There's a photo I often show my audience before starting my lectures on "reproductive tourism." It's from a marketing brochure of a fertility clinic in India, and features its medical director standing regally amongst a group of seated women, each with her face strategically concealed. These women are commercial surrogate mothers, whose wombs are for rent to wealthy Indians and foreigners alike. The word "stable" is sometimes uncomfortably used to describe such women, but effectively projects the problem many ethicists have with the practice, which some say reduces female fertility to something resembling an agricultural commodity.
The hiring of surrogate mothers is only part of the suite of services defining this emerging global sector. In vitro fertilization (IVF), sperm and egg purchase, sex selection, and a kind of genetic testing called pre-implantation genetic diagnosis (PGD) are the other popular products on offer. These technologies used to be the domain solely of the industrialized West. But in recent years, our globalized economy has made this a truly planetary phenomenon.
"Reproductive tourism" is the practice of infertile people crossing international borders to receive technologically advanced reproductive services. As many of us are waiting later in life to start families, as more same-sex couples are looking to create biological children, and as rising rates of obesity, diabetes and other chronic illnesses affect our ability to reproduce sexually without medical assistance, an increasing number of ordinary people are seeking to affordably access an expanding set of reproductive technologies.
Indeed, the international fertility trade is now big business, with India having recently emerged as the likely world leader in providing services -- most controversially the hiring of surrogate mothers -- at comparatively low costs. Depending on whom you ask, the Indian industry is worth somewhere between $500 million and $2.4 billion annually, and shows no signs of slowing.
The motivations of gamete donors and surrogate mothers are largely financial. An impoverished Indian surrogate can make $2,000-$10,000 per pregnancy, which is a life-changing sum for many. For the clients, the motivations for going abroad for services are a bit more varied. For many, it's reduced price: India's services can be 10 to 100 times cheaper than in the West. For some, it might be the touristic aspects of spending time in a vacation spot while creating a family. And for others, it might be the bypassing of domestic laws. Canada is one of the few countries that have a federal assisted reproduction law. It's illegal here to pay for sperm, eggs, or the services of a surrogate, and to select the sex of your child. So, if those services appeal to you, the Indian option is an attractive one.
While reproductive tourism may not affect as many people as other types of medical tourism (such as surgical tourism or organ transplant tourism), its relevance speaks to our fundamental social values. It subtends all the modern hot-button topics: life, death (through selective abortion), the changing definition of family, women's rights, same-sex rights, the limits of federal law, exploitation of the poor, the tendency for technology to outpace our legal system, the tension between autonomy and exploitation, and the uncomfortable marriage between commerce and medicine.
It's the latter few points that my research focuses on. In our recent paper, "Ethical concerns for maternal surrogacy and reproductive tourism" we attempted to elucidate some of the factors that make the maternal surrogacy industry ethically troubling to many people. On one hand, it's hard not to celebrate a desperately poor woman's opportunity to pull herself and her family out of poverty by exercising her autonomy over her body. On the other hand, there's no denying that when the poor and illiterate enter into a commercial relationship with people of greater wealth and power, there's usually more than a soupcon of exploitation involved.
We identified a variety of factors affecting the ethics of reproductive tourism, including whether informed consent (that thing that doctors must secure before performing a procedure on a patient) is really in play, whether the surrogate's health is sufficiently respected, the extent to which custody rights have been well considered, and whether the surrogates are indeed paid a global fair trade price. But one of the most interesting factors -- and one that may define how we look at a host of other global industries -- is the problem of mixing business ethics with medical ethics.
See, in a business negotiation all parties are required to only consider their own best interests, and whatever they end up agreeing to is by definition ethical -- assuming that no one was duplicitous in the negotiation. But in medicine, the clinician is required to always act in the patient's best interests. In maternal surrogacy, there's a paying client, a clinician, and a surrogate. It's the latter who's the actual clinical patient, but the business negotiation is between the clinician and the client, with the surrogate essentially acting as an independent contractor.
What this is means is that a business negotiation in this context essentially seeks to lower the value of the surrogate's health, as this is what defines a good return-on-investment for the client. The clinic is now conflicted: it is paid by the client, but must make decisions about the health of the surrogate, and indeed is ethically required to keep as paramount the value of her health. The nature of the commercial transaction means that the best interests of the surrogate are no longer first in the clinic's priorities, as defined by the ethics of business negotiation. This is a profoundly troubling conflict.
The manner in which we navigate a path through this conflict will ultimately inform how we deal with similar global issues that involve the collision of business with practices that are not traditionally businesslike; and indeed practices that are essential for defining the identity of the human animal, such as reproduction and family.