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

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

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  Pandora's eggs Social Darwinism v Economic Rationalism in access to IVF IVF technologies continue to raise ethical issues for policy makers. In addition to existential 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 the population 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 those who meets to society’s norms. Infertility – the new epidemic The IVF industry defines infertility as the inability to get pregnant after one year of trying,1 2, although the World Health Organisation expands the period to two years,3 acknowledging that many couples take more than one year but still conceive without medical assistance.4 Fertility, conversely is related to actual births, not potential to conceive. Infertility prevalence data is based on numbers of couples who seek treatment, or a population-based estimate of married women of reproductive age.5 Approximately 10% of Australians are estimated to be infertile6, with 40% of the cause lying with the male, 40% with the female and 20% unknown cause7. The narrow focus of study misses other women who may wish to access IVF procedures such as single women, lesbians and post-menopausal women. Although both males and females may be infertile, infertility as it relates to IVF generally considers only the female as potential recipient of the treatment ‘product’ – the embryo. Homosexual male couples may also wish to be parents, but would not be considered in infertility statistics. Demographic data on Australian infertility seems unavailable, however international data shows a link to lower socio-economic status8 through occupational and environmental exposure to chemicals and radiation9, shift-work and working long hours10 11, and higher incidence of infections. 1 US Department of Health and Human Services Centres for Disease Control and Prevention. http://www.cdc.gov/reproductivehealth/ART/index.htm 2 Ross R. The McBaby Business. http://searchsa.com.au/Diary/Diary_my23.asp 3 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 Program Evaluation. February 1992. 7 Victorian Department of Health. http://ofw.facs.gov.au/publications/wia/chapter3.html#f54 8 Leke JI et al. Regional and geographic variations in infertility: effects of environmental, cultural and socioeconomic factors. Environmental Health Perspectives Supplements 101 (Supplement 2):S73-80. 1993 9 Shahara F et al. Environmental toxicants and female reproduction. Fertility and Sterility. 70 (4): 613-622. 1998 10 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 study among couples from Southern Thailand. Occupationa ad environmetnal Medicine. 55:99-10. 1998.
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  Australian women arealso increasingly delaying motherhood12 13 14. The fertility rate of women over 40 doubled between 1982 and 2002 and highest fertility in the 30-34 age range in 200415. Social and biological causations16 reflect the changing role of women in society, ‘changing attitudes about relationships, families and careers”17, financial or employment insecurity18, delayed interest in having children and lack of awareness of the effect of age on fertility19 - delaying motherhood beyond biological reproductive ability. These women are often of high education and career attainment, able to pay for IVF treatment. Hence increased consumer demand for reproductive assistance. IVF In vitro fertilisation (IVF) refers to fertilisation outside the womb, with the resulting embryo/s being placed in a womb for development. Treatments may use the couple’s own genetic material, or donor material/s. In 2002, 32,958 cycles were attempted in Australia resulting in 6675 pregnancies and 5953 babies20 representing 3%21 of all births in Australia, (30,00022 children in the past five years). In the US a typical cycle will cost $US12,400 and may be partly covered by medical insurance.23 In Australia IVF treatment is ~50% funded by Medicare24, with a gap payment of around $408925 per cycle. The IVF industry is worth $170 million p.a. in Australia.26 IVF is not strictly speaking a health 'treatment'. Infertility is not a sickness, although it may result from disease or injury. IVF does not cure infertility, rather circumvents 12 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 http://www.abs.gov.au/Ausstats/[email protected]/1020492cfcd63696ca2568a1002477b5/3c467e74c23239ffca 256e8a0077add9!OpenDocument#BIRTHS%20AND%20CONFINEMENTS 15 Australian Bureau of Statistics. Australian Social Trends. Population. Echoes of the Baby Boom. 2004. http://www.abs.gov.au/Ausstats/[email protected]/0/47F151C90ADE4C73CA256E9E001F8973?Open 16 Baum F. Choosing not to have children. 