IVF dish with drops of material and micromanipulators over it in the laboratory of the in vitro fertilization. Macro photo with selective focus. Horizontal.

Bioethics Forum Essay

Polygenic Embryo Screening: Ethical and Legal Considerations

Last month, Bloomberg reported on what seems to be the first child born following a new kind of genome-wide screening. Four embryos were screened, and the embryo selected for implantation was the one given the best genetic odds of avoiding heart disease, diabetes, cancer, and schizophrenia in adulthood.  The test, called polygenic embryo screening, was performed by Genomic Prediction, a company in New Jersey.

The news has been met with concerns about the degree of control we may now have over future generations. While Genomic Prediction did not screen for intelligence or other non-disease traits, it is possible to do so, and this raises questions about eugenics and designer babies.

In this essay, we consider the ethical case for using polygenic scoring to select embryos that possess the best chance of a healthy life, as well as the need for regulation.

Polygenic embryo screening uses an algorithm to summarize the estimated effect of hundreds or thousands of genetic variants associated with an individual’s risk of having a particular condition or trait. It differs from more routine forms of embryo screening such as preimplantation genetic diagnosis (PGD), which detects single gene variants associated with a disease or trait. Polygenic scoring is not as precise as PGD, since it only represents an embryo’s risk of a particular condition or trait.

Polygenic embryo screening is essentially unregulated in most countries and is, therefore, available to prospective parents. Many countries that regulate genetic testing in general permit it only it for genetic disorders and conditions. In South Africa, for example, embryonic screening is governed by the regulations of the National Health Act. However, these regulations only specifically refer to one genetic trait – sex – and state that it can only be identified for purposes  relevant to the health of the embryo. Since polygenic embryo screening itself is not regulated, parents may request it as an add-on the in vitro fertilization based on their right to make decisions concerning reproduction, or reproductive autonomy, which is guaranteed by the South African constitution.

 Most European countries have legislation that restricts genetic testing to major diseases, such as beta thalassaemia. It is not clear whether an elevated probability of a disease would count. For example, in the United Kingdom, embryonic screening falls under the purview of the Human Fertilisation and Embryology Authority, which issues licences for preimplantation genetic testing. Licences are permitted to screen embryos against serious genetic diseases and sex-linked diseases, to identify tissue-compatible embryos, or to establish biological parentage.

Some concerns over using polygenic embryo screening are based on science. For instance, the score indicates the probable risk of a future child developing a certain condition, but it does not guarantee that this will be the case. Other concerns are based on ethics. If we consider one disease that polygenic embryo screening has been used for – heart disease – it is arguable that such screening is an extreme intervention. Heart disease is treatable and preventable; individuals can reduce their risk of heart disease through environmental management such as monitoring their diet. This raises the question of whether it is ethical to select against embryos with an increased probability of developing heart disease later in life when the condition can be managed. On the other hand, it can be argued that polygenic embryo screening would impact public health positively by reducing the burden on health care systems. It could be considered unethical not to use this technology as it would offer future generation the prospect of healthier lives. We may be morally obligated to check the polygenic risk scores of embryos and select the embryos with genetic traits that indicate the best prospect of quality of life.

Polygenic testing of embryos is currently offered by Genomic Prediction, MyOMe, and Orchid. It is available only to those with the ability to pay thousands of dollars. This raises the possibility of increasing inequality as the rich have babies with greater odds of good health and, potentially, other gifts and talents. However, increasing inequality is not inevitable. It is essential that, just as people have a right to basic health care, they also have a right to basic reproductive selection that is important to health and well-being. European countries are well placed to position this new revolution within state funded universal health care, but the demands of justice may be more difficult to meet elsewhere in the world.

Polygenic embryo screening has the potential to give babies a health advantage, but it may also be used to “score” embryos for social, or non-disease-based advantages. This raises the spectre of eugenics. For this reason, and to guard against misuse of the technology, broad discussion is needed around what advantages we would be prepared to allow to proliferate in future people. Some favor a regulatory model that would permit polygenic screening if it is correlated with increased odds of greater well-being. This would require a philosophical and ethical analysis of what constitutes well-being and a scientific analysis of the correlation between polygenic screening and that outcome. Societal discussion about these issues is necessary, too. Should genetic variants associated with diseases and non-disease traits be considered? Is there a difference, ethically, between justifying the selection of physical traits, such as eye color, and functional traits, such as intelligence, based on their potential to increase the well-being of a future person?

