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edited by Tuija Takala and Matti Häyry, welcomes contributions on the conceptual and theoretical dimensions of bioethics.
Dissecting Bioethics
“Dissecting Bioethics,” edited by Tuija Takala and Matti Häyry,
welcomes contributions on the conceptual and theoretical dimen-
sions of bioethics.
The section is dedicated to the idea that words defined by
bioethicists and others should not be allowed to imprison people’s
actual concerns, emotions, and thoughts. Papers that expose the
many meanings of a concept, describe the different readings of a
moral doctrine, or provide an alternative angle to seemingly self-
evident issues are therefore particularly appreciated.
The themes covered in the section so far include dignity, natu-
ralness, public interest, community, disability, autonomy, parity of
reasoning, symbolic appeals, and toleration.
All submitted papers are peer reviewed. To submit a paper or to
discuss a suitable topic, contact Tuija Takala at
The Moral Imperative for Ectogenesis
The United Kingdom, like many other
affluent Western societies, is appar-
ently in the grip of declining fertility.
The resultant strain on the economy
caused by an aging population is being
exacerbated by what has been charac-
terized as the selfishness of women
who delay reproduction in their ef-
forts to secure financial and social sta-
tus before getting around to starting a
Such women may only begin
to think about having children in their
mid-30s, an age that, according to re-
search, is a predictor of “serious mor-
bidity” in pregnancy and childbirth.
And for many of those who try to
start families when in their 30s, their
fertility may have declined so that they
may not be able to have children at all
or may need to resort to reproductive
therapies to do so.
The obvious response to this is to per-
suade women to reproduce earlier, re-
gardless of the effect on their careers or
other interests. However, there is more
at stake than just this. In fact, women
do not necessarily have children only
to fulfill their own biological desires. So-
ciety at large may also have an interest
in reproductive matters, and it is here
that the difficulty emerges. Encourag-
ing women to curb their other interests
and aspirations in order to have chil-
dren at biologically and socially opti-
mal times reemphasizes that it is women
who take on the risks, whereas society
in general profits from these sacrifices.
This, I suggest, is a prima facie injus-
tice. Yet it is founded on a physical ne-
cessity: Babies must be gestated in
women’s bodies.
But there is an alternative approach
to this problem: Rather than putting
the onus on women to have children
at times that suit societal rather than
women’s individual interests, we could
provide technical alternatives to ges-
tation and childbirth so that women
are no longer unjustly obliged to be
Thanks to Karen Gui.
Cambridge Quarterly of Healthcare Ethics (2007), 16, 336
345. Printed in the USA.
Copyright © 2007 Cambridge University Press 0963-1801/07 $20.00
DOI: 10.1017/S0963180107070405
the sole risk takers in reproductive
enterprises. In short, what is required
is ectogenesis: the development of ar-
tificial wombs that can sustain fetuses
to term without the need for women’s
bodies. Only by thus remedying the
natural or physical injustices involved
in the unequal gender roles of repro-
duction can we alleviate the social in-
justices that arise from them. My
argument that follows is based on work
by Justine Burley,
who in turn devel-
ops her position from Ronald Dwor-
kin’s views on the subject of equality
in healthcare distribution.
Burley’s Argument: A Right to
Fertility Treatment?
Dworkin talks of integrating health
care into other goods and regarding
all these goods in terms of distributive
He argues from this that nat-
ural inequalities may generate a prima
facie right to restitution. Thus, if a
person is born blind, she may be re-
garded as the victim of a prima facie
injustice that could lead to a claim for
compensation. Burley extrapolates from
this that the infertile can also claim
compensation in the form of state-
funded fertility treatment.
However, there is a potential diffi-
culty her e that Burley observes, namely,
that having children could be re-
garded as being merely an expensive
taste. On Burley’s reading of Dwor-
kin, those tastes that we cultivate do
not necessarily constitute grounds for
compensation, but where expensive
tastes have been acquired involun-
tarily, the claim for compensation could
still stand. Here she cites Dworkin’s
stipulation that if people’s tastes are
related to their conception of the “good
life,” then restitution is not necessarily
warranted. If individuals could be of-
fered the means of removing or reliev-
ing the desire or taste for X in a way
that did not encompass the provision
of X, but they chose to retain the de-
sire, they would not be eligible for
compensation. So someone addicted
to truffles and caviar could not de-
mand compensation if she character-
ized the possession of this desire as
being something desirable in itself.
The desire for children tends to be
characterized by its high place in
people’s priorities, as Burley notes.
Generally, if infertile people long for
children, they do not want to receive
treatment aimed at removing the de-
sire or healing the emotional pain of
childlessness: They want provision of
children themselves or at least the
wherewithal to generate them. Bur-
ley’s reading of Dworkin so far indi-
cates that state funding for fertility
treatment is not justified.
However, Burley then moves on to
consider the problem from a different
angle: We have established that the de-
sire for children is likely to be intri-
cately tied up with people’s conception
of the good life and as such cannot be
regarded as a handicap of which suf-
ferers have a right to be relieved. This
means that people who do have chil-
dren and who find that their finances
are adversely affected have no claim to
restitution despite the fact that their im-
personal resource holdings may be ad-
versely affected. This is not simply
because they have chosen to have chil-
dren, but more specifically because their
choice to do so is intrinsically connected
with their ethical beliefs and their as-
sumptions about what constitutes a good
life. If a deficit is to merit compensa-
tion, it must be possible to construe it
as a limitation upon the possibility of
one’s pursuit of the good life.
But people who cannot have chil-
dren do not choose their infertility,
nor do they construe childlessness as
part of their conception of the good
life. Individuals may be infertile
Dissecting Bioethics
through no fault or choice of their
own, but through mere brute luck.
