As a director of a reproductive clinic, you walk into your office Monday morning and are presented with a vexing problem. A couple is six months overdue on their maintenance fees for their cryopreserved fertilized eggs. Do you cancel their "account" and destroy the eggs? If not, are you under an ethical obligation to offer the eggs to an infertile couple who come to you seeking help with conception? If so, are you in essence "selling" the eggs so as to recoup a financial loss or are you safeguarding a (potential) life? As your head spins, you decide your best choice is to get some coffee.
What is life? When does life begin? While seemingly simple questions, these beginning of life questions send convulsions across the U.S. political and social landscape. Although most politicians and citizens shy away from publicly debating these questions, the questions are addressed by medical professionals and potential parents in reproductive clinics across the nation on a daily basis. More importantly, the decisions these people make, such as whether to genetically screen an embryo prior to implantation, shape the answers to these beginning of life questions. Ironically, the decisions made by these people stand to overshadow the controversy raised by the most volatile bioethical issue, abortion.
The purpose of this article is threefold: to place the study of bioethical issues, including abortion, in a curricular context; to provide a conceptual framework to use with students when exploring questions related to the beginning of life and the legal and social implications of these questions; and to offer suggestions on how to select issues and plans for teaching them.
Four reasons compel a study of bioethical issues. Students need to investigate future-related issues and learn how to make predictions about them; to recognize the relationship between ethics/morality and citizenship; to learn how to make informed, public decisions about controversial issues; and to prepare to engage in and encourage public debate on such issues.
Studying the Future Today
Students engage in social studies to learn from the past and the world around them so as to understand the issues confronting them today in order "to carry the ideals of our republic into the future" (National Council for the Social Studies 1994, xix) and to enable them "to see ahead more clearly, and to be ready to act with judgment and with respect for the shared humanity of all ..." (National Center for History in the Schools 1994, 2).
Often lost in social studies is the need to enable students to look and think into the future. Students need experience in making predictions about an issue when there is not one "right" answer but a multitude of them, and when the "rightness" of an answer depends on the perspective one brings to the issue. Just as importantly, the use of predictions enables students to learn to live with the ambiguity and uncertainty of their decisions.
The futuristic nature of bioethics lends itself to prediction making because the beginning of life questions raised by the use of reproductive technology are ones with which society grapples daily. As a result, students are likely to discover "answers" or, more appropriately, societal responses to their predictions during the course of the school year. Bioethical issues also illustrate how technological advances can lead society to perceive an issue as "new," rather than one debated by philosophers for centuries with technology simply adding a new twist.
Linking Ethics and Civics
Abortion is probably the most frequently taught bioethical issue. The abortion issue, however, is usually presented in a narrow social and political framework and in an almost ahistorical manner, with its history traced back only to the U.S. Supreme Court's decision in Roe v Wade (1973).
Teaching abortion through the lens of Roe v Wade permits only a limited, legalistic, peek into this controversial issue, and prevents students from recognizing the issue's true complexity. Decisions about abortion help to determine decisions about diverse but related issues such as whether to perform genetic therapy on an embryo or to criminalize an abortion resulting from an accident with a drunk driver. Whether to perform genetic therapy on a fetus poses difficult ethical questions for a couple and the doctor, while deciding whether to criminalize abortions induced by drunk drivers forces legislators to confront not only the legal but the moral status of the fetus. Failing to allow students to explore not simply abortion but other issues related to the inhibiting and initiating of reproduction cannot help but result in their moral ambivalence about such issues, and therefore in a discomfort about discussing them. The tension between morality and personal choice inherent in bioethical issues illustrates the need for society, and therefore schools, to discuss "the appropriate moral uses of free choice for those who have the legal right to do so" (Callahan 1993, 23).
Preparing Informed Decision Makers
Informed decision making requires not only an understanding of the problem at hand but also an ability to place it in a larger context by drawing connections with related issues. Using an earlier example, a legislator runs the risk of passing bad laws if the question of whether to criminalize a drunk driver's termination of a woman's pregnancy is discussed without reference to state and federal laws on abortion. While public debate typically centers on abortion, public policy questions abound about other beginning of life issues. To illustrate how beginning of life issues are related, stop and contemplate your position on abortion. Now, consider the public policy questions raised by the practices of donor banks in light of your position.
