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The parental investment factor and the child's right to an open future.

Parents have dreams for their children, sometimes quite specific and narrow. Musical families may assume that their children will choose an instrument early and devote so many hours to practice that other activities and even friendships are severely constrained. Ronald M. Green, a professor of ethics at Dartmouth, points to the many toddlers he sees at alumni events wearing "diminutive Dartmouth sweatshirts inscribed with their hoped-for graduation years." (1) Society tolerates such dreams quite well. But should we also encourage access to genetic and reproductive techniques that allow for the creation of "babies by design," or what I will term directed procreation? (2) And does it matter if these techniques require a large or small investment of parental time, money, and energy?

Two methods of directed procreation now available include sperm sorting, which increases the odds of having either a boy or a girl, and preimplantation genetic diagnosis (PGD), originally developed to detect and avoid serious genetic conditions such as Tay-Sachs disease but suitable for sex selection and eventually other purposes, such as choosing children with athletic potential. Links have been discovered between specific athletic potential and variations of the ACNT3 gene, for example. (3) Because changes in technology will soon permit whole genome embryo screening as a routine part of in vitro fertilization, parents testing embryos for conventional reasons such as avoiding lethal disease can choose to test for other traits at little additional cost. Indeed, some clinics that offer reproductive services report that they are beginning to receive requests for such services, and at least one has announced that it intends to begin to offer them in cases where the screening technology has progressed far enough to make it possible. (4) Gene modification after birth is another way in which parents can increase the likelihood of having a child with the specific traits they desire. (5)

The argument for permitting directed procreation is grounded in the respect Western culture gives to reproductive liberty. Respect for procreative choices can be seen, for example, in the value-neutral ethic of genetic counselors and in the unregulated state of reproductive technology in the United States. One of its most articulate champions is John Robertson, who argues that procreative liberty is "an important moral right" based on the "centrality of reproduction to personal identity, meaning, and dignity." (6) Even the U.K.'s Human Fertilisation and Embryology Authority, charged with policy decisions that severely constrain parental choice in assisted reproduction technology, nonetheless declares that its first loyalty is to procreative liberty. "The decision to have children is an area of private life in which people are generally best left to make their own choices." (7)

However, this respect, almost reverence, for autonomy in reproduction also grounds reasons for limiting directed procreation. The robust respect for parental autonomy ought to be complemented by a respect for the autonomy of the future child as well. One way of framing this concern is to appeal to a child's "right to an open future."

Parents so fixated on the importance of having a girl, or a musician, or an athlete, will find it extremely difficult to be open to the child's own interests and natural direction. Parents who go to great trouble to have a child with perfect pitch may find it very hard when the child spurns the piano for the basketball court. Parents who go to great lengths to have a girl-even and perhaps especially if it is to "balance" a family in which there are already sons--may want a child not merely with XX chromosomes and a female anatomy, but a daughter who will exhibit certain predetermined gender characteristics as well. (8)

Directed Procreation as a "Wake-Up Call"

Some will argue that we should not single out directed procreation as bearing unique risks to the child's future autonomy but instead tolerate it to the same extent that we tolerate religious education, Dartmouth sweatshirts, and pink flowered wallpaper for baby girls. Parents certainly do often have strong expectations that children will join the family business, attend the mother's school, or be "a chip off the old block" in any number of ways. But the startling aspects of directed procreation could be a "wake-up call" for a more considered critique of the trend in our current childrearing practices. Coaching children for their preschool interviews, scheduling every moment of a child's time, encouraging children to specialize early in one sport so as to increase their chances at a college scholarship despite the dangers to their health--all of these are ways in which parents risk narrowing their children's rights to an open future. As Michael Sandel has written, "Bioengineering gives us reason to question the low-tech, high-pressure child-rearing practices we commonly accept." (9)

But more importantly, I believe that directed procreation has the alchemy to turn a hope into a virtual entitlement. At present a couple can hope that they will have a boy with the requisite physique to play football for their alma mater, but even the most obsessed parents embark on each pregnancy knowing that the chances of having a boy are roughly fifty-fifty, and the chances are much less of having a child with the talent, build, and interest to play football. But if those parents pay large sums of money and make a huge investment in time, effort, and personal hassle (including temporarily railroading their sex life) in order to make sure that the child is a boy or in order to clone a successful football player, then they are likely to feel entitled to the desired result--or, at the very least, they will find it significantly more difficult to take their direction from the child as to whether football coaching or music camp is the best way to spend the summer.

