ESSAY REPRODUCTIVE NEGLIGENCE Dov Fox ∗ A pharmacist fills a prescription for birth control pills with prenatal vitamins. An in vitro lab loses a cancer survivor’s eggs. A fertility clinic exposes embryos to mad cow disease. A sperm bank switches a selected sample with one from a donor of a different race. An obstetrician predicts that a healthy fetus will be born with a debilitating condition. These errors go virtually unchecked in a profession that operates free of meaningful regulation. Private remedies meanwhile treat reproductive negligence more as trifle than tragedy. Courts do not deny that specialists are to blame for botching vasectomies or misimplanting embryos. But in the absence of property loss or physical injury, existing law provides little basis to recognize disrupted family planning as a harm worthy of protection. This Essay sets forth a novel framework of reproductive wrongs. It distinguishes misconduct that (1) imposes unwanted pregnancy or parenthood, (2) deprives wanted pregnancy or parenthood, and (3) confounds efforts to have or avoid a child born with particular traits. It also introduces a right to recover when reproductive professionals perpe- trate these wrongs. ∗. Associate Professor, University of San Diego School of Law. What a pleasure to explore these ideas with superb research assistants Patrick Denton, Lauren Friedenberg, Veneeta Jaswal, and Andre Lallande at University of San Diego (USD) and Columbia Law Review editor Kayasha Lyons. The USD reference librarians provided invaluable support. The project profited from the feedback of participants at the Reproductive Justice Conference at New York University School of Law, International Baby Markets Congress at University of California, Irvine School of Law, and law faculty workshops at several schools. I am indebted for conversations with uncommonly generous colleagues including Larry Alexander, Rene Almeling, Jordan Barry, Khiara Bridges, Naomi Cahn, Steve Calandrillo, June Carbone, Laurence Claus, Andrew Coan, I. Glenn Cohen, Mary Crossley, Judith Daar, Teun Dekker, Carter Dillard, Richard Epstein, Martha Ertman, Miranda Fleischer, Victor Fleischer, Michelle Goodwin, Mike Green, Jessie Hill, Adam Hirsch, Gregory Keating, Michael Kelly, Joshua Kleinfeld, Herbert Lazerow, Saul Levmore, Kristen Loveland, Jody Madeira, Miranda McGowan, Maxwell Mehlman, Jennifer Mnookin, Seema Mohapatra, Lyria Moses, Douglas NeJaime, Lars Noah, David Partlett, Frank Partnoy, Nicolette Priaulx, Dara Purvis, Robert Rabin, Natalie Ram, Richard Re, Rachel Rebouché, Nicole Ries Fox, John Robertson, Peter Schuck, Elizabeth Sepper, Ted Sichelman, Steven Smith, Mila Sohoni, Jane Stapleton, Alex Stein, Stephen Sugarman, Sonia Suter, Edmund Ursin, Ellen Wertheimer, Jonathan Will, Christopher Wonnell, Mary Ziegler, Benjamin Zipursky, and Matt Zwolinski. 149 150 COLUMBIA LAW REVIEW [Vol. 117:149 This new cause of action would measure the injuries of imposed, deprived, and confounded procreation as a function of their practical consequences for victims’ lives and the probability that wrongdoing was responsible for having caused those harms. Damages would accordingly be reduced, for example, by the plausible role of user error in cases of defective condoms, by preexisting infertility in cases of dropped embryos, and by genetic uncertainties in cases of prenatal misdiagnosis. INTRODUCTION ......................................................................................... 151 I. THE PUZZLE AND ITS STAKES.................................................................. 161 A. Inadequate Protections .............................................................. 162 1. Regulation ........................................................................... 163 2. Malpractice .......................................................................... 165 3. Emotional Distress............................................................... 169 4. Breach of Contract.............................................................. 172 5. Loss of Property. .................................................................. 174 B. Procreation Interests .................................................................. 176 1. Pregnancy ............................................................................ 177 2. Parenthood.......................................................................... 179 3. Particulars............................................................................ 180 II. MAPPING REPRODUCTIVE WRONGS ....................................................... 184 A. Procreation Imposed .................................................................. 185 1. Illuminating the Harm........................................................ 187 2. Causation Complications .................................................... 