One of the major concerns about surrogacy is the potential harm that may be inflicted upon the surrogate mother and the child after relinquishment. Even if one were to take the liberal view that surrogacy should be presumptively allowed on the basis of autonomy and/or compassion, evidence of harm must be taken seriously. In this paper I review the evidence from psychological studies on the effect that relinquishing a child has on the surrogate mother and while it appears that many surrogates are able to cope with relinquishment, I argue that there are good reasons, grounded in empirical evidence, to support the view that the subsequent management of the relinquishment necessarily objectifies the surrogate mother.
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For many women who have undergone repeated attempts at assisted reproductive technologies (ART) or those who have a non-functional uterus, surrogacy is often viewed as a viable alternative. It also seems to be a preferable alternative to adoption, given the importance placed on having a genetic link between child and parent, and being in close proximity to the gestational process. Pregnancy though is a profound experience that is unique amongst couples in which the outcome and their ability to manage the pregnancy are often unpredictable.
The biological and psychological health of the surrogate and child ought to be considered when commissioning couples and potential surrogates are making an informed decision to enter into an arrangement. However, given that the long-term health outcomes, relational complexities and the social implications of surrogacy are largely unknown, it seems difficult if not impossible for a potential surrogate to give informed consent. The ethical dilemmas are not only recognised by many individuals but also by governments, which is reflected in the legislative responses that attempt to deal with surrogacy arrangements. Some countries have opted for legislation permitting altruistic surrogacy (such as in the Australian Capital Territory) instead of commercial surrogacy (which is permitted in countries such as India and some states in the US), presumably because the latter gives rise to the potential for exploitation. Furthermore, surrogacy is illegal in some countries such as Germany and Italy,1 2 because it is regarded as being contrary to basic moral principles and human dignity.
In the context of altruistic surrogacy, one must ask: can a close relative or friend, viewed as a potential surrogate mother, provide genuine informed consent? Is she making an autonomous decision free from coercion, particularly in complex family contexts? Is she aware of the emotional impact of giving up a baby that she has carried for nine months? Can a potential surrogate mother be apprised of, process and understand all the details about pregnancy complications, risks associated with ART, psychological ramifications for herself, the child she may carry and others, the terms of a surrogacy contract and implications for future relational complexities, let alone the broader ethical implications for the community—about which she may have a genuine interest?
Consider, for example, women with low self-esteem, who may be inclined to enter into an arrangement to obtain approval of others to gain a sense of self-worth. This may be particularly pertinent where a surrogate acts for a friend or family member.3 4 In many cases, surrogate mothers overwhelmingly report that they choose to bear children primarily out of altruistic concerns,4 which must be distinguished from surrogates who state that money is the prime motive (commercial surrogacy). Other motives include sharing the enjoyment of pregnancy, and redemption from giving up a child for adoption and/or previous abortions.5
A study by Ragone6 revealed that for some women, the motivation to become a surrogate mother was due to feelings of guilt about having had a previous abortion and/or having to give up a child for adoption. In this study the statistics indicated that 26% of potential surrogates had previously had an abortion and 9% had placed a child up for adoption. This raises doubts about whether surrogates actually enter an agreement simply on altruistic grounds, which is often taken for granted, as well as whether surrogacy is an appropriate way of dealing with prior loss of a child.
Importantly, it has been shown that when surrogates were asked to justify their decision to become a surrogate mother, the verbal self-reports are often scripted to reflect socially accepted reasons for surrogacy.6 Most surrogates score within the normal range on personality tests such as the Minnesota multiphasic personality inventory. However, it has been suggested that those who are willing to be surrogates are more independent thinkers and are less bound by traditional moral values. It has been reported that surrogate mothers score lower in “conscientiousness and dutifulness” on the NEO five factor test.5
This demonstrates that the motivation underlying the decision to become a surrogate cannot always be taken for granted as purely altruistic. Motives such as redemption, guilt or money (as is the case in commercial surrogacy) demonstrate that the decision to become a surrogate is based on a complex range of factors and psychological dispositions.
