A System of Ethics for Food

A System of Ethics for Food

Preconception Gender Selection

November 19, 2003

R. Jeffrey Chang, MD

Professor of Reproductive Medicine

Director/Division of Reproductive Endocrinology and Infertility

V. Gabriel Garzo, MD, FACOG

Assistant Clinical Professor of Reproductive Medicine

Medical Director, Reproductive Partners Medical Group, Inc.

What follows is a synopsis of the discussion that followed Dr. Garzo and Dr. Chang’s Nov. 19th, 2003 presentation. It aims to summarize the range of views expressed following their talk. Not all of these views represent Dr. Garzo or Dr. Chang’s own thinking on the topic. Nor of course do they necessarily represent of views of everyone present at the discussion. Slides of the talk itself may be accessed at

PRESENTATION

Sex Selection

  • Main reasons for wanting to select gender:
  • Medical
  • To prevent diseases carried on the X-chromosome
  • Non-medical
  • Family balancing (if a couple has children of just one sex)
  • Other personal reasons (carry on the family name, can’t afford dowry, etc.)

Methods

  • Three stages at which one can select for sex:
  • Preconception
  • Separate sperm containing X- and Y-chromosomes, then fertilize via:
  • intrauterine insemination (IUI)
  • intracytoplasmic sperm injection (ICSI)
  • Pre-implantation
  • Post-implantation
  • Microsort: a technique using one of the most effective methods of separating sperm
  • Patented by the USDA
  • Uses flow cytometry:
  • Sperm colored with a DNA-binding dye
  • Sperm then scanned with a laser beam to separate heavier X- from Y-bearing sperm
  • Currently in clinical trials in Fairfax, VA and Laguna Hills, CA
  • Accuracy:
  • X-sort = 92.2% girls
  • Y-sort = 80.9% boys
  • Negative aspects of Microsort
  • Possible DNA damage
  • Dye and/or laser beam may negatively affect sperm
  • Animal tests have shown 3 generations with no malformations
  • Cost (depends on age of female & quality of sperm) typically $15,500 per cycle, with a 33% clinical pregnancy rate

Current Opinion Regarding (Non-medical) Sex Selection

  • In the United States, majority of couples have no preference as to the sex of their first child. However, many prefer the sex of the second child to be opposite of the first child.
  • In the United States, 75% of sex selection is for girls. Possible causes are:
  • Wife’s preference for a female child
  • Existing techniques offer better chance of successfully sorting for a girl
  • The Ethics Committee of the American Society for Reproductive Medicine maintains that, if assuming methods of preconception gender selection are found to be safe and effective, physicians should be free to offer them to couples seeking gender variety in their children. This recommendation is subject to the requirement that couples:
  • Are informed of the risks of failure
  • Affirm that they will accept children of the opposite sex if the sex selection fails
  • Are counseled about having unrealistic expectations about the behavior of the children of the preferred gender
  • Are offered the opportunity to participate in research on preconception selection

Common Arguments FOR (Non-medical) Sex Selection

  • Falls within the realm of individual autonomy – so long as no one is harmed, decision should be left to the individual couple
  • Avoids abortion
  • Results in a happier family

Common arguments AGAINST

o“Pre-selecting” gender of children = playing God

  • Constitutes or may lead to sex discrimination
  • Possibility of gender imbalances
  • May directly or indirectly endanger the welfare of the child
  • Cost prohibitive for all but the rich
  • Another step down a slippery slope to “designer babies”

DISCUSSION

Should doctors use medical techniques for non-medical reasons?

  • Just because we can do something, doesn’t mean that we should
  • Example: We can keep coma patients “alive” indefinitely, but many regard doing so

as an unacceptable medical practice

  • Gender selection is consumer-driven rather than medically-driven
  • Does this practice give too much weight to parental preference?
  • Does it create false needs and expectations, that is, needs or expectations that didn’t exist before?
  • Gender is not a disease, and should not be treated as one
  • Who will determine when and where these techniques are used? The government, medical professionals, parents?
  • What is the role of compassion in making this technology available for non-medical reasons? Is it wrong for medical personnel to help couples longing for a child of a certain sex?
  • On what basis do we decide what is medically acceptable? Should the relevant professional societies issue guidelines? For example, current guidelines governing elective vasectomy require that patients be of a certain age, already have children, etc.
  • Here too shouldn’t there be an agreed upon standard? There will always be doctors who will do any procedure a patient desires, so guidelines are necessary
  • Might there also be harms in not making gender selection available?
  • How might making gender selection available to all affect medical resources for infertile couples?

