Ethical Considerations of Commercial Gestational Surrogacy in the United States

Transcript

• 00:00Speakers for today.
• 00:07So for those of you
• 00:08who I've not met, my
• 00:09name is, Ben Tolchin. I'm
• 00:11a neurologist and a medical
• 00:13ethicist.
• 00:14I,
• 00:15direct the,
• 00:16Center for Clinical Ethics at
• 00:17the
• 00:19health system, and I co
• 00:21direct the program for biomedical
• 00:23ethics here along with, Jennifer
• 00:25Miller and along with,
• 00:27Sarah Hull
• 00:28who directs the,
• 00:30ethics concentration.
• 00:33Today, we are
• 00:34delighted to to
• 00:36host as our,
• 00:38speaker, Alice Baker, who I've
• 00:41had the the honor and
• 00:42pleasure to work with closely
• 00:44over the last,
• 00:46six months.
• 00:47Alice is a neonatologist,
• 00:49whose work integrates clinical neonatology
• 00:52and scholarship in bioethics
• 00:54and clinical ethics consultation.
• 00:56She completed her residency in
• 00:58in internal medicine and pediatrics
• 01:00at the University of Rochester
• 01:01and fellowship in neonatal
• 01:03neonatal and perinatal medicine at
• 01:05the Yale School of Medicine.
• 01:07Doctor Baker is currently a
• 01:08clinical associate in the division
• 01:10of neonatal and perinatal medicine
• 01:11here at Yale and a
• 01:12clinical ethics fellow at Yale
• 01:14New Haven,
• 01:16Hospital. And I'll I'll just
• 01:17say from my personal experience,
• 01:19I've been working very closely
• 01:20with,
• 01:21Alice over the last, six
• 01:23months. As I said, she
• 01:24has been integral to the
• 01:26ethics concentration service.
• 01:28If you've been to ethics
• 01:29committee meetings, you've seen her
• 01:30present,
• 01:32and and run
• 01:34a couple of meetings now
• 01:35very ably.
• 01:37We've been really delighted with
• 01:39Alice's work. I've heard,
• 01:42extremely positive feedback,
• 01:44not only from,
• 01:47patients and family members, but
• 01:48also from clinicians
• 01:50and,
• 01:51staff within the hospital.
• 01:53And and
• 01:54it it pains me to
• 01:56say that,
• 01:57Alice will be leaving us
• 01:58at the end of the
• 01:59year to begin a neonatology
• 02:01ethics program at Rochester,
• 02:04and we wish her all
• 02:05the best there. But we're
• 02:06fortunate to be able to
• 02:07take advantage of her presence
• 02:09here today to talk to
• 02:11us about ethical considerations
• 02:13of commercial
• 02:14gestational surrogacy in the United
• 02:16States. And this is an
• 02:17topic that has been receiving,
• 02:19significant press.
• 02:20There's a recent New York
• 02:22Times article, which and Alice
• 02:23will be introducing us all
• 02:25to this very hot topic
• 02:27in medical ethics and in
• 02:29obstetrics.
• 02:30Thank you so much, Alice.
• 02:38Thank thanks so much, Ben,
• 02:39and and thank you all
• 02:40for being here. I'm I'm
• 02:41really excited to
• 02:43be here tonight and to
• 02:44talk with you all about
• 02:45commercial surrogacy.
• 02:49I have nothing to disclose.
• 02:51Before I get started, there
• 02:52are a few people who
• 02:53I need to acknowledge. So
• 02:54first, Sarah Cross,
• 02:56who's a maternal fetal medicine
• 02:57specialist here at Yale who
• 02:59really inspired my initial interest
• 03:01in this topic and has
• 03:02been instrumental in sort of
• 03:04developing this work together.
• 03:06Laurie Bruce has brought her
• 03:08expertise in ethical policy making,
• 03:10which has been so helpful
• 03:12as we've considered
• 03:13what might be driving our
• 03:14current US policy as it
• 03:16relates to this topic.
• 03:18And then finally, I know
• 03:19I'm only one of, very
• 03:21many people in this room
• 03:22who can say that Mark
• 03:23Mercurio has been an incredible
• 03:24mentor to me.
• 03:26I'm very thankful for his
• 03:27support as I've fostered my
• 03:28interest in bioethics and for
• 03:29the wonderful
• 03:30bioethics community here at Yale
• 03:32that he's he's really helped
• 03:33to create.
• 03:35Mark introduced me to both
• 03:36both Sarah and Laurie, and
• 03:38was also very helpful as
• 03:39we initially considered how we
• 03:41might approach this topic.
• 03:44So my hopes today are
• 03:46to talk about commercial gestational
• 03:47surrogacy in the in the
• 03:49US as the title would
• 03:50suggest.
• 03:51I'll analyze some of the
• 03:52ethical considerations
• 03:54related to commercial surrogacy,
• 03:56and then I'll compare and
• 03:57contrast those with ethical considerations,
• 04:01of living kidney donation and
• 04:02payment for living kidney donation.
• 04:05And then finally, I'll examine
• 04:07some of the potential reasons
• 04:08that I I think could
• 04:09be driving the differences,
• 04:11in how we approach payment
• 04:13for gestational surrogacy and for
• 04:15living kidney donation within US
• 04:17policy.
• 04:18So we'll start with a
• 04:19case.
• 04:21And this is miss a.
• 04:22She's a healthy twenty eight
• 04:23year old woman. She's had
• 04:25one previous healthy pregnancy and
• 04:27deliver delivery,
• 04:29and she's a single mom.
• 04:30She's home for the holidays,
• 04:32sort of taking stock of
• 04:34her year and her life,
• 04:35and she's feeling unsatisfied with
• 04:37her current employment,
• 04:39and feeling like there's something
• 04:40missing in her life.
• 04:42Until she discovers,
• 04:44a side of TikTok,
• 04:46that's all about gestational surrogacy
• 04:48and and begins to wonder
• 04:49if this is something she
• 04:50should participate in.
• 04:53So
• 04:54I'll have to apologize. I
• 04:55took the actual TikTok videos
• 04:57out of the presentation because
• 04:59it seemed like it was,
• 05:00like,
• 05:01a little bit too technologically,
• 05:04risky for me.
• 05:06But but she she saw
• 05:07several TikToks,
• 05:09related to becoming a gestational
• 05:11surrogate.
• 05:12She saw that you can
• 05:13get to help a family
• 05:14and take home over sixty
• 05:15thousand dollars
• 05:18she saw that,
• 05:20you could get a pay
• 05:21base compensation of fifty five
• 05:22thousand dollars plus four hundred
• 05:24dollars a month plus additional
• 05:25a thousand dollar fees,
• 05:27at various other times throughout
• 05:29the surrogacy process.
• 05:33She saw this one woman
• 05:34who was very excited to
• 05:35be pregnant with somebody else's
• 05:37baby and not have to
• 05:38buy any baby items or
• 05:39take care of a baby,
• 05:40but to get paid to
• 05:41be pregnant plus stay at
• 05:42home with your babies.
• 05:45She,
• 05:46you know, saw people answer
• 05:48a lot of common questions,
• 05:49about surrogacy,
• 05:52you know, chronicled,
• 05:54one woman's
• 05:56whole process of surrogacy from
• 05:58start to finish,
• 06:01another woman's fourth surrogacy journey,
• 06:05another woman's second sort of
• 06:07journey,
• 06:08during labor and delivery.
• 06:11And then, again, she kept
• 06:12seeing sort of TikToks pop
• 06:13up about,
• 06:15how much money a gestational
• 06:17surrogacy a surrogate could make.
• 06:19So what is surrogacy?
• 06:21Gestational surrogacy
• 06:23involves the transfer of an
• 06:24embryo that's created via in
• 06:26vitro fertilization or IVF,
• 06:29using gametes, so eggs and
• 06:30sperm from intended parents or
• 06:32from donors,
• 06:33into a gestational carrier.
• 06:36The gestational carrier then gestates
• 06:38and births the pregnancy on
• 06:40behalf of the intended parents,
• 06:41and then the intended parents,
• 06:44take the baby. In commercial
• 06:46gestational surrogacy,
• 06:47the gestational carrier receives financial
• 06:50compensation for caring and delivering
• 06:52the pregnancy, and this is
• 06:53in contrast to altruistic surrogacy,
• 06:56which is,
• 06:57generally involves a friend or
• 06:58family member who,
• 07:00offers to gestate and deliver
• 07:02the pregnancy,
• 07:03without financial compensation.
• 07:07So so miss a is
• 07:09is really excited about this
• 07:10prospect and,
• 07:11shares,
• 07:13what she's learned with her
• 07:14brother, mister a.
• 07:16Mister a
• 07:17is also a healthy twenty
• 07:18eight year old who is
• 07:20home for the holidays,
• 07:22feeling a little down, feeling
• 07:23like his life is missing
• 07:24something too, and he wants
• 07:25to do something to make
• 07:26a difference. So so he
• 07:28actually,
• 07:30is considering becoming a living
• 07:31kidney donor or donating one
• 07:33of his kidneys,
• 07:34to somebody in need of
• 07:35a kidney transplant.
• 07:37He becomes very frustrated, though,
• 07:39that miss a could potentially
• 07:40be paid upwards of seventy
• 07:42five thousand dollars for becoming
• 07:43a surrogate, but he can't
• 07:45get paid at all to
• 07:45donate a kidney.
• 07:48So why is it okay
• 07:49for miss a to be
• 07:50paid so much, but not
• 07:51for mister a to be
• 07:52paid?
• 07:57Naturally, this comes up at
• 07:58the family dinner table,
• 08:00at the holiday dinner, and
• 08:01there are several family members
• 08:02who, have some ideas.
• 08:05So one one helpful family
• 08:06member says maybe you can
• 08:07get paid to donate a
• 08:08kidney.
• 08:09You know, I don't I
• 08:10don't know what the laws
• 08:11are. May maybe you could
• 08:13sell a kidney and also
• 08:14make seventy five thousand dollars.
• 08:17Another helpful family member suggests
• 08:19that maybe donating a kidney
• 08:20is too risky, and that's
• 08:21why it's not allowed to,
• 08:25you know,
• 08:26selling kidneys or being paid
• 08:28to donate kidneys,
• 08:29is not allowed.
• 08:31Another family suggests that paying
• 08:33potential kidney donors would be
• 08:35coercive.
• 08:36And so that's why mister
• 08:37a could not be paid
• 08:38to donate his kidney,
• 08:40whereas miss a could be
• 08:41paid to be a surrogate.
• 08:44And then finally, one family
• 08:45member says paying for a
• 08:46body part is just wrong.
• 08:49So are these statement statements
• 08:51valid?
• 08:52And are they legitimate reasons
• 08:54why we shouldn't allow mister
• 08:56a to be paid for
• 08:57donating a kidney?
• 08:59And and I think
• 09:00my question, if if so,
• 09:03is do any of these
• 09:04reasons apply to gestational surrogacy
• 09:07as well?
• 09:08So so we'll take a
• 09:09look at kind of each
• 09:09of these comments.
• 09:13So first, we'll address a
• 09:14family member who wondered if
• 09:16maybe mister a could get
• 09:17paid to donate a kidney.
• 09:19The short answer is no.
• 09:20He can't get paid,
• 09:21to donate a kidney in
• 09:22the US. And, yes, miss
• 09:24a can get paid to
• 09:25be a gestational surrogate in
• 09:27the US. But let's take
• 09:28a closer look at how
• 09:29these,
• 09:31practices are actually treated,
• 09:32within our current US policy.
• 09:40Alright. So,
• 09:42in terms of payment for
• 09:43living kidney donation,
• 09:45it is
• 09:46illegal in the United States.
• 09:48The National Organ Transplant Act
• 09:50of nineteen eighty four explicitly
• 09:53prohibits the purchase or sale
• 09:54of human organs for transplantation.
• 09:56So that would include,
• 09:58and, a kidney that a
• 09:59live donor
• 10:02donates to someone in need
• 10:03of transplant.
• 10:04And there are also strict
• 10:05limitations on reimbursement
• 10:07for direct out of pocket
• 10:09costs. Costs. So there are
• 10:09some costs that can be
• 10:11reimbursed,
• 10:12to the donor, but but
• 10:13those are very, very strictly
• 10:15regulated.
• 10:16And compensation to the donor
• 10:18for time, discomfort, or any
• 10:20assumption of risk is explicitly
• 10:22prohibited,
• 10:23by the National Organ Transplant
• 10:25Act.
• 10:26So I think a
• 10:27a telling example of what
• 10:29this actually looks like,
• 10:31for
• 10:32living kidney donors is,
• 10:34the case of Martha Gershen.
• 10:36Martha Gershen
• 10:37was a
• 10:40woman who saw an article
• 10:42in the newspaper about a
• 10:44community member that was in
• 10:45need of a kidney transplant.
• 10:47And she had had a
• 10:48cousin who had received a
• 10:50kidney transplant years before
• 10:52and decided that this was
• 10:53something that she was called
• 10:55to do, and she really
• 10:56wanted to sort of pay
• 10:57that forward and and give
• 10:58someone
• 10:59the gift of her kidney.
• 11:01So she decided to to
• 11:02move forward with living kidney
• 11:03donation,
• 11:04and and did donate her
• 11:06kidney to the woman from
• 11:08the new newspaper, but she
• 11:09encountered a lot of barriers
• 11:11along the way.
• 11:13So the the recipient's
• 11:15medical insurance did cover some
• 11:17of miss Gershyn's costs. So
• 11:18they paid for all of
• 11:20the medical and psychological
• 11:21evaluations that miss Gershyn needed,
• 11:24as part of the process.