Instead of parents dressing their toddler in a $20 sweatshirt advertising the child's future enrollment at Dartmouth, imagine if a parent were able to put down a $50,000 nonrefundable deposit on a child's place in the Dartmouth freshman class. How open would that parent be to the child's attending Juilliard instead or forgoing college entirely in favor of hitch-hiking around the world? But $50,000 is peanuts compared to what many people already pay for directed procreation.

Sperm sorting. The least technically complex method of directed procreation is sperm sorting. Although this technology is useful only for sex selection, it has the advantage of working before conception, so there are no concerns about the moral status and ethical disposition of human embryos. Sperm sorting, trademarked as MicroSort, is offered exclusively by the Genetics and In Vitro Fertilization Institute (GIVF) in Virginia and California. Exploiting the fact that X-bearing sperm have more DNA than Y-bearing sperm, MicroSort uses flow cytometric separation technology to separate out the desired sperm, which is then used for intrauterine insemination or IVF. The process is far from perfect but more effective than mere hope; MicroSort technology currently can increase the percentage of X-bearing sperm to 88 percent in the enriched X-sorted sample and increase the percentage of Y-bearing sperm to an average of 73 percent. (10)

The cheapest cost per cycle is $3,765 (excluding travel and accommodations, of course), but the cost jumps to $5,415 per cycle for sorting, monitoring, and intrauterine insemination. Fertility drugs, IVF, or other collateral costs are extra. MicroSort reports its pregnancy rate at 15.6 percent per cycle. The level of medical risk associated with the use of fertility drugs is still debated. Clomid can cause ovarian hyperstimulation syndrome, which in rare cases can be life-threatening. (11)

In vitro fertilization and preimplantation genetic diagnosis. Preimplantation genetic diagnosis, or PGD, piggybacks on the opportunities presented by in vitro fertilization. Originally developed to detect and avoid serious genetic conditions such as Tay-Sachs Disease, PGD can also be used for other purposes, including sex selection and choosing for desired genetic traits. IVF and PGD begin with the woman taking fertility drugs and having the ripe eggs removed through a minor surgical procedure. After a number of embryos are created in the lab through IVF, one or two cells from each embryo are carefully removed and analyzed for the relevant traits. Most embryos seem to be unharmed by this procedure, and embryos with the desired traits are then implanted in the uterus or frozen for subsequent use.

A successful pregnancy using IVF usually takes more than one cycle, and the likely number of cycles depends on many factors. In 2003, the Centers of Disease Control and Prevention estimated that for a woman younger than thirty-five, using fresh (not frozen) embryos, the likelihood of a successful pregnancy resulting in a live birth was about 37 percent per cycle. (12) IVF on its own costs $10,000 to $12,000 per cycle, with no guarantee of a successful pregnancy. PGD can add $2,500 to $4,000. (13) Risks to the resulting babies are not yet known, although there appears to be a slightly higher rate of abnormality; risks to the mother include ectopic pregnancy and ovarian hyperstimulation syndrome. (14) Embryo biopsy negatively affects the implantation rate of embryos; in other words, couples using IVF for infertility decrease their chances of success if they add on PGD in order to choose a genetic trait. (15)

In sum, every currently available method of trait selection comes at an extremely high price for most couples. The only exception would be parents who already need IVF and PGD to avoid a serious disease, and who, having discarded affected embryos, are left with a large number of equally healthy embryos whose other traits they also have "incidental" knowledge of. At that point, since only some embryos will be selected for the first attempt at implantation, there seems little harm in choosing on the basis of traits such as sex (or perhaps, in the future, perfect pitch).

The Hazard of Entitlement

Being born a girl as a result of chance (even to parents who had been hoping for a girl) is qualitatively different from being born a girl as a result of sex selection. What is important for the future of the child is not so much the nature of the trait selected as the expectations that motivate the parents to select it. This has important implications for the moral permissibility of the selection. Even traits that are useful for all life plans (such as intelligence) may be chosen with very particular life plans in mind, with expectations that may restrict the child's future freedom. (16) Choosing a girl through sex selection--which involves a huge investment in time, money, and personal inconvenience--will too often, I fear, give the parent a sense of entitlement to whatever "female" qualities the parent was hoping for; the parent may feel cheated if the child does not fulfill those expectations.

