Selective Abortion: Three Ethical Dilemmas
Anne Penner
Senior Seminar
Stan Grove
November 14, 2005
Outline:
Introduction
The burgeoning field of medical technology has raised many questions especially pertaining to ethics. The mapping of the human genome, cloning technologies, stem cell research, and of course reproductive technology has caused some very real dilemmas over the role of the human decision in the creation and orientation of new life. Humans are able to accomplish amazing things in science, but the question remains, at what cost? Upon recognizing the power that resides in scientific manipulations, one must ask, should we resist progress? The ubiquitous nature of reproductive technology has caused a new discipline of reproductive ethics, and it is extremely important to accompany any analysis of a new scientific advancement with the appropriate ethical implications that are inherent in the human questions that are raised.
Thesis: In a global society that has such technologies as prenatal genetic testing, in vitro fertilization, and ovulation induction, it is crucial to have a full understanding of the historical, social, and moral contexts that surround this very personal and very important debate of selective - abortion due to genetic disease diagnosis, sex preference, or fertility treatments.
Historical Background
The use of selective – abortion is usually discussed in three situations: testing positive for the possibility of a genetic disease, gender preference, and reduction of multiple fetuses usually due to fertility treatments. While the effects of these three outcomes have been historically significant, the ability to predetermine and change the outcome of these pregnancies is a new phenomenon that is still an issue for wanting parents.
The understanding of the fertilization process has undergone rapid changes and advancements in the past few decades, but in vitro fertilization (IVF) does have a long history of scientific research. Experiments attempting to fertilize a human oocyte were first performed in 1878. During the first half of the 20th century experiments, mostly on animals such as rabbits or hamsters, continued to be done with little success and poor background understanding. Finally, in 1969 the first confirmed case of IVF in humans was reported, but it was not until almost a decade later that a human birth resulted from this procedure. This technology has truly advanced throughout the 1900’s, and it is an important reproductive technology that questions the creation of human life which ultimately leads to the question of ending that life with abortion (Bavister, 2002).
IVF technology is not an isolated technique, and it is often used in conjunction with ovulation induction. Women typically release only one mature oocyte per month, but with gonadotropin therapy it is possible to increase this number raising the chance of the sperm finding the egg. It is also used to provide enough oocytes to make IVF feasible. In 1981, the first successful IVF with ovulation stimulation baby was born in the US (Jones, 2003). The first estrogen antagonist, Clomiphene, was developed in 1956 for women suffering from endometriosis and other reproductive problems. The researchers found that this drug was able to reestablish a normal menstrual cycle. Over the decades, the use of anti – estrogen drugs in order to stimulate ovulation has been well developed and remains the primary way that ovulation is artificially induced (Dorn, 2005).
Preference for a child of a certain gender has its roots in societies that reward maleness and make the female position one of struggle socially and economically. Some cultures still have major disparity in the opportunities offered to male and females throughout their life, and this has led to the issue of reproductive ethics when technology meets disadvantage. The ability of a physician, on the order of the parent, to discriminate between sexes and consider sex-selective abortion is only possible with the use of ultrasound and amniocentesis procedures (Weiss, 1997). Removal of fetal amniotic fluid has been described in clinical literature for over a hundred years. Ultrasounds were first used for clinical diagnoses by Karl Dussik, a neurologist from Vienna, but it was another decade before they were used for obstetrics (Woo, 2004). These procedures have allowed for reasonably accurate determination of a fetuses sex, and this technology has brought selective abortion on the basis of sex into the modern debate of reproductive ethics.
The practice of aborting a fetus prior to delivery has been around for centures. The United States allowed states to determine the legality of abortion until the 70’s, and universally the states banned the practice. In 1959 the American Law Institute proposed that the old laws should be revised in the cases of rape and incest, but it was not until the early 1970’s that the court battles reached the Supreme Court level. At that time the Court voted 7-2 in the Roe v. Wade case granting women the right to have an abortion in the first trimester of pregnancy. The ruling also allowed for later term abortions if there was immediate danger to the mother’s life. Planned Parenthood v. Casey in 1992 further upheld this ruling (Jung, 2003). Abortion is a complicated issue, but the general term is important to understand because it is the basis of selective abortion- the main topic of this paper.
