Equal Access to Parenthood and the Imperfect Duty to Benefit

Should involuntarily childless people have the same opportunities to access parenthood as those who are not involuntarily childless? In the context of assisted reproductive technologies, affirmative answers to this question are often cashed out in terms of positive rights, including rights to third-party reproduction. In this paper, we critically explore the scope and extent to which any such right would hold up morally. Ultimately, we argue for a departure away from positive parental rights. Instead, we argue that the state has an imperfect duty to benefit involuntarily childless people in relation to their parental aspirations.


Introduction
We often take for granted, as a society, that "people have a right to procreate" (Rulli 2016, 305). The value of procreation is, in most Western countries, "viewed as a fundamental right inherent in the very survival of the individual" (Blank 1997, 280). The framework of rights is therefore a dominant one when it comes to questions around procreation-or so we assume in this paper. The kinds of rights that are taken to be relevant in the realm of procreation are multifaceted. The right to procreate, which is about decisions to "conceive, bear, give birth to, and parent another human being" (Robertson 1982, 338) may involve discussions about liberties to reproduce or to not reproduce (Quigley 2010). 1 And either of these may be accompanied by negative rights, defined as a justified claim to noninterference, and positive rights, a justified claim to someone's assistance (Childress 1980).
A right not to procreate may invoke the negative right not to be interfered with when using contraception, and it may involve a positive right to access abortion. Alternatively, a right to procreate, or perhaps more precisely the right to attempt to have a child (Warnock 2002), might involve both the negative right not to be interfered with in terms of planning In this paper, we wish to focus on problematizing the discussion around ART, which takes for granted that a positive procreative right would commit healthcare professionals to "providing [involuntarily childless people] with appropriate services" (Courtwright and Doron 2007, 636). While this positive formulation of the right to procreate may seem intuitively appealing, we shall demonstrate in three parts why a rights-based approach is more restrictive than it may initially seem.
In section 2, we firstly ground why we ought to care about the desires of involuntarily childless people to procreate and parent from an egalitarian perspective. This justificatory work will issue a general endorsement of what we call the equal parental opportunities perspective: the view that involuntarily childless people ought, all things being equal, to have parental opportunities on a par with those who are not.
In section 3, however, we show that equal parental opportunities cannot be straightforwardly fulfilled. This is due to the fact that the content of positive rights formulations for equal parental opportunities must explicitly preclude undue infringements upon other people's bodily autonomy, which restricts (to varying degrees) the use of third-party services in ART especially.
To reconcile the seemingly conflicting conclusions of sections 2 and 3, we argue in section 4 that social institutions like the state have an imperfect duty to benefit those who are involuntarily childless within the realm of procreation/parenthood. By framing the issue with a duty-based (instead of a rights-based) account, we hope to provide a plausible and novel perspective on how to address the procreative and parental wishes of involuntarily childless people.

The Normative Appeal of Equal Procreative/Parental Opportunities
The standard, liberal view of procreation holds that the decision to procreate is so important and central to people's lives that the onus to demonstrate otherwise is placed on those who may want to limit that procreative freedom (Meijers 2020). People's individual willingness to undertake expensive and invasive fertility treatments when natural conception is not possible also testifies to the widespread desire for parenthood, and the importance that both individuals and society at large attach to becoming parents-especially genetic parenthood (Gheaus 2015;Van Zyl 2002). 4 Let us thus take at face value the presumption that people have some level of procreative freedom, and that having children is, on balance, a morally permissible thing to do (Segers, Pennings, and Mertes 2019). In addition, let us grant the generic view that people's welfare is to some extent determined by their desires being satisfied (Heathwood 2019). As Giulia Cavaliere and César Palacios-González have pointed out, the two major moral bases for ethically defending this sort of reproductive freedom are the "centrality of reproduction for the development of personal life plans," as well as people's well-being (2018,838).
