Sex selection: Treating different cases differently

Mapping ethical, legal, and social implications (ELSI) of preimplantation genetic testing (PGT)

PURPOSE

Preimplantation Genetic Testing (PGT) has attracted considerable ethical, legal, and social scrutiny, but academic debate often fails to reflect clinical realities.

METHODS

Addressing this disconnect, a review of 506 articles from 1999 to 2019 across humanities and social sciences was conducted to synthesize the Ethical, Legal, and Social Implications (ELSI) of PGT. This review mined PubMed, WoS, and Scopus databases, using both MeSH terms and keywords to map out the research terrain.

RESULTS

The findings reveal a tenfold increase in global research output on PGT's ELSI from 1999 to 2019, signifying rising interest and concern. Despite heightened theoretical discourse on selecting "optimal" offspring, such practices were scarcely reported in clinical environments. Conversely, critical issues like PGT funding and familial impacts remain underexplored. Notably, 86% of the ELSI literature originates from just 12 countries, pointing to a research concentration.

CONCLUSION

This review underscores an urgent need for ELSI research to align more closely with clinical practice, promoting collaborations among ethicists, clinicians, policymakers, and economists. Such efforts are essential for grounding debates in practical relevance, ultimately steering PGT towards ethical integrity, societal acceptance, and equitable access, aiming to harmonize PGT research with real-world clinical concerns, enhancing the relevance and impact of future ethical discussions.

Use of reproductive technology for sex selection for nonmedical reasons: an Ethics Committee opinion

Because the practice of preimplantation sex selection is ethically controversial, clinics are encouraged to develop and make available their policies regarding its use. Practitioners offering assisted reproductive services are under no ethical obligation to provide or refuse to provide nonmedically-indicated methods of sex selection. This document replaces the document of the same name, last published in 2015.

The impact of religion and culture on medically assisted reproduction in the Middle East and Europe

Infertility is a medico-socio-cultural problem associated with gender-based suffering. Infertility treatment, including assisted reproductive technology (ART), is a human right. Culture and religion were among the stumbling blocks to early acceptance of ART, particularly in the Middle East and to a lesser extent in Europe. This was mostly due to the different cultural and religious perspectives on the moral status of the embryo in the two regions and the concerns about what could be done with human embryos in the laboratory. There is an increased demand for ART in both the Middle East and Europe, although the reasons for this increased demand are not always the same. Although Europe leads the world in ART, there is an unmet need for ART in many countries in the Middle East. Where ART is not supported by governments or insurance companies, a large percentage of couples paying for ART themselves will stop before they succeed in having a baby. There are similarities and differences in ART practices in the two regions. If a healthcare provider has a conscientious objection to a certain ART modality, he/she is ethically obliged to refer the patient to where they could have it done, provided it is legal.

Figuring India and China in the Constitution of Globally Stratified Sex Selection

The advent of techniques of sex selection that rely on assisted reproduction led to a questioning of whether sex selection should be deemed always and everywhere unethical. While China and India are normally associated with condemned practices, they are also implicated in processes that constitute globally stratified sex selection inclusive of its more valued form, often referred to as family balancing. Through an application of Ong and Collier's concept of global assemblage, I demonstrate how family balancing, which has taken on a "global form," is tied to an "assemblage" of factors related to the anti-natal, population control contexts that have been pervasive in Asia. Three simultaneously occurring processes since the mid-1990s constituted stratified sex selection: the surfacing of China and India as figurative counter examples in deliberations of ethics on new techniques; active (inter)national surveillance of sex ratios as well as denunciation and criminalization of sex selective abortion in China and India; and the role of China and India in neoliberalizing population control and developing globalized markets in reproduction. Accounting for globally stratified sex selection requires a more robust interpretation of ethics that rethinks disciplinary approaches just as much as relativist ones in which respect for individual autonomy tends to overtake all other concerns.

Review of assisted reproduction techniques, laws, and regulations in Muslim countries

Background

Fourteen Muslim countries were explored for available national laws, regulations, and guidelines concerning assisted reproduction techniques (ART). These documents were studied with total consideration of the ethical and religious principles followed by Islamic religion. This study found different types of legal documents issued by legislatives authorities, ethical committees, or professional bodies. Documents reviewed are directly related to assisted reproduction techniques medical use, access, or research in the field of ART.

