In the past few weeks, the North American media has been rife with stories about unusual births following fertility treatment. The first was that of Nadya Suleman (christened by the media as Octo-Mom, or Madame Ovary) – a California woman who recently gave birth to octuplets. This case raised a number of challenging ethical questions: Should there be medical (and perhaps even legal) limits on the number of embryos transferred? And, in the event of a multiple pregnancy, should there be selective reduction? More generally, should there be “social” eligibility criteria for IVF, and how might we protect the interests of unborn children without discriminating against potential parents (based on, for example, marital status or sexual orientation)? What (if any) public financial support and “proper” care should be available for this unemployed, single mom faced with the challenge of raising octuplets in addition to her six other children?
On the heels of this story, an equally controversial case emerged involving a 60-year-old Canadian woman – Ranjit Hayer – who gave birth to premature twins following IVF and selective reduction. In this case, many ethical issues have been raised about justice and resource allocation. Some of these have focused narrowly on the issue of personal responsibility for health care. Although Canada has a publicly funded health care system, IVF is not a publicly funded benefit (except in Ontario, and then only for patients diagnosed with blocked fallopian tubes). As such, Ranjit and her husband Jagir Hayer (also 60) had to pay out of pocket for the IVF treatments that resulted in her pregnancy. However, the obstetrical care, hospital stay, and treatment of subsequent complications experienced by both mother and offspring will be paid for by the public purse. Some commentators have asked: “Why should Canadian taxpayers have to bear the cost of the Hayer’s desire to have children?”
Attending the Hayer case has been the question of whether older women should bear children: How old is “too old” for a woman to have kids? This challenging question is again front and center with the most recent story of fertility treatment gone awry. Interestingly, this story also involves Michael Kamrava, the fertility specialist who treated Suleman. This time the protagonist is an unnamed 49-year-old woman who is pregnant with quadruplets. Taken together, these three cases bring into sharp relief the question of whether doctors (and society) are overly concerned with women’s reproductive rights at the expense of the health and well-being of children conceived and born.
Beyond this, there are unique ethical issues in the Canadian case owing to the fact that the Hayers engaged in “reproductive travel” to India for the IVF treatments that facilitated the birth of their twins. Reportedly, the Hayers sought medical services abroad because they were unable to find a Canadian doctor willing to provide IVF to a 60-year-old woman. Were the Hayers “forced” to go abroad for medically assisted reproduction due to ageism? Alternatively, did Canadian doctors refuse to provide IVF to Ranjit Hayer based on concern for her health and that of her potential offspring? Did the Hayers go to India because they needed donor eggs and were unable to obtain them in Canada, where the purchase of gametes is legally prohibited? If so, why did they go to India instead of the neighboring United States? Was there a concern about cost of the eggs in the United States, or about the likely genetics of the eggs available for purchase in India?
The Canadian ban on payment for eggs is intended to protect poor young women from exploitation and undue inducement – that is, from being lured by financial compensation to participate in the painful and potentially harmful practice of egg retrieval. But the shortage of domestically available donor eggs, combined with the permissibility of international reproductive travel, is likely driving up demand for this limited resource in countries that permit payment for eggs and are relatively accessible to Canadians. To what extent is Canada ethically responsible for preventing the exploitation of poor young women in other countries? Furthermore, domestic bans on commercial procurement of eggs effectively apply only to Canadian women in lower income brackets who cannot afford to purchase the goods and services abroad. Given that these goods and services are available to wealthier patients who travel abroad, what implications does reproductive travel have for the Canadian commitment to equality in access to health care for patients regardless of socio-economic status?
Patients are increasingly drawn to seek reproductive treatment abroad – because of lower costs and the ready availability of human bodily resources such as commercially obtained gametes and surrogacy, and because the services available in the destination country more closely reflect the values (and risk tolerance) of the patients. The Hayer case is just the tip of the iceberg, and there is every reason to expect that the ethical questions raised by the reproductive travel industry will grow more pressing in the near future.
Disclaimer: Françoise Baylis is a member of the Board of Directors of Assisted Human Reproduction Canada. The views expressed herein are her own.
Françoise Baylis is professor and Canada research chair in bioethics and philosophy at Dalhousie University, Halifax, Canada. Gillian Crozier is a CIHR Post-doctoral Fellow with the department of philosophy and the Novel Tech Ethics research team at Dalhousie University.