1994. Vol 2, No 3. p22-25 17 Australian Bureau of Statistics. Year Book Australia 2002: Population. Special Article - Confinements resulting in multiple births. http://www.abs.gov.au/Ausstats/[email protected]/0/729445EA93DFE747CA256B20007EB589?Open 18 Australian Institute of Family Studies, cited in Cronin R. Birth rate linked to fear of losing job. The Canberra Times. 29 January 2005. http://canberra.yourguide.com.au/detail.asp? class=news&subclass=national&category=general%20news&story_id=367294&y=2005&m=1 19 Hammarberg K, Clarke VE. Reasons for delaying child-bearing – a survey of women aged over 35 years seeking assisted reproductive technology. Australian Family Physician. March 2005; 34 (3): 187-8, 206 20 Bryant J, Sullivan EA, Dean JH. Assisted reproductive technology in Australia and New Zealand 2002. 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 2005 22 ABC Online. Govt warned against IVF Medicare changes. 20 April 2005. 23 American Society of Reproductive Medicine. Frequently Asked Questions. http://www.asrm.org/Patients/faqs.html 24 ABC News Online. Govt warned against IVF Medicare changes. 20 April 2005. http://www.abc.net.au/news/newsitems/200504/s1349690.htm 25 Meatherall M. IVF fee rises no Medicare rort: clinics. Sydney Morning Herald. 23 April 2005. http:// www.smh.com.au/news/Health/IVF-fee-rises-no-Medicare-rort- clinics/2005/04/22/1114152325941.html?oneclick=true# 26 Ross R. The McBaby Business. Http://www.searchsa.com.au/diary/diary_my23.asp
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  it.27 Whether havingchildren is 'essential' depends on beliefs, but with the exception of children genetically matched to save ill siblings, not having a child does not directly endanger life. Evidence-based Medicine : defining success "Clinical decisions must respect, primarily, the interests and welfare of the persons who may be born, as well as the long-term health and psychosocial welfare of all participants"28 IVF is invasive, expensive and emotionally taxing – usually a treatment of last resort for the infertile and carriers of heritable diseases. Maximum success with the minimum number of cycles is an advantage for clinics competing for the Medicare dollar and research dollars. More than 30% of all IVF babies take at least three cycles.29 Definitions of success vary. In the US, the cycles begun to pregnancy rate is between 33-55%30, but data on live births show a live delivery rate of 29.1% per retrieval in 199831. Comparatively, a fertile couple has a 20% chance of pregnancy leading to live birth in any month.32 33 To further confuse the statistics, many couples (estimated as high as 38%) who register at fertility clinics achieve pregnancies independent of treatment,34 reflecting on the appropriateness of the infertility definition. In Australia, IVF statistics are collected on pregnancy, live births and neonatal survival compared to number of cycles attempted. Information such as gestation length and birth weight is recorded but no further information on the health of the baby, infant mortality, development or health outcomes of the older child. 2002 statistics show 61.7% of IVF pregnancies resulted in a live singleton birth and 14.2 resulted in a live multiple birth.35 (The remaining 24.1% are miscarriages or stillbirths.) A recent study showed IVF babies had over double the rate of birth defects by age one36 and other studies have shown higher incidence of ADD and autism, neurological impairments and cerebral palsy and developmental delays.37 27 Ratcliffe J The economics of the IVF Programme: A Critical Review. Centre fr Health program evaluation. February 1992. 28 Australian Health Ethics Committee. Section 4. Ethical guidelines on the use of assisted reproductive technology in clinical practice and research. National Health and Medical Research Council. Australian Government. 2004. 