When Autonomy Harms

The tension between an individual's right to self-determination and the duty to prevent harm is a defining struggle in bioethics. In this paper, I will present a framework to address the ethical conflict in reproductive decision-making, arguing that the moral duty to prevent serious harm must constrain parental autonomy. Living with Multiple Hereditary Exostoses (MHE), a rare genetic bone disorder marked by recurring tumors and persistent pain, gives me firsthand insight into how inherited conditions can drastically shape a person's world. The thought of having a child brings with it the possibility of passing on this disorder, with a 50% chance of inheritance. This situation raises a significant moral question: In cases involving procreative decisions that determine who exists, how should the moral imperative to prevent foreseeable harm (non-maleficence), particularly the duty to create the least seriously harmed child, be balanced against the perceived permission derived from parental autonomy, given the fundamental challenge posed by the Non-Identity Problem? 

I argue that parental autonomy does not supersede the moral imperative against causing severe, foreseeable harm. Following Elizabeth Harman, I claim that parents have a duty to create not the most advantaged child, but the least seriously harmed one (Harman, 2003, pp. 166, 189). 

To begin my exploration, I will first explain Beauchamp and Childress’s perspective on autonomy, then discuss how Harman’s framework addresses the Non-Identity Problem. Later, entertaining objections based on the Worse-Off claim, and reply that the moral reasons against serious harm are more significant than the benefits of mere existence. 

Beauchamp and Childress’s ethical framework provides a vital lens for unraveling the complexities of reproductive decision-making, with Respect for Autonomy as its cornerstone. This principle champions each individual’s right to think freely, make informed choices, and bring their deepest values and beliefs into action. To be considered autonomous, one must act intentionally, with understanding, and without controlling influences. Crucially, the principle of respect of autonomy is prima facie, meaning it does not automatically take priority over all other moral principles, and is subject to being overridden by competing moral considerations (Beauchamp and Childress, n.d., pp. 64–104). 

The competing moral obligation is often considered Non-Maleficence, which states that one ought not to inflict harm on a person (Emanuel, Wendler, and Grady, 2000, p. 2707). A non-contentious conflict arises when a person’s right to make their own choices could lead to personal harm, yet society allows it because it values autonomy. For example, a competent patient may refuse life-sustaining treatment, exercising their right to choose, even if this decision may not be in their best interest (Brudney, 2018, p. 104). The justification for restricting autonomy typically arises when choices endanger the public health or potentially harm others (Beauchamp and Childress, n.d., p. 104).

The clash between autonomy and the duty to prevent harm grows even more fraught when our decisions shape who enters the world. This creates a dilemma known as the Non-Identity Problem (2003, pp. 149–182), in which a potentially harmful act results in the existence of the individual who suffers the harm. These actions, often reproductive choices, result in the arrival of distinct future generations that would not have existed. 

Harman addresses the struggle to explain the wrongness of particular harmful creation acts if the resulting individuals are not “worse off than they otherwise would have been if the action had not been performed.” (Worse-Off claim) (Harman 2003, p. 152).

Philosopher Derek Parfit’s (1984) “Temporary Condition” case, a woman (Tammy) decides to conceive, fully aware that her child will be born deaf. She has the alternative option to delay conception for two months, potentially resulting in a non-disabled child. If Tammy conceives immediately, the deaf child that comes into existence is not considered to be worse off than if she had waited. This is because the specific child in question would not have existed if she had opted for the delay. Since the child’s life is worth living, person-affecting principles conclude that Tammy’s act is permissible despite the foreseeable harm. 

Philosopher Elisabeth Harman challenges this conclusion by basing moral wrongness not on comparisons of well-being, but on reasons for avoiding harm. This is crucial for prioritizing the duty of non-maleficence over parental autonomy in the context of procreation. 

Before presenting my argument, I will outline Harman’s approach to the Non-Identity Problem. Elisabeth Harman aims to address the NIP by focusing on reasons against causing harm and demonstrating their significance in scenarios where conventional person-affecting principles fall short. The core issue stems from the widely plausible claim: Worse-Off: An action harms a person if it places an individual in a worse-off situation than they would have been in had the action not been performed (Harman, 2003, p. 90). 

