Shopping at the Genetic Supermarket
Originally published in Spanish as 'De compras por el supermercado genético', Isegoría, 27 (2002) pp. 19-40
The genetic supermarket seems to have arrived, with advertisements in The Prince and other Ivy League campus newspapers offering large sums of money for eggs from women who are tall and have high SAT scores. But you ain't seen nothing yet.
Of course, we have had genetic selection for a long time, most obviously in prenatal diagnosis followed by abortion. Diane Beeson has opposed present practices of prenatal diagnosis on the grounds that:
The central assumption behind the deployment of prenatal diagnosis is that life with a disability is not worthwhile and is primarily a source of suffering… From a disability-rights perspective, prenatal testing for fetal anomalies gives a powerful message that we seek to eliminate future persons with disabilities, fails to recognize the social value of future persons with disabilities, and conveys a devaluation of those now living with disability… By focusing so many resources on the elimination of potential persons with disability, we are drifting toward a eugenic resurgence that differs only superficially from earlier patterns. In the process we are seriously distorting the historical purpose of medicine as healing. We are creating a society in which disability is becoming increasingly stigmatized, with the result that human imperfection of all kinds is becoming less tolerated and less likely to be accepted as normal human variation. 
The cochlear ear implant, the discovery of the gene for achondroplasia, and the use of selective abortion to prevent the birth of children with Down's syndrome serve to test the outer limits of our support for the politics of equality and diversity. We say that we believe that all humans are equal, and we value diversity. Does our belief in equality go so far that we hesitate to say that it is better not to have a disability than to have one? Does the value we place on diversity mean that we should oppose any measures that might weaken Deaf culture, or reduce the number of people born with Down's syndrome or achondroplasia? Should we stop the use of public funds for prenatal diagnosis or cochlear ear implants?
To assess these criticism of prenatal diagnosis, it will help to think for a moment about two related questions. First, how important is it to most parents to give their child the best possible start in life? Second, how serious a reason does a woman need in order to be justified in ending her pregnancy?
The answer to the first question is that, for most parents, giving their child the best possible start in life is extremely important. The desire to do so leads pregnant women who have smoked or drunk heavily to struggle to kick the addiction; it sells millions of books telling parents how to help their child achieve her or his potential; it causes couples to move out to suburbs where the schools are better, even though they then have to spend time in daily commuting; and it stimulates saving so that later the child will be able to go to a good college.
The answer to the second question must begin with the fact that, in accordance with the decision in Roe v. Wade, a woman in the United States can, in the first and second trimesters, or at least until the fetus is viable, terminate her pregnancy for any reason whatsoever. This does not, of course, mean that she is ethically justified in doing so. Some say that she is never ethically justified in terminating her pregnancy, and others that she is justified in doing so only to save her own life, or in cases of rape and incest. Beeson and many others who are concerned about prenatal diagnosis, however, do not rest their argument on opposition to abortion. So rather than argue this point in detail here, I shall simply state that, as I have argued elsewhere, I do not think that a fetus is the kind of being that has a right to life.  Hence it is not hard to justify terminating a pregnancy. For example, suppose that a couple plan to have children, but an unplanned pregnancy has occurred before they feel ready to do so - let's say that at present they are sharing a studio apartment and cannot afford anything larger, but in five years they will be able to move to a larger home. In my view, they would not be acting unethically if they decide to obtain an abortion.
Now think about a couple who are told that the child the woman is carrying will have a disability, let's say, Down's syndrome. Like most parents, the couple think it important to give their child the best possible start in life, and they do not believe that having Down's syndrome is the best possible start in life. Is it true that this couple must be making the assumption that "life with a disability is not worthwhile and is primarily a source of suffering"? There is no more reason to believe that these parents make that assumption, than there is to believe that parents who terminate a pregnancy because they can’t afford a larger apartment believe that "life as a child in one room with one's parents is not worthwhile and is primarily a source of suffering." In both cases, all that the parents need assume is that it would be better to have a child without Down's syndrome, or to have a child who can have a room of her own. After all, in neither case are the parents choosing whether or not to have a child at all. They are choosing whether to have this child or another child that they can, with reasonable confidence, expect to have later, under more auspicious circumstances. 
