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). One possible rationale for it would be that it’s strange for the NHS to fund procedures that will result in creating people who are more likely to require NHS treatment. (Let’s stick to the public sector for the sake of simplicity: this is only a blog, after all…) Fair enough: but there’s a number of tacit, but unexamined, claims here. One is that the costs to the NHS will be ongoing, rather than one-off. If a defect can be corrected with a just one procedure, then the difference seems to evaporate. After all, there is a higher chance that people without birth defects will suffer from sporting or industrial accidents (on the assumption that, when we consider birth defects in a sufficiently general way, people who have them are less likely than people who don’t to engage in certain dangerous physical pursuits): when that probability is multiplied through to cover the population as a whole, it might turn out that those without a birth defect actually cost more.
If the defect requires ongoing treatment, then there’s still a question to be asked about whether the cost argument is powerful. There’s no reason to suppose that a person with a condition requiring ongoing treatment is going to be economically inactive, though. And even if we’re really going to ramp up the thought experiment so that we’re specifically dealing with someone who generates a consistent and ongoing drain on public resources – such a person is a possibility – there’s still a question about whether this bare economic analysis really tells us all that much about what policy should be. Even with a hyperbolically medically demanding person, we might still think that the moral argument isn’t complete unless we happen to think that the value of healthcare is reducible to questions of cashflow. It might be. But we can’t take it for granted – and my hunch is that there’s at least a strong intuition that there’s more to say.
What about another rationale: that we ought, as far as possible, to ensure that babies are born healthy, and that (correspondingly) we ought to avoid deliberately embarking on procedures that create an increased risk of health problems?
This might appear to be particularly powerful if we think that there’s no right to reproduce or (relatedly) that the genetic link between parents and children isn’t important. As regular readers of this blog will know, I’m sympathetic to both these claims: I think that the importance of genetic relationships is massively over-inflated (I don’t think that they’re really important at all), and I don’t think that there’s much hope of sustaining a positive right to reproduce in the light of that claim.
But – all the same – I’m also not swayed by the idea that an increased risk of defects makes much of a case for a moratorium. That would only really work if you buy into procreative beneficence – but the idea of PB does seem rather to skate over the idea that a less-than-best-possible life might still be worth living, and that it’d be odd to criticise people for not having a less-than-best-possible child. (Becki has written on this, and I’ve not seen a convincing rebuttal yet.)
There’s likely to be some lives that aren’t worth living; and it might be wrong knowingly to create them. But even ISCI doesn’t knowingly create them: to use that is knowingly to create a life that might not actually worth living – but the same applies to all deliberate procreation; I suspect that there’s a distinction to be drawn between foreseen and intended outcomes here. Moreover, the foreseen outcomes come at a discount, because there’s only a 10% chance of any kind of defect at all. The risk of it being severe will be lower; and the risk of it being so severe that the life created isn’t worth living is lower still. Most lives, disabled, ill, with a birth defect, or none of those, are worth living.
This point speaks to the first, less radical, of the claims above. Granted that it might be better to create defect-free lives, it doesn’t follow that it’s bad not to. By the same token, while it might not be good to generate defects, it doesn’t follow that it’s bad to generate lives with defects; lives are usually morally separable from the characteristics that they have.
There don’t seem to me to be any particular moral problems raised by the research findings – and, anyway, the authors of the NEJM piece themselves admit that
[though t]he risk of birth defects associated with ICSI remained increased after multivariate adjustment, although the possibility of residual confounding cannot be excluded.
I don’t really see a need to worry.