ART, lesbians and justice in the distribution of health care

In the wake of our seemingly everlasting economic crisis, the Spanish health authorities have decided to exclude single women to access ART treatments – mainly artificial insemination- in the public health care system. “The lack of a male partner is not a medical problem”, has said Ana Mato, our Secretary of Health. Coming from a devout Catholic and extremely conservative politician, her remark, and ultimately, her Department’s policy, have been widely interpreted as another vindication of the idea that only traditional, i. e. heterosexual, families are suitable for rearing children. The spokeswomen of various feminist and lesbian NGOs have entered the public arena to denounce her lesbophobia.

The fact of the matter is that women in Spain, whether married to another woman or single, will still be authorized to be artificially inseminated (in some European countries such as France, Austria or Sweden, for instance, single women are excluded from medically assisted reproduction). Even the fertile, married heterosexual woman might still get artificial insemination – maybe she just wants to do things differently, for a change- although they will all have to bear the costs. The public health care system has, therefore, reconfigured ART as a pure medical remedy for a medical condition: infertility. The days of IA as an “alternative means of reproduction” for “alternative life-styles” are over. But with this new policy the demand made by economically disadvantaged lesbian couples willing to procreate finds an answer along the following lines: “go find a male”. A crude response if there is one.

So, beyond the lesbophobic conspiracy, the debate finally boils down to two complex issues: whether “infertility” is just a brute biological fact – many lesbian advocates are claiming that they are intrinsically “infertile”- and whether public health care systems should only provide health care understood in strict clinical terms. Both questions appear intertwined. Some critics have argued that our public health care system should be configured around the definition of “health” stated in the Preamble to the Constitution of the World Health Organization, which is, as you probably know, highly controversial (it defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”). I would contend that in circumstances such as ours, when resources are very scarce, abiding by this notion of health and the corresponding model of health care, is absolutely unfeasible. As a matter of fact we have traditionally excluded spas, non-conventional medicine, hypnosis or psychoanalysis from public coverage.

But one could also argue that if the underlying justification for denying lesbians access to public ART is prioritization in the distribution of health care, that we ought to take into account the opportunity costs for many orphan diseases and conditions that, being much more impairing and painful, lack sufficient coverage, infertility across the board should not merit public coverage be the couple lesbian or heterosexual. Otherwise we run the risk of unfair discrimination.

4 thoughts to “ART, lesbians and justice in the distribution of health care”

  1. Great post, Pablo. I agree with you. According to Ana Mato’s logic, lesbians or single women now excluded from ART could reply about heterosexual, married, and biologically fertile women: “If the husband is not able to procreate, the wife should go to look for a good one. A ‘wrong’ male partner is not a medical problem”.
    It is controversial if ART should be publicly funded at all, but this is another issue. Which services should be included in a public health care system is not only a problem of scarcity of resources -an argument that sometimes has been used as an excuse more than as a real reason-, but also a question of which goods and values are socially and politically priorized. For instance, it could be said that with a high percentage of elderly non-working population, and with the young migrant people running away from the economical situation in Spain, a pro-natal policy could include among its measures free ART for everyone. Don’t you think so?

  2. Great post Pablo! Dov Fox and I wrote about whether it makes sense to distinguish the infertile from the “dysfertile” for the Huffington Post here a few months ago. and I have a longer more philosophical piece on the justification for funding IVF here in a normative and empirical paper with Dan Chen”Trading-Off Reproductive Technology and Adoption: Does Subsidizing IVF Decrease Adoption Rates and Should It Matter?” 95 Minnesota Law Review 485 (2010). One interesting set of questions has to do with your normative theory for covering IVF in general. If it is about life plans open to all, then covering the dysfertile makes sense. If it is more about restoring species-typical “normal functioning” then I think there is a stronger argument for distinguishing the infertile from the dysfertile.

  3. Rosana, Glenn, thank you very much for your feedback. I will definitively look up those references. I am quite sympathetic, by the way, to the adoption argument in order to eliminate ART from the public health care provision both for homosexual and heterosexual couples. Elsewhere, I have defended that the fundamental right to procreate is not absolute and that might imply that once couples, no matter their sexual orientation, have had their first genetically related offspring – medically or by natural means-, the Government should put great incentives for them to adopt, and, inversely, great disincentives for them to have more genetically related children (and one of those disincentives is not funding ART). I am more pro-adoption than “pro-natal” even though in my personal life I was not able to be coherent… ;-(
    And yes, the problem with many public health care systems is that they do not fit neatly in the “normal-functioning” model, so why exclude ART and not “reconstructive plastic surgery” for example or surgery for gender reassignment?
    Rosana you are absolutely right in pointing out the heterosexual woman who happen to be married to an infertile man… May I use that example in future discussions? I will pay the license, of course… 😉

    1. Both, pro-adoption and pro-natal policies, imply factual and ethical problems (I definitely learnt it when I was in Ethiopia). For that reason, I think they should be compatible.
      And you don’t need my permission to use the example! I’m happy you liked it 🙂

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