The View From Here

Irrational forces are at work in all fields of medicine

As I listen to the discussions about today's health service, I am increasingly aware that there is a huge gap between the arguments people use and their motives - which tend to operate on a far more emotional, subconscious level. If we want to understand how to make today's health service work, we need to understand why the hidden agendas are hidden.

A classic example is infertility, a complaint with low priority in most health authority and GP budgets. Patients are often referred to me for a diagnosis, but not for treatment - which, when purchased, tends to be very limited. Just last week, I was instructed by a fund-holding GP to stop his patient's fertility injections, even though she was barely halfway through the course. The reason given? Lack of funds. The same series of arguments applies to in vitro fertilisation - too expensive, ineffective, causes too many multiple pregnancies. And anyway, don't we have a population crisis? Were any of these sketchy reasons to be true, the refusal to offer care to infertile couples might at least be understandable, if very short on humanity.

So what, in fact, are the chances of success for an infertile couple in 1997? There is no single answer, because much depends upon the causes, the woman's age and how long the couple have been trying. A 35-year-old woman's chances of becoming pregnant are about half those of her 25-year- old sister, and it is rare to see a first pregnancy after the age of 39. If the causes of the infertility are simple - for example, if the woman is not producing eggs each month - most couples can expect to leave the treatment programme with a baby. lf the problem is with the man, a new treatment enables the injection of sperm directly into the egg. The results are excellent. With IVF, the results vary, but the best units have a success rate that is normal taking into account the woman's age. So it is untrue to say that fertility treatment is ineffective.

So is it expensive? Compared to what? Infertility treatment certainly does not require admission to hospital, and the tests are simple (no MRI or CAT scans, no costly radioisotopes). Does it cause too many multiple pregnancies? ln fact, the rate of multiples has fallen dramatically since the number of embryos replaced has been limited to three. Over-population? Denying treatment to infertile couples is hardly the way to solve a population problem. In any case, the major fear in Northern Europe is that, with our present low birth rate, we will not have enough youngsters to fill our work-force in the 21st century.

So the arguments are not arguments at all, they do not add up. And since the ambivalent attitude towards infertility treatment is not rational, we have then to consider the irrational forces which underlie the decision not to fund it. Some people suggest that treating the infertile is unnatural, a defiance of what nature has intended. (Though in that case, all medicine would have to be seen as interference.) Others believe, even though they know it to be an offensive idea, that the infertile simply do not deserve to be treated. And because even they know the notion to be offensive, they defend their position with all the more vehemence. Some people maintain that the avoidance of death - the great unacceptable - should be the priority of medicine, over and above the creation of life. They feel that, since infertility does not threaten the life of the people it affects, its treatment is a luxury.

I am not making a special plea for my own field of expertise. The same emotive, irrational reactions, the hidden agendas, are at work in all fields of medicine. Infertility is an especially contentious issue but wherever logic is fragile and argument intense, should we not be asking whether unconscious motives are being covered over with a pale cast of thought?

The author is professor of reproductive endocrinology at University College London Medical School.