IJG-07961; No of Pages 4 International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
SPECIAL ARTICLE
Health concerns and ethical considerations regarding international surrogacy Jonathan W. Knoche ⁎ Department of Pediatrics, Mayo Graduate School of Medicine, Rochester, MN, USA
a r t i c l e
i n f o
Article history: Received 17 September 2013 Received in revised form 3 March 2014 Accepted 22 April 2014 Keywords: Autonomy Commodification Human dignity International surrogacy Public health
a b s t r a c t Since the advent of IVF, various arrangements for child bearing and rearing have developed. With the confluence of advanced medical technology, reproductive choice, and globalization, a market in international surrogacy has flourished. However, myriad health, social, and ethical concerns abound regarding the well-being of gestational carriers and children, the infringement of autonomy and free choice, and threats to human dignity. The present paper examines the scope, health risks, and ethical concerns of cross-border surrogacy, arguing that the risks may not exceed the benefits. © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction The confluence of medical advancement, reproductive choice, and globalization has enabled those who experience the profound sadness of childlessness to enter into an international surrogacy marketplace to craft genetic progeny of their own. The financial and economic forces, legal impediments, issues of control, health and safety, and ethical and social concerns prompt important unanswered questions as to whether this unregulated market is safe and ethical, and whether it should be controlled, outlawed, or further encouraged. 2. Scope of international surrogacy practice Infertility affects much of the world’s childbearing population. Worldwide, an estimated 40.2–120.6 million women aged 20–44 years, living in a committed relationship, fail to conceive after 12 months of trying. Of these, 12–90.4 million are likely to seek medical help [1]. For those wishing to satisfy the deep longing for genetically related children and who have the financial means, assisted reproductive technology (ART)—a multibillion dollar industry estimated to be worth more than $3 billion a year in the US alone—provides myriad therapeutic options for infertility. These treatments include IVF, fertility drugs, donor gametes, and surrogate carriers [2]. While ART is growing on national levels, there are many individuals crossing borders to seek reproductive services and commercial gestational surrogates.
⁎ Department of Pediatrics, Mayo Graduate School of Medicine, 200 First Street SW, Rochester, MN 55905, USA. Tel.: +1 507 696 4579; fax: +1 507 284 0160. E-mail address: [email protected].
Surrogacy itself can be either traditional or gestational. In a traditional arrangement, a surrogate mother contributes her ovum and is genetically related to the child. In contrast, gestational surrogacy involves a surrogate carrying a genetically unrelated child; IVF allows the commissioning mother to be genetically related to the child in this case. Either form of surrogacy may be commercial (the surrogate is compensated beyond accepted medical expenses) or altruistic (the surrogate carries the child without financial gain). The distinction between commercial and altruistic surrogacy may be obscured depending on the amount a surrogate is compensated. Legal restrictions forbid surrogacy arrangements in many countries. China, France, Germany, Sweden, and Switzerland prohibit all surrogacy arrangements, whether altruistic, commercial, gestational, or traditional [3]. The UK, Canada, and the Australian Capital Territory permit altruistic surrogacy but ban commercial surrogacy. Israel allows commercial surrogacy but forbids familial surrogacy on religious grounds [4]. In countries where the law is silent or not prohibitive, individuals may face a financial barrier to surrogacy. In the US, for example, surrogacy costs start at around US $70 000, but can easily exceed US $100 000. By comparison, in resource-poor countries, such as India, surrogacy can be a quarter of the cost or less where agencies charge prospective clients approximately US $25 000 [5]. Thus, international surrogacy has become an increasingly attractive option for many individuals. Indeed, India has developed a booming surrogacy business, estimated to be worth between US $500 million and US $2.0 billion [6,7]. Unfortunately, the economic growth in India’s medical tourism industry has not necessarily reached those it purports to help [8]. With increased cross-border demand and an ample supply of carriers willing to assume the risk and accept lower payment for their services in poorly regulated and low-resource countries, the industry
http://dx.doi.org/10.1016/j.ijgo.2014.03.020 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Knoche JW, Health concerns and ethical considerations regarding international surrogacy, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.03.020
2
J.W. Knoche / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
of international reproduction has flourished. In India, the number of births through surrogacy doubled between 2003 and 2006 [9]. The Centers for Disease Control and Prevention (CDC) and the Society for Assisted Reproductive Technology (SART) report that the number of infants born to gestational carriers doubled from 738 to 1400 in the US between 2004 and 2008 [10,11]. In comparison, about 2000 babies were born to carriers in India in 2011 alone. Investigators estimate that as many as 1000 of those births could be attributed to British customers, where commercial surrogacy is illegal and where only 100 surrogacy births occurred in 2011 [7]. While the number of surrogate births has increased substantially in India, the exact figure and scope of practice are likely to be larger than reported. Indian databases list some 600 IVF clinics, with another 400 more clinics supposedly operate without any regulation [7]. Thus, the reported scope of international surrogacy practice in resource-poor and unregulated countries is likely to represent a fraction of the entire industry. 