SEARCH

SEARCH BY CITATION

Keywords:

  • bioethics;
  • focus groups;
  • preimplantation genetic diagnosis;
  • public participation;
  • qualitative research;
  • social sex selection

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Ordinary Ethics study
  5. Metaphors of ‘gift’ and ‘commodity’
  6. Normative status
  7. Status of the metaphor
  8. Relevance of ‘ordinary ethics’ to bioethics
  9. Forms of public input
  10. Acknowledgements
  11. References

In this paper we explore lay people's discussions of the controversial topic of social sex selection (SSS). In the UK and many other countries, SSS is prohibited by law. In 2003 the UK Human Fertilisation and Embryology Authority, after an extensive public consultation, decided against changing the existing legislation. However, this initiative and similar consultation exercises have been criticised on the grounds that public opinion is poorly informed and reasoned. In our study, one of the most consistently expressed ideas was that children should be regarded as ‘a gift’ rather than ‘a commodity’. In contrast, the ‘gift not a commodity’ argument is rarely cited positively in Anglo-American, secular-liberal bioethics. These metaphorical statements are condensed articulations of complex but coherent moral intuitions. Where much of the bioethics literature stresses parental autonomy, our lay discussants balanced this principle with ideas about the need to respect the personhood of the potential child, and the characteristics of a good parent. We conclude our analysis by considering the implications for expanding bioethics’ knowledge base and improving the input of lay people in bioethical decision making.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Ordinary Ethics study
  5. Metaphors of ‘gift’ and ‘commodity’
  6. Normative status
  7. Status of the metaphor
  8. Relevance of ‘ordinary ethics’ to bioethics
  9. Forms of public input
  10. Acknowledgements
  11. References

Recent developments in genetics and reproductive medicine have had an increasing impact on the choices available to parents and families over reproduction and health. While there seems to be general support for technologies that offer promise in fighting disease, there is also deep anxiety about their implications, especially for personal identity and family relationships. One particularly contentious issue is prenatal sex selection for social reasons (SSS), by methods that include preimplantation genetic diagnosis (PGD). PGD was developed in the late 1980s to enable families at risk of genetic disease to select unaffected embryos without having to undergo prenatal diagnosis and abortion of affected pregnancies (Braude et al. 2002). Medical sex selection, to avoid male embryos potentially affected by X-linked conditions, was the first clinical application of PGD (Handyside et al. 1990), and PGD for medical sex selection continues to be regarded as acceptable clinical practice in the United Kingdom. The same technique, however, could be used to give couples the option of selecting a male or female embryo if they prefer children of one sex or wish for a ‘balanced family’ with children of both sexes. Social sex selection is prohibited under Article 14 of the Council of Europe's 1997 Convention on Human Rights and Biomedicine. To many commentators it represents an important boundary between therapeutic uses of technology to promote health, and the adoption of technologies for non-medical reasons (e.g. to increase choice, or satisfy individual desires). For critics concerned about the extension of genetic and reproductive technology, SSS seems another step on a path leading to ‘designer babies’ (Human Genetics Alert 2002, Center for Genetics and Society 2004).

In the UK, policy decisions on these and related areas of reproductive medicine have been delegated by act of legislation to regulatory bodies such as the Human Fertilisation and Embryology Authority (HFEA). Such bodies aim to make policy that is based on expert judgement and that also retains broad public confidence. Their membership covers a range of expertise in science, philosophy, law and business, and usually includes members drawn from lay interest groups. Regulatory authorities are also expected to consult formally with the wider public as part of their process of deliberation. Several problematic issues remain unresolved here. In practice, such consultations draw on rather limited constituencies, and there is uncertainty about the forms of consultation best suited to enabling the lay public to effectively contribute their views (Levitt 2003). There is also the question of what to do with the material obtained from public input. What kind of authority do lay contributions have? How can they best be interpreted and contribute to policy deliberations?

Using lay concerns to inform policy can be problematic. In particular, dilemmas arise where there is disparity between the views of expert scientists and ethicists and the consensus of lay views. Should regulation be crafted on the basis of broad social consensus, or should it prioritise the arguments of the experts? The divide between ‘expert’ and ‘lay’ knowledge and identities is being subjected to increasing critique (Callon and Rabeharisoa 2003, Nowotny, Scott and Gibbons 2001), with attention being paid to the ways members of the public perform as ‘scientific citizens’ (Irwin 2001, Irwin and Michael 2003, Michael and Brown 2005). A recent example of these questions arose in 2002, when the HFEA ran a public consultation on the acceptability of SSS (HFEA 2002). The use the HFEA made of public opinion in its final report (HFEA 2003) was controversial, prompting discussion by leading medical ethicists in the United Kingdom (Harris 2005a and b, Baldwin 2005, Holm 2004, Tizzard 2004), and was implicitly rejected by the response of the House of Commons Committee on Science and Technology to its recommendations (2005).

A key issue raised in the HFEA discussion was that many expert scientists and bioethicists find lay people's ethical judgements less trustworthy than professional ethicists’, arguing they are based solely on intuitions and prejudice rather than on knowledge and rational argument (Levitt 2003). These experts suggest that, instead of weighing the evidence and the arguments, non-philosophers usually have an immediate response to an issue, and then search for reasons to legitimate their intuitions. There is some evidence from moral psychology to support this claim about decision-making processes in general (Haidt 2001, and references therein). A further reason for caution is the culture-bound nature of popular intuitions. There are numerous historical examples to show that the public often find new developments initially threatening and distasteful. Responses such as ‘it's unnatural’ or ‘we should not play God’ are common when faced with novel technologies, and are sometimes encapsulated in the phrase ‘the yuck factor’ (Kass 1997). When it has previously not been possible to exercise choice in an area of social or family life, people initially seem to believe that it would be morally wrong to do so in the future. And so advocates of SSS argue that it is simple unfamiliarity with the idea of choosing the sex of children that makes people think it is wrong. Although moral philosophy does make use of appeals to intuition, and conservative bioethicists such as Leon Kass have approvingly cited ‘the wisdom of repugnance’ (Kass 1997, 2002), yuck factor arguments have not gained widespread philosophical backing.

