Pandora's eggs: Social Darwinism v. Economic Rationalism in access to IVF


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assisted reproduction remains a hot topic, polarising opinions. This paper examines some of the dominant discourses and the underlying assumptions and philosophies.

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Pandora's eggs: Social Darwinism v. Economic Rationalism in access to IVF

  1. 1. Pandoras eggs Social Darwinism v Economic Rationalism in access to IVFIVF technologies continue to raise ethical issues for policy makers. In addition toexistential questions about creating life, society can now control who can reproduce,in what circumstance and for what purpose, at least for that growing portion of thepopulation who require reproductive assistance. Since the first IVF birth in 1978,reproductive technologies have provided hope to many infertile women and couples.Funding structures and legislation create barriers to regulate access to IVF to thosewho meets to society’s norms.Infertility – the new epidemicThe IVF industry defines infertility as the inability to get pregnant after one year oftrying,1 2, although the World Health Organisation expands the period to two years,3acknowledging that many couples take more than one year but still conceive withoutmedical assistance.4 Fertility, conversely is related to actual births, not potential toconceive.Infertility prevalence data is based on numbers of couples who seek treatment, or apopulation-based estimate of married women of reproductive age.5 Approximately10% of Australians are estimated to be infertile6, with 40% of the cause lying with themale, 40% with the female and 20% unknown cause7. The narrow focus of studymisses other women who may wish to access IVF procedures such as single women,lesbians and post-menopausal women. Although both males and females may beinfertile, infertility as it relates to IVF generally considers only the female as potentialrecipient of the treatment ‘product’ – the embryo. Homosexual male couples may alsowish to be parents, but would not be considered in infertility statistics.Demographic data on Australian infertility seems unavailable, however internationaldata shows a link to lower socio-economic status8 through occupational andenvironmental exposure to chemicals and radiation9, shift-work and working longhours10 11, and higher incidence of infections.1 US Department of Health and Human Services Centres for Disease Control and Prevention. Ross R. The McBaby Business. World Health Organisation. Consultation on the place of in vitro fertilisation in infertility care.Summary Report, Copenhagen 18-22 June 1990.4 Fuentes A, Devoto L. Infertility after 8 years of marriage: a pilot study. Human Reproduction. 1994.9(2):273-78.5 Thonneau P, Spira A. Prevalence of infertility: international data and problems of measurement.European Journal of Obstetrics and Gynaecology and Reproductive Biology. 38:43-52. 1990.6 Ratcliffe J. The economics of the IVF Programme: A Critical Review. Centre for Health ProgramEvaluation. February 1992.7 Victorian Department of Health. Leke JI et al. Regional and geographic variations in infertility: effects of environmental, cultural andsocioeconomic factors. Environmental Health Perspectives Supplements 101 (Supplement 2):S73-80.19939 Shahara F et al. Environmental toxicants and female reproduction. Fertility and Sterility. 70 (4):613-622. 199810 Dawson D, McCulloch K, Baker A. Extended working hours in Australia: Counting the Costs.(2001) The Centre for Seep Research. University of SA.11 Tntiseranee P et al Are long working hours and shiftwork risk factors for subfecundity? A studyamong couples from Southern Thailand. Occupationa ad environmetnal Medicine. 55:99-10. 1998.
