Are companies ethically justified in offering nonmedical egg freezing as an employee benefit?

Abstract

All over the world, many companies are including oocyte cryopreservation for nonmedical reasons, also popularly known as nonmedical egg freezing (NMEF), within their employee benefits packages. However, it is important to ask whether companies are ethically justified in offering NMEF as a benefit for their employees. The inclusion of NMEF within companies' employee benefits packages could be ethically justified in two ways. On the one hand, company‐sponsored NMEF can serve as a strategy to mitigate or eliminate gender inequalities in the workplace, such as female underrepresentation in positions of authority and leadership and the so‐called work/motherhood conflict. On the other hand, company‐sponsored NMEF can be a means to expand women's reproductive autonomy by making egg freezing accessible to those women who are not able to afford it otherwise. This article calls into question these ethical justifications. We argue that by offering NMEF as an employee benefit, companies maintain current workplace inequalities and impose an option for women with multiple risks and externalities. Therefore, companies' offering of NMEF benefits cannot be ethically justified. Furthermore, we argue that companies that offer NMEF benefits incur fiduciary responsibilities related to the physiological, emotional, psychological, and financial costs of the use of company‐sponsored NMEF.

1. INTRODUCTION

There has been a trend in the last decade for some companies to include egg freezing (i.e., oocyte cryopreservation) for nonmedical reasons (NMEF)¹ within their employee benefits packages.² To cite an example, in 2015, 5% of large companies in the United States (i.e., companies with more than 500 employees) offered NMEF as an employee benefit.³ By 2022, the number of large companies sponsoring NMEF increased to 40%.⁴ This trend is expanding around the world and seems likely to increase.

Egg freezing is an assisted reproductive technology (ART) that involves collecting, dehydrating, and freezing unfertilized eggs to store them for a future pregnancy. Egg freezing has been used for more than three decades as a last‐resort medical treatment for infertility, which typically includes cases where women have been diagnosed with a medical condition or need treatment for a medical condition whose treatment will damage or destroy their eggs, women who are members of the Armed Forces who are being deployed to a war zone, women suffering from premature ovarian failure, and people undergoing sex reassignment surgeries.⁵ Some governments offer egg freezing for these reasons (popularly referred to as ‘egg freezing for medical reasons’).⁶ However, to date, only the public health systems of France⁷ and Israel⁸ cover some costs of NMEF. The decision by companies to include NMEF within their employee benefits packages can be seen as a progressive policy that challenges paradigms that prioritize medical reasons over nonmedical reasons when it comes to human reproduction and fertility while expanding women's reproductive options and offering women a biomedical means to prolong their fertility. Furthermore, the inclusion of NMEF as an employee benefit can serve as a strategy that helps resolve gender inequalities in the workplace, especially those associated with the underrepresentation of women in positions of authority and leadership and the work/motherhood conflict. However, many feminist bioethicists oppose the inclusion of NMEF as an employee benefit because they see it as a corporate mandate that puts undue pressure on their employees to postpone childbearing and devote themselves to their jobs,⁹ as a potentially discriminatory ART¹⁰ and as a deceitful promise to solve structural social problems.¹¹ Therefore, it is important to ask the following question: Are companies ethically justified in offering NMEF as an employee benefit? We shall answer this question by considering the ethical issues surrounding the inclusion of NMEF within companies' benefits packages.

There are many ethical issues involved in the inclusion of NMEF within companies' employee benefits packages. As is the case with other employee benefits and perks, company‐sponsored NMEF must meet ethical standards. Because NMEF is a biotechnology, it makes sense that its implementation should follow the bioethical principles of respect for autonomy, beneficence, nonmaleficence, and justice. The principle of respect for autonomy states that individuals have the moral right to make informed decisions about their own medical care goals based on their own values, beliefs, priorities, and circumstances, free from external pressures or constraints. To be ethical, companies that offer NMEF benefits must meet privacy requirements, provide counselling and guidance, and ensure that beneficiaries have access to relevant and reliable information. The principle of beneficence refers to the duty to act in ways that promote the well‐being and interests of individuals. Companies that sponsor NMEF must ensure that employees are provided with accurate information about the risks, benefits, and limitations of the procedures, as well as access to appropriate support services and resources to help them make informed decisions and cope with any challenges that may arise. Moreover, companies must ensure that the benefits of company‐sponsored NMEF will outweigh the risks and costs incurred by beneficiaries. The principle of nonmaleficence entails the obligation to avoid causing harm to others. The procedures and practices related to egg freezing should be conducted in a manner that reduces physical, psychological, and emotional harm to individuals undergoing the procedure, as well as any potential offspring resulting from the use of the frozen eggs. And, finally, to be ethical, the inclusion of NMEF within companies' employee benefits packages must meet the principle of justice. Companies that sponsor NMEF must ensure that their employees have equal access to NMEF services regardless of their socioeconomic status, age, and marital status and must address any disparities in access to information, education, and support related to reproductive technologies.