3. Public health risks Aside from the standard risks of pregnancy, international surrogacy arrangements raise public health concerns. For the ova donor, ovulation induction therapy can lead to ovarian hyperstimulation syndrome (OHSS) which, in severe cases, may cause renal failure, hypovolemic shock secondary to intravascular volume depletion, acute respiratory distress syndrome, pulmonary thromboembolism, and in some cases, death [12,13]. Unique obstetric risks to gestational carriers are poorly described, though in general, conception by IVF leads to higher rates of hypertension, pre-eclampsia, cholestasis, hyperemesis gravidarum, and venous thromboembolism [14,15]. A study in Denmark found that the venous thrombosis incidence rate ratio was 2.8 and 4.4 in singleton and multiple IVF pregnancies, respectively, compared with reference pregnancies [16]. Cesarean delivery also increased the risk of postpartum venous thromboembolism [16]. While these results may be generalizable to other high-resource nations, it remains unclear whether these data are predictive of outcomes in low-resource nations and whether there are differences between IVF pregnancies and IVFsurrogacy pregnancies. Women who carry a genetically related single fetus subsequent to IVF therapy are at higher risk of placenta previa (two- to six-fold) and abruption (two-fold) compared with women who conceived naturally [17]. How these data apply to gestational carriers of genetically unrelated fetuses must be better understood and investigated. In order to accommodate the paying couple in the international setting, gestational carriers are often forced to undergo cesarean delivery. This carries greater potential risks than a vaginal delivery and can lead to increased complications associated with a subsequent vaginal birth after cesarean (VBAC), such as a greater chance of uterine rupture [18]. Whether existing IVF clinics in low-resource countries are adequately equipped to address such complications is unclear. Children from international surrogacy may also face adverse health outcomes including an increased risk of perinatal morbidity and mortality due to a greater number of twin pregnancies from IVF [19]. Worldwide, about 25% of pregnancies conceived by ART are twins [20]. In general, based on the data we have, morbidity and mortality of surviving newborns could be lessened by reducing the multiple gestation pregnancy to one life. This solution, however, carries its own risks relating to the carrier’s health and the contested moral status of both carrier and fetus. Even when considering singleton pregnancies, compared with spontaneously conceived children, fetuses from IVF pregnancies experience more preterm births, lower birth weight, and perinatal mortality [21]. It is unclear whether fetuses from twin or singleton pregnancies carried by a gestational surrogate are at any greater risk than those carried by the genetic mother. One advantage conferred to fetuses of IVF-surrogacy is a lower incidence of low birth weight births compared with those born following conventional IVF [22].
The impact of international surrogacy on maternal−child health remains poorly defined and deserving of further attention. The potential harmful effects of international surrogacy on donors, carriers, and children should cause us to question whether the risks outweigh the benefits. It may be that the satisfaction childless parents feel and the financial compensation given to carriers still do not justify the potential consequences. 4. Ethics The relatively unregulated market of international surrogacy requires careful and critical ethical reflection about the potential for exploitation and abuse. Not all peoples have the same freedoms and autonomy in a legal or practical sense. For some, societal and economic constraints may functionally limit liberties guaranteed by law. Ethical concerns relate not only to autonomy and free choice, but also to philosophical and social paradigms regarding issues of human dignity, the value of women, and their commodification. 4.1. Autonomy and justice Many high-resource nations uphold liberty, choice, and the freedom to contract. In the international setting of surrogacy, commissioning couples enjoy these freedoms with the added benefits of significant savings and a reduced likelihood of the gestational carrier claiming maternal rights to the child. This arrangement also benefits the surrogate who receives significant financial compensation, in some cases garnering in nine months what can take as long as 15 years to earn [23]. This empowers poor women to use their bodies as they choose and to care for their families, pay off debt, and save for their own children’s future [24]. On the other hand, the financial compensation is not necessarily what is purported by surrogacy agencies, with carriers receiving only a fraction of what is claimed. Some fear that a lack of regulation could cause a price war for surrogacy, with countries underpricing fees and weakening legal protections for gestational carriers. Furthermore, if the practice of international organ selling is any indication, then the majority who vend their body to repay debts will have no economic improvement, may not be compensated the amount quoted, and experience deterioration of their general health [25,26]. Though the majority of citizens in the USA and Europe enjoy significant freedoms, privacy, and legal protection from exploitation and abuse, many women in resource-poor countries, such as India, do not benefit from similar philosophical, political, and legal frameworks. The assertion that Indian women are entirely and freely choosing to subject themselves to the risks of pregnancy without its natural rewards is misguided. The vulnerability of surrogates and the potential for trafficking led the European Parliament to write a resolution asking Member States: “to acknowledge the serious problem of surrogacy…[and] emphasize that women and children are subject to the same forms of exploitation and both can be regarded as commodities on the international reproductive