Assisted Reproduction, Prenatal Testing, and Sex Selection

Assisted Reproduction (AR)

• Assisted Reproduction (AR) is defined as techniques for creating a baby through means other than sexual intercourse between a woman and a man.
• AR techniques can involve:
  • A couple (usually married).
  • Singles or unmarried couples.
  • Third parties who provide bodily products or services.
• Examples of AR techniques include:
  • Artificial insemination by husband (AIH).
  • In vitro fertilization (IVF) and related technologies like gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT).
  • Intracytoplasmic sperm injection (ICSI).
  • Preimplantation genetic diagnosis (PGD).
  • Insemination by donor (AID).
  • IVF and PGD using donor eggs or sperm.
  • Contract pregnancy or surrogacy.
• Some AR approaches may involve:
  • Cryopreservation (freezing).
  • Precursor tissue such as ovarian tissue.
• Ongoing development of AR technologies brings rise to questions about family relationships
• Future possibilities in AR include:
  • Cloning.
  • Eggs using material from more than one individual.
  • Artificial gametes.
  • Artificial wombs.
• Widespread social values promote AR because many believe that having biological children is a natural and important part of life, and that women are unfulfilled unless they gestate babies
• Individuals unable to conceive on their own are encouraged to seek AR, preferably using their own gametes, but using donor services if necessary, before or instead of seeking to adopt
• Some AR techniques can help parents select children who meet certain criteria, such as:
  • Freedom from genetic diseases.
  • Tissue compatibility with a seriously ill sibling ("savior siblings").
  • Being a particular sex.
• Contract pregnancy can protect women at special risk of harm from pregnancy
• Demand for AR is increasing rapidly due to:
  • Infertility, which affects about 15 percent of couples worldwide.
  • Factors such as sexually transmitted diseases, poor health care, environmental pollution, unsafe illegal abortions, unnecessary hysterectomies, early sterilization.
  • Education and employment patterns that lead women to delay childbearing.
  • New technologies, including genetic tests and MicroSort®, that raise the possibility of selecting for or against particular characteristics.
  • Postmenopausal women can now sometimes give birth at very advanced ages by using donor eggs.
  • It is even possible to gestate fetuses in brain-dead women or use sperm from dead men to create post-mortem babies.

General Assessments of Assisted Reproduction

• Some oppose AR in principle from conservative or feminist (or, more generally, progressive) perspectives
• Conservative Objections:
  • Based on the separation of sex and reproduction.
  • Radical alteration of traditional relationships.
  • Resistance to separating sex and reproduction is based on natural law theory or religious principle.
  • Natural law theory assumes that what is “unnatural” is bad or wrong, or begs questions, it cannot provide a strong moral basis for prohibiting the separation of sex and reproduction
  • Religious principles are an unacceptable basis for social policy in pluralistic societies, although individuals who adhere to them are free, other things being equal, to live according to them
  • AR does alter tradition, but traditions can be less than optimal or even seriously harmful.
• Feminist Objections:
  • Fear that AR will reinforce and promote sexism.
  • Pronatalism and emphasis on biological relationships lead many women to undertake costly and potentially risky procedures to remedy infertility that would not otherwise trouble them or that they might be happy to alleviate via adoption.
  • Since men are still dominant in society, and are especially influential in science, technology, and medicine, AR adds to men’s power over women.
  • Some feminists claim that if additional techniques (such as ectogenesis or cloning) were perfected, men might seek to eliminate women from society altogether; other developments might also lead to morally objectionable forms of eugenics.
  • Many feminists believe it would be better to address sources of infertility, and eradicate the underlying sexism that makes it so problematic for women, especially in extremely patriarchal cultures.
  • Focusing on AR displaces these reforms.
  • Progressives are concerned about possible harm to women and children from innovative therapies now being routinely offered without prior extensive research to establish safety and efficacy
  • Infertility treatment is now a highly profitable business in the US, raising concerns about potential conflicts of interest.
  • Regulation may further particular agendas, such as those espoused by the Vatican, rather than protecting women or children.
• Given the benefits of some forms of AR, and the practical impossibility of stopping it, the best hope is informed and democratic discussion, followed by intelligent regulation

