The President's Council on Bioethics click here to skip navigation

 


This staff working paper was discussed at the Council's January 2003 meeting. It was prepared by staff solely to aid discussion, and does not represent the official views of the Council or of the United States Government.

Staff Working Paper

Ethical Aspects of Sex Control

Over the past several decades, disturbing evidence has accumulated of the widespread practice of sex control – that is, the use of various medical technologies to choose the sex of one's child.1 The standard sex ratio at birth is 105 baby boys born for every 100 baby girls, but in many countries today the ratio is upwards of 120 baby boys born for every 100 girls. This is a monumental shift in the sex ratio. It calls out for our attention and demands a broad ranging ethical evaluation. In this paper, we examine the spread of sex control here and abroad (though our emphasis is on the United States). We consider the factors that have contributed to its increasing use, taking up both the technological and ethical aspects of the issue. We also present our own ethical analysis of sex control, as well as some observations about how public policy might address the matter.

The paper is divided into two sections. We begin in Part One with a general introduction to the deep-seated human desire to control the sex of our children and the new technologies that now enable us to fulfill this desire. We also review the societal effects of the conjunction of ancient desire with modern technique. Next, we summarize the twenty-five year-old debate on sex control, and attempt to unearth the ethical and moral principles that have thus far guided the debate.

In Part Two, we set forth our ethical approach to sex control. We begin with a note on terminology: We explain our reasons for calling the practice sex control, as opposed to the more commonly used terms of gender selection or sex selection. Next, we take up the vexing question of whether our society's respect for individual liberty and reproductive freedom prevents the regulation or prohibition of sex control – we believe that it does not, and we attempt to show why. Having thus cleared the ground, we proceed to what we believe to be the heart of the matter: the salience of sexual identity. In our view, this is the central human context for understanding sex control. From here we move to considerations of the meaning of human procreation and how sex control might lead to its dehumanization and a new eugenics. We close with our policy recommendations.

Our focus throughout this paper, we wish to emphasize, is on the nonmedical use of sex control - that is, sex control for purposes of choosing sex unrelated to the treatment or prevention of disease. Sex control can be used, incidentally as it were, to prevent the transmission of sex-linked genetic diseases. In such instances, a clear medical good is being served. While some Members of Council would question whether sex control for this purpose is legitimate, or even whether the prevention of disease by selecting for sex is the same as treating a patient for disease, this paper will not take up these more general issues. Instead, our goal is to examine sex control for itself and to understand what is so troubling about the practice separate from the issues of elective abortion or the destruction of embryos. Our search is for the deeper sources of our collective unease with sex control.

PART ONE

A. Desire and Technique

Sex control offers a stark example of the strange marriage that can occur between modern technique, on the one hand, and ancient custom or primordial desire on the other. It is as good an example as any of the way in which progress in the arts and sciences is not matched by progress in morals, and it demonstrates why we must beware lest modern technique come to the aid of what may be deeply problematic human desires.

The human desire to choose the sex of one's offspring – usually to have a son rather than a daughter, but also on occasion a daughter rather than a son – is hardly new. The folk wisdom of times gone by attests to the enduring power of this human want, found in mothers and fathers alike. Consider just a few sex-control techniques of earlier times. In ancient Greece, it was believed that if men had sex while on their right side a boy would result, and in eighteenth-century France, it was recommended to men who wanted sons to tie off their left testicle during intercourse. And we have all heard repeated to our amusement the old advice to husbands who desired a son that they wear boots to bed, or that mothers who desired a daughter that they eat sweet foods (sour for a son). In our own time, books that claim to reveal the secrets of having a boy or a girl abound. One bestseller recommended the timing of sexual intercourse as the key in addition to myriad other strategies. Indeed, the importance to all of us of a baby's sex is revealed in the first question we nearly always ask upon news of a newborn (assuming, that is, we have not already found out by sonogram): "Is it a boy or a girl?"

Yet if the central importance of the baby's sex and our desire to choose one sex over the other is not new, the medical techniques for realizing our desires are new. In 1902, John Beard of the University of Jena declared that "any interference with or alteration of the determination of sex is absolutely beyond human power."2 But today sex-control has become practically routine. The principal means for doing so are: prenatal diagnosis (either through a sonogram, amniocentesis, or chorionic villus sampling) followed by abortion of fetuses having the unwanted sex; preimplantation genetic diagnosis (PGD) followed by selective implantation based on sex; and (a less certain technique) pre-fertilization separation of sperm into X- and Y-bearing spermatozoa followed by selective transfer.3 The first two techniques select post-conception; the last seeks to control for sex at the time of conception.4

