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IVF and Birth Defects: Is there a Moral Problem?

21 May, 12 | by Iain Brassington

It was reported a couple of weeks ago that researchers had found a link between certain forms of assisted conception and an increased risk of birth defects.  The paper, published in the NEJM, suggested that ICSI (intra-cytoplasmic sperm injection) correlated with defets in just about 10% of births.  The base rate is about 5.8%, rising to around a 7.2% defect rate from IVF.

Does this tell us anything of any great moral import?

Several things spring to mind.  One is that, granted the claim that it’s better not to be born with a defect, it’s presumably also better for assisted reproduction not to elevate the risk of defects above the natural level.  There might even be an obligation to do more research into assisted reproduction, so that we can ensure the fewest possible birth defects (and maybe get better at generating healthy babies than nature: even a rate of 5.8% looks a bit slapdash).  Slightly more radically, some might claim that there ought to be a moratorium on certain assisted reproduction procedures – ISCI in particular – for the sake of minimising the number of birth defects.

Let’s deal with the radical claim first (what can be said about that will also speak to the less radical one). more…

The benefits of contraception?

14 May, 12 | by David Hunter

The government in New Zealand is proposing to spend $1 million of funding for women on a benefit and their teenage daughters to get long-term reversible contraception – such as an implant. Advice on accessing this treatment and its implications will be provided by case workers in the Social Services.

The NZ government seems almost surprised that some people have been offended by the suggestion of this policy asserting that this is not interfering in the reproductive life of beneficiaries, and is just common sense – the Prime Minister John Key said

“Ultimately if people have unplanned pregnancies and are solely dependent on the state, you the taxpayer have to pay for a long period of time for that dependency and we know the outcomes aren’t terribly good.”

While I think they are quite right that this is not interfering in the reproductive life of beneficiaries this doesn’t exhaust the potential array of ethical issues involved in this sort of proposal.

It isn’t inherently coercive since offers are typically not coercive. However the close association between medical care and social services seems a little more sinister since it makes a connection (however unintended) between receiving social support and receiving this reproductive advice – and perhaps in the minds of some in taking it.

Could this connection be abused? Certainly. As one beneficiary notes

“she had already been told by a case officer to “shut your legs” I’ve even heard WINZ people say things worse than that to women. “I go in there for a fight, for an argument, every time. There are people in there who have huge power control issues and they just make it worse for us. They take their job description way too far.”

This doesn’t surprise me at all, any time policy is implemented it will sometimes be misapplied. And Work and Income New Zealand (WINZ) can be somewhat inflexible – when my first wife Kerry passed away I had to cancel her sickness benefit (she had cystic fibrosis) so her brother and I went into the nearest WINZ office to inform them. We were told we would need to fill in a change of circumstances form, and once we had completed this we were told that they couldn’t accept it because it would need to be signed by the recipient of the benefit… We eventually sorted it out, although we left with a copy of the paperwork to show to her…

Ronald Dworkin in his book Sovereign Virtue argues that the first and heaviest responsibility of a government is to treat its citizens equally. Does this constitute equal treatment? Targeting those on benefits in this way doesn’t seem to to me.

Providing long term contraception in general is a good thing (assuming cost-effectiveness & safety of course) since it provides for greater reproductive autonomy. But I’m not sure reproductive services ought to be targeted at the poor in this fashion. It seems to display the attitude of the government towards the reproduction of some of society’s poorest members – namely that it would be better if they didn’t breed – or as the government puts it “breaking the cycle of intergenerational welfare dependency”. And I am not sure that is an attitude that is defensible. While solving the cycle of intergenerational welfare dependency would be laudable, this strikes me more as a dissolution than a solution to the problem.

How Abortion Law Works in Texas

16 Mar, 12 | by Iain Brassington

Remember a little while ago there was a rash of proposals in the US that’d force women to see a sonogram of the foetus, or to listen to detailed descriptions of it, before having an abortion?

Yeah: them.  Well, via Ophelia, here’s an account of what really happens.