Regulation of polygenic embryo screening should explore these questions and address issues of justice and inequality. Crucially, regulators should make the technology broadly available, so that reaping its benefits does not depend on the ability to pay. Regulation should also ensure that screening that improves general health and well-being would be permitted.

Sheetal Soni (@Sheetal_Soni) is a senior lecturer at the University of KwaZulu-Natal in South Africa. Julian Savulescu (@juliansavulescu) is Director of the Oxford Centre for Neuroethics, Uehiro Chair in Practical Ethics at the University of Oxford, and a Hastings Center fellow.

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  1. In his book “Imperative of Responsibility”, Hans Jonas warned against the dangers of a scientific and technological civilization and laid the foundation for our responsibility to future generations. The characteristics of the modern technological civilization have changed the nature of our moral obligations. The concept of responsibility has been given a new dimension. He states: “Act so that the effects of your action are compatible with the permanence of genuine human life”. We must ensure that the effects of our actions do not destroy future “genuine human life”. To ensure “genuine human life” means to protect the future humanity’s autonomy, dignity, integrity and vulnerability, Hein Berdinesen comments.
    Jonas draws a heuristic of fear, and my question is, should not be fear the first of our thoughts if we prohibit trial and error from evolution by excluding all possible “damaged” gene loci from our genes. We do not have any idea about the impact on upcoming generations! Thus, should we dare just to proceed? I know, what can be done, will be done. However, that does not mean, it is good that we proceed. Do we know what we risk in optimizing the genome without knowing about any possible outcome?

  2. When we being to screen the genome for health related risks, we open the door to screening out diversity and normal variation in our population. There will always be individuals that want to take this science to its’ limits, using it to hand pick what they deem desirable. While in this instance, intelligence and other factors were not screened for, as long as the capability exits there is the possibility that it will be attempted. This science reminds me of the movie Gattaca, in which parents are told it is irresponsible to not have a genetically engineered child. Those children that are not engineered are relegated to the worst jobs and living conditions. While it may be aspirational to want the best possible future for our children, any screening will need to be regulated and offered more widely in order to combat the increasing inequality mentioned.

  3. I think this is an ethical dilemma that will only continue to get more difficult as technology evolves. At the other end of life, we see a similar question playing out around medical capabilities (life-extending) and quality of life. At the beginning, as is the case in this article, we see a question about medical capabilities (also life-extending) and an attempt to manage long-term quality of life. As everything else, money will govern who has access to this technology, who will benefit, and the gap that will widen between genetically modified (or chosen) infants and others would be harder to close than current wage gaps, or educational gaps. As this article notes, managing this level of accessibility would be imperative.

  4. What a curious position to be in… on the one hand, we wonder whether we should be engaging in this practice at all. On the other, we are sure that if we do allow the practice, justice demands it be available to all.

    If we do go forward without banning the technology, how would we ensure it is available to everyone? If the technology gets sufficiently popular such that people choose IVF in order to perform polygenetic embryo screening, then ensuring just access doesn’t just require access to the technology, but access to expensive IVF procedures as well. Regardless, it would seem difficult to design a governmental program to guarantee access that wouldn’t also look like governmental encouragement of the practice. Genetic selection of embryos is a topic that has already spawned many dystopian imaginings of the future. With polygenic embryo screening, we’re adding in a machine learning/artificial intelligence component which will only add fuel to the dystopian fires. If regulators step in to ensure just access to this technology, we should anticipate a firestorm of pushback along the lines of “the government is trying to make Artificial Intelligence choose your children.” While the statement might be a bit hyperbolic, there are real ethical concerns not just with genetic screening, but with genetic screening guided by proprietary algorithms.

    Given that the service is currently only offered by private companies, the algorithms they use are likely proprietary. We have already seen problems arise with proprietary algorithms in many contexts – often raising concerns about how they may reflect and solidify existing social biases (and whether they actually work at all). If we cannot examine a company’s algorithm and audit the development process, we cannot blindly assume that the algorithm does what the company says and that it is free from flaws. Before adopting an algorithm to select the best children, we need to ask questions like: what data was used to build the algorithm? How big was the data set? Where did the data come from? What machine learning techniques were used? How was it validated? What types bias might arise from the data set/algorithm development, and what steps were taken to address it? Of course, the ethical implications of genetic embryo selection are enormous. But the use of AI/ML algorithms add another large dimension of concern and regulators are not well positioned to address it. Ethicists have a lot of work to do here as well.

