10 Νοε 2014

The products of conception:The social context of reproductive choices

Journal of medical ethics, 1985, 11, 188-192

The products of conception: the social context
of reproductive choices
Barbara Katz Rothman Department of Sociology, Baruch College, City University of New York
Author's abstract
This paper addresses the changing ideology regarding
reproduction, an evolving American, and potentially
worldwide, value system regarding children and
parenthood. Children are increasingly being seen as
products, and the new technology ofreproduction,
including the sale ofreproductive material and services and
especially prenatal diagnosis and selective abortion,
encourage this commodification ofthefetus. While the new
technology does indeed offer new choices, it also creates
nev' structures and new limitations on choice. In the
contemporary American social structure, these choices are
inevitably couched in terms ofproduction and
commodification, and thus do not offer individuals
genuine choice or control.
It troubles me when a pregnant woman, suspecting a
bout of beer drinking may have harmed her baby,
aborts, saying 'It'll only set us back three months'.
It troubles me when a friend talks about hiding her
pregnancy from her daughters until after she has
gotten her amniocentesis results because 'How could I
explain an abortion to them?'
It troubles me when I am introduced to a pregnant
woman and after giving her name she pats her belly and
says 'And this is Heather'.
These issues which trouble me provide the impetus
for this paper. Taken together, they speak to an
evolving American value system regarding children
and parenthood. I see them as representing further
movement towards the commodification of life,
towards treating people and parts of people - our
organs, blood, energy - as commodities. When we talk
about the buying and selling of blood, the banking of
sperm, the costs of hiring a surrogate mother, we are
talking about bodies as commodities. And when we
talk about being able to 'afford' a second child, like a
second car, then we are talking about children as
luxury items, fine if you can afford them. And if all
children are luxuries, then special children are special
luxuries, as when we talk about how many extra dollars
a year it costs to raise a child with sickle cell disease.
In this value system, in this developing ideology, we
are learning to see our children as products, the
products of conception. Even while they still move
within us, they are not part of us - we have learned to
see them as other, as separate, as products. We work
hard, some of us, at making the perfect product, what
one of the doctors in the childbirth movement calls a
'blue ribbon baby'. Modern adoption practices have
long encouraged us to think of babies as commodities:
they are, after all, available for purchase.
The new technology of reproduction is building on
this commodification. Rather than buying whole
babies, we can now buy the parts. Sperm is relatively
cheap. It is sold by students for approximately the costs
of a textbook, or of an evening out. But it is the woman
who supplies all of the work, the labour as it were.
Purchasing the woman's services, if you can supply
your own sperm ('surrogate mothers') is considerably
more expensive. Egg donations are being done only on
an experimental basis now: will they eventually
become purchasable too? And what of embryo
transplants? Doctors have tried to patent the embryo
transfer process: how long will it be before human
embryos, like animal embryos, are up for sale?
Even in a more usual, 'naturally' occurring
pregnancy, the new technology of reproduction
encourages and reinforces the commodification
process: genetic counselling serves the function of
quality control, and the wrongful life suits are a form of
product liability litigation (1).
What is the underlying ideology that permits the
development of such a technology? And what does it do
to us to think this way? These are the questions which
I grapple with in this paper.
I am not claiming that the technology itself is
harmful. I think that the new technology of
reproduction offers us an opportunity to work on our
definitions of parenthood, of motherhood, fatherhood
and childhood, to rethink and improve our relations
with each other in families. Freed from some of the
biological constraints, we could evolve better, more
egalitarian ways of relating to our selves and each other
in reproduction. The technology is a promise,
beckoning us with new possibilities, limiting the role of
chance and accident in reproduction, giving us new
control. And the technology is a threat: control
towards what end? for what purpose? Or will the
technology simply be incorporated into the social order
and bring no social change? Technological change in
reproduction, whether the current ability to diagnose
genetic disease in utero, the future ability to grow
babies in test tubes, or the well-established ability to
substitute artificial milk for mother's milk, does not
necessarily mean social change. Think of how formula
feeding might have changed men's and women's roles
in childbearing.
