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doi: 10.1136/jme.2008.024679
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ABSTRACT One of the major concerns about surrogacy is the potential harm that may be inflicted upon the surrogate mother and the child after relinquishment. Even if one were to take the liberal view that surrogacy should be presumptively allowed on the basis of autonomy and/or compassion, evidence of harm must be taken seriously. In this paper I review the evidence from psychological studies on the effect that relinquishing a child has on the surrogate mother and while it appears that many surrogates are able to cope with relinquishment, I argue that there are good reasons, grounded in empirical evidence, to support the view that the subsequent management of the relinquishment necessarily objectifies the surrogate mother.
ALTRUISTIC MOTIVES
For many women who have undergone repeated attempts at assisted reproductive technologies (ART) or those who have a non-functional uterus, surrogacy is often viewed as a viable alternative. It also seems to be a preferable alternative to adoption, given the importance placed on having a genetic link between child and parent, and being in close proximity to the gestational process. Pregnancy though is a profound experience that is unique amongst couples in which the outcome and their ability to manage the pregnancy are often unpredictable. The biological and psychological health of the surrogate and child ought to be considered when commissioning couples and potential surrogates are making an informed decision to enter into an arrangement. However, given that the long-term health outcomes, relational complexities and the social implications of surrogacy are largely unknown, it seems difficult if not impossible for a potential surrogate to give informed consent. The ethical dilemmas are not only recognised by many individuals but also by governments, which is reflected in the legislative responses that attempt to deal with surrogacy arrangements. Some countries have opted for legislation permitting altruistic surrogacy (such as in the Australian Capital Territory) instead of commercial surrogacy (which is permitted in countries such as India and some states in the US), presumably because the latter gives rise to the potential for exploitation. Furthermore, surrogacy is illegal in some countries such as Germany and Italy,1 2 because it is regarded as being contrary to basic moral principles and human dignity. In the context of altruistic surrogacy, one must ask: can a close relative or friend, viewed as a
J Med Ethics 2009;35:171175. doi:10.1136/jme.2008.024679
potential surrogate mother, provide genuine informed consent? Is she making an autonomous decision free from coercion, particularly in complex family contexts? Is she aware of the emotional impact of giving up a baby that she has carried for nine months? Can a potential surrogate mother be apprised of, process and understand all the details about pregnancy complications, risks associated with ART, psychological ramifications for herself, the child she may carry and others, the terms of a surrogacy contract and implications for future relational complexities, let alone the broader ethical implications for the communityabout which she may have a genuine interest? Consider, for example, women with low selfesteem, who may be inclined to enter into an arrangement to obtain approval of others to gain a sense of self-worth. This may be particularly pertinent where a surrogate acts for a friend or family member.3 4 In many cases, surrogate mothers overwhelmingly report that they choose to bear children primarily out of altruistic concerns,4 which must be distinguished from surrogates who state that money is the prime motive (commercial surrogacy). Other motives include sharing the enjoyment of pregnancy, and redemption from giving up a child for adoption and/or previous abortions.5 A study by Ragone6 revealed that for some women, the motivation to become a surrogate mother was due to feelings of guilt about having had a previous abortion and/or having to give up a child for adoption. In this study the statistics indicated that 26% of potential surrogates had previously had an abortion and 9% had placed a child up for adoption. This raises doubts about whether surrogates actually enter an agreement simply on altruistic grounds, which is often taken for granted, as well as whether surrogacy is an appropriate way of dealing with prior loss of a child. Importantly, it has been shown that when surrogates were asked to justify their decision to become a surrogate mother, the verbal self-reports are often scripted to reflect socially accepted reasons for surrogacy.6 Most surrogates score within the normal range on personality tests such as the Minnesota multiphasic personality inventory. However, it has been suggested that those who are willing to be surrogates are more independent thinkers and are less bound by traditional moral values. It has been reported that surrogate mothers score lower in conscientiousness and dutifulness on the NEO five factor test.5 This demonstrates that the motivation underlying the decision to become a surrogate cannot
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Given such potential harms that a surrogate faces, surrogacy agencies must provide appropriate measures and counselling services. The services and programmes that surrogacy agencies provide for surrogates are an attempt to ensure the greatest likelihood of a successful outcome for all parties involved. This is especially the case with commercial surrogacy agencies, where unsuccessful arrangements are detrimental for business. While this is appropriate and both the interests of the agency and surrogate are taken into consideration, one of the psychological counselling strategies involves a deliberate effort to de-emphasise the significance of the gestational maternity of the surrogate, in order to allow the surrogate to cope with relinquishing the child. This is referred to as cognitive dissonance reduction. In the following section I will argue that such a measure requires what is essentially an objectification of the surrogate mother.