Therefore, when compared with fer-
tile people, the personal resource hold-
ings deficit of the infertile may merit
Thus, for Burley, fer-
tility treatments can be fitted into
Dworkin’s framework as a form of re-
distributive justice, based on redress-
ing the deficit in personal resource
holdings that may result from no
voluntary choice of the individual con-
cerned and that may inhibit that per-
son’s capacity to pursue her life goals.
So far, Burley’s argument doesn’t
prove anything more thanaprimafacie
entitlement: The question of where to
place fertility treatments in the fund-
ing hierarchy remains. There are many
prima facie claimants for funding, but
only limited resources. Dworkin rec-
ommends a quasi “veil of igno-
approach, in which people
would choose which handicaps to
make provision for, without necessar-
ily knowing which handicaps they
would suffer from. Only those condi-
tions that the aggregate have chosen
to insure against would be compen-
sated. Burley suggests that in this kind
of scenario, the social and economic
weight given to reproduction is so
pervasive that “[i]t is plausible to in-
sist that individuals in the aggregate
would stipulate infertility as one hand-
icap they were particularly concerned
to receive compensation for.”
Applying the Burley/Dworkin
Argument to “Natural” Fertility
As we have seen, natural inequalities
can be argued to constitute prima facie
grounds for restitution. In what fol-
lows I bring these arguments to bear
on my own contention: The fact that
women have to gestate and give birth
in order to have children, whereas men
do not, is a prima facie injustice that
should be addressed by the develop-
ment of ectogenesis.
At this point, it seems clear that
there may be a problem: Natural in-
equalities are frequently beyond our
power to remedy. If we cannot make
the blind see, increase someone’s IQ,
or relieve women of the burden of
gestation and childbirth, then surely it
follows that we cannot have any moral
obligation to do these things. An act
cannot be a duty unless we can be
sensibly be commanded to perform it
(ought implies can).
Accordingly, our
responsibilities in terms of redistribu-
tion of natural goods are circum-
scribed by what is feasible.
However, this seems short-sighted in
the context of our rapidly moving tech-
nological achievements. If the only ar-
gument against someone’s having a
need met is that no one can meet that
need, perhaps resources should be di-
verted toward being able to meet that
need. That is to say, in some circum-
stances, perhaps ought implies ought to
be able to. Kant’s point, of course, holds
when to fulfill a duty would be a logical
impossibility. However, many things
that are currently impossible (e.g., ec-
togenesis) are merely contingently so.
We have either chosen not to focus re-
search in these areas or are still strug-
gling to find answers to the problem.
As long as there is no logical impos-
sibility, we are not exempted from our
moral duties simply by the fact that
we do not yet have a way of solving
the problem.
In fact, although the possibility of in-
cubating babies in artificial wombs (ec-
togenesis) has long been regarded as the
province of science fiction, it no longer
seems incredible that within the fore-
seeable future, babies could be ges-
tated without the need for a woman’s
body. Ectopic pregnancies show that the
development and survival of a fetus out-
side the uterus is possible,
and ad-
Dissecting Bioethics
vances in neonatal care have meant that
the number of weeks’ gestation neces-
sary for a baby’s survival are diminish-
ing steadily.
Meanwhile, at the other
end of the spectrum, laboratory tech-
niques have enabled scientists to create
and cultivate embryos in vitro for up to
2 weeks before implantation. Restric-
tions on this timeframe have been due
to legal and ethical cutoff points rather
than technical problems. Thus, the win-
dow of time required for pregnancy is
shrinking and could feasibly become
Therefore, arguments such as those I
am making based on the Burley/
Dworkin angle cannot be dismissed on
the grounds that they are beyond our
current capabilities. If there is a prima
facie injustice involved in reproduc-
tion, then it would seem that there could
indeed be a prima facie moral duty to
consider the possibility of alleviating it.
But this seems to leave us with a
problem. If natural inequalities can con-
stitute prima facie grounds for restitu-
tion, and current impossibility does not
rule out a duty to channel resources in
particular areas, we might find our-
selves compelled to pour funds into re-
search to raise IQs or enhance people’s
memories or other physical or mental
attributes. Negative interventions might
also be claimed: If there are some peo-
ple who are “naturally” deaf, I could
demand to become deaf too, since
Dworkin’s theory
on which I am
basing my argument
avoids draw-
ing barriers and boundaries between
therapeutic interventions and enhance-
ments or stipulating any objective
benchmark as to what should be re-
garded as desirable.
I think this can be answered by em-
phasizing that all we have tried to es-
tablish at this stage is a prima facie right
to restitution. Although it might be sur-
prising if some of the kinds of interven-
tion I’ve mentioned, such as elective
deafening, were prioritized beyond the
prima facie stage, it does not seem in-
herently problematic that these possi-
bilities share with ectogenesis a place
at the merely prima facie stage of mer-
iting attention. We must simply be sure
that there is an effective means by which
competing claims can be judged.
To progress the claim for restitution
beyond the prima facie stage, we need
to consider the “veil of ignorance”-
type scenario as described above, where
individuals make judgments based on
which disabilities they would provide
for, without knowing in advance
whether they would suffer from these
disabilities. Although Dworkin rejects
explicitly using criteria such as well-
being or suffering to distinguish objec-
tively between claims, he leaves it open
as to what criteria the individual might
use in his/her analysis of the options
from behind the veil of ignorance and
how these considerations might affect
the aggregate outcome.
So what would motivate people’s
judgments in these conditions? The
probability of having a particular con-
dition is thought by Burley to be a
significant factor. Burley also assumes
that social proclivities, such as the de-
sire for genetically related offspring,
would be a motivating factor.
I want
to add my own ingredient to this spec-
ulative mix, namely, the association of
the condition with pain and suffering.
Gestation and childbirth, it seems
to me, are very likely to be associ-
ated with pain and suffering in a way
some other conditions might not be.
