Is access to egg freezing equitable and fair? A comparison between policies in Belgium and France

Abstract Study question What underlying norms and values are the inclusion and exclusion criteria for egg freezing in Belgium and France based on? Are they equitable and fair? Summary answer Exclusion criteria are desirable from a distributive justice viewpoint. While age limits are justifiable, criteria such as oncological vs non-oncological and gender are not equitable. What is known already In 2018, the Belgian federal institute for health insurance (RIZIV or ENAMI) decided on health insurance coverage for the retrieval, freezing and storing of gametes and gonadal tissues for fertility preservation. This coverage is however not available to all candidates for egg freezing, but strongly directed towards oncology patients. France took a different approach. Since the French Law on Bioethics was passed in August 2021, egg freezing is available to all women between their 29th and 37th birthday. Egg harvesting is covered by public health insurance, but not the storage costs. Study design, size, duration This is a normative analysis in which the different inclusion and exclusion criteria from the Belgian and French system are critically analysed in light of existing ethical scholarship on access to egg freezing from the past decade. Special attention is paid to arguments relating to justice as fairness. Participants/materials, setting, methods Literature research; normative analysis The method that is used to bring empirical data (as found in literature research) and normative ethics together is the ‘Wide Reflective Equilibrium’, the most commonly used method in bioethics. Main results and the role of chance While the French system, allowing access to a great range of people, appears to be the most fair, the opportunity costs involved plead for the implementation of inclusion and exclusion criteria to make sure that resources are allocated in a more equitable manner. These criteria should be based on effectiveness and social justice. Looking at the currently implemented criteria, the distinction between medical and non-medical or between oncological and non-oncological conditions is difficult to justify given the large grey area where these categories overlap. For example, in Belgium several categories of people at risk of losing their fertility are excluded: transmen receiving gender-confirming therapy, people needing a stem cell transplant for other than hematopoietic reasons (e.g. sickle cell anaemia) or women nearing the end of their reproductive lifespan (also if due to previous cancer treatment). Arguments in favour of age limits are effectiveness and the avoidance of false hope for people of advanced reproductive age. Arguments against are founded on concerns of ageism and social injustice. Of the potential arguments arguing for gender limits – specifically the exclusion of transmen – none appear convincing, while access for transmen is problematic both in Belgium and France. Limitations, reasons for caution This analysis is a case study of two countries, not a comprehensive or representative analysis of European policies. Wider implications of the findings Countries that are considering implementing systems for coverage of egg freezing by public funding, can learn from these case studies to better finetune their inclusion and exclusion criteria. Trial registration number N/A