Countries Where Prenatal Testing Is Mandatory – International Systems and Ethical Issues

Introduction

Non-Invasive Prenatal Testing (NIPT) has garnered significant attention as a breakthrough method that can detect fetal chromosomal abnormalities with high accuracy in early pregnancy. At the same time, some countries and regions have begun to institutionalize or mandate prenatal testing, raising complex ethical debates worldwide. This article explores real-world examples of where prenatal testing is effectively mandatory, examining institutional systems and ethical implications from a professional perspective.

What is Prenatal Testing?

Prenatal testing is a medical screening conducted during pregnancy to assess fetal health and identify congenital disorders.
NIPT, in particular, analyzes fetal DNA from maternal blood to detect chromosomal abnormalities such as trisomy 21 (Down syndrome).

• Timing: Available from the 10th week of pregnancy
• Conditions Detected: Trisomy 21, 18, 13, etc.
• Accuracy: Positive predictive value for Down syndrome exceeds 99%
• Source: Japan Society of Obstetrics and Gynecology

Are There Countries Where Prenatal Testing is Mandatory?

China: De Facto Mandate in Some Regions

In urban areas of China, NIPT has become widely adopted, and in some localities, medical institutions actively recommend or carry out prenatal testing for all pregnant women. Although not legally mandatory, systemic pressure and physician guidance effectively compel most women to undergo testing.

• Background: Rooted in the one-child policy and a national emphasis on healthy births
• Issues: Pressure to terminate pregnancies based on results, lack of transparency in information delivery

Singapore: Universal Prenatal Screening Program

Singapore is gradually standardizing NIPT as part of its national prenatal care framework. Major hospitals, including the National University Hospital, routinely offer NIPT to all pregnant women. In some cases, public insurance or government subsidies are available, making the program effectively compulsory in practice.

• Source: Singapore Ministry of Health

Israel: Recommended Screening Based on Genetic Background

Due to high genetic risks among Ashkenazi Jewish populations, Israel strongly recommends prenatal screening for specific inherited conditions. Under government-funded healthcare, all pregnant women are provided access to these tests, creating a system that approaches a formal mandate.

• Source: Zlotogora J. et al. (2009), Genetics in Medicine

Ethical Issues Raised by Mandatory Prenatal Testing

Mandatory prenatal screening raises numerous ethical concerns. Key issues include:

1. Infringement on Autonomy
   Mandating testing can undermine a woman’s right to choose. The right to decline testing must also be respected.
2. Promotion of Eugenics
   If testing leads to social pressure to abort fetuses with disabilities, it may fuel discriminatory notions that devalue certain lives.
3. Discrimination and Stigmatization
   Parents who choose to carry pregnancies with disabilities may face social criticism or isolation. Institutionalized screening could unintentionally reinforce discrimination against people with disabilities.
4. Lack of Information and Counseling
   Some women may feel pressured into testing without fully understanding its implications. Robust informed consent and proper counseling are essential.
   • Source: International Society for Prenatal Diagnosis (ISPD) Ethical Guidelines

Comparison of National Policies and Japan’s Position

Country	Mandate Status	Features & Institutional Background
China	De facto mandate	Some regions conduct testing for all pregnant women
Singapore	Effectively mandatory	Government-led universal screening program
Israel	Strongly recommended for specific groups	State-funded testing based on genetic risk
Japan	Completely voluntary	Offered only by certified institutions; not covered by public insurance

In Japan, NIPT is entirely voluntary and conducted under ethical guidelines. As of 2022, the Ministry of Health, Labour and Welfare has been reviewing the framework for prenatal testing with attention to legal and ethical considerations.

• Source: Ministry of Health, Labour and Welfare – NIPT Discussion Papers (2022)

Future Challenges and the Need for Public Dialogue

As more countries move toward mandated or quasi-mandated prenatal testing, balancing “technological progress” with “social and ethical consensus” is critical.

• Legal protections to guarantee free choice
• Public education to prevent discrimination based on test results
• Enhanced psychological and social support for pregnant women and families

These elements are essential to build a society that can properly integrate prenatal testing into ethical and equitable healthcare.

The Impact of Technological Advancements on Policy

The push toward institutionalizing prenatal testing is partly driven by rapid advances in testing technology:

• High Accuracy, Low Invasiveness
  Compared to traditional maternal serum or amniocentesis tests, NIPT offers superior safety and precision. For Down syndrome, the predictive value exceeds 99%, creating favorable conditions for national adoption.
• Declining Costs and Increased Accessibility
  Technological innovation has significantly lowered test costs. Once priced around ¥200,000 per test, NIPT is now available for less than ¥100,000 in many places. In some countries, public health insurance covers a portion, lowering barriers for policy implementation.
• Digitalization and Genomic Data Concerns
  As result delivery and counseling move online, concerns about genetic data privacy rise. Legal safeguards must be established to prevent misuse of personal genomic data by insurers or third parties.

The Influence of Religion and Culture

Cultural and religious beliefs significantly affect the acceptance and implementation of prenatal testing policies:

• Caution in Christian Societies
  In Catholic-majority nations (e.g., Poland, Ireland), strong beliefs in the sanctity of life often result in skepticism toward prenatal screening that could influence termination decisions. Institutional adoption of such testing is limited.
• Islamic Guidance on Medical Termination
  In Islamic jurisprudence, termination before 120 days of gestation may be permissible for medical reasons. Accordingly, some Middle Eastern countries (e.g., Saudi Arabia, Iran) actively promote testing for specific genetic disorders, though approval from ethical or religious authorities is often required.
  • Source: Gatrad, A. R. & Sheikh, A. (2001). Medical Ethics and Islam
• Japanese Cultural Sensitivities
  In Japan, societal stigma toward disabilities persists, but the public is also highly sensitive about “selecting” life. There is great individual variation in attitudes toward testing, and policy remains cautious. Information quality and support systems also vary by region, underscoring the need for a national framework.

From “Mandatory Testing” to “Supported Choice”

While technological advancements and social demand have boosted the availability of prenatal testing, mandating such testing carries ethical and legal risks. Recent discussions emphasize the importance of choice and informed consent over enforcement.

• Supportive Decision-Making: Provide tailored information and options based on each woman’s values and circumstances
• Multidisciplinary Counseling: Medical professionals, genetic counselors, and psychologists work together to offer personalized guidance
• Equitable Public Support Systems: Create structures that ensure access to testing and support regardless of income

This approach promotes a society where everyone can make informed and autonomous reproductive choices—without coercion.

Conclusion: Rethinking Mandatory Prenatal Testing in a Changing Society

While some countries have implemented mandatory or quasi-mandatory prenatal testing, such policies often arise from complex socio-political and ethical backgrounds. Although mandatory testing may appear logical in certain contexts, it must be weighed against individual autonomy, disability rights, informed choice, and the quality of institutional support.

Japan has much to learn from global examples, but it must develop its own model tailored to its values, laws, and social context. The core question is not “Should prenatal testing be mandatory?” but rather “How can we create a society where everyone can make choices they truly understand and accept?”

References

• Zlotogora, J. & Levy‑Lahad, E. (2009). Genetic Screening in Israel: An Overview. Annual Review of Genomics and Human Genetics
• International Society for Prenatal Diagnosis (2021). Ethical Guidelines for Non-Invasive Prenatal Testing
• Ministry of Health, Labour and Welfare (Japan), Expert Committee Reports on Prenatal Testing (2022)
• Japan Society of Obstetrics and Gynecology, Recommendations on Prenatal Diagnosis
• Singapore Ministry of Health – Prenatal Screening Guidelines