Main body of the abstract

Most of the studied documents showed various degrees of deficiencies concerning legal or ethical protections and considerations. Certain documents that were examined need to be updated or amended in order to follow the continuous medical progress. The research also showed certain difficulty of legislating in countries characterized by multiculturalism and different ethical and religious traits and beliefs. Recently, Muslim legislators have made many efforts. However, the spread of legal documents among the Muslim countries is partial in volume and nature.

Short conclusion

The comparison of the content with international documents shows us that most of assisted reproductions legal documents in use in the studied countries demonstrate numerous deficiencies in term of structure, nature, and the coverage of controversial subjects.

High and growing disapproval of sex-selection technology in Australia

BACKGROUND

In Australia, the National Health and Medical Research Council has banned the use of assisted reproductive technology for social sex selection, but notes "there is limited research into the question of whether Australians support the use of sex selection for non-medical purposes". This paper investigates Australian attitudes to sex-selection technology by different means (IVF, abortion, and a hypothetical pill), for different reasons (medical, family balancing, any reason), and by differing respondent characteristics (age, sex, education and religiosity).

METHODS

In 2007 and 2016, the Australian Survey of Social Attitudes (AuSSA) collected data on the attitudes of Australian adults to sex selection through IVF, abortion, and a hypothetical pill. We calculate population-weighted distributions and 95% confidence intervals of responses, and carry out logistic regressions to investigate the demographic characteristics of Australians who strongly disapprove of IVF or abortion for sex selection.

RESULTS

In 2016, around three-quarters of AuSSA respondents were opposed to legalising sex selection through IVF for any reason, or for family balancing for a second or third child. Thirty-seven per cent were opposed to IVF for medical sex selection. Two-thirds of respondents in both 2007 and 2016 disapproved or strongly disapproved of IVF for sex selection, while the proportion who strongly disapproved increased from 31 to 40%. Disapproval/strong disapproval of abortion for sex selection increased from 74 to 81% from 2007 to 2016, while strong disapproval alone rose from 44 to 55%. More than 70% of respondents in both 2007 and 2016 stated that a hypothetical pill for sex selection should not be legal. Our analysis finds that female, young, more-educated, and more religious respondents are more likely to strongly disapprove of sex selection via IVF or abortion, and that the increase in those who strongly disapprove from 2007 to 2016 is statistically significant.

CONCLUSIONS

Australians generally disapprove of the use of sex-selection technology. If legislation is to be guided by community attitudes, then the prohibition against sex selection for non-medical purposes through assisted reproductive technology should be maintained.

'Women think pregnancy management means obstetric ultrasound': Vietnamese obstetricians' views on the use of ultrasound during pregnancy

Objective

To explore Vietnamese obstetricians’ experiences and views on the role of obstetric ultrasound in clinical management of complicated pregnancy and in situations where maternal and fetal health interests conflict.

Design

Seventeen obstetricians in northern Vietnam were interviewed as part of the CROss-Country Ultrasound Study (CROCUS) project in 2013. Data were analysed using qualitative content analysis.

Results

The participants described ultrasound as a central tool in prenatal care, although they called for increased training and resources to prevent inappropriate management. A prevailing overuse driven by women's request and increased commercialisation was described. Other clinical examinations were seen as being disregarded by women in favour of ultrasound, resulting in missed opportunities for identifying potential pregnancy complications. The use of ultrasound for sex selection purposes raised concern among participants. Visualisation of human features or heartbeat during ultrasound was commonly described as the point where the fetus became regarded as a ‘person’. Women were said to prioritise fetal health interests over their own health, particularly if a woman had difficulties becoming pregnant or had undergone assisted fertilisation. The woman's husband and his family were described as having an important role in decision-making in situations of maternal and fetal health conflicts.

Conclusions

This study provides insight into issues surrounding ultrasound use in contemporary Vietnam, some of which may be specific to this low-income context. It is clear that ultrasound has become a central tool in prenatal care in Vietnam and that it has also been embraced by women. However, there seems to be a need to balance women's demands for obstetric ultrasound with better recognition of the valuable contribution to be made by the full range of clinical examinations in pregnancy, along with a more strategic allocation of resources, that is, use of obstetric ultrasound based on clinical indications. Better regulation of private obstetric practice also appears to be needed. While the root causes of sex selection need to be addressed at societal level, efforts are also required more immediately to find ways to combat the inappropriate use of ultrasound for the purpose of sex selection.