Artificial Insemination and Egg Donation

• Artificial insemination (AI) was the first AR technique developed
• AIH first opened up the possibility of separating sex and reproduction
• AID first involved a third party in the treatment without sexual intercourse
• AID is widely accepted, producing some 30,000 babies yearly in the United States alone
• Sperm banking has become big business, with more than 100 clinics in the US in 1999
• AID per se does not appear to harm the individuals it produces, although it raises questions about non-traditional family relationships
• The main risk of emotional harm comes not from the relationships themselves, but from secrecy and lies about them
• Inadequate screening for sexually transmitted diseases like AIDS or genetic disease could harm women or children
• Lack of screening capacity is the principal drawback of do-it-yourself AID
• Using a physician’s services should provide such protection, but in practice, it does not always do so
• Using physician AID is more costly than do-it-yourself AID, and raises the possibility of unjustifiable gate-keeping harmful to single women or lesbian couples
• Physicians have also been caught using their own sperm without consent
• AID could also theoretically cause marital problems if men are less attached to children to whom they are not genetically related
• Poor regulation raises the specter of custody claims by donors or demands for financial support by recipients
• Anonymity is another major issue: should children born of AID have a right to genetic or personal information about their biological fathers?
• AID appears a beneficial practice that circumvents male infertility and can be used to prevent serious genetic disease
• Egg donation is more physically and morally complicated
• Sperm for donation are obtained by masturbation, obtaining eggs is risky and unpleasant for donors
• Women are usually hormonally stimulated to produce multiple eggs; frequent blood tests and sonograms are required to monitor their development
• The resulting eggs are then retrieved by passing a needle through the vaginal wall
• The risks include hormonal overstimulation, possible damage from the needle, and potentially harmful long-term effects of these procedures, including a suspected risk of cancer
• In addition, because the procedure is relatively new (dating only to the early 1980s), in some countries there are few legal protections for participants
• One might question whether it is in women’s interest to donate eggs
• A flourishing market in eggs has developed in some countries, such as the US, where eggs from women considered the most desirable are advertised for as much as $50,000
• Other countries, like Germany and Egypt, prohibit egg donation, and in some it is permitted but compensation is limited
• Safer techniques and stringent safety-oriented regulation will reduce risk in the future