In an article published in this journal, Thomas Søbirk Petersen and Rune Hansen argue that company‐sponsored NMEF is ethically acceptable if certain conditions regarding information, privacy, and freedom are met, which would guarantee that an autonomous choice free from coercion is made.¹² We agree with Petersen and Hansen that some of the harms associated with company‐sponsored NMEF can be mitigated if these conditions are satisfied.¹³ However, this article is concerned with a different question which, to the best of our knowledge, has not been properly addressed in the existing literature surrounding the ethics of company‐sponsored NMEF. This article discusses the question of whether companies are ethically justified in including NMEF within their employee benefits packages.

To explain the difference between Petersen and Hansen's concern and ours, consider the following analogy: suppose a company offers abortion‐related benefits as an employee benefit.¹⁴ Abortion‐related benefits may include medical support, counselling services, and travel cost reimbursement (when abortion is not available locally). Some people might argue that corporate‐sponsored abortions can be ethically acceptable if certain conditions are met, such as whether informed consent is obtained, if the offer satisfies privacy requirements, and if the offer is free of pressure or coercion by the company, amongst other conditions. However, the fact that the offer meets conditions of ethical acceptability does not automatically imply that the company is ethically justified in offering abortion‐related benefits. Abortion‐related employee benefits are deeply controversial largely because there is no moral and legal consensus on abortion. To say that a company is ethically justified in offering abortion‐related benefits requires taking into account a number of moral considerations, including the question of whether companies have a moral duty to ensure that their benefit policies comply with relevant laws and regulations (so that companies may not be ethically justified in offering a benefit that is illegal in the regions where they operate) or whether companies have a moral duty to serve as a “firewall” to protect their employees against harmful legislation.

Unlike Petersen and Hansen's article, this article does not provide a list of ethical conditions that a company‐sponsored NMEF must meet to be ethically acceptable but instead seeks to discuss whether companies are ethically justified in offering such an employee benefit. Much of the company‐sponsored NMEF ethics literature looks at the individual (micro) aspect.¹⁵ However, as some have recently highlighted, it is necessary to critically analyse the challenges that ARTs have at the macro (society), meso (companies), and micro (individuals) levels.¹⁶ This article is novel in this regard, because it involves a detailed exploration of the ethics of corporate‐sponsored NMEF at the meso (companies) level, which has been little explored in the literature.¹⁷

Now, we could say that companies are ethically justified to include NMEF within their employee benefits packages because by offering NMEF companies express their social responsibilities and their duties to remedy social, legal, and regulatory injustices and inequalities, particularly in the regions they operate.¹⁸ A growing awareness of companies towards these responsibilities has caused companies to increase and improve benefits for their workers, in some cases going beyond what is required by law.

From an ethical point of view, one of the most important and difficult issues concerns what is being provided to employees by companies and what rights and benefits employees enjoy. Regardless of whether the employment relationship is considered a negotiation (i.e., US) or a partnership (i.e., Western Europe), in both cases, companies tended to catch up in terms of regulations, compliance, and employee rights/benefits. Governments defined the rules, regulations, and laws, while companies complied with this minimum. Employee rights and benefits were defined, regulated, and to some extent externally imposed, as companies caught up with health care, minimum wages, work hours, and even hiring and firing procedures. These minimum rights were defined following ethical principles (i.e., the British Poor Laws) that in some countries eventually evolved into different welfare states.¹⁹ Today, at least in developed economies and in certain sectors, companies are no longer playing catch‐up, but in some cases, going beyond what is required by law.

Companies, particularly in high‐level sectors, such as technology, science, consulting, or law, have a growing interest in environmental, social, and governance criteria, and are interested in resolving labour inequalities and increasing female participation within their organizations. Additionally, companies are aware of the effect that motherhood can have on women's careers and the role companies can play in achieving work–life balance. Company‐sponsored NMEF can be considered one of these over‐the‐top, progressive practices towards solving gender inequality. Yet, the availability of egg‐freezing benefits and other ARTs as an employment benefit has bioethical implications. For example, from a corporate point of view, it is still unclear if companies are offering ART‐related benefits as an equality or progressive policy towards women since current providers appear to offer these benefits more as a branding mechanism rather than an ethical or equality policy, which raises the question as to whether the provision is ethically justified and under which terms.

