Monday, March 29, 2021

Carroll and Crutchfield on Abortion and Organ Donation

 Sometimes reading bioethics and medical ethics papers feels like reading reports from some alien culture from another planet; even when you understand exactly what is being argued, everything is a little weird. I had this experience reading Emily Carroll's and Parker Crutchfield's "The Duty to Protect, Abortion, and Organ Donation", which argues that people opposed to abortion on the grounds that the fetus has the right to life should hold that parents are obligated to donate organs if doing so would save their children.

Carroll and Crutchfield always treat the latter as a kind of strange thing, which I find strange itself, since I'm pretty sure most people would say, "Of course parents are morally obligated to donate their organs to save their children if they can do so without thereby committing suicide". I certainly don't think you'd get more controversy over this than over abortion. You would get a wider variety of views about whether it is in fact practicable to make it legally compulsory, or whether the problem of parents deliberately letting their children die rather than donate organs is widespread enough that it is better handled by law than just by social custom and conscience, and so forth. But it wouldn't be surprising, in any random group  of people to find a significant number horrified at the idea of parents deliberately refusing to save their children when they could. Nor, I think, do medical risks involved in organ donation change this much; all medical operations involve some risk, and the primary relevant question is how well we can mitigate these risks. Most people would regard it as a moral obligation independently of any considerations of abortion; lots of pro-choice people are horrified by the notion of letting children die, and just think that this is not relevant to the abortion consideration.

But a great deal of the alienness is how Carroll and Crutchfield describe the situation:

Some people oppose abortion on the grounds that fetuses have full moral status and thus a right to not be killed. Furthermore, many opponents of abortion claim special obligations of a parent to their child, whether born or unborn. These special obligations go beyond simply not killing the fetus or child. Rather, they place responsibility on the parents to keep the fetus or child alive at cost to themselves. Pregnant women are therefore obligated to continue unwanted pregnancies, necessitating the sacrifice of their bodily autonomy. They are obligated to accept the medical risks of pregnancy and obligated to allow the fetus full use of their reproductive organs.

I could tell immediately from this first paragraph alone that Carroll and Crutchfield are not very well acquainted with people who are opponents of abortion. There are two obvious oddities. The first, less obvious, is that most opponents of abortion do not characterize their position in terms of "full moral status" when they are not actually arguing against supporters who deny that fetuses have full moral status. The reason for this is that most opponents of abortion think of the fetus as human, and in that context talking about "full moral status" is nastily eugenics-sounding. That the arguments of supporters of abortion often push the discussion into this territory is widely seen as itself something unfortunate and awful, for exactly the same reason that most people would find it unfortunate and awful to be drawn into an argument about whether Blacks or the disabled have "full moral status": there's something utterly presumptuous and horrible about it, and nobody likes it when they have to deal with people who insist on arguing the negative. Of course, if someone insisted on saying that (say) people with Down syndrome did not have full moral status, you would naturally respond by insisting that they do; but this doesn't mean that it would in any sense be natural to describe your own position that way. They are human, they have human rights, having to argue with people who even think in terms of whether they have "full moral status" is already a very grave misfortune.

