ETHICS FOR HOLISTIC PRACTICE

Debate topic – Couples wishing to undergo IVF treatment should be awarded the legal right to choose the sex of their child.

Good afternoon everyone our debate topic today is whether or not couples wishing to undergo IVF treatment should be awarded the legal right to choose the sex of their child. I’m Melinda and along with Angelique and Melissa we will be presenting the affirmative argument and the negative argument will be presented by Kristen, Judy and Deb.

Sex selection, also known as gender selection, has attracted great interest and controversy over the years. Gender selection has been associated with a number of ethical, moral, social and legal issues. Sex selection may be performed for medical reasons to avoid sex-linked diseases or for parental preference.

The topics I will be covering include eugenics, beneficence, utilitarianism and pre-genetic screening in regards to sex linked diseases. Eugenics can be defined as the study or belief in the possibility of improving the qualities of the human species. In the context of IVF treatment positive eugenics encourages reproduction by implantation of healthy embryos with inheritable desirable traits and negative eugenics seeks to identify and dispose of embryos found to carry undesirable inheritable traits.

Utilitarianism in the context of IVF sex selection and genetic screening is defined by the principle of utility which seeks to judge moral rules, actions and behaviours on the basis of their consequences. Where an action produces the best possible outcome; that being the greatest good for the greatest number it is seen as ethical and moral. Therefore the testing, screening and disposal of genetically impaired embryos and implantation of only healthy and preferred embryos is justifiable because the outcome is seen as beneficial for the majority.

The ethical principle of beneficence means to do good or an action done to benefit others, and therefore act to maximise benefits and minimise harm. The language of a principle or rule of beneficence refers to a normative statement of a moral obligation to act for the benefit of others, helping them to further their important and legitimate interests, often by preventing or removing possible harms. The obligation to act for the benefit of a person is constrained by the desires or choices of others (the majority). Beneficence requires individuals to balance benefits, risks and costs to produce the best outcomes overall.

We believe that by applying eugenics, the principle of beneficence and the use of pre-genetic screening to avoid having children with sex linked diseases, provides numerous benefits to society as a whole. Financial strain on the already burdened health care system is reduced, and parents have greater peace of mind knowing that they will carry healthy children resulting in an optimal quality of family life. By preventing the implantation of genetically impaired embryos the cycle of hereditary genetically linked diseases is interrupted.

PGD or Pre-genetic Diagnosis is a procedure used for testing the genetic makeup of very early embryos created through IVF. At this stage, the embryo has about eight cells, which are typically identical; they have started to multiply but have not yet begun to differentiate. One cell is extracted and analysed. The remaining cells are capable of developing into a complete foetus. Pre-genetic Diagnosis can therefore be used to select the embryos that do not have a particular genetic sequence or a predetermined diagnosis of particular diseases such as haemophilia, cystic fibrosis, turner syndrome, Huntington’s disease and muscular dystrophy.

If either the mother or the father is a carrier:

- 25% chance of having a normal boy

- 25% chance of having a boy with a disease

- 25% chance of having a normal girl

- 25% chance of having a carrier girl without the disease

If the mother and father have the disease:

- 100% chance of having a child with a disease regardless of the sex

Bruce and Jenny are seeking IVF treatment, as Jenny is a carrier of Huntington’s disease and they would like to prevent conceiving a male child that has a high risk of inheriting the genetic condition. Through the use of PGD healthy female embryos can be selected for the implantation process. As Jenny is a carrier of this disease, there is a 50% chance that her female child will either be a carrier or be free of the genetic trait. However if she was to have a male child the impact of the risk is greater as there is a 50% chance that this child will either have the disease or not.

Therefore having the option and the implementation of PGD prevents the continuation of genetically linked debilitating diseases as well as improving quality of life for the child, family and the wider community thus fulfilling the ethical theory of utilitarianism. This confirms the point that the use of eugenics will benefit society by creating a genetically healthier population. Through beneficence good is done by preventing the harm, stress and difficulties that could come from raising a child with a genetically preventable disease.

