My wife is a medical student who recently worked in a reproductive endocrinology and infertility (REI) clinic at which many in vitro fertilizations occur. The usual process for these fertilizations is:
1. Extracting eggs from the potential mother
2. Fertilizing the eggs to make a set of embryos
3. Optionally karyotyping the embryos
4. Selecting 2-3 embryos for implantation
5. Implanting the selected embryos into the potential mother
The optional third step of karyotyping the embryos is a process in which many attributes of the embryos can be determined including its sex and possibly any defects. The ethical issue arose in the situation where a couple asked for karyotyping to occur and further asked to know the sex of the embryos. At this point at the clinic, there had been many ethical issues that had been addressed through different policies but this particular issue had not been discussed on whether or not the doctor should tell the patient. This particular doctor made it his personal position to tell patients because he felt that it was not in his power to deny them this information, but another doctor could have easily made the exact opposite decision. This doctor did say that he wished there was a policy stating the correct course to be followed.
The further issue could possibly occur at the selection step. The karyotyping of embryos does give some information about the embryo; however, the overall makeup of most embryos is very similar and one embryo cannot be differentiated from another. Therefore, when choosing what embryo to implant, there really is not an objective test to follow. The selection could easily be influenced by outside knowledge of whether a patient prefers a boy or a girl. Furthermore, the idea that the sex of an embryo can be determined before implantation raises the possibility of a patient choosing if they want a boy or girl. The clinic did not have a policy dealing with this issue either. The overall concern stated by the doctor was that the clinic’s policies were inadequate guidance for doctors in the in vitro fertilization field. Further, there did not seem to be any state or national regulations to these particular questions either. In the end, more law and policies need to exist governing these and other ideas if there is going to be any consistency going from one clinic to another or even one doctor to another.
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Although you raise a number of good issues in your commentary, I am writing specifically about guidance in dealing with gender-based embryo selection. The clinic may want to consult the statement from the Ethics Committee of the American Society for Reproductive Medicine (ASRM): Sex Selection and Preimplantation Genetic Diagnosis.
http://www.asrm.org/Media/Ethics/Sex_Selection.pdf
I found it quite interesting to read through ASRM’s deliberations in weighing the various (and often conflicting) ethical concerns in gender-based embryo selection: the right to reproductive freedom, medical needs, gender equality, and the just distribution of medical resources. Subsequent response and commentary may have circulated after this was published in 1999, but I think the document still has value in laying out the issues and making an attempt to develop a decision frame.
PJM
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