Topic Guide

Fertility Tourism:
Fertility tourism in India is exploitative
It is estimated that 9% of couples worldwide are infertile. Although it remains difficult, women unable to conceive naturally, or who are past their reproductive prime, are still able to have a child. To do so, many seek high-tech, low cost help from India. Long waiting times related to a shortage of eggs and sperm in the UK and elsewhere, the lack of donor anonymity, over-regulation, high costs and poor experiences of treatment are cited as reasons for going abroad for help. In India, commissioning couples can expect high-quality care, cost effective treatment, a high success rate and few legal hurdles. Donor eggs, sperm, and embryos are available, and women can become pregnant through IVF or can hire a surrogate - a woman who bears a child, genetically unrelated to herself whom she will give up on delivery. But while demand for such services keeps growing, so too do the legal, moral and ethical concerns related to its practice. Dubbed the wild, wild west of medicine by bioethicist Arthur Caplan, many argue that the unregulated, global nature of commercial surrogacy and egg and sperm donation is highly vulnerable to exploitative practices. In India the Assisted Reproductive Technologies (Regulation) Bill - 2010, is just the latest attempt to regulate fertility services that some fear are spinning out of control. Should we celebrate the material and emotional gains brought about by fertility tourism, for surrogates, donors and commissioning parents alike? Or do we need to be more circumspect about the thriving rent-a-womb market and the outsourcing of pregnancy?

The debate in context:

Whats on offer? Egg donation and surrogacy remain the most controversial and talked about practices within the fertility tourism debate, both because of the potential health risks posed to the donor and surrogate, and because of the moral ambivalence involved. Both involve highly technical and complicated clinical procedures: egg donation is the process by which a woman provides one or several eggs for the purpose of assisted reproduction. Donors are injected with a follicle-stimulating hormone, which increases ovarian activity, producing more eggs than during a normal cycle - often between 10 and 15. Surrogacy refers to the process in which a woman carries the baby in her womb for another couple. Through in vitro fertilisation (IVF), an embryo created from the sperm or egg of donors or from the couple wanting a baby is implanted in the surrogates womb. In India, surrogates own eggs are not used, to ensure there is no biological link between her and the baby. Rules stipulate that a surrogate must already have a child of her own to minimise the potential negative emotional consequences of giving up the baby at birth. The ART Bill will allow a woman to act as a surrogate for 3 successful births in her lifetime. While acknowledging that success rate is a difficult thing to define and prone to exaggeration, experts such as Shivani Sachdev Gour suggest that pregnancy rates are higher in India than elsewhere because of healthier lifestyles and the relative leniency of surrogacy laws. A win-win situation? Egg and sperm donation and surrogacy afford many infertile, often desperate, couples the possibility of having a child. For many couples in the West, the procedure is forbiddingly expensive. Moreover, in many other countries legal issues and red tape deter couples from availing of surrogacy. Commercial egg and sperm donation and surrogacy can then be seen as having benefits for all parties. Donating or choosing to carry a child for contracting couples is an opportunity for financial empowerment, enabling donors, surrogates and their families the chance to secure a better life. Others point to an altruistic dimension: in a country where childbirth is almost sacred, Indian donors and surrogates may feel happy to help infertile couples. While there are always health risks involved in fertility treatment, pregnancy and childbirth, India has highly trained doctors and sound medical facilities that provide good healthcare for donors, surrogates and babies. Dehumanising and exploitative?

