Choosing One: Resolving the Epidemic of Multiples in Assisted Reproduction
59 Pages Posted: 10 Aug 2011 Last revised: 6 Feb 2014
Date Written: 2010
Fertility treatments have helped many individuals and couples exchange the heartbreak of infertility for the joys of parenthood. However, patients are often directed towards practices that greatly increase health risks by increasing their chances for multiple gestations. This Article highlights features of the context surrounding “assisted reproduction” that steer potential parents toward choices that heighten health risks for them and their hoped-for children.
The decision-making context patients confront in assisted reproduction leads many towards treatment choices that markedly increase the probability of twins, triplets, and higher order births. As a result, 30-35% of the births related to assisted reproduction are multiples. The public health community views the dramatic rise in multiple births related to assisted reproduction as a preventable epidemic. They emphasize that much more needs to be done to prevent the multiple pregnancies related to assisted reproduction. This policy imperative, however, runs head long into the market-based and institutionally fractured approach to fertility treatment in the United States.
The significant risks associated with multiple gestation raise an obvious question: why, despite strong evidence that single embryo transfer is the best way to reduce multiple gestations, do most women in the United States still select treatment approaches - hormone therapy or implanting multiple embryos in IVF - that often lead to multiple gestations? These practices stand in sharp contrast to several European countries, where women use IVF and transfer only one embryo at a time, the treatment approach best designed to reduce the risk of multiples? An important part of the answer to this puzzle lies in the context in which potential parents in the United States make decisions about assisted reproduction.
This Article critically analyzes the dominant approach to understanding patient choice in assisted reproduction. Drawing upon well-established findings in cognitive psychology and behavioral economics, it evaluates how patients are steered towards choices about assisted reproduction that disserve their long-range interests and well-being and reduce social welfare. This research demonstrates the myriad ways that organizational and legal rules and incentives substantially influence individual choice. In highlighting how patient choices are swayed by the context within which they seek medical assistance to conceive children, I provide a novel application of a school of thought that is gaining greater attention in the legal literature and in policy-making communities.
The Article also analyzes various legal and institutional strategies that other countries have used to address the risks created by multiple gestations related to assisted reproduction. This comparative perspective highlights shortcomings in the U.S. approaches to assisted reproduction and advances understanding of the strengths and limits of alternative policy options. Finally, and perhaps most importantly, I provide suggestions for both public and private actors to reshape the assisted reproduction decision-making context to guide patients towards one healthy baby.
Keywords: fertility treatment, assisted reproduction, public health, comparative law, cognitive psychology, behavioral economics
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