Ethical Dilemmas in Abortion
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A Presentation on the Ethical Dilemmas of Abortion

A Presentation on the Ethical Dilemmas of Abortion

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Ethical Dilemmas in Abortion Presentation Transcript

  • 1. Medical Ethical Dilemmas: Prenatal Diagnosis and Selective Abortion Guido de Wert Maastricht University FHML, Dept. Health, Ethics & Society
  • 2. Outline
    • Prospective parents at high risk
    • Reproductive options
    • Ethics of
      • genetic counseling
      • Prenatal Diagnosis  selective abortion
      • IVF/Preimplantation Genetic Diagnosis  selective transfer
  • 3. Reprogenetics: prospective parents at high risk
    • family history, mainly
    • * Mendelian disorders
    • * Chromosomal disorders
    • result of prenatal screeningtest (combitest, etc.)
  • 4. Reproductive options
    • Accept risk/’genetic lottery’
    • Refrain from having children
    • ‘ Avoidance’:
      • Oocyte donation
      • Artificial Insemination Donor sperm
      • Prenatal Diagnosis
      • IVF/Preimplantation Genetic Diagnosis
  • 5. 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
  • 6. Types of non-directive counseling
    • Information-only model
        • Pro
        • Con
    • Interpre(ta)tive model
        • Pro
        • Con
  • 7. Types of non-directive counseling
    • Moral education model
        • Pro
        • Con
    • Deliberative model
        • Pro
        • Con
  • 8. 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
  • 9. Prenatal diagnosis
    • PD ≠ 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
  • 10. 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
  • 11. 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
  • 12. 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?
  • 13. 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
  • 14. 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?
  • 15. 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
  • 16. 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
  • 17. 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?
  • 18. 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?
  • 19. 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
  • 20. 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
  • 21. 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?
  • 22. 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
  • 23. 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
  • 24. PGD: early PD
    • PGD = pars pro toto
    • Includes
    • IVF
      • hormones
      • oocyte pick up
    • biopsy at day 3
    • PGD stricto sensu
    • selective transfer  pregnancy?
  • 25. Possible advantages of PGD
    • High risk of affected child
      • (almost) certainty right from the start
      • avoid psychological burdens of
      • (repeated) selective abortion
      • moral advantage?
    • High risk of miscarriage
      • pregnancy
  • 26. Categorical objections to PGD?
    • unjustified selection?
    • unjustified biospy?
      • the totipotency argument
    • disproportionally burdensome?
  • 27. 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.
  • 28. 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
  • 29. 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