Ethical Aspects of Male Reproductive Disorders and their Treatment

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Disorders and their Treatment

Maurizio Mori

Abstract

The author provides a brief explanation of what ethics is, distinguishing between common sense ethics and critical ethics. Historically sexuality has always been strictly connected with reproduction, and this connection shedowed many issues were. Now that we are able to split sexuality from reproduction, any analysis of the various issues concerning sexual disorders has to consider that the reproduc-tive decision (that of bringing a new offspring into the world) springs from an existential choice, even if the process may have to resort to medical assistance and involve some clinical choice as well. An adequate analysis of sexual disorders issues from the point of view of a critical ethics needs a demarcation criterion between what is medical (or clinical) and what is non-medical (existential or pertaining to ethics in general). This distinction is crucial because sexuality is a mixture of various aspects and two are of the utmost importance:

(a) sexuality as (mere) mating for reproductive aims; (b) sexuality as acting for the self-realization of the person.

The so-called sexual and reproductive rights are the new cultural creation elaborated in order to promote and protect such a distinction, even if they are strongly opposed by part of common sense ethics and some religious fractions (notably the ofﬁcial teaching of the Roman Catholic Church).

This means that we have to acknowledge that our age is one of rapid transition and that there are two opposite ethical paradigms. According to the traditional “Hippocratical paradigm” together with some religious prespectives it is morally

M. Mori (*)

Università di Torino, Consulta di Bioetica Onlus, Turin, Italy e-mail:maurizio.mori@unito.it

# Springer International Publishing AG 2017

M. Simoni, I. Huhtaniemi (eds.), Endocrinology of the Testis and Male Reproduction, Endocrinology 1, DOI 10.1007/978-3-319-29456-8_47-1

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wrong to split sexuality from reproduction, any technology in the ﬁeld is to be rejected and sexual rights are nonsensical or wicked. According to the newer ethical paradigm reproductive technologies are wellcome since they can favor people’s wellbeing and self-realization. Therefore, ICSI as well as other forms of assisted reproduction are morally permitted. Moreover, since in most social systems parenthood depends on social criteria (responsability for the child, and not “genetic or blood” criteria), from the point of view of critical ethics, that donor insemination as well as surrogacy are to me permitted.

Other issues concerning sexual issues are examined such as erectile disfunc-tions, homosexuality, transexuality, intersexuality, sexuality of the disabled peo-ple, sexuality of the prisoners and chemical castration.

The conclusion is that from a critical ethics’ point of view the new treatments of sexual disorders that has been examined are morally valuable and supported by good reasons, even though the author is aware that they are open to questions and should be debated.

Keywords

Ethics, concept of • Ethics, different levels of • Professional Ethics, concept of • Medicine, demarcation criterion • Illness, as dynamic disorder • Illness, as existential condition • Sexuality, as mating • Sexuality, as relational self-realization • Marriage, traditional notion • Sexual health • Sexual rights • Sexual right, of citizens and disabled, and of prisoners • ICSI • Homosexuality • Transexuality • Intersexuality • Pregnancy for others (surrogacy) • Donor insemination • Erectile dysfunction • Chemical castration • Embryo, respect due to

What We Are Speaking about when Ethics Is Involved

Ethics (as well as its derivates) is a trendy word used in many different meanings and sometimes quite peculiar ones. It is important to make clear what we mean with such a term before we enter in the details of the specific issues concerning male repro-ductive disorders. In a very general sense, “ethics” is the ethos or the spirit of an age: ethics is part of the culture of a society or a community as manifested in its beliefs and aspirations in a certain period. From this point of view, it is important to acknowledge that only in the last decades, doctors begun to recognize that men may have various reproductive disorders apart from impotence and that such disor-ders raise real ethical issues. Until recent times, reproductive disordisor-ders appeared to be a problem reserved only to women. In this sense, ethics is making a significant improvement, and this is mainly due to careful scientific observation: science has provided us with new knowledge showing that similar troubles are involving males and females alike. This aspect is leading to a more egalitarian attitude among humans, which is one of the major moral progresses in the field. The fact that this book examines these problems is a piece of evidence of such a moral change as well as a contribution to it.

“Ethics” can be used synonimouly to “morals” to indicate that a specific social institution exists devoted to promote spontaneous and convinced motivation to comply with some norms and to endorse some values that are socially beneficial. Humans are social beings and live in communities included in larger societies. Social life needs reciprocal nonaggression as well as coordination of behavior in order to reach an adequate level of peace and individual flourishing. Our life is much calmer and more relaxed if we know that our neighbour will not endanger our life, and we are better off if he/she is ready to cooperate in activities that require the help of others to be realized or at least are greatly facilitated by such a help.

Law is the special institution establishing rules that enforce people not be aggressive toward other people and that state what has to be done in order to reach social coordination: people need to know what will be the others’ conduct to adjust one’s own behavior to the circumstances. Law provides such rules and forces people to abide under threat of sanctions which are explicitly stated.

Ethics or morality is another special insitution that establishes rules and values that are accepted voluntarily, and for this reason, normally the correspondent conduct follows spontaneously. In this sense, ethics is similar to a language which is the special institution establishing the rules for our verbal communication: both institu-tions are learned by imitation and complied with as if they were “natural,” i.e., something that is given and beyond human capacities. In fact one is astonished that others speak different languages or that they make mistakes of their own, as they are surprised that there are various folkways or are hurt by moral mistakes. As a language is a poweful set of linguistic rules for transmitting information of all sorts, a morality is a powerful code of deeply interiorized rules devoted to permit immediate and prompt social coordination. For this reason, ethics is so crucial in social life.

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As any important social structure, ethics or morality may present different levels of analysis as well. In the case of “law,” it is usual to distinguish, for instance, among different branches as civil law, criminal law, etc., with language among different kinds as ordinary language or technical language, etc.; in the case of ethics, the same word can have different meanings that should be carefully distinguished.

At the basic level, ethics indicates the folkways or the set of received opinions that form the so-called commonsense morality, i.e., the norms and values that are wide-spread in society and strongly internalized so to be spontaneously obeyed. Common-sense morality is analogous with our ordinary language that we use in our daily life spontaneusly and without knowing why it is used in such a way: we have learned it from our environment, and we simply use it unreﬂexibly. Our ordinary language is never “pure” but always laden with some “accent” (even if normally the speaker does not realize it) or local expressions. Similarly, our folkways may present biases depending on beliefs or taboos widespread in the community. In a sense, the opening remark concerning the new acknowledgment that males may have reproductive troubles is a point of commonsense morality: it was hardly imaginable a few decades ago, and it is still rooted in the most conservative factions of our societies.