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Commercial surrogacy in India is big business. Legalised in India in 2002, it is now a half-a billion-dollar a year industry, with surrogacy services offered in at least 350 clinics and is expected to grow into $2.3 billion industry by 2012. Indeed, Indias Ministry of Tourism promotes medical tourism and companies advertise healthy young women superovulated exclusively for you. Critics argue that placing a profit motive at the heart of fertility treatments can be dangerous, however, pointing to the risks posed to donors by clinicians who use high-tech fertility boosting techniques that can cause ovarian hyper-stimulation and pelvic infection; some have also expressed concern about the overuse and inappropriate use of commercial surrogacy, facilitated by unscrupulous fertility clinics. The growing number of western couples seeking donors and surrogates in India has prompted many to view this as the exploitation of women based on reproductive health inequalities. The charge of exploitation finds the use of bodies or the renting of wombs of poor women in developing countries in exchange for money disconcerting and dehumanising. Terms such as outsourced pregnancy suggest the practice of egg donation and commercial surrogacy is akin to other outsourced business operation exploiting cheap labour in India. In commercial surrogacy, it is argued, women are viewed primarily as an instrument of childbearing, and their wombs treated as commodities; all of which has implications for how society views women, and the emotional relationship between mother and child. The discussion has also become inextricable from concerns about poverty, with many questioning whether poor women, sometimes in financially desperate situations, really do have a choice. Others have also expressed concern that women may be coerced by their husbands or in-laws into becoming surrogates, and many argue that uneducated poor women are forced into surrogacy by middlemen. Some also note that the process is fraught with difficulties for the prospective parents. Not only are failed surrogacies frequent, but successful ones can involve a two or three month stay in India sorting paperwork. Ethical hazards and legal reform Commercial surrogacy in India has been regulated since 2005 by guidelines issued by the Indian Council of Medical Research (ICMR), but they are not legally binding and are ambiguous on issues like surrogates rights, informed consent and adoption requirements. The Assisted Reproductive Technologies Regulation Bill - 2010, purportedly an updated and improved version of the ICRM guidelines purportedly, is awaiting approval but proving controversial. Although clinic director Anand Kumar believes that surrogacy meets all three pillars of medical ethics: autonomy, beneficence and non-maleficence, fertility tourism continues to be fraught with ethical questions around reproductive autonomy, free-will and coercion. What happens to the surrogacy contract in case of a miscarriage? What if the baby is born with serious disabilities and is unwanted? Or what happens if the contracting couple change their mind about wanting a baby, if the surrogate dies during childbirth or if the commissioning couple are gay? Some suggest the lack of regulation in India make already complex and difficult situations more prone to confusion and abuse, and welcome the draft Assisted Reproductive Technologies (Regulation) Bill - 2010. But others suggest that it is Indias more liberal attitude to regulation that has given so many couples the opportunity to have children in the first place, in comparison with the more restrictive laws they face elsewhere. Accepting that the opportunities raised by fertility tourism raise difficult ethical questions, proponents suggest that none are insurmountable. If these ethical issues are more effectively negotiated, they argue that commercial surrogacy should be viewed as a welcome and effective means of assisting infertile couples, whilst at the same time providing reasonable financial compensation to those women prepared to help them.

Essential reading:

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The ART of marketing babies Imrana Qadeer Indian Journal of Medical Ethics Oct-Dec 2010 http://www.issuesinmedicalethics.org/184ar209.html India, the Rent-a-Womb Capital of the World Amana Fontanella-Khan Slate August 23 2010 http://www.slate.com/id/2263136/ Assembling the Global Baby Tamara Audi and Arlene Chang The Wall Street Journal December 10, 2010 http://online.wsj.com/article/SB10001424052748703493504576007774155273928.html Chapter 12: Gender. Case study: Commercial surrogacy. McKinnon: Issues in Political Theory, Oxford University Press http://www.oup.com/uk/orc/bin/9780199217007/01student/cases/mckinnon_ch12_cases.pdf Comments and Suggestions on the Assisted Reproductive Technology (Regulation) Bill and Rules-2008 (Draft) and request to incorporate suggestions Sama Resource Group for Women and Health, Delhi December 2 2008 http://www.samawomenshealth.org/downloads/ART%20Bill%20Critique_Sama.pdf FOR: A child of easy labour Kamayani B Mahabal Tehelka 8 June 2011 http://www.tehelka.com/story_main49.asp?filename=Ws080611ChildLabour.asp Dark Side of Rent-a-womb Market in India Aug 2010 http://bizcovering.com/business/dark-side-of-rent-a-womb-market-in-india/ Reproductive trafficking Hedva Eya Council for Responsible Genetics 2010 or 2011 http://www.councilforresponsiblegenetics.org/genewatch/GeneWatchPage.aspx?pageId=313 Outsourcing Pregnancy: Just Another Job? The Centre for Bioethics and Culture Network January 20 2011 http://www.cbc-network.org/2011/01/outsourcing-pregnancy-just-another-job/ Outsourcing Motherhood Prachi Bharadwaj MightyLaws.in May 1 2011 http://www.mightylaws.in/542/outsourcing-motherhood India surrogacy service not a good deal, one family says Mark Magnier Los Angeles Times April 18, 2011 http://www.geneticsandsociety.org/article.php?id=5680 Surrogacy goes into labour. The Times of India Pronoti Datta, May 15, 2010, http://articles.timesofindia.indiatimes.com/2010-05-15/india/28282187_1_manji-yamada-gay-couples-lawcommission-report Baby boom, baby bust The Telegraph, Calcutta Reena Martins Dec 13 2009 http://www.telegraphindia.com/1091213/jsp/7days/story_11857133.jsp

