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Emerging technologies that involve reproductive health offer the
promise of better care and services, and improved quality of life.
However, new technology can often raise unanticipated ethical concerns,
including the potential for abuse and misuse.
One central question is whether scientific advancements will be equally
available to rich and poor individuals and in rich and poor nations.
Another ethical concern is how technologies will be used – for altruism
or profit.
Relatively new reproductive health technologies that are becoming more
widely available include the use of ultrasound for determining the sex of
an unborn fetus, new ways to achieve long-term or permanent contraception,
treatments for people living with HIV/AIDS, and the use of in vitro
fertilization (IVF).
Some emerging technologies involving reproductive health matters may
not appear to affect developing countries directly. Yet these new ideas
may shape health research policies in developed countries like the United
States, which eventually could affect public health services or public
policies in other countries. For example, the current debate in the United
States over allowing embryonic stem-cell research is closely linked to an
ongoing worldwide debate about elective abortion and IVF, since the
specialized cells are removed from human embryos that are being destroyed
for other reasons. As U.S. research policy is shaped regarding embryonic
stem-cell research, the thinking in other countries about abortion could
change. And a decision to allow or prohibit stem-cell research will
determine how soon new cures and treatments can be found for a number of
diseases and illnesses, including options that may be better or cheaper
for use in developing countries.
Reproductive health providers, clinic managers and policy-makers should
be aware of ongoing ethical debates about these new technologies. As with
any existing technology, health providers must work to ensure that
tomorrow’s technologies are used ethically, with the client’s best
interest in mind.
Sex selection
Throughout the world, ultrasound technology has been used to produce
images of the fetus in the womb, aiding in the diagnosis of genetic
disorders. Ultra-sound scans also can reveal the sex of a fetus, and some
couples have used this information to abort unwanted female fetuses.
Abortion is a controversial procedure even in countries where it is
safe, legal, and widely available. When abortion is used for sex
selection, the controversy intensifies. Several studies have shown that
induced abortion has been used for this purpose.
FHI’s Women’s Studies Project found that in China, where government
policy limits urban couples to one child and rural couples to two
children, preference for sons remains strong. A survey of residents in six
counties in north Anhui, south Jiangsu, and central Yunnan provinces found
that some couples said daughters were good, but sons were better.
"Without sons your husband will dislike you, and you will have low
status," one 25-year-old woman said. An older woman said, "My
mother-in-law said it is inferior to have daughters. If you have a son,
even your house will look higher."
In China, many pregnant women use ultrasound to determine the sex of
their fetus. Using ultrasound for sex selection is illegal, but study
participants in the FHI study acknowledged it does occur. "People use
an ultrasound machine," one woman explained. "If it is a female
fetus, they don’t want it. . . . No matter how much money they have to
spend, they think it is worth it [to determine fetal sex]."1
A Population Council study found similar results. Researchers
interviewed 820 women in central China and found that nearly half of the
pregnancies were subjected to an ultrasound scan for sex selection. About
a third of 301 induced abortions were done to abort a female fetus.
In the same study, researchers learned that couples were most likely to
abort a pregnancy when the previous children were girls and the current
fetus was female. If the first child was a girl, 92 percent of the second
pregnancies were aborted if the fetus was female. If the first child was a
boy, 5 percent of second pregnancies were aborted if the fetus was female.
However, when women were questioned about sex-selective abortions, 92
percent said they did not believe it was right to abort female fetuses.
Many explained that they had an abortion because they felt pressured by
family members; others said it was their duty to have a son who would
carry on the family line. "I must have one son, no matter how many
measures are taken," a woman said.
In analyzing study results, researchers urged stricter enforcement of
laws and policies against sex selection. "More strenuous enforcement
of the regulations forbidding prenatal sex determination and sex-selective
abortion, and close monitoring of the uses of ultrasound" at
hospitals and family planning stations might change the situation, said
study author Chu Junhong.2
Some organizations and governments have taken steps to discourage
sex-selective abortions. The government of India banned abortion of
healthy female fetuses identified during genetic prenatal testing.3
A national convention of religious leaders recently condemned sex
selection. However, the practice continues, and census figures show that
the male-to-female ratio has dropped to 1,000:793 in the state of Punjab
and 1,000:820 in Haryana.
In Vietnam, where the government has implemented a two-child limit, son
preference is strong, especially in rural areas. Couples who have more
than two children risk steep fines and low priority for land allocation.
While sex-selective abortion has not been widely documented, son
preference apparently affects women’s contraceptive use. An analysis of
data from the Kien Xuong district found that women with one or two
daughters reported higher rates of intrauterine device (IUD) expulsion
than did women with at least one son. After the third year of IUD use,
one-third of women with two daughters reported IUD expulsion, compared
with 21 percent of women with two sons or a son and a daughter.