IVF and Its Relatives

• IVF provides a way to detour around blocked or damaged fallopian tubes
• GIFT and ZIFT are variants that raise most of the same moral issues
• Women must either undergo egg retrieval or acquire a donor egg; then sperm and egg are united in a Petri dish
• Where a husband’s sperm is known to be deficient in some way, intracytoplasmic sperm injection (ICSI) may be done, injecting a single sperm through the outer membrane of the egg wall
• Fertilization may also be helped along with so-called “assisted hatching”
• After a few cell multiplications, embryos with apparent defects are discarded, and some or all of the rest are implanted in the woman’s uterus
• Physicians are now getting equally good results in some cases using single embryo transfer, which prevents the risks of multiple pregnancy
• If a woman becomes pregnant, she receives frequent injections of progesterone until the 12-week point
• IVF raises the risk of ectopic pregnancy, miscarriage, and multiple births
• Success rates have risen somewhat, but are still relatively low: around 25–30 percent overall – much higher in some groups, but much lower for others; the use of donor eggs has increased the success rate for women over the age of 40
• Clinics have different success rates overall, and may measure “success” differently, in some cases focusing on the number of pregnancies rather than live births
• No procedures are acceptable that risk serious harm to future children
• Some people believe that the right to life begins at conception and that because IVF may lead to the production of “extra” individuals that may be discarded, it is tantamount to murder
• A Christian embryo adoption (the “snowflake Program”) is now being offered to address this problem
• Concern about IVF harm to future children is appropriate even if one does not share the view that moral personhood begins at conception
• Minor harms might be outweighed by the benefit to the child of existence; more serious ones should raise doubts about the morality of IVF
• There is some evidence that IVF babies have roughly double the risk of birth defects from normal pregnancies, although different studies produce different results
• Despite rapid growth, the procedure is still relatively new and so there can as yet be no evidence of its long-term safety
• Perhaps the high rate of unsuccessful cycles of treatment and pregnancies is weeding out most serious health problems
• Women are also at risk from IVF
• There is some risk in extracting eggs
• IVF pregnancies are frequently ectopic, a life-threatening condition; “normal” ones frequently fail for other (mostly unknown) reasons as well
• It usually requires several cycles of treatment to give birth, and even then many women do not achieve this goal
• This state of affairs may entice women into endless treatments which are hard on them both physically and emotionally
• IVF costs continue to increase, and, at best, costs are only partially covered by private insurance or national health insurance systems
• In the US, people may pay from 66,000 to 240,000 per live birth; when the real costs of multiple pregnancy are included, they run into the millions for society as a whole
• Cesarean section rates are higher than average, in part because these pregnancies are regarded as “precious” and in need of especially close physician management
• Cesarean deliveries are riskier for women and more costly than vaginal deliveries; subsequent deliveries must usually also be cesareans
• One might question whether women who undertake IVF fully understand its risk–benefit ratio
• Women’s consent might also be questioned on specifically feminist grounds
• Pronatalism is pervasive in human societies, as is the attitude that women who do not gestate babies are unfulfilled (or even worthless)
• These forces pressure women to produce children at almost any cost
• The onus of barrenness is so great for some that they will undertake IVF even when it is their partner who requires treatment
• Women considering IVF should at least have thorough counseling
• Many people believe that adoption would be preferable to using scarce resources to create more children
• Overpopulation is another concern
• Although adoption can be an excellent option, it raises moral questions of its own, as it may contribute to the exploitation of poor young women
• Interracial adoptions pose special difficulties
• There is a shortage of healthy, white babies because pregnancy rates have dropped and more women are keeping their babies
• Adopting older children with serious problems may be extremely demanding, and it would be unfair to expect only the infertile to take on these children, while the fertile can ignore their plight and have any number of genetically related children
