Journal of Bioethical Inquiry

, Volume 10, Issue 1, pp 79–91 | Cite as

Should There Be a Female Age Limit on Public Funding for Assisted Reproductive Technology?

Differing Conceptions of Justice in Resource Allocation
  • Drew Carter
  • Amber M. Watt
  • Annette Braunack-Mayer
  • Adam G. Elshaug
  • John R. Moss
  • Janet E. Hiller
  • The ASTUTE Health study group
Original Research


Should there be a female age limit on public funding for assisted reproductive technology (ART)? The question bears significant economic and sociopolitical implications and has been contentious in many countries. We conceptualise the question as one of justice in resource allocation, using three much-debated substantive principles of justice—the capacity to benefit, personal responsibility, and need—to structure and then explore a complex of arguments. Capacity-to-benefit arguments are not decisive: There are no clear cost-effectiveness grounds to restrict funding to those older women who still bear some capacity to benefit from ART. Personal responsibility arguments are challenged by structural determinants of delayed motherhood. Nor are need arguments decisive: They can speak either for or against a female age limit, depending on the conception of need used. We demonstrate how these principles can differ not only in content but also in the relative importance they are accorded by governments. Wide variation in ART public funding policy might be better understood in this light. We conclude with some inter-country comparison. New Zealand and Swedish policies are uncommonly transparent and thus demonstrate particularly well how the arguments we explore have been put into practice.


Reproductive techniques, assisted Ethical analysis Distributive justice Health care rationing Health policy Need Capacity to benefit Disinvestment 



In memory of Konrad Jamrozik. We thank: Dale Halliday and Stephanie Krawczyk for research assistance; Jason Gordon and Lisa Smithers for their help; Cindy Farquhar, Wayne Gillett, and Gavin Mooney for private correspondence on particular points; Tony Milligan and Jan Deckers, in addition to anonymous reviewers; and those who made suggestions at the Feminist Approaches to Bioethics 2010 Congress.

Funding Support

This paper was initiated as part of Changing Policy and Practice in Health Care, also known as The ASTUTE Health Study (Assessing Service and Technology Use to Enhance Health) (National Health and Medical Research Council of Australia Project, Grant ID 565327). Its chief investigators are Janet Hiller, Adam Elshaug, Annette Braunack-Mayer, John Moss, Janet Wale, and Heather Buchan. Drew Carter is a research fellow on the “Health Care in the Round” Capacity Building Grant in Population Health (NHMRC, Grant ID 565501). The NHMRC played no role in: study design; data collection, analysis, and interpretation; the writing of this article; or the decision to submit this article for publication.

