Provider biases and choices: the role of gender.

Abstract

Genetic counseling provides a unique opportunity to test the influence of gender on moral reasoning. The theories of Carol Gilligan on women's "relationship based" framework for ethical decision making were contrasted with Kohlberg's research on men's resolution of conflicts based on abstract, universal principles in an impersonal and fair manner. Discussion also focussed on the theories of sociologists, such as Kanter's that a profession prestige and income as well as the proportion of women in profession determine the approach to ethical problems. This study reports on survey data in 1985 and 1986 collected from medical geneticists in 19 countries that had at least 10 medical geneticists, with at least one available to distribute questionnaires, and the appropriate geographic distribution. The survey did not include genetic counselors and allied professionals. The questionnaire asked for responses to 14 case studies, 4 questions on genetic screening and access to test results, and 12 questions on the goals and conduct of genetic counseling. 62% responded. Sociodemographic data were also collected and analyzed in stepwise logistic regressions. THe results showed that gender was the single most important determinant of ethical decision making and ethical reasoning. There were gender differences in responses to 6 of the 14 cases and, in the US, for a 7th case: sex selection. In the US, women were 4.4 times more likely to counsel indirectly about XYY fetuses and 3.6 more likely to bring up issues like false paternity or genetic carriers in other family members. Patient autonomy was an issued in a case involving a 25-year-old woman who demanded prenatal diagnosis with no genetic or medical indications and another case involving a couple desiring a son after having 4 daughters. Rights based responses were provided by 49% and relationship based responses by 44%. Gilligan's hypothesis was not supported. Similar results were found in a survey of genetic counselors, who were 94% women. A summary of other studies involving actual practices was given. Further research is needed to determine the processes of professionals' self definition, ethical views, and extent to which views and practices are gender or profession related; training programs may affect provider attitudes.