Christine Gudorf's thoughtful essay on the McCaughey septuplets (Bulletin No. 4, May/June) focuses on ethical questions concerning God's will and individuals' moral responsibility for the reproductive choices they make. This focus reflects a common approach to reproduction. Reproduc-tive rights are often framed as a matter of individual autonomy and freedom from government interference in personal procreative decision making. For most Americans, reproductive freedom means the right to choose. Discussion about the ethics of reproduction tends to center on the morality of the choices people make.
I take a different approach to the controversy surrounding the McCaughey septuplets and to the ethics of reproductive decision making in general. While Gudorf explores the personal desires and emotions entailed in childbearing, I am concerned about the wisdom and fairness of social policies that regulate childbearing. The ethics of reproduction are more a question of social responsibility than individual moral culpability. I do not deny the importance of autonomy over one's own reproductive life or the obligation of each individual to make ethical decisions about his or her body. But people make these decisions in the context of their social circumstances, and reproductive policy affects the status of entire groups within our society. For me, reproductive freedom is a matter of social justice, not just individual choice.
If we focus too intently on whether or not the McCaugheys made the right decision when they chose to have seven more children, we miss far more critical issues raised by reproduction-assisting technologies. We should not be asking whether the McCaugheys contravened a moral consensus but what a moral social policy regarding fertility enhancement would be. At present, there are disturbing race and class disparities in policies concerning childbearing. The current consensus on the use of reproductive technologies appears to treat white middle-class couples and poor minority families in stark contrast. The fertility business serves primarily white people even though blacks have a higher infertility rate. White women seeking treatment for fertility problems are twice as likely as black women to use high-tech treatments, such as in vitro fertilization (IVF). Many black Americans were troubled by the celebration accompanying the birth of the McCaughey children, who are white, when compared with the media's disregard of a black couple in Washington, D.C., who conceived six babies (without medical intervention) at about the same time.
The cost of high-tech procedures places them out of the reach of most Americans. The median cost of one IVF cycle is approximately $8,000; because success rates are low, many patients make several tries before having a baby or giving up. Using donor eggs raises the price still higher — $10,000 to $20,000 for each attempt. Most medical insurance plans do not cover IVF, nor is it included in Medicaid benefits. Indeed, state lawmakers have begun eliminating any existing state subsidies for fertility treatment for the poor. The current political climate is quite hostile to the notion of helping poor women, especially women of color, have additional children. Treating infertility at public expense conflicts with popular policies designed to reduce the numbers of children born to mothers on welfare. At least 20 states have recently passed child exclusion laws, or "family caps," that deny additional benefits for children born or conceived while the mother is receiving public assistance.
We do not need to question individuals' reasons for using reproduction-assisting technologies in order to question the societal impact of these disparities. We should think carefully about a system that channels millions of dollars each year into the fertility business instead of spending similar amounts on programs that would provide more extensive benefits to infertile people. Researchers are already concerned about the social costs and benefits of IVF. Covering the cost of expensive high-tech procedures means raising the price of insurance for everyone. The Massachusetts Association of Health Maintenance Organizations, for example, says that its members pay $40 million more in premiums to cover infertility treatment for 2,000 couples. A study recently reported in The New England Journal of Medicine calculated the real cost of IVF at approximately $67,000 to $114,000 per successful delivery. For older couples with more complicated conditions, the cost rose to $800,000. One reason these figures are so astronomical is that IVF entails the high incidence of risky multiple births, like the McCaughey septuplets, that require extremely expensive neonatal care.
Can we justify devoting such exorbitant sums to risky, nontherapeutic procedures when so many Americans' basic health needs go unmet? How will we address the pernicious message sent by a fertility business that caters primarily to affluent white couples while welfare policy discourages childbearing by mothers who are poor and disproportionately black? Research designed to reduce infertility and policies that increase access to general health care would help a far broader range of people. As for God's will, I believe it is for human beings to strive for social justice here on earth.
Dorothy Roberts, who will join the faculty of Northwestern University School of Law this fall, is the author of Killing the Black Body: Race, Reproduction and the Meaning of Liberty (Pantheon, 1997).
