PEA Soup is pleased to introduce October’s Ethics discussion, featuring Kimberley Brownlee and Alyssa Izatt’s (University of British Columbia) paper, ‘Justice for Girls: On the Provision of Abortion as Adequate Care,’ with a précis by Japa Pallikkathayil (University of Pittsburgh).
The discussion is now open.
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Précis on ‘Justice for Girls: On the Provision of Abortion as Adequate Care’
Japa Pallikkathayil
In this excellent paper, Alyssa Izatt and Kimberley Brownlee aim to do two things. First, they identify a previously unnamed type of injustice—what they call ‘antigirlism’. Antigirlism “picks out the targeting, bias, abuse, and erasure that girls endure as girls” (546). Second, they use this concept to argue that both sides of the abortion debate have erred in their thinking about girls’ rights to reproductive care. In what follows, I say a bit more about both these important contributions before raising a few questions.
Izatt and Brownlee build to the identification of antigirlism with characterizations of childhood and girlhood. A child is a comparatively young human being “who is entitled to specific protections in virtue of not only her relative decision-making incompetence and lack of experience but also the distinctive goods and rights of childhood” (521). Among the goods of childhood that Izatt and Brownlee go on to emphasize is the possibility of enjoying being carefree, where that involves being unburdened by having to bear responsibility for weighty decisions.
Since Izatt and Brownlee’s focus in this piece is on the erasure of childhood in the context of abortion provision, they focus on the intersection of youth and female embodiment. Hence, antigirlism in this context targets “children who are female and who can in principle become pregnant once puberty begins” (523). In other contexts, antigirlism might also include discrimination that targets feminine gender identity or presentation. Izatt and Brownlee also note the need for a complementary analysis of antiboyism.
Izatt and Brownlee powerfully demonstrate the erasure of girlhood in discussions of abortion. Many abortion bans treat anyone with a uterus as a woman. This involves ignoring that many such people are children. This is important both because pregnancy poses an especially potent threat to the health and well-being of children and because children are owed distinctive protections in virtue of the distinctive vulnerabilities and goods involved in childhood.
With these features of childhood in view, Izatt and Brownlee argue that pregnancy in childhood is a malady that a child’s caregivers and medical providers have a duty to remedy through termination. This argument begins by drawing an analogy with the treatment of live organ donation by children. Younger children are typically legally prohibited from being live organ donors even when they are willing and doing so would save the life of a family member. Older children (16-17) are typically allowed to donate only as a last resort and only when the costs to them are minimal. These constraints are well-grounded in the vulnerabilities and goods of childhood. They protect children from enduring and being pressured to endure significant costs in health and well-being, even for the sake of a loved one.
Likewise, Izatt and Brownlee argue that children should be prevented from enduring and being pressured to endure the significant costs to health and well-being of continuing pregnancy. This is so even if we grant that the fetus has moral standing, much like the sibling a child might save through live organ donation. The analogy with live organ donation vividly demonstrates the perversity of the abortion bans that have been sweeping the United States, which typically apply to adults and children alike. These bans impose significant harms on children, harms they should be protected against. But this analogy also puts pressure on permissive views of abortion, which also typically do not distinguish between adults and children. Not only should children not be compelled to continue a pregnancy, they should not be given the option of doing so.
Izatt and Brownlee support this conclusion by extending the analogy with live organ donation. As noted, in older children live organ donation is sometimes permitted in exceptional circumstances: when doing so is a last resort, poses minimal risks to the child, reflects an informed, noncoerced choice on the part of the child, and serves her best interests overall. Even in older children, Izatt and Brownlee contend that continuing pregnancy will not meet these criteria. The physical and psychological risks of continuing pregnancy are so substantial that the minimal risk condition will not be met. The prevalence of familial and community pressure means that children’s choices about continuing pregnancy will not typically be free from coercion and manipulation. Moreover, terminating a child’s pregnancy serves her best interests overall: doing so protects a child’s ability to participate in the distinctive goods of childhood and best supports her future prospects. Thus, the exceptional conditions in which older children might be permitted to donate an organ do not obtain with respect to continuing pregnancy.
As Izatt and Brownlee recognize, this conclusion involves the uncomfortable implication that an older child may be compelled to have an abortion against her will. They note that they “have adopted a paradigm case of childhood that allows that, in rare cases, some older adolescents may no longer be children” (539). But they caution against treating pregnancy as an exceptional condition in making this assessment. If a patient would be treated in accordance with her best interests rather than her judgment in the context of other serious medical decisions, like receiving chemotherapy, that should be true with respect to continuing pregnancy as well. In this context, abortion is of a piece with other forms of care, where “it is understood that a child’s right to adequate care should not be compromised by their inability or unwillingness to comply with care” (544).
