Ethical Implications of Increased Access to IVF

Ethical Implications of Increased Access to IVF
June 4, 2021 No Comments Vision of Justice Clara S. '23

The Ethical Implications of Increasing Access to IVF, When Considering Socioeconomic, Regional, Ethnic, and Race-based Exclusivity

By Clara Schreibman

Table of Contents


Abstract

Advances in technology in the past half-century have made it possible to create a life outside the human body. In vitro fertilization (IVF) – has been available for over forty years but still is not equally accessible to infertile people of all races and socioeconomic backgrounds. Multiple barriers prevent the widespread use of this tool. This raises several ethical questions. Is IVF ethical? Is it ethical to allow some patients to access IVF when they are not equally available to everyone? Is there a duty to make IVF widely available? Who should bear that responsibility?

Introduction


This paper will be guided by the framework of consequentialism and the values of justice, autonomy, equality, fairness, and responsibility regarding the right to access IVF. Specifically, this research paper will outline inequalities in access to IVF. I will illuminate how insurance coverage and racial and ethnic prejudices discriminate against people of individual races and socioeconomic backgrounds. I will be using IVF as an example of infertility treatment. I will also offer suggestions for addressing these inequalities and acknowledge the objections and concerns that may arise from these suggestions.

I am a sophomore in high school, and throughout my middle and elementary school education, I was surprised by the high percentage of twins in my grade. I went to a PWI (predominantly white institution) middle school, which led me to question if the high percentage of twins was typical in other areas. I currently attend a high socioeconomic high school, and there are six pairs of twins in my grade of eighty girls. I have questioned this seeming anomaly and noticed that most of the twins in my grade are caucasian and have older parents. These commonalities initially piqued my interest in IVF. I questioned the availability of IVF for people of lower socioeconomic status and minority groups. Through my research, I have learned how access to IVF is unequal.

Key points

The creation of a family is a fundamental human right. In the United States, economic, racial, ethnic, geographic, and other disparities exist in access to fertility treatments and treatment outcomes. Economic factors are the chief contributors to disparities in access to effective treatment, but social and cultural factors also play a role. Further research is needed and encouraged to understand treatment and success disparities and improve treatment methods to reduce those significant disparities.


In Vitro Fertilization Background

In Vitro Fertilization is one of the most invasive, expensive, and successful treatments for infertility, where an egg is combined with sperm outside the body. Most people using IVF use three to six cycles to reach pregnancy. Pregnancy through IVF is achieved in an average of 27.3% of all cycles but is higher or lower depending on the woman’s age. The percentage of cycles that result in live births is 22.2% on average and is also higher or lower depending on the woman’s age. For example, a 35-year-old woman undergoing IVF has a 39.6% chance of success. (Webmd).

One might consider IVF if they or their partner; (a) have low sperm count, (b) have problems with ovulation due to conditions like polycystic ovary syndrome; (c) have problems with the fallopian tubes, (d) have endometriosis; (e) have been sterilized, or (f) wish to avoid passing on inherited genetic disorders to their children.

(“When to Consider IVF.” Pregnancy Birth and Baby)

The IVF process is as follows; sperm is collected, cleaned, and stored. Eggs are then harvested where ovaries are stimulated by injected medication, and eggs are removed. Egg and sperm are then combined in a laboratory setting, and embryos are grown and tested for genetic abnormalities and then frozen. The uterus is then prepared to implant embryos in a sterile setting, which involves a large and highly trained team of embryologists, andrologists, doctors, and nurses. Patients are required to come to daily ultrasounds for weeks and undergo and recover from anesthesia twice. IVF is a resource and time-intensive procedure. Therefore it is not surprising how expensive it is. (Penn Med.)

https://zealthy.in/en, CC BY-SA 4.0 https://creativecommons.org/licenses/by-sa/4.0, via Wikimedia Commons

While this 1981 life-creating technology is effective, its benefits are not shared equally across the US population. African American women have twice the rate of infertility when compared to their caucasian counterparts, controlling for many factors.