Commonsense morality guarantees and enables people in the group with certain moral norms and values to coordinate their social life. In this sense, folkways are the basis of a society looked in its static part (as a picture). However, we know that nothing is fixed and that social life is in a perennial state of change. This means that moral rules and values have to adjust to the new situations, if they want to perform their functions in an appropriate way. One reason to revise moral rules and values is that often they may depend on obsolete or even false beliefs about the machinery of the world or of the bodies. This is quite clear in the field of sexuality, which until a few decades ago was covered by a sort of mystery. Another reason is that historical circumstances change, and correspondent modifications are to be introduced if the specific institution has to work out its function: in winter it is appropriate to wear heavy clothes in order to maintain one’s health and well-being, but in summer to reach the same target, one has to do the opposite and wear light clothing. If social conditions change, morality has to adapt, if social coordinations are to be guaranteed successfully.

In the past the pace of social change was quite slow, and about a century ago, an Italian sociologist could remark:

if an ancient Greek or a Roman would resurrect now, I think that his brain would understand almost nothing of our modern world, but his heart would still beat in tune with many other hearts. . . .Ideas change quite quickly, while in many years and in many centuries, sentiments have undergone but a slow transformation. . . .The central sentiments regulating the morals of human existence are more or less the same as they always had been: nowadays a man behaves in his affective life more or less as his ancient ancestors behaved long ago. (Sighele1899)

In the last decades, the situation has changed signiﬁcantly, especially in the ﬁeld of human sexuality. We should not be too optimistic, since deep down many peoples’ atavistic feelings still remain well and alive. However, in the richer part of the world,

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there is an awareness that we have to renew some of the norms and values regulating our social life. Courts and parliaments are involved in a process of updating the laws, some of which are more advanced than folkways, while in other cases, they appear obsolete if not reactionary. As far as morality is concerned, such a process of renewal is propelled by two factors. On one hand there is the emergence of the codes of professional ethics formed by the set of norms and values that are stated by the members of a profession. A professional ethics is more refined than commonsense ethics (folkways), because it is stated after some reflection: in the practice of a profession, some quandaries emerge more often than in normal life, and the codes of ethics are developed in order to prescribe specific rules and values to prevent conflicts and to contribute to group identity.

On the other hand we have to acknowledge [or realize] that professional ethics can be a stimulus to improve commonsense morality, but this may not be enough. In most cases the basic intuitions of professional ethics come from commonsense morality, and this may be questioned. To accomplish this further task there is a third level of ethics, which is called critical ethics, which is the result of reflection on the received opinions in order to see whether or not they are rationally justified, i.e., that are supported by good reasons. Critical ethics is the branch that emerges from commonsense ethics when a moral agent starts to think on the reason supporting a given solution. Normally this occurs in quandaries, when the agent has to choose between two courses of action and she/he asks why to prefer the one to the other. This process brings to question the received customs that up to then have been accepted in an automatic way, by tradition. It is impossible to control each single received opinion, and this is the reason for which “a culture” (including religious and customary traditions) is so influential on each of us. It is the background that shapes our form of life, and we can control and possibly revise only some fraction of it.

Something similar occurs with a language: one can modify only a fraction of one’s mother tongue, as it occurs when one learns a technical language (for instance, becomes a doctor or a lawyer) that becomes so familiar to him that starts to inﬂuence his way of speaking. Analogously it may happen with morality: having faced a deep quandary, a moral agent can become aware of the values directing one’s choice and abide by them consciously. This marks a sort of new (moral) birth, which is typical of critical ethics: after such a clariﬁcation, the person not only promptly follows the moral values she/he sees but also knows why it is proper to do it, i.e., she/he knows that they are the right values and why they are to be applied in the circumstances.

In the following pages, the word ethics is used to indicate critical ethics, and I’ll try to apply as far as I can norms and values that are rationally justiﬁed, or at least I’ll do my best in providing a justiﬁcation for any step of my ethical arguments.

Ethical Issues of Human Reproduction

If we look at the ethical problems of human reproduction from a critical point of view, the ﬁrst thing we have to do is to clarify the peculiar nature of the issues that we have to face and how to classify them. In order to do so, we have to consider how

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these issues have been considered in the Hippocratic tradition, which is so important in Western culture and in medicine.

General Problems on Human Reproductions and the Demarcation

Criterion between What it Is “Medical” and “Nonmedical”

In the traditional medical ethics (Hippocratic), human reproduction is so strictly connected to sexuality and to its managment that the whole process is reduced on reproduction so that sexuality is practically equivalent to mating and hardly exists as an independent and speciﬁc reality. As it has always been written over the centuries, the primary goal of sexuality is reproduction (or “procreation” as theologians say), and this means that human sexual activity is reduced to mating analogously to what happens with other mammalians. In this sense, the so-called reproductive disorders of a human adult attracted medical attention and have been cured in view of restoring the possibility of mating so to make possible a new birth. This is in line with the medical (conceptual) paradigm underlying Hippocratic ethics, which was so inﬂu-ential in the Western culture to be unconsiously included in most of current practice. This conceptual paradigm states a demarcation line between medical and non-medical issues, i.e., problems which can be considered as clinical and problems that cannot be included in the clinics but are to be considered as social, artistic, economic, etc.

It is clear that the field of medicine is limited to a part of the world and that medicine claims neither to relieve from any kind of suffering nor to offer salvation from any evil. However, it is more difficult to assert a clear-cut of demarcation line between what belongs to medicine and what is outside medicine. To do so we can start with the old Latin dictum stating that the task of medicine is sanare infirmos et sedare dolorem: heal the sick and relieve pain. A first problem with this dictum is that it appears to individuate two tasks and not just a one, and the second – sedare dolorem – is quite large and can include almost everything.

A way of clearing the difficulty is to note that the primary goal of medicine is sanare infirmos and that the first duty of doctors is to heal the patient and oppose pathologies. This means that medicine is about infirmos in the sense that it has to do with people who are sick and affected by some pathology. Usually such a condition is also painful, and therefore a doctor has also the task of sedare dolorem, i.e., relieve the pain produced by the illness. The last clause is crucial, because it specifies the demarcation line between the medical and nonmedical. There is a lot of pain in the world, but medicine is not committed to relieve any pain but only a specific class of pain. Poverty is a source of enormous suffering, but it is a social problem, and it is not a medical one. Analogously, one can say that being ugly or deformed is often another source of intense pain, which is not a medical problem, but an aesthetic one. But in this case, we see that the situation is more complicated and that the demarcation line is not so straight and clear-cut. We are inclined to say that some ugly traits can be treated clinically, and it is important

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to try to understand which ones and why. So far we have stated that the sedare dolore is subordinated to the sanare inﬁrmos, and therefore that it is limited to the relief of pain brought about by a pathology or by a therapy and does not include any pain such as, for example, those produced by poverty or other existential condition.

Now, we have to make clear that a pathology, an illness, is to be undestood as a deviation from the normal process that prevents or interferes the working of the self-preservative finalism of the organism. A human being is an organized whole aiming to one’s own self-preservation and maintaince of the species. In this sense a body is coming to existence with a specific finalism tending to self-preservation. A pathol-ogy is what prevents or makes difficult the working of the finalism. In order to maintain its life, the body has a vis medicatrix naturae, nature’s healing force, that permits to overcome some troubles. However, sometimes it is not enough, and then a therapeutic intervention is required, which is the specific task of medicine. It is interesting to remark that in Greek, therapein means “to help”: a therapy is a help to the body and to the vis medicatrix naturae to restore the natural functionality of the body. In this sense, for the traditional paradigm medicine’s aim is neither to enhance nature nor to overcome the limits set by nature nor to try to substitute or modify the self-preservative finalism of the body. The Hippocratic physician is an assistant of nature who tries to increase the power of the vis medicatrix naturae, but he/she is not interested to change nature’s finalism: a task which is outside the goals of medicine (as presented by the traditional paradigm).

