Last week, I had three phone calls with my insurance company to find out whether my plan covers in-vitro fertilization (IVF). First they said yes, then they said, "What's IVF?" and third, they said no. Long story short, my husband and I are probably looking at least $15,000 for one round. That's including drugs, anesthesia and, when I'm feeling put-upon, car service to the fertility clinic with by far the best success rates in New York City -- why shop anywhere else? -- and, naturally, the least convenient coordinates (so far east it's practically in the river).
Fifteen thousand dollars. Sure would be nice to spend it on food, shelter and a Louis Vuitton diaper bag for an actual child, not the 30 percent likelihood of one. Should I "relocate" to, God help me, my parents' house in Massachusetts, where -- Gov. Mitt Romney's evolving anti-choice views notwithstanding - IVF is universally covered? Should we travel as "fertility tourists" to Israel, which covers all treatments and offers low out-of-foreign-pocket rates? Down the road, will we wish we'd saved the cash for adoption fees?
Whatever we decide, one thing is already clear: For us -- along with at least 10 percent of American couples -- fertility is not a miracle, it's a market. "Advances in reproductive medicine have indeed created a market for babies, a market in which parents choose traits, clinics woo clients, and specialized providers earn millions of dollars a year," writes Harvard economist Debora L. Spar in her provocative new book, "Baby Business: How Money, Science, and Politics Drive the Commerce of Conception." "Eggs are being sold; sperm is being sold; wombs and genes and orphans are being sold; and many individuals are profiting handsomely in the process."
And she's not saying that's wrong. The problem, Spar argues, is that -- because "it is difficult to conceive of a child as commerce" -- no one is willing to call the baby business what it is: an industry. And as long as it's not truly considered an industry, it will continue to fly under the regulatory radar, she says. Indeed, fertility is one of the extremely few U.S. industries that "operate with virtually no rules" -- not much more beyond a requirement that clinics report their success rates to the CDC (which has no means of actually enforcing that requirement). Spar's contention: "Governments need to play a more active role in regulating the baby trade."
Yeah, but ... this government? "The debate will not be cordial," Spar concedes in her book. In his recent State of the Union address, President Bush did take up certain bioethical matters, saying: "Tonight I ask you to pass legislation to prohibit the most egregious abuses of medical research, human cloning in all its forms, creating or implanting embryos for experiments, creating human-animal hybrids, and buying, selling or patenting human embryos." "Human-animal hybrids"? Yes. But the types of regulations Spar proposes would affect real people, not goat people, now -- without the not-so-hidden agenda of defining embryos as people."We need to acknowledge the market that reproductive technologies have created and then figure out how to channel this market toward our own best interests," she writes. "It's no use being coy about the baby market or cloaking it in fairy-tale prose. We are making babies now, for better or worse, in a very high-tech way ... We can moralize about these developments ... or we can plunge into the market that desire has created, imagining how we can shape our children and secure our children without destroying ourselves."
Salon recently spoke by phone with Spar, the Spangler Family Professor of Business Administration at Harvard Business School, about the economics of the baby trade and how reasonable regulation could democratize, rather than politicize, the fertility industry.
What drew you to this topic?
I wrote my last book on the politics of the Internet, and inevitably people would ask me: What is the next cycle of technology that will have the same effect? A technology so radical that it creates a market that didn't exist before, and people jump into it and do all kinds of wacky things because there are no rules -- though people will eventually want them? It hit me that the answer was reproductive medicine. What scientists are now able to do in terms of high-tech reproduction was going to create -- has created -- a market for conception that never existed before.
Give us some historical perspective. Don't we have a history of reacting to certain innovations -- say, birth control, IVF - like they're signs of the apocalypse, but then adjusting to and absorbing them into our culture?
As people know, there was major opposition to contraception for hundreds of years. If you go back to the witch trials of the 15th century, most of the witches were midwives. The argument, and it was partially true, was that midwives knew how to birth babies, but they also knew rudimentary forms of contraception -- and that was considered witchcraft. So this is an ancient prohibition against mucking around with Mother Nature.
