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doi: 10.1136/jme.2008.024679
2009 35: 171-175
J Med Ethics 
M M Tieu
objectification of surrogate mothersAltruistic surrogacy: the necessary
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Altruistic surrogacy: the necessary objectification ofsurrogate mothers
M M Tieu
Correspondence to:Mr M M Tieu, Southern CrossBioethics Institute, 1E/336Marion Road, North Plympton,South Australia 5037;matthewtieu@bioethics.org.auReceived 3 February 2008Revised 20 August 2008Accepted 7 October 2008
One of the major concerns about surrogacy is thepotential harm that may be inflicted upon the surrogatemother and the child after relinquishment. Even if onewere to take the liberal view that surrogacy should bepresumptively allowed on the basis of autonomy and/orcompassion, evidence of harm must be taken seriously. Inthis paper I review the evidence from psychologicalstudies on the effect that relinquishing a child has on thesurrogate mother and while it appears that manysurrogates are able to cope with relinquishment, I arguethat there are good reasons, grounded in empiricalevidence, to support the view that the subsequentmanagement of the relinquishment necessarily objectifiesthe surrogate mother.
For many women who have undergone repeatedattempts at assisted reproductive technologies(ART) or those who have a non-functional uterus,surrogacy is often viewed as a viable alternative. Italso seems to be a preferable alternative toadoption, given the importance placed on havinga genetic link between child and parent, and beingin close proximity to the gestational process.Pregnancy though is a profound experience thatis unique amongst couples in which the outcomeand their ability to manage the pregnancy are oftenunpredictable.The biological and psychological health of thesurrogate and child ought to be considered whencommissioning couples and potential surrogatesare making an informed decision to enter into anarrangement. However, given that the long-termhealth outcomes, relational complexities and thesocial implications of surrogacy are largelunknown, it seems difficult if not impossible fora potential surrogate to give informed consent. Theethical dilemmas are not only recognised by many individuals but also by governments, which isreflected in the legislative responses that attemptto deal with surrogacy arrangements. Some coun-tries have opted for legislation permitting altruisticsurrogacy (such as in the Australian CapitalTerritory) instead of commercial surrogacy (whichis permitted in countries such as India and somestates in the US), presumably because the lattergives rise to the potential for exploitation.Furthermore, surrogacy is illegal in some countriessuch as Germany and Italy,
1 2
because it is regardedas being contrary to basic moral principles andhuman dignity.In the context of altruistic surrogacy, one mustask: can a close relative or friend, viewed as apotential surrogate mother, provide genuineinformed consent
Is she making an autonomousdecision free from coercion, particularly in complexfamily contexts
Is she aware of the emotionalimpact of giving up a baby that she has carried fornine months
Can a potential surrogate mother beapprised of, process and understand all the detailsabout pregnancy complications, risks associatedwith ART, psychological ramifications for herself,the child she may carry and others, the terms of asurrogacy contract and implications for futurerelational complexities, let alone the broaderethical implications for the community—aboutwhich she may have a genuine interest
Consider, for example, women with low self-esteem, who may be inclined to enter into anarrangement to obtain approval of others to gain asense of self-worth. This may be particularly pertinent where a surrogate acts for a friend orfamily member.
3 4
In many cases, surrogatemothers overwhelmingly report that they chooseto bear children primarily out of altruistic con-cerns,
which must be distinguished from surro-gates who state that money is the prime motive(commercial surrogacy). Other motives includesharing the enjoyment of pregnancy, and redemp-tion from giving up a child for adoption and/orprevious abortions.
 A study by Ragone
revealed that for somewomen, the motivation to become a surrogatemother was due to feelings of guilt about havinghad a previous abortion and/or having to give up achild for adoption. In this study the statisticsindicated that 26% of potential surrogates hadpreviously had an abortion and 9% had placed achild up for adoption. This raises doubts aboutwhether surrogates actually enter an agreementsimply on altruistic grounds, which is often takenfor granted, as well as whether surrogacy is anappropriate way of dealing with prior loss of achild.Importantly, it has been shown that whensurrogates were asked to justify their decision tobecome a surrogate mother, the verbal self-reportsare often scripted to reflect socially acceptedreasons for surrogacy.
Most surrogates scorewithin the normal range on personality tests suchas the Minnesota multiphasic personality inven-tory. However, it has been suggested that thosewho are willing to be surrogates are moreindependent thinkers and are less bound by traditional moral values. It has been reported thatsurrogate mothers score lower in ‘‘conscientious-ness and dutifulness’’ on the NEO five factor test.
This demonstrates that the motivation under-lying the decision to become a surrogate cannot
Law, ethics and medicine
 J Med Ethics
:171175. doi:10.1136/jme.2008.024679 171
 group.bmj.comon September 13, 2010 - Published by  jme.bmj.comDownloaded from 
always be taken for granted as purely altruistic. Motives such asredemption, guilt or money (as is the case in commercialsurrogacy) demonstrate that the decision to become a surrogateis based on a complex range of factors and psychologicaldispositions.
Important biological bonds are established between the motherand her foetus during pregnancy. Even the scent of a newborncan attract the mother, as each mother can identify her owninfants’ odour when presented with the odour of several otherbabies.
One of the most concrete examples of the importance of the maternal-child bond comes from foetal-maternal physiol-ogy. The hormone oxytocin plays a crucial role in priming thegestational mother to respond in accordance with her naturalmaternal instincts. It is a response triggered by skin to skincontact and eye gazing, which promotes further psychologicaland physiological bonding.
