The baby industrial complex
- The baby industrial complex
A Harvard economist reveals that the booming fertility industry is
shockingly unregulated -- and says it's time for the U.S. government
to step in.
By Lynn Harris
Feb. 09, 2006
[Letters to the Editor:
Debora L. SparLast week, I had three phone calls with my insurance
company to find out whether my plan covers in-vitro fertilization
(IVF). First they said yes, then they said, "What's IVF?" and third,
they said no. Long story short, my husband and I are probably looking
at least $15,000 for one round. That's including drugs, anesthesia
and, when I'm feeling put-upon, car service to the fertility clinic
with by far the best success rates in New York City -- why shop
anywhere else? -- and, naturally, the least convenient coordinates
(so far east it's practically in the river).
Fifteen thousand dollars. Sure would be nice to spend it on food,
shelter and a Louis Vuitton diaper bag for an actual child, not the
30 percent likelihood of one. Should I "relocate" to, God help me, my
parents' house in Massachusetts, where -- Gov. Mitt Romney's evolving
anti-choice views notwithstanding - IVF is universally covered?
Should we travel as "fertility tourists" to Israel, which covers all
treatments and offers low out-of-foreign-pocket rates? Down the road,
will we wish we'd saved the cash for adoption fees?
Whatever we decide, one thing is already clear: For us -- along with
at least 10 percent of American couples -- fertility is not a
miracle, it's a market. "Advances in reproductive medicine have
indeed created a market for babies, a market in which parents choose
traits, clinics woo clients, and specialized providers earn millions
of dollars a year," writes Harvard economist Debora L. Spar in her
provocative new book, "Baby Business: How Money, Science, and
Politics Drive the Commerce of Conception." "Eggs are being sold;
sperm is being sold; wombs and genes and orphans are being sold; and
many individuals are profiting handsomely in the process."
And she's not saying that's wrong. The problem, Spar argues, is that
-- because "it is difficult to conceive of a child as commerce" -- no
one is willing to call the baby business what it is: an industry. And
as long as it's not truly considered an industry, it will continue to
fly under the regulatory radar, she says. Indeed, fertility is one of
the extremely few U.S. industries that "operate with virtually no
rules" -- not much more beyond a requirement that clinics report
their success rates to the CDC (which has no means of actually
enforcing that requirement). Spar's contention: "Governments need to
play a more active role in regulating the baby trade."
Yeah, but ... this government? "The debate will not be cordial," Spar
concedes in her book. In his recent State of the Union address,
President Bush did take up certain bioethical matters, saying:
"Tonight I ask you to pass legislation to prohibit the most egregious
abuses of medical research, human cloning in all its forms, creating
or implanting embryos for experiments, creating human-animal hybrids,
and buying, selling or patenting human embryos." "Human-animal
hybrids"? Yes. But the types of regulations Spar proposes would
affect real people, not goat people, now -- without the not-so-hidden
agenda of defining embryos as people."We need to acknowledge the
market that reproductive technologies have created and then figure
out how to channel this market toward our own best interests," she
writes. "It's no use being coy about the baby market or cloaking it
in fairy-tale prose. We are making babies now, for better or worse,
in a very high-tech way ... We can moralize about these developments
... or we can plunge into the market that desire has created,
imagining how we can shape our children and secure our children
without destroying ourselves."
Salon recently spoke by phone with Spar, the Spangler Family
Professor of Business Administration at Harvard Business School,
about the economics of the baby trade and how reasonable regulation
could democratize, rather than politicize, the fertility industry.
What drew you to this topic?
I wrote my last book on the politics of the Internet, and inevitably
people would ask me: What is the next cycle of technology that will
have the same effect? A technology so radical that it creates a
market that didn't exist before, and people jump into it and do all
kinds of wacky things because there are no rules -- though people
will eventually want them? It hit me that the answer was reproductive
medicine. What scientists are now able to do in terms of high-tech
reproduction was going to create -- has created -- a market for
conception that never existed before.
Give us some historical perspective. Don't we have a history of
reacting to certain innovations -- say, birth control, IVF - like
they're signs of the apocalypse, but then adjusting to and absorbing
them into our culture?
