Bruce P. Blackshaw

This book provides extensive and critical engagement with some of the most recent and compelling arguments favoring abortion choice. It features original essays from leading and emerging philosophers, bioethicists and medical professionals that present philosophically sophisticated and novel arguments against abortion choice. The chapters in this book are divided into three thematic sections. The first set of essays focuses primarily on unborn human individuals--zygotes, embryos and fetuses. In these chapters it is argued, for example, that human organisms begin to exist at conception and that zygotes, embryos and fetuses are persons. These chapters also explore questions about whether or not zygotes, embryos and fetuses are part of their mothers' bodies. The second set of essays focuses primarily on elective abortion and the debates surrounding it. These chapters consider whether or not opponents of abortion are commonly hypocritical, how opponents of abortion should think about adoption, how emerging technologies may affect the current debate and whether or not those participating in the debate should rely on analogies to support their case. Finally, the third set of essays shifts focus from the legal and moral status of elective abortion to its place in medical practice. In these chapters it is argued that elective abortion embodies a kind of ableism, and that elective abortion is medically unnecessary, harmful to women's mental health and that telemedicine abortion poses significant risks to women's health. Agency, Pregnancy and Persons offers an up-to-date examination of unborn human beings, the debates surrounding elective abortion and the place of elective abortion within medical practice. It will be of interest to medical professionals and those who work in philosophy, bioethics and medical ethics alike.

Prolife theorists typically hold to the claim that all human beings possess equal moral status from conception and consequently possess a right to life. This, they believe, entails that abortion is impermissible in all circumstances. Critics characterize this as an extreme anti-abortion position, as it prima facie allows no exceptions, even in cases of rape. Here, I examine whether the prolife claim regarding equal moral status is compatible with a more attractive moderate stance that permits an exception in the case of rape. I show that Judith Jarvis Thomson's analysis of rights can be used to modify the prolife position in this way, but that doing so involves concessions that prolife theorists are unlikely to find acceptable.

Perry Hendricks’ original impairment argument for the immorality of abortion is based on the impairment principle (TIP): if impairing an organism to some degree is immoral, then ceteris paribus, impairing it to a higher degree is also immoral. Since abortion impairs a fetus to a higher degree than fetal alcohol syndrome (FAS) and giving a fetus FAS is immoral, it follows that abortion is immoral. Critics have argued that the ceteris paribus is not met for FAS and abortion, and so we proposed the Modified Impairment Principle (MIP) to avoid these difficulties. Dustin Crummett has responded, arguing that MIP is open to various counterexamples which show it to be false. He also shows that MIP can generate moral dilemmas. Here, we propose a modification to MIP that resolves the issues Crummett raises. Additionally, Alex Gillham has criticized our appropriation of Don Marquis’ ‘future like ours’ reasoning about the wrongness of impairment. We show that his objections have minimal implications for our argument.

According to the psychological account of personal identity, our identity is based on the continuity of psychological connections, and so we do not begin to exist until these are possible, some months after conception. This entails the psychological account faces a challenge from the non-identity problem—our intuition that someone cannot be harmed by actions that are responsible for their existence, even if these actions seem clearly to cause them harm. It is usually discussed with regard to preconception harms, but in the context of the psychological account, it is also applicable to prenatal harms. Inflicting prenatal injury is widely thought to be morally impermissible, but if the injury is identity-determining on the psychological account, then no-one seems to be harmed—rather, the injury is responsible for bringing them into existence. Here, I argue that identity-determining injuries can routinely occur on the psychological account, and that this undermines the account. I assess Nicola Williams’ proposal to salvage the account based on a trans-world account of personal identity, and show that it is unsuccessful. I then show that Jeff McMahan’s embodied mind account of personal identity is also susceptible. I conclude that identity-determining prenatal injuries pose a significant challenge for the psychological account and its variants, and provide a reason for supporting alternative accounts that fix personal identity at conception.