The Ordinary Ethics study

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Ordinary Ethics study
  5. Metaphors of ‘gift’ and ‘commodity’
  6. Normative status
  7. Status of the metaphor
  8. Relevance of ‘ordinary ethics’ to bioethics
  9. Forms of public input
  10. Acknowledgements
  11. References

Our research project, entitled ‘Ordinary Ethics: the moral evaluation of the new genetics by non-professionals’, and funded by the Wellcome Trust, studied lay people's ethical evaluations about biomedical technologies. One of our fundamental aims was to see whether the ethical evaluations made by these lay participants were indeed based solely on prejudice or whether they had any reasoned basis. We investigated the kinds of opinions lay people expressed; the sorts of arguments they used; and how both their evaluative approaches and their conclusions compared to dominant forms of contemporary bioethical discourse. We chose SSS as our focus topic because the technology involved is relatively simple, there is an existing academic literature, and because the phenomenon of wanting a child of a certain sex would be familiar to most participants. In this paper we use some findings from the study to demonstrate how lay people's ethical arguments can be revealed, focusing on one motif in particular: that children are ‘a gift’. A broader discussion of the methods and findings in relation to the overall processes of ethical evaluation can be found in Banks et al. (2006).

Building on previous work (Scully 2002, Kerr et al. 1998), we used the method of group discussions based on a scenario about prenatal sex selection by PGD. Ten group discussions were held with different groups of people during 2002–4 in the north east of England. The groups covered a range of age, gender, class and disability perspectives, although no groups were convened from specifically religious, cultural or minority ethnic organisations or groupings. Participants included a women's community education group; postgraduate community and youth work students; a rural youth group; a group of Soroptimists (an organisation for women in management and the professions); a group from a regional user-led disability organisation; one group each of men and women aged over 65; a group of male social workers; a group of less professionalised men active in community and youth work; and a group from the Woodcraft Folk group (an educational movement for young people aiming to develop self-confidence and social participation).

All groups received a brief introduction to PGD and sex selection. We then used a fictional scenario about a couple wishing to use PGD to select the sex of their next child. The discussions lasted between 50 and 90 minutes, and were facilitated by a researcher who, after introducing the scenario and asking people to reflect individually, invited initial reactions. In the majority of groups, the following starting scenario was used:

Imagine a couple who have three daughters. They plan to have another child, and want to use PGD to make sure they have a son.

Offering a sketchy scenario like this opens a space for a less abstract discussion, inviting participants to imagine a plausible situation, consider what other information they would need to know about this particular case to make a judgement about it, take account of other people's reasons and motives, and so on. The facilitator introduced modifications of the scenario to explore the effect on the evaluation, for example if there were existing children of the ‘wrong’ sex in the family-balancing scenario; if the parents came from another culture; if they wanted to select to avoid an inherited disability instead of a particular sex; or if they wanted to select for a disability. Additionally, we conducted one-to-one, follow-up interviews with selected group members when we wanted to explore their comments in more depth than was possible in a group discussion.

At the end of each discussion participants were asked for their final opinion on the general question of whether SSS by PGD was acceptable. The majority opinion in all groups was that it was not morally justifiable. Forty out of 48 participants (83%) reported holding this view.

The taped discussions were transcribed, organised using the qualitative data analysis package NVivo (Bazeley and Richards 2000, Gibbs 2002), and analysed in detail for ethical themes and argumentation.

Metaphors of ‘gift’ and ‘commodity’

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Ordinary Ethics study
  5. Metaphors of ‘gift’ and ‘commodity’
  6. Normative status
  7. Status of the metaphor
  8. Relevance of ‘ordinary ethics’ to bioethics
  9. Forms of public input
  10. Acknowledgements
  11. References

While each discussion group differed in the interactions taking place and the configurations of views and arguments expressed, some common themes were observed throughout1. Among the most prominent were the psychological consequences for the individual child and the family, potential social consequences (such as gender imbalance), the individual right to choice, the nature of society and the individual, and the characteristics of the good parent. In the rest of this paper, we focus on one of the most common and extensively discussed themes, the idea that children should be a ‘gift’ (and not a ‘commodity’ or, less frequently, a ‘right’). As one of the group discussants commented:

I think that having a child is not some kind of human right to which you can attach conditions, whatever those conditions are . . . I feel that quite strongly. I think that's actually wrong, to me that is a wrong way of looking at having children. I would prefer to look at it as a gift, something like that (Social workers’ group).

Clearly the description of the child as a gift was not being used literally. A literal gift would imply a giver. This could be a person in cases of egg or sperm donation, or adoption, but these were not the topics being considered. In other instances the notion of a giver might be a reference to God. But in fact only one participant made explicit reference to God as a giver, and she was referring to pregnancy termination rather than SSS. In all other instances, the context in which participants referred to children as a gift did not suggest they were framing their concern in overtly religious terms. That is, they were not drawing explicitly on the idea of a child as a gift from God.

