The blockbuster movie Avengers – Infinity War features heroes and villains sacrificing for what they perceive is the greater good. The ethical issues in the movie are shared in how prenatal testing is administered, but with a key distinction.
For regular readers, I appreciate their leniency in indulging my comic book nerd fanaticism with the Marvel Comics/Cinematic Universe. But in watching the penultimate installment to the current version of the MCU, there are issues driving the plot and drama of the story that are also present in the focus of this blog, prenatal genetic testing. I don’t believe I give away any spoilers, but if you keep reading and have not seen the movie, you’ve been forewarned of the (inadvertent) possibility of them.
Utilitarianism in a superhero movie
Avengers – Infinity War has as its theme sacrifice. The protagonist of the movie is its villain Thanos (this is because there are so many superheroes included in this culmination of the MCU that not one of them has enough screen time to be the protagonist). Thanos’ passion is restoring balance to the universe, at least as he sees it. To Thanos, life itself is risking the viability of the universe and therefore half of all lives must be sacrificed to restore balance and prevent the universe from consuming itself from overpopulation.
In order to achieve his goal, Thanos must assemble all of the Infinity Stones, which several of the superheros have in their possession or know of their whereabouts. For these heroes, their sacrifice is to ask others to kill them should Thanos come close to getting what they have. And so goes the movie, tension building as the heroes try to thwart Thanos’ universal semi-genocide while offering their own deaths instead.
The commonality of each side’s motives is sacrificing the few for the good of the many (or in Thanos’ case, sacrificing half for the other half’s good). In key scenes, though, the distinction is shown between Thanos’ “sacrifice” and the heroes’ sacrifices. Thanos is certain that half of all life must die to preserve the other half, but one hero challenges his certainty, asking how can he be so sure? For the individual heroes’ sacrifices, in another scene one hero points out that their individual sacrifice is one of their own choosing, plus theirs is a sacrifice of themselves, not the killing of others.
The dynamic between Thanos’ master plan and the heroes’ individual decisions is the dynamic of the macro- versus the micro-.
Thanos’ plan is as macro- as it gets: surveying the universe and determining that if it is to go on living, then half are going to have to die. He justifies this apocalypse with the rationale that it is for the greater good for all life to continue. It is akin to the common bioethical thought problems of the lifeboat scenario or Would you kill the fat man?: should some die so that others may live. It is utilitarian logic: if it results in the greater good, then the sacrifice should be made.
For the individual heroes, their decisions are at the micro- level: personal decisions to sacrifice themselves so that others may live. Some have said this is the heart of every story, from the story of Christ, to Aslan in the Chronicles of Narnia, Neo in the Matrix, and Harry Potter. “Greater love has no one than this, that one lay down his life for his friends.”
Corallaries to prenatal genetic testing
It may not seem so, but these same dynamics play out in how prenatal genetic testing is administered, but with one factor missing from the Avengers movie that serves as a hidden hand in the decisions that are made.
Prenatal genetic testing, ethically, is premised on choice: respecting women and their partners’ decisions about what information is relevant to them. So much so that some commentators have argued it is ethically obligatory to offer expectant women prenatal genetic testing, because not doing so disrespects their autonomy. This is the micro- level in the administration of prenatal genetic testing: individuals making decisions according to their values and what they value as the greater good for themselves and their families.
There is also a macro- level to prenatal genetic testing’s administration. At the macro- level, economists, public health administrators, private health system analysts, governmental program administrators, and genetic testing laboratory CEOs justify the administration of prenatal genetic testing on a utilitarian basis: the greater good is served by “preventing” the “costly” lives that can be detected prenatally and aborted. While millions will be spent by Medicaid, private insurance, and, in countries with socialized medicine, their national healthcare systems for prenatal screening tests of women with incredibly low chances of having a child with Down syndrome or another tested-for condition, those millions are estimated at being less than the even greater millions in health care dollars that would be spent if those few lives with genetic conditions were ultimately born and then cared for by the health care systems.
These cost-benefit analyses even outdo Thanos’ goal: they require at least 50% of all expectant lives with the conditions, and oftentimes even more so, be aborted in order to offset the costs of screening tests for unaffected pregnancies. As reported in other posts, in certain Western European and Asian countries, not just half, but almost all future lives with Down syndrome are aborted due to the high uptake of prenatal testing and 90+% termination rates.
Distinctions between a superhero movie and prenatal genetic testing
There are two big distinctions to be drawn between the utilitarian ethic of Thanos and the way prenatal genetic testing is justified on a macro-level.
Viewers of the movie instinctively react to Thanos’ master-plan as something to be opposed. While even reviewers note that Thanos’ plan has a logic to it, the suspense is built because you want the superheroes to succeed in stopping him from wiping out half of all life. Conversely, the cost-benefit analyses that are published with regularity in several well-regarded scientific journals are not viewed as monstrously cold, calculating, eugenics-echoing screeds, but rather as respectable, logical, and reasonable justifications for public subsidization of prenatal genetic testing.
The other big distinction is that hidden hand I mentioned earlier. In the movie, all heroes are aligned in their opposition to Thanos. Not a one of them is shown on bended knee as one of the sacrificial heroes wrestles with his or her decision, whispering “you’re making the right choice to die; it’s for the greater good.” Alternatively, when an expectant mother is making the decision of whether to accept prenatal genetic testing, it is typically in a doctor’s office who has provided her with a pamphlet designed by the marketing team for the testing company to lead her to accept the testing; a doctor who him- or her-self or their colleague may financially benefit by performing the diagnostic test to confirm the screen result; a physician who’s professional guidelines require them to counsel the expectant mom about termination following a prenatal diagnosis; and a physician who may fear being sued if a child is born with a testable condition and the mother could claim she wasn’t adequately counseled about prenatal testing and termination.
The hidden hand is the money flowing throughout that whole dynamic: the lab makes profits only if the patient accepts their tests, so their materials are inherently biased in advising the patient about their tests; the physician may get paid more if the mother goes on to diagnostic testing or at least avoids possibly having to pay a settlement or judgment in a wrongful birth lawsuit; the testing laboratory funds or writes its own cost-benefit analysis to convince public and private insurers to pay for its testing (which it profits from) in order to “save” the overall system more money.
The hubris of utilitarianism
One last commonality shared between a summer blockbuster and prenatal genetic testing. The same question posed to Thanos can, is, and should continue to be posed to those authoring cost-benefit analyses and administrators who decide that subsidizing prenatal testing avoids lives considered too costly: how do they know?
Each generation of individuals with Down syndrome in the last hundred years has achieved more than ever expected of them. More and more studies and lived experiences evidence the overall improvement in workplace culture, happiness and resilience in families, and the health of a community in terms of generosity, compassion, and patience. How can we know the relative costs of these lives only just now being able to live as they always should have been able to?
And, if you are so bold to say we can put such a price on their lives, then what price do you calculate for your own life? Because there will always be a way to justify “avoiding” that for “savings” to someone else.
The protagonist is all of the heroes.