Menopause International >
Volume 14, Number 4 >
Pp. 173-177
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Clinical practice |
School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, UK
Correspondence: Anna Smajdor, Lecturer in Ethics, School of Medicine, Health Policy and Practice, University of East Anglia, Norwich NR4 7TJ, UK. Email: acsmajdor{at}googlemail.com
 | Abstract |
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Key Words: Menopause • oocyte donation • ethics • reproductive technology • fertility
| Introduction |
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Many other medical resources, such as drugs or diagnostic equipment, are scarce because they are time-consuming or costly to create or manufacture. However, human organs and eggs are scarce not specifically because they are expensive to obtain, but due to the physical risks and ethical complications involved. Because of their scarcity, the problem of how to discriminate between claimants arises. This raises a variety of ethical questions. Have postmenopausal women already had their chance? Should gametes be provided only to those who have a genuine medical need? Are there grounds for refusing donated eggs to women over 50 on the grounds of harm to the mothers and children? Or would this be discriminatory?
| A fair innings? |
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In 2005, a group of fertility experts writing in the British Medical Journal speculated that women who are currently of reproductive age are now deliberately delaying pregnancy on the assumption that reproductive technology will help them out in later years.6 This kind of assumption often feeds into an undercurrent of feeling that seems to inform attitudes towards older and postmenopausal motherhood. That is, women have a duty to reproduce at the ‘appropriate’ time and that they can be condemned for failing to do so. In particular, it tends to be assumed that career ambitions and a desire for social and economic status are at the root of women's failure to make appropriate reproductive choices.6
There are a number of questions to be asked here. Do women who fail to reproduce at the ‘right’ age display immoral characteristics? Is it really true that women are consciously delaying motherhood? Many of the underlying concerns about women's motivations and characteristics in making reproductive choices have been brought to the fore in the context of egg freezing. Again, there are two potential categories of claimant: those women who suffer from the kind of medical conditions outlined earlier and those who might seek to freeze their eggs as a kind of insurance policy. Dr Gillian Lockwood suggests that ‘...egg freezing may come to be seen as the ultimate kind of family planning’.7 However, the use of egg freezing as ‘insurance’ in this way was swiftly denounced by many fertility clinics and by the American Society for Reproductive Medicine.8
| Selfishness |
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The question of whether women really are showing selfish characteristics cannot be answered without considering the process by which these decisions are made. Part of the rhetoric of selfishness relies on the idea that women could do otherwise if they pleased, but choose not to do so, placing their own interests above those of their children. The language used to describe the decisions and choices faced by women often seems to emphasize this idea of choice and of deliberate postponement. A typical phrase reads: ‘[m]any people are choosing to put off having children until relatively late in life’.13 The use of terms such as ‘put off’, ‘delay’ and ‘postpone’ reinforces the idea that there is a specific choice being made here.11
| Deciding to postpone motherhood |
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 TopAbstractIntroductionA fair innings?Selfishness Deciding to postpone motherhood Factors beyond women's controlClinical needRisks to women and...DiscriminationConclusionCompeting interestsReferences |
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What is the nature of the decisions people make regarding pregnancy? Large numbers of women get pregnant accidentally, even in countries where contraceptive use is widespread.14 In these cases, no specific decision has been made. However, the decision to have a child can be a discrete event occurring at a particular time and place. It may be followed by noticeable changes of habit and action. (Indeed, it is often assumed that reproductive decisions should be of this type, and accidental pregnancies are typically regarded as a public health problem.)15 Likewise, not having a child may be either the result of a conscious choice or the result of an ‘accidental’ combination of circumstances.