We now have a prima facie case for making equal procreative/parental opportunities a central objective. Many people share the strong desire to both procreate and become parents in a social sense. Such desires are considered morally acceptable, if not essential, to a flourishing human life, so it would be plausible to presume that having those desires fulfilled would contribute to their well-being. Yet procreation is more difficult for those who require assistance/technological aid, often for reasons of discrimination, as we discuss throughout this article. To mitigate this, it would seem that endeavoring to give everybody equal opportunities to procreate/parent must be of central concern for the rectification of these existing inequalities of reproductive liberty.
Taking inspiration from a formulation of the right to procreate that Laura Shanner lays out as "an equal right of infertile people to procreate when fertile people can do so" (1995, 826), 5 we are sympathetic to the issue this formulation speaks to: the existing inequality in reproductive liberty between different groups who are able or unable to conceive manifests a gap in procreative ability, and also the ability to take on the social role of parents to an extent (though adoption might close the latter gap to some degree).
Existing reproductive inequalities between people are apparent in many cases. Nonstigmatized groups who have the resources to reproduce without assistance (for example, wealthy, heterosexual married couples) naturally appear to enjoy greater procreative liberty than stigmatized groups who are unable to conceive without assistance, or to access such opportunities (for example, nonheterosexual couples). The former group, it seems, "are free to procreate regardless of whether they are likely to be even minimally competent parents" (Shaw 2019, 90) whereas the process might be more costly and/or more difficult for nonheterosexual aspiring parents or even single people. Further, individuals in heterosexual partnerships who are able to conceive naturally are not often asked to justify their desire to have children-more often they might be asked to justify why they do not want to have children (Spriggs and Charles 2003).
Lesbian, gay, bisexual, trans, intersex and queer (LGBTIQ+) people, however, are often stigmatized and their capacity to be parents doubted, thanks to the association of fecundity and maternity, paternity, and parenthood to "heterosexual-cisgender parenting" (Alday-Mondaca and Lay-Lisboa 2021, 1). This is a classic example of a case where the ability, or lack thereof, to procreate (within a cis-heteronormative context) is wrongfully conflated with the status of being a social parent. This has led practitioners to point out that "the ethical duty to treat persons with equal respect" requires that single persons, as well as gay and lesbian persons, be treated on a par with heterosexual and married people with respect to procreative services (Ethics Committee of American Society for Reproductive Medicine 2013). Additionally, there have been calls for the alleviation of "disparities between highand low-resource countries in terms of provision of ART" (Inhorn 2009, 173).

Reproductive Liberty and the Problem of Third-Party Reproduction
It appears plausible to think that involuntarily childless persons ought to have the same opportunities to procreate/parent as their counterparts, where possible. This is because to be excluded from having opportunities central to many people's well-being and life plans would be unjust-especially given that involuntarily childless persons already face discrimination in trying to bring to fruition their desire to become parents. We believe this view is a prima facie morally appealing account, which takes seriously the disparities in reproductive liberty between different groups. In the effort to rectify such inequalities in reproductive liberty, however, we need to be careful about the measures we call for in response. As a consequence, this discussion calls into question whether procreative desires are morally on a par with parental ones.
Negative reproductive rights would entitle the rights-bearer to reasonable noninterference in their reproductive decision-making by other entities (Johnson 2021), at least within the realm of possibility. In the context of a society where ARTs are available for use, this might imply a corresponding duty of reasonable noninterference for agents who want to seek out fertility clinics of their own accord; or, in the case that public provisions for ART are available, that the relevant agents not be singled out or discriminated in their candidacy for ART treatment. Now, securing equal negative rights in terms of equal opportunities to procreate among involuntarily childless people should be easy enough, especially if we keep these rights minimal-we might simply try and get rid of discrimination against certain groups in their attempts to access existing health treatments and services, for example.