Amniocentesis for prenatal diagnosis is an
increasingly important part of the new technology of
reproduction, affecting more and more pregnancies
each year. By the 1990s it may very well become a
standard, routine part of all prenatal care (2). In this
procedure, a small amount of the amniotic fluid that
surrounds the fetus is withdrawn during the 16th to
20th week of pregnancy, and fetal cells are cultured, a
process which takes approximately four weeks. Studies
of the fluid and fetal cells can detect a variety of
abnormalities, notably Down's syndrome, but many
others as well; hundreds of other genetic diseases,
including sickle cell anaemia and Tay Sachs disease;
and also the neural tube defects such as hydrocephalus
and spina bifida. If the fetus is found to be diseased or
damaged, in almost all cases abortion is the only
treatment available.
For parents who have watched one child suffer and
slowly, inevitably die with a condition like Tay Sachs
disease, the availability of prenatal diagnosis can
fundanentally change their reproductive options,
when both parents are carriers of such a disease in each
pregnancy they have a one in four chance of producing
a fetus with the condition. Fortunately very few
parents are faced with such high risks of reproductive
tragedy. The much more common uses of prenatal
diagnosis are for the neural tube defects, such as spina
bifida, and for chromosomal disorders, especially
Down's syndrome.
The chances of bearing a fetus with Down's
syndrome, which causes mental retardation and is
associated with some physical problems as well, rises
with the age of both the mother and the father. There
is no particular age at which the risk jumps
dramatically, but rather the increase is steady.
For a woman at age 30 the chances are roughly one in
1000, at age 35 one in 350, and at age 40 one in 100. It
may well be that other age-related factors - perhaps
diet, general health, exposure to environmental toxins
and radiation - are the real causes of Down's
syndrome, and not age per se. So far however, age has
been the only factor demonstrably linked to Down's
syndrome in the general population.
When amniocentesis for the diagnosis of Down's
syndrome was first introduced, it was for women over
the age of 40. Within ten years the medical standard
dropped to age 35, and is currently inching its way
down to 33 or even lower in some centres.
Although some people have discussed the value of
being forewarned of genetic or other diseases even in a
pregnancy the woman intends to carry to term,
abortion is an integral part of this new technology.
Fetal treatments do not exist for these diseases. The
overwhelming majority of people who are told of
serious disease or damage in the fetus do abort. These
abortions, abortions to prevent the birth of a
handicapped or disabled child, are among the most
socially acceptable of abortions. In the United States,
over 80 per cent of people approve of the use of
abortion in this situation (3). Because they are socially
acceptable, many people have assumed that they are
psychologically more acceptable than are abortions for
what is called 'less reason', abortions because a woman
does not want to be pregnant. That is not true. The
reasons lie in the meaning of abortion for the women
who use it.
Women's use of abortion for unwanted pregnancies
has been perceived as a devaluing of motherhood. That
it is not. On the contrary, it is because women continue
to take motherhood so very seriously that abortion is
necessary. Women understand motherhood to change
their lives, to involve a deep and permanent
commitment. If women did not take motherhood
seriously, other options for managing an unwanted
pregnancy would be available, from simple
abandonment to the sale of babies. The current market
rate in America for a newborn baby is upwards of ten
thousand dollars - but very few women are willing to
bear babies to give them away.
In a sense, the motherhood-abortion paradox
parallels the marriage-divorce paradox. The divorce
rate is highest when expectations for marriage are
highest. If marriage were considered less important,
less central to one's life, divorce would be less
common. Thus the paradox is that the high divorce
rate demonstrates not a devaluing of marriage but a
commitment to the importance of the marriage
relationship; and abortion, as a solution to an
unwanted pregnancy demonstrates the importance to
women of the mother-child relationship.
Abortions to prevent the birth of a disabled child
may be more socially acceptable, but they are not in
any other sense easier. They present a deeper, more
fundamental challenge for both the individual woman
and the society at large. The challenge is to the
meaning of motherhood.