Statement of Competing Interests



  1. Assisted Reproductive Technologies Review Committee. 2006. Report of the independent review of assisted reproductive technologies. Canberra: Commonwealth Department of Health and Ageing.Google Scholar
  2. Australian Bureau of Statistics. 2008. Deaths, Australia (cat. no. 3302.0).Google Scholar
  3. Beauchamp, T.L., and J.F. Childress. 2009. Principles of biomedical ethics, 6th edition. Oxford: Oxford University Press.Google Scholar
  4. Bewley, S., L. Foo, and P. Braude. 2011. Adverse outcomes from IVF. British Medical Journal 342: d436. doi:
  5. Birenbaum-Carmeli, D., and M. Dirnfeld. 2008. In vitro fertilisation policy in Israel and women’s perspectives: The more the better? Reproductive Health Matters 16(31): 182–191.PubMedCrossRefGoogle Scholar
  6. Black, J.J. 2010. Egg donation: Issues and concerns. The American Journal of Maternal Child Nursing 35(3): 132–137. quiz 137–139.CrossRefGoogle Scholar
  7. Blyth, E. 2002. Subsidized IVF: The development of “egg sharing” in the United Kingdom. Human Reproduction 17(12): 3254–3259.PubMedCrossRefGoogle Scholar
  8. Bower, C., and M. Hansen. 2005. Assisted reproductive technologies and birth outcomes: Overview of recent systematic reviews. Reproduction, Fertility, and Development 17(3): 329–333.PubMedCrossRefGoogle Scholar
  9. Burr, J., and P. Reynolds. 2008. Thinking ethically about genetic inheritance: Liberal rights, communitarianism and the right to privacy for parents of donor insemination children. Journal of Medical Ethics 34(4): 281–284.PubMedCrossRefGoogle Scholar
  10. Carter, D., and A. Braunack-Mayer. 2011. The appeal to nature implicit in certain restrictions on public funding for assisted reproductive technology. Bioethics 25(8): 463–471.PubMedCrossRefGoogle Scholar
  11. Chambers, G.M., M.T. Ho, and E.A. Sullivan. 2006. Assisted reproductive technology treatment costs of a live birth: An age-stratified cost-outcome study of treatment in Australia. Medical Journal of Australia 184(4): 155–158.PubMedGoogle Scholar
  12. Chambers, G.M., E.A. Sullivan, O. Ishihara, M.G. Chapman, and G.D. Adamson. 2009. The economic impact of assisted reproductive technology: A review of selected developed countries. Fertility and Sterility 91(6): 2281–2294.PubMedCrossRefGoogle Scholar
  13. Cleemput, I., M. Neyt, N. Thiry, C. De Laet, and M. Leys. 2011. Using threshold values for cost per quality-adjusted life-year gained in healthcare decisions. International Journal of Technology Assessment in Health Care 27(1): 71–76.PubMedCrossRefGoogle Scholar
  14. Cookson, R., and P. Dolan. 2000. Principles of justice in health care rationing. Journal of Medical Ethics 26(5): 323–329.PubMedCrossRefGoogle Scholar
  15. Culyer, A.J. 2001. Equity: Some theory and its policy implications. Journal of Medical Ethics 27(4): 275–283.PubMedCrossRefGoogle Scholar
  16. Culyer, A.J. 2007. Need: An instrumental view. In Principles of health care ethics, ed. R. Ashcroft, A. Dawson, H. Draper, and J. McMillan, 231–238. Chichester: Wiley.Google Scholar
  17. Daniels, N. 1985. Just health care. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
  18. Devlin, N., and D. Parkin. 2003. Funding fertility: Issues in the allocation and distribution of resources to assisted reproduction technologies. Human Fertility (Cambridge) 6(suppl 1): S2–S6.CrossRefGoogle Scholar
  19. Ethics Committee of the American Society for Reproductive Medicine. 2009. Interests, obligations, and rights of the donor in gamete donation. Fertility and Sterility 91(1): 22–27.CrossRefGoogle Scholar
  20. Farquhar, C.M., Y.A. Wang, and E.A. Sullivan. 2010. A comparative analysis of assisted reproductive technology cycles in Australia and New Zealand 2004–2007. Human Reproduction 25(9): 2281–2289.PubMedCrossRefGoogle Scholar
  21. Frame, T. 2008. Children on demand: The ethics of defying nature. Sydney: New South.Google Scholar
  22. Gillett, W., and J. Peek. 1997. Access to infertility services: Development of priority criteria: A consultation document. Wellington: A report to the New Zealand Ministry of Health, National Health CommitteeGoogle Scholar
  23. Gillett, W., and J. Peek. 2000. Version 1 gynaecology referral guidelines and prioritisation criteria. New Zealand Ministry of Health.Google Scholar
  24. Gillett, W.R., J.C. Peek, and G.P. Herbison. 2012. Development of clinical priority access criteria for assisted reproduction and its evaluation on 1386 infertile couples in New Zealand. Human Reproduction 27(1): 131–141.PubMedCrossRefGoogle Scholar
  25. Griffiths, A., S.M. Dyer, S.J. Lord, C. Pardy, I.S. Fraser, and S. Eckermann. 2010. A cost-effectiveness analysis of in-vitro fertilization by maternal age and number of treatment attempts. Human Reproduction 25(4): 924–931.PubMedCrossRefGoogle Scholar
