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National self-sufficiency in reproductive resources: An innovative response to transnational
reproductive travel
Author(s): Dominique Martin and Stefan Kane
Source:
International Journal of Feminist Approaches to Bioethics,
Vol. 7, No. 2, Special Issue
on Transnational Reproductive Travel (Fall 2014), pp. 10-44
Published by: University of Toronto Press
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NATIONAL SELF-SUFFICIENCY IN
REPRODUCTIVE RESOURCES:
AN INNOVATIVE RESPONSE TO TRANSNATIONAL
REPRODUCTIVE TRAVEL
DOMINIQUE MARTIN AND STEFAN KANE
Abstract
Transnational reproductive travel is symptomatic of insufficient supplies of
reproductive resources, including donor gametes and gestational surrogacy ser-
vices, and inequities in access to these within domestic health-care jurisdic-
tions. Here, we argue that an innovative approach to domestic policy making
using the framework of the National Self-Sufficiency paradigm represents the
best solution to domestic challenges and the ethical hazards of the global mar-
ketplace in reproductive resources.
1. Transnational issues begin at home
Many Australians have traveled overseas to fulfill their hopes of parent-
hood by accessing reproductive services in countries such as the United States,
Thailand, and India: more than 269 babies were created for Australian repro-
ductive travelers in 2011 (Whitelaw 2012). Ova provided by third parties
1
and
gestational surrogates
2
are in short supply in Australia, where payment for
THE INTERNATIONAL JOURNAL OF FEMINIST APPROACHES TO BIOETHICS Vol. 7, No. 2 (FALL 2014). ©2014
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providing these reproductive resources is prohibited. In contrast, India has a
thriving legal trade that makes the country a popular, relatively affordable des-
tination for Australian reproductive travelers.
In response to news of changes in Indian policy that may restrict foreign
access to reproductive services (Ministry of Home Affairs 2012), as well as to
reports of ethical concerns about the fertility industry in India and elsewhere
(e.g., Medew 2013), some commentators have called for the introduction of
commercial surrogacy in Australia, arguing that a regulated national market
will protect the interests of surrogates, intending parents,
3
and the children cre-
ated (Haxton 2013;Millibank 2013). Similar arguments have been proposed in
favor of an Australian market in provider gametes as an alternative for the
many Australians who access assisted reproductive technologies (ART) using
ova or sperm purchased in foreign countries (Baker 2012;Nash 2012).
4
There has been little discussion of alternative strategies to encourage or
facilitate unpaid provision of reproductive resources, to promote equity in their
distribution, or to enhance the availability of resources and ART domestically.
In this paper, we hope to open a new dimension of debate and stimulate novel
approaches to policy and practice in this field. We will argue that transnational
reproductive travel is problematic, not only for its inherent ethical hazards but
also because it is symptomatic of a failure to recognize and address unmet
needs and inequities domestically. We will explore the concept of national self-
sufficiency in reproductive resources, a practical goal and social ethos that,
when adopted by policy makers, may encourage strategic innovations to
improve access to these resources, and to enhance equity in their provision
and distribution. The ethical foundations and implications of the self-
sufficiency concept have yet to be fully explored, particularly with respect to
reproductive resources, but we provide here a substantial, albeit preliminary,
examination. We suggest that the self-sufficiency ethos is more consistent with
a feminist bioethics than with the individualist, libertarian frameworks often
employed to support market-based policies and cross-border solutions pro-
posed in response to the challenge of meeting needs for these resources in the
domestic setting.
a. Why worry about reproductive travel?
The challenges of meeting needs for reproductive resources within coun-
tries and the hazards of the global marketplace reflect similar issues that have
arisen in the context of human blood and blood products, and organs for
DOMINIQUE MARTIN AND STEFAN KANE 11
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transplantation. In particular, reproductive travel mirrors many elements of
transnational travel for organ transplantation, or “transplant tourism.”Yet, as
Pfeffer (2011) highlights, there has been a marked contrast in the responses of
professional organizations and national and international authorities, such as
the World Health Organization (WHO), to these different practices. Extensive
efforts to discourage and prevent travel for commercial organ transplantation
have been complemented by efforts to achieve self-sufficiency in transplanta-
tion at the national or regional level by encouraging donation and facilitating
organ procurement (Delmonico et al. 2011;Noël and Martin 2009).
