Ethics Discussion: Kimberley Brownlee & Alyssa Izatt – Justice for Girls: On the Provision of Abortion as Adequate Care.

58 Replies to “Ethics Discussion: Kimberley Brownlee & Alyssa Izatt – Justice for Girls: On the Provision of Abortion as Adequate Care.”

1. 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.

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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!

9. 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.

10. 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.

11. Alyssa: Thank you for your thoughtful comments, Amy & for taking the time to participate in this discussion!

    Related to your point about adopting a more nuanced protocol for older adolescents, in writing the paper, we did consider the merits of a more nuanced protocol. It is worth emphasizing that we do think that in cases where an older adolescent would be treated as an adult in another serious medical context such as cancer treatment, she should be treated in the same way in relation to abortion care. We stress that pregnancy should not be treated exceptionally, and that physicians should be cautious about withdrawing the protections of childhood from an adolescent girl, due to antigirlist prejudice.

    We acknowledge that many might favour a more nuanced protocol that distinguishes younger girls (under 16) from older adolescents such that abortion care is at most the default treatment for older adolescents but that care would be withheld when an averse patient is properly supported by an independent advocate. This nuanced protocol resembles many organ donation protocols in not categorically preventing 16- 17-year-olds from proceeding. But, it deviates from organ donation protocols in a crucial way – it abandons the low risk condition. As we note in the paper, pregnancy is risky in many respects (i.e. physical health, mental health, life prospects, early morbidity). We resist the urge to withdraw the typical protections of childhood from older girls, which is what a more nuanced protocol would involve. Nonetheless, we acknowledge that the age-based contours of childhood are arbitrary in some cases, and some older adolescents might legitimately be treated as medically competent. In cases where the adolescent is generally medically competent (e.g., to refuse a lifesaving blood donation, to refuse lifesaving cancer treatment), abortion should not be compelled against her wishes.

    The comparison to gender affirming care is interesting. This is a question we have received before, especially relating to whether our view might be taken to endorse a prohibitive view of gender affirming care for adolescents. I do not think this is the case. Gender affirming care is different from abortion care, especially in light of our argument that pregnancy should be treated as a malady. We take it that abortion is a graver choice from which adolescents have a right to be shielded. First, gender affirming care, while a monumental choice and a reflection of the adolescent’s values, does not pose the same threat. Second, gender affirming care does not implicate the saving / creating of another human life. Third, a strong wellbeing argument can be made for proceeding with gender affirming care. I wonder if there is some balance to be reached, where adolescents are shielded from certain grave decisions (such as the decision to refuse a lifesaving blood transfusion, or chemotherapy, or continuing a pregnancy), while still permitting greater decisional deference to the adolescent’s values as they reach adulthood.

    As you note, older adolescence is characterized as a transition period, where the weight of an adolescent’s autonomy is not as easily overridden for welfare reasons, as it is with younger children. However, I do think that adolescents have a strong interest in having their last burden-free years protected, which is compatible with greater responsibility and autonomy in young adulthood.

12. On the response to my first question: I wonder if it may still be worth distinguishing pregnancy from other kinds of compulsory care. Pregnancy seems unique in a few respects. A girl will often be the first to know about her pregnancy and will often be able to hide it while she thinks through her options. This is unlike the emergency medical context in which a transfusion is needed or the context of chemotherapy in which the child is already receiving medical care of some kind. This opportunity to consider her options on her own makes her vulnerable in ways that are not present in these other cases. In this context, I wonder whether girls are better served by a practice that won’t deter them from seeking medical help.

    I also wonder if it might be important to think about the argument in a specific cultural context. When Jehovah’s Witnesses and the Amish are small minorities, it might not make sense to organize our practices specifically with an eye to the actions they incentivize in those communities. But the pro-life community in the United States is large and robust. In that context, I think it may make sense to think about whether compulsory abortion incentivizes pressuring a great many girls to avoid needed medical care.

13. Alyssa: Thank you for your thoughtful comments, Amy & for participating in this discussion.

    Related to your point about adopting a more nuanced protocol for older adolescents, in writing the paper, we did consider the merits of a more nuanced protocol. It is worth emphasizing that we do think that in cases where an older adolescent would be treated as an adult in another serious medical context such as cancer treatment, she should be treated in the same way in relation to abortion care. We stress that pregnancy should not be treated exceptionally, and that physicians should be cautious about withdrawing the protections of childhood from an adolescent girl, due to antigirlist prejudice.
    We acknowledge that many might favour a more nuanced protocol that distinguishes younger girls (under 16) from older adolescents such that abortion care is at most the default treatment for older adolescents but that care would be withheld when an averse patient is properly supported by an independent advocate. This nuanced protocol resembles many organ donation protocols in not categorically preventing 16- 17-year-olds from proceeding. But, it deviates from organ donation protocols in a crucial way – it abandons the low risk condition. As we note in the paper, pregnancy is risky in many respects (i.e. physical health, mental health, life prospects, early morbidity). We resist the urge to withdraw the typical protections of childhood from older girls, which is what a more nuanced protocol would involve. Nonetheless, we acknowledge that the age-based contours of childhood are arbitrary in some cases, and some older adolescents might legitimately be treated as medically competent. In cases where the adolescent is generally medically competent (e.g., to refuse a lifesaving blood donation, to refuse lifesaving cancer treatment), abortion should not be compelled against her wishes.

    The comparison to gender affirming care is interesting. This is a question we have received before, especially relating to whether our view might be taken to endorse a prohibitive view of gender affirming care for adolescents. I do not think this is the case. Gender affirming care is different from abortion care, especially in light of our argument that pregnancy should be treated as a malady. We take it that abortion is a graver choice from which adolescents have a right to be shielded. First, gender affirming care, while a monumental choice and a reflection of the adolescent’s values, does not pose the same threat. Second, gender affirming care does not implicate the saving / creating of another human life. Third, a strong wellbeing argument can be made for proceeding with gender affirming care. I wonder if there is some balance to be reached, where adolescents are shielded from certain grave decisions (such as the decision to refuse a lifesaving blood transfusion, or chemotherapy, or continuing a pregnancy), while still permitting greater decisional deference to the adolescent’s values as they reach adulthood.

    As you note, older adolescence is characterized as a transition period, where the weight of an adolescent’s autonomy is not as easily overridden for welfare reasons, as it is with younger children. However, I do think that adolescents have a strong interest in having their last burden-free years protected, which is compatible with greater responsibility and autonomy in young adulthood.

14. Alyssa and Kimberley: We are grateful to Kate Greasley for her powerfully-worded endorsement of our core position and for her detailed contribution to this discussion. We will post several replies, focusing on her different points. This reply pertains to girls’ best interests.

    The nuanced stance that Kate endorses (which would have doctors strongly encourage abortion care to older adolescents and provide care to younger children) is worth taking seriously, certainly as a necessary interim step toward a more uniform protocol, the success of which would depend on changing attitudes about girls.

    We are grateful to Kate for posing an objection concerning the subtleties of a child’s best interests and then answering that objection! We would agree that ‘despite [much] 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’. Given the relative clarity we can have about a person’s present interests, we have reason to privilege those interests – particularly a child’s present interests – over the vague prospect of her having contrary future interests.

15. Warning: my comment is one by a non-philosopher (but I asked for permission before posting).
    Hello Prof Brownlee and Prof Izatt. I was wondering what you would say in case the medical doctors are faced with an unusually mature pregnant 12-year-old who vocally insists on giving birth. I am thinking of the (totally unrealistically mature) fictional character of Diane in the 90s cult film Trainspotting. Intuitively, she would be wronged if she were not allowed to give birth (given how much she is a boss of herself though I am stressing that the fictional character is unrealistically mature for that age). But then this statistical aberration brings out the point that worries me: what happens to those extremely rare individuals that have to suffer the effects of a lesser evil policy that clearly wrongs them in that it clearly harms their future psychological well-being through the psychological impact of the violation of their autonomy, but for whom the Law made no provisions out of fear of weakening the effects of the policy? If I were Diane I would want that there be some sort of legal avenue that I could quickly (and obligatorily secretly so that the public policy’s effects wouldn’t be threatened) take so that I could be finally allowed to have the baby.

16. I enjoyed reading this paper, and I think that comparing the way we think about reproductive decisions for minors with the way we think about minors who might consider organ donation is quite fruitful.

    Here are a few questions I have:

    1. If this essay were mainly about abortion as adequate care for girls under the age of fifteen, then I would understand why pregnancy is depicted here as “usually … the result of specific wrongs that someone did to her, that is, someone male raped her.” But I don’t understand why sexual coercion is made the focal case, if we are also thinking about teenagers who are 16 or 17. I can’t find evidence that would indicate that the majority of pregnancies in this older age bracket are due to sexual coercion of some sort. And according to the figures the authors cite from the CDC on p. 524, it would seem that the vast majority of pregnancies among girls under the age of 18 are experienced by those who are 16 or 17 (about 95% if my math is correct.) So, I am just curious to know why so much emphasis is placed on being a victim of sexual assault. (This echoes a question that Anca Gheaus raised above).

    2. The authors say that there may be “rare exceptions” where older teenagers might no longer count as children. But they don’t really walk us through such a case. And apparently, they don’t think that decision-making competence is sufficient. So, I would be interested to hear more about cases in which older teens might no longer be children in this context. Just how rare is rare?

    3. It seems to me that a lot of weight is put on carefreeness as a distinctive good of childhood. While I wholeheartedly agree that “carefreeness” should ideally be a part of childhood, I am not sure how much weight it ought to receive when thinking about older teenagers. “Care-free” is not exactly how I would describe a teenager juggling academics, extracurriculars, and an often tumultuous social environment.

    I would say that, while the distinctive goods of childhood matter, they have to be taken into account along with the goods of adulthood that lie in the future. Many writers in bioethics would say that an adult’s well-being is profoundly shaped by her own values and goals. If we are thinking about how to think about the pregnancy of a 16-year-old, then we need to consider, not just the distinctive goods of childhood, but also the values and goals that she has or is likely to have as an adult. This does not mean that a teenager’s present preferences should necessarily be decisive. But I do think that they need to be given much more serious consideration than we might give to the preferences of a 14-year-old. It seems strange to say that we should ignore what the 16-year-old deeply cares about because we need to preserve her carefree existence. (This is similar to a point raised above by Amy Mullin).