FRAGMENTATION OF THE MATERNAL-INFANT BOND
Important biological bonds are established between the mother and her foetus during pregnancy. Even the scent of a newborn can attract the mother, as each mother can identify her own infants’ odour when presented with the odour of several other babies.7 One of the most concrete examples of the importance of the maternal-child bond comes from foetal-maternal physiology. The hormone oxytocin plays a crucial role in priming the gestational mother to respond in accordance with her natural maternal instincts. It is a response triggered by skin to skin contact and eye gazing, which promotes further psychological and physiological bonding.7 8 An interesting study by Widstrom et al9 revealed that if the lips of an infant touch the mother’s nipple in the first hour of life, a mother will decide to keep her baby in her room 100 min longer on the second and third day during her hospital stay than another mother who does not have contact with her infant until later. Additionally, the developmental psychology literature indicates that there is a crucial window of time from the moment of birth onwards, whereby a baby begins to form cognitive attachments through interactions with the gestational mother.10 The cognitive psychology literature on early childhood development also emphasises the importance of the psychological bonds formed from birth and onwards.10–12
Humans have a very basic response to expressions of emotion in others, and infants in particular display a basic drive to match behaviour and psychological expressions in persons closest to them at the earliest of stages. Numerous studies have revealed that infants react to their mother’s emotional expression with their own. They seek out the most immediate emotional being to participate with in an “inter-subjective game”. Rather than living in a buzz of ambivalence or confusion as envisaged by some, an infant’s behaviour is innately fashioned to coordinate with the social behaviour of other people. This demonstrates that an infant already has the cognitive mechanisms and psychological capacities in place to influence as well as be influenced by other people, and in particular his or her birth mother.11 12 Therefore, at the very least, one ought to be concerned with any process that disrupts the important bonding between mother and child which begins during gestation and continues after birth. Surrogacy ruptures this bonding.
Such is the strength of the bond and emotional attachment of the surrogate mother to the child that there have been many cases from around the world where a surrogate mother has been unwilling to relinquish her child; consider, for example, the Baby M13 and Evelyn cases.14 As evidenced in these much-publicised cases, having to relinquish a child can be heart-wrenching, the end result being custody battles. Added to this is the evidence that surrogates may live with the psychological burden associated with giving up their gestational child for many years.15 These matters reinforce the difficulty, if not impossibility for a surrogate mother to give informed consent.
In relation to the difficulties with relinquishment, certain critical questions must be asked. What happens when there is a reluctance or refusal to stick to the original surrogacy agreement? What if neither the surrogate nor the commissioning parents want the child? By its very nature, a surrogacy arrangement is likely to lead to more custody disputes because the child is born into such unusual circumstances by being the offspring of more than one family group. No legislation permitting surrogacy can accommodate such complications without leading to seriously undesirable consequences such as litigation, custody battles, all of which occur at the expense of the child’s welfare.
It could be argued that an argument against fracturing the maternal-infant bond in the case of surrogacy also applies to cases where a mother gives up her baby for adoption. As such, why would surrogacy be more ethically objectionable? Firstly, the arguments prescribed here do not constitute an objection to adoption per se, since the crucial distinction between adoption and surrogacy is that the latter is an intentional decision to relinquish a child to a commissioning couple without the welfare of the child being paramount, whereas adoption is, in a sense, “rescuing” a child from difficult circumstances, in which case it is the child’s welfare that is of primary concern.
The fracturing of family structures, due to divorce or separation, neglect and abuse is highly undesirable and children who find themselves in such unfortunate circumstances become no less than innocent victims. Single mothers who are socioeconomically disadvantaged may decide that placing the child up for adoption is in the best interests of her child (such circumstances are unfortunate and obviously undesirable). In some extreme cases of neglect, there may be grounds for removal of the child for adoption or placement in foster care. However, giving up a child for adoption is a decision that is never taken lightly. It is essentially a decision that is predicated on the primacy of the child’s welfare. It is essentially concerned with finding the best outcome for the child given the unfortunate situations that many find children find themselves in, which often cannot be reversed. The essential difference between surrogacy and adoption is, with regard to surrogacy, that the surrogate mother and commissioning parents have intentionally and consciously decided, prior to the conception and birth, to hand the child from the gestational mother to the commissioning couple. The ethically relevant difference resides in the difference in relation to intentions and foreseeable consequences. In a surrogacy arrangement, unlike adoption, the welfare of the child is not the primary objective, but instead, it is subordinated to fulfilling the desires of an infertile couple to have a child. It might be expected that a child born of surrogacy would experience the difficulties experienced by an adoptee in addition to those unique to surrogacy.
CONTRACTUAL ISSUES AND HEALTH RISKS
A diagnosis of disability or disease, even if equivocal, could lead to serious problems with a surrogacy arrangement. For example, a prenatal diagnosis of disability or perceived imperfection could result in the commissioning couple reneging (such a case has already occurred in the US).16 17 In the case of a diagnosis of disability, depending on the circumstances and severity, the option of abortion could be considered by the surrogate; however, differing moral perspectives on abortion have the potential to result in an irresolvable stalemate. The surrogate may still wish to proceed with the birth; however, the commissioning couple may no longer want the child. Alternatively, the surrogate may choose an abortion contrary to the wishes of the commissioning couple.
