Religious Values and Refusal of Highly Effective Life Saving Treatment by Minors

By Michael DiStefano

Caring for children with life-threatening illnesses is very difficult for both parents and health care providers. The experience can be even more painful when the child refuses highly effective life saving treatment (HELST). Most states have “mature minor” statutes or case law that recognize the rights of children with demonstrated decision-making capacity (and who are usually older than 14 years) to make decisions about their health care as a legal adult, regardless of the wishes of their parents or providers. Two notable examples are Dennis Lindberg, a 14-year-old Jehovah’s Witness who died from leukemia after refusing a blood transfusion, and Benny Agrelo, a 15-year-old who died after refusing to continue taking immunosuppressants following two liver transplants. In each case a judge declared the boy a mature minor whose medical decisions must be respected.

However, the standard criteria for determining whether a minor has capacity are only likely to be adequate in the case of minors who invoke non-religious values to refuse HELST. I will argue that, though controversial, heightened scrutiny ought to be applied when minors justify their refusal with religious values. It therefore may have been wrong to treat Dennis Lindberg and others like him as mature minors.

In general, decision-making capacity rests on four conditions: (1) the ability to communicate a choice, (2) an understanding of the facts and information related to the choice, (3) an appreciation of the situation and its consequences, and (4) the ability to rationally manipulate the relevant information and to reason about treatment options.[i] These criteria ensure that a minor’s decision is valid in the logical sense. They require the minor to clearly state premises (i.e., subjective value statements and objective medical facts) that logically entail the truth of a clearly stated conclusion (i.e., whether to accept or refuse some treatment). Crucially, none of the criteria requires that the conclusion be philosophically sound. If so, we would need to be able to objectively determine whether all of an individual’s premises are true, in addition to the objective medical facts. However, because value statements are subjective, capacity determinations cannot require that minors’ decisions be sound if they are motivated by a desire to respect patient autonomy.

Still, merely valid decisions lack a critical component, namely, whether minors themselves genuinely believe their stated value premises. Some will object by noting that people generally do not state things they do not believe, especially when making high stakes decisions like whether to refuse HELST. However, this additional consideration is intended precisely for the admittedly rare circumstances in which minors express value premises with which they do not genuinely agree—knowingly or not—as a result of coercion or social pressures. These circumstances are worrisome because attempts to respect minors’ autonomy by granting mature minor status should not instead enable circumstances that have already compromised autonomy.

Patients who invoke religious values to refuse HELST are more likely to have experienced coercion or social pressures than those whose refusals rest on non-religious values. First, the stakes associated with religious values are more coercive than those associated with non-religious values because there is more to be lost by failing to uphold religious values. Religious values are often linked to absolute gains or losses. Eternal salvation often depends on whether one has lived according to the dictates of one’s faith. Non-religious values lack similar stakes. Of course, the repercussions for failing to honor non-religious values (e.g., moral distress, disappointment of loved ones, ostracization) are significant, but cannot compare to the gain or loss of something with infinite value like eternal life-after-death.

Second, religious values are frequently cultivated within tightly knit communities of like-minded individuals. The disappointment of loved ones and ostracization felt by those who fail to honor religious values are likely to be more acute than that felt by those who flout non-religious values. Of course, non-religious values are also inculcated within communities, but modern communities, especially those in Western liberal democracies, are pluralist in nature. Diverse communities are likely to tolerate a greater degree of divergence from value-based behavioral norms than homogenous religious communities that are typically the result of self-selection.

Third, young people are more easily influenced by their peers and other external pressures.[ii] Therefore, the religious values of minors active in religious communities are more likely to result from either a fear of absolute gains or losses or a desire to act in accordance with the expectations of those around them. Their religious values are less likely to be the result of their own considered and reflective deliberation.

Finally, education within religious communities is sometimes regulated (e.g., through home schooling or programs to complement public curricula) to limit access to competing views that may impact the values its adherents develop. Insofar as minors receive this regulated education, their religious values may be more a product of the views of their parents or community leaders than their own deliberation.