7 8
 An interesting study by Widstrom
 et al
revealed that if the lips of an infant touch the mother’snipple in the first hour of life, a mother will decide to keep herbaby in her room 100 min longer on the second and third day during her hospital stay than another mother who does nothave contact with her infant until later. Additionally, thedevelopmental psychology literature indicates that there is acrucial window of time from the moment of birth onwards,whereby a baby begins to form cognitive attachments throughinteractions with the gestational mother.
The cognitivepsychology literature on early childhood development alsoemphasises the importance of the psychological bonds formedfrom birth and onwards.
Humans have a very basic response to expressions of emotionin others, and infants in particular display a basic drive to matchbehaviour and psychological expressions in persons closest tothem at the earliest of stages. Numerous studies have revealedthat infants react to their mother’s emotional expression withtheir own. They seek out the most immediate emotional beingto participate with in an ‘‘inter-subjective game’’. Rather thanliving in a buzz of ambivalence or confusion as envisaged by some, an infant’s behaviour is innately fashioned to coordinatewith the social behaviour of other people. This demonstratesthat an infant already has the cognitive mechanisms andpsychological capacities in place to influence as well as beinfluenced by other people, and in particular his or her birthmother.
11 12
Therefore, at the very least, one ought to beconcerned with any process that disrupts the importantbonding between mother and child which begins duringgestation and continues after birth. Surrogacy ruptures thisbonding.Such is the strength of the bond and emotional attachment of the surrogate mother to the child that there have been many cases from around the world where a surrogate mother has beenunwilling to relinquish her child; consider, for example, theBaby M
and Evelyn cases.
 As evidenced in these much-publicised cases, having to relinquish a child can be heart-wrenching, the end result being custody battles. Added to this isthe evidence that surrogates may live with the psychologicalburden associated with giving up their gestational child formany years.
These matters reinforce the difficulty, if notimpossibility for a surrogate mother to give informed consent.In relation to the difficulties with relinquishment, certaincritical questions must be asked. What happens when there is areluctance or refusal to stick to the original surrogacagreement
What if neither the surrogate nor the commission-ing parents want the child
By its very nature, a surrogacy arrangement is likely to lead to more custody disputes becausethe child is born into such unusual circumstances by being theoffspring of more than one family group. No legislationpermitting surrogacy can accommodate such complicationswithout leading to seriously undesirable consequences such aslitigation, custody battles, all of which occur at the expense of the child’s welfare.It could be argued that an argument against fracturing thematernal-infant bond in the case of surrogacy also applies tocases where a mother gives up her baby for adoption. As such,why would surrogacy be more ethically objectionable
Firstly,the arguments prescribed here do not constitute an objection toadoption per se, since the crucial distinction between adoptionand surrogacy is that the latter is an intentional decision torelinquish a child to a commissioning couple without thewelfare of the child being paramount, whereas adoption is, in asense, ‘‘rescuing’’ a child from difficult circumstances, in whichcase it is the child’s welfare that is of primary concern.The fracturing of family structures, due to divorce orseparation, neglect and abuse is highly undesirable and childrenwho find themselves in such unfortunate circumstances becomeno less than innocent victims. Single mothers who are socio-economically disadvantaged may decide that placing the childup for adoption is in the best interests of her child (suchcircumstances are unfortunate and obviously undesirable). Insome extreme cases of neglect, there may be grounds forremoval of the child for adoption or placement in foster care.However, giving up a child for adoption is a decision that isnever taken lightly. It is essentially a decision that is predicatedon the primacy of the child’s welfare. It is essentially concernedwith finding the best outcome for the child given theunfortunate situations that many find children find themselvesin, which often cannot be reversed. The essential differencebetween surrogacy and adoption is, with regard to surrogacy,that the surrogate mother and commissioning parents haveintentionally and consciously decided, prior to the conceptionand birth, to hand the child from the gestational mother to thecommissioning couple. The ethically relevant difference residesin the difference in relation to intentions and foreseeableconsequences. In a surrogacy arrangement, unlike adoption, thewelfare of the child is not the primary objective, but instead, itis subordinated to fulfilling the desires of an infertile couple tohave a child. It might be expected that a child born of surrogacy would experience the difficulties experienced by an adoptee inaddition to those unique to surrogacy.
 A diagnosis of disability or disease, even if equivocal, could leadto serious problems with a surrogacy arrangement. For example,a prenatal diagnosis of disability or perceived imperfection couldresult in the commissioning couple reneging (such a case hasalready occurred in the US).
16 17
In the case of a diagnosis of disability, depending on the circumstances and severity, theoption of abortion could be considered by the surrogate;however, differing moral perspectives on abortion have thepotential to result in an irresolvable stalemate. The surrogatemay still wish to proceed with the birth; however, thecommissioning couple may no longer want the child. Alternatively, the surrogate may choose an abortion contrary to the wishes of the commissioning couple.Given that gestational surrogacy involves ART, the healthrisks in ART are pertinent to surrogacy. According to a recentreview, ART is responsible for approximately 50% of allmultiple births worldwide,
and about half of IVF pregnancies
Law, ethics and medicine
J Med Ethics
:171–175. doi:10.1136/jme.2008.024679
 group.bmj.comon September 13, 2010 - Published by  jme.bmj.comDownloaded from 

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