To have children is not a right but an opportunity

Who is to judge if the joy of a child to a childless couple should take precedence over the life of a mother?
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The Independent Online

Sometimes you pine for those bygone days when babies materialised under gooseberry bushes, primary-school children learnt about birds and bees - and some couples just had children and others did not.

The guidelines on fertility treatment issued yesterday by the Government's strangely named health watchdog, NICE, seem about as remote from that innocent age as it is possible to be. Intended to launch one month of public discussion, they set out in minute medical detail all the aspects that should be considered before couples resort to in vitro fertilisation. If you want concentrated reading, the guidelines - all 44 pages - are posted on the NICE website.

The recommendation that has hit the headlines, though, is the proposal that IVF should be available on the National Health Service to any woman who has tried for three years to conceive and failed. This does not quite amount to children on demand, because the results cannot be 100 per cent guaranteed, but it is as close as we are going to get. So where is the problem?

First, the good points - and there are some. Establishing criteria will eliminate at a stroke the so-called postcode lottery for IVF treatment, and anything that chips away at this pernicious fact of NHS life is progress. We have a National Health Service in this country which is funded out of contributions collected nationally. If criteria for IVF can be standardised, so surely can criteria for other types of treatment and medical services. This will not please health administrators and doctors, who will fight anything that restricts their freedom to treat and prescribe. But where national guidelines can be established, they should be.

Setting comprehensible criteria for free treatment will also end rationing by wealth. Most women who currently undergo IVF treatment use private clinics and pay. Those who cannot afford the £6,000 or so are simply excluded. The age limit of 40 for free treatment is also entirely reasonable. It will inevitably be challenged by those just past 40, but if IVF is to be available on the NHS, the money must be used to best possible effect. It makes no sense to offer free treatment to those whose chances of conception are slight.

In terms of equalising access to treatment and optimising the cost-benefit ratio, the NICE guidelines probably represent the best compromise in a difficult and highly sensitive area. In accepting the reasonableness of the guidelines, however, we are perhaps unwittingly accepting the premise from which they proceed - a premise which is by no means self-evident. Free treatment for the childless presumes that procreation is desirable of and for itself and that people have a right - not the opportunity, but the right - to produce children.

It is not entirely clear to me how these twin assumptions have prevailed to the point where they are commandeering millions of pounds in public money. A favourite theory blames feminism and women's rights: it is supposedly all about a woman's right to control her body. Reliable birth control and abortion on demand should be matched, some say, by the right to have children. Adoption does not usually enter the argument. It has become so hedged about with conditions that it is seen as a peripheral possibility.

I would prefer to blame misguided faith in science, allied with the selfishness of affluence - the idea that we can have whatever we want, and have it now. In the 21st century, adoption and childlessness both seem somehow old-fashioned because they entail accepting what, thanks to science, modern men and women need not accept: the limits on their ability to produce children. Having IVF provided on the National Health Service will only reinforce this view, with social consequences that could be highly detrimental.

There is already a broad consensus that involuntary childlessness among couples is a personal tragedy for those concerned, while voluntary childlessness reflects a sadly deficient sense of social responsibility. Increasingly, though, these two judgements are conflated. As if to clinch the argument, those with the regulation two-plus children say that they are providing the childless among us with our future security - without apparently realising that in this country (unlike much of the Continent), it is not the taxes of future workers who will provide our pensions, but our own savings and investments and those of our employers.

Whether a couple does or does not have children may be decreed by fate, by medical condition or by choice - a choice that science has helped to make possible. But it should be a private matter that carries no social stigma one way or the other. The risk is that once IVF is available on the NHS, the "excuse" for not having children will seem to be diminished. The child-producing majority will feel free to judge childlessness even more harshly than they do at present as an irresponsible choice.

The plight of childless couples in the new reality created by free IVF may, however, be as nothing compared with the plight of the children. The bars to fertility treatment are currently set so high - in waiting time or money - that the number of children conceived in this way is limited. In 10 years' time we could be contemplating four, five or ten times the number of IVF children, a large proportion of whom will have no means of knowing their genetic parentage. In the past, this hardly seemed to matter, except in terms of the strange rootlessness that affects some adopted children as they grow older. With genetics promising so much to the medicine of the future, however, parentage becomes more of an issue, just as it is becoming less of one at the point of conception.

Then there are the specific risks to women. I often wonder whether the negative aspects of IVF are yet sufficiently known. The unpleasantness of the hormone therapy that attends much fertility treatment is one aspect. Another is the capacity of this treatment to "mask" other - potentially life-threatening - conditions, such as cancer, concealing them until it is too late. The risks of the pill are negligible compared with the benefits it affords - or the risks that attend childbearing. Those who have successfully given birth as a result of IVF may well argue that the discomfort and the risks were all worthwhile. There may come a time when this is no longer true.

Other questions crowd in. With IVF widely available, will men put undue pressure on their partners to have a child? How carefully will the state of a relationship be considered before treatment is provided, if at all? Will and should single women be given equal access?

The biggest issue of all, though, must be the cost. One estimate - not the highest - puts the price of free IVF at £100m a year. Assuming no more money is forthcoming from the Exchequer, this is £100m less for the treatment of chronic illnesses such as diabetes and multiple sclerosis, less for cancer detection, less for organ transplants, less for Alzheimer's, less for hard-pressed casualty departments.

Who is to judge whether the joy of a child to a childless couple should take precedence over prolonging the life of a young mother or a middle-aged breadwinner?

NICE has given us four weeks to discuss its guidelines. What we need is a longer, and far wider-ranging national discussion about what the NHS should provide.

m.dejevsky@independent.co.uk

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