Surrogate motherhood: the case for commodification

Nicole Kidman and Keith Urban have one. So do Elton John and David Furnish, and that woman in the New York Times. 

They all have children borne by surrogate mothers.

In Canada, as in the UK, Australia, France and several other countries, it is illegal to pay surrogate mothers for anything more than their expenses -- food, living costs, forgone wages, and so on.

Canada's ban was prompted by the recommendations of the 1993 Royal Commission on New Reproductive Technologies, which emphasized the potential harms of commercialization (p. 676):

Those who hold that commercial preconception arrangements should be prohibited believe that they are inherently exploitive; that they treat children as commodities; that they are dehumanizing and degrading to women and their reproductive capacity; that they are harmful to the participants and to children born as a result of these arrangements; that they foster harmful social attitudes about the role and value of women, children, and families; and that they reinforce and perpetuate sexual inequality in our society . They also point out that such arrangements have significant implications for the gestational woman,...

There is good reason to be concerned about exploitation. Surrogate mothers typically have fewer resources than the commissioning or intended parents. In India one study reports that "women are typically pressured into the socially unacceptable job of surrogacy by their economic conditions, and sometimes, by their own families desperate for income." In the US the typical surrogate is white, Christian, married, from a modest (but not poor) working-class background, with children of her own. Commissioning parents are, by definition, those able to pay tens or hundreds of thousands of dollars for a child. 

If surrogacy was something that we could ban - like, say, the mining and export of asbestos - there are reasons to do so: the potential for exploitation, and the risk of psychological or physical harm to one or more of the participants.

But the practice of surrogacy dates back to biblical times:

And Sarai Abram's wife took Hagar the Egyptian, her handmaid, after Abram had dwelt ten years in the land of Canaan, and gave her to Abram her husband to be his wife.

(Even back then, the arrangements didn't always work out.) Anything as easy to arrange and difficult to detect as traditional surrogacy, that is, fertilization using donor sperm and the surrogate's egg, is hard to ban.

Moreover, now that there is an established international surrogacy industry, anything less than a coordinated global ban on surrogacy will be ineffective or counter-productive. The current bans on payments in the UK, Canada, and elsewhere, to the extent that they make it harder for would-be parents to find local surrogates, increase the likelihood that such parents will seek out surrogacy services in India or other countries where protections for women are weak.

Also, there are real benefits to surrogacy arrangements, and people who are genuinely happy to be surrogates - if one of my sisters had needed me, I would have volunteered gladly. The joy that surrogacy arrangements can bring to so many people argues against a blanket ban.

Surrogacy is here to stay. The question is: to pay or not to pay? 

Adverse selection is a good reason not to pay for donations of blood or sperm. The story of donor 150 (see this movie trailer) is a case in point. Donor 150 was six foot tall, good looking, a musician, a dancer and a philosophy major. His sperm was so popular -- and his other sources of income so meagre -- that he donated about 500 times. What donor 150 did not disclose - simply because he was never asked - was a family history of alcoholism and mental health issues. It's the classic adverse selection problem: if you pay for sperm donation, you'll end up with donors who donate for the money. And that may not be the kind of sperm donor you want.

Yet there are far fewer reasons to believe that adverse selection is a problem for surrogacy. Payments to surrogate mothers in the US are around $22,500 to $25,000. Going through hormonal and in vitro fertilization treatments, carrying a baby or two for nine months (in vitro fertilization raises the risk of twins), and giving birth is a pretty tough way of earning $25,000. That alone makes adverse selection problems relatively unlikely. Moreover, monitoring of surrogates through nine months of pregnancy reduces the problems of adverse selection further.

Indeed, being a surrogate is so demanding that non-payment could lead to adverse selection problems, that is, you'd have to be crazy to do it for free. 

While writing this post I came across the blog of someone I'll call Jasmine (I've chosen not to include a link). Jasmine is 19 years old. She is now in the second trimester of her surrogate pregnancy, and she already has two children of her own. By my reckoning, she became pregnant as a surrogate when her youngest was five months old. She chose to become a surrogate in part because she had close family members who had trouble conceiving, and in part because, after experiencing childbirth, she knew that she was capable of giving up her own child. She describes the birth of her firstborn as being like a movie or a television show, like watching someone else's baby being born. Jasmine makes no mention of payment in her blog, and since she lives in Canada, it is entirely possible that she is an altruistic surrogate. 