Is a child born of sperm from a "father" who died years before an heir of that man? (A Louisiana court decided that such a child is entitled to the father's benefits.)
Is a donor bank liable for providing defective sperm or for misusing it? (A couple ended up with twins, each with a different genetic father, when a technician failed to properly clean the medical instruments between procedures.) Who is entitled to cryopreserved fertilized ova when a couple divorces? Are the ova potential persons (in which case a custody battle would be initiated) or property (which would require the couple to divide the ova with other assets)?
While these are critical questions, the most important one for educators is whether seniors are ready to make informed decisions about such vexing public policy concerns.
The paucity of public debate on such questions illustrates the importance of preparing students to investigate them. Students will hopefully engage in public discussion about such issues once they feel more comfortable debating them.
Two reasons typically are presented for why abortion and other topics related to the beginning of life are not discussed in school. The first concerns the moral implications of abortion and how such discussion is best reserved for the home. This ignores the connection made earlier between morality and civic life. Few public issues fail to possess at least some moral overtones. Witness the spate of education programs targeted at students, such as those dealing with gang prevention, drug prevention, teenage pregnancy, and conflict management. Imagine the response of students when they confront the irony of how adults desire them to acquire the knowledge and skills necessary to address youth-related problems yet avoid discussion of societal concerns such as abortion and surrogacy.
The apparently irreconcilable nature of abortion is used as a second reason to avoid discussion of it and related issues. When abortion is presented solely as a pro-life v. pro-choice issue, there is some validity in this reasoning. The results of polls indicate that the majority of people personally oppose abortion, but they still support a woman's right to choose. This illustrates that people's thoughts about abortion do not fall so easily into either camp. By failing to allow students curricular time to move beyond this dichotomous view of abortion, this argument becomes a self-fulfilling one that in turn limits their ability to thoughtfully debate other bioethical issues.
Questions related to the beginning of life serve to tie together discussion of actions that inhibit and enhance reproduction. These questions might include the following: What is life? When does (human) life begin? and When does life become a person? The students consider how their response to the questions might influence their stance on actions that inhibit reproduction, such as contraception and abortion, and those that assist in initiating it, such as artificial insemination and embryo implantation.
As implied earlier, there is no "right" answer to any of these questions. The key is helping students understand the questions and learn how to arrive at potential answers to them. Students need to learn the complexity and connectedness of the issues. Because the issues' complexity can seem daunting, teachers need to narrow the focus by addressing case examples of two or three issues. The following example illustrates the types of legal, biomedical, and societal questions raised by the involvement of a third party in reproduction.
Use of a Third Party to Conceive Life
Third-party conception refers to the involvement of three or more people to initiate conception. Examples of third-party conception include artificial insemination and in vitro fertilization. The third party might be a doctor, a sperm donor, an ova donor, or a woman to carry the fetus. Use of a third party raises the following questions:
Legal: What is the status of a cryopreserved fertilized egg? When considering implantation of a fertilized egg, what is the scope of one's personal autonomy?
Medical: What are a doctor's obligations when confronted with a couple who wish to bring a cryopreserved fertilized egg to term for the purpose of a bone marrow transplant?
Societal: What is society's responsibility, if any, toward a fertilized egg that a couple seeks to implant so that they can have a baby for the purpose of a bone marrow transplant?
The first legal questions raise larger ones, including What is life? and What is a person? If life begins at conception, is this fertilized egg life? If so, is it a person under the law? The dilemma confronting the doctor leads one to question the relationship between impregnation/pregnancy and the baby resulting from the act/process. Knowing the reason for the pregnancy and the operation facing the baby-to-be, is a doctor entitled to challenge the couple's decision and to prevent the pregnancy? Finally, does society need to explore what limits, if any, there are on who creates life and under what conditions it is created? Does the fact that impregnation no longer is an act reserved to the bedroom entitle society to consider the creation of life a matter of public morality?