First Speaker for Negative Team

I would like to begin by opposing a point made by the first speaker of the affirmative team. Melinda stated that eugenics is beneficial to society by reducing the incidence of implantation of genetically impaired embryos thus resulting in less diseased and/or disabled children being born into the community. I strongly oppose this statement as eugenics has historically been shown to infringe on human rights such as in the Nazi era where genetic variation was not respected or tolerated.

Today I will be discussing Deontology, the Slippery Slope effect of designer babies, the principle of Justice and costs involved with sex selection. Deontology originates from the Greek word Dion, which means binding duty and is guided by the 10 commandments, legal systems and family values. Deontology is concerned with putting what is right over what is good. Deontologists have a strong belief in the dignity of every human being and the sanctity of all human life. Therefore by choosing to implant female embryos and discarding the potentially genetically impaired male embryos, the fundamental principle of life and liberty is violated and this action is considered to be morally wrong even though it has good consequences.

Deep concern has been expressed about eugenics and the potential for a slippery slope in the use of PGD. PGD is currently restricted to serious medical conditions in Australia however sex selection is available in other countries and interest in Australia is growing. The use of PGD for sex selection represents a clear departure from preventative medicine and towards ‘designer babies’. Using PGD to pre-select embryos for sex is especially problematic, because it is a clear example of a non-medical application of this technology. Allowing PGD to be used for parental preference for sex selection would open the door to allowing parents to select embryos on the basis of non-essential genetic characteristics such as appearance, height and intelligence etc, blurring the line of what is right and what is good. Sex selection based on parental preference leading to designer babies creates an environment where having a child becomes more a shopping experience rather than a natural spiritual process of new life.

Justice as a principle is referred to as the obligation to be fair to all people, including the fair distribution of medical resources and equal access for all in the health care system.

PGD technology used for sex selection to prevent disease should be used appropriately and should be accessible to couples who require it regardless of their socioeconomic status.

Sex selection based on preference is costly and is therefore exclusive to the wealthy as families with lower incomes are unable to afford this advanced technology. This can be seen as unjust as it deprives family options creating inequity in accessing this particular medical service. On the other hand if costing for sex selection based of parental preference was made government funded through tax payers this may also be seen as unjust as medical resources could be better allocated. Devotion of limited resources to sex selection would be unfair to those couples requiring fertility treatment to conceive a baby in the first place.

In summary, deontology theory strongly opposes the use PGD for sex selection because human life is regarded has inherent value from conception. The inappropriate use of PGD may result in a slippery slope leading to the development of designer babies which fosters a consumer driven attitude to childbirth. The cost of PGD technology may cause inequitable access to families from low socioeconomic backgrounds and unfair resource allocation in the health care system.

Second Speaker for Affirmative Team

I will begin with a rebuttal to some of the points made by the negative team’s Criticisms of deontology:

- The rules and principals of deontology may be vague, controversial or difficult to define

- Interprets all morals as equal

- It may be necessary to accommodate another demand therefore the moral duty is no longer present eg. Non-maleficence VS autonomy

Criticism of sex ratio/costs and slippery slope:

Freedom of expression is protected even when it advocates subjects far more morally objectionable than genetic sex selection for example racists and sexist speech. In context where individuals have time to consider the merits of sex selection, the supposed slippery slope from sex selection to genetic enhancement does not itself provide grounds for making sex selection illegal even if genetic enhancement is in some way morally objectionable. Some regard the use of other reproductive technologies (for example contraceptives) to control the number of children they have as morally objectionable. Other regards reproductive technology to sex select as morally objectionable. There are insufficient grounds for restricting reproductive liberties in the first case, as there is in the second. Objections on the threat to sex ratio, resourcing costs and slippery slope do not by themselves provide grounds for restricting reproductive liberties. (McCarthy)

-----Rebuttal for slippery slope:

