Inherent Problems with Commercial Surrogacy in India

The degree to which financial incentives can muddle ethical deliberation and practice is evident in the commercial surrogacy trade in Indian. For years, “rent-a-womb” services to foreigners has been “big business” indeed, generating nearly $1 billion annually.

Would-be Western parents, many from the U.K. and Scandinavia, argue that commercial surrogacy arrangements are a win-win situation for everyone. They get the baby they’ve longed for and the Indian women receive significant financial compensation. Surrogates typically are paid $6,000 or more to provide their womb. In a country in which average monthly earnings are $215, this is an extraordinary amount. The financial incentives for Westerners to do business in Indian fertility clinics should not be underestimated either. Costs for a surrogate birth in India total $15,000-$20,000, approximately one-tenth the price that would be incurred in a California clinic. What’s not to like about people desperately desiring a baby receiving one at a bargain rate, while desperately poor Indian women receive several years’ worth of income for nine-months work?

There’s plenty not to like about these arrangements. One of the greatest concerns is the exploitation of the poor who comprise the vast majority of surrogates. Free and informed consent by Indian surrogates may not be as free as it appears. In her recently completed Ph.D. dissertation on commercial surrogacy in India, Kristin Engh Førde argues that financial desperation has the potential to override genuine personal autonomy: “They are forced to make money for their family and their chances for succeeding are extremely low…Some have a major debt to pay, such as a hospital bill…Many feel that surrogacy is a chance they have to take. And it’s important for them to distance themselves from the choice. It was not something they wanted; it was something they had to do.”

Julie Bindel contends that commercial surrogacy represents an exploitation of women generally, not simply of poor women specifically: “As a feminist campaigner against sexual abuse of women, and in particular the sex trade, I feel sick at the idea of wombs for rent. Sitting in the clinic, seeing smartly dressed women come in to access fertility services, all I could think about was how desperate a woman must be to carry a child for money. I know from other campaigners against womb trafficking that many surrogates are coerced by abusive husbands and pimps. Watching the smiling receptionist fill out forms on behalf of prospective commissioning parents, I could only wonder at the misery and pain experienced by the women who will end up being viewed as nothing but a vessel.”

Fortunately, the Indian government has taken notice of the actual and potential abuses inherent in commercial surrogacy. After all, what country wants to be known as the bargain-basement destination for the exploitation of women and the poor? As of October, 2016, foreigners are prohibited from “renting” Indian wombs, though it is doubtful this official action will shut down the trade completely and permanently. Big money talks, whether the market is officially opened or closed.

On a personal note, I am distressed by the effects of commercial surrogacy in India. Having travelled to India often over the years, I’ve come to love the country and its warm, friendly, and hospitable people. It is evident to this visitor that Indians highly value parenthood and family. I can hardly imagine a practice that has greater potential to destroy the wonderful family dynamics I’ve observed in my travels than commercial surrogacy marketed to rich Westerners. I applaud the India government for taking the first difficult step, at significant economic loss to the country’s economy. In the case of commercial surrogacy, market forces cannot help but impinge virtuous ethical decision-making.

Thoughts on varied subjects: commercial surrogacy, professionalism, and Obamacare

A potpourri of stories from this week that prompted bioethical musings, in no particular order . . .

The BBC News website ran a fascinating, heartbreaking story this week about women in India who are paid to gestate other women’s babies: commercial surrogacy, a billion-dollar-a-year industry in India. The main figures in the story — a woman named Vasanti living in a dormitory for commercial surrogates, who is carrying a baby for a Japanese couple; and the doctor who runs the IVF clinic and dormitory — spend much of the story talking about how positive the practice of surrogacy is. Thus it is jarring — and revealing —  to get to the last sentence in the story, where Vasanti says, “. . .we want a good future. That’s why we [did] this, and not in my entire life do I want my daughter to be a surrogate mother.” (Italics mine)

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Last week’s JAMA ran a narrative by Gordon Schiff, MD, which begins,

It’s 5 PM on a Friday afternoon. After 2 hours on the telephone trying (and failing) to get her insurance plan to pay for her medication refill, I reached into my pocket and handed the patient $30 so she could fill the prescription. It seemed both kinder and more honest than sending her away saying, “I’m sorry I can’t help you.” While I hardly expected a commendation for such a simple act of kindness, I was completely surprised to find myself being reprimanded for my “unprofessional boundary-crossing behavior” after the resident I was supervising shared this incident with the clinic directors.

(If you have a JAMA subscription you can read the whole thing here, otherwise it has been reposted for free  here.) Dr. Schiff’s reflections on this incident are eloquent and worth reading and pondering. From the perspective of a Christian physician who also works with the underserved, I am saddened at how far our profession strays from its moral foundations when  a detached, medicine-as-business model replaces the self-giving care that Christ modeled.

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You may have missed it, but new provisions of the enormous law affectionately known as “Obamacare” went into effect this week with the beginning of open enrollment and the opening of online insurance marketplaces. The new law is extremely complex and promises to raise health insurance costs for many, including myself, at least in the short term. Lots of people are complaining about it, some more savagely than others. Many of my colleagues and patients have bemoaned it, and with good reason. But there is one group who have not complained to me about it at all: my patients who do not have, and until now have not been able to afford, health insurance.