A dilemma for sonographers, and considering the greater good

I was on another panel last week. An annual gathering of sonographers (ultrasound specialists), nurses, radiologists and other imaging professionals. This conference covered a lot of ground, with sessions called ‘Face’, ‘Spine’, ‘Placental Function’ and other prosaic-sounding topics that didn’t leave much to the imagination. I didn’t attend these sessions, but somehow I can picture how they went.

The session in which I participated was titled ‘Sex and Ultrasound’ – sex, in this case, meaning gender. (I was amused to note we were slotted somewhere between ‘Diagnosis and Management of Limb Anomalies Which are not Part of a General Skeletal Dysplasia’ and ‘Thorax’.)

It was a small panel: me, a lawyer/bioethicist and a diagnostic radiologist; and a large crowd of several hundred people. The panel was assembled in chairs in front of the whole group to discuss Sex and Ultrasound as it pertained to a rather inflammatory news item (published in the Toronto Star) that had been making the rounds since last year.

The gist of the news report was this: some Toronto area hospitals were implementing communications policies which disallowed ultrasonographers from revealing the sex of their fetus. Instead, the patient would need to wait until she saw a physician, who had seen the written report signed by the radiologist. The journalist then noticed that, “whether by coincidence or by design”, these hospitals were situated amongst large concentrations of Southeast Asians, a cultural group thought to perform ‘female feticide’–aborting a fetus because it is female. The suggestion then, is that Toronto hospitals were making moves to combat this barbaric problem which immigrants have brought over with them.

(A follow-up editorial calling out this racism is here.)

Starting the session with this news item was intended to provoke and irritate. Fair enough. It was a conversation-starter, providing the backdrop for a number of questions posed to the audience.  Loosely paraphrased:

Do the audience members’ hospitals have a communications policy in place? Do the audience members feel comfortable talking to their patients? Do the audience members tell their patients what they see on the screen if it’s good news? If it’s bad news? Do the audience members tell their patients the baby’s gender but not other details? And more of the like.

This seemed an odd discourse to me.  Many pregnant women have had ultrasounds where the person scanning has pointed out fingers, toes, a healthy beating heart, and if it’s there and we want to know, also a penis.  I wouldn’t have guessed it was a matter of debate.

During the panel discussion I learned about some of the complicating factors:

Sonographers can ‘observe’ but not ‘diagnose’

The distinction between what you see and what you conclude because of what you see is an important one. Sonographers are allowed to make observations but not diagnoses. So one of the debated points was whether the sex of the fetus was an observation or a diagnosis.  Generally speaking most agreed it’s an observation–although things get murky if patients are getting abortions because of these off-the-record remarks.

The patient can generally tell what’s going on anyway

In the olden days before real-time scanning, the patient wasn’t immediately privy to the scan images or findings. The technician was essentially a specialist photographer, who would capture the images and send them to the radiologist.  The radiologist would then write a report and send it to the patient’s doctor – whose receptionist would phone the patient and tell them the news right then, or would schedule the patient for an appointment to discuss the results.

As technological advances made scanning more transparent to the patient, the sonographer, as yet unfettered by hospital bureaucracy, might freely chat with the patient and relay what he or she was seeing. Usually it’s a happy exchange, but what if the scan results aren’t as planned? In my case, the horrific discovery by the technician of Owen’s fetal hydrops rendered her speechless and insensitive, caught in her own discomfort. She wouldn’t look at me, turned the screen away from me and told me she couldn’t talk to me—all the while making a digital audio recording of the scan, narrating the abnormalities into a microphone which I could easily hear.

Real-time scanning has changed the nature of the testing. The patient can see what is happening, on the screen and on the technician’s face. She can ask questions, demand answers, look the unfortunate scanner in the eye while he tries to hide his panic when he can’t find the heartbeat the patient so eagerly wants to see.

