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Does it matter whether infertility is a disease?

11 December 2017
By Hane Maung
Research Associate in Philosophy, Lancaster University
Appeared in BioNews 930

Infertility affects one in seven couples in the United Kingdom. Currently in England, state-funded treatment for infertility is available under the NHS, although availability varies across different local clinical commissioning groups. Depending on the kind of infertility, treatment may include medical interventions, surgical procedures, and assisted reproductive technologies.

How do we justify state funding for infertility treatment? Some defend it by claiming that infertility is a disease. Accordingly, like any other disease, it deserves medical treatment. For example, the World Health Organization considers infertility to be 'a disease of the reproductive system' (1), while the Warnock Report states that 'an inability to have children is a malfunction and should be considered in exactly the same way as any other' (2). However, not everyone argues that infertility is a disease. In a 2002 survey by the BMJ, infertility appeared on the list of 'non-diseases' as a 'variant of normal' (3). Another survey published in Human Reproduction in 2000 found only 38 percent of participants agreeing that infertility is a disease (4).

This controversy over the disease-status of infertility is often considered to be significant, because it could have implications for whether or not state-funded treatment for it is justified. For example, ethicist Dr Vardit Ravitsky and lawyer Raphaelle Dupras-Leduc note, 'if perceived as a disease, public funding for its treatment is construed as justified… if not, funding it may not be justified from the outset' (5). Hence, it is tempting to think that a useful approach to evaluating whether or not infertility warrants state-funded treatment is to establish whether or not it is a disease.

However, this approach has problems. First, infertility is not a unitary condition. There are many different reasons why people are unable to conceive. Some cases may be attributable to identifiable physiological or anatomical anomalies. Other cases may be due to the declining reproductive capacity associated with advancing age. Furthermore, infertility is often relational. That is to say, a person might be unable to conceive with one partner but able to conceive with another. Then, there are cases of social infertility, which include people who cannot conceive due to being in same-sex relationships, being widowed or being single by choice. Given this dappled nature of infertility, it is possible that some cases of infertility could be considered diseases while other causes could not.

Second, there is the philosophical problem of defining the concept of disease. What determines whether a condition is a disease rather than a mere difference? Philosophers have proposed various theories. One influential view is that disease involves a deviation from statistically normal function. For example, diabetes involves the inability to maintain blood sugar at a level deemed normal for adult humans (6). Another popular view is that disease has to be harmful to a person by compromising the ability to achieve desired goals. For example, a bout of influenza interferes with one's ability to work, exercise and socialise (7). It has also been proposed that disease must involve both biological dysfunction and individual harm (8). For example, heart failure involves the heart's inability to adequately pump blood and is associated with considerable suffering.

Philosophers disagree over which of the aforementioned features are the most important of disease states. Nonetheless, despite their different underlying claims, the various theories they offer successfully capture many conditions that are uncontroversially considered diseases, such as cancers, infections, autoimmune syndromes and so on. Therefore, in the majority of cases, the theories serve as useful guides.

With respect to infertility, however, things are not so straightforward. Cases of infertility often do not possess all of the aforementioned features associated with disease. Moreover, different kinds of infertility can possess different combinations of features. For example, a case of infertility due to an anatomical anomaly involves a failure of biological function, but this may not be deemed harmful if the individual does not want children. The infertility associated with advancing age involves a loss of biological function which may be undesirable, but this loss of function is statistically normal relative to the relevant age group. Conversely, a case of social infertility may not involve biological dysfunction, but may nonetheless be harmful because it is stops the person from achieving his or her procreative goals.

It seems that we cannot reach agreement over whether infertility is a disease, even with our best theories of disease. How, then, are we to evaluate whether infertility warrants state-funded treatment? Perhaps a more favourable approach would be to shift the focus away from disease-status and instead explicitly address the specific ethical issues raised by infertility. The philosopher Dr Marc Ereshefsky argues that focusing too narrowly on the concept of disease in controversial cases can obscure the issues that are relevant to medical discussions of such cases (9)

Rather than worrying about whether or not infertility is a disease, I suggest that we should keep the debate centred on the key ethical issues. We need to focus on the distress associated with childlessness, the right to reproductive liberty, the perceived significance of genetic relatedness, the influence of pronatalism, and the structural inequalities that make it difficult for people from certain groups to form their desired families. These are the considerations that we should examine when debating whether fertility treatments should receive state funding. 

SOURCES & REFERENCES
1) Zegers-Hochschild, F., et al. 2009. International Committee for Monitoring Assisted Reproductive Technology (ICMART) and the World Health Organization (WHO) Revised Glossary of ART Terminology
Fertility and Sterility |  19 December 2018
2) Report of the committee of inquiry into human fertilisation and embryology
Department of Health and Social Security |  19 December 1984
3) In search of 'non-disease'
BMJ |  19 December 2018
4) Public perception on infertility and its treatment: an international survey
OUP |  19 December 2018
5) Emerging Legal and Ethical Issues in  Reproductive Technologies
Routledge Handbook of Medical Law and Ethics |  19 December 2018
6) Health as a theoretical concept
Philosophy of Science |  19 December 1977
7) The concepts of health and illness revisited
Medical Health Care Philosophy |  19 December 2018
8) The concept of mental disorder: On the boundary between biological facts and social values.
American Psychologist |  19 December 1992
9) Defining 'health' and 'disease'
Studies in History and Philosophy of Biological and Biomedical Sciences |  19 December 2018
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HAVE YOUR SAY
Reframing the Debate (User:122847 - 18/12/2017)
We agree that the debate about state funding of assisted reproduction should focus on the ethical issues, rather than the question of whether infertility is a disease. Our recent paper examining some of these ethical issues can be found at: https://academic.oup.com/phe/article/9/3/290/2451084 If you do not have access and would like to read it, feel free to contact me at rebecca.brown@philosophy.ox.ac.uk
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