It is true that going beyond nature’s limits set by life’s intrinsic ﬁnalism can bring about utilities and relieve a lot of human pain. But here we go back to the issue that medicine is not the universal remedy against any pain, but only to pain produced by pathologies understood as deviations from the intrinsic ﬁnalism of life. In this sense, being ugly or beautiful as well as being tall or short is a biological state or condition which can raise an aesthetic or a social problem, not a medical one. Of course if a noticeable nose is also obstructing the respiratory function, medicine can correct such a trouble and at the same time also change the shape of the nose and overcome the aesthetic problem. Thus there are occasions when aesthetics and functionality go together and are synergistic. But they are in principle different and must be kept distinct.

I am aware that the paradigm that I try to outline is an ideal and that it has a lot of problems and some notable exceptions as psychiatry. However, one can say that exceptions must be considered in a special category which does not modify the general frame or paradigm. In this sense, it is still plausible to remark that medicine is concerned with situations of illness or pathology as dynamic disorders that prevent or block the ﬁnalism. This remark is crucial to come to what are the two fundamental distinctions in the ﬁeld:

(a) The distiction between illness as dynamic disorder of the organism and biolog-ical state as a speciﬁc vital condition of the organism. For example, it is an illness to have a gangrenous arm, but it is a biological state not to have an arm

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(being born without it or having lost it). The ﬁrst situation raises a medical or clinical problem, while the other raises problems as well which are socially important but are nonmedical.

(b) The other basic distinction is between illness (as above defined) and basic existential state which is that specific biological state consisting in the coming into the world or of being born in a given condition. In fact, to choose or to decide that a new being has to enter or not to enter into the world is an existential or a moral question which has many social features, but it is not in itself a medical or clinical question even if it may have some kinds of medical impli-cations. The first one is that, for instance, a pathology could prevent the instantiation of a basic existential state, i.e., the coming into the world of a new being whose birth would be morally chosen. In this case, a medical or therapeutic intervention is required to favor such a choice.

Brieﬂy speaking, choosing or deciding that someone comes (or does not come) into the world is an existential choice and not a medical one. It belongs to general ethics (for this I call it “existential choice”), and not to medical ethics which has nothing to say on whether it is good to be born instead of not coming into the world (and at which conditions it could possibly be): medical ethics is about issues raising within an actual life and does to consider possible future lives.

However, it is an issue of medical ethics whether or not to contribute in some way to the existential choice of a person willing that someone enters or does not enter into the world. There are two basic situations: (1) one wants that another one comes into the world, but a pathology prevents it, and medicine is asked to promote such a choice by overcoming the obstacle, or (2) one does not want that another come into the world, and medicine is asked to promote such a choice by preventing births. In this sense, medical ethics is somehow involved in the issue which is existential or metaphysical, and its involvement is increasing: in the past medicine’s ability to favor or not to favor, such a choice was very limited, but now it has a role, and it is important to state whether cooperation is permitted or not, within which limits and for which purpose.

Not only is this relevant for the issues concerning basic existential state but is it even more signiﬁcant for the resulting biological state which continues after birth and which can be more or less pleasant or present positive or negative qualities. Once again, this situation raises social or psychological questions but not medical ones unless such a person is affected by some clear pathology. Here it is fundamental to stress that pathologies are dynamic disorders of the organism which may endanger life or become chronic, and they are to be distinguished from disabilities, deformi-ties, and other defects. For instance, being affected by Tay-Sachs syndrome or cystic ﬁbrosis is a medical issue, but not to have a hand or being ugly is not in itself a medical problem, but a social one. It is a kind of disadvantage more similar to living in a state of poverty or of physical handicap.

However, medicine can now be somewhat involved because the distinction is not clear-cut: the quality of life of some kinds of biological state can be improved by means of medical interventions, and this creates new problems.

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Application of the New Criterion of Demarcation to Reproductive

Field: Two Different Notions of “Sexuality”

The distinctions we have drawn allow us to provide some interesting remarks when they are applied to the reproductive field in general and in particular to the human male. The main point is that if medicine is no longer limited to sanare infirmos, i.e., to restore the self-conservative finalism, then the old distinction between different meanings of “sexuality” has to be considered in new light. Since ancient times it was well known that sexuality has various functions (or meanings) and can be directed toward different goals: specifically, either toward reproduction or toward a pleasant creative self-realization, i.e., the situation in which a person perceives to be committed in activities satisfying one’s deep plans and giving meaning to life. These two goals were usually so strictly tied to appear intrinsically connected, i.e., that they ought not to be separated. In this sense, reproduction and pleasant self-realization had to go always together, and reproduction was the primary meaning of marriage, the social institution devoted to regulate sexuality and guarantee perpetuation of the species. Accordingly in the Hippocratic tradition, medicine was devoted to find out therapies in order to restore sexuality devoted to repro-duction. This is the time-honored received opinion included in our commonsense morality.

However, in the last century, we gained the ability to split sexuality from reproduction, showing that such a relation is not at all intrinsic but is extrinsic: as a matter of fact, we can separate sexuality from reproduction so that we can have sex without children and children without sex as well. This means that we have to distinguish two different kinds of sexuality:

(i) Sexuality as (mere) mating which is devoted primarily or solely to reproduction and from which new offspring can derive

(ii) Sexuality as relational self-realization which is devoted to create new forms of personal committments without any reproductive goal, which could be included as a part of one’s plan of life (and not as a result of mere mating)

It is interesting to note that such a distinction was mainly brought about by medicine and that it raises basic problems concerning the goals of medicine itself and its speciﬁc ﬁeld of action. Medicine has to reestablish the criterion of demarca-tion about what is properly medical and what is not medical but simply raising other social issues. And this is to be done on ethical bases, since it is clear that from a biological point of view, the connection between the two kinds of sexuality is extrinsic, and we can split it. The problem is if from an ethical (or moral) point of view, we may do it or even ought to do it. This is the question that for about a century has torn many people and has been at the center of medical ethics as well as of a large social debate which is not yet over.

Possibly this traditional concept of naturalistic conception of sexuality is near to its end. The new concepts of sexual health and sexual rights (as claims to have a self-realizing sexual life) are a piece of evidence that the distinction drawn is widely

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spread at least in critical ethics as well as at the top in the agenda of WHO and other international institutions. But social change is not immediate (like to switch on and off the light), and we have to realize that the received (Hippocratic) opinion still maintains its influence on many quarters of society and of medicine. For instance, the Roman Catholic Church at least in theory still forbids and condemns contraception in principle. Other religions concur as well on the point, and some survivals of this conceptual frame become clear about the concept of sexual disorders which are those concerning sexuality as mating. On the other hand, in our society a great number of sexual disorders are about sexuality as relational self-realization, which are now included in the medical field, while they were outside it according to the Hippocratic paradigm. This means that the demarcation line has changed and that medicine has enlarged its field. Some problems which in the past were mere social problems are now proper medical problems. This is a great leap, whose conse-quences are explored in examining the list of the issues that are now normally treated.

