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Selling Medical Ultrasound Technology in Asia

Linda Trevino and Alessandro Gubbini

A surprising ethical dilemma arose for a young engineer during his first business trip to Asia to work with customers of his company’s ultrasound imaging technology. On the long airplane ride, Pat was dutifullyreading a travel book to learn more about Korean and Chinese cultures when he was shocked to learnhow ultrasound technologies were being used in these countries. A technology that he had alwaysconsidered to be a way to help people by diagnosing disease was being commonly used to intentionallyidentify and interrupt pregnancies when the fetus was female. As an engineer, Pat had been trained tobe passionate about innovation and problem solving. He was used to thinking about these technologiesas innovative high-tech solutions to serious health problems. He was also committed to developinghigher-quality, more efficient, affordable devices so that they could be used more widely. It had neveroccurred to him that in some Asian cultures, where overpopulation combined with a strong patriarchalculture led to a preference for sons over daughters, this technology that he considered to be innovative,helpful, and supportive of people’s well-being might be used to eliminate female lives.

As ultrasound technology has advanced and become more available, it has been used more widely in decisions to abort female fetuses in favor of sons. After some more research, Pat learned that thispractice has become quite common in China, which controls population growth by allowing families tohave only one child. In India, female children are more costly to families because the culture requiresthe family to bear the expenses of their daughters’ weddings and dowries. By comparison, an ultrasoundexam is a small expense even for these poor families. Pat was further surprised to learn that usingultrasound technology to identify fetus gender and abort the fetus based upon gender information isunlawful in most of these countries (for example, in India doctors are forbidden from disclosing the sexof fetuses). However, the enforcement of such laws is difficult and spotty, especially in clinics that arefar away from cities and regulators. The problem is being exacerbated because many ultrasoundmachines are being sold on the second-hand market, thus making ultrasound more available and moreaffordable to these clinics. The increasing use of the technology to abort female fetuses is beginning tocreate a huge societal problem because males are outnumbering females, distorting nature’s carefulgender balance. There are estimates that more than 150 million women are ‘‘missing’’ from the world asa result of sex-selective abortions and female infanticide. That’s equivalent to missing every woman inAmerica! The 2001 Indian census demonstrated a huge drop in the number of young girls relative toboys (927 girls for every 1,000 boys compared to 945 to 100 a decade earlier), and the problemcontinues to worsen as the use of ultrasound technology increases. According to UNICEF, China now hasonly 832 girls for every 1,000 boys aged 0–4. Looking to the future as these children grow up, some have predicted increasing trafficking of women for prostitution and violent crime as young males compete for the smaller number of available females.

In thinking through what he had learned, Pat found himself considering the patients, the health-care practitioners, and the health-care industry as well as his company, other technology developers, and the broader cultures involved. Patients benefit from access to life-saving technologies that can identifydiseases at an early stage so that they can be treated more successfully. But patients can also be harmed if, due to early identification of their child’s gender, mothers feel forced into abortions against their will.In these cultures, many mothers apparently do feel compelled by cultural or family pressures to abortfemale fetuses. Medical practitioners benefit from the ability to do faster and more accurate diagnoses,but they too can be pressured to use these systems for unethical purposes. The industry and thedevelopers (including Pat’s company) certainly profit from the production and sale of more of theseproducts. But the company and industry risk sullying their reputations if they are found responsible forselling these systems to unauthorized users for unlawful purposes. Imagine what the media could makeof that story. According to a prestigious British medical journal, The Lancet (2006), the unlawful use ofdiagnostic ultrasound technologies is contributing to an estimated 1 million abortions of female fetusesevery year. Yet, these diagnostic technologies still greatly benefit society worldwide in saving andimproving the lives of many millions of patients.