Slippery slope of non-medical indications
The concept of slide into designer babies is not inevitable. Regulatory boundary could be drawn at medical indications plus social sex selection and nothing more. From a biological perspective this would be sustainable. It will never be this simple with other common traits. Indeed, the use of the phrase 'designer babies' in the medical press, as if it will be technically feasible in the coming decades is genetically naïve and probably scientifically dishonest, given that we all know what the public understand by 'designer babies'.It is not just sex selection or HLA (human leukocyte antigen) tissue type selection but a shopping list of traits. As part of a British Medical Journal collection of papers. physical stamina, strength, speed, mathematical ability, dexterity, and acuity of vision, to name only a few-...". They state "...it could be argued that parents should be free to pick the eyebrow shape or freckle pattern of their children or other equally innocuous traits as long as their selection imposed no risk...". The ethical debate continues with no regard for the technical feasibility.
There are several reasons why this type of designer baby is not going to happen. Firstly, the predictive value of any relevant tests will be low, because the outcome will also be dependent on the environment. Secondly, the laws of genetics lead to diminishing returns as more genotypes are selected for. a modest shopping list will need thousands of embryos from independent eggs and spermatozoa. Finally, there will be 'swings and roundabouts' effects, such that the same genetic variant will have both beneficial and adverse influences. You cannot have one without the other.
(Marcus)

Hedonistic Utilitarianism:

A utilitarian theory which assumes that the rightness of an action depends entirely on the amount of pleasure it tends to produce and the amount of pain it tends to prevent. Bentham's utilitarianism is hedonistic. Although he describes the good not only as pleasure, but also as happiness, benefit, advantage, etc

- Which when applied to genetics, will support genetic selection which provides the opportunity to enjoy the best lives, through autonomy and family balancing.

Beginning of life:

- fertilization is a process that takes approximately 24 hours to complete therefore a specific time or moment when an individual person may be created cannot be confirmed

- As pointed out by Peter Singer; up to fourteen days after conception the fertilized egg has the capacity to divide into two and become identical twins, and in some cases theses divided eggs can blend back together into one blastocyte.

- Eggs fertilized in vitro can be have genetic structure testing by removing single cell, after which development can continue, unharmed and uninterrupted. In fact all cells of the blastocyte can be separated and each has the capacity to become a whole human being – supporting the concept that a blastocyte does not have true individuality, and therefore according to Singer this makes it difficult to view an organisms as a person (Peter Singer)

Autonomy acknowledges:

- The person’s right to hold view, make choices, take action

- The personal values and beliefs

- Asserts personal freedom

- According to Mill (1806-1873)

o It is not the business of the state or law to try and establish a common morality, but it its personally enforced

Parental autonomy: freedom of choice: similarly to the choice of pregnancy termination and contraception

Reproductive freedom contributes to individual happiness or well being – and that reproductive control encourages the equality of men and women. Reproductive freedom is an expression of personal liberty which draws from the value of the ethical principal autonomy.

Combined hedonistic and utilitarian views argue that the line of reasoning on the subject of gender selection support that the increasing array of reproductive choice results in increased reproductive freedom, which is good because it thereby maximises personal liberty and hence individual autonomy, which are both highly valued and seen as good.

(Epstein & Mill)

There is also the very practical point that there is no conception without professional intervention. Thus there is every opportunity to exercise professional duty of care. Despite its failings from time to time, the medical profession, and the laws and authorities that regulate its practice, are best placed to provide a safe and reliable service for those seeking PGD, including PGD for non-medical reasons, should these be permitted by law.
(Marcus)

Family balancing:

Scenario: a couple with three daughters may wish to use PGD to ensure they have a son as their fourth child, or if a couples only son dies and parents want to use PGD to have another boy, or if a couple wishes to choose a specific gender. Reasons for gender selection may not be as clear as onlookers seem to think they are, various factors can influence parent’s choices and decision to use PGD. Where certain circumstances may fall under the ‘exception’ category.

based on the second baby being wanted, unharmed as well as helping save the life of their sibling. Is it right to argue against PGD for this reason when there is life provided for not one, but two children

