Medical Ethical Dilemmas:  Prenatal Diagnosis and Selective Abortion   Guido de Wert Maastricht University FHML, Dept. Hea...
Outline   <ul><li>Prospective parents at high risk </li></ul><ul><li>Reproductive options </li></ul><ul><li>Ethics of </li...
Reprogenetics:  prospective parents at high risk <ul><li>family history, mainly </li></ul><ul><li>* Mendelian disorders </...
Reproductive options <ul><li>Accept risk/’genetic lottery’ </li></ul><ul><li>Refrain from having children </li></ul><ul><l...
Ethics of genetic counseling <ul><li>Historical background: eugenics </li></ul><ul><li>Reaction: a different normative fra...
Types  of non-directive counseling   <ul><li>Information-only model </li></ul><ul><ul><ul><li>Pro </li></ul></ul></ul><ul>...
Types  of non-directive counseling <ul><li>Moral education model </li></ul><ul><ul><ul><li>Pro </li></ul></ul></ul><ul><ul...
Case 1 Down syndrome <ul><li>woman at high risk to conceive a child with DS </li></ul><ul><li>content and risk of moral ed...
Prenatal diagnosis <ul><li>PD ≠ selective abortion </li></ul><ul><li>What about  conditional  access? </li></ul><ul><li>* ...
Ethics of (selective) abortion <ul><li>Beyond ‘fetalism’: simplistic one-dimensionality </li></ul><ul><li>The moral point ...
The status of the fetus: eternal dissent <ul><li>1. the metaphysical concept of a person: what matters  is the ‘radical ca...
Thomson <ul><li>The argument: </li></ul><ul><li>for the sake of debate: fetus is a person … </li></ul><ul><li>right to lif...
2. Beyond the metaphysical concept <ul><li>confuses persons - potential persons </li></ul><ul><li>personhood presumes: </l...
A moral conflict <ul><li>interests of woman (couple) vs moral status of fetus </li></ul><ul><li>dominant view/’overlapping...
The ‘disability rights’ critique <ul><li>Claim: ‘PD/SA is at odds with the rights and interests of people with disabilitie...
A moral justification of selective abortion <ul><li>‘ gesellschaftliche Nutzwert’? </li></ul><ul><ul><ul><li>social Darwin...
The slippery slope <ul><li>structure of the slippery slope argument: </li></ul><ul><li>- A    B </li></ul><ul><li>- B is ...
A detailed list of indications: a useful antidote? <ul><ul><li>pros </li></ul></ul><ul><ul><ul><li>avoid misuse </li></ul>...
The medical model <ul><li>Principle: ‘PD only for risk factors for the particular future child’s health’ </li></ul><ul><li...
The right to information <ul><li>informed consent </li></ul><ul><li>the result(s) of the test </li></ul><ul><ul><li>unexpe...
Case: I’ll continue pregnancy only if it’s a girl … <ul><li>couple has 2 sons & indication for karyotyping </li></ul><ul><...
PD for  late-onset  dirorders: HD as paradigm case <ul><li>Objections (Post) </li></ul><ul><li>-  child will have many dec...
Case: PD of HD – unconditional access? <ul><li>Couple at-risk requests PD of HD ‘just for reassurance’. Abortion is not a ...
PGD: early PD <ul><li>PGD =  pars pro toto </li></ul><ul><li>Includes </li></ul><ul><li>IVF </li></ul><ul><ul><li>hormones...
Possible advantages of PGD <ul><li>High risk of affected child </li></ul><ul><ul><li>(almost) certainty right from the sta...
Categorical objections to PGD? <ul><li>unjustified selection? </li></ul><ul><li>unjustified biospy? </li></ul><ul><ul><li>...
PGD of mutations in breast cancer genes? <ul><li>Case </li></ul><ul><li>A woman/couple asks for PGD, because several relat...
Working Party PGD <ul><li>Relevant considerations: </li></ul><ul><li>high risk/penetrance: breast cancer 60%-85%, ovarian ...
Dutch politics: towards a prohibition … <ul><li>Argument: ‘just a risk factor’ </li></ul><ul><li>Comments  </li></ul><ul><...