Opponents of abortion are often described as ‘inconsistent’ (hypocrites) in terms of their beliefs, actions and/or priorities. They are alleged to do too little to combat spontaneous abortion, they should be adopting cryopreserved embryos with greater frequency and so on. These types of arguments—which we call ‘inconsistency arguments’—conform to a common pattern. Each specifies what consistent opponents of abortion would do (or believe), asserts that they fail to act (or believe) accordingly and concludes that they are inconsistent. Here, we show that inconsistency arguments fail en masse. In short, inconsistency arguments typically face four problems. First, they usually fail to account for diversity among opponents of abortion. Second, they rely on inferences about consistency based on isolated beliefs shared by some opponents of abortion (and these inferences often do not survive once we consider other beliefs opponents of abortion tend to hold). Third, inconsistency arguments usually ignore the diverse ways in which opponents of abortion might act on their beliefs. Fourth, inconsistency arguments criticise groups of people without threatening their beliefs (eg, that abortion is immoral). Setting these problems aside, even supposing inconsistency arguments are successful, they hardly matter. In fact, in the two best-case scenarios—where inconsistency arguments succeed—they either encourage millions of people to make the world a (much) worse place (from the critic’s perspective) or promote epistemically and morally irresponsible practices. We conclude that a more valuable discussion would be had by focusing on the arguments made by opponents of abortion rather than opponents themselves.

Perry Hendricks’ impairment argument for the immorality of abortion is based on two premises: first, impairing a fetus with fetal alcohol syndrome is immoral, and second, if impairing an organism to some degree is immoral, then ceteris paribus, impairing it to a higher degree is also immoral. He calls this the impairment principle. Since abortion impairs a fetus to a higher degree than FAS, it follows from these two premises that abortion is immoral. Critics have focussed on the ceteris paribus clause of TIP, which requires that the relevant details surrounding each impairment be sufficiently similar. In this article, we show that the ceteris paribus clause is superfluous, and by replacing it with a more restrictive condition, the impairment argument is considerably strengthened. There are no data in this work.

The 14-day rule restricts the culturing of human embryos in vitro for the purposes of scientific research for no longer than 14 days. Since researchers recently developed the capability to exceed the 14-day limit, pressure to modify the rule has started to build. Sophia McCully argues that the limit should be extended to 28 days, listing numerous potential benefits of doing so. We contend that McCully has not engaged with the main reasons why the Warnock Committee set such a limit, and these still remain valid. As a result, her case for an extension of the 14-day rule is not persuasive.

The development of artificial womb technology is proceeding rapidly and will present important ethical and theological challenges for Christians. While there has been extensive secular discourse on artificial wombs in recent years, there has been little Christian engagement with this topic. There are broadly two primary uses of artificial womb technology—ectogestation as a form of enhanced neonatal care, where some of the gestation period takes place in an artificial womb, and ectogenesis, where the entire gestation period is within an artificial womb. Ectogestation for the latter weeks or months of pregnancy could be possible within a decade or so, while ectogenesis for humans is far more speculative. Ectogestation is likely to significantly decrease maternal and neonatal morbidity and mortality, and so there is a strong case for supporting its development. Ectogenesis, however, may bring a number of challenges, including the commodification of children, and the pathologizing of pregnancy and childbirth. Its long-term effects on those who are created through this process are also unknown. In the event that it becomes ubiquitous, we may also find the central theological significance of pregnancy and birth diminished. The dilemma for Christians is that the development of ectogestation seems likely to normalise the use of artificial gestation, and, in time, pave the way for ectogenesis

Pro-life advocates commonly argue that fetuses have the moral status of persons, and an accompanying right to life, a view most pro-choice advocates deny. A difficulty for this pro-life position has been Judith Jarvis Thomson’s violinist analogy, in which she argues that even if the fetus is a person, abortion is often permissible because a pregnant woman is not obliged to continue to offer her body as life support. Here, we outline the moral theories underlying public health ethics, and examine the COVID-19 pandemic as an example of public health considerations overriding individual rights. We argue that if fetuses are regarded as persons, then abortion is of such prevalence in society that it also constitutes a significant public health crisis. We show that on public health considerations, we are justified in overriding individual rights to bodily autonomy by prohibiting abortion. We conclude that in a society that values public health, abortion can only be tolerated if fetuses are not regarded as persons.