  5. Are the advancements in science and technology really making this world a better place? Sandel makes this statement in the article published in the Atlantic – “The Case Against Perfection” that conveyed all my feelings: “When science moves faster that moral understanding, as it does today, men and women struggle to articulate their unease”. This unease also translates to the use of Genetic Technology, Genetic Enhancement and Eugenics.
    The “liberal or new eugenics” movement declares that this is different than the old eugenics because the choices (to improve the population’s genetics composition) are “freely made”. But what happens then to the part of the population that cannot afford to make these choices, when the choices are not culturally acceptable or because they opt not to?
    I do not entirely disregard the idea, because eugenics, if used properly, could help us delete disease causing genes and should be available to all, nonetheless, it needs to take into consideration the social context and the possibility other people being affected. I argue that, with a lack of regulations, Genetic Engineering could easily become Privatized or Corporate Eugenics. As an example of “free market” eugenics we have what happened in Singapore in the mid-eighties, when the government encouraged wealthy and educated women to reproduce and would give material incentives like money and apartments to the poor, uneducated parents if they would “voluntarily” undergo sterilization. Is this what liberal eugenicists call non-coercive freedom? It seems to me that it can only be coined with the term non-coercive if you belong to a certain societal status and are free to make this choice.
    Some of the latest genetic technology and research is in the mainly for-profit fertility clinics and with pre-implantation genetic diagnosis. A few of these cater to people who are willing to pay a lot of money to buy sperm with very particular characteristics and discard embryos with undesired genes: height, sex, skin color, IQ, obesity, and dangerous genetic diseases.
    There is something troubling about the concept of enhancing or selecting our genes. Instead, why don’t we engage society in such activities before adding and/or deleting our genetic material? In the same sense, one can only blame their parents for their own mishaps and lack of achievement up to a certain extent, having a lazy parent will not condition the rest of your life. Take the example of the movie Gattaca, where the “natural” child works hard to obtain a position reserved for the intellectually enhanced elite and even makes it into space, against all odds; whereas his brother, genetically “superior” to him, does not care much and does not amount to his genetically “superior” capacities. A case for enhancement would be that if we continue living in such demanding, high-pressure societies especially in countries like Japan or China, maybe we do need to adapt. I ask myself whether this would make us more miserable, more depressed (we could probably also delete those genes) or a more productive society.
    Designer children wouldn’t be free, they would already have a path set for them in life, a path with no responsibility for the things they are, and they create and with no appreciation for the talents that they could have developed on their own.

    I don’t think that having a good memory or empathy would cause restrictions to a child’s future, but we live in a society where going to a medical appointment is a luxury, for some having three meals a day is a luxury. Basic human rights are a luxury. We cannot escape the reality that most people cannot even afford a general health check-up or, that IVF is only for the want-to-be-parents that can afford it. Let us just try to not call it medicine, it doesn’t treat anything that was wrong with us, it is in the business of making a better version of us, a version that doesn’t question, looks the same, is not aggressive, obeys the rules of society… We are playing god by changing our essence, it goes so much deeper than the use vaccines to protect us. We do not have the same OBLIGATION to enhance as we do to prevent disease. We must do more research before intervening, and most of all we must all do better as a society before irreversibly modifying it.

    Are the advancements in science and technology really making this world a better place? Sandel makes this statement in the article published in the Atlantic – “The Case Against Perfection” that conveyed all my feelings: “When science moves faster that moral understanding, as it does today, men and women struggle to articulate their unease”. This unease also translates to the use of Genetic Technology, Genetic Enhancement and Eugenics.
    The “liberal or new eugenics” movement declares that this is different than the old eugenics because the choices (to improve the population’s genetics composition) are “freely made”. But what happens then to the part of the population that cannot afford to make these choices, when the choices are not culturally acceptable or because they opt not to?
    I do not entirely disregard the idea, because eugenics, if used properly, could help us delete disease causing genes and should be available to all, nonetheless, it needs to take into consideration the social context and the possibility other people being affected. I argue that, with a lack of regulations, Genetic Engineering could easily become Privatized or Corporate Eugenics. As an example of “free market” eugenics we have what happened in Singapore in the mid-eighties, when the government encouraged wealthy and educated women to reproduce and would give material incentives like money and apartments to the poor, uneducated parents if they would “voluntarily” undergo sterilization. Is this what liberal eugenicists call non-coercive freedom? It seems to me that it can only be coined with the term non-coercive if you belong to a certain societal status and are free to make this choice.
    Some of the latest genetic technology and research is in the mainly for-profit fertility clinics and with pre-implantation genetic diagnosis. A few of these cater to people who are willing to pay a lot of money to buy sperm with very particular characteristics and discard embryos with undesired genes: height, sex, skin color, IQ, obesity, and dangerous genetic diseases.
    There is something troubling about the concept of enhancing or selecting our genes. Instead, why don’t we engage society in such activities before adding and/or deleting our genetic material? In the same sense, one can only blame their parents for their own mishaps and lack of achievement up to a certain extent, having a lazy parent will not condition the rest of your life. Take the example of the movie Gattaca, where the “natural” child works hard to obtain a position reserved for the intellectually enhanced elite and even makes it into space, against all odds; whereas his brother, genetically “superior” to him, does not care much and does not amount to his genetically “superior” capacities. A case for enhancement would be that if we continue living in such demanding, high-pressure societies especially in countries like Japan or China, maybe we do need to adapt. I ask myself whether this would make us more miserable, more depressed (we could probably also delete those genes) or a more productive society.
    Designer children wouldn’t be free, they would already have a path set for them in life, a path with no responsibility for the things they are, and they create and with no appreciation for the talents that they could have developed on their own.