These methods were developed (or at least the first two were) to ameliorate or prevent disease. However, as with many other medical technologies, nonmedical uses were quickly discovered and put into practice. The sex-determination techniques of amniocentesis and sonograms have been available respectively since the 1970s and 1980s, and have become increasingly widespread. Amniocentesis can make a determination of sex at 16 to 18 weeks of gestation; sonograms at 15 to 16 weeks. PGD is a relatively new medical technique, introduced about ten years ago for the purpose of screening early IVF embryos for genetic diseases. PGD is expensive, costing on average $3,000 for the test and upwards of $20,000 for the entire in vitro fertilization procedure. The newer and less tested sperm-sorting technology was originally a creation of the U.S. government, invented by a Department of Agriculture scientist in the 1980s for the purposes of selecting sex in livestock. The Genetics and IVF Institute in Fairfax Virginia developed the technology for humans and currently has an exclusive license on it – the technology is known as "MicroSort." The Genetics and IVF Institute charges about $2,300 per try, and currently claims a 90 percent success rate for girls and 73 percent success rate for boys. It offers this service only for the purpose of "family balancing" – that is, for achieving a mix of boys and girls in a family.

Even in just the short time that these various methods of sex control have been available, they have had dramatic effects on sex ratios in many parts of the world. Generally, any variation in the sex ratio exceeding 106 boys born per 100 girls born can be assumed to be evidence of sex control. Here are just a few examples of skewed sex ratios around the world today (most recent figures provided). The sex ratio in Venezuela is 107.5, in Yugoslavia 108.6, in Egypt 108.7, in Hong Kong 109.7, in South Korea 110, in Pakistan 110.9, in Delhi, India 117, in China 117, in Cuba 118, in the Caucuses nations of Azerbaijan, Armenia, and Georgia, the sex ratio has reached as high as 120. While the sex ratio in the United States has remained stable at 104.8, certain American ethnic groups have seen a statistically significant rise in their sex ratios. In 1984, the sex ratio for Chinese Americans was 104.6 and for Japanese Americans 102.6; in 2000, these ratios had risen respectively to 107.7 and 106.4.5

Imbalances in the sex ratio are certainly not evenly spread across every region of the globe. However, one cannot but be impressed by the fact that distortions in the sex ratio afflict developed as well as underdeveloped nations, Hindu and Moslem populations as well as Christian populations, Western as well as non-Western nations, wealthy and educated regions as well as those that are less so. One can only expect in the future that technologies of sex control will be further refined and that new and cheaper technologies will emerge on the market. The desire to use these technologies will likely grow too, in our country just as in others.6 One can thus also reasonably surmise a continuation and expansion of substantial distortions in the sex-ratio.

B. History of Public Discussion

What's especially interesting in the case of sex control is that despite widespread use it attracts few partisans. Almost no one argues (in the open, anyway) in favor of sex control, and when they do they rarely offer up the single most important reason for its spread - the desire for sons over daughters. (Though, as we shall see, this taboo may be changing.) Instead, for the most part, it is urged that there is nothing we can do about the practice without violating our most cherished principles of reproductive freedom and individual autonomy. Before proceeding to our own ethical analysis of sex control we will review these arguments and the history of public discussion of sex control in the United States. This history reveals the limitations of the standard approach in bioethics to this issue.

To date, several special panels and advisory bodies in the United States have considered the ethics of sex control. None of these has condoned the practice. Instead, they have generally raised serious ethical concerns while at the same time suggesting that sex control should not be made illegal and may at least in some instances be defensible.

In 1979, the New England Journal of Medicine published a report of the Genetics Research Group of the Hastings Center, co-directed by Tabitha M. Powledge and John Fletcher, which in looking at the social and legal aspects of prenatal diagnosis also briefly addressed the problem of sex control.7 Consisting of an interdisciplinary group of scholars with expertise in law, medicine, philosophy, theology, biology, and genetics, the committee was one of the first to turn its attention to sex control. They took up the subject before the introduction of later techniques of sex control such as PGD. Their report held that prenatal ascertainment of sex was justifiable in order to prevent disease. Yet while the report clearly frowned on the practice of sex control for its own sake, its condemnation was tempered by other principles:

    Although we strongly oppose any movement aimed at making diagnosis of sex and selective abortion a part of ordinary medical practice and family planning, we recommend that no legal restrictions be placed on ascertainment of fetal sex. We think such restrictions would be ineffective and impossible to administer, would lead to subterfuge and, more important, would violate our objective of noninterference with parental choice, even when we disagree with that choice. (172)

The report added that "though we support the right of individual physicians to refuse to perform prenatal diagnosis for sex choice, we also recognize that in special situations, sex choice can appear to parents to be justifiable." (172) Here we see a pattern to be repeated in future discussions of the issue. The Hastings panel argued that the "ultimate" goal of prenatal diagnosis was the treatment or cure of disease. But this medical ethic was placed in a larger "moral framework favoring the protection of individual choice and the autonomy of parents, even when we disagree with their courses of action." (171)

In 1983, a presidential commission, chaired by Morris B. Abram, also considered the ethics of using amniocentesis for purposes of sex control.8 The report covered the ethical, social, and legal implications of genetic screening in general, but took up in passing the matter of sex control. Like the Hastings report, the president's commission supported the use of genetic screening to treat disease, and also like the Hastings report, the commission drew a line (if a permeable one) when it came to sex control.