This article proceeds as follows: the next three sections discuss three ethical justifications why companies could include NMEF within their employee benefits packages: (i) Company‐sponsored NMEF is a mechanism to promote the representation of women in positions of authority and leadership in the workplace (Section 2); (ii) Company‐sponsored NMEF helps resolve the work/motherhood conflict (Section 3); and (iii) Company‐sponsored NMEF advances women's reproductive autonomy by facilitating a biomedical means by which they can prolong their fertility that they would otherwise not have access to or would be too costly for them (Section 4). The first two ethical justifications are related to the companies' duty to resolve gender inequalities in the workplace and the last with the companies' responsibility to promote women's reproductive autonomy. Here, we call into question these three ethical justifications. There could be other ethical justifications for the inclusion of NMEF within a company's employee benefits package, but, as we will show, these three ethical justifications cannot ground a moral justification for this benefit. We argue that, in the current context, the inclusion of NMEF as an employee benefit is a poor choice to resolve gender inequalities in the workplace and to promote women's reproductive autonomy. On the contrary, by offering, companies maintain current gender inequities and impose an option on their beneficiaries with multiple risks and externalities. Additionally, we argue that companies that currently offer company‐sponsored NMEF incur fiduciary duties related to the physiological, emotional, psychological, and financial costs of the use of this benefit.

2. FEMALE UNDERREPRESENTATION IN AUTHORITY AND LEADERSHIP POSITIONS

Globally, only 19.7% of management positions in companies are occupied by women, and only 6.7% of board president positions and 5% of CEO positions are held by women.²⁰ It is estimated that by 2041 gender parity will be achieved in positions of authority and leadership within companies.²¹ However, including NMEF as an employee benefit could accelerate gender parity within companies. Imogen Goold and Julian Savulescu delve into this issue and suggest that NMEF has the potential to serve as a type of ‘reproductive affirmative action’.²²

According to Goold and Savulescu, choosing to postpone motherhood can facilitate women's professional development, especially because the years in which women are most fertile coincide with the years in which their careers are consolidated and are more demanding. The offer of NMEF as an employee benefit may have the effect of more women opting to postpone motherhood and, therefore, more women advancing in their careers. Postponing motherhood would allow women to fully dedicate themselves to their jobs without worrying about their ‘biological clock’, which in turn would allow them to build networks with colleagues and clients and increase the chances of being promoted since they could be perceived as more committed to work and more competitive. Goold and Savulescu suggest that women who elect NMEF and advance in their careers can play a role in removing or mitigating workplace barriers that make it difficult for women to advance in their careers. They point out that once the discriminatory conditions change, companies will no longer need to sponsor NMEF.

However, although attractive, Goold and Savulescu's argument is flawed. It is debatable whether women who reach positions of leadership and authority within companies because they postponed their motherhood will defend the interests of women who decide not to postpone it. On the contrary, if a direct connection is established between the use of NMEF and the increase in the number of women in positions of leadership and authority, it seems likely that postponing motherhood will become a condition for the advancement of a woman's career. Goold and Savulescu point out that few women will use NMEF to adapt their reproduction to work needs and, therefore, the inclusion of NMEF within companies' employee benefits packages would not undermine other efforts to promote gender equality in the workplace and the labour market.²³ However, the available evidence suggests otherwise. More and more women are considering freezing their eggs for non‐medical reasons (although not necessarily linked to career growth). It is estimated that the number of women who have frozen their eggs in the United States has grown by 400% since the American Society of Reproductive Medicine (ASRM) lifted the experimental label on this ART in 2012.²⁴ Moreover, demand for NMEF increased in many countries during the COVID‐19 pandemic largely because opportunities for dating were minimal.²⁵ The normalization, availability, and rapid expansion of the use of NMEF may have the undesirable effect of making women less able to resist these pressures, especially if they want to advance in their careers.²⁶ Some studies show that women, especially young women, choose to delay their motherhood not as a result of a free and authentic choice or because ARTs are solving workplace inequalities, but to avoid discrimination in the workplace.²⁷ As Jennifer Parks puts it, ‘taking time off due to maternity leave, sick days for a child, and other duties of motherhood is putting your entire professional career at risk’.²⁸ More than a solution to resolve current gender inequalities in the workplace, the offer of NMEF as an employment benefit is a policy that can accommodate existing bias.