However, making up 13% of the population, African Americans only make up 3% of IVF patients. The USC-Fertility center found that out of 2,000 women undergoing IVF between 1994 and 1998, 91.5% were caucasian. 

These statistics highlight severe disparities in access to infertility treatment. To understand the complexity of these disparities, we first need to acknowledge the importance of reproduction and understand the highly harmful effects infertility has on people who desire biological children.


Addressing the Unfairness of Infertility by Recognizing It as a Disability

Access to IVF highlights a conflict between personal autonomy (the desire/ability to conceive a biological child) and justice (whether society should collectively bear the cost of this exercise of autonomy). Infertility represents a primary bodily system dysfunction and hinders life quality in significant ways. (The Ethics Committee of the American Society for Reproductive Medicine has recognized infertility as a disease).
Whether infertility is a disease or not is worth discussing. Most diseases are harmful to everyone who has them, but what about infertile women who do not desire biological children? Of course, even if it were true that infertility is not a disease, we still owe each other fair treatment for it (we require other kinds of medical care that are not specifically about treating a disease).
Arguments to the contrary or against the medical necessity of treatment are unpersuasive. The continued exclusion of infertility treatment from most private and public healthcare insurance policies (long after fertility treatment has ceased to be experimental) does not allow those who need medical help for procreation from the ability to obtain it. Involuntary childlessness due to infertility can profoundly impact people’s lives.

Infertility can cause medical, emotional, psychological, and social harm.

Anxiety is significantly higher in infertile couples when compared to the general population, with 8%-28% of infertile couples reporting clinically significant anxiety. Various research studies support the theory that distress is associated with lower pregnancy rates among women pursuing infertility treatment. “[…]exploration of this is also an important task to manage this devastating problem, which has a cultural and social impact” (Psychological aspects of infertility, Prasanta Kumar Deka, Swarnali Sarma). 

The CDC states, “[t]he stress of the non-fulfillment of a wish for a child has been associated with emotion[s] such as anger, depression, anxiety, marital problems and feelings of worthlessness among the parents.” Infertility poses significant barriers to quality of life.

Mental illnesses are not sole contributors to the pain for infertile couples. “Psychologists must understand that infertility is a trauma, and often a complex trauma,” Bradow, a psychologist who wrote a paper on infertility, writes. “While anxiety, depression, and grief and loss are all a part of the psychological impact of infertility, there is much more to the experience which is defined by the individual.” (Townsend, Regina. “The Lasting Trauma of Infertility.” The New York Times). Although access to IVF is not a cure for these conditions, lack of access is a primary contributor, and improving access and utilization is vital. A consequentialist might consider the highly adverse effect/impact of infertility on the US population. The consequence includes worse mental health of the public, which causes burden in all aspects of life. 

The Supreme Court has treated infertility similarly to blindness, deafness, and epilepsy. (Bragdon v. Abbott). Deafness is usually considered a disability, but it is one that many deaf people feel does not make their lives overall worse (and so is not a disease, even though it is clear that we should have the kinds of health care and health professionals equipped to care for people who are deaf) – similar to infertility. 

Acknowledging the significant struggle for infertile people who want to procreate often causes the desire for IVF to be understandable. This desire is not always met. Gaps and inequalities exist in treating specific disadvantaged subgroups of the US population; it is considered a health disparity. Many individuals in the United States with impaired fertility that they want to treat go untreated or undertreated. This lack of treatment may be detrimental to the individual’s, couple’s, or family’s overall health, social status, and family stability.


Legal Recognition of the Importance of Reproductive Capacity

The US legal system has recognized the importance of reproduction in modern American life for many decades. 

