The effect of the proposal

Richie believes that the environment is in bad shape, is getting worse, and can only get better by bringing carbon emissions under control. Every human practice can be analysed in terms of its carbon emissions, and Richie proposes to start that conversation with regard to fertility medicine. Fertility medicine is unique in that it has its own immediate costs as well as legacy costs.

To illustrate these costs, let me compare a fertility clinic with a hat manufacturer. The people who make hats must withdraw from the environment all the resources necessary to make the hats, and they must also withdraw the resources necessary to build and maintain the hat factory, the resources necessary to transport workers to and from work, the resources to heat the hat factory in winter and cool it in the summer, and so on. These are the production costs of making the hats. Once the hats go out the door, their cost to the environment is more or less done, with the exception of the cost of putting them in a landfill someday. Similarly, a fertility clinic has its own resource demands and production costs, but its ‘products’ are not environmentally inert. The ‘products’ are living and breathing people. The ‘products’ go on to burden the environment, produce carbon emissions, and repeat the cycle in having their own children.

How might these legacy costs, as Richie calls them, of fertility medicine be brought under control? Richie indicates that a moratorium on all ARTs would be desirable, at least until such time as CO₂ emissions stabilise. Surprisingly, she raises this prospect only to dismiss it. She says that “while a moratorium on all fertility clinics would be the most ecologically sound decision in this purview, it is unlikely that established fertility procedures or treatments would be effectively ‘banned’ until global CO₂ emissions stabilise”. If a moratorium is in fact the most ecologically sound decision, where is the defence of that approach?

Instead of defending ‘the most ecologically sound decision’, Richie proposes that governments and insurance companies withdraw all financial support for fertile people looking to have children via ARTs. Only people who are infertile by reason of disease or disorder would remain eligible for this kind of subsidy. As she sees things, this withdrawal of support will turn fertile people to old-fashioned, environmentally low-impact intercourse to conceive their children, and it will in practice reduce the overall number of births and obstruct some people from having children at all. This proposal would not obstruct all people to the same degree in their quest for ARTs, of course, because some people can afford fertility services on their own. Even so, withdrawing government and insurance subsidies would mean that fewer people will succeed in having children, and fewer carbon emissions will clot the atmosphere as a result. But is a meaningful reduction in environmental threat likely? The effect is difficult to assess precisely, but I submit that it would be virtually negligible.

Saving the environment?

Let's consider the general contours of the numbers involved. Richie cites a BBC estimate that 5 million babies were born between 1978 and 2012 through various ARTs. In 1978, there were some 4.3 billion people in the world, while in 2012 there were 7.02 billion.2 The ART births would account for 0.0712% of the population increase that occurred during those years, assuming all children lived past birth.

Let me offer an analogy as a way of estimating the value of reducing the human population by 0.0712% in the name of bringing carbon emissions under control. Suppose your roof at home has two leaks in it. Through leak no. 1 comes 99.9288% of all the rain that will do so much damage to your home as to make it uninhabitable. Through leak no. 2 comes 0.0712% of the rain. Which leak should you fix as a matter of first priority? Along these same lines, I submit that Richie's proposal to limit financial support for ARTs does not offer any kind of meaningful remedy to the threat of carbon emissions. It is very odd that Richie hopes to choke off a small number of births—those achieved through ARTs offered to fertile people—when the main threat to the environment by far comes from people who require no clinical assistance in having children.

Let's not forget either that innovation in fertility medicine will increase options for the infertile as it perfects its techniques. Over time, more infertile people who are infertile by reason of disease or disorder will be able to turn to clinicians for help, such that any reduction in closing off fertility medicine to the fertile will be offset by an increase in the number of infertile people who can succeed in having children and—according to Richie—should be eligible for government and/or insurance subsidies in trying to do so.

What's the effect for lesbian and gay people?