market, and that these new reproductive arrangements, such as surrogacy, augment the trafficking of women and children and illegal adoption across national borders…” [27]. Additionally, whereas gestational carriers in the USA and Europe are granted freedom, autonomy, and legal rights to make healthcare decisions (i.e. whether to abort), women in resource-poor countries do not have such guarantees. In the USA, the American College of Obstetricians and Gynecologists (ACOG) recognizes that surrogate mothers retain sole autonomy for “consent regarding clinical intervention and management of pregnancy, labor, and delivery…” and that the obstetrician is obliged to “make recommendations that are in the best interests of the pregnant woman and her fetus, regardless of prior agreements between her and the intended parents” [28]. By contrast, in India the Assisted Reproductive Technology (Regulation) Rules 2009 states that a gestational carrier must agree to relinquish all parental
Please cite this article as: Knoche JW, Health concerns and ethical considerations regarding international surrogacy, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.03.020
J.W. Knoche / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
rights concerning the child and agree to undergo fetal reduction if she is carrying more than one fetus [29]. The ART (Regulation) Rules 2010 states it more mildly: if a multiple gestation pregnancy occurs, the ART clinic “may carry out fetal reduction after appropriate counselling” [30]. It seems that we are caught in what Margaret Radin calls a double bind. On the one hand, by forbidding international surrogacy, we paternalistically encroach on a surrogate’s freedom to contract. She may prefer this position of surrogacy to other choices in life and by denying her this opportunity we oppress her and remove prospects to better her life. On the other hand, by permitting surrogacy we perpetuate the unregulated marketing of a woman’s body for a service and thereby objectify her, reduce her human dignity, and foster an inferior conception of flourishing [31]. In such a double bind, what ought to guide us? The notion of justice provides further guidance in assessing the ethical merits of surrogacy. Justice calls attention to the unfairness of exploitation of disadvantaged women as reproductive machines. In markets, however, the values of utility and liberty can crowd out the importance of justice. This should cause us pause about introducing a commercial market in international surrogacy when there are major inequalities in advantage, wealth, and sociopolitical protections. This is part of the reason why the USA forbids payment for organ donation. The rich should not be allowed to satisfy their health wants through the desperation of the poor. Furthermore, whether one views the surrogacy service itself or the child as that which is for sale, it is unjust and demeaning to separate the reproductive process from the child and to say that one can sell the service without it affecting our view of the child [32]. This can be illustrated by asking ourselves what an agency might do if the child comes out “defective.” Is there a money-back guarantee for this item? Such a view is unfair to our humanity and the value of persons. 4.2. Commodification and the market: Threats to human dignity On a psychological and philosophical level, the acceptance of international surrogacy requires an alteration of the view of a woman and the process of reproduction. The international market of industrialized reproduction necessitates the uterus to be viewed as a mere commodity—something distinct from the whole woman. Within this market-oriented mentality, the commodity of a womb is fungible (i.e. any one of them can be substituted for any other similar commodity, given that the quality and price are the same). Thus, a gestational surrogate is essentially seen as a glorified incubator. Carriers become commodities. To view human persons as parts or commodities primarily for our use and exploitation is dubious. No human being—or her parts— should be treated as a commodity precisely because we are whole subjects, not fragmented organs. When humans are viewed primarily as objects for amusement, experimentation, or manipulation, grave atrocities have been committed. Thus, to view and treat a woman as a mere incubator belies her dignity and worth as an individual person and defies the core tenets of international human rights. Furthermore, international surrogacy is a coalescing of the market mentality and globalization combined with modern notions of reproductive choice and reproductive industrialization. IVF, gamete catalogues, commercial surrogacy arrangements, and efforts to create an artificial womb reflect low-cost ways to fulfil our reproductive consumerist dreams. Harvard political philosopher Michael Sandel writes, “we live at a time when almost everything can be bought and sold… We have drifted from having a market economy, to being a market society” [33]. By employing market rhetoric to define individual rights, we think of inalienable freedom as having control over how to maximize overall gains. People are thus free to buy, rent, or sell commodified objects and body parts to maximize monetizable wealth. However, the ability to buy or market anything may not actually equate to freedom. What is an inalienable right should be based on our understanding of human flourishing. By answering issues surrounding international surrogacy based on the question of “how much?” we unreflectively