Things get more complicated when we make positive formulations of equal procreative and parental opportunities. As already mentioned, there is a distinction between procreation and social parenthood, yet people's desires to have children often combine both aspects. What could a rights-bearer reasonably have a claim to with regard to these complex desires? Is it sufficient to give involuntarily childless people the opportunity to partake in foster parenting, or to adopt fully, to address their parenting desires? Many might argue that this is insufficient, and that it is especially problematic to tell involuntarily childless people that they should just be happy to become a social parent without also giving them a certain level of procreative opportunities. While there are good reasons to push back and question why parenthood without procreation should be thought of as an inferior experience, we must acknowledge that people care deeply about the desire to have their own biologically related children. Given that this particular way of becoming a parent is a common and often deep-rooted desire, assistance with procreation for those who cannot conceive on their own appears at least ethically relevant.
Yet the question of how far we must go to provide positive assistance can be ethically difficult, especially where third-party service providers are involved. First of all, many countries have a shortage-rather than an abundance-of ART service providers, such as gamete donors (Pennings 2018). Certainly, we might try and do everything possible to incentivize more people to provide the services commensurate to the demand for them-by compensating gamete donors and surrogates better, for example (Daniels 2000). It appears that in countries like Spain, which has an extensive system of regulation for ART, and where egg donors are fairly reimbursed (around 1,000 euros) for their troubles, supply is plentiful (Bernardo 2022). In this case, interests of both recipients and donors seem to be positively facilitated within a legal framework that ensures a satisfactory exchange for both parties.
While the positive demand for access to third-party reproduction may certainly be met in cases where supply is plentiful and the arrangement can be made in a voluntary and consensual way, it remains problematic to frame the issue in terms of a positive right. This is because a "right" to third-party reproduction must be restricted by the negative rights consideration to not interfere with the bodily autonomy of potential service providers. Parallels could be made here to something like blood donation and living organ donation. These resources are, some might argue, even more medically urgent to provide (given their often life-saving and life-extending function) than attendance to any strong desire to procreate and have biologically related children. Moreover, it seems morally acceptable to at least encourage people to donate their blood. Yet the infringement of negative rights to bodily autonomy that would issue from demanding those resources from donors outweigh the good of acquiring those resources at any cost. The same problem would apply in the case of parenthood without procreation-a shortage of adoptable children does not license that children should be taken from others just to address the involuntarily childless person's strong desire to parent.
The caveat that equal opportunities must exclude infringements of the negative rights of others when it comes to procreation and parenthood is rather obvious. Perhaps within these parameters we might try to find socially acceptable forms of assistance for procreative and parental opportunities. For example, we might find it reasonable enough to try and incentivize gamete donation-especially sperm donation, which is less physically burdensome than egg donation-as a relatively easy way for more men to do their part in assisting those who have trouble conceiving with their own genetic materials and bodies. And while there is a long-standing critique objecting to the participation of third-party women in ART practices because it is risky and exploitative under a guise of "altruism" (Lee 2023), we may argue that these practices ought not to be forbidden because they can benefit third parties in other ways (for example, through compensation).
At some future stage, it might become possible to instrumentalize some of the resources we rely on others for-for example, by using artificial placenta technology instead of recruiting surrogates. Full ectogestation, for example, entirely hypothetical for the time being, has the potential for gestation that takes place completely outside of the human uterus (Finn and Isaac 2021;Statman 1996). If these kinds of biotechnologies were to become accessible, the question about the kinds of provisions we can make for involuntarily childless people would, of course, have to be revisited in light of the available resources. Until these kinds of biotechnologies become available, however, it remains crucial to recognize the embodiedness of the goods and people comprising third-party reproduction. We must acknowledge the huge ask involved in requesting resources and services that involve the bodily labor and materials of third parties, let alone in demanding such services.

Reproductive Inequality and the State's Imperfect Duty to Benefit
It seems as though we now have a dilemma on our hands. The notion that equal procreative/ parental opportunities ought to be available to all, including involuntarily childless aspiring parents, is intuitive enough. Yet it does not seem we can expect or demand third parties to participate (save for the possibility for people to volunteer their services), which means we cannot make guarantees that people who want to access third-party reproduction will ultimately succeed. So what, exactly, can be done to meaningfully address the intuitive idea that involuntarily childless people ought to have equal opportunities to procreate or become parents?