Some lesbians and gay men are individually infertile as a matter of disease or disorder, but most will be able to produce gametes, and lesbian women will mostly be able to gestate. Nevertheless, lesbian and gay people are as a class infertile in their same-sex relationships. Richie offers no exception to her proposal for this situational infertility.

As indicated, the number of births of children from ARTs is a very small percentage of the total number of births. The percentage of births of children from ARTs to lesbian and gay parents relying on ARTs is smaller still. There is no way to determine exactly how many births to lesbian and gay parents involve ARTs, but let me speculate that the number of assisted births involving gay and lesbian parents is 5% of the total number. That would mean 250 000 of the 5 million births that Richie mentions would be children born to lesbian and gay parents. That's a very small percentage of a total number of ART births (0.05%), and a scant percentage of the total human population of 7.02 billion (0.00003561%). The actual percentages could be somewhat smaller. What I have said about the proposal to cut fertile people off from government and insurance subsidy in general, I will say about the proposal's effect relative to lesbian and gay parents in particular: the withdrawal of financial support for ARTs for lesbian and gay people cannot be expected to offer meaningful environmental protection.

Moreover, the exclusion of lesbians and gay men as a class from subsidised fertility medicine comes with a differential moral cost. In one sense, lesbian and gay people are no different than any other fertile people who stand to lose financial assistance under Richie's proposal. But all coupled lesbians and gay men must necessarily reach outside their relationships for help in having children. By recommending against financial assistance, Richie does say “I am not suggesting that in order to achieve pregnancy one should be forced into…taking…an opposite-sex partner”, but “circumstances such as same-sex partnership should not be confused with biological infertility”. Richie is saying here that she does not want to be understood as suggesting that lesbian women who want children—but who are not able to pay for fertility assistance—should have sex with men in order to conceive a child, and neither should gay men enter into unwanted sexual relationships with women. Even having to rule out the prospect of unwanted sexual relationships starts to bring the difficulties she is raising for lesbians and gay men into focus.

The first effect of Richie's proposal would be to require lesbian and gay people to pay for the fertility help they want on their own. This effect would not obstruct all lesbian and gay people from having children. But why should lesbian and gay men have to forgo financial assistance since they are, after all, paying taxes like everyone else? Why should they be excluded from the government assistance and insurance coverage, when their contributions make those subsidies possible? Government and insurance subsidies for ARTs are not unlimited, but they can be generous. For example, the state of Illinois requires employers of a certain size to provide health insurance covering a certain number of these interventions: IVF, uterine embryo lavage, embryo transfer, artificial insemination, gamete intrafallopian tube transfer, zygote intrafallopian tube transfer, and low tubal ovum transfer.3 Given that lesbians and gay men help pay for these services, what argument is there to exclude them from all such services?

Equity in financial subsidies aside, Richie seems to believe that a more-or-less biological threshold can function as the criterion for eligibility for financial subsidy for ARTs, but let's be clear that a great deal of fertility medicine does not ‘treat’ underlying conditions that make someone infertile. A great deal of IVF will leave the men and women who turn to it exactly as anatomically or physiologically infertile as they were before the fertility interventions. An opposite-sex couple who turn to donor gametes—either sperm or ova—will remain afterwards in the same unfertile condition even after turning to a third party for help in having a child. Intracytoplasmic sperm injection (ICSI) will not restore a man's dysfunctionally low sperm production. Neither will one-time ovarian stimulation treatments restore ova production in a woman forever after. An infertile, opposite-sex couple will remain anatomically or physiologically infertile after turning to third parties for donor sperm, ova or both. All this is to say that much fertility medicine does not so much cure impediments to conception and gestation as bypass them. Richie does not follow the Catholic Church's lead and try to focus financial support in medicine on diseases and disorders that interfere with conception and gestation but forgo clinical services that bypass those impediments.4 It's therefore not clear why the situational infertility of lesbian and gay people should not also be enfolded under this same logic of treatment and social support: not treatment of underlying pathologies but interventions that confer fertility.