Bioethics

More remote sorts of consequences of PGD and sex selection, both good and bad, remain too speculative to place seriously in the balance of ethical assessments of the techniques. That is, potential good consequences such as population control, and potential bad consequences such as imbalance in a society’s sex ratio, seem too uncertain in their prediction to be determinative of the issues of sex selection. Even if, for example, the current rise in sex selection of offspring in a few countries suggests a correlation between the availability of sex selection methods and the concrete expression of son‐preference, there can be no easy transfer of these data to other societies. This does not mean, however, that all concerns for the general social consequences of sex selection techniques regarding general gender discrimination can be dismissed.

The United States is not likely to connect sex selection practices with severe needs to limit population (as may be the case in other countries). Moreover, gender discrimination is not as deeply intertwined with economic structures in the United States as it may be elsewhere. Nonetheless, ongoing problems with the status of women in the United States make it necessary to take account of concerns for the impact of sex selection on goals of gender equality.

Moreover, the issue of controlling offspring characteristics that are perceived as nonessential cannot be summarily dismissed. Those who argue that offering parental choices of sex selection is taking a major step toward “designing” offspring present concerns that are not unreasonable in a highly technologic culture. Yet it appears precipitous to assume that the possibility of gender choices will lead to a feared radical transformation of the meaning of human reproduction. A “slippery slope” argument seems overdrawn when it is used here. The desire to have some control over the gender of offspring is older than the new technologies that make this possible. This, however, suggests that should otherwise permissible technologies for sex selection be actively promoted for nonmedical reasons – as in (b), (c), and (d) above – their threat to widely valued meanings of human reproduction may call for more serious concern than other speculative and remote negative consequences of PGD and sex selection.

Objections to PGD and sex selection on the grounds of misallocation of resources are more difficult to sustain. Questions of this sort are not so obviously relevant to systems of medical care like the one in the United States. If an individual is able and willing to pay for desired (and medically reasonable) services, there is no direct, easy way to show how any particular set of choices takes away from the right of others to basic care. Yet even here, individual and group decisions do have an impact on the overall deployment of resources for medical care and on the availability of reproductive services.

Although, as already noted, there is little controversy about the seriousness of the need to prevent genetic diseases, it is doubtful that gender preference on the basis of other social and psychological desires should be given as high a priority. The distinction between medical needs and nonmedical desires is particularly relevant if PGD is done solely for sex selection based on nonmedical preferences. The greater the demand on medical resources to achieve PGD for no other reason than sex selection, as in descending order in (b) through (d) above, the more questions surround it regarding its appropriateness for medical practice. If, on the other hand, PGD is done as part of infertility treatment, and the information that allows sex selection is not gained through the additional use of medical resources, it presumably is free of more serious problems of fairness in the allocation of scarce resources and appropriateness to the practice of medicine.

The ethical issues that have emerged in this document’s concern for PGD and sex selection are in some ways particular to the uses and consequences of a specific reproductive technology. Their general significance is broader than this, however. For example, the concerns raised here provide at least a framework for an ethical assessment of new techniques for selecting X‐bearing or Y‐bearing sperm for IUI or IVF (ongoing clinical trial reports of which appeared while this document was being developed). Here, too, sex selection for the purposes of preventing the transmission of genetic diseases does not appear to present ethical problems. However, here also, sex selection for nonmedical reasons, especially if facilitated on a large scale, has the potential to reinforce gender bias in a society, and it may constitute inappropriate use and allocation of medical resources. Finally, although sperm sorting and IUI can entail less burden for parents, questions of the risk to offspring from techniques that involve staining and the use of a laser on sperm DNA remain under investigation.

Of the arguments in favor of PGD and sex selection, only the one based on the prevention of transmittable genetic diseases is strong enough to clearly avoid or override concerns regarding gender equality, acceptance of offspring for themselves and not their inessential characteristics, health risks and burdens for individuals attempting to achieve pregnancy, and equitable use and distribution of medical resources. These concerns remain for PGD and sex selection when it is used to fulfill nonmedical preferences or social and psychological needs. However, because it is not clear in every case that the use of PGD and sex selection for nonmedical reasons entails certainly grave wrongs or sufficiently predictable grave negative consequences, the Committee does not favor its legal prohibition. Nonetheless, the cumulative weight of the arguments against nonmedically motivated sex selection gives cause for serious ethical caution. The Committee’s recommendations therefore follow from an effort to respect and to weigh ethical concerns that are sometimes in conflict – namely, the right to reproductive freedom, genuine medical needs and goals, gender equality, and justice in the distribution of medical resources. On the basis of its foregoing ethical analysis, the Committee recommends the following:

1 Preimplantation genetic diagnosis used for sex selection to prevent the transmission of serious genetic disease is ethically acceptable. It is not inherently gender biased, bears little risk of consequences detrimental to individuals or to society, and represents a use of medical resources for reasons of human health.

2 In patients undergoing IVF, PGD used for sex selection for nonmedical reasons – as in (a) through (c) above – holds some risk of gender bias, harm to individuals and society, and inappropriateness in the use and allocation of limited medical resources. Although these risks are lower when sex identification is already part of a by‐product of PGD being done for medical reasons (a), they increase when sex identification is added to PGD solely for purposes of sex selection (b) and when PGD is itself initiated solely for sex selection (c). They remain a concern whenever sex selection is done for nonmedical reasons. Such use of PGD therefore should not be encouraged.

3 The initiation of IVF with PGD solely for sex selection (d) holds even greater risk of unwarranted gender bias, social harm, and the diversion of medical resources from genuine medical need. It therefore should be discouraged.

4 Ethical caution regarding PGD for sex selection calls for study of the consequences of this practice. Such study should include cross‐cultural as well as intracultural patterns, ongoing assessment of competing claims for medical resources, and reasonable efforts to discern changes in the level of social responsibility and respect for future generations.