Izatt and Brownlee make a compelling case that antigirlism is a distinctive form of injustice and one that is present in both restrictive and permissive treatments of abortion. As they predict, I feel more ambivalence about their proposal as concerns older children. My first two questions focus on difficulties the lived realities of such children may pose for their proposal.
First, notice that older children typically have considerably more opportunity to evade compulsory care than younger children. A sixteen-year-old in the United States will often have the wherewithal to run away. Doing so exposes her to considerable risk from inadequate medical attention, the dangers that accompany being unhoused, and the possibility of being trafficked. I wonder whether these risks might need to be considered when determining whether compulsory abortion is after all in the best interests of older children.
Second, I worry that there may be more pressure to recognize the autonomy of older children in a society in which they are already routinely ‘adultified’. The carefree life that Izatt and Brownlee rightly regard as worthy of protection is one that is already unavailable to many children, often due to disadvantages stemming from race and class. Is it fair to tell a child who has already been tasked with many adult responsibilities, like caring extensively for younger siblings and contributing to household income, that she is not yet adult enough to decide for herself whether to continue a pregnancy?
My final question invites Izatt and Brownlee to expand on their response to a commonplace claim in favor of restrictive views of abortion, namely, that a woman has a special responsibility to the fetus she is gestating. This might be thought to mark a difference between the case of pregnancy and the case of live organ donation. This claim is not at all plausible in the case of pregnancies resulting from rape. As Izatt and Brownlee emphasize, pregnancy in children is typically the result of rape. Indeed, in younger children, this is necessarily so. Any claim of special responsibility cannot get off the ground in these cases. But Izatt and Brownlee take their conclusions to apply not just to pregnancy resulting from rape but also to pregnancy resulting from sex between older children (522, fn. 23). Might a critic press treating such cases differently?
For my own part, I’ve argued elsewhere that the analogy with organ donation is not limited to cases of rape. So, I do not think that Izatt and Brownlee’s argument is vulnerable to this objection. But they seem to suggest a distinctive ground for rejecting this objection in the case of children: “Even if a pregnant adult could be deemed to have a special responsibility to preserve a fetus, ceteris paribus, this could never be so for a child because a child has a right to a childhood” (531). I’d like to better understand how the right to a childhood blocks the charge of special responsibility. Society very often invites and indeed encourages older teenagers to accept special responsibilities for others as babysitters and lifeguards. Even driving might be thought to involve accepting special responsibility for others. Since these activities do not seem to me to be obviously in tension with older children’s right to a childhood, I wonder if that right is capacious enough to block the charge of special responsibility for the fetus.
Thanks to the Pea Soup for organising this conversation, and for the precis, Japa!
The most intriguing claim of the paper is that we should impose abortion on underage girls who want to carry to term. Had someone asked me, before reading Alyssa and Kim’s paper, whether we should consider doing so, I would have probably said no. I still think it would be wrong for us to force girls to abort, yet reading the paper made me see how important it is to articulate why, because Alyssa and Kim are proposing some important reasons, namely that (a) carrying to term imposes great wellbeing costs on them and (b) when people under 18 consider taking on themselves similar health costs (for instance when they want to become living donors) the medical profession tends to prevent them from taking these costs.
Let me explain why I am unconvinced, and check where exactly the disagreement between the authors’ view and mine lies. There are two kinds of reason that should guide difficult decisions about letting children do what they want in difficult cases like those of abortion: concern for their wellbeing and respect for their autonomy, insofar as it has already developed.
On the first count, I learned a lot from Alyssa and Kim about how carrying to term jeopardises girls’ wellbeing. But I thought that more should have been said on how a girl’s wellbeing is jeopardised by an abortion she opposes, especially if her opposition is explained by her concern for the interest of the foetus (whether or not the concern is apt), and when the only way in which the procedure could be carried out involves force. It seems to me that imposed abortion carries a real risk of scaring girls psychologically, possibly in irreversible ways. A forced medical procedure of this amplitude is anyways likely to be perceived as a massive, humiliating intrusion. When the child truly believes that abortion is morally wrong, this compounds the potential trauma, and when believes it to be wrong as an affront to innocent life the magnitude of harm seems greater than in cases of forced blood transfusion on a Jehova’s Witness child, or in cases of disallowing a child to save a loved one’s life by donating an organ. In the abortion case, but not in the cases, the child might be convinced that the procedure is part of wrongful killing. The possibly life-long guilt – misguided as it might be – of having been causally involved, in a direct way, in the conception and killing of another human being is a very significant cost. And when the pregnant girl desires to carry to term, there is the additional question of regretting not having been able to do so. I don’t see how think these likely aspects of teenage pregnancy can be ignored.