    So, the question is, do the authors agree that the good of carefreeness diminishes (especially relative to other considerations) as girls reach their later teens?

17. Kimberley: Both Anca Gheaus and Kate Greasley consider the risk of trauma. Kate considers ‘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’. In reply, I don’t think it is ‘by the by’ that the girl holds positions – and expectations of herself – that are unreasonable. The parents who have raised her to believe that she is, from Day 1 of conception, a ‘mother’ (even in a case of rape) have compromised her ability to see herself as the child she is. The debate about religious freedom and parental exemptions from standards of adequate childcare is a fraught one. Nonetheless, parents who raise a girl to have such beliefs about herself during childhood bear some responsibility for any trauma she endures when she is provided care that is in her best interests.

    Kate observes, with regard to older adolescents, that ‘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’. This is a fair concern, but it applies also to the older adolescent whose religious community is averse to blood transfusions and who feels deeply violated by the provision of treatment. Ian McEwan offers a vivid picture of such a child in his novel The Children Act (2014). I summarize that novel thus in a paper in Religion in Liberal Political Philosophy. Cecile Laborde and Aurelia Bardon (eds.), OUP, 2017: Briefly, “High Court Family Law Judge, Fiona Maye, must rule on whether to order a life-saving blood transfusion for Adam, a 17-year-old boy with leukaemia, who is a member of Jehovah’s Witnesses. After visiting Adam in hospital, hearing his poetry, and singing with him, Fiona does order the transfusion on the grounds that his best interests are not served by letting him refuse treatment. McEwan graphically describes the effect of Fiona’s decision on Adam and his family, who’d been counselled by community elders to remain firm in their beliefs. When the transfusion is performed Adam vomits across his hospital bed. Later, in a letter to Fiona, he describes not only his sense of violation, but also his shock when his parents came into his hospital room in joyful tears. His parents were joyful because they’d stayed true to their beliefs and would not be shunned by their community, but nonetheless got to keep their son. Adam is repulsed by his parents’ joy. He leaves his family, having lost a secure sense of meaning. He seeks out Fiona for guidance and orientation, which she cannot give him. The climax of the story follows.”

18. Alyssa: Thanks for your thoughtful contributions to the discussion, Samantha.

    There are a lot of interesting points, but I’ll start with your thoughts about choice rights & adults. It’s true that an older adolescent and a young woman could have a comparable level of decisional competence, and that not having an abortion would ruin the 25-year old’s life does not count as a reason to disregard her choice. Nonetheless, minors, including older adolescents, are entitled to protections that 25-year-olds are not. We might think of equality rights (e.g., girls deserve the same chances as boys to determine the course of their lives) or a right to an education. I think it matters that the 25 year-old has had several years of adulthood to practice decision-making and to solidify her values (whether the 25-year-old is actually successful in doing this is less important). The structure of childhood does not generally allow for this same development, and this is morally pressing when it comes to grave choices like the choice to continue a pregnancy, or to refuse lifesaving treatment.

    If we accept a more deferential view of pregnancy treatment, I wonder if, for consistency, we would need to be more deferential about the other forms of treatment we consider (such as cancer treatment), and what harms this might impose on young people. I agree that older adolescents are in a zone of genuine moral transition, but I am hesitant about what protections we withdraw from them in light of this transition. To echo my thoughts in response to Amy’s comment, I wonder if acknowledgement of the transitional phase of adolescence, and genuine deference to adolescents in some domains of their lives, requires us to abandon the protection of adolescents in more extreme circumstances. I am inclined to think that adolescents should be shielded from certain grave decisions, but permitted greater freedoms in other domains.

    The weakest form of the protocol that we consider in the article is one where abortion is the baseline treatment, including for older adolescents, but where we allow for deference to older, competent adolescents. We reject this because of the abandonment of the low-risk criterion. I wonder if this is more aligned with the view of abortion care that you have in mind. At the very least, adolescents should be advised of the substantial harms that they are likely to suffer, and mothering, and adoption, should not be treated as equivalent options.

    I will be back with more later!

19. Kimberley: Thank you to Samantha for your thought-provoking comments.

    Samantha links teens’ sexual rights to their reproductive rights or, specifically, she links girls’ sexual rights to their right to choose abortion (or not). I disagree. I believe that teen sexuality is one thing and teen gestation, birthing, and mothering (or parenting) are something else entirely. Teens should have free and easy access to contraception. They should be well-informed about the nature and causes of pregnancy, and about its risks during childhood. They should be able to explore their sexuality without confronting the dangers of gestating. One reason that the two domains are distinct is that gestating is arduous, risky labour. Indeed, as I argue elsewhere, gestating is one of the most arduous undertakings the human body can withstand: https://www.youtube.com/watch?v=t6gF5EqBWy8. It is labour that children are generally too young to perform. It also comes with a momentous change in identity – to that of biological mother – and, usually, that change brings with it the responsibility of mothering (adoption is the exception, not the rule).

    Samantha speaks of the period of older adolescence – 16-17 years-old – as being a zone of genuine moral transition. The location of that ‘zone’ is, we note above, a matter of recent political history, linked to 20th century military interests. To the extent that it is a genuine zone of moral transition, it is contingently so. The age of the ‘zone’ has been lowered by laws, policies, and social norms, but arguably in ways that harm girls (and harm boys when they are drafted just as they finish high school). We live longer than we used to do, and yet we are nudged into adulthood earlier. Another relevant – though contingent – factor is that, on average, youths are engaging in various teen or adult-like activities at a later age than they used to do, i.e. they are taking longer to grow up, which makes the prospect of girls’ gestating and then trying to mother all the more striking.

20. With regard to the organ donation analogy, Kate Greasley says that, if we assume the foetus is a moral person, then abortion may differ in highly relevant ways from the organ donation case in which 14-year-old Stacy is prevented from aiding her three-year-old sister Suni. What is entailed in abortion cases, Kate says, ‘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…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.’ This point touches on a challenging debate about how different methods of abortion care impact the foetus, to which Japa Pallikkathayil, Serena Olsaretti, Elselijn Kingma and Fiona Woollard have contributed in different ways. Kingma and Woollard, while they do not focus on abortion, observe that most actions a pregnant person’s takes (and most things done to her during pregnancy, e.g. treatments she receives or not) affect her own body directly, not the foetus. They use this observation to argue that, in many cases, what the pregnant person does cannot count as doing harm to the foetus. This is not true of surgical abortion, which involves acting directly on the foetus. But, it does seem to be true of medication abortion: the drugs the person takes go into her body and, consequently, render her uterus inhospitable. The question is whether the treatment method matters for the bare description of the event and for the analysis of its moral permissibility. See: https://onlinelibrary.wiley.com/doi/full/10.1111/japp.12785; https://onlinelibrary.wiley.com/doi/10.1111/japp.70000; and https://www.journals.uchicago.edu/doi/full/10.1086/732613. See also: https://peasoupblog.com/2025/01/can-you-do-harm-to-your-fetus-pregnancy-barriers-and-the-doing-allowing-distinction-with-elselijn-kingma-fiona-woollard-and-elizabeth-harman/

21. Alyssa: Kate Greasley offers the conjoinment amendment to our Stacy & Suni thought experiment- thank you for this suggestion, it has been really interesting to consider.

    I’m still inclined to think that Stacy has a right to be detached (especially in consideration of the risk of death for Stacy), but intuitions might differ here. Part of this might be due to the metaphysics of pregnancy. Conjoinment seems to be, mereologically, a state of proper overlap, meaning that the organs are shared between both Stacy and Suni. In other words, we might be depriving Suni of her own organs when we detach the two girls. Can we say that Suni is depending on Stacy in this case? Rather, she is dependent on their shared organs. In contrast, I am more persuaded that pregnancy is a relationship of parthood (defended by Elselijn Kingma in Mind in 2019, “Were You a Part of Your Mother?”), or perhaps a process of the fetus splitting off from the pregnant person’s body (defended by Anne Sophie Meincke in Philosophical Studies in 2022, “One or two? A Process View of pregnancy”). On such a view, the conjoinment metaphor seems less apt.

    We might offer another hypothetical: a child is holding a heavy weight that will drop onto another person if they let go, killing them. Make this other person a child. The weight-carrying child is told she needs to do this only for the next nine months. This is apt analogy because, as Kimberley notes in other work, research indicates that gestating is one of the most arduous tasks the human body can undertake. It seems that those responsible for the weight carrying child should not allow her to make the sacrifice of bearing the weight for nine months, given the immense toll that this will take on her, and that she is at risk of being crushed by the weight herself.

22. I am grateful to have the opportunity to offer some reflections on this stimulating paper. Alyssa and Kimberly helpfully draw our attention to important ways in which pregnancy can jeopardize the health and well-being of girls. Insufficient recognition to these risks of the sort that is arguably commonplace in many societies can contribute to the injustice they dub ‘anti-girlism’. However, from these valuable observations Alyssa and Kimberley draw an erroneous conclusion about the appropriate response to the phenomenon of youth pregnancy. In their view, concern for the health and well-being of impregnated girls requires adoption of a policy I will label ‘mandatory abortions for minors’. This is, needless to say, an extremely controversial position. In my view, it is inadequately justified and offers a politically inapt response to anti-girlism. Let be briefly identify my reservations about the justification of the position and then comment briefly on how we might characterize a better response to anti-girlism than mandatory abortions.

