The birth of a child is a moment in time that parents cannot forget. The child may be born on his or her due date, a couple of days later, or even weeks early. Prior to this date, many decisions involving tests must be made. One test reveals whether a woman is pregnant, another test reports the gender of the child, and yet another test can determine whether the child will be born with a chromosomal abnormality, such as Down syndrome. Having or not having these tests is a parent's right, and learning the results of these tests causes a person to make decisions that may have ethical implications. Learning the gender of the child may assist in deciding on a color to paint the nursery, but learning that the child will be born with Down syndrome requires those involved in the pregnancy to make other decisions. In this paper I focus on the decision-making process from two distinct theories of moral development: the ethics of justice and care that were originally hypothesized from a gender perspective (Flanagan & Jackson, 1992; Nunner-Winkler, 1992).
Kohlberg's (1976) theory, the ethic of justice, is comprised of stages of moral development. These stages were developed from the results of a study in which 84 men were interviewed. The interview consisted of a hypothetical moral dilemma. The participants were asked whether the person did the right thing in the situation. From these men's responses, stages of moral development were identified. The underlying theme of the stages is laws and rules.
Gilligan challenged this theory and criticized its stages because they were developed from a sample of males only. Gilligan (1977) published a study where 24 pregnant women who were considering whether or not to terminate their pregnancies were interviewed. From these women's responses, another theory, the ethic of care, and its stages was developed. The underlying theme of these stages is relationships. The stages from both theories are compared in Table 1.
Deciding to have a prenatal screening test to detect any possible chromosomal abnormalities and later acting on the results of the test involve moral decisions. The person making these decisions may be influenced by their own moral development or the moral development of others. Helm, Miranda, and Chedd (1998) asked 10 mothers who had decided to continue with their pregnancy after learning that their child would be born with Down syndrome to describe pressures their physician had placed on them. Of the 10 mothers involved in this study, 4 of their obstetricians had negative attitudes regarding carrying the fetus to term. One mother was told that when she realized that she was carrying a child with Down syndrome, she would change her mind. Another physician requested that one expectant mother talk to her husband after the woman stated she would not have an abortion. A third mother was asked when she would like to schedule termination of the pregnancy. The fourth mother was told by her physician that in the field of medicine, these fetuses are aborted. These examples demonstrate how an other, in this case a physician, operating from the ethic of justice may attempt to influence a person who may make decisions based on an ethic of care.
A woman who is carrying a fetus with Down syndrome has options (e.g., terminate, continue the pregnancy and raise the child, or have the child and place him or her up for adoption). Genetic counseling is yet another option. The counselor, however, may or may not have current information regarding having a child with Down syndrome. For example, one parent received a pamphlet from her physician that referred to persons with Down syndrome as mongoloids (Helm et al., 1998).
Ethical arguments have been made for and against the selective abortion of fetuses with Down syndrome. Arguments for aborting such fetuses include benefits to the mother and family, benefits to society because aborting fetuses with Down syndrome will eliminate defective genes from the gene pool, reduced financial burdens on society, selective abortion as preventative medicine; increased quality of life of the family, and right of every fetus to be born healthy (Pueschel, 1991). All of these arguments can be linked to an ethic of justice perspective because they relate to societal rules and laws that allow this practice.
Arguments against the selective abortion of fetuses with Down syndrome include the following: abortion may complicate further pregnancies; some expectant mothers state that they would not even consider any prenatal screening because they would have their child regardless of any prenatal screening result (Helm, et al., 1998); the belief that all persons are beneficial to society; and parental opinion that because intelligence is not a valid measure of human potential, people with Down syndrome (and people with other types of mental retardation) should be given the opportunity to live to their fullest potential. The ethic of care relates to these arguments because the decisions involve relationships between the decision maker and the fetus. The ethic of justice theory cannot address what is right given these arguments because the issues do not relate to rules or laws.