• 11:26They paid for the surgery,
• 11:27for the removal of her
• 11:28kidney, and the postoperative care,
• 11:30and then for all sub
• 11:31subsequent monitoring,
• 11:33that she would need postoperatively
• 11:35going forward.
• 11:36But miss Gershen did encounter
• 11:38a lot of out of
• 11:39pocket costs that,
• 11:40were not reimbursed.
• 11:42So she calculated that she
• 11:44spent about four thousand dollars
• 11:45in travel to and from,
• 11:48the transplant center. She lived
• 11:50in a different city.
• 11:51So she would have to
• 11:52travel to the transplant center
• 11:54both for the surgery and
• 11:55and sort of during the
• 11:56postoperative time, but but also
• 11:58several times as part of
• 11:59the presurgical evaluation.
• 12:03She calculated that she and
• 12:04her husband,
• 12:06took off about three hundred
• 12:08and eighty hours or ten
• 12:09full work weeks
• 12:10in order to complete this
• 12:11process. And so that was,
• 12:13the screening,
• 12:14the surgery, the post op
• 12:15care, and then her husband
• 12:16sort of caring for her
• 12:17postoperatively.
• 12:19So so they took a
• 12:20significant financial hit
• 12:24in order to be able
• 12:25to donate,
• 12:26her kidney.
• 12:27She also felt like there
• 12:28was a a lot of
• 12:29stigma that she encountered,
• 12:31associated with the process.
• 12:33She disclosed some occasional marijuana
• 12:36use, and so they required
• 12:37her to have additional counseling
• 12:39as part of the screening.
• 12:40And they also required her
• 12:42her to provide
• 12:43detailed records from her psychologist
• 12:45who she had been seeing,
• 12:47to talk about some, like,
• 12:48stress at work that had
• 12:49nothing to do with with
• 12:51donating anxiety. And she she
• 12:52found that to be very
• 12:53stigmatizing and and felt like
• 12:54it was really a barrier,
• 12:57in the process.
• 12:59She also encountered several bureaucratic
• 13:01barriers.
• 13:02For example, if any of
• 13:04the preoperative evaluations could be
• 13:06scheduled at any time sort
• 13:07of at the convenience of
• 13:09the transplant center. So she
• 13:10would often have an appointment
• 13:12sort of scheduled,
• 13:14for her and and need
• 13:15to drop everything and travel
• 13:16to a different city,
• 13:18in order to attend those
• 13:19appointments.
• 13:21And and she also wasn't
• 13:22able to use outside labs
• 13:24to give blood work. And
• 13:26so when the transplant center
• 13:28requested blood work, she had
• 13:29to either travel
• 13:31there or I I think
• 13:32at one point, she, like,
• 13:34figured out how to coordinate
• 13:35getting blood drawn and shipping
• 13:37it on dry
• 13:38ice. And and she was
• 13:41felt
• 13:42under supported through that process.
• 13:46So so not only can
• 13:47living kidney donors not be
• 13:49paid, but but they do
• 13:50have sort of direct out
• 13:51of pocket costs that they
• 13:52end up incurring.
• 13:54And and there are a
• 13:55lot of barriers. So so,
• 13:58it's it's definitely not easy
• 14:00to become a living kidney
• 14:01donor. So so mister a,
• 14:04you know, if if you
• 14:05were to move forward with
• 14:06living kidney donation,
• 14:08definitely wouldn't be paid and
• 14:10and probably would end up
• 14:12worse off financially
• 14:14because of it.
• 14:17On the other hand, if
• 14:18we look at policy surrounding
• 14:20commercial gestational surrogacy, there are
• 14:22no federal laws or regulations
• 14:24in the US,
• 14:25surrounding this practice. So it's
• 14:27really left up to the
• 14:28states, and we'll look a
• 14:29little bit about some of
• 14:29the various policies in different
• 14:31states.
• 14:32But the American Society for
• 14:34Reproductive Medicine does support financial
• 14:36compensation for gestational carriers.
• 14:39They,
• 14:41you know, justify this by
• 14:42saying it's comparable to the
• 14:43reimbursement for time, discomfort, and
• 14:45risk that's assumed by research
• 14:47participants.
• 14:48So so they say it's
• 14:49okay, and and we probably
• 14:51should be paying gestational carriers
• 14:52in the same way that
• 14:53it's okay that we're paying
• 14:54research participants.
• 14:58Compensation typically ranges from around
• 15:00twenty five to forty five
• 15:01thousand dollars,
• 15:02plus reimbursement for travel, psychosocial,
• 15:05medical, legal, and administrative costs.
• 15:09Though this this number, according
• 15:11to several TikToks that I've
• 15:12now seen,
• 15:15may actually be be a
• 15:16little bit higher. I I
• 15:16don't know if the reimbursement
• 15:18is is in the quote
• 15:19that the people on TikTok
• 15:20are are quoting,
• 15:22but but it seems like
• 15:23some people are are making
• 15:25closer to fifty five to
• 15:26seventy five thousand dollars.
• 15:29So so miss a certainly
• 15:31could get paid, if she
• 15:32decided to move forward with
• 15:33becoming a surrogate.
• 15:36So this is a map
• 15:37of surrogacy laws by state
• 15:38that was published by a
• 15:40surrogacy agency.
• 15:41And as you can see
• 15:42here, there are a few
• 15:43states that ban surrogacy entirely.
• 15:46So this can you see
• 15:47my mouse? Oh, yeah. So
• 15:49so these states in gray,
• 15:52it do ban commercial surrogacy,
• 15:54or there's some states that
• 15:56only permit surrogacy in limited
• 15:58circumstances
• 15:59without financial compensation.
• 16:01But the majority of states
• 16:02are what this map refers
• 16:04to as surrogacy friendly.
• 16:07So these surrogacy friendly states
• 16:09either explicitly
• 16:10permit and regulate gestational surrogacy,
• 16:13including commercial surrogacy,
• 16:16or they lack specific laws
• 16:17addressing the practice.
• 16:19So So for example, in
• 16:20Alabama,
• 16:21there are laws that expressly
• 16:23permit both commercial and altruistic
• 16:25surrogacy for all couples,
• 16:27with no limit on compensation.
• 16:31And then on the other
• 16:32hand, Alaska doesn't have any
• 16:34laws or regulations pertaining to
• 16:35surrogacy. So effectively,
• 16:37it's also
• 16:38completely legal and unregulated in
• 16:40Alaska.
• 16:42In Arizona,
• 16:43which is listed here as
• 16:44a caution state,
• 16:46the surrogacy contracts are unenforceable.
• 16:49And so I I think
• 16:50that
• 16:51sort of gives surrogacy agents
• 16:53agencies cautious caution.
• 16:56And the gestational carrier legally
• 16:58is considered to be the
• 17:00mother.
• 17:01But but the courts
• 17:03in Arizona often will grant
• 17:05sort of pre birth parentage
• 17:07orders
• 17:08for genetically related intended parents.
• 17:12And and so there there
• 17:14is sort of, like there
• 17:15still are some surrogacy
• 17:17arrangements happening,
• 17:19in in some of those
• 17:20caution states. And then there
• 17:21are a few states like
• 17:22Nebraska, which expressly prohibit commercial
• 17:24surrogacy.
• 17:27So here in Connecticut, we
• 17:29do allow commercial surrogacy,
• 17:32and this is sort of
• 17:33governed under the Connecticut Parentage
• 17:36Act of twenty twenty two.
• 17:39It it's not a very
• 17:41sort of restrictive act. And
• 17:43so so in other words,
• 17:47there are all all different
• 17:48types of surrogacy arrangements and
• 17:50compensation for arrangements that can
• 17:52happen in Connecticut.
• 17:53The eligibility
• 17:55criteria that the Connecticut Parentage
• 17:57Act spells out for the
• 17:58gestational carriers,
• 18:00are that the carrier needs
• 18:01to be at least twenty
• 18:02one years old. They need
• 18:03to have previously given birth
• 18:04to at least one child.
• 18:07They need to have complete
• 18:08medical and mental health evaluations
• 18:10by licensed professionals.
• 18:12They need to have independent
• 18:13legal representation,
• 18:15and they need to have
• 18:16health insurance.
• 18:18And then for the intended
• 18:19parents,
• 18:20they
• 18:21have to be at least
• 18:22twenty one years old.
• 18:24They have to have a,
• 18:26mental health evaluation, and they
• 18:28also have to have their
• 18:29own independent legal representation.
• 18:31So so what this looks
• 18:33like at one of the
• 18:33agencies
• 18:34in Connecticut that I looked
• 18:36at,
• 18:37what this looks like for
• 18:38the intended parents,
• 18:39as long as they're twenty
• 18:40one years old and the
• 18:42agency's
• 18:43licensed therapist signs off on
• 18:45a mental health evaluation,
• 18:47they would pay a hundred
• 18:49and seventy nine thousand dollars
• 18:50to the surrogacy agency,
• 18:52plus they would be responsible
• 18:53for the cost of IVF.
• 18:56And then the surrogate,
• 18:59as long as they're twenty
• 19:00one years old and have
• 19:01had at least one child,
• 19:04and pass sort of medical
• 19:05and mental health evaluations by
• 19:07licensed professionals who, again, are
• 19:09are typically,
• 19:11hired by the surrogacy agency,
• 19:15would get paid
• 19:17from somewhere between fifty five
• 19:18and sixty five thousand dollars
• 19:20plus their expenses.
• 19:22So I I think it's
• 19:23really important when we look
• 19:24at these actual agencies to
• 19:25recognize that,
• 19:27though we have
• 19:29regulations sort of specifying that
• 19:31there need to be
• 19:33medical and mental health evaluations
• 19:34by licensed professionals, in practice,
• 19:36often these evaluations are happening
• 19:38by professionals who are hired
• 19:39by the agency.
• 19:41And and then, likewise,
• 19:43the surrogate
• 19:44or gestational carrier has to
• 19:46have independent legal representation,
• 19:49and that's legal representation that's
• 19:51paid for by the intended
• 19:53parents sort of via the,
• 19:55the agency. And and the
• 19:57agency on their website says
• 19:58they've got several sort of
• 20:00lawyers that they would recommend.
• 20:01So so the gestational carriers
• 20:03have legal representation, but it's,
• 20:04like, paid for and
• 20:06recommended by the surrogacy agency.
• 20:08So it's not as independent
• 20:11as one might think.
• 20:15So so the scope of
• 20:17this talk really,
• 20:19my hope is to focus
• 20:20on policy and practices within
• 20:22the United States.
• 20:23But I do think it's
• 20:24important to understand a little
• 20:26bit about the global context.
• 20:28So this is a map
• 20:29from twenty seventeen, so it's
• 20:30a little bit outdated.
• 20:32But you can see here
• 20:33in green
• 20:34are the countries where commercial
• 20:35surrogacy is legal.
• 20:38So you can see here
• 20:38it's allowed in the US.
• 20:39It's allowed in Russia,
• 20:41Ukraine,
• 20:42Belarus,
• 20:43Iran.
• 20:44India here is green,
• 20:46but actually has since this
• 20:48map was published,
• 20:49has prohibited,
• 20:52commercial surrogacy. So it's no
• 20:53longer legal in India.
• 20:55And then you can see
• 20:56here throughout most of Europe,
• 20:59this is all red here,
• 21:00which means they prohibit surrogacy
• 21:03altogether.
• 21:04And then there are a
• 21:05few,
• 21:06places that do allow
• 21:08altruistic or unpaid surrogacy.
• 21:10So it so it's definitely
• 21:13not universal that that we're
• 21:16allowing commercial gestational surrogacy, and
• 21:18and I think that,
• 21:20many of sort of our
• 21:21our peer countries are are
• 21:22treating this a little bit
• 21:23differently.
• 21:29So I won't get into
• 21:30it too much, but as
• 21:31Ben alluded to,
• 21:33there have has been a
• 21:34lot of attention on surrogacy
• 21:36in the media lately.
• 21:40And I I think it's
• 21:41important to acknowledge that there
• 21:42have been some really concerning
• 21:44stories coming out,
• 21:46of of gross human rights
• 21:48violations that are happening,
• 21:50in in other places where
• 21:51commercial surrogacy is legal. So
• 21:53this was a recent New
• 21:54York Times article,
• 21:56about an
• 21:58agency that and this is
• 22:00like a gross oversimplification,
• 22:02but but about an agency
• 22:03that,
• 22:04was bringing women to Georgia
• 22:06where commercial surrogacy is legal,
• 22:08from Thailand and from other
• 22:10places often under false pretenses
• 22:13to have them work as
• 22:14surrogates.
• 22:15And then when they got
• 22:16to Georgia,
• 22:17their passports ports were taken.
• 22:19They were told that they
• 22:20owed money for sort of
• 22:21the travel expenses and the
• 22:23initial kind of upfront costs
• 22:24of getting them there.
• 22:27And
• 22:28the women were forced to
• 22:29undergo various treatments,
• 22:32without understanding what exactly
• 22:35was happening to them. There
• 22:37was definitely no in informed
• 22:38consent involved,
• 22:40or or even an explanation,
• 22:43in the or or even
• 22:44someone available,
• 22:45who spoke the language that
• 22:47these women spoke.
• 22:50So these women weren't sure
• 22:51what was happening to them.
• 22:52There there was,
• 22:54you know, concern that several
• 22:55women women had their eggs
• 22:57harvested
• 22:58without their consent or knowledge.
