



































Ethical Case deliberation: 


Bangladesh Journal of Bioethics 2012;3(3): 21-26 
 

 21 

 
Ethical Case deliberation:  
 
 
BREAST CANCER WITH PREGNANCY IN CROSS CULTURAL SETTING 
 
Shamima P. Lasker 
Fellow of Erasmus Mundus Master of Bioethics 
University of Padova  
Italy  
Email: splasker04@yahoo.com  
 
 
CASE: Nadia, a 28-year-old Muslim woman from Bangladesh, is a PhD student at University of 
Padova, Italy. She used to feel a small lump at her breast. Sometimes it disappeared. Sometimes she 
had slight pain. Due to her busy schedule with study she ignored it and thought that she would have 
checked with doctor latter or going back to country of residence.  
 
Her be-husband Alam is as an engineer, was working at a multinational company in Canada. Recently 
he got confirmation latter of immigration to Italy. Two families arranged the marriage ceremony soon.  
About 6 month latter Nadia admitted to hospital in Padova, Italy.  After repeated investigation, doctor 
found to have a rapidly growing carcinoma of the breast. She said to doctor that she has been feeling 
a small mass at the 1

st
 year of her PhD study. Now she requires surgery and postoperative 

chemotherapy.  But she is 5 weeks into her first pregnancy. Attending gynecologist prescript her for 
early surgery. She is advised to terminate the pregnancy before the chemotherapy as well. She does 
not want to terminate pregnancy. Her fear is if she never be pregnant again. But she wants to do 
surgery and chemotherapy. 
 
Dr. Martha faced some ethical dilemma based on the best interest of patient. Dr Martha new that 
abortion is permitted in Islam by 1

st
 trimester of pregnancy.  She realized that this is the right time for 

termination of pregnancy as a Muslim and do surgery as early as possible for saving the patient. She 
asked Nadia about her decision on abortion and surgery. She had an extensive discussion with the 
patient about the possible risk of fetus as well. She advised Nadia for cryopreservation of ovum for 
letter IVF and surrogacy.  
Nadia let Alam know what doctor proposed to her to do and seek his permission. He did not agree 
about the termination of pregnancy as it is his first baby and he dream and crave to be father for long 
time. Neither has he accepted the concept of cryopreservation of ova and surrogacy as it may violate 
the Islamic regulation. But he agrees with the treatment. 
The case was placed at Hospital Ethical Committee and asked to review the situation and make 
recommendations. 
 
INTRODUCTION: With globalization, doctors and patients alike are moving around to different parts of 
the world. It becomes common that physicians may have to provide medical services to patients with 
ethical precept which are different from that of their own. Therefore, medical professions patients and 
family may face a lot of dilemma for cultural difference. As for example a physician may be faced 
moral conflict to take decisions concerning the beginning of life who may be suffering from a disease 
of cancer couple with pregnancy in different cultural and religious context. Doctor is expected to save 
life of patient at all cost and at the same time not to do any sort of harm of patients. Avoiding cultural, 
religious aspect of patient may violate the patient’s dignity. Physicians, healthcare professional need to 
be sensitive to this diversity and avoid a stereotyped approach aimed at good care to patients and to 
avoid conflict before making their judgment on medical practice.  
 
Thus the case of Nadia, a 28 year old Muslim woman is analyzed in ethical deliberation using by 
Padova method developed by Prof. Corrado Viafora. The choice of this method does not signify that it 
is the best of all existing method. But this paper will analyze how a moral conflict may arise in a case 
and how an ethical issue can be solved given the proper cultural importance by this structured 
method.  
 

mailto:splasker04@yahoo.com


Bangladesh Journal of Bioethics 2012;3(3): 21-26 
 

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ISLAMIC PERSPECTIVE ON ARTIFICIAL REPRODUCTIVE TECHNOLOGY (ART) 
 
Autonomy: Person has right to choose freely his or her reproductive performance including his or her 
reproductive potential. Though reproductive choice is basically a personal decision, in fact it is not 
totally so. This is because reproduction is a process which involves not only the person who makes 
the choice, but it also involves the other partner, the family, society and the world at large (Serous 
2012). 
 
However, in Islam, rights are coupled with responsibilities and the collective rights of the family and 
society. Communitarian right must always be given priority over individual rights (Zawawi 2012). 
Family often remains the important subject for the patient’s decisions in relations with the doctor. 
Consequently families and the male guardians demand and expect to be part of the medical decision 
making process. Therefore, family concerns can take precedence over autonomy of patient to medical 
decision-making process. This can limit the patient’s autonomy (Atighetchi 2007). 
 