Although some women do make a deliberate choice to delay or forego motherhood, there are many women for whom the failure to reproduce is not necessarily attributable to any conscious decision. Not deciding to conceive a child is not necessarily a discrete choice. Not deciding to have a child is not logically, morally or experientially the same as deciding not to have a child. For this reason, it may be wrong to assume that postmenopausal women who seek treatment must have made a deliberate choice not to have a child earlier. This being the case, it is relevant to ask whether postmenopausal women who are regarded as having had a fair innings have made a positive choice to postpone motherhood, or whether their childless status has transpired for other reasons.
| Factors beyond women's control |
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TopAbstractIntroductionA fair innings?SelfishnessDeciding to postpone motherhoodFactors beyond women's controlClinical needRisks to women and...DiscriminationConclusionCompeting interestsReferences |
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However, even if Pennings is correct that most women do not defer pregnancy for the sake of their careers, and if I am correct that women seldom make a discrete decision to delay motherhood, there may nevertheless be some women who do make these choices, and for these reasons. Supposing we could identify such women, would it be acceptable to withhold treatment from them?
One of the most obvious answers to make here is that medical resources are not usually withheld on this kind of punitive basis in the UK. A woman who develops type II diabetes may do so as a result of choices made earlier in life. But we would not normally see this as a reason to deny treatment. Perhaps, if a person's choices may make treatment ineffective (as in the case of liver transplants to alcoholics) there might be justification for denying treatment, especially where resources are very limited. However, it has been established that postmenopausal women can successfully gestate and give birth to children conceived with donated eggs. On this view, postmenopausal women have as much to gain from treatment as younger women.
| Clinical need |
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But what is clinical need in the context of reproductive technology? In her essay ‘Technologies of Procreation’, the feminist writer Ann Oakley asks what reproductive technologies are for. In answer to her own question, she quotes the debate on the protection of the unborn children bill, describing fertility clinicians as ‘medical scientists working in response to a great humane need’.18 Reproductive technologies are, apparently, the means by which this great need is met. Accordingly, it has been assumed by many commentators that egg donation can be incorporated into the health-care systems that encompass IVF as a means of meeting this need.
Yet, the relationship between reproductive technologies and clinical need is not always clear-cut. Writing about donor insemination, Simone Bateman asks ‘[w]hat reasoning led physicians to assume that they were providing treatment for infertility, when the technical act they were proposing may be understood as an alternative mode of conception to heterosexual intercourse?’19 Bateman's point – which applies equally to egg donation – is that donated gametes do not restore any faculty; they do not prolong life or cure a disease. This being the case, it is not clear that young infertile women have a greater clinical need for donated eggs than postmenopausal women. Indeed, it is not clear that anyone could be said to have a medical need for this kind of treatment. Richard Ashcroft asserts that ‘it is not at all clear how to specify the criteria for being a "proper" medical or health care intervention’.20 Arguably, this is particularly so in the context of reproductive technologies.
It is not within the scope of this paper to explore fully this vexed issue. However, it is important to note that reproductive therapies are a particular area of uncertainty, and that for this reason, establishing clinical need is more than ordinarily fraught. This being the case, it becomes still more important to establish what, if any, are the reasons for restricting access to donated eggs to those of premenopausal age.
The issue of age in general in the context of fertility treatment has been somewhat controversial. For example, the National Institute for Health and Clinical Excellence (NICE) stipulates that IVF should be provided to women aged only up to 39 years. John Harris has argued that this is discriminatory.21 However, he has been taken to task over this by Michael Rawlins and Andrew Dillon (respectively, the chairman and chief executive of NICE), who argue that the age limit is perfectly acceptable within NICE's framework.22 Ethical and social concerns do not fall within NICE's remit, which is the assessment of clinical need and efficacy alone.23 Thus, according to Rawlins and Dillon, there is nothing ageist in NICE's position.
