The hands that rock the cradle

As human beings we have much more complicated and, relative to our size, much larger brains than other animals. Our unique ability to reason has given us an irresistible urge - almost a duty - to understand ourselves and the physical world in which we live. As a result, those of us who live in the developed world are now dependent on science-based technologies. These have provided considerable benefits and some harm, but our intelligence has usually enabled us to adjust to both with little difficulty.

A current challenge is presented by the expanding biological knowledge that has led to an increased ability to control and modify human reproduction. To begin with this provided contraception, safe abortion and donor insemination, and these are now reasonably integrated into our individual and social behaviour. More recently, antenatal diagnosis and the option of abortion to avoid the birth of a handicapped child have become acceptable to many.

In vitro fertilisation is widely used in the management of certain categories of infertility, but there are wider, more controversial applications, such as allowing the preimplantation diagnosis of inherited abnormality, enabling women without a male partner to have a child, or allowing pregnancy after the menopause. In the future, it will become possible to modify the genes of an early embryo to avoid certain inherited diseases, and there is the prospect that the genetic constitution of essentially normal fetuses might be modified to enhance desirable characteristics.

These developments cause concern because they conflict to a greater or lesser extent with traditional rule-based morality and because they involve aspects of personal and social life that are of fundamental importance. These are: the role of the sexes, the regulation of sexual behaviour, the process of conception, the moral status of the embryo and fetus, marriage, the care of children, and the nature of the family.

The interpretation of the benefits and harms of reproductive technology depends on the stance of the commentator. The reproductive scientists who contributed to Issues in Fetal Medicine have a very different perspective from the professor of journalism, Jose Van Dyck in Manufacturing Babies and Public Consent, and from the social philosophers in The Family in the Age of Technology. The moral philosopher, Kurt Bayertz, links all three by arguing the need for a system of GenEthics, by which future developments can be judged.

Issues in Fetal Medicine contains the talks given at the annual Galton Institute Symposium in 1992. This brought together laboratory scientists, experts in fetal medicine and human genetics, ethicists and legal experts. The scientists are concerned primarily with unravelling the complex processes of reproduction, and their work is based on the careful collection and analysis of data. In this field basic understanding has to be obtained from work on animals and then extended cautiously to the human.

As an example, Mary Sellors has used scanning electron microscopy to study the early development of the mouse embryo. She has produced a sequence of fascinating images of the complex process in which sheets of cells form and fold to shape the major internal organs and then the outer structures of the body. These stages of development in the human have been inferred from the occasional human embryo that has become available through chance events such as miscarriage and legal abortion. Intellectual curiosity may be the primary drive of the reproductive scientist, but their accounts of their work show that they also hope to find solutions to human problems such as inability to conceive and the causes, detection and prevention of genetically determined disease.

The specialists in fetal medicine and medical genetics work directly with pregnant women and their writing is easier for the non-medical reader to understand. They too are fascinated by their power to investigate and treat the fetus in utero, but show an awareness that their actions are regarded by some as wrong - or at least as controversial. This is emphasised by the inclusion in the symposium of contributions on the ethics of screening for fetal defects, and on the legal status of the embryo and fetus.

Gordon Dunstan provides a particularly clear discussion of the moral status of the fetus. He argues that the fetus does not have autonomy, because this rests on a freedom to make responsible decisions that depends on a neural and rational capacity that the fetus does not possess; that there is a parental and professional duty to act in its best interests; and that the presumption in favour of its life is rebuttable only for grave reasons. The antenatal diagnosis of serious fetal abnormality gives the mother the choice of accepting the effects of the abnormality on behalf of her fetus, consenting to treatment for the fetus where this is possible, or deciding that it would be in the best interest of both the fetus and herself if the pregnancy were terminated. Her choice, within the law and contemporary ethics is not absolute. The doctor too, has a conscience, personal and professional: and she may not oblige him to violate it, but, given an adverse prognosis for the putative child, the presumption is in favour of her being free to choose.

Lacking from the symposium was any input from the women to whom the new reproductive technologies are being made available. The professionals see these as beneficial and as providing the women with choice. For some women these treatments bring fulfilment and great happiness, but there are costs. In Britain, antenatal diagnosis and genetic counselling are available free of charge through the National Health Service, but in general in vitro fertilisation has to be paid for privately. For a minority of those treated, antenatal diagnosis can lead to the miscarriage of a normal fetus; the treatment necessary to induce multiple ovulation in preparation for in vitro fertilisation may result in over-stimulation of the ovaries and a potentially fatal acute illness; and the accidental (or deliberate) production of a multiple pregnancy may end in premature labour and the birth of small babies that later become seriously handicapped children because of the complications of immaturity.