Prabhpal Singh has recently defended a relational account of the difference in moral status between fetuses and newborns as a way of explaining why abortion is permissible and infanticide is not. He claims that only a newborn can stand in a parent–child relation, not a fetus, and this relation has a moral dimension that bestows moral value. We challenge Singh’s reasoning, arguing that the case he presents is unconvincing. We suggest that the parent–child relation is better understood as an extension of an existing relationship formed during the gestational period. The change in this relation at birth is not sufficient to justify the radical change in moral status required to rule out infanticide while accepting the permissibility of abortion. Given that the moral status of orphans is also problematic under Singh’s account, we conclude that Singh has not shown that a newborn has greater moral worth than a fetus.

The debate regarding the role of conscientious objection in healthcare has been protracted, with increasing demands for curbs on conscientious objection. There is a growing body of evidence that indicates that in some cases, high rates of conscientious objection can affect access to legal medical services such as abortion—a major concern of critics of conscientious objection. Moreover, few solutions have been put forward that aim to satisfy both this concern and that of defenders of conscientious objection—being expected to participate in the provision of services that compromise their moral integrity. Here we attempt to bring some resolution to the debate by proposing a pragmatic, long-term solution offering what we believe to be an acceptable compromise—a quota system for medical trainees in specialties where a conscientious objection can be exercised, and is known to cause conflict. We envisage two main objectives of the quota system we propose. First, as a means to introduce conscientious objection into countries where this is not presently permitted. Second, to minimise or eliminate the effects of high rates of conscientious objection in countries such as Italy, where access to legal abortion provision can be negatively affected.

The rapid development of artificial womb technologies means that we must consider if and when it is permissible to kill the human subject of ectogestation—recently termed a ‘gestateling’ by Elizabeth Chloe Romanis—prior to ‘birth’. We describe the act of deliberately killing the gestateling as gestaticide, and argue that there are good reasons to maintain that gestaticide is morally equivalent to infanticide, which we consider to be morally impermissible. First, we argue that gestaticide is harder to justify than abortion, primarily because the gestateling is completely independent of its biological parents. Second, we argue that gestaticide is morally equivalent to infanticide. To demonstrate this, we explain that gestatelings are born in a straightforward sense, which entails that killing them is infanticide. However, to strengthen our overall claim, we also show that if gestatelings are not considered to have been born, killing them is still equivalent to killing neonates with congenital anomalies and disabilities, which again is infanticide. We conclude by considering how our discussion of gestaticide has implications for the permissibility of withdrawing life-sustaining treatment from gestatelings.

Jeremy Williams has argued that if we are committed to a liberal pro-choice stance with regard to selective abortion for disability, we will be unable to justify the prohibition of sex selective abortion. Here, I apply his reasoning to selective abortion based on other traits pregnant women may decide are undesirable. These include susceptibility to disease, level of intelligence, physical appearance, sexual orientation, religious belief and criminality—in fact any traits attributable to some degree to a genetic component. Firstly, I review Williams’ argument, which claims that if a woman is granted the right to abort based on fetal impairment, then by parity of reasoning she should also be granted the right to choose sex selective abortion. I show that these same considerations that entail the permissibility of sex selective abortion are also applicable to genetic selection abortion. I then examine the objections to sex selective abortion that Williams considers and rejects, and show that they also lack force against genetic selection abortion. Finally, I consider some additional objections that might be raised, and conclude that a liberal pro-choice stance on selective abortion for disability entails the permissibility of selective abortion for most genetic traits.