    I don’t think that having a good memory or empathy would cause restrictions to a child’s future, but we live in a society where going to a medical appointment is a luxury, for some having three meals a day is a luxury. Basic human rights are a luxury. We cannot escape the reality that most people cannot even afford a general health check-up or, that IVF is only for the want-to-be-parents that can afford it. Let us just try to not call it medicine, it doesn’t treat anything that was wrong with us, it is in the business of making a better version of us, a version that doesn’t question, looks the same, is not aggressive, obeys the rules of society… We are playing god by changing our essence, it goes so much deeper than the use vaccines to protect us. We do not have the same OBLIGATION to enhance as we do to prevent disease. We must do more research before intervening, and most of all we must all do better as a society before irreversibly modifying it.

    Are the advancements in science and technology really making this world a better place? Sandel makes this statement in the article published in the Atlantic – “The Case Against Perfection” that conveyed all my feelings: “When science moves faster that moral understanding, as it does today, men and women struggle to articulate their unease”. This unease also translates to the use of Genetic Technology, Genetic Enhancement and Eugenics.
    The “liberal or new eugenics” movement declares that this is different than the old eugenics because the choices (to improve the population’s genetics composition) are “freely made”. But what happens then to the part of the population that cannot afford to make these choices, when the choices are not culturally acceptable or because they opt not to?
    I do not entirely disregard the idea, because eugenics, if used properly, could help us delete disease causing genes and should be available to all, nonetheless, it needs to take into consideration the social context and the possibility other people being affected. I argue that, with a lack of regulations, Genetic Engineering could easily become Privatized or Corporate Eugenics. As an example of “free market” eugenics we have what happened in Singapore in the mid-eighties, when the government encouraged wealthy and educated women to reproduce and would give material incentives like money and apartments to the poor, uneducated parents if they would “voluntarily” undergo sterilization. Is this what liberal eugenicists call non-coercive freedom? It seems to me that it can only be coined with the term non-coercive if you belong to a certain societal status and are free to make this choice.
    Some of the latest genetic technology and research is in the mainly for-profit fertility clinics and with pre-implantation genetic diagnosis. A few of these cater to people who are willing to pay a lot of money to buy sperm with very particular characteristics and discard embryos with undesired genes: height, sex, skin color, IQ, obesity, and dangerous genetic diseases.
    There is something troubling about the concept of enhancing or selecting our genes. Instead, why don’t we engage society in such activities before adding and/or deleting our genetic material? In the same sense, one can only blame their parents for their own mishaps and lack of achievement up to a certain extent, having a lazy parent will not condition the rest of your life. Take the example of the movie Gattaca, where the “natural” child works hard to obtain a position reserved for the intellectually enhanced elite and even makes it into space, against all odds; whereas his brother, genetically “superior” to him, does not care much and does not amount to his genetically “superior” capacities. A case for enhancement would be that if we continue living in such demanding, high-pressure societies especially in countries like Japan or China, maybe we do need to adapt. I ask myself whether this would make us more miserable, more depressed (we could probably also delete those genes) or a more productive society.
    Designer children wouldn’t be free, they would already have a path set for them in life, a path with no responsibility for the things they are, and they create and with no appreciation for the talents that they could have developed on their own.