    First, even if we grant that youth pregnancy is usually detrimental to the health and well-being of girls, this will not always be the case. In a well-functioning health care system, decisions about patient care are appropriately tailored to individual patients with due recognition of the details of their situation both physically, psychologically and socially. A policy of mandatory abortions for minors rests on sweeping generalizations that may not hold true in particular cases. A more nuanced approach would allow decisions about care for pregnant girls to be informed by and sensitive to their particular circumstances. This need not involve ceding decisional authority entirely to parents or to children. Instead, the process of decision making can involve inputs from health care professionals and social workers who are charged with the responsibility of protecting the health and well-being of girls. It is extremely doubtful that an across-the-board policy of mandatory abortion for minors will, in practice, be suitably sensitive to the health and well-being of all girls.

    Second, Alyssa and Kimberley’s analysis is surprisingly insensitive to the importance of attending to voices of children about their own care. There is now quite a large literature on the importance of recognizing and respecting the emerging agency of children but this literature is not explored. In medical contexts, there is recognition of the fact that children can demonstrate that they are ‘mature minors’ with authority to make decisions about their own treatment. This can include authority to make decisions to refuse life-saving medical treatment. Exactly how much weight should be given to the voices of children regarding their own care is a complex matter. Sometimes it is appropriate to attend to the voices of children even if they are not permitted to make authoritative decisions about how they are treated. But sometimes respectful treatment of children requires permitting them to make decisions that jeopardize their own health or well-being. A policy of mandatory abortions for minors renders the voices of girls about their pregnancies as irrelevant to decision making about their treatment. Arguably that constitutes a form of silencing that is disrespectful to girls. Alyssa and Kimberly owe us an explanation of why girls should never have decisional authority to make decisions about their own pregnancies.

    Third, the appeal to the goods of childhood on which part of the argument rests is not sufficiently subtle. The very features of teenage pregnancy that make it an extremely serious matter are very likely to disrupt access to sense of innocence, carefreeness, or play that it would otherwise be important to secure for children. Damage to the goods of childhood will be even greater in cases of pregnancy arising from sexual assault. Against this background, it’s hard to see how a mandatory abortion (especially one against the wishes of the minor), can reliably help to facilitate access to those goods. Indeed, a forced abortion would arguably do more to block access to those goods. Moreover, ensuring that children have access to these goods requires some attention to their own voices and how they envision their good in their specific circumstances. Here too the protocol of mandatory abortions for minors is properly not attentive children’s voices and their capacities to articulate, to some important degree, their own conceptions of the good.

    Finally, I think the focus on mandatory abortions for minors is not constructive as a political proposal. Alyssa and Kimberley correctly point to ways in which the social and political environment in the United States (and other jurisdictions) is extremely hostile to recognition of the interests of girls and they are right to be concerned about the trauma that can accompany a teenage pregnancy. However, I am skeptical that advocating mandatory abortions for minors contributes to ameliorating this environment and advancing the pressing interests of girls. The evidence Alyssa and Kimberley cite about the risks posed to girls by pregnancies and the unwelcome pressures girls often experience to continue a pregnancy suggests that political attention is more fruitfully focused on other matters. In the U.S. where the situation is especially dire in light of recent legal and political developments, great moral and political urgency attaches to ensuring that children of all ages have access to safe, legal abortions that are fully publicly funded. Similarly, it makes sense for social policy in this domain to include the provision of resources to assist children, their guardians, and relevant health care providers in reaching a decision about whether to terminate a pregnancy. Ideally, decisions should be informed about whether to terminate a pregnancy should be informed and made under conditions that do not subject children to coercion, pressure, or stigmatization. Securing such conditions requires solidaristic political action of the sort that is not likely to be advanced by insisting that state policy should require all minors to terminate their pregnancies. Indeed, pursuing the proposal may jeopardize progressive political collaboration.

23. Kimberley: In her response above, Japa makes an important point that an impregnated girl might be the first to know about her pregnancy and she might be able to hide it while thinking through her options, which makes her vulnerable in distinctive ways. This is a fair concern. Education, free and accessible contraception, early detection, and adult support for children as children are all ways to mitigate that risk.

    Anecdotally, many girls are not the first to know that they have been impregnated. Former Member of Congress, Barbara Lee, gave testimony before the House Oversight Committee in 2021 about her experience of having a back-alley abortion in Mexico, reporting that sex education was non-existent in her Catholic girls school and she wasn’t sure how someone became pregnant when it turned out, at 16, that she was. In the case of the 12-year-old Mississippi girl Ashley (whom we discuss in the paper), her mother took her to the hospital for severe vomiting, at which point they learned that she’d be impregnated by the stranger who raped her in her front yard. Girls’ epistemic position is important. One point we note in the paper – but do not give the attention it deserves – is that abortion laws that have first-trimester or even second-trimester limits indirectly discriminate against girls, because girls are less well-placed to know that they are pregnant and less able to seek remedy expeditiously.

24. Alyssa: thanks for this follow-up, Japa.

    I would be hesitant to treat pregnancy differently from other forms of healthcare. We might consider that in many cases, children would conceal ailments if their communities refused to allow them medical treatment, but that this is not a decisive reason to lower our standard of care. If these communities were larger would we lower our standards of care more broadly? Perhaps this would be the only politically viable option, but I am struck by how profoundly we would be failing these children.

    As an aside, (as Kimberley has highlighted in her comment) one thing that was rather haunting about our research were the reports of young girls who were impregnated and gave birth, but had no idea what was happening to their bodies, and did not recognize the symptoms of pregnancy.

25. Alyssa: Thanks for your question Dionissis.

    In our discussion, we allow for exceptions to our paradigm case of a child for whom abortion care should be provided. We consider such (rare) exceptions primarily in relation to those older adolescents who should be viewed as functioning as adults (i.e. whom doctors would reasonably treat as adults in other serious medical contexts). However, if we entertain the idea of a species of rational aliens who reach adulthood at age 12, we could consider this case. Their reaching adulthood at that age would depend, most likely, on them having a shorter lifespan overall (i.e. their moving through their life stages more rapidly than we do) and, thus, a claim to a shorter period of protected childhood.

    In the case of persons, I am skeptical that a (human) 12-year-old could ever be sufficiently mature to make the decision to continue a pregnancy, given the extreme risk it poses her. Even setting aside her decisional competence, we would not (and should not) consider even a mature 12-year-old capable of refusing chemotherapy or a lifesaving blood transfusion.

26. Alyssa and Kimberley: We’d like to thank Andrew for pressing us on our emphasis on child sexual assault given the statistical details he notes in his comment. In reply:

    First, Andrew says that ‘If this essay were mainly about abortion as adequate care for girls under the age of fifteen, then I would understand why pregnancy is depicted here as…usually … the result of specific wrongs that someone did to her…’ Since the age of consent in many US states is 16, Andrew would presumably allow the revision: ‘If this essay were mainly about abortion as adequate care for girls under the age of sixteen…’

    That said, in close to 2/5ths of US states, the age of consent is even higher. We note in fn 23 that: ‘Statutory rape is defined as nonforced sex with a person who is under the age of consent. In over three-fifths of US states, the age of consent is sixteen. In two-fifths, it is either seventeen or eighteen. In some US states, children as young as fourteen may consent to sex under restricted conditions, such as when the two persons are of similar ages and the older is not an authority figure to the other.’ The differences across jurisdictions – which can result in radically different outcomes – is a distinct issue from the moral question of what the law should be: What should the age of consent be? For a survey of the legal differences, see: https://onlinelibrary.wiley.com/doi/10.1111/psrh.70055?af=R

    Second, with regard to rates of sexual assault, more children are raped by someone than we might imagine, and the majority of these child victims are girls. UNICEF reported in October 2024 that more than 370 million girls (1 in 8 girls) are raped or sexually assaulted by someone before they turn 18. UNICEF (2025), Sexual Violence: https://data.unicef.org/topic/child-protection/violence/sexual-violence/#status. What percentage of these rapes are impregnating rapes is difficult to ascertain, partly because evidence indicates that many, if not the majority of embryos, are engaged in a terminal process: https://pmc.ncbi.nlm.nih.gov/articles/PMC5443340/. In other words, more often than not, a girl might be impregnated and never know it.

27. Alyssa: Hi Andrew, thanks for your contribution to the discussion!

    I won’t say too much in response to your first point, as I think Kim is developing a comment on this that I agree with. I will just say that part of the reason that we focus on rape is that this has been a vastly underappreciated concern as it pertains to abortion care for minor girls, and gives rise to urgent reparative duties.

    Related to your third point, I am intrigued by your question related to carefreeness. This is something I have been developing in my own work, so I am sure that Kim’s thoughts might be different.

    To start, I do think that carefreeness is important in a different way for older adolescents compared to young children. It is, in and of itself, less important, or perhaps less fundamental to a good adolescence than carefreeness is to a good childhood. For instance, in the article we point to Luara Ferracioli’s (2023) work, that argues that carefreeness is a precondition for accessing the other goods of childhood. Perhaps the same is not true for older adolescents. Nonetheless, I would maintain that being burden free, and having the space to experiment and develop one’s identity, is of paramount importance in adolescence. I think there’s a risk of under-appreciating the value of ‘burdenfreeness’ in adolescence and of narrowing future life paths as a result. While it’s appropriate for adolescents to be preoccupied with academics, extracurriculars, and to be thinking about their futures, we would seriously wrong them by treating them as adults- for instance, by being a familial breadwinner, or treating an adolescent as an extra parent for their siblings. It is in this sense that I think we cannot abandon protecting carefreeness in adolescence.

    Another concern we consider is that girls are often adultified: they are pressured to grow up quickly. This is an instance of antigirlism. If we grant that maturity is a reason to forgo the protections of childhood, then we acquiesce (and likely compound) this antigirlist pressure, by withdrawing general childhood protections from girls.

    I’ll chime back in later with some responses to your second point.

28. Thanks for the comments so far, everyone! This has been a great discussion, We look forward to responding to those we didn’t get to yet & to hearing more contributions tomorrow.

29. Thank you for the opportunity to comment on this excellent article.

    At the conclusion of her influential article “A Defense of Abortion,” Judith Jarvis Thomson claims that an attractive feature of her view on the morality (and legality) of abortion is that it does not conclude that abortion is “always permissible'” (65).

