Babies by Design: A Public Health Promise or Social Justice Nightmare?

We are rapidly entering the era of "reprogenetic" medicine. This combines new technologies of gene identification with assisted reproductive technologies like IVF and preimplantation genetic diagnosis (PGD) to permit parents to select the genetic traits of their children. Within the past two years Britain's leading genetic regulatory body, the Human Fertilisation and Embryology Authority, has authorized the use of PGD to help families with histories of breast cancer avoid transmitting the risk to their children. As the list of genetically influenced conditions grows, so will the range of conditions and traits available for parental choice. In the not too distant future we will move from embryo selection to targeted gene change, and the era of human genetic engineering will begin.

Human gene modification has the potential for great harm if it is carelessly introduced and allowed to proceed untended, but sooner or later we will begin to modify our genes, and we will survive doing so. In my book Babies by Design: The Ethics of Genetic Choice (Yale University Press, 2007), I argue that we are capable of bringing intelligence -- "design" in the best sense of the word -- to our reproductive lives. Eventually we will grow accustomed to a world where human beings use genetics to make themselves physically and mentally better than they are today.

To put this view in perspective, consider how far we have come without genetic self-modification. Two centuries ago human beings died at an average age of about forty, many people suffered from the effects of serious ailments such as polio or tuberculosis, and others bore obvious deformities, from disfiguring skin lesions to clubfoot or cleft palate. Modern medicine has changed all that, extending life spans and eliminating many physical and cosmetic problems.

According to Robert W. Fogel, a University of Chicago researcher on economic and population trends, new studies show that many chronic ailments, such as heart disease, lung disease, and arthritis, are occurring, on average, ten to twenty-five years later than they used to. There is also less disability among older people today. Thanks to better nutrition, disease prevention, and treatments, says Fogel, humans in the industrialized world have undergone "a form of evolution that is unique not only to humankind, but unique among the seven thousand or so generations of humans who have ever inhabited the earth." In the future genetics will help us continue this evolutionary trajectory.

The first steps in reprogenetics will continue and expand what is already underway: the use of these technologies to prevent the occurrence of serious disease conditions like cancer. Eventually, we will move beyond immediate disease prevention to enhancement, with the goal of making people "better than well." This includes improved disease resistance generally, greater stamina, longer life spans, and maybe enhanced mental acuity in the form of improved reading and computational skills. We will probably also see cosmetico-genomics, where parents use prenatal (or preconceptional) genetics to improve a child's height, reduce his or her chances of obesity, and even select skin or hair color.

Trait selection in our offspring is not new. Our choice of people we find attractive as sexual partners has always somewhat allowed us somewhat to select our children's genetic characteristics. Nevertheless, the deliberate genetic choice of a child's qualities scares many people. Babies by Design explores some of the leading ethical and religious concerns. A leading worry is the risks posed to children -- and future generations -- through mishaps in gene manipulation. As I do throughout the book, I use fictional literature (Greg Bear's unsettling short story "Sisters") to try to imagine this frightening possibility. I agree that the physiological risks are among the most serious concerns, but I argue that technologies are on the horizon (including reversible DNA changes) that will someday make gene interventions both safe and routine.