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Ethical Dilemmas in Abortion

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A Presentation on the Ethical Dilemmas of Abortion

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Ethical Dilemmas in Abortion

  1. 1. Medical Ethical Dilemmas: Prenatal Diagnosis and Selective Abortion Guido de Wert Maastricht University FHML, Dept. Health, Ethics & Society
  2. 2. Outline <ul><li>Prospective parents at high risk </li></ul><ul><li>Reproductive options </li></ul><ul><li>Ethics of </li></ul><ul><ul><li>genetic counseling </li></ul></ul><ul><ul><li>Prenatal Diagnosis  selective abortion </li></ul></ul><ul><ul><li>IVF/Preimplantation Genetic Diagnosis  selective transfer </li></ul></ul>
  3. 3. Reprogenetics: prospective parents at high risk <ul><li>family history, mainly </li></ul><ul><li>* Mendelian disorders </li></ul><ul><li>* Chromosomal disorders </li></ul><ul><li>result of prenatal screeningtest (combitest, etc.) </li></ul>
  4. 4. Reproductive options <ul><li>Accept risk/’genetic lottery’ </li></ul><ul><li>Refrain from having children </li></ul><ul><li>‘ Avoidance’: </li></ul><ul><ul><li>Oocyte donation </li></ul></ul><ul><ul><li>Artificial Insemination Donor sperm </li></ul></ul><ul><ul><li>Prenatal Diagnosis </li></ul></ul><ul><ul><li>IVF/Preimplantation Genetic Diagnosis </li></ul></ul>
  5. 5. Ethics of genetic counseling <ul><li>Historical background: eugenics </li></ul><ul><li>Reaction: a different normative framework </li></ul><ul><li>Core principle: respect for reproductive autonomy </li></ul><ul><ul><ul><li>non-directiveness of the counselor </li></ul></ul></ul><ul><ul><ul><li>informed consent </li></ul></ul></ul>
  6. 6. Types of non-directive counseling <ul><li>Information-only model </li></ul><ul><ul><ul><li>Pro </li></ul></ul></ul><ul><ul><ul><li>Con </li></ul></ul></ul><ul><li>Interpre(ta)tive model </li></ul><ul><ul><ul><li>Pro </li></ul></ul></ul><ul><ul><ul><li>Con </li></ul></ul></ul>
  7. 7. Types of non-directive counseling <ul><li>Moral education model </li></ul><ul><ul><ul><li>Pro </li></ul></ul></ul><ul><ul><ul><li>Con </li></ul></ul></ul><ul><li>Deliberative model </li></ul><ul><ul><ul><li>Pro </li></ul></ul></ul><ul><ul><ul><li>Con </li></ul></ul></ul>
  8. 8. Case 1 Down syndrome <ul><li>woman at high risk to conceive a child with DS </li></ul><ul><li>content and risk of moral education </li></ul><ul><li>content and risk of deliberation </li></ul>
  9. 9. Prenatal diagnosis <ul><li>PD ≠ selective abortion </li></ul><ul><li>What about conditional access? </li></ul><ul><li>* Pros: </li></ul><ul><li>- paternalism </li></ul><ul><li>- risk of miscarriage (0.3%) </li></ul><ul><li>- costs </li></ul><ul><li>* Cons </li></ul><ul><li>- reassurance </li></ul><ul><li>- prepare for birth of affected child </li></ul><ul><li>- provide optimal neonatal care </li></ul>
  10. 10. Ethics of (selective) abortion <ul><li>Beyond ‘fetalism’: simplistic one-dimensionality </li></ul><ul><li>The moral point of view: all relevant interests </li></ul><ul><li>and values: </li></ul><ul><li>status of the fetus </li></ul><ul><li>interests of the future child </li></ul><ul><li>interests of prospective parents </li></ul><ul><li>interests of handicapped people </li></ul>
  11. 11. The status of the fetus: eternal dissent <ul><li>1. the metaphysical concept of a person: what matters is the ‘radical capacity’. </li></ul><ul><li>- fertilisation: ‘conceptionalism’ </li></ul><ul><li>- individuation (2 weeks) </li></ul><ul><li>- brain development (6-8 weeks) </li></ul><ul><li>Implication: abortion is murder, unless </li></ul><ul><li>(maybe) very early </li></ul><ul><li>JJ Thomson is right </li></ul>
  12. 12. Thomson <ul><li>The argument: </li></ul><ul><li>for the sake of debate: fetus is a person … </li></ul><ul><li>right to life ≠ right to use the woman’s body </li></ul><ul><li>the latter only if she accepted special responsibility </li></ul><ul><li>if not: charity, not moral duty </li></ul><ul><li>Comment: </li></ul><ul><li>do we have moral duties only towards </li></ul><ul><li>people for whom we have voluntarily </li></ul><ul><li>assumed a special responsibility? </li></ul>