The claim that ‘children are a gift’ is therefore a metaphorical one. Lakoff and Johnson (1980) define metaphor as conceiving of one thing in terms of another, in order to further understanding of the first concept. A metaphor is not a definition, but a way of getting a handle on a concept, and has the advantage that it can convey complex ideas succinctly. Metaphors are particularly important in understanding conceptual abstractions in concrete or physical terms. As a metaphor, ‘children are a gift’ is being used to convey something important about how the speaker believes parents should relate to their children, and the responsibilities this relationship involves.

Metaphors have entailments. Complex metaphors can carry multiple sets of entailments, and which set is mobilised depends on exactly what the user intends the metaphor to express. By using gift as a metaphor, then, what were our participants trying to say? This question has to be investigated by looking at the context in which the metaphor was being used, statements in which it was elaborated, and other metaphors with which it was compared. The large sociological and anthropological literature about gifts (for example, Mauss 1960, Cheal 1988, Osteen 2003) is predominantly framed in terms of economic models of exchange or of gift-giving's social function. Based in real-life gift-giving involving giver and recipient, these models focus on the function that the gift performs in the community. But in our setting, and in the absence of a giver, participants’ attention was instead directed to the relationship between recipient and gift and in particular to the appropriate response to receiving a gift. Here, it appeared that the key gift entailment being mobilised was acceptance. In the traditional pattern of gift-giving in western European culture, when someone gives you a gift you do not quibble about its specifications: you accept it unconditionally, with gratitude. The notion of gift implies a lack of control over what is received. To speak about children as a gift is therefore to say that they should be accepted as they are, and that it is not appropriate to refuse them or to want to change their characteristics. This interpretation of the entailment being drawn on is supported by numerous accompanying statements. For example, one focus group participant commented:

I just don't think it's right that people can actually just sit down and choose what colour hair they want [for the child], what colour eyes they want, what job they want the father to do, because you’re not loving a baby if you've got to sit and create it like that (Women's educational group).

The metaphor of the gift was often used in counterpoint with the metaphor of the commodity. In this case, however, the parallel was rejected: people said that a child is not a commodity. Again, the metaphor of commodity has numerous entailments. Although in some contexts it implies the role of the market and market forces, for our participants it seemed to be more about choice than about money. ‘Treating children as a commodity’ was less about the wrongness of buying and selling children than it was shorthand for ‘exceeding an appropriate level of choice’. Other comments indicated that by commodity people were describing an inanimate object rather than a subject, something that is uniform and not unique, and whose characteristics it is legitimate to select according to one's desires. Choosing the features of what one gets is seen as morally acceptable when buying a car or washing powder, but not when the object is actually a person:

It's about treating people as commodities which come off a shelf, rather than thinking of them as people (Soroptimists’ group).

It smacks of shopping for the child (Disability group).

Commodification is about treating a child not as a person, but as a thing: an ‘it’ rather than a ‘thou’, in Buber's (1937) terms.

We noted previously that complex metaphors like these are overdetermined – they carry diverse, sometimes incompatible associations and entailments, and careful exploration of what is actually being said and not said is needed to tease out the salient meanings. For example, in principle ‘gift’ might also be associated with marking a special event, repayment for past favours, and so on. However, in practice we saw no examples where participants’ speech indicated that they were drawing on these entailments when using the gift metaphor.

In considering how the metaphor of gift is being used in ethical evaluation, the question is whether the notion that children should be accepted (almost) unconditionally, as gifts, is an isolated free-floating intuition, or whether it is grounded in further reasons. As we followed the different discussions in close detail we noted that participants linked the virtue of acceptance with two things in particular: (i) an ontological claim about the nature of children and the person, and (ii) an aretaic claim about the characteristics of the good parent.

Nature of the person

As the following quotes illustrate, participants said that this level of choice (choosing the sex of a child for non-medical reasons) represents the placing of expectations on a child that fails to respect its individual personhood:

It's not accepting every person as an individual. It's not respecting the individual (Disability group).

The child isn't the parent's property, they are their own person, and putting expectations on them doesn't seem to respect them or treat them as autonomous . . . There is something there that you don't have control over you know, there is something I think intrinsic there. I don't know what it is but there is something. They are people . . . (Social workers’ group).

This participant was asked to expand on this in a follow-up interview. He said:

So it is something around that I think, around the detraction from, you know, who the individual really is. Actually seeing the person for what they are worth in their entirety rather than trying to put things onto them and sort of saying, well, actually you are this and this and everything. [Parents who select for sex] see them as different types of people [not individuals] if you start with ideas that are so definite about how a girl or boy should be (Social worker, follow-up interview).

Part of what people felt was wrong was indicated by another entailment of the gift metaphor. In the traditional pattern of gift-giving, the lack of control means the gift is a surprise. The following exchange comes from the older men's group:

A:Interesting question that, explain the surprise thing. Now providing the surprise is pleasant, everybody is happy about it, but it is difficult to explain the feeling. It's rather like Christmas in the days when you’re old-fashioned enough not to know what you were going to get for Christmas.
B:Anticipation.
A:Yes.
Facilitator:And that's a pleasant thing?
All:Yes.
A:And how you explain that I don't know, but that's the feeling.

For a small minority of participants the value of surprise seemed to cover knowing the sex ahead of the birth at all. But the majority were less inclined to take the ‘gift as surprise’ entailment that far: their reservations were directed at attempts to control the sex, and they were less or not at all concerned about simply knowing the sex beforehand (which is after all still a surprise, albeit brought forward in time).

By drawing on this entailment of gift, participants were saying that in the reproductive context, unpredictable outcomes are appropriate and indeed can have special value:

In a way [SSS] could be setting limits to what that child is going to be instead of letting the random element come into it. I don't know enough about the science. Perhaps a random element comes into it anyway. In which case, good! (Participant in disability group, follow-up interview).