In this final section, we argue for a duty-based approach to equal procreative/parental opportunities as a way to mitigate some of the troubling implications of a rights-based approach to procreative/parental opportunities. We do this by briefly canvassing the concept of imperfect duties, and connecting the nature of such duties with the social welfare responsibilities of the state throughout. Furthermore, we take the reader through the practicalities of such a proposal, providing some examples of how such imperfect duties might be implemented.

What Are Imperfect Duties?
Philosophically, the concept of imperfect duties follows from a distinction made of duty types (most prominently by Kant); that is, between perfect and imperfect duties. Perfect duties are commonly understood to be absolutely binding, such as the duty to keep promises and the duty not to murder, and correspond to rights held by others (Statman 1996). In short, it is "determinate in terms of who must carry it out and when it must be done" (Igneski 2006, 444). Imperfect duties, on the other hand, are binding in a different way. They are traditionally understood to leave "ample room for personal discretion" (Statman 1996, 211), such as the duty of beneficence, and are therefore not thought of as actions a specific rights-holder can demand. Rather, when it comes to duties to assist others, including the duty of beneficence, the idea is that we ought to help others where we can, while allowing for latitude and open-endedness in terms of fulfilling the duty. As some have proposed, the duty of beneficence is to be understood in a relational sense: to view people's needs not in isolation but as "embedded in a life" (Herman 2021). This would, of course, "require attentiveness to the institutional structures one lives under" (Hope 2023, 74), and demands that we actively exercise our judgment to figure out who to benefit, and be sensitive to the various ways they could be benefited.
There are further complexities to the Kantian conceptual machinery associated with the perfect/imperfect duty distinction that we do not explore here. Our interest lies in teasing out the open-ended (though no less binding) implications of imperfect duties as a way to articulate the social welfare responsibilities of the state in the context of involuntarily childless groups seeking assisted reproduction.

A Duty-Based Account
Identifying the state as a responsible entity whose function it is to set up an equitable healthcare system appears to be a viable way to construct a duty-based-rather than a rights-based-approach to procreative/parental opportunities. A well-functioning welfare state that cares about the well-being of its citizens, at least, could be said to have a general duty to equally benefit all its people. Beneficence is itself already a well-established primary bioethical principle, which recommends that physicians (and other key parties) "benefit patients and to promote their welfare" (Varkey 2021, 18). As Frank Stuart Kinsinger points out, beneficence within healthcare "embraces humanism"-a respectful attitude is to be shown to patients and their rights and interests, and beneficence should strive "for the best care" alongside not doing them any harm (2009,45). Here, we can see that the way beneficence is understood in the biomedical literature has some overlap with the imperfect duty to benefit, as understood from a Kantian perspective; the language of promoting wellbeing and striving for good care points to the wide scope of assistance we might expect healthcare providers to engage in to make good on their duty to benefit others. A functional state, which has a duty to benefit all its citizens, then, will analogously have as one of its responsibilities the setting up of a working healthcare system, and the fair allocation and distribution of existing resources.
A duty to benefit under this account should include involuntarily childless groups, if we take for granted that different people's desires to parent have equal importance and weight. If any involuntarily childless group might greatly benefit from having access to certain resources, states should, inasmuch as they are able to do so, naturally ensure that the health and well-being interests of such groups are equally attended to, on a par with groups that are not involuntarily childless (or any other group, for that matter). But what can the state actually do to benefit involuntarily childless people, and in what sense should this group be benefited? Clearly, the desire and perceived value of their procreative wishes are of utmost importance to the majority of those who seek assistance with reproduction-and it may well be that procreative or parental desires are incommensurable with other kinds of goods, such that one cannot simply replace these desires with other goods (for example, compensation for involuntary childlessness). This is very much reflected in the prevailing response toward involuntarily childless persons.