  2. 2. Australian women are also increasingly delaying motherhood12 13 14. The fertility rateof women over 40 doubled between 1982 and 2002 and highest fertility in the 30-34age range in 200415. Social and biological causations16 reflect the changing role ofwomen in society, ‘changing attitudes about relationships, families and careers”17,financial or employment insecurity18, delayed interest in having children and lack ofawareness of the effect of age on fertility19 - delaying motherhood beyond biologicalreproductive ability. These women are often of high education and career attainment,able to pay for IVF treatment. Hence increased consumer demand for reproductiveassistance.IVFIn vitro fertilisation (IVF) refers to fertilisation outside the womb, with the resultingembryo/s being placed in a womb for development. Treatments may use the couple’sown genetic material, or donor material/s. In 2002, 32,958 cycles were attempted inAustralia resulting in 6675 pregnancies and 5953 babies20 representing 3%21 of allbirths in Australia, (30,00022 children in the past five years). In the US a typical cyclewill cost $US12,400 and may be partly covered by medical insurance.23 In AustraliaIVF treatment is ~50% funded by Medicare24, with a gap payment of around $408925per cycle. The IVF industry is worth $170 million p.a. in Australia.26IVF is not strictly speaking a health treatment. Infertility is not a sickness, althoughit may result from disease or injury. IVF does not cure infertility, rather circumvents12 Australian Bureau of Statistics. Australian Demographic Statistics 2000. Population. Special Article– Lifetime Childlessness. September 1999.13 Rowland D. Cross-National Trends in Childlessness. Working Papers in Demography, No 73.Australian National University Research School of Social Sciences. 1998.14 Australian Bureau of Statistics. Demography, Australia!OpenDocument#BIRTHS%20AND%20CONFINEMENTS15 Australian Bureau of Statistics. Australian Social Trends. Population. Echoes of the Baby Boom.2004. Baum F. Choosing not to have children. 1994. Vol 2, No 3. p22-2517 Australian Bureau of Statistics. Year Book Australia 2002: Population. Special Article -Confinements resulting in multiple births. Australian Institute of Family Studies, cited in Cronin R. Birth rate linked to fear of losing job. TheCanberra Times. 29 January 2005. Hammarberg K, Clarke VE. Reasons for delaying child-bearing – a survey of women aged over 35years seeking assisted reproductive technology. Australian Family Physician. March 2005; 34 (3):187-8, 20620 Bryant J, Sullivan EA, Dean JH. Assisted reproductive technology in Australia and New Zealand2002. Australian Institute of Health and Welfare. National Perinatal Statistics Unit.21 Robotham J. Pregnancy rate fall forces clinic into U-turn. Sydney Morning Herald. 19 January 200522 ABC Online. Govt warned against IVF Medicare changes. 20 April 2005.23 American Society of Reproductive Medicine. Frequently Asked Questions. ABC News Online. Govt warned against IVF Medicare changes. 20 April 2005. Meatherall M. IVF fee rises no Medicare rort: clinics. Sydney Morning Herald. 23 April 2005. Ross R. The McBaby Business. Http://
  3. 3. it.27 Whether having children is essential depends on beliefs, but with the exceptionof children genetically matched to save ill siblings, not having a child does notdirectly endanger life.Evidence-based Medicine : defining success"Clinical decisions must respect, primarily, the interests and welfare of the personswho may be born, as well as the long-term health and psychosocial welfare of allparticipants"28IVF is invasive, expensive and emotionally taxing – usually a treatment of last resortfor the infertile and carriers of heritable diseases. Maximum success with theminimum number of cycles is an advantage for clinics competing for the Medicaredollar and research dollars. More than 30% of all IVF babies take at least threecycles.29Definitions of success vary. In the US, the cycles begun to pregnancy rate is between33-55%30, but data on live births show a live delivery rate of 29.1% per retrieval in199831. Comparatively, a fertile couple has a 20% chance of pregnancy leading tolive birth in any month.32 33 To further confuse the statistics, many couples (estimatedas high as 38%) who register at fertility clinics achieve pregnancies independent oftreatment,34 reflecting on the appropriateness of the infertility definition.In Australia, IVF statistics are collected on pregnancy, live births and neonatalsurvival compared to number of cycles attempted. Information such as gestationlength and birth weight is recorded but no further information on the health of thebaby, infant mortality, development or health outcomes of the older child. 