Gender bias, family balance and family size
There is a big difference between family balance and gender bias. Family balance pertains to the desire of some couples to have a 'balanced family' that is, a family with both sexes. This request, if fulfilled, should not disturb the overall sex ratio in society. Gender bias pertains to the desire of the couple to have a preference for one gender over the other.
In our experience, gender bias has never been an issue, because most couples requesting sex selection have on average 2-4 children of the same gender, have lost one child to illness or accident, or wish to have a balanced family without having to 'keep trying' to achieve their goal and still maintain a reasonable family size. By giving the couple this choice, the ethical principle of autonomy is maintained
(Kilhani)

Conclusion:

Therefore according to Buchanan, our argument concentrates on parental acts and their consequences for parental freedom, which follows the premises that arguments must be person-affecting; not yet-to-exist entities; which have a reduced moral relevance.

(Glover)

Arguments for PDG across the mentioned; perceived health benefits; family balancing or .......are intrinsically based on parental freedom of choice and autonomy.

Main conclusion:

Sex-selection technology providers argued that sex selection was an expression of reproductive rights, was initiated and pursued by women, and was a sign of female empowerment that allowed couples to make well-informed family planning decisions, prevented unwanted pregnancies and abortions, and minimized the abuse of wives and/or neglect of children.

Second Speaker for Negative Team

Rebuttal - Natural law ethicists believe that embryos are people from the moment of conception and therefore have an intrinsic dignity and value that cannot be compromised by other values, and therefore any destruction of embryos should be opposed.

Rebuttal – Family balancing – sex ratio imbalance in countries such as China and India where the male sex is preferred. An American study found the western couples preferred to have a male child for their first born and also desired a male child to carry on the family name – perceived as more useful to continue the family business or farming – helping on the land. This indicates that sex selection could result in a sex ratio imbalance in both western and developing nations with more male children than female.

Rebuttal – Hedonism may be viewed as a selfish act which focuses on the desires of the parents without taking into account the happiness of the child. Choosing the sex of your child does not guarantee happiness as real pleasure is derived from the feeling we get... The child may not fit the typical gender stereotype and may not meet parental expectations. This would have a negative effect on the child’s psychological health as he or she may feel they fail to please or meet their parents and society’s expectations/standards. Parents may feel disappointed if the child they selected doesn’t fill the void of the lost child and they may be resentful towards the replacement child.

I will be discussing the ethical theory of natural law, the ethical principle of non-maleficence and the negative implications of sex selection on the population and the parent/infant relationship.

Natural Law states that the human person should look to nature to determine what is a moral act – any action against nature is an act against the law. In this context sex selection for any reason is seen as inherently morally and legally wrong as it is unnatural.

The eternal law of God within natural law views life as a basis for human fulfilment and wellbeing. Disposal of unwanted gender embryos is considered an evil act. Natural law and God’s law are intertwined and inseparable.

Non-maleficence is an ethical principle concerned with preventing or minimising harm.

http://atheism.about.com/library/weekly/aa100301a.htm

http://www.marymeetsdolly.com/blog/index.php?/archives/2009/06/C13.html

http://www.tylermedicalclinic.com/sex_selection_and_pgd.htm

http://fds.oup.com/www.oup.com/pdf/13/9780199273966.pdf

http://www.ethicapublishing.com/ethical/3CH2.pdf

http://virtualmentor.ama-assn.org/2007/06/ccas3-0706.html

http://www.who.int/genomics/gender/en/index4.html

http://bmb.oxfordjournals.org/content/94/1/7.abstract

Third speaker for affirmative team:

As a feminist I believe in the females’ right to reproduce on her own terms, where her reproductive right is empowered by choice. Feminism is a collection of movements aimed at defining, establishing and defending equal political, economic, and social rights and equal opportunities for women. In response to your statement Judy I would like to put forward this idea written by Marcia Guttentag, who has studied in much detail the social implications of imbalanced sex ratios in various societies throughout human history. In societies where the population of women is less than that of men, the status and prestige of women is higher and monogamy is stronger. When the relative number of women increases and becomes larger than that of men, women lose their traditional prestige and become more like sex subjects, the number of divorces rises, one parent families become more prevalent and more women suffer from depression and suicide.

