Reprotech in France and the United States: Differences and similarities - An introduction.

‘Reprotech in France and the United States: differences and similarities’ grows out of a 2-year workshop cycle held in New York (2018) and Paris (2019) to consider the varied historical, cultural, ethical, religious and policy implications of how assisted reproductive technology (ART) has developed and the practical consequences in two national contexts.

In both France and the USA, ART has long been in development and is now in widespread use. In both countries, public commentary and debate concerning the use of ART have accompanied its routinization. French and US medical professionals in both research and clinical contexts are proficient at the deployment of ART and committed to its ethical use. Both France and the USA also share similar conceptions relative to kinship and gender, and both are undergoing comparable evolutions in the creation of new family configurations, in part due to the use of what Sarah Franklin long ago deemed as ‘hope technologies’.

However, these similarities underwrite significantly different practices in the two countries. In France, a public discourse of ‘social solidarity’ with people experiencing infertility is widespread. Public payment and access are designed and tightly controlled through biomedical regulation, excluding all who do not qualify via strict professional standards, articulated in national policy governed by national bioethical laws and public health codes. In the USA, in contrast, there are no national bioethical laws and most public health policy is set at the state level. ‘Privacy’ of family life and ‘consumer choice’ dominate public discussion in the USA, while few insurance schemes actually cover the cost of ART; market access shapes both popular imaginaries and practical use. Low-income women and couples facing reproductive health problems rely on a system that varies between states, rarely covering expenses beyond those of basic pregnancy care, including sonograms and early genetic screening.

When we think beyond public affect and sentiment, larger structural forces are clearly at work. France has arguably the most restrictive national regulatory environment in Western Europe/European Union. This may change with the ongoing revision of its bioethical laws. In the USA, most ART is not covered by insurance, and is regulated solely through medical professional associations rather than via national government standards. Thus, for different reasons, both French and US citizens increasingly travel outside their national boundaries to seek reproductive health care: the French because of strict and exclusionary national regulations, and the Americans due to market exclusions.

The articles included in this symposium volume of Reproductive Biomedicine and Society Online therefore highlight aspects of sociological difference within broad biosocial similarity. How do these two countries, so similar in some political, cultural and legal references, come to be so different in their ART practices? The contributing authors engage rich bases of comparison and contrast across the two national contexts, beginning with histories of medicine and family life. They continue through the interpretation of religious, popular, and medical practices and values. Some look forward to emergent controversies concerning the ethically unsettling nature of volatile, high-velocity technologies, such as new forms of preconceptual as well as prenatal genetic testing recently put into use, and gene editing, now poised on many national horizons. Likewise, the situation is more complex when we also consider how global medical travel affects both countries: French citizens who are refused infertility treatment or who have to wait too long at home will seek it elsewhere in Europe if they can afford to do so. The USA is both a receiving nation for well-resourced international medical travellers seeking reliable treatment, and a sending society for those with modest resources pursuing reproductive medical care in middle-income countries where costs are lower. How do we, as researchers as well as culture-bearing citizens of two national systems, understand their limits, and what reproductive practices escape national boundaries? How might our research contribute to comprehending the escalating complexities by which technologies, people, ‘body-bits’ and capital are in selectively global motion in pursuit of reproduction? And, perhaps more abstractly, how might these articles index that reprotech is in constant evolution and localization? This process is continual in the scientific heartlands where it is most likely to develop, and keep developing, and in the many other national and regional markets where it is now flourishing.

One of the objectives of this symposium volume is to interrogate potential common ways to analyse and interpret the differences between these two countries. How might important concepts, such as race, for example, be mobilized from different national perspectives when viewed through debates surrounding ART? What about notions of nature and commerce as they inform hopes and criticisms in the two countries? The papers assembled here not only probe different national contexts, but are also rooted in varied theoretical and methodological backgrounds including anthropology, sociology, political theory, history and law.

Across that diversity, we point out four themes. The first theme is globalization. Although commonly deployed across many fields and theories, researchers must always query what the term means, what might it enable, and how does it minimize or hide concrete relations of exploitation and ethical concern? While some heterosexual French couples are well served via national in-vitro fertilization (IVF) services, for example, other French citizens, if they can afford it, travel throughout Europe and sometimes across several continents in search of reproductive medical services from which they are barred at home. Some of these reproductive services/interventions are not legal in France (e.g. surrogacy, double gamete donation) or are extremely restricted (e.g. prenatal screening and diagnosis, egg donation). The current process of revision of the bioethical laws may change ART practices if they are opened up to lesbian couples and single women. However, these restrictions have governed the use of reprotech since the first French bioethics laws in 1994. In contrast, Americans, in principle, have theoretical access to virtually any fertility intervention deemed a ‘standard of care’ at home, yet they too often decide to travel in search of cross-border reproductive care because the interventions that they seek (mainly IVF and surrogacy) are too costly on the ‘wild west’ frontier of reprotech at home. But at what cost to themselves, and to those who ‘host’ their commodified searches for family formation? Who is monitoring and analysing the impact on women and children of being ‘donor’ or ‘receiver’ societies in a global reproductive marketplace? Moreover, we collectively raise issues of the presence of the local in the global: what does our research reveal about who travels into and out of national contexts? Who seeks cross-border reproductive care, and for what commodified services? Why does this matter from multiple points of view, including diverse feminist, bioethical and political–economic debates?

