Choosing to Conceive: Should IVF be Restricted in the Same Way We Restrict Unhealthy Food?

An article in today’s NYTimes online provocatively titled “The Gift of Life and It’s Price” discusses both the economic costs and emotional toll of the fertility industry. The issue of IVF is receiving renewed attention in light of the debate about healthcare and the significant costs that IVF children, particularly IVF-conceived twins who are frequently born premature with severe health problems, contribute to overall healthcare spending:

The hospitalization and doctor’s care for Ms. Hare and her son exceeded $1 million. Most of that, about $750,000 to $800,000, was for Carter. The bill was picked up by the self-funded health plan of the Trammell Crow Company, the Dallas real estate investment company where Ms. Hare worked.

“The following quarter during the earnings release, somebody asked why there was a sharp increase in medical costs,” Ms. Hare said. No one identified her, but Ms. Hare knew that her family had contributed heavily.

In Atlanta, the Centers for Disease Control and Prevention hired an economist to predict what would happen if single embryo transfer were used in a large number of IVF cases.

Dr. Macaluso, the C.D.C. reproductive health official, estimates the patients, businesses and insurance providers would save more than $500 million annually, even taking into consideration the cost of extra in-vitro rounds, by lowering neonatal intensive care, special education and other costs of premature babies.

In an effort to be competitive in today’s fertility industry, clinics grant the maximum autonomy possible to clients in choosing how many fertilized embryos to transfer, despite the fact that higher implantation success rates means that multiple transfers is significantly more likely to lead to multiple births. Potential parents know the risk, but since IVF procedures frequently come out of their own pocket, most are unable to afford multiple rounds, and multiple embryo transfers makes it much more likely that the first round of IVF will lead to conception. Twins are much more likely than single births to have complications at birth.

According to one federal study, about 30 percent of all twins end up in a neonatal intensive care unit, with twins eight times as likely as single babies to be born below 3 pounds, 4 ounces. These are the babies who often need the longest hospital care and face the most sever health problems. Dr. Macaluso, the doctor featured in the article, calls them “million-dollar babies.”

The story does a good job balancing between discussing the extreme financial costs of IVF and multiple births with the more emotional side of the story. The parents discussed (and many of the ones weighing in with comments at the end of the article) are couples who want ever-so-badly to have children and are willing to bear any costs to make this a reality. Moreover, they are providing their children the gift of life, a gift that outweighs any financial burden.

This article brings to the mind of the everydaythomist the morality of choice, and in particular, a distinction made by the renowned Servais Pinckaers between freedom of indifference and freedom for excellence. Pickaers argues that in the contemporary period, we are accustomed to thinking of choice as a matter of choosing between what he calls “freedom of indifference” and “freedom of excellence.” Much of Pinckaers discussion of these two freedoms is a rhetorically charged jab at a caricature of nominalism, and particularly William of Occam (I am more inclined to blame Scotus for the sins of nominalism), but in essence, freedom of indifference is a conception of human freedom that reduces the matter of choice completely to the will’s ability to choose between contraries.

Essentially, freedom of indifference for Pinckaers is the freedom to do whatever is within the realm of possibility for human beings. Human beings have the ability to implant one or two or ten embryos into a woman’s uterus, thus, a woman has the freedom to decide how many embryos will get transferred. Freedom of indifference is the freedom of choice, the choice to say “yes” or “no” to whatever is possible.

Freedom for excellence is, on the contrary, a more limited construal of freedom. This conception of freedom is not one that focuses on the will’s ability to choose “yes” or “no” to whatever possible, but rather the will and intellect’s ability to choose “yes” to whatever is good. Freedom for excellence is a freedom limited to the telos of human flourishing. Choosing what is conducive to flourishing, both for the individual and the community, is an exercise of such freedom; choosing what is not conducive to flourishing, despite the fact that it may look like an exercise of freedom, is actually a mere expression of the will and reason’s enslavement to the passions, or custom, or some other power that prevents the person from becoming the person that God intended.

Freedom for excellence is not something that is simply given, but is rather something that humans need to develop through the exercise of virtuous external activities, and particularly through the development of the virtues. When I resist gorging myself on Halloween candy because I know it will make me feel sick and sluggish afterwards, I am exercising my freedom for excellence. When my husband and I choose not to buy a TV because we know that our default evening activity will be to veg out in front of the tube rather than engaging in more productive and life-giving activities, we are developing our freedom for excellence, despite the fact that we are limiting our ability to “choose” what to do each night.

Pinckaers distinction between the two freedoms is overly-simplistic, and my summary is even more so, but I think this distinction can illuminate an element of this debate about the cost, both financial and human, about fertility treatment. We think of the ability to choose whether or not to engage in fertility treatment as a foregone conclusion. After all, the technology is available, and much that is good is resultant of the use of this technology, namely the freedom for infertile couples to have their own children. Couples previously denied a choice concerning whether or not to have children now have their freedom to choose restored. This article discusses the cost of couples choosing whether or not to utilize this technology, but does not discuss the choice itself.

