Made in India? Ethics of outsourcing surrogate motherhood to India

Outsourcing is a commonly used word today. Corporations outsource many of their functions and processes to developing countries, especially India, to cut costs and improve efficiency. Clinical trials were thus outsourced to India, and now it appears that children are being produced by outsourcing surrogate motherhood to India. Consequently, a new and unique enterprise known as “reproductive outsourcing” (also called “reproductive tourism”) is a rapidly expanding business in India (1, 2).

Many couples living in western countries use Indian surrogate mothers to bear their genetically related children (3). The reason for using Indian surrogate mothers is obvious: the cost comes to about $25,000, roughly a third of the price in the United States. That includes the medical procedures, payment to the surrogate mother, air tickets and hotel costs for two trips to India-one for the fertilisation and a second to collect the baby (1).

Every married couple has a right to have a child and we should not scorn the couple that turns to a surrogate mother. But the very process of outsourcing surrogate motherhood involves many issues and these needs to be addressed while endorsing or limiting the procedure.

Exploitation of women: The requirement of a surrogate mother for the procedure raises some apprehensions about the exploitation of women. The couple who want the child has to find a surrogate mother themselves or they can take the help of a law firm or semen bank to do so. These firms can advertise for surrogate mothers (4).

In the Indian context, the involvement of touts in “seeking business” cannot be ruled out, and the touts may employ dubious methods in this search. So, the question is, “Is it ethical to find a surrogate mother in this way?”

It is possible that due to poverty or some other reason, family members may compel a woman to act as a surrogate mother. The women who enrol for such procedures are mainly from a poor socio-economic background. The surrogate mother is paid by the couple who want the child, and it is possible that the mother may not be adequately paid.

The guidelines published by the Indian Council of Medical Research (4) provide for an agreement between the surrogate mother and the couple desiring the child regarding payment. But, since we are dealing with often illiterate and powerless women, the agreement may not be a fair one. The mandatory clauses that are to be included in the agreement are not spelt out nor is any specific format provided in the guidelines. In the absence of such a requirement, clauses favourable to the couple and not the surrogate mother may be incorporated.

Ethics of the procedure: The government is actively promoting India as a medical tourism destination, but the exchange of money for babies is making many people uncomfortable. There are no reliable statistics on how many surrogate births are being arranged in India for foreigners, but anecdotal evidence suggests a sharp increase (1). Surfing the internet, I have found many sites advertising the services of clinics. Is it ethical for medical practitioners to advertise in this manner?

The conditions or circumstances in which the surrogate mothers are kept in the clinics also warrant consideration. In Anand, a city in Gujarat where the practice was pioneered in India, more than 50 surrogate mothers are pregnant with the children of couples from the United States, Britain and elsewhere. Fifteen of them live together in a hostel attached to a clinic (1). The women are literally being kept in custody. Such practices violate basic human rights. In addition, these women may suffer mental anguish since the doctor ensures that they don’t bond with the babies by constantly reminding them that the foetuses they are carrying are not theirs (2).

It is possible that even basic procedures such as informed consent of the mother may not be taken, or may be obtained in a questionable manner. Also, considering the money involved, the mother may not be inclined to ask the doctor about the dangers or risks involved in the pregnancy. Money seems to be a crucial factor for many surrogates.

Another important issue that needs attention is what sort of protection would be given to the mother in case of prenatal or postnatal complications, or if death occurs. If continuing with the pregnancy endangers her life, is the mother entitled to terminate her pregnancy?

Interests of the child: Other issues that need to be addressed include what to do with the child if the couple does not return to India to claim it, or refuses to take the child for some reason, or the couple dies or they divorce.

What happens if the child is born retarded or physically challenged? Neither the surrogate mother nor the putative parents may want such a baby. Legally, if the couple refuses to accept the child, the surrogate mother and her husband are obliged to keep the child since it is she who has given birth to the child. In divorce cases, who would be entitled to the custody of the child? These questions need considerable thought and maybe the agreement between the surrogate mother and the couple should address these concerns.

The phenomenal increase in surrogate pregnancies makes it essential that these issues be properly addressed. Regulation that addresses these ethical and other issues will ensure that parenthood is achieved with dignity and not at the expense of any of the people involved.