    She thinks, for example, that it would be impermissible because indecent for a pregnant person

    “to request an abortion . . . if she is in her seventh month, and wants the abortion just to avoid the nuisance of postponing a trip abroad.” (65)

    But, she says, her view, to its credit,

    “allows for and supports our sense that, for example, a sick and desperately frightened fourteen-year-old schoolgirl, pregnant due to rape, may \textit{of course} choose abortion, and that any law which rules this out is an . . . [outrageous] law.” (65)

    Thomson’s remarks assume at least two things. First, that the correct position on the morality and legality of abortion applies to both women and female children without modification. Second, that the right approach to the case of the fourteen-year-old girl is to offer the girl a choice as to whether or not to have an abortion. On Thomson’s account, a defensible abortion law grants to children who become pregnant due to rape a choice as to whether or not to have an abortion.

    These two assumptions are connected. The idea seems to run as follows. It would be outrageous not to grant a pregnant adult the choice of whether or not to abort a foetus were she pregnant due to rape. We ought to apply to children the view of the morality (legality) of abortion that we apply to adults. From which it follows that, like pregnant adults, fourteen-year-old children ought to be given a choice, especially in the scenario Thomson describes.

    In their powerfully argued and timely article, “Justice For Girls,'” Alyssa Izatt and Kimberley Brownlee argue against both these assumptions. Specifically, Izatt and Brownlee argue that:

    1. We ought not to apply to children the view of the morality (legally) of abortion that we apply to women. Pregnant children have interests distinct from those of women and these “must be considered in their own right” (517). Children are owed differential treatment (521).

    2.We ought not (contra Thomson) to give children a choice as to whether or not to gestate and parent; we should view the pregnancy of a child as a “malady and take steps to terminate it” (517; also 520), even “against their [a child’s] wishes” (522) and preferences (542-46).

    That pregnant children, who “sit at the intersection of childhood and female embodiment” (519, 523–524), are treated as though they are adults in the context of abortion services is a brand of injustice that Izatt and Brownlee call anti-girlism (519, 528–529).

    Izatt and Brownlee rely on two arguments for 1 and 2.

    First, Izatt and Brownlee contend that abortion care is owed to children as part of “minimally adequate medical care” because the risks of pregnancy “for girls are far more serious than the risks for adults” (526). They think that the costs of gestation and rearing may not be imposed on or allowed to be borne by a child. They support this by way of analogy with living organ donation. Except in very select circumstances, children are not permitted to participate in living organ donation. In order for a donation of this sort to be permissible it must be voluntary (not the result of coercion or manipulation), minimally risky, and in the best interests of the child. However, in all but rare cases, these conditions are not met. The very same conditions are, in all but rare cases of impregnated children, not met. So just as we should not permit children to choose to make living organ donations, we should not permit them to choose to gestate and parent.

    Second, Izatt and Brownlee join those who think that childhood has distinctive values and rights, including the good of being shielded from the full responsibility of making certain consequential decisions (like the decision of whether or not to abort), and the right to enjoy certain goods of childhood (e.g., carefreeness) (540-542). This right protects children from taking on the burden of gestation and childcare which would involve forgoing these goods.

    I have two comments, both focusing on treating younger children and older children differentially.

    First, I would like to consider a potential feminist concern. Some feminists have argued that gaining complete control over their reproductive lives is key to ending the oppression of women. This control takes the form of granting women very liberal rights and full access to abortion. One might worry that in defending the claim that girls who become pregnant ought not to have control over their reproductive lives one contributes in one way to the oppression of those who are female embodied.

    Izatt and Brownlee’s view seems to imply that this makes sense in the case of adult females but not in the case of children. In fact, it is policies giving or claiming to give children control over their reproductive lives that contribute to oppression of pregnant children (not to mention policies denying abortion). Such policies involve leaving a young child to “decide” to assume a significant uncompensated sacrifice in order to gestate, a sacrifice we would most likely not permit a child to take on in the case of living organ donation.

    On the view I think that Izatt and Brownlee hold, the right feminist stance ought to be to give broad access to abortion services to all people capable of pregnancy but not liberty of choice to all such people. Their view seems to imply that, for feminist reasons, we ought to treat girls and women differentially. What ending oppression might seem to imply is limiting choice for children capable of pregnancy on grounds that the cost of gestation is much greater than the cost of mandated abortion and that girls qua children have a right to a childhood, which involves, in part, being shielded from making the decision of whether or not to abort.

    I find this view compelling but not altogether satisfactory. There seem to be two rights that are worth distinguishing: the right to control one’s reproductive capacities and the right to refuse medical treatment even if that treatment is good for you. The feminist concern focuses on the reproductive right, the right to control one’s reproductive capacities. A very young child could not be said to have such a right and so mandating abortion for such children may not militate against any feminist objectives concerning oppression. However, as a child matures and reaches the later stages of adolescence, it is plausible that this right emerges and constitutes a factor in determining how they ought to be treated. It seems that the thesis of Izatt and Brownlee’s article, that we ought to mandate abortion for all pregnant children, involves running roughshod over this right and may contribute to oppression or oppressive structures. This calls, in my view, for the differential treatment of young children and older children.

    Second, I agree that in general children who become pregnant should be shielded from the decision of whether or not to have an abortion, where being shielded involves being free from the burden of making the (adult-like) decision themselves. Being shielded is a form of freedom that permits children not so much to be carefree but to be free to care about the kinds of things children and adolescents distinctively care about (e.g., athletics, friendships, the type of person they want to be or become, and the like). These are goods that pregnancy in childhood prevents.

    These goods together with the cost of pregnancy do seem to justify forced abortions for young children who lack decision-making capacity. However, it is less clear that such goods justify abortions for an older teen who validly refuses one. An older, mature teen with decision-making capacity may plausibly have a right to refuse treatment even if it is on balance good for them.

    Consider the following case. Elisa is seventeen-years-old. She is in a relationship with another, mature seventeen-year-old. She unintentionally becomes pregnant. She has a supportive family and possesses the competence typical of adults whose decisions are granted compliance respect. She understands and appreciates her treatment options and their risks and benefits. If Elisa validly refuses an abortion in light of the information she is given and her reasoning on the basis of it in light of her values (not mere preferences or wishes), it is not obvious that we ought to proceed with it anyway. Elisa might have a right to autonomy grounded in her decision-making capacity, a right that constrains what we may do to her even to promote her own well-being.

    Izatt and Brownlee rightly stress that the harms of gestation in the case of pregnant children are greater than the harms of forced abortion, but it is not clear that in a case like Elisa’s there are not other factors apart from welfare benefits that matter to how they ought to be treated, including perhaps a right to refuse treatment and to have one’s wishes heard.

    It is typical in cases in which adolescents possessing decision-making capacity validly refuse medical treatment, e.g., a life-saving blood transfusion, that treatment is not mandated and not automatic. Instead, some normative weight is given to the valid refusal. This valid refusal must, it seems, be balanced against the benefit of the treatment. This balancing seems the right way to proceed in the case of older children who are pregnant but refuse an abortion.

    This again calls, in my view, for the differential treatment of young children and older children.

30. I wonder if Andrew’s first question might also reflect an interest in getting clearer about the role of rape in the argument. Would the argument be the same even if, perhaps contrary to fact, most childhood pregnancies were the result of consensual sex between children?

31. In their lucid and well-argued paper, Alyssa Izatt and Kimberlee Brownleee argue that impregnated girls – whatever their exact age – should be treated like children. They should be provided abortion care whether or not they consent to the termination of their pregnancy. This is because this protects their rights as children to a good childhood, does not burden them with decision-making that they are unable to make, and prevents them from substantial risk to their well-being.
    While I am impressed by many of Alyssa’s and Kim’s arguments, there are two points I would like to raise.
    First, they hardly mention how the girls become pregnant. They seem to focus on rape in passing, but do not motivate it any further. But if their arguments for abortion care in the case of girls depends on their being raped, does this fact not carry much more normative weight than the other reasons they mention (risks to health and well-being, violation of their rights and the undermining of their goods of childhood)? After all, even an adult woman who has been raped seems to have access to abortion care under many jurisdictions that are skeptical about abortion in other non-rape cases. So is it not the fact of rape that mandates abortion in any case?
    In contrast, could the fact that a seventeen-year old girl is pregnant even though she consented to sex beforehand, and was fully informed that having sex can lead to pregnancy, change Alyssa’s and Kim’s arguments for a duty to provide abortion care to girls? There is a danger of infantilizing their autonomous choices for sex if decisions regarding the known consequences of their choices (pregnancy) are fully taken out of their hands.
    Second, if we agree that girls should be treated more like children than like adults for the reasons Alyssa and Kim provide, I wonder what explains that we are licensed to treat young women (19 year olds, e.g.) as full adults. Their well-being may still be compromised, they may still not be fully autonomous, and a pregnancy may still carry more risks than for older women.
    Conversely, consider a seventeen-year-old who becomes pregnant following consensual sex, undertaken with an adequate understanding that pregnancy is a possible outcome. Would this not complicate Izatt’s and Brownlee’s argument for a duty to provide abortion care in all such cases? There is, it seems, a risk of infantilizing adolescents if the consequences of their informed and voluntary choices are removed entirely from their deliberative authority.
    Second, even if we grant that girls should, for the reasons Izatt and Brownlee offer, be treated more like children than like adults, it is not clear where the relevant threshold lies. What explains our readiness to treat young women—for instance, nineteen-year-olds—as fully adult in this context? Their well-being may still be comparatively fragile, their autonomy still developing, and pregnancy may pose greater risks for them than for older women. What, then, justifies the sharp normative transition?

32. I have enjoyed very much reading Alyssa’s and Kim’s excellent article and the discussion on this blog so far. Thank you to everyone.

    Like several others at this point, the issue regarding which Alyssa’s and Kim’s arguments seemed less than fully persuasive to me is the justification of mandatory abortion care for older teenagers (i.e. 16 & 17 year olds). I assume that at that age teenagers have the right to choose to have sexual relations, and accordingly, that various EU countries legislation that set the age of consent at 16 is justified.

