Disability rights advocates sometimes claim that prenatal tests to select against disabilities discriminate against people with disabilities. The “expressivist argument” that supports this position has been challenged on grounds of the difference between fetuses and born persons. In this essay, I explain why the expressivist argument is valid despite the questionableness of its conclusion, and why the distinction between fetuses and born persons fails to provide an adequate counterargument to the expressivist conclusion. I also consider a compelling argument for prenatal testing to select against disabilities and propose a reformulation of this argument that, I think, supports prenatal testing for disabilities while avoiding discrimination against people born with disabilities.

In my previous thinking about the considerations that go under the heading of the “expressivist argument,” I have been fascinated chiefly by two of its features: its (implicit) semantic commitments and its independence from disputes about the moral standing of fetuses. Abortions prompted by prenatal testing are undertaken because of indications that the fetus has physical features that would be configured as disabilities in the social world into which it would otherwise emerge. The expressivist argument's allegation, as I have understood it, is that abortions so motivated convey semantic content—“send a message”—to people who are currently living with disabilities that is somehow insulting, hateful, dismissive, or disparaging. It is thus uncontroversial moral subjects who are wronged, not—or, at least, not necessarily—the aborted fetuses. So far as this argument goes, a person might hold strongly pro-choice views about abortion generally and still object to “selective” abortions.

This section is meant to be a mutual effort. If you find an article you think should be abstracted in this section, do not be bashful—submit it for consideration to feature editor Kenneth V. Iserson care of CQ. If you do not like the editorial comments, this will give you an opportunity to respond in the letters section. Your input is desired and anticipated.

It is gratifying that thoughtful philosophers and bioethicists like Mahowald and Nelson are continuing to address the objections to prenatal testing that have been made by disability scholars and advocates. But it is frustrating to see those objections presented in ways that reflect the doubts of those who reject them more than the intentions of those who make them, in ways that make those objections appear censorious toward pregnant women and prospective parents or naïve about nonverbal expression. We recognize that disability critics share the responsibility for these misunderstandings, that their objections to prenatal disability testing have not always been made as clearly or consistently as they might have been. We therefore welcome this opportunity for clarification and rebuttal. Briefly, we will argue against Mahowald that it is not apparent how prospective parents could have a duty to potential offspring requiring them to prevent the birth of any child expected to have a life worth living. And we will remind Nelson that our primary concern is with the perpetuation of stigma; that even if any reason for abortion can be framed in terms of a trait of the fetus to be aborted, only certain reasons for abortion are based on the rejection of future children because of stigmatized traits.

In the portion of their reply directed to me, Professor Asch and Dr. Wasserman helpfully develop the synecdoche argument by highlighting its connections to stigma. I understand them to distinguish the situation of a woman making a decision concerning her pregnancy informed by prenatal testing from a woman making a similar decision informed by considerations of, for example, poverty, like so: In testing contexts, it will characteristically be the case that the woman's decision will be distorted by the stigma associated with impairment: She will consider only the fact that, should her pregnancy come to term, the child would be impaired; she will not be able to attend in a satisfactory manner to a fuller range of possible features, both good and bad, that may characterize the child's life and her experience of being the child's parent. The woman considering whether to terminate her pregnancy due to, say, poverty will, in contrast, typically be able to deliberate in ways more responsive to a broader range of relevant matters, as the possible child's poverty will not be the only thing she is in a position to take into account about her or his life and their life together. Further, even where poverty or some other factor influencing decisions about terminating or continuing pregnancy are stigmatizing, they are not as thoroughly stigmatizing as are impairment-related conditions, due to prevalent confusions about the immutability of traits seen as biological rather than social.

We are gratified by Nelson's response to our commentary. It shows, for the first time, an appreciation of the distinctive character of our criticism of individual decisions to test and terminate for fetal impairment. Although we still find much to disagree with in Nelson's characterization and critique of our views, he has given us a welcome opportunity to clarify and develop them.

Developments in the last several years have sparked renewed interest in the ethics of research involving humans. Issues relating to the global extent of research and its guiding principles are of particular importance to researchers, health officials, and individual ethics committees who want a deeper and more encompassing inquire regarding the foundation and evolution of human research. This department of CQ launches a long overdue effort to explore these wider issues. Readers are invited to submit papers to Charles MacKay, 5011 Worthington Drive, Bethesda, MD 20816, USA. E-mail: [email protected].Without intending to suggest their endorsement of my arguments, I wish to thank my colleagues in the CTRG group and two anonymous referees. This work was funded by the Canadian Institute of Health Research.

Sick: The Untold Story of America's Health Care Crisis and the People Who Pay the Price, by Jonathan Cohn. New York: HarperCollins, 2007. 302 pp. $25.95.

American healthcare reform has rather suddenly become, at least in political terms, sexy. Traditionally, healthcare has been a third rail of policymaking that few dare touch, but elected and aspiring officials at all levels are now proposing remedies to the chronic issues of the cost, quality, and, especially, lack of access to care. Not since the Clintons' well-intended but spectacularly sabotaged and unsuccessful 1994 attempt at sweeping reform has the issue been so prominently discussed.Readers are invited to contact Greg S. Loeben in writing at Midwestern University, Glendale Campus, Bioethics Program, 19555 N. 59th Ave., Glendale, AZ 85308 ([email protected]) regarding books they would like to see reviewed or books they are interested in reviewing.

(A previous version of this review appeared in the San Francisco Chronicle 10 May 2007.)

This section is meant to be a mutual effort. If you find an article you think should be abstracted in this section, do not be bashful—submit it for consideration to feature editor Kenneth V. Iserson care of CQ. If you do not like the editorial comments, this will give you an opportunity to respond in the letters section. Your input is desired and anticipated.