Others choose to volunteer for surrogacy for quasi-religious reasons. The Surrogacy in Canada On-line website suggests that women volunteer for  altruistic surrogacy because they 'feel they have a "calling" to carry a child for someone else.'  The same sentiments are echoed by one Christian surrogate mother-blogger who feels that being a surrogate is like being called to preach, an act ordained by God (again, I have chosen not to link). 

Then there is the rarely discussed side of new reproductive technology: eugenics. For example, a recent article on a Ukrainian surrogacy website announces Australian Ethicist Stands Up For A Smarter Society Via Genetic Embryo Screening. This thoughtful critique of surrogacy emphasizes the racial politics of reproductive technologies: "the high-tech frenzy to conceive has been whipped up by alarm over the falling birthrate of white career women." (emphasis added). Scary stuff. I would be happier knowing that someone was choosing to become a surrogate just for the money! 

Many people appear to be of sound mind and body when they choose altruistic surrogacy, like this sister and this grandmother. But certainly there are reasons to doubt that relying on altruism completely solves adverse selection concerns.

Another good reason not to pay surrogates would be evidence that altruistic surrogacy is psychologically or physically better for the woman involved. There is remarkably little known about the psychological impacts of surrogacy, but it is not hard to find illustrations of the risks surrogates face.

The most recent post by Jasmine, the 19-year old surro-mom introduced earlier, is a case in point. Jasmine is pregnant with twins, and has just been diagnosed with pregnancy-induced hyperthyroidism. With her two young children, she is overwhelmed by household chores. She and her partner are thinking about separating. She is still sympathetic towards infertile couples who don't have a lot of money, but her idealism has faded. Next time, she will be making sure that SHE gets something out of it. 

The psychological risks of surrogacy are as serious as the physical ones. One good reason for banning payment would be that altruism is psychologically protective. Although data on surrogate mothers is relatively scarce, one study I found reached the exact opposite conclusion. Payment helped protect women from forming a strong attachment to the baby. In the words of a surrogate interviewed during the research: "I feel the surrogate needs to have that to latch onto emotionally. I am doing the job, I am being paid to do a job, to keep the emotions a little bit at bay."

Advocates of altruistic surrogacy can point to an alternative strategy for psychological protection: the surrogate mother bonds with the intended parents and the new family she helps to create. Yet this ignores the psychological needs of the intended mother. Whether she feels jealous or threatened or guilty or just uncomfortable crossing the socio-economic gulf that separates her from the surrogate, it is more than likely that, as in this story, the intended mother will wish to distance herself from other mothers (surrogate, gestational,...) over time. As a psychological crutch, bonding with the intended parents is unlikely to work over the long term.

Moreover, the idea that the surrogate bonds with the new family she is helping to create ignores the fact that she almost invariably has a partner and children of her own. Her own family's financial needs can put a woman on the path towards surrogacy, as in this Ukrainian surrogate's story: "My mother was seriously ill and we needed money for her surgery." Is it totally unreasonable to think that a woman's family, and especially her husband, will be more supportive of her journey through surrogacy if they can see some concrete benefit? That a woman who is seen to make a substantive financial contribution to the family will have a higher status? That knowing she is doing something that will set her own children on a path to a better life - pay for their education, say - will make it easier for a surrogate mother to part with her newborn?

(As an aside, religious faith, and the belief that one's surrogacy is a calling, may also be psychologically protective for surrogate mothers, but this is just speculation).

In sum, the little that we know about the psychology of surrogacy provides no evidence to support the contention that altruistic surrogacy is less psychologically damaging that commercial surrogacy.

A final argument against paying surrogates is commodification: commercial arrangements treat children as commodities, things to be bought and sold. (As an aside, it is ironic that Canada's commission speaks of commodification of children, as if children were something  separate and separable from the woman who carries and gives birth. This alienates the child from the mother, and every good Marxist knows that alienation is the first step in commodification). Let me explain why concerns about commodification are misplaced.

First, it is not at all clear why the payment of surrogate mothers commodifies life any more than the payment of nurses, doctors, lawyers and all of the other folk who make a living in the reproductive technology business.