• The human population is outstripping its ability to make sure that all people are even minimally provided for
• Reproductive rates go down when there is intelligent economic development but it isn’t happening quickly enough to avoid further famines and environmental degradation
• It is unfair to expect the infertile to bear the brunt of measures to reduce population growth because of negative social views of infertile women and inadequate government social security programs
• Schemes to reduce births must spread the burden more equally
• A related issue is the scarce health-care resources used on IVF at a time when many people lack basic care, either because, as in Britain, their national insurance scheme is underfunded or because, as in the United States, there is no guarantee of even the most basic care
• Progressives raise additional worries about the justice of access
• Some argue against having the procedure available at all, whereas others lament that it should not be available to anyone if it is not available to all
• IVF means that the infertile do not have to accept their fate because there is always another procedure to try, and “giving up” means that they are perceived as responsible for their infertility
• Women especially, propelled by society’s sexism and pronatalism, may feel strongly pressured to pursue IVF and other ARs instead of getting on with their lives
• There needs to be much more democratic debate about the whole issue, alerting women to their options and empowering them to refuse IVF, or any invasive treatment
• Some technologies become so entrenched as part of standard care that it is hardly possible to refuse them
• For much of the world, the expense limits such pressures, although in some nations, like Denmark, IVF is much more accessible and therefore more difficult to refuse
• Some people also worry that IVF’s existence could lead to a stringent eugenic program that examines every embryo before implantation
• The objection is then to the eugenic program, not IVF
• The mere development of any innovation could lead to its use being made mandatory by an oppressive state
• The scientific and medical establishment does not have a particularly good record of meeting women’s real needs
• By focusing limited resources here, society emphasizes women’s childbearing role at the expense of other desirable goals such as a better understanding of women’s health
• The increasing medicalization of reproduction will also increase dependence on the scientific and health-care establishments, and also because of the potential for the imposition of gate-keeping ethical views.
• Among them are the views that only married couples should have children, either because other relationships are disapproved of or because of (unsubstantiated) concern that others may be poor parents
• In some countries, like the US, market forces are countering such discrimination by creating clinics that do cater to the unmarried
• Cryopreservation is still experimental in humans, and the long-term risks to children are unknown
• Storing embryos and other genetic materials may create opportunities for mix-ups, where the wrong material is used, and exacerbate problems about disposition and ownership
• Couples may come to disagree about what to do with their materials if their situation changes or embryos may be “orphaned” because of unexpected deaths
• These problems can be reduced (but not eradicated) by detailed contracts
• IVF also vastly increases the frequency of multiple pregnancies, both twins and triplets, but also so-called “supertwins” (quadruplets through octuplets)
• These pregnancies, especially the higher-order ones, are risky both for pregnant women and their fetuses
• Perinatal mortality is increased, and surviving babies are likely to suffer from serious disabilities, including blindness, or motor and learning problems
• Selective abortion of some of the fetuses can protect the remaining ones somewhat, although it slightly increases the risk of losing the whole pregnancy
• IVF plus egg donation also opens up the potential for pregnancy in postmenopausal women
• Many consider this practice immoral because it is unnatural and because elderly women might die before their children are self-sufficient
• Postmenopausal pregnancy is no more unnatural than any form of AR, and few object to old men fathering children
• IVF should not be banned, since that would treat women as legal incompetents, damaging them more than unwise reproductive decisions would do
• It would probably also give rise to medical tourism as the infertile seek treatment in less-regulated countries