A final thought on the wellbeing point: Alyssa and Kim appeal to the distinctive goods of childhood to explain why the decision to abort should not be left to the pregnant girl, since this would be corrosive of her carefreeness. My worry is that forced abortion and its aftermath can compromise carefreeness no less than allowing pregnant girls to have the last word on whether to abort.
Talk of choice brings us to the second count: it is by now quite common to note that children’s autonomy develops gradually, that many under-age individuals have levels of competence and self-control that surpass those of typical adults, and that it is disrespectful to make decisions on their behalf that they are autonomous enough to make for themselves (even when their decisions set back their wellbeing interests in important respects!) This is why the law takes seriously the possibility of letting underage people fly or sail alone around the world, for example, and why, I think, we ought to permit competent teenagers to engage in organ donation even in cases when this is not in their best interest. The paper doesn’t discuss this crucial consideration against forced abortion for teenage girls whose autonomy is highly developed. Even if, against my above wellbeing-based considerations, abortion is all-things-considered in the child’s best interest, it might still be disrespectful to take the decision away from her. Doing so might compromise the girl’s global autonomy, her chance of leading a life which by her own lights is free from serious moral taint (on a conception of what morality requires which might well be mistaken but is reasonable in the political-liberal sense of the term).
One more thought about (older) girls’ agency: at times, the paper seems to assume that all under-age pregnancies are on a par with pregnancies resulting from rape as far as the pregnant girl’s responsibility is concerned. I don’t think this is right. Some people under 18 can have consensual sex with each other; Romeo and Juliet is not a story of rape. They can end up being pregnant, whether intentionally or not. Taking seriously children’s gradual development of autonomy means that attribution of some level of moral responsibility for their sexual activity is also in order, and buttresses the worry that forced abortion, especially if it is public policy, can impose serious and lasting guilt in pregnant girls.
Alyssa and Kimberley: We would like to thank Japa Pallikkathayil for her generous summary of our article and for her thoughtful questions. In reply to her first question, the concern that an older child might run away (and then face serious dangers) is a live one in relation to other types of medical care. Unless bedridden, a Jehovah’s Witness child might try to evade a blood transfusion. A child averse to cancer treatment might try to evade chemotherapy or her family might flee to avoid court ordered treatment (see, for example, https://abcnews.com/US/amish-girl-leukemia-family-flees-us-avoid-chemotherapy/story?id=21040115). An older child who needs to be institutionalized to treat her eating disorder, psychiatric disorder, or drug dependency might have the wherewithal to run away (and could then face serious dangers). The risk of flight in those cases is not a compelling reason against providing care. The same is true for child gestation. If the risk of flight is greater in cases of child gestation, we must uncover the reasons for that. The mythologizing of pregnancy and the general disregard of girls’ rights as children will be part of the story. Counteracting that narrative is a key first step.