    My first, three-part, question for Alyssa and Kim, which take this observation as a starting point, is:

    a) Whether they agree that setting the legal age of consent at 16 is justified.

    Their references so far in this blog to historical vagaries that have determined where that age is set may imply they do not agree; the next part of my question is:

    b) Whether they think that where we stand with regard to where the age of consent should be set makes a difference for their view regarding older teenagers. More specifically, do they think that if we believe that older teenagers can have consensual sex, then the case for extending mandatory abortion care to them is weaker, if not undermined? Or do Alyssa and Kim think that their views about mandatory abortion care can stand wholly independently of questions about the age of consent? (This question is related to, but not the same as, Andrew’s and Japa’s question about the role of rape in causing pregnancies for Alyssa’s and Kim’s conclusions.)

    Finally, I wonder:

    c) What Alyssa and Kim think of the legally created inequality, on their proposal, between girls and boys who have sexual relations. On their proposal, it would be true of girls, but not boys, not only that only they can end up pregnant, but also that, if they do, they would receive mandatory abortion care. We may find this sex-related inequality concerning. (This point is similar to but not the same as the one Anthony raises, about the importance, for many feminists, of recognising women’s rights to control their reproductive lives. The concern I am raising makes reference to the fact that on Alyssa’s and Kim’s proposal only girls acquire a new liability to unchosen interferences with their bodily integrity. This may seem disturbing even if we think that older teenagers should not, at least not in principle, have interests in making reproductive decisions.)

    I may continue with more questions later!

33. I am intervening quite late in this fantastic debate (for which apologies). I am sympathetic to the worries raised about penumbral cases though I also agree that focusing on these puts us at risk of losing sight of the other cases and how radical the paper’s conclusions are in respect of these too.
    A couple of points. First, Monica Betzler’s point about what does the work here – rape, or the risks inherent in childbearing- is interesting. It seems to me though that those points work in tandem: it is precisely in so far as girls cannot be deemed to consent to those risks that mandatory abortion gets purchase . (There’s a related question here about severely cognitively disabled women).

    Second, a number of comments worry about the arbitrariness of thresholds. Unless we want to go case by case (and there may well be good reasons not to), thresholds are unavoidable. The question then is which risks morally we ought to run when setting the threshold: the risk of imposing an abortion on girls who in fact ought to be treated as women vs the risk of failing to rescue from the harms of pregnancy/childrearing a girl who ought to be treated as a girl. What we ought to do partly depends on one’s prior view on acts and omissions, as well as on one’s views about the comparability of those harms, does it not? If they are roughly comparable and if other things roughly equal harming is worse than allowing harm to happen, then this would cut against mandatory abortion.

    Isn’t that right?

34. On Colin MacLeod’s objection that the focus ought to be on properly supporting pregnant girls both during and after pregnancy (which implies substantial improvement to health care and other forms of material assistance) two questions:
    1. Would he accept mandatory abortion as a second-best proposal given that/if his preferred proposal is not implemented?
    2. Does he think that we ought to let a 10 year old girl carry on a foetus to term even if she says that this is what she wants? In other words I wonder how far he is willing to take his case-by-case basis+substantial provision approach.

35. On Colin McLeod’s objections: I wasn’t sure whether he would apply a case by case approach irrespective of age (eg even to a 10 year old girl), and whether he would accept mandatory abortion as a second best option if the fairly substantial improvements to health care and welfare provision he defends are not made.

36. Thank you for this thorough response, Colin.

    Here are a few initial thoughts on your response (I will try to follow up to some of your other thoughts later).

    Like Cecile, one query that I have after reading your response is whether your concerns apply only to older adolescents or to all children. And, if the latter, would you accept the implications that Kim raised in response to Anca? For the sake of clarity, I’ll restate Kim’s point here. Highlighting that the youngest girl on record to give birth was five, Kim wrote, “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.”

    One point you raise is that it is not always the case that pregnancy is detrimental to the health and wellbeing of girls. I have a concern here, which is epistemic in nature. As a matter of fact, we could concede that perhaps some girls will not experience detrimental effects from gestation and labour. This is an empirical stipulation, of which I am not convinced, if only for the fact that girls who gestate and give birth will experience immense pain in labour. Nonetheless, let us stipulate. How could a girl’s physicians be in a position to know that she will not hemorrhage during labour? Even if she is at a low personal risk, her physicians cannot know that this substantial harm will not occur if she continues with the pregnancy. In “Pregnancy, Caregiving, and a Supposed Obligation to Gestate,” Christie Hartley and Ashley Lindsley-Kim (2025) observe that one feature of pregnancy (in adulthood) is that oone cannot know whether a given pregnancy will be high risk. In childhood, we can be confident that it will be, even if we grant the possibility of exceptions.

    On another point, the political viability of our position is something that I’ve been thinking about. I think that if a more lenient (and politically viable) version of the protocol is adopted, it should at minimum be pro-abortion, that is to say, it should not present abortion, adoption, and mothering as equivalent options. However, it’s possible that pro-abortion (but not pro-mandatory abortion) policy would be politically unviable as well, especially in the US, a point that Japa gestures toward in her correct observation that “the pro-life community in the United States is large and robust”. Is this a reason not to argue in favour of the best interests of girls? If we couch our philosophical arguments for political reasons, we risk obscuring the truth of the matter.

    I take seriously the concern that our position could stigmatize adolescent mothers. I think that our view is compatible with one that urges greater support for girls who do gestate and for girls who do then try to mother. We can improve our understanding of what standard of care girls are owed without abandoning those girls who are failed by the system. If anything, our argument serves to highlight the reparative duties that are owed to these girls, and the urgency with which we should preserve their final carefree years. If hospitals, clinics, and medical associations do not adopt the protocol we recommend, then they must strive to ensure that girls who are impregnated and who mother in childhood are well-supported in preventative ways and remedial ways (in particular relating to education and contraception to prevent recurrent pregnancies).

    Relatedly, you mention the possibility that access to the goods of childhood might be radically compromised in cases of childhood impregnation, especially in the case of rape. We address this concern in the paper, “In reply, being carefree or burdened is not a binary. Cares and burdens fall along a spectrum of intensity and duration. Certain courses of action compromise the space of carefreeness to a greater or lesser degree. Rape and impregnation radically compromise carefreeness, but the child’s level of burden can often be mitigated, and her reprieve from adult cares can be salvaged. As a reparative measure, her adult caregivers owe it to her to relieve her of those burdens that they can relieve.” (p.542-543). Abortion ensures access to these goods by ensuring that girls do not take on the radically compromising role of motherhood, which would preclude their access to these goods entirely.

    You raise several concerns about the role of young people in decisional contexts. In writing the paper, we considered the concern that our proposal is actually antigirlist insofar as it might infantalize girls. We agree that infantilization (i.e. treating a competent person inappropriately or condescendingly like an infant or young child) is objectionable. However, we resist the suggestion that our recommendation infantilizes girls. The choices to gestate and to become a mother are not ones that girls are competent to make. As we note above, we might craft a slogan such as ‘Too young to fight, too young to gestate’ to make the point vivid. Setting aside the complex and transformative considerations that makes becoming a mother a difficult choice for an adult woman to make, gestation and motherhood carry substantial harms. Children – including older children – are shielded from assuming such harms for the sake of another person regardless of their preferences. We would need a good reason to differentiate pregnancy from these cases, otherwise, we merely perpetuate antigirlist injustice, which categorizes girls as wiser and more adultlike than their male counterparts, and denies them the protections of childhood.

    You write, “Exactly how much weight should be given to the voices of children regarding their own care is a complex matter. Sometimes it is appropriate to attend to the voices of children even if they are not permitted to make authoritative decisions about how they are treated.” I would be interested in hearing more about this- is our view incompatible with compassionately attending to girls’ voices, while not deferring to them? In the paper we argue that girls should be heard, they should have independent advocates, and they should be treated with compassion.

    Finally, I agree that the best course of treatment is something that is tailored to specific patients and circumstances. Nonetheless, there are standards of treatment, especially relating to what constitutes adequate care, especially when it comes to what vulnerable dependents are owed. When someone is dying from blood loss, they ought to receive a transfusion. When someone has cancer, they ought to receive chemotherapy (or radiation, surgery, etc.). In arguing that minor impregnation is a malady, the conclusion is that when a minor is impregnated, they ought to receive an abortion. I think our proposal has room to acknowledge that there might be scenarios when greater harm (or compromise of her rights) would arise to a child in providing an abortion. We acknowledge such cases as tragic, and we grant that, in certain cases, the best solution could be more complicated than the straightforward application of our protocol. This does not change that the default of abortion should be socially accepted. We should strive to have prevent girls from becoming mothers.

37. Thank you, Alyssa and Kimberly, for the thoughtful responses to my questions (and for your responses to all of the comments in this session). I really appreciate the opportunity this affords to get a better understanding of your thinking and to give me the impetus to explore my own.
    I have a couple of replies to your responses and a couple of novel reflections. But I very well understand that you may not have a chance to respond in turn.

    First, on the issue of sexual assault.

    Though I failed to fully explain my thinking, the reason I said the focus on sexual coercion makes the most sense in girls who are 14 or less is because (from what I have read) the rates of voluntary sexual activity significantly rises between the ages of 14 and 15. Therefore, I thought that (setting aside for a moment the issue of statutory rape) it started to become less safe to assume that pregnancies in girls 15 and up were typically the result of rape or coercion. But I don’t want to quibble about this.

    I would be worried about leaning too heavily on statutory rape laws to make the case that most pregnancies are the result of rape. First, it does not seem as if the fact that different states have different laws on the age of consent means that, from a moral point of view, what is “empirically” consensual sex between 16-year-olds in different states has a radically different moral import. Perhaps the authors’ real point, however, is that the states with the higher ages of consent (and which lack the “close-in-age” exemptions) are closer to the mark morally speaking. Here we might just disagree.