Returning to the cases introduced above, Dennis Lindberg, a Jehovah’s Witness, justified his refusal of HELST with the religious value that blood transfusions are contrary to the tenets of his faith. Per the traditional standards for demonstrating capacity, Dennis clearly articulated this value and logically demonstrated its relation to his refusal. However, the four reasons just discussed combined with the fact that his aunt—also a devoted Jehovah’s Witness—was raising him call into question how genuinely he believed the value. Benny Agrelo was not similarly influenced by religion.[iii] His refusal of HELST was based on the value that a shorter, but higher quality life is preferable to a more prolonged, but painful existence. He felt too sick while taking immunosuppressants to enjoy life. Benny’s parents initially held the opposite opinion,[iv] thus supporting the claim that non-religious values are less likely to be the result of social pressures.

When minors refuse HELST, providers should be especially mindful of the social forces that influence religious values. It is not enough to rely on the traditional criteria for determining decision-making capacity in these circumstances. Providers should engage more closely with these young patients, perhaps by adopting the deliberative model of the physician-patient relationship,[v] and do their best to ascertain how free they are from coercion or social pressures and how genuinely they believe their professed religious values. Similarly, the law should be revised with this heightened scrutiny in mind.

Michael is currently a Teaching and Research Assistant at the University of Pennsylvania where he recently completed a Master's degree in Bioethics. He graduated from Princeton University in 2011 with a degree in Religion and Philosophy. His research interests include religion and clinical ethics, the ethics of mobile health technologies and health incentives, and reproductive ethics. This post was chosen as a finalist for the 2014-2015 Daniel Callahan Young Writer's Prize. 

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[i] Paul S. Appelbaum, “Assessment of Patients’ Competence to Consent to Treatment,” The New England Journal of Medicine 357 (2007): 1834-40; Douglas S. Diekema, “Adolescent Refusal of Lifesaving Treatment,” Adolescent Medicine: State of the Art Reviews 22, no. 2 (2011): 213-28.

[ii] Diekema, “Adolescent Refusal of Lifesaving Treatment.”

[iii] Jonathan F. Will, “My God My Choice: The Mature Minor Doctrine and Adolescent Refusal of Life-Saving or Sustaining Medical Treatment Based Upon Religious Beliefs,” The Journal of Contemporary Health Law and Policy 22, no. 2 (2006): 233-300.

[iv] Ibid.

[v] Ezekiel J. Emanuel and Linda L. Emanuel, “Four Models of the Physician-Patient Relationship,” Journal of the American Medical Association 267, no. 16 (1992): 2221-6.

The Daniel Callahan Young Writer's Prize

Prize Summary 
This post is pleased to announce a new award, The Daniel Callahan Young Writer's Prize, sponsored by Daniel Callahan. Submissions will take the form of essays on a bioethics topic that are written as blog posts, designed for this blog, Bioethx Under 25. From all submissions, a group of finalists will be chosen and then an expert panel of bioethicists, including Daniel Callahan, will read the finalists' essays and award one prize amounting to $500. 

All submissions will be considered for publication on the blog and eligibility to be a finalist or receive the prize is dependent on willingness to edit and revise the essay for publication. Submissions will be judged anonymously. Please see guidelines below for further information. 

Prize Submission Guidelines

- Essays must be 500-1000 words and original submissions to Bioethx Under 25 i.e. never posted before on the blog. 

- Essays must conform to all other submission guidelines for the Bioethx Under 25 blog and thus, be clearly related to bioethics and be written in an accessible manner. Please refer to the blog's About Page for more information. 

- Essays will be accepted from September 10th, 2014 to November 15th, 2014. 

- Any writer who is also a student in high school, college, or a graduate program is eligible to submit. Any writer who is not a student is eligible so long as he/she has not completed a PhD and/or worked more than 5 years in the bioethics field with a terminal degree (e.g. JD or MD). So long as the other guidelines have been met there is no age limitation or requirement for submission. 

- Writers are not eligible if they currently or have previously worked full time for The Hastings Center or Daniel Callahan. Anyone affiliated with Bioethx Under 25 in an editing capacity is also ineligible. 

- To submit, please email bioethicsunder25@gmail.com with your essay attached in word format. In the body of the email please indicate that you are submitting for The Daniel Callahan Young Writers Prize and include your name, phone number, email address, current occupation and place of occupation (if a student, then your school, potential degree, and expected graduation year), and your highest degree attained with the school and year. 

- For any questions please email bioethicsunder25@gmail.com or comment below. 