In contrast, new markets in reproductive resources designed for foreign
consumers are emerging rapidly, often with the support of national authorities
(e.g., Sarojini et al. 2011). Legal conventions governing procurement of gametes
and provision of surrogacy services are usually subnational or national in
scope, reflecting a lack of international consensus (Van Hoof and Pennings
2012, 188). Although most jurisdictions nominally reject trade in ova, many
allow for the payment of lump-sum “compensation”to providers. Studies of
oocyte providers’motivations and recruitment strategies suggest compensation
often serves to incentivize “donation”(Purewal and van den Akker 2009c, 507;
García-Ruiz and Guerra-Diaz 2012, 123; Levine 2010). Compensation facili-
tates trade and encourages reproductive travel all over the world (Van Hoof
and Pennings 2012;Martin 2010). Many commentators advocate payment as
practically necessary and ethically justifiable, if not obligatory (e.g., Steinbock
2004;Ramskold and Posner 2013).
Reproductive travel has been hailed as a moral safety valve enabling indi-
viduals to enjoy procreative liberty (Pennings 2004). Rather than seeking to
reduce travel, many experts from a range of disciplines advocate modification
of current practices and policies so as to maximize the benefits and minimize
the harms of cross-border care. Hudson et al. (2011) suggest that most com-
mentators may regard this as the most feasible approach to the issue. Com-
mentators propose strategies to minimize harmful practices (e.g., Ireni-Saban
2013), untangle international legal complexities (e.g., Nelson 2013), and offer
guidelines for health-care professionals involved in transnational reproductive
care (e.g., Shenfield et al. 2011;Blyth et al. 2011;Ethics Committee 2013).
However, the current Australian debate highlights an emerging view that
the ethical issues of reproductive travel should be addressed at the national
level. More locally engaged governance is necessary to protect the providers of
gametes and surrogacy services, to meet the needs of intending parents, and to
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promote the interests of children produced through ART. Reliance on industry
self-regulation within the global market has proven ineffective and sometimes
harmful, exposing children to trafficking and abandonment, surrogates and egg
vendors to exploitation and coercion, and intending parents to devastating loss
as they struggle to bring home children caught in immigration tangles (Storrow
2011). Furthermore, in the absence of national solutions, poorer citizens
who cannot afford to travel remain disenfranchised from ART services. The
self-sufficiency paradigm, with its emphasis on national responsibility for meet-
ing needs locally, thus represents an important new approach to the challenges
of transnational reproductive care.
b. Introducing national self-sufficiency in reproductive
resources
Broadly speaking, self-sufficiency refers to the goal of meeting therapeutic
needs for medical products of human origin within a defined community—
usually the nation-state—using resources derived from within that community.
Thus, self-sufficiency in reproductive resources refers to the ability to meet
needs for gametes and surrogacy services within a particular social community,
using resources sourced from providers within that community.
National self-sufficiency was first invoked in the 1970s in response to eth-
ical and safety concerns about international trade in human blood products
(Leikola 1987). Although prevention of harmful cross-border trading was a
major element of the concept’s original framework, this was complemented by
efforts to meet needs ethically by promoting blood and plasma donation within
society. Respect for justice appears to have been a key ethical concern of early
self-sufficiency advocates, such as the WHO, with exploitation of foreign provi-
ders of biological materials, inequity in access to resources, and inequitable dis-
tributions of the burden of donation identified as issues to be addressed
through policies aimed at self-sufficiency (ibid.; Council of Europe 1990).
Similarly, the promotion of self-sufficiency in organ transplantation has
been advocated in recent years in response to ongoing global trade in human or-
gans, notably in the Declaration of Istanbul on Organ Trafficking and Transplant
Tourism (Participants 2008, 855). Following the WHO’s third Global Consulta-
tion on Organ Donation and Transplantation on the subject of self-sufficiency
(WHO 2011), international leaders in transplantation called for governments to
take responsibility for meeting needs for transplantation within their borders, or
in collaboration with regional neighbors (Delmonico et al. 2011).