If information is wrong, the hospital or clinician can be liable

If a patient makes a decision based on the unconfirmed ‘observation’ of a sonographer, and the observation proves to be wrong, the hospital may find itself at the wrong end of a lawsuit it perhaps felt could have prevented.  So rather than properly train the sonographers to have uncomfortable conversations (which, by the way, many can do quite capably), some hospitals and clinics wonder if they should ‘policy’ their way out of risk by not allowing them to talk.

So back to the matter at hand:

The discussion was focused on gender, and whether or not sonographers should tell patients the sex of their baby if, based on their observations and experience with the mother, they suspect female feticide.

Many in attendance (including the presenters) easily identified the racist undertones. But, the discussion brought out points that are worth exploring. So let’s unpack some of the details, and explore why the answer to the above question is an unequivocal yes.

Rights of the fetus

  • In Canada, women do not need to explain their reasons for wanting an abortion, and do not need to justify having had one.
  • In Canada, a fetus has no legal status as a person. A live baby of course does, but a mother or physician cannot be charged with murder (for example) if they participate in an abortion.

For these reasons alone, it should be obvious that a woman cannot be prevented from having an abortion or be granted fewer rights because someone finds a suspected or (even known) reason for wanting an abortion distasteful.

Rights of the patient

  • Unfortunately, we don’t have a charter of patient rights in Canada. However in Ontario we do have the Ontario Health Care Consent Act, which protects our rights to refuse or consent to treatment.  There is also legal precedence to support that healthcare providers have a variety of obligations to the patient, including right to information. And most professional colleges and governing bodies in healthcare acknowledge the patients’ right to access their own medical information.  I realize as I write this that my knowledge of patient rights legislation is quite low…  If anyone wants to chime in about patient rights in Canada as it pertains to access to information (whether documented or not), please do!

Reproductive and human rights

  • It’s not lost on me that we’re talking about a 100% female patient population. One could say it is a population which the ‘powers that be’ wish to influence and subjugate for what is perceived to be a greater good. I probably don’t have to throw a rock too far to hit examples of how this misguided ideal can go horribly wrong.
  • Historically, the arrogance of medicine and healthcare has had ill effects for men and women alike. Lobotomies, forced sterilizations, over-medication, institutionalization, over-surveillance… This particular issue–fear of female feticide and poor resulting public policy–is not out of place in this unfortunate narrative.

 Just when I thought everyone was on the same page

My last comment in the panel discussion was to say that fear of litigation (which had been another related topic) and the desire to socially engineer all of humanity were two different things and should be discussed as distinct issues. They could probably do something about the first problem, but the second?  I thought not.  The scan in the ultrasound clinic is not the time or the place to express one’s distaste (or act upon it by withholding information) for a patient’s motives, especially if she is behaving within the bounds of the law.

This prompted a question from the audience:  “But what if,” she said, “what if I know for sure that the patient is going to have an abortion if she finds out she is going to have a girl?  If I tell her, wouldn’t that be like handing her a loaded gun? Maybe I shouldn’t tell her?”

I answered in a way you may have guessed (“Yes you should, and it’s none of your business”) and the other panelists had similar remarks. But I felt for her and her internal conflict.  With technological progress comes some of most difficult moral dilemmas of our time.



  1. Okay…the conference titles…certainly “prosaic”! Very funny.
    Second…inflammatory article. Yes.
    Third…Lawyer/bio-ethicist? Gotta love that. Hoping for plumber/bio-ethicist too. It must be understood that, right now, as things stand, ANYIONE can be a bio-ethicist. As it is already a questionable “job title”, sticking lawyer along with that? OMG…it’s almost karmic.
    Fourth…the reply piece calling the first one racist? Sorry…an awful piece of writing. Just as inflammatory. I cannot help but wonder, Jennifer, about the whole “choice” issue. Does a woman who comes from a cultural background where girls are not as valued as boys really have “free choice over her body” when she goes home and announces to her family that she is carrying a female fetus? Is it not okay to say that, in Canada, the aborting of female fetuses is not acceptable? We don’t allow genital mutilation of girls, we don’t honour sharia law…do we let female feticide slide? I don’t see the problem with keeping sonographers out of a difficult situation: make sex disclosure something that happens between a doctor and the woman, but make it happen across the board, not just at some hospitals.