I am not so convinced that IVF and other fertility treatments are an authentic and moral exercise of human freedom. Consider this comment from one reader:

I’m sure I share many readers’ thoughts and feelings. Although I acknowledge people’s primal and mindless urges to procreate, in the world we share, “want” doesn’t equal “should have”. Our country and planet are places of finite resources of every kind. To squander them on IVF and its incredibly resource-intensive consequences is simply an outrage. There is no tenable argument in favor of IVF.

Many of the comments reflect this sentiment, and criticize the article for never mentioning adoption. The logic behind these comments is that it is more moral to choose adoption than to choose IVF.

Why wasn’t adoption ever mentioned in this article? Why do these women put themselves and their families through such risky procedures when there are so many children who could need loving, supportive families?

And another.

There are always options for adoption (although it is my understanding that this process can be equally time consuming, emotionally draining, and financially burdensome.

I think there is a case to be made for limiting the freedom to choose IVF, which is a restriction of one conception of freedom, in order to expand another conception of freedom. I think we need to bring the debate about IVF back down to the morality of the choice itself. Our society is limiting the ability to “choose” in all sorts of ways in order to make people “more free” in another way. We are taking coke and snack machines out of primary schools, for example, which is limiting the freedom our children have to choose between healthy and unhealthy dining options in order to make them more free by making them less disposed to obesity and diabetes as adults. In many cities across the US, including my own, it is illegal to smoke inside public buildings in order to make people more free to enjoy a meal or a drink without exposure to second-hand smoke.

We choose to limit our ability to choose in order to make us more free to make choices that are conducive to health, flourishing, and excellence. Why do we not do the same for IVF. Yes, in one sense, it is wonderful for parents who cannot conceive naturally to be able to conceive artificially, and there are many beautiful IVF success stories that serve as a testimony to its advantages. But are fertility procedures like IVF allowing individuals and society to make choices that are really conducive to excellence and flourishing?

This article points to one way in which IVF may be detracting from individual and societal flourishing by causing a huge burden to the health care system which is already over-stretched and under-accomplished. The comments about adoption point to another way in which the ability to choose IVF is not conducive to flourishing—it makes people more likely to choose IVF and less likely to choose adoption, leaving millions of kids unwanted in under-resourced foster care system. By restricting the freedom to choose IVF, we increase the freedom to choose adoption, in the same way that restricting the freedom to choose a treat from the snack machine increases the freedom to choose a healthy snack of veggies or whole grains.

Deep down, most of us are libertarians in some way. We want to maximize our choices as a way of maximizing our freedom. But most of us also recognize that on a society-wide scale, maximizing choices is not usually conducive to either making us more free or making us more happy. If given the choice to eat unhealthy snacks or a balanced lunch, most people are going to choose the latter. And we may say that it is a good in itself that they can make this choice, but when we get a society where over 30% of the population is obese, and we can’t provide adequate healthcare to all because the healthcare industry is already over-taxed in treating preventable illnesses like heart disease and obesity, we have to step back and ask whether the inherent ability to choose an unhealthy lifestyle is so good after all.

In a similar fashion, we might think it inherently good that couples at one time debilitated by the disease of infertility can now choose to bear a child of their own to love and care for. But when we get a bloated foster care system, and another giant strain on the healthcare system from couples having IVF babies demanding millions of dollars of expensive lifesaving treatments, maybe we have to step back again and ask whether the inherent ability to choose the IVF procedure is so good after all as well.


4 comments so far

  1. RCC on

    We clearly read the same articles at the NYT website. I’m sure you also read the followup piece today on IUI. But my question: can we (individually or collectively) expand another person’s freedom for excellence by setting limits on legitimate choices, or is freedom for excellence a benefit of setting my own limits? Relying on my own intuition, I would say that depriving someone else of a legitimate choice, even if I think it’s not a good one for society, is no exercise of freedom at all.

    Whether we all pay for it is another issue entirely. This is something that I think has not been taken seriously enough in health care reform discussions. There’s been a little about “death panels” and payments for abortion, but no one seems to consider the possibility that we won’t ever agree on what should be covered. This is one of the reasons why I like the *idea* of nationwide health care coverage, but in practice I suspect it won’t work well. We Americans just can’t agree on what’s justified and what’s not, what’s expected and what’s elective, what’s reasonable and what’s excessive, what’s moral and what’s immoral.

    • everydaythomist on

      Thanks for commenting. The question that is really consuming me right now is what is a legitimate choice and what is not? As a society, we make decisions to limit certain choices by deeming them illegitimate. One example would be falsely crying fire in a public space. Although our society protects free speech, we have deemed this particular choice an illegitimate exercise of that freedom. And we can clearly see why. But what about cigarette commercials? As a society, we have decided to not allow a particular exercise of freedom regarding the choice to market cigarettes on TV. Is this an illegitimate or a legitimate restriction of choice? What about snack machines in schools? We might say that with children, restricting choices is a different issue than restricting choices with adults, but what about banning trans fats in New York? Is that a legitimate restriction of freedom? In England, they have banned a particular commercial advertising Nutella as a part of a nutritious breakfast. Is that a legitimate restriction of choice?

