Surrogacy in the Market of Desire

The State of Florida has spilled no small quantity of ink outlining the legal confines of gestational surrogacy (see particularly sections 742.13-742.17, here).  Legally permitted gestational surrogacy in Florida does not include “bringing in and harboring aliens, sex trafficking of children, forced labor and furthering slave traffic,” however; these charges were leveled against Esthela Clark in 2015. Clark had held a Mexican woman in her one-bedroom apartment, repeatedly inseminating her with semen from Clark’s boyfriend. When the woman failed to become pregnant, she was forced to have sex with two strangers, and placed on a diet restricted to beans.  On 29 March 2017, the 47-year-old Clark from Jacksonville, FL, pled guilty to one count of forced labor. The woman had been forced to clean Clark’s apartment. (See story here.)  What happened to the issues surrounding the smuggling of the woman across the border in order to be a surrogate for Clark and her boyfriend?

On the other side of the globe, India is arguably the world’s leading provider of surrogate mothers, with the industry estimated several years ago as “likely worth $500 million to $2.3 billion.”  India legalized surrogacy in 2002, and is now considering reining in its surrogacy situation:

     The Surrogacy (Regulation) Bill, 2016

 

  • The Surrogacy (Regulation) Bill, 2016 was introduced by Minister of Health and Family Welfare, Mr. J. P. Nadda in Lok Sabha on November 21, 2016.  The Bill defines surrogacy as a practice where a woman gives birth to a child for an intending couple and agrees to hand over the child after the birth to the intending couple.
  • Regulation of surrogacy:  The Bill prohibits commercial surrogacy, but allows altruistic surrogacy.  Altruistic surrogacy involves no monetary compensation to the surrogate mother other than the medical expenses and insurance coverage during the pregnancy.  Commercial surrogacy includes surrogacy or its related procedures undertaken for a monetary benefit or reward (in cash or kind) exceeding the basic medical expenses and insurance coverage.
  • Purposes for which surrogacy is permitted:  Surrogacy is permitted when it is, (i) for intending couples who suffer from proven infertility; and (ii) altruistic; and (iii) not for commercial purposes; and (iv) not for producing children for sale, prostitution or other forms of exploitation.

In their 2012 Journal of Medical Ethics article, Deonandan, Green and van Beinum formulate eight “Ethical concerns for maternal surrogacy and reproductive tourism

Robustness of informed consent

Custody rights

Quality of surrogate care

Limits of surrogate care

Remuneration

Multiple embryo transfers and abortion

Medical advocacy

Exploitation of the poor

Of the eight ethical concerns Deonandan et al found in the Indian experience of surrogacy, at least five of them were present in the Florida case described above –and that would-be surrogate was not even pregnant! It seems that India is not the only entity that should reconsider commercial surrogacy.

 

— D. Joy Riley, M.D., M.A., is executive director of The Tennessee Center for Bioethics & Culture.

Party politics, people’s lives

As health care financing rises yet again to the top of our national legislative agenda, some fundamental questions ought to be strongly considered. First, and most fundamental: Is some level of healthcare a right, that the government is therefore obligated to protect? Is it better viewed as a common good, like roads and fire protection services, that everybody pays for through taxes and everybody benefits from? Should it be treated as a luxury item, like large-screen TVs and designer clothing, that only those who can afford it get to enjoy?

Other important questions: What are the strengths and weaknesses of the current system of financing health care? Who does it benefit? Who does it harm? What will be the effects on patients, intended and unintended, of changing the current system? Who will benefit, and who will be harmed by those changes? What will be the effects on physicians and health insurance companies? How will any changes affect the patient-physician relationship, for good or for ill?

Is the free market the best way to finance health care? Or is it best publicly financed? Or some mixture of both? Why?

A most important question is, How does the system treat the most disadvantaged, the poorest, the most helpless or down on their luck, and the ones who need it the most? How should it treat them?

What should the ideal health care system for patients look like? Can we start moving towards that ideal? How?

Other fundamental questions will no doubt present themselves to the reader. However, instead of questions like the ones above, it seems that the following questions are being debated instead: Which party and which president designed the system we have now? If it’s not my party, how can we get rid of the current system (and who cares if we have nothing to put in its place, let’s repeal it anyway)? How can we protect our party (whichever one it happens to be) from the political fallout that will occur as changes are made? What does the ideal health care system for my party look like?

I have many patients who have benefited from the most recent changes to the system. I have others who are starting to feel the downside of those changes. For patients, it is not primarily about parties or presidents, but about their health, their lives, and whether they are treated with dignity by the health care system. Health care financing will always be expensive, and therefore contentious. But our contentions should be based primarily on concern for patients. Recent legislative discord on the subject seems to stem not from concerns about what is best for patients, but what is best for political party power.

Life unworthy of living

Sometimes we need to remember the past. Of course that is what historians try to teach us. The recent translation into Italian of the 1920 German book Allowing the Destruction of Life Unworthy of Living by Karl Binding and Alfred Hoche prompted a reminder by Italian historian Lucetta Scaraffia about how the central idea of the book played out over the next few decades in Germany (see Washington Post article).