What is it to practise good medical ethics? A Muslim's perspective

Good medical ethics should aim at ensuring that all human beings enjoy the highest attainable standard of health. With the development of medical technology and health services, it became necessary to expand the four basic principles of medical ethics and link them to human rights. Despite the claim of the universality of those ethical principles, their perception and application in healthcare services are inevitably influenced by the religious background of the societies in which those services are provided. This paper highlights the methodology and principles employed by Muslim jurists in deriving rulings in the field of medical ethics, and it explains how ethical principles are interpreted through the lens of Islamic theory. The author explains how, as a Muslim obstetrician-gynaecologist with a special interest in medical ethics, including international consideration of reproductive ethics issues, he attempts to 'practise good medical ethics' by applying internationally accepted ethical principles in various healthcare contexts, in ways that are consistent with Islamic principles, and he identifies the evidence supporting his approach. He argues that healthcare providers have a right to respect for their conscientious convictions regarding both undertaking and not undertaking the delivery of lawful procedures. However, he also argues that withholding evidence-based medical services based on the conscientious objection of the healthcare provider is unethical as patients have the right to be referred to services providing such treatment.

Ethical issues in human reproduction: Islamic perspectives

Sexual and reproductive rights of women are essential components of human rights. They should never be transferred, renounced or denied for any reason based on race, religion, origin, political opinion or economic conditions. Women have the right to the highest attainable standard of health care for all aspects of their reproductive and sexual health (RSH). The principle of autonomy emphasizes the important role of women in the decision-making. Choices of women in reproduction, after providing evidence based information, should be respected. Risks, benefits and alternatives should be clearly explained before they make their free informed consent. Justice requires that all be treated with equal standard and have equal access to their health needs without discrimination or coercion. When resources are limited there is tension between the principle of justice and utility. Islamic perspectives of bioethics are influenced by primary Sharia namely the Holy Quran, authenticated traditions and saying of the Profit Mohamed (PBUH), Igmaa and Kias (analogy). All the contemporary ethical principles are emphasized in Islamic Shariaa, thus these principles should be observed when providing reproductive and sexual health services for Muslim families or communities. The Family is the basic unit in Islam. Safe motherhood, family planning, and quality reproductive and sexual health information and services and assisted reproductive technology are all encouraged within the frame of marriage. While the Shiaa sect permits egg donation, and surrogacy the Sunni sect forbids a third party contribution to reproduction. Harmful practices in RSH as FGM, child marriage and adolescent pregnancy are prohibited in Islam. Conscientious objection to treatment should not refrain the physician from appropriate referral.

ESHRE Task Force on ethics and Law 20: sex selection for non-medical reasons

This Task Force document revisits the debate about the ethics of sex selection for non-medical reasons in the light of relevant new technological developments. First, as a result of improvement of the Microsort® flow cytometry method, there is now a proven technique for preconception sex selection that can be combined both with IVF and IUI. Secondly, the scenario where new approaches that are currently being developed for preimplantation genetic screening (PGS) may lead to such screening becoming a routine part of all IVF treatment. In that scenario professionals will more often be confronted with parental requests for transfer of an embryo of a specific sex. Thirdly, the recent development of non-invasive prenatal testing based on cell-free fetal DNA in maternal plasma allows for easy and safe sex determination in the early stages of pregnancy. While stressing the new urgency that these developments give to the debate, the Task Force did not come to a unanimous position with regard to the acceptability of sex selection for non-medical reasons in the context of assisted reproduction. Whereas some think maintaining the current ban is the best approach, others are in favour of allowing sex selection for non-medical reasons under conditions that take account of societal concerns about the possible impact of the practice. By presenting these positions, the document reflects the different views about this issue that also exist in the field. Specific recommendations include the need for a wider delineation of accepted 'medical reasons' than in terms of avoiding a serious sex-linked disorder, and for a clarification of the legal position with regard to answering parental requests for 'additional sex selection' in the context of medically indicated preimplantation genetic diagnosis, or routine PGS.

Justice in the context of family balancing

Bioethics and feminist scholarship has explored various justice implications of non-medical sex selection and family balancing. However, prospective users' viewpoints have been absent from the debate over the socially acceptable bounds of non-medical sex selection. This qualitative study provides a set of empirically-grounded perspectives on the moral values that underpin prospective users' conceptualizations of justice in the context of a family balancing program in the United States. The results indicate that couples pursuing family balancing understand justice primarily in individualist and familial terms rather than in terms of social justice for women and girls or for children resulting from sex selection. Study participants indicated that an individual's desire for gender balance in their family is ethically complex and may not be inherently sexist, immoral or socially consequential, particularly given the social context in which they live. Our findings suggest that the social conditions that contribute to prospective users' desires for gender balance in their families may direct them away from recognizing or engaging broader social justice concerns relating to sexism and stratified reproduction.