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follow our desires and dreams without considering its impact on the very nature of our humanness. While a general commitment to reproductive choice in highresource countries is well established, values such as free choice, personal autonomy, and privacy may not be transferable in an international setting where different cultures, traditions, and pluralistic notions of life exist. The begetting and rearing of children and the relationships of those involved may suffer when reproduction is industrialized and commercialized. In a society with few technical limitations whose mindset is overwhelmed with making, the free choice to create children in order to satisfy a want or deep desire may predominate. This desire can take the ugliest form when the child itself is viewed as a commodity. For instance, in 2008, baby Manji was left parentless after a Japanese couple divorced in the middle of the surrogate pregnancy and the Indian carrier refused taking the child as her own [34]. This unfortunate scenario demonstrates how surrogacy turns reproduction into a market function that reduces persons to refundable goods. Societal and communal concerns, therefore, may be right to constrain reproductive choice especially when begetting children is reduced to creating with modern medical technology. Furthermore, society and couples ought to consider whether childlessness should be an opportunity to exercise consumer rights or to demonstrate an important expression of humanity—rearing and caring for a child who is not their genetic offspring. 5. Conclusion Childlessness is a problem faced by a significant number of people throughout the world. The deep loss couples experience cannot be minimized. Fortunately, medical advancements and technological prowess have overcome many impediments to fertility. However, attempts to create genetically related children by utilizing international surrogates have opened the door not only to more cost-effective treatment, but also to unknown health risk. Further investigation and research is thus required into the hazards that gestational carriers and children face as a result of IVF, particularly in the international context. Beyond the potential harms to public health, we must consider the potential exploitation and abuse of gestational carriers who live in lowresource and poorly regulated countries. Perhaps equally concerning is the market mentality that enables “value free” decisions that commodify carriers. This objectification similarly shapes our understanding of “having” children as if they were market goods. The international surrogacy enterprise thus denigrates our view of humanity. In the end, we must ask ourselves whether the elation childless couples experience following the birth of a genetically related child is sufficient to offset the health risks, the violation of a surrogate’s autonomy and her potential exploitation, the commodification of her person, and the resultant alteration of societal values. Conflict of interest The author has no conflicts of interest. References [1] Boivin J, Bunting L, Collins JA, Nygren K. International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical Care. Hum Reprod 2007;22(6):1506–12. [2] Spar DL. The Baby Business: How Money, Science, and Politics Drive the Commerce of Conception. Boston, MA: Harvard Business Press; 2006. [3] Hague Conference on Private International Law. A Preliminary Report on the Issues Arising from International Surrogacy Arrangements. http://www.hcch.net/upload/ wop/gap2012pd10en.pdf. Published March 2012. Accessed August 10, 2013. [4] Ber R. Ethical issues in gestational surrogacy. Theor Med Bioeth 2000;21(2):153–69. [5] Williams I, Kress R, Williams I, Kress R. A baby made in India: a couple’s dream comes true. http://todayhealth.today.com/_news/2012/05/28/11883566-a-babymade-in-india-a-couples-dream-comes-true. Published May 28, 2012. Accessed August 10, 2013.
Please cite this article as: Knoche JW, Health concerns and ethical considerations regarding international surrogacy, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.03.020
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[6] Ward C. More Americans Now Traveling to India for Surrogate Pregnancy. http://abcnews.go.com/WN/adoption-india-americans-plan-surrogacy-abroad/ story?id=10487880. Published April 27, 2010. Accessed August 10, 2013. [7] Bhatia S. Revealed: how more and more Britons are paying Indian women to become surrogate mothers. http://www.telegraph.co.uk/health/healthnews/9292343/ Revealed-how-more-and-more-Britons-are-paying-Indian-women-to-becomesurrogate-mothers.html. Published May 26, 2012. Accessed August 10, 2013. [8] Haimowitz R, Sinha V. Made in India [DVD]. New York, NY: The Fledgling Fund. Chicken and Egg Pictures; 2010. [9] Ramachandran S. India's New Outsourcing Business - Wombs. http://www.atimes. com/atimes/South_Asia/HF16Df03.html. Published June 16, 2006. Accessed August 10, 2013. [10] Gugucheva M. Surrogacy in America. http://www.councilforresponsiblegenetics. org/pagedocuments/kaevej0a1m.pdf. Published 2010. Accessed August 10, 2013. [11] US Department of Health and Human Services, Centers for Disease Control. 2007 Assisted Reproductive Technology Success Rates. http://www.cdc.gov/art/ART2007/ PDF/COMPLETE_2007_ART.pdf. Published December 2009. Accessed August 10, 2013. [12] Kaiser UB. The pathogenesis of the ovarian hyperstimulation syndrome. N Engl J Med 2003;349(8):729–32. [13] Abramov Y, Elchalal U, Schenker JG. Pulmonary manifestations of severe ovarian hyperstimulation syndrome: a multicenter study. Fertil Steril 1999;71(4):645–51. [14] Gonzalez MC, Reyes H, Arrese M, Figueroa D, Lorca B, Andresen M, et al. Intrahepatic cholestasis of pregnancy in twin pregnancies. J Hepatol 1989;9(1):84–90. [15] American College of Obstetricians and Gynecologists Committee on Practice Bulletins-Obstetrics, Society for Maternal-Fetal Medicine, ACOG Joint Editorial Committee. ACOG Practice Bulletin #56: Multiple gestation: complicated twin, triplet, and high-order multifetal pregnancy. Obstet Gynecol 2004;104(4):869–83. [16] Hansen AT, Kesmodel US, Juul S, Hvas AM. Increased venous thrombosis incidence in pregnancies after in vitro fertilization. Hum Reprod 2014;29(3):611–7. [17] Healy DL, Breheny S, Halliday J, Jaques A, Rushford D, Garrett C, et al. Prevalence and risk factors for obstetric haemorrhage in 6730 singleton births after assisted reproductive technology in Victoria Australia. Hum Reprod 2010;25(1):265–74. [18] National Institute for Health and Care Excellence. CG132 Caesarean section. http://guidance.nice.org.uk/cg132. Published November 2011. Accessed August 10, 2013.