• 23:00And these these women were
• 23:01basically stuck living in horrible
• 23:03conditions with really no way
• 23:04out. So so
• 23:06so this is, you know,
• 23:07I think I think
• 23:08important to acknowledge,
• 23:10that that this is,
• 23:12you know, a real
• 23:15thing happening. This is sort
• 23:17of human trafficking
• 23:19related specifically to commercial surrogacy,
• 23:22with women being brought to
• 23:24a country where the practice
• 23:25is legal.
• 23:29I haven't seen anything quite
• 23:30that egregious,
• 23:32happening here in the US,
• 23:34but there there have definitely
• 23:35been some concerning stories,
• 23:37coming out about surrogacy arrangements
• 23:40in the US. So so
• 23:41this is just one example,
• 23:43I chose. This is a
• 23:44story about,
• 23:46a venture capitalist
• 23:48in, I believe, California
• 23:50who elected to use a
• 23:51surrogate because by the time
• 23:52she was ready to have
• 23:53children, she was forty three
• 23:54years old,
• 23:56which she felt was too
• 23:57old to carry a pregnancy.
• 23:58And she had frozen some
• 24:00eggs before, so she,
• 24:02used actually two of her
• 24:03embryos
• 24:04to implant into two different
• 24:05gestational carriers
• 24:07in order to build her
• 24:08family.
• 24:10Unfortunately,
• 24:12one of the babies ended
• 24:13up being stillborn,
• 24:15and the intended mother really
• 24:18blamed the gestational carrier for
• 24:20this,
• 24:20and and went sort of
• 24:22completely off the rails.
• 24:24She started slandering the gest
• 24:26the surrogate,
• 24:27all over the Internet. There
• 24:28were all sorts of Facebook
• 24:30groups that were attacking this
• 24:31woman,
• 24:33saying she sort of was
• 24:35negligent for letting the baby
• 24:37die,
• 24:38although she was, like, admitted
• 24:40to the hospital for monitoring
• 24:42while this happened,
• 24:44and and there was really
• 24:46no evidence that, you know,
• 24:48the gestational carrier had done
• 24:49anything wrong.
• 24:52She ended up suing the
• 24:53gestational carrier. She made several
• 24:55allegations of fraud,
• 24:57and the carrier ended up
• 24:58being left with hundreds of
• 25:00thousands of dollars of medical
• 25:01bills that were unpaid.
• 25:04So even with some legal
• 25:06protections in place, there's often
• 25:07this power differential between the
• 25:09intended parents who,
• 25:11you know, have significant financial
• 25:14means in the gestational carriers.
• 25:15And and the intended parents
• 25:17may have the means to
• 25:18rack up a lot of
• 25:19legal bills to sue the
• 25:20gestational carriers. So even if
• 25:21they have sort of independent
• 25:23required legal counsel,
• 25:26it's it's still a really
• 25:28vulnerable position. And and there
• 25:29are, you know, certainly
• 25:31women in the US who
• 25:32are who are being mistreated
• 25:34and taken advantage of,
• 25:37specifically,
• 25:39related to commercial surrogacy.
• 25:43So just to take a
• 25:44step back and and summarize
• 25:45sort of the US policy
• 25:46on the two different practices
• 25:48we're talking about.
• 25:49For commercial surrogacy,
• 25:51again, there are no federal
• 25:52laws governing the practice.
• 25:54It's permitted in most states
• 25:56in the US,
• 25:58and and women can make
• 26:00tens of thousands of dollars
• 26:01plus receive reimbursement for,
• 26:03medical, travel, psychosocial, or legal
• 26:06costs.
• 26:08And then by contrast,
• 26:11living kidney donors,
• 26:13cannot
• 26:15receive any type of payment.
• 26:16Financial compensation is expressly prohibited
• 26:19by the National Organ Transplant
• 26:20Act,
• 26:21and and they end up
• 26:23often facing
• 26:24financial barriers to becoming donors.
• 26:30So now that we've established
• 26:32that commercial surrogacy and paid
• 26:33kidney donation are definitely treated
• 26:35differently
• 26:36in US policy,
• 26:38let's recall the second helpful
• 26:39family member at the dinner
• 26:41table,
• 26:42who suggested that maybe this
• 26:43is just because
• 26:44donating a kidney is too
• 26:45risky.
• 26:46In other words, maybe one
• 26:48reason
• 26:49payment for organ donation may
• 26:50be restricted in a way
• 26:51that commercial surrogacy is not
• 26:53could be related to the
• 26:54medical risks associated with giving
• 26:56up an organ.
• 26:59So what are the actual
• 27:01risks associated with living kidney
• 27:02donation?
• 27:03There is a perioperative mortality
• 27:05of about point o three
• 27:07one percent,
• 27:08and there's not been
• 27:11there's not been a significant
• 27:13increase in long term mortality
• 27:15demonstrated for living kidney donors.
• 27:17There's less than a three
• 27:19percent risk of major perioperative
• 27:21complications. So that that would
• 27:22include things like a pulmonary
• 27:24embolism
• 27:25or injuries that require reoperation
• 27:27after the initial,
• 27:29kidney donation.
• 27:31There's about a ten to
• 27:32twenty percent risk of minor
• 27:33perioperative complications.
• 27:35This would be things like,
• 27:37wound or urinary
• 27:38tract infections.
• 27:41And then living kidney donors
• 27:43go through a pretty rigorous
• 27:45screening process and tend to
• 27:46be healthier than the general
• 27:48population.
• 27:49So when you when you
• 27:50compare them to the general
• 27:51population, they don't have an
• 27:53increased long term risk of
• 27:54kidney failure.
• 27:56But if if you look
• 27:57at,
• 27:59you know, living donors compared
• 28:01to healthy non donors, they
• 28:03do have a slightly higher
• 28:04risk,
• 28:06of of kidney failure long
• 28:07term.
• 28:09Certain sub subgroups of donors,
• 28:11so, black male or older
• 28:14kidney donors have a slightly
• 28:16higher chronic risk of hypertension
• 28:18after donation,
• 28:19and then women who later
• 28:20become pregnant do have higher
• 28:22rates of hypertensive
• 28:23disorders of pregnancy,
• 28:25and preterm birth.
• 28:27The psychosocial outcomes generally are
• 28:29reported to be stable or
• 28:30improved after kidney donation.
• 28:33Those so some donors do
• 28:34report emotional stress or strained
• 28:36personal relationships.
• 28:44If we turn now and
• 28:44look at the risks associated
• 28:46with gestational surrogacy,
• 28:48we can see that in
• 28:49the US,
• 28:50maternal mortality is about
• 28:52zero point zero three three
• 28:54percent of all live births,
• 28:56Though this does exclude deaths
• 28:58that are associated with stillbirths,
• 29:00miscarriages, or terminations.
• 29:02And then severe maternal morbidity
• 29:04occurs in about two percent
• 29:06of all deliveries in the
• 29:07US.
• 29:08Severe maternal morbidity would include
• 29:11complications like amniotic fluid embolism,
• 29:14sepsis, cardiac arrest, and hysterectomy.
• 29:18It's it's important to note
• 29:19though that the risks that
• 29:20I've rest referenced
• 29:22associated with pregnancy are risks
• 29:24associated with all pregnancies within
• 29:25the US,
• 29:27and and the data pertaining
• 29:28specifically to surrogate pregnancies are
• 29:30a little bit more limited.
• 29:32I do think it's important
• 29:33to acknowledge that there there
• 29:34also is some screening and
• 29:36so surrogates,
• 29:38you know, may be healthier
• 29:39at baseline.
• 29:41But but I think it's
• 29:42important to recognize that,
• 29:45we we do know that
• 29:46pregnancies that involve the use
• 29:48of
• 29:49assisted reproductive technology or IVF,
• 29:51which all surrogate pregnancies
• 29:53must use, are associated with
• 29:55higher risks of severe maternal
• 29:57morbidity,
• 29:58of preeclampsia,
• 29:59gestational hypertension,
• 30:01placental complications, and cesarean delivery.
• 30:04There's also a higher risk
• 30:06with,
• 30:07assisted reproductive technology of multifetal
• 30:10gestation or twins or triplets,
• 30:13which we know is also
• 30:14associate associated with higher risks
• 30:16of pregnancy complications. So those
• 30:17include things like gestational diabetes,
• 30:19hemorrhage, anemia, hypertensive disorders of
• 30:22pregnancy,
• 30:23and postpartum depression.
• 30:26When we look specifically at
• 30:28individuals who have carried both
• 30:30spontaneous and surrogate pregnancies,
• 30:33We also see that the
• 30:34surrogate pregnancies do have higher
• 30:36rates of adverse outcomes.
• 30:38And then and then finally,
• 30:40while,
• 30:40gestational carriers generally report
• 30:43satisfaction with the surrogacy experience,
• 30:46they do have higher rates
• 30:47of new onset mental illness
• 30:48compared to others who undergo
• 30:50IVF.
• 30:53Many of these complications can
• 30:55pose risk to future pregnancies
• 30:57and and to, like, sort
• 30:58of current health status.
• 31:01But I I think even
• 31:02in sort of uncomplicated
• 31:04pregnancies, we know that there
• 31:05can be longer term complications,
• 31:08that are often overlooked. So
• 31:09things like incontinence,
• 31:10sexual dysfunction,
• 31:12mood disorders, or postpartum weight
• 31:14retention.
• 31:15So so this is definitely,
• 31:17I would say not a
• 31:18benign
• 31:19intervention.
• 31:24So so, again, to look
• 31:25at these risks side by
• 31:26side,
• 31:27both, gestational surrogacy
• 31:29and living kidney donation have
• 31:31a mortality of around point
• 31:33zero three percent.
• 31:35The risk of severe maternal
• 31:36morbidity with pregnancy is similar
• 31:38to the risk of major
• 31:40perioperative complications with living kidney
• 31:42donation.
• 31:43Both practices have many other
• 31:45sort of more minor risks,
• 31:47and there are some long
• 31:48term risks associated with both.
• 31:50So I think that overall,
• 31:52gestational carriers and living kidney
• 31:54donors do both face meaningful
• 31:56physical, psychological,
• 32:00risks. And and I think
• 32:01that these risks are broadly
• 32:02comparable in severity and frequency.
• 32:06So I don't think that
• 32:07that's a reason
• 32:08why
• 32:09they should be treated differently
• 32:11by US fall policy.
• 32:15So so this this next
• 32:16concern raises one of the
• 32:17major ethical concerns that that
• 32:19people have with financial compensation
• 32:21for both organ donors and
• 32:22for gestational carriers.
• 32:24And that and that's that
• 32:25paying potential kidney donors could
• 32:26be coercive.
• 32:29So so to break this
• 32:31down a little, let's first
• 32:32kind of go through a
• 32:33few def definitions. So coercion
• 32:35involves the use of a
• 32:36threat to obtain a person's
• 32:38compliance with a demand.
• 32:40So, for example,
• 32:42the women who who are
• 32:44flown from Thailand to Georgia
• 32:45under false pre pretenses and
• 32:47their passports are taken and
• 32:49they're required to repay costs,
• 32:51if they didn't cooperate
• 32:52with the surrogacy or or
• 32:54with whatever else,
• 32:55the agency was trying to
• 32:56do with them, they would
• 32:57essentially be stranded in Georgia
• 32:59with no money or passport.
• 33:01And so it becomes very
• 33:02hard not to comply.
• 33:04On on the other hand,
• 33:06inducement
• 33:06involves an offer
• 33:10that may persuade a person
• 33:12to do something. So, for
• 33:14example,
• 33:16the offer of Panera dinner
• 33:18may have induced many of
• 33:19you to join us in
• 33:20person tonight.
• 33:22But if you hadn't accepted
• 33:24that offer, you would be
• 33:25no worse off
• 33:27than before this all started.
• 33:31So there's not a cost
• 33:32for noncompliance with inducement.
• 33:35But but there is a
• 33:36concern that that sometimes there
• 33:39may be undue inducement, and
• 33:41this is a concern that
• 33:42an an offer that sort
• 33:44of can't be refused,
• 33:46may distort a person's judgment
• 33:48by causing the person to
• 33:49focus more on the short
• 33:50term benefits,
• 33:52than the long term consequences
• 33:54of an action.
• 33:55So a really attractive offer
• 33:57may lead someone to ignore
• 33:58or downplay risks that they
• 34:00otherwise wouldn't accept.
• 34:03And and so there's concern
• 34:04that sort of coercion or
• 34:06inducement can
• 34:09or or undo inducement can,
• 34:11potentially invalidate informed consent,
• 34:15and and could lead to
• 34:16exploitation of financially vulnerable individuals.
• 34:19So just as a reminder,
• 34:20we all know informed consent
• 34:22requires several things. So an
• 34:23individual to in order to
• 34:25provide informed consent needs to
• 34:27have capacity. There needs to
• 34:28be disclosure
• 34:29of the relevant medical information.
• 34:31They need to understand the
• 34:33information,
• 34:34and it needs to be
• 34:35voluntary. And so,
• 34:37coercion or undue inducement may
• 34:39threaten the voluntariness of informed
• 34:41consent and thus invalidate the
• 34:43consent
• 34:44and become exploitative.
• 34:48So the American Society for
• 34:49Reproductive Medicine does seem to
• 34:51acknowledge this risk in their
• 34:53position statement that argues financial
• 34:55compensation for gestational carriers
• 34:57is ethically justifiable,
• 34:59but should not create an
• 35:00undue inducement or risk of
• 35:02exploitation.
• 35:03So in this position statement,
• 35:04this is where the ASRM
• 35:06likens financial compensation for surrogates
• 35:08to the reimbursement,
• 35:10for human research participants for
• 35:12time discomfort and risk.