Instead of a broad egalitarian policy, the offer of NMEF as an employment benefit can be seen as an additional source of gender inequality in the workplace. Although the provision of NMEF is introduced alongside other measures as part of a comprehensive women's career development policy,²⁹ the inclusion of NMEF as an employee benefit places the burden on women to resolve unfair or inequitable work environments, in this case through biotechnology. In part, the decision to postpone motherhood comes from subjective, ‘soft’ information and perceptions of a workplace that does not accommodate women's needs and desires. It is well documented that women entering the workforce face a double bind: opting for professional success means sacrificing their desire to have a family and vice versa. NMEF is advertised as an ART that allows women to overcome rigid biological barriers and prolong their fertility, similar to the fertility of men. Therefore, the offer of NMEF by companies could be seen as the exit door women of childbearing age can use to escape the double bind. In fact, it has been documented that child‐free women of childbearing age who work in companies that sponsor NMEF see this benefit as a means to reconcile motherhood and professional career by adjusting women's reproductive timelines to ‘perfect’ the moment of reproduction and synchronize it with their career path.³⁰ However, this perception is tricked. The expectations and bias of employers that a child‐free woman of childbearing age has a very high probability of having a child in the near future increase the perceptions of the risks to the company associated with promoting a woman in her childbearing age.³¹ That is, employers assume that motherhood will impact in the longevity and/or performance of female employees at the company. However, the offer of NMEF by companies will not eliminate these expectations and bias, especially if privacy requirements are met, which are not an straightforward feature.³² On the one hand, the employer would not know which employees have used NMEF, so in the face of the risk of promoting a woman who might have a child in the near future, they will likely choose not to promote her. On the other hand, if the employer knows which employees have used NMEF (perhaps because the employee has voluntarily disclosed this information as a strategy to eliminate the bias and the expectation that she will have a baby in the near future because of her age, so privacy requirements are met), the perception of the risk associated with the idea that women of childbearing age have a high probability to have a child in the near future is still present. It is a mistake to see NMEF as a means to postpone fertility, but rather it is a biotechnology that prolongs it. In fact, most of the women who freeze their eggs for nonmedical reasons conceive children naturally.³³

Company‐sponsored NMEF can be seen as an extension of a rigid work model that supports companies' opposition to accommodating the needs and desires of employees in their childbearing ages. The inclusion of NMEF within companies' employee benefits packages sends the message to their employees that the norm for career advancement is to adapt to traditional employment models that were designed based on gender roles where women have to worry about becoming mothers and sacrificing their careers. In other words, instead of being a mechanism to promote gender equality and female representation in positions of authority and leadership, company‐sponsored NMEF maintains the imposition of a patriarchal work culture, but without any assurance that those who use NMEF benefits will advance in their careers.

3. THE WORK/MOTHERHOOD CONFLICT

After having their first child, women in the workforce tend to take longer work leaves than men and are more likely to shift to part‐time jobs or leave their jobs to take care of their children.³⁴ Moreover, women usually encounter barriers that prevent them from returning to full‐time work when their children are already in school.³⁵ These changes contribute to the growth of the wage gap between women and men—the so‐called ‘motherhood penalty’—which usually translates into working mothers having less aggregate income and a lower probability of being promoted in comparison to their male counterparts and their childless female counterparts.³⁶ In response to these concerns, many socially responsible companies employ family‐friendly policies. Typically, these policies include childcare subsidies, maternity and paternity leave, and flexible schedules, among others. Company‐sponsored NMEF could be seen as an additional policy aimed at resolving the work/motherhood conflict, as it allows companies to retain female human capital while expressing their commitment to the family. However, as we will see, company‐sponsored NMEF is a poor strategy for resolving the work/motherhood conflict.

NMEF promises women to have successful pregnancies at an advanced maternal age with a success rate and risks similar to those of their younger counterparts using IVF.³⁷ The inclusion of NMEF as an employee benefit offers women the chance to be competitive at work and become mothers once they have reached a career milestone but without the risks associated with using ‘old eggs’. In some countries, regulations on the number of years that frozen eggs can be stored suggest that childbearing can be postponed (almost) indefinitely. For instance, from July 2022, the UK government allows storing frozen eggs, for both medical and nonmedical reasons, for up to 55 years.³⁸ With the offer of NMEF as an employee benefit, women can push their decision about motherhood up to the point where they have retired and enjoy a pension, that is, in their 60s. It has been suggested that postponing childbearing has benefits for mothers and their children. For example, women may be better emotionally prepared for motherhood, have greater financial stability and less stress, can spend more quality time with their children, and offer them better opportunities, among other things.³⁹ However, there are physiological risks associated with pregnancies at advanced maternal age and costs to the future children that must be weighed.