Surrogacy

• “Surrogacy” involves one woman gestating a baby to be raised by another
• Initially, women who acted as surrogates used their own eggs, but it is increasingly common for them to use client or donor eggs
• Friends or relatives may carry babies for each other, or the transaction may be a commercial one
• Most of the controversy revolves about this latter practice, although the former may involve morally problematic familial coercion
• “Old-fashioned” surrogacy (where the woman who is to be pregnant contributes her own egg) raises the question whether the process should be called surrogacy at all, as that suggests that the contracting man’s sperm is more important than either her egg or gestational service
• It would make more sense to use a more accurate term like “contract pregnancy.”
• Such terminological issues are highlighted still more by “gestational” contract pregnancy that uses another woman’s egg: who is a mother?
• The traditional concept of motherhood (involving genetic, gestational, and social relationships) is being deconstructed, potentially leading to serious conceptual tensions, especially for feminists and other progressives
• Rearing relationships surely are central, although biological links should be neither devalued nor worshipped
• The more parties there are to the transaction, the more complicated the relationships and the legal difficulties when either too many or not enough people want to raise a given child
• An example of the first was the notorious Baby M case, where Mary Beth Whitehead, who had both provided her egg and gestated the child, refused to give up custody
• An example of the second happened when no one would take custody of a deformed baby
• Contract pregnancy raises important questions about the welfare of children resulting from it
• It raises equally important questions about its effect on women, both as individuals and as a disadvantaged group, and about the integrity and harmony of families
• Contract pregnancy has spread without the kind of careful research on its consequences that would help assure us that it is not seriously harmful
• In the US, fears about contract pregnancy have led to quite strict regulation in some states, despite generally lax regulation of other ARs
• Such regulation may well reflect vague ethical fears or influential religious agendas rather than the real needs of women and children
• The practice is highly regulated in some countries (e.g., the UK and Israel) and prohibited in others (e.g., Egypt, Germany, and Denmark)
• Gestational contract pregnancy exposes children to whatever risks might be inherent in the technologies used to create them
• Both kinds of pregnancies (simple and gestational) might also lead to psychological or emotional problems
• Children might be disturbed to think that they weren’t born the “usual way,” but it is plausible to believe that the more common the practice, the less of a problem that would be
• Recent (albeit preliminary) studies show that children (and families) are doing well; others suggest that lack of openness about children’s origins is more of a problem than those origins themselves
• Some people believe that the potential for emotional upset implies that contract pregnancy is wrong
• Many of the same people also believe that it is morally permissible to have children even when they are at risk of serious disease or disability, since otherwise they would not be alive
• There is also concern about the effect of contract pregnancy on a woman’s existing children, who may bond with the fetus and then have to watch the baby being given away
• It is possible to explain that their mother is so delighted with motherhood that she wants to make it possible for others who could not have healthy children without her help
• Rearing parents are “real” parents
• Many social problems may be attenuated by the increasing use of contracting women’s own (or donor) eggs, although that may raise medical risks somewhat
• Presumably, using their own (or donor) eggs makes it easier for women party to the contract to explain to the children that they merely needed or provided gestational services
• Another important line of argumentation objects to contract pregnancy on the grounds that it involves the commodification of human life, or baby-selling
• Some might question whether there is anything wrong with commodification
• Others would deny that baby-selling is the issue, contending that what is at issue is the rental of gestational services and/or the sale of a right to a parental relationship to a child
• Opponents argue that the practice exploits the women who undertake pregnancy for pay and may coerce the wives of men who engage outside women to carry pregnancies for them
• The practice reinforces undesirable stereotypes of women as breeders and promotes pronatalism
• It is doubtful that the existence of contract pregnancy strongly coerces women, although it is true that women may be pressured to participate in the practice by partners eager for genetically related offspring or a nice chunk of money
• Initially the worry was that the prospect of 10,000 or more would constitute an irresistible inducement for very impoverished women
• Most women who undertake contract pregnancy for pay tend to be working or lower-middle class and are poorer than those who contract for it
• The going rate varies tremendously, from 10,000 to at least 75,000, with those who broker the relationships usually earning a comparable sum
• Without a fuller critique of market transactions and/or a demonstration that there is something unusual about such transactions that makes them illegitimate even in the context of a market-based economy, this allegation fails to show that there is anything wrong with contract pregnancy
• The possibility of exploitation seems more plausible in the case of gestational contract pregnancy
• A contracting couple might be more willing to employ a very poor woman with health problems since the quality of the egg is not at issue
• Very poor women might be apt to find the compensation less resistible, even where poor health might put them at more risk; of course, this line of reasoning ignores the developing fetus’s need for a healthy environment
• Gestational contract pregnancy opens up the possibility of hiring a minority or third world woman who could not easily sue for custody should they change their mind about giving up the baby
• Social conditions coupled with cheap international travel probably mean that these practices would just go underground if prohibited
• There are also more general worries about women’s competence to consent to contract pregnancy
• Brokers now try to hire only women who already have children, but some object that each pregnancy is different and so women can never be expected to know how she will react to a new pregnancy
• There have been relatively few cases of women changing their minds; in the notorious Baby M case, psychological tests showing that Mary Beth Whitehead would have trouble detaching herself from the baby were ignored
• The conflict-of-interest inherent in such for-profit brokering suggests that only public authorities should be doing this work
• Regulations could require a period of grace during which women can decide to keep children, returning payments by contracting individuals
• Any such claim that women can never know how they will respond to a given pregnancy should be subjected to the highest standards of evidence
• The increase in gestational (as opposed to simple) contract pregnancy may render this concern less plausible
• One important issue is the laissez-faire regulatory environment that allows for contracts that subject women who undertake contract pregnancy to stringent health practices or that require them to abort fetuses at the behest of the contractors
• It seems clear that morality requires women not to harm their fetuses, but it does not follow that there is, or ought to be, any such legal duty
• Contracts that give this kind of control over a woman’s body to others are morally suspect and may constitute a first step toward totalitarian control over their bodies and their lives
• Some current practices are clearly unfair to women, especially where they deliver a stillborn child and are deprived of some portion of their fee
• There is clearly a need for a model contract that strikes a reasonable balance in favor of women’s rights while taking account of the needs of fetuses and other contracting parties
• Regulations of this sort would also provide reasonable protection for all from breaches of contract where the practice is unregulated or takes place despite prohibition
• Additional questions about women’s welfare are raised if a man can engage in contract pregnancy without the consent of his wife (especially since AID generally requires the consent of husbands)
• This could saddle women with children they do not want
• A wife’s relationships with the children necessarily legally protected if the couple’s relationship fails
• These are serious harms to women that also require regulation