About Daniel Callahan

Daniel Callahan is Senior Research Scholar and President Emeritus of The Hastings Center. He was its cofounder in 1969 and served as Director and President between 1969 and 1996.  Over the years his research and writing have covered a wide range of issues, from the beginning until the end of life. In recent years, he has focused his attention on ethics and health policy.

He has served as a Senior Lecturer at the Harvard Medical School and is now a Senior Scholar at Yale. He received his B.A. from Yale and a PhD in philosophy from Harvard. He has honorary degrees from the Charles University, Prague, the Czech Republic, the University of Colorado, Williams College, Oregon State University, the State University of New York and the University of Medicine and Dentistry of New Jersey.

Callahan is an elected member of the Institute of Medicine, National Academy of Sciences; a former member of the Director’s Advisory Committee, the Center for Disease Control and Prevention, and of the Advisory Council, Office of Scientific Responsibility, Department of Health and Human Services. He won the 1996 Freedom and Scientific Responsibility Award of the American Association for the Advancement of Science. He is the editor or author of 47 books. 

Hobby Lobby and Freedom from Religious Employers

By Naomi Scheinerman

The decision in Burwell v. Hobby Lobby Stores has been severely scrutinized, from rebukes against corporate personhood to feminists decrying that the Court’s majority, five conservative male judges, devalue and deny women’s personhood. Justice Ginsburg’s scathing dissent and Justices Sotomayor and Kagan’s equally passionate disapproval offer a gendered lens that is impossible to ignore. And further, the Hobby Lobby decision actually does far more harm than good in protecting religious freedoms.

First, Hobby Lobby’s anti-contraception argument relies on fallacious scientific claims that will facilitate further violations of the corporation’s religious beliefs. Hobby Lobby objects to the two IUD’s and Plan B and Ella (emergency contraception) by claiming that using them is akin to having an abortion. This is false. Plan B and Ella prevent ovulation which prevents pregnancy after sex. The International Federation of Gynecology & Obstetrics published a study concluding that because Plan B does not inhibit implantation, it is therefore not an “abortifacient,” a substance that induces abortion. Because Hobby Lobby argued that emergency contraception equals abortions, when in fact emergency contraception does NOT equal abortions, the Court should have thrown out Hobby Lobby’s arguments. As a result of this decision, women who work for Hobby Lobby and are now denied emergency contraception coverage will be much more likely to seek an abortion in their future. Half of women who purchase Plan B do so because of unplanned pregnancy (which includes both consensual and non-consensual sex). Hobby Lobby is paving the way for more abortions, not fewer.

Second, Hobby Lobby’s small closely held corporation’s religious freedoms are being protected at the expense of the freedom from religious imposition on its employees who rely on health insurance to access reproductive freedoms. A closely held company is one in which five or fewer people own the majority of the company. Not only is it strange to treat a corporation as a person with its own convictions, but this decision shows that the Court prefers the religious arguments of a few people in charge over the views of many more who actually work for the corporation. The Religious Freedom Restoration Act of 1993 (RFRA) – the legislation that Hobby Lobby claimed the contraception mandate violated - was originally enacted to protect Native Americans from laws that burdened their exercise of religion. As such, the RFRA was originally constructed to protect employees from theburdensome religious standards of employers and laws. In fact, Catholic and other Christian denominations were even opposed to the RFRA initially because they thought it would protect the “right to a religiously-motivated abortion.” Even if an employee of Hobby Lobby does not have a religious conviction to use contraception, the employers of Hobby Lobby are imposing their religious views by forcing the employees’ actions to align with their own religious practices that forbid abortions. An individual at Hobby Lobby, who is not one of the five people in the entire corporation who wants to prevent contraceptive access, is burdened, something the RFRA was meant to prevent, not allow.

Third, there is real danger in granting religious freedom to corporations that claim exemptions to laws. In Callahan v. Woods, for example, taxpayers used the RFRA to object to the use of social security numbers, arguing that they related to the “mark of the beast.” The Court dismissed this argument. Since the release of the Hobby Lobby decision, many companies have come out of the woodwork, claiming religious exemption to other laws that ban discrimination in hiring or protect women’s reproductive freedoms. The Court ruled that the religious freedom is protected when the law imposes a “substantial burden” on the corporation. This should be interpreted to what the corporation does (its business and goals) rather than how the five or fewer owners feel about the actions of their employees. Is it a substantial burdensome to the selling of paint and brushes to allow female employees to obtain emergency contraption or an IUD?