[19] Moise J, Laor A, Armon Y, Gur I, Gale R. The outcome of twin pregnancies after IVF. Hum Reprod 1998;13(6):1702–5. [20] Nygren KG, Sullivan E, Zegers-Hochschild F, Mansour R, Ishihara O, Adamson GD, et al. International Committee for Monitoring Assisted Reproductive Technology (ICMART) world report: assisted reproductive technology 2003. Fertil Steril 2011;95(7):2209–22. [21] Jackson RA, Gibson KA, Wu YW, Croughan MS. Perinatal outcomes in singletons following in vitro fertilization: a meta-analysis. Obstet Gynecol 2004;103(3):551. [22] Serafini P. Outcome and follow-up of children born after IVF-surrogacy. Hum Reprod Update 2001;7(1):23–7. [23] Hochschild A. Childbirth at the Global Crossroads. http://prospect.org/article/ childbirth-global-crossroads-0. Published September 19, 2009. Accessed August 10, 2013. [24] Parks JA. Care Ethics and the Global Practice of Commercial Surrogacy. Bioethics 2010;24(7):333–40. [25] Goyal M, Mehta RL, Schneiderman LJ, Sehgal AR. Economic and health consequences of selling a kidney in India. JAMA 2002;288(13):1589–93. [26] Naqvi SA, Ali B, Mazhar F, Zafar MN, Rizvi SA. A socioeconomic survey of kidney vendors in Pakistan. Transpl Int 2007;20(11):934–9. [27] European Parliament. New EU policy framework to fight violence against women. http://www.europarl.europa.eu/sides/getDoc.do?type=TA&reference=P7-TA2011-0127&language=EN. Published April 5, 2011. Accessed August 10, 2013. [28] Committee on Ethics. ACOG committee opinion number 397, February 2008: surrogate motherhood. Obstet Gynecol 2008;111(2 Pt 1):465–70. [29] Palattiyil G, Blyth E, Sidhva D, Balakrishnan G. Globalization and cross-border reproductive services: Ethical implications of surrogacy in India for social work. Int Soc Work 2010;53(5):686–700. [30] Ministry of Health and Family Welfare, Govt. of India. The Assisted Reproductive Technologies (Regulation) Bill - 2010. http://www.icmr.nic.in/guide/ART%20 REGULATION%20Draft%20Bill1.pdf. Published 2010. Accessed August 10, 2013. [31] Radin MJ. Market-inalienability. Harv Law Rev 1987;100(8):1849–937. [32] May WF. The Patient’s Ordeal. Bloomington, Indiana: Indiana University Press; 1994. [33] Sandel MJ. What Money Can't Buy: The Moral Limits of Markets. New York: Penguin UK; 2012. [34] Points K. Commercial surrogacy and fertility tourism in India: The case of Baby Manji. http://kenan.ethics.duke.edu/wp-content/uploads/2012/07/Case-StudySurrogacy.pdf. Published 2009. Accessed August 10, 2013.
Please cite this article as: Knoche JW, Health concerns and ethical considerations regarding international surrogacy, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.03.020
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
SPECIAL ARTICLE
Health concerns and ethical considerations regarding international surrogacy Jonathan W. Knoche ⁎ Department of Pediatrics, Mayo Graduate School of Medicine, Rochester, MN, USA
a r t i c l e
i n f o
Article history: Received 17 September 2013 Received in revised form 3 March 2014 Accepted 22 April 2014 Keywords: Autonomy Commodification Human dignity International surrogacy Public health
a b s t r a c t Since the advent of IVF, various arrangements for child bearing and rearing have developed. With the confluence of advanced medical technology, reproductive choice, and globalization, a market in international surrogacy has flourished. However, myriad health, social, and ethical concerns abound regarding the well-being of gestational carriers and children, the infringement of autonomy and free choice, and threats to human dignity. The present paper examines the scope, health risks, and ethical concerns of cross-border surrogacy, arguing that the risks may not exceed the benefits. © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction The confluence of medical advancement, reproductive choice, and globalization has enabled those who experience the profound sadness of childlessness to enter into an international surrogacy marketplace to craft genetic progeny of their own. The financial and economic forces, legal impediments, issues of control, health and safety, and ethical and social concerns prompt important unanswered questions as to whether this unregulated market is safe and ethical, and whether it should be controlled, outlawed, or further encouraged. 2. Scope of international surrogacy practice Infertility affects much of the world’s childbearing population. Worldwide, an estimated 40.2–120.6 million women aged 20–44 years, living in a committed relationship, fail to conceive after 12 months of trying. Of these, 12–90.4 million are likely to seek medical help [1]. For those wishing to satisfy the deep longing for genetically related children and who have the financial means, assisted reproductive technology (ART)—a multibillion dollar industry estimated to be worth more than $3 billion a year in the US alone—provides myriad therapeutic options for infertility. These treatments include IVF, fertility drugs, donor gametes, and surrogate carriers [2]. While ART is growing on national levels, there are many individuals crossing borders to seek reproductive services and commercial gestational surrogates.