    I also think we need to be careful about distinguishing between the text of the law and how the law actually functions. As I understand it, US states that have high age-of-consent laws and no close-in-age exceptions simply attribute more importance to prosecutorial discretion in deciding when someone ought to be charged with the offense. While statutory rape laws were once specifically gendered and meant to protect the virginity of girls, the more modern approach (if I am not mistaken) is animated by the principle that we should prevent older or more powerful individuals from manipulating or taking advantage of vulnerable, younger children.

    My point is that what looks like consensual sexual activity is not rare in older teenagers. According to the Guttmacher Institute, about 40% of American high school students report ever having had sexual intercourse. What about sexual violence? According to the same source, about 13% of American females aged 18-24 report having ever been forced to have vaginal sex (and, by 24, over 90% of Americans have had sexual intercourse). I agree that this number of females reporting sexual coercion is disturbing (and it does not even account for all sexual assault), but this still suggests that most sexual activity among high schoolers is probably not experienced as coerced. Therefore, it seems doubtful to me that pregnancies among older teens are generally the result of sexual coercion. You could argue that some people might think that they are engaging in sex in a voluntary way, when in fact they are being manipulated. But I don’t see how it is plausible to maintain that this is almost always true.

    Maybe the authors’ view is that sexual assault is so underreported that it is not safe to assume that any significant rate of pregnancy in teenagers is the result of voluntary sexual activity. That seems like an epistemic overcorrection to me, but perhaps this is just another place where we differ.

    The more important reason I asked this question has to do with the nature of the argument and the method of the paradigm approach adopted here. There are some passages which suggest that the reason why we have such firm duties to protect girls’ well-being is because they have already been victimized. For example, the authors write, “failing to terminate a child’s pregnancy amounts to a further imposition on a child who has in most cases already been violated by someone. If anything differentiates child organ donation from child pregnancy, it is this. The impregnated child has already been violated by someone and thereby has had her right to a childhood compromised…” (531-532, emphasis added). This makes it look like the assumption that pregnancy is a violation is doing real work. But there is a footnote that points in the other direction: “We … treat impregnating rape as the paradigm case requiring analysis, but our argument that abortion is part of adequate care for a child applies equally to cases in which two children have sex resulting in pregnancy” (522, fn. 23). If the argument works regardless of how the pregnancy came about, then I am a little puzzled why the much more controversial claim about most pregnancies being due to violation is being made.

    Perhaps the thinking went like this. Discourse about reproductive choice often treats everyone who can get pregnant as an adult. But that is wrong, because people who we still ought to treat as children can get pregnant too. The paradigm case of the pregnant child is someone (say) between the ages of 10 and 14. And how do children, in this paradigm case, get to be pregnant? Mostly by rape. Older teenagers, then, are treated as liminal cases, mostly to be assimilated to the paradigm of the child, but in “rare exceptions” to be treated more like adults.

    You could see the discourse in other medical contexts (like organ donation) taking a similar path. We already have a paradigm for how to treat adults. Next, we need a paradigm for thinking about what is special about children’s interests and vulnerabilities. Then we treat older teenagers as the borderline cases.
    Myself, I think adolescents deserve more specific attention than this. But at least in most medical contexts, the issues arise in a roughly regular way for people at different ages. Ten-year-olds get leukemia and so do 16-year-olds.

    But this method seems to me especially problematic when we are thinking about pregnancy in minors, because the vast majority of pregnancies are occurring in the “liminal cases.” This makes me think that, while it is a good idea to develop a model for how to handle pregnancy in younger girls, it is a mistake to think that this is the right starting point for thinking about older teenagers. All of this is of a piece with my fundamental concern here, which is that, while the paper makes the good point that we should not “adultify” girls, there is also a danger of infantilizing teenagers.

38. On the issue of the value of being free from certain burdens in childhood: I appreciate Alyssa’s suggestion that being carefree might be valuable for children and teenagers, though the nature of being carefree in those ages might differ. That is a good response to my somewhat glib point about how I wouldn’t describe the teenager’s existence as particularly carefree.

    I particularly agree (as I argued in “On Becoming an Adult” [Phil Quarterly 2013]), that we are justified in trying to prevent adolescents from starting adult commitments too early in life. That might seem to put me in the same camp as Izatt and Brownlee. However, I was thinking that an unexpected pregnancy (and some serious medical questions) showed the limits of that principle, since they represent what I called “forced, momentous decisions”: cases where a decision of some sort needs to be made and where the decision, however it is made, will have a significant impact on the person’s life story. In those cases, my view was that, if we care about people being the authors of their own lives, we couldn’t just make the decision for the young person and say that she’ll have plenty of time to make her own decisions of that sort when she’s grown up. (I won’t try to sketch here my views about how to think about medical decision-making for adolescents, but it is an issue I have explored in “Competence for Minors” in Consenting Children edited by Forsberg, Black, and Skelton. Indeed, most of the essays in that book are relevant to this issue. )

39. Finally, if I may make a new intervention, just to put it on the table, without any expectation that it requires a response.

    As I have said, I commend the authors for drawing our attention to the very interesting comparisons between pregnancy/abortion and other forms of medical intervention, like organ donation and treatment for cancer. I think that we can learn a lot from this way of proceeding. But here are two reflections on potential disanalogies that a critic might seize on. I do not raise these as decisive objections; I am just exploring the ways that reproductive choices are like-or-unlike these other cases.

    First, in the case of organ donation, the question is whether medical professionals ought to paternalistically refuse to intervene at the request of a child-or-adolescent patient. In the case of abortion, we are talking about a highly intrusive paternalistic bodily intervention against the child-or-adolescent’s will. It’s going to strike many people as plausible to think that the moral requirement against paternalistically intervening on a person’s body contrary to her will is stronger than not-paternalistically-intervening against the patient’s will.

    Izatt and Brownlee anticipate an objection along these lines. If I understand them correctly, they are saying that the doing/allowing distinction, even if valid, does not apply so well to cases of medical intervention. That is, a doctor can wrong a patient by not performing an intervention. I agree, but I am not sure this is the final word.

    Think about this in the case of a lower-stakes decision.

    Case A: Adolescent patient wants a medical intervention that the doctor considers averse to the patient’s best interests. The doctor refuses.

    We may think this is in line with the doctor’s professional duty to use her own clinical judgment.

    Case B: Adolescent refuses a treatment that the doctor considers to be in the patient’s best interests.

    To my mind, accepting that the doctor may permissibly refuse in Case A does not settle whether intervention against the patient’s objections is justified in Case B.

    This might seem to make the comparison to compulsory treatment for cancer the better analogy, because this is also a highly intrusive bodily intervention.
    But take the case of Cassandra Callender. Cassandra was virtually certain to die without treatment. Nevertheless, whether she should have been strapped down and forced to undergo treatment that she refused is controversial. I am inclined to think that the compulsory treatment was justified, but I still feel very uneasy about it. Suppose that there was only 1% chance that Cassandra would die from not receiving treatment. In that case, I certainly would not think the compulsory treatment was justified, even if the treatment was still in her best interests. While it is true that carrying a pregnancy to term for an older teenager carries elevated physical risk compared to young adults, the danger of dying in a country like the United States is not 1%. (Correct me if I am wrong). I recognize that this does not settle whether teenagers ought to be allowed to take these risks. And I grant that there are risks beyond the strictly medical ones. I only mean to raise a question about how far the analogy between the compulsory treatment of cancer for adolescents (or blood transfusions, for that matter) can be used as a kind of “moral precedent” to advance the argument about abortion.

40. I hope I am not breaching this blog’s etiquette by posting twice in a row.

    I wanted to mention one more question and a concern.

    First, the question: focusing only on the range of cases where Alyssa’s and Kim’s arguments, at the level of principle, are most compelling, i.e. where younger impregnated girls are at issue, I would be curious to know what stance Alyssa and Kim would take about abortion post-viability.

    Some things they say suggest that that their argument would extend to permit and require an abortion even once the fetus is viable. For example, they note that young girls (and their family) might not realise until quite late that they have been impregnated. Alyssa’s and Kim’s concerns about the substantial health risks of continuing a pregnancy and of delivery play an important role in their view that pregnancy for girls should be treated as a malady, and these considerations continue to be weighty even post-viability. Alyssa’s and Kim’s argument, furthermore, is supposed to work even granting moral status to the fetus.

    It seems to be that Alyssa’s and Kim’s arguments in this paper would be important enough if they could be taken to ground even just the legal right to have an abortion after fetal viability for girls below the age of consent.

    Second, I would like to raise a concern about the possible undesired effects of promoting and of implementing the mandatory scheme which Alyssa and Kim favour – issues which Colin and Japa have already spoken about. I think we could take Japa’s worry even further, and should take into consideration the potentially perverse effects of implementing a mandatory abortion programme even in the case where, in principle, it seems most justified, i.e. with younger girls.

    My thought is the following. As Alyssa and Kim themselves note, in countries like the US, teenage pregnancy is correlated with a number of other vulnerabilities, and sometimes, the very families of the impregnated girls may not think of abortion as an acceptable option. In fact, Alyssa and Kim’s proposal for mandatory abortion care aims, among other things, to protect these girls from their parents’ and other family members’ pressure. A mandatory abortion care scheme may incentivise families to not seek, and in fact, to shun, medical care for their younger girls even once the adults in the families realise that the girls are pregnant. Especially insofar as this happened to girls who are already vulnerable in other ways, the possible harm to them of implementing this scheme may be very great.

    A similar concern arises if we think of Alyssa’s and Kim’s proposal as one they would wish to defend globally. I take it that it is fully in the spirit of their proposal that it should be seen as advocating a standard for reproductive healthcare for girls that has global reach. The majority of all teenage pregnancies happen in developing countries and it is there that they are most dangerous (e.g. see
    https://pmc.ncbi.nlm.nih.gov/articles/PMC411126/). Yet in those contexts, too, the concern arises that girls may on balance suffer more harm if a proposal of the kind that Alyssa and Kim defends were implemented. In light of that concern, I wonder whether Alyssa and Kim, even if their argument at the level of principle were justified, should not favour softer measures, e.g. educational campaigns, over legally enforceable duties to provide mandatory abortion.

