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Spring 2001
Volume 00, Number 2

Newsletter on Philosophy and Medicine

Papers, Poems and Narratives

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Just Allocation of Reproductive Choice: The Case of Israel's Sick Funds

Adi Bar-Lev
Mount Sinai School of Medicine

Consider two women in opposing predicaments: one wishes to conceive a child, the other seeks to terminate her pregnancy. Under the auspices of Israel's universal healthcare system, the needs of only one woman would be met. The former would receive all medical interventions modern technology has availed; the latter would not. Given that the resources available to Israel's Sick Funds are finite, is it just to provide unlimited cycles of in vitro fertilization (IVF) to any woman needing such treatment, and to concurrently deny the utilization of these same resources to women seeking abortion?

Withholding treatment from one woman in favor of assisting another is not, in and of itself, unjust. "Fairness demands that we treat people equally, [while…j]ustice requires that we give each person what he or she is due. A policy that is both fair and just examines the differences among patients and then treats similar differences similarly" (Rhodes et al., p. 328). Determining what each patient is due necessitates an evaluation of the predicaments in question, and of the efficacy of available treatments.

The predicaments at hand are far more similar than they may appear. Neither woman is in grave physical jeopardy; neither requires treatment to prolong her life. Both would suffer a decline in perceived quality of life if denied the procedures they seek. A measurement of Quality Adjusted Life Years (QALYs) would ideally provide an objective assessment of the magnitude of these effects. Yet it seems intrinsically difficult to assign different weights to the conditions of bearing an unwanted child and remaining involuntarily childless.

"Weights given to non-fatal health outcomes are provided by a consensus of health professionals rather than by people who actually live their lives with the conditions being weighted…. [This not only] produces inaccurate or prejudicial weighting…, but also…den[ies] a voice to those whose lives will be more directly affected by the results of the weighting exercise" (Bickenbach, p. 13). Allowing the ailing to do such weighting, however, remains problematic. Those affected by a particular condition are not in the position to objectively ascertain the relative value of their anguish when compared with anguish due to circumstances they have not experienced.

Deontological theories emphasize that a just procedure for allocation of resources is important in ensuring that the resulting distribution would indeed be just. For this we turn to John Rawls' conception of "a veil of ignorance" as a tool in removing decision-making bias conferred by one's own interests. Individuals behind such a veil, could imagine the possibility of representing women carring unwanted pregnancies, be sympathetic to the need for funding abortions. They would be unlikely to support Israel's current system unless, by following the rational decision-making processes advocated by Rawls, they could be persuaded that the QALYs per cost of abortions pales in comparison to that of IVF.

It does not. Assuming their benefits are comparable, the efficacy of funding these procedures rests on their cost to society. In monetary terms, an abortion is far less expensive than a cycle of IVF. Furthermore, an abortion is far more successful in attaining its desired outcome. A single cycle of IVF will produce a child only 25% of the time. If funding of one cycle was warranted in attempting to better the quality of a woman's life, the funding of a second cycle for a woman whose first IVF failed would likewise be called for. Since an unfruitful cycle neither ameliorates the woman's circumstances nor indicates that a subsequent cycle of IVF will be unsuccessful, there would be no basis for restricting the number of cycles a woman should receive.

Yet failing to fund any IVF because of its comparatively lower rate of success would not be easily justifiable. A 25% chance of success per cycle does not readily fit into our conception of a futile intervention. Even where expectations fall below this rate, as they do for older women (Ron-El et al., 2000), we lack acceptable criteria by which such attempts may be determined futile. Norman Fost notes that "quantitative medical futility…refers to a situation in which the "likelihood of a medical benefit…is extremely small…for example, < 1:100. [But] why is 1:101 futile but 1:99 not?" (in Munson, pp. 175-6). That is, what rational basis would we have for establishing any specific cutoff?

As long as we can successfully assist infertile women in conceiving, we ought to try and do so. Yet, if we were indeed preventing other women from receiving abortions, what justification would we have for denying them public resources? Could considerations other than cost provide justification for unilaterally funding one treatment but not the other? Could we differentially fund these procedures by taking into account patients' roles in bringing about the predicaments they are in? Should we distinguish between the woman who requests an abortion because she was raped and the one who irresponsibly engaged in numerous acts of unprotected sex? What if the pregnancy resulted from just one act of unprotected sex? Where would we draw a line? Would we begin examining self-selected behavior promoting infertility? Should we question a partner's preference for boxers or briefs when ascertaining entitlement to IVF?

Drawing lines to identify those deserving of abortions or the opportunity for parenthood would be difficult to rationally justify. If we proceed in the attempt to distinguish between patients by considering past or future contributions to society, we run into similar difficulties. "Standards that make a person's education, accomplishments, or social position relevant seem contrary to [Kant's contention that]…rationality confers upon everyone an intrinsic worth and dignity" (Munson, p. 13).

Withholding funding for abortion and providing limitless cycles of IVF may seem to satisfy our desire to fairly treat those in similar circumstances in a similar manner. Yet, we can ask whether the distinction between these groups of patients has a relevant bases. Without clear, explicit, and public agreement on the relevant distinction this approach remains problematic when evaluated in terms of justice. If we agree that reproductive choice, in either direction, is critical to a woman's quality of life, an ensuing cost-benefit analysis favors funding the more efficacious and affordable abortion procedure. The system currently in place, therefore, seems to reflect consideration of additional factors-perhaps some measure of life years granted to future children by IVF and removed by abortions, perhaps a societal value of life, or a religious, social or political interest in population expansion. Apparently, just allocation of resources was not Israel's sole concern in establishing its healthcare system.

References

Bickenbach, Jerome. Disability, Justice and Health Systems Performance Assessment. Medicine and Social Justice, ed. Rosamond Rhodes, Margaret P. Battin, Anita Silvers. New York: Oxford University Press, forthcoming 2002.

Fost, Norman. Medical Futility: Commentary. Ethics and Perinatology, ed. Amnon Goldworth, William Silverman, David K. Stevenson, Ernle W.D. Young, and Rodney Rivers, pp.72- 77. New York: Oxford University Press, 1995.

Munson, Ronald. Intervention and Reflection. U.S.: Wadsworth/Thomson Learning, 2000.

National Health Insurance: www.israel.org/mfa/go.asp?MFAH00km0 and www.israel.org/mfa/go.asp?MFAH01vx0

Rhodes R, Miller C, Schwartz M. Transplant Recipient Selection: Peacetime vs. Wartime Triage. Cambridge Quarterly of Healthcare Ethics (1992), 4: 327-331.

Ron-El R, Raziel A, Strassburger D, Schachter M, Kasterstein E, Friedler S. Outcome of assisted reproductive technology in women over the age of 41. Fertility and Sterility (2000), 74: 471-475.

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APA Newsletters

Spring 2001 Volume 00, Number 2

Spring 2001
Volume 00, Number 2