Seavilleklein and Sherwin point out that parents who engage in sex selection with certain gendered characteristics in mind may be especially intolerant and disappointed if the child turns out to be lesbian or gay. "The emphasis placed on 'family balancing' in Western arguments in support of sex selection techniques also suggests that what is desired by families ... is not primarily a child with different genitals but a child who conforms to the opposite gender role to the children they already have.... Part of what is expected from sex selection techniques is a child that will conform to assumed (and desired) gender roles." (17) The mother who uses preconception sperm sorting to increase her chances of having a girl "who can wear my wedding dress" probably does not imagine that her daughter would don that dress to marry another woman. (18)

But parental expectations would not necessarily conform to conventional stereotypes. Feminist parents might well want a girl in order to groom her to be the first female president. Thus, Rosamond Scott misses an important point when she writes that:
 If ... we think simply about the interests of the future children
 who might be selected on the grounds of their sex, if parents do
 have particular ideas about girls or boys, then when they have
 either a boy or a girl without sex selection, they are very likely
 in any event to raise a child according to these ideas.... If the
 child they happen to have is not seriously harmed by these
 presumptions--and it seems inherently unlikely that it would be
 harmed--then we can also say that sex selection itself would not
 risk serious harm to another child selected according to its sex.
 (19)


What Scott ignores is the quality of investment--and, therefore, entitlement--that parents are likely to feel once they have gone through the substantial rigors and sacrifice of directed procreation for sex selection.

Green makes the same mistake when he says that "genetic choice does not seem so different from the various forms of socialization that parents undertake." (20) Green argues that, although genetic choices may "seem to be more hard-wired and less easily set aside than the lessons and experiences that parents provide," a child can use his enhanced capabilities for very different goals than the ones his parents had in mind. "I may dream that my son or daughter will become an astronaut, but the child may choose to apply the given analytical skills to a business career." (21) Green is correct that some forms of "socialization" are so rigorous and expensive that they are comparable in effect to directed procreation. A parent who rises at 4 a.m. six mornings a week for five years to supervise his child's swim lessons, or who moves the whole family to another state, perhaps causing the parents to live apart from one another, in order to support a child's talent for ballet may well be making sacrifices and investments that equal those of directed procreation. One hopes that such a parent is following the child's lead and can accept with grace the child's possible decision to take a different direction. But directed procreation cannot be described as following the child's lead; directed procreation is like moving to Arizona, installing a tennis court at great expense, and signing up for nonrefundable lessons with the country's best tennis coach--all before conception.

Parental Investment: How Much is Too Much?

What if future research allows us to choose girls or boys in a simple, inexpensive way that interferes little with sexual intercourse? We could imagine a vaginal spermicide that would be hostile only to X- or Y-bearing sperm, or some food supplement a man could eat that would cause him to produce only one or the other. (22) If producing a girl or boy child became almost as easy as in the old folk beliefs--hanging one's overalls on one or the other side of the bed, sliding a knife beneath the pillow--would there still be cause for concern about parental constraint of the child's future autonomy? If choosing a child's genetic traits is as simple as designing the Mini Cooper I recently ordered from England, need we still worry about parental entitlement?

I think not. My concerns about directed procreation are not ontological but contingent on the practical factors that make up parental investment. For those who share Michael Sandel's concerns about "the moral status of nature, and the proper stance of human beings towards the given world," or fear that any trait selection automatically "commodifies" or "instrumentalizes" the child (more than parents always to some extent commodify children), the extent of investment will probably play a small role in their thinking. (23) I do not share these concerns. I am more pragmatic. The more time, money, and travel that a parent invests in directed procreation, and the more inconvenience, physical discomfort, and medical risk that the parent bears, the more I fear that the parent will feel entitled to the desired result. As market forces and medical research make such investments relatively trivial, the less I fear that effect. True, the cost may matter little to the very wealthy among us, but even the wealthiest still have to contend with a great investment in time and personal discomfort.

The President's Council on Bioethics, in its 2003 report, Beyond Therapy, wrote:
 The salient fact about human procreation in its natural context is
 that children are not made but begotten. By this we mean that
 children are the issue of our love, not the product of our wills. A
 man and a woman do not produce or choose a particular child, as
 they might buy a particular brand of soap; rather, they stand in
 relation to their child as recipients of a gift. (24)


In contrast to the council's perspective, if choosing the sex or any other trait of one's children were as simple and inexpensive as choosing a bar of soap, I would be much less worried.

