Tax-financed health systems like the UK's National Health Service (NHS) are 'pay-as-you-go' systems reliant on younger and healthier individuals paying into a system used by citizens throughout their lifetimes, but mostly consumed in older ages.
The entire public finance system is reliant on replenishing the population with new citizens and immigrants to work and pay taxes to continue funding health and other government programmes. This fiscal interdependency, that transcends across generations, highlights the social contract that exists in society today. Failing to maintain this order or allocating more resources to one generation than another generation, can cause intergenerational injustice as other generations are expected to pay more taxes for programmes that they may not themselves be entitled to in the future.
The intergenerational dependency that holds public economics together leads to the realisation that children, regardless of being naturally conceived or conceived through IVF, can be viewed as public goods from which all members of society benefit.
Specifically, current working-aged people will make some claim on the output in the form of tax contributions from the children of today who will become the workers of tomorrow. In turn, this would suggest parenthood is a public service from which all citizens benefit.
Childless couples, by choice or due to infertility, that do not pursue the public service of parenthood could be seen as 'freeriding' on a system that relies on us to contribute to the pool of future workers. However, this perceived freeriding by childless couples is partially counterbalanced by having to pay higher taxes and paying for programmes used by other people's children.
The extended benefits of parenthood on public finances transcend traditional outcome metrics such as quality-adjusted life-years (QALYs) that are often applied to healthcare interventions. It turns out that parenthood is not an entirely selfless act, as benefits can materialise for parents as they age.
Investigations into ageing parents have shown that elderly individuals who have children are less likely to be in nursing homes, receive less funded nursing care, and when they do enter nursing homes, will enter at older ages. Across the fiscal cycle of life, the returns from non-market labour of parenting offer future benefits for public programmes by minimising claims on public resources made by older generations as children are willing to provide support to ageing parents.
All this would suggest the need for applying a broader perspective and longer time horizon for evaluating the benefits from a technology that creates human life ie assisted reproductive technology. In technical terms, the child born from a successful pregnancy is an economic externality of treatment that is not captured in conventional cost-effectiveness analysis.
Whilst the UK's National Institute for Health and Care Excellence has a preference for evaluating QALYs of parents, the child does not feature in the calculation. However, the child 'is the benefit' not only to the parents, but also to society and public coffers in the future. In an intergenerational economy, the child will become the future taxpayer that funds the system.
Essentially, the IVF-conceived child will be funding their parent's future healthcare needs as they grow, work and pay taxes. Previous calculations in the UK and replicated elsewhere, demonstrate that governments do in fact yield long-run fiscal benefits from funding IVF - based on the taxes extracted from these children in the future.
Estimates suggest that net discounted lifetime taxes are 8-10 times greater than the costs of funding fertility programmes. Few currently funded NHS technologies are likely to generate as much future net tax revenue. This raises the question as to which government sector should fund one of the most fiscally beneficial technologies that partially helps to sustain the pay-as-you-go financing model.
Failing to fund fertility treatment does not lessen the desire for children, rather couples will seek an option that suits their own economic needs to optimise success. This can entail travelling abroad for treatments unaffordable in their home country, or pursuing more aggressive treatment options leading to multiple pregnancies. Neonatal units across the UK have cared for preterm children conceived abroad and born at home. One of the peculiarities of treating infertility is that couples can benefit even when treatment fails as this offers closure for couples that desire a child.
Few health interventions that do not succeed provide benefits, which highlights the importance of closure for many couples knowing that they have pursued every option available.
Emotive and biological claims of couples are frequently the cornerstone of pleas to improve publicly-financed fertility treatments. From a fiscal lens, we can see that the issue is much broader than any single government sector can appreciate or fulfil. Furthermore, within an intergenerational economy, all members of society lose from the inability of our health systems to identify funds to treat infertile couples. The needs of the visibly urgent are real. However, denying access to fertility care, in a small way undermines the sustainability of the system that children born from assisted reproduction would help to sustain in the future.