Abortion:  There are two anthropological models with major consequences on the bioethical positions 
concerning the start of life in Islam. According to majority scholar status of embryo as human is alleged 
to take place about 120 days after fecundation (4 lunar months plus 10 days) when self movement of 
embryo is established.  On the other hand, according to a minority thesis, embryo as human around 
the 40th day from fecundation is acknowledged. Therefore, life can be divided into two clearly distinct 
phases: without a soul and with a soul. The consequences can be very important on several levels, 
including the bioethical and criminal law levels. The abortion of a foetus without a soul should not be 
considered as equivalent to killing a human being (with a soul). However, the embryo or the foetus has 
a soul can offer them better protection (Atigatchi 2007).  
 
In some juridical or medical reasons, abortion is allowed after implantation and before ensoulment e.g. 
rape, mother’s life is in danger. If a choice has to be made to save either the fetus or the mother, but 
not both, then the mother’s life would take precedence. She is seen as the root, the fetus as an 
offshoot. Some modern Islamic opinions and rulings have also accepted prenatal diagnosis and 
accept abortion in severe congenital anomalies and malformations per se as a reason (Daa r and 
khitamy 2001).  
 
At the practical level, physicians who are aware of Islamic bioethics will understand that the provision 
of simple measures can make big differences for their Muslim patients. 
 
Invitro fertilization (IVF): Islam permits in-vitro fertilization, cryopreservation of gamete and artificial 
insemination with the husband. In vitro fertilization of an egg from the wife with the sperm of her 
husband and transfer of this fertilized embryo(s) back to the uterus of the wife is allowed, provided that 
the procedure is indicated for a medical reason and is carried out by an expert physician in order to 
reduce the chances of failure. If the marriage contract has come to an end because of divorce or death 
of the husband, medically assisted conception cannot be performed on the ex-wife even if the sperm 
comes from the former husband (El Ghar, and Serour 2000 cited in Inhorn 2006; Abduljubbar 2009). 
According to Islamic Jurisprudence (Shari’a Law) procreative and parenting relationships are lawful 
between valid spouses because of designated role-responsibilities (Lasker 2012). 
 
Surrogacy: All type of third-party reproductive assistance (ovum or sperm donation) is prohibited in 
Islam (Inhorn 2006). Introduction of sperm/ova other then husband/wife is as adultery (Zina). 
According to Sharia law, procreation is only allowed within a legally binding marriage and a child from 
without a valid marriage is illegal (Inhorn et al 2010). Use of third party gametes donation for 
reproduction is problematic as these violate the precepts of Islam concerning legitimacy, lineage, 
inheritance and incest. 
 
Gestational surrogacy is not permissible as it involves introducing the sperm of a man into the uterus 
of a woman to whom she is not married. Furthermore, confusion can be resulted from surrogate 
motherhood: who is the real mother, the genetic mother or the birth mother? For the definition of 
motherhood Qur’an says: their mothers are only those who conceived them and gave birth to them (Al 
Quran Surah al-Mujadalah 58: 2). Thus, this ayah categorically denies any rights of motherhood to the 



Bangladesh Journal of Bioethics 2012;3(3): 21-26 
 

 23 

genetic mother. Since neither the biological mother nor the surrogate has comprehensively fulfilled the 
definition of motherhood. There is problem to determine who the mother is in gestational surrogacy 
that will definitely lead to dispute and harm. In genetic gestation surrogate arrangement the child may 
be a source of perpetual stress for all parties involved which will invariably cause harm to the child 
also. “Harm is to be avoided before benefit is derived” is a well established maxim in Islamic law 
(Kholwadia 2012). 
 
Prenatal diagnosis: First trimester chorionic villous biopsy (performed before ensoulment) is allowed. 
Therapeutic foetal medicine may lead to a greater willingness to engage in genetic counseling and 
prenatal screening (Shaikh and Grady 2001). 
 
 
 
CASE ANALYSIS 
 
This methodology evaluates the ethical issues arising from clinical practice based on respect of human 
dignity. Its structure aim to organize the ethical analysis of case along the following steps:  
1. Collecting clinical data (The essential starting point in the ethical analysis of a clinical case consists 
in collecting clinical data, adopting a model if clinical analysis that considers not only strictly medical 
aspect but also personal, relational and cultural ones). 
2. Assessing responsibilities 
3. Identifying the ethical problems 
4. Proposing alternative solution and justifying ethical judgment 
 
 
1. COLLECTING CLINICAL DATA  
 
a) Medical aspect (Diagnosis, prognosis and potential treatment): Patient Nadia, had rapidly 
growing carcinoma of breast. According to medical history she has been suffering from breast lump for 
about four years. It is assumed that she is at stage III of breast cancer. She requires surgery and 
postoperative chemotherapy. As she is pregnant, termination of the pregnancy is advisable before the 
chemotherapy. Chemotherapy itself causes the foetal abnormality. 
 
