Like Sandel, I’ve focused on the state of mind of the person making procreative choices. While Sandel worries about the molding and beholding of prospective parents, I’ve focused on other attitudes. Savulescu, by contrast, is entirely concerned with the newborn’s attributes. Decisions are good when they lead to better attributes, no matter whether the process involves protection, selection, or modification, and whether the aim is therapy, enhancement, or something else. Procreative beneficence involves too much concern with newborn attributes, I’ve argued, but we do have to have some concern. What needs to be added and clarified is that a good parent will care about securing or avoiding some attributes more and some attributes less.

Let’s go back to the Accutane case. I said it was innocent to delay conception until you are through with the treatment. But that sounds too weak. It is not just innocent: you should delay conception to avoid a child having malformed external ears. At the same time, it seems problematic to insert genes for extra prettiness— doing so is inconsistent with parental receptiveness. How can this pair of assessments make sense? If we compare these cases carefully, I think we can see that they do.

Imagine you’re taking Accutane and could have baby A (with abnormalities) now or baby B (with no abnormalities) in a year. Whatever you do, the other child will not wind up languishing, unborn, in a cosmic orphanage. You won’t harm the child who doesn’t exist. It’s also somewhat reassuring that the relevant abnormalities are small; the child who exists, whether it’s A or B, will have a good chance of a good life. So far it sounds like you don’t have to select normal baby B, but is that right? Another relevant consideration is this: A would be a little worse off than B, and in a way that is bound to involve medical interventions and accommodations. If you decide to have A, you will inevitably work hard, after A is born, to get him to be as well off as B would have been. But what an absurd situation! Since you could have had B to begin with, without any significant effort or sacrifice, it’s downright irrational to have A. It’s foolish. And beyond that, it’s also a harbinger of bad parenting. Since it’s so easy to have B instead of A, the person who doesn’t make the effort to have B probably doesn’t have proper empathy for what A will feel as she deals with the inevitable interventions and the sense of being born with an abnormality. Worse, it’s hard to imagine what could make someone do this, besides carelessness. All these points add up to the intuitive assessment: "You should wait and have B.”

When the choice is between unpretty baby A and pretty baby B, and the procedure is PGD, with selection of traits from the Additions™ catalog, things look different. Being an unpretty baby isn’t seen as an abnormality in need of medical remedy. Parents aren’t going to intervene after birth to get baby A to be in baby B’s better position. There’s also much more effort involved in selecting traits from the catalog and inserting them using PGD. So where it does seem foolish, careless, and uncaring to conceive while on Accutane, it doesn’t seem foolish, careless, and uncaring to throw out the catalog and let nature take its course instead of inserting genes for extra prettiness. The parents who throw it out are just feeling open and receptive—which is admirable.

How we look at any particular case of selection depends on many factors: the desirable attribute in question; what will happen after birth to a child without it; and the effort and sacrifice involved in pursuing it. One of the thoughts in the mix is a legitimate distinction having to do with sheer normality. Each of us would like to have a fortunate birth—a birth with all the normal human anatomy and physiology. Considering that this is a universal and rather deep- seated preference, it’s worth more effort to secure simple normality than to secure extra talents and assets. But so much for relatively small things like normal external ears and extra prettiness. What about more important attributes?

Genetic counseling can reveal to prospective parents that they have a high risk of having a child with serious problems. Perhaps the most common risk factor is sheer age. Many women who postpone parenthood until their careers are established find themselves having to think about the risk of having a child with Down syndrome. Older women are also more likely to be using assisted reproduction, which increases the chances of multiple births. If you are a forty- year-old woman having twins, the chances that one or the other of the babies has Down syndrome is about 2 percent. Should you have pursued pregnancy to begin with? Must you opt for prenatal testing, to find out if you are carrying a baby with Down syndrome? What should you do if you find out that one of the fetuses has the syndrome, and the other does not? There are lots of hard questions here.

In this new situation all the stakes are much higher. I won’t presume to offer advice or reach a verdict, but will just point out that we do not, out of consistency, have to reach the same conclusion as in the Accutane case. Now the choice is between possibly having a child with an abnormality, and having no child at all—the effort and sacrifice involved is much greater. The attribute is much more significant as well. It’s certainly less clear than in the previous cases what we will do, if we are receptive, careful, and caring. I think reasonable, good people will avoid conception on Accutane and throw out the Additions™ catalog. But here, when the worry is about Down syndrome, and in many other situations, it’s much less clear how to integrate all of the morally relevant considerations pushing us either toward procreation or away from it.

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