Ethics in Reproductive and Perinatal Medicine: A New Framework.

Hartle, Ann ; GUNN, ALBERT E.

STRONG, Carson. Ethics in Reproductive and Perinatal Medicine: A New Framework. New Haven: Yale University Press, 1997. 256 pp. Cloth, $30.00--This book is an attempt to provide a new "ethical framework" that can then be applied to issues in reproductive and perinatal medicine. A new framework is needed because moral theories such as utilitarianism and Kantian ethics have proved to be deficient in deciding specific cases. The author seeks to balance two fundamental values: reproductive freedom and respect for life.

Part 1 consists of four chapters in which a new ethical framework is developed in terms of these two fundamental values. Chapter I examines the question of reproductive freedom, formulated as the questions of whether there is a right to reproduce and why procreative freedom should be valued. It is necessary, apparently, to justify and give "defensible reasons" for wanting "genetic offspring" (p. 18). The reasons defended here are participation in the creation of a person, affirmation of mutual love, sexual intimacy, link to future persons, and the experiences of pregnancy, childbirth, and child rearing. A person is defined as an individual who is self-conscious. This general guideline is set out: "our from intuitions can constitute a strong presumption concerning the rightness or wrongness of actions" (p. 25).

Chapter 2 is entitled "Constitutional and Women-Centered Perspectives" and is primarily about the right not to reproduce. Strong points out that the so-called right to privacy that provided the basis for the majority opinion in Roe v. Wade is a dubious basis. Instead, he claims that the basis for the legal rights to contraception and abortion is really respect for autonomy. Autonomy is self-determination and involves freedom from interference by others "as well as freedom from personal limitations such as lack of understanding that prevents informed choices" (p. 33). The "women-centered perspectives" discussed in this chapter are all feminist perspectives.

Chapter 3 addresses the moral standing of embryos, fetuses, and infants. Strong's ethical framework includes the principle that "moral status increases as the fetus develops during pregnancy" (p. 42). He prepares the way for his defense of this principle by making two distinctions. First, we must distinguish between two senses of the term personhood. "The first sense is normative and refers to a status that we might call full moral standing. It involves having a substantial set of fights, including but not limited to a strong right to life. The second sense is descriptive and refers to the possession of self-consciousness" (p. 53). Individuals who are self-conscious are persons in both the normative and descriptive senses. The second distinction is that between "intrinsic" and "conferred" moral standing. Descriptive, that is, self-conscious individuals have full moral standing and intrinsic moral standing (p. 53).

Now where do embryos, fetuses, and infants fit into this schema? Since they lack self-consciousness, they cannot be descriptive persons and therefore they cannot have full and intrinsic moral standing. Any moral status that they have is conferred upon them. Yet how is this conferred moral standing to be justified? Strong takes a "consequentialist approach" to this question (p. 56). It is the overall degree of similarity that an individual has to the paradigm of descriptive persons that determines the degree of conferred moral standing. This is a consequentialist approach because what justifies this degree of standing are the consequences for descriptive persons: there would be adverse consequences to descriptive persons--"normal adult human beings"--if advanced fetuses, for example, were not treated with "respect" (pp. 59-60). Descriptive persons would feel threatened.

Chapter 4, "Assigning Priorities," addresses "the central question in reproductive ethics," that is, when reproductive freedom should be overridden by other values (p. 63). Strong proposes what he calls a "modified casuistic approach," which involves identifying a paradigm case for each alternative course of action, then comparing the case at hand with the paradigm cases (p. 75). The values of reproductive freedom and respect for life are brought to bear on the decision in accordance with the principle that moral standing increases as the fetus develops and becomes more similar to a descriptive person.

Part 2 consists of four chapters in which the new ethical framework is applied to general issues in reproductive and perinatal ethics. The general issues are nontraditional families, the status of preembryos especially for research, the decisions that are made necessary by developments in genetics, and fetal anomalies, treatment, and abortion decisions. Specific cases are included to illustrate the ways in which the new framework allows us to make right decisions.

Strong wants very much to be fair minded and measured in his approach to these issues and this is evident in the tone of the book. Yet is it really possible to "balance" the values of reproductive freedom and respect for life in the way that he proposes? In the end, Strong's book is another example of the mental contortions that defenders of abortion must go through in order to remain consistent.

To his credit, Strong's intuition is that late terms abortions are not morally justifiable. Yet on what grounds? Instead of arguing for intrinsic moral standing for the fetus, Strong goes through an elaborate set of distinctions so as to be able to "confer" moral status. The fetus is described by some as a "symbol" of descriptive persons. In Strong's terminology, it is "similar to" descriptive persons. The dust jacket on this book shows a picture produced by sonogram. It is perfectly obvious that this is a child, a human being in the womb, not a symbol of a person or some thing that just happens to resemble a human being.

Strong explains that within twenty-four hours after conception, a new and unique genome forms. Yet he is unwilling to confer moral status on this new and unique individual. What, then, does the value of "respect for life" amount to? Strong's discussion of whether preembryos should be regarded as property is a good example of the emptiness of this value and of the consistency that is sought. "Regarding preembryos as property seems inconsistent with the idea that at least some degree of respect should be given. Respect implies that there are limits to what we may do with them. The question was raised above concerning what might be involved in treating preembryos with `respect.' One way to show respect--to acknowledge that they have at least some moral status--is to avoid labeling them as `property' and, whenever possible, to avoid the language of property rights and property interests in regard to them" (p. 118). Given the fact that preembryos may be disposed of at will, this is surely a notion of respect that is completely empty and merely verbal.

It is puzzling, then, that Strong thinks it important to claim that surrogate mothers are not treating their children "merely as means" (p. 108) since preembryos are not ends in themselves (pp. 126-7), and that he is so eager to dissociate genetic counseling from eugenics: "In Germany during World War II, the worst conceivable nightmares became reality, in the name of eugenics" (p. 141). Again, this is merely verbal respect for life, since "severe anomalies have the effect of diminishing the degree of similarity a fetus has to the paradigm" (p. 161), thus weakening even its conferred moral standing.

Strong wants us to consider "what would be involved in not conferring a right to life upon infants and others who are very similar to persons in the descriptive sense. If infants and others who lack self-consciousness because of severe mental retardation, senility, or other debilitation were regarded as not having a right to life, then the proscription against killing them would be removed. Not only would individuals in those categories be in jeopardy, but so would individuals who border on those categories. Persons in the descriptive sense would reasonably feel threatened in this situation" (p. 61). This is certainly true. To paraphrase Mother Theresa, if a mother can kill the child in her womb, then you can kill me and I can kill you. What Strong seems to be unwilling to admit is that the only consistent conclusion is to acknowledge the intrinsic moral standing of the individual from the moment of conception.

Ann Hartle, Emory University.