Ecofeminists argue that women have a right to reproductive technology because their bodies belong to them. To control their wombs, they argue, is to oppress them and treat them as less than human.

It is not feminism's goal to control any woman's fertility, only to free each woman to control her own – that is, to have the right to not only NOT reproduce via contraception and abortion, but the right TO reproduce – whether that be via natural conception or IVF AND the right to choose the sex of her baby.

Sex selection is an expression of reproductive rights, was initiated and pursued by women, and was a sign of female empowerment that allowed couples to make well-informed family planning decisions, prevented occurrences of unintended pregnancy and abortion, and minimized intimate partner violence and/or child neglect (Puri).

A feminist oriented assessment of all reproductive technologies is needed because IVF deals directly with the female body; via the female body (Koch & Morgall).

The United Nations' Universal Declaration of Human Rights (1948) emphasizes the right to marry and found a family "without limitation due to race, nationality or religion." So why should there be limitation to IVF options? (blank)

Women are an autonomous individual who is the author or owner of her own body (Oliver) Although some limits are placed on reproductive choices in all societies, in most Western nations procreation is viewed as a fundamental right inherent in the very survival of the individual (Blank)

Another point that I would like to address in relation to the general idea addressed earlier by the negative team about the disposal of embryos and the rights of the unborn baby, through my research I have come across the development of a sperm sorting technique which eliminates the need for the embryo creation before the implantation. The method known as the Ericsson method, which was first applied in a clinical setting in the 1970s by Dr. Ronald J. Ericsson. This method uses higher concentrations of sperm of the desired sex to increase the likelihood of conceiving that gender.

The Ericsson method separates male and female sperm by passing them through a column filled with blood protein, human serum albumin. As the sperm enter the human serum albumin, the differences in mass between the X and Y chromosomes manifest as the lighter male sperm push deeper into the protein than the females dragged down by the weight of the extra “leg” of the X sex chromosome. This tiny difference creates separate layers of concentrated male and female sperm. The layers of gender-selected sperm are of higher concentrations but not pure.

Therefore to sum up the arguments made by the affirmative side, that couples should be awarded the legal right to choose the sex of their child when using IVF treatment. This is backed up by the application of the utilitarian ethical theory, the science of eugenics and the use of PGD for sex linked diseases in order to achieve the greatest outcome for the greatest number. This is accomplished by reducing medical costs associated with the care of the disabled persons.

Third speaker for negative side:

I will be discussing the ethical theory of Kantianism and the laws involved in regards to sex selection, embryo rights and the disposal of unwanted embryos.

In response to the argument made by Melisa that sperm sorting is a valid ethical technique for sex selection, well I think we need to look first at the facts, the facts are, sperm sorting is not available in Australia, is still only in the trial period and the success rate is not standout, so using sperm sorting as an argument is not really valid at all. Regarding the Ericsson method of sperm sorting, the research that I have conducted states that this method has a 70-72% success rate for boys and a 69-75% success rate for girls (Beernink) This lack of purity explains the 30% chance of gender selection failure.(Chen; Dmowski). Due to these facts and lack of trust in this method, it is possible that this method will never reach its intended outcome. Even if sperm sorting did eventuate it still does not change the ethics regarding sex selection, it only changes the “plumbing”.

Kantianism is a philosophy of ethics by Immanuel Kant. Kant believed that people should be treated as an end and never as a mere means to an end. In other words, it is unethical to use people for your own personal gain because people are valuable in themselves. Kantianism is a non-consequential theory meaning the act itself is more important than the outcome of that act. For example: If a building is on fire it is your duty to save the people inside even if the people inside are murderers. You would save the people for the sake of saving them and no other reason.

One objection in bioethics is that sex selection represents a violation of Kant’s dictum never to use a person as a means, but always to treat him or her as an end. So according to this argument, by selecting the gender, parents use their child to fulfil their own desires and fail to respect the child as a person. In one way this objection is fanciful. Parents have many desires relating to their children, perhaps to have a companion, to have a friend to their first child, or to hold a marriage together. It is unlikely that any parent ever desires a child solely as an end in itself. More so Kant’s dictum is actually never to use a person solely as a means and should not be created just to a means of ending up with a particular outcome, in this case the gender of a child.