The president's commission reviewed several reasons why the use of amniocentesis and abortion for sex control was, in its judgment, "morally suspect." (57) First, such a practice was "an expression of sex prejudice." Second, it was incompatible with the findings of developmental psychology that the parent-child relationship depends upon "the attitude of virtually unconditional acceptance." (57) And finally, in the commission's view, sex control treated the child "as an artifact and the reproductive process as a chance to design and produce human beings according to parental standards of excellence" – an attitude that it condemned. (58) Despite these powerful objections to sex control, the commission did not see the matter in black and white terms either, and its policy recommendations were mild:

    This is not to say that every decision to undergo amniocentesis solely for purposes of sex selection is subject to moral criticism. Nonetheless, widespread use of amniocentesis for sex selection would be a matter of serious moral concern. Therefore, the Commission concludes that although individual physicians are free to follow the dictates of conscience, public policy should discourage the use of amniocentesis for sex selection. The Commission recognizes, however, that a legal prohibition would probably be ineffective and, worse, offensive to important social values (because vigorous enforcement of any such statute might depend on coercive state inquiries into private motivations). (58)

Much has changed, at least technologically, since the appearance of these two policy statements. Several new methods of sex control have arrived on the scene -- in particular, PGD and more recently sperm sorting. The change in the technological landscape has brought forth new ethical considerations and analysis.

In 1996, the American College of Obstetricians and Gynecologists (ACOG) issued a "committee opinion" critical of sex control.9 While it supported sex control to avoid sex-linked genetic diseases, it opposed the practice for the sole end of gratifying the parental desire for a child of a particular sex or for family-balancing. In its conclusion, it stated "that nonmedical uses of sex selection techniques have the potential to undermine equality between the sexes; moreover, this ethical objection arises irrespective of the stage of development of the preembryo or fetus." In 1997, the International Federation of Gynecology and Obstetrics (FIGO) offered a somewhat more lenient conclusion.10 It rejected sex- selection abortion on the grounds that "no fetus should be sacrificed because of its sex alone." But it also reached the conclusion that "preconceptional sex selection can be justified on social grounds in certain cases for the objective of allowing children of the two sexes to enjoy the love and care of parents."

The most thorough ethical inquiries into the new technologies of sex control have been undertaken by the American Society for Reproductive Medicine (ASRM) In 1999, the ASRM issued a report that criticized the use of PGD exclusively for sex control.11 (In 1994, it had reached similar conclusions.) The ASRM noted in its 1999 report that there is little cause for concern when sex control is used to prevent the transmission of sex-linked genetic disorders. The report also raised several possible objections to PGD for sex control, including whether it would lead to imbalances in society's sex ratio, or become a gateway to other forms of selection (say for eye color or intelligence), or whether it might lead to a misallocation of scarce medical resources. For the most part, though not entirely, it rejected these ethical concerns as too speculative to be taken seriously. The report tended to place more weight on the problem of how PGD for sex control might "contribute to a society's gender stereotyping and overall gender discrimination." Significantly, the 1999 ASRM report noted that this ethical objection would apply equally to the new sperm-sorting technologies: "The concerns raised here provide at least a framework for an ethical assessment of new techniques for selecting X-bearing or Y-bearing sperm for IUI or IVF.. Here also, sex selection for nonmedical reasons, especially if facilitated on a large scale, has the potential to reinforce gender bias in a society."

Not long after, however, the ASRM retreated somewhat from its opposition to sex control using either sperm-sorting or PGD technologies. First, in a May 2001 report on preconception gender selection for nonmedical reasons, it backed away from its earlier suggestion in 1999 that sperm sorting for sex control was as morally suspect as using PGD for sex control.12 Now the ASRM reasoned that were it shown to be safe and effective this method of sex control would be morally acceptable for "gender balancing." However, the ASRM also indicated its willingness to consider sex control for other ends: "The most prudent approach at present for the nonmedical use of these techniques [of sperm sorting] would be to use them only for gender variety in a family, i.e., only to have a child of the gender opposite of an existing child or children. If the social, psychological, and demographic effects of those uses of preconception gender selection have been found acceptable, then other nonmedical uses of preconception selection might be considered [emphases added]."

