'Older Mothers': a report on the '21st century motherhood’ conference held at UCL, 18 September 2009
19 October 2009
ByAppeared in BioNews 530
Reproductive autonomy versus the best interests of the child
From an ethical perspective, the issue of 'older mothers' creates tension between the principles of the reproductive autonomy of the mother and the best interests of the child, but also the interests of wider society. It is a classic exposition of the clash between neo-liberal attitudes towards private behaviour, facilitated by the rise of the fertility industry to meet the demands of 'consumers', and paternalistic efforts to protect women from their own possibly ill-founded decisions and also to protect the unborn child.
Naomi Pfeffer raised the point first of all when speaking of the woman's right to choose what to do with her body. Surely this is absolutely central to the whole issue - if a woman believes she is fit and healthy to raise children then why should be prevented from doing so? The problem is that Maria Bousada thought just this, believing that longevity ran in the family, yet was diagnosed with fatal cancer just months before her children were born. It is a trite point but statistically speaking 'older' mothers are more likely to die sooner after giving birth than younger mothers. Commenting on the issue at the time, Josephine Quintavalle of Comment on Reproductive Ethics, summed up the ethical problem: 'Why would a woman want to become a mother at an age when she knows her children are much more likely to be orphaned when they're young?' she asked.
Yet the rights of the women cannot be ignored. The 'right' to bear children is evidenced in Article 16 of the Universal Declaration of Human Rights: 'Men and women of full age, without any limitation due to race, nationality or religion, have the right to marry and to found a family.' Whether rights discourse covers fertility treatment is unclear but for these purposes assuming that it does, the question arises as to at what point is the state permitted to interfere with a woman's right to bear children? The only true principle, I believe, that justifies such a measure, is the best interests of the children which, in other areas of the law such as consent, operates above the decision-making rights of the parents.
Health and wellbeing of mother and child
Practically, the question of safety both for the mother and the unborn children featured prominently in the discussions. First and foremost, children born to 'older mothers' are arguably placed at risk of physical harm during the pregnancy and birth, but also to psychological harm if their mother dies of 'old age' whilst they are still in their infancy. Anna Smajdor of the University of East Anglia pointed out that pregnancy is inherently risky anyway but mothers choose to assume this risk rather than not having children at all. But this inherent risk of pregnancy increases as the mother becomes older and this cannot be ignored when providing IVF to, say, a woman over 60. It is a question of thresholds and where we must draw the line is when the risks to either to mother or child become excessive to make such a pregnancy unadvisable.
Second, there is the problem of 'fertility tourism', whereby residents who are either denied or cannot access fertility treatment in their own countries travel abroad to countries with more permissive regulations. This issue is always relevant when limits to IVF are considered. Such patients are exposed to exploitation and health risks as fertility services in some countries is not regulated as strictly as they are elsewhere. Further, if, for example, a clinic in the UK denies a 65 year old woman IVF on the basis of risks to her and the child's health, despite the fact that a clinic in, say, India, may be willing to perform the service, the risk to mother and baby remain exactly the same. Fertility tourism does not get around the problem but merely allows women to circumvent protectionist rules.
Social attitudes towards 'older mothers'
The conference also touched upon social attitudes towards older mothers. Here, the discussion moved towards changes in social attitudes over the last few decades. Peter Brinsden, Consultant Medical Director at Bourn Hall Clinic, told the audience that in the 1980s mothers were considered 'old' at the age of 40. Today, many women would contest this view and indeed women between the ages of 40-44 have a 65 per cent of conceiving naturally. The lifestyle choices of women have also developed over the years with an increasing number choosing to postpone motherhood to pursue a career. Yet the difference between women who conceives naturally at 40, or for that matter any age, to a women who requires fertility treatment is the crux of the issue here. Fertility technology allows women as old as 70 to successfully conceive - but should they?
There may be in-built sexism in the way society views older parents. Sammy Lee illustrated how the media portray older mothers as being selfish yet they appear to congratulate older fathers. When approaching the issue we must there be mindful that we are not simply expressing prejudice about the woman's role in bringing up a child - if possible, both parents are in it for equal measure.
The conference provided an opportunity to discuss various perspectives and left those attending with no clear answer. Indeed, none was expected. The conference met its purposes to the engage the public in debate and to delineate the approaches to the issue but there is more that needs to be done. From a regulatory perspective, this concoction of various issues invites the question whether IVF is indeed properly regulated at present and whether there should be greater regulation of the provision of IVF for older mothers, either in guideline or legislative form.
The central question that emerged was when is it legitimate to interfere with the reproductive rights of the woman and on what grounds such an intervention should be justified. Introducing the debate, Professor Lord Robert Winston stressed that the medical profession should not interfere with what is essentially a personal decision for the woman. Analogies to abortion may be drawn here, which remains in the hands of doctors, in theory at least.
Yet I do not feel that the decision to have a child is solely the mother's decision and the best interests of that child should always be paramount. Guidelines make it clear that the primary factor to be considered when providing fertility treatment to older mothers is the wellbeing of the child. This includes both physical and psychological risks and I believe where there is a 'real' risk of either materialising then fertility treatment should not be offered. This is essentially a medical question and when we introduce the notion of safety into the decision-making process then it unavoidably medicalises the issue.
Another approach is to withhold fertility treatment on the basis that is does not take away from the mother - nothing lost, nothing gained. If IVF is viewed as a positive intervention dependant on the will of the medical profession (a woman cannot perform IVF alone) then those offered such services as legitimately permitted to deny treatment - as they are today. This merely infringes reproductive autonomy in an indirect manner. Yet such an approach leads to a negative conclusion that fertility treatment is a 'luxury' rather than akin to other medical interventions.What is clear, however, is that if further regulatory steps are to be introduced, however, it must be done is a sensitive and measured fashion so not to alienate older fertility patients and to not put pressure on patients to seek treatment abroad. The conference has set the scene for further avenues of debate but what is yet to emerge is a clear normative principle to guide it. I feel this can only be the welfare of the child, a principle that should never be curtailed, but then not everyone would readily agree.