Reproduction of the Past: 

Reproductive capability has not always been legally validated and protected in the United States and other countries. During and just before World War II, the Third Reich sterilized millions of people whom the government did not want to reproduce.  In the past, several states in the United States also engaged in the sterilization of people. In Buck v. Bell (1927), the United States Supreme Court upheld a Virginia law that allowed the involuntary sterilization of people with specific mental disabilities. However, in Skinner v. Oklahoma (1942), the Supreme Court ruled that forced sterilization of habitual inmates is unconstitutional. Such actions violated the Equal Protection Clause of the Fourteenth Amendment to the US Constitution. The Court noted that reproduction is “one of the basic civil rights of man, fundamental to the very survival of humanity.”  Since the Skinner case, the Supreme Court has become sympathetic to people with reproductive challenges. 

Image by jessica45 from Pixabay

The Inter-American Court of Human Rights too recognized the obligation not to obstruct the fundamental right to reproduction in its decision to overturn Costa Rica’s ban on in vitro fertilization.  [(Case of Murillo et al. (“In Vitro Fertilization”) v. Costa Rica, Inter-American-)]. Costa Rica overturned the 12-year ban because the Court found that citizens’ rights to enjoy reproductive autonomy and privacy, access reproductive health services, and create a family outweighed the state’s concern about the interests of non-implanted embryos. When valuing autonomy, the government should have no part in obstructing one’s right to have a child. In 2011 the World Health Organization (WHO) declared, “Infertility generates disability (an impairment of function), and thus access to health care falls under the Convention on the Rights of Persons with Disability.”

Now that we have established the challenges of infertility and the importance of reproduction – this begs the question: Should access to infertility treatments increase despite the critiques of IVF and the cost? This ethical question highlights the values of safety, equality, autonomy, responsibility, and fairness. 


Economic Barriers to Infertility Treatment

(Assisted Reproductive Technologies(ART)  procedures per million women 15–44 years of age by race/ethnicity and presence of insurance coverage mandate for IVF treatment in the United States, 2014.)

  • This graph highlights how insurance mandates for IVF treatments increase utilization across races. 

The majority of patients who undergo IVF in the United States pay out of pocket for their medical treatment. Which means that their health insurance, if they have health insurance, does not pay for their IVF procedures. This is often because patients lack health insurance, or their insurance policies do not include fertility care, cover infertility diagnosis only, or exclude IVF. 

A recent report places the median price of a cycle of IVF in the United States, including medications, at $19,200. (IVF by the numbers, Pennmedicine). 

A single cycle may represent 50% of an average person’s annual disposable income. The full course of treatment may cost significantly more. The main reason why an IVF is so expensive is because it requires many stages of preparation before and after the treatment that add up over time. When valuing justice, placing IVF at such a high price without government subsidies is unethical because it only provides IVF treatments to those with higher incomes. Under the consequentialist theory, these high costs exclude lower socioeconomic women which further divided socioeconomic differences in America. Financial burdens must be overcome if the US prioritizes the health of its people, despite socioeconomic status. Studies confirm that persons of middle to lower socioeconomic status and persons of African American or Hispanic ethnicity are underrepresented in the population of US infertility patients seeking care (Chandra A, Copen CE, Stephen EH. Infertility service use in the United States: data from the National Survey of Family Growth, 1982–2010. (DCD National Health Statistics).

State-mandated insurance coverage has been shown to increase the utilization of infertility services, making better insurance coverage a realistic solution to infertility disparities. An unintended consequence is high insurance premiums. This requires that insurance companies authorizes the medical community to address fertility needs that go unmet in other states.

Broader insurance coverage is linked to better public health outcomes

 A series of studies have shown that in states with mandated insurance coverage, the rate of IVF usage increases. Connecticut, Illinois, Maryland, Massachusetts, New Jersey, and Rhode Island provide comprehensive (or near-comprehensive) coverage for infertility treatment through legal mandates. These mandates require that private insurers cover the diagnosis and treatment of infertility, including IVF.  The consequence of these mandates impact the lives of many Americans who can now have more of an opportunity to have biological children. 