    I don’t think that having a good memory or empathy would cause restrictions to a child’s future, but we live in a society where going to a medical appointment is a luxury, for some having three meals a day is a luxury. Basic human rights are a luxury. We cannot escape the reality that most people cannot even afford a general health check-up or, that IVF is only for the want-to-be-parents that can afford it. Let us just try to not call it medicine, it doesn’t treat anything that was wrong with us, it is in the business of making a better version of us, a version that doesn’t question, looks the same, is not aggressive, obeys the rules of society… We are playing god by changing our essence, it goes so much deeper than the use vaccines to protect us. We do not have the same OBLIGATION to enhance as we do to prevent disease. We must do more research before intervening, and most of all we must all do better as a society before irreversibly modifying it.

    Are the advancements in science and technology really making this world a better place? Sandel makes this statement in the article published in the Atlantic – “The Case Against Perfection” that conveyed all my feelings: “When science moves faster that moral understanding, as it does today, men and women struggle to articulate their unease”. This unease also translates to the use of Genetic Technology, Genetic Enhancement and Eugenics. The “liberal or new eugenics” movement declares that this is different than the old eugenics because the choices (to improve the population’s genetics composition) are “freely made”. But what happens then to the part of the population that cannot afford to make these choices, when the choices are not culturally acceptable or because they opt not to?
    I do not entirely disregard the idea, because eugenics, if used properly, could help us delete disease causing genes and should be available to all, nonetheless, it needs to take into consideration the social context and the possibility other people being affected. I argue that, with a lack of regulations, Genetic Engineering could easily become Privatized or Corporate Eugenics. As an example of “free market” eugenics we have what happened in Singapore in the mid-eighties, when the government encouraged wealthy and educated women to reproduce and would give material incentives like money and apartments to the poor, uneducated parents if they would “voluntarily” undergo sterilization. Is this what liberal eugenicists call non-coercive freedom? It seems to me that it can only be coined with the term non-coercive if you belong to a certain societal status and are free to make this choice.
    There is something troubling about the concept of enhancing or selecting our genes. Instead, why don’t we engage society in such activities before adding and/or deleting our genetic material? In the same sense, one can only blame their parents for their own mishaps and lack of achievement up to a certain extent, having a lazy parent will not condition the rest of your life. Take the example of the movie Gattaca, where the “natural” child works hard to obtain a position reserved for the intellectually enhanced elite and even makes it into space, against all odds; whereas his brother, genetically “superior” to him, does not care much and does not amount to his genetically “superior” capacities. A case for enhancement would be that if we continue living in such demanding, high-pressure societies especially in countries like Japan or China, maybe we do need to adapt. I ask myself whether this would make us more miserable, more depressed (we could probably also delete those genes) or a more productive society.
    Designer children wouldn’t be free, they would already have a path set for them in life, a path with no responsibility for the things they are, and they create and with no appreciation for the talents that they could have developed on their own.

  6. For a relatively short piece it certainly packs an emotional punch. We are buoyed by the prospect of avoiding serious diseases by employing polygenic embryo screening (PES), but then checked when warned that excluding manageable illnesses may be immoral. We are made to feel worried by the spectre of eugenics, and yet simultaneously sad, with the potential hinderance of future lives. However, despite these vicissitudes we are forced to reckon with the possibility that we are obligated to seek improvement. The case is then made by the authors for using this technology to select embryos that maximise health and well-being. However, the aspect that intrigued me the most was the concurrent plea for regulation of this new technology, which is already available and likely to become increasingly accessible.

    The need for regulation is pressing as Big Tech companies like Google and Meta begin to develop their own healthcare tools. The problem is complex and although the ideal would be that new innovations such as PES should be equally available and accessible to all by virtue of not being dependent on the ability to pay, the reality is that technological discovery and development is costly, especially in a competitive environment. Therefore, companies would be unwilling to endure the enormous costs and not recoup their investment. Further, even if governments were to buy the technology and make it accessible, the companies that fail in getting government support would still likely operate in the private sector which would create a two-tier system driven by the ability to pay. The NHS in the UK is a good example. An operation that is essentially free in the NHS but may have a long waitlist can be accessed much sooner via the private sector if one can pay. For technology such as polygenic embryo screening very strict regulation will be necessary across all boards. Further, there will need to be clear guidelines around private companies and public use.

    In addition to financial factors driving inequity there are many social and cultural influences that are likely to introduce potentially insurmountable ethical challenges. It is likely that these pieces of tech will be equipped to detect a range of illnesses and diseases. The impact of excluding certain illnesses is obviously beneficial but for others the gain may not be so evident. I agree that polygenic embryo screening could be beneficial for lifting strain on health systems while also prioritizing ‘quality of life.’ However, it is vital that we consider and clearly define what we recognize as a ‘quality life.’ It is important that we think about how these technologies may engender stereotypes and stigmas for those presently living with certain illnesses. These technologies prioritize future lives, rather than helping present lives.