With regard to the desire to have biologically related children, the primary moral imperative has been to innovate ART interventions that involuntarily childless persons might use, where "the end point is establishing a live birth" (Parikh 2013, 328). This is perhaps why the issue of access to ART and third-party reproduction, especially as a rights claim, has been so passionately advocated for on behalf of involuntarily childless groups. But even if, say, the ideal scenario for most involuntarily childless persons would be to have their own, biologically related children, we must acknowledge that ARTs do not offer foolproof methods to this end. It would not be reasonable to expect guarantees of live births even on the basis of equal opportunities to access ART. In fact, the rate of live births using IVF can vary widely, depending on age group and other factors (Awadalla et al. 2021), despite individual clinics advertising high rates of success (Timoney 2022). According to the Human Fertilisation and Embryology Authority (HFEA n.d.) in the United Kingdom, around three-quarters of IVF treatment is unsuccessful-meaning many hopeful parents may unfortunately not conceive at all, even with assistance.
Thus, framing ART as the best option for involuntarily childless people to fulfill their procreative and parenting wishes can be misleading, even before taking into account the obvious restrictions on the infringement of third parties' liberties. We should therefore not be so quick to dismiss more general possibilities and alternatives in order to benefit involuntarily childless groups, even if not purely in terms of directly enabling them to procreate. This is where the notion of an imperfect duty to benefit can therefore still place due normative interest on people's procreative and parental desires, and include such wishes in conceptualizations about what would help make their lives go well. But it can do so without having to commit to any positive right to specific ART outcomes or third-party reproduction. 6 Because the sense of duty implied here is an imperfect-rather than a perfect-duty, we can move away from the narrow focus on procreation as the only desideratum. Instead, the latitude associated with imperfect duties ought to encourage further reflection on a broader view of how to leave those whose strong parental desires are thwarted better off.
An imperfect duty to benefit could be dispensed with in a number of different ways, because there may be many ways to leave involuntarily childless groups better off than they would be had their procreative and parental interests not been duly attended to. For example: • they could get their procreative wishes fulfilled (for example, with ART methods); • they could endorse the gap between procreation and parenthood (for example, through adoption); • they could change the way they value procreation and parenthood, and so on.
The main advantage of such an account is that it opens up space to implement interventions and objectives other than the innovation of ART, or the recruitment of third-party service providers. As alternatives to things like third-party reproduction, for instance, a state could try to make options other than biologically related children easier and more appealing to pursue. This could take the form of making adoption more affordable when there are enough children in need of adoption by aspiring parents. 7 Moreover, we could systematically ensure that there are no unnecessary barriers to adoption, such as high competency thresholds that do not apply to biological parents, or discrimination against certain aspiring parent groups like LGBTIQ+. The way such options are framed makes a difference too: adoption could be presented as a first-rather than last-resort for involuntarily childless people seeking fertility treatment. Some scholars have even argued in favor of a duty to adopt, rather than to have biological children, in virtue of the fact that there are already children out there who are in need of loving families (Friedrich 2013).
Besides adoption, however, which in principle aims to at least fulfill the parenting aspect of aspirational parenthood (if not the procreative aspect), there are still many other responses we might take seriously when it comes to the issue of procreation and parenting. One priority that might be tackled here are the oppressive gendered responsibilities that befall women, especially with regard to fertility struggles. To this end, a state might offer counseling services and public education and health campaigns to challenge "the dogma that women cannot lead worthwhile lives without bearing children" (Donchin 2010, 100), especially given that medical infertility is often framed as a woman's issue or problem. Campaigns that raise awareness about male factor infertility-which accounts for up to half of medical infertility cases (Kumar and Singh 2015)-would equally be part of this picture, given the under-discussed role of men and risk factors for fertility such as lifestyle and environmental issues (Babakhanzadeh et al. 2020). These kinds of interventions endeavor to mitigate the pressures placed on women to deal with their infertility via ART, and to increase the inclusion of men and the role they have to play in the discussion. Such changes-consciousness-raising, inclusive consultations, and so on-may plausibly be viewed as a relevant benefit, even if not in terms of outcomes such as successful live births. While these suggestions are not to claim that they will resolve people's struggles to conceive, they provide an example of interventions that can form part of a broader coordinated effort to improve outcomes not only in terms of utilizing biomedical technologies but also in terms of social advances we can prospectively make to change the way we value procreation/ parenthood and narrativize the problems people face around that.