In retreating from its earlier condemnation of sex control (albeit by sperm sorting) the ASRM did not seem to garner much critical attention in the popular press. Then in the fall of 2001, the chairman of the ASRM's ethics committee, John Robertson, appeared to endorse the use of PGD for sex control.13 Interestingly, the reversal came following a request for a policy review by the Center for Human Reproduction, a for-profit fertility company that wanted to offer this service to its customers. The Center for Reproduction noted in its appeal that the ASRM had in its 2001 report approved of the use of sperm sorting for family balancing, and asked why it therefore would be ethically impermissible to use a more exact method of sex control like PGD. Robertson sent a letter of approval to the center, at which point the issue of sex control received considerable public attention. Many objected to extending sex control from sperm sorting to PGD because of concerns over the status of the embryo. As even the New York Times editors wrote: The ASRM earlier "concluded that it would be permissible to use a different method-sorting sperm to greatly increase the odds of having a child of a particular sex.. But extending that approach to the selection and discarding of embryos based on their sex surely deserves more consideration."14

Subsequently, the ASRM returned to (or reaffirmed) its earlier position, saying that PGD should be discouraged for sex control. But now the rationale was somewhat different. In 1999, the ASRM's opposition had been mainly based on the problem of gender bias and sex discrimination. But since the ASRM later approved of sex control by sperm sorting, the ethical status of the embryo was now also highlighted. To summarize: the ASRM has concluded that it is permissible to use the technology of sperm sorting for sex control but not yet the technology of PGD for the same end, and raises concerns about both gender bias and the moral status of the embryo.

C. Analysis of the Debate

Several salient themes emerge from this review of the major ethical statements on sex control. The first is that few substantive rationales have over the years been put forward in favor of sex control, with the possible exception of family balancing. Now, it is certainly true that independent scholars and bioethicists have offered additional positive reasons for approving of sex control. These include slowing population growth (since many families continue to have children only to achieve a particular balance of sons and daughters), increasing the happiness of parents (who get to fulfill their desires for a boy or girl), making children feel more wanted (since they will know that they were in fact chosen down to the specifics of sexual identity), and advancing the project of genetic control over the species. But in the more sober analyses of sex control to date the preponderance of moral analysis goes in the opposite direction: Sex control is frowned upon by most bioethicists and the authoritative bodies that have explored the issue.

Over the years, the single most often broached objection to sex control is its discriminatory effect on women. The ASRM, for example, canvassed the many possible objections to sex control and singled out the prospect of gender discrimination as one of the most weighty. It is indeed a very important ethical consideration. As practiced, sex control has involved the abortion of female fetuses on a massive scale, or the selection of male embryos over female ones for implantation. Sex ratios have been altered in a very short period of time. The Nobel Prize-winning economist Amartya Sen has dramatically referred to actions taken to assure the birth of boys rather than girls as "high-tech sexism" and "natality inequality."15

We agree that sex control is a particularly pernicious form of sex discrimination. But we also note with some sadness that almost thirty years of progress on the matter of sexual equality has not led to any firm public policy proposals to put an end to sex control in the United States or abroad. In fact, during these same years, sex control has become more widespread. One problem, as in the debate over stem cells and human cloning, is that the issue of sex control became a casualty of the abortion wars. In the early years of sex control, when post-conception determination of sex followed by abortion was the only means of sex control, it was widely argued by many feminist-oriented scholars as well as other liberal thinkers that any legal or policy actions taken against abortion for sex control would put the abortion right itself at risk. Some scholars also argued that the principles established by Roe v. Wade required acceptance of sex control. The distinguished bioethicist John C. Fletcher in 1980 put it this way:

    My major argument is that it is inconsistent to support an abortion law that protects the absolute right of women to decide and, at the same time, to block access to information about the fetus because one thinks that an abortion may be foolishly sought on the basis of the information.16

This line of reasoning, as has been pointed out, led to certain unfortunate ironies and unintended consequences. The abortion right, which was grounded in the principle of equality for women, could now be used, rightly or wrongly, as a pretext for aborting female fetuses. And the slogan of pro-choice advocates of "every child a wanted child" could now be invoked, again rightly or wrongly, to defend the abortion of unwanted female fetuses. Equality's cause was not well served by this turn in the public debate.

The practice of sex control threw into disarray other cherished principles as well. Since the end of World War II genetic counselors have adhered to the ethical norm of "nondirectiveness." It was hoped that by this principle they would avoid the coercive eugenic policies of the past, from forced sterilization to genocide. Nondirectiveness was thought to be the moral antidote to eugenics. Yet by mandating the moral neutrality of genetic counselors, nondirectiveness in fact made it easier for individual couples to practice sex control, which is arguably a form of eugenics. And here too the culture wars over abortion played a part. In one study it was found that genetic counselors were reluctant to recommend against sex control since they considered it a "logical extension of parents' rights to control the number, timing, spacing, and quality of their offspring."17

If the abortion debate has posed one obstacle to public policy in the area of sex control, the fact of multiculturalism will soon present another. We have noted that at least in the United States defenders of sex control rarely cite what is certainly the most powerful motivation behind the practice - the desire of parents for sons. But many cultures place a special value on sons, and they would openly defend sex control on these grounds. In a recent issue of Reproductive BioMedicine Online, for example, Z. Kilani and L. Haj Hassan argue that the ASRM's moral analysis does not apply in their particular social and religious context.18 After noting that neither the Quran nor Sunna (Islam's holy books) proscribe sex control, the authors state that "among the most pressing motivations for sex selection in Islamic culture is the expectation that couples will bear and raise at least one child of the culturally preferred gender (male)." We are confronted then with two difficult questions: How do we address the practice of sex control in countries where sexual equality is not so highly regarded (or is perhaps understood differently), and how do we address the issue within our own country when immigrants or ethnic and religious sub-groups opt for sex control on religious or cultural grounds? A moral consensus seems to have been reached in the United States that sex control is acceptable for family balancing. But in an increasingly multicultural society that prides itself in respecting cultural differences, the question will soon arise: Why not also allow sex control to fulfill a religiously ordained value?