Some readers might dismiss the latter argument, but they should first consider the following. Homosexual relationships are not legally recognized in most states because such couples are unable to fulfill what is portrayed as the societal and moral imperative of marriage, procreation. Because biotechnology now permits a lesbian couple, for example, to bear a child, are the societal and moral barriers to forbidding such marriages now gone? This tangent serves to illustrate both the complexity and connectedness of questions surrounding the beginning of life, but just as importantly, shows how these questions pervade present and future public policy matters.
Although abortion tends to receive public attention because of the act's purpose of termination of a pregnancy, third-party conception poses an interesting dilemma for pro-life advocates because people are trying to create life, not end it. If the technology exists for those who are unable to naturally conceive, why oppose sincere people wishing to create a new life? Where, though, is discussion not simply of the morality and ethics of such action but of the potential life's interest? Contrasting their views on third-party conception with those on abortion enables students to clarify their thinking about the beginning of life issues and moves classroom debate beyond the abortion controversy.
Conceptual Applications beyond the Beginning of Life
Imagine a child in the near future who walks into your class and claims a genetic mother and father, a gestational mother, and a rearing mother and father. The changes wrought by biotechnology require us to reconceptualize seemingly immutable and fundamental concepts, such as family and parent. This in turn requires students to continually explore the ethical, legal, and social meaning of these concepts. Is a family, for example, a social institution designed to provide stability and future generations, as well as to serve as the fundamental unit of society, or is it a contractual relationship between two or more people as witnessed by the plethora of contracts such as pre-nuptial and child custody agreements, property settlements, and surrogate motherhood contracts? Unless we and our students, and society, agree as to the potential meanings of these concepts, public debate on beginning of life issues becomes meaningless.
Students also need to investigate the historical roots of these questions. Religious groups such as the Catholic Church, for example, possess a strong interest in bioethical issues. While the Church's present stance on the beginning of life is well known, one need look back only about a hundred years to find a very different position. What was its stance in the past? What were the reasons for the change? How does the Church's position relate to that of other religious groups? Coming to an understanding of the evolving position of religious organizations on beginning of life issues helps to illuminate today's debate. As educators, we need to guard against allowing the technological side of bioethical issues to overshadow the history behind societies' attempts to provide answers to the beginning of life questions.
Making Instructional Sense
A unit approach best serves students' needs when exploring controversial issues. What follows are some proposed outcomes, a unit outline, and some suggested activities for a unit built around the previously explained conceptual focus.
Unit Outcomes-Students Will:
1.Explain and offer examples of ethical issues raised by beginning of life questions and by the use of technology to inhibit and initiate reproduction.
2.Analyze and evaluate an issue related to the beginning of life in a briefing paper and journal.
3.Analyze the relationship between society, technology, and law in a briefing paper and journal.
4.Demonstrate an understanding of a bioethical issue by presenting an argument from the perspective of an interested party, such as a doctor or theologian.
5.Make and defend a prediction related to the bioethical issue in a journal.
The unit follows a problem-solving approach. Students are presented with a prediction and work to "test" the prediction. Let us assume that students receive the following prediction: Couples will begin to use a form of genetic therapy known as genetic enhancement to enhance the physical characteristics of an embryo.
After discussing the prediction, students consider related issues, such as the appropriateness of determining the genetic make-up of an embryo prior to implantation, and explore how their initial views on genetic enhancement influenced their thinking on these issues. They also identify the people, such as a doctor, politician, and theologian, who might possess an interest in the issue and explore each person's perspective. Finally, after examining genetic therapy in a broader context, students return to the opening prediction and discuss their thinking about it.
The unit consists of six parts: Lay the Groundwork, Research Issue, Synthesize Research Results, Plan Presentation, Closing Performance, and Debriefing. An explanation of each follows, and when appropriate, sample activities are included.
Lay the Groundwork. This part sets the stage for addressing both the genetic therapy prediction and questions related to the beginning of life. Teachers need to desensitize the issue, alerting students to the fact that people hold a variety of opinions and beliefs about the issue. Students need to realize that an informed public debate depends on peoples' willingness to try to understand and respect, though not necessarily accept, other peoples' points of view.