Disorders Connected to Reproductive Sexuality

Having distinguished two different kinds of sexuality, we are now examining the various issues concerning each. We start with problems connected to some sort of reproductive failure which up to a few years ago were the only issues treated as medical problems. Our analysis will be developed according to the central distinc-tion between commonsense ethics and critical ethics in the sense that we will present both what is the opinion received from the tradition and spread in society and the position which can be held on the basis of critical ethics.

Male Infertility and Assisted Reproduction

One of the main reproductive disorders is infertility, which is the inability to produce live offsprings. In the past, infertility was usually ascribed only to the woman, but now we know that also the man can cooperate to create such a situation since sometimes he is unable to produce the adequate number of spermatozoa required for fertilization. Oligozoospermia and azoospermia are the most common forms of male infertility.

Donor insemination is a way used to overcome male infertility, and I shall examine some of the issues concerning such a practice soon. For reasons that will become clear, it is preferable to start considering another more recent technique which people can resort to: the so-called ICSI, acronym for “intracytoplasmic sperm injection,” i.e., the practice of injecting one sperm into one oocyte so to get a new embryo to transfer into the woman’s womb. ICSI became available in 1992 and since then is one of the most widespead practices to treat male infertility. It is enough that a man produces a few sperm to enable him to fertilize an oocyte.

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ICSI and two Different Moral Paradigms on Assisted Reproduction

From a critical ethics viewpoint, ICSI appears to be positive since it opens up the possibility of having children. A positive aspect of the practice is that both gametes come from the couple and there are no issues concerning the genetic part: difﬁculties that may be involved in donor insemination. In this sense ICSI is a very useful and simple case to be studied to examine the problems involved in the practice. Secular ethicists strongly support assisted reproduction in general, and some Christian churches concur in saying that the technique is morally good on the basis of an argument in the following line: God provided man of reason and wanted him to use it to overcome the troubles of life and increase human self-realization. Reason applied in the reproductive ﬁeld led to the new techniques, which are positive gifts since they allow people to have desired children. In this sense, assisted reproduction is consid-ered in a favorable way, and the problem is to state adequate rulings in order to get the maximum and avoid possible harms.

However, other religions are against assisted reproduction, and in this they can count on the approval of that large part of commonsense ethics which is conservative and abhors any change: as Reverend Sydney Smith (1771–1845) said “there are always a set of worthy and moderately-gifted men who bawl out death and ruin upon every valuable change which the varying aspect of human affairs absolutely and imperiously requires.” This common sensical negative attitude is peculiarly strong when modifications are about human reproduction, a field that for long time was mysterious and winded up by false knowledge, and where feelings are so intense and deeply rooted that sometimes opposition becomes vehement. But intensity of a feeling is by itself neither an evidence of its correctness nor a reason for its justification: people may have deep and intense feelings against racial and sexual equality, but any form of discrimination is morally wrong. Only rational justified feelings can count as moral, and therefore we can dismiss commonsensical received opinions.

Some religions, however, present reasons for their opposition to the new tech-nique, and it is interesting to examine those put forward by the Roman Catholic Church, which is possibly the most important institution constrasting ICSI as well as other forms of assisted reproduction. As it is stated in a specific official statement issued in 2008, one reason depends on the fact that “indeed ICSI takes place “outside the bodies of the couple through actions of third parties whose competence and technical activity determine the success of the procedure. Such fertilization entrusts the life and identity of the embryo into the power of doctors and biologists and establishes the domination of technology over the origin and destiny of the human person. Such a relationship of domination is in itself contrary to the dignity and equality that must be common to parents and children. Conception in vitro is the result of the technical action which presides over fertilization. Such fertilization is neither in fact achieved nor positively willed as the expression and fruit of a specific act of the conjugal union” (Congregation for the Doctrine of the Faith, Dignitatis Personae,2008, n. 17).

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This passage may lead people to the conclusion that the main reason against ICSI has to do with the more general opposition to the intrusion of techniques in human reproduction and life, which seems to be justified by the urgent need to prevent the excesses of technology. However, if it would be the need to constrain technology the reason that justifies such an opposition, then it would be an extrinsic reason that could be modified or replaced. For instance, the same result could be accomplished by some adequate rulings. This means that – properly speaking – that reason (the need to constrain technology) is a complementary remark, that may get stronger a view that is already asserted on other grounds. The real justification of the Roman Catholic position is that “Just as in general with in vitro fertilization, of which it is a variety, ICSI is intrinsically illicit: it causes a complete separation between procre-ation and the conjugal act.” This is an intrinsic reason connected with the very nature of the practice and not on its possible (and contingent) consequences. In this sense ICSI is ethically wrong because it violates the moral principle of the inseparability of the unitive and procreative meaning of sexual intercourse.

It is this principle that justifies the Catholic prohibition of the new technique. It is important to be aware of this point because if an ethical principle is involved, then the Catholic view can claim to be supported by a rational justification. Therefore, it is not simply a variation of commonsense ethics based on received opinions transmit-ted by traditional emotions. We have to evaluate this perspective on the basis of its assumption, and to do so, we have to deepen the perspective and see the role of the principle for the doctrine of marriage and to examine some implications stemming from it. To the point the following passage seems to be enlightening: “The Church’s teaching on marriage and human procreation affirms the “inseparable connection, willed by God and unable to be broken by man on his own initiative, between the two meanings of the conjugal act: the unitive meaning and the procreative meaning. Indeed, by its intimate structure, the conjugal act, while most closely uniting husband and wife, capacitates them for the generation of new lives, according to laws inscribed in the very being of man and of woman.” This principle, which is based upon the nature of marriage and the intimate connection of the goods of marriage, has well-known consequences on the level of responsible fatherhood and motherhood. “By safeguarding both these essential aspects, the unitive and the procreative, the conjugal act preserves in its fullness the sense of true mutual love and its ordination toward man’s exalted vocation to parenthood.” The same doctrine concerning the link between the meanings of the conjugal act and between the goods of marriage throws light on the moral problem of homologous artificial fertilization, since “it is never permitted to separate these different aspects to such a degree as positively to exclude either the procreative intention or the conjugal relation.” Contraception deliberately deprives the conjugal act of its openness to procreation and in this way brings about a voluntary dissociation of the ends of marriage. Homologous artificial fertilization, in seeking a procreation which is not the fruit of a specific act of conjugal union, objectively effects an analogous separation between the goods and the meanings of marriage. Thus, fertilization is licitly sought when it is the result of a “conjugal act which is per se suitable for the generation of children to which marriage is ordered by its nature and by which the spouses become

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one ﬂesh” (Congregation for the Doctrine of the Faith, Instruction Donum Vitae, 1987, II. B, 4.a).