Sex selection by PGD is the only type of sex selection procedure permitted under Australian legislation. In saying that it is important to point out the legal law that-The Infertility Treatment Act 1995 bans treatment procedures which attempt to ensure the child’s sex, except where It is necessary ‘for the child to be of a particular sex so as to avoid the risk of transmission of a genetic abnormality of a disease to the child’. The National Health and Medical Research Council ethical guidelines also prohibit sex selection by whatever means, except where it would reduce the risk of transmitting a serious genetic condition. The guidelines maintain that ‘admission to life should not be conditional upon a child being a particular sex’.

As previously stated in other theories, life begins at conception therefore Kant believes that to kill any innocent human being (for example the killing or disposal of an embryo) is unjust. Therefore the disposal of unwanted embryos is unethical as we regard all life as valuable and irreplaceable. As we regard an embryo as a human being, it is then understood that the embryo has as much moral and ethical standing as any human being and should be respected as such.

The code of ethics for nurses and midwives in Australia has been developed for the midwifery/nursing profession in Australia and is used to guide education, clinical practice and decision making. The codes outlines the midwifery/nursing professions commitment to respect, promote, protect and uphold the fundamental rights of people who are both recipients and providers of health care midwifery/nursing. The relevant value statements for this topic of debate include Value statement 1 - Midwives and nurses value quality care for each person, Value statement 2 – Nurses and midwives value respect and kindness for self and others, Value statement 4 – Nurses and midwives value access to quality health care for all people involved, Value statement 5 – Nurses and midwives value informed decision making. Nurses and midwives can fulfil these guidelines by being sensitive to the needs and feelings of the couples in their care and provide them with accurate information in a non bias manner which is easy to understand.

In conclusion the negative team believes that couples choosing to undergo IVF treatment should not be awarded the legal right to choose the sex of their baby and this is based on the arguments put forward from the ethical theories of deontology, natural law and Kantianism. There are concerns that PGD has the potential to open the door to a slippery slope effect resulting in the creation of designer babies and resulting in issues regarding costs to society and the health care system and resource allocation. Sex selection for parental preference may result in a sex ratio imbalance and is incompatible with the parent/child relationship being one of unconditional love and acceptance. Based on the ethical theories stated above, an embryo is classified as a human being and therefore the selection and implantation of an embryo based solely on its gender and the disposal of unwanted embryos is seen as immoral and unethical.

References

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Puri, S., & Nachtigall, R. D. (2010). The ethics of sex selection: a comparison of the attitudes and experiences of primary care physicians and physician providers of clinical sex selection services. Fertility and Sterility, 93(7), 2107-2114.

Savulescu, J. (1999). Sex selection: the case for. Medical Journal of Australia, 171, 373-375.

Ethics Committee of the American Society for Reproductive Medicine. (2001). Preconception gender selection for nonmedical reasons. Fertility and Sterility, 25(5), 1-4.

Strange, h. (2010). Non-medical sex selection: ethical issues. British Medical Bulletin, 94(1), 7-20.

McDougall, R. (2005). Acting parentally: an argument against sex selection. Journal of Medical Ethics, 31(10), 601-605.

Dahl, E. (2007). The 10 cost common objections to sex-selection and why they are far from being conclusive: a Western perspective. Reproductive BioMedicine Online, 14(1) 158-161.

Dahl, E., Gupta, R., Beutel, M., Stoebel-Richter, Y., Brosiq, B., Tinneberg, H., & Jain, T. (2006). Preconception sex selection demand and preferences in the United States, Fertility and Sterility, 85(2), 468-473.

Blyth, E., Frith, L., & Crawshaw, M. (2008). Ethical objections to sex selection for non-medical reasons, Reproductive BioMedicine Online, 16(1), 41-45.

Dahl, E., Beutel, M., Brosig, B., & Hinsch, K. (2003). Preconception sex selection for non-medical reasons: a representative survey from Germany. Human Reproduction, 18(10), 2231-2234.