Cross border reproductive services

Rationale

Social workers have committed themselves to enhancing the rights and well-being of all human beings through a variety of previous policy statements. Those that are especially relevant to cross border reproductive services (sometimes described in the literature as fertility or reproductive ‘tourism’), because of their particular impact on women, are:

• International Policy on Health (International Federation of Social Workers, undated)
• International Policy on Human Rights (International Federation of Social Workers, 1996)
• International Policy on Women (International Federation of Social Workers, 1999)
• Ethics in Social Work: Statement of Principles (International Federation of Social Workers and International Association of Schools of Social Work, 2004)

The particular challenges of cross border reproductive service provision involve balancing the reproductive rights of involuntarily childless adults seeking to build a family through forms of assisted conception that are dependent on the involvement of a third party as a donor or surrogate, and their right to impartial advice with protection from exploitation and harm of (1) potential donors and surrogates – the latter almost invariably young women in the world’s least wealthy countries – and (2) any child who may be conceived or affected by the procedure.

This specific commitment is especially necessary where systems are not in place at a national level to ensure that the rights, physical and mental health interests of all individuals personally involved in assisted reproduction procedures are adequately safeguarded.

Background

Fertility difficulties are experienced by an estimated 12-15% of couples of child-bearing age in industrialized countries (Centers for Disease Control, 2007; Human Fertilisation and Embryology Authority, 2007) and more than 180 million couples in the world’s developing countries (World Health Organization, 2003 (a)). Involuntary childlessness may be the result of either reproductive impairment experienced by one or both members of a heterosexual couple or because an individual or a couple are engaged in an alternative lifestyle.

Since the birth of the first child conceived following in vitro fertilization (IVF) in 1978, it is estimated that over 3 million children (Horsey, 2006) – around 200,000 children annually (Adamson, 2006) – have been born as a result of a range of assisted reproductive technologies (ARTs).

The key ethical principle of reproductive autonomy, derived from international conventions (such as the Universal Declaration of Human Rights and the European Convention on Human Rights and Fundamental Freedoms) and national laws enjoys virtually universal acceptance; this respects the right of an individual to make reproductive decisions free from external interference, unless these infringe the rights of others.

Different jurisdictions have responded in various ways both to the regulation and provision of different ARTs, reflecting diverse cultural, economic, historical, political, religious and social traditions (Jones et al., 2007). Such variations have both made possible – and encourage – the development of services for fertility difficulties as a globalized endeavour, demonstrating the positive and negative characteristics of globalization evident more generally. Involuntarily childless individuals experiencing fertility difficulties may decide to travel to other countries to access ARTs for a variety of reasons:

• Services may be unavailable in their home country because of a lack of technical expertise (particularly likely in countries with small populations and/or limited resources)
• More established/expert/successful provision may be available in another country
• Services in their home country may be subject to lengthy waiting lists – a particularly salient issue given that female fertility, in particular, declines rapidly from the mid 30s (Bongaarts, 1982)
• In the absence of – or limits to – publicly funded or otherwise affordable services in their home country – they may be cheaper and therefore more accessible in another country
• Services available in their home country may be denied to particular groups (e.g. single people; couples in same-sex relationships; individuals over a specified age)
• Services may be prohibited in their home country.

Cross border reproductive services therefore, encompass a wide range of activities whose objectives are designed to promote individual reproductive autonomy – not all of which necessarily give grounds for concern. However, in recent years, media reports and personal accounts have drawn attention to activities in which young women, primarily in economically disadvantaged countries, act as surrogates or egg “donors” for comparatively wealthier citizens of other countries (b).

Typically in countries where these practices are reported, ARTs are largely unregulated and systems to ensure the protection of the interests of all participants do not operate (see Barnett and Smith, 2006; Braid, 2006; Chopra, 2006; Mukherjee, 2007). Even where such practices are not formally prohibited, they may be conducted surreptitiously because of a lack of community support or endorsement (Nanda, 2007). On the one hand, fees offered to prospective surrogates and “donors” in destination countries may be low compared to fees payable in the recipients’ home country (in those countries where payment of fees is permitted and not prohibited). On the other hand, relative to income levels in the destination country, fees offered may be at such a high level that the physical and emotional risks may be discounted by the prospective surrogate or “donor”.