She suggests that the history of that idea is relevant to current bioethical issues. Some of those have been discussed recently on this blog. A few days ago Joe Gibes wrote about decisions to abort fetuses found to have major abnormalities such as Down syndrome. Back in December Jon Holmlund wrote about the use of PGD to diagnose embryos with major genetic disorders so that parents at risk for having a child with such a disorder could choose to give birth to a child without the disorder and not bring embryos with the disorder to birth.

Both the practice of aborting fetuses with a major disorder and doing PGD to choose which embryos should be brought to birth to avoid giving birth to a child with a genetic disorder involve the concept of a life unworthy of living that Binding and Hoche wrote about. If we make a decision to abort a fetus with Down syndrome or even one with a more serious disorder we are making a decision that the life of the person who that fetus will be is not worth living. If we choose to create multiple embryos and choose to implant those who do not have a serious genetic disorder so that they can live, but choose not to implant those who have the disorder so that they will not live we are saying that the lives that would be lived by those embryos who are discarded are not worth living. Whether one believes that and embryo or a fetus has full moral status or not they are unique individuals who have live that they would live if they are allowed to. Not allowing them to live those lives due to the presence of a disorder is saying that those lives are not worth living.

Remembering what happened in Germany helps us remember what a serious thing it is to say that a person’s life is not worth living. The idea that Binding and Hoche wrote about began as a philosophical concept, but it was embraced by the German government under Hitler as a reason for German physicians to put to death mentally deficient children whose lives were thought to be not worth living. Later that was expanded to large numbers of Jews and others whose lives were not thought to be worth living. The experience in Germany helps us to see that the idea that there are people whose lives are not worth living depends on a negation of the fundamental idea that every human life has inherent value. As Christians we understand that this value is due to our being created in the image of God. Even for those who do not have that understanding the inherent value of every human being underlies the concept of universal human rights that has become the foundation for global justice.

The German experience reminds us that there are some lines that we must not cross. One of those is saying that another human being has a life that is not worth living and using that as the justification for ending the life of an embryo or fetus.

Human rights and euthanasia

The Parliamentary Assembly of the Council of Europe recently added an amendment to a resolution on advance directives to state that “euthanasia, in the sense of the intentional killing by act or omission of a dependent human being for his or her alleged benefit, must always be prohibited”. It is refreshing that the body charged with harmonizing the human rights laws among European states, and which bases its decisions on the European Convention on Human Rights, appears to have understood that the protection of human rights should lead to the prohibition of euthanasia.

Those who promote euthanasia see human rights in terms of individual autonomy and the ability of an individual to do whatever he or she wants. If we understand more clearly what is involved in human rights it is easier to see why those charged with upholding human rights should prohibit euthanasia.

Universal human rights are based on an understanding that all human beings have an inherent moral worth by virtue of being human beings. There are no characteristics other than being a member of the human family that are needed for a person to have full moral worth. The intentional ending of an innocent human life is a violation of the inherent worth of that human life. Since the inherent worth of every human life is the foundation of universal human rights, euthanasia is an attack on the foundation on which all human rights depend.

The Council of Europe appears to have made that connection.

Bioethics and Christmas

I just got back from the Taylor Christmas chapel and as my thoughts have been focused on the amazing incarnation of Jesus, I thought I would share some thoughts over the next few weeks on how Jesus’ incarnation impacts bioethics.

One of the most fundamental principles of bioethics is the inherent value and dignity of all human life. Our ideas of equality for human beings and equal human rights, moral status, and justice all depend on our understanding of the value that each of us has as a human being. When Christians think about the value of human beings we usually think about creation and our biblical understanding of human beings from the account of creation in Genesis 1 and the moral laws given to Noah in Genesis 9. Both of these passages refer to human beings being made in the image of God. We find an understanding of our inherent moral worth in how we were made.

Jesus’ incarnation adds richness to our understanding of who we are as human beings. God made us in his image not just so that we could be enough like him that he could communicate with us and have a relationship with us, but so that Jesus could become one of us. He made us able to choose between right and wrong, knowing we would choose the wrong. He planned all along to have Jesus, the Son, leave his glory as eternal God to become one of us, so that he could be the ransom for our sin. Being made in God’s image helps us see why every human being has moral value. Being one of the class of beings that God chose to become, and for whom he chose to die helps us see that value even more.

Glory to God in the highest.

Human Rights and the Significance of Human Dignity

One of the current students in the MA in Bioethics program at Trinity has also been observing in my medical office the past few months.  When there is a lull in the care of patients our conversations often turn to bioethics (while the paperwork on my desk waits a little longer to be attended to).  The other day we were talking about the concept of human dignity and whether it was a morally significant concept.  We agreed that it was and that we need to be clear that it has to do with the intrinsic worth of human beings.  It also needs to be distinguished from the concept of being dignified which is a very different cultural concept with which it is confused.

That discussion made me think about an essay by David Little in the book Prospects for a Common Morality. In his essay Little points to the impact of the rising concept of universal human rights that is changing the face of our global community.  He says that “some advocates and defenders of human rights seem to suggest that there are certain moral beliefs and concomitant claims about the world that are universally true and universally justified.”  This universally justified understanding of human rights is closely related to the idea that human beings have intrinsic moral value or dignity.  The impact this idea is having in global political processes makes it clear how significant this idea really is.