Second, one has to ask, as Naila Kabeer does in this excellent analysis of women's empowerment: what are the alternatives? Is meaningful, rewarding work that does not involve commodification on offer? If not, that is the problem, not the availability of commercial surrogacy.

Third, process of commodification begins when a worker experiences alienation - she is separated from the product of her labour, and from the act of production.

Not one of the articles that I have read about surrogacy and commodification has noticed: this is the point of surrogacy! The surrogate must separate herself from the child she is carrying, she must be ready to give him or her up. If payment for surrogacy, by alienating the child from the gestational carrier, makes that separation easier, then it is a good thing. 

People often risk their bodily integrity for the good of others: soldiers, participants in medical trials, workers who clean up toxic or hazardous materials.

In Canada there is no conscription - people who do such jobs are volunteers. But they are compensated for the dangers that they face. 

As surrogate mothers, too, should be compensated.

 

Comments

[Patrick]

I recently heard a medical ethicist (a woman) on CBC radio talking about surrogacy. The story was about a disastrous situation where the lab in India screwed-up and one child of a pair (can't really say twins as you'll see) was not genetically related to the parents (donated eggs, fathers sperm, surrogate gestation). The Canadian government refused to issue citizenship papers, and the parent refused to abandon the child. They're in limbo, have exhausted their savings, and are faced with the real prospect of chosen between ruin and abandoning the child (which they apparent refuse to do). I think they where an older couple, 'cause if it was me I'd have thought about moving to India (but I suppose not everyone is up for that!).

Putting aside that particular case, the ethicist said that the solution to the problem was to criminalize traveling abroad to use surrogacy, and she essentially argued it was immoral and exploitive to exchange money for surrogacy services. Period. Full stop. I could just imagine the result of criminalization: couples desperate to have children arriving in Canada being tasered and arrested by the RCMP, their newborns deported back to 3rd world orphanage while they are prosecuted and thrown in jail.

It was clear that the ethicist took as given that the surrogate was by definition being exploited by exchanging money for surrogacy services. She wasn't arguing that they weren't being paid enough. It was the fact that they were being paid AT ALL that bothered her. There was mention of the fact that surrogates where often not well treated, but that wasn't her bone of contention. It was the fact that money was changing hands that, according to her, made the whole things just plain evil. She never made the case for why this MUST be true, and I remain unconvinced. I can easily imagine situations where a healthy but poor young woman would gladly exchange carrying a child for a big chunk of money.

In any case, it seems to me that this is a situation where sunlight is the best disinfectant. A regulated, transparent market where mutually beneficial exchange takes place has to be better than throwing people in jail or shadowy third world operators running stables of human heifers.

[Patrick]

Aha! Found it. Here's the CBC radio show I was talking about above:

http://www.cbc.ca/thecurrent/episode/2010/12/17/assisted-reproduction

[Frances Woolley]

Patrick, thanks for the comments/link.

In some ways hope is the most brutal thing to come out of the Pandora's box of new reproductive technologies. The hope that somehow, somewhere, sometime, if one just tries hard enough, it is possible to have a child of one's own.

But now that we've opened up that whole can of worms the only thing left to do is, as you say, open it wide and let the sun shine in.

[Determinant]

Is economics the science of deontological argumentation?

Grr, the arguments used in favour of surrogacy, namely that "it's common, people pay for it, and there is some utility to be derived from it" can also be used to describe the institution of slavery in the 19th Century. We outlawed slavery as a moral wrong. Why are we allowing them to be used for surrogacy?

Is there some irreducible and necessary connection of motherhood, of family life that should not be given a price signal? Yes, on moral, ethical and religious grounds.

[Kien]

Hi, Frances. Doesn't your argument about exploitation apply equally to child labour in developing countries? Yet (correct me if I am wrong) my impression is that economists generally argue that children are better off working in factories than going hungry. Or have I mischaracterised the position of mainstream economists who are proponents of free trade?

Just to be clear, I'm not arguing in favour of surrogacy. But it seems to me that exploitation of child labour is more harmful than exploitation of surrogacy. Child labour seems detrimental to the long-term development of an economy that depends (even partially) on child labour.

[Blikktheterrible]

"Is meaningful, rewarding work that does not involve commodification on offer? If not, that is the problem, not the availability of commercial surrogacy."

