Introduction
Routine prenatal screening is an integral part of most modern healthcare systems. This kind of routine prenatal screening is typically the process where women are routinely offered screening tests for conditions such as aneuploidies as part of their antenatal care with an implicit recommendation that they accept these offers in most cases (Bennett
2001, pp. 463–464; Suter
2002, pp. 241–242; NICE
2008; Kater-Kuipers et al.
2018, p. 626). This is not mandatory screening but involves making these screening tests a routine part of antenatal care for all women accessing healthcare. Looking at healthcare systems in the western world and particularly, in Europe and the US which constitute the focus of this work, one can observe that despite the “national variations” (Vassy et al.
2014, p. 73) of screening strategies, prenatal screening and testing (PST)
1 technologies have been an indispensable part of prenatal care likely to be offered in a routine manner.
In particular, the clinical use of several types of PST technologies differs from time to time and among different jurisdictions and countries. For instance, PST can be part of a prenatal care system funded by the state or it might be accessible through different systems which are in place in private healthcare settings; The types of PST technologies and the way these become available to the public can differ not only among different countries but also from place to place in the same country; The reasons and criteria behind the choice of particular prenatal screening strategies may differ too (Boyd et al.
2010). Nevertheless, apart from these variations, the widespread use of PST technologies and their routine offer has been a common place for many years and in many countries with different healthcare systems.
Looking at the more recent past for instance, between 2001 and 2010 we encounter similar clinical practice guidelines in France, the UK, Australia, New Zealand, Canada and the US, recommending “that all pregnant women be offered prenatal screening” (Vassy et al.
2014, p. 69; Pioro et al.
2008, pp. 1027–1028; Tapon
2010, p. 114). Looking at Europe, in a study of 2004 which aimed “to ‘map’ the […] state of prenatal screening and diagnosis in 18 countries in Europe that are members of EUROCAT” (Boyd et al.
2008, p. 690), it was found that “the majority of countries had moved from solely offering older mothers a diagnostic test to having some form of Down’s syndrome screening in place, with over half having an official country-wide policy or recommendation for first or second-trimester screening” (Boyd et al.
2008, p. 693). Similar observations can be made by reading the equivalent special report of EUROCAT in 2010 (Boyd et al.
2010). What is more interesting is that the adoption of the wide use and routinised offer of some kind of PST technology is not encountered only in one type of system, such as a publicly funded system. For instance, in the UK prenatal screening and testing is part of a publicly funded healthcare system, France has adopted a reimbursement scheme (Vassy et al.
2014, p. 69) and in the US, although there is no unified guidance and PST technologies constitute private options “more determined by individual preference and health insurance” (Tapon
2010, p. 120), the idea of routine is well established (Hunt
2000; Staff reporter-genomeweb
2020).
But how did we get to this point where this screening has become an often unquestioned and integral part of healthcare and why might looking back at the origins of PST be important to the current ethical debate around routine PST?
The development, establishment and continued provision of PST is regularly characterised as being motivated by women’s demands. One typical example can be seen in a letter by two gynaecologists in the late 1980s where they emphasise that “[p]eople want to start now” (Harbers
2005, p. 241). The claim that the introduction of prenatal screening was motivated by women’s demands (Powledge
1979, p. 16; Löwy
2014, p. 293), and further justified in terms of choice empowerment, has been used by clinicians, the media and the scientific literature to support the introduction and expansion of PST since the 1970s (Shakespeare
2011, p. 38). However, while those promoting PST have claimed that these techniques empower women over reproductive choice, there has been a great deal of criticism of this claim too (Suter
2002; Bennett
2001; Lippman
1991; Tymstra
1991). Those who criticise it, argue that the reality of PST is that its offer is one that is very difficult to refuse (Schmitz et al.
2009; Wahlberg and Gammeltoft
2018, p. 78), and where prenatal screening is part of routine prenatal care, deliberate choice is limited (Suter
2002, pp. 254–255).
Recent developments, such as the introduction of Non-Invasive Prenatal Testing (NIPT) into existing routine screening, have fanned the flames of a longstanding debate concerning the challenges that routine prenatal screening presents to women’s autonomous choice (Kater-Kuipers et al.
2018; Deans et al.
2013; van den Heuvel et al.
2010). The example of NIPT shows that, notwithstanding continuing attempts to improve the quality of women’s choices when it comes to PST (Nuffield Council on Bioethics
1993,
2017,
2018, Gregg et al.