Alyssa Izatt and Kimberley Brownlee’s Justice for Girls is an important contribution to two areas of philosophy. Their essay convincingly argues that injustice against girls, which they call antigirlism, is an insufficiently recognized area of injustice. Wrongfully treating girls as if they were adult women is one form this injustice can take. They also make a persuasive case that pregnant girls, in particular, are subject to injustice when treated as if they were adult women, and not provided the special protections we typically think justified when it comes to evaluating medical procedures that impact both boys and girls. These include live organ donation and cancer treatment. They give compelling arguments that decisions about whether or not a girl’s pregnancy should be terminated should routinely involve assessment of the physical and psychological risks to the particular child, determination of whether she is being coerced or manipulated, and that girls can benefit from an independent advocate in making this determination. They also valuably draw our attention to the fact that risks associated with pregnancy are higher in girls than women. They argue that decisions about girls’ pregnancies should either be determined by what is in their best interests, or when girls are sufficiently mature to make their own decisions, by them. They recognize that some critics may give more weight to girls’ autonomy than they do, and that accordingly critics may dispute their claim that age eighteen is the appropriate time for caregivers to stop making decisions for girls about their pregnancies. Given how strongly people can be committed to views about the moral acceptability of abortion and value of a fetus, it strikes me as more appropriate to think that such a view may represent a girl’s values rather than merely what they call her preferences. Therefore being forced to have an abortion against her will may be a serious violation of both a girl’s body and her autonomy. While the authors acknowledge that there may a few girls under eighteen who are sufficiently informed, free from manipulation and coercion, and competent to make decisions about abortions for themselves, it seems more appropriate to me to treat older girls, especially those sixteen and over, differently than younger ones, both in terms of recognizing their autonomy and with respect to protecting them from the burden of adult decisions and awareness of life’s challenges. Unlike younger girls, we often authorize sixteen year old girls to drive, to determine whether or not to continue with their education, to choose to have sex with their peers, to learn about burdensome aspects of reality, and more generally to decide for themselves when a course of action is worth its risks and disadvantages. When it comes to the importance of adolescent girls’ autonomy, I suggest that, in addition to considering live organ donation and cancer treatment as potential guides to decision making about girls’ pregnancies, we should also consider the weight we think appropriate to give to children’s views about gender affirming procedures. In addition, when we seek to determine what best serves the interests of those pregnant girls who are not judged competent to make their own decisions, we should take what they care about into consideration as a factor to weigh alongside risks to their health. While I agree with the authors that pregnant girls might later regret either continuing with or ending their pregnancies, and that speculations about regret are not helpful when taken in isolation from a girl’s values, those who decide for pregnant girls about their pregnancies should be expected to discover and give considerable weight to those girls’ values, alongside the risks involved with ending or continuing their pregnancies. Finally, while the authors make useful reference to philosophical arguments about the value of experiencing a carefree childhood, these arguments are more persuasive when focused on younger children, and not those near the transition to adulthood. Part of the transition to adulthood includes increasing opportunities to make decisions for oneself, and increasing exposure to social realities we can reasonably wish to shield younger children from learning about.
Alyssa and Kimberley: In reply to Japa’s second question, the debate about penumbral cases is striking for several reasons. First, the tendency to see 16- and 17-year-olds as the tricky, penumbral cases of childhood is tied to 20th century history and to the military draft. Historically, the age of majority for young men was 21, a standard that held for centuries in English common law, traceable back to Roman Law, which influenced US law for much of its history:
The immediate historical origins of the U.S. age of majority lie in the English common law tradition. The American colonies, then the United States, adopted age twenty-one as the near universal age of majority. The U.S. age of majority remained unchanged from the country’s founding well into the twentieth century. In 1942 wartime needs prompted Congress to lower the age of conscription from twenty-one to eighteen, a change that would eventually lead to the lowering of the age of majority generally.
Until the Vietnam War, the voting age in the US was 21. Then, because so many 18- and 19-year-old youths were being conscripted to fight in the Vietnam War, the 26th Amendment was ratified, lowering the voting age to 18. Seana Shiffrin discusses the campaign of ‘Old enough to fight, old enough to vote’ in her 2025 article, ‘Old Enough to Carry, Old Enough to Vote’, which is a reply to Japa Pallikkathayil’s article ‘Abortion and Democratic Equality’. In the mid-20th century, many other countries coalesced around 18 as the age of majority. If the default had remained 21, the drafters of the UN Convention on the Rights of the Child (1989) might have defined a ‘child’ as every human being below the age of twenty-one unless under the law applicable to the child, majority is attained earlier, rather than as ‘every human being below the age of eighteen years…’ in which case we might be debating the ‘penumbral’ cases of 19- and 20-year-olds instead of younger teens. The key question for philosophers is: If young persons are entitled to a certain number years protected from adult burdens as part of their right to a childhood, how many years are they entitled to have and why? Here is a slogan that makes the issue vivid: ‘Too young to fight, too young to gestate’.
Second, we grant that the penumbral cases are indeed tricky (regardless of which ones are truly penumbral): persons on the cusp of adulthood are differently placed from younger children. Our paradigm case approach to specifying childhood accommodates this reality. The deeper worry is that, by focusing on penumbral cases, we draw attention away from the key observation that neither opponents of abortion nor defenders of women’s autonomy have appreciated that impregnated children are not women. Medical care for impregnated girls should be animated – first and foremost – by the fact that girls are children.