Ethical attitudes of German specialists in reproductive medicine and legal regulation of preimplantation sex selection in Germany

BACKGROUND

Because of its ethical and social implications, preimplantation sex selection is frequently the subject of debates.

METHODS

In 2006, we surveyed specialists in reproductive medicine in Germany using an anonymous questionnaire, including sociodemographic data and questions regarding ethical problems occurring in the practice of reproductive medicine. Most questions focused on preimplantation sex selection, including 10 case vignettes, since these enabled us to describe the most difficult and ethically controversial situations. This is the first survey among specialists in reproductive medicine regarding this topic in Germany.

RESULTS

114 specialists in reproductive medicine participated, 72 males (63%) and 42 females (37%), average age was 48 years (age range 29-67 years). The majority of respondents (79%) favoured a regulation that limits the use of preimplantation sex selection only for medical reasons, such as X-linked diseases (including 18%: summoning an ethics commission for every case). A minority of 18% approved of the use of sex selection for non-medical reasons (4% generally and further 14% for family balancing). 90% had received obvious requests from patients. The highest approval (46%) got the counselling guideline against a preimplantation sex selection and advising a normal pregnancy, if preimplantation sex selection would be allowed in Germany. The majority (67%) was opposed the personal use of preimplantation sex selection for non-medical reasons, but would think about it in medical cases. In opposite to woman, 14% of the men were in favour of personal use for non-medical reasons (p=0,043). 25% of specialists in reproductive medicine feared that an allowance of preimplantation sex selection would cause a shift in the sex ratio.

CONCLUSIONS

The majority of German specialists in reproductive medicine opposes preimplantation sex selection for non-medical reasons while recommending preimplantation sex selection for medical reasons, e.g. X-linked diseases like haemophilia.

Ethical arguments for and against sperm sorting for non-medical sex selection: a review

Much has been written about the ethics of sex selection. This article thoroughly explores the ethical arguments put forth in the literature both for and against non-medical sex selection using sperm sorting. While most of these arguments come from philosophers, feminist scholars, social scientists and members of the healthcare community, they are often echoed in empirical studies that have explored community values. This review is timely because the first efficacious method for sex selection via sperm sorting, MicroSort, is currently in clinical trials and moving closer to FDA approval for marketing in the USA. While the clinical trials are currently focused on the use of MicroSort to avoid X-linked genetic diseases, MicroSort can also be used to satisfy parental preferences.

Non-medical sex-selective abortion in China: ethical and public policy issues in the context of 40 million missing females

INTRODUCTION

The rapidly growing imbalance of the sex ratio at birth (SRB) in China since the late 1980s demonstrates that, despite an extensive official prohibition, sex-selective abortion has been widely practised there in the past two or three decades. Given the reality of 30-40 million missing females, China has a more challenging set of ethical and social policy issues to be addressed regarding sex-selective abortion than is the case in Western and many other countries.

SOURCES OF DATA

This article is based on a search and review of Chinese and English-language literature, including several very recent books in Chinese on the imbalance of the sex ratio at birth in China. It also draws on first-hand information gathered from the author's extensive fieldwork on Chinese views and experiences of abortion.

AREAS OF AGREEMENT

The current female deficit is a real and serious problem in China-not a 'false alarm' as earlier alleged. It is a direct consequence of the widespread practice of sex-selective abortion and is chiefly caused by the strong socio-cultural preference for sons in China. Chinese academics-demographers and medical ethicists-in general agree with the official position that sex-selective abortion is morally wrong and should be legally prohibited.

AREAS OF CONTROVERSY

Some critical voices, mainly in the English-language literature, have asked whether coercive state intervention in this area is ethically justifiable. Another controversial question is whether and to what degree China's ambitious and rigorous population control programme, widely known as the 'one child' policy, is a contributing factor to the phenomenon of millions of missing females.

AREAS TIMELY FOR DEVELOPING RESEARCH

Much further research on the ethical and social policy issues surrounding sex-selective abortion in the Chinese context needs to be done. Systematic quantitative and in-depth qualitative sociological investigations into Chinese people's attitudes toward the subject, and the role of medical professionals, are long overdue.

The ethics of sex selection: a comparison of the attitudes and experiences of primary care physicians and physician providers of clinical sex selection services

OBJECTIVE

To compare the perspectives of primary care physicians (PCPs) and physician sex-selection technology providers (SSTPs) about the ethics of sex selection.