Recent studies show that pregnancies in healthy women aged 50 and older using donated eggs from younger women are at higher risk of preeclampsia and gestational diabetes and are more likely to have C‐sections.⁴⁰ These risks remain in women of advanced maternal age using frozen eggs. These risks, however, can be avoided through surrogacy, which may also be sponsored by the company. However, surrogacy is a contentious practice that has been accused of exploitation, relying on women's vulnerability, reinforcing gender inequality, commodifying children, and wrongfully objectifying women.⁴¹ These moral concerns aside, surrogacy involves practical issues that companies must take into account when offering NMEF as an employee benefit, especially if companies want to comply with the bioethical principle of justice. In what follows, we mention three practical problems.

First, surrogacy can never guarantee the birth of a healthy baby. Pregnancy is a process whose success can never be assured, as all kinds of things can go wrong during its course. Moreover, opting for surrogacy does not eliminate the physiological risks of a pregnancy, but only transfers them to another (more vulnerable) woman. Second, the legal context in which surrogacy takes place constrains women's freedom to elect company‐sponsored NMEF. For instance, if the jurisdiction in which the company offers NMEF benefits bans surrogacy in all its forms, company‐sponsored NMEF would not be a feasible option for women who suffer from absolute uterine factor infertility (AUFI), unless they travel to another country where surrogacy is permitted (which entails its own problems)⁴² or undergo uterus transplants (UTx) (which is a risky practice and cannot guarantee the birth of a baby).⁴³ Alternatively, if the jurisdiction in which NMEF is offered by companies only allows altruistic surrogacy, some women may have difficulty finding someone willing to offer their uterus.⁴⁴ The third practical problem is that there is no uniformity among jurisdictions when it comes to the allocation of legal parenthood. In some jurisdictions, such as the United Kingdom, surrogacy agreements are not enforceable, so there is a risk that the surrogate refuses to hand over the baby.

In addition to these concerns associated with the possibility of postponing motherhood to an older age through the use of NMEF, postponing motherhood to an older age can impose costs on the future children. On the one hand, becoming a mother at an advanced maternal age may place disproportionate burdens of care and assistance on children when they are still young, especially in contexts where social norms dictate that children must take care of their elderly parents. This may impose unacceptable burdens on children which can jeopardize the children's prospects of life, since informal and unpaid care is correlated with the increase in poverty of caregivers and the worsening of their mental health.⁴⁵ Furthermore, postponing childbearing until later in life increases the chances that children will become orphans at an early age. As Onora O'Neill claims ‘there is a difference between the misfortune of the early death of a young parent, and actively setting up a situation in which the likelihood of death while the child is young is increased’.⁴⁶ These considerations, in and of themselves, do not play against company‐sponsored NMEF, but they do suggest that there should be an age limit for postponing motherhood.⁴⁷ However, if this age limit is established, say before 50, company‐sponsored NMEF does not resolve the work/motherhood conflict, since it does not contribute in any way to women ceasing to be perceived as the main caregivers of their children.

Besides the fact that company‐sponsored NMEF is a poor strategy to solve the work/motherhood conflict, the offer of NMEF by companies places the burden on women of having to resolve structural labour inequities to achieve work–family balance. NMEF is advertised as a risk‐free option, particularly in terms of physiological costs, and with psychological benefits that could not be achieved otherwise. However, the chances of success are not the same for all patients. Two factors have been shown to make a significant difference in the probability of live birth followed by NMEF: the age of the woman when she freezes her eggs and the number of eggs she freezes.⁴⁸

It has been established that there is a relationship between the age at which a woman freezes her eggs and the number of eggs without chromosomal abnormalities that can be obtained per ovarian stimulation cycle.⁴⁹ The later a woman freezes her eggs, the more egg collection cycles she will have to undergo to increase her chances for a live birth.⁵⁰ To illustrate this point, one study found that to have a reasonable chance of one live birth (75% of probability), patients must freeze 10, 20, and 65 eggs, if they are 34, 37, and 42 years old, respectively.⁵¹ However, the number of eggs that can be obtained per cycle does not only depend on the age of the patient when she freezes her eggs but also on her ovarian reserve, her response to ovarian stimulation medications, her medical history, among other things. In addition, to calculate the number of eggs needed to have a reasonable chance of a live birth, one must also consider the probability that the eggs have of surviving the thawing process, their fertility rate, and the probabilities of achieving a pregnancy and that the pregnancy produces a live birth. A study that evaluated the rate of live births followed by NMEF in a clinic in London found that only 74% of frozen eggs survived the thawing process, the fertilization rate was 67%, the percentage of pregnancies achieved was 48%, of which only 35% resulted in a live birth.⁵² Interestingly, the study found that there is no correlation between the age at which a woman freezes her eggs and the chances of survival after being thawed but using ‘young eggs’ does increase the chances of a successful pregnancy.