Alyssa and Kimberley: In reply to Japa’s third question, not all special responsibilities are on a par in their moral significance or their burdensomeness for the duty-bearer. The teenage lifeguard is not on duty 24 hours a day for nine months in a constant state of risk to his health, future, or life. The teenage lifeguard is also not faced with a momentous status change – to that of biological mother – regardless of whether he continues to serve after his ‘nine months’ are up. Finally, the teenage lifeguard is presumably in his seat by choice. The gestating teenager is usually not in that position by choice. As Anne Martin and Jeanne Brooks‐Gunn write (focusing on the US):
“Teenagers whose families are poor, who live in single‐parent households, whose mothers have had less education, whose families earn less income, who have received welfare and who reside in socioeconomically depressed neighborhoods are all more likely than teenagers without those characteristics to become mothers before reaching their adult years. Martin, A., and Brooks‐Gunn, J. (2016).” “Teenage childbearing in the United States: Do our programs and policies reflect our knowledge base?” in The Wiley Handbook of Developmental Psychology in Practice: Implementation and Impact. Wiley, 172.
In short, gestating in childhood has far more to do with socio-economic position than preference.
Hi everyone, my quotation & sources weren’t retained in my previous comment. Here is the quote: “The immediate historical origins of the U.S. age of majority lie in the English common law tradition. The American colonies, then the United States, adopted age twenty-one as the near universal age of majority. The U.S. age of majority remained unchanged from the country’s founding well into the twentieth century. In 1942 wartime needs prompted Congress to lower the age of conscription from twenty-one to eighteen, a change that would eventually lead to the lowering of the age of majority generally.” from, Hamilton, V., (2016). “Adulthood in Law and Culture”, William & Mary Law School Scholarship Repository, 64.
I am glad about the existence of this important, bold, and excellent paper. Brownlee and Izatt’s intervention on behalf of impregnated girls and their pointed consideration of what such girls are owed by way of abortion care is a crucial and overdue addition to abortion ethics scholarship. Their central contention that, for a child, the pregnancy situation is straightforwardly a malady—medically, but also socially and developmentally—and ought to be treated as such by adults charged with their care strikes me as a correct contention which it is vitally important for abortion law and politics to appreciate. Moreover, their adumbration of the distinctive harms of childhood gestation and premature motherhood addresses a glaring gap in abortion discourse, including liberal defences of abortion choice, which, I believe the authors are right to say, far too blithely treats the stakeholders in abortion choice as a homogenous group.
The point that, wanted or unwanted, gestation and motherhood is profoundly more detrimental to minors than to adult women, not the least by cutting short a childhood which they are owed as of right, is powerful and all too easily overlooked.
I particularly appreciate the claim that one of the things such girls are owed, as children, is freedom from the weighty decision over whether or not to terminate a pregnancy. I am largely persuaded, then, albeit with some caveats, of their provocative claim that what impregnated children are owed by surrounding adults is not abortion choice, but rather abortion treatment, even against their express wishes, in the service of their best interests. Accounting for those caveats (which I expand below), I think I would embrace a position very close to, though perhaps not exactly aligned with, the authors’ one, namely: that what impregnated minors are owed is at the very least encouragement toward abortion and a presumption by their responsible adults that the abortion path will be chosen, and in some cases—and surely all those involving younger minors—compelled abortion treatment if necessary.
The main substantive comments I have about the argument as a whole concern two core issues in the piece: 1. the best interests assessment and, 2. the living organ donation analogy.
The Best Interests of Impregnated Girls
As I said – quite convinced of the authors’ premise (supported by evidence) that a simple best interests determination for impregnated girls will favour abortion treatment as being in their medical, social, and developmental best interests. The harms and risks of pregnancy and childbirth make it axiomatic that abortion is in their medical best interests (that holds for adult women too, in light of risks of pregnancy and childbirth, although, as authors detail, to a lesser extent). As the authors are attuned to, though, a proper best interests assessment of any course of action takes in a wider array of factors than strict medical best interests. What is in a person’s best interests is also a foreward-looking determination, and is not time-limited (that’s why one would force a child to undergo an unpleasant and temporarily painful procedure to prevent a more serious long-term affliction). These features can make best interests determinations around reproductive choices particularly complex and uncertain. Suppose a girl gives birth to a child, resulting in sharp detriments to her early life, but that this particular child (not exchangeable with a different, hypothetical child) becomes the saving grace of her life in her later years? How do we trade off, in a best interests assessment, the earlier suffering against the later benefits?
