Any discussion of genetic engineering leads naturally to questions about what are the rights of people to benefit from this work. Present-day medical practice is loosely founded on a generally accepted, but often unstated right of all persons to live healthy, normal lives. There are two possible ways of viewing this right. One is to suppose that everyone ought to have the best possible medical and genetic treatments available to bring that person's individual health to an optimal level. A second is to conclude that the human race as a whole should be brought to an optimal health. The danger in the latter approach is that it may also lead to mandating that "undesirable" persons have no right to live.

Improving the human race as a whole through a program of selective breeding and the elimination of those considered undesirable gained great popularity in the early third of the twentieth century under the name of eugenics. The acceptance of this idea was enhanced by the way in which it fit the prevailing model of evolutionary progress. There was great optimism that the human race could take control of its own evolutionary destiny this way, and few voices of concern were raised for the consequences. By the time World War II started, Hitler's program of eugenics was already well under way in Germany, but it was not until the war was over that the horrifying consequences of arbitrarily defining who is acceptably human were seen. State-run eugenics has been anathema ever since, but new medical techniques now mean that individuals could practice a more personal eugenics for their offspring. This apparently attractive option still has the same potential negatives, however, and it would not do to lose sight of those in some euphoric optimism that a new age is dawning for the human race.

On the one hand, selection and modification, as well as effective means of birth control, could well do away with the demand for abortion and infanticide. This would be beneficial for all concerned--child, mother, family, and society. On the other hand, those born before or without the benefit of genetic selection, or whose abilities came to be regarded as inferior would be at a disadvantage. Their genes would not be the latest models. In addition, long life spans will not necessarily solve the problem of caring for the old, who might need more rather than less medical care. A future society could become so obsessed with obtaining and maintaining genetic perfection that individuals of any age who were perceived to fall short could simply be discarded. The state now can permit death at the request of a sufferer--"pulling the plug" on someone who wishes to die in peace. As with other issues, the state that can permit a death can easily assume the power to require the same death. If it has the power to allow certain lives never to develop past the point of discovery of some physical deformity, then it might also claim the power to deny life to any individual for any defect, including economic, political, racial, and religious ones.

Pressures on the medical system lead to questions about when it is appropriate to deny medical treatment. Likewise, economic and demographic pressures conspire to persuade people to limit new life, and abortion or infanticide are used where birth control has not been employed successfully. In addition, the continued existence of humans with limitations caused by genetic defects, accidents or even old age is threatened. All the issues involving life itself are difficult ones; even where the individual involved makes the choice.

What should a physician do when a terminally ill patient facing painful treatment asks the doctor to withhold further treatment in order to allow a relatively peaceful death? This is a difficult question. Free will and freedom of choice are argued in favour of the patient's freedom to make that choice. Yet, some would say, the doctor is in the position of deciding whether to become an accomplice to suicide. If a woman was about to jump to her death from a bridge, a passer-by would be expected to intervene, to attempt to prevent the suicide, or to call for more help. Most involved would exert themselves in the cause of life, not being willing to give up until she actually jumped, and even then launching an extensive search of the water below in case she lived. If she were to survive, every resource of the medical establishment would be brought to bear to save her life, restore her body to functionality, and provide the necessary counselling to ward off another such attempt on her own life. Shall a doctor do less in the treatment of other patients? If not, what is the essential difference between the two situations, and who decides when that difference exists? Is it more humane to allow an escape from suffering for those who desire it? Or, is the desire to escape from life prima facie evidence of lack of competence, which should therefore be ignored?.

These questions have already been resolved, in the West's legal and medical systems at least. Living wills, in which the testator dictates a do not resuscitate order for extreme eventualities, are now accepted and acted upon in most jurisdictions. However, this has taken place without much debate, and it seems to have escaped the notice of most that if a state has the power to permit a practice, it also has the power to require it.

Some utilitarians who focus on the money issues, and some proponents of a right to die argue that death in terminal illness should be made quick and easy. Some act-ethic moralists would condemn this conclusion, pointing out that cures might still be possible, and suggesting that participating in another's suicide is not different from murdering the person. One possible conclusion that a consensus moralist could come to is that if the majority of, say, inoperable cancer patients wanted to die, they all should. If this conclusion seems stark, consider a single paralysed patient whose doctor has already participated in assisted suicides in similar situations. It would not be difficult in such circumstances, especially with the permission of anxious heirs, to have the patient declared incompetent and then argue that if the person were able, she would want to die, and therefore must do so. Indeed, such a decision may seem quite utilitarian. A society that had already allowed assisted suicide would have little motivation to enquire about such deaths, and perhaps not much to care about them either.

