Sexual and reproductive health, defined as the physical, mental, and social state related to sexuality and the reproductive capacity of individuals, involves various aspects and procedures, some of which are controversial and raise ethical dilemmas regarding what is considered morally correct. Bioethics is a discipline concerned with examining the ethical dilemmas that arise in the field of health and biology. In the context of sexual and reproductive health it plays a crucial role in addressing reproduction, fertility control, sexual health, and other related issues.

It is important to note that ethical debates in sexual and reproductive health are complex and vary according to the cultures, religious beliefs and legal frameworks of each country. Bioethics provides a basis for analysis and reflection on these issues, encouraging an ethical and respectful approach to the sexual and reproductive health of individuals. In sexual and reproductive health, bioethics deals with complex and controversial issues, such as the right to reproductive autonomy, the ethics of human reproductive research, genetic manipulation, the use of assisted reproductive technologies and the voluntary interruption of pregnancy, among others.

Considering the above, this symposium includes four topics that are complex and generate controversy:

The first topic is related to the bioethical aspects of therapeutic abortion in girls and adolescents under 15 years of age. If abortion is already a topic that generates conflict and controversy, abortion in girls and adolescents induces even more conflict and controversy. In our country, abortion in adolescents in general and in adolescents under 15 years of age in particular is a public health problem awaiting solution and is immersed in reproductive health care.

Adolescent pregnancy occurs because many of the developmental changes related to adult reproductive capacities are usually completed long before intellectual capacities are fully mature as well as decision making and awareness regarding their future. It is generally an unplanned or unexpected pregnancy that occurs in a woman or couple who are economically dependent on others, who do not have a stable relationship and who are usually forced to interrupt their personal development process (schooling, employment, life plans). The girl or adolescent under 15 years of age is often abandoned by her partner and/or family when she has not yet acquired physical or psychological maturity.

To address this issue is to talk about a human-rights and public health problem which, despite its frequency and the implications it has on physical, emotional and social health, still lacks a multisectoral health approach and ethical content, as it is a population group that is quite unprotected in terms of health.

Another important aspect is that these pregnancies may not occur after consensual relations when girls and their partners start their sexual activity, without having considered contraception or without access to appropriate services, but after being exposed to gender-based violence, especially sexual violence, which further aggravates the situation.

The question of abortion following an unintended pregnancy in girls and adolescents under 15 years of age is a complex issue that gives rise to dilemmas between the ethical principles of the relationship between a patient and health care providers, even more so if it is raised in the context of therapeutic abortion, which has its regulations already established by the Ministry of Health. For this reason, it is of great interest to learn how therapeutic abortion in girls and adolescents under 15 years of age is proposed by Dr. Luis Távara who has been working for many years on this and other issues related to sexual and reproductive health and can provide a solution for these people.

In the next topic, Dr. Miguel Gutiérrez develops the issues of abortion, assisted reproduction and contraception. He refers that in the last 50 years there have been advances in assisted reproduction, in contraception and in the approach to abortion. However, in the past few years these issues have been facing setbacks worldwide, often as a result of ideologies rather than scientific knowledge, which give rise to opposing opinions of individuals or institutions, not always the result of a fair, honest, non-ideologized reflection, and not considering the welfare of people. Sometimes, it is the result of the satisfaction of a personal or institutional interest. While it is true that in our country therapeutic abortion is legal, other types of abortion such as eugenic abortion or abortion for rape are still illegal and safe abortion is always questioned, and in some countries such as the U.S. is in decline.

If there is one area of medicine where the advance of science and medical technology has generated a great development, it is in the treatment of infertility since the birth of Louise Brown in 1978 -the first 'test-tube baby' in the world-. The success rates of assisted fertilization procedures are getting better and better, but this development is not without ethical questions that always need to be analyzed.

Concluding his paper, Dr. Gutiérrez refers to the subject of contraception with the topic of emergency oral contraception, which in March 2023 focused the attention of the population when the free distribution of the emergency oral contraceptive pill was approved by the Constitutional Court after years of debate. This ended the inequity that the pill could only be purchased in pharmacies, but not distributed free of charge by state health services. Emergency oral contraception is now available to the entire population, although some conservative groups continue to question its use.

There are several assisted fertilization treatments, incredible procedures that modify the conceptions of life and death and make possible the dream of many couples to achieve the desired child. The principle of biological life with spontaneous conception and the consideration of the beginning of the human person has changed considerably with the appearance of in vitro fertilization and its variants, and its limits have come to be questioned, which should be established considering the respect for the dignity of the person.

We observe multiple factors that go beyond the purely technological field and involve ethical, religious and social aspects, such as the performance of procedures on single persons, same-sex couples or, as is the case of the so-called surrogate uterus, in which the uterus of another woman is used to carry the pregnancy when the genetic mother (who provides the egg) cannot carry the pregnancy, either because she has no uterus or because it is seriously affected by some pathology. The recognition by the Health Organization of sexual and reproductive health rights (1994) has meant a milestone that has allowed the realization of various assisted fertilization procedures, such as surrogacy or surrogate motherhood. However, this in turn creates the need to seek proposals for ethical and legal solutions, since the problem is not technical but basically legal, since according to our legislation 'the child belongs to the one who gives birth to it', and a whole problem is generated after birth with the identity of the newborn.

On the other hand, ethical conflicts arise where, in the background, there is the respect for the rights of the intervening persons and the different cultural and economic contexts where this medical practice is developed.

Dr. Virginia Garaycochea develops this complex issue, which, although it solves the problem of infertility, has several nuances that need to be analyzed. On the one hand, there are liberal positions and, on the other hand, quite conservative positions. Ethical reflection can help us to find the right middle ground, considering the primacy of reality. The problem exists and must be solved but considering respect for the rights and dignity of the persons involved.

The last topic of this symposium refers to cesarean section at maternal request, also known as 'cesarean section on demand' or elective cesarean section, in which the pregnant woman, using her autonomy, asks the obstetrician-gynecologist to terminate her pregnancy by cesarean section, without any medical indication other than the desire of the pregnant patient. The request for cesarean section by the pregnant woman raises some important bioethical aspects to consider and that should be analyzed in order to provide an answer to them, such as:

All these aspects are analyzed by Dr. Enrique Guevara on a central aspect of controversy, which is the issue of autonomy with respect to the route of termination of pregnancy. The question may be: why is it considered appropriate for the pregnant woman to exercise her autonomy when she requests a vaginal delivery and why is it questioned when, exercising the same right to freedom of decision over her body, she requests a cesarean section?

Medical ethics orients the conduct of physicians towards the good, towards seeking the right, the ideal and excellence. Medical deontology, on the other hand, establishes what doctors should and should not do in order to act ethically. For this reason, it is important what each of the authors tell us so that the actions and behaviors proposed by them help us to make appropriate decisions within the framework of bioethics with respect to the topics chosen for this symposium.