Hello everyone and welcome to this week's blog post. In this article, I will be discussing surrogacy. I will first explain what surrogacy is before summarising the main legal and ethical concerns with its practice.
What is surrogacy?
According to the Human Fertilisation and Embryology Authority in the UK, surrogacy is 'when a woman (called a surrogate mother) carries and gives birth to a baby for another person or couple'. This arrangement is usually accompanied by a legal agreement which stipulates that the surrogate mother does not have any claim to the child after birth.
Surrogacy is quite common in cases where pregnancy by traditional methods is not possible. For example, surrogacy is sometimes used in situations where pregnancy would be too dangerous for the mother, where one or both of the partners are infertile, or where both partners are male.
There are two different types of surrogacy. The first is called traditional surrogacy. This is where the surrogate's egg is fertilised by the father or a donor (this can be done by artificial insemination). The child is then adopted by the intended parents. The second type of surrogacy, which is known as gestational surrogacy, is when an embryo is formed by in vitro fertilisation. This is where eggs are removed from a woman's ovaries and fertilised with a male's sperm in the laboratory. These embryos are then implanted into the surrogate's uterus. The hope is that one of these embryos successfully implants into the uterus lining, thus allowing pregnancy to continue as normal. Gestational surrogacy can be performed using the gametes from the intended mother and father, as well as from donors.
The risk of medication complications for traditional surrogacy is no different from normal pregnancies. For gestational surrogacy, risks are similar to babies born via IVF, in that many foetuses many develop, resulting in multiple births (and thus a higher risk of complications such as premature births, birth defects and gestational hypertension).
What are the main ethical considerations of surrogacy?
One of the main ethical concerns with surrogate pregnancies is to do with beneficence. This principle outlines how doctors should always act in the best interests of their patient. Surrogacy could be seen to go against this principle, as pregnancy can be very dangerous for the mother.
Despite recent advancements in medical knowledge, which have drastically reduced the frequency and severity of complications, Johns Hopkins estimates that around 8% of pregnancies result in a complication which could cause harm to the mother or the baby. These complications range from UTIs to potentially fatal ectopic pregnancies. In addition, according to the World Health Organisation, there were between 291,000 - 349,000 cases in 2015 where the mother died during childbirth. Consequently, as surrogacy places the expectant mother at risk, it is not medically in her best interests.
Surrogacy also has similar ethical concerns to IVF, in terms of the debate regarding unused embryos. While some would say that embryos do not have the characteristics required for personhood, there is significant pro-life opposition to IVF and surrogacy. This is because the unused embryos are often discarded after a course of treatment is completed.
In addition, surrogacy can also cause issues with the principle of patient autonomy. This principle states that patients must be able to make informed decisions by themselves; they can't be coerced or forced into making a decision. In the UK, the law attempts to uphold this principle by stating that surrogacy agreements can't be enforced. This means that the surrogate is the child's mother until legal parenthood is transferred (this occurs after birth through adoption). Consequently, surrogates can void surrogacy agreements at any point, even if they have already received payment.
In addition, the UK also restricts the payment a surrogate can receive to only cover reasonable expenses, thus reducing the risk of financial manipulation. What's more, in the UK, legal parenthood can't be transferred to the biological parents for six weeks after the birth of the child. This makes sure that the surrogate has enough time to make a decision.
Nevertheless, while these restrictions do partially protect the right to patient autonomy, they do not work for all cases. In particular, they don't prevent family or friends putting pressure on the expectant mother, in an attempt to influence her decision. Furthermore, while there are surrogacy laws in the UK, this does very little to influence how surrogacy is conducted in other countries.
Over the last few years, many couples have used surrogacy services offered abroad, in countries such as Cambodia. Unfortunately, it is very common for surrogates in these countries to be manipulated into joining these agreements. Indeed, according to GADC (a gender equality group based in Cambodia), women can be offered around $10,000 to act as surrogates for foreign couples. GADC also explains how these women often don't have many other options to earn a living, and thus have to risk the complications of pregnancy for the financial reward.
In an attempt to combat the rise of surrogacy in Asia, many countries (including India, Nepal, Thailand and Cambodia) have banned commercial surrogacy. As part of this crackdown, Cambodian authorities have prosecuted any women who participate in commercial surrogacy. While this has reduced the incidence of commercial surrogacy in Cambodia, this policy is not ideal, as there is a high probability that these women were coerced into these agreements. Instead, these laws should target those that organise these businesses.
The map above shows the legality of surrogacy in different jurisdictions. Those countries in which surrogacy is completely banned are shown in red.
In conclusion, I would suggest that surrogacy should be a highly regulated industry to ensure that the rights of the mother are protected. In addition, I also agree with the UK position that payment for surrogacy should only cover reasonable expenses. This would allow the risk of financial manipulation to be minimised. Furthermore, doctors and medical professionals involved with surrogacy should continually check with the expectant mother and ensure that no coercion is taking place.
Sources:
Trends in Maternal Mortality: 1990 to 2015 (Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division, https://apps.who.int/iris/bitstream/handle/10665/193994/WHO_RHR_15.23_eng.pdf;jsessionid=F7C57277C2064C4AAF19D5365AE36FE1?sequence=1)
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