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Subfertility deserves attention, but not because it is a disease

16 July 2018
Appeared in BioNews 958

Philosophers have debated how best to define health and disease for some time. The main two approaches focus on biological nature and social construction. The first identifies disease as biological deviations from the norm. The second argues that societies construct diseases by responding to certain conditions in particular ways, for instance by treating them with medicine. Neither of these definitions is universally accepted. Subfertility provides an example of why it can be so difficult to determine exactly what makes something a disease. 

Subfertility is recognised as a disease by the World Health Organization; however, it doesn't fit the disease paradigm particularly well. Sometimes couples can't conceive, despite having no identifiable biomedical problem; some individuals are completely sterile but experience no harm since they don't wish to have children. People in same-sex relationships or who are single may have functional reproductive systems but suffer terribly from being unable to conceive children. Many of the harms associated with subfertility are social, emotional and psychological in nature, rather than the familiar physical pains of more prototypical diseases.

Recognising something as a disease can have real-world implications. Diseases tend to attract attention, and those who have diseases receive state support and healthcare. For those campaigning for more support for people with subfertility, it has often seemed important to emphasise the 'fact' that subfertility is a disease. Similarly, those opposed to generous funding for fertility treatment tend to disparage subfertility's significance. The argument runs that wanting children is a lifestyle choice, and being unable to have children is akin to not having the kind of job, home or partner that one desires.

But there is a cost to placing so much emphasis on the argument that subfertility is a disease, and that this, therefore, entitles people to state-funded fertility treatment. The danger of this argument is that it does not find space for people who are unable to have children for reasons unrelated to biomedical health. 

People in same-sex relationships, single individuals and others whose childlessness is not due to malfunctioning biology are left behind by such arguments. But they still suffer in the same way from being unable to have children. It also seems unsympathetic to those whose subfertility results from choices they've made, such as to delay attempts to conceive or to smoke or over-indulge, resulting in obesity and reduced fertility.

Another disadvantage of focusing on this argument is that it encourages us to see the solutions as medical: IVF, hormone injections, trips to clinics, constant medical surveillance. For those whose subfertility has a clear biomedical basis which can be overcome through medical technologies and care the outcome is positive. For those whose condition fails to be recognised in the first place, because they are not seen as having a disease, or for whom medical technologies are unhelpful, then the failure to consider non-medical ways of addressing childlessness can be harmful.

An alternative approach is to back away from the continued emphasis on disease. When faced with accusations that wanting a child is merely a lifestyle choice unworthy of state support, one could argue that, like other social problems – from unemployment to inadequate housing and loneliness – subfertility deserves attention and state support. 

Rather than distancing subfertility from non-health-related forms of suffering, one could embrace these causes as allies. What matters is not an arbitrary notion of naturalness or some optimum version of health, but the imperative to reduce suffering and promote well-being.

This might encourage consideration of non-medical forms of tackling the suffering that accompanies subfertility. These do not 'cure' subfertility by providing the opportunity of pregnancy and genetically related children. They involve seeking to relieve suffering in other ways, by promoting alternative opportunities to engage in child-rearing relationships through adoption and fostering, providing more counselling and support, and by tackling the stigma and financial penalties that often accompany childlessness.

Reframing the Debate Around State Responses to Infertility: Considering the Harms of Subfertility and Involuntary Childlessness
Public Health Ethics |  1 November 2016
12 November 2018 - by Sarah Pritchard 
Improvements in the success rates of IVF treatment have been cited as part of the reason fewer people are choosing to adopt children in the UK, despite the number of children currently in care reaching a record high...
16 April 2018 - by Dr Nicoletta Charolidi 
'The Real Cost of IVF' event organised by Progress Educational Trust (PET), despite its an ambiguous title, had a very specific purpose: to acknowledge, discuss, and to raise awareness of the emotional and psychological price paid by people who undergo fertility treatment...
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