A recent article discussed the inequitable nature of infertility treatment, with which I agree. Yet, its remediation raised several ethical questions. First, why use IVF when there are 329,000 children in domestic foster care in 2024, many awaiting adoption? The drive to reproduce may be biological, but the desire for an infant is societal, and there is no evidence that adopting an older child is less rewarding.
Foster children are in limbo. They are uncertain about where “home” is, which school they will attend, and they struggle to identify adults they can depend on for love and support, as living in multiple foster homes is common and cannot provide the stability of a family. Leaving these youth adrift negatively affects their personalities and future relationships, as it communicates to them that they are of lesser value, which, in a humanistic-oriented culture, as we claim ours to be, is nonfeasance (avoidance of doing good).
IVF is expensive and has bankrupted couples or placed them in long-term debt. It takes four to five attempts for a successful pregnancy, costing $67,000 or more. This may be partially covered by some private insurers, but not at all by government programs. Those with inadequate funds or who cannot obtain loans are disqualified, mostly people of color. Some argue that to redress this, the government should pay for all IVF procedures. There are roughly 130,000 annually, which would increase with this funding as entrepreneurs took advantage of market growth and more women accessed IVF. Assuming a modest 30 percent increase, or about 169,000 annual procedures, this could cost taxpayers roughly $11.3 billion for 2027.
An IVF pregnancy is high-risk due to increased maternal and fetal complications requiring more clinician visits and tests, which are not part of the proposed coverage. Many with limited incomes will be unable to pay for what insurance does not cover. Hospitals and physicians can absorb these losses to a limited extent without increasing rates or reducing maternity services.
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Even with low-risk pregnancies and deliveries, maternal complications can arise, and some can be life-threatening. In high-risk cases, this likelihood is increased. If the woman survives, there can be residual cardiac problems or cancers, increasing uncovered costs, and decreased life span.
Prematurity and birth defects are increased in children born through IVF. Very-premature infants, as early as 22 weeks of gestation, will likely have at least one lifelong, major medical problem. Is it ethical to intentionally birth a child with a likelihood of disability? There is a profound difference in conceiving a child who may be born with a disability and choosing a method of conception that increases this likelihood. Also, infants born at less than roughly 32 weeks have a shortened lifespan, and the same question applies about deliberately conceiving a child with an increased likelihood of premature mortality.
Finally, there are over eight billion people on Earth, far more than it can sustain. Environmental damage is rapidly affecting the quality of life for everyone, most especially the poor. Can we justify adding children by artificial means when we cannot care for those already present, and we are doing little to remediate environmental crises and overpopulation?
Should infertility, which affects about 15 percent of U.S. women, take primacy over a demonstrably overpopulated planet, or twice as many (roughly 31 percent) citizens who depend on government assistance? Is it ethical to provide a poor family with an IVF pregnancy, knowing that presently the child will be raised in poverty with poor-quality health care and education, greater violence, overt racism, lower-quality nutrition, and more likely exposure to toxins? Could this be considered malfeasance (deliberately doing bad), especially if the child has a severe disability?
According to a current NIH Consensus Report, “It is well established that there are increased pregnancy-related complications for a woman who conceives through assisted reproductive treatment. Furthermore, it is known that the risk to the child born is greater.” Given this, it can be argued that IVF needs continued perfecting and perhaps its use should be restricted rather than broadened until its deficiencies are reduced. It also needs safeguards, presently lacking, to assure quality.
There are more pressing problems to address than implanting embryos with an increased chance of morbidity and mortality while adoptable children remain without families, and numerous people desiring children cannot afford IVF. Both are ethical failings in a just and humane culture, with poverty especially so.
It is a further ethical failing that adoption is not offered as an equivalent option to IVF. As Dr. Trevor Hedberg stated, “Prospective parents should reflect on the moral dimensions of procreation” and “adoption may be the best way of experiencing parenthood without creating a new person.”
M. Bennet Broner is a medical ethicist.