• 35:15The federal policy for protection
• 35:17of human subjects with which
• 35:18governs human research,
• 35:21does require efforts to minimize
• 35:23the possibility of coercion or
• 35:24undue influence.
• 35:26And there's been a lot
• 35:27of work in the realm
• 35:28of human sub subjects research
• 35:29and research ethics,
• 35:31analyzing how we can fairly
• 35:33compensate research participants
• 35:35while minimizing the risk of
• 35:36undue influence.
• 35:38Ultimately, though, the boundary between
• 35:40what represents fair comp compensation
• 35:43versus undue influence is nearly
• 35:45impossible to to define as
• 35:47it's highly contextual,
• 35:48and the magnitude of compensation
• 35:50that becomes coercive
• 35:51will will vary
• 35:53widely based on sort of
• 35:54individual vulnerabilities.
• 35:58Many bioethics
• 35:59bioethicists
• 36:00sort of
• 36:02research ethicists and other bioethicists
• 36:05have written really extensively on
• 36:06this topic,
• 36:07on the risk of coercion
• 36:09or undue inducement, on how
• 36:10these incentives may or may
• 36:12not invalidate true informed consent,
• 36:15and how certain groups of
• 36:16individuals may be exploited as
• 36:18a result of financial incentives.
• 36:20But without diving too deeply
• 36:22into those discussions, I I'll
• 36:24just note that it seems
• 36:26to me this is a
• 36:27really important and valid risk,
• 36:29but it's really not clear
• 36:30to me,
• 36:32that that this risk would
• 36:33be greater,
• 36:34with financial compensation for organ
• 36:36donors than it is with
• 36:38compensation for gestational carriers. So
• 36:40I so, again, I don't
• 36:41think that
• 36:42this is a risk that
• 36:43explains,
• 36:45why there's such a difference
• 36:46in how the two practices
• 36:47are treated within
• 36:54US policy.
• 36:58Uh-uh.
• 36:59Okay. So if there's not
• 37:01a large difference in the
• 37:02medical risk or the risk
• 37:03of coercion when we're thinking
• 37:05about paying either kidney donors
• 37:07or gestational carriers,
• 37:08then we have to ask
• 37:09if there's something else that's
• 37:10categorically different,
• 37:12between these two practices. And
• 37:14and another sort of risk
• 37:16that's commonly discussed
• 37:18in relation to both kidney
• 37:20donation,
• 37:21and gestational surrogacy is this
• 37:23risk of commodification
• 37:25or transforming something that's inherently
• 37:27personal
• 37:28into a product for sale.
• 37:29And I think that's what
• 37:30this comment probably gets at.
• 37:32So paying for a body
• 37:33part is just wrong. And
• 37:35and I think that it's
• 37:36it it feels wrong that
• 37:38we're turning something that's a
• 37:39part of the body that's
• 37:40so personal into a product
• 37:42that's for sale.
• 37:44So we'll talk a little
• 37:46a little bit more about
• 37:46this concern over commodification as
• 37:48it relates,
• 37:49to both living kidney donation
• 37:50and to gestational surrogacy.
• 37:53So there's often a distinction
• 37:55that's made between selling body
• 37:57parts and selling bodily labor.
• 37:59And and some people argue
• 38:00that,
• 38:01one is okay and not
• 38:02the other.
• 38:03And and there is a
• 38:04lot of robust debate within
• 38:06the bioethics literature.
• 38:09But but,
• 38:11you know, I think another
• 38:12complicating factor with gestational surrogacy,
• 38:15is there's a lot of
• 38:16debate over what's actually being
• 38:18sold.
• 38:20So the selling of body
• 38:22parts
• 38:22reduces a person or part
• 38:24of a person to an
• 38:25object of market exchange.
• 38:27And so if we were
• 38:28to pay living kidney donors
• 38:29for their donation,
• 38:31the practice could very well
• 38:32be considered to be paying
• 38:34for the kidneys themselves,
• 38:36which many people consider it
• 38:37to be unacceptable.
• 38:39In the US and in
• 38:41in in other places,
• 38:42there does seem seem to
• 38:43be a general acceptance of
• 38:45selling some types of body
• 38:46parts or body products. So
• 38:49plasma, eggs, and sperm,
• 38:51are sort sort of bought
• 38:52and
• 38:53sold.
• 38:55But selling a kidney, I
• 38:56I do recognize, may be
• 38:58categorically different from selling plasma
• 39:00or from gametes,
• 39:01because kidneys aren't a renewable
• 39:03body product. It's a sort
• 39:04of a major or body
• 39:06part. So it's a it's
• 39:07a major organ that you
• 39:08don't get back after you
• 39:09donate.
• 39:11On the other hand, bodily
• 39:13labor
• 39:14involves work that uses the
• 39:15body itself as the site
• 39:17and the instrument of labor.
• 39:19So sex work is a
• 39:20classic example of bodily labor,
• 39:22but other types of embodied
• 39:24labor include modeling or participation
• 39:26in professional sports.
• 39:29Many people argue that gestational
• 39:30surrogacy is a form of
• 39:31bodily labor in which the
• 39:33gestation and delivery of the
• 39:35pregnant
• 39:36pregnancy is the service that's
• 39:38being sold.
• 39:39But others have argued that
• 39:40the intended parents aren't paying
• 39:41for the act of gestation
• 39:43itself,
• 39:44but rather for the baby
• 39:45that's delivered.
• 39:46And so, in fact, some
• 39:48people argue commercial surrogacy would
• 39:50constitute the buying and selling
• 39:51of complete human beings.
• 39:54Either way, I to me,
• 39:57what the gestational carrier is
• 39:59selling is inextricable
• 40:01from the body itself.
• 40:03Pregnancy
• 40:04involves more than just sort
• 40:05of the use of the
• 40:06body for a forty week
• 40:08period. It also involves the
• 40:10creation of the placenta, which
• 40:12is its own organ,
• 40:14and it permanently transforms the
• 40:16body in many ways.
• 40:19So, again,
• 40:20I find myself sort of
• 40:22wondering here why we as
• 40:24a society are not okay
• 40:25with paying kidney donors,
• 40:27but we're comfortable with paying
• 40:28gestational carriers for,
• 40:30deeply embodied labor that permanently
• 40:32transforms their bodies.
• 40:35So there
• 40:37perhaps there could be some
• 40:38categorical different here that difference
• 40:40here that that some people
• 40:41would argue,
• 40:43makes it okay
• 40:44to be paying gestational carriers,
• 40:46but not organ donor donors.
• 40:48But I do wonder what
• 40:49else could be driving sort
• 40:51of the difference in how
• 40:52US policy treats these two
• 40:54practices.
• 41:02Alright.
• 41:07So I think it's interesting
• 41:08now to shift our focus,
• 41:11and instead look at who's
• 41:12actually participating in and benefiting
• 41:15from these practices.
• 41:17So we've looked at a
• 41:18lot of the risks
• 41:19that are faced by gestational
• 41:21carriers and by living kidney
• 41:22donors.
• 41:23But I'd also like to
• 41:24look at the risks that
• 41:25intended,
• 41:26parents and organ recipients face,
• 41:29as well as how each
• 41:30of these parties
• 41:33may benefit. And then through
• 41:34this approach, I'm hoping,
• 41:38we we can examine what
• 41:39values may actually be driving
• 41:41our current US policy.
• 41:45So
• 41:45we've talked a fair amount
• 41:47about risk in the in
• 41:48the discussion as far as
• 41:49primarily been focused on risk
• 41:51in the context of
• 41:53allowing financial compensation for participating
• 41:56in these practices.
• 41:58But if if we look
• 41:59now at the risks that
• 41:59are associated with
• 42:01potentially restricting or regulating payments,
• 42:04for the gestational carrier and
• 42:06for the organ donors,
• 42:07the biggest risk would be
• 42:08that they're not compensated fairly
• 42:10for their time, discomfort, and
• 42:11the the bodily risks that
• 42:13they assume.
• 42:14Some people have argued that
• 42:15policies that are purporting to
• 42:17protect women who may wanna
• 42:19act as surrogates
• 42:20undermine potential surrogates' reproductive autonomy
• 42:23and rely on an assumption
• 42:24that these women lack the
• 42:26sophistication
• 42:27to properly assess assess risk
• 42:28and give it informed consent.
• 42:31But but I think a
• 42:31similar argument could be made
• 42:33about restrictions
• 42:34surrounding financial compensation for living
• 42:36kidney donation.
• 42:39So if if we look
• 42:40now at intended parents and
• 42:41at potential organ recipients,
• 42:43there's
• 42:46compensation,
• 42:47fewer people will be willing
• 42:48to serve as gestational carriers
• 42:50or as living organ donors.
• 42:52For many family families, gestational
• 42:54surrogacy is the only possible
• 42:56path to having a biologically
• 42:58related child. And so without
• 43:00surrogacy,
• 43:01these families may not be
• 43:02able to have children at
• 43:03all.
• 43:04When considering living kidney donation,
• 43:07policies that create barriers for
• 43:09potential donors and,
• 43:11you know,
• 43:13discourage people from becoming donors,
• 43:15will mean there are fewer
• 43:16people who will receive kidneys
• 43:18and and more people will
• 43:20may die while awaiting transplant.
• 43:29Alright. So if we look
• 43:30now at the potential benefits
• 43:32for these four different groups,
• 43:34for gestational carriers and for
• 43:36organ donor donors,
• 43:38allowing payments for these practices
• 43:40would, of course, confer a
• 43:41financial benefit.
• 43:44And and another major presumed
• 43:46benefit of allowing financial compensation
• 43:48is the expectation that more
• 43:49people may be willing to
• 43:51sign up to be
• 43:52gestational carriers or living kidney
• 43:54donors.
• 43:54So for intended parents,
• 43:57the benefit of this would
• 43:58then be that they get
• 43:59a baby.
• 44:00And for kidney recipient recipients,
• 44:02the benefit would be a
• 44:03greater chance of receiving a
• 44:05life saving transplant.
• 44:06So it's I I think
• 44:07it's really important that we
• 44:08consider sort of the differences
• 44:10between these outcomes.
• 44:13In US sort of bioethical
• 44:15and policy discourse,
• 44:18it it seems that facilitating
• 44:19the creation of a child
• 44:21appears to carry greater moral
• 44:23weight,
• 44:24than saving the life of
• 44:25an adult patient with organ
• 44:26failure.
• 44:28Babies
• 44:29produced through surrogacy are treated
• 44:30as intrinsically valuable outcomes,
• 44:33and the risks that are
• 44:34borne by gestational carriers are
• 44:36often justified to appeal the
• 44:38profound
• 44:39to to appeal to the
• 44:40profound moral and social value
• 44:42of parenthood.
• 44:43By contrast,
• 44:44the beneficiaries
• 44:46of kidney transplantation are typically
• 44:48medically complex adults
• 44:50whose continued survival does not
• 44:51carry the same cultural or
• 44:53symbolic weight.
• 44:54So the moral urgency of
• 44:56saving adult lives,
• 44:58though substantial doesn't appear to
• 45:00generate the same tolerance for
• 45:02these market mechanism
• 45:03mechanisms or bodily risk as
• 45:05does the creation
• 45:06of a baby.
• 45:08I'm definitely not trying to
• 45:09argue that adult lives are
• 45:11less valuable than babies,
• 45:13but rather they appear to
• 45:14be treated as such within
• 45:16our existing regulatory framework.
• 45:18And I think this difference
• 45:20in moral framing may help
• 45:21explain why our society is
• 45:23more willing to accept sort
• 45:25of compensated bodily risk when
• 45:28the outcome is a baby
• 45:29when than when it's,
• 45:30the extension of an adult
• 45:32life.
• 45:35And then finally, I think
• 45:36it's important to consider the
• 45:37demographics of each of these
• 45:39groups.
• 45:40So in gestational
• 45:41surrogacy,
• 45:42the intended parents who are
• 45:44the primary beneficiaries of this
• 45:46practice
• 45:46tend to be more affluent,
• 45:48socially powerful, and culturally privileged.
• 45:51So if you'll recall,
• 45:53the out of pocket cost
• 45:54to intended parents,
• 45:56at the one of the
• 45:57agencies I looked at was
• 45:58a hundred and seventy nine
• 46:00thousand dollars,
• 46:01plus the costs associated with
• 46:03IVF.
• 46:04So individuals or couples who
• 46:05lack really significant
• 46:07financial resources are effectively excluded
• 46:10from these arrangements
• 46:11regardless of their reproductive desires.
• 46:15On the other hand,
• 46:17people in need of kidney
• 46:18transplants encompass
• 46:20a much broader spectrum of
• 46:21socioeconomic
• 46:23backgrounds,
• 46:24with socially disadvantaged individuals
• 46:27much less likely to receive
• 46:29the transplants that they need.
• 46:30So currently,
• 46:31in the US, living kidney
• 46:33donors are more likely to
• 46:34be white and tend to
• 46:35come from financially stable backgrounds,
• 46:38which is likely related to
• 46:39the financial barriers,
• 46:41that are resulting from restrictions
• 46:43on compensation for donors.
• 46:45Women are more likely to
• 46:46donate kidneys,
• 46:48but both men and women
• 46:48definitely do participate in living
• 46:48kidney donation. And then
• 46:49these
• 46:56demographics of who is receiving
• 46:58kidney donations. Most living kidney
• 47:00donations are directed donations. So,
• 47:03the the kidney is directed
• 47:04to a specific person. And
• 47:06so,
• 47:08if sort of wealthier
• 47:10white donors are more likely
• 47:12to participate, they're often,
• 47:15directing their kidneys to wealthier
• 47:16white recipients.