Eric Vogelstein has defended Don Marquis’ ‘future-like-ours’ argument for the immorality of abortion against what is known as the Identity Objection, which contends that for a fetus to have a future like ours, it must be numerically identical to an entity like us that possesses valuable experiences some time in the future. On psychological accounts of personal identity, there is no identity relationship between the fetus and the entity with valuable experiences that it will become. Vogelstein maintains that a non‐sentient fetus nonetheless has a future like ours because it is numerically identical with a future organism that has a mind that bears valuable experiences. Skott Brill, drawing on Jeff McMahan’s embodied mind account, denies that human organisms directly have experiences, claiming that they only have experiences derivatively by virtue of their thinking part, and the loss of a future like ours is not transferred to the organism. I show that on McMahan’s account, a strong case can be made for the organism having experiences directly, and the subject having these experiences derivatively. This negates Brill’s reasoning, although it does imply that non-sentient fetuses do not have a future like ours in quite the same way as we do. I conclude this is not problematic for Marquis’ argument.

Perry Hendricks has recently presented the impairment argument for the immorality of abortion, to which I responded and he has now replied. The argument is based on the premise that impairing a fetus with fetal alcohol syndrome is immoral, and on the principle that if impairing an organism is immoral, impairing it to a higher degree is also—the impairment principle. If abortion impairs a fetus to a higher degree, then this principle entails abortion is immoral. In my reply, I argued that abortion does not impair an organism in the way fetal alcohol syndrome does, and showed that interest theorists can avoid the argument. Hendricks has responded to my criticisms by demonstrating how abortion does impair an organism. In this reply, I acknowledge Hendricks’ point, but proceed to criticise the application of the impairment principle to abortion, showing that it is invalid if we accept his explanation for why inflicting fetal alcohol syndrome is immoral. I also argue that counter-examples show the impairment principle itself to be dubitable, concluding that the impairment argument remains unpersuasive.

Florence Ashley has responded to our response to ‘Gatekeeping hormone replacement therapy for transgender patients is dehumanising.’ Ashley criticises some of our objections to their view that patients seeking hormone replacement therapy (HRT) for gender dysphoria should not have to undergo a prior psychological assessment. Here we clarify our objections, most importantly that concerning the parity between cosmetic surgery and the sort of intervention Ashley has in mind. Firstly, we show Ashley’s criticism of our comparison is insubstantial. We then examine their comments regarding the analogy between abortion and HRT, and the language of informed consent. We also scrutinize the data upon which Ashley relies to defend the claim that informed consent without assessment always yields positive outcomes, finding this conclusion to be overstated. Finally, even if Ashley’s arguments were vindicated, the claim that the gatekeeping of HRT is motivated by hostility towards transgender people remains unsupported.

The substance view is an account of personhood that regards all human beings as possessing instrinsic value and moral status equivalent to that of an adult human being. Consequently, substance view proponents typically regard abortion as impermissible in most circumstances. The substance view, however, has difficulty accounting for certain intuitions regarding the badness of death for embryos and fetuses, and the wrongness of killing them. Jeff McMahan’s time-relative interest account is designed to cater for such intuitions, and so I present a proposal for strengthening the substance view by incorporating McMahan’s account – the Dual-Aspect Account of the morality of killing. I show that it resolves some important issues for the substance view while preserving its central premise of moral equality for all human beings. I then compare the Dual-Aspect Account with McMahan’s Two-Tiered Account of the morality of killing, which he derives from his time-relative interest account.

Florence Ashley has argued that requiring patients with gender dysphoria to undergo an assessment and referral from a mental health professional before undergoing hormone replacement therapy (HRT) is unethical and may represent an unconscious hostility towards transgender people. We respond, first, by showing that Ashley has conflated the self-reporting of symptoms with self-diagnosis, and that this is not consistent with the standard model of informed consent to medical treatment. Second, we note that the model of informed consent involved in cosmetic surgery resembles the model Ashley defends, and that psychological assessment and referral is recognised as an important aspect of such a model. Third, we suggest that the increased prevalence of psychiatric morbidity in the transgender population arguably supports the requirement of assessment and referral from a mental health professional prior to undergoing HRT.

