Guest post by Carolyn McLeod and Andrew Botterell:
The provincial government of Ontario recently announced that beginning in 2015, it will fund one cycle of IVF for people suffering from infertility. At the same time, it will require single embryo transfer for each funded cycle and will not pay for the drugs required for IVF, nor for the cost of ancillary services, such as embryo freezing. Although this proposal is not as comprehensive as Quebec’s program, which pays for up to three cycles of IVF (with ovarian stimulation), this is undoubtedly good news for women who would otherwise be unable to afford IVF, and for those who see in this proposal the promise of stricter oversight of fertility clinics, which currently operate in a regulatory grey zone.
To state the obvious, this public policy decision raises many medical, economic, political, legal, and ethical questions. But the central question arguably is, “On what basis, if any, can this program be justified?” The cynical view is that the justification is political, pure and simple. A provincial election is on the horizon, and the announcement of the program, the details of which will not be finalized until well after the election, promises to boost the Liberal party’s chances of electoral success. On this view, the proposal is simply an attempt to curry favour with voters. A recent article by Martin Regg Cohn in the Toronto Star supports this view. According to Regg Cohn, Deb Matthews—Deputy Premier and Minister of Health and Long-Term Care, and co-chair of the Liberal re-election team—has in the past opposed funding IVF, saying that it was too expensive, and claiming that the cost of funding IVF was not likely to be offset by future savings. She has now decided that funding IVF is in the best economic interests of the province. Says Regg Cohn: “Same health minister, several years of gestation. What changed, other than the election cycle?” That’s a good question.
But let’s set the political issue to one side. For even if the immediate reason for the government’s decision to fund IVF is based in part on political calculations, there may be other, more principled, grounds on which the decision could be justified.
With this in mind, consider the oft-repeated claim, made by fertility doctors and Ontario’s Ministry of Health and Long-Term Care, and endorsed by Ontario’s Expert Panel on Infertility and Adoption, that public funding for IVF is needed in order to reduce the number of multiple births in the province. On one reading, this claim is disingenuous; on another, it is false. (For a similar criticism, see Françoise Baylis’s Impact Ethics blog post here.) It is disingenuous for fertility doctors to claim that only a publicly funded IVF program can reduce multiple births when they themselves could simply avoid procedures—such as IVF with multiple embryo transfer or intrauterine insemination (IUI)—that increase the likelihood of a multiple pregnancy. If this is good medical practice, then physicians should simply do it. To suggest that they will practice good medicine only if IVF is publicly funded is to abdicate their responsibilities as medical professionals. Moreover, even if such criticism is unfounded, the claim that the government needs to fund IVF in order to address concerns about multiple births is demonstrably false. This is because the government has other options available to it. Most obviously, it could simply regulate fertility clinics and refuse to license those clinics that provide IVF with multiple embryo transfer. It could also choose to discourage other procedures that are themselves a significant cause of multiple births, most notably IUI, which is currently funded by the government. Again, no multi-million dollar program is required.
A related argument in support of public funding of IVF also involves purely economic considerations. Privately funded IVF with multiple embryo transfer currently gives rise to many costs associated with multiple births. But—goes the argument—publicly funding IVF with single embryo transfer promises to reduce the overall cost to the healthcare system. For if fewer multiple births result from IVF, less money will need to be devoted to caring for the health complications that are typically experienced by such children, and by the women who gestate and give birth to them. We can quibble about the exact numbers, but let us assume that this is more or less correct: that the costs of funding IVF upfront will be offset by savings elsewhere in the healthcare system. All the same, this argument should be resisted. For one thing, it ignores the fact, discussed above, that similar savings could be realized by regulation alone. But more importantly, if this is a good argument for funding IVF, then it is a good argument for doing much more than what the Ontario government is currently proposing to do. Recall that the Ontario government is proposing to fund one cycle of IVF, minus the cost of the drugs. However, after an unsuccessful cycle of IVF—and according to the Canadian Fertility and Andrology Society, 66-90% of all IVF cycles are unsuccessful—individuals will again be free to undergo IVF with multiple embryo transfer. In short, if the goal is to cut down on multiple births by women undergoing IVF, a much more expansive program would seem to be required. But this is not what the Ontario government is proposing. This suggests that overall cost savings to the health care system cannot be the main justification for the government’s recent announcement since again, if it were, the government would be proposing to do much more.
(As an aside, it is also sometimes said that the costs of funding IVF upfront will be offset by an increase to the future tax base of the province made by children created via IVF. Perhaps. But if this is a good argument for funding IVF then it ought also to be a good argument for funding international adoption, and there is no indication that the Ontario government is proposing to do that.)
What about the claim that IVF ought to be funded because infertility is a disease (according to the World Health Organization), or, more broadly, a medical condition (according to the Ontario government)? Here attention must be paid to the condition that the government is seeking to rectify. In announcing its IVF program, the Ontario government indicated that the program is designed to help people “start and expand families,” which is not the same as saying that the program is designed to help people create biological offspring. But there are other ways to start and expand families that do not involve funding risky medical procedures. Adoption springs to mind. In other words, if the goal is to enable Ontarians to start and expand families, there is already a public policy option available, viz., adoption. So why fund a program that will surely result in fewer children being adopted? To this, it will no doubt be replied that not everybody wishes to start or expand their family by adoption, and it might be thought that the desires of these individuals for biological offspring should be accorded a certain amount of deference. A number of philosophers have questioned the basis for this desire. But even if the desire is a legitimate one, does it follow that taxpayers must subsidize what economists would call the “expensive tastes” of those individuals who are interested in creating or expanding only a biological family? We very much doubt it.
A final argument in support of public funding for IVF relies on the so-called right to reproduce. Very simply, the thought is that individuals have a right to reproduce or procreate, and that by failing to fund IVF, the Ontario government is unduly interfering with the exercise of this right. We have expressed our skepticism about this right elsewhere, but for the moment the following observations will suffice. The right to reproduce, properly understood, is what philosophers call a negative right: it protects people from arbitrary interferences with its exercise. (If I have a right to reproduce, the government cannot tell me who I can reproduce with, or force me to be sterilized or to have an abortion.) On the other hand, my right to reproduce does not include an entitlement to any of the resources I might need to exercise that right. Why? Because I may not have a right to those resources. Thus, even if people have a right to reproduce, it does not follow that the government must provide infertile people with the resources that will enable them to exercise this right. That conclusion requires a separate justification.
As we noted, the government’s decision to publicly fund IVF raises a host of difficult issues. The evaluation of this decision also cannot take place in a vacuum: that is, in isolation from current health care spending (which consumes approximately 40% of Ontario’s budget) or from the general economic situation of the province, or without taking into account the provincial government’s attitude toward adoption. Still, even when this decision is considered in isolation, it is difficult to discern any principled justification for it. The need to reduce multiple births cannot justify the program, since that goal can be accomplished by less costly means, viz., by legislation and regulation. Classifying infertility as a disease or a medical condition cannot justify funding IVF since the inability to start or expand a family can be addressed in other, non-medical ways. And an appeal to a right to reproduce cannot justify funding IVF because, being a negative right, it does not include an entitlement to government aid. We would appear to be left, then, with some variation on the cynical view with which we began: that the only true basis for the Ontario government’s recent decision to fund IVF is political maneuvering.