It is the federal government’s responsibility to ensure the health of its citizens. This places responsibility on the government to provide health services at rates that are accessible to the entire population. Reproductive health should be an utmost priority included in health mandates. 

When compared to Europe

IVF accounts for approximately 1.5% of births in the United States, compared with an average of 3% of births in Europe, and higher percentages in many countries that publicly fund IVF, such as Denmark (5.9%), Belgium (4.0%), and Sweden (3.5%). (Assisted reproductive technology surveillance–United States 2011. And European Society of Human Reproduction and Embryology. ART fact sheet.)

It is apparent that many US women and men with impaired fecundity, or the threat of the inability to produce offspring go untreated or under-treated. 

Cost should not be as significant a barrier, as the price of insurance coverage for fertility treatment is modest. States with mandated insurance coverages that include IVF allow more people to benefit from treatments, and overall reduces the cost of IVF. Massachusetts, which has the most comprehensive infertility insurance mandate in the US and no monetary cap, also reports modest costs for coverage. According to a 2013 report submitted to the Commonwealth as part of legislatively required reporting, infertility treatment accounted for somewhere between the outer bounds of 0.23% and 0.95% of premium costs. Viewed in a broader context, infertility treatment is significantly less expensive than many insured medical procedures. For example, a cycle of IVF costs one third as much as hip replacement surgery. (fertstert.org). A hip replacement surgery and inability to have biological children are not comparable, but this study brings light to the possibility of comprehensive insurance mandates across the US that aren’t extreme burdens to the state. (The Ethics Committee of the American Society for Reproductive Medicine).


Equality and Fairness Regarding Regional, Ethnic and Racial Disparities in access to infertility treatment

Economics are not the only barrier  to accessing infertility care. Disparities in access to effective treatment in reproductive medicine are also tied to socioeconomic status, geography, race, ethnicity, religion, sexual orientation, and conscious or unconscious discrimination (Peterson MM. Assisted reproductive technologies and equity of access issues. J Med Ethics 2005). If specific groups continue to be barred from receiving infertility treatment, margins of health and social inequalities will increase.  Researchers who have studied African American, Hispanic, Muslim, and Asian populations in the United States have recorded that communication differences, cultural stigmas, and unfamiliarity or prior bad experiences with the US medical system can keep members of certain racial, ethnic, or religious groups from accessing infertility treatment.  Language differences discourage non–English speaking patients from seeking needed medical care. According to the ARSM, Physicians have been recorded to (consciously or unconsciously) make assumptions or biases about who deserves to be a parent and who does not. It is unethical for these experts to make assumptions that may negatively affect marginalized communities due to doctor-patient misunderstandings. African American women experienced a significantly longer duration of infertility before seeking care compared with Caucasian women (4.3 vs. 3.3 years, respectively). (PubMed, Jain T. Socioeconomic and racial disparities among infertility patients seeking care.) This longer waiting period was theorized to be a result of health care workers having biases and assumptions about African American’s pain and desire to treat infertility. 

Time Burden

Another obstacle is the time burden of pursuing cycle-based treatments, like IVF. In addition to being able to afford treatment, patients must be able to take substantial time off from work for office visits and travel to medical facilities that may be geographically distant. Many treatments require repeated visits and the ability to follow complicated medical instructions. These required visits are necessary when administering IVF, and jobs should allow these absences without a pay decrease. A potential consequence of paid leave for IVF would be an increased burden on employers. This could result in fewer women in general, or fewer infertle women in particular, being desirable in the workforce. It could also result in more women who desire biological children to have the ability to have them.

Racial disparities

Cost, though a major factor, is not the only factor keeping African American women from fertility clinic waiting rooms. In a world where African American women have the highest rates of maternal deaths and fetal deaths, it is unsurprising how infertility treatments are accessed unequally. It’s impossible to ignore the role of social factors and cultural perceptions surrounding infertility. A Nigerian American entrepreneur, Ijeoma Kola, Ph.D., who holds a doctoral degree in the history of public health, was just 28 when she experienced fertility struggles. She had a troubling trip to the doctor, where she was told she would need IVF to conceive. However, Kola suffered in silence for many months. She felt that she could not talk to others about what she was going through—she even struggled to talk to her own mother about it.

