ethical dilemmas in abortion
TRANSCRIPT
Medical Ethical Dilemmas: Prenatal Diagnosis and Selective Abortion
Guido de WertMaastricht UniversityFHML, Dept. Health, Ethics & Society
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Outline
• Prospective parents at high risk• Reproductive options• Ethics of
– genetic counseling– Prenatal Diagnosis selective abortion– IVF/Preimplantation Genetic Diagnosis
selective transfer
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Reprogenetics: prospective parents at high risk
- family history, mainly* Mendelian disorders* Chromosomal disorders
- result of prenatal screeningtest (combitest, etc.)
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Reproductive options
• Accept risk/’genetic lottery’
• Refrain from having children
• ‘Avoidance’:– Oocyte donation– Artificial Insemination Donor sperm– Prenatal Diagnosis– IVF/Preimplantation Genetic Diagnosis
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Ethics of genetic counseling
• Historical background: eugenics
• Reaction: a different normative framework
Core principle: respect for reproductive autonomy
• non-directiveness of the counselor
• informed consent
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Types of non-directive counseling
• Information-only model• Pro• Con
• Interpre(ta)tive model• Pro• Con
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Types of non-directive counseling
• Moral education model• Pro• Con
• Deliberative model• Pro• Con
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Case 1 Down syndrome
• woman at high risk to conceive a child with DS
• content and risk of moral education
• content and risk of deliberation
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Prenatal diagnosisPD ≠ selective abortion
What about conditional access?* Pros:
- paternalism- risk of miscarriage (0.3%)- costs
* Cons- reassurance- prepare for birth of affected child- provide optimal neonatal care
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Ethics of (selective) abortion
Beyond ‘fetalism’: simplistic one-dimensionality
The moral point of view: all relevant interests and values:
- status of the fetus- interests of the future child- interests of prospective parents- interests of handicapped people
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The status of the fetus: eternal dissent
1. the metaphysical concept of a person: what matters is the ‘radical capacity’. - fertilisation: ‘conceptionalism’- individuation (2 weeks)- brain development (6-8 weeks)
Implication: abortion is murder, unless- (maybe) very early- JJ Thomson is right
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Thomson
The argument:- for the sake of debate: fetus is a person …- right to life ≠ right to use the woman’s body- the latter only if she accepted special responsibility- if not: charity, not moral duty
Comment:- do we have moral duties only towards
people for whom we have voluntarily assumed a special responsibility?
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2. Beyond the metaphysical concept• confuses persons - potential persons• personhood presumes:
• presently exercisable abilities• most: self-consciousness
• what about the moral status of potential persons?• preferences of ‘third parties’• symbolic value• the potentiality argument
– strong version– weak version
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A moral conflict• interests of woman (couple) vs moral status of fetus• dominant view/’overlapping consensus’ (Rawls):
relative status• abortion may be ‘the lesser of two evils’• ‘good reasons’?
• rape• medical indications• psychosocial reasons?
– ‘nurturance matters’ (Gilligan)• condition of the fetus?
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The ‘disability rights’ critique• Claim: ‘PD/SA is at odds with the rights and interests of
people with disabilities’
• Arguments include:– the ‘expressivist’ argument:
• discrimination • denial of equal worth
– the ‘loss of support’ argument• public support will dwindle
• Comments: no juxtaposition of interests
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A moral justification of selective abortion• ‘gesellschaftliche Nutzwert’?
• social Darwinism
• the perfect child?
• prevention of (serious) suffering• the child
» worse off?» if not, still a harmful condition
• the family
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The slippery slope• structure of the slippery slope argument:
- A B- B is unacceptable, so- don’t accept A
• 2 variants
– logical: no sharp boundaries
– empirical: prediction - evidence?
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A detailed list of indications: a useful antidote?– pros
• avoid misuse
• clarity
– cons• impossible in view of both nature’s diversity (variable expression)
and progress in medicine
• the moral importance of contextualization
• adverse societal effects: stigmatization?
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The medical model
• Principle: ‘PD only for risk factors for the particular future child’s health’
• Morally relevant variables include:• severity of the disorder, taking into account
preventive/therapeutic options• age of onset of the disease• penetrance of the mutation• personal situation of the woman/couple
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The right to information• informed consent
• the result(s) of the test– unexpected findings:
the right not to know– medically irrelevant information:
the right to know * the sex of the fetus
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Case: I’ll continue pregnancy only if it’s a girl …• couple has 2 sons & indication for karyotyping• “if it’s a boy again, I’ll opt for TOP”• what to do?
• what’s the big fuzz?• withhold PD in order to prevent misuse?• refer to colleague?• inform about sex only in third trimester?
– legal right to access file– limit right to access file?– are all pregnant women suspected persons …?
• ‘moral education’/deliberative model of counseling?
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PD for late-onset dirorders: HD as paradigm case
• Objections (Post)- child will have many decades of good living- parents are not directly affected- ‘humanist considerations’:
- suffering is part of life- moral ambiguity of perfect child
• Comments- high risk of serious disorder- ‘genetic perfectionism’?- prospect of eventual fate imposes severe burden
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Case: PD of HD – unconditional access?Couple at-risk requests PD of HD ‘just for reassurance’.
Abortion is not a option for moral reasons.
Comment• understandable – but what about the carrier-child?
– harmful knowledge– right not to know
• counseling: ‘moral education’ or directiveness based on professional ethics?
• couples usually accept a restrictive policy
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PGD: early PD
PGD = pars pro toto
Includes- IVF
- hormones- oocyte pick up
- biopsy at day 3- PGD stricto sensu- selective transfer pregnancy?
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Possible advantages of PGDHigh risk of affected child
– (almost) certainty right from the start– avoid psychological burdens of
(repeated) selective abortion– moral advantage?
High risk of miscarriage– pregnancy
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Categorical objections to PGD?
• unjustified selection?
• unjustified biospy?– the totipotency argument
• disproportionally burdensome?
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PGD of mutations in breast cancer genes?
Case
A woman/couple asks for PGD, because several relatives have died from HBOC, and she carries a BRCA1 mutation. After counseling, she/the couple is even more convinced that PGD is the better option for her/them.
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Working Party PGD
Relevant considerations:- high risk/penetrance: breast cancer 60%-85%,
ovarian cancer 20-60% (cfr family history)- serious disorder- preventive options (periodic exams, preventive
surgery) are only partially effective and burdensome - request well-considered- respect for reproductive autonomy
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Dutch politics: towards a prohibition …
• Argument: ‘just a risk factor’
• Comments – even if incomplete penetrance: still a
high risk of serious disease– departure from guidance so far– ‘PD yes, PGD no’?!– top-down one-dimensionality
• Political wisdom: May 26, 2008