Written by Professor Julian Savulescu and Professor Kelton Tremellen
This is a cross posting of an article which was originally published at The Conversation
How much should the state spend on helping people to have children? At present, government support for infertility treatment is approximately A$240 million a year. The success of fertility treatments such as IVF is good if you are under 35 years of age, but once a woman hits 40 it plummets, falling to an almost futile one-in-80 chance of producing a baby for women 45 years and older. This raises the question – is IVF a cost-effective use of taxpayers’ money? And what about for older women?
Decisions about funding are usually made on grounds of cost-effectiveness. In Australia, the cost-effectiveness threshold is about A$40,000 per “QALY”. A QALY is a quality adjusted life year. Thus the government will spend, for example, A$40,000 to add a year of full health, or improve the quality of life by 10% for 10 years.
Is IVF cost-effective? It depends on how we measure it.
The life of the child
If we count the life of the child who is produced by reproduction as a benefit, then IVF for infertility is highly cost-effective. Latest figures state that more than 13,000 babies were born through IVF treatment, at an average cost to government of A$19,000 per child.
Likewise pre-implantation genetic diagnosis to test for genetic disorders in potentially fertile couples is cost-effective. Genetic testing costs on average A$3,000-$5,000 per cycleof IVF, plus the additional IVF treatment costs. Even for a 45-year-old woman, at A$5,000 per cycle, total cost to bring about a live birth would be A$400,000. But this buys a whole life of 80 QALYs, so works out to be A$5,000 per QALY, well below the threshold and great value for money.
While the Australian government does pick up the tab for the majority of IVF costs, it pays absolutely nothing towards the costs of genetic testing, which are borne by the prospective parents. This appears to be a strange position when one considers the costs associated with care for a child born with cystic fibrosis, estimated to be over A$30,000 a year.
Let’s say the person with cystic fibrosis lives 30 years. This gives a total cost of nearly A$1 million for lifetime care. Genetic testing costs maximum about A$5,000 and IVF about A$19,000. That is A$1 million versus A$24,000.
It is thus vastly more cost-effective to provide genetic testing for free and have children born without cystic fibrosis. It could be that fears of “designer babies” are holding back improving access to this life-saving and economically sound medical care.
If we count the value of the life of a child produced by IVF as a benefit, it is a hugely cost-effective medical procedure.
The life of the parents
There is great philosophical debate about how to value bringing new people into existence. For example, it is much worse to kill someone than to decide not to have a child (using contraception or abstinence). Killing someone harms them but failing to bring someone into existence harms no one. Likewise, it is often said that bringing someone into existence does not directly benefit any individual.
For this reason, it can be argued that the relevant harms and benefits are those to the parents. That is, the success of IVF should not be counted in terms of the life of the child produced but in terms of the unhappiness, anxiety and other mental distress couples or individuals feel at not being able to have a child. This makes IVF much less cost-effective because the benefits are so much smaller.
Impersonal reasons
Should the life of the child count in us deciding how to fund and prioritise IVF? We think it should, but in a way that is different to counting its full value. Consider the simple case of genetic selection to avoid a genetic disease such as cystic fibrosis.
If IVF and genetic testing are used to select a healthy embryo, call her Jane, we avoid hundreds of thousands of dollars in lifetime health-care costs and all the difficulty and misery of a life with cystic fibrosis. But did the genetic selection benefit Jane? No – if it were not performed, another child, call him Peter, would have been born with cystic fibrosis.
This is puzzling. We want to say it is good that people don’t have genetic diseases in the future, but when this is achieved by genetic selection it does not appear to benefit anyone. Of course parents and society benefit by not having to care and worry about treatment for cystic fibrosis. But we also feel intuitively that a world without cystic fibrosis is a better world.
Sometimes these reasons are called “impersonal reasons”, reasons that are unconnected to harm and benefit to persons. These reasons give us some cause to act. But they appear weaker than ordinary person-affecting reasons, which involve direct harm and benefit to persons. For example, it is worse to give someone cystic fibrosis who was previously healthy than it is to fail to have genetic selection and so conceive a child with cystic fibrosis.
Nonetheless, impersonal reasons to care about the next generation are an important ground for making the world a better place – for example, by selecting policies aimed at reducing carbon emissions. Such policies will inevitably affect the timing of reproduction, and so the identity of who is born. Nonetheless the world is better for these different future people.
The implication of this for IVF and genetic selection is that we have some direct impersonal reasons to support these. These arguments extend to having children. It is better if there are children in the future.