⁎ Department of Pediatrics, Mayo Graduate School of Medicine, 200 First Street SW, Rochester, MN 55905, USA. Tel.: +1 507 696 4579; fax: +1 507 284 0160. E-mail address: [email protected].
Surrogacy itself can be either traditional or gestational. In a traditional arrangement, a surrogate mother contributes her ovum and is genetically related to the child. In contrast, gestational surrogacy involves a surrogate carrying a genetically unrelated child; IVF allows the commissioning mother to be genetically related to the child in this case. Either form of surrogacy may be commercial (the surrogate is compensated beyond accepted medical expenses) or altruistic (the surrogate carries the child without financial gain). The distinction between commercial and altruistic surrogacy may be obscured depending on the amount a surrogate is compensated. Legal restrictions forbid surrogacy arrangements in many countries. China, France, Germany, Sweden, and Switzerland prohibit all surrogacy arrangements, whether altruistic, commercial, gestational, or traditional [3]. The UK, Canada, and the Australian Capital Territory permit altruistic surrogacy but ban commercial surrogacy. Israel allows commercial surrogacy but forbids familial surrogacy on religious grounds [4]. In countries where the law is silent or not prohibitive, individuals may face a financial barrier to surrogacy. In the US, for example, surrogacy costs start at around US $70 000, but can easily exceed US $100 000. By comparison, in resource-poor countries, such as India, surrogacy can be a quarter of the cost or less where agencies charge prospective clients approximately US $25 000 [5]. Thus, international surrogacy has become an increasingly attractive option for many individuals. Indeed, India has developed a booming surrogacy business, estimated to be worth between US $500 million and US $2.0 billion [6,7]. Unfortunately, the economic growth in India’s medical tourism industry has not necessarily reached those it purports to help [8]. With increased cross-border demand and an ample supply of carriers willing to assume the risk and accept lower payment for their services in poorly regulated and low-resource countries, the industry
http://dx.doi.org/10.1016/j.ijgo.2014.03.020 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Knoche JW, Health concerns and ethical considerations regarding international surrogacy, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.03.020
2
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of international reproduction has flourished. In India, the number of births through surrogacy doubled between 2003 and 2006 [9]. The Centers for Disease Control and Prevention (CDC) and the Society for Assisted Reproductive Technology (SART) report that the number of infants born to gestational carriers doubled from 738 to 1400 in the US between 2004 and 2008 [10,11]. In comparison, about 2000 babies were born to carriers in India in 2011 alone. Investigators estimate that as many as 1000 of those births could be attributed to British customers, where commercial surrogacy is illegal and where only 100 surrogacy births occurred in 2011 [7]. While the number of surrogate births has increased substantially in India, the exact figure and scope of practice are likely to be larger than reported. Indian databases list some 600 IVF clinics, with another 400 more clinics supposedly operate without any regulation [7]. Thus, the reported scope of international surrogacy practice in resource-poor and unregulated countries is likely to represent a fraction of the entire industry. 3. Public health risks Aside from the standard risks of pregnancy, international surrogacy arrangements raise public health concerns. For the ova donor, ovulation induction therapy can lead to ovarian hyperstimulation syndrome (OHSS) which, in severe cases, may cause renal failure, hypovolemic shock secondary to intravascular volume depletion, acute respiratory distress syndrome, pulmonary thromboembolism, and in some cases, death [12,13]. Unique obstetric risks to gestational carriers are poorly described, though in general, conception by IVF leads to higher rates of hypertension, pre-eclampsia, cholestasis, hyperemesis gravidarum, and venous thromboembolism [14,15]. A study in Denmark found that the venous thrombosis incidence rate ratio was 2.8 and 4.4 in singleton and multiple IVF pregnancies, respectively, compared with reference pregnancies [16]. Cesarean delivery also increased the risk of postpartum venous thromboembolism [16]. While these results may be generalizable to other high-resource nations, it remains unclear whether these data are predictive of outcomes in low-resource nations and whether there are differences between IVF pregnancies and IVFsurrogacy pregnancies. Women who carry a genetically related single fetus subsequent to IVF therapy are at higher risk of placenta previa (two- to six-fold) and abruption (two-fold) compared with women who conceived naturally [17]. How these data apply to gestational carriers of genetically unrelated fetuses must be better understood and investigated. In order to accommodate the paying couple in the international setting, gestational carriers are often forced to undergo cesarean delivery. This carries greater potential risks than a vaginal delivery and can lead to increased complications associated with a subsequent vaginal birth after cesarean (VBAC), such as a greater chance of uterine rupture [18]. Whether existing IVF clinics in low-resource countries are adequately equipped to address such complications is unclear. Children from international surrogacy may also face adverse health outcomes including an increased risk of perinatal morbidity and mortality due to a greater number of twin pregnancies from IVF [19]. Worldwide, about 25% of pregnancies conceived by ART are twins [20]. In general, based on the data we have, morbidity and mortality of surviving newborns could be lessened by reducing the multiple gestation pregnancy to one life. This solution, however, carries its own risks relating to the carrier’s health and the contested moral status of both carrier and fetus. Even when considering singleton pregnancies, compared with spontaneously conceived children, fetuses from IVF pregnancies experience more preterm births, lower birth weight, and perinatal mortality [21]. It is unclear whether fetuses from twin or singleton pregnancies carried by a gestational surrogate are at any greater risk than those carried by the genetic mother. One advantage conferred to fetuses of IVF-surrogacy is a lower incidence of low birth weight births compared with those born following conventional IVF [22].