While this womans desire to assist others was generous, her resultant death is all the more tragic because of its circumstances. It could be argued that if she had died bearing a child she would raise, the tragedy would have been tempered by the authentic commitment to motherhood that her pregnancy entailed.
J Med Ethics 2009;35:171175. doi:10.1136/jme.2008.024679
That is, a surrogate mother must become a commodity for the purposes of conceiving and producing a child who is to be relinquished to the commissioning couple. Treating the surrogate as mere means to an end may be a method by which some attempt to deal with the disruption to natural relationships that surrogacy entails, however, this also places the surrogate at greater risk of exploitation. Indeed there is much evidence demonstrating the need for surrogate mothers to reconcile the circumstances of the surrogacy arrangement with the norms of maternal-foetal relationships. There is evidence that the attempted reconciliation proceeds in a manner that is deceptive or underhanded, for in order to make it easier for a surrogate to relinquish the child, she must invoke a number of cognitive dissonance reduction strategies which I will argue, amounts to a form of objectification via self-deception. In a study by Ciccarelli,5 14 surrogate mothers were asked to report their feelings or concerns about relinquishing the child. One mother reported emotional distress over the relinquishment and two others reported a strong instinctual urge to bond
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Another surrogate found it hard to relinquish her baby, grieving the loss more than expected, suffering post-natal depression and experiencing a sense of guilt. These and other studies highlight recurring themes such as self-denial, objectification and the need for subverting natural intuitions for the sake of the surrogacy arrangement. One other interesting data point was that a major cause of emotional distress or regret on the part of the surrogate depended on whether a relationship was maintained with the commissioning parents. What this indicates is concern on the part of the surrogate to develop a relationship with the commissioning parents that actually goes beyond the surrogacy arrangement and beyond the mere utilisation of a functional womb. The surrogate wanted to be more than just a womb for rent. She did not want to feel used, merely because she has a womb that works, but rather she wanted to be a part of the commissioning couples lives. As van den Akker comments:
It is seen as a betrayal when the intended couple with the surrogate baby disappears from the surrogate and her childrens lives.27
This entirely unusual and discordant ongoing effort to deal with a surrogacy arrangement, and the subsequent relinquishment, underscores the damage that some surrogates go through, even though in most cases it is masked at least temporarily by considerable cognitive dissonance reduction techniques. Thus a womans natural intuitions are being subverted by cognitive dissonance reduction strategies. It is clear from these studies and the statements by surrogates, that the nature of such strategies requires the surrogate to view herself as an object or as mere means. This view is reinforced by other researchers in this area, for example Baslington26 who states:
During the research I discovered that the surrogate mother membership were encouraged by the self-help group to think of their surrogacy arrangement as a job incorporating payment, suggesting that the subcultural influences engendered by the social organisation of surrogacy arrangements were important in the detachment process.
In this study by Baslington, the majority (10 out of 14) of the surrogates reported that they were able to cope well with the relinquishment, though the general experience was to feel unhappy in the short term but if a good relationship was forged with the commissioning couple then this also eased the burden of relinquishment. However, the study also revealed that one of the surrogates still suffered from feelings of guilt, regret and loss after having relinquished her baby two and a half years earlier.