To restate this concern in more conventional ethical terms, choosing the characteristic of sex is seen as a failure to respect the intrinsic value of the individual child. Moreover, this does not appear to be a consequentialist claim. It does not rest on the belief that choosing the sex will have bad results for society, the relationship between parent and child, or the child itself (although claims like these were made as part of separate arguments). Rather than any direct harmful consequences, the metaphor seems to be chosen to express a judgement about the ontological implications of the act:

If it [SSS] happened and . . . the dire consequences didn't materialise . . . I think I would still be sad at the lack of, I'd still feel we'd lost something (Participant in disability group, follow-up interview).

By drawing on the entailments of the gift metaphor, therefore, our respondents are expressing something similar to a deontological idea of ‘respect for persons’.

The good parent

The metaphors of ‘gift’ and ‘commodity’ could also be viewed in terms of virtue ethics – sometimes known as an aretaic model – thereby calling attention to the behaviours that identify a good parent. Participants expressed their concern that people choosing the sex of their child are placing their own desires or ambitions above the needs and interests of the child, and that this is not behaviour characteristic of good parents. In the group of male social workers one said:

I think as a parent I'm at my best when I'm not imposing my expectations on my children but rather providing them with the wherewithal to do what it is they want to do. I don't mean that quite literally in that they can go and wreck the place if that is what they want to do, but I mean you know within social confines and all the rest of it, to achieve what they want to achieve. . . . That doesn't mean pushing them down a particular route that actually meets my needs.

Similarly, a postgraduate student respondent argued that:

There is something really selfish about it: I want my child to be like this. When being a parent you have to be so unselfish, and it can be such an enriching experience to have this level of unselfishness.

And a member of the older men's group linked the lack of choice with ideas about love in families that were not definable but were, he claimed, shared:

I also think you’re in grave danger of disturbing something here, that is hard to define. I love my family, each and every one of them, not because of what they are but in spite of what they are. I love them because they are there . . . It doesn't matter to me whether they are tall, short, fat, thin or what. No, I didn't put in an order to have them the way they are, that just happens to be the way they are and as I see it, who can define love. That is something that none of us can really define. You can't put an equation down. We’re all family men here and I'm quite sure these two think as I do.

To these participants, then, the good parent is one who allows and enables the unfolding of their child's potential. Doing so means that good parents limit the interventions they make. Permissible interventions are those that protect the child or really do enable it to develop:

As a mother I would want to make my child's life as good as possible. And I think most parents try and do that. . . . I think the parenting bit would want to protect . . . at the end of the day if I knew before that I had a hereditary problem with a boy or a girl, and somebody told me we could do something about that, I think as a protective mother I would ask for something to be done (Soroptimists’ group).

This meant that although most of the participants took the virtue of acceptance as a marker for the good parent, the degree of acceptance expected of a good parent is not unlimited and in fact varied from participant to participant. Elsewhere (Scully et al. 2006) we discuss in greater detail the participants’ reasoning about the limits to chance and choice in reproductive decision making. To give one example, most participants drew a distinction between using PGD to choose sex and to avoid disability, the latter including sex selection to avoid sex-linked conditions:

The other thing is that I have no objections or no fears about using this system where there is a medical reason for it, where, you know, something in the genes can be carried on to a certain sex, that doesn't upset me at all. It's just in this case, just choosing, well we've got three of one so it's high time we had one of another. I don't like that at all (Older women's group).

Like it could be valid though, you know, you have diseases that can only be passed on to one sex? I don't know . . . there is one that only happens to men, but like if their family had a history of that, they might want to have a girl just for the sake of that, (Facilitator: So that would be okay?) That would be fine (Woodcraft Folk youth group).

The consensus in eight groups was that there was a morally valid distinction to be made between using PGD to select for sex and using it to select against disease and impairment. But all discussions also recognised the difficulty of deciding where the cut-off point might fall between impairments, and two groups contained participants who were adamant that parental acceptance should always be unlimited, even to accepting disease and impairment where termination or PGD might have been options.

Normative status

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Ordinary Ethics study
  5. Metaphors of ‘gift’ and ‘commodity’
  6. Normative status
  7. Status of the metaphor
  8. Relevance of ‘ordinary ethics’ to bioethics
  9. Forms of public input
  10. Acknowledgements
  11. References

Our participants were also sensitive to the normative status of their own opinions. That is, most of their discussion was about what they thought would be the morally correct thing to do for themselves. But they acknowledged the difficulty of making normative statements about other people in situations of which they themselves had no experience:

People who would argue against the technology may be people who have no understanding of what it's like to be in that situation (Postgraduate students’ group).

Nevertheless, acknowledgement of this did not affect participants’ normative ethical evaluation. Referring to a hypothetical Asian family introduced as a modification of the scenario, one participant in the disability group's discussion said:

As far as I'm concerned it doesn't affect my decision. I can understand more why they would want a boy than a European family who had three girls and fancied a boy, it does make a difference . . . I don't think that makes it right, though I can understand the pressures they would be under.

On the other hand, although this awareness did not alter their ethical evaluation, it did make them reluctant to advocate drawing a hard and fast line in legislation:

. . . I would find it very difficult to impose that principle on somebody else, because I wouldn't know what their situation was . . . I wouldn't be able to say no, you shouldn't do that (Social worker).

However, knowing that this line was already drawn (since UK law currently forbids SSS) meant they saw no reason to change it.

