:
After-bornChildren: Succession
LawandPosthumous Conception Last Updated: November
23 2015 Miller Thomson LLP.
http://www.millerthomson.com/en/publications/co
mmuniques-and-updates/wealthmatters/november-2015-wealth-matters/afterborn-children-succession-law-and/63- In the matter of Gray [2000] QSC 390, para 18
64- Ruth Zafran, Dying to Be A Father: Legal Paternity
in Cases of Posthumous Conception, Hous. J. Health
L.& Pol’y, 2008, p 47-102.
65- Belinda Bennett. “Posthumous Reproduction and
the Meanings of Autonomy”. [1999] MelbULawRw
13; 23(2) Melbourne University Law Review 286.
66- Cindy L. Steeb “A Child Conceived after His
Father's Death: Posthumous Reproduction andInheritance Rights - An Analysis of Ohio Statutes”,
48 Clev. St. L. Rev. 137 (2000) p. 138-139.
67- Ibid 51.
68- Ibid 50
69- Sutton, Stacey (2012) "The Real Sexual
Revolution: Posthumously Conceived Children," St.
John's Law Review: Vol. 73: Iss. 3, Article 12.
http://scholarship.law.stjohns.edu/lawreview/vol7
3/iss3/12
70- Anne R. Schiff, Arising from the Dead: Challenges ofPosthumous Procreation, 75 N.C. L. Rev. 901 (1997).
http://scholarship.law.unc.edu/nclr/vol75/iss3/4
71- Ibid 54.
Disclosure: I have no financial or other interest to
disclose.

201

Palatal rugae pattern
identification to determine family
lineage in Minangkabau, West
Sumatera, Indonesia- Dr.drg. Nila Kasuma, M.Biomed,
Faculty of Dentistry, Andalas University
nilakasuma10@gmail.com
Dr. drg. Dewi Elianora, Sp KGA,
Faculty of Dentistry, Baiturrahmah University
dewielianora12345@gmail.com
drg. Aida Fitriana, M.Biomed,
Faculty of Dentistry, Andalas University
aidanoferi@gmail.com
drg. Fildzah Nurul Fajrin,
Faculty of Medicine, Andalas University
rin.inoochi@gmail.com
drg. Haria Fitri,
Faculty of Dentistry, Andalas University
hariafitri5@gmail.com

Abstract

Background: This paper discusses palatal rugae
patterns and their contribution in the identificationof individuals and the determination of family
lineage in West Sumatera, Indonesia. Identifying an
individual is very useful for postmortem
examination, for personal, social and legal
purposes. The most common techniques used inthis context are dental records, fingerprint and DNA
comparisons. However, these methods cannot be
used under certain circumstances. But interestingly
palatal rugae patterns are preservable because they
are stable, and impervious to disasters and hostile
conditions and therefore can be used as alternative
human identification techniques. This paper argues
that the study of palatal rugae (rugoscopy) not only
help reveal a person’s identity but also help
determine their family lineage.
Objective: The present study was carried out toascertain whether there are any hereditarypatterns in the palatal rugae patterns of the mother,father, and the offpring in one family.
Method: This is a cross sectional study of 48
samples consisting of 12 families in Luhak Nan
Tigo. The parents and offspring (son or daughter) of
each family were randomly selected. Palatal rugae
impression was recorded using alginate, whilepalatal rugae patterns were noted and recorded.
One Way ANOVA test (SPSS 17) was used forstatistical anaysis.
Result: The study shows that there is a significant
similarity in curved, wavy, and straight rugae
patterns (p> 0.05) as well as in primary, secondary,
and fragmented rugae based on the family tie
between the father, mother, sons and daughters of202

Eubios Journal of Asian and International Bioethics 27 (November 2017)

the Minangkabau ethnics. Unilateral and circularrugae tests are insignificant (p <0.05).
Conclussion: This is a cross sectional study whose
results are only based on 48 samples consisting of
12 families, therefore further studies are neededwith a larger sample quantity. The results of thisstudy indicate the role of factors in palatal rugae
patterns.