Such decisions can be even more difficult if a second condition exists that will kill the patient anyway and the (possibly expensive) treatment would only postpone the apparently inevitable. This issue was discussed earlier in the chapter without the complication of the patient's own request for death. When simultaneously faced with such a request as well as a waiting list of patients who can be treated more inexpensively, the pressure to allow or require death increases. There must, some would argue, be some limit on paying for extending the lives of the terminally ill. That there are such limits cannot be disputed. What is in question here is the degree to which active intervention in allowing or encouraging death should be tolerated. Even the most enthusiastic spenders realize that economic considerations ultimately force many life-and-death issues, even if these may be hidden in government appropriations measures and seen as entirely political in nature. It is therefore part of the challenge for new medical technologies to remove as many of the limitations as possible to the extension of productive life, making it cheaper and easier to achieve year by year.

The opposite problem may also arise, for in some cases the technology is available to save the life of a patient, but treatment is refused, perhaps for religious reasons. The doctor, the hospital, the law, and the state must in such cases decide whether the extension of a patient's life is to take precedence over that patient's beliefs. The difficulty is particularly acute when the patient is a child, and it is the parents who are refusing medical treatment. In the case of religious sects refusing blood transfusions for children, the courts have sometimes stepped in and ordered the treatment over those objections. Would they do so for someone old and infirm? Parents have also in some cases been charged with manslaughter when they have refused to seek medical help for life-threatening conditions and allowed a child to die. In other cases, the opposite is done, and permission to rely on such alternatives as faith healing is explicitly written into the laws of some states, with such parents being protected from prosecution.

In either type of situation, the hierarchical ethic of Chapter 3 would insist on the primacy of life, and the making of every reasonable effort to preserve it. However, there would be many who would not accept such an ethical framework and would arrive at the opposite conclusion. The problem for a utilitarian, for example, would be to decide whether there is more good in preserving one life, or more good in alternative uses of the same medical resources. Limits are bound to be reached in some cases, and it may be necessary to force treatment in others, but great care must be taken in making life and death decisions for other people without their personal and informed consent; for the right to life is the most fundamental of all.

As already suggested, similar considerations apply to the terminally ill who cannot themselves request a quick death because of a coma or some other circumstance. Proponents of euthanasia would put such people out of their misery, much as they would compassionately shoot a dying horse. They reason that while perhaps extending life might be good, supplying a pain-free death is better. Given the reality of pain and the other pressures cited above, this argument cannot simply be dismissed. An ethical absolutist, on the other hand, is likely to draw the line at "relative good" when it comes to life and death issues. As long as there is any hope, this argument goes, the patient should be kept alive, even at great cost. To the absolutist, death may be an enemy to be fought with all available resources, and its victims to be sorrowfully mourned as casualties in a war. Paradoxically, many religious persons who hold this position believe death to be a release to a new and better kind of life--to be welcomed--even while being fought against as an enemy.

One of the major difficulties with any policy that allows such deaths to be administered has already been mentioned--what the state can once allow, it can at a later time require. People who support the voluntary euthanizing of the aged may one day find the process forcibly applied to them too, for reasons could be found for declaring almost anyone an undesirable or an incompetent.

It was for similar absolutist reasons that in the early days of the Church, Christians collected unwanted infants who had been abandoned by their parents to die of exposure, even though the rescuers then suffered being accused of killing and eating the children they rescued. The Christian view of the sacredness of life prevailed, and for centuries after, infanticide was close to unthinkable--an act that evoked universal moral outrage. In this century it has become respectable again. For instance, at issue at the moment is whether severely damaged or impaired newborns should be left to die without food, water, and treatment, or whether they should be provided with extensive, painful, and costly attention to allow them to live. In China of the 1980s, infanticide was reported to be widespread after the government decreed that couples could have no more than one child. Boys were more desirable than girls, so many female infants were killed. Population pressures as well as political, economic, and racial considerations are potential factors in deciding which infants shall live or die. These have already been decisive in liberalizing the availability of abortion, and it is surely an arbitrary legal fiction to say that a child situated at one end of a birth canal is disposable tissue, and at the other end is a protected human. All the same arguments that allow abortion can therefore be brought to bear on newborn infants, or on children of an older age, or indeed on adults.

While this issue will not go away soon, one major contribution of the new medical technologies may be to render it moot. The goal is to remove from the genetic pool the causes for severe birth handicaps, but it will not be achieved soon, and in the interim there are likely to be renewed calls to do away with "defective" infants and a new insistence that no life at all is better than one lived impaired. Again, ethical absolutists will oppose any such policy, insisting as always that the quality of life is not pre-judgeable or even knowable in another, and that it is a lesser ethical consideration than life itself.

The practice of abortion also generates many issues not likely to be settled soon, and it is one on which the medical profession has done a complete about-face in recent years, switching from a long standing view of an unborn child as a patient, to that of it as a disposable appendage of the mother. The debate is sometimes couched in terms of the mother's right to privacy with respect to parts of her own body versus the right of an unborn child to life itself. The mass of cells that will become a child cannot, with current technology, be separated from the mother and live, and in this sense is a part of her. On the other hand, these cells are genetically distinct from her even at the point of conception, and there is therefore a sense in which even the first cell is not part of her body at all. Some regard a particular demarcation point (e.g., end of first trimester) as the start of a distinct human life. To others, any boundaries are purely arbitrary. What is really in dispute is the point at which full human rights ought to be accorded--at birth or at some prior time. Or, do the rights grow gradually with the developing child, and does the ratio of these rights to those of the mother change from zero at first to equal at birth? Does equality come at some earlier time, or at some later time?

