Samaritans at the gates: sex determination and the ethics of informational gatekeeping

By Anson Fehross

It is common in Australia to provide fetal sex information to prospective parents during routine ultrasounds.[i] Studies across the world similarly indicate a high level of support for this practice by prospective parents.[ii] This practise has enabled new traditions around pregnancy, Square cake with green American football decoration on one half and pink ballet theme on the otherfrom preparing siblings for the arrival of a brother or sister, to the ‘gender reveal party’, in which the results of a sonogram are announced to family and friends bearing gendered gifts.[iii] It is intuitively plausible, furthermore, that the provision of information to patients improves their autonomy. After all, access to information allows individuals to make informed choices about their own lives.[iv]

Tamara Browne has recently provided a compelling case against this appeal to patient autonomy, concluding that medical professionals should withhold sex information because of its propensity to undermine autonomy.[v] Her argument proceeds as follows.

Browne notes first that there is a high likelihood of patients misinterpreting information about fetal sex. Due to widespread belief in gender essentialism, parents routinely mistake information about sex as information about gender. The importance of sex information to parents is symptomatic of this: presumably they are not merely interested in what genitalia or chromosomes the fetus possesses. Rather, they consider sex information to be information about the gender traits of the future child. The problem is that sex is not gender and nor does sex determine gender: gender refers to socially constructed and mediated traits, rather than biological features of the fetus.[vi]  So, if a parent were to take information that their fetus is female as indicating that, say, the child will be more emotional than rational, or interested in dolls rather than cars, they would be erroneously conflating sex with gender and subscribing to gender essentialism.

Browne’s second point is that acting on this misinterpretation is against patients’ interests. The ultimate goal of parents is to have certain kinds of childrearing experiences: fathers expect that sons will share their interest in sport or fishing, women imagine daughters will take to caregiving and shopping.[vii] The parental interest in these activities is, of course, not the problem—the problem is that conflating sex with gender leads parents to act on the erroneous belief that these childrearing experiences are contingent upon having a child of the appropriate gender. This is clearly false, as girls are just as capable as boys at outdoor activities, and boys are equally capable of valuing caregiving and shopping. More worrying still, belief in this kind of gender essentialism is self-fulfilling, as future childrearing experiences are ruled out based on fetal sex. This means, by providing sex information, the medical profession undermines parental autonomy, as parents understand sex information as foreclosing upon on the exact types of ultimate goals the parents had in mind. Browne therefore argues in favour of prohibiting the provision of sex information for any non-medical reason.

Browne’s argument is thus an instance of what I call informational gatekeeping. Informational gatekeeping occurs whenever a medical professional is justified in withholding information from a patient because they will misunderstand the information and, crucially, acting on this misunderstanding is against the patient’s interests.

The problem with Browne’s account is that it relies on parents making a factual error. It is, of course, plausible that many parents are factually mistaken of the research revealing how gender and sex come apart. Gatekeeping in such cases might be justified, then, precisely because encouraging the idea that sex information is important limits the autonomy of these parents by undermining their ultimate goals.

However, this does not seem uniformly the case. A good many individuals are limiting, in effect, themselves because of their values. Let us take the example provided above of a father who wants a boy with whom to play sport. It is true that female children are no less capable of playing sport than any boy, so if the story was left here it would appear as if Browne’s point holds. But what of those parents who claims, in effect, that a girl ought not play sport, rather than cannot? Such a parent could concede that a child’s sex does not limit their capacity to play baseball, while maintaining the normative claim that girls ought to stick to certain kinds of activities—such as caring and domestic duties. The claim, then, would be that certain parents do not want to have a certain kind of child rearing experience with just any child. They take sex information as indicative of their child-rearing futures because they think that children of that sex ought to conform to a traditional gender identity. This is their autonomous ultimate goal, repugnant as it may be.

If I am right, then gatekeeping information from these parents amounts to an unwarranted imposition of values upon them. Gatekeeping would then amount to precisely the kind of paternalism bioethics and medicine have turned their back on long ago. We ought not allow medicine to override the values of patients based on parents acting according to unjustified or, indeed, repugnant values.

So, then, does this mean that medical professionals can only educate parents, simply demonstrating how sex and gender come apart in important ways? If this was all that we could claim, it would mean that things will remain largely as they are, as many (if not most) parents will dismiss such concerns and plough on regardless.

Not so. I suggest that medical professionals should be willing to challenge their patients regarding the value that they place on having gendered childrearing experiences.[viii] I envisage that challenging patient values in this domain would involve three stages.