My last fear is that real and compelling claims of religious exemption, wherein an employer or employee has a true and ethical, religious  belief that a law severely infringes, will become watered down by the numerous unethical claims. About 90% of all American businesses fit the category of closelyheld.  Corporations should not be in the business of determining the appropriate health care package for employees based on religious convictions when it overrides the individual employees’ values. This places an inordinate amount of control on employees’ actions outside the office, such as their reproductive decisions, something the Supreme Court declared was protected by the right to privacy. Employers should not define employee competency by her personal life decisions, but rather based on qualifications and aptitude for the job. This is why employers should not discriminate against gay applicants and should not dictate the sexual freedom of its female employees. Justice Ginsburg accurate identified the dangers of the Hobby Lobby decision: it validates inordinately unethical claims of religious exemption that employers have no right to make.

Naomi Scheinerman is a Research Assistant at The Hastings Center. She graduated Phi Beta Kappa, with high honors and in distinction from the University of Michigan in Ann Arbor, where she received bachelor’s degrees in philosophy, political science, and Hebrew and Jewish Cultural Studies. She contributes a bi-weekly column on reproductive health.

Mitochondrial Donation: Why the Controversy?

By: Michelle Bayefsky

Late last month, the Cellular, Tissue, and Gene Therapies Advisory Committee of the Food and Drug Administration (FDA) met to consider whether research on mitochondrial donation, which could be used to prevent women from passing on mitochondrial disease to their children, was ready to begin testing in humans.  Instead of excitement at the prospect of eradicating mitochondrial disease, which can cause blindness, dementia, epilepsy, and many other conditions, much of the public reaction was characterized by fear, confusion, and hostility.  Headlines from “Genetically Modified Babies” to “Tinkering with Frankenstein: Obama Admin Considers Three-Parent Embryos” flooded the internet, and scientists and bioethicists struggled to refocus attention on the medical feat that is close to being achieved.[1]

Mitochondrial donation involves either transferring healthy mitochondria from a donor into the egg of an affected woman, or inserting the pronuclei of two prospective parents into an enucleated donor egg.[2]  Since mitochondria carry their own DNA and are maternally inherited, children born after mitochondrial donation will technically have DNA from three people – hence the nickname “three-parent IVF” given to the procedure by the press.  This nickname is misleading, however.  The degree to which genetic parentage should be considered synonymous with parentage has already been questioned in debates regarding egg and sperm donation, surrogacy, and adoption.  “Three-parent IVF” suggests a complicated family situation which would be not at all necessary; if social and legal norms have been successfully established for donating gametes containing nuclear DNA to couples with infertility, surely the same could be accomplished with donating mitochondrial DNA.  Furthermore, it seems highly unlikely that we would come to view the donor of mitochondria, an organelle about which most members of the public have little knowledge, as a parent on equal footing with the parents who contribute nuclear DNA and/or intend to raise the resulting child.

Aside from the question of parentage, the major source of controversy surrounding mitochondrial donation is the fact that the technique constitutes a germline modification; the donated mitochondrial DNA would be passed down from generation to generation.  Previously, a line has been drawn (in law, in some countries) between gene therapies that treat problems in somatic cells, like muscular disorders, and modifications that are heritable.  Though mitochondrial donation is aimed at preventing disease, some worry that it will open the door to other types of germline modifications and the creation of ‘designer babies.’  These concerns are misplaced for two reasons.

First, it is unclear why the somatic-germ cell distinction in gene therapy should be our primary criterion rather than a distinction between healing and enhancing.  If our problem with the creation of designer babies – which, given the current state of reproductive medicine, embryology, and genetics is a very long way off – has something to do with satisfying petty parental preferences, we should focus our efforts on preventing the use of powerful reproductive procedures for insufficiently serious purposes.  We should debate what counts as the prevention of a serious genetic condition and what counts as enhancement, not ban germline modifications that are aimed at eradicating disease and reducing suffering.