Sex selection: effects on society

  • Justice of offering sex selection in one country, but not in others
  • Gender imbalances
  • To prevent gender imbalances, doctors could be licensed to select for only an even number of boys and girls
  • In such a case, sex selection would essentially become a lottery system – which is what we have now in terms of the natural odds of conceiving one sex or the other
  • Initial gender imbalances, if they occurred, would even out as the rare sex became more valuable
  • The Chinese policy of restricting couples to one child led to a predominance of male children. One outcome was the “spoiling” of this only child by the parents and grandparents. As a result, the government now allows families to have multiple children.
  • The Chinese policy required government-imposed rules of a kind unacceptable in this country, making their experience an unlikely model for thinking about US policy
  • Is sex selection inherently sexist in assigning value to one gender over the other?
  • Does allowing gender selection in the absence of pressing medical reasons reinforce sex discrimination and gender stereotypes?
  • Mightn’t the very act of sorting sperm convey permissiveness towards the idea of discrimination against women, even if this is not actually the case?
  • For many, the sorting of sperm on gender lines elicits the “yuck factor”
  • Is gender selection the first step down a slippery slope? In allowing couples to select for gender, are we opening the door to the selection of hair color, IQ, etc.?

Sex selection: effects on the individual

  • Does sex selection foster unrealistic parental expectations, moving us towards a picture of children as “consumer products” rather than unique individuals?
  • Preferences originate with the parents, not with the technique of gender selection. If a couple wants a boy and ends up with a girl, they will be disappointed whether they used flow cytometry, IVF, or conceived naturally
  • Not so – the act of choosing one cup of sperm over the other, or paying $15,000, elevates the couple’s expectations
  • In the family, who will actually make the choice about the intended gender of future offspring? In the US, most couples using sex selection choose to have a female baby, presumably because of the mother’s preference. However, societal and family pressures for a male (or female) offspring can be very strong. How can medical personnel ensure the autonomous consent of both parents?
  • Use of Microsort process requires the signature of both parents

Risk-benefit analysis

  • How do scientists and medical personnel assess the rightness or wrongness of making a given technology widely available? Making this determination based on presumed benefit to patients may require more study of the technology
  • Flow cytometry has been used with human subjects for 6-7 years, with over 500 births. Only 7 out of 296 had major malformations, a lower than average outcome.
  • With this limited data, can we really determine that the risk is so small?
  • The technology is here now - the world won’t wait for more research
  • It’s hard to believe that flow cytometry doesn’t do any damage at all. Some animal studies show increased chromosomal damage, and the use of IVF and ICSI may increase the incidence of some cancers
  • Flow cytometry may actually result in healthier offspring because it sorts for the best sperm samples – damaged or flawed sperm are eliminated
  • The risk seems so low that the benefit outweighs it
  • We are in agreement that there is low risk at birth, but what about the long-term risk?
  • Science used genetics to create better, bigger crops with no apparent ill effects. However, this led to a monoculture susceptible to pest problems. Flow cytometry may be fine for the first few generations, but what if down the road this population suddenly starts developing schizophrenia, etc?
  • Doctors need to explain the possible long-term risk to couples – this is what informed consent is all about. In many, the desire for a certain gender is so strong that it will outweigh any possible risks.

How does non-medical sex selection differ from IVF embryo selection?

 When an infertile couple undergoes IVF, they choose which of the viable embryos to use. Confronted with two embryos of equally high quality, one male and one female, does it matter ethically if the embryo is chosen according to gender?

  • Is there an ethical difference between selecting embryos & selecting among sperm?
  • When undergoing IVF, couples must make a choice regarding which embryo to use. However, a couple is not placed in this same situation regarding sperm – they can get pregnant without making a decision regarding which type of sperm to use. The whole point of flow cytometry is to distinguish between the X- and Y-bearing sperm.
  • The risk-benefit analysis is also different in the two situations. In order to identify the gender of an embryo, it must first be biopsied, which could result in damage to the embryo and jeopardize the IVF treatment. Flow cytometry does not (apparently) carry this risk.
  • Is the situation any different when a couple is selecting a sperm or an egg donor based on hair & eye color, IQ, nationality, height, etc?
  • What about the practice of aborting babies with Down Syndrome?
  • In this instance, we select against defects, rather than for intelligence, sex, etc.
  • In genetic counseling, couples choose the “best” baby everyday. Might genetic counseling provide an adequate model for preconception sex selection, i.e., requiring informed consent, teaching couples how to interpret results, etc?
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