Children of Choice: a doctor's perspective.

The introduction of in vitro fertilization (IVF) into North America in the early 1980s brought unanticipated and vigorous opposition from orthodox moral theologians of several traditions and from right-to-life groups, who erroneously equated IVF with abortion. If IVF proponents, including myself, had known of John Robertson and his advocacy of the constitutional concept of procreative liberty at the time, we would have found considerable protection behind the constitutional shield of procreative liberty. As simple IVF has grown to include donor sperm, donor eggs, cryopreservation, a variety of microtechniques, and other permutations and combinations known as Assisted Reproductive Technology (ART), procreative liberty and John Robertson have become staunch allies of these technologies. Procreative liberty has indeed shielded these procedures and may even shield some procedures that do not yet exist. Therefore, the medical practitioner can find comfort in giving presumptive priority to procreative liberty when seeking to resolve the legal issues surrounding new reproductive technologies.I. Various Perceptions of ProcreationNonetheless, in the consulting and examining rooms, the fact that procreative liberty may have presumptive priority from a legal perspective is but one consideration that the physician must examine when attempting to resolve the patient's dilemma. As this Article will show, many considerations other than legal ones impinge on reproductive problems and options, such as contraception, elective termination of pregnancy, the pathological condition of repeated miscarriage, and problems with menopause. To sharpen the focus of this discussion, however, I will limit my study to those patients who suffer from infertility.What indeed is procreative liberty as it exists between the doctor and patient?To establish what procreative liberty means in a particular situation, it often helps to ask infertility patients an important preliminary question: "Why do you want a baby?" In my twenty or more years of asking this question, I have elicited a variety of responses.* Sometimes I get an astonished stare, which conveys the message that the questioner must be slightly daft, to say the least. Other times, there is an expressionless silence for a prolonged period of time.Couples in these categories probably have not thought about this preliminary question specifically and, as events unfold, seem to represent those who think that children follow marriage like night follows day. Medical follow-through in this group is problematic and spotty. Some of these couples are from the religious right and are comfortable in explaining reproductive vagaries in terms of "the Will of God." I remember one couple who consulted me after ten years of infertility, and then only on the urging of a friend who had been successfully treated at my clinic. The patient was a schoolteacher, and her husband was a lawyer--both highly educated individuals. Although they missed a few appointments along the way, they did finally complete the work-up, which revealed a condition likely amenable to IVF. This therapy was too much for their convictions, however, and they disappeared, hopefully better prepared to accept childlessness as a result of being confronted by the preliminary question.* "From childhood, as I played with dolls, I fantasized and anticipated marriage and motherhood. Not to have a baby shatters my childhood dreams." This response calls for a second question: "And what does your husband think of all this?" The answer is usually reassuring, but it sometimes gives the impression that the sought-for baby is really a replacement for the childhood doll. How important is it in this situation for the physician to initiate a discussion on the seriousness of childbearing and the responsibilities, as well as the joys and rewards of parenting?Edgar Guest, a populist poet of the early twentieth century, put it this way:"How much do babies cost? …