Genetic Testing and Abortion:
The ability to test fetuses and even newly fertilized “preembryos” for genetic diseases is a new technology that is an important one to consider. Since the mapping of the human genome, scientists have been able to pinpoint the genes responsible for diseases such as cystic fibrosis, sickle-cell anemia, hemophilia, Huntington’s disease, and polycystic kidney disease (Strong, 1997). The ability to test for these diseases raises numerous ethical considerations involving severity of the condition, quality of life of child, possible contributions of the child, and even economic factors that should be considered.
What range of diseases should be tested for? This is the question of severity, and it is important because there are different implications for severe, mild, late-onset, and treatable diseases. These labels have significant meaning when a parent and their physicians receive the news of a prenatal genetic test. The increase of available information to young mothers may increase their likelihood of desiring an abortion in order to avoid complications. In cases like phenylketonuria the disease is very easily treatable, so testing seems like a logical step in ensuring a healthy baby. A survey conducted by the New England Regional Genetics Group found that 6% of couples would abort a fetus if it was found to be susceptible to Alzheimer’s; 11% would abort if susceptible to obesity. This study assumed that they had the information already in hand (Strong, 1997).
There are competing views for the question of what types of diseases to test for. A group of geneticists and general physicians agree that tests should only be performed for the most severe disorders. Diseases in this category would be ones that result in serious mental or physical disabilities or that would cause long term suffering such as Huntington’s. In 3-5% of positive prenatal diagnoses, “the genetic disorder is so severe that no approximation of a fulfilling life is possible” (Peters, 2003, pg. 182). Another view tries to limit testing to somewhere in the middle weighing factors such as the onset of the disease and the probability of occurrence (Strong, 1997). The lines that physicians and geneticists draw is difficult, and there will be ethical pros and cons of each choice based on the desire for information weighed against the desire to preserve life without too much interference.
The option to terminate the pregnancy on the basis of the genetic test has been available for parents since genetic tests were developed. It is important to consider that this decision is usually made within the context of physicians and hopefully genetic counselors helping the couple make the choice that is ultimately theirs. It is important to point out that for parents who either have already suffered with a sick baby or feel certain of that outcome, terminating the pregnancy may bring about relief, happiness, and a chance to have a substantially healthier child (Strong, 1997). This argument lies strictly opposed to those who argue that a positive result for a genetic disease cannot be an indication for the living child of the future. It is impossible to understand the severity of certain diseases that can have ranges (of disability, and the contribution of even a moderately disabled child should not be underestimated. The test should not define the child’s identity (Asch, 1999). The results of genetic testing have been and will continue to be a reason for abortion, and the ethical discussions will undoubtedly continue over this controversial combination of two hotly debated issues.
Sex-selective Abortion:
The preference for male heirs is a common occurrence the world over, but in some Asian societies female babies have become a liability for families for a variety of reasons. Sons are able to help in fields and care for the elderly, but girls can even be seen as an economic concern when dowries have to be paid prior to marriage. Poverty can have an enormous impact on family planning decisions, but there can also be social reasons for choosing to terminate a female fetus. In some societies prestige can only be achieved with a male child, and for some families that is incredibly important (Weiss, 1997).
As mentioned earlier amniocentesis and ultrasound techniques are the most common ways for couples to determine the sex of the child before it is born. In the US such tests are routine and not usually alarming, but in nations such as India and China those tests, and others, have become an issue of debate since the results could mean life or death. Newer, faster, and more private tests are also being developed such as a new $250 home test kit that works with just a finger prick. The test checks for a Y chromosome as early as the fifth week of pregnancy. This test has raised the issue for American women who simply want to balance their three children (Prenatal sex determination, 2005). However, the major problem of selective-abortion still resides in certain parts of the world where early termination is a real likelihood when a female fetus tests positive (Moazam, 2004).
Since 1979 China requires that its citizens follow a government mandated family planning program in which regional laws regulate the number of children people can have. Typically it is one, but Zhao Bingli, vice minister of the State Family Planning Commission, points out in a newspaper interview that this is due to regional differences in population density and economic capabilities. He claims that poor rural families are able to have two children if their first is a girl, provided they go through the bureaucracy required (Family Planning Law, 2001). Regardless of the government assertions, the requirement is typically one child, and since 2001 there has been a law fining parents who disregard the accepted family planning by giving birth a second time. The restrictions have worked, according to Chinese authorities. The fertility rate (number of children per woman) has decreased from 2.9 in 1979 to 1.7 in 2004 (Hesketh, Lu, and Xing, 2005).