The meaning of the abortion lies in the meanings the
pregnancy holds for the woman. If a woman sees a
pregnancy as an accident, if for example her pregnancy
is a by-product of contraception that did not work,
then in her definition the fetus is not a person and not
meant to be one. The abortion is the solution to the
problem of failed contraception.
But if the fetus is to be her child, if she has chosen to
have this baby - chosen by consciously and purposively
becoming pregnant, or by willingly and openly
accepting an unintended pregnancy - then she
considers that fetus to be a person. It is her baby. She190 Barbara Katz Rothman
means it to be her baby. To abort an accident is one
thing. To abort your baby, even your very imperfect
baby, is something else again. And that is equally true
even if two fetuses are identical in size, in ounces, and
in 'viability'. There is an understanding in sociology,
and a deeply held belief ofmine, that situations defined
as real are real in their consequences (3). If a woman
defines the products of conception within her as
accidental, then that is what they are. If she defines
those products as her baby, then she treats them as her
The problem, or one of the problems, with the
technology of amniocentesis and selective abortion is
what it does to us, to mothers and to fathers and to
families. It sets up a contradiction in definitions. It
asks women to accept their pregnancies and their
babies, to take care of the babies within them, and yet
be willing to abort them. We ask them to think about
the needs of the coming baby, to fantasise about the
baby, to begin to become the mother of the baby, and
to be willing to abort the genetically damaged fetus. At
the same time. For twenty to twenty-four weeks.
Women suffer in this contradiction of demands.
They want to have amniocentesis to identify and to be
able to abort a damaged fetus, but are afraid of the
procedure's possible harm to their baby. As one couple
said during a counselling session as they struggled with
the (remote) possibility of miscarriage caused by
amniocentesis, and the (equally remote) possibility of
having a child with Down's syndrome:
'Husband: "We really want this baby. . Wife: ". . . and if it's a healthy baby I really hate the
thought of losing this person".'
If it is healthy, if it is genetically acceptable, then it is
a person, her baby. If it is not, then it is just a fetus, a
genetically damaged fetus.
Parenthood demands such total acceptance from us.
We expect mothers to love, to accept their babies
unreservedly, with the fullness of their hearts, no
matter what. We joke about it: 'A face only a mother
could love'. It is not that women have always been able
to achieve that unconditional love. Indeed, the fear of
having a child one cannot love is one of the more
common fears that haunt pregnancy. But never before
have we asked women to make rational, intellectual
determinations based on that fear. What does it do to
motherhood, to women, and to men as fathers too,
when we make parental acceptance conditional,
pending further testing? We ask the mother and her
family to say, in essence, 'These are my standards. If
you meet these standards of acceptability, then you are
mine and I will love and accept you totally. After you
pass this test'.
The amniocentesis comes so late in the pregnancy.
The problems will be very different when fetal testing
is done earlier in pregnancy. But now there are months
that women wait in this limbo of 'tentative pregnancy',
unsure whether they are 'mothers' or 'carriers of a
defective fetus'. For some women the amniocentesis
comes too late:
'. . . by the time the results came in, the baby had been
leaping in my womb for a month . .. During one of
the sleepless nights before the results were in I decided
I would raise the child if it looked like ET (4)'.
A face only a mother could love.
An irony in all this is that the technology still cannot
guarantee a 'blue ribbon baby'. A fetus can pass all of
the tests, and still be far from perfect at birth. A child
can be born or become retarded, crippled, disfigured
from thousands of causes. One can rationally decide to
abort a fetus with spina bifida because life in a
wheelchair is not acceptable - and then have a baby's
back broken in a car accident. One can choose not to
carry to term a fetus with Down's syndrome because
the quality of life of the retarded is not acceptable - and
then have the baby suffer permanent brain damage
from some illness. There are limits to control, and our
children are always 'hostages to fortune'. Does the
conscious, deliberate emphasis on control and
'standards of acceptability' prepare us for the reality of
Another of the problems with the commodification
process and its ensuing technology is that it allows
some people, the richest and the most powerful, to buy
their way out. Individual solutions are found while
leaving social problems intact. Let us take as an
example, the situation of having a retarded child. Why
do I recoil at the thought of having as my son a grown
man who drools and behaves like a child? If the person
is, as most people with Down's syndrome are, able to
learn to walk, to talk, to do simple tasks, then why do
we so fear retardation?