Halfway through my pregnancy, I learned that my baby was ill. Profoundly so. [...] “I’m worried about your baby’s head shape,” she said.  “I want you to see a specialist—now.”

[... B]efore I’d even known I was pregnant, a molecular flaw had determined that our son’s brain, spine and legs wouldn’t develop correctly.  If he were to make it to term—something our doctor couldn’t guarantee—he’d need a lifetime of medical care.  From the moment he was born, my doctor told us, our son would suffer greatly.

So, softly, haltingly, my husband asked about termination.  The doctor shot me a glance that said: Are you okay to hear this now?  I nodded, clenched my fists and focused on the cowboy boots beneath her scrubs.

She started with an apology[...]

That’s not a good start, is it?  An expression of sympathy, maybe.  But an apology?  It’s as if she knows that things are about to get worse.  And they are. more…

Workshop: The Baby Gaga Saga: Regulation of Human Products and the Politics of Breastfeeding

8 Mar, 12 | by David Hunter

Posted on behalf of Sorcha Uí Chonnachtaigh.

All are welcome to our multi-disciplinary workshop on the regulation of human breast milk and the ethics and politics of breastfeeding! Please circulate the programme and information below to anyone who may be interested.


Some Responses to Giubilini and Minerva

5 Mar, 12 | by Iain Brassington

I did mention last week that I’d post links to sites that mentioned Giubilini and Minerva’s paper as they crossed my radar; but it turned out very quickly that there’d be no way to keep up.  And, to be frank, a lot of the blogosphere’s response has been fairly scattergun outrage rather than dispassionate engagement with the paper, and directed at Giubilini and Minerva themselves rather than at the argument they put forward.  There’s been much more heat than light.

This is perhaps unsurprising, as considered responses are almost certainly going to take a while to materialise.  However, they have begun to appear.  Here’s the first that I’ve spotted; I’ll post links to more in this thread as and when.  And if any readers have responses on or SSRN that they’d like mentioning, or if anyone spots anything of interest, do let me know. more…

An open letter from Giubilini and Minerva

2 Mar, 12 | by Iain Brassington

When we decided to write this article about after-birth abortion we had no idea that our paper would raise such a heated debate.

“Why not? You should have known!” people keep on repeating everywhere on the web.  The answer is very simple: the article was supposed to be read by other fellow bioethicists who were already familiar with this topic and our arguments.  Indeed, as Professor Savulescu explains in his editorial, this debate has been going on for 40 years.

We started from the definition of person introduced by Michael Tooley in 1975 and we tried to draw the logical conclusions deriving from this premise.  It was meant to be a pure exercise of logic: if X, then Y.  We expected that other bioethicists would challenge either the premise or the logical pattern we followed, because this is what happens in academic debates.  And we believed we were going to read interesting responses to the argument, as we already read a few on this topic in religious websites.

However, we never meant to suggest that after-birth abortion should become legal.  This was not made clear enough in the paper.  Laws are not just about rational ethical arguments, because there are many practical, emotional, social aspects that are relevant in policy making (such as respecting the plurality of ethical views, people’s emotional reactions etc).  But we are not policy makers, we are philosophers, and we deal with concepts, not with legal policy.

Moreover, we did not suggest that after birth abortion should be permissible for months or years as the media erroneously reported.

If we wanted to suggest something about policy, we would have written, for example, a comment related the Groningen Protocol (in the Netherlands), which is a guideline that permits killing newborns under certain circumstances (e.g. when the newborn is affected by serious diseases).  But we do not discuss guidelines in the paper.  Rather we acknowledged the fact that such a protocol exists and this is a good reason to discuss the topic (and probably also for publishing papers on this topic).

However, the content of (the abstract of) the paper started to be picked up by newspapers, radio  and on the web.  What people understood was that we were in favour of killing people.  This, of course, is not what we suggested.  This is easier to see when our thesis is read in the context of the history of the debate.