Thus it is possible to justify abortion in these circumstances while accepting Beeson's claims that people with congenital disabilities "often achieve the same high levels of life satisfaction as non-disabled persons". A couple may reasonably think that "often" is not good enough. They may also accept - as I do - that people with Down's syndrome often are loving, warm people who live happy lives. But they may still think that this is not the best they can do for their child. Perhaps they just want to have a child who will, eventually, come to be their intellectual equal, someone with whom they can have good conversations, someone whom they can expect to give them grandchildren, and to help them in their old age. Those are not unreasonable desires for parents to have.
What of the “powerful message that we seek to eliminate future persons with disabilities” that Beeson tells us is sent by prenatal diagnosis and abortion to people with disabilities? Her concern seems highly selective. She has surely noticed that every bottle of alcoholic beverage sold in the United States bears the words:
GOVERNMENT WARNING: (1) ACCORDING TO THE SURGEON GENERAL, WOMEN SHOULD NOT DRINK ALCOHOLIC BEVERAGES DURING PREGNANCY BECAUSE OF THE RISK OF BIRTH DEFECTS
Does not that warning - much more visible to ordinary Americans than prenatal diagnosis - send out a “powerful message” that we should prevent the birth of children with defects? What about the message sent by programs that immunize girls against rubella? Is anyone seriously proposing to withdraw such government warnings, or end such immunization programs?
The Surgeon General's desire that women should not, through alcohol consumption, give birth to people with disabilities, does not in any way imply that he has less concern for the interests of people living with disabilities than he has for those without disabilities. As I have argued elsewhere, we can and should have equal consideration for the interests of all beings that have interests.  Although this is, in my view, the fundamental basis of equality both within our own species and between our species and beings of other species that have interests, for that very reason it may not satisfy the advocates of people with disabilities. But what other defensible sense can we give to the idea of equal worth?
Even if cochlear implants are not genocidal, and prenatal diagnosis combined with selective abortion is not at all like past eugenic practices, they might be considered wrong. But consider the following principle:
For any condition X, if it would be a form of child abuse for parents to inflict X on their child soon after birth, then it must, other things being equal, at least be permissible to take steps to prevent one's child having that condition.
I propose this not as a self-evident truth, nor as a derivation from any particular moral foundation, but as something that might appeal to many people, irrespective of the foundations of their moral views. The "preventive principle" as I shall call it, requires us to reject the view that the fact that something is the outcome of the genetic lottery is enough to make it right. Why would anyone believe that? Only, I suggest, if somewhere deep down, they think of the genetic lottery as no lottery at all, but rather the workings of a divine Providence. If that were the case, then we might think it wrong to interfere with the natural order of things. But let us put that view aside, for lack of supporting evidence, and assume that the genetic lottery really is a lottery. Then, if there is no moral barrier that says we must not interfere with the way things are, the preventive principle seems sound.
Now let us apply the preventive principle to the cases we have been considering. Suppose that a Deaf couple give birth to a daughter who can hear normally. Because they value very highly their membership of the Deaf community, and they fear that their daughter will not be a part of the Deaf community, they make arrangements with a sympathetic surgeon to destroy the child's hearing. The operation, performed under general anaesthesia, causes the child no pain, but achieves its goal. The child will now be permanently deaf. Is this a case of child abuse? I suggest that it is. What the parents have done ensures that their child will never be able to hear Beethoven, or a babbling brook, or listen to lectures and debates delivered in spoken languages, except in translation. The child will also be at a disadvantage in countless other ways in getting through life. Admittedly, we must also take into account the benefits that the child will get from being part of the Deaf community, especially when being a part of the Deaf community means that the child grows up in the community to which her parents already belong. But that does not justify what they have done.
If you respond to this example in the way I do, and accept the principle I stated above, it follows that it must at least be permissible, other things being equal, for parents to take steps to ensure that their child will not be deaf.
This argument does raise the difficulty of where to draw the line. Is being black a disability? Is being gay a disability? The racial case is easy to distinguish from the case of deafness, because although it may be true deaf people must contend with some socially constructed barriers, it is also indisputable that they lack the ability to hear. African Americans do not lack any ability that people of other races possess. There are only patterns of discrimination or prejudice. Hence being black is not a disability.