Glover and Glover (1996) raised some ethical considerations. One consideration is, why is it right to abort a fetus with a chromosomal disorder at a point in the pregnancy where, if the fetus were healthy, the abortion would be illegal? Another ethical consideration regards how the quality of life of the family may be different by having a child with a disability. To respond to the latter consideration, parents have stated that they would not be the people they are today had they not had their child with a disability because their child has taught them about life and has given their lives meaning.
A person's choice of action may be influenced by the theory of ethical decision-making to which they ascribe. Theories of ethical decision-making are founded in the philosophical notion that people are moral and people's morality varies. Variations in morality are referred to in the literature as stages of moral development. Kohlberg and Gilligan have proposed the two most prominent theories and stages of moral development.
Examining the six stages of the ethic of justice and considering how people at Stage I (punishment and obedience) make moral decisions, the decision makers would choose whether or not to abort the fetus knowing whether the act would end in punishment. If therapeutic abortion is legal in a state, the decision would not end in legal punishment; however, from some religious aspects, the decision makers may find the act to be inconsistent with their beliefs and that the act will end in a form of punishment. A person at the second stage (instrumental exchange) may choose to have or not have the child based on the thought that this decision may give them something they want. For example, the decision maker may want to have a child regardless of the presence of Down syndrome. A person may also make their decision based on the desire that they want a “healthy” child, so they might abort a fetus in order to try again. The third stage of moral development (interpersonal conformity) is to do what one is expected to do. Is the woman expected to terminate or continue the pregnancy according to society? The fourth stage (social systems and conscience maintenance) considers whether having or not having the fetus is best for society. A decision may be made from the fifth stage of the ethic of justice (prior rights and social contract); however, a decision at this stage is neither black nor white. Decision makers at this stage follow society's rules as they realize that laws are to protect the rights of all. The person may understand that they could have an abortion because laws allow them to do so, or the person might not have an abortion because of an understanding that society accepts all people. The sixth stage of moral development (universal ethical principals) is the one stage that does not fit this discussion. As a commentator on Kohlberg's work stated, the last person who operated from the sixth stage was Gandhi.
Examining the stages developed from an ethic of care theory, a decision maker at the first stage (caring for self) understands that the right thing is that which ensures survival of the self. These survival decisions may be medical, emotional, relational, and/or financial. All of these aspects have the potential to influence the survival of the mother. If the decision maker, the expectant mother, is at the first transitional stage (from survival to responsibility), she will consider how the decision affects others. At this stage, the mother is still centered on her own survival; however, she begins to consider how her decision might affect an other (i.e., the fetus). A decision at this stage ultimately is based on survival. If an expectant mother is at Stage II (caring for others), she will do what she feels is best for the other. The woman would make her decision based on what she feels is right for the fetus, regardless of how the decision affects herself. She might feel that it is unfair to bring a child with Down syndrome into the world, or she may feel that the right thing to do is to give birth and raise the child. A decision maker at the second transitional stage (from goodness to truth about relationships) will make a decision based on what the person honestly feels. If an expectant mother truly feels that the right thing to do is to not have the child, then she is right from this stage. If the mother is honest and truthfully does not feel that denying life to a child with Down syndrome is right, then the right thing to do from this stage would be to continue with the pregnancy. A person at the third stage of moral development (caring for self and others) will consider the effect the decision has on both the self and the other. A decision might be viewed as being very selfish or selfless, depending on whether it is based on survival or on what is best for the other. What distinguishes a decision at Stage III from the other stages is the decision maker's consideration of how the decision affects both the self and the other.
Two theories of moral development and their stages have been presented. These theories were individually developed from samples of both genders; however, later studies suggest that men and women use both theories when facing moral dilemmas, but men tend to use justice and women tend to use a care perspective (Gilligan & Attanucci, 1988). This finding is important to remember when physicians report the results of prenatal tests and moral decisions need to be made.
Author:Craig Rice, EdD, Providence College, Education Department, 315 Harkins Hall, Providence, RI 02918. ( Crice@providence.edu)