The long quotation makes clear that the inseparability principle has a central place in the general view of marriage as a divine institution and that it is included in a worldview that from an internal point of view is consistent. In this sense speciﬁc practical solutions can be justiﬁed within the accepted paradigm. Of course, it is possible to criticize such solutions by rejecting the whole paradigm and by appealing to an external point of view with different criteria of rationality. But to do it is not an intellectual challenge, but something equivalent to a victory of a political election or of a military action: it is analogous to the occupation of a territory (be it physical or intellectual) which has nothing to do with rational arguments.

A very interesting aspect of the question is that the paradigm implicit in the Catholic view is quite close to and consistent with the Hippocratic tradition and its demarcation line between medical and nonmedical. Here we see that the Catholic perspective is not simply “religious” in the sense of being dependent on a mere faith, because it is claimed that such a faith is grounded in a long-standing and honorated rational tradition. It is this general paradigm inherited from the Greek culture that is at stake. As a matter of fact, it is a controversial issue whether assisted reproduction is “therapeutic” or not in the strict sense of the word, i.e., whether it is really a help to the living process of transmission of life or it is a substitution of it that allows human control of the process (as the Congregation for the Doctrine of the Faith stresses in the quoted passages). It goes without saying that this new control of the reproductive process on one hand blurs the distinction between what is medical and not medical and on the other one at the same time marks the distinction between the two senses of sexuality that we have distin-guished. If sexuality is not any longer intrinsically connected with reproduction, then it can be detachted and freed from such an aspect and become an independent ﬁeld to be explored in its own terms.

It is crucial to see which sort of reasons we can give pro or con the inseparability principle. We are well aware that they cannot be definitive or striking down the opposite view, because cultural paradigms are incommensurable, i.e. cannot be compared. However, it is important to present some of these reasons and see the limits within which they can be held. The first reason in favor of the Roman Catholic Paradigm is general and is about the nature of marriage. As we have seen, for the Catholic doctrine marriage is a divine and natural institution, and on this ground, the Catholic teaching affirms the “inseparable connection, willed by God and unable to be broken by man on his own initiative, between the two meanings of the conjugal act: the unitive meaning and the procreative meaning. Indeed, by its intimate structure, the conjugal act, while most closely uniting husband and wife, capacitates them for the generation of new lives, according to laws inscribed in the very being of man and of woman.” This view presupposes a very specific concept of God and of the order of nature, i.e., metaphysical assumptions which are controversial and are shared neither by many other religions nor by the secular perspectives. Within a given paradigm and seen from its internal point of view, such assumptions may be “rational,” but they cannot be brought to the public arena, where only scientific and

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secular reasons are apt to be considered. In this sense, that view may be held as a private opinion but cannot claim to be valid at the public level.

The second reason is more specific and is about one practical consequence deriving from the Catholic conception of marriage. The inseparability principle forbids not only the ICSI and the other forms of assisted reproduction but also contraception. As stated above, “contraception deliberately deprives the conjugal act of its openness to procreation and in this way brings about a voluntary dissociation of the ends of marriage. Homologous artificial fertilization, in seeking a procreation which is not the fruit of a specific act of conjugal union, objectively effects an analogous separation between the goods and the meanings of marriage.” This clear statement forces us to a choice: either contraception is a medical practice as well as homologous-assisted fertilization and the inseparability principle is to be rejected or the inseparability principle is morally valid and contraception is a nonmedical practice as well as other forms of assisted reproduction. It is clear that this choice has more general consequences on the demarcation line between the medical and nonmedical and states the Gestalt switch between the two different paradigms.

Since contraception is a well-established medical practice, we can say to have a good reason for rejecting the inseparability principle and to support the new medical paradigm. In this sense, at least in principle, ICSI and other forms of assisted reproduction are morally welcome on the basis of a critical ethics. As already mentioned, the new practice opens up the horizons of human reproduction, and this increases the possibilities of self-realization of both prospective parents and the future newborn. If there are no principled objection to the ICSI as a therapy to overcome reproductive failures, there may be practical objections concerning the application of the ICSI which are morally relevant. This train of argument has to be examined with due attention.

Medical Objection to ICSI which Are Relevant from a Moral Point

of View

Some people claim that ICSI is not yet a reliable technique because its effects on future children are not precisely known, and it is possible that they are exposed to an increased risk of birth defects. Medical objections to ICSI point to these sorts of troubles to conclude that the practice is ethically unacceptable and ought to be abandoned (at least until more reliable results are available). Objections of this sort are certainly relevant to the moral debate on the issue: if the technique is not safe enough and it could possibly produce damages to the future child, this fact has to be taken into account and carefully evaluated from a moral point of view. A basic moral principle enjoins to do what is good, and assisted reproduction is a morally good practice if it does the good of the people involved in it, including the child. If the ICSI is a source of troubles for the newborn, it is morally wrong.

Before being focused on the ICSI, this kind of criticism was used against IVF in general since assisted reproduction was available in 1978. After four decades of experience and about 5 million infants born through various forms of assisted

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reproduction, this criticism appears to be specious and somewhat arbitrary, at least prima facie. If such techniques were to be really risky or involved a visible and palpable danger, people would have perceived it by now and would have ceased to resort to it. The fast development of these techniques and the growing demand for them seem to conﬁrm that the risk is not signiﬁcant enough as to lead to the conclusion that assisted reproduction is to be abandoned and banned: if the possi-bility of any harm would be perceived, people would prevent from resorting to it.

Nevertheless, it is true that sometimes assisted reproduction ends up in problem-atic births, and these events seem to support the idea that such practices are risky and dangerous. The issue has to be dug out and two preliminary remarks are to be considered. The ﬁrst is that any birth is risky to some degree because unfortunately not every birth is perfect. Also sexually conceived birth (SBC) involves some risk and that this basis has to be taken as the criterion of comparison to say that assisted reproduction technology (ART) birth is riskier than SCB. Scientiﬁc research done since the 1980s shows that SCB involves the following risks: about 3% of malformations at birth, plus about 3% of mental retardation, to which one should add another 1% of infants with Mendelian disorders and another 1% of chromosomal disorder (this latter may increase up to 10% depending on the age of the mother). Roughly speaking, about 7% of all infants resulting from SCB have birth defects upon coming into the world (at least in societies with an infant mortality rate of less than 1%). Therefore, we can assume that about 7% is the basic criterion of compar-ison for the two forms of reproduction, and some further adjustment can be required (as maternal age and other factors).