Moreover, a susceptibility to these pr ob-
lems afflicts around 50% of the popu-
lation (assuming that in this particular
veil of ignorance scenario, the individ-
ual does not know which gender they
will be). Thus, on these two grounds
alone, I would suggest that choos-
if the choice was open
a tech-
nological alternative to gestation and
Dissecting Bioethics
childbirth from behind the veil of ig-
norance would be entirely plausible.
Pregnancy Is Barbaric
There has been a conceptual failure in
medical and social and ethical terms
to address the pathological nature of
gestation and childbirth and to tackle
the health problems it poses from a
justice perspective. Here, I want briefly
to highlight some of the risks in-
volved in pregnancy and childbirth. I
want to suggest that the desire of
women to be able to reproduce as men
do, without risking their physical and
mental health, economic and social
well-being, and
their bodily
integrity, can be defended against
charges of being mere whim, prefer-
ence, or expensive taste. The effects of
gestation and childbirth on women’s
health alone mean that the claim of
women to be relieved from this means
of reproduction can be firmly located
within a recognizably health-oriented
Fifteen percent of all pregnant women
develop potentially life-threatening
Over the years 2000
2002, the overall maternal mortality
rate in the United Kingdom was 13.1
maternal deaths per 100,000 materni-
Pregnant women are likely to
suffer health problems including back
pain, exhaustion, bowel problems, and
urinary incontinence extending for 6
months after delivery and beyond.
The prevalence in particular of fecal
incontinence following childbirth is
something that has only just begun to
be recognized, and it has been sug-
gested that for this reason alone, “nat-
ural” birth should be something for
which women give informed consent
based on a full understanding of these
Morbidity associated with child-
birth has been systematically neglect-
Perhaps for this reason, research
shows that mothers experiencing their
first childbirth find the event worse than
they had expected.
Where women are
aware of the risks involved, this can
increase fear of childbirth.
Fear it-
self can raise the likelihood of their
having caesarean sections due to com-
plications arising from tension and
trauma at the time of birth.
eans, of course, entail all the usual
risks of major surgery.
Despite the known dangers associ-
ated with caesareans, more and more
women choose this option with all the
attendant risks.
They are often casti-
gated for this (“too posh to push”
But no one likes having major surgery;
the fact that some women are tempted
by the possibility of this procedure
can be taken to demonstrate that “nat-
ural” childbirth is a fearsome pros-
pect. As Shulamith Firestone said,
“pregnancy is barbaric.”
Put simply, however much modern
medicine can do to improve outcomes
in pregnancy and childbirth, it cannot
remedy the fact that these processes
impose risks on women that far ex-
ceed the risks of normal day-to-day
living. The health-related consequences
of childbirth and labor also permeate
into women’s ability to function as
mothers and as members of society. A
difficult labor increases the chances of
posttraumatic stress syndrome
; in-
continence and back pain may keep
women out of work or severely re-
strict their employment options and
thus impair their financial well-being.
The final point to make here is the
well-known one that, for expectant
mothers, the fact of encompassing an-
other life in their bodies often takes a
serious toll on their autonomy. Preg-
nant women are routinely expected to
subsume their appetites and desires
into those that would be in keeping
with the well-being of the fetus. Not
Dissecting Bioethics
only this, but their abilities and rights
to make decisions about their medical
care are at risk of being overridden in
favor of the interests of the unborn
child. Respect for one’s bodily integ-
rity, something that most men may
take for granted at least in a medical
setting, is by no means assured for
women even in societies that pride
themselves on concern for ethics and
autonomy. Women are still sterilized
against their will and undergo forced
abortions and forced caesareans.
Voluntary Risk
One could, of course, argue that in
these days of modern contraception,
women aren’t forced to have children.
It is a choice that women make. If they
choose to accept the risks involved,
they can have no claim to restitution.
Burley neatly illustrates the idea of
choice and risk in an analogy that I
borrow here.
Suppose two people go
bungee jumping, knowing that this is
a sport that entails a certain degree of
risk. One of the jumpers suffers de-
tached retinas; the other is unscathed.
Burley states that the injured bungee
jumper does not have a claim to com-
pensation, because she voluntarily un-
derwent the same risks as the other
jumper. In fact, it is a case of option
luck as opposed to brute luck.
In my argument, pregnancy is the
bungee jump. Granted, women do often
voluntarily make the choice to jump and
thus assume the risks involved. How-
ever, the prima facie injustice involved
lies in the fact that when men decide to
or to have a genetically related
they are able to do so without
assuming any of these risks that affect
women in similar situations. When a
man wishes to have offspring, he is able
to do so without risking his bodily in-
tegrity, his health, or his privacy. Thus,
in terms of personal resource holdings,
women are systematically at a disad-
vantage. In the context of reproduc-
tion, men and women are not like the
two bungee jumpers in Burley’s anal-
ogy: The choices and risks open to them
are vastly unequal.
Applicability of the Argument to
Men or Surrogates
Just as some women might wish to be
free of the burdens of childbirth and ges-
tation, so some men might long to be
able to experience these things. I con-
cede that if there were men who wished
to gestate and give birth, the lack of this
capacity could be regarded by such men
as a deficit in their personal resource
holdings. Such men, according to my
argument, would also have a prima facie
right to restitution. However, just as
women would have to rely on other fac-
tors to advance their cause beyond a
mere prima facie right, so would men
in these circumstances.
There is another possibility to con-
sider here. In fact, a woman does not
always necessarily have to gestate and
give birth in order to have genetically
related children. A less technologically
pleasing solution is currently at hand:
surrogacy. If those women who do not
wish to give birth could routinely del-
egate the task to those who do, the
injustices I’ve been describing would
seemingly evaporate. Just as a man
can currently use his wife or partner
as a surrogate to carry his child, rather
than carrying it in his own body, so in
this new arrangement, his wife or part-
ner would also be able to avail herself
of a surrogate.