    Such considerations are difficult to regulate as is the particularly vexing problem of balancing the needs of future generations against those that are presently in existence. Further, it is unclear to what extent future lives matter – in other words, what rights do they have and, are they more, or less important than those currently alive. The question is made even more complicated by the fact that future lives are inevitably dependent on the lives of those living now and indeed their choices.

  7. For a relatively short piece it certainly packs an emotional punch. We are buoyed by the prospect of avoiding serious diseases by employing polygenic embryo screening (PES), but then checked when warned that excluding manageable illnesses may be immoral. We are made to feel worried by the spectre of eugenics, and yet simultaneously sad, with the potential hinderance of future lives. However, despite these vicissitudes we are forced to reckon with the possibility that we are obligated to seek improvement. The case is then made by the authors for using this technology to select embryos that maximise health and well-being. However, the aspect that intrigued me the most was the concurrent plea for regulation of this new technology, which is already available and likely to become increasingly accessible.

    The need for regulation is pressing as Big Tech companies like Google and Meta begin to develop their own healthcare tools. The problem is complex and although the ideal would be that new innovations such as PES should be equally available and accessible to all by virtue of not being dependent on the ability to pay, the reality is that technological discovery and development is costly, especially in a competitive environment. Therefore, companies would be unwilling to endure the enormous costs and not recoup their investment. Further, even if governments were to buy the technology and make it accessible, the companies that fail in getting government support would still likely operate in the private sector which would create a two-tier system driven by the ability to pay. The NHS in the UK is a good example. An operation that is essentially free in the NHS but may have a long waitlist can be accessed much sooner via the private sector if one can pay. For technology such as polygenic embryo screening very strict regulation will be necessary across all boards. Further, there will need to be clear guidelines around private companies and public use.

    In addition to financial factors driving inequity there are many social and cultural influences that are likely to introduce potentially insurmountable ethical challenges. It is likely that these pieces of tech will be equipped to detect a range of illnesses and diseases. The impact of excluding certain illnesses is obviously beneficial but for others the gain may not be so evident. I agree that polygenic embryo screening could be beneficial for lifting strain on health systems while also prioritizing ‘quality of life.’ However, it is vital that we consider and clearly define what we recognize as a ‘quality life.’ It is important that we think about how these technologies may engender stereotypes and stigmas for those presently living with certain illnesses. These technologies prioritize future lives, rather than helping present lives.

    Such considerations are difficult to regulate as is the particularly vexing problem of balancing the needs of future generations against those that are presently in existence. Further, it is unclear to what extent future lives matter – in other words, what rights do they have and, are they more, or less important than those currently alive. The question is made even more complicated by the fact that future lives are inevitably dependent on the lives of those living now and indeed their choices.

  8. As datasets increase, costs decrease and predictions become better, it seems obvious that polygenic embryo screening (PES) will be increasingly used to select desired embryos (barring regulatory prohibitions). I found a couple of the concerns against the use of PES curious. One such concern mentioned was that the screening score is a probability, not a guarantee, of developing a certain condition. But few things are guaranteed when it comes to genetics and environment, and we make decisions based on probabilities of expected outcomes all the time. While there will definitely need to be some agreement on what probabilities will be considered acceptable for what conditions, that we are not speaking of certainties should not be counted as a strike against PES.

    Another concern mentioned is that PES could be seen as an extreme intervention in the case of something like heart disease, because it is preventable and treatable. (I am not sure that such selection should be properly considered an intervention in the usual sense since the embryo selected is not the one with the higher probability of the disease.) However, if PES is otherwise found to be acceptable and parents are already allowed to select against known genetic diseases, why should selecting against preventable and manageable diseases be problematic? It is not clear that such a distinction need exist. Parents seek to confer advantages to their children in myriad ways that are considered acceptable, and one can argue that choosing an embryo with the highest probability of good health is a moral obligation better aligned with such parental goals than selecting by chance from those embryos remaining after screening for monogenetic diseases.

    The most controversial issue surrounding PES will be whether to allow it for non-disease traits thought to confer social advantages, and some are sure to bring up the slippery slope argument if a society does allow PES for the screening of preventable and treatable diseases. I agree with the authors that this will require much public discussion, as general societal agreement and an appropriate regulatory framework will be prerequisites for such use.

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