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The concept of self-sufficiency in reproductive resources was recently in-
troduced to the literature by Martin (2010) as a strategic response to reproduc-
tive travel (see also Crozier and Martin 2012). Thorn et al. (2012, 4) also
suggest that pursuit of self-sufficiency will reduce reproductive travel. More re-
cently, Downie and Baylis argue that “Canadian authorities should promote
national self-sufficiency in an effort to contain (if not decrease) the demand for
transnational trade in human eggs”(2013, 234).
The concept of national self-sufficiency has undergone little critical exam-
ination from an ethical perspective, with the exception of debate regarding
payment for provision of blood and plasma (Keown 1997). The ethical implica-
tions of a society’s adoption of responsibility for meeting needs for human
biological materials, the justification of the persisting requirement for “non-
remunerated, voluntary”donation that was entrenched in the first World
Health Assembly (1975) resolution on the development of national blood
donation programs, and the complexities inherent in defining “needs”are all
overdue for in-depth analysis.
We provide a preliminary discussion of these critical points in the context
of self-sufficiency in reproductive resources in the final section of this paper.
We also explore the additional complexities surrounding the definition of
needs that arise in the context of infertility (e.g., Peterson 2005) and the unique
burdens that may be associated with provision of resources that may engender
desires for relationships on the part of children, intending parents, or providers
(Crozier and Martin 2012, 49). We will argue that within the self-sufficiency
ethos, the core themes of social community, shared responsibility for meeting
needs, protection of the vulnerable, and promotion of justice resituate infertility
as a fundamentally social concern, for which effective and ethical solutions
must be shaped through societal mechanisms and strategies. In contrast,
transnational and domestic market mechanisms—whether regulated, state-
controlled, or free—perpetuate and exacerbate the social neglect and isolation
of infertile individuals and couples and increase the vulnerability and invisibil-
ity of providers of reproductive resources and potential children created.
Before presenting our account of self-sufficiency, we must first review the
reasons underpinning travel for reproductive resources—namely, failure to meet
needs within domestic systems—the hazards of transnational travel, and pro-
posed responses to the phenomenon, including market regulation (both interna-
tional and domestic), harmonization of laws, and prohibitions on travel or trade
in the absence of efforts to meet needs for reproductive resources domestically.
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2. Travel is symptomatic of domestic problems
a. Insufficiency of resources
Demand or needs for reproductive resources are rarely estimated;
5
how-
ever, studies suggest that insufficient supplies of these resources are a major
factor influencing reproductive travel (Hudson et al. 2011). The relative abun-
dance of these resources in some countries is often associated with payment for
gamete providers and surrogates (Shenfield et al. 2010, 1367), and financial
“compensation”is often cited as a secondary, if not primary, motivation for
providers of reproductive resources (Van den Broeck et al. 2013;Purewal and
van den Akker 2009c, 507; Lee 2009, 289). Additional considerations for pro-
spective buyers and providers may include factors such as regulation of pro-
vider anonymity, but resources tend to flow from countries in which trade is
legal to those in which payment is prohibited (e.g., Martin 2010, 382). The posi-
tive association often found between payment and increased supplies has
helped to place markets at the forefront of proposed solutions to the problem
of insufficiency in many countries. However, rather than necessarily indicating
superior efficacy, financial incentives stand out because of a lack of alternative
strategies to increase donation.
Few countries have sought to promote or facilitate donation of gametes or
surrogacy services as part of a societal response to infertility and unmet needs
for these resources. There is little in the way of public education about infertil-
ity, needs for reproductive resources, risks and benefits of their provision, and
potential strategies to minimize disincentives for providers. These disincentives
may include immediate costs incurred by providers, such as lost wages; costs of
travel, testing, and insurance; and the discomfort and physical side effects of in-
vasive procedures. Surrogates who carry a baby to term will experience a longer
period of physiological disruption and medical attention compared with single-
cycle oocyte providers. Yet both oocyte providers and surrogates face serious—
albeit rare—health risks, potential legal complications, possible social stigma,
and psychological concerns, some of which may arise years later (Kalfoglou
and Gittelsohn 2000;Maxwell et al. 2008;Bodri 2013;Duffy et al. 2005;Berend
2010;Pande 2009). Concerns about the possible negative impact of removing
gamete provider anonymity on recruitment in the United Kingdom reflect
some of the potential long-term psychosocial risks of genetic parenthood, such
as emotional or financial liability (Frith et al. 2007, 1679).