However, this scenario is unlikely to
be appealing. Apart from the difficulty
of ensuring that sufficient surrogates
would offer themselves, without veer-
ing into coercion, it simply seems to re-
frame the problem in a narrower context.
Part of the objection about the current
Dissecting Bioethics
reproductive situation is that a subset
of individuals in society (women) is, in
effect, obliged to act as surrogates for
men. If we simply reduce the number
of that subset, without addressing the
inherent inequality (namely, that it has
to be women who are the surrogates,
rather than men), we come no closer to
solving the injustice.
Effects on the Child
There is, of course, a fundamental eth-
ical consideration to be addressed in
relation to the question of ectogenesis:
What effect would it have on the child?
It might be argued that “ecto-children”
would lack some essential bond with
their mothers that other children have.
At the very least, it would seem ex-
tremely technically demanding to en-
sure that an artificial womb provided
all the nutrients necessary for the well-
being of the child. And what about
the effect on the mother/child relation-
ship? Surely this would be fractured
by the removal of the physical bond
between them.
With regard to the safety of ecto-
genesis, I assume for the purpose of
this argument, that sufficient research
would need to be carried out to estab-
lish this. However, the difficulties of
mother/child bonding still remain. I
want to make two points in response
to this possible obstacle. First, those
who suppose that the mother’s bond
is entirely dependent on her physical
gestation of her child do a huge dis-
service to all the step- and adoptive
parents who love their children dearly.
More importantly, they sweep away
any possibility of claiming that fathers
can love their children as much as
mothers do. Of course I don’t claim
that fathers always do love their chil-
dren as much as mothers, but I think
it self-evident that they can.
Conversely, mothers’ physical con-
nection with their babies does not guar-
antee a secure and unconditional flow
of motherly love. Plenty of women
fail to bond with their naturally born
children. Arguably, the traumatic pro-
cesses of birth are partly implicated in
this: Postpartum depression (which af-
fects 13% of women who have given
birth) may cause the mother to reject
her child or to refuse to nurture it, all
of which have a negative effect on the
child’s subsequent development.
Another point to make here is that,
in the current age of prenatal testing
and diagnosis, the phenomenon of the
“tentative pregnancy” has been well-
That is to say, women
undergoing prenatal tests speak of a
need to re-form bonds with their fe-
tuses after receiving test results. There
are also considerations related to the
development of visualization tech-
niques during pregnancy: For many
couples, being able to “see” the baby
on screen is a highly significant mo-
ment. This is not connected with the
knowledge that the baby is inside,
which has been evident all along, but
is tied up with the idea that the baby
looks like something, that it can be
seen despite being inside the mother.
Physical gestation of a child is thus
neither necessary nor sufficient for the
development of a loving parental bond.
The permutations of childrearing in
our society are diverse, and it seems
highly dubious to locate some kind of
mystic essence of parenthood in ges-
tation and childbirth if neither of these
things can be directly associated with
the development of the loving bond
or with benefits to the child.
Arguing for Prioritization
To return to the argument in favor of
ectogenesis: I have suggested that there
are prima facie grounds for women to
Dissecting Bioethics
be relieved of the natural inequalities
involved in reproduction and have at-
tempted to deal briefly with some of
the more obvious objections to this
claim. In this final section, I want to
address the major difficulty: where to
locate ectogenesis in a competing hi-
erarchy of claims for state assistance.
As suggested by the Dworkin/Burley
model, a version of the veil of igno-
rance is required, in which individu-
als make decisions based on their
preferences and their judgments of the
likelihood of being afflicted by certain
disorders, and the aggregate of these
choices receives priority in funding.
I’ve emphasized that Dworkin’s ap-
proach does not require that anything
be objectively definable as a disease,
disability, or disorder, so the fact that
gestation and childbirth are “natural”
for women is not in itself an argument
against their appearance in the list of
contenders for restitution.
Burley’s argument in favor of the
provision of state-funded artificial re-
productive technologies rests heavily
on her assumption that this veil of
ignorance test would yield a result
that prioritized fertility treatments. I
think that this assumption is hasty.
Burley does not discuss the relation-
ship between fertility treatments and
remedies for other natural inequali-
ties, and I see no reason to suppose
that it would necessarily be prioritized
in the way she assumes. Infertility as
a condition is not necessarily associ-
ated with suffering in the way that
say, appendicitis is. Only a subset of
those who are infertile will actually
wish to reproduce. For those who do
not, they might never even realize that
they lacked the capacity.
In theory at least, there might be
greater scope for ectogenesis to be pri-
oritized due in part to the pain and
trauma that even the best-managed
childbirth entails. There is also the fact,
as I’ve pointed out, that susceptibility
to this trauma affects around 50% of
the population
considerably more than
Burley’s 1 in 10 couples who may suf-
fer from infertility. But our society
would need to undergo a major con-
ceptual shift for sufficient numbers to
regard female fertility per se as some-
thing that merits compensation. For
this reason, I suspect that the veil of
ignorance test would be unlikely to
work if embarked on now. However,
if women
and men
feel that there
is a genuine justice issue here, it re-
mains with them to convince the skep-
tical masses of this fact.
The democratic nature of the
Dworkin/Burley argument that I’ve
borrowed here requires more than ab-
stract theorizing: People need to be
persuaded. Probably the “yuck factor”
will be too strong for it to prevail as
yet. But just as it was thought absurd
that women should vote or ride horses
astride, so it may come to seem ab-
surd that they were chained to the
degrading and dangerous processes of
pregnancy and childbirth simply be-
cause of our inability to get our heads
round the possibility of an alternative.