The second is the talk of "necessitating the sacrifice of their bodily autonomy". Perhaps there marginal exceptions, but people opposed to abortion who think about matters of bodily autonomy would not generally see the situation of not aborting as one in which you are 'sacrificing your bodily autonomy'. If you and I accidentally get stuck together, and someone tells me that I can't fix this situation by hacking your arm off, it's not a very natural interpretation of this situation to say that they are telling me that I have to sacrifice my bodily autonomy; rather, if anything they are telling me that I can't sacrifice yours. My right of bodily autonomy does not give me any right to violate your right of bodily autonomy. But more than that, most people would not see this situation as one in which I am being asked to sacrifice my bodily autonomy; rather, you and I happen to be both stuck in a situation in which we will have to use some ingenuity and effort and patience to find a solution that will respect both my bodily autonomy and yours. The reason is that almost all, and perhaps all, coherent accounts of something like bodily autonomy require consistency: I can't formulate what respects my bodily autonomy in a situation without also taking into account what respects yours in this situation. The fact of being stuck together makes it so that we are both in this unfortunate situation together; nothing even counts as my bodily autonomy or yours except what we can at some level both lay claim to. I can reasonably say that hacking off my arm to free you violates my bodily autonomy, but you can say the same about your arm; but the fact that we both have to be patient and endure the situation until we can find a solution that respects the autonomy of both of us is not a sacrifice of bodily autonomy. It's just that the situation practically complicates the questions of how we can respect each other's bodily autonomy. And likewise, many opponents of abortion will say that pregnancy, as such, is not a violation of bodily autonomy, but it is a complicating situation in which both mother and child find themselves together, and in which it is necessary to find a solution that requires neither the mother nor the child to sacrifice their bodily autonomy. Recognizing this is actually quite important for understanding the dispute over abortion.

But the strangest part of their argument is later, in the attempt to glide easily from moral obligation to legal obligation. Take it as given that parents have a moral obligation to donate organs to their children, if doing so would save the child's life and if it can be done without actually killing the parent. And let's assume that there is a similar duty-to-protect obligation in the abortion case. Does it follow that they are therefore equivalent enough for legal purposes, so that making one legally required forces us to make the other legally required?

Not simply from this barebones description. Reasonable legal obligation does not follow directly from moral obligation, but also has to consider things like (1) how serious a problem there is, (2) how difficult it would be to enforce the legal obligation, (3) whether the alternatives to legal compulsion are the same in both cases, (4) how strong the state interest is, and so forth. All of these have to be considered. There are somewhere between 600,000 and 900,000 abortions in the United States every year, depending on what you think the best way to count them is. If we look at the statistics for organ donations, there are about 30,000 total organ donations and about 6000 living organ donations a year in the United States, and about 7000 or so people die each year while on the organ transplant waiting lists -- these numbers include everybody, not just children. So if one regarded both of these as problems, it seems clear that the abortion case is literally magnitudes more serious, in terms of how many people are directly affected. Possibly it would be easier to enforce a law in a particular organ transplant case, but arguably not by much; but in terms of the general law, it's a lot easier to enforce a law against a few thousand cases than against a few hundred thousand cases. And state interest is stronger in the organ transplant case, as well: in the abortion case, the state has an interest in protecting possible citizens and having a society that is hospitable and welcoming to them, but in the organ transplant case, the children are usually citizen minors already, and therefore are entitled to a greater degree of protection by law. But it's also quite clear, given the technology we have now, that in most cases the alternatives are more favorable in the organ transplant case. A baby has the mother it has, and transplanting a baby would be, I dare say, a vastly more complicated endeavor than most organ transplant surgeries; but most of the time, parents would not be the only possible donors who could provide organs for their children. Thus, given a regime in which abortion is illegal, there are still things that could be said both in favor and against legally compulsory organ donation.

None of this is unusual -- these are things that must be considered whenever we are considering laws, and that we take into account all the time. But Carroll and Crutchford's argument considers none of this at all, as if none of it were relevant. For instance, they say things like,

It may be that the fetus in the mother’s body is significantly more vulnerable to its mother than the average child is to its parents. But the child who needs an organ is just as vulnerable to their parent as the fetus is to its mother.

But this is obviously false if you consider the relative difficulties of transplanting a baby in the womb and transplanting most organs; the latter may not be easy, but we have a much better grip on how to do it than the former. And it is also false when you consider that children in need of organs have more options as to who can provide what they need.

But more than that, despite the fact that they keep slipping it in, they never actually argue the legal obligation at all -- they just treat it as following directly from the moral points, whereas in no situation does reasonable legal compulsion follow directly and without further considerations from moral obligation. 

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