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Prof. Glenn Cohen is one of the world's leading experts on the intersection of bioethics (sometimes also called "medical ethics") and the law, as well as health law. He also[…]

Harvard bioethicist Glenn Cohen knows in his gut that sex and sexual reproduction are areas of human life that involve moral dilemmas. But when it comes to resolving those dilemmas and taking action, he recognizes the need to “go beyond the gut.”

The impulses we feel toward issues of sexual reproduction—whether it’s abortion, sperm donation, or surrogacy—are undeniable. The true reasons we feel one way or another, however, can be complex, and not immediately available to ourselves, even if we perform introspection. Here Cohen discusses human reproduction, and the difference between our current moral concerns, and what kinds of concerns we may have in the future, mainly resulting from technological innovation.

Should a mother or father be able to select an intelligent sperm or egg donor for their future children? If so, why not allow parents to genetically improve the intelligence of their unborn children? We feel a distinction between natural methods and contrived methods in our gut, but what do those feelings really come down to? Are they just feelings? Is that a good enough defense of moral reasoning?

Cohen describes the hoops that ethicists jump through to determine the difference between right and wrong, or least understand why we feel certain behaviors to be right, and other to be wrong. Crucial to many disagreements over morality is the question of human agency. Explore that topic, and many others, with the fascinating and articulate Professor Cohen.

Glenn Cohen’s book is Patients with Passports: Medical Tourism, Law, and Ethics.

Glenn Cohen:  So, reproductive technology is sort of a family of technologies. We have in vitro fertilization where essentially an egg is being fertilized outside of the body. So that involves harvesting eggs from women and then implanting sperm into that and putting it in. There are some variations on that. Another very common form of productive technology is surrogacy. In surrogacy an embryo is being carried by a woman who is not the genetic mother of the child, so another woman is caring the egg and sperm combined into a fetus. And then we have a series of other brand new technologies like mitochondrial replacement therapy where you're taking the egg from one woman, you're removing the mitochondria from that egg and putting in the mitochondria from another egg to deal with mitochondrial disease and here there's an idea that there's actually three genetic parents: the genetic father who provides the sperm, there's the mitochondrial donor and there's the woman who donates the rest of the egg. So in reality there's three genetic parents, even though the mitochondrial donor is only giving a very small part of genetic material in the DNA. So those are three reproductive technologies. Two are very common. One is brand-new.

And, of course, the oldest one that we have is artificial insemination. And in fact this goes back to the 1800s I believe in the United States at least. And this is essentially when a man ejaculates his sperm and it's used to inseminate a woman typically through an injection, although the old things they say about turkey basters are actually true. You can do at home insemination with a turkey baster. So those are four technologies: artificial insemination, in vitro fertilization, surrogacy and mitochondrial replacement therapy.

As a society there's a series of I would say traditional and then more novel challenges posed by these technologies. So the traditional ones involves first of all how do you get the sperm and egg? Is it ethical to purchase sperm and egg, and in particular egg were women have to take hormones, with egg retrieval there's some medical risks. Is it ethical or unethical to ask a woman to donate her egg or to sell her egg? How much can you pay a woman for that purpose? With sperm there's also in particular a question of sperm donor anonymity. In the United States we allows sperm donors to be anonymous if they want to be. Most sperm donors in the United States are anonymous. Many other countries in the world require individuals to put their names and identifying information into a registry available to the child that's born. The donor can see child at age 18. So the child can try to track down that person and try to make contact. And many donor conceived children say they have a right to know their genetic origins, a right to encounter this person. In the U.S. as a matter of law we don't recognize that right.

In terms of surrogacy we really have two kinds of surrogacy. We have gestational surrogacy where a woman carries a fetus from the sperm and egg of other people. In traditional surrogacy where the surrogate is inseminated by a man's sperm but it's her egg. In traditional surrogacy she's both the carrier of the baby as well as the genetic mother. In gestational surrogacy she only carries the baby. There are cases that we have reported in literature like the famous Baby M case where women who carry babies for other people become attached to them. They want to have the children as their own. And there is a break up of the agreement that was made ahead of time when the baby is delivered. How should we adjudicate the rights of a surrogate? Do we think of the surrogate, just to use a provocative a phrase, just an oven, just a cupboard? Or do we think about that as a person who is a real mother to the child and not to have rights? There's also a lot of transnational surrogacy where people go abroad to use surrogates, in particular to India in part because the cost is so much lower and you have women serving as surrogates from poor villages making for them a lot of money, much less than surrogates make in the United States living in compounds signing contracts where they can't have an abortion. They get paid by the month and if they miscarry they stop getting paid and there's questions about whether this is exploitative of these poor women or say giving them a great economic opportunity.