I would like to close with an imag-
inary scenario: You, the reader, from
behind the veil of ignorance, are asked
whether you would prefer to be born
into society A, where women bear all
the risks and burdens of gestation and
childbirth, as they do now, or society
B, where ectogenesis has been per-
fected and is routinely used. You do
not know whether you will be born as
a man or a woman. Which would you
1. Foggo D, Rogers L. Fertility experts urge
end to “selfish” late motherhood. The Sun-
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day Times 2006 Jul 9; Templeton SK. Late
motherhood “as big a problem” as teenage
mums. The Sunday Times 2006:Aug 13.
2. Hebert PR, Reed G, Entman SS, Mitchel EF
Jr, Berg C, Griffin MR. Serious maternal
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3. Burley JC. The price of eggs: Who should
bear the cost of fertility treatments? In: Har-
ris J, Holm S, eds. The Future of Human
Reproduction. Oxford: Clarendon Press; 1998:
4. Dworkin R. The foundations of liberal equal-
ity. In: Peterson GB, ed. The Tanner Lectures
on Human Values. Salt Lake City: University
of Utah Press; 1990:XI:3
5. See, for example, Dworkin R. Justice in the
distribution of health care. McGill Law Jour-
nal 1993;38(4):883
98 at p. 886.
6. See note 3, Burley 1998:132.
7. See note 3, Burley 1998:142.
8. There is a question here, of course, about
the degree to which infertility is brought on
by personal choices and the degree to which
this might affect Burley’s argument. How-
ever, there is not scope to address this prob-
lem in this paper, and, although I think it
may be a problem for Burley, it does not
apply in the same way to my application of
the Burley/Dworkin argument.
9. See note 5, Dworkin 1993:889.
10. See note 3, Burley 1998:142.
11. Kant I. The Moral Law Groundwork of the
Metaphysics of Morals. London: Hutchinson
& Co LTD; 1948.
12. Even if it were impossible to develop artifi-
cial wombs, it would still be feasible to
compensate women for their unequal re-
source holdings by offering financial resti-
tution. Arguably, this is what we should be
offering during the period in which the
technology is being developed.
13. Tshivhula F, Hall DR. Expectant manage-
ment of an advanced abdominal pregnancy.
Journal of Obstetrics and Gynaecology 2005;
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15. See note 3, Burley 1998:142.
16. In fact, although Dworkin does not explic-
itly endorse freedom from pain as being an
objective good, he assumes that freedom
from pain is likely to be an important as-
pect of well-being, so my inclusion of pain
as a consideration here may be seen to be in
line with what Dworkin himself might ac-
cept as being a likely factor in people’s
decisionmaking from behind the veil of ig-
norance. See note 4, Dworkin 1990:43 (espe-
cially the footnote on that page).
17. Of course, from Dworkin’s perspective, cat-
egorizing something as an authentic medical
need is not in itself necessary to justify pro-
viding compensation. However, I am focus-
ing on the criteria that might motivate people
to elect for the provision of such compensa-
tion, and I am aware that concepts of medi-
cal need might play a role here.
18. World Health Organization. Managing com-
plications in pregnancy and childbirth. Geneva,
Switzerland: World Health Organization;
19. Lewis G, ed. Why Mothers Die 2000
The Sixth Report of Confidential Enquiries into
Maternal Deaths in the United Kingdom. Lon-
don: RCOG Press; 2004.
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23. See, for example, Oakley A. From Here to
Maternity. Harmondsworth: Penguin; 1979,
especially chapter 5: The Agony and the
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maki RL, Repokari L, Vilska S, et al. Fear of
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tion. Obstetrics and Gynecology 2006;108(1):
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ated with pregnancy and childbirth: A study
of 329 pregnant women. Birth 2002;29(2):
26. Alves B, Sheikh A. Investigating the rela-
tionship between affluence and elective cae-
Dissecting Bioethics
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27. See, for example, Asthana A. Too posh to
push” births under fire. The Observer 2005
Sep 4.
28. Firestone S. The Dialectic of Sex: The Case for
Feminist Revolution. New York: Farrar, Straus
and Giroux; 1971:198
29. Czarnocka J, Slade P. Prevalence and predic-
tors of post-traumatic stress symptoms fol-
lowing childbirth. British Journal of Clinical
Psychology 2000;39(Pt 1):35
30. Dyer C. Woman can challenge hospital over
forced caesarean. British Medical Journal
31. See note 3, Burley 1998:136.
32. Petrou S, Cooper P, Murray L, Davidson LL.
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high-risk British cohort. British Journal of
Psychiatry 2002;181:505
12; Stein A, Gath DH,
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relationship between post-natal depression
and mother
child interaction. British Journal
of Psychiatry 1991;158:46
33. Rothman BK. The Tentative Pregnancy: Pre-
natal Diagnosis and the Future of Motherhood.
London: Unwin and Hyman; 1988; Taylor
JS. Image of contradiction: Obstetrical ultra-
sound in American culture. In: Franklin S,
Ragoné H, eds. Reproducing Reproduction: Kin-
ship, Power, and Technological Innovation. Phil-
adelphia: University of Pennsylvania Press;
34. Jackson E. Regulating Reproduction: Law,
Technology and Autonomy. Oxford: Hart; 2001:
Dissecting Bioethics
... These arguments, which are primarily interested in increasing the reproductive decision-making capacities of cisgender men, intersect with a recurring claim in the feminist literature that ectogenesis could allow women to share the physical and social consequences of gestating a pregnancy. The potential of an artificial womb to someday contribute to "the freeing of women from the tyranny of their reproductive biology by every means available, and the diffusion of childbearing and childrearing role to the society as a whole" (Firestone 1970;206), has continually resurfaced in feminist engagements with this technology (Oakley, 1986;Kamm 1992;Murphy 2006;Woolfrey 2006;Sander-Staudt 2006;Smajdor 2007;Takala 2009;Kendal 2015;Overall 2015). Writing nearly 40 years after Firestone, Smajdor argues that "the fact that women have to gestate and give birth in order to have children, whereas men do not, is a prima facie injustice that should be addressed by the development of ectogenesis" (2007,338). ...