2013, p. 396; Benn et al.
2013, p. 623; Harcombe and Armstrong
2008, pp. 579–581), the concerns persist (Hyacinth
2017; Brownsword and Wale
2018; Vanstone et al.
2018; Cernat et al.
2019). It has been argued that the problem of the quality of consent given during PST is one that ultimately may not be able to be solved due to a fundamental incompatibility between women’s choices and routine PST (Bennett
2007). It is this claim that this paper aims to explore. However, instead of exploring it in the context of current PST, this paper takes a different approach. This different approach pertains to an exploration of the history of PST in order to gain an understanding of the root causes of why the concerns about the choice to engage in screening for disability persist despite well-meaning attempts to mitigate these concerns.
As such, this paper provides a detailed overview of the historical events that influenced the emergence, development and establishment of PST. At this point I should clarify that given that the wide diffusion of PST use and the involvement of some kind of routine offer concern a variety of healthcare systems, in this work I do not examine the case of the routinisation of PST in a particular healthcare system. Also, this work is not a critique of the various reasons and interests (e.g. resource allocation, cost effectiveness, disability care, access to abortion, other aims) that may justify or deny the establishment of a routine PST system in a healthcare system (Vassy et al.
2014, p. 68; Gilbert et al.
2001; Boyd et al.
2010); I do not examine the routinisation of PST as a ‘problem’ that needs to be solved. Through a historical review I attempted to find out the extent to which the wide and routine use of PST was based on the aim to empower women’s reproductive choice. Therefore, this historical account provides evidence that women’s choice was not a primary motivator of PST development and expansion. In fact, there is strong evidence to infer that those who championed the early use of these technologies were motivated by further scientific discovery, eugenic goals and financial profit rather than women’s choice and empowerment. Although this evidence does not offer a solution to this longstanding ethical debate, it is important that it is acknowledged as by understanding what motivated the development of PST we can understand why it has been difficult to improve the quality of women’s consent in this context. By this, I do not mean to say that routine PST should necessarily be abandoned. Instead, I am arguing that, given the historical foundations of PST it will continue to be extremely difficult to base the justification of it clearly on women’s choice and empowerment. Ultimately, I suggest that if we really do value women’s choice and empowerment, then understanding the origins of PST will enable us to develop policies that really do put women’s choices at the centre of these endeavours.
The role of a historical review in the debate around the ethics of women’s reproductive choices within routine PST
A number of different time periods in the nineteenth century have been touted as the ‘birth’ of modern prenatal screening. For instance, it has been argued that the introduction of amniocentesis in the 1950s signaled the beginning of the use of prenatal screening technologies (Ettorre
2001, p. 38). Similarly, the 1960s has been characterised as the decade which gave birth to the contemporary prenatal diagnosis (Löwy
2017, p. 43). The 1970s has also been identified as crucial in the development of PST as the point where medical innovations such as amniocentesis, the study of human chromosomes and obstetrical ultrasound, were first available alongside the legalisation of abortion (Löwy
2014, p. 290). Whether we hold that modern PST was ‘born’ in the 1950s, 1960s or 1970s, these different claims about the origin of PST all have some common ground. What these claims have to unite them is that they argue that, since the end of the 1950s, the clinical use of PST began and expanded as a response to women’s demand and it was morally justified as a way to empower women and their reproductive choices (Seavilleklein
2009, p. 73; Vassy
2006, p. 2043; Cowan
1993, pp. 10–17).
Respect for autonomy and the empowering of individuals to make choices about their lives has been a central principle of modern medical ethics since around the 1970s (Saad
2018, p. 125; Morley and Floridi
2019, p. 1160) and as a result, notions of medical coercion have become not just unpopular, but in most instances, unjustifiable. As a result, it is easy to see why basing the justification of PST on respecting and enhancing autonomy might have a strong appeal. According to the autonomy oriented approach “access to prenatal testing supports and promotes women’s informed choices, empowering them to manage their pregnancies—and hence their lives—in ways that align with their preferences and values” (Ravitsky
2017, p. S34). Similarly, Stapleton argues that “prenatal screening is […] aimed at empowering couples with sufficient capabilities for making meaningful reproductive choices” (Stapleton
2017, pp. 203–204). Moreover, it has been acknowledged that the major aim of prenatal screening is the promotion of informed choices (Williams et al.