Introduction

In the last few decades, Indonesia has dealt withmore than 400 natural disasters of which floods,
fires, typhoons and landslides are the mostcommon. In addition to this, disasters such as
earthquakes, tsunamis and volcano eruptions also
occur on a yearly basis.1 These natural disasters
have caused the death of tens of thousands ofpeople in West Sumatran, one of the disaster-prone
areas in Indonesia. Sadly however, many of thesevictims were not identified due to the lack offinancial or material means to conduct
identification procedures.
In order to issue the death certificate of an
unknown/unidentified deceased person, or for
personal, social and legal reasons, DNA test, retina,
fingerprints and dental characteristics are the mostcommon techniques referred to in forensic science.
However, many of these methods may not be totallyeffective or conclusive.2 Hence the need for the
study of palatal rugae as an alternative method forthe scientific identification of individuals. Palatalrugae can be very useful for the identification of
victims of mass disasters such as earthquakes,
landslides and tsunamis, etc., crime investigations,
ethnic studies, and in the identification of
decomposed and disfigured bodies as a result ofdrowning, burns, and accidents.3
Rugoscopy, cheiloscopy, bite marks, tooth prints,
radiographs, photographic study, and molecularmethods are various methods employed in forensic
odontology. When these methods of identification
are unavailable, however, palatal rugae may beconsidered as an alternative source of information
to facilatate the identification process.2 There areseveral classifiations of palatal rugae. But the mostfrequent used is the classification given by Thomas
and Kotze,2 which classifies Palatal rugaes in three
categories based on their length: Primary rugae(more than 5 mm in length), secondary rugae (3-5mm in length) and fragmented rugae (<2 mm inlength).
The patterns of the rugae are classified into
curved, wavy, straight and circular types. Straightpatterns have a direct course from the point oforigin to their insertion in a straight line. Curved
patterns have a crescent shaped pattern with a mild
curvature. Wavy rugae are serpentine in shape.
Rugae with specific continuous ring typemorphology are classified as circular. Unified
rugaes are united either in their origin or in theirinsertion giving a forked appearance. These are thepatterns involved in this study conducted to assess
the association of palatal rugae patterns amongfamily members of the Minangkabau, a subgroup of
the Deutro Malay ethnic, which consist of Aceh,
Malay, Minahasa, Bugis, Makasar, Sasak, Bali, Java,and Minangkabau.5

MethodThis research was conducted in Luhak Nan Tigo
located at Guguak, Situjuh, and Tanjung Subdistricts in the District of 50 Kota, Tanjung Baru
subdistrict situated at the District of Luhak Tanah
Datar, and in Baso, Banuhampu, and Tanjung Raya
Subdistricts located at the District of Luhak Agam.
The study was conducted from January to June
2017. A total of 489 palatal rugaes were observedin 48 palatal rugae models from 12 families. The
study was conducted with the door to door systemin each subdistrict. Prints of jaws of the
respondents were obtained after the research was
explained to them and informed consent wasprovided. The Commitee of the Research Ethics ofthe Faculty of Medicine, Andalas University, withregard to the protection of human rights andwelfare in medical health research has carefully
reviewed the research protocol with Ethical
Clearance number 073 / KEP / FK2017 on March
2nd 2017.

Figure 1: Delineation of palatal rugae pattern on
dental casts

Maxillary impression was done using irreversiblehydrocolloid alginate. The impressions were castusing dental stone type 3. The jaws were printed
using irreversible hydrocolloid material i.e., alginat.
The result of the jaw printing was cast using dentalstone tipe 3. The maxillary cast analysis was
performed single-blind by two different observers
to get accurate measurements and reliable results,then classified based on Thomas- Kotze and Sunita
Kapali classification method. Observers are dentistsof the Faculty of Dentistry University Andalas who
have good eyesight, understanding and perception.

Eubios Journal of Asian and International Bioethics 27 (November 2017)
The same procedure was used in length
measurement and observation of palatal rugae
patterns. The Result Measurement of each observer
was tested using Technical Error of test
Measurement (TEM), intra-observer and interobserver. TEM test was performed on 20 samplesof maxillary cast having primary rugae andsecondary rugae.

Results
This study was conducted to assess the similarity ofpalatal rugae patterns between family members,i.e., father, mother, sons and daughters of the
Minangkabau ethnic. A total of 489 palatal rugaes
were observed in 48 palatal rugae models from 12
families. One Way Anova test results of curved,
wavy, and straight rugaes are p> 0.05, whichindicates that there is a significant similarity in the
shape patterns. The results of the unilateral andcircular rugae form test are p <0.05, whichindicates there is an insignificant similarity in thepatterns of uniform and circular form. The resultsof the primary, secondary, and fragmented rugae
test are p> 0.05, indicating a significant similarity inthe palatal rugae patterns based on the family tie
between the father, mother, sons and daughters of a
Minangkabau family. The average number of palatalrugae and p value in this study are as follows:
Tabel 1: Average Amount of Palatal Rugae
Rugae Pattern Mothe Fathe
Son
Daugh
r
r
ter
Curve
2,92±1 4,08±1 3,08±1 2,92±1
,67
,92
,78
,37
Wavy
2,92±1 3,42±1 4,05±2 4,75±2
,67
,92
,19
,52
Sha Straight 2,00±1 1,75±1 2,50±1 1,83±1
pe
,70
,28
,44
,11
Unified 1,50±1 0.50±0 1,08±0 0,50±0
,16
,90
,99
,67
Circular000,08±0 0,42±0,28,66
Primary 7,25±1 7,83±1 8,33±1 8,17±1
,81
,26
,07
,26
Size Second
1,67±1 1,83±1 2,17±1 1,75±1
ary
,37
,40
,74
,13
Fragme 0,42±0 0,08±0 0,75±1 0,05±0
nted
,66
,66
,71
,90