Another looming problem in the debate is that while sex-control technologies originally developed within the moral framework of medicine and were thus directed towards disease prevention, the commercial possibilities of these technologies are becoming increasingly evident. Today, sex-control services are openly advertised on the Internet, and sex control could in the future become a big business. Here's how Fortune magazine recently summed up at least the potential market for MicroSort alone: "Each year, some 3.9 million babies are born in the U.S. In surveys, a consistent 25 percent to 35 percent of parents and prospective parents say they would use sex selection if it were available. If just 2 percent of the 25 percent were to use MicroSort, that's 20,000 customers.. [and] a $200-million-a-year business in the U.S. alone."19

In sum, the debate over sex control has never been aired in full because it has become entangled in the abortion controversy. Certain widely accepted political and ethical principles, such as individual autonomy, equality, the right to choose, and nondirectiveness, were thought to be threatened by any thoroughgoing critique of sex control. And today, new challenges are on the horizon, from multiculturalism to a consumer-driven economy, both of which will also make it difficult to slow the future spread of sex control.

PART TWO

What are we to make of the fact from the very first introduction of sex control by scientific means it has been generally condemned (or at least not overtly championed) but has at the very same time spread in its use, with better and more efficient means of sex control steadily developed? And what are we to make of the lack of any firm public policies in the United States on sex control, and the apparent erosion of earlier moral objections to the practice? In our view, what is required is a deeper ethical analysis of sex control, lest its spread continue as the technology of sex control becomes more refined and less expensive. Our approach is set forth in five sections. We begin with a note on terminology. We then discuss the issue of liberty and its necessary limits in the context of sex control. The moral center of our analysis is found in the next section where we explore the proper human context of this issue, which we take to be the overwhelming importance of sexual identity. This is followed by a discussion of the meaning of procreation, the problem of turning procreation into manufacture, and the dangerous specter of eugenics. All these considerations tell against the advisability of sex control. We close with several policy recommendations, and a review of policies adopted in other countries.

Our goal throughout is to unearth the deep causes of our unease with the practice of sex control – to go beyond the commonly raised objections in the name of abortion, embryo destruction, or gender discrimination. And thus for the sake of argument we assume a form of sex control that would not necessitate the destruction of embryos or require abortion.

A. On Terminology

Readers of this paper will have noticed that we have generally spoken of sex control, whereas in popular and scholarly discussions, the term of art is more often than not, "gender selection." The evolution of the terms is in and of itself interesting, and suggestive as to why it has been so difficult to gain purchase on the issue. In a seminal article dating back to 1968, the sociologist Amitai Etzioni used the term "sex control,"20 but since then the terminology has shifted to "sex selection" and currently to "gender selection." The evolution of terms is visible in the ASRM reports we have summarized above. The ASRM went from analyzing something called "sex selection" in its 1999 report to analyzing something called "gender selection" in its 2001 report. As a descriptive matter, we believe Etzioni's original terminology to be more accurate. We do not urge a reform in terminology to win the argument by sleight of hand; rather, we believe sex control to be a better description of what is in fact taking place. In what follows, we examine the usefulness of the words "gender" and "selection" in this context.

The problem with the word gender in this context is that it does not capture the medical procedure of choosing for sex. In recent years, there has been an effort to replace the term sex with that of gender when discussing male/female differences. Influential voices in the academy have taken the view that sexual identity is infinitely malleable, and that sex is not rooted in biology but in socially constructed interpretations of what it means to be male or female. "Gender" is the term that is meant to convey this understanding of sexual differences - that they are rooted not in our genes but in socially imposed meanings. But a moment's reflection will show that the issue before us cannot be gender selection. What is being selected is not a socially constructed identity but a particular biological identity. Now, we would be the last to deny that socially constructed expectations go into the desire to have a girl or a boy, but what is being selected is emphatically biological in its nature – an X or Y chromosome and the respective genitalia and secondary characteristics that go with each. These are not socially constructed entities but biological facts.

But if "gender selection" is not the right term, why not simply speak of "sex selection"? It was this term that was commonly used throughout the 1980s, and was used by the President's Commission in 1983. As a brief aside it's worth noting that the origins of the term have nothing to do with its present usage. "Sexual selection" was most famously used by Charles Darwin in his Descent of Man to describe the advantage certain members of the same sex have over their fellows in respect to reproduction, as opposed to survival (i.e., natural selection). Clearly, the term sex selection, as currently employed, is unrelated to what Darwin had in mind, and thus suggests a meaning wholly unintended.