We are really sorry that many people, who do not share the background of the intended audience for this article, felt offended, outraged, or even threatened.  We apologise to them, but we could not control how the message was promulgated across the internet and then conveyed by the media.  In fact, we personally do not agree with much of what the media suggest we think.  Because of these misleading messages pumped by certain groups on the internet and picked up for a controversy-hungry media, we started to receive many emails from very angry people (most of whom claimed to be Pro-Life and very religious) who threatened to kill us or which were extremely abusive.  Prof Savulescu said these responses were out of place, and he himself was attacked because, after all, “we deserve it.”

We do not think anyone should be abused for writing an academic paper on a controversial topic.

However, we also received many emails from people thanking us for raising this debate which is stimulating in an academic sense.  These people understood there was no legal implication in the paper.  We did not recommend or suggest anything in the paper about what people should do (or about what policies should allow).

We apologise for offence caused by our paper, and we hope this letter helps people to understand the essential distinction between academic language and the misleading media presentation, and between what could be discussed in an academic paper and what could be legally permissible.

Alberto Giubilini and Francesca Minerva

Why Is Infanticide Worse Than Abortion?

2 Mar, 12 | by BMJ

Guest Post by James Wilson

The controversy over the Giubilini and Minerva article has highlighted an important disconnect between the way that academic bioethicists think about their role, and what ordinary people think should be the role of bioethics.  The style of this dispute – its acrimony and apparent incomprehension on both sides – are a sure sign that we as bioethicists need to think harder about what we are doing, and who we are doing it for.

At the heart of tempest has been the authors’ claim that abortion and infanticide are morally equivalent. Nearly everyone will agree that the authors are wrong about this, and that infanticide is and should always remain beyond the pale.

The US Born-Alive Infants Protection Act 2002 stipulates that the category of person – and the full protection due to persons – must be extended to “every infant member of the species homo sapiens who is born alive at any stage of development“.  The deep question – from the perspective of academic ethics – is why every human being that is born alive should count as a person.

Often in bioethics the most difficult task is to articulate just what it is that lies behind the sorts of intuitive moral certainties that we all have: that is, to make clear to ourselves, and to those who are inclined to hold opposing views, just what our confidence in our own intuitive moral judgments is based on.  This is often extremely difficult to do.

Why Some Bioethicists Think that Birth does not Matter

At the heart of Giubilini and Minerva’s claim that infanticide is morally on a par with abortion is the premise birth by itself does nothing to change the moral status of a developing human.

According to them (and like minded philosophers such as John Harris, Peter Singer and Michael Tooley) what makes the difference between a person and something that isn’t a person must be something to do with the capacities and abilities that a person has.  On such views, if we want to say that all human beings should count as persons then we need to provide some account of what feature or features it is that all human beings have that renders it appropriate to treat them as persons.  The feature of being born alive to a human mother does not – according to them – fit the bill.

According to these philosophers, this definition of “person” is both too narrow, and too broad.  It’s too narrow, because it’s clear that there could be intelligent alien species who had the ability to engage in moral thinking; but yet who clearly would not be born to a human mother.  They need not be born at all: perhaps the aliens from the planet Zog assemble themselves out of flatpacks from an interplanetary Ikea.  But so long as they are able to live and to value things as we do, why should we deny them the status of persons?  To do so looks like a human-centred chauvinism, no more than speciesism.

But the feature of being born alive to a human also looks too broad: what if the brain of the infant has been irreparably damaged, so that it will remain in its intellectual functioning at a level far below that of a chimpanzee and will never be able to love, to form plans or even to recognize itself in the mirror?  Why (and in what sense) does an infant like this count as an equal of a fully functional adult?

John Harris has argued that we should strike down the thought that it is being born that makes the difference.  As he once put it, “the geographical location of the developing human, whether it is inside the womb or not, is not the sort of thing that can make a moral difference”.  (Even here, he was careful to clarify – as he has on this blog, that he was neither advocating infanticide, nor arguing for a change in the law.)

A Poor Reply: Banging the Table

The cheapest and easiest response to this challenge is to merely bang the table and assert the sheer obviousness of the difference that birth makes.  As an example of this approach, Richard Nicholson once accused John Harris of indulging in “a philosopher’s mind game”.  He continued, “He is wrong in saying there is no moral change that occurs in the process of birth.  That is a change that is recognised in the law.  Most parents would recognise their views about their newborn baby are considerably different than their views about the foetus in the mother a day earlier.”