Researchers suggested that women may have removed their own IUDs and
reported it as an expulsion, hoping they would become pregnant and have a
son.4
Long-term methods
While long-term contraceptive methods are highly effective in
preventing pregnancy and require little action on the part of the user,
clients must rely on providers to obtain them and to discontinue their
use. Consequently, some women’s advocates have expressed concerns about
the potential for abuse and coercion, with existing long-term or permanent
methods such as IUDs, implants, and sterilization, as well as for newer
options being developed.
In India in the 1960s and 1970s, family planning workers were
encouraged to attract new contraceptive users. The Tamil Nadu state
exceeded others in recruiting IUD acceptors, but research showed that some
health workers were routinely inserting IUDs postpartum – often without
women’s knowledge or permission. Some women sought health treatment for
unexplained bleeding and cramping – routine side effects of IUD use –
apparently unaware that they were using IUDs.5 In 1996, India
implemented a "target-free" approach to contraceptive service
delivery, designed to focus health workers’ attitudes on quality care
and reduce concern with numbers of clients served.
One of the most controversial contraceptive technologies is
sterilization. Reports of coerced sterilization have surfaced in several
countries. Women resisting sterilization have been jailed, and women
refusing to undergo sterilization have been threatened with a suspension
of food and milk programs if they did not submit.6 Meanwhile,
research on nonsurgical methods of sterilization, such as drugs that block
fallopian tubes, has generated concerns. Among the many ethical questions
about these experimental sterilization technologies is the potential for
use without a woman’s consent or knowledge. Supporters say these new
ideas may improve access to contraception and could save lives by avoiding
pregnancy-related deaths.7 Because sterilization is permanent,
health experts stress that informed choice and informed consent are
critical (see "Choices
Must be Informed, Voluntary").
Because of the potential for abuse, some health advocates have asked
that researchers cease work on other long-term experimental methods,
including immunocontraceptives or antifertility vaccines. Some women’s
health groups have suggested that family planning programs should promote
only methods that are controlled by the user and are not dependent upon
the provider, such as condoms and dia-phragms. International health
organizations, including the World Health Organization, have responded by
saying that men and women deserve a variety of contraceptive choices and
quality services and that research on a variety of long-acting methods
should continue.8
HIV/AIDS treatments
The development of antiretroviral drugs has improved the life
expectancy of many people living with HIV/AIDS and has reduced the
incidence of mother-to-child transmission. Yet, these drugs are often too
costly for governments and individuals in developing nations. AIDS
advocates say that drug companies have an obligation to make drugs more
widely available in geographic regions where the need is critical.
In 2001, the Pharmaceutical Manufacturers Association of South Africa
and 39 international pharmaceutical companies ended three years of legal
action contesting a South African law that allows the government to ignore
patent protection and to manufacture the drug without paying the
patent’s owners, if deemed appropriate by the government. While viewed
as a victory for HIV/AIDS activists, some health experts have suggested
that low-cost drugs will not become widely available in South Africa.
Meanwhile, a conflict has arisen in Brazil over the nation’s right to
import or manufacture low-cost generic forms of HIV/AIDS drugs. At the
heart of this debate is an important ethical question: whether expensive
new health technologies should be available to those who cannot afford to
pay and, if so, who should pay.
Women and men who are HIV-positive face other ethical issues. If an
unintended pregnancy occurs, should the woman risk giving birth to an
HIV-infected child or have an abortion?
Dr. Willard Cates, Jr., FHI president, recommends that to help
HIV-infected women make informed choices about contraception and
childbearing, voluntary counseling and HIV testing — if available —
should be linked to family planning services. He recommends several
options, including: referral to family planning programs if a woman does
not wish to become pregnant; education about infertility and prenatal
services for women who do wish to become pregnant, as well as information
about drugs that might be available to prevent HIV transmission to
infants; and antiretroviral therapy for women who are already pregnant and
wish to continue their pregnancies.9
Women who decide to use contraception should be advised that male latex
condoms can protect them and their partners from pregnancy and from
further transmission of sexually transmitted infections (STIs), Dr. Cates
says. However, they also should be encouraged to consider whether their
male partner will be able to or will want to use condoms consistently.
Women also should be informed about local availability of the female
condom, and should be cautioned that other methods offer protection from
pregnancy but no protection from STIs. Ultimately, the woman must be
allowed to decide which method she will use, Dr. Cates says.
Other emerging technologies
In industrialized nations, "assisted reproductive
technologies" (ART) involve the use of expensive equipment and tests
to help infertile couples conceive a child. One of the technologies is in
vitro fertilization, in which egg and sperm cells are united outside the
body, then fertilized eggs are implanted in a woman’s uterus. While the
technique has helped many couples give birth to healthy children, it also
has raised serious questions. Should such technologies be available only
to married couples or to single women as well? Should fertile women and
men be allowed to donate eggs and sperm so that infertile couples can have
children? Should these donors be paid? Once an egg is fertilized, is the
resulting group of cells a potential person, or a person with the same
rights as any other?
