In a recent article, Oxford University’s director of medical ethics, Dominic Wilkinson, argued that birth control was a key way of tackling the Zika virus’s apparently devastating effects on unborn children – a strategy that comes with the extra benefit of meeting the need for reproductive health across much of the affected areas.
However, although this approach might be one solution to a medical issue, it doesn’t consider the demographic implications of delaying pregnancy on such an unprecedented scale – some of which could have a significant impact on people and societies.
In most of the world, Zika outbreaks have had no noticeable effect on children, but the most recent outbreak in Brazil was associated with a significant spike in the incidence of microcephaly, a condition that causes babies to have small heads and underdeveloped brains. This rose from a background incidence of around 0.07% of live births to 2% – around 4,000 new cases since October in a country of just over 200m.
Microcephaly causes intellectual impairment in almost all cases and can also cause developmental problems and mild seizure. Life expectancy is also thought to be reduced, although whether this is caused by microcephaly itself or its associated disability is unknown.
Let us assume that children born with microcephaly suffer a reduction in life expectancy. And each year of life lived with microcephaly is also associated with an 82% reduction in quality of life. However, since only around 2% of children born during the current outbreak seem to develop microcephaly, the expected loss of welfare for a child conceived in an affected area is only around 2%. Crucially, it should be this loss, not the devastating effects of the virus on particular individual children, that we should consider when weighing the benefits of delaying pregnancy.
Another kind of cost
While delaying pregnancy may be relatively costless for individuals, if many people simultaneously decide to delay conception this will have significant demographic implications. In the short term it will cause the birth rate to fall. However, once the outbreak subsides or the advice changes, the number of pregnancies can be expected to swell beyond normal expectations. Depending on how many people delay conception this could severely stretch maternal and paediatric services once people start trying again for a baby, causing overcrowding in certain educational year groups and, in the long run, skewing the labour market.
Let us take just one potential effect. Improving maternal health is considered a key global priority for development. At present, Jamaica has around one nurse or midwife per 1,000 people and El Salvador has only one per 2,500 people. While some countries, such as Brazil, are better provided for, this reflects a chronic shortage of trained birth attendants across much of the area under threat from the Zika virus. In many of these countries, the infant mortality rate is more than 1% of all live births and maternal mortality and disability rates are high. A short-term rise in the birth rate would put maternal services in these countries under severe strain and could make these problems considerably worse.
The non-identity problem
Unfortunately it is impossible to provide any precise estimate for the costs of a sudden fall and then rise in the birth rate. However, philosophically speaking there is a crucial difference between these costs and the suffering of children with microcephaly. Children who suffer from poor healthcare and overcrowded schools when they are young could all have been better off. However, children who suffer from a disability such as microcephaly could not have been better off – had these children not had microcephaly they would not have existed. This is known as the non-identity problem.
Take this example: saving a dying child seems much more important to us than bringing a new child into existence – even if we imagine that both children will live equally long and happy lives. One reason for this seems to be the idea that letting the child die means do harm. However, if we simply fail to bring the other child into existence then we do no harm. Similarly, if we bring about a situation in which children will receive inadequate health and education, then we harm those children. However, if we act in a way that will produce a disabled child when we could have instead acted in a way that will produce a, different, able-bodied child, we harm neither child.
There are many different responses to the non-identity problem, some of which would imply that in this case having a child with microcephaly harms that child. However, to many philosophers the harm, if any, that we do when we create a child who will be worse off through disability is much less important than that which we do when we make an already existing child worse off.
As philosopher Jan Narvason famously put it: “We are in favour of making people happy, but neutral about making happy people.” On this account, even if it turned out that the social problems caused by delaying pregnancy were much less than the suffering of children born with microcephaly, it could still be wrong to delay these pregnancies.
As I’ve argued before, the welfare of potential people is morally important. However, while having a disabled child rather than an able bodied child may seem bad, it would still be worse to disable a child who would otherwise have been able. So the moral problems with delaying pregnancy may be far greater than they seem.
Of course, we must not forget that the costs of microcephaly are not only borne by those who suffer it, but also by their families and those who care for them. Nevertheless, the view that delaying pregnancy is an easy or costless solution only tells one side of the story.
In conjunction with Oxford University’s Practical Ethics blog