Some interventions are obviously required: you eat healthfully during pregnancy, you don’t smoke. Ordinary prenatal care protects one specific future child who’s already on the way. A baby who could have been born with certain problems is instead born healthier. We ought, surely, to protect a child we are committed to bringing to term. Not binge drinking during pregnancy is no different from putting your child in a car seat on the way home from the hospital—in both cases you are doing as you straightforwardly should. There are hard questions to be faced about how much protecting we must do—what we must protect our children from and at what cost to them and ourselves—but there is no question that we should be protective.

Other interventions are more puzzling, because what they accomplish is quite different. Suppose you have acne, and a dermatologist prescribes isotretinoin (commonly known as Accutane—an obsolete brand). The thick “iPledge” booklet you are given urges you to use more than one form of contraception, to avoid getting pregnant while using the drug. If you do conceive, your child has a significant chance of being born with abnormalities, it says. For example, the child’s external ears might wind up being malformed (for the sake of simplicity, I will focus exclusively on this risk). You won’t be able to stop the drug on time to prevent the malformations, since they can be caused in the first few weeks of gestation, before the pregnancy has been detected.

On the face of it, avoiding Accutane while you’re trying to conceive (or avoiding conception while taking Accutane) is just like taking prenatal vitamins—you must do it because you ought to protect your future child. When we look closer, though, it’s clear the rationale is actually very different. If you avoid conceiving while on Accutane and conceive a year later, it’s not as if you’ll be helping any baby who would have been born with abnormal ears. That baby won’t be born at all, as opposed to being born later with normal ears. Rather, you’ll be switching to having a different baby altogether— a baby formed from a different egg and different sperm. You will not have protected one baby, but will have instead selected between the earlier-born baby with malformed ears and a later-born normal baby. If protection is mandatory, selection may seem mandatory, only because it’s so easily confused with protection. Is it really mandatory to select the better off of two different babies? (Because it involves two nonidentical babies, this puzzle exemplifies what philosophers refer to as "the nonidentity problem”)

This becomes a more urgent question when we notice all the different ways we can be selective. Another way, besides optimally timing conception, is by getting advice from a genetic counselor or buying a genetic testing kit—they are even available online.

Information can be obtained simply by swabbing the inside of your cheek and mailing the sample back to a lab. The test will disclose your chances of having a child with hundreds of conditions. If you found out you were a carrier for a very serious condition, you might think it was worthwhile to opt for IVF and preimplantation genetic diagnosis (PGD); that would give you the chance to select among several embryos, discarding those with abnormalities. Once again, you would be selecting among several embryos, as opposed to protecting one—giving one already destined for existence the best chance in life.

Selection is also an option for someone who undergoes IVF simply due to infertility—with no particular desire to control which child she conceives. If conception is successful, there may be too many embryos to implant them all safely. A choice among them will have to be made somehow. PGD could be used to decide which embryo or embryos to implant.

Besides protecting one embryo (or fetus) and selecting between two, there is also the possibility of modifying an embryo, thereby altering the characteristics of a future child. So we have a total of three ways to optimize: through protection, selection, and modification. But each of those can take several forms. For instance, you can protect your future child from having abnormal ears, or protect the child from being deprived of stellar intelligence. Likewise, for selection and modification: they can be done to avoid unwanted traits or pursue desired traits. The literature on optimizing refers to avoiding the unwanted as “therapy” and pursuing the wanted as “enhancement,” terms that I will occasionally use but with a warning: in cases of selection they’re misleading. For in cases of selection, no one child is enhanced or receives therapy. Rather, the more advantaged of two possible children is selected.

At some point along the spectrum from taking prenatal vitamins, to timing conception auspiciously, to selecting better embryos, to modifying embryos, does the practice of optimizing pregnancy outcome become too meddlesome? At what point, if ever, do parents go from acceptable or even obligatory protecting to something more pernicious?

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