Ethics on procreation: Does everyone have the right to found a family?

Over the last few decades, emerging technologies in the field of reproduction have opened up new options to procreate and have made it possible for otherwise infertile couples to have children. Assisted reproductive techniques are widely accepted by both the scientific community and the society. Criticisms are only limited now to very special applications of them, such as gender selection, or to their medical safety, such as high-order gestations and pregnancy risks, rather than against the techniques themselves. As a result, the terminology surrounding the right to procreate comes under renewed scrutiny. The question of how far there is, or should be, a right to procreate and whether it includes a right to in vitro fertilization (IVF) treatment arises in debates about reproductive technologies. National Institute for Health and Clinical Excellence (NICE) draft guidelines on fertility, which have been presented for discussion, recommend expansion of the eligibility criteria for access to IVF on the National Health Service (NHS). However, if the right to found a family is accorded to all, should eligibility criteria be banned altogether and assisted reproductive techniques be included in the health care services that are offered to everyone?

In order to answer the question of whether eligibility criteria for access to assisted reproductive techniques on the NHS should be banned, it is necessary to unfold the foundation of family and reveal how it is interconnected to the human nature. In all times and all societies, people have been seen to relate to others through affection, collaboration, obligation or reliance. The natural human need for support, companionship and love leads to the formation of lifelong bonds between individuals with the purpose of building a home, welcoming and raising a new human life. That leads to the formation of the natural family. ¹ Stack describes family as the smallest, organized, durable network of kin and non-kin who interact daily, providing domestic needs of children and assuring their survival. ² The European Convention on Human Rights (ECHR) has recognized that men and women of marriageable age have the right to marry and to found a family ³ and that their family is entitled to protection by the State. ⁴ However, over the last decades, the traditional nuclear family pattern has changed significantly. Family has now expanded to include single parents, blended families, unrelated individuals living cooperatively and homosexual couples among others. ⁵ Moreover, the development of assisted reproductive techniques has changed the context of human reproduction considerably. Human rights law does not dictate the pattern of family unit that is deemed acceptable. Are these new types of family to be protected and supported by the State? And is everyone to be helped to found a family?

Although the right to found a family seems to be directly related to the human nature and it is generally accepted as a de facto possession, there are attempts to restrict it for those, for example, past the usual childbearing age, with severe learning difficulties, hereditary conditions or problems with drugs or alcohol. In practice, as long as a couple can naturally reproduce, there is no way of stopping them to do so. Therefore, the question of whether or not the right to found a family should be restricted applies only to those couples who need help to procreate. In the publicly financed NHS, assisted reproductive techniques are offered to subfertile couples. However, eligibility criteria, which have been imposed by organizations such as Primary Care Trusts (PCTs), the NICE and the Department of Health and which are not always based on clinical grounds, allow access to IVF to a highly selected group of patients. In order to evaluate the restraints on application of assisted reproductive techniques for procreation, the principles of the moral law will be used.

In the present context, it seems wise to consider morality and justice. According to the late Harvard philosopher Robert Nozick, morality and justice are merely a matter of respecting existing moral rights and the most fundamental moral rights are the right to self-ownership, autonomy, justice, equality, beneficence, non-maleficence and collective rationality. Eligibility criteria that restrict access to assisted reproductive techniques are against reproductive freedom and the right to choose what one believes best life prospects for their children based on their own values. It is against the principle of autonomy as it restricts people’s ability to make decisions and be accountable for them. Moreover, imposing restrictions to those who require assistance to reproduce when there are no restrictions to those who can reproduce without assistance is unfair and lead to discrimination against the former group. Furthermore, provided that appropriate medical care is offered, restricting access to treatments that have been shown to be safe and effective ⁶ is against the fundamental medical culture of ‘do good but first do no harm’. Last but not least, limited access to assisted reproduction hampers economic growth and development by reducing the economic base to support an ageing population. ⁷

We have seen that the right to found a family and the right to assisted reproductive techniques should be accorded to all. And therefore, in a health care system that is publicly financed, such as the NHS, IVF should be an ordinary part of the services that are offered to all. Arguments that infertility is not a life-threatening condition can be disputed by the fact that many other non-life-threatening conditions, such as urinary incontinence, heavy menstrual bleeding and others, are routinely treated in the NHS with no restrictions. Moreover, infertility can lead to significant psychological morbidity if left untreated. Since as many as one in six couples are affected by infertility, ⁸ it can negatively affect a significant proportion of the workforce, leading to additional burdens on society. Furthermore, arguments about the cost-effectiveness of infertility treatments can be challenged by the current assisted reproductive techniques’ success rates; ⁹ one baby who is going to live a full life is born per four cycles in average. These results are outstanding if compared to those of any form of transplant surgery as underlined by the philosopher Torbjorn Tannsjo; ¹⁰ heart transplantation surgery only gives an additional 10 years survival of less-than-satisfactory quality of life and at much higher costs, while even renal transplantation surgery, the most cost-effective transplant surgery known today, cannot give the full life that IVF can. It is apparent that even though assisted reproductive techniques cannot compete with life-saving treatments for young people, they do compete with costly, life-prolonging treatments for the elderly. Therefore, if a health care system can support the latter treatments, it should also include assisted reproductive techniques without restrictions. The conclusion eventually drawn is that eligibility criteria for NHS access to IVF should be banned all together and assisted reproductive techniques should be provided to everyone who requires them.