A second reason that the emphasis on germline modification is misplaced is that technology is already available to select, if not modify, embryo’s genes.  Pre-implantation genetic diagnosis (PGD) is a technique that is used to test embryo’s genes during in vitro fertilization, before deciding which embryos to transfer into the woman’s uterus.  PGD can be used to select against serious heritable diseases, but it can also be used to select for sex, milder disabilities such as deafness or dwarfism, and children who can serve as tissue donors for sick siblings.  The US has no laws or regulations on the acceptable usage of PGD, and elective sex selection is relatively common.[3]  It seems inconsistent to object to the use of mitochondrial donation to prevent serious diseases when a technique that uses selection, rather than modification, to choose non-medical characteristics of future generations is currently unregulated and in use.

Finally, if we decide that the germline criterion must continue to be respected, even when using genetic modification to prevent disease, we could require that mitochondrial donation only be used to create male embryos.  We could use sperm sorting to select male sperm which would be combined with a female pronuclei and an enucleated egg with healthy mitochondria.  Since mitochondria are inherited maternally, if only males are created, the mitochondrial DNA would not be passed on to the next generation.  Though many people find sex selection objectionable, there is precedent for performing sex selection for medical purposes.  For example, PGD is sometimes used to select female embryos to avoid passing on X-linked disorders.

It is understandable that new developments at the intersection of reproductive medicine and genetic technology raise concerns about our attitudes towards future generations, especially given the history of eugenics.  However, we should regard mitochondrial donation for what it is – a tool designed to allow mothers suffering from mitochondrial disorders to have children to whom they are genetically related – rather than focusing on potential future abuses in the general area of genetics and fertility.  Though it is important to exercise caution in the modification of heritable genes, the distinction between healing and enhancing should be our primary criterion for deciding what techniques are ethical and permissible.

Michelle Bayefsky is a senior at Yale University, where she was elected to Phi Beta Kappa and founded and serves as Editor-in-Chief of the Yale Bioethics Journal.  After working as a research assistant at the Yale Interdisciplinary Center for Bioethics for over two years, she will graduate in May with a B.A. in Ethics, Politics and Economics.

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[1] Last week, the UK’s Human Fertilisation and Embryology Authority, the governmental body responsible for regulating reproductive medical care, released draft guidelines that would permit mitochondrial donation in humans. Children of mitochondrial donation could be born in the UK as early as next year. See Telegraph article here.

[2] Lewis, Ricki. "FDA Considers Mitochondrial DNA Replacement." Medscape Medical News. Medscape, 26 Feb. 2014. Web. 09 Mar. 2014. <http://www.medscape.com/viewarticle/821115>.

[3] Ginsburg, Elizabeth S., Valerie L. Baker, Catherine Racowsky, Ethan Wantman, James Goldfarb, and Judy E. Stern. "Use of Preimplantation Genetic Diagnosis and Preimplantation Genetic Screening in the United States: A Society for Assisted Reproductive Technology Writing Group Paper." Fertility and Sterility 96.4 (2011): 865-68.

Occupy Womb

By Naomi Scheinerman

Sweden is the first and only country to complete not just one, but nine, uterine transplants. The women were either born without a uterus or had it removed because of cervical cancer and received wombs donated from relatives. The ultimate goal, of course, is to become pregnant and now four of those women have also had embryos transferred into their new wombs (through IVF). The womb transplants are meant to be temporary i.e. they will be removed after birth. The discussions surrounding these procedures invoke a number of important ethical and philosophical questions related to the goals of medicine, resource allocation, and procreation.

One of the main concerns surrounds the ethicality of purposeful risk to the wombs’ donors, recipients, and occupants (the fetuses). In other words, absent a valid medical reason, can risk ever be ethically permissible? Further, are these procedures legitimate uses of medical resources in light of the risks? The recipients must take drugs and be monitored closely throughout their pregnancy to ensure that their bodies do not reject the uterus. It is also relatively unknown how a fetus will fare in a transplanted womb and in its future life.

Calculations of risk entail weighing the relevant options. In the case of medicine, risky surgeries are usually only conducted if the alternative (not having the surgery) is even riskier (such as a bone marrow transplant for a cancer patient). Thus, in the case of a well-functioning, decently healthy individual (such as the women in Sweden), engaging in a significant surgery, and putting relatives through an intensive surgery as well, seems to carry avoidable risks.