The financial rewards for service providers in both home and destination countries may compromise the information and advice given to prospective surrogates and “donors”, especially if the provision of such advice and information is likely to discourage their continuing participation. Fees to Indian surrogates equivalent to six years’ salary for a school teacher have been reported (Chu, 2006), while Abrams (2006) reports a Romanian carpet factory worker paid the equivalent of 3 months’ wages to act as an egg “donor” and whose subsequent health problems adversely affecting her own future fertility were ignored by the clinic with whom she contracted to sell her eggs (c). By comparison, in the United States, the national inter-disciplinary professional organization, the American Society for Reproductive Medicine, has stated: “Total payments to donors in excess of $5,000 require justification and sums above $10,000 are not appropriate” (Ethics Committee of the American Society for Reproductive Medicine, 2007).

Where third party ARTs are not specifically prohibited, there is a general acceptance globally for a prohibition on the outright sale and purchase of human sperm, eggs and embryos. However, there is some institutionalized support for the compensation of “donors” in recognition of the “inconveniences” (European Union, 2004) or the “time, inconvenience, and discomfort” (Ethics Committee of the American Society for Reproductive Medicine, 2007) related to the “donation”. There is less formalized agreement on the compensation of surrogates, although limits to compensation are mandated in some jurisdictions (e.g. Human Fertilisation and Embryology Act 1990: UK; Assisted Human Reproduction Act 2004: Canada).

“Issues” statement

Financial compensation to “donors” and surrogates creates the possibility of exploitation, lack of due respect to, and regard for, the dignity of women and the commodification of their reproductive capacities. The provision of cross border reproductive services involving participants of unequal economic status and/or where levels of compensation are excessive in the context of domestic economies, may be exploitative of “donors”. Financial need may encourage potential “donors” or surrogates to discount or disregard the risks inherent in acting as a “donor” or surrogate.

The specific role of women acting as an egg “donor” or as a surrogate exposes them to particular risks of exploitation.

Unless remuneration to “donors” and to surrogates is limited to making good necessary expenses and compensation for the risk and/or inconvenience incurred, there is a possibility that such procedures may be perceived as the commodification of reproductive capacity and/or the commodification of children.

The right of a child conceived following an ART procedure involving a “donor” or surrogate to information about their genetic heritage is frequently compromised

In jurisdictions where assisted conception services are not regulated, insufficient advance information may be provided to potential donors or surrogates; insufficient regard may be given to the legal rights, physical or emotional health of one or more of the participants – including any child who may be affected by the procedures.

Policy position

IFSW endorses the principle that human life, human sperm, eggs and embryos, should not be subject to commodification or commercial exchange.

IFSW recognizes that historically women – especially indigenous and poor women – and children, have not been afforded equal access to basic human rights, protections, resources, and services. All humans are entitled to protection from all forms of discrimination and exploitation, including where this affects their reproductive capacities.

IFSW promotes the empowerment of people in all aspects of decisions and actions affecting their lives, and endorses the right to self-determination, subject only to the constraint that exercise of such rights does not impair the rights and legitimate interests of others.

IFSW endorses rights to receive competent, safe and affordable reproductive and sexual health care advice and services free from government, institutional, professional, familial, or other interpersonal coercion. Such advice and services should be provided free of charge to gamete and embryo “donors” and surrogates.

IFSW endorses the rights of individuals conceived as a result of ARTs to full information about their genetic heritage

IFSW endorses the application of its ethical standards and of ethical codes of national professional associations to reproductive health care, and to cross border reproductive services in particular
IFSW promotes the participation of social workers in all appropriate aspects of reproductive health, including fertility clinics, regulatory bodies and government departments and encourages member organizations to:

• promote regulation and/or legislation in individual jurisdictions to ensure the necessary protection of all individuals affected by ARTs, in particular those seeking reproductive services, “donors”, surrogates, and children
• seek representation on bodies that monitor and/or regulate reproductive services
• promote the development of safe and affordable reproductive health services
• promote community education in respect of fertility and reproductive health issues

IFSW promotes engagement with international organisations such as the World Health Organization to develop international guidelines for cross border reproductive care

(a) These figures are an under-estimate because the data do not include China.