What about being gay? While gays and lesbians lack the ability to be sexually attracted to the opposite sex, straight people lack the ability to be sexually attracted to their own sex. This line of argument implies that unless we are bisexual we are suffering from an erotic disability. Is it possible to argue that homosexuals are disabled because they cannot enjoy "normal" sexual intercourse, involving a penis and a vagina? That would require an argument to the effect that this mode of sexual intercourse is superior to others that are available to gays and lesbians, and I do not know how, in the absence of an argument from "natural law", such an argument could be grounded. Nor do I think that a natural law grounding would be satisfactory.  Perhaps the best case for seeing homosexuality as a disability would be made on the grounds that gay people are unable to have children with the person to whom they are sexually attracted. Thus they are unable to have a "normal" family life. It is questionable whether this is a disability, in the same sense that being unable to hear is a disability. But suppose that we grant that it is. Even then, it is one that seems likely to be overcome very soon, as we learn how to mix gametes from same sex partners and inject them into a denucleated egg. Then lesbian couples would only have to decide which of them would bear the child, and male homosexuals would have to find a surrogate willing to carry the child for them. Once this is possible, then it is hard to see any respect in which homosexuals could be said to be disabled.
I conclude, then, that in selecting against having disabled children, parents show that they value having a child without a disability more highly than having a child with a disability, and that this judgment can, in principle, be a sound one. But what about choosing a child with above-average characteristics, rather than avoiding one with a disability?
2. Shopping for Beauty and Brains
As we have already noted, parents already do their best to influence the environmental factors that undoubtedly also play a part in shaping these characteristics. They can now influence genetic factors as well as environmental ones, in one of three ways. By using in vitro fertilization, they can have the embryo screened before implantation; they can use prenatal diagnosis and selective abortion; and they can obtain eggs, sperm or embryos from people they regard as genetically superior. All of these techniques have disadvantages. The first is costly, inconvenient, and does not always lead to a pregnancy. The second involves an abortion, which is not a pleasant procedure for a woman, irrespective of her views about the moral status of the fetus. The third means that the child will not be a biological child of the couple, but will carry the genes of at least one other person. Probably within the next two decades, however, we will have a fourth option: genetic enhancement of our own embryos.
Once this possibility becomes available, many parents will want to use it. We go to so much effort to shape our children's environment to give them the best possible start in life, that once we gain the ability to select their genes, we are unlikely to reject it. What might restrain some potential parents are factors like risk, cost, and whether the children will still be their own children, in a biological sense. The last of these has up to now been a constraint on the number of couples willing to use donor eggs and sperm. But our rapidly increasing knowledge of human genetics will soon make it possible for us to have children who are genetically our own, and yet who are genetically superior to the children we would produce if we left it to the random process of normal reproduction. This will come initially through increasingly sophisticated genetic screening of in vitro embryos. Before very long, however, it will become possible to insert new genetic material safely into the in vitro embryo. Both of these techniques will enable couples to have a child whose abilities are likely to be superior to those offered by the natural lottery but who will be "theirs" in the sense of having their genes, not the genes of only one of them, or the genes of a third person, except (when genetic modification rather than simply genetic selection is used) to the extent necessary to produce the specific desired characteristics.
Many people say that they accept selection against serious diseases and disabilities, but not for enhancement above what is normal. There is, however, no bright line between selection against disabilities and selection for positive characteristics. From selecting against Huntington's Disease it is no great step to selecting against genes that carry a significantly elevated risk of breast or colon cancer, and from there it is easy to move to giving one's child a better than average genetic health profile. Similarly, if almost all of us are willing to abort a fetus that has Down's syndrome, most of us will also be willing to abort one with genes that indicate other intellectual limitations, for example genes that correlate with IQ scores below 80. But why stop at 80? Why not select for at least average IQ? Or a bit above average? The existing market in human eggs suggests that some people will also select for height, which in turn correlates to some extent with income.
3. Choices, Private and Public
How should we react to this scenario? We could treat it as a slippery slope argument, one that proves that we must act now to stop prenatal screening, because otherwise we are heading towards a nightmarish future in which children are made to order, and wanted for their specifications, not loved for what they are. But taking the argument that way forces us either to reject something - current practices of prenatal diagnosis - that most people regard as a great boon, or to show that we can stop somewhere short of permitting the choices I have described. Neither is a convincing option. A second possibility is to say that the future just sketched is no nightmare, but a better society than we now have, one full of healthier, more intelligent, taller, better-looking - perhaps even more ethical? - people. There is, therefore, no "slippery slope", because the slope not down to an abyss, but upward to a higher level of civilization than we have achieved so far.