Pre-birth Testing

• Pre-birth testing is a reproductive service that falls quite naturally under the general heading of AR, even though it does not necessarily use methods other than sexual intercourse, or involve the materials or services of third parties, to reproduce
• Some forms of such testing may lead to AR, and they may also be more common after AR has been used
• Pre-birth testing can take place either before or after conception
• Screening is aimed rather generally at those planning to reproduce or at pregnant women
• Diagnostic testing is recommended in response to specific risk factors in individuals or couples
• Participants may be seeking information about widespread risks (such as Down syndrome) or about specific genetic diseases (such as Huntington’s) or about other characteristics (sex, for example)
• As genetic science advances, new tests for characteristics of both kinds will make it possible for parents to attempt to exert ever greater control over what their offspring will be like
• Moral evaluation of pre-birth testing varies according to its demands, responses to undesired results, and different moral perspectives.
• Some object to the very notion of pre-birth testing, except perhaps in those cases where it is intended to provide parents with information to help them prepare for a child with special needs
• The main reason is that in most cases the only way to guarantee the prevention of a disease or disability is to prevent the birth of the individual at risk
• Among the most vocal opponents are disability rights activists who argue that preventing the birth of children with disease or disability is a form of unjustifiable discrimination against the children, and against disease and disability communities more generally
• They contend that individuals are harmed by not being born
• Communities of those with disease or disability are also harmed because preventing such births reduces the number of those living with disease or disability (and therefore the strength and political clout of those communities); it also broadcasts the hurtful message that life with disease or disability is not worth living
• Focusing exclusively on keeping the number of diseased and disabled up seems to violate the Kantian imperative against using others as mere means
• Disability activists tend to adhere to the social model of disease and disability that, for every condition, attributes most or all suffering to inadequate social supports provided by society; This is implausible
• It is true that much unnecessary suffering comes from inadequate social responses to disease and disability, but it is also true that some conditions are inherently miserable in a way that could not be alleviated by any conceivable social measures
• The social model self-destructs if it asserts that there is nothing intrinsically bad about disease or disability; on what grounds then is sacrifice by others to help required?
• The motivation for wanting to prevent the births of those at risk for serious disease or disability is generally the desire to see offspring flourish, not gratuitously to insult existing persons with disease or disability
• Nor is it necessarily predicated on the view that life with disease or disability is not worth living; it could merely be based on the understanding that life is better without them and that no possible child has any more right to be born than any other
• Attempting to prevent the birth of children with disease or disability could be (and has in the past been) motivated by prejudice or the desire to avoid the burdens associated with their care, but that fact does not render moral arguments in favor of the enterprise unsound
• Possible, potential, and future children are at the center of arguments about the permissibility of pre-birth testing
• According to disability rights activists, the children who are prevented from being born are unjustly discriminated against
• Nonexistent individuals cannot be the objects of discrimination
• Focusing solely on those already conceived assumes that it is as wrong to kill fetuses as it is to kill born persons, and conflicts with the view that abortion is morally justifiable
• If children are brought into existence when it is known that their afflictions will likely be so great that they would rather be dead, then they are unjustly treated
• Others would lose more by being prevented from being born than by their less serious afflictions
• There are moral concerns about two aspects of its procedures and methods
• Tests may yield false positives or negatives, or simply fail to provide the certainty that would be helpful in deciding how to act in response to them; their results may also have far-reaching social consequences
• Post-conception testing disproportionately burdens women, since fetuses are housed in their bodies
• Some genetic tests are highly reliable; others merely suggest a higher than average probability of a given condition
• In the latter case, additional (and often more invasive) tests may be required
• This period of uncertainty and testing is often stressful, especially where a pregnancy is strongly wanted
• Some forms of testing may provide more information than is desired, as for example when the fetus is found to carry the mutations for Huntington’s disease or BRCA1; in each of these cases, others may learn that they too are at risk for disease even if they would prefer not to have this knowledge