... It is important to note here that while a number of these feminist and bioethical authors are cautious as to what they anticipate the outcome of this reorganising may be (see especially Murphy 2006;Woolfrey 2006), much of this scholarship concludes that it will have the effect of producing "true equality" (Takala 2009, 191). In other words, these scholars surmise that ectogenesis will produce equality within families through the sharing of gestation, which will in turn result in a more equal society (Kendal 2015;Pence 2006;Smajdor 2007;Singer and Wells 2006). As will become clear in this paper, I believe the binary understanding of sex and gender that informs this literature to be fundamentally inaccurate. ...
... What we can read from this is the possibility that with the introduction of ectogenesis, couples with the financial means to do so, perhaps regardless of their gender, might experience a sense of equality in responsibility for gestation that would be supported in law. This does not, however, act as a clear indication that artificial wombs will have the effect that some predict of changing gendered familial roles in the family and thus addressing gender inequality in society on the whole (Pence 2006;Singer and Wells 2006;Smajdor 2007;Kendal 2015). At most, it suggests that shifting relations to gestation could be accessible to some individuals or families. ...
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A growing body of scholarship argues that by disentangling gestation from the body, artificial wombs will alter the relationship between men, women, and fetuses such that reproduction is effectively ‘degendered’. Scholars have claimed that this purported ‘degendering’ of gestation will subsequently create greater equity between men and women. I argue that, contrary to the assumptions made in this literature, it is law, not biology, that acts as a primary barrier to the ‘degendering’ of gestation. With reference to contemporary case law involving disputes over frozen embryos, I demonstrate that though reproductive technologies have already made it possible for gendered progenitors to have an ‘equal’ say in gestation, law mires the possibilities of these technologies in traditional stories of gendered parenthood. Looking to the way binary assumptions about gender limit the self-determination of trans men and nonbinary and genderqueer people who are gestational parents, I argue the ‘degendering’ of gestation will come not with artificial wombs but with the end of limited legal paradigms for gendered gestational parenthood.
... More broadly, ectogenesis could make a fundamental contribution to achieving sexual equality in human reproduction, by reducing some of the disproportionate risks and burdens of procreation impacting women (Firestone, 1970;Smajdor, 2007). While the current methods of gamete extraction are not equivalent between men and women, particularly in terms of invasiveness and risk of complications, removing gestational burdens from one partner significantly reduces the overall imbalance in reproductive labour between the biological sexes. ...
... While the current methods of gamete extraction are not equivalent between men and women, particularly in terms of invasiveness and risk of complications, removing gestational burdens from one partner significantly reduces the overall imbalance in reproductive labour between the biological sexes. It is certainly true that some view pregnancy as a desirable state and would not wish to avoid it, but in the absence of a functional alternative many who are 'choosing' pregnancy are not making a genuinely free choice (Smajdor, 2007). ...
Ectogenesis (artificial womb technology) could yield many benefits on Earth and provide a safe and sustainable way to populate an off-world human colony. Gestating foetuses in a protected and controlled environment could help prevent damage caused by radiation exposure, nutritional deficits or the impact of microgravity during pregnancy. This method of reproduction would also reduce the risks and burdens to female settlers and avoid losing members of the early settlement workforce to maternal morbidity and mortality. Realising the potential of ectogenesis to improve sexual equality in reproductive endeavours on Earth and promote the creation of new human settlements in space, will require substantial legal, political and scientific support. It will also require the development of ethical standards for the development, testing and distribution of this new reproductive biotechnology. Key Concepts • Human settlements in space will need a safe way to reproduce the next generation of settlers. • Ectogenesis (artificial womb technology) could yield many benefits on Earth and in off-world human colonies. • Removing the risks and burdens of pregnancy and childbirth could make a fundamental contribution to achieving sexual equality in human reproduction. • Ectogenesis services will need to be distributed equitably to avoiding exacerbating social inequality in reproduction. • There are a number of ethical and legal barriers to developing ectogenesis that will need to be addressed before the technology can achieve its potential.
... Since Others have argued that artificial wombs are a welcome technology. [26][27] and that it could offer a unique moral compromise from the pro-life and pro-choice positions. 28 If I am right, we could also reach a compromise regarding post-ectogestative abortion legislation. ...
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A few decades from now, it might become possible to gestate fetuses in artificial wombs. Ectogestation as this is called, raises major legal and ethical issues, especially for abortion rights. In countries allowing abortion, regulation often revolves around the viability threshold—the point in fetal development after which the fetus can survive outside the womb. How should viability be understood—and abortion thus regulated—after ectogestation? Should we ban, allow or require the use of artificial wombs as an alternative to standard abortions? Drawing on Cohen, I evaluate three possible positions for the post-ectogestative abortion laws: restrictive, conservative and liberal. While the restrictive position appears untenable, I argue that the liberal and conservative positions can be combined to form a legally and morally coherent basis for post-ectogestative abortion legislation, offering an improvement from the point of both prolife and prochoice positions.
... Social pressures may also help to speed its adoption. Secular bioethicists such as Anna Smajdor (2007) believe that developing and utilising ectogenesis is a justice issue-a way to relieve women of the inherent burdens and risks of pregnancy and childbirth. Smajdor argues that ectogenesis would help to ensure that women with access to this technology can reproduce as men do, without risking their physical and mental health as well as avoiding the significant demands that pregnancy places on their bodily autonomy. ...