2002statistics show 61.7% of IVF pregnancies resulted in a live singleton birth and 14.2resulted in a live multiple birth.35 (The remaining 24.1% are miscarriages orstillbirths.) A recent study showed IVF babies had over double the rate of birthdefects by age one36 and other studies have shown higher incidence of ADD andautism, neurological impairments and cerebral palsy and developmental delays.3727 Ratcliffe J The economics of the IVF Programme: A Critical Review. Centre fr Health programevaluation. February 1992.28 Australian Health Ethics Committee. Section 4. Ethical guidelines on the use of assisted reproductivetechnology in clinical practice and research. National Health and Medical Research Council. AustralianGovernment. 2004.29 McBain J (Melbourne IVF Group) quoted in ABC Online. Govt Warned against IVF MedicareChanges. 20 April 2005. Ratcliffe J The economics of the IVF Programme: A Critical Review. Centre fr Health programevaluation. February 1992. Section 2.31 US Department of Health and Human Services Centres for Disease Control and Prevention.Frequently Asked Questions. American Society of Reproductive Medicine Victorian Department of Health, Ratcliffe J The economics of the IVF Programme: A Critical Review. Centre fr Health programevaluation. February 1992. Section 235 Table W, Bryant J, Sullivan EA, Dean JH. Supplement to Assisted reproductive technology inAustralia and New Zealand 2002. Australian institute of Health an Welfare National Perinatal StatisticsUnit and the Fertility Society of Australia36 Ross R. The McBaby Business. ibid
  4. 4. While parents may feel live multiple births are a success, they are not the idealoutcome. Twins account for 20% of IVF births p.a. in Australia,38 an increase of 71%since 1980, a trend predicted to continue.39 (Triplet births have increased 257% in thesame period.) Multiple births are associated with higher rates of stillbirth andmiscarriage, a higher risk of prematurity associated with higher infant morbidity andmortality,40 and higher costs to the health system for both mother and babies. Due tothe health risks and considering higher embryo transplant success rates, Australianclinics now limit the number of embryos transferred per cycle to one or two -although transferring only one embryo does not eliminate the possibility of a multiplebirth as IVF babies also have a higher rate of monozygotic twinning.41 42 Whensuccess is defined as the live birth of a singleton at term gestation the rate is 11.1%per cycle begun.43One of the most successful fertility options is surrogacy. Commercial surrogacy isillegal. Non-commercial surrogacy is legal in some states although the NationalHealth and Medical Research Council (NHMRC)’s guidelines warn of ethical, socialand legal implications44 (including the potential for exploitation). Surrogacy has fewintrinsic barriers except cost and hence is potentially open to all including post-hysterectomy women and men. The Medicare rebate for IVF does not apply tosurrogate pregnancies.Legislative Barriers to IVFThe Australian Government acknowledges the right of Australians to define their ownfamily through choice45, a principle upheld in law.46 However access to IVF to fulfillthis right is governed by a range of state and Commonwealth legislations.47 Somestates have specific legislation regarding IVF, while others rely on the NHMRCethical guidelines for the clinical practice of ART,48 which state that the clinic needs38 Perinatal Statistics Unit. Quoted in: Robotham J. Pregnancy rate fall forces clinic into U-turn. SydneyMorning Herald, 19 January 200539 Australian Bureau of Statistics. Year Book Australia 2002: Population. Special Article -Confinements resulting in multiple births. MMWR, June 23, 2000/ 49(24); 535-8.41 National Organisation of Mothers of twins Clubs Inc. Twinning Facts. Robotham J. Pregnancy rate fall forces clinic into U-turn. Sydney Morning Herald. 19 January 200543 Min JK. Breheny SA. MacLachlan V. Healy DL. What is the most relevant standard of success inassisted reproduction? The singleton, live birth rate per cycle initiated: the BESST endpoint for assistedreproduction. Human Reproduction. Vol 19 No 1, 3-7 January 2004.44 National Health and Medical Research Council. Ethical Guidelines for the clinical practice of ART.Part B, p42.45 Retreating from the full realisation of economic, social and cultural right in Australia: A genderedanalysis shadow report to Australia’s third periodic report to the Committee on Economic, Social andCultural Rights. Article 10. Cannold L, Cica N, The Law. The Price of Parenthood. 28 July 2003. Posting on Australian policyonline website. SA Department of Health. Reproductive Technology. Legislation Around Australia. Australian Health Ethics Committee. Ethical Guidelines for the clinical practice of ART. Part B, p42.National Health and Medical Research Council. Australian Government. 2004.