I suppose the authors can plausibly reply to this that these uncertainties don’t feature in ordinary medical best interests assessments for children. For example, professionals would not withhold treatment to rectify a child’s disability on the grounds that, if left disabled, that child may, in the future, come to develop close and valuable relationships with other members of the disabled community, as well as other interests and capabilities, which outstrip the costs of the disability (which is surely plausible). The authors may be right to think that, likewise, despite any uncertainty about long-term best interests, the profound immediate detriment and developmental stunting inflicted by childhood pregnancy and childbirth means that “best interests” points squarely to abortion. I nevertheless wonder whether the especially complex relationship between reproductive decision-making and best interests muddies the waters here a little more than Brownlee and Izatt want to allow.
Compelling abortion for impregnated minors
In many and perhaps most cases I agree with the authors that a straightforward best interests assessment will favour abortion even if the girl in question is averse to it. But I think the authors are right to consider how that aversion might affect the best interests calculation, in light of the consequent trauma wrought by a forced procedure. The degree of trauma experienced by a minor compelled to abort is naturally going to be a sliding scale. But the trauma in question that needs to be accounted for is not just that of physically forced treatment (if it comes to that), but the emotional and psychological impact of undergoing a termination to which the girl is deeply averse, perhaps having formed an emotional investment in the pregnancy and believing that the fetus has high moral status. That these are unreasonable positions is by the by when it comes to contribution they make to trauma. I also wonder whether the girl’s relative maturity is likely to have a compounding effect on these more secondary kinds of trauma, in the sense that the more developed as an agent the girl is, the more sense of her own autonomy and what it means for it to be violated she has, and the better able she is to appreciate and reason about her situation (even if she makes erroneous calculations), the more harmful a compelled abortion will be to her. If that is right, it means that the trauma of compelled abortion will usually increase along with the girl’s maturity.
The authors’ reply to those who may be sceptical about compelled abortion is that, notwithstanding the patient’s aversion, best interests will still almost certainly fall down on the side of abortion treatment, because the detriment that abortion inflicts is still less than all the harm that will befall a girl who gestates all the way to childbirth. ‘What matters’, they say, ‘is that the harms of gestation is worse than those of abortion’. They go on: ‘…there is overwhelming evidence that child pregnancy is extremely harmful. Substantial risks of injury, disability, and death accompany gestation, as do long-term limitations on personal and sexual autonomy. To change our stance, we would need decisive evidence that abortion care is worse.’ I find the position persuasive. But it is important to be clear that it is not ordinary, consented-to (indeed, sought out) abortion with which we need to compare the harms of gestation here, but a compelled abortion to which the girl is deeply averse. Brownlee and Izatt’s proposed calculation may still be right in most cases. But it is conceivable, to me, that in a particular case the aversion could be deep enough, or the girl’s sense of her bodily autonomy robust enough, that the impacts of a compelled procedure of this kind are severe – so severe that they cast doubt on the best interests determination.
The Living Organ Donation Analogy
The living donor analogy is an extremely useful tool in getting readers to think about usual approaches to medical best interests assessments in the case of children, and usual approaches to children’s altruistic bodily assistance of others—including their own relative—when that assistance endangers or limits their own health. I find the argument deeply persuasive, but I suspect this is because I attribute low moral status to the developing embryo/foetus. I’m particularly interested in what opponents of abortion on the grounds that it destroys a human being with full moral status should make of this argument. In positing the analogy, Brownlee and Izatt make the Thomson-esque move of structuring an argument in such a way as assumes foetal moral status (Suni is a full moral person), but still prevails on the side of abortion choice—or, in their case, abortion treatment. For similar reasons that dog Thomson’s violinist analogy argument, I am not sure it is successful in this particular respect. At the very least, I would say it replays some fundamental debates that spring up in response to Thomson’s analysis.
The set-up of the analogy assumes, I think, that by not donating a kidney to Suni, Stacey is just declining to give life-saving bodily assistance to Suni (or rather, her responsible adults are declining on her behalf). But on the assumption the foetus is a moral person, the abortion situation may be distinct in a highly relevant way. What is entailed in much abortion is arguably not merely the withholding of life-sustaining aid, but, often, an act which kills the foetus outright, either prior to or in the course of removal. If that is a correct analysis, and assuming foetal personhood, the ethical problem is not one of when the “host” party is permitted to refuse aid, but of when they are permitted to kill so as to avoid proffering aid and the bodily burdens associated with that, and of when they can enlist others to do so on their behalf. That is arguably a different question, in need of a different analysis.