“Black women are presented as hypersexual—we get pregnant like this; we’re welfare queens. There’s this perception of an African woman having 10 kids and being hyper fertile,” says Kola. “That can be difficult to push back against if you are struggling to get pregnant.”

These harmful stereotypes not only make it difficult for African American women to talk about their infertility but may also have implications for their care. When an African American woman comes in for her annual visit, infertility may be the last thing that is discussed. This can have implications that extend past the inability to conceive. Loss of fertility can be an indication of underlying health issues such as PCOS and ovulatory disorders. (“Where Are All the Black Women at the Fertility Clinic?”)

A University of Michigan study recorded that African American women deal with infertility in isolation.  For the study, researchers interviewed 50 African-American women of different socioeconomic backgrounds about infertility and relationships with friends, relatives, and doctors. Their ages ranged from 21 to 52, and most were married. In describing the difficulties of getting pregnant, 32% of the women discussed stereotyped beliefs that equated being a woman with motherhood. Some responses included: “[e]motionally, I felt that I was not complete, because I had not had a child. I did not feel like I was a complete woman,” and “[i]t (having no biological children) would label you as a failure.” Overall, when African American women could not conceive a child, it negatively affected their self-esteem. When considering consequentialism, keeping African American women from receiving infertility treatment has both adverse and significant effects on the African American community (futurity.org). 

Among non-surgically sterile women, African Americans had a two-fold increased odds of infertility compared with White women after adjustment for socioeconomic status, maternal status, pregnancy intent, and risk factors for infertility (age, smoking, testosterone, fibroid presence, obesity, and ovarian volume). In this population-based sample, African American women were still more likely to have experienced infertility.

Common risk factors do not explain this disparity in infertility rates. If it is more common for an African American woman to be infertile, why aren’t they receiving treatment at a higher rate? (fertstert.org)  A National Health Statistics study found that only 8% of African American women access medical care for fertility-related concerns compared to 15% of white women. However, research also shows that African American women may have a higher need for these services—12% of African American women will have infertility than 7% of White women, according to the Association of Obstetricians and Gynecologists (ACOG)—leading to a vast fertility gap. The consequence of these factors are that African American women may face more challenges in achieving their dreams of biological motherhood. (Brown edu. Osinubi, Adeiyewunmi.)  

Unequal distribution of obstetrician-gynecologists and IVF centers – making infertility treatment inaccessible for many.

Unequal distribution of obstetrician-gynecologists and IVF centers – making infertility treatment inaccessible for many. 

Image result for gynecologists geographica area distribution
29-1064 Obstetricians and Gynecologists.” U.S. Bureau of Labor Statistics, U.S. Bureau of Labor Statistics, 30 Mar. 2018

As of 2015, 16 US states had five or fewer reproductive endocrinologists in practices accredited by the Society for Assisted Reproductive Technology (SART) (familybuilding.org).  The graph above shows the highest number of IVF centers are found in states with mandated IVF insurance and high median income. The concentration of physicians offering IVF per 100,000 reproductive-age women was also significantly higher in mandated vs. non-mandated states, which suggests it is economically feasible to practice IVF when most patients are covered by insurance.  (Hammoud A, Gibson M, Stanford J, White G, Carrell DT, Peterson M. In vitro fertilization and utilization in the United States: a study of demographic, social, and economic factors). This map shows that geographic unavailability may keep many from seeking treatment.