  5. 5. documented practices and procedures, and specific protocols regarding access to IVFtreatment49, but do not specify a framework for decision making.Legislative barriers centre around two factors: medical need (clinical infertility) andthe nature of the parental relationship (married or heterosexual de facto). While allAustralians have access Commonwealth funded Medicare rebates, States regulate theclinics and have the power to close them and de-register doctors if they do notcomply. The clinics and doctors must do the policing.Women who access IVF in the US tend to be older, of higher education attainmentand higher socio-economic status50 whereas infertility is more prevalent amongstthose of lower socio-economic status. The out-of-pocket costs of IVF along with thedisruption to paid employment form barriers to access51 and will affect peopledifferently across the socio-economic stratum. Australia’s Medicare subsidising ofcosts may dampen this effect, but the demographics could be expected to look similar.The use of public funding for IVF has brought a private matter into the public arenaand given the tax-paying public an arguable right to comment on access issues52, but ifa woman is willing to pay for the procedure privately, this argument is baseless. Stateswould still be liable for antenatal and post-natal hospital care.Health for all or babies for all?Is it an inalienable right for human beings to reproduce? "...the original motherhood issue is motherhood itself. Everyones for it (if not for oneself, then at least in principle). No one would be caught dead opposing it (not publicly anyway). It is, unambiguously, a good thing. End of story."53The concept of reproduction is tied to many fundamental beliefs about society. Thebook of Genesis says "Go forth and be fruitful54". Darwinists believe the drive toreproduce is a biological urge to ensure the perpetuation of the species. TheInternational Covenant on Civil and Political Rights proclaims the right of "men andwomen of marriageable age to marry and found a family"55.In subsistence cultures women’s identity, role and value in society is defined by theirability to bear children. An infertile woman may be abandoned by her husband.56Children support their parents in old age. Australia parallels this with baby-boomers49 Australian Health Ethics Committee. Section 5.3 Ethical guidelines on the use of assistedreproductive technology in clinical practice and research. National Health and Medical ResearchCouncil. Australian Government. 2004.50 Stephen EH, Chandra A. use of infertility services in the United States: 1995. Family planningPerspectives. Vol 32. No 3. May/June 2000. Phelps K. Informed debate on IVF costs must still go ahead. Medical Observer. 20 May 2005. p2452 ibid53 Maushart S. The Mask of Motherhood. How mothering changes everything and why we pretend itdoesnt. 1997. Random House Australia Ltd. P154 Genesis 1:27-2855 International Covenant on Civil and Political Rights. Article 23.2 . New York, 16 December 1966 Dyer SJ, Abrahams N. Hoffman M. van der Spuy ZM. ‘Men leave me as I cannot have children’:women’s experiences with involuntary childlessness. Human Reproduction Vol 17, No 6, p1663-1668.June 2002.