29 McBain J (Melbourne IVF Group) quoted in ABC Online. Govt Warned against IVF Medicare Changes. 20 April 2005. http://www.abc.net.au/news/newsitems/200504/s1349690.htm 30 Ratcliffe J The economics of the IVF Programme: A Critical Review. Centre fr Health program evaluation. February 1992. Section 2. 31 US Department of Health and Human Services Centres for Disease Control and Prevention. Frequently Asked Questions. http://www.cdc.gov/reproductivehealth/ART02/faq.htm#4 32 American Society of Reproductive Medicine http://www.asrm.org/Patients/faqs.html 33 Victorian Department of Health, http://www.ofw.facs.gov.au/publications/wia/chater3.html#f54 34 Ratcliffe J The economics of the IVF Programme: A Critical Review. Centre fr Health program evaluation. February 1992. Section 2 35 Table W, Bryant J, Sullivan EA, Dean JH. Supplement to Assisted reproductive technology in Australia and New Zealand 2002. Australian institute of Health an Welfare National Perinatal Statistics Unit and the Fertility Society of Australia 36 Ross R. The McBaby Business. http://searchsa.com.au/Diary/Diary_my23.asp 37 ibid
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  While parents mayfeel live multiple births are a success, they are not the ideal outcome. 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 the same period.) Multiple births are associated with higher rates of stillbirth and miscarriage, a higher risk of prematurity associated with higher infant morbidity and mortality,40 and higher costs to the health system for both mother and babies. Due to the health risks and considering higher embryo transplant success rates, Australian clinics 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 multiple birth as IVF babies also have a higher rate of monozygotic twinning.41 42 When success is defined as the live birth of a singleton at term gestation the rate is 11.1% per cycle begun.43 One of the most successful fertility options is surrogacy. Commercial surrogacy is illegal. Non-commercial surrogacy is legal in some states although the National Health and Medical Research Council (NHMRC)’s guidelines warn of ethical, social and legal implications44 (including the potential for exploitation). Surrogacy has few intrinsic barriers except cost and hence is potentially open to all including post- hysterectomy women and men. The Medicare rebate for IVF does not apply to surrogate pregnancies. Legislative Barriers to IVF The Australian Government acknowledges the right of Australians to define their own family through choice45, a principle upheld in law.46 However access to IVF to fulfill this right is governed by a range of state and Commonwealth legislations.47 Some states have specific legislation regarding IVF, while others rely on the NHMRC ethical guidelines for the clinical practice of ART,48 which state that the clinic needs 38 Perinatal Statistics Unit. Quoted in: Robotham J. Pregnancy rate fall forces clinic into U-turn. Sydney Morning Herald, 19 January 2005 39 Australian Bureau of Statistics. Year Book Australia 2002: Population. Special Article - Confinements resulting in multiple births. http://www.abs.gov.au/Ausstats/[email protected]/0/729445EA93DFE747CA256B20007EB589?Open 40 MMWR, June 23, 2000/ 49(24); 535-8. 41 National Organisation of Mothers of twins Clubs Inc. Twinning Facts. http://www.nomotc.org/library/twinning_facts.html 42 Robotham J. Pregnancy rate fall forces clinic into U-turn. Sydney Morning Herald. 19 January 2005 43 Min JK. Breheny SA. MacLachlan V. Healy DL. What is the most relevant standard of success in assisted reproduction? The singleton, live birth rate per cycle initiated: the BESST endpoint for assisted reproduction. 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 gendered analysis shadow report to Australia’s third periodic report to the Committee on Economic, Social and Cultural Rights. Article 10. http://home.vicnet.au/~wrana/advocacyfiles/escr.pdf 46 Cannold L, Cica N, The Law. The Price of Parenthood. 28 July 2003. Posting on Australian policy online website. www.apo.org.au 47 SA Department of Health. Reproductive Technology. Legislation Around Australia. http://dh.sa.gov.au/reproductive-technology/other.asp 48 Australian Health Ethics Committee. Ethical Guidelines for the clinical practice of ART. Part B, p42. National Health and Medical Research Council. Australian Government. 2004.