Then in the late 19th century it began to be possible to get better forms of contraception. There was major moral opposition to the use of contraception, particularly the use of condoms. But it turned out that contraception was a really good business. So as the manufacturers continued to make the stuff, they started doing so well that they became a lobbying force in their own right. Then Margaret Sanger came along. She got the American Medical Association to come out in support of contraception. They supported contraception only when it was prescribed by a doctor. Now think about that: Maybe they had a change of heart, but they also created a whole new area of business for themselves. That's the market trumping morality for you.
Fast forward once again: The science behind the pill was known for some time. But none of the corporations wanted to touch it because the moral outrage was so high. The work that finally brought the pill out of the laboratory was entirely funded by one woman who was the heiress to the McCormick reaper fortune, whose husband was schizophrenic and she didn't want to risk having a schizophrenic child. Once the pill was actually out, companies were very nervous about getting behind it. But when they did, the sales were so big that it just trumped the opposition because there was so much money in it -- and there still is.
So the first IVF is performed in 1978, and people go wild. There's massive opposition. There's marching in the streets. There are people declaring that the end of the world is nigh. And you know what? It turns out there's an awful lot of people who want to use this service. Literally within a year or two all of the public opposition goes away. Because the people for whom this technology works, they want it to work so badly, they're willing to do anything, pay anything, and they really drown out the critics -- even though it's not a public, politically organized fight. And so the market, the combination of supply finally emerging to meet this long-standing demand for reproductive options, just trumps the opposition. I'm predicting we're going to see the same thing with stem cells. The science just isn't good enough yet.
Why are there so few regulations on reproductive technologies, especially from a government so rattled by stem cell research?
People don't like talking about this. There is still a puritan element among many people who really want to believe that reproduction is a private, intimate process, guided by Mother Nature. It's not the kind of issue on which people have felt comfortable organizing politically. Unlike cancer sufferers or AIDS sufferers, there's been no momentum. And of course, the doctors and clinics have no interest in being regulated.
Meanwhile, the politicians don't want to touch this with a 10-foot pole. You cannot talk about reproductive technology without touching on abortion, because the underlying mechanism is the same.
Right. There are starting to be murmurs of protest against IVF for that reason, because it creates excess embryos.
Yes, that's where IVF does run straight into abortion. You are creating in almost all cases excess embryos that do not subsequently become children. But it turns out there are ways you can avoid that -- and the European countries do a pretty good job -- you can limit the number of embryos that you create and implant. I think some discussions along those lines would actually be useful, and we could probably find a way to make both the IVF proponents and the abortion opponents happy. This is where a business perspective is helpful, because ultimately it's a cost thing. If you have a couple who has saved up exactly $12,400 they can do IVF once. They're going to be inclined to push the doctor to implant five embryos at once. And the doctor's going to be inclined to go along. That is probably going to create excess embryos. And implanting more than two embryos may lead to a more dangerous pregnancy. Whereas if you were to say, "Let's control costs and change the incentive so that parents, doctors and society have an interest in implanting only one or two embryos," you get a very different outcome. That's what many of the European countries do.
And when that woman has quintuplets, there's also a cost to society. So it's not as if the people who manage to afford fertility treatments are doing what they do in a vacuum.
That's one of the most important and overlooked pieces -- that these private choices impose public costs. These "miracle quintuplets" we see? We're all paying for those miracle quintuplets. They are hundreds of thousands of dollars in delivery costs that our insurances are all picking up in one way or another. Many times these kids, sadly, have learning disabilities, delays, medical issues throughout their lives. The parents pay upfront. But we are shouldering the cost over time.
You're dispassionate in the book about the "business" of the baby trade, yet there's a hint of sarcasm about couples who'll pay whatever it takes to have a child -- specifically, the kind of baby they want. What kind of regulations should address the kind of genetic tinkering that can produce "designer babies"?