• 47:19And and so if we
• 47:20were to allow financial compensation
• 47:23or or remove some of
• 47:24the barriers,
• 47:26to to organ donation,
• 47:28we would very likely benefit,
• 47:31preferentially
• 47:31individuals with lower socioeconomic
• 47:33status.
• 47:37If if we look now
• 47:38at the gestational carriers,
• 47:40these are women who are
• 47:41performing reproductive labor on behalf
• 47:43of others.
• 47:45Unfortunately,
• 47:46reproductive labor has historically been
• 47:47under recognized and undervalued,
• 47:50And we live in a
• 47:50society in which women are
• 47:51expected to bear the risks
• 47:53associated with pregnancy,
• 47:55and are granted less autonomous
• 47:56moral agency
• 47:57regarding whether or not to
• 47:59perform this labor. And I
• 48:00think that is is becoming
• 48:01even
• 48:03quite evident
• 48:04in the post Dobbs era
• 48:06that we're
• 48:07currently in.
• 48:09And if we sort of
• 48:11look through this lens,
• 48:13surrogacy
• 48:14could be seen as a
• 48:15continuation of a long standing
• 48:17pattern in which women's bodies
• 48:18are expected to bear risk
• 48:20for others
• 48:21and where that risk is
• 48:22normalized rather than sort of
• 48:24critically examined.
• 48:26The framing of surrogacy as
• 48:27a contractual
• 48:29service
• 48:30may reflect not just sort
• 48:31of a market logic, but
• 48:33a deeper
• 48:34gendered assumption that the female
• 48:35body, especially in the context
• 48:37of reproduction,
• 48:38is more sort of naturally
• 48:40imagined as a site of
• 48:41labor than as a source
• 48:42of autonomous moral agency.
• 48:45I think this framing subtly
• 48:46distances surrogates from sort of
• 48:48the category of people who
• 48:50must be protected from exploitation,
• 48:53and places them instead among
• 48:54sort of those who can
• 48:56be ethically instrumentalized
• 48:57as long as there's sort
• 48:58of consent and compensation.
• 49:02Meanwhile, living organ donors,
• 49:04who are both men and
• 49:05women, are treated much more
• 49:07cost cautiously by US policy,
• 49:10and and policy reflects sort
• 49:11of a paternalistic
• 49:12stance that's aimed at protecting
• 49:15individuals
• 49:16from the potential harms of
• 49:17commercialization.
• 49:19But that protective stance appears
• 49:21to be inconsistently applied
• 49:23when the labor in question
• 49:24is historically gendered as female.
• 49:25So I I'd wonder,
• 49:28if surrogates were predominantly male,
• 49:29if we'd be more concerned
• 49:31about sort of protecting them,
• 49:33with restrictions on compensation
• 49:35and commercialization.
• 49:38Overall, I think when we
• 49:40look at the various stakeholders
• 49:41and how they stand to
• 49:43benefit from either,
• 49:45allowing or restricting,
• 49:47payment.
• 49:49It seems that we're okay
• 49:51with the risks associated with
• 49:53financial compensation when we're talking
• 49:55about ho helping socially powerful
• 49:57and privileged individuals to have
• 49:59a baby,
• 50:00but not when we're considering
• 50:02expanding access to to life
• 50:03saving therapy for folks who
• 50:04are in need of a
• 50:05kidney transplant who are often
• 50:06less privileged.
• 50:10So in conclusion,
• 50:12in the US,
• 50:14there definitely is inconsistent regulatory
• 50:16treatment of practices involving
• 50:19financial compensation for bodily risk.
• 50:22With both commercial surrogacy and
• 50:24paid organ donation, I think
• 50:25there are legitimate concerns
• 50:28about,
• 50:29coercion,
• 50:30exploitation, and commodification,
• 50:32but I think there are
• 50:33a lot more commonalities
• 50:34between these two practices than
• 50:36we've acknowledged.
• 50:38And I think the differences
• 50:39in our policy approach may
• 50:41be more related to power
• 50:42imbalances and to deeply ingrained
• 50:44gender norms.
• 50:47It seems to me that
• 50:48reproductive
• 50:49desires of affluent, socially powerful
• 50:51individuals
• 50:52are being framed as legitimate
• 50:54needs,
• 50:55and we've normalized a system
• 50:57of paying people for reproductive
• 50:58labor that meets those needs.
• 51:00But in contrast, paid organ
• 51:02donation,
• 51:03which would primarily benefit individuals
• 51:05of diverse or lower socioeconomic
• 51:07status,
• 51:08is regarded with a lot
• 51:10greater moral suspicion, and and
• 51:11that's sort of reflected in
• 51:13our US policy.
• 51:15I think that we as
• 51:16clinicians,
• 51:17policymakers, and bioethicists
• 51:19are obligated to critically,
• 51:21evaluate this difference,
• 51:23and how these two practices
• 51:24are approached.
• 51:26I think,
• 51:27we need to recognize
• 51:28that they may not reflect
• 51:30sort of rigorous
• 51:33ethical,
• 51:35consideration.
• 51:36And and I think we
• 51:37need to question whether
• 51:39we're being complicit in a
• 51:41in a system that is
• 51:42resulting in significant exploitation.
• 51:48So what should we do,
• 51:49about all this? I I
• 51:50think that's sort of, like,
• 51:51the big question.
• 51:54You know,
• 51:54as I've sort of recognized
• 51:56that I I think these
• 51:57practices are are actually sort
• 51:59of ethically kind of similar,
• 52:01but treated differently. Should we
• 52:03fully outlaw commercial surrogacy? And
• 52:05I I think there are
• 52:06a lot of people who
• 52:07would advocate for that, And
• 52:08and I think we can
• 52:09see that's sort of what
• 52:11all of Europe has chosen
• 52:13to do and and many
• 52:13other countries throughout the world.
• 52:16Should we, on the other
• 52:17hand, just fully legalize paid
• 52:18organ donation? I think that's
• 52:20probably a less
• 52:22popular opinion.
• 52:25And and I and I
• 52:26think I sort of land
• 52:28somewhere in the middle of
• 52:29those two things, and and
• 52:30I'm interested to sort of
• 52:31hear what what other folks
• 52:33think. But but I think
• 52:34that
• 52:35we should sort of consider
• 52:40improving our sort of regulation
• 52:42surrounding the practice of commercial
• 52:43surrogacy if we are gonna
• 52:45continue to allow it,
• 52:46and and really focus on
• 52:48increasing protection for gestational carriers.
• 52:48A few things that that
• 52:49for gestational carriers.
• 52:51A few things that that
• 52:53I think could be helpful
• 52:54when we think about doing
• 52:55that,
• 52:57would be to require an
• 52:58independent high risk obstetrician
• 53:01to screen and counsel prospective
• 53:03gestational carriers.
• 53:06So it's it's not somebody
• 53:07sort of just hired by
• 53:08the surrogacy agency to say,
• 53:10yep. You're healthy enough. You
• 53:11can do it. But sitting
• 53:13down,
• 53:14with with a high risk
• 53:15obstetrician who can really sort
• 53:17of screen for
• 53:19high risk sort of conditions
• 53:21that would preclude someone from
• 53:22being a carrier and really
• 53:23counsel them
• 53:24appropriately on the risk with
• 53:26surrogacy.
• 53:28I think we should have
• 53:30explicit medical exclusion criteria for
• 53:32gestational carriers. Currently, we don't.
• 53:36As as you saw in
• 53:37Connecticut, you just have to
• 53:38be twenty one and have
• 53:39had a healthy pregnancy.
• 53:43I think we should require
• 53:44licensing for the surrogacy agencies.
• 53:48I shared sort of one
• 53:50story of a surrogacy agency
• 53:52and a in a
• 53:53sort of a surrogacy arrangement
• 53:55in the US that went
• 53:56quite poorly, but there are
• 53:58a lot,
• 53:59of other stories coming out
• 54:00about agencies who are really
• 54:02taking advantage of both gestational
• 54:04carriers and of intended parents.
• 54:06So I think that's
• 54:07an industry that that should
• 54:09be regulated, and and these
• 54:10agencies should be licensed.
• 54:12Currently, New York state does
• 54:13require licensing by the New
• 54:15York Department of Health, but
• 54:16they're the only state that
• 54:18require,
• 54:19any licensing for the agencies.
• 54:22I think we should
• 54:24consider
• 54:25requiring a medical indication for
• 54:27using surrogacy. So rather than,
• 54:30an intended parent saying, I
• 54:32I think I'm too old
• 54:33or I just don't wanna
• 54:34be pregnant.
• 54:35I'll just pay someone to
• 54:36do it. I I think
• 54:36that we should probably only
• 54:38be using this
• 54:40in
• 54:41in scenarios where there's a
• 54:42true medical indication.
• 54:45And I I think that
• 54:45we should improve regulatory consistency
• 54:47across the states.
• 54:49I think it's
• 54:50difficult for me,
• 54:52at at this time to
• 54:53to to try to advocate
• 54:54for, like,
• 54:55a a federal
• 54:58policy or an involvement, but
• 55:00but but I do think
• 55:00that sort of, like, inconsistent
• 55:02policies
• 55:03from state to state is,
• 55:05is not beneficial and is
• 55:06something we can improve.
• 55:08And and then I I
• 55:09also think there's potentially a
• 55:10role for expanding
• 55:12access to reimbursement for costs
• 55:14associated with living kidney donation.
• 55:16I don't I don't know
• 55:17that I'm quite comfortable, like,
• 55:19having financial incentives for
• 55:23organ donors.
• 55:25But but I think sort
• 55:26of expanding
• 55:27what can be reimbursed and
• 55:29and removing some of those
• 55:30barriers
• 55:34is another sort of thing
• 55:35that we could do to
• 55:36to try to
• 55:39bring kind of the way
• 55:40we treat these two practices
• 55:42and have them a little
• 55:43bit more aligned.
• 55:44So I'm I'm interested to
• 55:46to hear others' thoughts and
• 55:47kind of what people think
• 55:49we should do. Should we
• 55:50fully outlaw surrogacy?
• 55:52Should we think about sort
• 55:54of other interventions to make
• 55:55it safer?
• 55:59Yeah. I'm I'm interested to
• 56:00hear what people think. So
• 56:02with that, I will take
• 56:03any questions or comments.
• 56:16Switch over to
• 56:22where is the
• 56:24I'm gonna have the slide
• 56:25with the
• 56:29You want for the, slide
• 56:30with the, The Sammy. Yeah.
• 56:32Sammy.
• 56:36If you do open your
• 56:37side.
• 56:40I just wanted to open
• 56:41the slide with the CMA.
• 56:44And then what should have
• 56:45been
• 56:46it's just minimized here. Okay.
• 56:49Yeah.
• 56:49Sure about that.
• 56:51Sure. Yeah.
• 56:55Great.
• 56:56Thank you so much, Allison.
• 56:58That was really great. It
• 56:59was really thought provoking.
• 57:01I wanna just start off.
• 57:04I had a question about
• 57:06the you know, you you
• 57:07pointed to
• 57:08the you know, a number
• 57:09of countries have have
• 57:12taken a different direction in
• 57:13in Western Europe,
• 57:15in some of the other
• 57:16countries with with
• 57:19anglophone common law tradition have
• 57:21either forbidden,
• 57:23surrogacy or forbidden,
• 57:25commercial surrogacy specifically.
• 57:27Did you have a sense
• 57:29as you're researching this, as
• 57:30as you're,
• 57:31writing and and and
• 57:33developing your talk about
• 57:36where the
• 57:37the difference in thinking arose
• 57:39between the United States and
• 57:40and these other countries that
• 57:41took such a different position.
• 57:44Yeah. I mean, I I
• 57:45think,
• 57:47many of many of the
• 57:48other countries
• 57:49have have taken definitely a
• 57:51more restrictive approach. I I
• 57:52think there's been a lot
• 57:53more concerns
• 57:54raised about exploitation,
• 57:58and I think sort of
• 58:00many other countries are are
• 58:01really treating it
• 58:04more more like organ donation
• 58:06and and saying, like, for
• 58:08for
• 58:09many of the same reasons
• 58:10people
• 58:11are not okay with paying
• 58:12for organ donation,
• 58:15you know, that they're not
• 58:16okay with paying for surrogacy.
• 58:21If there are there are
• 58:22folks, please raise your hand.
• 58:22We'll try to bring, mics
• 58:24around to you.
• 58:26Hi. I've noticed in the
• 58:28past month that Times has
• 58:29had a number of articles
• 58:32about
• 58:33foreigners
• 58:34coming to this country for
• 58:35transplants
• 58:37and that they pay money,
• 58:40significant amounts,
• 58:42and I just wasn't clear
• 58:44where the money is going.
• 58:46Is it going to the
• 58:47hospitals?
• 58:48Is it all separate agencies?
• 58:51I mean, who's getting paid?
• 58:53And and and they're getting
• 58:55transplants. And I know a
• 58:57number of Americans who are
• 58:58looking for transplants
• 59:00have had to go on
• 59:01TV and sort of beg
• 59:03people
• 59:04to try and and become
• 59:05a viable
• 59:07donor.
• 59:08And that takes a long
• 59:10time, but it often works.
• 59:12Yeah. Yeah. I I think
• 59:14that that's a really great
• 59:15question. And and to to
• 59:17answer succinctly, I I don't
• 59:18know where the money's going.
• 59:21I suspect much of it
• 59:22is is going to the
• 59:24agencies that are sort of
• 59:25arranging,
• 59:28these situations. I I think,
• 59:31I'm I'm not as familiar
• 59:33with with sort of the
• 59:33practice of people coming for
• 59:35transplant. I will say there
• 59:37there are also,
• 59:38many families who who come
• 59:40to the US to hire
• 59:42a surrogate.