Further, the role the state could play in trying to tackle medical infertility more preventively could be emphasized even more. For example, the state might undertake campaigns to tackle "nutritional deficiencies, exposure to hazardous work situations, and damaging medical and environmental conditions" (Donchin 2010, 100). There are also structural or social determinants that might contribute to difficulties with conception-such as pregnancy-related workplace discrimination-which lead women especially to delay childbearing. These issues ought to be addressed alongside or perhaps even ahead of ARTbased solutions such as social egg freezing. Social egg freezing is an example of a popular ART that is often misleadingly framed as a viable way for women to preserve or lengthen their fertility by storing away their eggs, while potentially exacerbating infertility issues down the line.
There is also another sense in which preventive measures could be part of the discussion-our proposal does not rule out the more radical discussions that might be had about avoiding procreation and parenthood altogether, so that people could also consider the option to not have children at all. Even if not having children is not the desired option for many involuntarily childless individuals, it is possible to make the case that people can still benefit from such decisions. Recently, for example, scholarly and public debates have highlighted the relation between procreation and accountability for climate change, with some people claiming that procreation ought to be treated as analogous to overconsumption or "eco-gluttony" to the extent that they "arise from the same desires and produce similar foreseeable, unintended environmental impacts" (Young 2001, 183).
If these claims have any legitimacy, we cannot completely preclude the possibility that those who are involuntarily childless may reconsider whether procreating is really the best way-on balance-to further their own perceived well-being without violating other important values that might benefit them. After all, even discounting the climate question, more and more people are nowadays voluntarily childless, or childfree, precisely because other values such as personal freedom can come to take precedence over having children (Blackstone and Stewart 2012, 721). While we should recognize that the making of families can be a much more challenging process for those who require assistance relative to those who do not require assistance, we can also acknowledge that prospective parents could benefit from reflecting on the multiple values that would enrich their lives. Without putting the responsibility on any specific aspiring parent, the point here is that institutions can play a role not only in positively assisting aspiring parents but also by opening up the conceptual space to discuss alternatives to procreation and parenthood, and destigmatizing the diverse reasons we may have to refrain from having children.
Overall, drawing attention away from individual positive rights to procreation, and talking instead about the imperfect state duty to benefit its citizens with respect to their procreative and parenting desires, would help us imagine how to diversify responses we endorse as appropriate for involuntary childlessness. This broader framework would hopefully contain the resources to provide such individuals with more ways to address, manage, and rethink-if not always satisfy-their parental wishes. Moreover, because our approach recognizes that there are different ways we can benefit people with respect to their values, preferences, and needs, our view has the added advantage of offering a way of rethinking and reframing reproduction and parenthood in response to plural values.

Conclusion
In this paper, we have shown that it is prima facie intuitive to endorse equal access to parental opportunities for involuntarily childless groups, who are otherwise disadvantaged with respect to the reproductive liberties they can exercise. We have pointed out, however, that reproductive liberty is limited by people's negative rights, which in fact means that the scope of ways in which involuntarily childless people might be entitled to have their parental desires fulfilled is narrower than what might standardly come to mind. Still, our proposal that the state has an imperfect duty to benefit its citizens equally should allow those who are disadvantaged with respect to their reproductive liberties to not necessarily be left worse off because of involuntary childlessness. Their options might even be enhanced by the diversity of ways the state can offer to attend to their procreative interests and parental wishes.