b) Personal and relational aspect: Nadia is well educated. It is important to point out here that she is 
newly married. There has psychological tension as she fears that if she never be pregnant again. It 
may hamper personal happiness. She did not want to terminate pregnancy but she wants to do 
surgery and chemotherapy according gynecologist. Her husband, Alam is also well educated. He did 
not agree with the termination of pregnancy. He can not accept the loose of his baby as it is his first 
baby. From this point of view Alam is emotional in nature about the family. He has some religious 
misinterpretation on cryopreservation. But hehas right understanding on surrogacy in his religion. This 
misconception has risks to compromise with the medical benefit. 
 
c) Cultural aspects: Nadia’s case take place in cultural context (Bangladeshi Muslim). Culturally, 
husband has all responsibility and liability to take care of wife. Moreover, as a Muslim, communitarian 
right is given priority over individual rights. Consequently families and the male guardians demand and 
expect to be part of the medical decision making process. However, Bangladeshi women do not 
usually go beyond the husband decisions. It is very import point to make note that Alam should be 
included in all medical decision making process.  
 
 
2. ASSESSING RESPONSIBILITIES 
 
a) What are the specific responsibilities of health care professional in this given case? 
Considering the nature of disease the responsibility of healthcare professional are  1. To alleviate 
suffering based on the best interest of patient. 2. To communicate about the possible risk of the 
patient’s health and possible risk of foetal health after chemotherapy e.g. malformation. 
 
b) Has the patient (or his/her legal guardian) been adequately informed?  



Bangladesh Journal of Bioethics 2012;3(3): 21-26 
 

 24 

Patient is clearly well informed about the disease, prognosis and therapeutic possibility. But the legal 
guardian seems totally ignored. 
 
c) Has the family been adequately involved? 
It seems family is adequately involved since (1) He is providing the emotional support to the patient (2) 
taking care of his wife. (3)  He continuously supports the patients and dreaming for new life. 
 
d) What are the possibilities of social bodies (Social service. etc)?  Patient’s husband has some 
religious misinterpretation on ART (e.g.cryopreservation is not accepted in religion). The gynecologist 
only has concrete religion knowledge on abortion but has not complete information on religious verdict 
on ART.  Therefore, there is short come of religious interpretation on ART. Both the doctor and patient 
need help of social service e.g. spiritual. Counseling of by theologian/religious clergy in present of both 
doctor and patient and his family may support for the better understanding to get/provide the utmost 
medical benefit.  
 
 
3. IDENTIFYING THE ETHICAL PROBLEMS 
 
What ethical problems are involved in the evaluation of given case?  
a) Conflict of interest between doctor and patient and patient’s family. Pregnancy terminate or not  
b) Patient is informed and patient’s autonomy is only considered. Husband is ignored totally.  
c) Roll and responsibilities of the health care provider, the patient and the family are not clearly stated 
to avoid confusion and conflict. 
d) Surrogacy is advised that is against the precept of patient’s religion.  
e) Misconception of religious notion on abortion, cryopreservation and surrogacy of the legal guardian 
and attending doctor. 
 
What is the case, the main ethical problem? 
The clinical context of the case is the progressive, degenerative breast cancer couple with pregnancy 
of 5

th
 week. Doctor advises to terminate the pregnancy on the medical ground for the best interest of 

the patient before the surgery and chemotherapy. Patient does not want to terminate pregnancy due to 
emotional and social cause.  There is conflict of interest between doctor and patient regarding 
termination of pregnancy due to miscommunication and religious misinterpretation of ART. 
 
 
4. PROPOSING ALTERNATIVE SOLUTION  
 
What are the possible choices for this case? 
1. Termination of pregnancy and do surgery as early as possible for saving the patient.  
2. Cryopreservation of ovum for letter IVF for future pregnancy, in possible case by surrogacy. 
3. Communication between the doctor, patient and patient family to achieve the foreseen medical 
benefit.  
4. Group discussion with social body (theologian/religion scholar) and different stake holders e.g. 
doctor, patient and family  
4. Do surgery and go with pregnancy and then start chemotherapy after delivery. 
 
 
 
JUSTIFYING ETHICAL JUDGMENT:  
 
Among the above identified possible choice, which one better promotes in principle, the 
human dignity of the patients? Why 
 
Communication between the doctor, patient and patient’s family as well as group discussion with 
social body will remove the knowledge gap of medical and religion that may influence to change the 
decision of patient and patient’s family. This way, autonomy, beneficence, non maleficent and justice 
will be restored and better promotes the human dignity in the given case. 
 