  13. 13. 2. Beyond the metaphysical concept <ul><li>confuses persons - potential persons </li></ul><ul><li>personhood presumes: </li></ul><ul><ul><ul><li>presently exercisable abilities </li></ul></ul></ul><ul><ul><ul><li>most: self-consciousness </li></ul></ul></ul><ul><li>what about the moral status of potential persons? </li></ul><ul><ul><ul><li>preferences of ‘third parties’ </li></ul></ul></ul><ul><ul><ul><li>symbolic value </li></ul></ul></ul><ul><ul><ul><li>the potentiality argument </li></ul></ul></ul><ul><ul><ul><ul><li>strong version </li></ul></ul></ul></ul><ul><ul><ul><ul><li>weak version </li></ul></ul></ul></ul>
  14. 14. A moral conflict <ul><li>interests of woman (couple) vs moral status of fetus </li></ul><ul><li>dominant view/’overlapping consensus’ (Rawls): relative status </li></ul><ul><li>abortion may be ‘the lesser of two evils’ </li></ul><ul><li>‘ good reasons’? </li></ul><ul><ul><ul><li>rape </li></ul></ul></ul><ul><ul><ul><li>medical indications </li></ul></ul></ul><ul><ul><ul><li>psychosocial reasons? </li></ul></ul></ul><ul><ul><ul><ul><li>‘ nurturance matters’ (Gilligan) </li></ul></ul></ul></ul><ul><ul><ul><li>condition of the fetus? </li></ul></ul></ul>
  15. 15. The ‘disability rights’ critique <ul><li>Claim: ‘PD/SA is at odds with the rights and interests of people with disabilities’ </li></ul><ul><li>Arguments include: </li></ul><ul><ul><li>the ‘expressivist’ argument: </li></ul></ul><ul><ul><ul><li>discrimination </li></ul></ul></ul><ul><ul><ul><li>denial of equal worth </li></ul></ul></ul><ul><ul><li>the ‘loss of support’ argument </li></ul></ul><ul><ul><ul><li>public support will dwindle </li></ul></ul></ul><ul><li>Comments: no juxtaposition of interests </li></ul>
  16. 16. A moral justification of selective abortion <ul><li>‘ gesellschaftliche Nutzwert’? </li></ul><ul><ul><ul><li>social Darwinism </li></ul></ul></ul><ul><li>the perfect child? </li></ul><ul><li>prevention of (serious) suffering </li></ul><ul><ul><ul><li>the child </li></ul></ul></ul><ul><ul><ul><ul><ul><li>worse off? </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>if not, still a harmful condition </li></ul></ul></ul></ul></ul><ul><ul><ul><li>the family </li></ul></ul></ul>
  17. 17. The slippery slope <ul><li>structure of the slippery slope argument: </li></ul><ul><li>- A  B </li></ul><ul><li>- B is unacceptable, so </li></ul><ul><li>- don’t accept A </li></ul><ul><li>2 variants </li></ul><ul><ul><li>logical: no sharp boundaries </li></ul></ul><ul><ul><li>empirical: prediction - evidence? </li></ul></ul>
  18. 18. A detailed list of indications: a useful antidote? <ul><ul><li>pros </li></ul></ul><ul><ul><ul><li>avoid misuse </li></ul></ul></ul><ul><ul><ul><li>clarity </li></ul></ul></ul><ul><ul><li>cons </li></ul></ul><ul><ul><ul><li>impossible in view of both nature’s diversity (variable expression) and progress in medicine </li></ul></ul></ul><ul><ul><ul><li>the moral importance of contextualization </li></ul></ul></ul><ul><ul><ul><li>adverse societal effects: stigmatization? </li></ul></ul></ul>
  19. 19. The medical model <ul><li>Principle: ‘PD only for risk factors for the particular future child’s health’ </li></ul><ul><li>Morally relevant variables include: </li></ul><ul><ul><ul><li>severity of the disorder, taking into account preventive/therapeutic options </li></ul></ul></ul><ul><ul><ul><li>age of onset of the disease </li></ul></ul></ul><ul><ul><ul><li>penetrance of the mutation </li></ul></ul></ul><ul><ul><ul><li>personal situation of the woman/couple </li></ul></ul></ul>
  20. 20. The right to information <ul><li>informed consent </li></ul><ul><li>the result(s) of the test </li></ul><ul><ul><li>unexpected findings: </li></ul></ul><ul><ul><li>the right not to know </li></ul></ul><ul><ul><li>medically irrelevant information: </li></ul></ul><ul><ul><li>the right to know </li></ul></ul><ul><ul><li>* the sex of the fetus </li></ul></ul>
