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The Future of Human Reproduction: Ethics, Choice and Regulation
  1. Juliet Tizzard
  1. Director, Progress Educational Trust, London

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    Edited by John Harris and Soren Holm, Oxford, Clarendon Press, 1998, 254 pages, £35.00.

    It is often the case that the subheading of a book is more revealing than its title. The Future of Human Reproduction is not really about the future of human reproduction. Apart from John Harris's projections into the future, most of the book is concerned with the present of human reproduction. The subheading, instead, tells us more. Harris and Holm's collection is about choice; about who should decide and why, about whether the state should regulate our choices and even about whether choice is such a desirable thing after all.

    This theme fits well into today's debate on medical ethics in general and reproductive ethics in particular. Choice is no longer viewed as necessarily a good thing. Instead, it is often regarded as problematic, bringing with it dilemmas, confusion and even guilt. At the very least, choice means valuing one thing over another. As Jonathan Glover observes in his impressive chapter on eugenics: “As soon as we start choosing at all, we enter a zone of great moral difficulty where there are important boundaries to be drawn”.

    Many of the contributors to The Future of Human Reproduction are quick to observe that, contrary to popular perception, reproductive choice is not universally respected, particularly when reproduction is assisted. Margaret Brazier, for instance, notes that UK legislation governing in vitro fertilisation leaves little room for reproductive autonomy, especially when it comes to access to services. Marie Fox demonstrates how choice in abortion is limited by the law; Simone Bateman Novaes and Tania Salem remind us that frozen gametes are often the property of the clinic; and Harris observes that as far as cloning and gender selection are concerned, reproductive choice is severely limited.

    For Harris, this lack of choice is troubling. He argues that our approach to issues of reproductive ethics should be guided by the principle of procreative autonomy. According to this principle, competent members of society should be left to make their own decisions about how, when and where to reproduce. Only when there is a compelling reason—such as evidence of significant harm—should the state be allowed to intervene in such decision making.

    Harris's justification for this principle draws on the writings of Ronald Dworkin, who has argued that procreative autonomy should be regarded as a democratic liberty just as freedom of speech and racial equality are. Dworkin—and Harris—maintain that procreative autonomy is a freedom not just for those who live in societies, such as the United States, with written constitutions, but for anyone living in a democracy.

    One suspects, however, that this elegant defence of procreative autonomy would not wash with a number of the other contributors to the book. Marie Fox, for instance, doubts whether choice is such a good thing after all. Fox thinks that “feminism must be prepared to abandon its sacred cows” and accept that the notion of choice has not served women's interests. Choice has made women look self-serving and has encouraged conflict between a woman and her fetus. Fox suggests that the picture of the “selfish, amoral woman produced by choice discourse” means that feminists must change their tack. One course of action might be, Fox argues, to communicate with opponents, rather than demanding things from them.

    In the context of fertility treatment, it is often easier to argue for limits upon procreative liberty because of the children that it aims to produce. So, whilst Marie Fox is unconvincing, those contributors who suggest that policy in assisted reproduction should be guided by the interests of the children born, rather than the interests of the parents, have a better case. In their challenging chapter, Bateman Novaes and Salem suggest that assisted conception has modified women's role in reproduction. Such high-tech interventions mean an increased concentration upon the embryo and a weakened role in decision making for the woman having treatment.

    Bonnie Steinbock thinks constraints upon reproductive liberty may not be such a bad thing, although she is concerned that such limits are not the preserve of the state. Steinbock suggests that judges would be acting irresponsibly if they ignored evidence that a child born of, say, surrogacy is likely to be psychologically impaired as a result. After all, she says, “no one is harmed or deprived by not being brought into existence”.

    Guido de Vert takes the concern about the welfare of others one stage further. He argues that there are three parties to consider in assisted reproduction: the woman (or couple), the embryo/child and the doctor. According to de Vert, the doctor “has his own responsibility for the consequences of his acts”. He therefore has a duty to consider whether his patients will make good parents and, if he is not convinced of their suitability, to refuse to provide treatment.

    The recurrent problem here is evidence. Fisher and Sommerville, in their chapter on postmenopausal women, as well as Steinbock and de Vert, all worry that there is little data showing what harm might be inflicted on children born of assisted reproduction. Such a lack of evidence of harm should, arguably, make these contributors abandon the notion of limited access to assisted reproduction. But they do not. Ultimately, it is only Harris who is prepared to stick by the principle that reproduction should be an autonomous activity, free from outside interference unless a significant chance of serious harm can be demonstrated in advance.

    In his introduction, John Harris suggests that the eclectic group of contributors to the volume reflect the central theme of choice. An extension of that theme might be to choose to read the book or to choose not to. From my point of view, however, reading it is the right choice to make.