The impact of international surrogacy on maternal−child health remains poorly defined and deserving of further attention. The potential harmful effects of international surrogacy on donors, carriers, and children should cause us to question whether the risks outweigh the benefits. It may be that the satisfaction childless parents feel and the financial compensation given to carriers still do not justify the potential consequences. 4. Ethics The relatively unregulated market of international surrogacy requires careful and critical ethical reflection about the potential for exploitation and abuse. Not all peoples have the same freedoms and autonomy in a legal or practical sense. For some, societal and economic constraints may functionally limit liberties guaranteed by law. Ethical concerns relate not only to autonomy and free choice, but also to philosophical and social paradigms regarding issues of human dignity, the value of women, and their commodification. 4.1. Autonomy and justice Many high-resource nations uphold liberty, choice, and the freedom to contract. In the international setting of surrogacy, commissioning couples enjoy these freedoms with the added benefits of significant savings and a reduced likelihood of the gestational carrier claiming maternal rights to the child. This arrangement also benefits the surrogate who receives significant financial compensation, in some cases garnering in nine months what can take as long as 15 years to earn [23]. This empowers poor women to use their bodies as they choose and to care for their families, pay off debt, and save for their own children’s future [24]. On the other hand, the financial compensation is not necessarily what is purported by surrogacy agencies, with carriers receiving only a fraction of what is claimed. Some fear that a lack of regulation could cause a price war for surrogacy, with countries underpricing fees and weakening legal protections for gestational carriers. Furthermore, if the practice of international organ selling is any indication, then the majority who vend their body to repay debts will have no economic improvement, may not be compensated the amount quoted, and experience deterioration of their general health [25,26]. Though the majority of citizens in the USA and Europe enjoy significant freedoms, privacy, and legal protection from exploitation and abuse, many women in resource-poor countries, such as India, do not benefit from similar philosophical, political, and legal frameworks. The assertion that Indian women are entirely and freely choosing to subject themselves to the risks of pregnancy without its natural rewards is misguided. The vulnerability of surrogates and the potential for trafficking led the European Parliament to write a resolution asking Member States: “to acknowledge the serious problem of surrogacy…[and] emphasize that women and children are subject to the same forms of exploitation and both can be regarded as commodities on the international reproductive market, and that these new reproductive arrangements, such as surrogacy, augment the trafficking of women and children and illegal adoption across national borders…” [27]. Additionally, whereas gestational carriers in the USA and Europe are granted freedom, autonomy, and legal rights to make healthcare decisions (i.e. whether to abort), women in resource-poor countries do not have such guarantees. In the USA, the American College of Obstetricians and Gynecologists (ACOG) recognizes that surrogate mothers retain sole autonomy for “consent regarding clinical intervention and management of pregnancy, labor, and delivery…” and that the obstetrician is obliged to “make recommendations that are in the best interests of the pregnant woman and her fetus, regardless of prior agreements between her and the intended parents” [28]. By contrast, in India the Assisted Reproductive Technology (Regulation) Rules 2009 states that a gestational carrier must agree to relinquish all parental
Please cite this article as: Knoche JW, Health concerns and ethical considerations regarding international surrogacy, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.03.020
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rights concerning the child and agree to undergo fetal reduction if she is carrying more than one fetus [29]. The ART (Regulation) Rules 2010 states it more mildly: if a multiple gestation pregnancy occurs, the ART clinic “may carry out fetal reduction after appropriate counselling” [30]. It seems that we are caught in what Margaret Radin calls a double bind. On the one hand, by forbidding international surrogacy, we paternalistically encroach on a surrogate’s freedom to contract. She may prefer this position of surrogacy to other choices in life and by denying her this opportunity we oppress her and remove prospects to better her life. On the other hand, by permitting surrogacy we perpetuate the unregulated marketing of a woman’s body for a service and thereby objectify her, reduce her human dignity, and foster an inferior conception of flourishing [31]. In such a double bind, what ought to guide us? The notion of justice provides further guidance in assessing the ethical merits of surrogacy. Justice calls attention to the unfairness of exploitation of disadvantaged women as reproductive machines. In markets, however, the values of utility and liberty can crowd out the importance of justice. This should cause us pause about introducing a commercial market in international surrogacy when there are major inequalities in advantage, wealth, and sociopolitical protections. This is part of the reason why the USA forbids payment for organ donation. The rich should not be allowed to satisfy their health wants through the desperation of the poor. Furthermore, whether one views the surrogacy service itself or the child as that which is for sale, it is unjust and demeaning to separate the reproductive process from the child and to say that one can sell the service without it affecting our view of the child [32]. This can be illustrated by asking ourselves what an agency might do if the child comes out “defective.” Is there a money-back guarantee for this item? Such a view is unfair to our humanity and the value of persons. 