One reason is what it does to our lives. You cannot
even afford to die ifyou have a retarded child: what will
become of her or him? This is just the extreme case of
what is true of all children in our society - they are
private property, and the economic and social burden
is not shared. Support services for children in the
United States are abysmal: it is United States policy to
allow children to live in great poverty unless their
individual parents and families can provide for them.
With retarded or other damaged children, the stakes
rise. One may be able to afford twenty years of
expenses for a normal child, but a lifetime of expenses
for a damaged child is just too much. The economic
burden of a retarded or disabled child is beyond most
of us. And the emotional burdens are inextricably tied
up with the financial burdens.
The economic ties are basic. Most of the causes of
disability and retardation among children are related to
class position: one's chances of having a healthy child
kept safe in a safe environmemt increase as we go up
the socio-economic scale. The children of the poor
suffer disproportionately from premature birth, from
illness, from lead paint, from pollutants that parents in
factories bring home on their clothes, from starvationThe products ofconception: the social context ofreproductive choices 191
and deficiency diseases, from cold dwellings, from
overcrowding, from poor medical care. One of the few
causes of disability and retardation that seems truly not
to be class-linked is genetic disease: Down's syndrome,
for example, appears to be associated exclusively with
parental age, and not their class position. Haemophilia
brought in by Queen Victoria destroyed the royal house
ot Russia (5). As we increasingly solve genetic causes of
disability, the population of the disabled will become
even more disproportionately drawn from the
population of the poor. As the wealthiest, and
therefore the most powerful, in society increasingly
buy their way out of retardation and disability, what
will happen to the support services that do exist? Who
will monitor the State schools for the retarded then?
Retardation and disability are social issues (6)
threatening the stated values of our society: the values of
equal opportunity and a fair share for everyone. We
treat these social issues as individual troubles, to be
individually solved. We treat them clinically, not
politically. It fits in with the private property idea of
children: the needs ofyour children are your problem.
From the point of view of the individual pregnant
woman and her family, amniocentesis and selective
abortion make great sense. I am not suggesting that we
force wealthier and more educated people to have
retarded children so that they will make that their
political issue, their fight. I cannot accuse the people
who offer the services or those who use them of doing
the wrong thing. Mostly they are doing the only thing
they can do. They are absolutely right when they say
that they cannot afford, emotionally or financially, the
burden of a disabled child. It is equally true that the
infertile couple who can afford to buy a baby or to buy
surrogate services may be making absolutely the right
choice in purchasing such a baby or such services.
We cannot solve the social issues of dealing with the
less-than-perfect people by making disability an
individual trouble. We live in a society designed for the
physically and mentally competent. It is children and
old people who most often get hit by cars. Part of the
issue then is redesigning the physical and social
environment to meet the needs of all people. This is
what the people in the disability rights movement are
calling for. The decision to abort a fetus with spina
bifida when you live in a fourth-floor apartment with
no lift in a city designed without access for wheelchairs
is not really an exercise in tree choice.
But there are other issues as well. We must consider
what it means to us to commodify life, to affix price
tags to body parts. I include semen, ova, embryos, and
fetuses as body parts. An important lesson can be
learned from what happens when other body parts are
available for purchase. Richard Titmuss's study of
blood donation in England and in the United States,
The Gift Relationship, provides a model (7). In
England, where there is still resistance to total
commodification of life, there is a right to health
services, and blood is free. It is freely given. In the
United States, blood is purchased either for money
from paid donors, or for insurance, blood donors
earning access to free blood for themselves and their
families as needed. Blood is purchased twice then, once
from the donor and once again from the blood bank.