The opening activities enable students to realize that society confronts many decisions once considered futuristic. After discussing the prediction, students turn to the underlying questions, such as when life begins. The activity in Figure 1 allows students to consider several medical points at which life's beginning is possible. As a follow-up, students can be presented with situations that cause them to question their hypothesis about life's beginning. One such situation follows:
Situation 1: You and your spouse wish the best for your future child. You decide to visit a reproductive clinic. The doctor informs you that the clinic is able to use the man's sperm to fertilize the woman's ova outside her body. Then the clinic can conduct a genetic screening of the fertilized ova so as to determine if any serious genetic defect is present. The doctor indicates that if a genetic defect exists, the clinic either can perform genetic therapy to correct the defect or the couple can simply decide not to implant the fertilized ova.
Questions: Would you fertilize ova outside the woman's body? Would you allow the genetic screening? If a serious genetic defect were present, would you allow the genetic therapy? If not, would you implant the fertilized ova?
These situations enable students to raise questions about the scope of an individual's autonomy and society's responsibility in matters relating to life's beginning, and to test the reasoning behind their hypothesis about life's beginning point.
After allowing them time to formulate and apply some initial decisions, introduce students to the range of public policy issues raised by beginning of life questions. Figure 2 illustrates one way to reach this end. The activity allows students to explore an issue from several perspectives.
By making hypotheses about life's beginning and the point at which life becomes a person, students establish a conceptual framework for themselves. These hypotheses become useful as they consider a range of bioethical issues and serve as guideposts for their research on a specific issue. Initially, students' hypotheses about life's beginning will tend to be grounded in their thinking about abortion because this is the issue with which they are most familiar. By studying other bioethical issues in light of life's beginning, students extend their thinking beyond abortion. In this part of the unit, students are encouraged to pose possible answers to beginning of life questions, as well as to consider the implications of the opening prediction.
Given the personal nature of the questions, students might use a journal to express their thoughts about life's beginning and their reaction to genetic enhancement. A journal provides students with a forum to express their personal beliefs without feeling the pressure of their peers. Later activities require students to make public statements about their stance on an issue, but these statements are presented from the safety of a perspective they have chosen. Journals also enable students to trace the evolution of their thinking throughout the unit.
Research Issue. After making their initial journal entries, students engage in a transition activity that demonstrates the range of public policy concerns raised by genetic engineering.
Students begin by discussing what they believe, but eventually move to discussing the societal implications of each action. The discussion might revolve around the question about where society should draw the line. Figure 3 provides a series of actions that can be reviewed. By the end of the discussion, the teacher provides students with a question to consider, such as, Should society permit genetic therapy? If so, under what conditions? Make sure the discussion stays grounded in the beginning of life questions. The discussion helps students to clarify what they need to learn about the issue so as to make a reasoned response to the prediction, thus providing direction for their research.
For the sake of discussion, let us assume that the performance piece entails a presentation to a mock congressional committee on legislation permitting/forbidding genetic therapy. During the research, students work in groups of four or five. Each group chooses a perspective, such as that of a doctor, theologian, special interest, or politician. They conduct research to familiarize themselves with the issue and a medical or political perspective on it.
Synthesis. Once the research is complete, the students discuss their findings and work as a group to craft a "briefing paper," a paper explaining the pros and cons of genetic therapy from the vantage point of the group's perspective. The briefing paper might represent the position of an organization such as the American Medical Association or the National Right to Life Committee. The papers are intended for the students who will serve on the mock congressional committee.
Planning. The teacher selects one member from each group to serve on the congressional committee. The committee members read the briefing papers and prepare themselves to question the presenters. The remaining members of each research group prepare a statement for the committee. Their position is presented from the perspective of a doctor or potential parent, depending on the role they adopt. Through the presentation to the committee, the students seek to convince the members of their position and to answer the question, whether genetic therapy should be permitted or forbidden, in their favor. After completing their statement, students might seek out other groups that are supportive of their position or lobby committee members. While the other groups are planning their presentations, the congressional committee members read each group's briefing paper and prepare questions for the presenters.
