On February 16, the Alabama Supreme Court issued a ruling that embryos created by in vitro fertilization (IVF) are considered children. This ruling has sparked a lot of public discussion, as it has the potential to reshape the future of IVF. IVF is the process by which eggs fertilized in a lab are subsequently implanted in the uterus. In recent years, IVF has been on the rise, with nearly 42% of adults in the United States reporting use of fertility treatments or knowledge of someone else using fertility treatments compared to only 33% five years ago. However, due to this recent ruling, IVF was suspended in Alabama.While a bill was recently passed to protect IVF treatments there, the future of IVF remains in doubt. It is common practice for embryos to be destroyed if deemed inadequate for implantation or after an individual or couple is finished with the IVF process. Clinics fear that with this new ruling, these common destruction practices may result in wrongful death lawsuits. While this fear has disastrous implications for IVF as a whole, it is particularly threatening to the practice of Preimplantation Genetic Testing (PGT). 

PGT involves testing embryos created by IVF for various genetic diseases or abnormalities before selecting embryos for implantation. PGT can be split into three main categories: PGT-A, PGT-M, and PGT-P. PGT-A tests the embryos for aneuploidy: either too few or too many chromosomes. Most cases of aneuploidy are lethal, but few are not, such as trisomy 21, also known as Down syndrome. Clinics usually suggest PGT-A before implantation in most IVF cycles to ensure the highest probability of the embryos surviving in the uterus. PGT-M is less common and tests the embryos for either single gene disorders (Huntington’s disease, cystic fibrosis, sickle cell anemia, etc.) or hereditary cancer syndromes. PGT-P, the least common and newest form of PGT, tests the embryos for polygenic disorders by utilizing information from polygenic risk scores. A polygenic trait is something that results from the influence of two or more genes, as well as environmental factors. Some examples include cancer and heart disease, but also traits like skin color and intelligence. 

When PGT is carried out, the embryos that are not selected for implantation after PGT testing are typically destroyed. The new ruling in Alabama raises the specter of further legal ramifications as a result of PGT testing, particularly if undesirable embryos are destroyed as a result of testing. However, even beyond these legal implications, many have debated the ethics of using PGT in the first place. The current discussion around IVF affords us the opportunity to carefully consider whether PGT should be common practice even where clinics are no longer concerned about the legal implications of destroying embryos. PGT has received criticism due to its potential to perpetuate income inequality and devalue the lives of people who have traits that are selected against. It is especially important for young adults to be brought into these discussions, because they are the ones who will be making decisions about their offspring in the near future. A successful future for society depends on the thoughtful consideration of how these technologies should be implemented today.

As someone who exists only because of IVF and PGT, I have spent a lot of time considering the ethics surrounding the use of these technologies. My dad’s brother had cystic fibrosis, so my dad knew there was a chance he might be a carrier. After a genetic test confirmed my dad’s suspicion, my mom decided to also get tested, only to find out she too is a carrier of cystic fibrosis. When my parents found out that they needed to use IVF if they wanted to have biological children, they decided to use PGT-M to test their embryos for cystic fibrosis. My parents were told they were not allowed to implant the embryos based on sex. Additionally, they were only allowed to select against embryos with cystic fibrosis, allowing carrier embryos to be implanted. However, this occurred in 2001, and a lot has changed with respect to PGT since then—for example, parents using PGT-A to test for chromosomal abnormalities can now also choose the sex of their baby if they wish, and new types of testing, such as PGT-P, have become available. As these practices become more common, it is important to consider the problems associated with these types of PGT. 

One of the most pressing ethical issues associated with PGT is the idea that it has the potential to perpetuate the cycle of increasing income inequality. IVF alone can cost anywhere between $15,000 and $30,000. PGT-A costs anywhere between $4,000-$10,000, and PGT-M and PGT-P are even more expensive. The high cost of these technologies means that only wealthy individuals have access to them. Moreover, these technologies serve to potentially ensure favorable genetics for offspring, creating a system in which wealthy individuals have children with fewer medical complications. As a result, their children could become less of a financial burden for their parents, and could be set up to have a more prosperous future themselves. This is one of many ways in which income inequality is perpetuated in America, and as such it deserves serious consideration. 

Beyond increasing inequality for future generations, these technologies have the potential to devalue the current lives of individuals. If individuals begin to use different forms of PGT to select against embryos with traits associated with deafness, blindness, autism, dwarfism and other traits of a similar nature, it sends a message to individuals in those communities that their lives are not worthy of living. It is understandable that parents would want their offspring to have the easiest life possible, but individuals with these traits can have fulfilling and meaningful lives. Unless the individual considering PGT has a personal experience with the trait in question, they should not have the authority to control whether or not their offspring have that trait. This does not apply to life-threatening diseases, as there is little to be gained from suffering from a disease of that nature. 

Due to the potential of devaluing  people’s lives and individuals and directly contributing  to perpetuating the cycle of increasing income inequality, the use of PGT should be carefully considered moving forward. PGT-A and PGT-M pose fewer ethical problems if the price barrier is reduced and if it is only allowed to be used to select against life-threatening diseases. One way to begin reducing the price barrier is to require insurance to cover fertility treatments, as currently only 15 states require insurance to cover the cost of fertility treatments. However, even when considering the use of less problematic forms of PGT, it is important that individuals think critically about why they are using these technologies. Furthermore, it is necessary to engage those who support the idea that people should be permitted to select embryos based on favorable polygenic traits, such as genes that are associated with increased intelligence, in order to promote a deeper understanding of the types of challenges and problems associated with these technologies.