The more fundamental problem is that the term "selection," by definition, suggests that nothing more momentous is taking place than a choice by parents between, say, pink and blue. But that is emphatically not the case with sex selection, where the very purpose (unconscious or not) of the selection is to exercise a large degree of control and authority over the nature and identity of one's offspring or of the next generation. After all, if the choice were completely indifferent, completely free of consequences, biological ramifications, or implicit social meanings, there would scarcely be a reason for making it in the first place. Quite the contrary: The parents expect certain things to follow from their "selection" – from their control of the sex of the child. They are not merely selecting but determining – in the sense of foreordaining – something in their offspring, and something, moreover, that is not trivial but central to the child's lifelong identity. To capture these defining aspects of what takes place in aborting a fetus because it is male or female, or preselecting an embryo for implantation because of its sex, or choosing to impregnate a women with X- or Y-bearing sperm only, we recommend the term control.

In conclusion, we hold that the term sex control is to be preferred to either gender selection or sex selection since it captures both the fact that important biological entities are implicated and that a significant degree of authority is being exercised over the next generation.

B. The Limits of Liberty

As we noted earlier, few policy makers or opinion leaders argue openly in favor of sex control. Rather, the assumption is made that our most cherished ideals of individual autonomy and the right to choose preclude an unambiguous condemnation of sex control or anti-sex control public polices. In our view, this assumption is wrong.

Our society, to be sure, deeply cherishes liberty and rightfully gives a wide berth to its exercise. But liberty is never without its limits. In the case of actions that are purely self-regarding – i.e., actions that affect only ourselves – society tends to give the greatest protections. But as we move outwards, away from purely self-regarding actions to those actions that affect others, our liberty is necessarily more liable to societal and governmental oversight and restraint. Sex control clearly does not belong in the category of purely self-regarding action. The parents' actions (their choice of a boy or a girl) are directed not towards themselves but towards the child-to-be.

One might argue that, since each child must be either a girl or a boy, the parents' actions in controlling sex do not constitute much of an intrusion on the prospective child's freedom and well being. But the binary choice among highly natural and familiar types hardly makes the choice a trivial one. And having one's sex foreordained by another is different from having it determined by the lottery of sexual union. There is thus at least a prima facie case for suggesting that the power to foreordain or control the nature of one's child's sexual identity is not encompassed in the protected sphere of inviolable reproductive liberty.

But it is not only that sex control affects the individual child-to-be that puts it in a class of actions subject to oversight, regulation, and curtailment. Sex control can also have powerful societal effects that reach far beyond individuals and their families to the nation as a whole. The dramatic alteration in sex ratios in such countries as South Korea and Cuba bear this out. Whether or not one views the preference of individuals for sons over daughters as rational, taken together these individual preferences could and do have devastating society-wide effects.

To use the language of the economists, sex control is a text-book illustration of "negative externalities." An externality is any effect, positive or negative, on a third party to a transaction. The classic example of a positive externality is education, which is beneficial not just for the person being educated but for employers, the government, and other parties besides the individual. A classic negative externality is pollution. In both cases, the government steps in, on the one hand, to mandate education requirements, and on the other hand, to limit pollution.

In the instance of sex selection, there is a presumed negative externality that arises for the males on whose behalf the selection is being made,21 as well as the broader society as a result of the predictable lopsided sex ratios and social effects. The males will have diminished chances of finding an acceptable mate, while the broader society will very likely suffer as a result of the skewed sex ratios from higher crime, greater social unrest, increased incidence of prostitution, etc. – social variables closely associated with men. One could argue that the choice of a male child is individually rational for parents, given the strong preference in certain cultures for males. But such individual choices are socially costly – a case where individual parental eugenic choices do not yield a social optimum. In such cases, where the negative externalities are considerable, it is acceptable (and arguably necessary) for a liberal polity to place limits on individual liberty.

C. The Human Context: The Meaning of Sexuality

The two aspects of sex control – it is control of sex, and it is a form of control of offspring – locate the deeper significance of this practice in two important human contexts: the meaning of sexuality, and the nature of procreation and family relations. The first topic is, today perhaps more than ever, a subject of extensive public discussion and political agitation. We shall not here offer any Council-wide view of the matter other than to suggest that it deserves deeper and more serious consideration than it has hitherto received in discussions of sex control. Some of the remarks that have been made by previous commentators strike us as puzzling or ill-considered.