(b) Currently, in the absence of more formal and systematic data about cross border reproductive services, these provide the sole sources of information. In 2007, the European Society for Human Reproduction and Embryology (ESHRE), a multi-disciplinary body with 4247 members in 114 countries, established an investigation into cross-border reproductive care with the aim of providing this information, although the remit of this project is confined to Europe in the first instance.

(c) In response to the wide publicity given to this case, on 10 April 2005 the European Parliament adopted a resolution banning trade in human cells and embryos:

www.europarl.europa.eu/sides/getDoc.do;jsessionid=DFABA61A764E316D78BFACF810DFD2B8.node1?language=EN&pubRef=-//EP//TEXT+TA+P6-TA-2005-0074+0+DOC+XML+V0//EN

This Policy Paper was approved by the IFSW General Meeting in Salvador de Bahia, Brazil August 14, 2008. It is authored by Eric Blyth CQSW BA MA PhD (1), Professor of Social Work, University of Huddersfield, Queensgate, Huddersfield HD1 3DH, England, Tel +44 1484 472457, Fax +44 1484 472794, and Monique Auffrey, MSW, RSW (2), Executive Director, Family SOS, 337-7071 Bayers Road, Halifax, NS B3L 2C2, Canada, Tel + 1 902-455-5515, Fax: +1 902-455-7190

(1) British Association of Social Workers

(2) Canadian Association of Social Workers

References

Abrams, F. (2006) The misery behind the baby trade. Daily Mail 17 July.
www.dailymail.co.uk/pages/live/femail/article.html?in_article_id=396220&in_page_id=1879&in_a_source

Adamson, G.., de Mouzon, J., Lancaster, P., Nygren, K.-G.., Sullivan, E. and Zegers-Hochschild, F. (2006) “World collaborative report on in vitro fertilization, 2000”, Fertility and Sterility (85) 1586-1622.

Barnett, A. and Smith, H. (2006) Cruel cost of the human egg trade. The Observer. 30 April.
www.guardian.co.uk/uk/2006/apr/30/health.healthandwellbeing

Bongaarts J. (1982) Infertility after age 30: a false alarm. Family Planning Perspectives. 14:75–8.

Braid, M. (2006) The donor business: The price of eggs. The Independent. 26 March.
news.independent.co.uk/health/article353598.ece

Centers for Disease Control and Prevention (2007) 2005 Assisted Reproductive Technology Success Rates: National Summary and Fertility Clinic Reports. U.S. Department of Health and Human Services Centers for Disease Control and Prevention: Atlanta, GA. www.cdc.gov/ART/ART2005/508PDF/2005ART508.pdf.

Chopra, S. (2006) Childless couples look to India for surrogate mothers. Christian Science Monitor. 3 April. www.csmonitor.com/2006/0403/p01s04-wosc.html

Chu, H. (2006) ‘It’s win-win. It’s a completely capitalistic enterprise’. Toronto Star. 20 Apr. A03.

Ethics Committee of the American Society for Reproductive Medicine (2007) Financial compensation of oocyte donors. Fertility and Sterility. 88 (2) 305-309.

European Union (2004) Directive 2004/23/EC of the European Parliament and of the Council of 31 March 2004 on setting standards of quality and safety for the donation, procurement, testing, processing, preservation, storage and distribution of human tissues and cells. Official Journal of the European Union L102: 48–58.
eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX:32004L0023:EN:HTML

Horsey, K. (2006) Three million IVF babies born worldwide. BioNews. 364 26 June.
www.bionews.org.uk/new.lasso?storyid=3086

Human Fertilisation and Embryology Authority (2007) For Patients www.hfea.gov.uk/en/270.html

International Federation of Social Workers (undated) International Policy on Health
www.ifsw.org/en/p38000081.html

International Federation of Social Workers (1996) International Policy on Human Rights
www.ifsw.org/en/p38000212.html

International Federation of Social Workers (1999) International Policy on Women
www.ifsw.org/en/p38000218.html

International Federation of Social Workers and International Association of Schools of Social Work (2004) Ethics in Social Work: Statement of Principles. Bern: International Federation of Social Workers and International Association of Schools of Social Work.
www.ifsw.org/en/p38000324.html

Jones, H, Cohen, J., Cooke, I. and Kempers, R (2007) IFFS Surveillance 07. Fertility and Sterility 87 (4) Suppl. 1.