Given that gestational surrogacy involves ART, the health risks in ART are pertinent to surrogacy. According to a recent review, ART is responsible for approximately 50% of all multiple births worldwide,18 and about half of IVF pregnancies in the US result in multiple births, with a high risk of premature delivery.19 One-third or even one-half of infant mortality is due to complications of prematurity, and a large contributor to prematurity is infertility treatment. (It is granted that the risks associated with multiple births can be mitigated by the practice of single embryo transfer, however, this does reduce the likelihood of pregnancy.) In addition to these risks, there is a growing concern that other risks to children born of ART may occur. The point here is that in gestational surrogacy a contractual arrangement makes these problems more acute as it involves parties whose response to these issues cannot be predicted. Yet these matters have the potential to undermine the whole arrangement in seriously damaging ways. In a gestational surrogacy agreement the increased chance of multiple births could lead to contractual disputes if the intention of the commissioning couple was to have only one baby. For example, a British woman pregnant with twins sued a California couple because they backed out of their surrogacy contract after she refused to abort one of the foetuses.20 Another unfortunate, yet foreseeable outcome where the best interests of the child conflicted with the interests of the commissioning couple is exemplified in the infamous case of Jaycee B versus the Supreme Court of Orange County. In this dispute the commissioning couple divorced prior to the surrogate mother giving birth to baby Jaycee. However, the commissioning father contended that he was not legally obligated to pay child support, arguing that he was not genetically related, his wife had not given birth to the child, and that he had never formally adopted the child. This also demonstrates the difficulties with providing adequate legislative responses to rapid progress in reproductive technology along with particular reproductive demands. This issue is in fact a very pertinent one given the diversity of legislative responses to surrogacy observed in the USA. The case cited above, along with many other legal disputes is discussed in a recent book by Susan Markens, which focuses on the struggle for adequate legislative responses to surrogacy in the USA.21
While pregnancy is a natural process, it is not without risk. Whereas a woman choosing to become pregnant and committed to raising her child is prepared to bear that risk, in surrogacy, the concern is that she bears the risk without the natural benefit of motherhood. There is therefore a sense of futility if something goes wrong for her, which is especially the case if a woman becomes a surrogate for purely altruistic purposes, essentially placing herself under risk primarily for the benefit of the commissioning couple. For example the Daily Mail reported that a surrogate mother, aged 29, had died shortly after giving birth. She developed high blood pressure and a ruptured aorta after the delivery, dying 90 minutes later. Her mother said:
Surrogacy caused Natasha’s death. People must realise that childbirth isn’t something you enter into lightly. It’s still dangerous but that is something surrogate agencies don’t go into … Natasha didn’t want any more children herself but she comes from a big family and she felt for people who couldn’t have children. Her children had brought her a lot of pleasure so she wanted other parents to share some of that joy.22
While this woman’s desire to assist others was generous, her resultant death is all the more tragic because of its circumstances. It could be argued that if she had died bearing a child she would raise, the tragedy would have been tempered by the authentic commitment to motherhood that her pregnancy entailed.
Given such potential harms that a surrogate faces, surrogacy agencies must provide appropriate measures and counselling services. The services and programmes that surrogacy agencies provide for surrogates are an attempt to ensure the greatest likelihood of a successful outcome for all parties involved. This is especially the case with commercial surrogacy agencies, where unsuccessful arrangements are detrimental for business. While this is appropriate and both the interests of the agency and surrogate are taken into consideration, one of the psychological counselling strategies involves a deliberate effort to de-emphasise the significance of the gestational maternity of the surrogate, in order to allow the surrogate to cope with relinquishing the child. This is referred to as “cognitive dissonance reduction”. In the following section I will argue that such a measure requires what is essentially an objectification of the surrogate mother.
OBJECTIFICATION OF THE SURROGATE MOTHER
It is rather counterintuitive to consciously decide to terminate one’s parental rights and duties prior to conception. Legal norms typically affirm parental duties and the existing moral obligations that come with it, but the concept of parenthood is grounded largely in biology and not in an arbitrary agreement. Hence, there is a sense in which even though a gestational mother has decided to relinquish her child (parenthood discharged via an agreement) she is still the child’s mother (parenthood grounded in biology).23 Therefore there is a sense in which, at best, a re-conception of motherhood, or at worst, self-deception, are required on the part of the surrogate in order to break the natural, biological, maternal bond she has with her child in order to make it easier to relinquish the child she has nurtured in her womb.