      I think one of the ways we decide whether the restriction of a choice is a legitimate one is whether or not such a restriction is ultimately conducive to the common good. We restrict “free speech” regarding certain advertisements, hate speech, and false speech (like crying fire in a public building) because if people were to exercise these “freedoms,” it would have a negative impact on the common good. We restrict people’s food choices and ability to smoke in certain areas because exercising these “freedoms” is not conducive to the common good.

      In the US, we tend to think that what one does with one’s own body and one’s own money in one’s own time in one’s own house is private and not subject to intervention, but I think that the question of food choices and reproductive choices effectively blur the line between private and public. I may consider it my own private choice when and how to have a child, but when that child (or children) ends up needing millions of dollars of medical treatment, my decisions has effectively had an impact on the common good, especially when my company’s health care is paying the bill. I may decide that what I choose to eat in my own home is a private decision, but when I only buy processed, unhealthy foods that I eat in excess and then lead a sedentary life afterwards, thereby necessitating expensive medical treatment, missed days at work, etc., my “private” decision takes on a new “public” dimension.

      This is why my questions are more moral and anthropological than they are political. We are relational creatures, and everything we do is done in relationships with other persons, and has an impact that extends beyond ourselves. Obviously, we can’t regulate everything legally, but I think that food are reproductive decisions are two ways in which we can clearly see the broader impact of our choices on the public, and so maybe the public has a role in regulating what private individuals can decide to do.

  2. RCC on

    I haven’t forgotten this discussion …

    Interesting that you pick up on the question of legitimacy of choice. I almost addressed that but felt my comment was already getting too long!

    I frankly think we in America restrict or try to limit far too many behaviors, and I say this as someone who’s more conservative in her own behavior than any of my family or peers. Among the examples you list, I think banning cigarette ads on TV and banning trans fats in restaurants are excessive regulations. Most arguments in favor of such restrictions involve money, i.e., if we share responsibility for the health costs associated with smoking cigarettes or eating trans fats, then we can legitimately limit access to those products. I would agree that, if someone else shares with me responsibility for the bill, my autonomy in deciding how to act is limited. This is why I think it’s ok to limit children’s choices: they don’t pay their own bills (and, of course, their ability to make good choices is age-limited). But if I, as an adult, want to do something that might not be good for me, that might cost me more money down the line or compromise my health, well, I think that’s my choice. But, crucially, I also think the responsibility for living with those choices should be mine too. The exception for adults, I think, is the option of family involvement. If I choose a reckless life as a 30-year-old, my siblings, in-laws, and niece and nephew will (no doubt) take care of me as a 60-year-old who didn’t plan well. So I think that relationship (and the responsibility that comes with it) should entitle them to step in should I prove unable to make good decisions for myself. But I’d limit this to extreme circumstances – say I am so difficult to get along with that I’m unable to keep a job, lose my home, and don’t eat regularly. If they didn’t step in, I’d probably not make it to age 60. (An aside here is that public health officials really don’t understand the relationship between diet and health sufficiently well to make good policy in this realm. Remember, trans fats used to be considered a good alternative to butter. For a couple of generations, people with hypertension were advised to eat very little salt, but some data suggests that’s only good advice for a minority of hypertensives.)

    But there is a second type of argument to be made in favor of limiting reproductive technologies, even those paid for by the individuals having the procedures – essentially the “humans shouldn’t mess around with nature” argument. I’ll say here that these are medical interventions I would never choose to have – they’re risky and unpredictable, healthy children often come only after the selective reduction of other embryos, no one knows what to do with unimplanted embryos, they’re emotionally difficult procedures, they’re expensive, no one knows the long-term effects of such interventions on the children they produce, and for me, they would be completely unnecessary, as I’d be happy to adopt a child (although I recognize that not everyone would, and I don’t consider unwillingness to adopt to be a moral failing). I really don’t think they’re a good idea, and I wish people wouldn’t do this. Even so, I don’t think it’s my place to tell them they *can’t*.

    This isn’t because I’m a hands-off, to-each-her-own sort of citizen. I completely agree with you when you say, “We are relational creatures, and everything we do is done in relationships with other persons, and has an impact that extends beyond ourselves.” But I don’t think we can force other people to accept our moral judgments. We can try to convince them of our positions, and we can refuse to help them do something we consider unwise. Just as importantly, we can try to convince them that acting with the best interest of society in mind is better than being selfish. But if they choose to do these things and accept responsibility for the consequences, that’s their right. But I think people behave responsibly when they are held responsible.

    So I don’t think legitimacy can be determined by the ultimate result of the act, including implications for the future (which, frankly, no one can predict). In general, I’d say that actions which directly and clearly cause harm to another person are illegitimate (and hence should be illegal) choices: yelling fire when there isn’t one, speeding, flying an airplane while drunk, paying an equally qualified female architect less than you pay a man, selling sugar pills as heart medication, and so on. On most other issues (although some gray area remains), I think it’s not my place to make choices for others.

    Again, this is only my intuition, which is only so reliable.

  3. DS on

    Do you have kids?

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