NMEF's chances of success place a burden on patients. To increase the chances of a live birth followed by NMEF, women should undergo as many egg retrieval cycles as possible to accumulate enough eggs. Unfortunately, NMEF is a complex and even dangerous biomedical option. The more egg retrieval cycles performed, the greater the risk of harm for women who undergo these procedures. Each egg collection cycle consists of daily hormonal injections for a month with the goal of stimulating the ovaries and producing more eggs. Ovarian stimulation has been reported to have side effects such as hormonal imbalances, a higher chance of causing long‐term damage to the ovaries and reproductive system, the possibility of developing ovarian hyperstimulation syndrome (OHSS), and the risk of developing different types of cancer.⁵³ Moreover, eggs are retrieved through vaginal surgery, which carries its own risks due to the use of anaesthesia and other complications.

Companies that offer NMEF as an employee benefit place disproportionate burdens on their employees to solve the work/motherhood conflict: employees who opt for company‐sponsored NMEF increase the risks of harm to their physical health associated with the repeated egg retrieval cycles and pregnancy (especially for women of advanced maternal age) but, at the same time, their opportunities to become mothers are reduced.⁵⁴ In other words, the risks incurred by employees who undergo company‐sponsored NMEF procedures outweigh the benefits: on the one hand, NMEF cuts the chances to become mothers, on the other hand, company‐sponsored NMEF does not resolve the work/motherhood conflict.

4. WOMEN'S REPRODUCTIVE AUTONOMY

The third ethical justification is that the inclusion of NMEF within a company's benefits packages advances women's reproductive autonomy by making available to them an option to prolong their fertility which otherwise would be prohibitively expensive. According to the UK Human Fertilisation and Embryology Authority (HFEA), the average cost of the collection and freezing of eggs in the United Kingdom is £3350, medicalization costs range between £500 and £1500 and annual storage costs range from £125 to £350.⁵⁵ It could be said that company‐sponsored NMEF is a means by which companies express their social responsibilities and their duties to remedy social, legal, and regulatory injustices and inequalities, particularly in the regions in which they operate.⁵⁶ The possibility of freezing eggs expands women's reproductive options who, due to personal circumstances—such as finding a suitable partner, achieving a professional or educational milestone, reaching greater financial security, or fulfil some other personal goal—are not looking for a pregnancy in the short‐term, but want to keep open the possibility of becoming genetic mothers in the future without having to worry about their ‘biological clock’ ticking.⁵⁷

However, as we have already seen in the previous section, NMEF is a complex biomedical option with multiple risks and externalities. Taking into account the context in which companies offer NMEF benefits calls into question how much the inclusion of this benefit advances women's reproductive autonomy. In this section, we unpack some disagreements we have with Petersen and Hansen's article. More specifically, we show that the premises on which their argument rests are false. While they affirm that company‐sponsored NMEF is not necessarily in conflict with common requirements for autonomous choice and that employees (women) are generally adequately informed by medical providers of what the procedures imply and the risks involved, evidence shows otherwise.

There are conflicts of interest between those who demand egg freezing (i.e., patients) and those who offer it (i.e., clinics). Since the overwhelming majority of clinics are private and owned by private equity groups, the primary interest of providers is the maximization of profits and returns rather than the care and attention of their patients. For instance, in the United States, less than 15% of fertility clinics are located within academic research centres and the rest are private, for‐profit companies.⁵⁸ Procedures include interventions, tests, and treatments that are not validated and whose medical efficacy is doubtful but whose inclusion is not in question. Not all egg freezing procedures are regulated and disclosure of results data is not mandatory. For example, 10% of fertility clinics in the United States do not comply with federal law and do not report statistics to the Centers for Disease Control and Prevention (CDC) and the Society for Assisted Reproductive Technology (SART).⁵⁹ Those that do report focus on ‘successful pregnancies’, which only means that a woman managed to get pregnant and carried the pregnancy to term, but not necessarily that the pregnancy was healthy.⁶⁰ The lack of mandatory legislation requiring the submission of information about treatments performed or medical complications creates a conflict of interest that favours clinics over the interests of patients.

