The IVF lottery

In 2007, the world's media reported - with various degrees of shock and disapproval - on a Big Brother-style TV programme being created in Holland. This was Big Brother with a bizarre twist: instead of a cash prize and a moment of minor celebrity, the winner would get ... a kidney. The programme never took place; instead, it was announced that it had been a hoax (1), designed to highlight the need for kidney donors to come forward.

Fast forward to 2011. A similar media outcry has been provoked by the announcement by fertility charity To Hatch of a lottery where the prize is - not cash; not a kidney, but... fertility treatment. At the time of writing, the lottery draw has been mysteriously postponed, raising questions about whether - as with the kidney competition - this is a media circus deliberately whipped up to highlight the plight of people who wish to access IVF, but cannot afford to do so.

Setting aside the issue of its veracity, why should a lottery for fertility treatment be controversial? A variety of critical comments have been published. A headline in the Telegraph states 'Babies to be won monthly in first IVF lottery'. The British Fertility Society has condemned the scheme as unfair, while the UK's fertility regulator - the Human Fertilisation and Embryology Authority (HFEA) - denounced the planned lottery as 'trivialising'.

The idea that babies could be given as prizes, as suggested by the Telegraph, is clearly designed to shock. But the headline is misleading. The prize is fertility treatment, not babies. Success rates for IVF are fairly low so there is no guarantee that any winner will have a child.

Even so, some people may find it objectionable that the means of having a baby are being offered by lottery. But why should this be so? The winner of a TV cash prize game show I watched recently declared her intention of using the money to start a family. This drew approving 'awww' sounds from the audience rather than horrified gasps. If it is OK to enter a competition to facilitate your reproductive aspirations, why not a lottery?

Perhaps the answer lies in the prize. Cash is a fundamentally different thing from medical treatment. Anyone who wins £1,000 will be better off than before. A lottery for, for example, removal of an appendix, would seem ludicrous: the prize would be harmful to most winners.

Offering medical treatment as a lottery prize seems to present medicine as something which, like other transferable commodities, may be valued - not on the basis of need - but by whether it helps to achieve a particular end. Perhaps this is what led the HFEA to state that this lottery is 'trivialising'. Lottery prizes may be nice to have, but are rarely desperately needed. Lotteries can be fun and entertaining, whereas medical treatment is normally viewed as inherently serious.

But lotteries are not unknown in medicine. What one PCT decides to fund may be unavailable to people living only a few miles away. The perceived arbitrariness of such discrepancies is widely condemned hence the pejorative term 'postcode lottery'. A lottery is intrinsically arbitrary: the winner is not the person with the greatest need or entitlement. Surely medical treatment should be allocated to those whose need is greatest, not to those whom chance favours?

Among the biggest problems for IVF provision is this question of need. Needing IVF depends on many factors that do not fit easily into a medical paradigm, which makes it difficult to gauge whose need is greatest. Physiological infertility (for example, blocked fallopian tubes) is not a sufficient criterion since not everyone who is clinically infertile perceives themselves as needing IVF. Conversely, physiological fertility is no guarantee of not needing IVF: women in perfect reproductive health may have infertile partners, or no partner, or partners of the same sex.

This subjectivity in establishing who 'needs' IVF has led PCTs to interpret eligibility for IVF in different ways. The British Fertility Society says the To Hatch lottery is as unfair as the postcode lottery. But could the To Hatch lottery be fairer since participants know it is a lottery - and can decide to enter or not?

People affected by the 'postcode' lottery do not have this option. A PCT may withhold treatment from women who are single, who are overweight, who smoke, who have previously had children... Prospective patients will not know in advance what criteria their jurisdiction will be using. Unless they are very lucky or very rich, they probably cannot move to where they would be eligible. In a sense, these people have been unwittingly entered into a postcode lottery. Many will have lost without having been fully aware of the nature of the game.

The To Hatch lottery is at least open about being a lottery. All entrants have an equal chance of winning, and participants can make the decision to enter or not based on their own judgment of its value. People may well feel that such a lottery is tasteless or disturbing; yet the treatment is nothing different from what already takes place in IVF clinics across the UK. All that is different is the means of allocation. And arguably the explicit adoption of a lottery mechanism is more open, and less discriminatory, than today's morass of IVF eligibility criteria.