This is a point that SHOULD be made in many policy discussions, but rarely is. Many occupations, in brothels, sweatshops, and elsewhere, are often deemed undesirable to the point of moral offense. People sensibly assert that a world in which no one had to do those jobs would be better than one in which individuals did. The tricky bit is how we can get (closer) to that better world. A ban is the most straightforward and easy method of attack, but it generally fails spectacularly at addressing the underlying problem.

[Frances Woolley]

Kien - actually, banning child labour generally fails spectacularly. What works is compulsory schooling, programs that pay parents to send their children to school, programs that provide food for children at school, etc. The problem with child labour is not the work itself (my kids have worked since they were both about 12 or 14 because they wanted to, and it's been good for them). The problem is the terms and conditions of employment. Fortunately - although child labour is still a serious problem - there are proven strategies that work to reduce its prevalence.

Determinant - we ban slavery. And perhaps we should ban all surrogacy also. Or ban all surrogacy by non-related individuals (I'd still like the option of helping my sisters out). The best argument against a global ban is the joy surrogacy gives to others.

Consider that phrase in your last sentence: "irreducible and necessary connection of motherhood, of family life." Surrogates are being asked to have a child and *not* connect with it. It is inconsistent to argue that motherhood involves some kind of necessary connection (between, say, mother and child) and ask women to give up the child they have carried in their womb.

What puzzles me is why paying surrogates makes the arrangement *more* like slavery. Surely paying surrogates would make it less like slavery?

Blikktheterrible - Agreed.

[Patrick]

Determinant, that's a spurious analogy. Reasoning like that we would claim that work must be immoral because slaves do it.

[Bee]

Perhaps I'm overly sensitive (I'm pregnant right now) but as a woman from a low-income background, the idea of allowing someone to pay for the right to use women's bodies in such a way is absolutely horrifying. I know that I was in the demographic that would end up playing the Handmaid's role.

Would you allow surrogates to be held in breach of contract if they changed their minds? Do you force women to continue pregnancies they don't want? Do you force them through economic pressure (they've devoted four months to a pregnancy that has made them so ill they've stopped working and can't return any deposit the prospective parents have given them)? Do you force them to terminate children the prospective parents deem unworthy (child diagnosed prenatally with some kind of disorder)? What impact that this have on women's reproductive rights in general?

What about medical risks? Are the prospective parents on the hook if something goes terribly wrong with the pregnancy and the surrogate is rendered incapable of having any more children or develops a different long term health complication? Are they on the hook for payment to her family if she dies?

Do the prospective parents have the right to police the surrogate's diet or activities?

The labour (haha) conditions are potentially TERRIBLE. In order for surrogacy to be ethical/minimally exploitive, there needs to be clear respect for a surrogate's autonomy. Paying for something lends a sense of entitlement that is completely inappropriate when it comes to someone else's body. If you could mitigate that through strict regulation, maybe it could work.

[Determinant]

Patrick:

It's not spurious. I'm saying if we allow morality to hold sway in one area, we have to allow it in in other areas like this debate. Work is not immoral because slaves do it, but the products of slaver and gaining by slavery, that is slave-owning, is immoral.

Frances is arguing from a deontological position and I am coming in and asserting a teleological one. In support of that I am showing other cases where teleological arguments won over deontological ones.

Frances:

Consider that phrase in your last sentence: "irreducible and necessary connection of motherhood, of family life." Surrogates are being asked to have a child and *not* connect with it. It is inconsistent to argue that motherhood involves some kind of necessary connection (between, say, mother and child) and ask women to give up the child they have carried in their womb.

What are you trying to argue here? I'm saying surrogacy, particularly paid surrogacy, crosses the line and brings up all the issues that Bee kindly laid out. Yes, it is too far. I'm not inconsistent.

Consider adoption. Do we allow women to be paid to give birth to babies and then put them up for adoption as a commerical activity? No.

[Frances Woolley]

Bee:

In answer to a few of your questions: One of the reasons that India is so popular as a surrogacy destination is that surrogates have no legal right to the child that they carry. States in the US vary in terms of their recognition of surrogacy contracts - one of the issues for surrogate moms is that their travel is limited, as their contracts generally specify that they must give birth in a particular state (what happens if a family member becomes gravely ill in a state where surrogacy is not legal and the surrogate mother's contract says she's not allowed to travel?). It is, in general, a legal nightmare.