As people know, there was major opposition to contraception for
hundreds of years. If you go back to the witch trials of the 15th
century, most of the witches were midwives. The argument, and it was
partially true, was that midwives knew how to birth babies, but they
also knew rudimentary forms of contraception -- and that was
considered witchcraft. So this is an ancient prohibition against
mucking around with Mother Nature.
Then in the late 19th century it began to be possible to get better
forms of contraception. There was major moral opposition to the use
of contraception, particularly the use of condoms. But it turned out
that contraception was a really good business. So as the
manufacturers continued to make the stuff, they started doing so well
that they became a lobbying force in their own right. Then Margaret
Sanger came along. She got the American Medical Association to come
out in support of contraception. They supported contraception only
when it was prescribed by a doctor. Now think about that: Maybe they
had a change of heart, but they also created a whole new area of
business for themselves. That's the market trumping morality for you.
Fast forward once again: The science behind the pill was known for
some time. But none of the corporations wanted to touch it because
the moral outrage was so high. The work that finally brought the pill
out of the laboratory was entirely funded by one woman who was the
heiress to the McCormick reaper fortune, whose husband was
schizophrenic and she didn't want to risk having a schizophrenic
child. Once the pill was actually out, companies were very nervous
about getting behind it. But when they did, the sales were so big
that it just trumped the opposition because there was so much money
in it -- and there still is.
So the first IVF is performed in 1978, and people go wild. There's
massive opposition. There's marching in the streets. There are people
declaring that the end of the world is nigh. And you know what? It
turns out there's an awful lot of people who want to use this
service. Literally within a year or two all of the public opposition
goes away. Because the people for whom this technology works, they
want it to work so badly, they're willing to do anything, pay
anything, and they really drown out the critics -- even though it's
not a public, politically organized fight. And so the market, the
combination of supply finally emerging to meet this long-standing
demand for reproductive options, just trumps the opposition. I'm
predicting we're going to see the same thing with stem cells. The
science just isn't good enough yet.
Why are there so few regulations on reproductive technologies,
especially from a government so rattled by stem cell research?
People don't like talking about this. There is still a puritan
element among many people who really want to believe that
reproduction is a private, intimate process, guided by Mother Nature.
It's not the kind of issue on which people have felt comfortable
organizing politically. Unlike cancer sufferers or AIDS sufferers,
there's been no momentum. And of course, the doctors and clinics have
no interest in being regulated.
Meanwhile, the politicians don't want to touch this with a 10-foot
pole. You cannot talk about reproductive technology without touching
on abortion, because the underlying mechanism is the same.
Right. There are starting to be murmurs of protest against IVF for
that reason, because it creates excess embryos.
Yes, that's where IVF does run straight into abortion. You are
creating in almost all cases excess embryos that do not subsequently
become children. But it turns out there are ways you can avoid that
-- and the European countries do a pretty good job -- you can limit
the number of embryos that you create and implant. I think some
discussions along those lines would actually be useful, and we could
probably find a way to make both the IVF proponents and the abortion
opponents happy. This is where a business perspective is helpful,
because ultimately it's a cost thing. If you have a couple who has
saved up exactly $12,400 they can do IVF once. They're going to be
inclined to push the doctor to implant five embryos at once. And the
doctor's going to be inclined to go along. That is probably going to
create excess embryos. And implanting more than two embryos may lead
to a more dangerous pregnancy. Whereas if you were to say, "Let's
control costs and change the incentive so that parents, doctors and
society have an interest in implanting only one or two embryos," you
get a very different outcome. That's what many of the European
And when that woman has quintuplets, there's also a cost to society.
So it's not as if the people who manage to afford fertility
treatments are doing what they do in a vacuum.
That's one of the most important and overlooked pieces -- that these
private choices impose public costs. These "miracle quintuplets" we
see? We're all paying for those miracle quintuplets. They are
hundreds of thousands of dollars in delivery costs that our
insurances are all picking up in one way or another. Many times these
kids, sadly, have learning disabilities, delays, medical issues
throughout their lives. The parents pay upfront. But we are
shouldering the cost over time.
You're dispassionate in the book about the "business" of the baby
trade, yet there's a hint of sarcasm about couples who'll pay
whatever it takes to have a child -- specifically, the kind of baby
they want. What kind of regulations should address the kind of
genetic tinkering that can produce "designer babies"?
