Audrey L’Espérance interrogates medical and social understandings of infertility and access to reproductive technologies in the report of the Commissaire à la Santé et au Bien-Être in Quebec.

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On June 6^, 2014, Quebec’s Commissaire à la Santé et au Bien-Être released its review of the provincial program on assisted reproductive technologies (ART). Since 2009, Quebec has offered a broad array of publicly funded reproductive technologies—including up to three cycles of in vitro fertilization (IVF)—though reports suggest that the costs of the program have been significantly greater than anticipated.

The 386-page long report recommended that the program be maintained, but unsurprisingly recommended the addition of specific guidelines to ensure better health outcomes and more cost controls. It also makes recommendations about issues of access to information, oversight of best practices, commercialization and ethically contentious issues such as surrogacy.

Following the release of the report, Quebec Health Minister Gaétan Barrette suggested that despite the report’s recommendations, he could still abolish the program as cost-saving measure. Barrette explained he is considering either a new bill implementing the commissioner’s recommendations this fall or simply ending public funding of the program, in part or in whole, shifting costs of fertility treatments back to the private sector. Barrette emphasized to reporters that assisted reproduction is not a medically necessary service and will be re-evaluated as part of the Liberal government’s review of spending.

The program’s existence—unique as the only provincial medical health insurance to fully fund a range of fertility treatments in Canada—relies in great part on the slow but steady medicalization of infertility and assisted reproduction in the past years. The report reaffirms this model by maintaining that infertility is a medical problem to which assisted reproductive technologies are the solution. In order to limit the program, in a time of restricted health care resources, the report calls for new criteria for access to treatment. This includes establishing an age limit for treatment, and that both partners are covered within the provincial health insurance program.

However, for the first time in fifteen years, the Commissioner’s report also asks if infertility could be a social as well as a medical matter. It introduces four considerations about how Quebec should proceed with its assisted reproduction program that are identifiably social, namely: 1) the possibility of denying access to people who have undergone voluntary sterilization; 2) the exclusion of fertility preservation for “social reasons” from the program; 3) the need for psychosocial evaluation of intended parents before access to fertility services is granted; and, 4) the need to limit access to services for intended parents who already have children. In this way, the report suggests that life choices are important variables to consider in the distribution of resources, therefore defining infertility not only in medical, but also in social terms.

Whereas this nuanced understanding of infertility is fundamental to discussing the continuation of Quebec’s assisted reproduction program, many questions remain: if Minister Barrette decides to establish criteria for access, both social and medical, will he keep in mind other guiding principles such as gender equality and the prominence of women’s health in reproduction? Will he question the interplay between public and private health care providers in assisted reproduction? Who will he identify as responsible for the assessment of such criteria?

The openness shown by the Commissioner’s report, by including social criteria in its understanding of infertility, is proof of an intention to go beyond mere economic reappraisal of the program. It is clear that money is one of the factors to consider when discussing the relevance of such programs, but are there not other issues, human and ethical, to launch a broader national dialogue on this question?

The British experience could provide insight to define and implement medical and social access criteria for Quebec. For instance, local authorities in England impose access criteria including: limits on a patient’s Body Mass Index, whether the patient already has children, the age of women and/or male partners, whether women and/or partners are smokers, whether either partner had a previous sterilization, and the stability of the partners’ relationship. The constant reevaluation of such criteria in the last twenty years in England is proof of the difficulty to maintain coherence between the use of reproductive technologies and social values, as well as the availability of health resources. Reforming Quebec’s program would require a long-term commitment to evaluate and reformulate accessibility criteria on a regular basis in order to match regulatory guidelines and public needs.

Even if the Minister decides to abolish the program, the debate over assisted reproduction and its practices should not be considered resolved. On the contrary, we should take advantage of the attention being paid to the program to concentrate on regulating, organizing, and planning third party reproductive services in a conscientious way. Quebec should become a provincial leader in Canada in creating a safe, accessible and fair system of assisted reproductive services, a system oriented toward the health and wellbeing of women and children.

Quebec’s legislature recently showed how consultation and time can lead to consensus on contentious issues with the adoption of its end-of-life care legislation. Minister Barrette now has the opportunity to initiate a comparable legislative process for assisted reproduction, which could ultimately lead to better care, cost-controlled expenses, ethical regulations and an improved distribution of rights and responsibilities among stakeholders of medically assisted reproduction.

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Audrey L’Espérance is a postdoctoral fellow in the Department of Political Science at the University of Toronto. @AuLEsp