People generally write a policy about termination into the surrogacy contract. Given that many surrogates have strongly held Christian beliefs, they often will not consider termination under any circumstances, and so this is discussed beforehand, as the intended parents often want a 'reduction' if, say, four embryos are successfully implanted.

Formal surrogacy contracts generally include insurance coverage in case of, say, death, but I'm sure it would be impossible to get coverage for, say, post partum depression. Pregnancy complications are often covered under the surrogate mother's insurance if she has an insurance policy, and women who are covered with health insurance will typically receive a higher fee for their surrogacy.

In response to: "the idea of allowing someone to pay for the right to use women's bodies in such a way is absolutely horrifying"
*what is the alternative?*
- Indian and Ukrainian women's bodies can be used that way, but not Canadian women's bodies?
- We use moral suasion to convince potential surrogates that this is a noble, altruistic sacrifice?
- We push surrogacy underground?
None of these are good alternatives. The moral suasion/language of sacrifice and altruism makes me particularly angry - it's such a cheap trick on idealistic and naive people.

It is precisely when surrogacy is seen as labour and NOT bound up in the some kind of myth of noble sacrifice that we might start getting some answers to hard questions. These are the kind of things that I would like to know:

- what percentage of gestational surrogates end up with twins or multiple pregnancies?
- why is it the gestational surrogates medical insurance, rather than the intended parents' medical insurance, that ends up paying the pregnancy bills (in the US)?
- does egg donation affect the timing of the onset of menopause? Does it have long term impacts on women's fertility?
- what percentage of surrogates end up suffering from post-partum depression?
- what percentage of surrogates end up experiencing mental health issues one, two, ten, twenty years down the road?
- what percentage of surrogates maintain contact with the intended parents five, ten, fifteen years down the road?

Only if we have an open, regulated, legal surrogacy system, with long term tracking of the health of surrogates and egg donors, will these kinds of questions ever be answered.

We agree on the need for women's autonomy. I would argue that when women are being paid to do something, they will think "O.k., what does this involve, and what is a reasonable compensation?" Instead, we either send people off to places where women have even less autonomy than they do here, or pretend that this is something like donating blood or signing an organ donor form, something that it's reasonable to ask a person to do.

[Mandos]

This is an argument based on the idea that people will continue to engage in an objectifying behaviour, so we need to compensate the (permanent supply of) victims rather than end the objectifying behaviour.

I'm not necessarily criticizing here; but it's practically the norm for intra-progressive flamewars on the Internet to focus on whether we can end objectification or take the liberal stance that objectification will always be with us and we need to find ways to make it safer...

[Patrick]

Why is it necessarily objectifying or exploitive? People willingly engage in all sorts of activities in exchange for money that are risky and frought with emotional turmoil and yet we don't say it is immoral: police, fire fighter, soldiers, coal miners, techs in a nuke plant, drug trial volunteers, just to name a few.

As Francis points out, the only way to deal with all the hard issues is to actually deal with them. The genie is not going back in the bottle.

[Luis H Arroyo]

I din´t like it. The idea repulse me. I am perhaps very conservative, but I belive in blood links.
I´d prefer a direct insemination of the male in the female, BTW. As in the Bible case. Is not a hipocrisy the modern way?

[Patrick]

Luis: Of course, the problem is there are couples who have no success with the usual method of reproduction, and if they have money ... well, enough money can solve most problems. Personally, I'd agree that there are probably better ways to get babies - adoption comes to mind - but people really, really want babies who share their DNA.

At least in Canada the direct 'biblical' method of inseminating surrogates isn't going to fly. Communicating for the purposes of exchanging money for sex is illegal (though actually exchanging money for sex is not - go figure), so you could go to jail for trying to arrange such a thing. You need the turkey baster middle-man to make it all legal.

[Mandos]

Patrick,

Well, that's kind of what this whole discussion hinges around. Whether or not there is a dimension in which pregnancy is different from risky professional choices. There's a lot of reason to say that it is, that how we think about women's, um, labour and the way in which childbearing is both fetishized and taken for granted puts an added moral weight on its commodification.