Bangladesh Journal of Bioethics 2012;3(3): 21-26 
 

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Argument 1.   Termination of pregnancy and go for surgery as early as possible for saving the patient.  
The case presented here the chemotherapy is necessary for the patient’s health. If cancer spread her 
body it may kill the patient that is not desirable. Chemotherapy might cause a miscarriage of baby and 
severe developmental abnormalities in the fetus. The pregnancy itself may worsen her prognosis. 
Therefore, abortion would be advisable. 
 
Counter argument 1.   Family is the network of relationship. If discuss with family, he got the more 
responsibility and cannot take decision that is not good for patient health and future baby. Termination 
of pregnancy with the consent of not only patient but also her husband is needed. 
 
Answer to counter argument 1. Because, culturally her all social and medical responsibility on her 
husband’s shoulder and it is emerge that he is the only close relative of patient in foreign country.  
 
Argument 2.  The couple says that they would dearly love to have a child in the future and inform the 
physician that as well. Cryopreservation of ovum for letter IVF for future pregnancy by means of 
surrogacy may be good alternative this particular case. 
 
Counter argument 2. To retrieve and freeze her ova, before chemotherapy to be fertilized later would 
be permissible in patient religion provided the sperm, with certainty, came from her husband, and that 
at the time of fertilization they are still married and the husband is alive. 
 
Answer to counter argument 2. The option of surrogacy is broached by the physicians as an 
alternative. But problem is with the definition of legal mother in patient’s religion. The birth mother is 
the real mother, not the ovum donor. Surrogate cannot fulfill their desire to be mother. Surrogacy is 
therefore excluded. 
 
Argument 3.  Do surgery and go with pregnancy and then start chemotherapy after delivery.  
Doctor’s duty is to serve the patient.  So do surgery for the best interest of patient.   And continue the 
pregnancy as the patient wishes.  Respecting patient’s wish in principal better promote patient 
personal dignity. In this way family wish can be restored as well. 
 
Counter argument 3. Anesthesia during surgery have some complication on baby e.g. fetal syndrome 
distress and kill the baby within womb. 
 
Answer to counter argument 3. It is true that there will have complication of anesthesia during 
surgery on baby but it may be medically manageable. However, the drugs itself have possibility on 
serious affect on fetal development and growth. This may cause patient and her family especially for 
child burdensome and unbearable in future. 
 
 
WHICH CHOICE ACTUALLY BETTER PROMOTE THE HUMAN DIGNITY OF THIS PATIENT IN 
THIS PARTICULAR CASE? WHY?  
 
a) Facts related to this clinical contest Termination of pregnancy and do surgery as early as 
possible for saving the patient. Preservation of life means preservation of human dignity. 
 
b) Facts related to this particular patient 
 
C) Communication between the doctor, patient and patient’s family as well as group discussion with 
social body may remove the information gap of medical and religion that may influence to change the 
decision of patient and family. This way, autonomy, beneficence, non maleficent and justice will be 
restored and promotes the human dignity. 
 
 
 
 
 
 



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REFERENCES 
 
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and ethical approaches to surrogacy. Eubios Ethics Institute. http://www.Eubios.Info/ABC4/Abc4389  
(accessed on May 01, 2012) 
 
 
 
COMPETING INTERESTS: The authors declare that they have no competing interests.  
 
 
ACKNOWLEDGEMENTS: It has been a tremendous privilege to work on this case under the 
supervision of Dr Enrico Furlan, Course coordinator, EMMB, University of Padova. I express my 
sincere thanks for his constant criticism with support that provides me the way of thinking 
philosophically on this case deliberation BREAST CANCER WITH PREGNANCY IN CROSS 
CULTURAL SETTING..  My deepest gratitude to Dr. Marcello Ghilardi, Lecturer, University of Padova, 
Italy for  all the advice, attention and encouragement he has given me and the knowledge he has 
shared with me in this field. I express my sincere thanks to Prof. Corrado Viafora, Professor of Moral 
Philosophy, Chair of Bioethics, Department of Philosophy, Sociology, Educational Sciences and 
Applied Psychology, University of Padova for his every cooperation.  
 

http://www.ilmgate.org/the-islamic-ruling-on-surrogate-motherhood/
http://www.ilmgate.org/the-islamic-ruling-on-surrogate-motherhood/
http://www.banglajol.info/index.php/BIOETHICS/article/view/10865/7966
http://www.islamic-world.net/sister/h12.htm
http://www.islamic-world.net/sister/h12.htm
http://www.eubios.info/ABC4/Abc4389