Titmuss's most dramatic finding is that the
commodification of blood does not work: where blood
is purchased, it is scarce where needed, wasted where
hoarded, in uneven, unreliable supply. Where blood is
given freely, it is made freely available, and the supply
is more even, with considerably less waste.
Titmuss's conclusions are not merely pragmatic,
regarding the most efficient way to distribute blood.
He reaches beyond to analyse the social bond, to claim
a right to give, a right to be 'my stranger's keeper', a
right which is violated when social policy supports
commodification. He says of the altruistic English
blood donors:
'In not asking for or expecting any payment of money
these donors signified their belief in the willingness of
other men to act altruistically in the future, and to
combine together to make a gift freely should they have
need for it. By expressing confidence in the behaviour
of future unknown strangers they are thus denying the
Hobbesian thesis that men are devoid of any
distinctively moral sense (8).'
I want to argue from blood to gametes, to embyros, to
fetuses, to children. The commodification of life and
bodies feeds upon itself and destroys, as Titmuss
claims, the right to be altruistic. In a society which
claims little joint responsibility for children, children
are inevitably private property, and just as inevitably it
follows they will be sold and it further follows they will
carry different price tags based on social desirability.
And some will be rejects, not salable at any price: too
damaged, or the wrong colour, or too old, too long on
the shelf.
In a world that does not value children, I do not
know what it means to be altruistic with my seed.
Could I give away an embryo, as many men have given
or sold semen, when I know that child may grow to
have needs that will be unmet? Is that kind of giving
away altruism, or is it abnegation of responsibility?
One of the things mothers who have given up babies tor
adoption often say is that they just wish there was some
way that the child could reach them if she or he needed
them. In this world, in this society, we do not, cannot
trust that the needs of all children, of our children, will
be met. Thus the right to give is lost.
As we lose the right to give, so too do we lose the
right to accept, to accept our less-than-perfect, our
needful children. In gaining the choice to control the
quality of our children, we may rapidly lose the choice
not to control the quality, the choice of simply
accepting them as they are. The new reproductive
technology is offered to us in terms of expanding
choices. But it is always true that while new technology
opens up some choices, it closes down others. The new
choice is often greeted with such fanfare that the silent192 Barbara Katz Rothman
closing of the door on the old choice goes unheeded. To
take a simple example, is there any meaningful way one
could now choose horses over cars as a means of
transportation? The new choice ofa 'horseless carriage'
eventually left us 'no choice' but to live with the
pollution and dangers (as well as the convenience and
speed, of course) of a car-based transportation system.
It happened first with the quantity of children. The
oldest and most basic reproductive technology is the
technology of fertility limitation. Self-imposed limits
on fertility, through contraception or abortion, are the
sine qua non of the reproductive rights movement. And
yet, we must realise that the choice of contraception
simultaneously closed down some of the choice for
larger families. North American society is geared to
small families, if indeed to any children at all. Without
the provision of good medical care, day care, decent
housing and schooling, children are a luxury item, fine
if you can afford them.
And so it may also be with the technology of quality
control: the ability to control the quality of our
children may ultimately cost the choice of not
controlling that quality. It is individual families, but it
is most especially individual mothers who bear the
costs of children, and the special costs of special
children. How much any given child costs a mother is
based not only on the condition of the child, but even
more on the conditions of the mother's life. Any
analysis of a woman's right to choose an abortion has to
recognise the context in which the decision to abort is
made, the circumstances in which the woman is
placed. As Rosalind Petchesky has stated.
'The "right to choose" means very little when women
are powerless . . . Women make their own
reproductive choices, but they do not make them just
as they please; they do not make them under conditions
which they themselves create, but under social
conditions and constraints which they, as mere
individuals, are powerless to change (9).'
