Free fetal DNA for non-invasive prenatal diagnosis (NIPD): ethical aspects

Abstract

Dr Phillipa Brice's accompanying commentary highlights how non-invasive testing of free fetal DNA (ffDNA) in pregnancy could transform women's experiences of antenatal screening and prenatal diagnosis. NIPD is already available for foetal sex, rhesus D blood type and some Mendelian inheritance such as achondroplasia, with tests for aneuploidy detection and Down syndrome being developed. These tests will not pose a risk to the pregnancy and could provide women and couples with definitive information earlier than current methods. The advantages over 'traditional' prenatal screening and diagnosis seem obvious - so is NIPD ethically problematic? Unsurprisingly, a pithy 'yes' or 'no' answer to this question is impossible and would undermine the opportunity for a rich and important discussion of how the ethics of NIPD might depart from 'traditional' testing in pregnancy. But in short, expectations are that NIPD can be conducted ethically if the right conditions are in place, and it is laudable that those working in this field are liaising so closely with ethicists to address emerging concerns as this technology develops.(1) An initial question is whether this technology gives rise to any new ethical questions over and above existing screening, diagnostic or assisted reproductive technologies. Existing debates in prenatal diagnosis, such as the disability rights critique, will continue to be relevant and may be exacerbated. So too will issues of the 'seriousness' threshold for offering PND and the routinisation of testing. Whilst NIPD does not depart too far from these existing issues, there may be important changes to the moral landscape of testing. If offered widely (for suitable conditions), NIPD will effectively become a screening test with a definitive outcome, akin to HIV (human immunodeficiency virus) testing in pregnant women, but one that may lead to termination. We need to decide which method of consent is appropriate and be mindful that a major justification for declining prenatal diagnosis (risk to the pregnancy) will be removed. Overall termination rates may also increase. Women will need sound and unbiased information about NIPD and will require time to reflect before deciding about testing.