Is sex selection illegal and immoral?

The use of PGD (preimplantation genetic diagnosis) for sex selection has proven extremely controversial in the UK, where the procedure is illegal unless medically justified to avoid producing a child with a sex-linked genetic disorder, such as Duchenne muscular dystrophy. One reason often given for the restrictions is the fear that the technology will be used mainly to select male embryos. Research from the US, where sex selection for 'social reasons' is legal, suggests that its most frequent use would be for 'family balancing', or to select a child of the opposite sex to those a couple may already have (1).

The UK's policy was reviewed in 2003, during which a public consultation showed that 80 percent of the respondents did not agree with sex selection for non-medical reasons. The Human Fertility and Embryology Authority (HFEA) subsequently decided to both maintain its original ban and extend it to the previously-unregulated area of sex selection by sperm sorting, despite growing evidence of couples travelling abroad for such services.

One such destination is Northern Cyprus - the only territory in Europe in which sex selection through PGD is not banned. Recently, two articles in the Daily Mail (2,3) claimed that a British fertility doctor had offered to send patients to a clinic in Northern Cyprus to choose the sex of their baby, via the UK Cypriot Fertility Association (UKCFA), in which he was a named shareholder. Although the Daily Mail does report the doctor is under investigation by his hospital, the grounds for the investigation have not been made clear. However, the case still raises serious legal and ethical concerns.

The UKCFA's website says it offers 'preparation' for clients seeking to go abroad for family balancing via PGD. It also says it offers anonymous egg donation from mostly Slavic women living or studying in Turkey or Cyprus through its partnership with the Cyprus IVF Centre (CIC) in Famagusta, Northern Cyprus. This service could allow couples wishing to avoid the new donor identity regulations in the UK to obtain eggs donated anonymously. The two doctors involved with UKCFA are both listed as 'NHS Consultants' (4) and are directors of a separate HFEA-accredited clinic combining NHS and private treatment (5).

None of this is illegal in the UK. Although social sex selection is illegal in the UK, the HFEA does not have the power to penalise UK clinics for recommending overseas partners for services which are not legal here. Moreover, HFEA guidelines allow an unlicensed clinic to carry out assessment, drug therapy in preparation for IVF, and even egg retrieval, so long as a licensed clinic handles embryology and embryo replacement. This is a protocol known as 'Transport IVF' used by any number of clinics, which could help clients defray the cost of overseas treatment.

Rather than re-opening the debate about sex selection itself, perhaps the pertinent questions in this case should be directed towards the appropriateness of an HFEA-licensed doctor drawing salary from a publicly-funded fertility clinic, while also having a financial interest in an association that helps patients travel outside the UK's legal jurisdiction for treatment. While any number of fertility specialists run private clinics in addition to their NHS work, it is this last aspect, and the possibility that some portions of the 'preparation' may be associated with publicly-funded, NHS-run services, which makes it a matter of public concern.

From a standpoint of medical ethics, sex selection via PGD for purely social reasons requires a healthy woman with no infertility problems to undergo IVF and to undergo the pain, expense and danger of egg collection and embryo transfer only for the purpose of choosing the baby's sex. While not commenting on the specific allegations, the above case leads us to imagine a possible scenario whereby an NHS doctor could recommend a potentially-harmful (but very lucrative) medical procedure for no medical benefit to either mother or child to be partly carried out by a private clinic in which he has a financial interest. In light of the current government's push towards devolving commissioning of services to consortiums of GPs who may choose from any available bidder, this should be a matter of concern even to those who have no opinion or interest in reproductive technology whatsoever.

Whatever the outcome of this particular case, it is not surprising that couples determined to use banned techniques will simply travel to a place where they are permitted. Unlike the legal complications of international surrogacy, where parents 'commissioning' a genetically-unrelated child frequently run into problems obtaining passports to bring the children home, it would be extremely difficult for any agency to prove that a woman's own pregnancy has been achieved through methods which, in this jurisdiction, would be unlawful.

Even if it were possible, few would advocate labelling some pregnancies as 'suspect' and allowing the circumstances by which a child was conceived to be investigated. While it might be possible to enforce the ban on anonymous donation by requiring parents of children born through reproductive procedures involving overseas clinics to provide either proof of genetic relationship, or documentation of donor identity according to UK law in order to register the birth, there is no palatable way to enforce penalties for illegal procedures on a woman carrying a genetically-related, sex-selected child.

This leads to the inevitable question over the effectiveness of banning certain procedures at all - and if, in fact, this is not bolstering morally-questionable practices elsewhere - if it should be lawful for British clinics to profit from partial involvement in procedures, which would be illegal if wholly carried out at home. This is the underlying problem when attempting to achieve any useful sort of regulation of reproductive technology: The market is not always right, but the more we allow the rhetoric of consumer choice to be applied to the creation of new people, the closer it comes to being an immutable force.