The second preliminary remark is that many studies have been done on the issue, and some of them have instilled doubts. Also the report of the Italian Commission for the so-called “Fertility Day” in 2015 stated that the effects of assisted reproduc-tion “on the health [of newborns] are in part unknown” and listed 18 possible complications such as congenital anomalies, neurologic or cognitive deficiencies, etc. (Ministero della Salute2015). It is true that some studies are alarming, but we have also to keep in mind that the authoritative meta-analysis of the epidemiological studies done by Wen et al. in2012found that out a list of 925 studies examined, only 56 (6.05%) have been judged worthy of being considered. All the others have been discarded because of various defects like poor or inadequate designs, false data, etc. This is to say that great attention has to be reserved to the analysis of empirical data reported on the issue: only reliable and serious studies are worthy to be considered. Looking with the due attention to the best available knowledge, we can report that an important and detailed study by Davies et al. (2012) compared an Australian cohort of 6163 IVF/ICSI infants born from 1986 to 2002, of which 1407 were ICSI, with SCB infants, and reached the conclusion that “the increased risk of birth defects associated with IVF was no longer significant after adjustment for parental factors.” This means that IVF is not more dangerous than SCB, if due distinctions are considered – such as the fact that many IVF pregnancies involve twins or triplets which may cause birth defects and other problems. In this sense, Davies reports that the general adjusted risk is 1.28%, i.e., significantly higher than 1.0% (the basic “natural” risk). However, among singleton IVF newborns from fresh embryos, the

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adjusted risk is 1.06, showing that IVF as such entails no increased overall risk for birth defects (Davies et al.2012).

Davies’ report also compared IVF and ICSI infants and concluded that “the risk of birth defects associated with ICSI remained increased after multivariate adjust-ment, although the possibility of residual confounding cannot be excluded.” This conclusion was immediately amplified by the media all over the world and still serves as the base of many critics who say that ICSI is a serious danger for the newborn. Many ICSI parents were worried and many physicians had doubts about it. This is not the place to enter into a detailed analysis of such a conclusion, but it is important to say that this conclusion depends on the observation that among singleton newborns after ICSI with fresh embryos, the adjusted risk rose up to 1.55%, i.e., 0.55% above the 1.0% threshold. This is a statistically significant increase, and Davies reported it correctly (mentioning the possibility of residual confounding). But in general terms, the number of ICSI infants with birth defects would only increase a few units. Moreover, that conclusion is criticized by Pinborg et al. (2012) on the ground of a recent study of a larger cohort of Swedish infants. This new study is based on 15,570 IVF/ICSI infants born between 2001 and 2007, of which 9372 were born after ICSI. This new data appears to be more reliable than that deriving from the Australian cohort where most children were born when the ICSI was just beginning. In contrast to Davis’ conclusion, Pinborg’s result is that “the adjusted risk of birth defects for the ICSI vs. IVF cohort (2001–2007)” is 0.90%, i.e., lower than the basic “natural risk.” This thesis is also confirmed by Wen et al. (2012), who remarked at the end of their meta-analysis that “there is no risk difference between children conceived by IVF and/or ICSI.” Finally, in a more recent study concerning newborns in the Nordic countries over the last two decades, Henningsen et al. (2015) register that the number of multiple births decreased with time as well as perinatal deaths and low birth weight. In brief, ART-conceived children are better off than those who are conceived naturally.

The aforementioned data seems to be the best that has been made available as of yet, and the situation it describes is not as discouraging as critics point out. There-fore, ICSI can be a viable solution to male reproductive disorders. It is ethically positive since it favors self-realization of everyone.

Donor Insemination

The analysis we have done has shown that from the point of view of critical ethics, ICSI can be a valuable therapy for male infertility. We are now in a more adequate position to examine the morality of donor insemination, which has two other important problems to be considered: the issue of parenthood and that of the embryo. What Is Parenthood? Genetic Vs. Social Criteria

A great advantage of the ICSI is that in it, the genetic endowment is internal to the couple, and therefore there are no controversies on parenthood. For this reason I preferred to examine the issue before donor insemination where part of the gametes

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is external to the couple, and this would raise a further problem stemming from the fact that parenthood is depending from genetic connection to the child. According to a widespread received opinion, the parental relationship is constituted by “blood connection.” This means that donor insemination is morally and legally problematic because it violates one of the basic tenets of the family.

We have to distinguish the moral level from the legal one and also keep in mind that different legal systems have suggested different solutions. Here I cannot enter into the details of these various proposals advanced in different countries, but some ideas can be useful to distinguish the general perspectives and orientate our thinking. The ﬁrst point is to make clear that among humans, parenthood is primarily a legal concept: father is who the law states he is, as mother is who the law states she is. However, articles of law are not stated by chance but are informed to some criterion and are giving voice to it. Our problem is to grasp the criterion which is underneath the letter (formulation) of the various single articles of the positive law of different countries. Let’s consider the question: is it the genetic relation itself that constitutes legal parenthood or is it the social responsibility for the child that constitutes such a legal relation, and the genetic connection is (only) evidence of an act concerning the child which the man ought to be responsible of?

The answer to this question brings us to distinguish two different criteria of parenthood: the social criterion for which fatherhood is created any time the law ascribes to a man the responsibility for the child, regardless of any genetic connec-tion even if it can be a reason for ascripconnec-tion of parental responsibility; and the genetic criterion for which fatherhood constitutes any time a biological connection between a child and an adult is discovered, as if such a relation would be immediate and by itself binding.

As soon as we distinguish the two criteria, we can see that most of Western legislations presuppose the social criterion. Because they do it, they can envisage and do envisage adoption as a form of parenthood: in adoption we know that there is no genetic relation between the father and the child, and it would be impossible if the genetic criterion had been accepted. It is true that adoption is a special kind of parenthood and that normally parenthood presupposes genetic relationship. But even in these normal cases, it is not the genetic relation that per se creates parenthood, but the genetic relation is simply a sign showing that what the man did had some consequences [the birth of a child] which he has to be responsible for, since it is this responsibility for the child that creates parenthood.

In the past the distinction between social and genetic criteria hardly appeared because marriage was the great social institution in charge of controlling how human life ought to be correctly transmitted to the next generation. In this perspective, children are born within and from marriage, and those born outside marriage are not acknowledged. Adultery is a most heinous crime just because it can bring to the light the distinction between the two criteria and conjugal ﬁdelity a most valuable virtue because it guarantees the equivalence of the two.

In the last decades, the situation has radically changed. Marriage is no longer so important for the transmission of life, and the decision to bring a child into the world may be independent of marriage. In these new historical conditions, it is not easy to

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establish who is the father, and we have to be careful. In “normal” cases father is the man who did some acts whose consequences end up in the birth of a new child whom he ought to be responsible for: to do those acts is equivalent to decide to bring a new being into the world, and therefore the responsibility for the child is ascribed to him. However, in some cases it may occur that a man wants to bring a new being into the world and decides to do so, but for the most different reasons, he may be physically unable to do so. Therefore, he decides to ask someone else to help him in the venture by donating the required gametes. If the donor accepts the request, then a new child is born, and the situation is the following: the newborn has a genetic relationship with the donor who accepted to cooperate with the man who decided to bring the child into the world, did most of the acts to such an effect, and in this sense is responsible for that birth, even if he has no genetic connection with the child. If in this case we ask who is the father, the answer is that the father is the man who is accountable for such a birth and has to assume legal responsibility for the child he decided to bring into the world.