• 59:44And I think
• 59:45that, the surrogacy agencies are
• 59:47definitely
• 59:48making a significant
• 59:50profit from from those families
• 59:51as well as from the
• 59:52families within the US,
• 59:56who are,
• 59:57you know, choosing to use
• 59:58a surrogate.
• 60:00And that's why I think
• 01:00:00it's, like, incredibly important
• 01:00:03to regulate these agencies. I
• 01:00:05I think there's gotta be
• 01:00:06some quality control. I think
• 01:00:07there's a lot of exploitative
• 01:00:09practices,
• 01:00:10certainly with the surrogacy agencies,
• 01:00:12and I would imagine with
• 01:00:13with the agencies that are
• 01:00:15arranging people to to come
• 01:00:17for transplant as well.
• 01:00:21Oh, sure.
• 01:00:24Thank you. I I was
• 01:00:25just wondering, you talked a
• 01:00:26lot about how there's not
• 01:00:27really federal regulation about this
• 01:00:29in the United States as
• 01:00:30opposed to something like organ
• 01:00:31transplant. And I was just
• 01:00:32wondering if you had any
• 01:00:33thoughts as to why that
• 01:00:34is,
• 01:00:35especially where other countries are
• 01:00:37making, like, federal regulations about
• 01:00:39this. Is there a reason
• 01:00:41either historically,
• 01:00:43or something else that you
• 01:00:44think that the US has
• 01:00:45shied away from coming up
• 01:00:46with federal guidelines?
• 01:00:48You you know, I'm not
• 01:00:48sure. That's that's a really
• 01:00:49great question. And and I'm
• 01:00:51not sure. I I don't
• 01:00:52know if it's just more
• 01:00:53so, like, states' rights.
• 01:00:56Although the federal government has
• 01:00:58not shied away from
• 01:01:00sort of
• 01:01:01regulating
• 01:01:03medical and reproductive practices in
• 01:01:05in other ways, I I
• 01:01:06don't know if it's something
• 01:01:07that just hasn't sort of
• 01:01:08received enough national attention to
• 01:01:10really, like,
• 01:01:12get kind of that wave
• 01:01:14of of,
• 01:01:17you know, support that's needed
• 01:01:19to pass something at the
• 01:01:20federal level.
• 01:01:22There certainly are countries. So,
• 01:01:23like, Mexico
• 01:01:25does not have a national,
• 01:01:28policy on surrogacy.
• 01:01:30There was a recent sort
• 01:01:31of, like, Mexico Supreme Court
• 01:01:33decision that made it,
• 01:01:35you know, that that ruled
• 01:01:37that surrogacy
• 01:01:38was, like, okay,
• 01:01:40federally in Mexico, but there
• 01:01:41are certain states within Mexico
• 01:01:44that have different policies and
• 01:01:45restrictions. So we're not, like,
• 01:01:46the only country that leaves
• 01:01:48it up to the states.
• 01:01:50And and it it may
• 01:01:51be that there are other
• 01:01:52countries that have more sort
• 01:01:53of, like, local variation, but
• 01:01:54when you just sort of
• 01:01:55look at Google things on
• 01:01:56a global perspective, it just
• 01:01:58says, like,
• 01:01:59it's legal in all of
• 01:02:01Russia. Like,
• 01:02:03but but I think that
• 01:02:04probably it's mostly related to
• 01:02:06there just hasn't been national
• 01:02:07attention.
• 01:02:08And and we are seeing
• 01:02:09more and more kind of
• 01:02:11articles coming out about this
• 01:02:12practice. So so maybe that's
• 01:02:14something that's coming.
• 01:02:17I I worry about sort
• 01:02:19of, like,
• 01:02:20federal
• 01:02:22policies
• 01:02:23sort
• 01:02:26of governing sort of reproductive
• 01:02:28choices
• 01:02:31to some extent.
• 01:02:33Sure. Jack, anything else? Thanks,
• 01:02:34Alice.
• 01:02:36So it sounds like there's
• 01:02:37consensus
• 01:02:39against
• 01:02:40undue inducement.
• 01:02:42So how do we recognize
• 01:02:44when the inducement becomes,
• 01:02:47undue?
• 01:02:48Is there is there
• 01:02:50a consensus on this?
• 01:02:51You know, are there statements?
• 01:02:53How do we, are there
• 01:02:54criteria?
• 01:02:55How do we figure this
• 01:02:56out? That that's a really
• 01:02:58good question. And I I
• 01:02:59think there's not, like, an
• 01:03:00easy answer. I think that's,
• 01:03:03and I I don't know
• 01:03:04if people who are more
• 01:03:05familiar with like the research
• 01:03:07ethics literature may know this
• 01:03:09I I know that a
• 01:03:10lot of the sort of
• 01:03:11research ethics people have have
• 01:03:13really focused on this question
• 01:03:14of like,
• 01:03:15well, what is undo it?
• 01:03:16You know that that, you
• 01:03:18know, federal policy for production
• 01:03:20of human subjects says we
• 01:03:21shouldn't have undue inducement, but
• 01:03:23but I don't think it's
• 01:03:24got, at least to my
• 01:03:25knowledge, like, strict criteria for
• 01:03:27when that is. And I
• 01:03:28think it's so individual, but
• 01:03:29I I could be wrong,
• 01:03:31seems like.
• 01:03:34Thank you for your talk.
• 01:03:35It was very interesting.
• 01:03:37And I I like how
• 01:03:38you,
• 01:03:40have provided the,
• 01:03:41like, view of that,
• 01:03:45or maybe that we can
• 01:03:46we can interpret
• 01:03:48the fact that
• 01:03:49there is commercial surrogacy and
• 01:03:51people have to pay for
• 01:03:52it,
• 01:03:53because maybe our society value,
• 01:03:57babies or, like, yeah, giving
• 01:03:59a chance to see babies
• 01:04:00to be born more than,
• 01:04:03lives of,
• 01:04:04adults who are in a
• 01:04:06need of a kidney. But
• 01:04:07I wonder if
• 01:04:09that could actually be more
• 01:04:11the other way around that
• 01:04:12the fact that we now
• 01:04:14have to pay for surrogacy
• 01:04:16is a reflection that surrogacy
• 01:04:18is something extra like having
• 01:04:19a biological baby is not
• 01:04:21a need, is not
• 01:04:22needed for survival. So let's
• 01:04:25say it's something extra that's
• 01:04:26why people have to pay
• 01:04:27for it as opposed to,
• 01:04:30like
• 01:04:31kidney donation or like getting
• 01:04:33a new kidney is, is
• 01:04:35needed for survival and that
• 01:04:37the fact that it's free
• 01:04:38makes it more accessible,
• 01:04:40at least in theory for
• 01:04:41everybody as opposed to when
• 01:04:43it's
• 01:04:44commercialized that people would have
• 01:04:45to pay for it then
• 01:04:46I I could imagine that
• 01:04:48they would actually cause more
• 01:04:49disparity in, you know, like
• 01:04:51wealthier people would be able
• 01:04:53to,
• 01:04:54afford it as opposed to
• 01:04:56people who do who don't
• 01:04:57have the financial means.
• 01:04:59Yeah. I think that's that's
• 01:05:00a really interesting perspective.
• 01:05:03And and I think that,
• 01:05:04in in theory sort of
• 01:05:06I I agree with you
• 01:05:07if we're saying this is
• 01:05:08not like, it's certainly like
• 01:05:09if we consider you can
• 01:05:11pay for an organ,
• 01:05:13you know, the the pool
• 01:05:14of available organs may shift
• 01:05:16more towards
• 01:05:18people who can pay for
• 01:05:19the organ,
• 01:05:20or will shift more towards,
• 01:05:22you know, that that population.
• 01:05:25I I don't know in
• 01:05:26practice
• 01:05:27that sort of
• 01:05:29allowing
• 01:05:30I I guess the question
• 01:05:31would be if if we
• 01:05:32say
• 01:05:33we're no longer gonna allow
• 01:05:35commercial surrogacy,
• 01:05:36would there be the same
• 01:05:37number of women who are
• 01:05:39signing up to be gestational
• 01:05:40carriers? And and would that
• 01:05:41same pool of people be
• 01:05:42redistributed
• 01:05:44more equitably?
• 01:05:46And and
• 01:05:47I I don't think that's
• 01:05:48probably the case. I think,
• 01:05:50there's there's a more limited
• 01:05:52number of people who are
• 01:05:53interested in altruistic
• 01:05:54surrogacy.
• 01:05:55And and I think we
• 01:05:56we certainly still see that
• 01:05:57happening.
• 01:05:59But I think in practice,
• 01:06:03there's just gonna be much
• 01:06:04fewer surrogates if if you're
• 01:06:06not paying them.
• 01:06:10Sure.
• 01:06:11Thank you for your talk.
• 01:06:14I have two questions. One
• 01:06:15of them is kind of
• 01:06:15quick.
• 01:06:16The first is I'm curious
• 01:06:18whether or not there's, like,
• 01:06:19higher rates of adoption or,
• 01:06:21like, becoming a parent in
• 01:06:22other by other means,
• 01:06:24in countries where only altruistic
• 01:06:26surrogacy is allowed, and whether
• 01:06:28or not
• 01:06:29with that in mind, if
• 01:06:30that's true, like, we're kind
• 01:06:31of doing ourselves, like, a
• 01:06:33societal disservice by emphasizing
• 01:06:36biological children or having biological
• 01:06:38children,
• 01:06:40versus, like, bolstering these other
• 01:06:42ways of becoming a parent
• 01:06:43if surrogacy is, like, not
• 01:06:44available or if the, like,
• 01:06:46pool of people willing to
• 01:06:47be a surrogate has shrunk
• 01:06:49because we only allow altruistic
• 01:06:51surrogacy?
• 01:06:52And then the second question
• 01:06:53is whether or not, carriers
• 01:06:55experiencing
• 01:06:56like, because you have to
• 01:06:57have gone through one pregnancy
• 01:06:59to be, like, a gestational
• 01:07:01carrier,
• 01:07:03whether or not, like, the
• 01:07:05in practice, people rate the
• 01:07:06experience as less risky or,
• 01:07:07like, have a poor understanding
• 01:07:09of the risk the second
• 01:07:10time because you've, like, successfully
• 01:07:12lived through the experience the
• 01:07:13first time? Yeah. Yeah. Great
• 01:07:15question.
• 01:07:15So,
• 01:07:17in terms of your first
• 01:07:18question, I don't know,
• 01:07:21the answer to that. I
• 01:07:22I I would imagine,
• 01:07:23more people would want to
• 01:07:25pursue adoption
• 01:07:28if surrogacy was not an
• 01:07:30option.
• 01:07:31But but I don't actually
• 01:07:32know those data.
• 01:07:34And then
• 01:07:35in terms of
• 01:07:38remind me what your second
• 01:07:39question was. I I got
• 01:07:40distracted for a second. I'm
• 01:07:41sorry. Yeah. Second question was
• 01:07:43about whether or not
• 01:07:45there is food experience Oh,
• 01:07:47yeah. Yeah. Since they've already
• 01:07:48had a pregnancy. Yeah. I
• 01:07:49mean, I I I think
• 01:07:50that certainly contributes. I I
• 01:07:52think you
• 01:07:53if you've had one healthy
• 01:07:54pregnancy, you're inclined to think,
• 01:07:58you know, you're gonna have
• 01:07:59another healthy pregnancy.
• 01:08:01You know, there there are
• 01:08:02some people who who argue
• 01:08:04that because they've already gone
• 01:08:06through an a pregnancy, the
• 01:08:08the consent is much more
• 01:08:09informed because they know what
• 01:08:11they're getting into.
• 01:08:13But I but I do
• 01:08:14think it's important to recognize
• 01:08:15that, like, just because you've
• 01:08:16had one healthy pregnancy,
• 01:08:19your second pregnancy may not
• 01:08:21go the same, especially when
• 01:08:23when we're considering
• 01:08:24the sort of risks associated
• 01:08:25with IVF.
• 01:08:27We actually know that there's
• 01:08:28higher rates of complications,
• 01:08:31in the surrogate pregnancies
• 01:08:33compared to other pregnancies the
• 01:08:34same individuals have had. So
• 01:08:36I think that's that's a
• 01:08:37really important consideration.
• 01:08:40Hi. I just,
• 01:08:42I
• 01:08:43I wanna
• 01:08:43provide a little bit of
• 01:08:44clarification of to a few
• 01:08:46issues.
• 01:08:47You you know,
• 01:08:49you said that there was
• 01:08:50no federal regulation. It was
• 01:08:51it's probably about commercial,
• 01:08:53surrogacy that you're talking about
• 01:08:54because
• 01:08:55the act of surrogacy medically
• 01:08:57is regulated at the federal
• 01:08:58level.
• 01:08:59H department of HHS through
• 01:09:01FDA has strict rules about
• 01:09:03how you donate eggs that
• 01:09:05will then be put into
• 01:09:06a surrogate. Actually, it's the
• 01:09:07same rules that apply to
• 01:09:08kidney donation. So it's another
• 01:09:10similarity for your purposes.
• 01:09:11It's the same document. It's
• 01:09:13a seventy page document and
• 01:09:14all the tests you need
• 01:09:15to do to personal generates
• 01:09:17the eggs or sperm that
• 01:09:18will end up causing the
• 01:09:19embryo that will then be
• 01:09:21transferred to the surrogate. And
• 01:09:22it's very strictly regulated
• 01:09:24in the whole country. Every
• 01:09:25every every person who does
• 01:09:27surrogacy
• 01:09:28needs to follow that rule.