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  documented practices andprocedures, and specific protocols regarding access to IVF treatment49, but do not specify a framework for decision making. Legislative barriers centre around two factors: medical need (clinical infertility) and the nature of the parental relationship (married or heterosexual de facto). While all Australians have access Commonwealth funded Medicare rebates, States regulate the clinics and have the power to close them and de-register doctors if they do not comply. The clinics and doctors must do the policing. Women who access IVF in the US tend to be older, of higher education attainment and higher socio-economic status50 whereas infertility is more prevalent amongst those of lower socio-economic status. The out-of-pocket costs of IVF along with the disruption to paid employment form barriers to access51 and will affect people differently across the socio-economic stratum. Australia’s Medicare subsidising of costs 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 arena and given the tax-paying public an arguable right to comment on access issues52, but if a woman is willing to pay for the procedure privately, this argument is baseless. States would 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. Everyone's 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."53 The concept of reproduction is tied to many fundamental beliefs about society. The book of Genesis says "Go forth and be fruitful54". Darwinists believe the drive to reproduce is a biological urge to ensure the perpetuation of the species. The International Covenant on Civil and Political Rights proclaims the right of "men and women of marriageable age to marry and found a family"55. In subsistence cultures women’s identity, role and value in society is defined by their ability to bear children. An infertile woman may be abandoned by her husband.56 Children support their parents in old age. Australia parallels this with baby-boomers 49 Australian Health Ethics Committee. Section 5.3 Ethical guidelines on the use of assisted reproductive technology in clinical practice and research. National Health and Medical Research Council. Australian Government. 2004. 50 Stephen EH, Chandra A. use of infertility services in the United States: 1995. Family planning Perspectives. Vol 32. No 3. May/June 2000. http://guttmacher.org/pbs/journals/3213200.html 51 Phelps K. Informed debate on IVF costs must still go ahead. Medical Observer. 20 May 2005. p24 52 ibid 53 Maushart S. The Mask of Motherhood. How mothering changes everything and why we pretend it doesn't. 1997. Random House Australia Ltd. P1 54 Genesis 1:27-28 55 International Covenant on Civil and Political Rights. Article 23.2 . New York, 16 December 1966 http://www.austlii.edu.au/au/other/dfat/treaties/1980/23.html 56 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. http://humrep.oxfordjournals.org/cgi/cntent/fll/17/6/1663
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  needing a youngergeneration of taxpayers to support their welfare and health in retirement. The American Society of Reproductive Medicine website states “[t]he desire to have children and be parents is one of the most fundamental aspects of being human” 57 in arguing for health insurance for treatment costs. This argument is self-serving and fails to consider the increasing number of people who choose not to have children. 58 59 In 2000, the ABS estimated that 25% of women who had not yet ended their reproductive 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 argument for 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 right to decide who can reproduce and who cannot? The economic rationalists argue that we have the right to say how our taxes are spent when it comes to publicly funded reproductive treatments61 but it could equally be argued that dominant social norms are not necessarily the best standards for forming legislation. Conservatives and some religious groups say we do not have the right to over-ride the will of God (sometimes this relates to IVF generally, sometimes to access for lesbians and single women). Darwinists argue that IVF over-rides evolutionary mechanisms of survival of the fittest by reproducing those genes that would not naturally have survived in the wild to reproduce, and the result will be a weakened human race. There is evidence that IVF children may have poorer developmental and health outcomes than the general community, whether because of genetics or damage done by the IVF procedures.62 How do we value a live baby compared to some notional concept of perfection in these days of wrongful life cases? Arguments about limiting access to IVF fall on both sides of the nature v nurture debate. On the nature side, can we value-judge genes on their positive or negative values? Few would choose to have the genes for predisposition to breast cancer, lower than average IQ or other factors affecting length or quality of life. But does this give us the right to eliminate these genes from the population either by limiting people’s access to reproduction or by genetic screening of embryos? Maybe their value is in what they can offer to genetic variation. Taking the nature debate a step further, is it ethical or fiscally responsible to reproduce people inherently unable to survive by themselves (in the case of genetically inherited disorders) and hence destined to be a burden on the welfare and health systems, and society in general? Does it differ if we are talking about someone whose body is physically unable to sustain life without medical assistance compared to someone who might be able to survive quite happily in society but be unable to 57 American Society of Reproductive Medicine http://www.asrm.org/Patients/faqs.html 58 Baum F. 1994. Choosing not to have children. Vol 2, No 3. p22-25 59 Australian Demographic Statistics 2002. Population. Special Articles- Lifetime Childlessness (Sep 1999). 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. http://www.abs.gov.au/Ausstats/[email protected]/0/47F151C90ADE4C73CA256E9E001F8973?Open 61 Phelps K. Informed debate on IVF costs must still go ahead. Medical Observer. 20 May 2005. p24 62 Ross R. The McBaby Business. http://searchsa.com.au/Diary/Diary_my23.asp