• Positive results may also become grounds for discrimination on the part of employers or insurance companies unless there is legislation protecting citizens
• Women may be expected to participate in testing without adequate informed consent about the nature, goals, or pitfalls of particular tests
• Some tests, such as amniocentesis, may be invasive or risk the pregnancy
• Although the expressed goal of professional genetic counseling is non-directive, women may feel (or be) pressured to respond to test results in ways they feel uncertain about or disapprove of
• By failing to prevent the birth of children with serious disease or disability, mothers and children are vulnerable to discrimination by insurance companies refusing to insure them on the grounds that they have pre-existing conditions, or, more broadly, because their expenses could have been foreseen and prevented
• Society will need to regulate these new scientific developments to insure their benefits while at the same time protecting from unnecessary harm
• Although pre-birth testing for disease or disability is now quite widespread in some environments, some people are concerned that rapid progress in genetics will facilitate a slippery slope to much more widespread pre-birth testing
• Two prospects are considered especially worrisome
  • It may become possible to select against characteristics that some consider intrinsically undesirable, such as homosexuality or short stature
  • It may become possible to select for other characteristics (such as strength or intelligence) considered desirable
• People speculate that such testing could lead to so-called “designer babies,” oppressive eugenics, and an increase in the gap between rich and poor; it could weaken parent–child relationships, pervert the proper goals of medicine, or exacerbate problems about the allocation of scarce resources
• Although there is no immediate prospect of such testing, it is now possible to test for sex
• Sex selection is most commonly done post-conception by sonogram followed by abortion of fetuses of the unwanted sex
• Recently, a quite effective pre-conception method of sex pre-selection was developed: sperm-sorting (MicroSort®) followed by AI
• Sperm-sorting is about 88 percent effective in selecting for females, 74 percent in selecting for males
• Most observers believe that there are some justifiable uses of sex selection
• One is selection against fetuses carrying sex-linked diseases
• Another is so-called “family balancing,” when parents have many children of one sex and want one of the other sex
• Relatively easy access to the low-tech approach (sonogram plus abortion) has led to widespread sex pre-selection in some countries like India and China, where males are very strongly preferred to females
• Many more couples will probably consider sex pre-selection given that MicroSort® is less burdensome for women and obviates the need for abortions that some see as morally problematic
• Sex pre-selection in cultures that strongly prefer males has already created serious imbalances in sex ratios
• The average sex ratio at birth in human populations is 105 boys to 100 girls
• Yet in China there are currently 121 boys to 100 girls; the sex ratio in India is also becoming increasingly skewed in favor of males
• The consequences are to some extent unknown, except for the obvious fact that mature males will have difficulty finding mates
• Some argue that this state of affairs could be beneficial for women, who would then be valued more. But others suggest that that wouldn’t necessarily enhance women’s autonomy but might instead lead to more stringent controls on them
• Some also worry that societies with a surplus of young, unattached males might become very aggressive
• Sex pre-selection may promote and reinforce sexism
• Preference for males over females is usually a manifestation of sexism
• It may be based on imagined differences between the sexes, differences created by differential treatment or customs, or the unwillingness to acknowledge women’s (at least) equal contribution to society
• None is a legitimate base for preferring boys: they result from errors in reasoning and ethics that can and should be remedied instead
• Questions remain about some preferences for a child of one sex rather than the other
• Is it sexist for an Indian woman to abort a female fetus to prevent her future suffering in a sexist society?
• Is family-balancing (or wanting a girl) necessarily sexist and, if so, why?

Conclusion

• AR and its related technologies are an increasingly important part of the reproductive scene
• They are also a battleground where conflicting values lead to regulatory measures that may or may not prevent harm
• Recent legislation has switched Italy from a reproductive wild west to a tightly controlled world where many procedures accepted elsewhere are prohibited
• The limits reflect the Vatican’s moral principles rather than the harm principle, participants are not necessarily better protected
• Regulation tends to reflect predominant social, political, and economic influences instead of principles that protect and advance human welfare
• There is also still plenty of disagreement about what the latter might require, as is shown by contradictory regulation of sex pre-selection in different countries.