This shows that fatherhood is a social concept sanctioned by the law. The donor is not at all “father” in any sense, because he does not have the responsibility for such a birth but simply has provided some cooperation. In order to avoid confusion, I would recommend not to say that the donor is the “genetic father” opposed to the “legal or social father,” because adjectives modify in part the noun but do not cancel the evocative force hidden in it. I would say, instead, that the donor is the “genetic ancestor” of the child, because such an expression would make clear that he has no responsibility and cannot be involved in parental roles.

Conclusion: from a critical ethics’ point of view donor insemination is a valuable solution to male infertility troubles. This result, however, does not solve all the problems raised by the practice and many remain open. For instance, still unclear is the answer to the psychological problems about whether or not revealing the identity of the sperm donor to the new person: when to do it, who has to do it, for which reasons, etc. There may be medical reasons connected to protect the newborn’s health, or social resons dependent on the opportunity of maintaining transparent relations. Other issues may raise from the sperm donor’s point of view, and again others at legal levels.

I am well aware of these further problems and I have no pretence to give a deﬁnite answer to them all. I tried to provide some ethical indications: once we have clearer ideas at this level, we can also face the other aspects of the question.

Pregnancy for Others (or Surrogacy)

IVF makes it possible that also women can donate their gametes or provide gestation for another woman. The result is a new medical practice in which women can be involved in two ways:

(a) A woman can donate both her gametes for the creation of the embryo and the pregnency reuired to bring it [him/her?] to birth.

(b) A woman can donate only the pregnancy of an embryo created with gametes of others.

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One problem of this practice is how to call it. In English the term used to indicate it is “surrogacy,” which is adequate as it is rather neutral. However, its translation in other languages (mainly neo-Latin) is problematic because “surrogate” means “of second choice” and has a negative tone. For this reason, one adequate name for such a practice can be “pregnacy for others,” meaning that a woman provides the service of bringing to birth a newborn for other people. This term has no negative conno-tation and appears not to be evalutative. It has also the advantage of making clear that the main moral problems to be examined are the following:

1. Whether such a service is morally permissible or not.

2. Granted that the practice is permitted, at which conditions it is.

One way to test our reﬂective intuitions about the practice is to compare it with time-honored wet nursing, which was the help provided by a woman who had milk to another woman, the mother, who was without milk or did not want to breastfeed in order to make possible that the newborn will survive and grow up. Without such a help, the newborn would have died in a short time, which is practically equivalent to saying that it had never come into the world. Wet nursing was a help provided after birth, while pregnancy for others is a help provided before birth to make it possible that a newborn can come into the world. If it is positive that a new person comes into existence and continues to live, then both practices are prima facie morally good.

The clause “prima facie” is to be considered, because it signals that such practices are good at first sight or ceteris paribus, i.e., other things being equal, but sometimes in specific circumstances, other things are not equal, and therefore to a more careful inspection, the action may be morally wrong. So the analogy with wet nurses shows only that in itself, surrogacy is not morally wrong, but in some circumstances, it may be morally reprehensible. Here I cannot examine all the various circumstances, but one point appears to be clear: when pregnancy for others is completed for merely altruistic reasons and without financial compensation, the practice is judged morally good and also commendable. This means that circulation of money is the disruptive element, which may justify the negative judgment.

On this issue one remark is due: in the past wet nurses were usually rather well paid and had a remarkable place in the family, while nowadays surrogate women have to disappear immediately, and many claim that they are poorly compensated and grossly exploited. This is not the place to consider all these details, but it is enough for us to observe that the issue of “exploitation” (without any gender discrimination) belongs to the ethics of economics and labor, and it should be considered under that class. We can acknowledge that there are problems, and serious ones, because people are always ready to take advantage of others. This, however, is a more general problem of social justice which has little to do with the ethical evaluation of the specific issue concerning whether or not surrogacy is prima facie morally good. It is important to note that I am saying “prima facie morally good”, where prima facie means “at a first sight” or “at a first consideration” assuming that there may be “a second one” (that could be heavier). Other issues remain open in the matter, as the social and legal questions connected to the

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relationship with the child. Ethics is focused on justice and beneficence and evaluate human actions and their consequences from this viewpoint. Empirical data are to be acquired in order to establish if the new practice meets the ethical criteria. But of course we need at least a “prima facie evaluation” to start the new pratice and see how it can work. This holds also for other new situations, such as lesbians having children through donor insemination or gays having them through surrogacy. In this latter case one crucial point is about reciprocal relationship between the surrogate and the newborn: it is not clear if the psychological bond with the child is stronger or more intense in the case of surrogacy or in that of wet-nursing. More experience seems to be needed before we can take a final stand and give a definitive moral evaluation.

A final point is to be considered. If our analysis is correct, then pregnancy for others is prima facie morally permissible, and this holds for everyone independently of one’s sexual orientation. It may be that surrogacy will become a practice analo-gous to wet nursing, even if we’ll have to consider the influence of possible new knowledge concerning the pre-natal development of the child. This new control on reproduction will bring to the fore the difference between bringing someone into the world (pregnancy) and raising him (education) and the issue of who is fitted to do it or more fitted to accomplish the specific task. Up to now the two functions have been unified but it could be that in the future it is good for the child (as well as for the women involved) that the two functions will be distinct. Problems of this sort are so far too complex to be considered here and in any case they would require a specific study. However, it was opportune to mention them because they may become prominent in the future.

Notes on the Issue of the Moral Duties toward the Embryo

This is an immense issue, and here I can say only very little in order to orient the mind in the proper direction. As we have seen, in the Hippocratic tradition, medicine is “assistance to nature’s goals of the human body” which are self-maintenance of the individual and of the species. Sexuality is primarily devoted to preserve the species, and medicine as therapy has to be helpful in the transmission of human life from one generation to the other. In this sense, any action against reproductive teleology was seen as worse than action against single individuals, because they endangered the species. In this sense all the so-called “sexual deviations” were punished most severely. In the last decades, the Western culture entered in a sort of “new world” in which sexuality is regulated by a new paradigm, and it is difﬁcult for us to understand the deep sense of repugnance for any action classiﬁed as “against nature” and why such violations were even more heinous than violence against people.

In this respect, one crucial change is found in the fact that in the West, sexuality among consenting adults has ﬁnished to be considered a “private affair” which is relevant only for the involved individuals. In this sense sexuality has become a matter of private taste and has lost its public dimension. In the past, sexuality was “public” in the sense of serving that non-private function which is the permanence of

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the group. For this reason, anything connected with reproduction appeared to be more precious than any individual (or private) matter. Other aspects reinforced this attitude, such as the fact that the reproductive functions were circumvented by an aura of mystery that supported the view that reproduction was a holy or sacred ﬁeld. This more general perspective was translated in institutional terms into the idea that marriage was the great institution in charge of the transmission of human life. Any violation of marital bonds was considered a serious crime, even more serious than private violence. This view is compatible with Hippocratism that acknowledges the natural teleology of the reproductive functions and aims at “therapy” which is the aid provided to any life’s process in troubles. But of course, Hippocratism is very much against any action aiming at interfering or at preventing the natural ﬁnalism. In this sense, the recent slogan “Abortion is not Health Care” grasps a Hippocratic intuition and is in line with Hippocratism.