We live in a system in which women and children are
both disvalued, an anti-child, anti-woman society. It is
women and children who are poor, whose needs are not
being met. In this system women and children are
often pitted against each other, competing for scarce
resources. The mother finds herself becoming a
resource: her own life, and specifically her own time, to
be divided between herself and her children. Whatever
the children get, it may very well be coming off the life
of the mother - in time, in attention, in emotional
support, sometimes in tood and basic necessities. It is
in this context that mothers are judged in terms of their
willingness to sacrifice. The more she gives ofherself to
her children, the better a mother the society says she is.
The more she holds back of herself, for herself, the
more she runs the risk of being the 'wicked
stepmother', evil in her selfishness.
When women and children are both disvalued, to
speak for the rights or needs of either to be met is then
to contribute to the devaluation of the other. When one
adds to the situation the virtually total disvaluation of
the needs of the disabled, the 'defective', 'in-valid'
people, the place of selective abortion in our society is
highlighted. Women know that children with 'special
needs' make special demands. The society as a whole
has shown itself unwilling to meet those demands - we
are as a society unwilling to meet the ordinary needs of
ordinary children. With wonderful and notable
exceptions, fathers and other family members have not
risen to the occasion. The burden of childrearing, of all
childrearing, has fallen overwhelmingly on individual
mothers. While those in the disability rights movement
rightly resent the use of the word 'burden' to describe
their lives, it is not a description unique to the disabled.
Children, all children, can be described as burdensome
when their needs fall almost exclusively on one person.
Yes, they are also delightful, joyous, pleasures and
treasures, whether able-bodied or disabled. But side by
side with the joys of childrearing are the burdens; along
with the pleasures come the sacrifices. The individual
woman, or at very best, the individual couple or
f-amily, can demand more and more from the society
for the child - and in fact making such demands
becomes one of the chief responsibilities of the parents
of a disabled child. But it is clear to us all that the
society will not respond with openness and generosity,
and most assuredly cannot be depended on to continue
responding to the child's needs when the mother is no
longer there. Even if the woman were to be willing to
sacrifice herself entirely to meet the needs of the child,
it might still not be enough.
It is in this context that amniocentesis and selective
abortion are introduced, giving an illusion of choice,
allowing individuals to believe that they have gained
control over the products of conception. But the
choices are made within an ever-narrowing structure.
Issues of basic values, beliefs, the larger moral
questions will be lost in this narrowing of choices, as
decisions become pragmatic, often clinical, always
individual. Irving Kenneth Zola puts it this way:
'Bombarded on all sides by realistic concerns (the
escalations of costs) and objective evidence (genetics)
and techniques (genetic counsellors), the basic value
issues at stake will be obfuscated. The freedom to
choose will be illusory. Someone will already have set
the limits of choice (cuts in medical care and social
benefits but not in defence spending), the dimensions
of choice (if you do this then you will have an X
probability of a defective child) and the outcomes of
choice (you will have to endure the following social,
political, legal and economic costs) (10).'
Thus the new technology of prenatal diagnosis and
selective abortion does indeed offer new choices, but it
also creates new structures and new limitations on
choice. Because of the society in which we live, the
choices are inevitably couched in terms of productionThe products ofconception: the social context ofreproductive choices 193
and commodification, and thus do not move us to see
new levels of genuine choice, or to provide us with
genuine control.
Barabara Katz Rothman is Associate Professor of
Sociology, Baruch College of the City University ofNew
York. She is the author ofIn Labor: Women and Power
in the Birthplace WWNorton, 1982 and The Tentative
Pregnancy: Prenatal Diagnosis and the Future of
Motherhood. Her address is 17 Lexington Avenue, New
York, NY 10010.
References and notes
(1) This phrasing was suggested by Rosalyn Weinman
(2) President's Commission for the Study of Ethical
Problems in Medicine and Biomedical and Behavioral
Research. Screening and counselling for genetic conditions:
the ethical, social and legal implications ofgenetic screening,
counselling and education programs. US Government
Printing Office, 1983.