  21. 21. Case: I’ll continue pregnancy only if it’s a girl … <ul><li>couple has 2 sons & indication for karyotyping </li></ul><ul><li>“ if it’s a boy again, I’ll opt for TOP” </li></ul><ul><li>what to do? </li></ul><ul><ul><ul><li>what’s the big fuzz? </li></ul></ul></ul><ul><ul><ul><li>withhold PD in order to prevent misuse? </li></ul></ul></ul><ul><ul><ul><li>refer to colleague? </li></ul></ul></ul><ul><ul><ul><li>inform about sex only in third trimester? </li></ul></ul></ul><ul><ul><ul><ul><li>legal right to access file </li></ul></ul></ul></ul><ul><ul><ul><ul><li>limit right to access file? </li></ul></ul></ul></ul><ul><ul><ul><ul><li>are all pregnant women suspected persons …? </li></ul></ul></ul></ul><ul><ul><ul><li>‘ moral education’/deliberative model of counseling? </li></ul></ul></ul>
  22. 22. PD for late-onset dirorders: HD as paradigm case <ul><li>Objections (Post) </li></ul><ul><li>- child will have many decades of good living </li></ul><ul><li>- parents are not directly affected </li></ul><ul><li>‘ humanist considerations’: </li></ul><ul><ul><li>suffering is part of life </li></ul></ul><ul><ul><li>moral ambiguity of perfect child </li></ul></ul><ul><li>Comments </li></ul><ul><li>- high risk of serious disorder </li></ul><ul><li>- ‘genetic perfectionism’? </li></ul><ul><li>- prospect of eventual fate imposes severe burden </li></ul>
  23. 23. Case: PD of HD – unconditional access? <ul><li>Couple at-risk requests PD of HD ‘just for reassurance’. Abortion is not a option for moral reasons. </li></ul><ul><li>Comment </li></ul><ul><li>understandable – but what about the carrier-child? </li></ul><ul><ul><li>harmful knowledge </li></ul></ul><ul><ul><li>right not to know </li></ul></ul><ul><li>counseling: ‘moral education’ or directiveness based on professional ethics? </li></ul><ul><li>couples usually accept a restrictive policy </li></ul>
  24. 24. PGD: early PD <ul><li>PGD = pars pro toto </li></ul><ul><li>Includes </li></ul><ul><li>IVF </li></ul><ul><ul><li>hormones </li></ul></ul><ul><ul><li>oocyte pick up </li></ul></ul><ul><li>biopsy at day 3 </li></ul><ul><li>PGD stricto sensu </li></ul><ul><li>selective transfer  pregnancy? </li></ul>
  25. 25. Possible advantages of PGD <ul><li>High risk of affected child </li></ul><ul><ul><li>(almost) certainty right from the start </li></ul></ul><ul><ul><li>avoid psychological burdens of </li></ul></ul><ul><ul><li>(repeated) selective abortion </li></ul></ul><ul><ul><li>moral advantage? </li></ul></ul><ul><li>High risk of miscarriage </li></ul><ul><ul><li>pregnancy </li></ul></ul>
  26. 26. Categorical objections to PGD? <ul><li>unjustified selection? </li></ul><ul><li>unjustified biospy? </li></ul><ul><ul><li>the totipotency argument </li></ul></ul><ul><li>disproportionally burdensome? </li></ul>
  27. 27. PGD of mutations in breast cancer genes? <ul><li>Case </li></ul><ul><li>A woman/couple asks for PGD, because several relatives have died from HBOC, and she carries a BRCA1 mutation. After counseling, she/the couple </li></ul><ul><li>is even more convinced that PGD is the better option for her/them. </li></ul>
  28. 28. Working Party PGD <ul><li>Relevant considerations: </li></ul><ul><li>high risk/penetrance: breast cancer 60%-85%, ovarian cancer 20-60% (cfr family history) </li></ul><ul><li>serious disorder </li></ul><ul><li>preventive options (periodic exams, preventive surgery) are only partially effective and burdensome </li></ul><ul><li>request well-considered </li></ul><ul><li>respect for reproductive autonomy </li></ul>
  29. 29. Dutch politics: towards a prohibition … <ul><li>Argument: ‘just a risk factor’ </li></ul><ul><li>Comments </li></ul><ul><ul><li>even if incomplete penetrance: still a </li></ul></ul><ul><ul><li>high risk of serious disease </li></ul></ul><ul><ul><li>departure from guidance so far </li></ul></ul><ul><ul><li>‘ PD yes, PGD no’?! </li></ul></ul><ul><ul><li>top-down one-dimensionality </li></ul></ul><ul><li>Political wisdom: May 26, 2008 </li></ul>
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