Cosmetic Reproductive Services and Professional Integrity

John Robertson's article primarily addresses whether state prohibitions on nonmedical uses of preconception sex selection (PSS; Robertson uses PGS, "preconception gender selection") would be justified and constitutionally permissible. However, he concludes that, "[u]ltimately, the use of PGS and other reprogenetic procedures will depend on how well they serve ethical norms of care and concern for children." Clinicians will play a pivotal role in determining the availability of PSS. Should physicians and other health professionals offer PSS for nonmedical reasons? Is this a service that falls within the realm of legitimate health care?

Definitions of health and health care are contested and imprecise. Few would argue, however, that PSS to satisfy preferences for gender variety or the gender of firstborn children falls within the definition of health care. The attempt to include PSS as simply another infertility service is strained. Helping people to have children is different from helping people to have a particular kind of child. Because infertility interferes with a basic life activity, one can reasonably argue that it merits the attention of health professionals. The inability to have a child of a particular gender presents no such interference.

Rather than being a form of health care, PSS for nonmedical reasons is like breast augmentation and other forms of cosmetic surgery. Like PSS,people strongly de-sire cosmetic surgery based on a hope that the interven-tion will enhance their psychological and social well- being. Neverthe- less, health insurers exclude cosmetic surgery fromcoverage, and this exclusion is rarely criticized.

Cosmetic surgery is regarded more as a consumer good than as a medical treatment. It is heavily promoted through advertising, which typically inflates the benefits surgical interventions will bring. Information on risks and "failure rates" is often downplayed. The same pattern is evident with PSS techniques that are currently offered.

The question is whether supplying such services is an appropriate activity for health professionals. It is difficult to distinguish between clinicians furnishing such services and hairdressers or travel agents meeting their clients' demands. In providing cosmetic surgery and PSS, clinicians act as workers in a service industry that caters to consumer preferences.

Although I applaud the move away from the "Doctor knows best" tradition, I question whether medicine should be so strongly influenced by consumer preferences. Society trusts physicians and other health professionals to define and set standards for their work. Society also subsidizes the training and infrastructure enabling them to practice their professions. In turn, clinicians assume some responsibility to use their skills and resources to meet the legitimate health needs of society.

Even if it were found to be safe and reasonably effective, PSS for nonmedical reasons would be far from risk-free. It would reinforce parental expectations that could be damaging to children of both the "right" and "wrong" genders. It would reinforce restrictive gender stereotypes. It would re- inforce the same cultural beliefs that lead to female infanticide and neglect in other nations. It would reinforce the conviction that one gender would be superior and one inferior for a particular family.

Clinicians and infertility programs should give careful thought to the issues raised by offering PSS as a medical service. They ought to consider whether this is an appropriate use of their skills and resources in light of the many urgent health needs commanding their attention. They ought to consider whether they want to reinforce the attitudes and beliefs associated with gender preferences. They ought to consider the long-term effects that performing such a service could have on public respect for and trust of the medical profession. In the long run, medicine and society will be better served if professionals exclude cosmetic PSS from the activities they perform.