There will, of course, always be new technological manipulations on the horizon, as unimaginable today as IVF was unimaginable to all but science-fiction writers in the years before the birth of Louise Brown. These new manipulations, if they are likely to be burdensome in any number of ways, will give rise to new concerns about parental investment, even as some old manipulations become cheaper and simpler. The key is to keep our eye not only on the quality of the desired traits themselves, but on how many sacrifices parents must make to achieve them.

Acknowledgments

The idea for this essay was born in a discussion with Erik Malmqvist, for whose scholarly engagement I am grateful. I am also grateful to the Fulbright Senior Specialist program for supporting two wonderfully collegial weeks at Linkoping University. This work was partially supported by the Center for Genetic Research Ethics and Law at Case Western Reserve University, through grant #P50-HG-03390 from the National Human Genome Research Institute at the National Institutes of Health, and by a generous summer research grant from the Cleveland-Marshall Fund at Cleveland-Marshall College of Law.

(1.) R.M. Green, "Much Ado about Mutton," in Cloning and the Future of Human Embryo Research, ed. P. Lauritzen (New York: Oxford University Press, 2001), 114-31, at 125.

(2.) I follow Ronald Green's lead in using "babies by design" rather than "designer babies," as the latter tends to mock and trivialize parental choices by implicitly comparing children to clothes or accessories.

(3.) J. Macur, "Born to Run? Little Ones Get Test for Sports Gene," New York Times, November 30, 2008.

(4.) G. Naik, "A Baby, Please. Blond, Freckles--Hold the Colic," Wall Street Journal, February 12, 2009.

(5.) R.M. Green, Babies by Design: The Ethics of Genetic Choice (New Haven, Conn.: Yale University Press, 2007), 33-52.

(6.) J. Robertson, Children of Choice (Princeton, N.J.: Princeton University Press, 1994), 30.

(7.) Human Fertilisation and Embryology Authority, Sex Selection: Options for Regulation, 2003, http://www.hfea.gov.uk.

(8.) D.S. Davis, Genetic Dilemmas: Reproductive Technology, Parental Choices, and Children's Futures (New York: Routledge, 2001).

(9.) M. Sandel, "The Case against Perfection," Atlantic Monthly 292, no. 3 (2004): 50-54, 56-60, 62.

(10.) MicroSort, "MicroSort Current Results," http://microsort.net/results.php, accessed February 13, 2009.

(11.) The Practice Committee of the American Society for Reproductive Medicine, Use of Clomiphene Citrate in Women, Fertility and Sterility 80, no. 5 (2003): 1302-8.

(12.) Centers for Disease Control, "2003 Assisted Reproductive Technology (ART) Report: National Summary," http://apps.nccd.cdc.gov/ ART2003/nation03.asp.

(13.) Ibid., 22.

(14.) D. Grady, "Birth Defects Tied to Fertility Techniques," New York Times, November 17, 2008.

(15.) N. Gleicher, A. Weghofer, and D. Barad, "Preimplantation Genetic Screening: 'Established' and Ready for Prime Time?" Fertility and Sterility 89, no. 4 (2008): 780-88.

(16.) E. Malmqvist, "Reproductive Technologies and the Question of the Child's Future Freedom," in Ethics, Law and Society IV, ed. S. Holm, J. Gunning, and I. Kenway (Farnham, U.K.: Ashgate, forthcoming).

(17.) V. Seavilleklein and S. Sherwin, "The Myth of the Gendered Chromosome: Sex Selection and the Social Interest," Cambridge Quarterly of Healthcare Ethics 16 (2007): 7-19, at 11.

(18.) L. Belkin, "Getting the Girl," New York Times Magazine, July 25, 1999.

(19.) R. Scott, Choosing Between Possible Lives: Law and Ethics of Prenatal and Preimplantation Genetic Diagnosis (Oxford, U.K.: Hart Publishing, 2007), 322.

(20.) Green, Babies by Design, 130.

(21.) Ibid., 129.

(22.) This might be disastrous for cultures in which boys are preferred and in which there is already a dramatically skewed sex ratio, but that is a different topic.

(23.) Sandel, "The Case Against Perfection."

(24.) President's Council on Bioethics, Beyond Therapy: Biotechnology and the Pursuit of Happiness (Washington, D.C.: President's Council on Bioethics, 2003).

Dena S. Davis, "The Parental Investment Factor and the Child's Right to an Open Future," Hastings Center Report 39, no. 2 (2009): 24-27.
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Author:Davis, Dena S.
Publication:The Hastings Center Report
Article Type:Essay
Geographic Code:4EUUK
Date:Mar 1, 2009
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