I think the early cases of what we now call "designer babies" are things with which most people would have absolutely no trouble whatsoever. They're people dealing with horrific genetic diseases. And if you're facing the prospect of having another child with Tay-Sachs or cystic fibrosis, you will do anything to ensure that you get a healthy kid. I'd go so far as to say that these poor folks shouldn't have to pay everything out of pocket. If we can help people give birth to children who do not bear these horrific genetic diseases, I think that's a good thing for society to be willing to pay for.
The problem is that it's a slippery slope. It's pretty easy to say yes when the disease you're talking about is a genetic disease that's going to give the child an early, horrible, painful death. What do you do when it's a predisposition to breast cancer? Then how do you choose? That's a problem this technology has created.
And the part that's easiest to be cynical about is gender selection. I would suggest that there's going to be a real market in that. And we need to worry a lot when we get to the level of choosing sort of trivial characteristics: height, hair and eye color -- but we're not there yet. I have not heard of your stereotypical rich older couple going to a fertility clinic demanding a blond tall girl. That is not out there yet.
But they do demand the eggs of a tall blond girl.
They sure do.
What other technologies are screaming for regulation?
Well, the irony is that the only technology that is getting loaded with regulation in this country is stem cell technology. Which arguably is the one that has the greatest probability of saving existing lives. So we're not regulating the technologies that are allowing us to produce new lives, but we are regulating the ones that can save existing lives. That makes no sense.
Also, what do we do about these cases -- which are small in number but very emotionally loaded -- where parents are choosing to create a second child to act as a donor, of cord blood let's say, to save the life of the first? Those are cases where I think regulation can help a lot. You can create limits to how far that goes. Can you create a child to be destroyed in utero to save another? I don't think so. Would you create a child who would be sick in order to save an existing child? Probably not. However, can you create a child who will be a perfectly happy, healthy child and all you need is their umbilical cord blood? Yeah, I'm OK with that. In fact, if you want to be business schooly about it, it's probably a more efficient means. Because otherwise the existing child is going to have a much longer and more costly decline -- costly to society. It's not the only frame I would want to use, but it's actually pretty useful. Once you've also looked at the obvious ethical issues. Is the second child liable to be exploited in any way? And as long as you're relatively convinced that that won't happen, there's a real cost savings here.
And at some point we're going to have to deal with cloning. We're not there yet but some crazy doctor is going to produce a clone. Where the doctors are reporting that they're hearing the most demand is: a child dies tragically; the parents don't want just any old baby, they want that baby back. And any of the scientists who report success in animal cloning are besieged by parents saying, "I'll pay anything, I'll do anything, I want you to bring back my kid -- here's a lock of hair." So the demand is out there, and there are a couple of doctors who have said publicly they're trying to do it. Someone's going to succeed. But in a regulatory sense it's pretty straightforward: You just say no.
Is it idealistic, even naive, to think that this country could engage in a reasoned debate about regulating this industry?
That would be the hope. The reality is probably a lot more pessimistic. I think at the moment the answer is probably no. We're too divided. We'll have to see what the next administration looks like. And we'll have to see where we can get some kind of national consensus. My guess is we can get consensus slowly, painfully, on some of the basics. Maybe the question of the number of embryos that can be implanted. Reproductive cloning. Go for the things that we can agree upon. There are enough of those to make a worthwhile discussion. And then as we get further and further into the complicated realm, we may be forced down to state-level legislation. I'd rather the whole country cover them, but I'm willing to settle for state-level law if the national debate becomes too divisive.
When. But some of it's not that hard. One of the things I argue for in the book, which sounds trivial but it's not, is providing information. People shouldn't have to go mucking around on all these Web sites, some of which are not very reputable, to get information on procedures, or to buy eggs from a shady operator. There should be information out there. There is only one bill that has passed Congress, to provide success rates. And that piece of legislation is not as good as it could be. But just getting information out about treatment options, reputable egg donors, risks and considerations of certain treatments That's really low-hanging fruit. We could definitely start there.