MANAGED CARE September 2000. ©2000 MediMedia USA
Bioethical issues in women's health mostly revolve around reproduction. Who, why, when, where, and how people reproduce have been sources of discussion and sharp disagreement for a few thousand years. Birth occupies a seat — next to death — in the front row of the great bioethics study hall.
Most ethical questions arise from someone's ability to control something. Today this includes sexuality; fertility and infertility; parental control over children; technological control of gestation; birth; newborns; fetuses; gametes; the power to predict characteristics of offspring before birth or even conception; and an ocean of other capabilities novel in mankind's experience. These changes sweep society along in a furious tide, guaranteeing material for 100 future generations (if we still have "generations") of poets, playwrights and, of course, ethicists.
Because many of the niftier aspects of reproduction take place inside women, it's hard to separate moral, cultural, legal, religious, and physiologic aspects of reproduction from other women's issues.
Suppose they weren't separated? What if human reproduction changed so drastically that the automatic association between women and procreation were uncoupled? What philosophical questions would emerge in a world where "woman" and "man" merely described two ordinary features of physiognomy, like "curly" and "straight?"
Nurture or nature?
For one thing, we would have to think more about when to say, "woman and man," as opposed to "female and male." Rich cultural and literary traditions (not always commendable) are attached to "womanly" and "manly." How much of this luggage is packed with genes, and how much with heritage of another sort?
Then, look at the ruckus that effective birth control has caused in the 20th century. Think of the benefits, responsibilities, hazards, advantages, and philosophical quandaries of women who can detach heterosexual intercourse from pregnancy. What are the meaningful differences between families or cultures where childbearing is voluntary, deliberate, and optional, and those where it is involuntary, unpredictable, and inevitable? What does this mean for men, apart from its meaning for women?
Now, imagine completely severing the cord that ties women (literally) to reproduction. Extracorporeal gestation. ("Honey, could you stop off at the nursery after work and see if the new baby is done yet?") Many ethical problems revolve around our dependence on a human incubator. How long does a fetus need one now? Is it 22 weeks? 26? 32? It depends on how fussy you are about the outcome. Long-term data on the karma of neonatal intensive care unit alumni don't resolve the question.
This uncertainty will be traded for others once we perfect even the most rudimentary artificial uterus. The promise this will offer the desperate — and the freedom it may offer the well-to-do — will overwhelm qualms about its appropriateness.
The proof of this is the current infertility industry, of which the "robowomb" is merely a logical extension. You might as well tell dogs not to bark as tell a society not to adopt a device that gives more control over its children. (The same goes for implantable behavior-control remote guidance command centers, too, when those come along. "Harry, can you hand me the remote? Little Filbert is acting up again.")
Technology's mantra is, "Better, cheaper, faster." How wonderful to apply these principles to family life! However, I'm not sure I clearly see how they improve my relationships with parents, spouse, children. (Well, cheaper might be OK.)
Users and use-nots
Technology tugs irresistibly on those who can afford it, widening a profound rift in every culture between "users" and "use-nots." This makes nonusers controls in a great clinical trial. When is it morally imperative to apply our powers over nature? ("Is it mandatory to resuscitate every newborn?" "Is it permissible to decline an emergency C-section?") When is technology optional? ("We are able to offer you in-vitro fertilization using recombinant platypus ova...") When is it potentially harmful? ("Testing shows you to be 0.0281 percent African/Jewish/Irish/Labrador Retriever...")
Consider the harrowing experiences of parents facing critical decisions about ill newborns. The destinies of those babies exemplify both miracles and tragedies.
For some, choices will be easier, heartaches fewer, as the range of treatments broadens. For others, the opposite. ("We are now able to offer full-organ replacement, psychological testing, body tattooing — to your two-week-old fetus...")
Some decisions leap upon us with no time for thought. Early detection is a great benefit of diagnostic technology, yet it can be a two-edged scalpel.
One of my more memorable consultations was with a woman whose young husband was just showing signs of Huntington's. They had two sons, 6 and 8 years old. She asked for advice about when they should be told or tested. We were grateful that nothing had to be decided that day.
Some things can't be pondered too long. Others shouldn't be pondered too soon. Meanwhile, cost disparities tend to increase.
Technology widens differences between users and nonusers. Compare a Wall Street day trader and an Amish farmer. Who is more robust, in a Darwinian sense? It depends on what the world will be like after a while.
What can prepare our tender sensibilities for the dramatic expansion of social options that seems already to have surpassed comprehension? Talk to your grandparents.
Finally, there is an embarrassing difficulty that arises when we give attention to these enthralling topics, and ignore the mundane. In women's medical care we have solved many of the basic problems.
We know how to reduce cancer, STDs, heart disease, violence, illiteracy, alcoholism, teen pregnancy, traffic death, and osteoporosis. There are no big conceptual questions about whether any of these is good to do. The real question is "What keeps us from doing them?"
Adaptation to catastrophic moral disorientation is surely a survival trait. As Buddha says, "You think this is, like, new?"