She boldly challenges this claim, arguing instead that genuine harm can—and does—occur in non-identity cases, shedding light on why such actions may be morally wrong (Harman, 2003, p. 90). She advocates for a sufficient condition for harm that functions independently of the Worse-Off criterion, proposing that an action harms a person if the action causes pain, early death, bodily damage, or deformity to her, she would not have existed if the action had not been performed (Harman, 2003, pp. 93-107). Harm is assessed by contrasting the resultant state with a healthy body condition, which represents the normal, healthy state of the organism with the species, free from damage, diseases, deformities, or premature death (Harman, 2003, p. 96).

Harman’s definition also covers psychological distress, as in the Teenage Mother case, where insufficient parenting leads to the child experiencing trauma and significant emotional issues. This suffering is regarded as harm, even in the absence of any physical injury (Harman, 2003, pp. 94–96)

Harman’s thesis is anchored in an intriguing principle of moral asymmetry when evaluating moral reasons. She posits that arguments against causing harm are inherently more robust than those advocating for benefits. This insight is key because while bringing a person into existence presents advantages, the reasons opposing harm are “morally serious reasons that are difficult to outweigh” (Harman, 2003, pp. 93–107). Consequently, actions that lead to preventable suffering, like opting to conceive a deaf child when a non-disabled child could be created later (Temporary Condition), are considered ethically wrong (Harman, 2003, p. 94). Even if the positives outweigh the negatives, the positives do not morally outweigh the compelling reasons against inflicting harm when there is an alternative offering similar benefits (Harman, 2003, pp. 92–93). This leads to a fascinating conclusion: we have a moral ground to strive to create the least impaired child we can (Harman, 2003, pp. 104–107). 

I will now defend this view against an objection from the traditional non-identity problem. 

One may object that my argument withstands the classic Non-Identity Problem. The conventional philosophical challenge to the claim that bringing a foreseeably harmed child into the world is wrong rests on the Worse-Off claim.

Given that the decision is to conceive even in adverse circumstances (like the risk of Multiple Hereditary Exostoses) determines who comes into existence, the child born is not actually worse off than they would have been, because they would not have existed at all (Parfit, 1982, p. 113; Harman, 2003, p. 90–91). Consequently, the act can be morally justified if the life created is “worth living.” In most situations, even those lives characterized by significant challenges are deemed worth living, suggesting that the benefits surpass the harms. 

This rationale gains substantial moral strength by invoking parental autonomy (Beauchamp and Childress, n.d., p. 64). If the act does not harm the child when assessed by the Worse-Off standard,  and the choice arises from essential parental autonomy, curbing that decision becomes difficult to rationalize, especially since independence stands as a prima facie value and may only be overridden by compelling contrary reasons (Beauchamp and Childress, n.d., p. 104).

If existence itself is regarded as a benefit that surpasses the harm, it may seem as though parental autonomy cannot be readily overridden by the arguments based on harm (Harman, 2003, pp. 92–97). 

The moral reasons against causing serious harm are pretty challenging to override. The objection rooted in the Worse-Off claim stumbles by misjudging the ethical significance of harm relative to that of benefits in the context of creation. The clash between parental autonomy and the principle of non-maleficence finds resolution when we prioritize the obligation to avert foreseeable harm.

Harman’s asymmetry indicates that objections to harming carry greater weight than reasons to promote benefit (Harman, 2003, pp. 97–107). Although the benefits might outweigh harms overall in a person's well-being, they fail to counterbalance the imperative to avoid causing harm itself morally (Harman, 2003, p. 149). We miss an opportunity to do something good by failing to create a joyful child, yet we do not act immorally (Harman, 2003, p. 142). 

