Katharine Browne argues that exclusion from coverage for IVF on the basis of voluntary sterilization is unjustified.

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A rally was held this past weekend in Montreal to protest Bill 20‘s promise to scale back funding for Quebec’s in vitro fertilization (IVF) program. The controversial Bill was introduced in November 2014 as part of Minister of Health Gaétan Barrett’s efforts to reform Quebec’s healthcare system. The Bill will replace coverage of IVF by public health insurance (RAMQ) with sliding tax credits, which vary depending on income. Minister Barrette has indicated that the government will introduce exclusion criteria for those tax credits. Among those who will be excluded are women younger than 18 and older than 42, individuals and couples who have already had a child, those who have not tried to conceive naturally for a fixed period of time, and those who have undergone voluntary sterilization for reasons other than medical necessity.

The limitations imposed by the Bill have been the subject of much debate. Attention has been focused on the upper age limit on access, and whether a variable tax credit, which would require families to pay for IVF treatment upfront, would unfairly disadvantage lower-income families. However, the exclusion of individuals on the basis of voluntary sterilization has gone largely unnoticed, leaving some important questions unaddressed.

Mary Cassatt, Mother and Child (ca. 1889)

To restrict access to IVF funding on the basis of having undergone voluntary sterilization is to make the claim that individuals who have not undergone voluntary sterilization have a greater claim on health resources than those who have. Can the government of Quebec justify that claim?

One way to do so is to appeal to the following principle: If an individual is personally responsible for a condition that they now want remedied, society should not have to pay for that remedy. According to this principle, society should not be saddled with the cost of IVF treatment for those who have chosen to become sterilized. It would also follow from this principle that society should not have to pay for treatment for lung disease of an individual who chooses to smoke. Or for treatment for a broken leg for an individual who deliberately goes skiing out of bounds.

Are we prepared to accept a healthcare system that allocates resources on the basis of personal responsibility? On the one hand, one might say people should have understood that the activities they engaged in might well lead to the health outcome that now requires treatment. Cigarettes come with warning labels. Ski runs have clearly marked boundaries. Sterilization procedures have a consent process. It should come as no surprise to the pack-a-day smoker that she now finds herself with lung disease; or to the skier who went out of bounds that he now has a broken leg; or to the sterilized person that she cannot now have children. Why should society now pay for these choices?

On the other hand, persons can only be properly held responsible for the choices they make freely, and there are numerous factors that affect the freedom under which certain choices are made. Clever advertising campaigns and peer pressure may be said to affect the freedom of an individual’s “choice” to smoke. There are also social and economic considerations that may affect the freedom of an individual’s choice. For example, women who underwent sterilization before the age of 30 or began building their families early are often the ones who later come to regret their decision to become sterilized. These factors are associated with lower income and education levels. Some women who experience regret after sterilization were in abusive relationships, and turned to sterilization as a means of exercising reproductive autonomy. These women may now seek counsel regarding sterilization reversal because they would like to start a family with a new partner. We thus might say that the circumstances surrounding voluntary sterilization and subsequent regret are not always things for which individuals can be properly held responsible, and that penalizing individuals for the outcome of their choices is improper.

More generally, the fact that there are several factors that mitigate responsibility for choice suggests that personal responsibility ought not to serve as a basis upon which to make decisions about the allocation of any healthcare resource. Indeed, basing such decisions on personal responsibility contravenes the values that underlie the Canadian healthcare system, according to which need and need alone should determine access to healthcare. Those who wish to defend Bill 20’s proposed exclusion from IVF coverage on the basis of voluntary sterilization will need to offer some other justification for this criterion.

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Katharine Browne is a Postdoctoral Research Fellow at Novel Tech Ethics in the Faculty of Medicine at Dalhousie University. @BrowneKatharine