Another way to frame this concern: are womb transplants medically necessary or enhancing? Medically necessary procedures are those that save the individual’s life, such as a heart transplant or a blood transfusion. Medical enhancements are not crucial to an individual’s life but make it better, such as a cochlear device for a deaf person or LASIK eye surgery to correct imperfect vision. However, the distinction between a medical necessity and enhancement is often difficult to defend and can crumble upon further scrutiny. Often, procedures we think of as enhancing dramatically “save” one’s emotional life which itself is morally significant enough to legitimize the procedure. For example, a face transplant for a burn victim is not medically necessary in the sense that the burn victim could survive without it, but can be socially necessary for future happiness and success. The implications of this distinction are important because we tend to allocate our scarce medical resources for medical necessities and view enhancements as illegitimate uses of these resources. And yet, we can concurrently make the case that enhancements do some significant medical good. For a woman who desperately wants to be pregnant the distinction between necessity and enhancement begins to collapse.

My final concern, which most powerfully objects to womb transplantation, is whether it is a healthy model of procreation in today’s society. In a world filled with opportunities for sperm and egg donation, surrogacy, and now womb transplants, I worry that there is an undo emphasis placed on the desire for a genetic connection with one’s offspring. I have no doubt that it is a miraculous thing to be pregnant and create a new life using one’s own genetic material, and perhaps also the genetic material of one’s partner. However, I worry when that is the most important desire for a family. Instead we should focus on building healthy relationships with one’s child and finding a home for children worldwide. I worry that womb transplants and IVF can and do detract from what’s important about procreation and place undo emphasis on carrying to term and having a genetic relationship with one’s child.

Naomi Scheinerman is a Research Assistant at The Hastings Center. She graduated Phi Beta Kappa, with high honors and in distinction from the University of Michigan in Ann Arbor, where she received bachelor’s degrees in philosophy, political science, and Hebrew and Jewish Cultural Studies. She contributes a bi-weekly column on reproductive health.

Lowered Abortion Rates: Good or Bad Sign?

By: Naomi Scheinerman

On Monday, February 3, 2014, the Guttmacher Institute published a study revealing that U.S. abortion rates are the lowest since the Supreme Court upheld the right to have an abortion in Roe v. Wade (1973). Although the study did not investigate reasons for the decline, it concludes that it was not due to the surge of abortion access restrictions passed from 2011 to 2013, nor was it due to a decreased number of providers. The authors also found that there was a proportional increase of early stage abortion inducements to later surgical procedures.

So, what can we conclude about the study? Why have abortion rates gone down? And, how should we feel about lowered abortion rates? Is this a good thing? What might this indicate about our society?

The Guttmacher Institute’s overarching goal is “to ensure the highest standard of sexual and reproductive health for all people worldwide.” Do lowered abortion rates mean that women are achieving a higher level of sexual and reproductive health in connection with the Institute’s goals? On the one hand, women should have access to means of contraception: the pill, condoms, IUD’s, etc. On the other hand, women should also have access to abortions. It seems that lowered abortion rates indicate a rise in access to contraception, increased freedom for women, and overall awareness of rights, access, and sexual health. So, abortion rates lowering (when it is not due to restrictions or scarcity of providers) is a good thing.

If we peer further, are lowered abortion rates beneficial for reasons other than their indications of other rights (access to contraception) in society? In other words, could they be ethically preferable? 

What differentiates an action between being ethically preferable and permissible? In order to determine ethical preference, it is important to compare the action being evaluated with its alternatives. The relative value of an action must be viewed in context with the array of other possibilities. Ethical permissibility indicates that the action, in isolation, is itself ethically allowed. Planting a tree to help with carbon sequestration is ethically permissible, and can often be ethically preferable (to chopping down a tree, for example), but not ethically preferable to taking public transportation to avoid carbon emissions in the first place.

The act of having an abortion itself is ethically permissible because a woman has the right to determine what happens to her body insofar as she does not harm another living human being. A fetus, until viability, does not have the moral status of a human being. The fetus deserves our respect, but ultimately its life should not be valued above either the physical or emotional welfare of the mother. Thus, for any reason: whether she and her partner’s condom broke or she was raped, a woman should have access to an abortion, and not be compelled to undertake the burden of bringing a life into the world.

