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Richer views of the ethics of reproduction.

Writing in the Wall Street Journal in March, Jerome Groopman discussed the recent case of the thirty-year-old woman who screened her IVF embryos for the early-onset Alzheimer's gene that she herself carries. Although the woman will likely succumb to Alzheimer's disease before her daughter reaches her tenth birthday, the girl at least will presumably be free of this disease. Groopman had little patience with the reservations raised about this case by physicians and ethicists. Those who oppose preimplantation genetic diagnosis (PGD) to screen for genetic disease, he wrote derisively, "do so primarily because of religious beliefs." To the concern that this girl would grow up in a household where her mother would soon be neurologically compromised and incapable of caring for her, Groopman simply affirmed the judgment of the physician who performed the PGD that such decisions should be left to the parents.

I begin with this op-ed piece because it illustrates the sort of narrow, individualistic model of moral reflection that often passes for serious analysis of reproductive medicine. Groopman would do well to read both of the books under review, for both Shanley and Ryan--albeit in very different ways--make the case that it is not enough simply to attend to the desires of prospective parents. Indeed, both Shanley and Ryan argue that we need to reconceptualize debates about reproductive medicine in order to discharge the grave responsibility we have in bringing children into the world.

Shanley examines this responsibility to children through the lens of family law. As we have responded to the challenges posed to traditional definitions of parenthood and family by reproductive technology, there has been a tendency to rely, as apparently Groopman does, on the principle of the primacy of individual liberty. The problem with this, says Shanley, is that we live in a society structured by sexual, racial, and economic inequality and governed by market mechanisms. In such a society, unregulated procreative liberty is not likely to safeguard the welfare of children.

In order to articulate an alternative to an atomistic, individualistic approach to family law, Shanley undertakes a child-centered analysis of various ways of creating families, including adoption, sperm and egg donation, and surrogate motherhood. Although she continues to use the language of rights, her nuanced analysis of parenthood demonstrates that parental rights "should not be viewed as pertaining to an individual per se, but only to an individual-in-relationship with a dependent child" (p. 63). For this reason, parental rights are grounded on more than genetic connection; they rest on a foundation of concrete acts of care and commitment to children.

This analysis of parenting and parental rights grounds most of the normative claims Shanley makes. She argues, for example, that unwed biological fathers may have parental rights, but not simply on the basis of genetic connection. Because parental rights are based on both genetic connection and concrete care, unwed fathers cannot seek custody merely by asserting genetic paternity and meeting a minimal "fitness" test. Instead, a genetic relationship, writes Shanley, "becomes a reason to look to see if he has attempted to assume responsibility for the child, and has done so without interfering with the mother's well-being" (p. 62).

Her reasoning about the system of gamete transfer in the United States is similarly shaped by a child-centered perspective. According to Shanley, the current policies and practices governing gamete transfer are designed to serve the interests of adults rather than of children. For example, the practice of secrecy and anonymity fails to recognize that children may have interests in knowing the identity of their genetic forebears (p. 90). So, too, does a market in gametes create the possibility that children may come to see themselves as worth less, if the gametes used in their conception were not highly valued.

Although Shanley occasionally reverts to an individualistic, volitional account of rights and responsibilities, on the whole her book offers a carefully reasoned and persuasive argument that parental rights and responsibilities must be defined by children's needs and not by parents' interests.

Although Ryan is more concerned about issues of distributive justice and access to assisted reproduction than Shanley, she shares Shanley's negative assessment of the liberal, individualist model of procreative rights. Like Shanley, Ryan decries the way in which reproductive medicine frames infertility treatment and the quest for children merely as matters of consumer choice. As Ryan puts it, the prevailing paradigm of procreative liberty "encourages an objectifying notion of `acquiring children' over a relational notion of `having children'" (p. 97). According to Ryan, we need to move beyond a conception of procreative liberty that focuses on an individual's right to privacy to a social conception of rights that emphasizes social and relational responsibilities.