Fair access is also impaired by providers who decline to treat unpartnered individuals and same-sex couples. Despite prohibitions against fertility programs denying assisted reproductive technology (ART) services to patients on the basis of their marital status or sexual orientation, fertility programs are not always in accordance with requirements.  In 2008, the California Supreme Court ruled that refusal to treat a lesbian patient based on the physician’s religious views violated state law. The court found that assertions of religious freedom are pre-empted by state law that prohibits discrimination in public accommodations based on sexual orientation.  Fertility treatment of the LGBTQ communutiy and unmarried persons reaserch survey indicates that at least some practices refuse to accept single women, single men, and same-sex couples as patients, leaving gaps in protection against discrimination based on patient demographics. (North Coast Women’s Care Medical Group v. Benitez, 44 Cal. 4th 1145 (2008).) Physicians have an obligation to prioritize equality when administering infertility care such as IVF. 

If equality of care is a goal, the medical field must strive to mend relationships with marginalized communities, reach underserved geographic areas and provide doctors with anti-bias training.


Ethical Benefits of Improving IVF Access

Reproduction is a fundamental interest and human right, and the access, treatment, and outcome disparities associated with IVF are a form of stratified reproduction that warrants correction. Moreover, supporting increased access to IVF appropriately recognizes infertility as a disease, keeping with pronouncements by the WHO and worldwide trends.

A consequence of infertility treatment being available mainly to non-Hispanic whites and the “economic elite” perpetuates the dismissal of fertility treatment as a “lifestyle choice” or a luxury comparable to elective cosmetic surgery. This is a false idea. Infertility is, considered by many, a disability and deserves governmental mandates. Without governmental mandates to overcome these untrue beliefs, women who seek treatment will continue to lack access. 

Improved access to IVF serves social justice ends:

An Ontario, Canada, governmental panel on reproductive health states, “We believe all Ontarians should have opportunities to build a family free from discrimination based on socio-economic status, geography, reproductive health needs, marital status, or sexual orientation.”

(Ontario Ministry of Children and Youth Services).

This statement made in Canada has not been mirrored in the US. Legal scholars have argued that the lack of insurance coverage for infertility in the United States discriminates against significant groups of people and prevents them from obtaining medical assistance to reproduce. 

The cost of services means that treatments are out of reach for many people. In places like Ontario, where people are given information on fertility and assisted reproduction, those who desire IVF are not limited by what they can afford to pay. These interests apply equally in the United States and argue for universal coverage for infertility on par with other diseases coverage. In December 2014, the Canadian Fertility and Andrology Society issued a position statement supporting public funding of IVF in Canada. The ASRM, in its 2014–2019 Strategic Plan, lists as a priority, “assuring that infertility is treated by medical establishments and governmental agencies with the same level of attention and concern as are all other diseases” and calls for “a specific new focus on accessible care for all as a stretch goal.” 

I urge all IVF stakeholders to actively support legislation to reduce the economic burden on patients paying for infertility treatment. Some theorists believe in a more general duty of the state: to promote the health of its population. Moreover, conclude that genetic reproduction is an essential part of health. In Just Health: Meeting Health Needs Fairly, Norman Daniels writes, “[i]nfertility is a departure from normal functioning that reduces an individual’s fair share of the normal opportunity range and gives rise to claims for assistance” because infertility interferes with “basic functions of free and equal citizens, such as reproducing themselves biologically, an aspect of plans of life that reasonable people commonly pursue.” If this is believed, one should welcome increased access to IVF through insurance mandates. The responsibility to change disparities should be placed on physicians, policymakers, and insurance providers. (ncbj.gov) . The consequence of increasing access includes more equality in America. If infertile women who desire biological children can obtain medical resources to do so, American society should make strides to lessen disparities in access regardless of race or ethnicities. Fewer women will have the earlier described negative side-effects of untreated infertility, and society will be more equal, just, and fair.

One might object to expanding access to IVF through insurance mandates on many grounds, including health, cost, religion, or political ideology. 


Arguments Against Expanding Access to IVF through mandates

One might object to expanding access to IVF through insurance mandates on many grounds, including health, cost, religion, or political ideology. 