2002, p. 743; John
2015) or, in other words, the major aim of offering prenatal screening is to enable “meaningful reproductive choices” (De Jong et al.
2011, p. 657)
. This approach is reflected in the language used to justify the use PST, where it is invariably suggested that PST promotes, enables, empowers or, similarly, strengthens, facilitates, increases or enhances women’s reproductive choices. In essence, the claim is that the substantial aim of using these technologies is to uphold the idea of reproductive autonomy by empowering women-in terms of enabling and liberating them-to make their own authentic choices about reproduction.
Considering that this aim has morally justified the introduction and wide use of PST technologies in theory, here I examine the extent to which this justification has been in fact the foundation of the introduction and the wide use of PST. In other words, by looking at the historical past of these technologies, I intend to find out whether their introduction and wide use was a response to women’s demands and truly served the substantial meaning of the idea of empowering women’s reproductive choice.
In particular, I examine the period of the emergence of prenatal diagnosis techniques, the influential role of eugenics in their development, the historical events that influenced the trajectory of PST after the 1960s, and the role that governmental, scientific and clinical intentions have played towards the expansion of PST use. The reason why I look to history to put forward a moral argument is reflected in the following quote by Montgomery:
Bioethics governance should provide a process for truth and reconciliation in relation to past failures […] [a] work which requires detailed documentary analysis, judgments on personal responsibility and liability, and historical insight to avoid anachronistic assessments (
2017, pp. S25–S26).
Following Montgomery’s approach, in the subsequent sections, I consider the many attempts to reconcile women’s autonomy and empowerment with prenatal screening. I argue that by identifying the actual rationales and goals that motivated PST, that often have very little to do with women’s choice, we can begin to better understand why it has been so difficult to reconcile women’s choice with PST. By understanding past failures to safeguard reproductive choice within routine PST plans, I attempt to identify the root causes of such failures. In particular, I show that given the lack of consideration of women’s choices in the foundations, the development, the introduction and the subsequent routinisation of PST, it is not surprising that the resulting practice continues to resist compatibility with women’s choice and empowerment. This observation is a lesson to be learnt from the past which helps in the understanding of perpetual challenges when it comes to women’s autonomous choices about prenatal screening and testing. Hence, the historical overview that follows could be considered as a contribution to “the process for truth and reconciliation in relation to past failures” (Montgomery
2017, pp. S25–S26) to safeguard and serve the essential meaning of women’s choice empowerment in the case of PST. By understanding the historical foundations of PST we can more effectively assess how to reconcile women’s reproductive autonomy with routine prenatal screening.
The dawning of prenatal diagnosis techniques until the 1960s: science and eugenics were in action while women’s choice was on mute
In the previous section, I noted that there is a common claim encountered in the literature suggesting that PST was developed and introduced in response to women’s demand. Although below I challenge this claim, before we move onto this challenge let us assume for now that this claim is true. This leaves us with a reasonable question: if women’s requests for access to prenatal diagnostic technologies initiated these technologies’ introduction and expansion, did women’s requests initiate the scientific processes for PST technological invention too? The historical analysis that follows provides evidence that this technological invention was the result of many years of scientific research; whereas this research was often supported and promoted by eugenics, a women’s demand and the idea of women’s choice were absent.
Scientific trajectory
Looking at the historical literature, we learn that since before the 1940s there had been research and scientific interest in prenatal diagnosis (Suter
2002, p. 234; Löwy
2017, p. 43; Casper
1998, pp. 30–72). For example in the 1930s, we encounter the famous study by Dr. Penrose, who had observed the significant relation between increasing maternal age and birth of Down syndrome (DS) offspring (Penrose
1938; Russo and Blakemore
2014) which set the basis for the development of ‘the primary method to identify women at risk for aneuploidy’ (Russo and Blakemore
2014, p. 183).
In particular, there is evidence about the technology of prenatal diagnosis suggesting that this did not occur as a response to women’s demand. It mostly constituted the development of clinical practice, namely the amniotic tap, which, since the end of the nineteenth century, had been used for entirely different obstetric purposes than prenatal diagnosis (Cowan
2008, pp. 74–75). Neither did this technology develop as a response to a women’s demand for prenatal diagnosis of aneuploidies, such as DS, although later, DS became the focus of massive PST strategies allegedly aiming to satisfy women’s demand. In fact, the successful efforts since the 1940s to understand the causes of Rh disease (a condition where the expectant mother’s antibodies damage the fetuses red blood cells causing developmental impairments) resulted in Bevis’ confirmation that “in pregnancies at risk for Rh disease, the extent of damage to the fetus could be estimated by optical examination of amniotic fluid obtained by amniotic tap before birth” (Cowan
2008, p. 76). Eventually, in the late 1950s, after the observation that the amniotic tap could be used as a diagnostic tool, the technique was renamed to amniocentesis, the application of which would aim for prenatal diagnosis, an entirely different goal than the technique’s primary goal (Cowan
2008, pp. 76–78).