Secondly, what does it mean to take the nation-state as the unit of comparison? Why not focus on selective networks of knowledge about reprotech or its investment capacities? Or the routes through which reproductive ‘matériel’ and labour travel? Many studies by both French and anglophone researchers1 have been focused on the developing world: what does it mean to repatriate our gaze, insisting that ‘the West’ in all its localized, national diversity continues to evolve and be challenged by the transformations to kinship and family formation that ART represents?

Next we note a third theme: public affect. Feelings run strong, whether along religious or professional lines, or individual aspiration and desire, when speaking of possibilities and limits surrounding family formation. These are literally ‘life-and-death’ issues when thinking, speaking and acting on the possibilities of in/fertility. Thus, past, present and future imaginaries are all at stake. The question of public affect and emotion permeates into daily dilemmas as many of the authors show: these are not simply matters of the sentiments that construct legislation and public testimony. In both of these countries, anthropologists and sociologists interviewing professionals and individuals involved with ART note powerful emotions in play. Many describe extensive reflection on the limits of technology in terms of their own feelings and discomforts. They are part of a longstanding tradition.

Utopian or dystopian fantasies are commonly articulated when speaking of ART, whether in science fiction literature, legal cases or influential media. In the anglophone tradition, utopic visions are easily mobilized to represent either liberation for gay people formerly barred from imagining baby-making for themselves; or dystopic eugenic suppression of nature itself, whether Catholic/Christian or via secular normative and/or ecological philosophy. This dystopic narrative also pervades French commentary. Early anglophone feminist science fiction, for example, included ideas of female-with-female reproduction like those of Charlotte Perkins Gilman and later, Joanna Russ, Marge Piercy and Margaret Atwood. And we cannot forget the harrowing influence of Aldous Huxley. However, these were also subject to racial ethnicized critique and renewal in works by authors such as the speculative fiction writer Olivia Butler and, more recently, Adrienne Maree Brown, Alexis Pauline Gumbs, Alexis Lothian, Shelley Streeby and Sami Schalk (Moisseeff, 2005). In France, dystopic discourse continues to permeate public testimony concerning the new bioethical laws in the national Parliament. For example, Tugdual Derville, from the conservative association Alliance Vita, stated that in opening ART to all women, France will ‘lose her soul’.

Finally, disability should be added into this mix as a fourth theme, although it is too infrequently made explicit in the literature. Disability perspectives enable us to see that both cultural affect and political imagination are always already present in even the most objectivist empirical or philosophical discussions of inclusions and exclusions that focus on ART. This subject haunts the development, routinization and desire for most, perhaps all, ART, yet its influence is often tacit, or left undiscussed. This is true when we speak of ‘positive’ eugenics, enabling people with putatively ‘good’ hereditary to reproduce rather than accepting infertility as a type of disability. It also characterizes ‘negative’ eugenics in practices of preconception and prenatal screening, embryo selection and selective abortion, or discrimination practised against people with disabilities when they seek access to ART. This symposium volume welcomes its presence as a valuable aspect of our discussions, recognizing that groups conventionally considered ‘left’ or ‘right’, conservative or liberal may (mis)understand the range of disability perspectives on reprotech.2

The articles published here, have been organized into four sections.

First, how do we reflect on the very concepts used to discuss reproduction and its transformations? Simone Bateman provides an insightful reflection on the difficulties, perhaps impossibilities, of settling on specific word choices in francophone/anglophone exchanges when speaking of the study of assisted reproduction (Bateman, 2020). How (well) do we understand the subtleties of analysis when interpreting across languages? How might we conceptualize national/international tensions in the uses and limits of reprotech in both France and the USA? Exploring these two specific national contexts in light of globalization adds philosophical, historical and theoretical weight to understanding how ART is developed, policed and used so differently. Marcia Inhorn reviews where ‘the quest for conception’ has taken us in these two national contexts (Inhorn, 2020). Her adroit global overview provides specific questions that might inform future research in France and the USA. Jennifer Merchant focuses on the concepts that undergird public policy in this transatlantic comparison (Merchant, 2020), sensitizing us as readers and researchers to both the articulated and tacit norms that underpin our national governance of these biomedical interventions into reproductive life.