  6. 6. needing a younger generation of taxpayers to support their welfare and health inretirement.The American Society of Reproductive Medicine website states “[t]he desire to havechildren and be parents is one of the most fundamental aspects of being human” 57 inarguing for health insurance for treatment costs. This argument is self-serving andfails to consider the increasing number of people who choose not to have children. 58 59In 2000, the ABS estimated that 25% of women who had not yet ended theirreproductive lives would remain childless60 by choice or circumstance, up from 9%for women born between 1930 and 1946. These people give the lie to the argumentfor parenthood as a fundamental aspect of humanity on an individual level.However, if we accept that the drive for parenthood is natural, part of being human,valued in society, perhaps genetically programmed into us, then do we have the rightto decide who can reproduce and who cannot? The economic rationalists argue thatwe have the right to say how our taxes are spent when it comes to publicly fundedreproductive treatments61 but it could equally be argued that dominant social normsare not necessarily the best standards for forming legislation. Conservatives and somereligious groups say we do not have the right to over-ride the will of God (sometimesthis relates to IVF generally, sometimes to access for lesbians and single women).Darwinists argue that IVF over-rides evolutionary mechanisms of survival of thefittest by reproducing those genes that would not naturally have survived in the wildto reproduce, and the result will be a weakened human race. There is evidence thatIVF children may have poorer developmental and health outcomes than the generalcommunity, whether because of genetics or damage done by the IVF procedures.62How do we value a live baby compared to some notional concept of perfection inthese days of wrongful life cases?Arguments about limiting access to IVF fall on both sides of the nature v nurturedebate. On the nature side, can we value-judge genes on their positive or negativevalues? Few would choose to have the genes for predisposition to breast cancer, lowerthan average IQ or other factors affecting length or quality of life. But does this giveus the right to eliminate these genes from the population either by limiting people’saccess to reproduction or by genetic screening of embryos? Maybe their value is inwhat they can offer to genetic variation.Taking the nature debate a step further, is it ethical or fiscally responsible toreproduce people inherently unable to survive by themselves (in the case ofgenetically inherited disorders) and hence destined to be a burden on the welfare andhealth systems, and society in general? Does it differ if we are talking about someonewhose body is physically unable to sustain life without medical assistance comparedto someone who might be able to survive quite happily in society but be unable to57 American Society of Reproductive Medicine Baum F. 1994. Choosing not to have children. Vol 2, No 3. p22-2559 Australian Demographic Statistics 2002. Population. Special Articles- Lifetime Childlessness (Sep1999). Australian Bureau of Statistics.60 Australian Bureau of Statistics. Australian Social Trends 2002, Trends in childlessness, pp. 37-40.Quoted in Australian Social Trends Population. Echoes of the baby boom. Phelps K. Informed debate on IVF costs must still go ahead. Medical Observer. 20 May 2005. p2462 Ross R. The McBaby Business.
  7. 7. compete for resources and hence reliant on welfare? While sterilisation withoutconsent of the intellectually disabled was only outlawed in 199263 there is now nolegal barrier to an intellectually disabled infertile woman in a relationship seeking IVFusing her own (or donated) genetic material.Lesbian access to IVF illustrates the nature v. nurture debate in its two central issues:replication of “gay genes” and gay parenthood. Some Australian states havespecifically legislated against IVF access for women outside a male-femalerelationship (marriage or de facto), or only to the clinically infertile64 (and theirpartners) in order to exclude those whose infertility is seen by the state as being bychoice.While these policies do limit gay parenthood, the limits do not apply to donors ofgenetic material. There is no requirement on sperm or egg donors that they beheterosexual, although recipients have brief information about the donor and canchoose between donors. Hence it would appear that either policy-makers, correctly orincorrectly, do not believe that homosexuality has a genetic basis or perhaps nurturetheory is the rationale for the policies.The Commonwealth Sex Discrimination Amendment Bill 200265 was drafted toexempt state reproductive technology legislation from the Commonwealth SexDiscrimination Act following two legal challenges where Commonwealth legislationover-rode the state legislation regarding access to IVF66 for a single woman inVictoria (McBain v State of Victoria) and a woman separated from her husband in SA(Pearce v SA Health Commission67). While the Amendment does not mandateexclusion of homosexual or single women from access to IVF, it specifically enablesthe states to do so. The Amendment does prevent discrimination between married andde facto couples (defined as "of the opposite sex"), and removes the time-basedcriteria on relationships. While there is no evidence that parental marital status affectsthe wellbeing of the child68, access can also be restricted to those clinically infertile,effectively excluding single and lesbian women without risking accusations ofdiscrimination.The International Covenant on Civil and Political Rights (1966) declares that thefamily is "the natural and fundamental group unit of society and is entitled toprotection by society and the State"69 and proclaims the right of "men and women ofmarriageable age to marry and found a family"70. The preamble to the United NationsConvention on the Rights of the Child state that “the family, [is] the fundamental63 Grover SR. Menstrual and contraceptive management in women with an intellectual disability.Medical Journal of Australia . February 2002. 176 :108-110.64 SA Department of Health. Reproductive Technology. Legislation Around Australia. Sex Discrimination Bill 2002: Explanatory Memorandum. Del Villar K. McBain v State of Victoria: Access to IVF for all Women. 15 August 2000. Pearce v SA Health Commission68 Victorian Law Reform Commission. IVF access changes in air. Media release. 11 May 2005.69 International Covenant on Civil and Political Rights. Article 23.1 . New York, 16 December 1966 International Covenant on Civil and Political Rights. Article 23.2 New York, 16 December 1966
  8. 8. group of society and the natural environment for the growth and well-being of ….children” and “the child, for the full and harmonious development of his or herpersonality, should grow up in a family environment, in an atmosphere of happiness,love and understanding.”71 These statements do not define what makes a family innumeric or gender specific terms. Arguments that it is ‘natural’ and best for a child tohave a mother and a father as opposed to two parents of the same gender prioritisegender over other factors perhaps more germane to parental quality.Perhaps this policy reflects environmental causation belief – that sexuality is a socialconstruct and the homosexual parents may influence their child to be homosexual. Isit intrinsically bad if the child does turn out to be homosexual? The InternationalCovenant on Civil and Political Rights states signatories “undertake to have respectfor the liberty of parents and, when applicable, legal guardians to ensure the religiousand moral education of their children in conformity with their own convictions,”72 andif the parent is homosexual they would presumably consider their behaviour to bemorally acceptable.A less contentious use of environmental causation in policy-formation is SAlegislation preventing access to IVF for anyone with a child protection order, foundguilty of a sexual or violent offence, or suffering from an illness, disease or disabilitythat may hinder their care for the child.73 74 While this aims to provide a safeenvironment for the child the argument does not hold true of the convicted person issentenced to prison for a long period and hence poses no environmental threat to thechild. In the end, the nature/nurture arguments are insoluble as the expression ofgenetic potential is influenced by environmental factors, and policy must reflect thisdichotomy.Another contentious access to IVF issue relates to posthumous use of gametes. Thiscovers both the harvesting of gametes posthumously and the use of gametes harvestedwith consent during the person’s life but used posthumously. State legislation ismixed, some allowing for use of existing embryos, or use of embryos/gametes onlywith prior consent, but NSW also requires clinics to contact (presumably consented)donors to ensure they are still alive75. No states allow for posthumous harvesting,which, while potentially traumatic for bereaved partners, does prevent children beingcreated for the purpose of financial inheritance.Valuing lives - economic rationalismThe economic rationalism of allocating the health budget funds between competingneeds must consider health priorities, size of demand, relative costs and likelihood ofsuccess. Recent debate has centred around whether there should be a cap on fundingIVF treatments, particularly for older mothers, who have a statistically lower chanceof achieving IVF success.71 Preamble. United Nations Convention on the Rights of the Child. 1990. ibid73 Victorian Law Reform Commission. Legislative background. 11 May 2005.74 Ratcliffe J The economics of the IVF Programme: A Critical Review. Centre fr Health programevaluation. February 1992. Section 275 Victorian Law Reform Commission. Legislative background. 11 May 2005.
