Surrogacy is much more than just a financial transaction or a sequence of medical procedures because it builds relationships that will last for generations, creating new families and bonding existing families to each other. It is no wonder that the topic is often the subject of passionate discussions. I was recently reminded of this when I was invited to speak at a conference about Surrogacy Ethics in France, where surrogacy is illegal and still controversial, and even a topic in the current presidential campaign. But rather than list pros or cons, pretending that all surrogacy journeys are identical, I proposed there that we concentrate on providing guidelines on how surrogacy can be carried out more ethically in general, and in line with various moral convictions prospective parents may hold.
Since every surrogacy journey may be different, clinics and agencies should guide prospective parents in way they can assert control and shape their surrogacy journey based on their ethical and moral convictions (for instance, regarding pregnancy termination). But first, I believe medical and agency professionals should strive to set basic ethical standards that will apply to all cases. These standards should be guided by the following principles:
- All involved parties should be treated with the outmost dignity and respect. This would require professionals must prioritize the families and relationships at least as much as the medical interventions, logistical arrangements and the financial considerations.
- Medical and psychological risks should be minimized and all parties should be fully informed and provide full consent free of external pressure. For instance, the women involved must always have the option to remove themselves from the process and change their mind without penalty at any time before the pregnancy occurs.
- It is critical that we support and consider the well being of all involved parties, including the surrogate and donor’s families, and the future children that will result from the decisions that we make today. An example of such principle may be the offering parents the option of working with a known egg donor, a practice that may afford both long term medical benefits in the form of updated medical history, and psychological ones should the future kids wish to meet their donor.
The role of the medical clinic is to maximize the efficiency and quality of the services it offers, minimize the risk that each party is subjected to, and to control the costs of that process. It is essential that the physician fully informs everyone involves concerning the medical steps, alternatives and risks even though these risks are now extremely rare and can be further minimized with adequate screening, tests and ethical treatment protocols. For instance, minimizing the risk for surrogates involves transferring the fewest number of embryos of the highest quality, which increasingly in the United States is a single embryo transfer. If an egg donor is used, she too must be made aware of the risks associated with the fertility medications and the egg retrieval procedure, even though these risks are extremely rare. Given the advanced technology that we currently have and the high success rates we now routinely achieve, the challenge lies not in making the process work, but in making them as safe as possible, while enhancing the experience and relationships that result from the process.
A self-proclaimed feminist skeptic in the Paris conference voiced concerns that surrogates may be exploited, perhaps by business women who may wish to hire a surrogate just to avoid disrupting their careers. Indeed we have to realize that there will always be unscrupulous people who may wish to exploit and take advantage of others, and it is the responsibility of those of us in the practice to maintain the highest possible ethical and professional standards and refuse to cooperate with these individuals. However it is important for so called feminists not to doubt the ability of other women to make decisions that are in their best interest. From my experience with the numerous women I have worked with, they are proud and independent women for whom surrogacy has been one of the most empowering experiences of their lives.
Additional concerns we heard in Paris and elsewhere regard such issues as babies that may be abandoned due to birth defects, and that surrogacy could lead to more questionable practices like cloning. While cloning, birth defects, or gender selection may be ethical issues worthy of separate discussion, we must refrain from linking these controversies to surrogacy, because none of these are specific to surrogacy and should not be used to attack this very noble practice. Nevertheless we have to acknowledge that in many societies surrogacy is still controversial and suffers from bad press due to the way it is practiced in some places. I hope we can avoid distractions and advance the discourse to the point we can formulate ethical surrogacy guidelines across the field, at least in the United States. I am confident this will go a long way to bring forth wider embrace of this practice internationally.