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It would be hard to imagine that commissioning couples could be legally obliged to enter into a long-term relationship with the surrogate, even though she might suffer without that relationship. Hence this data further demonstrates how a surrogate is objectified by virtue of requiring the subsequent negative experiences to be quelled via maintaining a good relationship with the commissioning couple, in addition to cognitive dissonance reduction strategies. The argument can be summarised as follows: 1. Surrogacy is destructive of the natural and intuitive intimate mother/child relationship. 2. To try and circumvent this problem surrogates employ, and agencies promote, a number of cognitive dissonance reduction strategies. 3. The cognitive dissonance reduction strategies implicitly require the objectification of the surrogate. 4. If the first premise is correct, then surrogacy is morally problematic; if the second and third premises are correct, then surrogacy is additionally morally problematic. 5. There is empirical evidence to support premises 1, 2 and 3. 6. Therefore surrogacy is morally problematic. In relation to cognitive dissonance reduction, the principle of not using people as means to an end is deliberately undermined in an attempt to uphold the principle of do no harm. In attempting to reduce her own psychological pain from relinquishing her baby the surrogate has to think of herself as an object. Furthermore, perhaps the strategies not only objectify surrogates but also act to deny the reality that a problem exists and in doing so only serve to bury the problem which may then emerge later with significantly increased power to harm the surrogate. Whether this is the case will depend on further longitudinal studies. However, there is no doubt that the potential for exploitation exists, even more so under a commercial arrangement, given the disparity in income and social class between potential surrogates and commissioning parents. Already we are witnessing a big surge in commissioning couples from affluent societies entering into surrogacy arrangements with agencies from India (such as the one in Anand) for what seem to be bargain basement prices.28 While there is little in the way of empirical studies into the long-term effects that a surrogacy arrangement has on the surrogate, the child and the family of the commissioning couple,
J Med Ethics 2009;35:171175. doi:10.1136/jme.2008.024679
CONCLUSION
While surrogacy can be seen as enhancing reproductive freedom for the commissioning mother to have a genetic child, and for a surrogate mother to utilise her reproductive capacities for altruistic or financial reasons, surrogacy arrangements are ripe with possibilities for womens reproductive freedom to be severely violated. The inherent objectification of women that surrogacy necessitates leaves a surrogate susceptible to exploitation and coercion. The risks are particularly acute in the context of commercial surrogacy. Furthermore, the diversity of legislative responses throughout the world reflects the difficulties law makers have in dealing with these ethical dilemmas. These data cited in this review indicate that those entering into a surrogacy arrangement know they are making a radical departure from established intuitions and social norms of parenthood and in attempting to reconcile their situation with those established norms they experience parental, familial and psychological bewilderment. This is particularly true for the surrogate who faces the greatest challenge because of her intimate psychological and gestational relationship with the child. After all, it is the surrogate mother who must to face the challenge of becoming pregnant, most likely through ART, carry out the pregnancy, give birth and then relinquish the child. Furthermore, surrogacy fails to respect the dignity and primacy of the welfare of the child. It ignores the fact that foetal/early infant development is a critical determinant of a childs welfare, whereby the biological and psychological bond between the surrogate and the child is of crucial significance for this development. It requires the subordination of the welfare of the surrogate and her child in favour of the commissioning parents desires to have a child. The law ought to be congruous with such concerns hence it ought to prohibit all forms of surrogacy arrangements.
Competing interests: None.
9. 10. 11.
16. 17.
21. 22.
REFERENCES
1. 2. Federal Law Gazette, Part I, No. 69, issued in Bonn, 19 December 1990, page 2746. Act for Protection of Embryos (The Embryo Protection Act), Section 1 Improper use of reproduction technology. Anon. Italy passes Europes toughest IVF law. Bioedge 12 December 2003, Issue 104. http://www.australasianbioethics.org/Newsletters/104-2003-12-12.html#top (accessed 19 Nov 2008).
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