Thus, in the case of abortion, the alternatives are often not preferable. If a woman feels she is incapable of having a child or cannot offer that child the best life possible, it is ethically preferable to terminate the pregnancy. However, in light of access to contraception, education, and increased awareness of women’s rights that can avoid an unwanted pregnancy, abortion is not ethically preferable.

As such, we return to the conclusion that lowered abortion rates are good insofar as they indicate increased access to contraception and awareness of women’s rights. Abortions are themselves ethically permissible; therefore, there should not be a huge cause for moral concern if there is an increase of them. However, in light of ethically preferable alternatives, we should celebrate decreased abortion rates, which often herald opting for those alternatives.

Naomi Scheinerman is a Research Assistant at The Hastings Center. She graduated Phi Beta Kappa, with high honors and in distinction from the University of Michigan in Ann Arbor, where she received bachelor’s degrees in philosophy, political science, and Hebrew and Jewish Cultural Studies. She contributes a bi-weekly column on reproductive health. 

Creating Children for Children

This piece begins a bi-weekly column devoted to reproductive issues. 

By Naomi Scheinerman

Those thinking of having children or who find themselves accidentally pregnant ask many important questions: Am I ready to be a parent? Am I financially able to support myself and a child? Do I have the time and energy? Though these questions are undoubtedly crucial, they are incomplete. One should also ask: would the child want its life?

The politics of childbirth in the United States are replete with problems: states passing draconian anti-abortion legislation, a hospital keeping a brain-dead pregnant woman on a ventilator because of her nonviable fetus, employers denying paid maternal or parental leave, and religious groups denying their employees the freedom to choose contraception. Our system is also hypocritical: we stigmatize teen or single mother pregnancy while fighting contraceptive access; we fight expanding needed health care to poor and impoverished children while mistreating obese pregnant women; and we harass abortion clinics while pushing for abstinence-only education in schools.

When deciding whether to conceive, it is crucial to ask whether the fetus’s future life is optimal, rather than whether our life is optimal with a child in it. This does not mean that we are obligated to have a child when we can provide an optimal life, nor does it mean that we must define optimal according to one rigid standard. Rather, it means that we should reformulate “Are we ready to have a child?” as “Is the child going to be happy with this life?” I do not posit that either a woman’s right to reproduce or her interests and welfare should ever be compromised because of our concern for the fetus. Indeed, we too often disproportionately value the welfare of the fetus over the mother, resulting at times in tragic death. Though a fetus deserves our respect and women do have certain obligations to maintain a reasonable level of health for the fetus’s welfare, fetuses do not carry nearly the same moral standing as the mothers. Further, there is a connection between the above questions: if a woman, or man, is neither emotionally nor financially ready to have a child, then that child most likely will not want the life offered at that point in time.

There are certain philosophical objections one could raise with my position. First, the classic nonidentity problem: it is wrong to say that being born in a diminished state of existence has harmed a child because the child could not have existed otherwise, For example, a woman who gives birth to a child she knows has a debilitating genetic disorder has not harmed the child because that unique child could not have lived any other way. The problem with the nonidentity objection is that it assumes it is always good to create life, no matter what quality that life has. Further, it does not make sense to talk about eggs, sperm, embryos, and early stage fetuses as though they have consciousness and autonomous rights over their future selves.

A second possible objection is that precisely because the fetus does not have autonomous rights over its future self, we cannot project its preferences regarding life into the future. I agree with this statement, however it does not do enough to dispute my claim. I am arguing for reframing procreative decision-making to place the child as the most important recipient of its life, rather than the parents. This is not because the fetus has a right to that life, but rather because the child who is born has a right to the best life possible.

Many posit that having a child is a selfish act. However, this does not concern me: if it is selfish and the child is happy, what’s the problem? And if it’s not selfish, and the child is happy, again what’s the problem? There are many decisions prospective parents or parents thinking of having another child must consider. Reframing the question in terms of the perspective of the newborn child and the development of that individual would yield a far more desirous outcome for all involved.

Naomi Scheinerman is a Research Assistant at The Hastings Center. She graduated Phi Beta Kappa, with high honors and in distinction from the University of Michigan in Ann Arbor, where she received bachelor’s degrees in philosophy, political science, and Hebrew and Jewish Cultural Studies.