The development of artificial womb technology is proceeding rapidly and will present important ethical and theological challenges for Christians. While there has been extensive secular discourse on artificial wombs in recent years, there has been little Christian engagement with this topic. There are broadly two primary uses of artificial womb technology—ectogestation as a form of enhanced neonatal care, where some of the gestation period takes place in an artificial womb, and ectogenesis, where the entire gestation period is within an artificial womb. Ectogestation for the latter weeks or months of pregnancy could be possible within a decade or so, while ectogenesis for humans is far more speculative. Ectogestation is likely to significantly decrease maternal and neonatal morbidity and mortality, and so there is a strong case for supporting its development. Ectogenesis, however, may bring a number of challenges, including the commodification of children, and the pathologizing of pregnancy and childbirth. Its long-term effects on those who are created through this process are also unknown. In the event that it becomes ubiquitous, we may also find the central theological significance of pregnancy and birth diminished. The dilemma for Christians is that the development of ectogestation seems likely to normalise the use of artificial gestation, and, in time, pave the way for ectogenesis.
The purpose of this article is to reflect on the changes that the implementation of artificial wombs would bring to society, the family, and the concept of motherhood and fatherhood through the lens of two recent books: Helen Sedgwick's The Growing Season and Rebecca Ann Smith's Baby X. Each of the two novels, set in a near future, follows the work of a scientist who develops artificial womb technology. Significantly, both women experience concerns about the technology and its long-term effects that make both of them leave their laboratories and rethink the technology they invented, while considering its many ethical implications. Both novels can be seen as feminist revisionary rewritings of Aldous Huxley's Brave New World, rejecting the vision of rows of mass-produced, anonymous babies in artificial wombs, stressing instead the closeness of the parents to their offspring. They nevertheless critically evaluate not only the many potential benefits for women of ectogenetic technology but also the possible disadvantages and pitfalls.
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A prototype artificial womb is anticipated to be ready for human trials within five years. This technology departs from previous forms of neonatal care. Rather than treating the complications of premature birth, if successful, it will prevent these complications from arising to begin with by extending the period of gestation and allowing the neonate to continue to develop in an environment analogous to the uterus. Much of the social-scientific literature suggests that artificial wombs will improve health outcomes for pregnant people and neonates in general and may improve or expand reproductive choice in pregnancy. Using a critical lens informed by a reproductive justice framework, I argue that this approach to artificial wombs meets a challenge in (1), the persistence of racialized inequity in health outcomes for pregnant people and neonates and (2) historical and contemporary instances of classed and racialized reproductive coercion. I argue that beyond acting to prevent circumstances in which the artificial womb creates opportunities for coercion or exacerbates existing inequity, we might explore alternative paths for this technology as a tool to benefit all pregnant people by reorienting the discourse toward a focus on justice. I propose an approach to artificial wombs informed by a reproductive justice framework that centralizes those who have been most marginalized within reproductive care at each stage of the technology’s design, development, and implementation.
Scientists worldwide have tried to replicate birth processes for years, which have resulted in many new infertility solutions like in vitro fertilization (IVF) or surrogacy, but Artificial Womb Technology (AWT) is the most advanced and unique. AWT proposes an alternative to conventional pregnancy and childbirth. Presently, there is no prototype of an artificial womb for people. The innovation is particularly in its early stages. However, we do have to think about the scientific moral, and legal issues before racing into this innovation. We also need to deal with social, religious economic, and health issues. Here in this paper, we have specifically done a critical analysis of the bioethical issues concerning this upcoming technology. A transdisciplinary approach encompassing both the legal and scientific viewpoints, concerns, and suggestions related to this new technology has been discussed. We strongly suggest a worldwide discussion and be ready with a strong framework before we practice AWT, a venture whose outcomes are yet awaited.
Anna Smajdor claims that one means of addressing the declining fertility rate of Western countries is to develop artificial womb technology and to provide widespread access to this technology. Smajdor claims that Ronald Dworkin’s resource egalitarianism justifies this approach. In this essay, I argue that Dworkin’s resource egalitarianism does not justify the development of artificial womb technology. I furthermore claim that we must examine a variety of issues, including how the presence of artificial womb technology will affect society, before developing this technology.
In this contribution, I will defend the view of AWT (artificial-womb technology) as free reproductive choice and argue that ectogenesis technology should become a morally acceptable option. The chapter is divided in two parts. In the first part, I shall point out arguments against and in favour, advantages and advantages, of AWT. In the second part, I shall show how artificial-womb can be seen as a technology that might be used also by women who are not infertile and for whom pregnancy is not a risk and a tool for partially ending the unequal division of reproductive labour.
In their detailed chapter “Producing Parenthood: Islamic Juridical Perspectives & Theological Implications”, Aasim I. Padela, Katherine Klima and Rosie Duivenbode take into account a number of biomedical means that have given us the potential possibility to become parents in ways that were unthinkable until a decade or two ago. In this short reply, I will provide some comments that might spark further thoughts applicable to most of them. Also, not being an expert in Islamic law, I will try to contribute to the debate by raising a number of points that -hopefully- will continue to bring to the surface relevant concerns related to the way biotechnologies are affecting and will affect our lives: religious or not, Muslim or otherwise.
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The study was based on an index group of 49 mothers who had had depressive disorders in the post-natal year, and 49 control mothers who had been free from any psychiatric disorder since delivery. Nineteen months after childbirth, the interaction between mother and child was assessed by blind assessors using defined observational methods. Compared with controls, index mother-child pairs showed a reduced quality of interaction (e.g. mothers showed less facilitation of their children, children showed less affective sharing and less initial sociability with a stranger). Similar but reduced effects were seen in a subgroup of index mothers and children where the mother had recovered from depression by 19 months. Social and marital difficulties were associated with reduced quality of mother-child interaction.