Nozick's words cited at the head of this paper suggest a third possible answer: it is not up to us to judge whether the outcome of this process will be better or worse. In a free society, all we can legitimately do is make sure that the process consists of freely chosen individual transactions. Let the genetic supermarket rule - and not only the market, but also altruistic individuals, or voluntary organizations, anyone who wishes, for whatever reason, to offer genetic services to anyone who wants them and is willing to accept them on the terms on which they are offered.
That the United States should allow a market in eggs and sperm which goes some way towards fulfilling Nozick's prophecy is no accident. In other countries a practice that threatens to turn the child of a marriage into an item of commerce would meet powerful opposition from both conservative "family values" politics and from left of center groups horrified at the idea of leaving to the market something as socially momentous as the way in which future generations are conceived. In the United States, however, that leftist attitude is restricted to groups on the margins of political life, and the conservatives who dominate Congress show their support for family values merely by preventing the use of federal funds for ends that they dislike; in all other respect, they allow their belief that the market always knows best to override their support for traditional family values.
There are strong arguments against state interference in reproductive decisions, at least when those decisions are made by competent adults. If we follow Mill's principle that the state is justified in interfering with its citizens only to prevent harm to others, we could see such decisions as private ones, harming no-one, and therefore properly left to the private realm.  For who is harmed by the genetic supermarket? The parents are not harmed by having the healthier, handsomer and more intelligent children that they want. Are the children harmed? In an article on the practice of buying eggs from women with specific desired characteristics like height and intelligence, George Annas has commented:
What's troubling is this commodification, this treating kids like products. Ordering children to specification can't be good for the children. It may be good for adults in the short run, but it's not good for kids to be thought of that way. 
ut to say that this is "not good" for these children forces us to ask the question: not good compared with what? The children for whom this is supposed not to be good could not have existed by any other means. If the egg had not been purchased, to be fertilized with the husband's sperm, that child would not have been alive. Is life going to be so bad for this child that he or she will wish never to have been born? That hardly seems likely. So on one reading of what the standard of comparison should be, it is clearly false that the purchase of these eggs is not good for the kids. 
Suppose that we read "not good for kids" as meaning "not the best thing for the next child of this couple". Then whether the purchase of the egg is or is not good for the kid will depend on a comparison with other ways in which the couple could have had a child. Suppose, to make the comparison easier, they are not infertile - they bought an egg only in order to increase their chances of having a tall, athletic child who would get into a very good university. If they had not done so, they would have had a child in the normal way, who would have been their genetic child. Was it bad for their child to buy the egg? Their child may have a more difficult life because he or she was "made to order", and perhaps will disappoint his or her parents. But perhaps their own child would have disappointed them even more, by being less likely to be any of the things that they wanted their child to be. I don't see how we can know which of these outcomes is more likely. So I do not think we have grounds for concluding that a genetic supermarket would harm either those who choose to shop there, or those who are created from the materials they purchase.
If we switch from an individualist perspective to a broader social one, however, the negative aspects of a genetic supermarket become more serious. Even if we make the optimistic assumption that parents will select only genes that are of benefit to their children, there are at least three separate grounds for thinking that this may have adverse social consequences. The first is that some of the traits that people seek to ensure for their children will be advantageous for them only in comparative, not absolute terms. To increase one's children's longevity is good for them, whether or not everyone else’s longevity has been increased by a similar amount. To increase one’s children’s height, however, is beneficial only if it also moves them up relative to the height of others in their society. There would be no disadvantage in being 5 feet tall, if the average height in the community were 4’ 9” and there will be no advantage in being 6’3” if the average height is 6’6”. Arguably, it would be better if everyone were shorter, because we would require less food to sustain us, could live in smaller houses, drive smaller, less powerful cars, and make a smaller impact on the environment. Thus being able to select for height – something couples are already doing, on a small scale, by offering more for the eggs of tall women – could start the human equivalent of the peacock’s tail – an escalating “height race” in which the height that distinguishes “tall” people from those who are “normal” increases year by year, to no-one’s benefit, at considerable environmental cost, and perhaps eventually even at some health cost to the children themselves. 