Mukherjee, K. (2007) Rent-a-womb in India fuels surrogate motherhood debate. Reuters. 4 February. www.reuters.com/article/latestCrisis/idUSDEL298735

Nanda, P. (2007) Donating motherhood for money. Hindustan Times. 2 August
www.hindustantimes.com/Redir.aspx?ID=e918a200-0cfc-4aa5-b0cd-8907fc3f32dd

World Health Organization (2003) Assisted conception in developing countries – facing up to the issues. Progress in Human Reproduction Research 63
www.who.int/reproductive-health/hrp/progress/63/63.pdf

Image: © Flying seed by Richard Kittenberger | Dreamstime.com

Appendix A

IFSW General Meeting 2006

Agenda item 23

International Federation of Social Workers

Resolution to the General Meeting 27th – 29th July 2006 – Munich

An increasing number of people, primarily from wealthy countries, are obtaining fertility treatment in countries other than their own, because such treatment is illegal or otherwise unobtainable in their own country or because it can be obtained more cheaply in the destination country. This General Meeting requires IFSW to consult with members about the impact of these activities on the well being of all concerned and bring forward policy proposals to the 2008 General Meeting.

On the authority of the British Association of Social Workers (BASW).

Explanation:

For more than 20 years BASW’s Project Group on Assisted Reproduction (PROGAR) has successfully campaigned both in the UK and internationally for the best possible care for people with fertility problems and donors of gametes and embryos and the right of donor conceived people to learn the identity of their donor.

Whilst BASW respects the rights of individuals to seek health care abroad, the Association is currently concerned about two particular practices: (1) a global trade in “donor” eggs and (2) international surrogacy.

In countries that have become destinations for “fertility tourists”, a lack of adequate regulation can put at risk the physical and mental health of “donors” and surrogates, who are offered comparatively lucrative financial inducements to become a “donor” or surrogate, as judged by the material standards of their own country, but who may be poorly informed of the physical and psychological risks to which they may be exposed, and may not be provided with adequate aftercare.

In India, for example, where thousands of women die each year as a result of pregnancy and childbirth, it is reported that young women are recruited to be surrogates for western couples for around US$5000 – equivalent to six years’ salary for a school teacher – but a fraction of the cost charged by a western surrogate in countries where commercial surrogacy is permitted.

In Romania, impoverished young women recruited as egg “donors” by a clinic in Bucharest were subjected to hormone injections to maximize the number of eggs available for “donation” – around 20 – for which they received US$250. The clinic made huge profits by charging recipients up to US$13,000 for each cycle of treatment using a fertilized “donated” egg. When the “donors” subsequently experienced medical complications, the clinic showed no interest in them.

Although the Bucharest clinic has since been closed by the authorities, the lack of regulation in many countries means that similar practices flourish in many parts of the world; women are also reported to be traveling abroad to “donate” their eggs in foreign countries.

While “donors” and surrogates are evidently at risk, the interests of the children who may be born as a result of these procedures and of the couples or individuals who pursue them may also be jeopardized. For example, inadequate screening of “donors” or surrogates may have adverse health consequences for children and egg recipients; false or limited information may be provided about the “donors” or surrogate, compromising the child’s knowledge of their biographical, cultural and genetic heritage; the legal status of these procedures may be uncertain, resulting in legal and nationality ambiguities for children and families.

European Union member states are required to ensure that the donation of human tissue, including sperm, eggs and embryos, is voluntary, unpaid and altruistic, and that imports of human tissue into EU countries are subject to similar standards. In 2005 the European Parliament supported a resolution prohibiting trade in human eggs and embryos. However, this is self-evidently not simply a European problem, but one that has global implications.

If this proposal gains support BASW would be pleased to take the lead in working with other members to consider the prevalence of “fertility tourism” in member countries and the ethical issues that arise from these and prepare a policy paper for the 2008 IFSW World Conference.

Ian Johnston
Chief Executive
British Association of Social Workers
18th July 2006