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  compete for resourcesand hence reliant on welfare? While sterilisation without consent of the intellectually disabled was only outlawed in 199263 there is now no legal barrier to an intellectually disabled infertile woman in a relationship seeking IVF using 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 have specifically legislated against IVF access for women outside a male-female relationship (marriage or de facto), or only to the clinically infertile64 (and their partners) in order to exclude those whose infertility is seen by the state as being by choice. While these policies do limit gay parenthood, the limits do not apply to donors of genetic material. There is no requirement on sperm or egg donors that they be heterosexual, although recipients have brief information about the donor and can choose between donors. Hence it would appear that either policy-makers, correctly or incorrectly, do not believe that homosexuality has a genetic basis or perhaps nurture theory is the rationale for the policies. The Commonwealth Sex Discrimination Amendment Bill 200265 was drafted to exempt state reproductive technology legislation from the Commonwealth Sex Discrimination Act following two legal challenges where Commonwealth legislation over-rode the state legislation regarding access to IVF66 for a single woman in Victoria (McBain v State of Victoria) and a woman separated from her husband in SA (Pearce v SA Health Commission67). While the Amendment does not mandate exclusion of homosexual or single women from access to IVF, it specifically enables the states to do so. The Amendment does prevent discrimination between married and de facto couples (defined as "of the opposite sex"), and removes the time-based criteria on relationships. While there is no evidence that parental marital status affects the wellbeing of the child68, access can also be restricted to those clinically infertile, effectively excluding single and lesbian women without risking accusations of discrimination. The International Covenant on Civil and Political Rights (1966) declares that the family is "the natural and fundamental group unit of society and is entitled to protection by society and the State"69 and proclaims the right of "men and women of marriageable age to marry and found a family"70. The preamble to the United Nations Convention on the Rights of the Child state that “the family, [is] the fundamental 63 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. http://dh.sa.gov.au/reproductive-technology/other.asp 65 Sex Discrimination Bill 2002: Explanatory Memorandum. www.scaleplus.law.gov.au/cgi- bin/topicSrch.pl?action=View&VdkVgwKey=%2Fscale 66 Del Villar K. McBain v State of Victoria: Access to IVF for all Women. 15 August 2000. http://www.aph.gov.au/library/pubs/rn/2000-01/01RN03.htm 67 Pearce v SA Health Commission 68 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 http://www.austlii.edu.au/au/other/dfat/treaties/1980/23.html 70 International Covenant on Civil and Political Rights. Article 23.2 New York, 16 December 1966 http://www.austlii.edu.au/au/other/dfat/treaties/1980/23.html
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  group of societyand the natural environment for the growth and well-being of …. children” and “the child, for the full and harmonious development of his or her personality, 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 in numeric or gender specific terms. Arguments that it is ‘natural’ and best for a child to have a mother and a father as opposed to two parents of the same gender prioritise gender over other factors perhaps more germane to parental quality. Perhaps this policy reflects environmental causation belief – that sexuality is a social construct and the homosexual parents may influence their child to be homosexual. Is it intrinsically bad if the child does turn out to be homosexual? The International Covenant on Civil and Political Rights states signatories “undertake to have respect for the liberty of parents and, when applicable, legal guardians to ensure the religious and moral education of their children in conformity with their own convictions,”72 and if the parent is homosexual they would presumably consider their behaviour to be morally acceptable. A less contentious use of environmental causation in policy-formation is SA legislation preventing access to IVF for anyone with a child protection order, found guilty of a sexual or violent offence, or suffering from an illness, disease or disability that may hinder their care for the child.73 74 While this aims to provide a safe environment for the child the argument does not hold true of the convicted person is sentenced to prison for a long period and hence poses no environmental threat to the child. In the end, the nature/nurture arguments are insoluble as the expression of genetic potential is influenced by environmental factors, and policy must reflect this dichotomy. Another contentious access to IVF issue relates to posthumous use of gametes. This covers both the harvesting of gametes posthumously and the use of gametes harvested with consent during the person’s life but used posthumously. State legislation is mixed, some allowing for use of existing embryos, or use of embryos/gametes only with 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 being created for the purpose of financial inheritance. Valuing lives - economic rationalism The economic rationalism of allocating the health budget funds between competing needs must consider health priorities, size of demand, relative costs and likelihood of success. Recent debate has centred around whether there should be a cap on funding IVF treatments, particularly for older mothers, who have a statistically lower chance of achieving IVF success. 71 Preamble. United Nations Convention on the Rights of the Child. 1990. http://www.unicef.org/crc/crc.htm 72 ibid 73 Victorian Law Reform Commission. Legislative background. 11 May 2005. 74 Ratcliffe J The economics of the IVF Programme: A Critical Review. Centre fr Health program evaluation. February 1992. Section 2 75 Victorian Law Reform Commission. Legislative background. 11 May 2005.