  26. Hansen, M., C. Bower, E. Milne, N. de Klerk, and J.J. Kurinczuk. 2005. Assisted reproductive technologies and the risk of birth defects—a systematic review. Human Reproduction 20(2): 328–338.PubMedCrossRefGoogle Scholar
  27. Heng, B.C. 2008. Should fertility doctors and clinical embryologists be involved in the recruitment, counselling and reimbursement of egg donors? Journal of Medical Ethics 34(5): 414.PubMedCrossRefGoogle Scholar
  28. Hope, T., L.P. Osterdal, and A. Hasman. 2010. An inquiry into the principles of needs-based allocation of health care. Bioethics 24(9): 470–480.PubMedCrossRefGoogle Scholar
  29. Kalbian, A. 2011. Considering the risks to economically disadvantaged egg donors. Americal Journal of Bioethics 11(9): 44–45.CrossRefGoogle Scholar
  30. Lancaster, P., E. Shafir, and J. Huang. 1995. Assisted conception Australia and New Zealand 1992 and 1993. Sydney: Australian Institute of Health and Welfare National Perinatal Statistics Unit.Google Scholar
  31. Lindström, H., and S. Waldau. 2008. Ethically acceptable prioritisation of childless couples and treatment rationing: “Accountability for reasonableness”. European Journal of Obstetrics, Gynecology, and Reproductive Biology 139(2): 176–186.PubMedCrossRefGoogle Scholar
  32. Medicare Item Reports. No date. Accessed January 25, 2012.
  33. Middelburg, K.J., M.J. Heineman, A.F. Bos, and M. Hadders-Algra. 2008. Neuromotor, cognitive, language and behavioural outcome in children born following IVF or ICSI-a systematic review. Human Reproduction Update 14(3): 219–231.PubMedCrossRefGoogle Scholar
  34. Mladovsky, P., and C. Sorenson. 2010. Public financing of IVF: A review of policy rationales. Health Care Analysis 18(2): 113–128.PubMedCrossRefGoogle Scholar
  35. Mooney, G., and S. Houston. 2004. An alternative approach to resource allocation: Weighted capacity to benefit plus MESH infrastructure. Applied Health Economics and Health Policy 3(1): 29–33.PubMedCrossRefGoogle Scholar
  36. National Collaborating Centre for Women’s and Children’s Health. 2004. Fertility: Assessment and treatment for people with fertility problems. London: National Institute for Clinical Excellence.Google Scholar
  37. Rawlins, M.D., and A.J. Culyer. 2004. National Institute for Clinical Excellence and its value judgments. British Mecical Journal 329(7459): 224–227.CrossRefGoogle Scholar
  38. Reefhuis, J., M.A. Honein, L.A. Schieve, A. Correa, C.A. Hobbs, and S.A. Rasmussen. 2009. Assisted reproductive technology and major structural birth defects in the United States. Human Reproduction 24(2): 360–366.PubMedCrossRefGoogle Scholar
  39. Repromed. No date. Accessed January 25, 2012.
  40. Ryan, M. 1996. Using willingness to pay to assess the benefits of assisted reproductive techniques. Health Economics 5(6): 543–558.PubMedCrossRefGoogle Scholar
  41. Slade, P., C. O’Neill, A.J. Simpson, and H. Lashen. 2007. The relationship between perceived stigma, disclosure patterns, support and distress in new attendees at an infertility clinic. Human Reproduction 22(8): 2309–2317.PubMedCrossRefGoogle Scholar
  42. Steele, E.J., L.C. Giles, M.J. Davies, and V.M. Moore. 2011. The life journeys of young women project: Objectives, design, and recruitment results. American Journal of Epidemiology 174(1): 72–80.PubMedCrossRefGoogle Scholar
  43. Verhaak, C.M., J.M. Smeenk, A.W. Evers, J.A. Kremer, F.W. Kraaimaat, and D.D. Braat. 2007. Women’s emotional adjustment to IVF: A systematic review of 25 years of research. Human Reproduction Update 13(1): 27–36.PubMedCrossRefGoogle Scholar
  44. Wang, Y., G. Chambers, M. Dieng, and E. Sullivan. 2009. Assisted reproductive technology in Australia and New Zealand 2007. Canberra: Australian Institute of Health and Welfare.Google Scholar
  45. Wang, Y.A., G.M. Chambers, and E.A. Sullivan. 2010. Assisted reproductive technology in Australia and New Zealand 2008. Canberra: Australian Institute of Health and Welfare.Google Scholar
  46. Watt, A.M., A.G. Elshaug, C.D. Willis, and J.E. Hiller. 2011. Assisted reproductive technologies: A systematic review of safety and effectiveness to inform disinvestment policy. Health Policy 102(2–3): 200–213.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2012

Authors and Affiliations

  • Drew Carter
    • 1
  • Amber M. Watt
    • 1
  • Annette Braunack-Mayer
    • 1
  • Adam G. Elshaug
    • 1
    • 2
  • John R. Moss
    • 1
  • Janet E. Hiller
    • 1
    • 3
  • The ASTUTE Health study group
    • 1
  1. 1.School of Population HealthThe University of AdelaideAdelaideAustralia
  2. 2.Department of Health Care PolicyHarvard Medical SchoolBostonUSA
  3. 3.Faculty of Health SciencesAustralian Catholic UniversityMelbourneAustralia

Personalised recommendations