Risk of more IVF births: Safety

A New England Journal of Medicine study found that the use of IVF appears to roughly double the risk of having a singleton with low birth weight or a child with a significant congenital disability. Lasting effects of premature births include cerebral palsy, impaired learning, vision, and hearing, behavioral and psychological problems, and chronic health issues. These effects have lifelong costs. These defects occur even when the study controls for multiple births, maternal age and parity, the sex of the infant, and the correlation between siblings. (Mayo Clinic). 

The risk for premature birth is even more significant in African Americans when receiving IVF. This fact should not lessen the need for women aware of these possibilities to have access, if they choose, to infertility treatments. The medical field too must acknowledge racial discrimination and systematic oppression that has caused minority women to have higher obesity rates and increase premature birth rates. According to “Obesity and time to pregnancy.” (PubMed), fertility in obese women seems to be impaired. Being overweight or obese is also associated with adverse outcomes for patients undergoing in vitro fertilization (IVF) due to the poor oocyte quality and lower preimplantation rate and uterine receptivity. The higher rates of obesity in Black, Indigenous, and People of Color (BIPOC) compared with other groups in the United States can be attributed in large part to systemic racism, according to a new perspective article published in the Journal of Internal Medicine. Daniel Aaron, J.D., MD, an attorney at the U.S. Food and Drug Administration,* Harvard Law School fellow, and member of The Justice Initiative, a collaboration between Harvard Law School and Howard University School of Law aimed at furthering racial justice, states, “[t]oo many people are unaware of how racist structures, institutions, and people may be contributing to the direct harm of BIPOC, leading to obesity.” Society has failed to provide essential public health services and comprehensive and equitable medical care to Americans who are not white. We have not held accountable the institutions that profit from obesity among BIPOC and propagate systemic racism. Many voices have raised alarms for years, yet they have often gone unheard.

 According to a Danish study (insider), when valuing and prioritizing safety in conversations regarding In Vitro Fertilization, the risk of childhood cancer is dramatically higher in children born via IVF, according to a Danish study (insider).

A consequentialist may deem IVF as a whole or an increase in access to the technology unethical.  This raises more questions about the increased health costs for children born through IVF. There are hard questions regarding how a state should recognize such “harm” to the child (i.e., cancer) when the said child would not exist without IVF. How do we address this ethical dilemma associated with IVF?  How do we balance the value of life against our concern for the safety of the person who is conceived through IVF? 

Feminist Critique

Others object to government programs that expand access to IVF are problematic because they reinforce the necessity of biological ties for family. People who argue this believe that the government aiding women who cannot have biological children would cause said women to be less likely to want to adopt or abstain from having children.  They argue expanding access will undermine the self-worth of infertile women who try IVF and fail. Making IVF available to anyone who wants it is not promoting infertility care. If one doesn’t want to have children, the government isn’t saying they should, they are simply providing women who do want biological children with the best opportunity 

This brings me to the concern for adoption rates and IVF. Does IVF cause many children to go without a family, because couples will choose IVF over adoption:(Trading-Off Reproductive Technology and Adoption: Does Subsidizing IVF Decrease Adoption Rates and Should It Matter?, Minnesota Law Review).  Others have argued that expanded insurance coverage is not appropriate. This argument includes a disavowal that infertility is a disease or its treatment a medical necessity. Some may argue that adoption is a suitable substitute for a biological child( Falloon K, Rosoff PM. Who pays? Mandated insurance coverage for assisted reproductive technology. Virtual Mentor 2014;); In the last 40 years since the first “test-tube baby” was born, adoptions in England and Wales have fallen by 62%. (BBC). This finding confirms the risk that some will choose to not adopt when IVF is an option.  Adoption is an excellent family-building choice for many people, and an increase of IVF access will increase IVF use and possibly lower adoption rates. It is paternalistic to have adoption be the only means of creating a family for women who have the disability of infertility. It is only just that everyone has fair access to infertility care. It is paternalistic to mandate that it should be the sole (and again, expensive and self-pay) family-building option for all those who cannot conceive without medical assistance and that does not negate the need for fair access to medical treatment.