Background: Moral distress can be broadly described as the psychological distress that can develop in response to a morally challenging event. In the context of healthcare, its effects are well documented in the nursing profession, but there is a paucity of research exploring its relevance to healthcare assistants. Objective: This article aims to examine the existing research on moral distress in healthcare assistants, identity the important factors that are likely to contribute to moral distress, and propose preventative measures. Research Design: This is a survey of the existing literature on moral distress in healthcare assistants. It uses insights from moral distress in nursing to argue that healthcare assistants are also likely to experience moral distress in certain contexts. Participants and Research Context: No research participants were part of this analysis. Ethical Considerations: This article offers a conceptual analysis and recommendations only. Findings: The analysis identifies certain factors that may be particularly applicable to healthcare assistants such as powerlessness and a lack of ethical knowledge. We demonstrate that these factors contribute to moral distress. Discussion: Recommendations include various preventative measures such as regular reflective debriefing sessions involving healthcare assistants, nurses and other clinicians, joint workplace ethical training, and modifications to the Care Certificate. Implementation of these measures should be monitored carefully and the results published to augment our existing knowledge of moral distress in healthcare assistants. Conclusion: This analysis establishes the need for more research and discussion on this topic. Future research should focus on evaluating the effectiveness of the proposed recommendations.

Conscientious objection in healthcare has come under heavy criticism on two grounds recently, particularly regarding abortion provision. First, critics claim conscientious objection involves a refusal to provide a legal and beneficial procedure requested by a patient, denying them access to healthcare. Second, they argue the exercise of conscientious objection is based on unverifiable personal beliefs. These characteristics, it is claimed, disqualify conscientious objection in healthcare. Here, we defend conscientious objection in the context of abortion provision. We show that abortion has a dubitable claim to be medically beneficial, is rarely clinically indicated, and that conscientious objections should be accepted in these circumstances. We also show that reliance on personal beliefs is difficult to avoid if any form of objection is to be permitted, even if it is based on criteria such as the principles and values of the profession or the scope of professional practice.

Animal-derived constituents are frequently used in anaesthesia and surgery, and patients are seldom informed of this. This is problematic for a growing minority of patients who may have religious or secular concerns about their use in their care. It is not currently common practice to inform patients about the use of animal-derived constituents, yet what little empirical data does exist indicates that many patients want the opportunity to give their informed consent. First, we review the nature and scale of the problem by looking at the groups who may have concerns about the use of animal-derived constituents in their care. We then summarise some of the products used in anaesthesia and surgery that can contain such constituents, such as anaesthetic drugs, surgical implants and dressings. Finally, we explore the problem of animal-derived constituents and consent using Beauchamp and Childress’ four principles approach, examining issues of autonomy, beneficence, nonmaleficence and justice. Disclosing the use of animal-derived constituents in anaesthesia and surgery is warranted under Beauchamp and Childress’ four principles approach to the problem. Although there exist systemic and practical challenges to implementing this in practice, the ethical case for doing so is strong. The Montgomery ruling presents additional legal reason for disclosure because it entails that patients must be made aware of risks associated with their treatment that they attach significance to.

Joona Räsänen has argued that pro‐life arguments against the permissibility of infanticide are not persuasive, and fail to show it to be immoral. We responded to Räsänen’s arguments, concluding that his critique of pro‐life arguments was misplaced. Räsänen has recently replied in ‘Why pro‐life arguments still are not convincing: A reply to my critics’, providing some additional arguments as to why he does not find pro‐life arguments against infanticide convincing. Here, we respond briefly to Räsänen’s critique of the substance view, and also to his most important claim: that possession of a right to life by an infant does not rule out the permissibility of infanticide. We demonstrate that this claim is unfounded, and conclude that Räsänen has not refuted pro‐life arguments against infanticide.