Liberal Limitations of Autonomy

I’ve recently spent many hours pouring over publications of the American College of Obstetrician/Gynecologists (ACOG)–something I rarely do–in preparation for my board recertification exams next week. In all fairness, and despite my negative attitude toward this newly instituted requirement, I confess that I have learned, or relearned, a few facts of practical clinical importance. However, I have also discovered many glaring inconsistencies in ACOG’s recommendations for patient care based on their desire to present “evidence-based” data—evidence that varies from study to study. In addition, one seemingly inconsistent ethical position also surprised me: ACOG’s opposition to sex selection techniques, whether pre- or post-conceptual (Committee Opinion 360).

Concerning the issue of sex selection, the American Society for Reproductive Medicine (ASRM) opposes post-fertilization/pre-implantation sex selection for non-medical indications because it “necessarily involves the destruction and discarding of embryos.” While ACOG does not oppose post-fertilization or post-implantation sex selection techniques for medical indications such as X-linked genetic disorders, it too opposes sex selection for personal, social, economic, or cultural reasons. But ACOG’s opposition is not based on the destruction of human embryos: ACOG opposes such desires because of the risk that they are motivated by “sexist” attitudes that reinforce the devaluation of women. They state, “individual parents may consistently judge sex selection to be an important personal or family goal and, at the same time, reject the idea that children of one sex are inherently more valuable than children of another sex. Although this stance is, in principle, consistent with the principle of equality between the sexes, it nonetheless raises ethical concerns…it often is impossible to ascertain patients’ true motives for requesting sex selection procedures (italics mine)…even when sex selection is requested for nonsexist reasons, the very idea of preferring a child of a particular sex may be interpreted as condoning sexist values and, hence, create a climate in which sex discrimination can more easily flourish” (note the “slippery slope” argument).

Wait a minute…what happened to autonomy? What about a woman’s right to choose? ACOG has always supported abortion on demand—a woman’s right to terminate the life of her unborn baby at any stage for any reason–no questions asked. Why can she then not choose to carry a baby of a particular sex? Why and how do motivations—which even they admit no one can truly know–limit a woman’s right to choose? It seems that there is a “higher principle” at work here that can limit a woman’s autonomy: the principle of equality of the sexes.

It is difficult to see how such a nebulous principle as “equality of the sexes” can serve as a limiting principle to autonomy. Are they referring to qualitative or quantitative aspects of equality? Perhaps they perceive it to be an issue of justice, for justice does indeed at times serve as a check and balance on personal autonomy. But it is unclear why it is acceptable to destroy the unborn because they are perceived to be a personal inconvenience, but impermissible to do so for other reasons of personal preference? They seem to be saying that a woman’s autonomous choices can be trumped by societal justice but not by the individual justice due the unborn. Terminating the life of the unborn is acceptable as long as it doesn’t violate societal values.

But even more sinister is the fact that not only does the life of the unborn have no intrinsic value, its moral significance is contingent upon whether its “beingness” promotes values and agendas of others, whether those of the mother or–if the mother’s values are not properly aligned–of society. That makes the moral status of the unborn merely a “means” to the ends of others, ends which change as frequently as the tides.

Perhaps we should rejoice that at least in this one area of women’s reproductive health, the position of ACOG is, in part, consistent with those who value life from conception. But motivations and foundational values are indeed important. We should not be quick to join forces with those whose convoluted ethical position is nothing more than a house of cards built on the sinking sand of social values.

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Jon Holmlund
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Jon Holmlund

Well, Amen to all that.

I wonder why ASRM takes the position stated, as stated. Surely it supports “donation” of embryos for [embryo-destructive] research? Or does it? Does that society in fact worry about the creation and destruction of embryos solely for research? I’d be surprised, but just wondering.