Saviors as saints or sinners?

Advances in medical science are frequently characterized by two related phenomena. First, they create the opportunity for individuals to make choices previously unavailable and thereby pose new moral questions that challenge both our moral intuitions and social institutions. Second, innovation in healthcare unfolds, both in the sense that its utilization spreads geographically but also that it triggers further innovation in science and in practice. A new kind of prenatal diagnosis is a recent example. Preimplantation genetic diagnosis allows parents to select and bear a child whose genetic make-up can help a sibling survive a chronic or life-threatening health problem. The growing incidence of nurturing what have been called ‘‘savior siblings’’ offers an occasion for moral reflection while, at the same time, is a vivid example of repeating patterns of progress in medicine. This brief comment will focus on moral issues, but a passing reference to the pattern of scientific progress will be helpful, if only to remind us that further developments in reproductive science and therapeutics will render some of the moral quandaries otiose. Breeding and bearing genetically selected donors would not be possible were it not for our ability to fertilize ova in vitro, to identify the genetic make-up of embryos, and to successfully implant the embryos chosen. Each element prompted moral debate when it was introduced. Our future ability to genetically engineer gametes and embryos and to rear them in artificial environments will eliminate some of the current ethical concerns but, of course, raise others. The current focus of the moral conversation is the creation of savior siblings and to that I turn. Couples have children for all sorts of reasons – some laudable and others questionable – and some have children for no reason at all. Wanting to have a child to benefit another child – if only as a companion – is rather common. Furthermore, people have often wished to and have sought to influence, if not determine, the characteristics of their offspring. Sometimes this involves prenatal testing and terminating a pregnancy when the fetus is found to carry some unwanted genetic condition. What has raised eyebrows is parents choosing to bear children with the avowed intention of ameliorating or even eliminating a genetic condition or other illness of a living sibling. How might we think about this issue? What are the values involved? Whose and which values should have priority when, as is the case here, they do not all line up? Before addressing questions about nurturing a savior sibling, we must recognize that some people believe we should not think about them at all. They believe that moral quandaries like this one are best addressed by an appeal to moral intuitions or instincts rather than rational thought (1). On this view the practice of creating savior siblings violates such basic ethical values, is so abhorrent that the exercise of balancing benefits and burdens or looking at rights and duties is entirely misdirected. Nurturing savior siblings – like cannibalism or mother/son incest – is simply revolting and reasoning about it beside the point. Especially odious activities have a ‘‘Yuk Factor’’ to which our moral intuitions respond. The problem with this view is that there is seldom agreement across cultures or over time on what qualifies as Yukkie. Those of you who believe that creating savior siblings is a revolting idea and either unworthy of or not amenable to moral argument should stop reading and skip to the end. Likewise, if you believe that IVF itself is immoral, you may skip to the end. Given our current technology, producing savior siblings with reasonable probability of success involves IVF. There are, of course, various reasons one might have for questioning the morality of IVF. I mention two but do not scrutinize them here. Some object to IVF because it is a presumptuous use of our scientific abilities and involves an excursion into realms best left to God. Others question the procedures for handling unused Pediatr Transplantation 2008: 12: 493–495 Copyright 2008 Blackwell Munksgaard