Proponents of a women's right to an abortion on demand consider the procedure to be a cheap, safe, and effective way of ensuring that only wanted children are born. Opponents point to the right of the child to life, and also claim abortion to be both physically and psychologically threatening or damaging to the health of the woman. Furthermore, they consider abortion to be reckless of human life in general, and to be murder of a child in particular.

New technologies may enliven the abortion debate even more, for it is possible sometimes to save infants born prematurely at a stage earlier than many others who are aborted. Two surgeons can work side-by-side on two pregnant women, each the same number of months past the point of conception, with one performing an abortion and the other delivering a premature baby. As the ability to live outside the womb (with technological help) is pushed back closer to the point of conception, the medical establishment in particular, and society in general, faces an ethical problem whose difficulty is increasing with time and with the availability of new life-saving techniques. As a result, arguments about the point at which life begins become increasingly irrelevant and the abortion issue becomes more an ethical and political one. That is, the answer to the medical and scientific question "From what point is an unborn child alive?" is now obviously "from conception", so it is now the economic and political question "From what point is an unborn child human?" that has become the central issue, and North American courts have now answered "not until birth". As we have seen, however, this answer itself raises new questions about what can or should be done to (for) the child before it takes its first breath of air.

New techniques may also take all of the risk out of having an abortion, as they will for many other surgical procedures. It may even become possible to reverse the sterility that is a an occasional side effect. Furthermore, it has already been noted that there will be a tendency to reduce birth rates in the face of increased life spans and to exercise quality control over births as this becomes possible. Three points are worth making:

First, it is not yet possible to discern what are the very long term effects on total population of combining increased longevity and declining birth rates. In developed (and nearly developed) countries, the birth rate is below replacement levels. This would argue for an eventual population decline,except that any substantial longevity increase would overwhelm this trend. Indeed, increased longevity is the main reason for the world's population increase over the last century. It may be over the next as well. Thus, current methods of birth control may be either already more effective than necessary, or woefully inadequate to control population. It is too soon to tell.

Second, abortion-inducing drugs have already been produced. Recent history would suggest that religious protests over such drugs will have no effect on their marketing. Thus, although it may take some time to sort out potential side-effects, it will only be a matter of time before these are available worldwide. The significance of these drugs is that they have the potential to take the matter of abortion out of highly visible hospitals and clinics and make it a decision that can be undertaken entirely in private. Thus, there would be no specific targets to protest against once the sale a drug was approved. In view of the fact that ever fewer doctors are interested in doing abortions, drugs may eventually become the only means of providing them--yet another example of the scarcity of medical resources forcing the adoption of non-surgical procedures (whether one likes the outcome or not).

Third, the technologies considered in this chapter may also be capable of producing cheap and efficient conception control agents for men or women that the state could widely disperse and then require a licence to obtain the antidote. There are several ways in which this could be done. The simplest might be a drug that could cause sterility even in very low doses. Another possibility for the genetic engineer might be a communicable virus like those that cause common colds that would be capable of preventing conception without causing any other symptoms. Since several research teams could build variations on one or both of these themes, it might be expected that at least one of the sponsoring governments involved would release the agent. An antivirus might be as easy to produce, but the opportunity to control it and regulate population would likely be seized upon by most of those involved. After all, it is difficult to imagine some types of government passing up the opportunity to regulate population growth absolutely. Such a development and deployment would imply extensive and intimate control by the state over the lives of citizens, but such things do have a way of coming about, even in Western democracies.

Another way to regulate population growth would be to include a sterilizing agent in longevity drugs, or to package sterility and longevity antidotes together. There would have then to be a strong incentive in order to have children, for they would cost parents potential life span. Abortions would cease almost entirely if an enforceable conception licensing scheme were devised. While this might remove some of the population pressures caused by longevity, it would simultaneously change the whole structure of society by cutting off renewal, all but eliminating the family, and promoting a long-term status quo. Could such a scheme be enforced if it were to become technically feasible? It seems likely that an antidote to the agent would quickly become available on the black market--perhaps even supplied by foreign governments bent on destabilizing a country by increasing its population. Moreover, given the record of the West on control of now illicit drugs, it seems hard to imagine the pharmaceuticals suggested here could be so tightly controlled as this. The net result on population could be neutral with the single exception of eliminating unwanted births and therefore removing most of the desire for abortion.

Such a technological "fix" seems to be unsatisfying, but the alternatives are unclear. Neither unlimited population growth nor unlimited abortions are politically, economically, or ethically desirable. The population question must therefore be left unresolved with a technical answer only intimated.