RBMOnline Vol 10 Supp 1 2005 97 101 Reproductive BioMedicine Online www rbmonline com Article 1626 on web 31 January 2005 Ethics and the future of preimplantation genetic diagnosis John A Robertson holds the Vinson and Elkins Chair at The University of Texas School of Law at Austin USA He is the author of Children of Choice Freedom and the New Reproductive Technologies 1994 and numerous articles on reproductive rights genetics organ transplantation human experimentation and other issues in bioethics He serves currently as Chair of the Ethics Committee of the American Society for Reproductive Medicine John A Robertson University of Texas Law School 727 East Dean Keeton Street Austin TX 78705 USA Correspondence e mail jrobertson mail law utexas edu Abstract The future growth of preimplantation genetic diagnosis PGD will depend on refinements in genetic knowledge and genetic analysis of blastomeres Equally important however is an acceptance of the ethical legitimacy of parents using technologies to select genetic traits of offspring Objections based on embryo status the giftedness of reproduction eugenics and protecting the child s welfare are not convincing grounds to oppose most uses of PGD Whether PGD should be accepted for new medical or non medical uses should depend upon a careful assessment of the proposed use s importance to the person or couple requesting it and the harmful effects if any which it might cause Such an approach leads to the conclusion that most new medical uses of PGD and some non medical uses should be permitted Keywords embryos deafness eugenics preimplantation genetic diagnosis regulation sex selection Introduction The use of preimplantation genetic diagnosis PGD is rapidly growing and in coming years is likely to continue to grow PGD is now used primarily for aneuploidy screening to identify chromosomal translocations and to avoid the transfer of embryos with autosomal and X linked Mendelian early onset diseases International Working Group on Preimplantation Genetics 2001 In addition some persons seek PGD in order to have an HLA matched child to provide haematopoietic stem cells for an existing child and for non medical gender selection Some commentators predict that PGD will eventually be used to screen for other non medical traits as well This paper discusses technical and ethical factors that will affect future applications of the technique and provides a methodology for resolving ethical conflicts about new indications for PGD It then illustrates that methodology by examining one medical and two non medical extensions of PGD Technical and economic factors The scope of future application of PGD depends on many factors both technical and ethical Unless the technique works safely and effectively at a reasonable cost it will play but a small role in the reproductive plans of most individuals The IVF on which it depends must be safe effective and within the financial means of persons who would benefit from it In addition the personnel and resources for highly accurate PGD must also be available While many IVF clinics are equipped to remove the individual cells needed for chromosomal or genetic analysis fewer of them will have the expertise to do chromosomal and genetic analysis to the highest levels of accuracy necessary for wide dissemination of PGD A system of reference centres organized on a regional or even national basis may have to be developed to provide the quick and accurate analysis needed A second important technical factor is the state of genetic and genomic knowledge The most prevalent single gene disorders have now been identified and PGD is available for most of them With most of the low hanging genetic fruit now having been picked scientists will have a harder time identifying other single gene mutations for diseases and non medical traits that are of potential interest to future parents particularly since developmental and environmental factors may play a more important role than single genes or clusters of genes in causing the chronic diseases of widest concern Similarly few of the non medical traits of apparent interest to prospective parents e g intelligence height beauty memory longevity etc are Ethics Law and Moral Philosophy of Reproductive Biomedicine Vol 1 No 1 March 2005 2005 Reproductive Healthcare Limited Published by Reproductive Healthcare Limited 97 Ethics Ethics and the future of PGD JA Robertson likely to correlate with mutations in a few genes or loci that can be easily tested by PGD The use of microarrays which allow transcripts of thousands of genes to be tested at one time could expand the reach of PGD However unless genes predisposing to conditions or traits of interest to prospective parents are expressed at the blastomere stage microarray tests will be of little use Even if they can identify single nucleotide polymorphisms SNPs associated with those traits SNP tests of blastomeres might not provide specific enough information for selecting among the relatively few embryos available for testing that are also likely to implant in the uterus On the other hand a rapid growth in genomic knowledge and advances in microarray technology could lead to much wider use of PGD for both fertile and infertile couples A third factor limiting future use of PGD is its cost IVF itself is expensive and adding on PGD will increase that cost Persons considering reproduction will incur those costs only when the burdens of infertility the risks of genetic disease or the desire for a particular trait in a child are great enough to justify the financial and physical burdens of the process While an argument can be made for national health insurance coverage of basic IVF for infertility as the UK s NHS has recently done the case for covering IVF and PGD is a more difficult one Ashcroft 2003 It is strongest when a strong health need for PGD exists for example to have a matched sibling donor for an existing sick child or to avoid a child with a severe genetic disease and weakest when sought for nonmedical and susceptibility purposes Because many other projected uses of PGD will not warrant insurance coverage e g PGD for gender variety those uses will be available only for those with the money to pay for it Economic factors are thus likely to be a strong limiting factor in the future spread of PGD The ethical controversy over PGD In addition to technical and economic factors a key factor in determining future use of PGD will be the ethical and