The Effects of Individual Reproductive Choices on Society

In addition to advantageous or deleterious effects on individual women and couples, concerns exist about the effects of prenatal testing on society.

THE DISABILITY CRITIQUE. The most forceful critique of prenatal testing is that made by disability theorists (Parens and Asch). Their most straightforward claim is that prenatal testing represents "search and destroy" missions against those who would be born with disability and is, simply, a eugenic program. A more subtle disability critique states that the choice to abort an otherwise desired fetus on the basis of one trait or characteristic sends the message that the lives of those with disability are not valuable and that the disability makes the child unacceptable (Asch and Geller); this has been termed the expressivist argument. Objections to the expressivist argument share a skepticism about the ability of individual acts to constitute a message. Objections to the disability critique in general often point to the increasing societal protections of individuals with disability that have co-occurred with the growth of prenatal testing.

THE LIMITS OF AUTONOMY. The argument that prenatal testing is not eugenic and not disvaluing of living individuals with disability rests largely on the way that testing programs protect the autonomy of women's or couple's decisions in regard to the use of testing and test results. A central ethical issue, therefore, concerns the actuality and the limits of such autonomy. Specifically: Are women or couples making autonomous decisions in regard to prenatal testing? Can the aggregate effect of autonomous choices be eugenic? And, if they can, how problematic is this?

Are prenatal testing decisions truly autonomous?

Individual autonomy is a foundational principle in Western bioethics, and there is virtually universal agreement that women and/or couples should make informed decisions about the use of testing and should not be coerced into pregnancy terminations following a positive prenatal test. The disagreement that exists, therefore, is about the possibility and actuality of such autonomy.

On a narrow level, there is concern that women do not understand the implications of an offer of prenatal testing; this has led to attempts to improve the informed consent process. Yet empirical research suggests that such attempts are only partly successful in the prenatal testing arena, as is true of informed consent in general. Empirical data suggest that, especially low risk women who are offered prenatal testing in a context of routine prenatal care, are likely to conflate prenatal testing for fetal anomalies with tests which can directly benefit themselves and their fetus (Press and Browner). It is possible that this misunderstanding is enabled by healthcare providers who are likely to find greater liability risk in the woman who refuses testing and has a baby born with a disability than one who does not fully understand the implications of prenatal screening and participates regardless; it may also reflect a reluctance on the part of both providers and pregnant women to discuss pregnancy termination. Some critics suggest, however, that some women would not have started down the prenatal testing path if they had truly understood the implications in terms of pregnancy termination; they argue that this may represent a compromise of their autonomy.

A broader concern is that the very existence of large-scale prenatal testing compromises the possibility of individual autonomous decision making. Feminist critics, among others, point out that prenatal screening has become routinized, with an offer of some sort of prenatal screening standard of care for all pregnant women. These critics assert that in this setting, not being screened, while a possible choice, becomes a marked one that requires justification to one's healthcare providers and one's peers. Concern has also been expressed that mothers who decide to forgo testing and give birth to a child with a disability will be blamed by society and even, perhaps, denied healthcare insurance for the child. There is little empirical support at this time for these latter claims.

Can the aggregate impact of autonomous choices be eugenic? Even if each choice to use prenatal testing and terminate a pregnancy is informed and autonomous, the net effect might be considered eugenic. And, in fact, there are those who do not consider this to be problematic. Thus, for example, some public health statements clearly cite the measure of success of screening for neural tube defects as the lowering of the number of children born with these defects. Some bioethicists also suggest that eugenics, premised on individual, autonomous choices, is not necessarily bad.

Pregnancy And Childbirth

Pregnancy And Childbirth

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