• 01:09:29And you gave an example,
• 01:09:32of a person who had
• 01:09:33some who volunteered
• 01:09:35to be a kidney donor,
• 01:09:37and then she was, I
• 01:09:38think,
• 01:09:40upset that, you know, she
• 01:09:41had to go to a
• 01:09:41specific lab. I think the
• 01:09:43reason for that is the
• 01:09:44same because she has to
• 01:09:45do the FDA labs Mhmm.
• 01:09:46And they cannot be done
• 01:09:47in certain labs. You have
• 01:09:48to actually go to a
• 01:09:50specific lab to to give
• 01:09:52blood. Let's say you cannot
• 01:09:53be tested at Yale,
• 01:09:55if
• 01:09:56it's gonna be used for
• 01:09:57surrogacy purposes or kidney donation
• 01:09:59purposes. It has to go
• 01:10:00to an FDA approved lab.
• 01:10:01So those are the two
• 01:10:02things.
• 01:10:03As far as for all
• 01:10:05the people who may need
• 01:10:06IVF, some clarifications.
• 01:10:09In this day and age
• 01:10:10actually,
• 01:10:11when you limit frozen embryo
• 01:10:13transfer and single embryo transfer,
• 01:10:15preterm birth rate
• 01:10:18and twin rates and low
• 01:10:20birth rates are very similar
• 01:10:21to spontaneous pregnancies with IVF.
• 01:10:23Just
• 01:10:24so that you know for
• 01:10:25everyone for that this is
• 01:10:26the last five years IVF
• 01:10:28results, so less to worry.
• 01:10:30And,
• 01:10:31and,
• 01:10:32what was I gonna say?
• 01:10:33A clarification to your comment
• 01:10:36about the European
• 01:10:38surrogacy.
• 01:10:39Surrogacy, forbidden, and Western Europe
• 01:10:41both,
• 01:10:43you know, I I can't
• 01:10:44remember the terms you used,
• 01:10:45compensated or uncompensated.
• 01:10:47They're both it's it's not
• 01:10:49one over the other.
• 01:10:50They're all banned, and they
• 01:10:52have more religious reasons than
• 01:10:53anything else.
• 01:10:56And finally, I just want
• 01:10:57to say, I agree with
• 01:10:58your suggestions and YETIEL
• 01:11:01about what to do in
• 01:11:02surrogacy, and we've been following
• 01:11:03actually that. I guess we
• 01:11:04came to the same conclusion
• 01:11:05fifteen years ago.
• 01:11:07We don't
• 01:11:08do surrogacy
• 01:11:10without referring to MFM. The
• 01:11:11reason is exactly what you
• 01:11:13said. Because we felt that,
• 01:11:15everybody has a stake in
• 01:11:16this. I mean, because I'm
• 01:11:18employed by Yale, I don't
• 01:11:19really benefit
• 01:11:21personally
• 01:11:22from doing IVF, but many
• 01:11:23IVF centers
• 01:11:24do benefit financially of doing
• 01:11:26IVF.
• 01:11:28And even the husband, if
• 01:11:29there's a husband of a
• 01:11:30surrogate, could, you know, could
• 01:11:32push for it, in a
• 01:11:34sense, or the family members.
• 01:11:35So we thought MFM would
• 01:11:36be an independent
• 01:11:38I guess they they don't
• 01:11:39care whether you do the
• 01:11:41cycle or don't don't do
• 01:11:42the cycle. So they're just
• 01:11:43openly giving advice. So at
• 01:11:44Yale for the last fifteen
• 01:11:46years we've been sending, I
• 01:11:47agree completely with you. And,
• 01:11:48yes, definitely
• 01:11:49for medical reasons. So thank
• 01:11:50you. It was a great
• 01:11:51talk. Yeah. Thank thank you
• 01:11:52so much. I I think,
• 01:11:54you know, I I think
• 01:11:55it's great that we're doing
• 01:11:56that at Yale. I I
• 01:11:57think that's not universal. I'm
• 01:11:59Sarah has shared with me.
• 01:12:00She she's had, you know,
• 01:12:02as an m In other
• 01:12:03places when I did. Yeah.
• 01:12:04Yeah. Yeah. Like, as an
• 01:12:06MFM, she's she's definitely done
• 01:12:07some of these count like,
• 01:12:08consults, but then also had
• 01:12:10patients who have not had
• 01:12:11an independent consult and who
• 01:12:13probably should never have been
• 01:12:15approved for surrogacy and and
• 01:12:17had significant complications. So
• 01:12:19thank you.
• 01:12:21Hi. I just have two,
• 01:12:22comments and then a a
• 01:12:23question. So thank you. Excellent
• 01:12:24talk. I'm a surgeon who
• 01:12:26has an interest in ethics,
• 01:12:27but no no formal background
• 01:12:29in that. So comments in
• 01:12:30terms of the,
• 01:12:33differences between organ transplant donation
• 01:12:36and,
• 01:12:37commercial surrogacy, which is what
• 01:12:38you're saying is poorly federally
• 01:12:40regulated, which is clear. Right?
• 01:12:42So I think most people
• 01:12:44have an altruistic reason for
• 01:12:45going into,
• 01:12:48organ transplantation. Right? So is
• 01:12:51I I think the focus
• 01:12:53should be less on trying
• 01:12:54to see, can we compensate
• 01:12:55them, which you didn't say
• 01:12:57that at all, of course.
• 01:12:58Like, how surrogate,
• 01:13:01people are being compensated for.
• 01:13:03And more so, how can
• 01:13:04we offset the burden for
• 01:13:05their altruism? Right? So if
• 01:13:06we can take the out
• 01:13:07of pocket cost
• 01:13:09out of the that patient
• 01:13:10population or that potential donor
• 01:13:12population, I think you'd have
• 01:13:13an increase in donors that
• 01:13:14would would and it would
• 01:13:16be more universally beneficial to
• 01:13:18all patients. So that's one
• 01:13:19thing to that a focus
• 01:13:20could be on for that.
• 01:13:20But specifically for this talk,
• 01:13:22you mentioned about, the,
• 01:13:24maternal mortality of being, like,
• 01:13:25something like point zero zero
• 01:13:27three percent. That's all comers.
• 01:13:28Right? Mhmm. But that rate
• 01:13:29is three times the, amount
• 01:13:31when you're talking about underrepresented,
• 01:13:33minorities,
• 01:13:34specifically black females. And I'm
• 01:13:36interested to see,
• 01:13:37do
• 01:13:38do is that, fleshed out
• 01:13:40more? Do they have an
• 01:13:41understanding that you have a
• 01:13:42higher
• 01:13:43risk depending on what your
• 01:13:45own,
• 01:13:46ethnicity is. Right? And so
• 01:13:47because and then that goes
• 01:13:48on into this inducement. So
• 01:13:50my question is, do you
• 01:13:52have any data or information
• 01:13:54about the demographics
• 01:13:55of the women who are
• 01:13:57these gestational carrier carriers. Are
• 01:13:59they younger? I mean, I'm
• 01:14:00sure yeah. They are younger,
• 01:14:01clearly. Right? Are what is
• 01:14:03their, ethnicity, ethnic background? What
• 01:14:06is their socioeconomic
• 01:14:07status? Because just by the
• 01:14:09that nature alone, there's gonna
• 01:14:10be some inherent inducement that
• 01:14:12is there in that population
• 01:14:14that's gonna they're gonna be
• 01:14:15more enticed to, yeah. Sure.
• 01:14:16I'll take seventy five thousand
• 01:14:17dollars and give a baby.
• 01:14:18Right?
• 01:14:19And and lastly, last comment
• 01:14:21is
• 01:14:22without having better regulation, you
• 01:14:23can easily see this going
• 01:14:25into, okay, there are pregnant
• 01:14:27women who young women
• 01:14:28who do not want their,
• 01:14:31child or their pregnancy and
• 01:14:33may be considering abortion.
• 01:14:34But now, hey. We can
• 01:14:35reach out to this group
• 01:14:37and potentially bring them into
• 01:14:39this surrogacy commercial surrogacy. Right?
• 01:14:41So there I I definitely
• 01:14:43think under regulation is is
• 01:14:45very much
• 01:14:47present and needs to be
• 01:14:48addressed, but this is a
• 01:14:49very,
• 01:14:50excellent talk. Alright.
• 01:14:52Thank thank you. And I
• 01:14:53I appreciate having, like, a
• 01:14:54surgical perspective. I I'm talking
• 01:14:56a lot about organ transplant,
• 01:14:57but it's not an area
• 01:14:59that I definitely have expertise
• 01:15:00in. So I I really
• 01:15:02appreciate that perspective. I I
• 01:15:03I think that's sort of
• 01:15:04one of the big concerns
• 01:15:05is, like,
• 01:15:06is that is there gonna
• 01:15:07be a group who's at
• 01:15:08higher risk for pregnancy complications
• 01:15:10who is and also, you
• 01:15:12know, more financially vulnerable and
• 01:15:14and at at risk of,
• 01:15:16you know,
• 01:15:17being exploited by these practices.
• 01:15:19And and so I I
• 01:15:20think that's that's a big
• 01:15:22concern that I have.
• 01:15:25I don't think there are
• 01:15:26great demographic data that I
• 01:15:28could find
• 01:15:29about who's actually
• 01:15:31serving as surrogates.
• 01:15:33But I think that is
• 01:15:34a valid and concerning point.
• 01:15:38Thank you so much for
• 01:15:39a really interesting talk. My
• 01:15:40name is Kieran O'Donnell. I'm
• 01:15:42a faculty member here in
• 01:15:43the Charles City Centre and
• 01:15:44also in OB GYN.
• 01:15:45I have a few reflections
• 01:15:46on your talk from a
• 01:15:47professional and a personal standpoint.
• 01:15:50Professionally,
• 01:15:51I work in the area
• 01:15:51of perinatal mental health and
• 01:15:53its impact on child development.
• 01:15:55And I think just an
• 01:15:56interesting nuance to add to
• 01:15:57the study that you described
• 01:15:59about nuance and mental illness
• 01:16:01in gestational carriers is that
• 01:16:02that study was actually carried
• 01:16:04I'm assuming you're referring to
• 01:16:05the Maria Velez
• 01:16:06study by Simone B. Goode
• 01:16:08that was conducted in Ottawa
• 01:16:10in Canada, where, actually, it's
• 01:16:11altruistic surrogacy.
• 01:16:13And so those new onset
• 01:16:14mental disorders that you're describing
• 01:16:16was actually, you know, kind
• 01:16:17of not in the context
• 01:16:19of commercial
• 01:16:20surrogacy. And I think the
• 01:16:21actual point difference was around
• 01:16:22a six point difference
• 01:16:24with a cohort around one
• 01:16:25hundred and seventy. So it
• 01:16:26was a pretty small cohort,
• 01:16:28but I agree there's much
• 01:16:29more that needs to be
• 01:16:31done. But I just think
• 01:16:32it's an interesting nuance that
• 01:16:33that was occurring in the
• 01:16:35context of altruistic gestational care.
• 01:16:38From a personal perspective, so
• 01:16:39I was an intended parent,
• 01:16:41and I welcomed my son,
• 01:16:42through, commercial gestational surrogacy here
• 01:16:45in the United States.
• 01:16:47And I'm a gay man,
• 01:16:49so it was my only
• 01:16:50route to having a biological
• 01:16:52child.
• 01:16:54My husband and I discussed
• 01:16:55the ethical considerations
• 01:16:56of adoption,
• 01:16:58the overrepresentation
• 01:16:59of underrepresented
• 01:17:00groups
• 01:17:01in the welfare system and
• 01:17:03thinking about,
• 01:17:04whether or not that was
• 01:17:05a path we wanted to
• 01:17:06go down. We couldn't at
• 01:17:07the time due to our
• 01:17:08immigration status, so gestational surrogacy
• 01:17:11was our only option. I
• 01:17:13think that maybe one thing
• 01:17:14that I did get from
• 01:17:15your presentation that you kind
• 01:17:16of downplayed the exploitation or
• 01:17:18the potential exploitation of intended
• 01:17:19parents.
• 01:17:20So a lot of intended
• 01:17:21parents that are seeking to
• 01:17:22build their families through international
• 01:17:24gestational surrogacy are at real
• 01:17:26risk for exploitation,
• 01:17:28with many examples of families
• 01:17:30who have been asked to
• 01:17:30pay another five thousand dollars,
• 01:17:32another five thousand dollars until
• 01:17:34they can get their child.
• 01:17:35So what I think I
• 01:17:36would agree with is that
• 01:17:37there's a real need
• 01:17:38for greater regulation,
• 01:17:40both in the context of
• 01:17:41IVF practices.
• 01:17:43So thinking about some of
• 01:17:44the IVF practices that are
• 01:17:45somewhat predatory
• 01:17:46for intended parents, thinking of
• 01:17:48some of the recommendations,
• 01:17:50I will say that our
• 01:17:51experience with surrogacy agencies was
• 01:17:53that all of the agencies
• 01:17:54that we considered,
• 01:17:55did follow the ASRM
• 01:17:57guidelines in terms of BMI
• 01:17:59parity.
• 01:18:01And, you know, the all
• 01:18:02of the agencies that we
• 01:18:03worked with, wouldn't allow gestational
• 01:18:05carriers that were on Medicaid.
• 01:18:07So thinking about that exploitation
• 01:18:09coercion,
• 01:18:10obviously, that needs to be
• 01:18:11better defined and better, you
• 01:18:13know, kind of thought out.
• 01:18:14But I do think that
• 01:18:15at least the agencies that
• 01:18:16we experienced
• 01:18:17were were thinking deeply about
• 01:18:19that.