41. Thank you, Anthony, this thorough and thoughtful response.

    I’ll say a bit about the argument to treat older and younger children differentially. I think the Elisa hypothetical is useful in shedding some light on a concern that has come up in other comments this morning, from Monika and Serena (I will respond more directly to these comments in a moment).

    I do find the hypothetical compelling. Like you, I would not think that Elisa should be mandated to have an abortion. I wonder, however, if this is the sort of paradigm exception that Kim and I meant to account for. One of the realities of adopting a paradigm approach is that it is fuzzy at the edges (it avoids the hard and fast boundaries of a definition), but policy proposals require thresholds (as Cecile mentions). We adopted this approach nonetheless both to bring the treatment of abortion care into alignment with other forms of care and to offer robust protections in a context where there is a prevailing inclination to defer to girls’ wishes despite their being children. Additionally, I do think it is important not presume that adolescents are competent, when they are still entitled to the protections of childhood. For instance, should we let Elisa quit school, or take on independent debt, or join the military?* I would be inclined to say no. It seems like she’s still entitled to the protections of childhood, even in light of her maturity and competence.

    We acknowledge that the paradigm of childhood might not always map perfectly onto the UNCR definition of a ‘child’ as a person 18 years or younger (unless under the laws that apply to her majority is attained earlier). There are many cases where one might think persons under 18 are harmlessly and justly permitted into the realm of adulthood. For instance, it is routine (at least in Canada, for students who are born late in the year) for 17-year-olds to start University and live independently from their families as adults. While this might be viewed as a form of adultification, it seems to be a kind that would not harm or wrong the 17-year old, especially since they are likely a matter of months from the age of majority. Such a person, living in that way, would sit outside the paradigm of childhood and our protocol would not apply.

    This relates to Andrew’s question of just how rare these exceptions to the paradigm might be. I am working on my response to this and will chime in on this later.

    *the point about the military might be controversial, as in Canada and the US minors can join at 17 with parental consent. I do not agree with the practice of recruiting minors for the military.

42. Sorry, I just realized I didn’t tag my name to the last two post I made, in response to Colin and Anthony. These are meant to represent my own thoughts!

43. Kimberley: Thank you, Anthony, for your thoughtful comments.

    Anthony summarizes our contention to be that ‘abortion care is owed to children as part of “minimally adequate medical care” because the risks of pregnancy “for girls are far more serious than the risks for adults” (526).’ We should clarify that even if the risks were comparable – which they are not – children should be treated differently from adult women because children are not adults. Children should not bear comparable risks to adults in this context, and children should certainly not bear graver risks than adults do in this context.

    With regard to the case of Elisa, it’s worth noting that she is limited – legally and socially – in her ability to operate like an adult. In Canada, a 17-year-old will find it hard to rent an apartment, impossible to buy a house, hard to sign a contract, hard to work full time or do night shifts unless she has finished school, hard to get married without parental consent, and so on. Those are contingent realities, but they will confront any person who sits below the threshold their society has set for majority. They are relevant to the assessment of what is in her best interests and of what autonomy she should have over the risks that she – and any baby she would be trying to raise – must assume.

44. Alyssa and Kimberley: Thank you, Monika, for pressing us to clarify several key points. This post focuses on the first point raised.

    Monika’s first point (concerning our focus on rape) pertains to the question that Andrew raised about statistics, which I (KB) answered provisionally but noting, first, that rape of children is more common than we might imagine (and often goes unreported); second, that rape includes statutory rape, but jurisdictions differ in their specification of the age of consent; and, third, that positive law should not be our guide in moral debates about the age of consent. Japa then clarified the central question: ‘Would the argument be the same even if, perhaps contrary to fact, most childhood pregnancies were the result of consensual sex between children?’ In reply, we should distinguish three concepts: a) voluntary or intentional pregnancy, b) unintentional impregnation, and c) involuntary impregnation (these are amendments of Japa’s terminology in ‘Abortion and Democratic Equality’). Voluntary pregnancy would include the case of a girl seeking to become pregnant, but recall the correlation with poor socio-economic position and low education (i.e. the reality of desire-deformation). Unintentional impregnation would include a Romeo-and-Juliet case in which one child unintentionally impregnates another. Involuntary impregnation would include impregnation due to nonconsensual intercourse; this would include not only standard cases of sexual assault but all forms of statutory rape (even when the victim sought to become pregnant or was indifferent to impregnation). Unintentional impregnation might be compared to other kinds of sexually transmitted conditions, which doctors view as maladies and seek to remedy. Treatment for a child who has acquired a sexually transmitted disease is part of the clinical response. Older adolescents might, out of shame, seek to avoid such care, an issue we addressed above.

    With regard to Monika’s observation that ‘…even an adult woman who has been raped seems to have access to abortion care under many jurisdictions that are skeptical about abortion in other non-rape cases’, this is unfortunately not the case in several US states which have bans that make no exception for rape or incest: https://www.nytimes.com/interactive/2024/us/abortion-laws-roe-v-wade.html

45. Alyssa: A few questions this morning, from Monika, Japa, and Serena, have touched on the connection between sex rights and abortion rights. This also relates to concerns that Samantha raised yesterday, and which Andrew raised about rape. I hope that my response to Anthony, about paradigm exceptions, is helpful in addressing some of the concerns that Monika had about the 17-year-old who chooses to have sex knowing about the risk of pregnancy.
    I want to say a bit more about the connection between sex rights and reproductive rights, and why I think we’re justified in arguing that the two don’t go hand in hand when it comes to girls.

    It will be helpful to address Serena’s first two questions to do this.

    A) Whether they agree that setting the legal age of consent at 16 is justified.

    I will speak for myself when I say that I don’t see an issue with this, and that in setting the consent age below the age of majority, I think that this implies duties from the state relating to healthcare and education for minors. I also am inclined to agree with the arguments that many others have made already in this discussion, that adolescents do have developmentally appropriate rights relating to sex (i.e., I’m not making an abstinence-until-18 argument).

    B) Is the case for extending mandatory abortion care to older adolescents weaker, if not undermined?

    Here, I agree with the thoughts that Kim articulated yesterday- teen sexuality is one thing, and teen gestation, birthing, and mothering is another. Arguably, this is a good thing, one which is compatible with a developmental sense of autonomy, in that it allows teens to explore sexuality without being confronted with the significant burden of mothering in childhood. While, for adults, sexual rights go hand in hand with choice reproductive rights, the distinctive youthful position of girls gives us reasons to think that this is not the case for them, or that youth reproductive rights are primarily about rights against gestation and parenthood.

    Serena also flags that our proposal seems to license inequality related to sexual rights for (adolescent) boys and girls. In our article, Kim and I are attuned to the inequality that gestation and mothering in childhood licenses. This is something worth emphasizing, since even setting aside the unfair, gendered divisions of labour that might occur if two adolescents parent a child together, the majority of minor parents are girls.* Motherhood in childhood limits the life paths that a girl can choose later on. Girls deserve the same chances as boys to determine the course of their lives.

    The contributions I’ve responded to here contain other ideas which I will try to come back to. Thank you all for the excellent questions.

    *This is unfortunately an outdated statistic, but this study estimates that 27% of adolescents mothers between 15-17 had a partner at least five years older than themselves. https://pubmed.ncbi.nlm.nih.gov/9099568/

46. Kimberley: Thank you, Serena, for these probing questions.

    In reply to Serena’s first question of whether Alyssa and I agree that setting the legal age of consent at 16 is justified, I honestly do not know whether 16, 17, or some other age is an appropriate benchmark for sexual consent. The key point, I believe, is that sexual rights are distinct from both reproduction-related rights and parental rights. (So, even if 16 or 17 is an appropriate age for consent, it doesn’t follow that the impregnated teen should then be treated like an adult for the purposes of reproduction or parenting.) Second, the intuition that 16 and 17 are the penumbral cases in the context of reproduction or parenting, meriting a different analysis from that for the younger child, is informed by recent political history. It’s a history that still says the 16-year-old and (usually) the 17-year-old are too young to fight, and it’s a history that must explain why the 18- 19- or 20-year-old is old enough to fight when he was not thought to be so before. Political exigencies arguably robbed many children of their final years of childhood. Medical practice should not do worse.

47. Alyssa and Kimberley: Thanks for your further questions, Serena. I will respond here to your question about viability. I’m responding somewhat out of order, because our response is straightforward.

    We think that our argument applies post-viability. This was part of our motivation for choosing the organ donation analogy. I (Alyssa) personally don’t think that viability determines the moral status of the fetus, but many countries have abortion restrictions based on viability. I think that one upshot of our paper is that imposing cutoffs for abortion access for girls based on viability seriously wrongs them, especially because girls are more likely to find out about their pregnancies later in gestation. Such abortion restrictions license the exploitation of girls for the sake of a viable fetus. We don’t think the exploitation of girls is justified even for another human being, with full moral status.

48. Kimberley: In reply to Serena’s third point – about equality for girls and boys – it is worth noting that conservative religious views on reproduction, which heavily shape the current debate about abortion access, impact girls, not boys. In my writing on civil disobedience, I commented on the limits of US states’ accommodation of religious parents’ choices:

    “In many US states, the law includes a religious exemption for child abuse and neglect that allows parents to appeal to religion or faith-based rituals as a legal defence for such abuse. In a 2008 case in Wisconsin, this defence was not available to a couple, as they were charged with second-degree reckless homicide, not child abuse and neglect, after allowing their 11-year-old daughter to slip into a coma and die due to curable juvenile diabetes while the family stood around her and prayed. The parents could have faced 25 years in prison, but were sentenced very leniently to six months’ imprisonment respectively (one month per year for six years) and 10 years’ probation. The couple, Dale and Leilani Neumann, appealed the ruling to the Wisconsin State Supreme Court, which upheld the conviction in 2013.” https://academic.oup.com/book/3103

    I would propose that, when a doctor warns a girl’s parents that she has a heightened risk of dying due to pregnancy, or when those parents refuse to seek care for her at all, and she then dies, those parents’ decisions should be viewed in the same light as the case above. The actual number of children who die each year in the US due to pregnancy is not in the public record. According to CDC data released in March 2026, the rate of maternal death for “Under 25s” increased slightly between 2023 and 2024, with over 100 people 24-years or younger dying in the US due to pregnancy in 2024: https://www.cdc.gov/nchs/data/hestat/hestat113.pdf. Since pregnancy in childhood comes with higher risks of complications, some of those deaths were certainly children. But, the exact numbers are suppressed.