Status of the metaphor

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Ordinary Ethics study
  5. Metaphors of ‘gift’ and ‘commodity’
  6. Normative status
  7. Status of the metaphor
  8. Relevance of ‘ordinary ethics’ to bioethics
  9. Forms of public input
  10. Acknowledgements
  11. References

Close scrutiny of the metaphors of gift and commodity helps identify which entailments our participants felt were the relevant ones, so clarifying the complex set of beliefs that they were trying to express through them. In drawing on associations of acceptance and surprise, participants were underlining the unpredictable nature of having children. In their emphasis on the individuality of persons against the reproducibility of commodities, participants were saying that a child's individual personhood was worthy of special respect. Taken together, these two metaphors suggest that the important thing about treating children as gifts and not as commodities is that the former shows appropriate respect for unique personhood. It is ethically unacceptable to encroach too much on the characteristics of children because this demonstrates precisely a lack of this respect, and in practice can infringe their autonomy by preventing them from doing ‘what they want to do’. In this way the gift metaphor succinctly imports a cluster of deontological beliefs about the child's personhood, individuality and autonomy into the ethical discussion.

Our participants’ thinking drew on the resources of interlocking ethical concepts: of respect for the personhood of the child; the obligation to show this respect by minimising the constraints placed on the child's future choices; the characterisation of a good parent as one who does this by accepting children ‘as they are’; and a model that sees the parent-child relationship as vulnerable to encroachments in this respect, by such acts as choosing the sex. These are background concepts that are, at least initially, expressed through metaphor and analogy rather than directly articulated, and they seem to provide a set of constraints that enable participants to make moral sense of an unfamiliar situation. (See Holland 2003 for a similar discussion of cases where appeals to ‘nature’ express something about the need for a particular set of background constraints.)

Citing a metaphor is not an argument in itself. Nor would it be correct to think of either the gift or the commodity metaphor as a premise from which the participants argue to a conclusion about the permissibility or not of SSS. People did not ground their moral claims in the child's status as a gift. Rather, selected entailments of the gift metaphor express what these participants felt was the appropriate way to treat a child, and (we argue) in turn express an interlocking set of beliefs about the child's moral status and the moral responsibilities of parents in terms of protection and control. The metaphor is a condensed articulation of this set of beliefs rather than a philosophical premise.

Relevance of ‘ordinary ethics’ to bioethics

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Ordinary Ethics study
  5. Metaphors of ‘gift’ and ‘commodity’
  6. Normative status
  7. Status of the metaphor
  8. Relevance of ‘ordinary ethics’ to bioethics
  9. Forms of public input
  10. Acknowledgements
  11. References

What relationship do these processes bear to the bioethics of academia and policy? How much can what people actually think and do, morally, contribute to ethical theorising?

Bioethics is an interdisciplinary field that encompasses a variety of analytical approaches and theoretical traditions (Jonsen 1998: 118). In recent years, however, it has come under attack for what critics view as its narrowness of approach. One side of this critique relates to the sources of material drawn on for ethical analyses – the ‘social and cultural myopia’ of bioethics (Light and McGee 1998: 1). Some critics argue that this should be remedied by greater use of empirical data from a range of cultural settings (Solomon 2005, Borry et al. 2005, Hedgecoe 2004, Zussman 2000, De Vries 2004, De Vries and Subedi 1998, Walker 1998).

But there is a separate issue to do with the ethical analyses themselves – how moral positions and arguments, wherever they come from, are handled. As commentators have noted, most of the philosophical work in bioethics comes from within the Anglo-American tradition of analytic philosophy (Light and McGee 1998). It is true that alternative traditions and approaches are present in bioethics, such as virtue ethics (e.g. Weed and McKeown 1998), care ethics (e.g. Tong 1998), feminist ethics (e.g. Wolf 1996, Rawlinson 2001, Mahowald 2001, Moazam 2004), and narrative ethics (e.g. Nelson 1997), not to mention the Continental bioethical traditions. Some of these alternatives more closely resemble the approaches of our lay participants with respect to their ontology of the person, the normative weight given to relationships between parent and child, and the styles of reasoning they prioritise. Nevertheless, we share the opinion of the critics that the most influential strands in contemporary Anglo-American bioethics are liberal (and in the United Kingdom at least predominantly secular), prioritising logic and abstract rationality, and drawing extensively on the formalism of consequentialist, utilitarian and rights-based approaches to ethics (Jonsen 1998: 378–380).

This form of bioethics, which for the sake of conciseness we call here ‘secular-liberal bioethics’, also appears to provide the bulk of bioethical input into policy, at least in the United Kingdom and much of Europe. Our own impression of media discussion, political debates and the make-up of advisory and regulatory bodies is that the most substantial ethical contributions are currently made by bioethicists from within these traditions, and, although the literature here is sparse, this impression is supported by other commentators (e.g. Capps 2005: footnote 31, Salter and Jones 2005). This may be because the conclusions of secular-liberal analyses, and the analytical processes through which they are reached, are easier to integrate into the procedures of policy making than the more relational, socially embedded approaches of alternative traditions. Thus Salter and Jones note both that the disciplinary breakdown of national and international bioethics committees shows a predominance of medical genetics and law, and that ‘The rationality of science [and, we would add, of philosophy and law] resonates easily with the rationality of the policy process’ (2005: 728).