• 01:18:20Great. Thank you so much
• 01:18:21for for sharing that perspective.
• 01:18:23That's it's really sort of
• 01:18:25helpful to to hear from
• 01:18:26from a lens that that
• 01:18:27I, you know, hadn't hadn't
• 01:18:29considered as much, and,
• 01:18:31I really appreciate you sharing
• 01:18:32that.
• 01:18:37I was wondering in the
• 01:18:38discussion of, like, bodily labor
• 01:18:41and,
• 01:18:43like, you you mentioned that
• 01:18:45it
• 01:18:46that reproductive labor, the,
• 01:18:48has often been underappreciated.
• 01:18:51But I fear
• 01:18:53the
• 01:18:54push to making women just
• 01:18:55baby making machines. Like, I
• 01:18:57think it's impossible to talk
• 01:18:58about this and not talk
• 01:18:59about,
• 01:19:00gosh, what was the book?
• 01:19:03The book?
• 01:19:04Yeah. The Handmaid's Tale.
• 01:19:07Like, does does give that
• 01:19:08vibe.
• 01:19:10Yeah. And so,
• 01:19:11like, I think that there's,
• 01:19:12like, a bajillion
• 01:19:14articles that show that when
• 01:19:15women work, like,
• 01:19:18real jobs, that, like, a
• 01:19:20lot of,
• 01:19:21things improve for society. And
• 01:19:23this disincentivizes
• 01:19:24women to work real jobs
• 01:19:26because their real job is
• 01:19:27being pregnant.
• 01:19:29And that just wasn't something
• 01:19:30that you discussed.
• 01:19:32Yeah. I I think that
• 01:19:33that that's a really
• 01:19:35interesting point, and I I
• 01:19:37I I'm I'm glad that
• 01:19:38you brought up sort of
• 01:19:39The Handmaid's Tale. I I
• 01:19:40think there's, like, a
• 01:19:42you know, I I think
• 01:19:43there can be a very
• 01:19:44kind of concerning undertone to
• 01:19:46this conversation. And and that's
• 01:19:47why I think it's, like,
• 01:19:48so important to be
• 01:19:51methodically regulating
• 01:19:53how we're gonna
• 01:19:54engage with this practice if
• 01:19:56if we're if we're going
• 01:19:57to, which which I, you
• 01:19:58know, I I think, you
• 01:20:01know, surrogacy serves an important
• 01:20:03purpose. And I I think
• 01:20:04that, you know, for me,
• 01:20:05from an ethical perspective, I
• 01:20:07I think there's a lot
• 01:20:07of benefits to be offered.
• 01:20:08But but, again, I I
• 01:20:10think it needs to be
• 01:20:11strictly
• 01:20:12regulated.
• 01:20:18Thank thank you for your
• 01:20:19talk. I found this quite
• 01:20:20interesting.
• 01:20:21One my question kind of
• 01:20:22focuses,
• 01:20:23perhaps, in a different direction
• 01:20:25than many of you are
• 01:20:26going. So please don't hate
• 01:20:28me for this.
• 01:20:29But my my undergraduate research
• 01:20:31focused a lot on the
• 01:20:33effects
• 01:20:34of the, like, prenatal environment
• 01:20:36that that in the environment
• 01:20:37of the mother on the
• 01:20:39developing neurology of a fetus.
• 01:20:41And so that's perhaps made
• 01:20:43me too aware of the
• 01:20:44environmental effects that kind of
• 01:20:46preprogram can preprogram
• 01:20:48fetuses and affect even adult
• 01:20:50life, you know, years after
• 01:20:52the actual birth. And so
• 01:20:54at least from my point
• 01:20:55of view, I've always seen
• 01:20:57paying surrogacy as a way
• 01:20:58of kind of establishing that
• 01:21:00your surrogate isn't going to
• 01:21:02be exposed to many of
• 01:21:04the the mental and physical
• 01:21:05stressors
• 01:21:06that might actually negatively
• 01:21:08impact your future baby.
• 01:21:10You know, especially given that
• 01:21:11most surrogates most parents seeking
• 01:21:14surrogacy are often significantly more
• 01:21:16wealthy, like you talked about,
• 01:21:18than the surrogate themselves.
• 01:21:20I I wonder if there
• 01:21:21isn't an ethical obligation or
• 01:21:23at least perhaps that's a
• 01:21:24bit strong of saying but
• 01:21:26and
• 01:21:26perhaps an ethical,
• 01:21:29or moral,
• 01:21:30not prerogative, but impetus
• 01:21:33to provide, at least for
• 01:21:34the duration of the pregnancy,
• 01:21:36a significantly elevated quality of
• 01:21:38life in order to not
• 01:21:39just pay the the surrogate,
• 01:21:42but improve the,
• 01:21:44standing of the fetus and
• 01:21:46perhaps neuroprotect them in some
• 01:21:48ways
• 01:21:49from the negative stressors that
• 01:21:51could otherwise detrimentally affect them.
• 01:21:53And I wonder if that
• 01:21:54isn't some opposite tension here,
• 01:21:56or perhaps this is veering
• 01:21:58much too close to designer
• 01:21:59babies. But that that's that's
• 01:22:01kind of my question. Isn't
• 01:22:02there also some moral obligation
• 01:22:04for a parent who can
• 01:22:06to ensure that the prenatal
• 01:22:07environment of their kid is
• 01:22:08as well as it can
• 01:22:09be accomplished?
• 01:22:10Yeah. I I think I'm
• 01:22:12I'm so glad that you
• 01:22:13sort of raised that question.
• 01:22:14And I I am,
• 01:22:16also recognizing that I'm a
• 01:22:17neonatologist who gave a whole
• 01:22:19presentation about sort of
• 01:22:21pregnancy related topic without kind
• 01:22:22of considering the baby.
• 01:22:25So I'm glad that that
• 01:22:26someone brought it up.
• 01:22:28But but but I think,
• 01:22:30you know, I think I
• 01:22:31think that's a valid consideration.
• 01:22:33I think that that
• 01:22:36one concern I would have
• 01:22:37with kind of, like,
• 01:22:39delving deeper into that argument
• 01:22:40is is I
• 01:22:43I think there are a
• 01:22:43lot of,
• 01:22:47you you know, there are
• 01:22:47a lot of things you
• 01:22:48can do to to make
• 01:22:49a healthy pregnancy and and
• 01:22:51sort of be the healthiest
• 01:22:52you can be during pregnancy.
• 01:22:54And and I I do
• 01:22:55worry, like, how much are
• 01:22:56we gonna sort of, like,
• 01:22:58want to regulate what
• 01:23:00surrogates can and cannot do
• 01:23:02while they're pregnant? And, I
• 01:23:03mean, I I I do
• 01:23:04think that, like,
• 01:23:06fair to say, like, shouldn't
• 01:23:07smoke, shouldn't drink. You know?
• 01:23:09Like but but at at
• 01:23:10some point,
• 01:23:13I I would become a
• 01:23:15little bit concerned about, like,
• 01:23:17how
• 01:23:18how much can we
• 01:23:19reg like like, is this
• 01:23:21are we further limiting
• 01:23:23sort of autonomy by kind
• 01:23:24of focusing
• 01:23:27so much on, like, having
• 01:23:28this healthy environment. And and
• 01:23:29the the reason I say
• 01:23:30that is, one of the
• 01:23:31articles that I I mentioned
• 01:23:33about the sort of intended
• 01:23:34mother who kinda went crazy
• 01:23:36on
• 01:23:38and and kind of attacked
• 01:23:40the the carrier who, you
• 01:23:41know, had a stillbirth.
• 01:23:43It she sort of made
• 01:23:44a lot of allegations about,
• 01:23:46well, you were under too
• 01:23:47much stress. You started a
• 01:23:48new job during the pregnancy,
• 01:23:49so this is your fault.
• 01:23:52And and that makes me
• 01:23:53very concerned about, like, how
• 01:23:54do we protect,
• 01:23:57women from from those types
• 01:23:58of allegations while also, like,
• 01:23:59of course,
• 01:24:01promoting
• 01:24:02an environment
• 01:24:03for an optimal,
• 01:24:04fetal development.
• 01:24:07I just wanna say I
• 01:24:08really appreciate everybody's
• 01:24:10interest. I really
• 01:24:11especially appreciate the personal
• 01:24:13and clinical perspectives that have
• 01:24:15been shared. We do have
• 01:24:16to have a sharp cutoff
• 01:24:17at six thirty to be
• 01:24:18respectful of people's time. I
• 01:24:19know there are more people
• 01:24:20who wanna participate. I think
• 01:24:21we have time for one
• 01:24:22final question,
• 01:24:24and and, we'll have to
• 01:24:25cut off after that. Thank
• 01:24:26you so much. So, you
• 01:24:27sort of set it up
• 01:24:28a little bit by talking
• 01:24:29about,
• 01:24:30restriction of autonomy or choice
• 01:24:32for the gestational carrier during
• 01:24:33pregnancy.
• 01:24:34And I was wondering
• 01:24:36how much of this is
• 01:24:37written into contracts. And the
• 01:24:39reason I'm asking about this
• 01:24:41is
• 01:24:41with regards to my particular
• 01:24:43work and
• 01:24:44a case I've seen. So
• 01:24:46I'm a prenatal general counselor
• 01:24:47and I see
• 01:24:49women who are usually in
• 01:24:50very difficult circumstances during pregnancy.
• 01:24:53And
• 01:24:54I had a case where
• 01:24:55there was an ultrasound finding
• 01:24:57and both the surrogate
• 01:25:00and the intended parents were
• 01:25:02very involved in the case.
• 01:25:03But there are very difficult
• 01:25:05decisions about testing,
• 01:25:06about abortion,
• 01:25:09moral decision making that goes
• 01:25:11in.
• 01:25:12And what really was clear
• 01:25:14to me was how there's
• 01:25:16another harm than what you've
• 01:25:17mentioned potentially
• 01:25:18to gestational carries a kind
• 01:25:20of moral harm that could
• 01:25:21come in that's very unique
• 01:25:22for this kind of circumstance.
• 01:25:24So I wonder if you
• 01:25:24have anything to say about
• 01:25:25the contracts or
• 01:25:27that kind of issue. Yeah.
• 01:25:28I think there are a
• 01:25:29lot of things that are
• 01:25:30written in and including sort
• 01:25:31of like who's gonna be
• 01:25:32able to make decisions
• 01:25:34surrounding things like
• 01:25:36termination or or, you know,
• 01:25:38other sort of like does
• 01:25:39it medical decisions affecting specifically
• 01:25:41the pregnancy. I think there
• 01:25:42are a lot of things
• 01:25:43that are are written in.
• 01:25:45I feel like Sarah is
• 01:25:46nodding very aggressively. I feel
• 01:25:47like you've got something wise
• 01:25:48to say.
• 01:25:51Happens to provide.
• 01:25:52But it's very difficult to
• 01:25:54make a reproductive choice against
• 01:25:56that of the intended parents.
• 01:25:57It's what are you gonna
• 01:25:58do, carry a pregnancy that
• 01:25:59they don't know how to
• 01:26:00carry you? Right. And there's
• 01:26:01also is your contract terminated?
• 01:26:03You have to, you know,
• 01:26:04you have to be able
• 01:26:05to undergo a termination.
• 01:26:06But the the the details
• 01:26:08of, like you know, I
• 01:26:09I've been involved in these
• 01:26:10conversations too where where they're
• 01:26:12picturing you all all have
• 01:26:13a termination if there's a
• 01:26:14major heart defect.
• 01:26:16But what about agenesis of
• 01:26:17the corpus callosum? Partial agenesis
• 01:26:19of the corpus callosum.
• 01:26:21And and I've had a
• 01:26:22gestational period, had to go
• 01:26:23through a termination for that,
• 01:26:24and she would've, you know,
• 01:26:25never done that for her
• 01:26:27own pregnancy. And the moral,
• 01:26:29like, fallout from that was
• 01:26:31huge because it's it's not
• 01:26:33you know, it's what is
• 01:26:34how
• 01:26:35anomalous
• 01:26:36does an anomaly have to
• 01:26:38be?
• 01:26:38And it's you know, you
• 01:26:39know, there's, like, a million
• 01:26:41different things that we can
• 01:26:43diagnose in this mattering of
• 01:26:45what that could mean.
• 01:26:46You you can't first follow
• 01:26:48that out in a contract.
• 01:26:49You just can't. And so
• 01:26:51the the real life examples
• 01:26:52of this are can be
• 01:26:54quite,
• 01:26:56quite.
• 01:26:58I'm afraid we're gonna have
• 01:26:59to wrap there. I wanna
• 01:27:01say a few things. One,
• 01:27:01if you haven't had the
• 01:27:02if you're a ethics concentrator
• 01:27:05and you haven't had the
• 01:27:05chance to sign in, please
• 01:27:06sign in at the back.
• 01:27:08I wanna thank Karen Kolb
• 01:27:09who puts an enormous amount
• 01:27:11of labor and, into these
• 01:27:14events.
• 01:27:15None of none of these
• 01:27:16talks would happen without Karen.
• 01:27:17She she is the unsung
• 01:27:19hero of this entire seminar
• 01:27:21series.
• 01:27:22Finally, I wanna thank Alice
• 01:27:23and,
• 01:27:24both for your work here
• 01:27:25and on the ethics consultation
• 01:27:27service. Thank you so much,
• 01:27:28Alex. It's been great.
• 01:27:41Hey.
• 01:27:43Hey. Yeah. Hi. I I
• 01:27:45certainly can't.
• 01:27:46So so