Second, how do we analyse the inclusions and exclusions that regulate ART, both through official policy and practical politics? How is access imagined, legislated and/or regulated and actually deployed in different national contexts? Who is in charge of ART regulation: political legislative actors, doctors, lawyers, psychologists, entrepreneurial business interests, individuals and couples themselves? Whose expertise legitimates the limits and access to ART? How do these national differences open up and shut down cross-border reproductive care? For example, Dána-Ain Davis uses her ethnographic examples to highlight the barriers to fertility treatment encountered by middle-class African American women, presenting a provocative argument for the unexamined role of race in this aspect of reproductive health care (Davis, 2020). Hélène Malmanche also deploys her ethnographic and survey research to analyse tensions across Anglo American and French legal apparatuses in addressing the novel situations called forth by the use of ART (Malmanche, 2020). Rajani Bhatia shows how national political borders create barriers and loopholes surrounding the fraught process of sex selection transnationally (Bhatia, 2020), while Heather Jacobson explores the under-analysed topic of international commerce bringing non-US citizens into the USA for cross-border reproductive care (Jacobson, 2020). The lack of both state and national data on this ‘baby-making trade’ suggests that few (besides feminist researchers!) hold any interest in tracking this escalating phenomenon.

Third, whilst ART potentially destabilizes religious beliefs and practices, it is also challenged, opposed and often contained by the presence of religious guidelines, both official and tacit. In both France and the USA, notions of secular and religious regimes diffuse into the governance of reprotech, whether through national bioethics debates, public legislation or more informal ways of navigating the search for services. Séverine Mathieu reveals the Catholic religious stakes in a secular debate about the current revisions of the national bioethics laws in France (Mathieu, 2020). Corinne Fortier shows how the biomedical separation of sex from reproduction meets its limits in practice when Muslim infertile married couples must integrate this so-called ‘separation’ into the profound fusion of these intimate duties and accomplishments provided by their religion (Fortier, 2020). Risa Cromer mobilizes her ethnographic research to show how Evangelical Christians in the USA adopt explicitly racialized embryos to demonstrate their commitment to acceptance of all God’s children and his design for pious family life (Cromer, 2020). Finally, Faye Ginsburg and Rayna Rapp explore uses of preconceptual genetic screening technologies amongst Orthodox Jews in the USA, a population that has high rates of intra-marriage (endogamy) and therefore of expressed autosomal-recessive disorders (Ginsburg and Rapp, 2020). How do such communities design and utilize culturally appropriate gate-keeping protocols of genetic testing in their encounters with contemporary secular medicine?

Fourth, ART continues to evolve and the implications remain unstable at every level, from the individual to the national to global networks of access and commerce. The forces that now fashion reproduction are moving at increasing speed, both within and across national boundaries. Invoking the authority and limits of science, the irreducible mysteries of nature, and the variability of human experiences and aspirations in the realm of reproduction, these papers make a collective claim that the tensions provoked by such interventions have no literal end.

Ilana Löwy analyses the distinct national standards of risk, norms and regulations revealed in scrutiny of prenatal genetic diagnosis: medical descriptions of technological benefits elide the heterogeneous lived experiences of those who access them (Löwy, 2020). Anne-Sophie Giraud shows how decisions surrounding every stage of IVF are situated in national contexts (Giraud, 2020). Finally, Noémie Merleau-Ponty offers a glimpse of the near-future of reprotech in analysing mediated ‘shows’ of the makings/ethical deliberations surrounding artificial in-vitro gametogenesis (i.e. bioengineered gametes), soon available on the biotech horizon (Merleau-Ponty, 2020).

In conclusion, by focusing on comparison between France and the USA, this symposium volume highlights tensions provoked as technologies, persons, biological materials and discourses continue to circulate both internally and in a selectively globalizing world. Indeed, this rapid evolution opens up new questions to ethnographic and other qualitative and quantitative methods of investigation. We cede the last word to Charis Thompson who asks us to enlarge the reproductive landscape that we explore by taking migration into account (Thompson, 2021). Her speculative afterword highlights the importance of comparative scholarship. It also opens up new theoretical spaces of reflection on transnational reproduction and policies that might regulate it; an ongoing challenge to the work that brings us together in this symposium volume of Reproductive Biomedicine and Society Online.

Declaration

The authors report no financial or commercial conflicts of interest.