So I would say these fall in the bundle of the more traditional objection questions. The new technologies we've been talking about, mitochondrial replacement therapy, also CRISPR/Cas9 gene editing, which is a technology we're going in the lab. They're not yet human beings in terms of reproduction where we edit some of the genes, you particularly try to eliminate disease causing genes. Both of these raise issues about human enhancement. What should be the limits of enhancing human beings? When do we stop being human and start becoming post human? Is that a problem? Are there safety risks involved? Is it problematic for parents to try to control not only the upbringing of children but their genetic make up as well? At what point does it become oppressive? And these technologies pose really interesting but ethical but also biological and safety questions for what the future of humanity might look like.

So let me say a word about method of how does one go about analyzing this if you're new to the field how should we think about this? So I often call the method going beyond the gut. Think about things, we think about case, a concrete case. It might be a real case you encounter. For example, the story of a woman in her 60s or 70s in India having her first child with reproductive technologies, how old mother can be just for example, or it could be a fictional case something from literature like Brave New World for something from films. The film Ex Machina or the film Gattaca where we talk about a kind of genetic arms race in Gattaca among people who are becomingly increasingly perfect and those who are instead the products of traditional births.

So we have a concrete case that we think about. And we have a gut reaction. That's very normal. But then the next thing we have to do is kind of interrogate where that gut reaction comes from and it's kind of a top down and bottom up. We start with the gut but then we ask ourselves let me compare this case to a series of cases that are like this in some relevant respects but unlike this in others and ask myself how do I react to these new cases adding more items on the board if you will? From those in sorting through my reactions to new cases, our reactions and talking about it to people, we then try to test out some principles and derive some principles. So we say case A, case B, case C, yes, case D no. And we ask ourselves what distinguishes those cases and identify a principal. Say this is the principle that distinguishes them and then we try to apply that principle to a new set of cases to see whether it's a good principle; does it have to be thrown out; can it be refined? So that's a very abstract way of putting it.

Now let me just try to put it in practice in thinking about human enhancement and what makes us better. So take the case of trying to enhance genetically enhancing intelligence genetically as an example. So imagine we could make an alteration and we could either do this and the question would be would it be different to do it this way through choosing entirely intelligent sperm donors and egg donors or actually manipulating the genome. So one question we'd have to ask ourselves is does it matter in which way I arrive at that end? And imagine now the goal is to produce a set of children who will do better on a test where you're a wealthy parent and you want your children to succeed academically. People have strong reactions to that case. Maybe they think it's wrong because we're controlling these children's future; it's oppressive. Maybe they think it's wrong because it has bad distributive consequences. The rich have a way of perfecting themselves and getting better, poor do not. Well now we want to test it against a very different kind of case and that's the kind of SAT tutoring for example.

There are test centers across America where children can get tutored for standardized test to improve their performance, tutors for all sorts of subjects. Ordinarily most people don't have a strong negative moral reaction to the idea of tutoring and the pressure point to ask yourself is are the tutoring examples different from the enhancement examples I've started with? Both have the aim of improving the intelligence or the performance of children. And then we could throw in other cases, performance enhancing drugs in sports, for example, versus the use of Adderall and other drugs to cram for exams in colleges. Now we have four kinds of cases. We have doping in sports, we've got college students doing Adderall, we've got tutoring and then we have genetic enhancements. So now the question is we have a pattern of reactions to these cases, can we derive a set of principles or distinctions and make a difference and help explain these intuitions? And then also can be used for new cases in ways that are satisfactory. So kinds of lines I draw is the difference between biological versus non biological enhancement. Now all forms of learning are really biological deep down, but you might think the biological enhancement of altering the genome looks different from the biological enhancement of taking Adderall or cramming for a test or getting tutored.

You might also try to draw and distinctions between who's making the decision as to who will be enhanced. The case of this sports player or the case of the student who's cramming for an exam there is a lot of self agency; the person is choosing for themselves. In the case of a parent choosing will be the sperm or egg donor or choosing what genetic manipulations to do to an early embryo you have someone else imposing the will. Does that help explain our intuitions? And so on and so on and so forth. It gets pretty complex. You start drawing charts of distinctions and thinking about it. But in this form of contestation you can try to get really to understand what we really think.