Secular-liberal bioethics overall takes a broadly permissive view of SSS. Its moral position is generally grounded in support for a citizen's reproductive liberty or procreative autonomy, defined by Ronald Dworkin (1993) as the ‘right to control their own role in procreation unless the state has a compelling reason for denying them that control’. Reproduction is seen as central to personal identity and freedom and values, and a range of authors have argued for the right of individuals to choose their own lifestyle and pursue family life in their own way, and in accordance with their own notions of their children's wellbeing, unless exercising this right infringes other adults’ liberty (Harris 2005 a and b, Robertson 2003, Savulescu 1999, Savulescu and Dahl 2000, Buchanan et al. 2000). According to this line of argument SSS might undermine the public good if the sex ratio were affected, or if sexism were reinforced through preference for one sex over the other. In the absence of these effects, however, the freedom of parents to choose should be defended. Examining the possible consequences of SSS, most secular-liberal bioethicists find that there is no empirical evidence of such psychological or social harms, and they conclude from this that there is no good or sufficient cause for restricting the freedom of others to create children via different forms of sex selection (see also McCarthy 2001, Dickens 2002, Robertson 2003, Pembrey 2002).

Both the conclusion and the style of reasoning contrast markedly with the ethical concerns articulated by participants in our study. Although they did not exclude issues of principles and rights, or the narrower issues of reproductive autonomy and harm, they were primarily concerned with questions of the relationship between children and their parents, and what it means to be a good parent. These questions are certainly not absent in the wider academic bioethical literature, but are given limited coverage in the secular-liberal approaches of the UK and US.

We conclude from this study that the ethical views of our participants were not, as has been suggested, either uninformed or ‘simply incoherent’ (Harris 2005b: 287). Their views were grounded in intuitions that were usually presented through metaphor rather than through the logical argument that is more familiar to moral philosophy. These intuitions were of genuine moral salience to the lay participants and were, to them, more compelling than arguments based on reproductive autonomy or the moral status of the embryo. Furthermore, our participants did not use a logical, step-by-step propositional argument to arrive at their position (Banks et al. 2006) but relied on something closer to a coherence argument. In the example we have explored here, the metaphor of gift was a condensed articulation of a set of interlocking intuitions that were given high priority in our participants’ evaluations. Our participants’ position on SSS draws on a background of moral understandings that formed the basis for their judgements. We are not suggesting that ‘ordinary ethics’ provides better ethical arguments than professional bioethics, or that both use the same kind of argument. We conclude, however, that the divide between professional and lay bioethics has less to do with the ‘good arguments’ of philosophy versus the ‘poor arguments’ of the public, than the difference between two styles of reasoning.

If it is also true that secular-liberal bioethics generally draws on a limited range of experience, as well as a narrow repertoire of arguments, then the input of lay people is especially needed to illuminate areas of moral importance that this style of bioethics is likely to miss. For example, Tizzard (2004: 64) refers to the public's ‘deep-seated belief that children are gifts and not consumer commodities’ and goes on to question the belief by asking whether children born as the result of sex selection are likely to be psychologically harmed – apparently missing the point that the lay belief is not in fact about consequentialist harms. Additionally, some lay experiences and moral perceptions may simply lie outside the experience of experts. Many of the life experiences of the women in the educational group in our study, for example, might fit into this category. Here, empirical data on moral life or lay moral opinions can be taken as not in themselves normative, but as extending our knowledge of the moral values that lay people find salient and the rationales they find compelling as they go through their ethical deliberations. This extended database can challenge what secular-liberal, or indeed other forms of bioethics, assume to be normative values, goals or acts.

Forms of public input

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Ordinary Ethics study
  5. Metaphors of ‘gift’ and ‘commodity’
  6. Normative status
  7. Status of the metaphor
  8. Relevance of ‘ordinary ethics’ to bioethics
  9. Forms of public input
  10. Acknowledgements
  11. References

The commonly used approaches to accessing public opinion all have drawbacks. For instance, public consultation exercises are likely to be dominated by vested interests: professional bodies and campaigning organisations (such as ‘Pro-Life’ groups) will usually respond to invitations to give opinions, whereas lay people may not be aware of the opportunity, or may not consider their ideas worthy of consideration (Irwin 2001). More carefully designed ways of giving people a voice need to be well planned in order to be inclusive of a range of perspectives among different groups in society. Where statistical representativeness is achieved by reaching large numbers of people, the form of enquiry is often shallow: opinion polls or other forms of survey may be successful in quantifying stances, but are less helpful in understanding respondents’ more considered rationales. With an issue of moral or technical complexity, where some familiarity with the background and context may be desirable, ‘thin’ forms of engagement can be particularly misleading.

Deliberative methodologies – such as the consensus conference or the citizens’ jury – entail a more sustained discussion of issues, with participants having the opportunity to hear from expert witnesses (Joss and Durant 1995). Arguably, the group interviews conducted for this study begin to approach this deliberative ideal, because information was provided on request, and space provided for extensive discussion (Wakeford 2002, Glasner 2001). We suggest that more engaged forms of democratic input like these are less likely to generate superficial and unreflected lay responses, of which the critics mentioned earlier are so wary. Regulatory and advisory public bodies could, for instance, commission a citizens’ jury to deliberate on specific questions, the results of which could then be fed into the final decision-making process. We note that the UK National Institute for Health and Clinical Excellence (NICE) has a Citizens Council that meets several times a year to advise on questions of overall values and priorities. This approach could be emulated more widely (but see Davies et al. 2005, Barnett et al. 2006). The result might be a greater legitimacy for the resulting decisions, as well as a more democratic and less elitist style of policy-making.