  9. 9. "Nothing in life is free, nor should it be." Prime Minister John Howard "There needs to be some restraint when it comes to the availability of taxpayer funds for non-essential procedures." Federal Health Minister Tony Abbott "taxpayer funding [of health] needs to be based on the likelihood of success of medical treatments." Federal Treasurer Peter Costello.76Balanced against these arguments for economic rationalism, we have the perceivedneed for future taxpayers to support the population bulge of baby-boomers in theirretirement.77 Australia’s population profile is ageing, the birth rate is in decline78, andmany women are choosing to remain childless. “health budgets have to address priorities for a nation79”While the financial burden is disputed,80 the predictions appear to be driving Federalpolicy. The 2004 Federal Budget had financial incentives to have children and the2005 Budget contained efforts to increase the workforce by getting the disabled andsingle mothers to work. Federal Treasurer Peter Costello urged Australians to haveone baby for the mother, one for the father and "one for the country".81Perhaps current taxpayers, considering the population profile and the increasingnumber of women remaining childless, should finance IVF for all women who ask forit, even those of whose lifestyles they may disapprove and those who have a lowlikelihood of success as a societal investment. Those who choose to remain childlessmay not share in the experience of being a parent, but they will benefit from the taxes(hopefully) paid by these child-products of IVF procedures when they (the childless)are past their financially productive days.On the other hand, as health spending continues to consume an increasingly largeportion of the budget, can we afford such big ticket, low success, non-essential itemsas IVF? In 2003 the total IVF bill funded by Medicare was $50 million. Followingthe introduction of the Safety Net in 2004, costs leapt to $78.6 million year.82 This isapproximately $15,720 of taxpayer funding per live baby born - arguably still not ahuge commitment in times of falling birth rates and less than the costs the parent/swill incur in raising the child.8376 quoted in Glasson B. Beware the IVF trojan horse. Medical Observer 13 May 2005 p2477 Australian Bureau of Statistics. The Health of Older People, Australia. 2004. Australian Bureau of Statistics. Year Book Australia. 2005. Population. Births. Phelps K. Informed debate on IVF costs must still go ahead. Medical Observer. 20 May 2005 p2480 Lie back and think of Australia. Sydney Morning Herald. 5 June 2004. Fairfax Digital Website. Australian Institute of Family Studies, cited in Cronin R. Birth rate linked to fear of losing job. TheCanberra Times. 29 January 2005. Meatherall M. IVF fee rises no Medicare rort: clinics. Sydney Morning Herald. 23 April 2005. Henman P. (Macquarie University sociologist) quoted in The Cost of Kids. Macquarie UniversityNews. October 2002.
  10. 10. Where the costs of IVF should be borne depends on whether we considerreproduction to be a personal or population issue. If we having children is a personalissue with personal benefits then the costs should also be borne on a personal level. Ifwe believe that benefits will accrue to the population as a whole (through the creationof a new generation of tax payers) then there exists an argument for public funding.The Federal Government consideration of restricting women under age 42 to amaximum three Medicare funded cycles p.a. and limiting funding for women agedover 42 to a total of three IVF cycles84 was seen as hypocritical in the context of therecent funding to boost the birth rate. The limit for older women was related to thesuccess rates for implantation. Perhaps smokers and those living with smokers shouldalso be limited as a recent study linked smoking and passive smoking with lowerimplantation success85.ConclusionWhether we consider the state has the right to restrict access to IVF from anyAustralian woman, and on what grounds we consider this acceptable involves anumber of inter-related factors including our beliefs about ‘human-ness’, society,parenthood and what we consider to be the best interests of the child. Who we chooseto prevent from reproducing either genetically or in terms of parenting, depends onour values and whether we believe the ‘unacceptable’ factors are determined bynature or nurture.While Medicare funds are involved this argument will remain in the public arena,whether we consider it to be a public or personal issue. Deciding how much society isprepared to pay for children, and in what circumstances, involves existential questionssuch as whether we should be valuing children in financial terms, in terms of whatthey can contribute to society, for their genetic variation or some other basis.84 ABC Online. Govt warned against IVF Medicare changes. 20 April 2005. Passive smoking affects IVF. Australian Doctor. 10 June 2005. P19