ETHICAL ISSUES OF CONGENITAL RUBELLA SYNDROME

GROWTH AND DEVELOPMENT MODULE

Group 2

1. ShintyaDewi (I1011151012)
2. KartikaNurulFatmi (I1011141013)
3. Heru Chris Sunariyanto (I1011151020)
4. Aprilia Tri Wahyuningsih (I1011151033)
5. ZaitinNur (I1011151040)
6. Muhammad OktiIchsandra (I1011151042)
7. Gerry Albilardo (I1011151046)
8. Chalchi Ruhita Mlatti (I1011151055)
9. SeptiAdelia (I1011151057)
10. Vica Vionita Rosalim (I1011151058)
11. Isabella (I1011151069)
12. HendiRizaldi (I1011151074)

MEDICAL EDUCATION PROGRAM

MEDICAL FACULTY

TANJUNGPURA UNIVERSITY

PONTIANAK
2016
 CHAPTER I

BACKGROUND

Congenital rubella syndrome is infant abnormalities that is caused by rubella virus

which can infect fetus and damage the fetus. [1] Infection with rubella virus is most severe in
early gestation. The virus may affect all organs and cause a variety of congenital defects.
Infection may lead to fetal death, spontaneous abortion, or preterm delivery. The severity of
the effects of rubella virus on the fetus depends largely on the time of gestation at which
infection occurs. As many as 85% of infants infected in the first trimester of pregnancy will
be found to be affected if followed after birth. [2]
Congenital Rubella sydrome is one of health problem in the world. Even though there
are not a lot of congenital rubella syndromes patients that died, but the it has bad impact in a
children's life. Both from the physical to the mental defects of children can be caused by
congenital rubella syndrome. Therefore WHO and each country aggressively combating the
causes of congenital rubella syndrome, Rubella virus. Rubella is one part of the TORCH,
infectious agents of children in gestation.
To prevent the infection agents, we can use vaccine. Vaccine is an antigen such as
microorganisms already dead, is still alive but weakened, intact or parts thereof, which have been
processed, the form of the toxin microorganisms that have been processed into a toxoid, a
recombinant protein which, when given to someone will give rise to specific active immunity against
infectious diseases certain.[3] In this case, according to New Yorks article about Mother Wins
Legal Battle to Refuse Vaccine From Aborted Baby Parts the solution to prevent congenital
rubella syndrome is using MMR vaccine. But in the manufacture of vaccines, the materials
that used are the fetal tissue of aborted babies. The vaccine manufacturerss use of aborted
fetal cells. As we know, there are lot of pro and contra of using aborted babies cell for
vaccine. Based on this case, we conducted a study of ethical issue of using MMR vaccine
from aborted fetal cells.
 CHAPTER II

ARTICLE AND DISCUSSION

2.1 Article

Title: Mother Wins Legal Battle to Refuse Vaccine From Aborted Baby Parts

State-Sarah Zagorski-3/Sep/2015-New York, NY

In New York, a woman has won a legal battle to refuse a vaccine for her child because
it was made from aborted baby body parts. The vaccine, MMR, is for measles, mumps and
rubella and required by New York City school for anrollment.
However, the women was granted an exemption on religious grounds because she
opposes abortion and the vaccine was used from tissue collected from them. The New York
Post reports that the mothers name have been with held for privacy reasons.
As LifeNews previously reported, in July, The Center for Medical Progress released
multiple videos showing Planned Parenthoods executives negotiating the sale of aborted
babies, admitting to using altered abortion procuring fetal parts for harvesting and casually
discussing less crunchy methods for procuring fetal tissue. The videos reignited debates
about fetal tissue sales and sparked investigations into Planned Parenthood across the
country. Shockingly, one of the newest videos cathes the abortion company harvesting the
brain of an aborted baby who was still alive. The mother said the following about her
decision to refuse the vaccine: Abortion is clearly considered a mortal sin and is [an]
abhorrent act to any Christioan. The vaccine manufacturerss use of aborted fetal cells in its
products and research means that I cannot assoiate with them or support them financially (by
buying their products), for such support would make me complicit to their sin and answerable
to God for this violation.
Mary Ellen, from New York State Department of Education Commissioner said, the
weight of the evidence supports petitioners contentions that her opposition to the MMR
vaccine stems from sincerely held religious beliefs, but she also argued that the mothers
case is undermined by the fact she opposes all vaccinations, regardless of it aborted babies
were used to create them.
The Director of Federal Reproductive Health Policies at the National Womens Law
Center, Sharon Levin, weighed in on the case and claimed it will open a can of worms just
like the Hobby Lobby decision/
 Keep up with the latest pro-life news and information on Twitter.
She explained, The woman in New York is not the first to argue that her child should
not have a comply with the vaccination requirements because of religion. The danger of these
exemptions for vaccinations is that one person is making a decision that impacts the health of
other peoples children. Vaccination regulations are put into place to protect public health.
When one person opts-out, they are making a decision for everyone else who comes into
contact with their child.
In 2014, the United State Supreme Court ruled that Hobby Lobby, a Christian-run
store, doesnt have to obey the HHS mandate that is a part of Obamacare and requires
businesses to pay for abortifacents in their employed health care plans. Of course, abortion
advocates said the decision violated womens right even though many Americans do not
believe a private family owned business should not have to pay for abortifacent drugs.