(3) Thomas WI, Thomas D S. Situations defined as real are
real in their consequences. This excerpt from their work
was printed in Stone G P, Farberman H A, eds. Social
psychology through symbolic interaction, Waltham,
Massachusetts: Xerox Publishing, 1970: 154-156,
where the importance of this idea for the symbolic
interactionist approach to sociology is discussed.
(4) Burke M B, Kolker A. Amniocentesis and the social
construction ofpregnancy: preliminary findings. J'ournal of
marriage and family relations. Forthcoming, expected
date of publication 1987.
(5) For an interesting account of the role of haemophilia in
the Russian Revolution, see Massie R. Nicholas and
Alexandria. New York: Atheneum Publishing, 1967.
(6) Mills C W. The sociological imagination. New York:
Oxford University Press, 1969.
(7) Titmuss R. The gift relationship: from human blood to
social policy. New York: Pantheum Books, 1972.
(8) See reference (7): 239.
(9) Petchesky R P. Reproductive freedom: beyond 'a
woman's right to choose'. Signs: journal of women in
culture and society 1980; 5: 674.
(10) Zola I K. Socio-medical inquiries: recollections, reflections
and reconsiderations. Philadelphia: Temple University
Press, 1983.
Margaret Stacey University of Warwick
Dr Rothman's paper is timely. The implications of the
new reproductive technologies are profound. They are
generally thought of in terms of relieving the suffering
of individual couples either by enabling them to
overcome infertility or by eliminating the risk of
bearing a handicapped child. Dr Rothman speaks of
Key words
Prenatal diagnosis; reproduction; abortion; gene therapy;
amniocentesis and abortion when handicap is detected.
Already medical practitioners have 'genetic
engineering' or 'gene therapy' on their agenda to
remove 'faulty' genes before birth, although many of
the techniques still require much development for
clinical practice and are not so near as some imagine.
When designed to prevent haemophilia, for example,
this must appear unobjectionable. But as Dr Rothman
points out, to remove the possibility of having and
accepting handicapped children may have unintended
and at present unknown consequences in the reduction
of choice, even though the new technologies may
appear to offer more choice. Bearing and rearing a
handicapped child might become normatively
There are also ethical problems about which
children it will be deemed unacceptable to bear, just as
there are already children deemed unsuitable for
adoption, although far fewer than when there was a
larger supply of unwanted children. There will be
problems about which potential children should have
gene therapy. Who shall decide? Who will in practice
decide? We already know that in the care of the
handicapped the dividing line between medical and
social intervention is continually blurred. Our social
ability to define some other human beings as less than
human (on account of their body shape, brain
functioning, skin colour or sexual orientation) and thus
let ourselves off the hook of having to treat them as
fellow human beings is already well known.
Dr Rothman is writing from US experience and, so
it seems, to a US audience. She herself (p. 191) draws
out contrasts between the UK and the US using
Titmuss's study of blood donation as an example not
only of the morally correct way of doing things (in
being based on altruism) but also the technically more
efficient. This model is also used by the Council for
Science and Society (1). Although the UK, like the US,
is predominantly a capitalist society, we have hitherto
consistently sought to prevent the intrusion of
capitalist values into our health and welfare services. In
the UK, issues associated with health and reproduction
are less blatantly exploited for profit than in the US (2).
However, many may be the indirect ways in which the
profit motive, or corporate or self interest permeates
our health service (3). In the UK well over 90 per cent
of our health care is provided on a collective basis and
is not for profit. In the specific area of fertility we have
turned our face against womb leasing (4). We do not
permit the selling of children for adoption (5).
Dr Rothman presents a powerful plea against the
intrusion of capitalist values, the values of the
commodity market, into affairs ofhuman reproduction
for as she rightly indicates this has consequences for
the basic values upon which society rests and the
respect in which we hold each other (6). Given the
pressure to privatisation in the UK at present and the
introduction of for-profit hospitals with international
finance capital (7), it is well that those of us in the UK
also heed her warnings, remembering that private

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