Environmental ethics and medical reproduction

Scientific evidence has established the link between global climate change and its impacts on human health, including its effects on reproductive health. Last year I was part of the European Society of Human Reproduction and Embryology (ESHRE) Expert Panel for Environmental Factors and Fertility, which produced a number of factsheets and recommendations to address these issues. Furthermore, while climate affects human health, health care also affects the climate through resource use, carbon emissions, and pollution.

Global healthcare activities comprise 4.6 percent of global greenhouse gas emissions. Part of this environmental impact comes from reproductive medicine – which may include everything from annual gynaecological check-ups, prenatal care, to assisted reproductive technologies.

Assisted reproductive technologies span a number of technological interventions into human reproduction, including gamete retrieval, IVF, intrauterine insemination (IUI), gamete and embryo freezing and intracytoplasmic sperm injection (ICSI).

While all health care has a carbon impact, assisted reproductive technologies, or medical reproduction as I term in my second book, Environmental Ethics and Medical Reproduction, is particularly resource intense as it is the only 'medical' procedure that adds to population growth by creating new human life.

At the recent ESHRE annual meeting in Amsterdam, the Netherlands, I was invited to speak about the ethical issues involved in medical reproduction as it relates to the environment. I noted a few ways medical reproduction is exceptional, both in reproductive medicine and in health care.

First, unlike life-saving medical treatments, medical reproduction is, very often, a lifestyle procedure that is given to meet a reproductive project. While biomedical ethics maintain that health care has a responsibility to provide lifesaving medicine to all, medical reproduction is not lifesaving. Moreover, it does not cure, treat, or prevent infertility; it temporarily circumvents infertility to provide options in reproduction.

While some might object that targeting medical reproduction for environmental scrutiny is 'unfair' to those with infertility, medical reproduction caters to the fertile and infertile, with growing numbers of people availing themselves of services. For instance, sex-selection and IVF for those who have one or more children are examples of medical reproduction that are used by both fertile and infertile people. Given the imperative to reduce health care carbon emissions, the provision of medical reproduction as a non-lifesaving procedure, given in a time of environmental precarity, is worth evaluation.

Second, while all health care has a carbon footprint and impacts the environment through resource use – such as an outpatient doctor appointment – and some health care puts pressure on earth's carrying capacity by extending lifespans (eg, a heart bypass operation) medical reproduction is the only medical procedure that has a carbon footprint, impacts carrying capacity, and increases population growth.

This is not to say that medical care should be refused simply because it has an environmental impact. Rather, it points to the fact that medical carbon should be 'spent' on people alive today who have a stronger claim to medicine (some would say a right) than on creating new people who might otherwise not be born. To be sure, these issues are not the blame of only medical reproduction, but all human reproduction. Still, medical reproduction is poised for environmental assessment not only as procedure which increases population and uses resources, but also as a reproductive choice in a time of climate change (unlike unplanned pregnancies).

Third, medical reproduction funnels intellectual and financial resources into meeting lifestyle desires, not meeting basic medical care. The World Health Organisation shows that some countries have unmet healthcare needs of up to 50 percent of adult populations. Beyond this, lack of maternal care, infant care, palliative care, and cancer care are widely reported worldwide. Over 12 million IVF babies have been born since 1978 and mostly in countries which use a disproportionate share of resources. Thus, medical reproduction can be scrutinised for its place in exacerbating global healthcare disparities.

At the conclusion of my ESHRE talk, I delivered three take-home messages about environmental ethics and medical reproduction.

• There are numerous ways to be a parent and all people – fertile or not – should consider options which do not increase population like adoption, co-parenting, and other forms of raising children from coaching sports teams to working in education. Most children are born naturally and therefore all adults must consider if it is ethical to reproduce in a time of climate change.
• Prevention of infertility fits within basic health care and should be a priority in reproductive medicine; not high-tech reactive procedures, which expend more carbon. Carbon should be reserved for what people really value – if it is biological reproduction, then we as a society need to consider what other forms of resource use (eg, fast fashion; fast food) we are willing to give up to make the planet inhabitable for all.
• Medical reproduction carbon can be ethically reduced by life cycle assessments of the procedures and components, for instance, in IVF laboratories. New medical reproduction developments must consider sustainability proactively, not reactively, thus putting ethics in the pipeline. Going forward, policies that only reduce the number and kind of medical reproduction procedures could be created. IVF add-ons (tests or treatments not clinically relevant for an IVF/ICSI cycle, but optional, additional procedures that are sometimes offered on top of standard fertility procedures) are seen as medically unnecessary, but use carbon. These could be eliminated without affecting IVF success rates.

Global climate change affects everyone; all aspects of life from transportation to technology to medicine should be made more sustainable. For over a decade I've been writing on ethical ways to address the environmental issues of MR and still respect those who desire children (see the Journal of Medical Ethics). My first book, Principles of Green Bioethics, looked at the environmental impacts of medicine and offered four principles for sustainable health care. Medical reproduction can follow those principles, while medical care decarbonises, and health, including reproductive health, is assessed for environmental impact.