This article has been cited by other articles in PMC. Abstract Sex selection for non-medical reasons is forbidden in many countries.
The article further provides a critical review of the arguments for the prohibition of sex selection for non-medical reasons and finds that none of these are conclusive. The authors conclude that the ban should be reconsidered, but also that existing societal concerns about possible harmful effects should be taken seriously. Finally, a difficult set of questions is raised by concerns about the reliability and unproven long-term safety of the only technology flow cytometry proven to work.
Preconception sex selection, non-medical reasons, flow cytometry, ethics, regulation Introduction Since ancient times, prospective parents have tried to influence the sex of their future children. Aristotle, for example, advised those wanting a boy to have intercourse when the wind is in the north. Other people have assumed that special diets, the timing of intercourse in relation to ovulation, binding up one of the testicles during intercourse, or the position during intercourse, might facilitate sex selection.
Apparently, every folk culture has its own strategies. Modern science provides people with new, more effective, methods for sex selection. This is widely though not universally seen as a welcome development insofar as sex selection for medical reasons is concerned. However, sex selection for non-medical reasons has been the subject of recurrent ethical and public policy debate in many countries.
A recent overview Darnovsky, shows that a similar restrictive stance is adopted in all 36 countries with laws and policies on sex selection, including China, India, Turkey, Australia, Canada, and 25 European countries among which are also Belgium and the Netherlands. Some countries in Europe: Austria and Switzerland go even further and prohibit sex selection for any reason. Although it may seem that the sheer weight of this prohibitive consensus between jurisdictions, at least in Europe, has brought the debate about allowing sex selection for non-medical reasons to a closure, and although it is clear as again confirmed in the consultation held in the UK that among the public there are strong moral feelings against more liberal policies, we will argue that there are still good reasons for questioning the arguments behind this international consensus.
Some further distinctions and specifications are important. A second distinction concerns the timing of sex selection. Sex selection can be performed at three stages: This strategy is called preconception sex selection, primary sex selection or sex pre-selection; — just after fertilization, by means of in vitro fertilization IVF combined with preimplantation genetic diagnosis PGD , aiming at a selective transfer of an embryo of the desired sex.
This procedure is called preimplantation - or secondary sex selection. This is post-implantation, prenatal or tertiary sex selection. A third distinction concerns the reasons for sex selection. The literature generally makes a distinction between medical and non-medical reasons.
Medical reasons are often defined in terms of preventing the conception or birth of a child suffering from a sex-linked disorder, like Duchenne muscular dystrophy or haemophilia. But obviously, a third category of possible reasons should be added, which can be regarded as intermediate between medical and non-medical reasons De Wert, ; De Wert, Think of males affected with an X-linked recessive disorder, like haemophilia.
What, then, if one of these male patients and their partners were to request sex selection in order to avoid the conception or birth of a carrier-daughter? More in particular, this paper focuses on the ethics of preconception sex selection for non-medical and intermediate reasons, as preconception sex selection for medical reasons is widely considered to be acceptable from a moral point of view. In the next paragraph, we will first summarize the normative views of some relevant committees and some inter- national legal regulations section 2.
Next, we will provide an ethical evaluation of the main arguments in the debate section 3. The technology presently available for preconception sex selection will be sketched thereafter, with particular attention to its efficacy and safety section 4.
Finally, we will draw some conclusions and present some recommendations section 5. Clearly, the overview is not exhaustive - but it is, we think, representative. The Warnock Report These considerations made the Committee dubious about the use of sex selection techniques on a wide scale, but because of the difficulty of predicting the outcome of any such trend the Committee has not found it possible to make any positive recommendations on this issue.
Nevertheless, the Committee considered that the question of the acceptability of sex selection should be kept under review Warnock report, The Glover Report According to this report, submitted to the European Commission, it could be argued that there is nothing intrinsically wrong with sex selection for social reasons. So we think that sex selection should be strongly discouraged.
It would be desirable for clinics to be banned from providing pre-conceptual techniques as a service. The Law Reform Commission This Canadian Commission states: It therefore seems appropriate to limit individual freedoms in the name of respect for human dignity.
According to this committee, there is no cause to prohibit preconception sex selection in the Netherlands. Governments ought, in principle, to respect the reproductive freedom of parents - any exception to this basic principle can only be justified if the interests of others are harmed.
However, the Committee did emphasize the provisional nature of this conclusion concerning social implications; it cannot be excluded that the availability of opportunities for sex selection as part of family planning might lead to parents finding the gender of their children to be more important than now appears the case. Developments in this area should, therefore, be monitored very critically Health Council, This Committee concluded that if trials show that the techniques of preconception gender selection are safe and effective, the most prudent approach at present for the non-medical use of these techniques would be to use them only with the aim of establishing gender variety in a family.
If the social, psychological, and demographic effects of those uses have been found acceptable, then other nonmedical uses of preconception sex selection might be considered Ethics Committee of the ASRM, Dutch and Belgian Embryos Acts , The Belgian Embryos Act contains a similar provision. According to a commentary by Hansen et al.