Effectively, there is evidence that the obstetric world was experimenting with prenatal diagnosis alongside the needs of clinical practice. However, there is not clear evidence of these developments being motivated by women’s demands. It seems that prenatal diagnostic technology was a fortunate finding rather than a response to a demand. Yet, while there is no indication of women’s demand during this period, the invention of PST technologies and their subsequent extensive use cannot be attributed to scientific interest and curiosity or coincidence only. In this period there is significant evidence about the influence of eugenics, although the movement’s decline had begun.
Eugenics until the 1960s
The rise and peak of the modern eugenics movement, “a form of social engineering than a science” (Suter
2002, p. 234), came in the late nineteenth and early twentieth century (Kerr and Shakespeare
2002, pp. 13–19). In Britain, Mazumdar informs us that “[t]he eugenic problematic had grown out of the union of a middle-class activism focused upon the pauper class, with a biological view of human failings” (
1992, p. 258). The decline of eugenics’ popularity began in the 1930s and intensified after the Second World War’s Nazi atrocities. This change has also been attributed to this period’s economic and political changes (Kerr and Shakespeare
2002, p. 62); “In the egalitarian world of welfare and economic growth, the pauper class had disappeared. A class analysis no longer carried weight, and with the loss of the class dimension the eugenic problematic could no longer survive in its original form” (Mazumdar
1992, p. 258). A third reason for the movement’s decline was the realisation that eugenics’ rationale about human deficiencies was scientifically wrong (Kerr and Shakespeare
2002, p. 64). During the eugenics decline period, scientific research, such as the famous study by Penrose, on maternal age and increased chance of Down’s syndrome (Penrose
1938), undermined the more extreme aspects of eugenics narrative and many scientists including Penrose had been criticising the movement’s concept (Kerr and Shakespeare
2002, p. 64).
Nevertheless, Penrose’s famous study was partly funded by the Eugenics Society and Penrose himself, although he disagreed with eugenics, was motivated by the “eugenic problematic” (Mazumdar
1992, p. 258 in Kerr and Shakespeare
2002, p. 63). Generally, in the 1930s and 1940s, the majority of human genetics sponsors were motivated by eugenics. Apparently, despite the decline, eugenics remained active in the 1940s when we also encounter a new move towards reform eugenics “aiming to achieve the best children possible” (Kerr and Shakespeare
2002, p. 65). This move remained in the 1950s when links between human genetics and eugenics were still encountered. For example, Kerr and Shakespeare note that during the 1950s “five out of six presidents of the American Society of Human Genetics were also members of the Eugenics Society’s board of directors,” as well as, that “genetic clinics were often […] eugenically inspired” and “various important geneticists also applauded the eugenic significance of genetic clinics” (
2002, p. 67).
Thus, evidently, amniocentesis, which was first developed in the 1950s (Suter
2002, p. 235) and recognised as a prenatal diagnostic technique by the end of the same decade (Cowan
2008, p. 78), emerged in the same period that eugenics rhetoric and influence were still active. Consequently, it would be an oversight to claim that prenatal diagnosis that came to the forefront this period was left uninfluenced by eugenics ideology, even if influence was exerted in a more muted and implicit way (Kerr and Shakespeare
2002, p. 77).