But even when supported by considered reasons such as those gathered in our research, public opinion (just like expert opinion) can be flawed, and philosophy provides an invaluable scrutiny of intuitions, arguments and claims. As we see it, the issue here is not about whether professional or lay ethical evaluation provides the best arguments, but about how to avoid the excessive use of a limited kind of philosophical analysis and mode of argumentation in public bioethical debate and policy discussions (Holm 2005). This is one reason why joint input by both expert and lay reasoning is necessary to inform policy and, we would argue, why more research is needed to explore how this input can be achieved. One conclusion of this study is that some of the reasons given by lay participants are akin to those used in the professional ethical analyses – for instance, where the ethical impermissibility of social sex selection derives from a claim about the intrinsic value of the human individual, or that SSS would not be the act of a virtuous parent. This is important for the practice of joint public and professional bioethical consultations, because it means that the insights of lay bioethics can be articulated in ways that make them compatible with those of professional ethics in a joint discourse (without saying that the two are the same). But in order for this to happen, the lay arguments first need to be excavated and articulated, in the way we have illustrated here; a more diverse range of bioethical approaches needs to become firmly established in public debate; and bioethics itself needs to become more knowledgeable about the concerns, values and forms of reasoning that lay people bring to their ethical deliberations.

Note

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Ordinary Ethics study
  5. Metaphors of ‘gift’ and ‘commodity’
  6. Normative status
  7. Status of the metaphor
  8. Relevance of ‘ordinary ethics’ to bioethics
  9. Forms of public input
  10. Acknowledgements
  11. References