The second ground for objecting to a genetic supermarket is the fear that it would mean less diversity among human beings. Not all forms of diversity are good. Diversity in longevity is greater when there are more people with genes that doom them to an early death. The loss of this diversity is welcome. But what about the loss of the merely unusual, or eccentric? Antony Rao, a specialist in behavioral therapy in children, finds that many middle and upper class parents come to him when their children behave in unusual ways, wanting them to be medicated, because "they fear that any deviation from the norm may cripple their child's future."  If this is true of behavioral abnormalities that for many children are merely a passing phase, it is likely to be even more true of genetic abnormalities. It is easy to imagine genetic screening reports that indicate that the child's genes are unusual, although the significance of the abnormality is not well understood (usually medical shorthand for "We don't have a clue."). Would many parents decide to terminate the pregnancy in those circumstances, and if so, would there be a loss of diversity that would leave human society a less rich place, and perhaps even, in the long run, reduce the species' capacity to adapt to changing circumstances?
The third and in my view most significant ground for objecting to a genetic supermarket is its threat to the ideal of equality of opportunity. John Schaar has written: "No policy formula is better designed to fortify the dominant institutions, values, and ends of the American social order than the formula of equality of opportunity, for it offers everyone a fair and equal chance to find a place within that order."  It is, of course, something of a myth to believe that equality of opportunity prevails in the United States, because wealthy parents already give their children enormous advantages in the race for success. Nevertheless, the Ron's Angels slogan of “beauty and brains to the highest bidder” points to a future in which the rich have beautiful, brainy, healthy children, while the poor, stuck with the old genetic lottery, fall further and further behind. Thus inequalities of wealth will be turned into genetic inequalities, and the clock will be turned back on centuries of struggle to overcome the privileges of aristocracy. Instead the present generation of wealthy people will have the opportunity to embed their advantages in the genes of their offspring. These offspring will then have not only the abundant advantages that the rich already give their children, but also whatever additional advantages the latest development in genetics can bestow on them. They will most probably therefore continue to be wealthier, longer-lived and more successful than the children of the poor, and will in turn pass these advantages on to their children, who will take advantage of the ever more sophisticated genetic techniques available to them. A free market in genetic enhancement will widen the gap between the top and bottom strata of our society, undermine belief in equality of opportunity, and close the "safety valve" of upward mobility. 
Suppose that we do not wish to accept this situation: what choices do we have? We can ban all uses of genetic selection and genetic engineering that go beyond the elimination of what are clearly defects. There are some obvious difficulties with this course of action. Who will decide what is clearly a defect? Presumably, a government panel will be assigned the task of keeping abreast with relevant genetic techniques, and deciding which are lawful and which are not. This allows the government a role in reproductive decisions, which some may see as even more dangerous than the alternative of leaving them to the market. There are also serious questions about whether a ban on genetic selection and engineering for enhancement purposes could be made to work across the United States, given that matters regulating conception and birth are in the hands of the states, rather than the federal government. In the case of surrogacy, attempts by various states of the U.S. to make the practice illegal, or to make surrogacy contracts void, have had little effect because Arkansas, California and Ohio are more friendly to surrogacy. Couples seeking a surrogate to bear a child for them are prepared to travel to achieve what they want.
Assuming that we could get the U.S. Congress to ban genetic selection and engineering when used for enhancement, persuade the Supreme Court that the legislation violates neither the rights of the states to legislate in this area, nor any constitutional rights to privacy in reproduction, and effectively enforce the ban within the U.S., we would still have to deal with the fact that we now live in a global economy. A small impoverished nation might be tempted to allow enhancement genetics, thus setting up a niche industry serving wealthy couples from the United States and other countries that have banned enhancement. Moreover, in view of the competitive nature of the global economy, it may even pay industrialized nations to encourage enhancement genetics, thus giving them an edge those that do not. On Singapore's National Day, in 1983, Prime Minister Lee Kuan Yew gave a speech about the heritability of intelligence, and its importance for Singapore's future. Shortly afterwards, the government introduced measures explicitly designed to encourage university graduates to have more children.  Had genetic enhancement been available to Lee Kuan Yew at the time, he might well have preferred it to the government-sponsored computer dating services and financial incentives on which he was then forced to rely.