A later report from this Committee contained a more comprehensive discussion of arguments both for and against allowing preconception sex selection for non-medical reasons, but without this leading to a consensus view or policy advice. Accordingly, the Authority decided that treatment services provided for the purpose of selecting the sex of children, by whatever means this is to be achieved, should be restricted under license to cases in which there is a clear and overriding medical justification HFEA, The notion of a disease or condition being gender-related is further specified as either affecting only one sex or as affecting one sex significantly more than the other.
Parents already having more than one children affected by disorders in this category, such as autism, are at a significantly higher risk that any further child will also be affected. Whether sex selection to avoid this risk would be legal in Britain may still depend on the interpretation of whether the disease in question would satisfy the requirement of seriousness.
Interestingly, the Belgian Act does not require the disease in question to be of a serious or severe nature, whereas the German, Dutch and British Acts do. None of these Acts, nor any of the reports we are aware of, refer to sex selection for intermediate reasons. On the basis of this short overview, the following conclusions can be drawn: Firstly, there is wide approval, in principle, of the application of preconception sex selection for medical reasons, although both the precise definition of this category and the conditions imposed differ.
Secondly, opinions differ widely with regard to the moral acceptability of preconception sex selection for non-medical reasons. Indeed, some committees do not or hardly present any arguments in favor of their recommendations. The objections are very diverse and different committees use rather different objections. However, the often quite narrow definition of the category of non-prohibited medical reasons in terms of avoiding the birth of a child with a sex-linked disease and the rigid, binary distinction between medical and non-medical reasons, seems to rule out sex selection for intermediate reasons in most if not all jurisdictions with legislation on sex-selection.
In the next section, we will scrutinize the arguments for disallowing preconception sex selection for non-medical reasons. Where relevant, we will also discuss whether and how these arguments apply to the use of preconception sex selection for intermediate reasons. Ethical analysis For the sake of debate, we assume, for the moment, that preconception sex selection techniques are completely efficient and of proven safety.
That this is not yet an established fact will be addressed in section 4. Several types of moral objections to preconception sex selection for non-medical reasons need to be discerned Warren, On the one hand, so-called non-consequentialist or deontological objections refer to what those making such objections regard as morally problematic aspects of the act of sex selection for non-medical reasons taken in itself, that is to say: Consequentialist objections, on the other hand, refer to its presumed adverse consequences.
Non-consequentialist objections include the following: Appealing to Nature as a moral norm is quite common in societal debates — but highly questionable. It is doubtful whether there any such interpretations which are convincing. If valid, therefore, the argument would apply to all forms of sex selection, including medical and what we have called intermediate reasons.
However, since it surely is an important part of human nature to be inventive, to intervene in nature, and thus to create culture, we must look elsewhere for criteria to ethically evaluate our actions.
This objection implicitly refers to the traditional goals of medicine, namely the prevention of disease, curing the ill, and caring for sick people who can not be cured. Sex selection for non-medical reasons can not be subsumed under any of these traditional tasks of the physician, so there is no medical indication for this practice RCO, This criticism seems to mistakenly suggest that the domain of medicine and health care is surrounded by clear and fixed borders.
For a start, one may ask how sex-selection for what we have called intermediate reasons would relate to the goals of medicine as traditionally understood. As in those cases sex selection will not change the health status of the child to be born, reasoning from a strict understanding of those goals would lead to the conclusion that sex selection for intermediate reasons is beyond the scope of medicine. After all, the prospect that a daughter may have to face difficult reproductive decisions later in her life is not in itself a medical condition.
The further question here is why an appeal to the bounds of medicine as concerned with health related issues would imply that sex selection for what are clearly non-medical reasons is not acceptable. In fact, there are various widely accepted medical solutions for non-medical problems.
Classical examples are sterilisation for the purpose of family planning or cosmetic surgery. If these are acceptable practices, one may doubt as to whether the absence of a medical indication as such is a strong moral objection to assisting in preconception sex selection for non-medical reasons. Sexism can be defined as the wrongful discrimination between individuals on grounds of sex. It is obvious that a sexist motivation for sex choice is morally wrong, as it stands in denial of the principle that all human beings have the same worth.
If so, that would indeed amount to a strong argument for disallowing sex selection for such reasons. However, it is far from obvious that it is necessarily sexist for someone to want to select the sex of a child for a non-medical reason.
Consider the following examples Warren, ; Health Council, Firstly, in some subcultures in some countries, a son is an economic asset; a son will earn more money, and parents will have to provide their daughter s with a dowry, which might almost ruin their own family. Against the background of such conditions, son-preference is not necessarily a sign of sexism of the prospective parents — even though their preference would be related to sexism at the socio-cultural level.
It may even be the case that couples prefer to have sons because they want to spare their daughters the plight of having to live in a sexist society. Of course, the fact that such choices may reinforce sexist structures and institutions is a relevant consideration where the possible social consequences of sex selection are concerned. However, this does not mean that those choices are inherently sexist themselves Warren Are those who believe that family dynamics would be enhanced by having children of both sexes guilty of a sexist attitude?
Think of couples who have one or more sons and prefer their next child to be a girl, or vice versa.