A parental choice that inflicts harm by bringing a child into existence is deemed wrong if an alternative exists that promises parallel benefits without the corresponding harms. In the Temporary Condition, for example, postponing for two months entails minimal inconvenience (a weak argument for immediate conception) and allows for a different child free from disability who can still relish the great benefit of life. As parents can fulfill their desire for a child, both parental joy and the child's existence, without inflicting parallel harm, like deafness (or in my case, MHE), choosing to move forward immediately is ethically wrong (Harman, 2003, p. 127-226)

As we know, the moral imperative is to diminish foreseeable suffering. This hinges on a non-comparative understanding of harm: inflicting pain, premature death, physical injury, or deformity is enough to harm an individual, regardless of their potential existence (Harman, 2003, p. 93-121). This emphasizes the need to prevent predictable harm, which encompasses trauma and severe emotional distress stemming from inadequate support (Teenage Mother case). This principle doesn’t imply that all disability should be avoided; typical creation involves minor unavoidable harms, which are acceptable as they are not severe, and no alternatives exist that wouldn't cause harm. 

I will apply this to a parent who deliberately conceived during a high-risk exposure to the Zika virus, breaches this duty, even if the ensuing child’s life holds value. The act of inflicting harm, like severe deformity or brain injury, is impermissible when the parent has the option to wait until the danger passes. The slight delay does not justify the infliction of serious harm, just as the slight burden on Tammy of postponing for two months is inadequate to excuse causing deafness (Harman, 2003, p. 153, 252, 350). Hence, the duty is not to create a perfectly happy child but to ensure one with the least serious harm. 

Suppose we accept that reasons against harm have a more potent force than reasons to benefit and that the moral duty is to create the least seriously harmed child. In that case, the ethical consequences for biomedical practice are profound. 

This framework provides a nuanced clarification of moral responsibility in reproductive choices, particularly in areas like gene editing and assisted reproduction. It asserts that while parental autonomy is a crucial prima facie principle, it must be balanced with the duty of non-maleficence, creating a framework that honors the right to make decisions regarding one's body (Thompson, 1971, p. 55) while insisting that these decisions prioritize the avoidance of significant preventable suffering in the resulting child. 

Importantly, this perspective avoids the pitfalls of perfectionism and coercive eugenics. The principle that reasons against harm carry greater moral weight than those in favor of benefits underpins this framework, explicitly rejecting the idea that parents should strive to produce the “most perfect,” “most advantaged” child (Harman, 2003, p. 104). It emphasizes the imperative of preventing avoidable serious harm rather than focusing on maximizing genetic advantages. In doing so, it upholds autonomy by restricting moral intervention solely to situations where the risk of trauma, deformity, or damage is evident and preventable (Harman, 2003, pp. 93-107). 

In defending the principle that autonomy must be tempered by the duty to avert serious harm, I will now conclude by reiterating its significant moral implications. 

Reflecting on the profound moral stakes in creation ethics, I conclude that parental autonomy does not supersede the moral imperative against causing severe, foreseeable harm. This stance does not dismiss reproductive freedom; rather, it acknowledges the essential boundaries that arise when core responsibilities intersect. 

Elisabeth Harman’s insightful framework addresses the dilemma of the Non-Identity problem (Harman, 2003, p. 90) by anchoring our moral obligations not in the conventional “Worse-Off” argument, but in the notion that reasons against causing harm can carry greater weight than those aimed at providing benefits (Harman, 2003, pp. 97–107). By framing harm in non-comparative terms, I argue that causing avoidable suffering is inherently wrong, even if the life that results is deemed “worth living.” In this way, we promote both compassion and moral integrity, focusing on our ethical responsibilities to minimize suffering while rejecting the oppressive logic of eugenic perfectionism.

References

Beauchamp, T. L., & Childress, J. F. (n.d.). Principles of biomedical ethics. Oxford University 

Press.

Brudney, D. (2018). Choosing for another: Beyond autonomy and best interests. In S. J.

Youngner & R. M. Arnold (Eds.), The Oxford handbook of ethics at the end of life (pp. 103–117). Oxford University Press.

Emanuel, E. J., Wendler, D., & Grady, C. (2000). What makes clinical research ethical? JAMA, 

283(20), 2701–2711.

Harman, E. (2003). Can we harm and benefit in creating? Philosophical Perspectives, 17, 

89–113.

Parfit, D. (1984). Reasons and persons. Oxford University Press.

Thomson, J. J. (1971). A defense of abortion. Philosophy & Public Affairs, 1(1), 47–66.