Most women who elect to freeze their eggs are usually informed by assisted reproduction clinics about the procedures involved and the chances of success.⁶¹ However, it has been reported that the information available on the websites of the clinics is poor,⁶² making it difficult for a woman to make an informed decision and give valid consent to NMEF. As far as we could find, no clinic discloses data and results specific to that clinic on their website, including how many women have frozen their eggs at that clinic, how many women have their eggs thawed at that clinic, which is the survival, fertilization, and embryonic development rate for eggs frozen at that clinic and what is the live (and healthy) birth rate for each egg thawed at that clinic and for each embryo transferred at that clinic.

Typically, the information offered by clinics is limited to describing the procedures that the patient will have to undergo to freeze her eggs, such as the tests to determine the patient's ovarian reserve, and the ovarian stimulation procedures, egg retrieval, vitrification, and storage. However, the language that clinics use to present this information is intended to encourage women to accept these procedures and not so that they can make a free and informed decision. The potential benefits of NMEF are highlighted, but its risks are not discussed. For example, patients are informed that assessment tests on their ovarian reserve are an indicator to establish the number of cycles of ovarian stimulation and egg retrieval that they will need. However, this is problematic, as it suggests that a woman with low ovarian reserve should undergo repeated cycles of ovarian stimulation, but nothing is said about the risks associated with these procedures such as the likelihood of causing long‐term damage to the ovaries and reproductive system or the risk of OHSS, neither about how these risks increase per cycle. Another example is that the probabilities of failure are underestimated. Although clinics often tell their patients about the survival rates of thawed eggs, they say nothing about the chances of any egg surviving. Patients are also not informed about possible risks such as the possibility that the clinic will cease operations and that the eggs will have to be transferred to another clinic, or the possibility that the eggs may be lost as a result of a laboratory accident or events that go beyond the control of the clinic. In addition to the little information patients receive about these risks, clinics often do not offer adequate follow‐up care, for instance, in the event the patient develops OHSS or cancer as a consequence of these procedures.

Moreover, clinics have been reported to hide costs when it comes to NMEF. An investigation into 15 clinics in the United Kingdom found that true costs often exceed advertised costs by a third.⁶³ This can compromise the financial future of women who choose company‐sponsored NMEF, especially if the financing scheme that the company uses to sponsor NMEF is through reimbursement or a set amount of money since companies calculate the cost of NMEF based on the costs advertised by the clinics. Moreover, the lack of transparency in the true costs makes it difficult for a woman who elects NMEF to plan and have control over her fertility. When a woman initiates a NMEF procedure, she does not know how many egg retrieval cycles she will have to undergo, how much money the whole procedure will cost, how many eggs will survive the thawing, if any will be fertilized (let alone whether she will get pregnant at some point and that the pregnancy will be successful). Leaving a NMEF procedure incomplete (e.g., because the actual costs exceed the amount that the company sponsors and the patient cannot pay the rest of the procedure or because the patient is no longer a beneficiary of NMEF because she no longer works for that company) entails physiological and emotional costs for patients. In addition to the risks of harm associated with egg retrieval, incomplete NMEF processes impact fertility and women's opportunities to become mothers in the future.

Likewise, the lack of effective regulations around NMEF raises concerns about conflicts of interest, since the law, clinics, and medical personnel can put the interests of companies, as the paying party, above the interests of the patients. Clinics have an interest in companies financing NMEF, as this contributes to the increase in demand for NMEF and other ARTs, even if its benefits never materialize. It has been reported that only 12% of women who freeze their eggs for non‐medical reasons actually use them.⁶⁴ Fertility clinics know this, but their interest is not in ensuring that the benefits of NMEF outweigh the risks that patients incur, but in increasing their profits. This conflict of interests can undermine patients' reproductive autonomy more profoundly if companies offer NMEF through an agreement with a specific clinic not only because this scheme constraints patients' options to elect the clinic of their choice but also because it fuels pernicious incentives for clinics to prioritize the interests of the companies over those of the patients to the extent that it is in the interest of the clinics to maintain this agreement.⁶⁵

5. COMPANIES' FIDUCIARY DUTIES

So far, we have shown that companies cannot be ethically justified in offering NMEF benefits on the basis that (i) company‐sponsored NMEF promotes women's representation in positions of authority and leadership, (ii) company‐sponsored NMEF helps resolve conflicts between work and motherhood, and (iii) company‐sponsored NMEF promotes women's reproductive autonomy, since they currently fail to do these. As we saw, by offering NMEF benefits, companies place the burden on their female employees to resolve structural problems related to gender inequality in the workplace, while they continue business as usual. Furthermore, the offering of NMEF benefits often places beneficiaries in a position of physiological, financial, emotional, and psychological vulnerability, especially because egg‐freezing procedures, like other ARTs, have become a for‐profit commercial practice that takes place in a deeply deregulated sector.⁶⁶