Closing Performance. Each group makes a presentation and is questioned by the committee. A useful strategy is to require at least one person to make the presentation while the other group members are responsible for answering the committee's questions. After hearing each student, the committee meets to decide whether to permit or forbid genetic therapy, and to prepare a justification for its decision. If the committee decides on a middle ground, the members need to explain under what conditions genetic therapy is permissible.
Debriefing and Closure. Upon completion of the committee meeting, students debrief the exercise not simply by discussing the presentations but also by exploring how their work ties in with questions about the beginning of life. If one believes, for example, that life begins at conception, does this position require or prohibit a medical procedure that corrects a serious genetic defect? In closing the discussion, students consider the opening prediction about genetic enhancement and determine more feasible and desirable ways to state the prediction. Students make one final journal entry in which they record their thinking about the opening prediction, the beginning of life questions, and the ways their thinking evolved during the unit.
Evaluating Students' Work
During the unit, each student keeps an individual journal, prepares a briefing paper as part of a group, and participates as a group member in either a presentation or on a mock congressional committee. It is possible to assess students' communication, research, critical-thinking, and problem-solving skills, as well as their understanding of an issue. The presentation and briefing paper enable the teacher to consider the following:
Research. How well did students combine information from two or more sources? Were they able to locate sources appropriate for their perspective? Were they able to find an adequate amount of accurate information to support a position on the issue?
Critical Thinking and Problem Solving. How well did the students identify and explain reasonable positions on the issue? How well were they able to select and justify a position appropriate to their perspective?
Communication. How clearly and persuasively did they communicate their positions? How well organized were their written and oral presentations?
While the briefing paper and committee presentation are limited to the genetic therapy issue, the journals offer insights not only into students' thoughts on this issue but also on the larger beginning of life questions. The journal entries enable teachers once more to assess students' critical thinking and communication skills, but more importantly to examine their ability to address a controversial issue in personal terms and to evaluate their own thinking. Given the sensitive nature of the issue, I suggest that the students' journals are not formally evaluated. While it is possible to assess how well they support their thinking with sound reasoning, why evaluate them on how well they articulate and justify their personal thoughts and feelings?
No one aspect of bioethics is paramount. Rather, the preparation of students to engage in thoughtful public discussion of controversial issues is the critical lesson. Just as students need to place abortion in a larger bioethical context, so we need to model and teach students the skills and understanding necessary to place such issues in a broader societal and future perspective. Otherwise, we stand to substantiate the words of concern voiced by Leon Kass:
In the past 25 years, ... our society has overcome longstanding taboos and repugnances to accept test-tube fertilization, commercial sperm-banking, surrogate motherhood, abortion on demand, exploitation of fetal tissue, patenting of living human tissue, ... the deliberate generation of human beings to serve as transplant donors-not to speak of massive changes in the culture regarding shame, privacy, and exposure. Perhaps more worrisome than the changes themselves is the coarsening of sensibilities and attitudes, and the irreversible effects on our imaginations and the way we conceive of ourselves. For there is a sad irony.... We expend enormous energy to preserve and prolong bodily life, but in the process our embodied life is stripped of its gravity and much of its dignity. This is, in a word, progress as tragedy. (Kass 1992, 85)
Kass speaks eloquently of the danger inherent in attempting to address questions concerning life's beginning in amoral and simplistic terms. Moreover, by simply acting on these questions without a corresponding thoughtful public debate about the implications of these actions, we stand to model for students a way to trivialize some of life's fundamental questions.
Callahan, Daniel. "An Ethical Challenge to Prochoice Advocates: Abortion and the Pluralistic Proposition." In Bioethics, 4th ed, 21-35. Mahwah, N.J.: Paulist Press, 1993.Kass, Leon. "Organs for Sale? Propriety, Property, and the Price of Progress." Public Interest (Spring 1992): 67-86.National Center for History in the Schools. National Standards for World History: Exploring Paths to the Present - Grades 5-12. Los Angeles: University of California, 1994.National Council for the Social Studies. Expectations of Excellence: Curriculum Standards for Social Studies. Washington, D.C.: National Council for the Social Studies, 1994.
Joseph O'Brien is an Assistant Professor of Education at the University of Kansas in Lawrence.