2.2 Discussion

2.2.1 Congenital Rubella Syndrome

Congenital rubella syndrome is infant abnormalities that is caused by rubella virus

which can infect fetus and damage the fetus. [1] Maternal viremia associated with rubella
infection during pregnancy may result in infection of the placenta and fetus. Only a limited
number of fetal cells become infected. The growth rate of infected cells is reduced, resulting
in fewer numbers of cells in affected organs at birth. The infection may lead to deranged and
hypoplastic organ development, resulting in structural anomalies in the newborn.[4]
Rubella virus has been isolated from many different organs and cell types from infants
infected in utero, and rubellainduced damage is similarly widespread. Clinical features of
congenital rubella syndrome may be grouped into three broad categories: (1) transient effects
in infants, (2) permanent manifestations that may be apparent at birth or become recognized
during the first year, and (3) developmental abnormalities that appear and progress during
childhood and adolescence. The classic triad of congenital rubella consists of cataracts,
cardiac abnormalities, and deafness. Infants may also display transient symptoms of growth
retardation, rash, hepatosplenomegaly, jaundice, and meningoencephalitis. Central nervous
system involvement is more global. The most common developmental manifestation of
congenital rubella is moderate to profound mental retardation. Problems with balance and
motor skills develop in preschool children. Severely affected infants may require
institutionalization. Progressive rubella panencephalitis, a rare complication that develops in
the second decade of life in children with congenital rubella, is a severe neurologic
deterioration that inevitably progresses to death.[4]

2.2.2 Four Fundamental Principles of Ethics Issue that Related to MMR Vaccine in
Congenital Rubella Syndrome

Ideally, for a medical practice to be considered ethical, it must respect all four of these
principles: autonomy, justice, beneficence, and non-maleficence.
1. Autonomy
Requires that the patient have autonomy of thought, intention, and action
when making decisions regarding health care procedures. Therefore, the decision-
making process must be free of coercion or coaxing. In order for a patient to make a
fully informed decision, she or he must understand all risks and benefits of the
procedure and the likelihood of success.
In this case, there is The Director of the Federal Reproductive Health Policies
at the National Women's Law Center, Sharon Levin who said that children did not
have to comply with the requirements of the vaccinations because of religion, it is in
accordance with the rules of Autonomy because of the absence of any interventions to
a mother for taking a decision. If before vaccination, the medical side explained to the
woman about what would happen if the children are not given the vaccine and
patients get information about vaccine ingredient, so that not breaking autonomy.
2. Justice
The idea that the burdens and benefits of new or experimental treatments must
be distributed equally among all groups in society. Requires that procedures uphold
the spirit of existing laws and are fair to all players involved. The health care provider
must consider four main areas when evaluating justice: fair distribution of scarce
resources, competing needs, rights and obligations, and potential conflicts with
established legislation. Reproductive technologies create ethical dilemmas because
treatment is not equally available to all people.
Based on the article above Shockingly, one of the newest videos catches the
abortion company harvesting the brain of an aborted baby who was still alive, based
on the rules of justice it is certainly contradictory because it violated the rights of
healthy babies. The medical side here do not apply the principle of justice to babies
 that have been aborted, it was reported that medics took the baby's brain abortion as
vaccine material when the baby is still alive
3. Beneficence
Requires that the procedure be provided with the intent of doing good for the
patient involved. Demands that health care providers develop and maintain skills and
knowledge, continually update training, consider individual circumstances of all
patients, and strive for net benefit.
Based from the text, a woman has won a legal battle to refuse a vaccine for her
child because it was made from aborted baby body parts. If we see from morality and
religion a vaccine was made from aborted baby body parts is not ethical but from
ethical principles it has been applying beneficence cause it helps prevent the impact
more dangerous like measles, mumps and rubella. But if we look into the other side, it
is not beneficence when they using aborted babies fetal cells.
4. Non-maleficence
Requires that a procedure does not harm the patient involved or others in
society. Infertility specialists operate under the assumption that they are doing no
harm or at least minimizing harm by pursuing the greater good. However, because
assistive reproductive technologies have limited success rates uncertain overall
outcomes, the emotional state of the patient may be impacted negatively. In some
cases, it is difficult for doctors to successfully apply the do no harm principle.
In this case, the medical side here seeks to not aggravate the situation of
children by giving them vaccines. However if we look at another side, there is a
company that caters to the baby's fetal tissue sales abort, of course this situatuin is
contrary to the principle of non-maleficence because it is the same as doing the killing
of a fetus that still alive and taking the fetal tissue.