Strategies For Increasing Access to IVF

There is no easy method to remove the obstacles of disparities in access to IVF. Individuals’ actions are necessary but do not stand alone in being sufficient in addressing systemic problems in access to reproductive health care. Physicians and other healthcare providers must be informed of evident and subtle restrictions to access. They must be mindful of measures that can be taken to improve fertility and fertility-preserving treatment. To reduce the impact of disparities and improve pregnancy outcomes for all, anti-bias training can be helpful, according to Harvard Edu on “What Makes Effective Anti-Bias Training” stated. The article elaborates upon how selecting an interracial team of facilitators to lead the anti-bias training, district and school leaders are creating the best chance of safe and productive sessions for their staff. An interracial team heightens awareness of power and place and the role individuals play in perpetuating systemic inequality. Once a medical team has learned to acknowledge that discomfort, an interracial team can provide a model for how to disagree productively and acknowledge inflicted harm and talk about it in a way that encourages transformation.

Other methods include raising awareness of health disparities among colleagues, practice staff, and administrators through grand rounds presentations, office staff meetings, and resident and student lectures.

Multilingual staff and physicians, as well as interpreters, may help overcome some barriers. Diversifying the medical field can cause marginalized and minority groups to be less hesitant to seek medical treatment. In most medical schools and residencies, cultural competence training has been implemented ( Horvat L, Horey D, Romios P, Kis-Rigo J. Cultural competence education for health professionals. Cochrane Database ). If physicians avoid specific treatments because of their own or their institutions’ religious beliefs, patients should be informed of those treatments and where they may be obtained if their doctor refuses. Public education about prevention, signs, and treatment of infertility, mainly if aimed at underserved populations and geographic areas, may alert patients to the possibility of treatment.

Physicians in all settings should be aware and sensitized to their patients’ fertility needs regardless of race, ethnicity, socioeconomic status, marital status, gender identity, or sexual orientation. Providers may assist researchers in monitoring trends in access by more consistently reporting patients’ race/ethnicity when requested on the Society for Assisted Reproductive Technology Clinic Outcomes ReportingSystem (SART-CORS) forms.

Employer and insurer exclusion of coverage for infertility from most private healthcare policies and public healthcare programs in this country remains a significant barrier to access to IVF treatment in the United States. 

I support the expansion of this coverage as a matter of just access to healthcare resources. IVF providers are further encouraged to establish or continue programs for lower-resource patients, either offering pro bono, shared-risk, or reduced-price care or contributing to or partnering with nonprofit organizations who helps patients afford fertility treatment. 


Conclusion

The ability to have a child is deserving of protection under the federal law prohibiting discrimination against persons with disabilities. In the United States, healthcare disparities are pervasive; infertility prevention and treatment are not exceptions. The high price of treatment, inaccessibility of medical care, infertility that could have been prevented but was not (e.g., untreated infections leading to tubal damage), and differences in success rates pose immense burdens for infertile individuals. Several international organizations, including the WHO and the United Nations, have made reproductive well-being a global healthcare priority. In the United States, the CDC has issued a National Action Plan on the public health implications of infertility. Under the consequentialist framework, all reproductive medicine stakeholders should pursue opportunities to establish affordable, safe, effective infertility services and treatments for underserved populations and those in the United States who lack insurance coverage for needed treatment. This will lead to a more just system of infertility treatments, allowing more people to have access to procreation. It is the responsibility of health care providers and policymakers to make access to infertility care more just and equal. Oftentimes, protecting a right or protecting someone’s autonomy is costly. But, one may say, the consequences may be relatively worse. In my opinion, it is worth defending someone’s right or some minority group’s right to some good or thing. Even if the overall well-being of the entire population would be better served if that right was violated. Increasing access, under the consequentialist theory, will have positive and significant benefits to the US population.

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