First, challenge the importance of their values. This would go beyond asking whether the operative values are appropriately weighted against other, contrary, values but also asking whether the values ought to be regarded as important by the patient at all. Practitioners would thus ask questions like ‘Why should this kind of childrearing experience be of greater value to you than others?’ ‘Why is having a child adhere to gender norms so important to you?’ ‘Why aren’t you open to experiencing life with a child of whichever gender?’

Second, practitioners would seek to clarify decisions as being reflections of values. This does not only mean that the practitioner would demonstrate how the decision to seek out sex information amounts, in many cases, to subscribing to gender essentialism. It would also involve the professional demonstrating how the medical response is also a reflection of values. This serves to combat the pervasive assumption that gender norms are reflections of biological reality while also demonstrating that medicine is committed to combating sexism.

Third, and finally, practitioners would root out contradictory values. This would involve challenging the patient to locate the decision she makes within her larger value set in cases where her decision appears to clearly contradict her explicitly held values. So, for example, a patient who is steadfast that she harbours no sexist norms whatsoever would be asked to explain how that squares with the decision to seek out sex information.

The goal of value challenge amounts to an attempt to change minds. If, after appropriate challenge, the patient is undeterred in her desire to receive sex information the medical profession must, unfortunately, comply. This does not mean that value challenge has failed. Challenging the patient communicates that medicine, as a discipline, does not endorse sexist norms nor the values underlying them. This is the best we can do in this situation, but it is still a worthy goal.

 

With thanks to Caitrin Donovan, John Forge and Chris Ryan for their helpful feedback. [edited to add]

Anson Fehross is a PhD student at Sydney Health Ethics, University of Sydney. He joined the centre in 2015, after completing a MSc in the Unit for History and Philosophy of Science. Much of his research focuses on the interface of metaphysics and applied ethics. His thesis sets out a new model for substituted decision making in both general medicine and psychiatry.

[i] E. S. Bauman et al., “What Factors Are Associated with Parental Desire to Find out the Sex of Their Baby?,” Ultrasound Bulletin 11, no. 1 (2008): 19–24.

[ii] Thomas D. Shipp et al., “What Factors Are Associated with Parents’ Desire to Know the Sex of Their Unborn Child?,” Birth (Berkeley, Calif.) 31, no. 4 (December 2004): 272–79, https://doi.org/10.1111/j.0730-7659.2004.00319.x; Chibuike Ogwuegbu Chigbu, Boniface Odugu, and Obioma Okezie, “Implications of Incorrect Determination of Fetal Sex by Ultrasound,” International Journal of Gynecology & Obstetrics 100, no. 3 (November 26, 2007): 287–90,https://doi.org/10.1016/j.ijgo.2007.09.021; Angelique J. A. Kooper et al., “Why Do Parents Prefer to Know the Fetal Sex as Part of Invasive Prenatal Testing?,” ISRN Obstetrics and Gynecology 2012 (2012): 524537, https://doi.org/10.5402/2012/524537.

[iii] Leena Nahata, “The Gender Reveal: Implications of a Cultural Tradition for Pediatric Health,” Pediatrics 140, no. 6 (December 2017).

[iv] K. Grill and S. O. Hansson, “Epistemic Paternalism in Public Health,” Journal of Medical Ethics 31, no. 11 (November 1, 2005): 648–53, https://doi.org/10.1136/jme.2004.010850.

[v] Tamara Kayali Browne, “Why Parents Should Not Be Told the Sex of Their Fetus,” Journal of Medical Ethics 43, no. 1 (January 2017): 5–10, https://doi.org/10.1136/medethics-2015-102989; Tamara Kayali Browne, “How Sex Selection Undermines Reproductive Autonomy,” Journal of Bioethical Inquiry 14, no. 2 (June 1, 2017): 195–204, https://doi.org/10.1007/s11673-017-9783-z.

[vi] It is worth noting there are good reasons to be suspicious of the claim that ‘sex’ is a biological, natural, kind whereas gender is uniquely a social kind. For more see: John Dupré, “Sex, Gender, and Essence,” Midwest Studies In Philosophy 11, no. 1 (1986): 441–57, https://doi.org/10.1111/j.1475-4975.1986.tb00508.x; Judith Lorber, “Believing Is Seeing: Biology as Ideology,” Gender & Society 7, no. 4 (December 1, 1993): 568–81, https://doi.org/10.1177/089124393007004006.

[vii] Browne, “How Sex Selection Undermines Reproductive Autonomy,” 196.

[viii] C.f. Julian Savulescu, “Rational Non-Interventional Paternalism: Why Doctors Ought to Make Judgments of What Is Best for Their Patients.,” Journal of Medical Ethics 21, no. 6 (December 1995): 327–31.

Image from Karen’s Cake Shoppe, used with permission.