A particular example proving that such influence existed is the one of a Danish Act of Parliament which in 1956 legalised “eugenic” abortion after prenatal diagnosis (Cowan
2008, pp. 93–94; Löwy
2014, p. 293). Also, evidence about the influential role of eugenics can be found in the years that followed. In the 1960s and until the 1970s genetic technological advances which became useful for prenatal testing (Suter
2002, p. 235) were accompanied by eugenics motivations. From the literature we learn that during this period the discovery of DNA inspired eugenic sympathies among geneticists (Kerr and Shakespeare
2002, p. 68) and “throughout the 1960s, most of the leading figures in medical genetics […] bluntly described their work as a form of ‘eugenics’” (Paul
1998, p. 137). In the same period we also encounter a controversial discussion on the idea of a “biological revolution” regarding the creation of a “super-race” while famous geneticists were adopting from less extreme up to absurdly extreme eugenics stands (Kerr and Shakespeare
2002, pp. 69–70). Particularly, regarding prenatal diagnosis, it is interesting to consider Glanville William’s statement in
1964:
[I]t is now quite standard practice in a number of hospitals to terminate pregnancy on eugenic grounds where the woman has caught German measles (rubella) during the first trimester […] because there is then grave danger that the child will suffer from deafness, blindness, heart disease or mental deficiency. Some obstetric surgeons operate purely and simply because of the danger of the child being imperfect… (p. 563)
Therefore, unequivocally, the influence of eugenics was present before and in the beginning of the wide use of prenatal screening technology. By looking into the relevant historical evidence until the 1960s, one discovers that the eugenics movement, either explicitly or implicitly, has played a substantial role in the initiation of prenatal diagnosis techniques’ development alongside scientific interest, curiosity and coincidence and in the absence of a women’s request or the idea of women’s choice empowerment as motivation. This is an important observation because it arguably leads to the conclusion that the scientific research that led to the invention of PST techniques did not aim to empower women’s reproductive choice, instead, considering the involvement of eugenics, in many occasions the incentives for such scientific research were, at least to many, morally questionable.
This does not necessarily suggest that PST technology which resulted from this kind of research is inherently morally problematic. Neither does it suggest that the introduction and the subsequent wide expansion of PST techniques was motivate exclusively by eugenics simply because eugenic ideology continued to be influential. However, the fact that there have been continued ethical concerns regarding women’s choices during the wide use of PST suggests that women’s choice empowerment may not have received the required attention in the development of PST strategies. Following this thought, below I examine whether the idea of women’s choice empowerment was the purpose for the wide and routine use of PST techniques or it was used, purposely to an extent, to satisfy different aims.
Why the current routine offering of PST does not provide adequate protection of women’s choice
Let us now see what the contribution of this historical review can be in solving current and enduring ethical problems and allaying concerns related to women’s reproductive choice limitations when it comes to routine PST plans. Ultimately, with this work I stress the necessity to ‘look back to move forward’. In other words, “we do not just start off with a set of axioms and apply them to particular cases, we also try to learn from experience” (Glover
1998). Respectively, before the introduction and clinical use of new and future PST technologies in the usual routine manner in the name of the axiom of reproductive choice, it is worthwhile exploring past actions, events and motivations which contributed to the consolidation of such routine. Having done this in this paper, I observed that the problem is much deeper and mostly related to the foundation of the establishment of routine and wide use of PST and not only to particular mistakes occurring within this establishment as a result of human faulty perception and action.
Essentially, I argue that the problem is detected in the general perception, which has been taken for granted, that the wide and routine offer of PST is a ‘shelter’ for women’s choice. By analogy, imagine for a moment that the widespread and routine use of PST techniques can be represented by a building which aims to be a shelter for women’s reproductive choice. However, this shelter is not built on foundations that are compatible with women’s reproductive choice. As a result, the building cracks and weakens whatever remedies are tried. Effectively, this analogy shows that trying to support women’s reproductive choices using practices based on unrelated principles of eugenics and scientific advancement, will cause persisting problems in reconciling these two aims.
Beginning with the invention and tracing the development of PST technologies up to their wide and subsequent routine use which reaches today, this historical review has shown that these technologies’ trajectory and their final consolidation as routine part of prenatal care mostly resulted from a combination of different intentions, motivations, influences, and coincidental events and for purposes other than women’s choice empowerment. In my analogy, this combination constitutes the construction specifications for the foundation of ‘the widespread and routine use of PST’. Nevertheless, whereas the foundation meets its construction specifications, these specifications did not prescribe the operation of the building as a shelter capable to provide adequate protection to women’s choice. Effectively, what is meant by this analogy is that whereas the wide and routine use of PST directly satisfied the purposes for which it was built, the idea of women’s choice was instead fitted within a system that was never created for this purpose. Although women’s choice seems to fit in the supposed shelter, the wears and tears on the building, essentially, the perpetuation of concerns around the quality of women’s choice when it comes to PST, shows that women’s autonomy is not well protected in there.
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