189 3. Abortion/Adoption Option................................................ 191 B. Procreation Deprived ................................................................. 193 1. Intangible Losses................................................................. 195 2. Preexisting Infertility........................................................... 197 C. Procreation Confounded ........................................................... 200 1. Reasons and Repercussions ................................................ 202 2. Prenatal Genetic Uncertainties .......................................... 206 III. PROCREATION RIGHTS AND REMEDIES................................................. 209 A. The Private Right of Procreation ............................................... 210 1. Why: Values, Compensation, Deterrence........................... 211 2. Who: Professionals, Patients, Partners ............................... 214 3. What: Avoidance, Pursuit, Selection................................... 218 B. Determining Damages................................................................ 224 1. Tailoring Injury Severity...................................................... 225 2. Loss-of-Chance Probabilities............................................... 226 3. Institutional Competence ................................................... 228 4. Public Policy Concerns........................................................ 231 2017] REPRODUCTIVE NEGLIGENCE 151 CONCLUSION ............................................................................................. 240 INTRODUCTION More and more Americans are turning to health care professionals to help plan their family lives.1 Nearly two in seven women of child- bearing age in the United States now rely on surgical sterilization or long-term birth contraception to prevent pregnancy.2 Almost two percent of all babies born in this country today are conceived using reproductive technologies like in vitro fertilization (IVF).3 And advances in genetic selection among donors and embryos afford many prospective parents increasing measures of control over offspring traits.4 1. The steep cost of many reproductive interventions limits access to them. See A. Law et al., Are Women Benefiting from the Affordable Care Act? A Real-World Evaluation of the Impact of the Affordable Care Act on Out-of-Pocket Costs for Contraceptives, 93 Contraception 392, 394 (2016) (noting substantial up-front costs for the most effective methods of birth control, even as mean total out-of-pocket expenses for FDA-approved contraceptives decreased by two-thirds, after the implementation of the Affordable Care Act’s mandate in 2011 requiring health plans to cover most contraceptive methods); Molly Quinn & Victor Fujimoto, Racial and Ethnic Disparities in Assisted Reproductive Technology Access and Outcomes, 105 Fertility & Sterility 1119, 1120 (2016) (calling cost of care “the greatest barrier to access to infertility care in the U.S.,” where “a single IVF cycle” costs more than “50% of the average individual’s annual disposable income” and “the majority of patients undergoing specialized infertility treatment” pay out of pocket due to deficient insurance coverage); Suzanne Woolley, Couples Desperate for Children Turn to Crowdfunding Fertility, Bloomberg (Oct. 20, 2016, 6:00 AM), http://www. bloomberg.com/news/articles/2016-10-20/how-to-pay-for-that-baby-crowdfund-it [http:// perma.cc/R57G-NV2W] (“In America, some use credit cards, 401(k)s, and even loans to pay for in vitro fertilization . Crowdfunding has become a popular mechanism for many couples who can’t afford the high costs of IVF, or adoption and surrogacy.”). 2. See Contraceptive Use, Nat’l Ctr. for Health Statistics, Ctrs. for Disease Control & Prevention, http://www.cdc.gov/nchs/fastats/contraceptive.htm [http://perma.cc/ UXM3-RCD2] (last updated July 15, 2016) (reporting that 27.8% of women aged fifteen to forty-four in the United States use either female sterilization (15.5%), male sterilization (5.1%), or long-acting reversible birth control like an intrauterine device or contraceptive implant (7.2%)); see also Kimberly Daniels et al., Current Contraceptive Use and Variation by Selected Characteristics Among Women Aged 15–44: United States 2011–2013, Nat’l Health Stat. Rep., Nov. 10, 2015, http://www.cdc.gov/nchs/data/nhsr/nhsr086.pdf [http:// perma.cc/X2RN-MK8N] (reporting that among the 61.7% of American women aged 15– 44 who use birth control, the most common methods are oral contraception (25.9%), female sterilization (25.1%), the male condom (15.3%), and long-acting reversible contraception (11.6%)). 3. ART Success Rates, Ctrs. for Disease Control & Prevention, http://www.cdc.gov/