Reproductive health, fairness, and optimal policies

• Published date: 01 September 2020
• DOI: http://doi.org/10.1111/jpet.12436
• Date: 01 September 2020

J Public Econ Theory. 2020;22:1213–1244. wileyonlinelibrary.com/journal/jpet © 2020 Wiley Periodicals, Inc.

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Received: 10 June 2019

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Accepted: 18 February 2020

DOI: 10.1111/jpet.12436

ORIGINAL ARTICLE

Reproductive health, fairness, and optimal

policies

Johanna Etner

1

|Natacha Raffin

1,2

|Thomas Seegmuller

3

1

EconomiX, Université Paris Nanterre,

CNRS, Nanterre, France

2

CREAM, Université Rouen Normandie,

Rouen, France

3

Aix‐Marseille University, CNRS, EHESS,

Centrale Marseille, AMSE

Correspondence

Natacha Raffin, CREAM, Université Rouen

Normandie, Rouen 76000, France.

Email: natacha.raffin@univ-rouen.fr

Abstract

We consider an overlapping generations economy in

which agents differ through their ability to procreate.

Ex‐ante infertile households may incur health ex-

penditure to increase their chances of parenthood.

This health heterogeneity generates welfare inequal-

ities that deserve to be ruled out. We explore three

different criteria of social evaluation in the long‐run:

the utilitarian approach, the ex‐ante egalitarian cri-

terion and the ex‐post egalitarian one. We propose a

set of economic instruments to decentralize each

solution. To correct for the externalities and health

inequalities, both a preventive (a taxation of capital)

and a redistributive policy are required. We show

that a more egalitarian allocation is associated with

higher productive investment but reduced health

expenditure and thus, lower population growth.

1|INTRODUCTION

The state of human reproductive health has been one important debate in medical sciences in

recent years. The issue raised by a bench of papers concerns the natural ability for a couple to

have a child since it has been observed that infertility affects around 9% of procreating‐aged

couples worldwide (Inhorn & Patrizio, 2015).

Regarding this question, we draw the reader's attention that it differs from fertility issues

generally addressed in the economic literature. Indeed, following the Barro‐Becker analysis

(1989), a huge literature has developed on the economic determinants of fertility, that is the

number of children a household chooses to have. Some papers, among others, have focused on

the quality‐quantity trade‐off to justify the negative relationship between fertility and economic

growth; others dealt with the development of a unified growth theory that allows to understand

the demographic transition (Galor & Weil, 2000); others are more interested in fertility dif-

ferentials to better figure out economic inequalities (De la Croix & Doepke, 2003). In this paper,

we study equity in a model with undesired infertility.

Our concern focuses on biological impairments that prevent couples to reproduce, based on

relevant measures of human fertility, independently from individual choices. The deterioration

of human reproductive health has been widely documented from a functional perspective in the

epidemiological literature. Many studies point out the decline in men semen quality since the

beginning of the 20th century, the expanding Time To Pregnancy or the prevalence of new

female complex reproductive disorders (like endometriosis, ovarian quality, etc.), independent

of the age‐related natural decline in women fertility. For instance, following the seminal paper

by Carlsen, Giwercman, Keiding, and Skakkebk (1992) that gave birth to the famous “falling

sperm counts”story, many studies have established a global declining quality of the sperma-

togenis. Figure 1illustrates some trends established in the literature, using one specific bio‐

marker for male fertility. As for women reproductive health, there are ongoing research with

respect to the use of bio‐markers like antral follicular count and antimuëllerian hormone

(Nelson, 2013). Meanwhile, a recent epidemiological literature has studied the prevalence of

endocrine disorders like polycystic ovarian symptoms (PCOs) or diagnosed endometriosis

which are among the main causes of infertility. For instance, March et al. (2010) show that

PCOs are diagnosed for around 15% or more of reproductive‐aged women.