2.2.3 Medical Ethics and Indonesian Law that Related to MMR Vaccine in Congenital
Rubella Syndrome
According to medical ethics in KODEKI 2012:[5]
1. Article 6 : Wisdom In the New Discoveries. Every physician shall always be cautious
in announcing any discovery or apply a technique or a new treatment that has not
been substantiated and the things that can cause public anxiety.
Clause 1: A doctor is justified only announced the results of new research done
by themselves for the first time only in the scientific media in accordance with
 a recognized profession of medical research is common and is valid. The new
research should have escaped examine the ethics committee / committee of
assessors according to applicable regulations.
Clause 11: A doctor is prohibited from using the goods or equipment or
traditional health products, alternative-complementary for diagnosis and
causal therapy which already has a gold standard (golden standard) in the
conventional treatment systems. That have meaning, efforts to protect the
public in the policy of integration of traditional health care into conventional
healthcare or formal.
explanation of the article: The act of a doctor can influence the public opinion, the
opposite reaction to deviate the public can return affect their perceptions of the entire
medical corps. Therefore, physicians should be cautious in announcing the results of
research, engineering and medicine that has not been substantiated or may cause
public unrest.
2. Article 10, Respect for the rights of patients and colleagues. A physician shall always
respects the rights of patients, colleagues, and other health personnel, and must
maintain the trust of patients. Explanation of the article : Medical ethics characterized
by ethical obligations that puts their conscience calls help patients as human beings
who are suffering as a doctor highest duty as servants of the profession. Patient is a
unique person that is a destination for his own life, not as an object to be intervened
doctors or other health professionals. Respect for the rights of patients and colleagues
who are part of the obligation of the doctor will maintain the trust of patients, in order
to speed up his recovery.
3. Article 11, Protector of life. Every physician shall always remember her obligations in
protecting the lives of human beings.
Clause (1) A physician shall understand or comprehend the cycle and the
quality of human life, beginning at conception and or when life begins, the
natural processes of life take place until towards or when or after the death of
a man, with the purpose to respect, protect and maintain the living creatures
human.
Clause (2) A physician may not engage or involve themselves in abortion,
euthanasia, and the death penalty can not be justified morality.
Clause (3) A physician shall be careful, considering various aspects of
diagnosis, treatment or treatment and prognosis in the context of reproductive
life in general as well as using various advances or sophistication of any
 reproductive technology that can eliminate or degrade human dignity and
human dignity.
Explanation of the article : Each physician should serve as "keeper and preserver of
life" of human rights is raised, ranging from conception or fertilization until death.
Every human being is created by God Almighty. God has created each man the same
age as the goal. When it became a client or patient, no matter how severe or disability
they are, every doctor must realize sacred calling her conscience to keep the patient's
life. A doctor must put all of his patients maintain natural life and not to end it.

According to Forensic and Legal Medicine about abortion in KUHP dan UU 36/09:[6,7]
1. KUHP
Article 346 : A women who deliberately abortion or tell others to do it, is
threatened with a maximum imprisonment of four years.
Article 347 :
Clause 1 Whoever deliberately abort or shut the womb of a woman without
her consent, can be punished by a maximum imprisonment of twelve years.
Clause 2 If the act results in the death of the woman, can be punished by a
maximum imprisonment of fifteen years.
Rubella vaccine is made from aborted fetal cell line deliberately, based on KUHP
mentioned that the abortion is done intentionally it is strictly prohibited and obtain a
criminal conviction. So the vaccine is made using aborted baby on purpose is contrary
to the law of medicine and law in Indonesia.