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  "Nothing in lifeis 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.76 Balanced against these arguments for economic rationalism, we have the perceived need for future taxpayers to support the population bulge of baby-boomers in their retirement.77 Australia’s population profile is ageing, the birth rate is in decline78, and many 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 Federal policy. The 2004 Federal Budget had financial incentives to have children and the 2005 Budget contained efforts to increase the workforce by getting the disabled and single mothers to work. Federal Treasurer Peter Costello urged Australians to have one baby for the mother, one for the father and "one for the country".81 Perhaps current taxpayers, considering the population profile and the increasing number of women remaining childless, should finance IVF for all women who ask for it, even those of whose lifestyles they may disapprove and those who have a low likelihood of success as a societal investment. Those who choose to remain childless may 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 large portion of the budget, can we afford such big ticket, low success, 'non-essential' items as IVF? In 2003 the total IVF bill funded by Medicare was $50 million. Following the introduction of the Safety Net in 2004, costs leapt to $78.6 million year.82 This is approximately $15,720 of taxpayer funding per live baby born - arguably still not a huge commitment in times of falling birth rates and less than the costs the parent/s will incur in raising the child.83 76 quoted in Glasson B. Beware the IVF trojan horse. Medical Observer 13 May 2005 p24 77 Australian Bureau of Statistics. The Health of Older People, Australia. 2004. http://www.abs.gov.au/ Ausstats/[email protected]/0/5B3A04650641EF75CA256F4700715847?Open 78 Australian Bureau of Statistics. Year Book Australia. 2005. Population. Births. http://www.abs.gov.au/Ausstats/[email protected]/0/B9D7BE2CDD8D623FCA256F7200833029?Open 79 Phelps K. Informed debate on IVF costs must still go ahead. Medical Observer. 20 May 2005 p24 80 Lie back and think of Australia. Sydney Morning Herald. 5 June 2004. Fairfax Digital Website. http://www.smh.com.au/articles/2004/06/04/1086203630799.html?oneclick=true 81 Australian Institute of Family Studies, cited in Cronin R. Birth rate linked to fear of losing job. The Canberra Times. 29 January 2005. http://canberra.yourguide.com.au/detail.asp? class=news&subclass=national&category=general%20news&story_id=367294&y=2005&m=1 82 Meatherall M. IVF fee rises no Medicare rort: clinics. Sydney Morning Herald. 23 April 2005. http:// www.smh.com.au/news/Health/IVF-fee-rises-no-Medicare-rort- clinics/2005/04/22/1114152325941.html?oneclick=true# 83 Henman P. (Macquarie University sociologist) quoted in The Cost of Kids. Macquarie University News. October 2002. http://www.pr.mq.edu.au/macnews/ShowItem.asp?ItemID=137
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  Where the costsof IVF should be borne depends on whether we consider reproduction to be a personal or population issue. If we having children is a personal issue with personal benefits then the costs should also be borne on a personal level. If we believe that benefits will accrue to the population as a whole (through the creation of 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 a maximum three Medicare funded cycles p.a. and limiting funding for women aged over 42 to a total of three IVF cycles84 was seen as hypocritical in the context of the recent funding to boost the birth rate. The limit for older women was related to the success rates for implantation. Perhaps smokers and those living with smokers should also be limited as a recent study linked smoking and passive smoking with lower implantation success85. Conclusion Whether we consider the state has the right to restrict access to IVF from any Australian woman, and on what grounds we consider this acceptable involves a number 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 choose to prevent from reproducing either genetically or in terms of parenting, depends on our values and whether we believe the ‘unacceptable’ factors are determined by nature 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 is prepared to pay for children, and in what circumstances, involves existential questions such as whether we should be valuing children in financial terms, in terms of what they can contribute to society, for their genetic variation or some other basis. 84 ABC Online. Govt warned against IVF Medicare changes. 20 April 2005. http://www.abc.net.au/ news/newsitems/200504/s1349690.htm 85 Passive smoking affects IVF. Australian Doctor. 10 June 2005. P19