Could governments mandate that we quit reproducing sexually for the sake of public health? It sounds outlandish, but there are prominent thinkers making that case. Their argument is superficially plausible but ultimately absurd, both for scientific and ethical reasons.
The battle over COVID-19 vaccine mandates has added another layer of controversy to our bitter, partisan dialogue surrounding the pandemic. Getting immunized against SARS-CoV-2, one side argues, is an ethical obligation we owe to each other as Americans. Nonsense, retorts the opposition. There's nothing less patriotic than allowing the government to forcefully stick a powerful pharmaceutical drug in your arm.
However this particular dispute ends, the opposing sides and the underlying point of contention, who controls your body, aren't going anywhere soon. The reason is that advances in health care are enabling physicians to identify the genetic underpinnings of serious diseases and take preventative measures before their patients suffer the debilitating effects of these disorders.
Using in vitro fertilization (IVF) and pre-implantation genetic testing (PGT), prospective parents can choose which embryo they want before a pregnancy begins based on that embryo's polygenic risk score (PRS), its chances of developing certain diseases. IVF and embryo screening have been used for years, but advances in whole genome analysis are allowing scientists to target diseases influenced by many mutations, not just Mendelian disorders linked to single genes. Eventually this capability could extend to selecting for traits like height, intelligence and strength.
Considered on its own, that's an impressive development. But when we evaluate this technology alongside the ethical baggage it carries, all sorts of awkward questions materialize. Here's perhaps the most important one: If parents can reduce their risk of bringing disease-prone children into the world, should they be forced to do so?
Citing the existing vaccine controversy, some commentators say “yes.” Preventing sickness and death is the ethical thing to do, they argue: it's a “moral obligation to create children with the best chance of the best life.” Furthermore, we all cover each other's health care costs, either through private insurance plans or federal programs. As a result, there's no reason these treatments should be voluntary. Sex should be for fun and bonding, IVF and PGT for making babies.
It's my contention that it would be hopelessly unethical to mandate this kind of shift in human reproduction. When we follow the argument in support of this policy to its logical conclusion, it implodes into a pile of absurdity.
Uncertainty abounds
There are a lot of open questions surrounding the efficacy of PRS. For instance, it can tell you that someone may have a higher risk for a particular disease, but it can't tell you when the condition will develop or even if it will develop. Polygenic risk scores are statistical associations between patterns of mutations and health outcomes, nothing more.
It's also likely that an embryo with a lower risk of developing one disease could have a higher risk of experiencing another. One gene can have multiple effects. These so-called pleiotropic genes may also cause unintended positive effects, reducing the risk of one disease could also reduce the risk of a second. But the ultimate problem is the uncertainty involved in the screening process. After all, we're talking about making heritable changes to a person's genome. This is a messier question than breeding spicy tomatoes with CRISPR gene editing.
Good(ish) technology, bad policy
Assuming for the moment that PRS reliably predicts disease risk and people are allowed (but not required) to use it, the technology seems rather benign. Sure, there are some ethically difficult edges, though these are nothing new. Parents can already abort their developing babies based on the results of prenatal testing, for example. “Is it really more ethically problematic,” some experts have asked, “to allow parents to choose an embryo to implant than it is to allow parents to terminate a pregnancy on the basis of a genetic anomaly?”
That's a great rhetorical question, but it strikes me as a better argument against abortion than for using assisted reproduction. The crucial question is, do the costs of using this technology outweigh its benefits? There are at least two reasons to think so. IVF carries certain risks, some inherent in the procedure and others that stem from negligence on the part of IVF clinics. If the use of in vitro fertilization expands, these risks will likely multiply.
We need an appropriate regulatory framework to mitigate this possibility, and that leads to a second set of tough questions. Who gets to do the regulating? And on what assumptions are their regulations based?
There aren't easy answers. For example, is deafness a unique culture or a disability we should try to select out of the gene pool? There are proponents of both views; who's to say which side has the moral high ground? Imagine a similar situation in which parents want a child who will be more prone to depression, on the grounds that depressed people often become great artists and comedians. You may consider depression an obvious example of mental illness, but there's an influential field of scholarship that views the very concept of mental illness as a concerted effort to “medicalize” (and thus pathologize) the unique identities of millions of individuals.
Many similar considerations are worth contemplating. What if our hypothetical depressed child grows up and decides that a genetic predisposition for depression was harmful? Does he sue his parents for compensation? Moreover, parents from different cultural backgrounds could prize different outcomes, a problem that will become more pronounced once we begin selecting for traits like height or intelligence and not just disease prevention. [1]
A “global dialogue” that leads to sensible regulation is supposed to be the all-purpose salve for our technophobia. That sounds wonderful in the abstract, but solving the problems outlined above will be much more complicated than signing an international treaty to oversee the deployment of these powerful genetic technologies. Author and philosopher CS Lewis presciently spelled this out in his 1943 book The Abolition of Man:
... Unless we have a world state, this [regulation] will still mean the power of one nation over others. And even within the world state or the nation it will mean (in principle) the power of majorities over minorities and (in the concrete) of a government over the people. And all long-term exercises of power, especially in breeding, must mean the power of earlier generations over later ones (p 719, The Complete CS Lewis Signature Classics).
Say goodbye to “my body, my choice” arguments
An even greater issue arises when coercion enters the picture, however. If the government can literally dictate how you reproduce, any argument based on bodily autonomy goes out the window. Consider this related scenario. In the coming decades, it will be possible to gestate a baby in vitro for all nine months of a pregnancy, no mother required. This invites all sorts of ethically fraught issues, as RealClearScience editor Ross Pomeroy explained:
As artificial wombs arrive and push the age of fetal viability earlier and earlier, the debate over abortion will transition to one over 'extraction.' Imagine a world where the developing embryo is viable immediately at conception. Under current laws, states could potentially prohibit mothers from killing the fetus and require them instead to undergo an extraction procedure to place it in an artificial womb until it is ready to survive outside as a fully-formed baby.
If the state can mandate that you implant certain embryos, why couldn't it also require “extraction” instead of abortion should you decide to terminate a pregnancy? Some feminist scholars have asserted that fetuses don't have a right to exist if their mothers don't want them to, but this answer “looks problematically ad hoc,” as some philosophers have pointed out in response. Besides, why should you have a say in what happens to a child you don't want when public health officials disagree? Don't be so selfish; your country needs you!
These are, I concede, creepy Handmaid's Tale-inspired scenarios; we are many years away from confronting these sorts of policy questions, and the regulatory framework to do so is still under debate. That said, such outcomes are not beyond possibility in a world where reproduction is treated as a public good. If we give governments the power to dictate how we reproduce, don't be surprised when they expand that authority over related issues. Mission creep in government bureaucracies is a well-documented phenomenon.
This has always been the logic underlying arguments against mandatory vaccination. We're beginning to see why that decades-old argument is so important.
[1] ACSH contributor and scholar in law and bioethics Barbara Pfeffer Billauer has written two excellent articles outlining these ethical challenges here and here. But the conclusions in this article are my own; I don't attribute any of my views to her.