All this, one feels, may be true; but it is hardly intellectually satisfying.  Just because most parents would feel differently, it doesn’t in itself follow that they are justified in changing their feelings this way.  It’s weak to counter an argument that puts forward reasons by merely appealing to force of numbers – pointing out that most people judge the same way you do.

Explaining the Significance of Birth

If we want to defend the moral significance of birth, then we need to provide some positive account of why birth matters.  I want to outline very briefly three possible positive accounts.

(1) The infant now counts as a person because he or she is now a separate living entity: he or she is viable and is not dependent on anyone else for existence.

Some worries: it seems that this explanation misfires, because ‘being a separate living entity’ is both too broad, and too narrow, to serve as the feature that makes the difference between a person and a non-person.  It’s too broad because dogs and cats are separate entities in their own right, but this does not make them persons.  But it’s too narrow, because there can be persons who are not viable separate living entities: both of a pair of conjoined twins can count as separate persons, but in a severe case it might be quite impossible for both to be able to survive separation.

(2) The infant was already a person, previously it was lodged in the mother’s body like a guest lodged in a house owned by someone else.

On this view, there were conditions under which it would have been legitimate to expel the foetus despite the fact that it was a person (in circumstances such as those that Judith Jarvis Thomson considers in her famous defence of abortion, for instance). The significance of birth is that all these reasons that the mother may have to abort the foetus are then defeated.

Some Worries: This approach seems initially promising, but it may only push the problem further back: (a) we now need to give some non-arbitrary account of why the foetus was already a person, and how it became a person. (b) On this view it turns out that it isn’t birth that is actually doing the work here in making an entity a person.

(3) Ethical vision beyond explicit arguments

Charles Taylor makes a useful distinction between two different modes of ethical argumentation, which he calls offering basic reasons and articulating a vision of the good.  As he says in Sources of the Self, “It is one thing to say that I ought to refrain from manipulating your emotions or threatening you because that is what respecting your rights as a human being requires.  It is quite another to set out just what makes human beings worthy of commanding our respect, and to describe the higher mode of life and feeling which is involved in recognising this.”

Ethicists often place a very high degree of value on explicitness and arguments from consistency, invoking basic reasons in Taylor’s sense.  A key part of Giubilini and Minerva’s argument has the following structure, for instance:

1. Persons are creatures with feature F.

2. The newborn does not have feature F.

3. Therefore the newborn is not a person.

A large part of the acrimony of the dispute seems to arise from the fact that many feel that to adopt this kind of schema fundamentally misunderstands the foundations of ethical consciousness.  For them, what is foundational is the fragility of the life of the infant, and that once that has been appropriately noticed or articulated, one should be called upon to respond.  So on this view, the answer may not be to describe those valuable features of human beings in terms that are applicable to any potential being at all, but rather to draw attention to just what it is about human being that we mean when we talk about the intrinsic dignity and value of human life.

This is something that is extremely difficult to do within the confines of analytic philosophy.  For such articulation of the phenomenology of our fundamental moral commitments, literature is far more powerful.  I’ll conclude this post with a bit from Tolstoy’s Anna Karenin, which perhaps provides some of this vision.  Levin is struck by wonder at the birth of his son:

Meanwhile, at the foot of the bed, in Lizaveta Petrovna’s skilful hands flickered the life of a human being, like the small uncertain flame of a night-light – a human being who had not existed a moment ago but who, with the same rights and importance to itself as the rest of humanity, would live and create others in its own image… Whence, wherefore had it come, and who was it? He could not understand at all, nor accustom himself to the idea. It seemed to him too much, a superabundance, to which he was unable to get used for a long time.

A Conscience Clause with Claws

16 Dec, 11 | by Iain Brassington

There’s a flurry of papers on conscientious objection in the latest JME: Giles Birchley argues, taking his cue from Arendt, that conscientious objection has a place in medicine here; Sophie Strickland’s paper on medical students’ attitude to conscientious objection (which I mentioned in July) is here; and Morten Magelssen wonders when conscientious objection should be accepted here.