Returning to Stacey and Suni, modifications would have to be made to match this feature of the abortion situation. I think a more closely matching analogy would be this:
Stacy and Suni are, at present, in a state of bodily conjoinment. Stacy is able to live independently, but Suni relies on Stacy’s organs to sustain her, and will need to do so for a further nine months before she could survive detachment. Continuing the state of conjoinment poses some fairly significant health risks and costs (as well as day-to-day burdens) on Stacy, as well as some moderate longer-term social and developmental consequences—she is, after all, going to spend a significant proportion of her childhood hooked up to another person. Both are innocent as regards the situation, and both are children with full moral status but without capacity to make their own medical decisions. If the doctors separate them, Suni will die immediately, but Stacy will be spared all the aforementioned costs.
Are the doctors permitted to separate them, knowing that Suni will immediately die? Are they permitted to separate them if the only way of doing so, safely enough for Stacy, is to kill Suni prior to detaching her, or to detach her in a way that violently attacks her body, with that attack (rather than the fact of detachment) then being the immediate cause of death?
We can grant that Stacy would have had no moral obligation to offer Suni the use of her body for nine months, at such a cost to her. I am also happy to assume, given that Stacy is a minor, that were she to suggest the aid, adults around her should prevent her from proffering it, even knowing that Suni will die as a result. (Although I think there is more to consider here by way of a full best interests analysis, the author’s point about the existing rules around such things is a powerful one.) But the amended analogy is, arguably, not a life-sustaining assistance situation.
The crunch point here concerns when the lack of a moral requirement to proffer life-sustaining bodily support translates into a right to kill in order to prevent that assistance from happening, or the right to kill on someone else’s behalf. Thomson’s position was that, given the first premise, they are really two sides of the same coin: even if one is killing the violinist by disconnecting him, it all amounts to the mere refusal of aid which one is not obligated to give. But pressure can surely be put on this assimilation—and, indeed, I think my modified analogy might do just that. If we are not sure the doctors are permitted to kill Suni so as to spare Stacy, it is surely because we think we are now in the territory of killing rather than refusing aid, and that the rules for moral permissibility therefore change.
To be clear, it doesn’t follow from any of this that I disagree with the authors’ core propositions. Moreover, their analogy still does the very important work of demonstrating what follows if approach we girlhood gestation using the same rules about medical decision-making on behalf of minors that apply in other contexts. It is only that there is, for me, a remaining question about whether the analogy should persuade those who, because of their prior commitments about foetal moral status, believe that in abortion, the lives of two children hang in the balance, and about what that would mean for everyone’s moral permissions.
There’s lots to love about this paper and lots to think about. Like many of the commentators above, the issue I’m least sure about concerns older teenagers.
While I am largely in agreement with Izatt and Brownlee’s argument, I think the ethical position of adolescents is much more complicated, and I think it deserves acknowledgment. They defend a uniform protocol, arguing that absent exceptional circumstances (such as an older adolescent credibly deemed no longer a child), caregivers should provide abortion care to all impregnated children, even against the child’s wishes. They acknowledge this position is contentious for older adolescents, but defend it on the grounds of consistency. But I’m not convinced. I think older adolescents have both rights that protect their interests but also rights that protect their choices. I’ve defended the sexual rights of older teenagers, and I think those rights will also have to include their right to choose abortion (or not).
A developmental account of rights, where children move from interest rights to choice rights as they mature, suggests that this uniformity, while practically appealing, misses a morally significant distinction. For very young children, rights are overwhelmingly interest-protecting, and the case for acting on the child’s best interests over her expressed preferences is strong. But for older adolescents, sixteen- and seventeen-year-olds, we are in a zone of genuine moral transition. At this stage, I have argued, children have both interest-protecting and choice-protecting rights, and the relative weight of the latter is beginning to increase. Their emerging autonomy is morally significant in ways that go beyond what the best interests standard alone can capture.
Izatt and Brownlee think that the older child’s expressed preference against abortion may itself reflect the kind of coercion, misinformation, or trauma that makes reliance on the preference problematic. Note however, that’s also true for lots of fully adult women. Sometimes when we exercise our rights, we set back our own interests. Not having an abortion because I believe abortions to be morally wrong, could also ruin my life at 25. And yet feminists think it’s important we protect women’s choices. I think that’s part of what it is to be a rights bearer.
Can we meet in the middle here when it comes to older teens? Perhaps the mode of advocacy appropriate for an older teen is different than what’s appropriate for a ten-year-old. For the older adolescent, we might advocate for a robust process of consultation, transparency, and support for deliberation, one that takes her expressed preferences seriously. I think that this may be both morally required and practically achievable.