    • Claire! There you are…! :)

      Okay, bit by bit:


      was just my shorthand – first being her last paid job, second being her former training. She was brought to comment mostly on the legal aspects of whether or not someone must disclose sex, and whether the patient has the right to know. And you’re right in calling out that Bioethicist is not a regulated credential…

      Both articles are inflammatory:

      Yes, I agree. I forgive the second one because it was an opinion/editorial piece.

      Condoning female feticide:

      I don’t condone it for a second. But, I was there representing the patient in the healthcare setting, not the fetus. Should information be hidden from a patient because someone suspects something is amiss, possibly because of racial profiling…? Of course not. I didn’t comment on public policy or need for counseling or whether or not the law should change. it was a 30 minute session :)

      Abortion of female fetuses:

      Is it not just as upsetting that a deeply religious family might shame and pressure their pregnant daughter to keep a pregnancy to term, despite her desire to abort? Or that one chooses to abort a fetus with Down Syndrome just because of that fact…? I don’t see how we can address any of these issues through legislation. In fact it would be deeply compromising to womens’ rights to do so. Motive is NOT a criteria for abortion in this country.

      In this sentence: “Is it not okay to say that, in Canada, the aborting of female fetuses is not acceptable?” – I’m not sure if ‘acceptable’ refers to a law you would like to see in place, or if you just mean that regular Canadians find it offensive… Either way, I’m very surprised at the suggestion. Any woman in this country can get an abortion or carry a pregnancy for her own private reasons. It is lamentable to be sure that it could be due to pressures, for example – if I do [this], I won’t be ostrasized. But surely it is a problem if we construe a set of laws or policies to govern one type of woman over another? This isn’t a mental health issue or a capacity issue. My guess is these women likely know all too well what they are facing, and I think it’s patronizing to think we can legislate the problem away.

  2. I was surprised that there wasn’t anything in your piece about ways of creating awareness so that people feel they do have choices — not that they “have” to abort because it’s a female, or that they “have” to abort because the child has down syndrome. I don’t believe in legislating change but to just throw our hands up and say these are cultural forces and there’s nothing we can do about them is really empty to me. I don’t have it in front of me, but I thought your last piece was about ensuring that deeply held medical and cultural biases about the impact of a child’s disability on a family are not the only pieces of information presented to a woman who receives a prenatal diagnosis. I’m certainly not advocating not telling the truth to patients. But this article makes me feel that there’s nothing we can do to improve a woman’s informed choice.

    And congrats on getting into school!

    • Hey Louise!

      My interest here, in this piece, is exploring whether or not information should be conveyed. It’s not meant to be a journalistic exercise where I explore all the related issues. I’m sharing my experience from this conference. Also, I didn’t say anything about bending to cultural forces – I only said that the law provides for a woman to have an abortion without justification, and this should equally apply to those who are influenced by a different cultural agenda. Until the law catches up in some way with whatever it needs to catch up with, it is not up to individual clinicians to make up special exceptions.

      And re: school – thanks :)

  3. ” Until the law catches up in some way with whatever it needs to catch up with, it is not up to individual clinicians to make up special exceptions.”

    Right…then maybe clinicians need to be kept out of the picture, as i said before by making, shall I now say “all” information something that is to be passed on from the doctor to the woman. Recently, I got a chest x-ray. The technician is not allowed to pass on any information about the scan to the patient. This is a clearly written policy, written on placards, all over the clinic. Why not the same for ultrasounds? Solves a lot of problems for the techs. Lets the docs handle any trickier situations, should any arise.

    Your points are well taken…and I was merely joking about the lawyer/bio-ethicist thing. I am not particularly fond of either. To put them together in one package was just too funny to me!

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