AGAINST:

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Changing face of Indian surrogacy MedIndia Health Network 22 June 2010 http://www.medindia.net/healthnetwork/medblogs/general/changing-face-of-indian-surrogacy-1101.htm India's Rent-a-Womb Industry Faces New Restrictions Hillary Brenhouse Time 5 June 2010 http://www.time.com/time/world/article/0,8599,1993665,00.html First it was Medical Tourism and now it is Fertility Tourism Reena Daruwalla Hub Pages http://hubpages.com/hub/First-it-was-Medical-Tourism-and-now-it-is-Fertility-Tourism More seek international surrogate mothers Nov 8, 2010 http://thenewyorkworld.com/2010/11/08/more-seek-international-surrogate-mothers/ Womb for Rent: Surrogate Mothers in India Abigail Haworth Marie Clare http://www.webmd.com/infertilityand-reproduction/features/womb-rent-surrogate-mothers-india Inside Indias international baby farm Nicola Smith The Sunday Times May 9, 2010 http://www.timesonline.co.uk/tol/news/world/asia/article7113463.ece Happy to rent a womb Hemlata Aithan Oman Tribune http://www.omantribune.com/index.php?page=leisure_details&id=3624&heading=Cinema Donating a womb Uday Mahurkar India Today 13 September 2007 http://indiatoday.intoday.in/site/story/Donating+a+womb/1/1174.html

Further reading:
Egg donors abroad - exploitation and risks of donation Pride Angel December 16 2010 http://blogs.prideangel.com/post/2010/12/Egg-donors-abroad---exploitation-and-risks-of-donation.aspx Google Baby documentary sheds light on outsourcing surrogacy Speakeasy June 16 2010 http://blogs.wsj.com/speakeasy/2010/06/16/google-baby-documentary-sheds-light-on-outsourcing-surrogacy/ Reproductive tourism as moral pluralism in action Dr G Pennings Journal of Medical Ethics 2002; 28: 337341 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1757095/pdf/v028p00337.pdf For love or motherhood the legal regulation of surrogate motherhood Anita Stuhmcke Murdoch University Electronic Law Journal Vol 2, Number 3, 1995 http://www.murdoch.edu.au/elaw/issues/v2n3/stuhmcke23.html Surrogate motherhood In India. Moral and ethical implications Stanford University 2008 http://www.stanford.edu/group/womenscourage/Surrogacy/moralethical.html Variations in IVF laws fuel market for 'fertility tourism The New Zealand Herald September 14 2010 http://www.nzherald.co.nz/world/news/article.cfm?c_id=2&objectid=10673537 Inside Indias Rent A Womb Business Scott Carney Mother Jones March/April 2010 http://motherjones.com/politics/2010/02/surrogacy-tourism-india-nayna-patel?page=2 Bioethics and transnational medical travel: India, medical tourism, and the globalisation of healthcare. V Runnels, L Turner Issues in Medical Ethics Jan-March 2011 http://www.issuesinmedicalethics.org/pdfs/191co42.pdf