Many European and Asian countries are suffering from having too few young people to support their ageing populations. Of course the limitation of resources places an upper limit on how many people there should be. But in the absence of such a limit, it is better if there are more happy, healthy people.
These arguments suggest much more funding should be put into IVF and genetic selection to avoid serious disease. But they also extend to other non-disease traits. It is better if people have talents and gifts, are happy, co-operative, empathetic, altruistic and so on.
What goes on the list of personally and socially valuable traits is contentious, but there is consensus on some traits. Psychopathy is not a trait there is a reason to preserve, or to select for. We should support selecting against it, just as we should support preventing disease.
Genetic selection should be supported to have children who will have better lives, not merely healthier lives. It ought to be a priority.
Now that whole genome analysis is becoming cheap and widely available, it ought to be employed where IVF is already being used for infertility or avoiding genetic disease. But should we lift laws that prevent access to IVF for healthy couples?
Should the state support genetic selection where there is not a high risk of genetic disease or infertility? The answer to this question will depend on just how much genetic selection is capable of adding to the quality of the lives of the next generation or the benefits to future society.
At present, most complex traits like intelligence have many genes contributing. When only 20 embryos are produced, it is not possible to select across a large number of genes. For this reason, genetic selection is unlikely to be cost-effective when dealing with polygenic traits.
Nonetheless, laws banning such genetic selection ought to be lifted. And if technologies that amplify genetic selection for polygenic traits become available, perhaps the state ought to provide these.
Including the value of new people in our moral and economic thinking would cause us in many cases to give greater economic support to IVF and genetic selection than we currently do.
Another set of right-wing assertions embedded in what is ostensibly a comment on medical ethics…
That sounds like something from a Tony Blair advisor, sometime around 1997. It is a political assertion, no more, and of course no evidence or argument is presented. The whole tone of the piece is propagandistic and evasive. What about parents who think being gay is a genetic defect? Should they get money for a gay-gene test, if and when it becomes available? And what exactly is the ‘psychopathy’ that Julian Savulescu and Kelton Tremellen want eliminated?
‘Psychopathy is not a trait there is a reason to preserve, or to select for. We should support selecting against it, just as we should support preventing disease.’ I agree with Paul, what on earth does this mean? There really is no point in doing ethics with this nonsense.
How about the state stop subsidizing women’s poor life choices? Why should everyone pay for the few women who are waiting to the end of their biological fertility window to try to have kids.
Julian Savulescu claims that a society of talented, gifted people is desirable, and implies that it should be created by genetic selection. That is identifiably a right-wing proposal (or utopia), and a reasonable person would not want such a society.
Talented people have significant disadvantages. In western countries, ‘talent’ is a self-description used by socially advantaged individuals from the upper class, upper-middle-class, and partly from the middle class. One or both parents usually have a university degree.
The talented regard themselves as natural elite, and sociologically they are indeed an elite. There is no official definition, and therefore no statistics, but we are talking about perhaps 2% to 10% of the population. Some marginalised groups, for instance the Roma in Europe, are fully excluded from the category ‘talented’. Consequently a transition to a Europe of talented people, would entail a de facto genocide against the Roma people.
As individuals, talented people are generally arrogant and self-centred. They see themselves as inherently superior to the untalented, who form the majority of the population. Their attitude is therefore contemptuous, and sometimes hostile.
Talented people have identifiable political preferences, some of which logically derive from their own status. They support selective education, which has favoured them, and oppose social mobility, which would undermine their socio-economic advantages. They are contra-egalitarian, and oppose the redistributionist left. If politically active, talented people are found in centre-right parties in western Europe, and on the right wing of social-democratic / centre-left parties.
Talented people are usually moderates. Typically they consider radical positions to be stupid and ill-informed. They are therefore anti-radical and anti-extremist, which politically translates to support for the security services, and for strategies of repression directed at extremists. They are structurally conservative, since they oppose the radical changes in society which are associated with any fundamental innovation. Typically they support NATO, the nation-state, and the Atlantic alliance.
As an example of a specific issue, take the European refugee crisis. Talented people in Europe generally see refugee flows as a threat to the continent, rather than as people who need help. They favour securitisation of the issue, such as the use of the military to stem refugee flows, and they would favour an anti-migration task for NATO. Similarly, on terrorism policy, talented people prioritise security over liberty. Although terrorism has a very low death rate compared to, for instance, road accidents, talented people treat it as an existential threat, and regard it as absurd to simply accept it. Talented people generally support a ‘war on terror’ strategy.
The choice for a world of talented people is therefore a choice for a right-wing world. It may be a logical preference for right-wing people, but it cannot, on that ground alone, override other preferences, other values, and other utopias.
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