If a ban in the United States turns out to be unattainable, ineffective, or contrary to the vital interests of the U.S. economy, a bolder strategy could be tried. Assuming that the objective is to avoid a society divided in two along genetic lines, genetic enhancement services could be subsidized, so that everyone can afford them. But could society afford to provide everyone with the services that otherwise only the rich could afford? Mehlman and Botkin propose an ingenious solution: the state should run a lottery in which the prize is the same package of genetic services that the rich commonly buy for themselves. Tickets in the lottery would not be sold; instead every adult citizen would be given one. The number of prizes would relate to how many of these packages society could afford to pay for, and thus would vary with the costs of the genetic services, as well as with the resources available to provide them. To avoid placing a financial burden on the state, Mehlman and Botkin suggest, the use of genetic technologies could be taxed, with the revenue going to fund the lottery.  Clearly universal coverage would be preferable, but the use of a lottery would at least ensure that everyone has some hope that their children will join ranks of the elite, and taxing those who are, by their use of genetic enhancement for their own children, changing the meaning of human reproduction seems a fair way to provide funds for it.
Thus shopping at the genetic supermarket has taken us to the surprising conclusion that perhaps the state should be directly involved in promoting genetic enhancement. The justification for this conclusion is simply that it is preferable to the most probable alternative - leaving genetic enhancement to the marketplace.
1 Diane Beeson, "Social and ethical challenges of prenatal diagnosis", Medical Ethics Newsletter (Lahey Clinic) Winter 2000, p. 2; for similar claims, see Christopher Newell, "Critical Reflections on Disability, Difference and the New Genetics", in Gabrielle O'Sullivan, Everlyn Sharman and Stephanie Short, eds, Goodbye Normal Gene: Confronting the Genetic Revolution, Pluto Press, Annandale, New South Wales, 1999, p.68; Adrienne Asch, "Prenatal Diagnosis and Selective Abortion: A Challenge to Practice and Policy", American Journal of Public Health, 89 (1999), pp. 1649-1657, esp. p. 1650.
2 See my Practical Ethics, 2nd ed., Cambridge University Press, 1993, ch. 5.
3 Allen Buchanan makes the same point, using the example of a woman who postpones having a child because she is living in a refugee camp, in his "Choosing who will be disabled: genetic intervention and the morality of inclusion", Social Philosophy and Policy, 13 (1996) 18-45, at p.29.
4 Peter Singer, Animal Liberation, New York Review/Random House, New York, 2nd ed. 1990, ch. 1.
5 See Peter Singer and Deane Wells, Making Babies, Scribner, New York, 1985, pp. 24-29.
7 Lisa Gerson, "Human Harvest", Boston Magazine, May 1999.
8 On the difficult issue of whether we can benefit a child by bringing it into existence, see Derek Parfit, Reasons and Persons, Clarendon Press, Oxford, 1984, p 367, and Peter Singer, Practical Ethics, Cambridge University Press, Cambridge, 2nd ed., 1993, pp. 123-5.
9 Helena Cronin, The Ant and the Peacock, Cambridge University Press, 1991, ch. 5.
10 Jerome Groopman, "The Doubting Disease", New Yorker, April 10, 2000, p. 55.
11 John Schaar, Legitimacy in the Modern State, Transaction Books, New Brunswick, NJ, 1981, p. 195; cited in Maxwell Mehlman and Jeffrey Botkin, Access to the Genome: The Challenge to Equality, Georgetown University Press, Washington, DC 1998, p. 100.
12 Maxwell Mehlman and Jeffrey Botkin, Access to the Genome: The Challenge to Equality, Georgetown University Press, Washington, DC 1998, ch. 6.
13 Chan Chee Khoon and Chee Heng Leng, "Singapore 1984: Breeding for Big Brother", in Chan Chee Khoon and Chee Heng Leng, Designer Genes: I.Q., Ideology and Biology, Institute for Social Analysis (Insan) Selangor, Malaysia, 1984, pp. 4-13.
14 Mehlman and Botkin, op. cit., pp. 126-8.