Within this paradigm the whole process of life’s transmission is rigorously protected, and the question “When does human life begin?” becomes meaningless: if any interference with the process is strictly forbidden, there is no reason to distinguish a part from another. It is interesting to note that according to the Roman Catholic Church, the techniques of artificial human procreation are to be evaluated in reference to two fundamental values: (i) “the life of the human being called into existence and (ii) the special nature of the transmission of human life in marriage” (Congregation for the Doctrine of the Faith. (1987) Instruction Donum Vitae on respect for human life at its origins and for the dignity of procreation, Intro., 4). According to my view, this second value (“the special nature of the transmission of human life in marriage”) is enough to guarantee a general protection to the whole reproductive process, apart from any distinction of stages in prenatal life. As a matter of fact, the Roman Catholic Church never states when “human life begins” which nowdays is equivalent to state when a “human person” is there. In the Catholic paradigm, this latter issue is a philosophical one, and it is explicitly asserted that “the Magisterium has not expressly committed itself to an affirmation of a philosophical nature, but it constantly reaffirms the moral condemnation of any kind of procured abortion” (Ibid. I, 1). This shows that the Catholic prohibition of abortion is independent of the problem of whether or not it is a form of “killing a person” and goes back to a form of Hippocratic perspective.

This is an interesting result because most Roman Catholics think that the real value at stake is the first one, i.e., that concerning “the life of the human being called into existence.” On the contrary, this value is not relevant at all because no answer is provided to the question (when does a person begin?) that is at the basis of such a value. I am well aware that a huge controversy opens up at this point and that I cannot here discuss the details. I can only say that the first value as well as its basic question (when does a person begin?) becomes meaningful only in a social and cultural context where the value of marriage has already faded away. In order to defend the same prohibition in the new cultural context, a new argument had to be presented. Here is the source of the idea that any destruction of embryonic life is already a form of homicide. There is no scientific or rational support for such a thesis, but it appears persuasive to many people already accustomed to the traditional

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prohibition and willing to reafﬁrm it. These few remarks are suggested as a basis of a new rethinking of the issue concerning the value of the human embryo.

Conditions Connected to Sexuality as Self-Realization

So far we have examined the problems connected to sexuality as mating, which are connected to reproduction and have always been in the center of medical attention, whose goal was to help mating. Now that the ability to split sexuality from repro-duction has tremendously increased, we can turn to other problems of sexuality as creative self-realization and to its problems. This part is new and had hardly any tradition in the past.

Erectile Dysfunction

According to a standard medical deﬁnition, impotence is the inability to achieve or maintain an erection long enough to engage in sexual intercourse. There are several causes for such a dysfunction which form a part of the clinical workup. From the point of view of a critical ethics, we want to understand which are the reasons that justify such clinical interventions.

A lot of attention was devoted to erectile dysfunction as a cause of infertility, when sexual intercourse was the only way to have children. However, thanks to assisted reproduction, this problem can now be overcome, and a man can have children even if impotent. This means that nowadays erectile dysfunction has to be treated mainly in order to allow a man’s self-realization and couple’s strengthening. It is well known that sexuality can be a strong resource for bringing a couple together: if the partners undertake sexuality by autonomous choice, this is ethically positive because it increases human welfare and self-realization. Moreover, impo-tency is a source of depression as well as of a sense of frustration, and the possibility of overcoming such a condition is a most beneﬁcent action. Only people supporting old taboos can think that effective treatment of erectile dysfunction is evil and perversed. There are no reasons at all to limit therapies against erectile dysfunctions in order to extend as much as possible the chances to entertain sexuality as self-realization (splitted from reproduction). This is one of the main arguments in favor of sexual rights, which are valid claims to have the opportunity to enjoy “sexual health” understood as the ability to start and to continue sexual activities between consenting partners when the subjects choose to do it.

In this sense the advent of the sildenaﬁl citrate known under the brand name Viagra is certainly an outstanding achievement of medical research. Approved by the FDA on March 27, 1998, the drug obtained immediate success on the market: an evidence that it accomplished a real positive revolution in the ﬁeld of sexuality. Before the advent of Viagra and similar drugs, men had to resort only to herbs and other ineffective treatment: the result was that the problem was concealed. As soon as an effective treatment was available, the problem emerged and became public, and

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we now know that according to a study published in 2007 in the US, “52% of men aged 40–70 experienced some degree of erectile dysfunction (ED), while 10% experienced complete erectile dysfunction.” This shows the social dimension of the treatment and its beneﬁciality.

Two problems are to be mentioned. The ﬁrst is whether it is ethical to treat erectile dysfunction in people affected by sexually transmitted diseases (serious and poten-tially fatal) who can then participate in unsafe sex or whether it is more prudent to deny any treatment in order to prevent the risk. The question is important but in a sense obsolete, because in the last two decades, Viagra was sold mainly throughout Internet, and it is hardly possible to deny the treatment to any person. In any case it must be clear that respect for persons requires that the request of a competent adult patient ought to be complied with, unless there are clear medical contraindications. It is up to the treated person to be responsible and engage in safe sex.

The other problem has a wider social dimension, having to do with aging. We know that age is the most important factor causing erectile dysfunction. If for young people erectile dysfunction can be correctly classiﬁed as a disease, some think that such a condition is normal for the old people, and no treatment is due. In one sense it is a normal deﬁciency of a non-vital function, and for this reason it should be quitely accepted as it is accepted that an 80-year-old man runs slower than a 20-year-old one. Trying to overcome these limits – so the argument runs – is not a therapy but a form of enhancing which is (and should be) outside medicine.

However, once we have abandoned the Hippocratic paradigm, the difference between therapy and enhancement is fuzzy, and in any case, there are no reasons against enhancing sexual capacities. Old people have a right to enjoy sexual life as a form of self-realization, at least as long as they are alert of their choice, are consenting, and are responsible. If this is true, then nursing homes have to be equipped for the new opportunity: this means that they have to provide enough privacy and that their pharmacies should dispense such drugs.

Homosexuality, Transexuality, and Intersexuality

Under this big?? Categories are listed in three different topics because they raise similar moral problems. For the sake of brevity, I take homosexuality as the heading issue, and once the situation is cleared with it, the others will follow in the same line. Homosexuality is here taken as a general class including both gay men, lesbians, and bisexual people: all together represent about 15–20% of the whole population.

If we approach homosexuality from the point of view of critical ethics (as we should), we have to realize that the issue raises no special moral problems, if not that possible treatment of their sexual and reproductive problems deserve some attention and care in order to avoid prejudices, stigma, or other negative attitudes which still prevail in our societies. One consequence of this analysis is that if any person has the right to become a parent, this should apply irrespective of one’s own physical limitations (infertility, aging, etc.) including his/her own sexual orientation. This