The authors would like to thank all those who volunteered to take part in this study, two anonymous referees for their helpful comments, and Tom Wakeford for some invaluable input. The financial support of the Wellcome Trust project grant number 068439/Z/02/Z is gratefully acknowledged.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. The Ordinary Ethics study
  5. Metaphors of ‘gift’ and ‘commodity’
  6. Normative status
  7. Status of the metaphor
  8. Relevance of ‘ordinary ethics’ to bioethics
  9. Forms of public input
  10. Acknowledgements
  11. References
  • Baldwin, T. (2005) Reproductive liberty and elitist contempt, Journal of Medical Ethics, 31, 28890.
  • Banks, S., Scully, J.L. and Shakespeare, T.W. (2006) Ordinary ethics: the ethical evaluation of the new genetics by lay people, New Genetics and Society, in press.
  • Barnett, E., Davies, C. and Wetherell, M.S. (2006) Citizens at the Centre: Deliberative Participation in Healthcare Decisions. London: The Policy Press.
  • Bazeley, P. and Richards, L. (2000) The NvIvo Qualitative Project Book. London: Sage.
  • Borry, P., Schotsman, P. and Dierickx, K. (2005) The birth of the empirical turn in bioethics, Bioethics, 19, 4971.
  • Braude, P., Pickering, S., Flinter, F. and Ogilvie, C.M. (2002) Preimplantation genetic diagnosis, Nature Reviews Genetics, 3, 94153.
  • Buber, M. (1937) I and Thou. Trans Gregor Smith, R. Edinburgh: T. and T. Clark.
  • Buchanan, A., Brock, D.W., Daniels, N. and Wikler, D. (2000) From Chance to Choice: Genetics and Justice. Harvard: Cambridge University Press.
  • Callon, M. and Rabeharisoa, V. (2003) Research ‘in the wild’ and the mapping of new social identities, Technology in Society, 25, 193204.
  • Capps, B. (2005) Bioethics and misrepresentation in the stem cell debate, Cardiff Centre for Ethics, Law and Society. http://www.ccels.cf.ac.uk/literature/publications/2005/Capspaper.html
  • Cheal, D. (1988) The Gift Economy. London: Routledge.
  • Davies, C., Wetherell, M., Barnett, E. and Seymour-Smith, S. (2005) Opening the Box: Evaluating the Citizens Council of NICE. Milton Keynes: Open University Press. http://pcpoh.bham.ac.uk/publichealth/nccrm/PDFs%20and%20documents/Publications/Citizens%20council%20Mar05.pdf
  • De Vries, R. (2004) How can we help? From ‘sociology in’ bioethics to ‘sociology of’ bioethics’, Journal of Law, Medicine and Ethics, 32, 27992.
  • De Vries, R. and Subedi, J. (eds) (1998) Bioethics and Society. Constructing the Ethical Enterprise. Englewood, New Jersey: Prentice Hall.
  • Dickens, B.M. (2002) Can sex selection be ethically tolerated? Journal of Medical Ethics, 28, 3356.
  • Dworkin, R. (1993) Life's Dominion: An Argument about Abortion, Euthanasia and Individual Freedom. New York: Knopf.
  • Gibbs, G. (2002) Qualitative Data Analysis: Explorations with NVivo. Buckingham: Open University Press.
  • Glasner, P. (2001) Rights or rituals? Why juries can do more harm than good. In Pimbert, M.P. and Wakeford, T. (eds) Deliberative Democracy and Citizen Empowerment. Special issue of PLA Notes 40, IIED. Co-published by The Commonwealth Foundation, ActionAid, DFID, Sida and IIED (download from http://www.iied.org/NR/agbioliv/pla_notes/pla_backissues/40.html)
  • Haidt, J. (2001) The emotional dog and its rational tail: a social intuitionist approch to moral judgement, Psychological Review, 108, 81434.
  • Handyside, A.H., Kontogianni, E.H., Hardy, K. and Winston, R.M. (1990) Pregnancies from biopsied human preimplantation embryos sexed by Y-specific DNA amplification, Nature, 344, 76870.
  • Harris, J. (2005a) No sex selection please, we’re British, Journal of Medical Ethics, 31, 28688.
  • Harris, J. (2005b) Sex selection and regulated hatred, Journal of Medical Ethics, 31, 2914.
  • Hedgecoe, A.M. (2004) Critical bioethics: beyond the social science critique of applied ethics, Bioethics, 18, 12043.
  • Holland, S. (2003) Bioethics: a Philosophical Introduction. Cambridge: Polity.
  • Holm, S. (2004) Like a frog in boiling water: the public, the HFEA and sex selection, Health Care Analysis, 12, 2739.
  • Holm, S. (2005) Bioethics down under-medical ethics engages with political philosophy, Journal of Medical Ethics, 31, 1.
  • House of Commons Committee on Science and Technology (2005) Report on Human Technologies and the Law. London: The Stationery Office.
  • Human Fertilisation and Embryology Authority (2002) Sex Selection: Choice and Responsibility in Human Reproduction. London: HFEA.
  • Human Fertilisation and Embryology Authority (2003) Sex Selection: Options for Regulation. London: HFEA.
  • Irwin, A. (2001) Constructing the scientific citizen: science and democracy in the biosciences, Public Understanding of Science, 10, 118.
  • Irwin, A. and Michael, M. (2003) Science, Social Theory and Public Knowledge. Maidenhead, Berks: Open University Press/McGraw Hill.
  • Jonsen, A. (1998) The Birth of Bioethics. Oxford: Oxford University Press.
  • Joss, S. and Durant, J. (eds) (1995) Public Participation in Science: the Role of Consensus Conferences in Europe. London: Science Museum.
  • Kass, L. (1997) The wisdom of repugnance, The New Republic, 2 June 1997, 17–26.
  • Kass, L. (2002) Life, Liberty, and the Defense of Dignity: the Challenge for Bioethics. Milwaukee: Encounter Books.
  • Kerr, A., Cunningham-Burley, S. and Amos, A. (1998) Drawing the line: an analysis of lay people's discussions about the new genetics, Public Understanding of Science, 7, 11333.
  • Lakoff, G. and Johnson, M. (1980) Metaphors We Live By. Chicago: University of Chicago Press.
  • Levitt, M. (2003) Public consultation in bioethics. What's the point of asking the public when they have neither scientific nor ethical expertise? Health Care Analysis, 11, 1525.
  • Light, D.W. and McGee, G. (1998) On the social embeddedness of bioethics. In De Vries, R. and Subedi, J. (eds) Bioethics and Society. Constructing the Ethical Enterprise. New Jersey: Prentice Hall.
  • Mahowald, M.B. (2001) Cultural differences and sex selection. In Tong, R. (Ed.) Globalizing Feminist Bioethics: Crosscultural Perspectives. Boulder, Colorado: Westview Press.
  • Mauss, M. (1960) The Gift: Forms and Functions of Exchange in Archaic Societies. New York: Norton.
  • McCarthy, D. (2001) Why sex selection should be legal, Journal of Medical Ethics, 27, 30207.
  • Michael, M. and Brown, N. (2005) Scientific citizenships: self-representations of xenotransplantation's Publics, Science as Culture, 14, 3957.
  • Moazam, F. (2004) Feminist discourse on sex screening and selective abortion of female foetuses, Bioethics, 18, 20520.
  • Nelson, H.L. (1997) Stories and their Limits: Narrative Approaches to Bioethics. New York: Routledge.
  • Nowotny, H., Scott, P. and Gibbons, M. (2001) Re-thinking Science: Knowledge and the Public in an Age of Uncertainty. Cambridge: Polity.
  • Osteen, M. (ed.) (2003) The Question of the Gift. London: Routledge.
  • Pembrey, M. (2002) Social sex selection by preimplantation genetic diagnosis, Reproductive BioMedicine Online, 4, 157–9, http://www.rbmonline.com/Article/418
  • Rawlinson, M.C. (2001) The concept of a feminist bioethics, Journal of Medicine and Philosophy, 26, 40516.
  • Robertson, J.A. (2003) Extending preimplantation genetic diagnosis: medical and non-medical uses, Journal of Medical Ethics, 29, 21316.
  • Salter, B. and Jones, M. (2005) Biobanks and bioethics: the politics of legitimation, Journal of European Public Policy, 12, 71032.
  • Savulescu, J. (1999) Sex selection: the case for, Medical Journal of Australia, 171, 3735.
  • Savulescu, J. and Dahl, E. (2000) Sex selection and preimplantation diagnosis. A response to the Ethics Committee of the American Society of Reproductive Medicine, Human Reproduction, 15, 187980.
  • Scully, J.L. (2002) Quaker Approaches to Moral Issues in Genetics. Lampeter: Mellen.
  • Scully, J.L., Banks, S. and Shakespeare, T.W. (2006) Chance, choice and control: lay debate on prenatal social sex selection, Social Science and Medicine, 63, 2131.
  • Solomon, M.Z. (2005) Realizing bioethics’ goals in practice: ten ways ‘is’ can help ‘ought’, Hastings Center Report, 35, 407.
  • Tizzard, J. (2004) Sex selection, child welfare and risk: a critique of the HFEA's recommendations on sex selection, Health Care Analysis, 12, 618.
  • Tong, R. (1998) The ethics of care. A feminist virtue ethics of care for healthcare practitioners, Journal of Medicine and Philosophy, 23, 13152.
  • Wakeford, T. (2002) Citizens Juries: a radical alternative for social research, Social Research Update, 37, http://www.soc.surrey.ac.uk/sru/SRU37.html
  • Walker, M.U. (1998) Moral Understandings: A Feminist Study in Ethics. New York: Routledge.
  • Weed, D.L. and McKeown, R.E. (1998) Epidemiology and virtue ethics, International Journal of Epidemiology, 27, 3439.
  • Wolf, S. (1996) Feminism and Bioethics: Beyond Reproduction. New York: Oxford University Press.
  • Zussman, R. (2000) The contribution of sociology to medical ethics, The Hastings Center Report, 30, 711.