Accutane Ethics

My son has been taking Accutane for the last several months.  Boy it works well (for acne).  It also raises some first class ethical questions.  There's an extremely strict regimen for taking Accutane, because apparently if a woman takes it and conceives a child, the child will likely be born with significant but not super-serious abnormalities. For example, the child's external ears may be malformed.  As a result of this (and for other reasons), patients taking the drug have to see a doctor every 30 days. Women have to promise to use two forms of birth control while using the drug. Every time you break the seal on a pill, you see a warning about avoiding pregnancy.  The assumption behind all this is that it would be wrong or bad to conceive a child with malformed ears, when you could easily wait just 6 months (the usual course) and conceive a child with normal ears.  Of course it would be wrong or bad!

But maybe ... (Note: I truly love the Louis C.K. "Of course...but maybe" routine.  Do watch if you haven't seen it.  Start at 34:00.)   Enter: David Boonin's new book The Non-Identity Problem and the Ethics of Future People, reviewed here by Molly Gardner. At least in the review, the focus is on a slightly different sort of case.  Boonin contemplates Wilma, who can either conceive now and have Pebbles, who will be blind but will have a life worth living, or take a pill for two months and have Rocks, who won't be blind.  Boonin embraces the argument that concludes it wouldn't be wrong to conceive Pebbles. Here's how it goes--

According to Garnder, Boonin's book looks at all sorts of ways of rebutting this argument and finds them all wanting.  So we should just accept the conclusion. It really wouldn't be wrong to conceive Pebbles.

There's an Accutane version of the argument, and I would rather see that be the focus for two reasons. First of all, Wilma and Pebbles are just cartoon characters--literally.  These issues have a different feel when they come up in real life.  Thousands of women are right now considering whether to heed their doctors' warnings about conceiving while taking Accutane.  It's easy to give Wilma the green light to conceive Pebbles, but surely not so easy to give a real woman the green light to conceive on Accutane.  I'm not sure we're thinking seriously about these things until we're thinking about real people's decisions.

The Accutane version is more real world-ish, and also has some parameters that may make a difference to our intuitions.  In the Accutane scenario, a drug causes the undesirable features--the malformed ears. In the Wilma scenario, a drug causes the desirable features--sight, rather than blindness.  Unconsciously, what might make someone accept (C) in the Wilma argument is the intuition that nobody has to go out of their way, taking special drugs, to have a "better" child.  It might not really be that the conclusion gains whatever plausibility it has from the argument's explicit premises.

So let's look at an Accutane scenario. Mary is thinking about ignoring all the warnings and conceiving in July while taking Accutane. If she does so, she'll have a baby we'll call "July"--a baby with malformed external ears. If she waits until she's finished taking the drug, she'll have a different baby we'll call "December," one with normal ears.  Is it wrong to conceive July?  The argument parallel to the Wilma argument would go like this:

Now that we're talking about real decisions in the real world, not cartoon characters, the conclusion looks quite a bit more amazing, even thought the abnormality in question is far more minor.  Or so it seems to me.  I would be absolutely amazed if the wisdom of our best ethics gave permission to Accutane users to ignore all the warnings and conceive while using the drug.  That would be incredible.

So what's going on here?  July is not worse off for being born--P1 seems right.  So she's not harmed by being conceived--P2 seems right.  Let's ignore P3, since even if it were false, that's not the heart of the matter, surely.  If July is not harmed by being born, then she's not wronged--that's what P4 says.  OK, that seems plausible.  That leaves P5.  If an act wrongs no individual could it still be wrong?

Yes.  Mary wrongs no individual yet she causes more suffering than necessary.  The suffering of July about her ears--surely inevitable--just didn't need to be. It would have been no worse to create December, and creating December would have eliminated that suffering.  Usually what matters is harming individuals, wronging individuals and moral categories of that sort, but it doesn't seem surprising that in the special area of procreative ethics, other principles kick in.  "Cause no more suffering than necessary" is that sort of non-individual-specific principle.  Not that this is the only principle relevant to procreative decisions--the one and only master principle--but it seems relevant if you're a woman wanting to both clear up your acne and have a child.  Refusing to wait six months to conceive is wrong because you'll thereby cause more suffering than necessary.

I bet somewhere in Boonin's book this response is discussed and disparaged--I will have to read the book and find out.  Truth be told, I'm sure I'd shift to some other explanation if I could be convinced that this one was wanting, because what I'm absolutely sure about is that Mary shouldn't conceive while taking Accutane.  That's what's so extremely evident, not the reasons why.