Thursday, May 27, 2004

Bioethics of Gender Selection, part II:
Preconception Gender Selection

Because the two main technologies for gender selection are so different, the bioethical issues must be analyzed separately.  Flow cytometry is a method that sorts sperm into two pools.  one pool contains sperm with two X chromosomes, which will produce girls; the other contains sperm with one X and one Y, which will produce boys.  For technical reasons, it is easier to produce a sperm sample that contains only XX sperm.  Thus, this method is more commonly used to select for girl babies.  Using it to select for boy babies will greatly increase the odds of getting a boy, but there still is a significance chance of getting a girl.  GIVF, a company that offers Microsort® flow cytometry sperm-sorting technology, claims  that XX-sorted sperm has produced girls 88% of the time, whereas XY-sorted sperm produces boys 73% of the time.  Because sperm have a limited life span, it is not possible to run the sample through the machine enough times to get a more highly purified sample.  Presumably, technological improvements will improve the accuracy of the sorting process, but it probably will not be possible to guarantee absolutely the outcome of a pregnancy with this method.

Note that the pregnancy occurs after either artificial insemination with the enriched sperm sample, or after in-vitro fertilization.  No zygotes  are destroyed in the process.  As a result, the use of flow cytometry does not raise the ethical issues that arise when multiple zygotes are produced, then tested, and the unwanted ones are destroyed.  For this reason, the analysis is simpler.

The ASRM ethics report identifies several potentially negative issues with this kind of gender selection:

They also identified a few potential positives:

They point out that some couples who might otherwise choose to have no children, or to stop having children, might decide to go ahead and have a child if they can influence the probability of having a child of a preferred gender.  Another issue is that the use of pre-conception gender selection could result in fewer abortions.  They also point out the argument:

[U]nless substantial harm to others resulted from a reproductive practice, couples should in many circumstances be permitted to act on preferences for children of a particular gender.

This brings up a critical issue.  Regardless of whether the practice of gender selection is good or bad, the decision about whether to impose governmental restriction is a separate issue.  Also, even if the government does get involved in regulation, it does not necessary follow that the procedure should be prohibited.  In some cases, regulation short of prohibition may be appropriate.  This is the position the government has taken with cigarette smoking, for example: the government restricts cigarette use to adults, restricts sales and advertising, and taxes the product heavily, but it does not prohibit smoking entirely. 

The ASRM seems to have the position that unless substantial harm to others can be demonstrated, the practice of gender selection should be permitted.   Analysis of this is not entirely straightforward.  They point out that the use of flow cytometry for gender selection is costly and consumes significant medical resources.  Would it be better if these resources be diverted elsewhere?  If so, does the medical profession have a moral obligation to direct the resources to where they will do the most good? 

Regarding the question of psychological harm to the children, or to society, this is an area in which there are many opinions, but few clear answers.  I was not able to locate any actual studies on the subject.  (Although I did not look very hard, and it is not a literature that I routinely read; there could be a study out there somewhere.)  The post on Evangelical Outpost suggests that there is something inherently dehumanizing about gender selection, even when used for medical purposes.  This is a concern expressed also by the President's Council on Bioethics (PCBE).  The potential for gender selection to be dehumanizing is something that could have an impact on specific individuals, namely, the parents involved in the procedure or their children; or, it could have an impact on society as a whole.  This is what was referred to as an "intangible harm" in the Hastings Center report, Reprogenetics and Public Policy (470KB PDF).   The Hastings report includes expressions of concern that use of gender selection technology could lower the overall "well-being" of society.  But they point out also that restrictions on individual liberty could have the same effect. 

The potential for sex ratio imbalance is a serious one.  There are countries, such as China, where the sex ratio is abnormal.  According to a Guardian newspapers report, there are 116.9 males for every 100 females in China.  Futurepundit reports  that the sex ratio was 121 in China in the early 1990's.  (The normal ratio is 105.)  This indicates that it is possible for parental preference to have a large impact on the sex ration of the population.  This is due to "human intervention."  However, since gender selection via flow cytometry is expensive and requires so much time from specialists, it is not likely that it could be done often enough to have a measurable impact on the sex ratio of the population.  It is assumed widely that use of gender selection would result in a preponderance of boys, but so far, that has not been the case.  Most couples who are looking for a child to adopt, want girls.  Clinics offering Microsort® gender selection report that more clients want girls.  If the technology advances to the point that XY sorting is as accurate at XX sorting, that could change. 

The concern that gender selection could be a kind of sex discrimination, or that it could reinforce gender prejudice is another intangible risk, difficult to study objectively.  However, the ASRM found the possibility to be sufficiently disturbing that they consider it to be a major argument against nonmedical gender selection.  They raise an interesting point, though, that could come only from those with experience in a clinical setting:

Medical techniques intended for other purposes have the potential of being used for sex selection without the provider's knowledge or consent.  Because patients are entitled to obtain personal medical information, including information about the sex of their fetus, it will sometimes be impossible for health professionals to avoid unwitting participation in sex selection. 

This is an important point, because it provides an argument against governmental prohibition of the technology.  The technologies are inherently dual-use, since they do have medical purposes that are generally regarded to be appropriate. 

Reading through the various news reports, committee reports, and blogger commentary, I have not seen any argument that is sufficiently compelling to warrant governmental prohibition against gender selection.  Furthermore, the Hastings Center report mentioned above includes a consideration of possible governmental regulation, but they express doubt that the government could act quickly enough to put such regulations in place before there is a substantial precedent set by current and near-future private behaviors.  Indeed, even as the PCBE has been considering the issue since 2002, and many couples already have had children using flow cytometry based gender selection, there still is no law regulating the practice.  Therefore, at present, the only regulations are the self-imposed ethical guidelines developed by the ASRM. SInce the ACOG ethics committee concluded that nonmedical gender selection is inappropriate, they did not recommend ethical guidelines for this practice.  The ASRM ethics committee reached the opposite conclusion, and they did make recommendations for the ethical implementation of nonmedical gender selection:

[P]hysicians should be free to offer preconception gender selection in clinical settings to couples who are seeking gender variety in their offspring if the couples [1] are fully informed of the risks of failure, [2] affirm that they will fully accept children of the opposite sex if the preconception gender selection fails, [3] are counseled about having unrealistic expectations about the behavior of children of the preferred gender, and [4] are offered the opportunity to participate in research to track and assess the safety, efficacy, and demographics of preconception selection. Practitioners offering assisted reproductive services are under no legal or ethical obligation to provide nonmedically indicated preconception methods of gender selection.

I suggest that the ASRM guidelines be implemented in a structured fashion.  That is, they should develop a mandatory curriculum to ensure that couples contemplating nonmedical gender selection are fully informed about the procedure and the attendant ethical issues; that true informed consent is obtained; and that specialized counseling should be available post-delivery. 

Even if there is no role for governmental prohibition of nonmedical gender selection, there still is a role for governmental intervention.  Specifically, the FDA should be involved in their usual role of testing for safety and effectiveness before any products or procedures are marketed, as well as monitoring postmarking surveillance studies.  State congressional committees should develop legislation regarding safe implementation of the procedures, as well as mandating pre-procedure counseling and standards for informed consent. 

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baby-gender-selection.com helped us choose the baby boy we have always wanted.
They had a preconception gender diet to follow which helped us have the baby boy of our dreams.
baby-gender-selection.com helped us choose the baby boy we have always wanted.
They had a preconception gender diet to follow which helped us have the baby boy of our dreams.
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good choices
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