Unfortunately due to economic realities in China, the decrease in births has not been evenly distributed between the sexes. The altered sex ratio in urban Chinese cities is hard to ignore. Hesketh, et. al. (2005) state that it has risen from 1.06 to 1.17 between 1979 and 2001. They continue to discuss how the sex-selective abortion is most likely the number one cause. They say, “Actual figures are impossible to obtain, because sex-selective abortion is illegal but is known to be widely carried out, helped by a burgeoning private sector” (p.1173). Other explanations for the sex ratio are possible such as not registering girls, but the reality of abortion is undeniable. When technology to test the sex of the child became available the decrease in female infants was marked. Legislation against sex-selective abortion may help, but a change will only come when attitudes toward familial preservation are changed in the society.
Fertility Treatments
Many couples who desperately want children undergo ovulation stimulation either to improve the fertility of the woman or to stimulate oocyte production for in vitro fertilization. This technology is sometimes difficult to control, and it often results in higher than normal prevalence of multiple births. Fertility Weekly reports that ovulation stimulation increases multiple births from 10-40% per cycle (2005). Triplets or higher order multiples are caused by fertility treatments 50% of the time, and this type of birth comes with much greater risk to the fetuses and the mother.
Single fetuses have a much greater start on life than those who share the womb with a brother or sister or several. The mortality rate for triplets is six-fold higher than individual births says Fertility Weekly (2005). There is also a proven risk for low birthweight and prematurity among multiple births both of which can lead to serious disabilities later in life. Mothers are also put at a greater risk carrying a multiple pregnancy. There is a greater risk of developing anemia, gestational diabetes, postpartum hemorrhage, and even death (Fauser, Devroey, Macklon, 2005).
Thus, it is plain to see that multiple deliveries are dangerous, and their prevalence has risen astoundingly over the most recent decades. Currently, reducing the number through abortion is widely practiced as a means to accomplish the desired one child per pregnancy goal. The ethical question raised is similar to that of genetic testing; if we are certain that the quality of life will be better if such reduction occurs, then is selective-abortion the best option? Many people would say that this way one or two babies will be able to lead normal, happy lives. This also preserves the health of the mother since multiple births can be so dangerous to her health. On the other hand, has any quality of life been preserved if one was ended outright? Many people view this as choosing between one child’s life over another, but is it fair or smart to risk the health of all? Bart Fauser and his colleagues (2005) argue that there are other options to consider in the undoubtedly important task of lessening the risk of multiple births.
The question lingers of what can be done to prevent damage and pain caused by artificial reproductive technologies (ARTs). Fauser et. al. list a number of clinical options that are tailored to the individual woman’s reason for being infertile. For example, anovulatory women (with polycystic ovary syndrome) could undergo lifestyle changes or laser surgery on the ovaries (Fauser et al., 2005) to increase natural fertility. It is also likely that if IVF was less cost-prohibitive couples would be less likely to desire several embryos implanted since they could attempt a second time if the one or two did not attach. Having such technology controlled by market prices has potentially increased the risks associated with multiple births. Such techniques would greatly reduce the risk of multiple birth without relying on abortion, but more technology is required to improve the IVF technique.
Conclusion:
The unstoppable march of progress has caused amazing advances in reproductive technologies. There is an unquestionable benefit to couples everywhere who have been able to give birth to children due to these advancements, but it is necessary to take a step back and analyze the history, the technology, and the ethics surrounding such concerns as sex-selection, genetic diseases, and multiple births. The science involved in testing for and possibly eliminating these problems is not inherently good or bad, but it must be acknowledged that humans make choices and sometimes those choices affect a society, such as the case of sex-selection. Also, it is important to understand the reasons behind some people’s choice to have an abortion for the reasons of genetic disease, social pressure, or health problems due to multiple pregnancy. Finally, it is equally important to highlight that there are sometimes options such as genetic counseling, adoption, social change, and alternative medicines. All of these things could provide another option for parents. Overall, it is the job of the physicians to encourage knowledge for the couples they treat, and to discuss such things as the ethics inherent when something as personal as carrying a child is in question.
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