49. Alyssa: Thank you very much for your contribution to the debate Cécile!

    I agree with your observation, “First, Monica Betzler’s point about what does the work here – rape, or the risks inherent in childbearing – is interesting. It seems to me though that those points work in tandem: it is precisely in so far as girls cannot be deemed to consent to those risks that mandatory abortion gets purchase”. I also think you raise some good concerns about adopting a case-by-case approach, especially as it relates to younger girls. I think that this is especially relevant given the predisposition to defer to girls about pregnancy, which adultifies them and obscures their protected status as children.

    Kim & I have some thoughts about your question related to doing and allowing.

    Alyssa and Kimberley: The most important insight from our discussion of the doing/allowing problem is that many of our “allowings” in relation to children often have the force of “doings,” e.g. choosing not to feed a baby who is in our care constitutes starving a baby. In “allowing” a child’s pregnancy to progress, her adult caregivers neglect her in the same way that they would neglect their son if they allowed his cancer to progress untreated or allowed him to bleed to death by withholding a blood transfusion. Pregnancy is a noteworthy condition in that a person cannot safely remedy her situation without assistance. (This is one reason that the privacy argument underpinning Roe was unsatisfactory: when all that the state offers a person is a willingness to respect her medical privacy, it does nothing to ensure that she receives the care she needs.) We know that much more could be said on doing versus allowing, but we hope that what we have said alerts readers to the distinctive vulnerability of children, who are generally not in a position to seek assistance themselves or protect themselves.

50. Hello Dr Izzat and thank you so much for your response.

    My major worry is ,more generally, about the avenues that are open to those few individuals (children in our case, or adult in others) who, due to their unusual psychologies, will be clearly psychologically harmed by coercive lesser evil medical policies that are very beneficial at the population level and which invoke paternalistic rationales based on objective (or quasi-objective) conceptions of well-being, but which seem to forget that they should care in advance for the few outliers too. Here are 2 conditions that I see as necessary for protecting those outliers, and I was wondering what you would think about each one of them:

    1 Medical doctors urgently need training in analytic Ethics.

    2 There should be a higher level (above that of medical doctors) of screening of the individuals who can be exempted from a justified coercive paternalistic lesser evil medical policy, a level consisting of philosophers and psychologists to whom the medical doctors could address the individuals that are very averse to coerced medical interventions. The ultimate determination for these individuals will be coming from the teams of philosophers and psychologists, not the medical doctors.

    Thanks again so much for your first response, for the ground-breaking philosophical considerations that both you and Prof Brownlee offered, for a proposed policy that will increase the well-being of girls and that delivers one more blow to the dead man walking that Patriarchy is, and thanks to Pea Soup for making these discussions happen.

51. Alyssa: Thanks for your further queries, Andrew! You raise some good points, and I am enjoying mulling them over.

    I’ll start with a response to your discussion about life stages. You note that forced, momentous decisions are an exception to your life stages approach, and that adolescence is a life stage which would typically offer certain protections. However, in cases where “a decision of some sort needs to be made and where the decision, however it is made, will have a significant impact on the person’s life story.” we should defer to the competent adolescent.

    Does the symmetry of the choice matter for your view on forced, momentous choices? One thought is that, at least as we’ve presented it, there is a drastic asymmetry between abortion and motherhood when it comes to girls’ rights and wellbeing. This is arguably true in other such cases you mention, so perhaps this response will not be persuasive (e.g., refusing a blood transfusion might qualify as a momentous decision, and this involves a vast asymmetry in the stakes for a child).

    Another thought I have is that abortion can absolutely be a momentous decision. But I don’t think it has to be. The narrative significance that the person having the abortion ascribes to the procedure carries a lot of weight in the overall significance of an abortion in a person’s life story. Given that we argue that pregnancy should be thought of as a malady for children, perhaps it’s better to deflate the momentousness of abortion. On our view, abortion is healthcare, rather than the momentous choice between embracing the transformative identity of motherhood, or maintaining the status of childhood. The momentousness of some choices is arguably culturally situated and might change with time. A choice to abort will seem more momentous in a pro-life society, but would seem less momentous in a society that viewed abortion as the status quo for pregnant girls.

    I will be back soon with further thoughts about your other concerns.

    As an aside, it’s definitely true that the Consenting Children collection is relevant to our work here. It’s great to hear to perspectives of the discussants who either contributed to or edited the volume. It was published just after our manuscript was finalized, so I’m looking forward to engaging with it in subsequent work on this issue.

52. Alyssa: Hi again Dionissis, thanks for your question and kind words.

    I’d probably always agree that training in analytic ethics is a good thing, for the average person or for a physician. I also think that there are good bioethics programs out there that involve collaboration between physicians and ethicists. Of course, the clinical ethics landscape is far from uniform. Speculatively, I might say that training in clinical ethics is the most important thing for physicians, rather than an analytic training.

    I think that if we take the analogy with organ donation seriously, our protocol would likely look something like a collaborative engagement between physicians, independent advocates for the minors, the minors themselves, and their families, and perhaps ethicist support. I am not sure if there needs to be a specific structure involving philosophers- I actually think clinical ethicists (many of whom are philosophers with clinical training) would be better-placed to be involved in these discussions.

    We do acknowledge & account for the possibility that there could be outliers in our discussion of a paradigm approach, especially those older adolescents who are close to the age of majority.

53. Hi Alyssa,
    I characterized the decision as to whether to abort or carry a pregnancy to term as a “forced, momentous choice.”

    You make the interesting response that the choice may be asymmetrical and the decision to abort need not be momentous, while the decisions to give birth and (even more) to raise the child are certainly momentous.

    I think that is a helpful correction to the assumption I was making. I agree, some people may not consider an abortion an especially defining event in their lives. That being said, it does not seem to me consistent with liberal principles for either doctors or the state to insist on a particular meaning of an abortion. Some (many?) people who are unreservedly pro-choice would still feel like making this decision for themselves, either way, is a big deal. It seems to me that a liberal society has to accept that. I concede that the point about forced, momentous choices may not have much purchase with the youngest girls capable of pregnancy, but I see it as important for thinking about older teens.

54. Alyssa: Hi Andrew,

    Thanks for this follow-up. I don’t have much more to say about this at the moment, but I will be thinking more about both what assumptions the liberal state would have to make about which choices count as momentous, and also what significance personal narratives (including the personal narratives of adolescents) have in defining such choices as momentous- it’s a compelling problem.

55. With respect to Cecile’s questions
    1. Would he accept mandatory abortion as a second-best proposal given that/if his preferred proposal is not implemented?

    Although I think there are cases in which the appropriate care for the health and well-being of girls requires termination of a pregnancy (even against the wishes the girl and/or her parents), I do not believe that having a standing policy of mandatory abortions for all minors is justifiable even as a second-best policy. If we are contemplating second-best policies, there is a range of other options that might be considered beyond the proposed in the paper – e.g., for a range of very young pregnancies, there could be a defeasible default presumption in favour of termination or in a range of cases determination of appropriate treatment could be made by a court appointed independent person who acts a fiduciary for the pregnant child. There are too many objectionable facets of the general policy of mandatory abortions for minors to make it a viable second-best policy.

    2. Does he think that we ought to let a 10 year old girl carry on a foetus to term even if she says that this is what she wants? In other words I wonder how far he is willing to take his case-by-case basis+substantial provision approach.

    I do not think the children’s views about their care in such cases should be viewed as authoritative. How we should assess the authority of children’s voices depends on many factors – their cognitive, psychological and moral maturity, their understanding of their situation and features of their social circumstances. In the case at hand, I think it’s extremely unlikely that a 10 year old’s view about continuing a pregnancy would be sufficient to support a decision by caring parents and responsible health care professionals to continue the pregnancy. But I can also imagine cases in which termination of the pregnancy might not be obviously the right decision. Suppose, for instance, that there is strong evidence that forced termination of the pregnancy is highly likely to trigger powerful suicidal ideation?

56. Since Ignacio will be closing the discussion soon, I’d like to say a heartfelt ‘thank you’ to everyone for participating in this discussion. Thank you for your detailed and thought-provoking interventions. Alyssa and I have tried to answer most of the comments, but we haven’t been able to answer all of them satisfactorily in this forum. We hope we’ll have an opportunity to follow up in a formal setting with more fully worked-out replies. Thank you, Ignacio, Patrick, and the Pea Soup team for hosting this discussion. Thank you very much, Japa, for your excellent precis, questions, and subsequent comments. Finally, thank you, Alyssa, for your superb contributions!

57. I will follow Kim’s lead in saying a warm thank you to everyone, for such an excellent discussion and your thoughtful contributions. I am grateful for all the engagement with our arguments over the past two days, to Japa, for writing an excellent precis, to Ignacio for being a tireless host, and to the PEA soup team for facilitating this discussion. Thank you as well to Kim, who has been a great partner in this discussion!

    You’ve given us much to consider for subsequent research, and I look forward to discussing this further with many of you. Our impetus for writing this article was that position of girls has been woefully under-considered in the abortion debate. I think this was an important step forward in filling this lacuna, so again, I thank you all for participating!

58. We now bring this discussion to a close. On behalf of PEA Soup Blog, I want to thank Kimberley Brownlee and Alyssa Izatt for their excellent paper and Japa Pallikkathayil for her thoughtful précis. We are also grateful to all the contributors whose comments have enriched the exchange.

    The comment box will now be closed.

    Thank you all for participating.

    PEA Soup Blog.

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