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A 37 year old multiparous woman at 37th week gestation presented with an undiagnosed abdominal pregnancy and acute abdomen following forceful reduction of an associated utero-vaginal prolapse. She had an urgent laparotomy with delivery of a live female baby lying in the left broad ligament. The baby weighed 2.6kg with Apgar scores of 2 and 6 at first and fifth minutes respectively. The partially detached placenta was easily delivered complete with membranes. Haemostasis was secured by ligation and excision of the left adnexum (broad ligament with the pregnancy sac and uterine appendages). She was transfused with two units of whole blood. This case highlights the importance of excluding pregnancy in any woman of reproductive age with undiagnosed abdominal mass and utero-vaginal prolapse before any manipulation. It also underscores the importance of ultrasound scan in early pregnancy by a competent sonologist.
To identify the prevalence and potential predictors of post-traumatic stress type symptoms following labour. A large sample, within-participants design with initial assessment and postal follow-up was utilized. Two hundred and sixty-four women who had 'normal' births were assessed within 72 hours on potential predictive measures and at 6 weeks post-partum for levels of symptoms of intrusions, avoidance and hyperarousal on a questionnaire derived from DSM-IV (American Psychiatric Association, 1994) criteria. Symptoms of depression and anxiety were also assessed. Three per cent showed questionnaire responses suggesting clinically significant levels on all three post-traumatic stress dimensions and a further 24% on at least one of these dimensions. Forward stepwise regression analysis yielded models for predicting outcome variables. Perceptions of low levels of support from partner and staff, patterns of blame and low perceived control in labour were found to be particularly related to experience of post-traumatic stress symptoms. Personal vulnerability factors such as previous mental health difficulties and trait anxiety were also related to such symptoms as well as being relevant predictors for anxiety and depression. A proportion of women reports all three aspects of post-traumatic stress type symptoms following childbirth with many more reporting some components. A broader conceptualization of post-partum distress which takes account of the impact of labour is required. There may be opportunities for prevention through providing care in labour that enhances perceptions of control and support.
Awareness about the extent of maternal physical and emotional health problems after childbirth is increasing, but few longitudinal studies examining their duration have been published. The aim of this study was to describe changes in the prevalence of maternal health problems in the 6 months after birth and their association with parity and method of birth. A population-based, cohort study was conducted in the Australian Capital Territory (ACT), Australia. The study population, comprising women who gave birth to a live baby from March to October 1997, completed 4 questionnaires on the fourth postpartum day, and at 8, 16, and 24 weeks postpartum. Outcome measures were self-reported health problems during each of the three 8-week postpartum periods up to 24 weeks. A total of 1295 women participated, and 1193 (92) completed the study. Health problems showing resolution between 8 and 24 weeks postpartum were exhaustion/extreme tiredness (60-49), backache (53-45), bowel problems (37-17), lack of sleep/baby crying (30-15), hemorrhoids (30-13), perineal pain (22-4), excessive/prolonged bleeding (20-2), urinary incontinence (19-11), mastitis (15-3), and other urinary problems (5-3). No significant changes occurred in the prevalence of frequent headaches or migraines, sexual problems, or depression over the 6 months. Adjusting for method of birth, primiparas were more likely than multiparas to report perineal pain and sexual problems. Compared with unassisted vaginal births, women who had cesarean sections reported more exhaustion, lack of sleep, and bowel problems; reported less perineal pain and urinary incontinence in the first 8 weeks; and were more likely to be readmitted to hospital within 8 weeks of the birth. Women with forceps or vacuum extraction reported more perineal pain and sexual problems than those with unassisted vaginal births after adjusting for parity, perineal trauma, and length of labor. Health problems commonly occurred after childbirth with some resolution over the 6 months postpartum. Some important differences in prevalence of health problems were evident when parity and method of birth were considered.
Women may experience a variety of fears in association with pregnancy and childbirth. The purpose of this study was to describe their objects, causes, and manifestations, and to identify factors associated with the fears. The study sample comprised 481 pregnant women in western Finland, of whom 329 (response rate 69) completed a questionnaire. It was developed on the basis of semi-structured interviews and previous studies and had a 4-point scale and a dichotomous scale. Data were subjected to rotated factor analysis, and sum variables were produced. The effects of various demographic variables were calculated using the Kruskal-Wallis and Mann-Whitney U tests. Of the 329 respondents, 78 percent expressed fears relating to pregnancy, to childbirth, or to both. Specific fears concerned childbirth, the child's and mother's well-being, health care staff, family life, and cesarean section. Causes of fears were negative mood, negative stories told by others, alarming information, diseases and child-related problems, and, in multiparas, negative experiences of previous pregnancy, childbirth, and baby's health and care; causes were significantly related to occupation. Fears were manifested as symptoms of stress, effects on everyday life, and a wish to have a cesarean section or to avoid pregnancy and childbirth; employment situation and elective cesarean section were the most important factors related to manifestation of fears. Parity and antenatal training were the most important variables related to objects of fears. Women's fears that are associated with pregnancy and childbirth can be explained by different factors. It is important for perinatal health caregivers to ask pregnant women about their feelings related to the current pregnancy, childbirth, and future motherhood, and to give women who express fears an opportunity to discuss them, paying special attention to primiparas and to multiparas with negative experiences of earlier pregnancies.
The proportion of women delivering by caesarean section has increased dramatically in England and many westernised countries. It has been suggested that one important reason for this increase is the growing proportion of women opting for elective caesareans for lifestyle reasons, a trend that is, it is argued, most common among the affluent. We investigated the hypothesis that affluent women are more likely to deliver by elective caesarean section. Logistic regression modelling was used to analyse data from half a million women who delivered in English NHS hospitals between 1996 and 2000. We found that women living in the most affluent areas of England were significantly more likely to have an elective caesarean section than their deprived counterparts.