It is true that IVF is less successful in older women. However, it has been suggested that this can be circumvented if donated ova are used. That is to say, it is largely the egg's age rather than the woman's that determines the efficacy of treatment. Writing in Human Reproduction, Paulson and Sauer comment that from a purely physiological perspective, there is no obvious age-related cut-off point for treatment with donated eggs. Because of this, they argue that any limit must inevitably reflect ethical or social criteria rather than medical ones.2 It is, therefore, extremely difficult to find a conclusive clinical argument in favour of restricting access to donated gametes to one group or another.
| Risks to women and children |
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However, it should be remembered that all pregnancies involve health risks for women.24,25 In fact, despite the risks associated with the contraceptive pill, it is safer to be on the pill than to get pregnant. If one does become pregnant, it is statistically safer to have an early abortion than to continue with the pregnancy.26 Undoubtedly, the risks of pregnancy and childbirth increase with age, but perhaps – within reasonable parameters – women themselves should be permitted to weigh the risks and make their decisions on this basis.
But mothers' choices also affect offspring. Babies born to older women are at greater risk of being underweight and suffering from genetic disorders.27 However, postmenopausal women who use donated gametes can circumvent many of the genetic risks associated with later pregnancies. And although the risks involved in later reproduction are greater than those involved in reproduction at the ‘optimal’ age, studies show that women of advanced age are likely to survive and take home a healthy child.28,29
Yet, even if the woman brings home a healthy child, she cannot guarantee her own health and lifespan. For many people, the risk of early orphanhood is a significant consideration.3 Takahide Mori cites the right of children to be brought up by their parents, according to United Nations declaration on the rights of the child.30 But, as Mori himself notes, lifespans in the developed world have been increasing to the extent that a woman of 60 can expect to live beyond the age of 80. It is also worth considering that younger women who seek to use donated eggs may do so precisely because their health and/or fertility has been impaired by cancer or genetic diseases, such as Huntington's disease. Therefore, postmenopausal women cannot systematically be assumed to have a lower life-expectancy than younger claimants for donated eggs.2
| Discrimination |
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The case of Liz Buttle highlighted a paradoxical social attitude towards parenthood. When pop star Rod Stewart announced he was going to become a father for the seventh time, also at the age of 60, the media focused on his joy at having a new son.34 However, attitudes towards Liz Buttle were vastly different, focusing on anxieties for the child. George Monbiot has suggested that some of the condemnation arose from an underlying assumption that once women are no longer attractive to men, they should no longer be regarded as fit to be mothers.35
Men and women are treated very differently in reproductive terms. Is this a natural corollary of their physiological differences, or evidence of discrimination? It is interesting to consider a hypothetical example. Suppose a 60-year-old woman seeks treatment with donated oocytes. She plans to have them fertilized with the sperm of her much younger husband. She is refused treatment based on the idea that at her age she could not satisfy the child's needs.
Now imagine a 60-year-old man seeking treatment with donated sperm. His much younger wife is planning to use her own eggs. Would the man be refused treatment by the same clinics that refuse the woman of the same age? Both patients are the same age, and both plan to be the social parent of a child conceived with donated gametes. Yet, it seems highly likely that the two patients would be treated very differently. Indeed, the ‘father’ in the latter case might scarcely be regarded as a patient at all. Is it simply that mothers are more important to their children than fathers? Or is the difference simply based on discriminatory prejudices?
Perhaps, it is not as terrible to lack or lose a father as it is to lack or lose a mother. But if this were true, should women's reproductive choices be constrained relative to men's simply because women are inherently more important to their offspring? This would place women at a double disadvantage. Not only are they denied the choices open to men but also their options are constrained by the very ‘needs’ of the children they wish to have. Can it be right to argue that because the woman is so vital to the child, the child is not to be born at all?
| Conclusion |
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Finally, it is important to note that there remains a fundamental ethical concern: I have argued that it is not necessarily more unethical for postmenopausal women to use donated oocytes than for younger women to do so. But is the use of donated oocytes ethically acceptable at all? Egg harvesting is a risky procedure. In some countries, women can be paid for donating eggs, which raises ethical questions about commodifying gametes, and the possibility of coercion. But if donors are not paid, they undergo the risks and reap none of the benefits. There is a burgeoning market for eggs from which fertility clinicians and their patients stand to make significant gains. Perhaps to ignore this, and encourage ‘altruistic’ donation is just as exploitative as offering payment.
| Competing interests |
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| References |
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