To that end, Ryan undertakes an analysis of the economic, ethical, and political realities of reproductive medicine. In chapters on the ethics and economics of infertility, on access to infertility services, and on reconceiving procreative rights, Ryan combines a feminist commitment to the welfare of women with a Catholic vision of the common good to argue that assisted reproduction is not a private matter and that access to infertility treatment should not be left to an unregulated market. As Ryan trenchantly remarks, "inequalities of access mask social judgments about who is fit to reproduce" (p. 33). Indeed, a review of the demographics of infertility reveals that some of the medical and social causes of infertility disproportionately affect poor women and women of color. This fact, combined with the recognition that infertility separates the infertile from important relationships and goals that help shape self-identity, leads Ryan to argue that a concern for social justice may require us to acknowledge a right to assisted reproduction.

As with Shanley, however, Ryan makes clear that any talk about rights must be framed in social terms. Thus to talk about a right to assisted reproduction does not mean that individuals have claims against the community but rather that procreation is an individual and social good, such that individuals and societies share mutual accountability for the welfare of children and the human flourishing that having and raising children may bring. This notion of mutual accountability is precisely what an individualistic conception of procreative liberty, like that developed by legal scholar John Robertson, cannot provide. Robertson ultimately seeks a way to limit procreative liberty in extreme cases, such as reproductive cloning, but given his reductive account of the meaning of reproduction to an individual's interest in procreating, Ryan concludes that he has no coherent way of limiting reproductive technology.

The case with which I began shows best the great value of these two books. Ryan's articulation of a social conception of rights suggests that any analysis of the decision to screen for the gene for early-onset Alzheimer's that frames the issue primarily as one of parental choice will be inadequate. "Because consistency and intimacy in nurture contribute to the development of intellectual and emotional capacities in children," Ryan writes, "there are good reasons to question reproductive practices that detach interests in creating offspring from commitments to care for them ..." (pp. 111-12).

Shanley's list of questionable reproductive practices would not be the same as Ryan's, but she, too, would insist that the needs of children mandate constraints on procreative liberty. Parental rights are not solitary rights. "Only by taking account of the dependency, reciprocity, and responsibility of family relationships; current gender inequality; and the primary of children's needs," says Shanley, "will we be able to overturn models of family life and move toward a world that takes seriously men's and women's equality and children's right to committed parents and to care."

John Evans has recently noted that bioethics discourse has become so thin and preoccupied with autonomy that the primary concern raised about germline genetic engineering for enhancement purposes now appears to be that the child who would be created could not give his consent to such a procedure, because he does not yet exist. I have not yet heard such an argument made about preimplantation genetic diagnosis, but it would not surprise me to hear some bioethicist worry more about whether the Alzheimer's-gene-free child could have consented to PGD than about the pain and suffering this child will endure when her mother disintegrates before her eyes. The great merit of both books reviewed here is that they move away from the stultifying and unnatural run way-model thinness of so much contemporary work in bioethics. Carefully researched and reasoned, thick with accounts of what human flourishing requires in parent-child relationships, both these books are fine and welcome additions to the literature on the ethics of assisted reproduction.

Making Babies, Making Family. By Mary Lyndon Shanley. Boston: Beacon Press, 2001. 206 pp. $27, cloth.

The Ethics and Economics of Assisted Reproduction. By Maura A. Ryan. Washington: Georgetown University Press, 2001. 183 pp. $44.95, hardback.

Paul Lauritzen is chair of the Religious Studies Department and director of the Program in Applied Ethics at John Carroll University in Cleveland. He is editor of Cloning and the Future of Human Embryo Research (Oxford, 2001) and co-editor with Diana Fritz Cates of Medicine and the Ethics of Care (Georgetown, 2002).
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Author:Lauritzen, Paul
Publication:The Hastings Center Report
Geographic Code:1USA
Date:Sep 1, 2002
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