Transferring parental rights does not annul the existing parental bonds, which for many are grounded in biology, between the gestational mother and her child. Therefore, one must go further and depersonalise the whole process of pregnancy and childbirth in order to reconcile ones intuitive concept of parenthood with ones altruistic motives, as Rosalie Ber states:
The question of whether the suffering of a childless woman is greater than that of the gestational surrogate, who “abandons” her baby, is “solved” when the surrogate mother is de-personalised, and looked upon solely as a “womb for rent”.24
That is, a surrogate mother must become a commodity for the purposes of conceiving and producing a child who is to be relinquished to the commissioning couple. Treating the surrogate as mere means to an end may be a method by which some attempt to deal with the disruption to natural relationships that surrogacy entails, however, this also places the surrogate at greater risk of exploitation. Indeed there is much evidence demonstrating the need for surrogate mothers to reconcile the circumstances of the surrogacy arrangement with the norms of maternal-foetal relationships. There is evidence that the attempted reconciliation proceeds in a manner that is deceptive or underhanded, for in order to make it easier for a surrogate to relinquish the child, she must invoke a number of “cognitive dissonance” reduction strategies which I will argue, amounts to a form of objectification via self-deception.
In a study by Ciccarelli,5 14 surrogate mothers were asked to report their feelings or concerns about relinquishing the child. One mother reported emotional distress over the relinquishment and two others reported a strong instinctual urge to bond with the child. The remaining 11 did not feel bonded with the child, which may seem to indicate that for the majority of surrogates the issue of having to relinquish the child did not appear to be a problem. However, surrogates employ cognitive dissonance reduction strategies to cope with their loss, implying that the issue is much more deep-seated, which accords with knowledge about the strength of the bond between gestational mother and child, and our intuitive concept of parenthood. So why did it seem relatively easy for 11 out of 14 mothers to relinquish the child in this study? The typical response given was that “I had it in my mind from the beginning that it was not my child, I didn’t feel bonded”, or “I almost felt guilty for not feeling bad about giving up the baby”.25
In another study by van Zyl and van Nierkerk,23 the typical responses given by surrogate mothers, with regard to how they felt about their relationship with the foetus, were as follows: “I don’t think of the baby as mine. I donated an egg I wasn’t going to be using”; “The baby isn’t mine. I am only carrying the baby” and “I am strictly a hotel”. Hence, having effectively denied that the surrogate is the mother of the child, the only logical outcome is to view the relationship as one of ownership, the surrogate as a “human incubator” and the child as the “product” who bears no relationship to her other than partly being the result of her biological and physical labour.23
Furthermore, a study by Ragone6 identified the surrogate’s perception that the child was not hers as crucial in determining her experience of the whole surrogacy arrangement. In one instance, therapy that was designed to maintain the “desired state of mind” of the surrogate was withdrawn due to the surrogacy agency becoming bankrupt, and as a result all of the surrogates involved subsequently expressed intense separation anxiety, as Ragone states:
When the support services are removed and the structure of the programme dissolves, it is difficult, if not impossible to maintain the prescribed and desired boundaries between the surrogate and her child: hence, surrogates report feelings of loss, pain, and despair when parting with the child.6
This entirely unusual and discordant ongoing effort to deal with a surrogacy arrangement, and the subsequent relinquishment, underscores the damage that some surrogates go through, even though in most cases it is masked at least temporarily by considerable cognitive dissonance reduction techniques. Thus a woman’s natural intuitions are being subverted by cognitive dissonance reduction strategies. It is clear from these studies and the statements by surrogates, that the nature of such strategies requires the surrogate to view herself as an object or as mere means. This view is reinforced by other researchers in this area, for example Baslington26 who states:
During the research I discovered that the surrogate mother membership were encouraged by the self-help group to think of their surrogacy arrangement as a job incorporating payment, suggesting that the subcultural influences engendered by the social organisation of surrogacy arrangements were important in the detachment process.
In this study by Baslington, the majority (10 out of 14) of the surrogates reported that they were able to cope well with the relinquishment, though the general experience was to feel unhappy in the short term but if a good relationship was forged with the commissioning couple then this also eased the burden of relinquishment. However, the study also revealed that one of the surrogates still suffered from feelings of guilt, regret and loss after having relinquished her baby two and a half years earlier. Another surrogate found it hard to relinquish her baby, grieving the loss more than expected, suffering post-natal depression and experiencing a sense of guilt. These and other studies highlight recurring themes such as self-denial, objectification and the need for subverting natural intuitions for the sake of the surrogacy arrangement.