Discussion

P
0,
28
0,
11
0,
56
0,
03
0,
02
0,
24
0,
83
0,
47

Sumatra is the second biggest island in Indonesia
after Java Island, and the sixth biggest in the world.
Its Western coast, known as Sumatera Barat (WestSumatera), is home to the Minangkabau people
whose culture (budaya Minang) is handed down inregions such as Luhak Nan Tigo –Luhak Agam,
Luihak Tanah Datar and Luhak Lima Puluh.6 This is
the reason why the research was conduted at theselocations.

203

Palatal rugaes are irregular, asymmetric ridges ofmucous membrane of the incisive papilla and theanterior part of the median palatal raphe, locatedbehind the maxillary central incisor teeth.7
Harrison Allen was the first to suggest the use ofpalatal rugae as a method of personal identificationin 1889. But it was not until 1932 that the term
“palatal rugoscopy” was brought up by Trobo
Hermosa, a Spanish investigator.2 Palatal rugae
normally begin to form towards the third month ofprenatal life. Palatal rugae patterns are unique. The
uniqueness of palatal rugae patterns may facilitate
their use in postmortem identification. This is dueto the fact that palatal rugae is stable and can resist
postmortem decomposition changes for up to 7
days after death and can withstand great thermal
insults like third degree burns.
Because palatal rugae is protected by the tongue,
dentition, and cheeks, it can resist other forms of
massive trauma.8 The identification of a person
through DNA examination has limitations such as
contamination and high cost, while the use ofpalatal rugae can provide ideal parameters becauseof its uniqueness, stability, resistance, and simple
and inexpensive methods. The potential use ofpalatal rugae in forensic identification has
advantages because it is sufficiently able todiscriminate between individuals as no two palatalrugae configurations are alike. Certain rugae
patterns are specific to a particular population andmay also have utility in population differentiation.9
Observing rugae patterns, Selvamani et al foundthat wavy patterns are common in males andfemales, followed by curved and straight patterns.
Circular patterns are very few in number but
significant (P = 0.05).10 Some scientists claim thatenvironmental factors are unlikely to affect theformation of rugae and believe that its patterns are
determined by genes. Genes influence theorientation of the collagen fibers during
embryogenesis and govern rugae patterns indifferent populations.11 Observing the length ofrugae, it appears that primary rugaes are mostprevalent than secondary and fragmented rugaes.12
Examining the types and origins of palatal rugae
according to the Lysell classifications, the study ofBeatrice's (2013) showed that the palatal rugae ofmales is different from that of females. Primary andSecondary rugaes are all found in males comparedto females, whereas fragmented rugaes are morecommon in females than males. Primary rugae
derived from raphae are found in males, whereas
medial origin is found in many women, the study
concludes.
Another study was carried out by Patel to assess
whether there is any hereditary pattern in palatalrugae patterns between the offspring and theirparents. The study showed that there is a positive

204

Eubios Journal of Asian and International Bioethics 27 (November 2017)

correlation of palatal rugae patterns between theoffspring and either of their parents.13
Finally, a study by Indira suggests that thecomparison of palatal rugae patterns among family
members also shows different patterns. Although in
one family few forms were similar, rugae patterns
are not identical. This means that the role ofheredity is uncertain in determining the orientationof rugae patterns.

Conclusion

The patterns of palatal rugae in Minangkabaufamily has the same number of rugae based on thesignificant shapes i.e., curved, wavy, and straight,
and based on the significant length i.e., primary,secondary and fragmented. Because the results ofthis study are rather partial as they rely on a dataconsisting of only 48 individuals from 12 families, amore detailed follow-up study is needed with alarger sample size to reach an ultimate conclusion.
The results of this study indicate that there arehereditary factors in the rugae patterns, whichmakes them very useful for the identification ofindividuals. Chemicals, disease, heat, and trauma
cannot alter palatal rugae patterns. Cheeks, lips,
tongue, buccal pad of fat, teeth and bones protect
palatal rugae from trauma and high temperature.
Although we acknowledge that the limited numberof families studied does not allow us to reach a final
deduction, it is important to note that rugae
patterns may be used as genetic markers forfurther research. We hope this research is acontribution of data in the field of forensic
odontology on individuals, especially ethnics of the
Minangkabau and the Deutro Melayu.
Source of Funding:This research was funded by the Indonesian
Ministry of Research and Technology (Kemrestek
DIKTI) under the Elite Research Skim of Higher
Education. The authors are grateful to LPPM andthe Rector of Andalas University for faciliting thisresearch.
Conflict of Interest:
The authors confirm that there are no conflicts ofinterest to disclose.

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