The ordinary woman's view of reproductive technology is the theme of Manufacturing Babies and Public Consent. The writings of reproductive scientists and experts in fetal medicine tend to be inaccessible to the ordinary reader, both geographically and in content. As a result, partial and frequently inaccurate information is gained from the media. Journalists, often with little or no biological or medical knowledge, write "stories" that highlight sensational or controversial aspects of reproductive technology and which fail to provide the balancing and relatively dull facts that are necessary for a proper perspective. Misinformation of the public is increased by the writers of science fiction who invent possible, or impossible, developments in reproductive technology to create gripping and disturbing plots. Sometimes such fiction is presented in such a way that the casual reader can be deceived into believing that the fiction is true. Television and radio stage discussions of the more controversial issues, but almost always in the form of a limited debate between experts with strongly opposing views and with audience participation limited to either a "yes" or "no". This is not real public debate and Jose Van Dyck suggests that there is a need for innovatory forums that would stimulate expansive and better informed argument.

Van Dyck makes a number of controversial points. In particular, she maintains that reproductive technology has been forced on women by doctors whose primary interests are making money and furthering their careers in reproductive science. She suggests that reproductive technology is yet a further way in which predominantly male doctors gain control of women's bodies. Her viewpoint is that of a journalist who has scanned the relevant scientific reports, who has focused on statements that support her ideas and who has absorbed the themes highlighted by the media. She may be correct in judging that a minority of doctors are avaricious but technology really is expensive. She unfairly discounts both the desire of the medical profession to help couples seriously distressed by infertility and the consideration that has been given to the ethics of such treatment. But she is right that doctors tend to develop new treatments within their personal view of what women want, and have shown too little interest in the effect that such treatments may have on the recipients, particularly when there are unexpected complications.

The control of fertility is slowly enabling women to take a more equal place in our male-dominated society. This, and the use of donor eggs or sperm for in vitro fertilisation, have implications for the concepts of parenthood, marriage and family life. Perhaps marriage has become a disadvantage for women because society still insists that the interests of husbands have priority. Perhaps the nuclear family confers more disadvantage than advantage on children. Perhaps we do not need monogamy and there may be advantages in expressing our feelings with less restraint through sexual activity. These ideas and others are discussed in a series of essays by social philosophers in The Family in the Age of Technology. These provoke thought but have little practical value. This is because they are largely based on argument, citing where necessary the work of previous thinkers, and not on data collected from randomly selected samples of people and families. The pattern of sexual behaviour and the structure and function of the family are changing in our society, but understanding of the harmful and beneficial effects must be gained from research in the field rather than from abstract discussion.

GenEthics is a major work of moral philosophy concerning the rights and wrongs of modifying the genetic constitution of the embryo. The history of philosophical thought in relation to reproduction is reviewed. Particularly valuable is a critical history of the eugenics movement as an example of the error of developing philosophical arguments on the basis of an imperfect understanding of science. This is followed by closely argued chapters in which the established rule-based ethics of the Judeo-Christian heritage is examined and shown not to be intellectually acceptable. Consequentialist ethics also fail because of the insurmountable difficulty of assessing the outcomes of interventions that may be delayed for many years or even for centuries. Instead, Bayertz argues that ethical principles must be derived from the unique ability of the human to be self-aware and to reason. These capacities have allowed humans not only to use the scientific method to understand and then to manipulate themselves and their environment, but also to develop ways of judging whether actions are right or wrong. Readers educated in science will welcome this approach but will be disconcerted by the author's continued use of "Nature" when describing the total environment in which we live. The concept of "Nature" is part of substantialist ethics and suggests that there are aspects of our environment that are beyond our understanding, and, by implication, are predetermined by non-human will. This conflicts with Bayertz's view that morality can originate only from human thought.

Bayertz writes: "The GenEthics which we are in need of cannot and must not be 'invented' by experts, but must crystallise gradually from the process of public and communal debate." He points out that while philosophers can guide society by clarifying issues, the development and acceptance of moral standards is a political rather than a philosophical problem. He suggests guidelines in relation to reproductive technology. These include: respect for human autonomy and reasoning as the source of all specifically human activity; the freedom of individuals to decide the number of children they have and the way in which they are conceived; the need to protect the fetus from genetic manipulation that would restrict the right of the resulting child to self determination; the idea that genetic intervention is moral only if unequivocally in the interests of the individual concerned, and that the application of gene technology to the human is moral only if it has a therapeutic objective. Many will consider that Bayertz's subjectivist ethics provides a useful base from which to guide developments in reproductive technology.

David Paintin is chairman, Birth Control Trust, and emeritus reader in obstetrics and gynaecology, St Mary's Hospital Medical School, London.