All this is coincident with the recent passing of the “Protection of Life” Bill by the American House of Representatives.  This also has a significant clause about conscientious objection: I’ll come to that  in a little while.

Magelssen claims that conscience is important for integrity, and there is a social interest in protecting integrity.  His position is that objections should be accepted if

1. Providing health care would seriously damage the health professional’s moral integrity by (a) constituting a serious violation (b) of a deeply held conviction.

2. The objection has a plausible moral or religious rationale

3. The treatment is not considered an essential part of the health professional’s work

4. The burdens to the patient are acceptably small ((a) The patient’s condition is not life-threatening; (b) Refusal does not lead to the patient not getting the treatment, or to unacceptable delay or expenses (c) Measures have been taken to reduce the burdens to the patient)

5. The burdens to colleagues and healthcare institutions are acceptably small

As elaboration, he claims that “[a]n objection does not have a plausible rationale if it is based on erroneous factual premises”.  more…

A Philosopher Writes on her own Infertility

13 Dec, 11 | by Iain Brassington

Over at Feminist Philosophers, there’s a great little series of posts by an anonymous female philosopher about her experience of becoming infertile.  It’s well worth a read: part 1 is here; part 2 here; and part 3 here.

I’m going to take the liberty of reproducing the penultimate paragraph:

My partner and I are a family. We are a childless family, but that doesn’t make our family any less real or legitimate.  The implication that people who don’t have children don’t have families – don’t have parents and siblings, aunts and uncles, nieces and nephews, partners, friends, pets – is beyond insulting.  People have sometimes clarified their comment by saying that they were talking about a “nuclear family” (whatever that means).  But just as I have an extended family, I also have a nuclear family.  We are simply a family of two, rather than some n greater than two.  Likewise, people without children and without romantic partners have nuclear families just as much as I do – those families are simply composed a little differently than my own.  Whatever child-bearing abilities infertile women may lack, they do not lack families.

Yes!  There’s lots of ways to have a family.  Sometimes it involves a genetic link; sometimes a gestational one; sometimes a genetic and gestational one.  But it doesn’t have to.  A person can have kids that are neither genetic nor gestational; or they can not have kids at all.  And they’re all possible ways of having a family.

And in that case, the surgeons mentioned in part 1 who suggested deferring surgery in order to preserve the chance of having a family… well, they were just plain wrong.  Doubtless well-intentioned, but plain wrong.

(Thanks to Catarina for the pointer.)

Personhood in Mississippi

13 Nov, 11 | by Iain Brassington

Phew, I thought, when I heard that Measure 26, the proposal to redefine “personhood” to cover the unborn, had been thrown out by the electorate of Mississippi.  To catch up: the prosaically-named piece of legislation would have

amend[ed] the Mississippi Constitution to define the word “person” or “persons”, as those terms are used in Article III of the state constitution, to include every human being from the moment of fertilization, cloning, or the functional equivalent thereof.

(In the end, 58% of the electorate voted against it; it is, for now, dead.)

In the light of this, it’s a bit of a disappointment to learn that there’s still a live-and-kicking (if you’ll excuse the expression) attempt to achieve the same thing, only this time on a national level: H.R. 212 IH aims to protect all human life from the moment of conception.

A curious feature of such attempts is the weight they put on defining the moment at which life starts; thus HR 212 specifically states that

the life of each human being begins with fertilization, cloning, or its functional equivalent, irrespective of sex, health, function or disability, defect, stage of biological development, or condition of dependency, at which time every human being shall have all the legal and constitutional attributes and privileges of personhood

- a point that is singularly unimportant.  What counts is not when a (discrete) human life begins, but when that life becomes morally important enough to warrant legal protection.  But, still: let’s imagine a world in which one of these proposals, or one significantly like them, makes it on to the statute books.  Leaving aside, too, the difference between the meanings of the word “personhood” in the mouth of the lawyer, the philosopher, and the person on the street, would they make all that much of  a difference? more…

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