Learning through conflict: ethical debates in sexual and reproductive health.

Impassioned international calls to action to protect re productive rights-for example, the Glion Call to Action (UNFPA 2004) and the Maputo Declaration (2004)-are remarkable in their ability to mobilize activism. Indeed, there is something profound, even sacred, about the con cept of health as a human right. Yet, as new cultural, tech nological, and institutional developments emerge, new challenges to ensuring that the sacred right to reproduc tive health is ensured for all social groups have arisen. These challenges pose a number of ethical issues and di lemmas, many of which have yet to be as methodically examined or as widely debated as they should be. Since the time that consensus was reached at the 1994 International Conference on Population and Develop ment (ICPD) in Cairo and the confirmation of the fun damental rights of women and men was declared at the 1995 International Conference on Women in Beijing, the interest in the ethics of service initiatives and research pri orities in sexual and reproductive health has sharpened considerably (Cook et al. 2003). This refined concept of rights goes beyond commonly recognized civil and po litical rights and focuses more clearly on the right to life and health. Rights are by nature indivisible, so they are inextricably linked with each other without a clear hierar chy, and they are immutable in that they cannot be taken away from individuals. Yet they can be breached within families, communities, and institutions, and in the exer cise of official power. The fundamental principles associated with ethics in reproductive health-care service delivery and in re search-namely, respect for autonomy, beneficence and nonmaleficence, and justice-are articulated in a series of international agreements and are generally accepted by national bodies responsible for the review of service guidelines, research proposals, and the oversight of pro fessional conduct (Cook et al. 2003). This general accep tance, however, does not guarantee that the principles implicit in international law and guidance are reflected faithfully in the policies and guidelines of member states. The interpretation of ethical principles is embedded in the complex and sometimes contradictory web of interna tional agreements, national and provincial laws, and local customs and culture. Conflicts arise during implementa tion of the core principles. Most of these conflicts emerge from the challenges and ambiguities associated with try ing to implement ethical standards rather than from fun damental disagreements about the basic principles. Resolving ethical conflicts requires careful analysis, consideration of competing interests and perspectives, and ideally, a forum in which ideas about rights and re sponsibilities can be formulated and refined. The articles that follow have been collected with the aims of raising awareness of important ethical issues and providing a starting point for further discussion and debate. The focus of this special issue of Studies in Family Planning is on critical ethical issues in the areas of sexual and reproductive health services and research. The ethi cal debate on issues is broadened and enriched when ap proached from varied perspectives and when examined through distinct analytical and disciplinary lenses. The articles collected here, contributed by scholars from a va riety of fields including philosophy, law, social science, and public health, and discussing developments across diverse national contexts, expand our understanding of some of the most important health-related ethical issues that have produced conflict for individuals, health-care systems, and societies. RamaRao and her colleagues describe the turning points in the history of ethics in health research and ser vices, such as the revelations of the Nuremberg trials following World War II and the Tuskegee Study of Un treated Syphilis in the Negro Male (1932-72), and how the lessons and guidance from this history apply to modern problems in health-care services and research. Ringheim addresses the complex issues associated with satisfying the unmet reproductive health needs of young girls and boys. She maintains that adolescents' right to protec tion of their health and their development should not be constrained by negative attitudes toward their ability to make appropriate decisions about their health and long term interests. Wynn and her colleagues focus on the regulatory processes of the governments of the United John W. Townsend is Director, Reproductive Health Program, Population Council. E-mail: jtownsend@popcouncil org.