Izatt and Brownlee anticipate this objection and respond partly by noting the practical difficulties of case-by-case assessment. But just because something is difficult it doesn’t mean it’s not morally required. Doctors in Canada routinely make decisions about mature minors who can make their own medical decisions. There isn’t a fixed age. All this said I actually think that the developmental account of children’s rights is on the authors’ side. It explains why a child’s interests are so weighty and in need of protection.
I have more to say about what a child’s interests are but I’ll stop back later!
Alyssa and Kimberley: Anca Gheaus raises several important points. She suggests that a girl’s wellbeing, autonomy, and competence are grounds for deferring to her wishes about a pregnancy. We will offer a first round of replies here, and then will try to follow up again later.
With regard to autonomy and competence, Alyssa’s and my defence of the right to a period of burden-free childhood does not centre on incompetence. We are conscious that many girls are competent. Indeed, on average, girls’ brains mature faster than boys’ brains do. But, a difference in the average pace of maturation should not lead us to grant fewer years of protected childhood to girls. Whatever period of protected time children are entitled to have is an entitlement that all children have regardless of their competence.
Second, Anca observes that ‘the law takes seriously the possibility of letting underage people fly or sail alone around the world’. A contrasting example is professional athleticism. Most professional sports organisations will not permit children under 16 to compete. Possibly, Anca intends for her argument to apply only to older adolescents, i.e. those over 16 (she says a few things that suggest this is the case). But, equally, she might be advocating that, by default, we should defer to all impregnated girls regardless of their age (noting that the youngest girl to give birth was five years-old). Such a view either would have significant implications for how we treat girls generally (i.e. allowing young girls to refuse all healthcare, leave school, marry, etc.) or would have to explain why pregnancy is the one area in which deference to a child – including a young child – is appropriate. Anca offers some reasons to think that pregnancy is distinct from other contexts such as organ donation or blood transfusions. I (KB) do not share her intuition that a child who is not permitted to save her twin through organ donation, or a child who receives a blood transfusion in contravention of her faith, would necessarily suffer less than an impregnated child who receives abortion care. Much depends on how the child has been raised and what she has been taught to believe.
Third, once we have settled into our adult years for a decade or two – which is the time it takes most of us to be in a position to weigh in on important matters – we have most likely forgotten what it was like to be a child. Caitlin Moran seems to have kept a grip on her memory of the experience. In her book, How to Be a Woman, she has this to say about turning thirteen:
“…from being benevolently generally ignored – the baseline existence of most children – a teenage girl is suddenly fascinating to others and gets bombarded with questions: What size are you? Have you done it yet? Will you have sex with me? Have you got ID? Do you want to try a puff of this? Are you seeing anyone? Have you got protection? What’s your signature style? Can you walk in heels? Who are your heroes? Are you getting a Brazilian? What porn do you like? Do you want to get married? When are you going to have kids? Are you a feminist? Were you just flirting with that man? What do you want to do? WHO ARE YOU? All ridiculous questions to ask of a 13-year-old simply because she now needs a bra. They might as well have been asking my dog. I had absolutely no idea.”
Moran’s passage stresses not the 13-year-old’s incompetence – which is probably on full display – but her ignorance and her inexperience. Due to her ignorance and inexperience, she cannot take charge of monumental matters such as whether to risk her health by gestating, whether to undertake the excruciating effort to birth a baby, whether to try to mother, or whether to give her baby up for adoption and live with the realities of that choice.
The other thing we tend to forget, even when we are parents, is how brutally hard it is – as an adult – to parent a child, especially in the early years. Once we get through those first few years, we blank out the wretched bone-aching fatigue of caring for a baby, the constant vigilance, the relentlessness, the inability to find five minutes alone, the sleep deprivation in being woken, then woken, then woken again, the terror in being constantly needed as the crucial party ensuring a tiny being’s moment-to-moment survival. And all of that is just the beginning. To expose a child to such unremitting toil is inhumane. But, if we should defer to a child about gestating, then presumably we should defer to her about parenting. If we should not defer to her choice to parent, then we stage a rupture that could have been avoided. Elizabeth Harman, whom we cite in the paper, is eloquent in her defence of the right to abortion access for reasons related to anticipated love.
That’s a really interesting point about considering the broader context of care when we think about abortion. I hadn’t fully considered how differently the concept of ‘adequate care’ might be understood in different situations.