on its own.17 17 Again, a troubling exception might be the isolated Venezuelan group Nancy Wexler found, where, because of inbreeding, a large proportion of the population is affected by Huntington’s. See Revkin, “Hunting Down Huntington’s.”
18 18 Or surrogacy, as it has been popularly known. I think that “contract pregnancy” is more accurate and more respectful of women. Eggs can be provided either by a woman who also gestates the fetus or by a third party.
19 19 The most powerful objections to new reproductive technologies and arrangements concern possible bad consequences for women. However, I do not think that the arguments against them on these grounds have yet shown the dangers to be as great as some believe. So although it is perhaps true that new reproductive technologies and arrangements should not be used lightly, avoiding the conceptions discussed here is well worth the risk. For a series of viewpoints on this issue, including my own “Another Look at Contract Pregnancy” (ch. 12 of Reproducing Persons), see Helen B. Holmes, Issues in Reproductive Technology I: An Anthology (New York: Garland, 1992).
20 20 William James, Essays in Pragmatism, ed. A. Castell (New York: Hafner, 1948), p. 73.
9 Sex Selection and Preimplantation Genetic Diagnosis
The Ethics Committee of the American Society of Reproductive Medicine
In 1994, the Ethics Committee of the American Society of Reproductive Medicine concluded, although not unanimously, that whereas preimplantation sex selection is appropriate to avoid the birth of children with genetic disorders, it is not acceptable when used solely for nonmedical reasons. Since 1994, the further development of less burdensome and invasive medical technologies for sex selection suggests a need to revisit the complex ethical questions involved.
Background
Interest in sex selection has a long history dating to ancient cultures. Methods have varied from special modes and timing of coitus to the practice of infanticide. Only recently have medical technologies made it possible to attempt sex selection of children before their conception or birth. For example, screening for carriers of X‐linked genetic diseases allows potential parents not only to decide whether to have children but also to select the sex of their offspring before pregnancy or before birth.
Among the methods now available for prepregnancy and prebirth sex selection are [1] prefertilization separation of X‐bearing from Y‐bearing spermatozoa (through a technique that is now available although still investigational for humans), with subsequent selection for artificial insemination or for IVF; [2] preimplantation genetic diagnosis (PGD), followed by the sex selection of embryos for transfer; and [3] prenatal genetic diagnosis, followed by sex‐selective abortion. The primary focus of this document is on the second method, sex selection through PGD, although the issues particular to this method overlap with the issues relevant to the others. Preimplantation genetic diagnosis is used with assisted reproductive technologies such as IVF to identify genetic disorders, but it also can provide information regarding the sex of embryos either as a by‐product of testing for genetic disorders or when it is done purely for sex selection (Table 9.1).
As the methods of sex selection have varied throughout history, so have the motivations for it. Among the most prominent of motivations historically have been simple desires to bear and raise children of the culturally preferred gender, to ensure the economic usefulness of offspring within a family, to achieve gender balance among children in a given family, and to determine a gendered birth order. New technologies also have served these aims, but they have raised to prominence the goal of avoiding the birth of children with sex‐related genetic disorders.
Table 9.1 Embryo sex identification by preimplantation genetic diagnosis for nonmedical reasons
| (a) | Patient is undergoing IVF and PGD. |
| Patient learns sex identification of embryo as part of, or as a by‐product of, PGD done for other medical reasons. | |
| (b) | Patient is undergoing IVF and PGD. |
| Patient requests that sex identification be added to PGD being done for other medical reasons. | |
| (c) | Patient is undergoing IVF, but PGD is not necessary to treatment. |
| Patient requests PGD solely for the purpose of sex identification. | |
| (d) | Patient is not undergoing either IVF or PGD (for the treatment of infertility or any other medical reason). |
| Patient requests IVF and PGD solely for the purpose of sex identification. |
Whatever its methods or its reasons, sex selection has encountered significant ethical objections throughout its history. Religious traditions and societies in general have responded with concerns varying from moral outrage at infanticide to moral reservations regarding the use of some prebirth methods of diagnosis for the sole purpose of sex selection. More recently, concerns have focused on the dangers of gender discrimination and the perpetuation of gender oppression in contemporary societies.
This document’s focus on PGD for sex selection is prompted by the increasing attractiveness of prepregnancy sex selection over prenatal diagnosis and sex‐selective abortion, and by the current limited availability of methods of prefertilization sex selection techniques that are both reliable and safe. Although the actual use of PGD for sex selection is still infrequent, its potential use continues to raise important ethical questions.
Central to the controversies over the use of PGD for sex selection, particularly for nonmedical reasons, are issues of gender discrimination, the appropriateness of expanding control over nonessential characteristics of offspring, and the relative importance of sex selection when weighed against medical and financial burdens to parents and against multiple demands for limited medical resources. In western societies, these concerns inevitably encounter what has become a strong presumption in favor of reproductive choice.
The General Ethical Debate
Arguments for PGD and sex selection make two primary appeals. The first is to the right to reproductive choice on the part of the person or persons who seek to bear a child. Sex selection, it is argued, is a logical extension of this right. The second is an appeal to the important goods to be achieved through this technique and the choices it allows – above all, the medical good of preventing the transmission of sex‐linked genetic disorders such as hemophilia A and B, Lesch‐Nyhan syndrome, Duchenne‐Becker muscular dystrophy, and Hunter syndrome. There also are perceived individual and social goods such as gender balance or distribution in a family with more than one child, parental companionship with a child of one’s own gender, and a preferred gender order among one’s children. More remotely, it sometimes is argued that PGD and sex selection of embryos for transfer is a lesser evil (medically and ethically) than the alternative