However, there is a normative expectation that companies offering NMEF benefits will act in the best interests of their employees. Companies that offer NMEF benefits must be subject to fiduciary duties. Normally, companies are assumed to have a legal obligation to provide a safe workplace and comply with various labour laws, but these obligations generally do not fall within fiduciary duties. Fiduciary duties are moral duties that emerge from relationships where there is an asymmetry in power and knowledge, such as the relationships of parents and children, state and citizens, or doctors and patients. Fiduciaries must act in the best interests of the less powerful and less knowledgeable party. However, while the employer–company–employee relationship is not a prototypical fiduciary relationship, we can say that companies and employees maintain a fiduciary relationship marked by the normative expectation that one party (the company) will use their judgement to act in the best interests of the other (the employee).⁶⁷ By using company‐sponsored NMEF, employees (i.e., beneficiaries) entrust their employers with something very valuable to them: their fertility, their health, their body, and their desires to become parents. As a result, the beneficiary becomes vulnerable to the company. By offering NMEF benefits, companies accept what they are entrusted with and recognize the vulnerability of their employees. Therefore, companies that offer NMEF benefits owe their employees a duty of care and trustworthiness.⁶⁸

However, companies that offer NMEF benefits are not successful in discharging their fiduciary duties. Companies that sponsor NMEF are careless or negligent because they partner with providers who put profits before caring for their patients (employees) and who operate in a deeply unregulated sector (as we saw in the previous section). If an employee uses company‐sponsored NMEF and, as a result, gets OHSS or cancer, or suffers damage to her reproductive system that prevents her from becoming pregnant in the future, or she falls into a psychological trauma associated with multiple failures, or her financial future is compromised due to lack of information about the real costs of NMEF, we could say that the company is morally responsible for the harm caused.

Now, if companies do not want to have to deal with fiduciary duties, then they should not accept being entrusted with valuable goods of their employees (i.e., their fertility, their health, their bodies, and their desires to become parents) by including NMEF within their employee benefits packages.

6. CONCLUSION

All over the world, many companies are including NMEF within their employee benefits packages. In this article, we argued that companies are not ethically justified in offering NMEF benefits. More specifically, we discussed three potential ethical justifications for the offering of NMEF by companies: first, company‐sponsored NMEF promotes women's representation in positions of authority and leadership; second, company‐sponsored NMEF helps resolve the work–motherhood conflict; and third, company‐sponsored NMEF advances women's reproductive autonomy by making available to them an option to prolong their fertility which otherwise would be prohibitively expensive. We concluded that none of these arguments serves as an ethical justification for companies to offer NMEF benefits. On the contrary, by offering NMEF as an employee benefit, companies maintain current workplace inequalities and impose an option for women with multiple risks and externalities, while distracting them from addressing pernicious gender‐based (unconscious) bias and attitudes in the workplace. Of course, there may be other ethical justifications for companies offering NMEF as an employee benefit. For instance, some might argue that companies have a moral responsibility to take a public stand in social and political issues, including women's reproductive freedom, and that one way to do so is by sponsoring NMEF. However, the three ethical justifications we discussed in this article cannot ground a moral justification for companies to offer NMEF benefits. Furthermore, we argued that companies that sponsor NMEF incur fiduciary duties related to the physiological, emotional, psychological, and financial costs of the use of this benefit. We pointed out that if companies do not want to deal with fiduciary duties, they should not offer NMEF as an employee benefit.

Biographies

Alejandro Espinosa‐Herrera (PhD, University of Oxford, Nuffield College) is a professor in the Department of Social and Political Environment at IPADE Business School. His research interests focus on geopolitics, populism and challenges of democracy, public policies and the private sector, the future of capitalism, politics, security and energy transition, and inclusive and sustainable growth.

Maria‐Jose Pietrini‐Sanchez (PhD, University of Sheffield) is a DGAPA postdoctoral researcher at the Institute for Philosophical Research at the National Autonomous University of Mexico (UNAM), working under the supervision of Moises Vaca. Her main research interests focus on reproductive ethics, sexual autonomy, and the philosophy of parenthood.

Espinosa‐Herrera, A. , & Pietrini‐Sanchez, M.‐J. (2025). Are companies ethically justified in offering nonmedical egg freezing as an employee benefit? Bioethics, 39, 117–126. 10.1111/bioe.13347