4.2. Commodification and the market: Threats to human dignity On a psychological and philosophical level, the acceptance of international surrogacy requires an alteration of the view of a woman and the process of reproduction. The international market of industrialized reproduction necessitates the uterus to be viewed as a mere commodity—something distinct from the whole woman. Within this market-oriented mentality, the commodity of a womb is fungible (i.e. any one of them can be substituted for any other similar commodity, given that the quality and price are the same). Thus, a gestational surrogate is essentially seen as a glorified incubator. Carriers become commodities. To view human persons as parts or commodities primarily for our use and exploitation is dubious. No human being—or her parts— should be treated as a commodity precisely because we are whole subjects, not fragmented organs. When humans are viewed primarily as objects for amusement, experimentation, or manipulation, grave atrocities have been committed. Thus, to view and treat a woman as a mere incubator belies her dignity and worth as an individual person and defies the core tenets of international human rights. Furthermore, international surrogacy is a coalescing of the market mentality and globalization combined with modern notions of reproductive choice and reproductive industrialization. IVF, gamete catalogues, commercial surrogacy arrangements, and efforts to create an artificial womb reflect low-cost ways to fulfil our reproductive consumerist dreams. Harvard political philosopher Michael Sandel writes, “we live at a time when almost everything can be bought and sold… We have drifted from having a market economy, to being a market society” [33]. By employing market rhetoric to define individual rights, we think of inalienable freedom as having control over how to maximize overall gains. People are thus free to buy, rent, or sell commodified objects and body parts to maximize monetizable wealth. However, the ability to buy or market anything may not actually equate to freedom. What is an inalienable right should be based on our understanding of human flourishing. By answering issues surrounding international surrogacy based on the question of “how much?” we unreflectively
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follow our desires and dreams without considering its impact on the very nature of our humanness. While a general commitment to reproductive choice in highresource countries is well established, values such as free choice, personal autonomy, and privacy may not be transferable in an international setting where different cultures, traditions, and pluralistic notions of life exist. The begetting and rearing of children and the relationships of those involved may suffer when reproduction is industrialized and commercialized. In a society with few technical limitations whose mindset is overwhelmed with making, the free choice to create children in order to satisfy a want or deep desire may predominate. This desire can take the ugliest form when the child itself is viewed as a commodity. For instance, in 2008, baby Manji was left parentless after a Japanese couple divorced in the middle of the surrogate pregnancy and the Indian carrier refused taking the child as her own [34]. This unfortunate scenario demonstrates how surrogacy turns reproduction into a market function that reduces persons to refundable goods. Societal and communal concerns, therefore, may be right to constrain reproductive choice especially when begetting children is reduced to creating with modern medical technology. Furthermore, society and couples ought to consider whether childlessness should be an opportunity to exercise consumer rights or to demonstrate an important expression of humanity—rearing and caring for a child who is not their genetic offspring. 5. Conclusion Childlessness is a problem faced by a significant number of people throughout the world. The deep loss couples experience cannot be minimized. Fortunately, medical advancements and technological prowess have overcome many impediments to fertility. However, attempts to create genetically related children by utilizing international surrogates have opened the door not only to more cost-effective treatment, but also to unknown health risk. Further investigation and research is thus required into the hazards that gestational carriers and children face as a result of IVF, particularly in the international context. Beyond the potential harms to public health, we must consider the potential exploitation and abuse of gestational carriers who live in lowresource and poorly regulated countries. Perhaps equally concerning is the market mentality that enables “value free” decisions that commodify carriers. This objectification similarly shapes our understanding of “having” children as if they were market goods. The international surrogacy enterprise thus denigrates our view of humanity. In the end, we must ask ourselves whether the elation childless couples experience following the birth of a genetically related child is sufficient to offset the health risks, the violation of a surrogate’s autonomy and her potential exploitation, the commodification of her person, and the resultant alteration of societal values. Conflict of interest The author has no conflicts of interest. References [1] Boivin J, Bunting L, Collins JA, Nygren K. International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical Care. Hum Reprod 2007;22(6):1506–12. [2] Spar DL. The Baby Business: How Money, Science, and Politics Drive the Commerce of Conception. Boston, MA: Harvard Business Press; 2006. [3] Hague Conference on Private International Law. A Preliminary Report on the Issues Arising from International Surrogacy Arrangements. http://www.hcch.net/upload/ wop/gap2012pd10en.pdf. Published March 2012. Accessed August 10, 2013. [4] Ber R. Ethical issues in gestational surrogacy. Theor Med Bioeth 2000;21(2):153–69. [5] Williams I, Kress R, Williams I, Kress R. A baby made in India: a couple’s dream comes true. http://todayhealth.today.com/_news/2012/05/28/11883566-a-babymade-in-india-a-couples-dream-comes-true. Published May 28, 2012. Accessed August 10, 2013.
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