I think the early cases of what we now call "designer babies" are
things with which most people would have absolutely no trouble
whatsoever. They're people dealing with horrific genetic diseases.
And if you're facing the prospect of having another child with
Tay-Sachs or cystic fibrosis, you will do anything to ensure that you
get a healthy kid. I'd go so far as to say that these poor folks
shouldn't have to pay everything out of pocket. If we can help people
give birth to children who do not bear these horrific genetic
diseases, I think that's a good thing for society to be willing to
The problem is that it's a slippery slope. It's pretty easy to say
yes when the disease you're talking about is a genetic disease that's
going to give the child an early, horrible, painful death. What do
you do when it's a predisposition to breast cancer? Then how do you
choose? That's a problem this technology has created.
And the part that's easiest to be cynical about is gender selection.
I would suggest that there's going to be a real market in that. And
we need to worry a lot when we get to the level of choosing sort of
trivial characteristics: height, hair and eye color -- but we're not
there yet. I have not heard of your stereotypical rich older couple
going to a fertility clinic demanding a blond tall girl. That is not
out there yet.
But they do demand the eggs of a tall blond girl.
They sure do.
What other technologies are screaming for regulation?
Well, the irony is that the only technology that is getting loaded
with regulation in this country is stem cell technology. Which
arguably is the one that has the greatest probability of saving
existing lives. So we're not regulating the technologies that are
allowing us to produce new lives, but we are regulating the ones that
can save existing lives. That makes no sense.
Also, what do we do about these cases -- which are small in number
but very emotionally loaded -- where parents are choosing to create a
second child to act as a donor, of cord blood let's say, to save the
life of the first? Those are cases where I think regulation can help
a lot. You can create limits to how far that goes. Can you create a
child to be destroyed in utero to save another? I don't think so.
Would you create a child who would be sick in order to save an
existing child? Probably not. However, can you create a child who
will be a perfectly happy, healthy child and all you need is their
umbilical cord blood? Yeah, I'm OK with that. In fact, if you want to
be business schooly about it, it's probably a more efficient means.
Because otherwise the existing child is going to have a much longer
and more costly decline -- costly to society. It's not the only frame
I would want to use, but it's actually pretty useful. Once you've
also looked at the obvious ethical issues. Is the second child liable
to be exploited in any way? And as long as you're relatively
convinced that that won't happen, there's a real cost savings here.
And at some point we're going to have to deal with cloning. We're not
there yet but some crazy doctor is going to produce a clone. Where
the doctors are reporting that they're hearing the most demand is: a
child dies tragically; the parents don't want just any old baby, they
want that baby back. And any of the scientists who report success in
animal cloning are besieged by parents saying, "I'll pay anything,
I'll do anything, I want you to bring back my kid -- here's a lock of
hair." So the demand is out there, and there are a couple of doctors
who have said publicly they're trying to do it. Someone's going to
succeed. But in a regulatory sense it's pretty straightforward: You
just say no.
Is it idealistic, even naive, to think that this country could engage
in a reasoned debate about regulating this industry?
That would be the hope. The reality is probably a lot more
pessimistic. I think at the moment the answer is probably no. We're
too divided. We'll have to see what the next administration looks
like. And we'll have to see where we can get some kind of national
consensus. My guess is we can get consensus slowly, painfully, on
some of the basics. Maybe the question of the number of embryos that
can be implanted. Reproductive cloning. Go for the things that we can
agree upon. There are enough of those to make a worthwhile
discussion. And then as we get further and further into the
complicated realm, we may be forced down to state-level legislation.
I'd rather the whole country cover them, but I'm willing to settle
for state-level law if the national debate becomes too divisive.
When. But some of it's not that hard. One of the things I argue for
in the book, which sounds trivial but it's not, is providing
information. People shouldn't have to go mucking around on all these
Web sites, some of which are not very reputable, to get information
on procedures, or to buy eggs from a shady operator. There should be
information out there. There is only one bill that has passed
Congress, to provide success rates. And that piece of legislation is
not as good as it could be. But just getting information out about
treatment options, reputable egg donors, risks and considerations of
certain treatments That's really low-hanging fruit. We could
definitely start there.
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Others May Simply Live