The potential ethical implications of SST+ stem from the anticipated changes, broadly classified in three clusters, namely: the demedicalization of the sex selection practice, the transformation of SST to a direct-to-consumer technology and the move of SST to an open market. The clusters represent overarching themes across specific ethical considerations, identified through literature analysis. The themes often overlap and certain ethical concerns within them could fit multiple categories. The purpose of the cluster scheme below is to allow a somewhat structured navigation of the ways in which SST+ can mediate the moral landscape.
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1.
Demedicalization of the Sex Selection Practice
Shahvisi (2018, 135) suggests that “The authority and infrastructure of healthcare should not be used to facilitate practices [of SST] which play upon misunderstandings and perpetual injustice.” Yet what happens when SST withdraws from the medical domain? A major difference of SST+ in relation to the existing techniques is the potential move from the clinical to the home setting. Currently, sex selection predominantly implies PGD/IVF, which requires time, financial investment, logistical planning, invasive physical interventions and often results in psychological burden to the prospective parents (Franklin and Roberts 2006). SST+ could demedicalize the practice of sex selection by offering an affordable, non-invasive technique for use at home.
Performing sex selection at home can reintroduce elements of the value of naturalness in pregnancy-related practices, facilitated by technology. It can also enhance the value of privacy in the family planning practice, regarding not only the privacy of decision-making, but also concerning the bodily privacy, by allowing prospective parents to have the procedure at home, without an involvement of the third party. As such, SST+ could facilitate the value of naturalness in assisted reproduction and enhance the procreative liberties and autonomy of the prospective parents.
Interestingly, SST+ could increase the role and importance of men in the reproductive process. Some argue that ART increased the autonomy and procreative rights of the prospective mother and diminished the significance of a father in parenting, contributing to “the end of men” (Rosin 2012). SST+, on the contrary, could highlight the significance of the prospective father by giving him a primary role in the beginning of the conception journey. SST+ requires proactive decision-making from a father-to-be by asking whether he wants to determine the sex of his future child (hopefully in discussion with a prospective mother); and if so, demands an active contribution. Sexing of a child is one of the key practices in transition to parenthood and attaining the moral status and responsibility of parents (Schadler 2014). By placing the sexing process ahead of obtaining evidence about pregnancy and the health status of the embryo, SST+ allows prospective parents to transition to parenthood and assume parental roles and responsibilities much earlier. By placing the prospective father in charge of the sexing process, SST+ uplifts his role and importance in decision-making on having children. The increase in paternal role can mediate the parental relations and power balance in different ways, from levelling the responsibilities and participation in childbearing to fostering patriarchal authority and exploiting the power of required male role with SST+.
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SST+ as a Direct-to-Consumer Technology
Framing SST+ as an on-demand direct-to-consumer technology assumes the status of prospective parents as customers, not as patients, continuing the trend started by ART. SST+ as an open market technology, directly available to prospective parents without medical oversight, could further exacerbate the shift from patients to customers, as well as reaffirm the commodification of reproduction. SST+ would nearly eliminate the need for medical assistance, in parallel offering the pre-pregnancy sexing as a new norm in reproduction, available at a local drugstore at low cost. SST+ appears here as a facilitator to realize parental choices. The history of PGD indicates that assuming a customer status provides an enhanced feeling of entitlement to choice and increases the perception of control over one’s destiny (Franklin and Roberts 2006). Such an increased sense of autonomy with the patient-to-customer shift in SST+ could mediate parental perceptions and expectations of themselves and their child.
SST+ as a direct-to-consumer technology could further intensify an existing fate vs. choice discussion in assisted reproduction. In order to determine the moral status of sex selection practice, its opponents often appeal to parental virtues (Sandel 2004; McDougall 2005). Assuming that unpredictability is one of the facts of nature, to enable a child’s flourishing, a good parent needs to possess a virtue of acceptance. Following this logic, SST+ would entice a parent to perform a wrong parental action because selecting a sex of a child means violating the virtue of acceptance. Hence, SST+ would be morally wrong. Yet if we look at the technology through the lens of mediation approach, we seem to take for granted an assumption that “unpredictability […] is an intrinsic feature of human reproduction” (McDougall 2005, 603). Merely an existence of SST challenges that assumption. The sex of a baby is now available for choice. Whether a couple chooses to select a sex of their child or not, is up to them, but it has escaped the domain of fate and is now a profoundly technologically mediated option. By significantly simplifying the process of sex selection, SST+ can decrease the factor of unpredictability in childbearing, creating a threshold to the unconditional acceptance, traditionally associated with good parenthood.
Transforming SST into a direct-to-consumer low cost and at-home technology may invite public curiosity, feed into the existing interest on sex selection and facilitate acceptability of the practice. Moreover, a change in the material setting of SST+ may invite prospective parents who never considered the possibility of sex selection to do so. After all, if the technology promises to be affordable, safe and easy to use, it could invite the prospective parents to answer the question why not to use SST+. This may provide additional stress and anxiety in justifying private reproductive choices. Therefore, while SST+ may increase parental autonomy and reproductive liberty, the “Why not?” reconfiguration may simultaneously decrease them, creating a sense of pressure to justify private choices.