All these compelling evidence raise concerns that the reproductive health at a couple level

could fall below some threshold levels that could impact fecundity, since those bio‐markers and

diseases are suitable indicators of chances to parenthood. In addition and crucial to our ana-

lysis, these studies that point out a rapid change in human reproductive health cover periods of

fast economic development. Hence, we argue that postindustrial societies have created the

potential for increasing the exposure to specific lifestyle factors that might impair reproductive

health. Among them, one can identify pollution or diet that might contribute to explain

the current worldwide infertility and came along with the development process. We may find in

the epidemiological literature many studies to support our view and that have long suggested

FIGURE 1 Evolution of sperm concentration. Data from Borges et al. (2015), Carlsen et al. (1992), Huang

et al. (2017), Lackner et al. (2005), Levine et al. (2017), Rolland et al. (2013), Romero‐Otero et al. (2015)

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adverse effects of exposure to environmental contaminants, such as persistent organic pollu-

tants, on men and women reproductive health.

1

Moreover, parenthood is a source of well‐being and we should be concerned that some

couples can not reproduce.

2

To satisfy their desire of parenthood, some agents may be

compelled to use costly medical services like Assisted Reproductive Technology (ART). For

instance, since 2000, ART cycles annually grows by 5%–10% in developed countries (Kupka

et al., 2016). This reduced ability to conceive children may be also costly to overcome for the

society. As shown by Chambers, Sullivan, Ishihara, Chapman, and Adamson (2009), the use

of ARTs represents substantial out‐of‐pocket health expenses. The estimated cost of a

standard in vitro fecundation (IVF) cycle ranges from 28% of Gross National Income (GNI)

per capita in the United States to 10% of GNI per capita in Japan. Also before any public

policy, the gross cost of a standard IVF cycle ranges from 50% of an individual's annual

disposable income in the United States, approximately 20% in the UK, Scandinavian coun-

tries and Australia, to 12% in Japan.

In our paper, we propose to explore the welfare inequalities induced by a health het-

erogeneity since infertility entails a loss of utility. What matters to us is the unfair feature of

such a health heterogeneity because agents are not totally responsible for their reproductive

health status. This is true if we think, for instance, to intra‐utero pollution exposure or living

conditions during childhood. We consider an overlapping generations model in which the

development process generates an externality as a form of a health heterogeneity: two types

of households coexist within one generation, the fertile and infertile households. Moreover,

ex‐ante infertile couples incur health treatments to increase their chances of parenthood.

Hence, the laissez‐faire economy is characterized by several externalities: beyond the

oligodendrocytes (OLG)‐induced inefficiency, the accumulation of capital slackens

population growth meanwhile health care spending create positive external effects on the

demographic dynamics.

We aim at discussing the efficient way to correct these externalities in the long term. At first,

we consider the usual utilitarian social objective, but in contrast to Renström and Spataro

(2019), we do not restrict our attention to a welfarist approach, even though they enrich it with

a critical level of utility. Indeed, in the utilitarian case, health inequalities still prevail and we

can be concerned that the utility of the fertile is larger than the utility of the ex‐ante infertile.

Because heterogeneity is not the result of any actions held by agents but rather due to cir-

cumstances (let us refer for instance to pollution exposure), we also explore alternative criteria

of social evaluation according to Fleurbaey (2008), Ponthière (2016), or Fleurbaey, Leroux,

Pestieau, Ponthière, and Zuber (2018). More precisely, we consider an inequality averse social

planner who either maximizes the expected long‐run well‐being of the worst‐off (ex‐ante ega-

litarian social criteria) or maximizes the long‐run realized well‐being of the worst‐off (ex‐post

egalitarian social criteria).

Our results drive us to formulate some policy recommendations. To rule out inefficiencies,

capital accumulation should be taxed. We argue that this preventive policy should be favored

1

See for instance Mendola, Messer, and Rappazzo (2008), Recio‐Vega, Ocampo‐Gomez, Borja‐Aburto, Moran‐Martinez,

and Cebrian‐Garcia (2008), Perry et al. (2011), Martenies and Perry (2013), Slama et al. (2013), Mehrpour, Karrari,

Zamani, Tsatsakis, and Abdollahi (2014), Zhou et al. (2014), Chiu et al. (2015), Bolden, Rochester, Schultz, and

Kwiatkowski (2017), or Sifakis, Androutsopoulos, Tsatsakis, and Spandidos (2017).

2

The distress associated with subfertility or treatments of infertility causes induces substantial sociopsychological costs,

like a severe degradation of self‐esteem, syndromes of depression, loss of gender identity, self‐assessed social pressure

from families, friendships, and so forth (Greil, 1997; Moura‐Ramos, Gameiro, Canavarro, & Soares, 2012).

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