How should Pat think about this? Do the benefits to society of the technology outweigh the harms?Even if they do, does the company want to be connected to a practice that many people find immoraland that is illegal in many countries? Pat found this practice particularly distasteful when looking at itfrom the perspective of the females who would not be born simply because of their gender. Patwondered, is this practice fair to them? And aren’t we all facilitating the practice by looking the otherway? What would happen if such gender discrimination were globally accepted as normal practice?Could that ever be the right thing to do?’’ What would international health organizations such as theWorld Federation for Ultrasound in Medicine and Biology (WFUMB), which provides training andeducation to doctors worldwide, have to say about such practices? Pat wondered what his wife wouldthink if she knew that his work involved this unexpected result? Would she expect him to do something?What is his individual responsibility here? What is his company’s responsibility?

Because Pat felt so confused by what he had read, and he didn’t fully understand the legal or cultural environment, he never mentioned the subject to his Asian clients. But it remained in the back of hismind. When he returned home, he kept thinking about it. There was no formal structure for him tosurface the issue within the company, so he decided to discuss the subject with some trustedcolleagues. He wondered whether they were aware of the issue and what they might think about it.Were they as bothered as he was? It turns out that they were as unaware of these practices as he hadbeen. It also seemed more distant to them because they had not traveled to Asia as he had, and therewas no agreement about what to do. Engineers tend to think about products only in technical terms—the potential for technical flaws and dangers that might harm patients. They rarely encounter theultimate end users, and they’re not trained to think about cultural implications.

As a Westerner, all of this was particularly hard for Pat to deal with. He was caught completely off guard.He asked himself: What do I need to do, if anything? I’m scheduled to return to these countries tosupport our clients’ use of our technology, so I won’t be able to avoid the issue for long. It seems almostridiculous that I became aware of this issue through a travel book. If it hadn’t been for that book, Iprobably never would have thought about the issue at all. My company had not prepared me. It offeredno special training on cultural or ethical issues for employees they send to work overseas. It seemed likethe company’s values of providing people with the opportunity for earlier diagnoses prevented us fromexploring the potential misuse of our product. The company and industry focus on how to developtechnologies to identify life-threatening conditions earlier, better, and faster. We like to think ofourselves and our technologies as saving lives, not risking them. The company’s stated value is toprovide health-care solutions to patients worldwide. But, in this case, our technology was being used to both save and end lives. Do our values need to change? I think of our company as being good andethical, but we were obviously unprepared in this case. We had not done our homework. Even if thecompany wanted to do something, Pat wondered what they could do. The company is an originalequipment manufacturer (OEM), meaning that it doesn’t sell directly to the end users. Therefore theresponsibility for putting these technologies into the wrong hands is widely dispersed across differentmanufacturers, distributors and local institutions. Pat also wondered whether and how the companycould influence these different parties to take action even if it decided it was right to do so. On top ofthat, the company is in the United States, and these end users are halfway across the world.

Case Questions

Consider Pat’s concerns as described in this case and prepare a memorandum that addresses the concerns described below. Your memo should be completed in narrative form (you may use headings ifyou choose to do so for organizational purposes, but do not list your responses in bullet form). Maximumpage length: 10 pages (double spaced).

Identify all of the potential ethical issues you see (if any). Describe and analyze the implications of eachissue, including who or what may be affected by the company’s response. In identifying issues andaddressing their implications, your discussion should be as comprehensive as possible—you shouldconsider any economic, social, or ecological implications, as well as the potential impact at least twocultural differences you can identify.

Additionally, your analysis should thoroughly identify and discuss at least two potential courses of action that the company could take with respect to each issue you have discussed. Clearly demonstrateyour reasoning process—identify and explain any ethical principles or arguments you are relying on; donot simply state unsupported conclusions.

If you choose to apply any approaches to ethical reasoning that you learned about in this course, clearly state what they are and how you are applying them to this case. Of the possible solutions youidentified, which would you recommend that the company adopt as a resolution? Again, fully explainand justify your recommendations. Finally, explain how you would implement each solution you have recommended.