Boy or girl, we choose! (PART 1)

Chance, choice and control: Lay debate on prenatal social sex selection.

The promise of increased choice is now one of the key drivers to the new genetic and reproductive technologies. Assisted reproductive technologies (ARTs) enable individuals or couples, who in the past would have been unable to have healthy children, to choose to conceive. Greater understanding of the genetic components of diseases and disabilities offers potential parents the choice of preventing the conception or birth of affected individuals, through genetic counselling, prenatal diagnosis (PND) or increasingly sophisticated methods such as preimplantation genetic diagnosis (PGD). These technologies are positioned as increasing the range of choices open to the healthcare consumer, and enhancing “reproductive freedom” more generally.

Intervening in an area like reproduction raises significant ethical issues, which have been extensively debated by ethicists and policy makers as the technology has developed. There is broad consensus that a major element in the evaluation of any ART is the increased reproductive choice that it offers, since increased choice is generally viewed positively. There is also an underlying assumption that “more choice” means “more freedom”.

Assisted reproductive technologies are typically positioned as increasing the range of choices open to the healthcare consumer, thereby enhancing ‘reproductive freedom’. In this paper, we question the equivalence of reproductive choice and personal freedom in ethical theory, using results from a project investigating how lay people make ethical evaluations about the new genetic and reproductive technologies.

We took the topic of social sex selection by preimplantation genetic diagnosis (PGD), and used group discussions and interviews in the north-east of England to trace how lay people develop and express their ethical evaluations, and to identify the implicit or explicit normative framework that gave rise to their opinions on prenatal sex selection. There was a striking level of ambivalence towards choice in general and reproductive choice in particular. Participants offered few positive statements and numerous reasons why reproductive choice might be problematic. Our participants’ argumentation shares with mainstream bioethical analysis the weighing of the possible harms of prenatal sex selection for social reasons against the harm of restricting reproductive freedom. However, unlike most secular–liberal bioethicists, many of our participants concluded that prenatal sex selection is undesirable because it is an expression of parental preference instead of a response to the future child's need. Our interpretation of their reasoning is that they work from an ideal of “good parents”, one of the features of which is the relinquishing of control over their children, except to protect them from harm. This voluntary self-limitation does not indicate reduced autonomy, because parental autonomy can only operate within the limits set by this relational framework.

We suggest that a model of relational autonomy captures our lay participants’ framing of the problem better than a more traditional understanding of autonomy. Our study also shows that in appropriately structured discussion of bioethical issues, lay people can articulate reasons for their opinions that are grounded in sophisticated and morally relevant concepts.

Harms and choice

Our participants were often doubtful about the unequivocal benefits of choice in general. They were able to give a number of reasons why they thought reproductive choice in particular might be morally problematic. Many of these reasons concerned the potential harmful consequences of extending reproductive choice to social sex selection. Here our participants raised much the same points as are raised in the bioethics literature—that sex selection might lead to future large-scale gender imbalance, increases discrimination against one sex, is the start of the slippery slope to more widespread selection, leads to the child being treated as a consumer good or is an inappropriate use of limited healthcare resources. These are the major potential consequences that are debated in consultation documents and in the literature of secular–liberal bioethics.

As well as identifying possible harmful consequences, our participants also weighed the consequences up against other factors in their moral deliberations. To an extent, these judgements resembled the approach taken by the dominant form of contemporary western bioethics, in that the potential harms of sex selection were balanced against the effect on the freedom of the individual. As numerous commentators have noted, most of the philosophical work in bioethics comes from within the Anglo-American tradition of analytic philosophy. While it is true that alternative traditions and approaches, such as virtue ethics, care ethics, feminist ethics and narrative ethics, are represented, we nonetheless share the opinion of these critics that the dominant form of contemporary Anglo-American bioethics is a secular, liberal (and often libertarian) one, focusing on the individual moral agent, prioritising logic and abstract rationality, and drawing extensively on the formalism of consequentialist, utilitarian and rights-based approaches to ethics. For the sake of conciseness, we will call this “secular–liberal bioethics”.

For many bioethicists working within this tradition, individual liberty is a, if not the, primary ethical–political value. Dating back to Mill, the liberal position is that restrictions on a person's freedom are only justified in order to prevent probable, significant harm to others. It is in line with this ethical approach that the UK and several other European countries have recognised in principle the potential individual and collective harms that might result from new genetic and reproductive technologies (like the termination of an otherwise viable pregnancy, or overt eugenic or discriminatory attitudes towards disabled people), but have not considered these harms to be either probable or significant enough to warrant banning technologies such as PND.
The same form of reasoning about harms was used in the group discussions. For example, people often initially suggested that prenatal sex selection might lead to a gender imbalance, as has already been observed in some parts of the world (China and India were usually mentioned here). Even if a numerical gender imbalance did not develop, or was not large enough to cause social problems, our participants tended to feel it would still be unjust in that it would reflect a systematic bias against one gender. But on further reflection, many participants felt that neither an actual gender imbalance nor systematic prenatal gender discrimination were likely to happen in the prevailing culture of the north-east of England. They thought that prenatal sex selection by PGD or other means would be used more for “family balancing” reasons and would therefore not lead to one sex being preferred over the other. So although potentially serious, neither a future gender imbalance nor systematic gender discrimination were thought to be very probable harms, and so to our participants did not provide strong enough grounds to restrict parental choice.

What about the harms or benefits to the individual child? Sex selection for social reasons occupies a peculiar position along the spectrum of reproductive choice when individual costs and benefits are considered. On the one hand, it is not a therapeutic intervention: by definition, social sex selection does not prevent a medical harm. For most of our participants, this immediately takes away the major argument in favour of any intervention. But equally, it is not an enhancement: it gives no unusual advantage to the sex-selected child. Under normal circumstances, the two outcomes (male or female) are more or less equally prevalent, and both are equally biologically and socially viable. The study participants generally agreed that many societies are still inclined to favour males and discriminate against females, but did not feel that the bias was large or immutable enough to say that being born male is objectively advantageous, or being born female objectively disadvantageous. This contrasts sharply with their discussions of PGD for genetic disease, where almost all agreed that being born without an impairment is preferable to being born with one. And it was also in contrast to the discussions about PGD for enhancement (theoretical only at the moment), where they saw clear injustice in the production of a child with a major social or biological advantage solely because its parents have access to this technology.

The possible harm that group participants seemed to find the most likely was psychological damage to the child through the pressure of parental expectations, in this case about gender-specific behaviour. The majority of groups raised this issue at some point, but differed in whether they concluded it was peculiar to sex selection. Although some discussants felt the prenatal selection of sex (or other nonmedical characteristics) expressed parental desires in an unacceptably stark way, others argued that it was no different from any situation where parents have strong expectations that the child may have difficulty meeting. The bioethics literature concentrates on physical harms to the child, such as possible damage to the embryo, while this was mentioned much less often by the lay participants. But like our participants, leading bioethical commentators tend to consider potential psychological harms as speculative or not unique to prenatal sex selection. And the act of choosing which embryo to transfer was simply not seen by most of our participants as causing equivalent harm to the child itself as sex-selective abortion.

On balance, then, the consensus of opinion amongst the group participants was that prenatal social sex selection by PGD did not present either a special harm or special advantage to the child, a conclusion in line with much of secular–liberal bioethical opinion.

PART 2 WILL BE PUBLISHED ON 23/7/06.