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The Move of the SST+ to an Open Market
The transfer of SST from the medical to the open market domain can affect the way people approach the subject of responsibility regarding sex selection. The questions of responsibility related to SST+ are multidimensional and involve different actors. Judging from historical and current cases of ART, the concerned stakeholders in the case of SST+ include at least prospective parents, the industry developing this technology and bringing it to the market, and medical professionals.
One could argue that the “Why not?” attitude that SST+ could facilitate denigrates the responsibility of prospective parents by commodifying children and inciting consumerism in the childbearing decisions. I would argue that SST+ mediates the value of responsibility by simultaneously bringing its multiple dimensions to the fore: while it may invite a simplified perception of complex decision-making regarding the childbearing (as suggested above), SST+ also brings about a new responsibility to recognize the inherent uncertainty that accompanies parental choices regarding sex selection. Prospective parents routinely face responsibility for their reproductive choices, when choosing to conceive a child or facing an unwanted pregnancy, deliberating on how to manage pregnancy, how to raise a child, etc. However, SST+ confronts prospective parents with an additional responsibility, the one that comes with using the technology.
Prospective parents might rejoice at the opportunity to fulfil their preferences and, some may say, a natural right to decide on the future of their children. While SST+ highlights the option to choose, the approach of technological mediation helps to reveal what the technology foreshadows. If one frames SST+ as a manifestation of parental rights and liberties, as the right to choose, this would also entail a duty, a responsibility to accept the limitations of that choice. While SST+ allows parents to select the biological characteristics typical to one sex or the other, it does not change the inherent uncertainty regarding the sociocultural inclinations, identifications, and preferences of the child. The way prospective parents take up this responsibility depends on their personal histories and dynamic sociocultural contexts, which may result in multiple scenarios of parent–child relations depending on the degree to which parents enforce their perceptions and expectations on the child. In parallel, public discussion forums, medical practitioners, and government Technology Assessment efforts can help prospective parents to make informed decisions about the use/non-use of SST+ and its consequences by helping to scrutinize the technological promises and to recognize and account for the ethical implications of this technology.
The industry and particularly its marketing branches have a responsibility to ensure that prospective SST+ users make informed choices about the use (or non-use) of their product. Marketing informs the mindset and facilitates the decisions of prospective customers, thus influencing the way people appropriate the object of advertisement. SST+ is not a neutral diagnostic tool but a technological mediator that contributes to shaping the choices of people about the future of their offspring. With regard to SST+, it is important to deliver a balanced message, emotionally and scientifically, about what SST+ can and cannot do. For instance, it would be misleading to foster a connection in the minds of people between choosing the sex of the sperm and having a successful pregnancy; or about choosing the biological sex of a child and the gender identity they develop later in life. The complicated relationship between sex and gender has received a considerable amount of scholarly attention (c.f. Goffman 1979; Eckert 2017). In particular, Goffman (1979) has exposed and analysed the influence of the mass media and advertising on the sex/gender discussion and public perception of gender roles and identities. SST+, with only two options to choose from and the possible “Why not?” attitude, can further challenge the sex–gender discussion in society. Promoting SST+ with direct appeal to preferred gender characteristics could further inscribe public stereotypes about the direct correlation of sex and gender and reduce the visibility of other possible gender identities.
The stakeholders who develop technology and put it to market always have responsibility towards their consumers and the public at large, at least regarding the safety, security, and other “hard impacts” regarding the direct use of their product. As history shows, an open market setting under a legislative regime that cannot keep up with the pace of technological development offers little incentive to private companies for ethical self-reflection beyond the legally-mandated requirements. However, recent developments in the direct-to-consumer genetic testing business indicate that such efforts can arise within the industry itself in an effort to innovate responsibly and address ethical concerns. Addressing the consumer boom with genetic testing technologies, private genetic testing companies collaborated with a public think-tank, including academics, legal practitioners, and advocacy groups, to produce self-imposed industry-wide ethical guidelines (Future of privacy forum 2018). The impact and effectiveness of these guidelines have yet to be ascertained but, “While no policy could ever eradicate risks for consumers who agreed to give their DNA, the industry guidelines are attempting to address some of the biggest fears” (Brown 2018, ¶25). However impactful these guidelines might be, they indicate an acknowledgment on behalf of the industry of their responsibilities beyond the direct use of their product and offer an example for other direct-to-consumer diagnostic tools, such as SST+.
Finally, it is easy to assume that if SST+ moves from a medical to a private domain, it would eliminate the involvement of the medical professionals. Drawing again on the example of direct-to-consumer genetic testing, the transition may not obliterate the role and responsibility of medical professionals (Lovett Rockwell 2017). Lack of market oversight and accountability may exploit the hopes and fears of prospective parents, leading them back to the doctor’s office to help navigate the complexities of the selection and conception process (emotionally and practically). This could bring medical context back into the equation, raising questions regarding physicians’ responsibilities and burden on the scarce resources when the original cause is not medically justified.