One other interesting data point was that a major cause of emotional distress or regret on the part of the surrogate depended on whether a relationship was maintained with the commissioning parents. What this indicates is concern on the part of the surrogate to develop a relationship with the commissioning parents that actually goes beyond the surrogacy arrangement and beyond the mere utilisation of a functional womb. The surrogate wanted to be more than just a “womb for rent”. She did not want to feel used, merely because she has a womb that works, but rather she wanted to be a part of the commissioning couple’s lives. As van den Akker comments:
It is seen as a betrayal when the intended couple with the surrogate baby disappears from the surrogate and her children’s lives.27
It would be hard to imagine that commissioning couples could be legally obliged to enter into a long-term relationship with the surrogate, even though she might suffer without that relationship. Hence this data further demonstrates how a surrogate is objectified by virtue of requiring the subsequent negative experiences to be quelled via maintaining a good relationship with the commissioning couple, in addition to cognitive dissonance reduction strategies.
The argument can be summarised as follows:
1. Surrogacy is destructive of the natural and intuitive intimate mother/child relationship.
2. To try and circumvent this problem surrogates employ, and agencies promote, a number of cognitive dissonance reduction strategies.
3. The cognitive dissonance reduction strategies implicitly require the objectification of the surrogate.
4. If the first premise is correct, then surrogacy is morally problematic; if the second and third premises are correct, then surrogacy is additionally morally problematic.
5. There is empirical evidence to support premises 1, 2 and 3.
6. Therefore surrogacy is morally problematic.
In relation to cognitive dissonance reduction, the principle of not using people as “means to an end” is deliberately undermined in an attempt to uphold the principle of “do no harm”. In attempting to reduce her own psychological pain from relinquishing her baby the surrogate has to think of herself as an object. Furthermore, perhaps the strategies not only objectify surrogates but also act to deny the reality that a problem exists and in doing so only serve to bury the problem which may then emerge later with significantly increased power to harm the surrogate. Whether this is the case will depend on further longitudinal studies. However, there is no doubt that the potential for exploitation exists, even more so under a commercial arrangement, given the disparity in income and social class between potential surrogates and commissioning parents. Already we are witnessing a big surge in commissioning couples from affluent societies entering into surrogacy arrangements with agencies from India (such as the one in Anand) for what seem to be bargain basement prices.28
While there is little in the way of empirical studies into the long-term effects that a surrogacy arrangement has on the surrogate, the child and the family of the commissioning couple, there have been many studies conducted by Susan Golombok and her group. They report that the various procedures in ART and surrogacy do not have a negative impact on the social or emotional development of all parties involved in ART procedures and surrogacy arrangements.29–32 However, the studies are limited in their longitudinal extent and at this stage more research is required before one can be certain that the potential for harm is non-existent.
While surrogacy can be seen as enhancing reproductive freedom for the commissioning mother to have a genetic child, and for a surrogate mother to utilise her reproductive capacities for altruistic or financial reasons, surrogacy arrangements are ripe with possibilities for women’s reproductive freedom to be severely violated. The inherent objectification of women that surrogacy necessitates leaves a surrogate susceptible to exploitation and coercion. The risks are particularly acute in the context of commercial surrogacy. Furthermore, the diversity of legislative responses throughout the world reflects the difficulties law makers have in dealing with these ethical dilemmas.
These data cited in this review indicate that those entering into a surrogacy arrangement know they are making a radical departure from established intuitions and social norms of parenthood and in attempting to reconcile their situation with those established norms they experience parental, familial and psychological bewilderment. This is particularly true for the surrogate who faces the greatest challenge because of her intimate psychological and gestational relationship with the child. After all, it is the surrogate mother who must to face the challenge of becoming pregnant, most likely through ART, carry out the pregnancy, give birth and then relinquish the child. Furthermore, surrogacy fails to respect the dignity and primacy of the welfare of the child. It ignores the fact that foetal/early infant development is a critical determinant of a child’s welfare, whereby the biological and psychological bond between the surrogate and the child is of crucial significance for this development. It requires the subordination of the welfare of the surrogate and her child in favour of the commissioning parents desires to have a child. The law ought to be congruous with such concerns hence it ought to prohibit all forms of surrogacy arrangements.
Competing interests: None.
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