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.