DESIGN

Qualitative interview study.

SETTING(S)

Academic, private, and HMO-based infertility and general medical practices.

PATIENT(S)

Forty PCPs and 15 SSTPs.

INTERVENTION(S)

Semistructured interviews.

MAIN OUTCOME MEASURE(S)

Comparisons of bioethical attitudes towards sex selection.

RESULT(S)

Primary care physicians and SSTPs had distinctly different perceptions of the ethical concepts of autonomy, beneficence, and nonmaleficence as applied to sex selection. Sex-selection technology providers argued that sex selection was an expression of reproductive rights, was initiated and pursued by women, and was a sign of female empowerment that allowed couples to make well-informed family planning decisions, prevented unwanted pregnancies and abortions, and minimized the abuse of wives and/or neglect of children. In contrast, PCPs challenged the concept of "family balancing" and questioned whether women could truly express free choice under family and community pressure. In addition, PCPs voiced the concerns that sex selection technologies led to invasive medical interventions in the absence of therapeutic indications, contributed to gender stereotypes that could result in neglect of children of the lesser-desired sex, and were not a solution to domestic violence.

CONCLUSION(S)

Primary care physicians and SSTPs had markedly different ethical perspectives on the provision of sex selection services that were informed by their professional and personal attitudes and experiences.

Millions of missing girls: from fetal sexing to high technology sex selection in India

The morality and acceptability of using prenatal diagnosis for sex selection is being extensively debated around the world as advances in assisted reproductive technologies (ART) and embryology have enabled selective implantation of embryos of the desired sex (George and Dahiya, 1998; Savulescu, 1999; Raphael, 2002; Harris, 2005; Robertson, 2005; Snider, 2005). Sophisticated methods of separation of semen, originally developed for cattle breeding, are being used for human sex selection. Recently, non-invasive methods of fetal sex determination in the first trimester (from 6 weeks) of pregnancy have also emerged (Hahn and Chitty, 2005). Market forces that promote sex selection along with libertarian ideologues have assisted in blurring the ethical limits (Paul, 2001; President's Council on Bioethics, 2003). The widespread misuse of sex selection for eliminating girls before birth in India and among the Indian diaspora needs to be brought into the global 'intellectual discourse'. It is imperative that Western ethicists recognize the genocidal nature of sex selection taking place in certain Asian countries. Even if they believe that these trends will not affect mainstream Western societies, the promotion or tolerance of sex selection amounts to a 'crime of silence' against this ongoing genocide in China and India. I have been concerned with issues of the girl child in India for over two decades and sex selection among Asian Indians in North America (George et al., 1992; George et al., 1993; George and Dahiya, 1998). This article examines the missing millions of girls, but will not consider the 1980s campaign against fetal sex determination, Indian feminists' recognition of sex selection as violence against women (unlike several Western feminists, Moazam, 2004), or the Government's response to regulate prenatal diagnostic techniques in 1994 (George and Dahiya, 1998; George, 2002).

Social sex selection and the balance of the sexes: Empirical evidence from Germany, the UK, and the US

Preconception sex selection for nonmedical reasons is one of the most controversial issues in bioethics today. The most powerful objection to social sex selection is based on the assumption that it may severely distort the natural sex ratio and lead to a socially disruptive imbalance of the sexes. Based on representative social surveys conducted in Germany, the United Kingdom, and the United States, this paper argues that the fear of an impending sex ratio distortion is unfounded. Given the predominant preference for a "gender balanced family," a widely available service for social sex selection is highly unlikely to upset the balance of the sexes in Western societies.

Legal and ethical issues in telemedicine and robotics

Modern medical concerns with telemedicine and robotics practiced across national or other jurisdictional boundaries engage the historical, complex area of law called conflict of laws. An initial concern is whether a practitioner licensed only in jurisdiction A who treats a patient in jurisdiction B violates B's laws. Further concerns are whether a practitioner in A who violates a contract or treats a patient in B negligently incurs liability in B, A, or both, and, if treatment lawful in A is unlawful in B, whether the practitioner commits a crime. Judicial procedures are set by courts in which proceedings are initiated, but courts may decline jurisdiction due to inconvenience to parties. If courts accept jurisdiction, they may apply their own substantive legal rules, but may find that the rules of a conflicting jurisdiction should apply. Cross-border care should not change usual medical ethics, for instance on confidentiality, but may mitigate or aggravate migration of specialists.