One aspect of sex control that most bothers some critics is that it would reinforce gender stereotypes and threaten gender equality – presumably because it would manifest preferences for boys. Yet they do not specify what they mean by "gender stereotypes" and "gender equality." Sometimes it seems that they are worried about a return to the world of 1950s-style stereotypes. But it also seems that they are pushing for something in addition, a movement toward a more genuinely genderless (or androgynous) society, one in which our socially constructed human identities overwhelm the mere biology of sexual differentiation. (This may partly explain why the ASRM refers to sex as a "nonessential characteristic.") But in the perfectly genderless society, it would presumably make no difference whether you are a girl or boy, a woman or a man. And thus the choice of parents of a boy rather than a girl, or vice versa, would have no negative implications of gender stereotyping and would not threaten the equality of the sexes. In the genderless utopia, the choice between a girl and a boy is purely an aesthetic choice – a choice between pink and blue. And who could then object to letting parents choose that? The very logic and language of gender equality would seem to soften opposition to sex control. Further, there seems to be a contradiction between saying "sex should not count" in opposing free parental choice, and saying (tacitly) that sex counts plenty in approving sex control for "family balancing." If sex does not or should not count, why is a sexually balanced family humanly better than an unbalanced one?

Following up a different objection to sex control takes us closer to the truth of the matter. The 1999 ASRM Report on "Sex Selection and Preimplantation Genetic Diagnosis" offers as one of the arguments against use of PGD for sex selection that it would involve "inappropriate control over nonessential characteristics of children." Or, again, it says that this might "trivialize human reproduction by making it depend on the selection of nonessential features of offspring." Later the statement contrasts accepting offspring "for themselves" with selections based on "inessential characteristics" (such as sex).

Now, in one sense, the meaning is clear. If, when hiring someone we turn down a female applicant because a male applicant is clearly more qualified, we do her no wrong – and we do not engage in anything that would be regarded as unjust discrimination. If, despite her obvious strong qualifications, we turn her down because we prefer to hire a man, we act in a way generally regarded as unjust.

Thus, in matters of employment, if a man or woman can do the job equally well, one's sex is not an "essential" characteristic to consider when filling the position. It's likely that something like that is what the ASRM report has in mind.

But this remains a peculiar way to talk about sexual identity. Humanity exists as a sexually differentiated species; it is constituted in part by the sexual differentiation. Or, at least, one must say something like this if one takes seriously the body as integral to our humanity. There is not some generic or androgynous human self to which is added, then, as a kind of accidental addition, either a female or a male body. Were that the case, sexual identity really would be "nonessential" or "inessential" to our self. It would not in any sense help to constitute a person's identity.

If, however, we do not accept that kind of dualism in which the real self simply is attached to and makes use of a (male or female) body, then we will have to take sexual identity seriously as given with our body. Every cell of the body marks us as either male or female, and it is hard to imagine any more fundamental or essential characteristic of a person. It is surely odd, to the say the least, to deny the importance of sexual identity in the very activity of initiating a life!

Seeing this, we see in the first place why it might often seem so important to people that they have either a boy or a girl. Indeed, it would be surprising if no one cared about a difference so fundamental. But seeing this, we can also understand why we should be reluctant to see ourselves as people who may appropriately determine something that actually constitutes in part the identity of our child. Many prospective parents will say quite honestly that they don't care whether their baby is a boy or a girl; they'll be happy to have either. That attitude is desirable not because the sex of the child is a matter for indifference but because it counts for so much. Far too much to be seen as their responsibility to determine.

D. The Human Context: Human Procreation, Manufacture, and Eugenics

In our July, 2002 cloning report,22 we emphasized how cloning-to-produce-children alters the very nature and meaning of human procreation, implicitly turning it into a form of manufacture and opening the door to a new eugenics. Sex control raises similar concerns.

The salient fact about human procreation in its natural context is that children are not made but begotten. By this we mean that children are the issue of our love, not the product of our wills. A man and a woman do not produce or choose a particular child, as they might buy a particular brand of soap; rather, they stand in relation to their child as recipients of a gift. Gifts and blessings we learn to accept as gratefully as we can; products of our wills we try to shape in accordance with our wants and desires. Procreation as traditionally understood invites acceptance, not reshaping or engineering. It encourages us to see that we do not own our children and that our children exist not simply for our fulfillment. Of course, parents seek to shape and nurture their children in a variety of ways; but being a parent also means being open to the unbidden and unelected in life.

Sex control challenges this fundamental understanding of procreation and parenthood. When we select for sex we are, consciously or not, seeking to design our children according to our wants and desires. Instead of being grateful for who the child is, whether a boy or a girl, we specify in advance the sex we desire. The choice is never merely innocent nor indifferent since a host of powerful expectations go into the selection of a boy or a girl. In choosing one sex over the other, we are necessarily making a statement about what we expect of that child. As fathers, we may want a son to go fishing with; or as mothers, we may want a daughter to dress for the prom. The problem goes deeper than sexual stereotyping, however. For it could also be the case that we may want a daughter who will become president to show that women are the equal of men. But in making this kind of selection we have hardly escaped the problem, for we are still having a child in order to fulfill some particular desire of our own. If this were not the case then there would be no felt need to choose the sex of our child in the first place. And thus does it happen that in practicing sex control our acceptance of our children becomes highly conditional – a stance that is fundamentally incompatible with the deeper meanings of procreation and parenthood.

In the process of controlling for sex we also transform procreation into a form of manufacture. Parents have always had the right to decide whether to try to have children. But with sex control they begin for the first time to decide in addition what kind of child they will have. Increasingly, we will come to see our children as commodities of the marketplace, rather than as gifts.