The question of an embryo’s status has become the focal point of
recent debates on the ethics of stem-cell research. Stem cells – the
body’s "master" cells that can produce millions of genetically
identical cells and transform themselves into any type of cell in the body
– might be used to regenerate damaged tissue or organs, or to find new
cures for a variety of illnesses and diseases. Stem cells can be taken
from adults, but scientists have said that cells from embryos are more
useful and versatile.
While some critics have suggested that taking cells from embryos would
be the equivalent of destroying a human life, some scientists have argued
that the cells would be taken from surplus embryos created in laboratories
for infertile couples wanting children. Because more embryos are created
than are actually implanted, researchers say they could use cells from
embryos to improve treatment or cures for Alzheimer’s disease, diabetes,
or other debilitating ailments.
In addition to affecting how quickly new cures or cheaper health
treatments might be developed, the outcome of the stem-cell debate in the
United States could affect developing countries in other ways. For
example, if embryonic stem-cell research were banned in the United States,
research might be done instead in other countries, perhaps in the
developing world.
Another controversy in assisted reproductive technologies is
"selective reduction." Because several embryos are implanted to
increase the couples’ chance of having a baby, multiple births can
occur. Some couples have chosen selective reduction instead – the
destruction of a certain number of embryos by injection of potassium
during the first trimester of pregnancy.
In the future, scientists predict they will be able to screen human
embryos for chromosomal abnormalities and genetic diseases prior to
implantation. They also expect to be able to alter genetic material. While
some scientists suggest this could prevent diseases such as diabetes,
hypertension, and schizophrenia, others say the procedure could be misused
by parents seeking children with specific features, such as eye and hair
color or higher intelligence.10
A new technique developed at the Genetics and IVF Institute in the
United States may be able to guarantee a child’s sex. The technique
involves isolating sperm that will produce a female embryo (the sperm that
carry an X chromosome). Currently being evaluated in clinical trials, the
technique has the advantage of allowing couples to determine the sex of
their child before the egg is fertilized, not after, and could potentially
be used to prevent genetic disorders such as hemophilia or muscular
dystrophy. These conditions are caused by defects in the X chromosome and
primarily affect male children. Other scientists have speculated that the
new technique could become a tool for sex selection. "Ultimately we
have to wonder whether [you will] ever have sex selection kits available
at your chemist," says Ian Craft, a professor at the London Fertility
Clinic in the United Kingdom.11
Cloning has been used to produce human cell tissues and to split
embryos in animals, allowing scientists to make identical genetic matches
of sheep, cows, pigs, goats, and mice. Some researchers have been
concerned that the process will be done in humans, allowing people to
predetermine characteristics of the new cloned individual. For example, a
family might request an individual be cloned to produce an organ donor.
Other researchers have suggested cloning might be an option for infertile
couples trying to have a child.
– Barbara Barnett
Barbara Barnett is a journalism doctoral candidate at the University
of North Carolina at Chapel Hill and a former senior science writer/editor
for Network.
References
- Gu B, Xie Z, Hardee K. Family Planning and
Women’s Lives in Three Provinces of the People’s Republic of China.
Research Triangle Park, NC: China Population Information and Research
Center, Family Health International, and The Futures Group
International, 2000.
- Junhong C. Prenatal sex determinants in rural China. Popul
Dev Rev 2001;27(2):259-81.
- Sudha S, Rajan SI. Female demographic disadvantage in
India, 1981-1991: Sex-selective abortions and female infanticide. Dev
and Change 1999;30(3):585-618.
- Johansson A, Nguyen TL, Hoang TH, et al. Population
policy, son preference and the use of IUDs in North Vietnam. Reprod
Health Matters 1998;6(11):66-76.
- Van Hollen C. Moving targets: routine IUD insertion
in maternity wards in Tamil Nadu, India. Reprod Health Matters
1998;6(11):98-106.
- Pine RN. Maintaining a focus on informed choice. AVSC
News 1998;36(3):6-8.
- Quinacrine for female sterilization: health and
ethical concerns. IPPF Med Bull 2000;34(2):3-4.
- Richter J. Anti-fertility ‘vaccine’: a plea for
open debate on the prospects of research. Women’s Global Network
Reprod Rights 1994;(46):3-5; Long-acting contraceptives: ethical
considerations. Popul Briefs 1995;1(3):5.
- Cates W Jr. Use of contraception by HIV-infected
women. IPPF Med Bull 2001; 35(1):1-2.
- Brenner C, Cohen J. The genetic revolution in
artificial reproduction: a view of the future. Human Reprod
2000;15(Suppl. 5):111-16.
- Concern over baby sex ‘guarantee.’ BBC News, July
5, 2001.
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