2. UU 36/09 of health
Article 75
Clause 1 : Every person is prohibited from having an abortion.
Clause 2 : The prohibition referred to in Clause (1) may be excluded on:
a. Emergency medical indications detected early age pregnancy, both of
which threaten the lives of mother and or fetus, who suffered from severe
genetic disease and or birth defects, or that can not be repaired so difficult
for the baby to live outside the womb; or
b. Pregnancies resulting from rape can cause psychological trauma for rape
victims.
Clause 3 : Measures referred to in Clause (2) can only be done after going
through counseling or counseling and pre-action and ending with after-action
counseling carried out by competent and authorized counselor.
 Clause 4 : Further provisions on emergency medical indications and rape, as
described in Clause (2) and (3) is regulated by the Government.
Article 76 Abortion as referred in Article 75 can only be done:
a. Before pregnancy age of 6 (six) weeks counted from the first day of the
last menstrual period, except in cases of medical emergencies;
b. By health workers who have the skills and authority a certificate
established by the minister;
c. With the approval of the concerned pregnant women;
d. With the permission of her husband, except victims of rape; and
e. Health care providers who meet the conditions set by the Minister.
Article 77 The government is obliged to protect and prevent women from
abortions as referred to in Article 75 Clause (2) and (3) which is inferior,
unsafe, and irresponsible and contrary to religious norms and provisions of
laws and regulations.
Article 3: rights and obligations
Clause 4 : Everyone has the right to health.
Clause 5 :
(1) Everyone has the same right to gain access to resources in health.
(2) Everyone has the right to obtain health services that are safe, quality, and
affordable.
So according to Indonesia law above, everyone have a right for being safe and
healthy. Vaccine MMR is one of the solution as a secondary protection of
Rubella. Vaccine MMR is the best solution to eradicated TORCH. As a doctor,
we should help people in health aspect. Every legal vaccine are good for our
immunity because vaccine helps us to protect our immunity. The important
things is by vaccine we hope that we can wipe out every infectious virus or
bacterium. So people can live more safely and every disease cause by
infectious agent can be decreased.
In addiction, human right according to Indonesia Law Clause 28 A (1) Everyone has
the right to live and to defend life and livelihood. Clause 28 B (1) Every child has the right to
live, grow, and develop as well as the right to protection from violence and discrimination.
The statement before, we discuss about every children has a right to get MMR vaccine, now
we will discuss the case in aborted babies perspective. Every human has a human right. We
have the rights to born, live freely and make a decision. A fetus who does not yet birth in the
world, has had a soul. But the problem, the fetus can not say what is their decision. Thats
why abortion is not a right thing to do. We have to against it, appropriate with Clause 28
about Human Rights. It is wrong if the abortion is being done purposely. But if the abortion is
being done because of the fetus dead in the pregnant, we should do the abortion. So first we
should find out more information about the MMR vaccine before we against it wether it is
right or not that the vaccine made from a aborted baby that still alive. Actually if the baby had
death, we can use the tissue to create a vaccine that can help many people. Negative or
positive it is, we should look in every viewpoint.

CHAPTER III

CONCLUSION

3.1 Conclusion

From the study above, it can be concluded:

1. Congenital rubella syndrome is infant abnormalities that is caused by rubella virus

which can infect fetus and damage the fetus. Maternal viremia associated with
rubella infection during pregnancy may result in infection of the placenta and
 fetus. The solution to prevent congenital rubella syndrome is using MMR vaccine.
But the vaccine manufacturerss use of aborted fetal cells.

2. Four fundamental principles of ethic issues that related into MMR vaccine is
autonomy, justice, beneficence, and non-maleficence. It is in accordance with the
rules of Autonomy because of the absence of any interventions to a mother for
taking a decision if they didnt know that the vaccine are made from aborted
babies. The medical side here do not apply the principle of justice to babies that
have been aborted, it was reported that medics took the baby's brain abortion as
vaccine material when the baby is still alive. It has been applying beneficence
cause it helps prevent the impact more dangerous like measles, mumps and
rubella. But if we look into the other side, it is not beneficence when they using
aborted babies fetal cells. In this case, the medical side here seeks to not aggravate
the situation of children by giving them vaccines

3. According to medical ethic, when it became a client or patient, no matter how

severe or disability they are, every doctor must realize sacred calling her
conscience to keep the patient's life. A doctor must put all of his patients maintain
natural life and not to end it. Rubella vaccine is made from aborted fetal cell line
deliberately, based on KUHP and UU 36/09 mentioned that the abortion is done
intentionally it is strictly prohibited and obtain a criminal conviction. So the
vaccine is made using aborted baby on purpose is contrary to the law of medicine
and law in Indonesia.

REFERENCES

1. Kliegman, R. M., et al. Nelson Textbook of Pediatric. 19th Edition. Canada: Elsevier;
2011.
2. CDC. Centers for Disease Control and Prevention Epidemiology and Prevention of
Vaccine-Preventable Diseases 13th Edition: Rubella. MMWR; 2015.
3. Health Minister of the Indonesia Republic. Minister Regulation of the Indonesia Republic
Number 42 of 2013. The Health Minister of the Indonesia Republic; 2013.
4. Jawetz., et al.Medical Microbiology 27th Ed. McGraw-Hill Education. 2016
5. Kode Etik Kedokteran Indonesia. Pengurus Besar Ikatan Dokter Indonesia. 2012.
6. Hukum Kedokteran Forensik - Pengguguran Kandungan (Aborsi) menurut KUHP dan
UU 36/09
7. Undang-undang Republik Indonesia No. 39 tahun 2009 tentang Kesehatan. Disahkan oleh
Indonesia Republic President; 2009.