It should be noted as well that sex control may be a step down the road of eugenics and "designer children." It is a short step, logically and psychologically if not technologically, from choosing the sex of our children to choosing their eye color, or skin color, or height, or sexual orientation, or IQ – when and if the technology for identifying their genetic determinants and implementing these kinds of wants becomes available. Now, it is generally thought that eugenics is dangerous or wrong only by its connection to state power. But sex control is a case study of how private eugenic choices are in fact strongly dictated by public opinion. With private eugenics, as with all eugenics, the question is by what standard of excellence parents will choose the traits of their children. The practice of sex control suggests that they may very likely follow the fads and cultural prejudices of their particular time and place – with possibly devastating social consequences. As we described earlier, the individual choices of parents in such countries as South Korea and India have created heavily skewed sex ratios in favor of boys. The social pressures that produce these results in favor of boys belie the notion that there can be such a thing as a non-coercive, private eugenics.

E. Policy Recommendations

The substance of this section, to be written later, will depend upon how far Council Members wish to take the issue and how hard they wish to press. We can imagine three broad possibilities in the area of public policy: 1) The Council offers no policy proposals and simply lets moral suasion do its work; 2) The Council attempts to enter into a dialogue with the various medical governing bodies to encourage them to enact vigorous self-regulation; 3) The Council suggests legislative action as it did in the cloning case.

An additional section (perhaps as an introduction to the policy discussion or as an appendix) might describe what steps other countries have taken (or not taken) to curtail sex control.

References

  1. An explanation of our choice of the term "sex control" is provided in Part Two, Section A below


  2. Quoted in R. Clay Jackson, The Cause and Control of Sex in Human Offspring (Tacoma, Washington: Allstrum Printing Co., 1926),
    p. 11.


  3. For the time being, the separation is physical. But researchers are also interested in finding immunological techniques that might differentially find x- and y-bearing sperm.


  4. Discussion of the specifics of these techniques will be expanded in a future draft


  5. These figures were presented to the Council by Nicholas Eberstadt on October 17, 2002


  6. In a recent poll conducted by the Genetics and Public Policy Center, nearly a quarter of American women and a third of American men said they would approve of using PGD to select the sex of a child.


  7. The New England Journal of Medicine, Volume 300, Number 4 (January 25, 1979), pp. 168-172.


  8. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Screening and Counseling for Genetic Conditions: A Report on the Ethical, Social, and Legal Implications of Genetic Screening, Counseling, and Education Programs, February 1983.


  9. The American College of Obstetricians and Gynecologists Committee on Ethics, "Committee Opinion: Sex Selection," Number 177 (November 1996).


  10. FIGO, "Recommendations on Ethical Issues in Obstetrics and Gynecology by the FIGO Committee for the Study of Ethical Aspects of Human Reproduction, July 1997.


  11. The Ethics Committee of the ASRM, "Sex Selection and Preimplantation Genetic Diagnosis," Fertility and Sterility, Volume 72, Number 4 (October 1999).


  12. The Ethics Committee of the ASRM, "Preconception Gender Selection for Nonmedical Reasons," Fertility and Sterility, Volume 75, Number 5 (May 2001).


  13. "Gina Kolata, "Fertility Ethics Authority Approves Sex Selection," The New York Times, September 28, 2001, P. A16.


  14. "Choosing the Sex of Your Baby" (editorial), The New York Times, September 30, 2001.


  15. Amartya Sen, "Many Faces of Gender Inequality," originally published in The Frontline, India, November 9, 2001.


  16. John C. Fletcher, "Ethics and Amniocentesis for Fetal Sex Identification," The Hastings Center Report, Volume 10, Number 1 (February 1980), p. 16. However, Fletcher has over the years argued both sides of the moral issue.


  17. See Dena S. Davis, Genetic Dilemmas: Reproductive Technology, Parental Choices, and Children's Futures (New York: Routledge, 2001), p. 98.


  18. Z. Kilani, L. Haj Hassan, "Sex Selection and Preimplantation Genetic Diagnosis at the Farah Hospital," Reproductive BioMedicine Online (January-February 2002).


  19. Meredith Wadman, "So You Want a Girl?" Fortune, February 9, 2001.


  20. Amitai Etzioni, "Sex Control, Science, and Society," Science, Volume 161, Issue 3846 (September 13, 1968).


  21. Paradoxically, the allegedly sexist and anti-female bias thought by critics to be the likely cause and effect of permitting sex control might in fact redound to the advantage of women, at least regarding marriage: their relative scarcity could give them greater selectivity, choice, and control of partners.


  22. The President's Council on Bioethics, Human Cloning and Human Dignity: An Ethical Inquiry (Washington, D.C.: Government Printing Office, 2002.)

  - The President's Council on Bioethics -  
 
Home Site Map Disclaimers Privacy Notice Accessibility NBAC HHS