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Commercial surrogacy and fertility tourism in India Aug 2010 http://www.duke.edu/web/kenanethics/CaseStudies/BabyManji.pdf Manufacturing a perfect mother worker Amrita Pande Scribd 2010 http://www.scribd.com/doc/45019739/Commercial-Surrogacy-in-India-Manufacturing-a-Perfect-Mother-Worker Opinion piece. Outsourcing Motherhood May 1st 2011 (Need to register with site) http://www.medscape.com/viewarticle/569829 Is India promoting reproductive tourism? MightyLaws.in May 28 2011 http://www.mightylaws.in/643/india-promoting-reproductive-tourism Birth of surrogate child highlights difficulties with Indian surrogacy laws Nishat Hyder BioNews Feb 21, 2011 http://www.bionews.org.uk/topics#BMAJID_INNERB They are just the wombs Gina Maranto Biopolitical Times 6 December 2010 http://www.biopoliticaltimes.org/article.php?id=5497 Web-blog of Indian Surrogacy Law Centre http://blog.indiansurrogacylaw.com/ What Money Cant Buy: The Moral Limits of Markets Michael J Sandel The Tanner Lectures on Human Values 11 May 1998 http://www.tannerlectures.utah.edu/lectures/documents/sandel00.pdf Pregnant with Science Lovechild: Should Surrogacy Be Aborted or Enhanced? Dana Saade 02.01.2011 http://www.aub.edu.lb/fm/shbpp/ref/Documents/Pregnant%20with%20Science%20Lovechild-%20Should %20Surrogacy%20Be%20Aborted%20or%20Enhanced-%20By%20Dana%20Saadeh.pdf Do we confuse surrogacy with prostitution? Practical Ethics. Jan 20 2011 http://blog.practicalethics.ox.ac.uk/2011/01/do-we-confuse-surrogacy-with-prostitution/

Key terms: Surrogacy India Guide http://www.globaldoctoroptions.com/ Gestational Surrogacy http://www.suite101.com/article.cfm/surrogacy_new/64753 Altruistic Surrogacy http://www.information-on-surrogacy.com/altruistic-surrogacy.html Surrogacy http://en.wikipedia.org/wiki/Surrogacy Assisted Reproductive Technology (ART) Bill 2010 http://www.prsindia.org/uploads/media/vikas_doc/docs/1241500084~~DraftARTBill.pdf

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Criteria for surrogacy http://delhi-ivf.com/become_surrogarcy.html Criteria for egg donor http://www.fertilityindia.com/egg-donation.php Criteria for sperm donor http://www.fertilityindia.com/sperm-donation.php In the news: Film Review: Made in India Rachel Lyons BioNews March 14, 2011 http://www.bionews.org.uk/page_89652.asp India bans gay couples from surrogacy Jessica Green Pink News 25 Feb 2011 http://www.pinknews.co.uk/2011/02/25/india-bans-gay-couples-from-surrogacy/ Moral questions arise in surrogacy Express India 22 March 2011 http://www.expressindia.com/latest-news/moral-questions-arise-in-surrogacy/765652/ Young Bangalore girls donate their eggs for easy money Prajwal Hegde The Times of India 27 Jan 2011 http://articles.timesofindia.indiatimes.com/2011-01-27/bangalore/28362718_1_egg-donor-ovarianhyperstimulation-syndrome-programmes No to pregnancy, yes to surrogacy for UK couples Niyata Rana Daily News Analysis May 14 2010 http://www.dnaindia.com/india/report_no-to-pregnancy-yes-to-surrogacy-for-uk-couples_1382865 Event Review: Making Babies in the 21st Century - The Rise of Reproductive Technologies Zeynep GurtinBroadbent and Ruth Saunders Bio News 8 November 2010 http://www.bionews.org.uk/page_81597.asp The ethics of international surrogacy Nobal.Glomad. 1 July 2011 http://www.nobalglomad.com/index.php/2011/07/the-ethics-of-international-surrogacy/