[Patrick]

"Whether or not there is a dimension in which pregnancy is different from risky professional choices"

I don't see that there is any inherent difference from other things human do with their bodies for money. Strong men can lift big stones. Women can produce babies. In my view if we say there is a difference, then it's because we say there is, not because there is something inherently different. There may be others reasons to treat them differently, and there is precedent for that. For example we don't regulate all labour identically.

But I do realize that my view is largely formed by the fact that I'm a 30-something white male atheist - not a particularly representative demographic.

[Mandos]

In this case women have been expected throughout history to do this kind of labour for free, with compensation in large part remitted...emotionally (even when such was not actually present it was presumed as a matter of course that it was there). Nuclear techs do not, um, have this history. And there was never any long cultural history of people being kidnapped to work as nuclear techs.

Surrogacy purports to replace the traditional emotional compensation for pregnancy with another form of compensation. Insofar as we are dealing with a form of labour that was considered not economically valuable enough to significant merit payment in most cases, I think the sorts of gendered exploitation that could exist even under "fair" compensation are worth considering.

[Patrick]

Mandos: I don't agree, but to some extent I'm not comfortable arguing over women's reproductive rights too vigorously because no matter what I'll never be subject to any position I take. There's something a little ... odd ... about two men duking it out over this. As I mentioned earlier, I do think the genie ain't going back in the bottle, and I'd hate to see people put in jail for wanting to have children. In light of that, bringing it out into the open and dealing with the issue openly seems to me to be the only way. Call it harm reduction if you want.

[Kien]

Hi, Frances. Thank you for pointing out that compulsory schooling plus income support is more effective than banning child labour. I think that is right. I also like your point that the problem with child labour is not the work itself, although I think the context makes a difference. Your kids aren't forced to work, and they probably enjoy the work and become better people through the experience. (They probably also get to go to school at the same time.) In a different context where the child hates the work but is forced (by the lack of better alternatives) to work, the child may not only find the experience distressing, but end up harmed in a permanent way.

If there were an effective global convention against "exploitative" child labour in developing countries, this could encourage governments to make the long-term investment in compulsory schooling and funding universal education for children. The global ban would reduce the opportunity cost of the long-term investment in human capital.

Having said that, I appreciate that it would be prudent to approach the issue of child labour locally and in an experimental way. Perhaps a global ban on child labour is not the way to go; neither (I would argue) is it good policy to permit child labour everywhere at all times. Perhaps there could be a global ban on child labour, but the World Bank (in consultation with the ILO?) could grant (say) 5 to 10 year exemptions from the ban to countries that (say) implement compulsory schooling and fund universal education for children (perhaps with assistance from the World Bank). Something like that.

[Determinant]

Margaret Somerville has publishes an article on surrogacy in Saturday's Globe & Mail. Very timely for this thread.

[Linda]

Margaret Somerville's article was an eye-opener for me: I was shocked by her reference to the "natural family" to which each child should be entitled. (Yes, I am paraphrasing, but I no longer have the article in front of me.) I have problems with surrogacy, as I do with prostitution; many, but not all, I think, would disappear if we could ensure that all who entered into these activities were actually "choosing" to do so, in the sense that economists usually discuss choice. As I see it, our version of choice applies to people above "subsistence levels", however we define that; I'd start with some guaranteed minimun income level, and insurance. Somerville's "natural family" comment made me realize (again) that although I cannot say I support surrogacy, I do not agree with all of the people who take a stand similar to mine.
Fran: I liked this posting, and meant to respond earlier.

[Frances Woolley]

Linda, yes, well. That's why I felt I needed to write this - the debate has been dominated by Margaret Somerville for a long time.

I'm not sure that I like surrogacy either. But I really *don't* like the model of surrogacy-as-noble-sacrifice. And I especially don't like the model of surrogacy-as-noble-sacrifice-streamed-live-on-youtube.

Surrogacy (and egg donation also) are not like donating blood. Donating blood is a little bit uncomfortable, but for 90% or 99% of the population is totally harmless, and might in some cases actually be good for you. They're not like signing an organ donor card, when nothing happens until you're no longer around to be bothered. They involve serious health risks to the gestational surrogate or egg donor. There is case for an outright ban - I'm a little on two minds on that one.

Failing that, requiring adequate compensation - like we do for soldiers or astronauts or firefighters or other people who put their lives and health on the line for others - seems reasonable.