Book Review

Children of Choice: Freedom and the New Reproductive Technologies

N Engl J Med 1994; 331:1032-1033October 13, 1994

Article

Children of Choice: Freedom and the New Reproductive Technologies
By John A. Robertson. 281 pp. Princeton, N.J., Princeton University Press, 1994. $29.95. ISBN: 0-691-03353-6

Robertson charts an ethical and legal course through the questions and concern posed by the reproductive techniques that are now available rather than merely material for science-fiction novels. These questions confront us professionally as physicians or personally as people choosing whether or not to have children. Robertson weaves his way through a tangle of fascinating and often disturbing issues, guided by the consistent notion of reproductive liberty: the right to reproduce (or not to reproduce) either genetically, gestationally, or by rearing offspring.

With this steady focus, Robertson addresses the controversy surrounding each technique, including methods to prevent or terminate pregnancy (such as abortion, the levonorgestrel implant Norplant, and mifepristone [RU 486]) and techniques to assist the infertile (such as in vitro fertilization and the use of donors and surrogates).

With its ethical and legal perspective, this book is a refreshing change from the usual sanitized medical textbooks on reproduction that sidestep these weighty questions. When do the fetus's rights outweigh those of the mother or the parents? Can society enforce the use of contraceptives such as Norplant? Should irresponsible reproduction be punishable? Who has the power to decide the fate of excess embryos created by in vitro fertilization? Are frozen embryos entitled to inheritance? Can sperm and egg donors demand parental rights? Should limitations be placed on cloning, on genetic enhancement, or on reproduction intended simply to yield tissue for transplantation? Robertson's responses to these questions both stimulate and unsettle the reader.

Establishing the premise that procreative liberty is central to one's identity, dignity, and self-respect, Robertson argues forcefully that this liberty should be given presumptive primacy in conflicts about exercising control or limiting this basic right. Robertson tracks the legal background for this argument from the 1965 Griswold v. Connecticut case that allowed couples to use contraceptives, through the 1973 Roe v. Wade case and the 1992 Planned Parenthood v. Casey case, which essentially upheld the right to terminate a pregnancy up to the time of viability of the fetus. This legal framework is concise, informative, and provides the foundation for discussions of ethical issues, such as embryo research, discarding, and donation. The juxtaposition of conflicts about elective abortion with those about the treatment of embryos created by in vitro fertilization reveals a consistent ethical perspective on early embryonic life -- one often at odds with current law.

The author addresses the issue of irresponsible reproduction by using the example of Norplant as an alternative to probation for a child-abusing mother. While I disagree with his conclusion that a financial incentive to encourage the use of Norplant is not coercive and protects one's reproductive liberty, he does not go on to argue that Norplant, or other long-acting contraceptives, should be used forcibly to limit reproduction.

As Robertson advances to a thorough discussion of infertility and techniques related to it, the guiding principle is again one's right to do everything necessary or possible to produce healthy offspring. Robertson takes this argument to its natural extremes, accepting the cloning and delivery of identical twins at distant times, the selection of the characteristics of the offspring, including sex, height, and eye color (if ever possible), as well as embryo enhancement by gene alteration, as being legally sound when primacy is given procreative liberty. He illustrates the difficulty of establishing that “substantial harm” has been caused with the argument that one is better off alive as the result of some form of technology than not alive at all.

Robertson uses the “substantial harm” argument in discussing the prevention of prenatal damage through criminal sanctions or even the seizure of women (and possibly men) who directly harm an unborn child. Citing expanded parental duty, he finds women who use drugs or alcohol during pregnancy culpable because they directly, knowingly, and preventably harm their unborn children. Robertson believes that punishing such a woman does not restrict her procreative liberty, because she chose not to have an abortion and thus transformed the fetus into an unborn child with its own rights. This argument is persuasive, but it does not acknowledge the extreme social and economic situations that often deny these women their reproductive choices. However, Robertson does present important alternatives to restraints and seizures, such as education, rehabilitation programs, and better access to contraception and abortion services.

Children of Choice discusses a broad range of real and imaginary scenarios. One relative oversight is the situation in which a pregnant mother is brain-dead or terminally ill, but is supported medically until a viable infant may be delivered. The decisions made in these tragic situations have important social and economic ramifications, in addition to the ethical and legal difficulty of making procreative choices posthumously. The author considers the posthumous problems of in vitro embryos but overlooks those in vivo.

Children of Choice is indispensable for anyone caring for women, couples, or families -- anyone who reaches out for guidance in making reproductive choices. It would also be valuable to women or couples contemplating abortion or the use of infertility services. Robertson's occasionally confrontational style takes the reader to the limits of the possible and beyond, to the extraordinary repercussions of reproductive techniques. Well referenced and annotated, this clear and thought-provoking book demands a careful reading. It provides rich legal and ethical insights that will challenge and shape one's personal beliefs and professional ethics.

Dilys M. Walker, M.D.
University of California, San Francisco, San Francisco, CA 94143