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Many of the potential disincentives to provision of reproductive resources
may be effectively removed, rather than overcome by lump-sum financial in-
centives: by reimbursement of health-care costs; by provision of health insur-
ance related to the donation or surrogacy; by provision of counselling services
(ibid.); and by providing clarity and transparency of laws governing, for exam-
ple, anonymity, liability (Jayanti 2008), and surrogacy rights.
b. Neglect of inequities
Lack of public efforts to encourage or facilitate altruistic donation may
reflect a view that infertility is not an important health and social issue (Jones
and Nisker 2013). Setting aside the problem of insufficient resources, and the
role that markets may play in providing them, many societies are also content
to leave regulation of ART, including allocation of reproductive resources, to
the market sphere. In many countries, most ART is provided in private clinics,
even where care is publicly subsidized (Mladovsky and Sorenson 2010, 122;
Chambers et al. 2013, 1682). Equity in global access to ART remains a major
challenge (Pennings et al. 2008), and one that is particularly neglected where
reproductive resources are concerned.
In countries where ART is available, the costs of accessing services may
exclude many intending parents. Subsidization of costs through public health
funds positively influences utilization of ART (Chambers et al. 2009); however,
subsidies are usually limited to a fixed number of cycles, such that many
patients need to pursue further treatment at their own expense. Financial bar-
riers to ART include additional costs when using third-party reproductive re-
sources—regardless of whether providers are paid. In addition to direct
financial barriers, a range of legislative, regulatory, and policy barriers may
impede access to specific procedures or resources. Individuals or couples may
be excluded from or receive lower priority in accessing ART on the grounds of
eligibility criteria that seek to evaluate suitability for parenting (Storrow 2006)
and to rank “needs”for ART. Although specific legislation in some countries
may act clearly as a gatekeeper to ART—for example, by excluding unmarried
heterosexual couples or lesbian, gay, bisexual, transgender, or queer (LGBTQ)
couples or individuals—the criteria or processes used to allocate available re-
sources are rarely transparent.
6
The risk of injustice in allocation is magnified
in the setting of privately run health systems and clinics.
In contrast to relatively transparent systems frequently governing alloca-
tion of organs for transplantation, and vigorous professional and academic
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debates about organ allocation criteria, the allocation of reproductive resources
is rarely discussed. There are no public ova banks or national pools of donated
gametes, nor waiting list reports. Those who lack a friend or relative willing to
provide resources may solicit an unrelated donor, or solicit or select a paid pro-
vider in countries where this legal. Alternatively, they may join the “waiting list”
of specific clinics or health-care institutions, where provided or “shared”
7
eggs
are distributed at the discretion of the clinic. Waiting lists and times are fre-
quently invoked, despite lack of transparency regarding the allocation process in
the media, patient websites, industry, and academic forums. The Agence de la
Biomédicine (2012b, 4) publicly warns that average waiting times in French
clinics range from six to sixty months, and notes that times vary according to
the availability of “suitably matched”donors who present to the clinic at which
one is registered. Some clinics boast of no waiting time at all, such as the London
Clinic (2013) in the United Kingdom, which offers free IVF to “eligible egg-
sharers.”
In a rare article discussing possible criteria for use in an ova allocation sys-
tem, Pennings (2001, 31) suggests that a criterion concerning the degree of phe-
notypic match between prospective recipients and providers should receive little
weight. However, evidence suggests that matching phenotypic and social charac-
teristics of gamete providers and recipients is one of the most important criteria
employed by clinics and used by prospective recipients in selecting from
available providers (Almeling 2007). Those seeking surrogates are also subject
to market vagaries, reliant on paying fees to brokering agencies, soliciting
surrogates through advertisements, or competing with other intending parents
for services advertised by prospective surrogates (e.g., Hibino and Shimazono
2013). The perceived desirability of particular surrogate, gamete provider, or
intending parent attributes plays an important role in advertisements, influen-
cing both commercial value and the probability of meeting one’s needs for
reproductive resources (Almeling 2009;Nowoweiski et al. 2011;Roberts 2009).
While it is difficult to evaluate equity in access to these resources due to lack of
systematic research, current practices appear highly vulnerable to unjust dis-
crimination.
3. An undesirable solution to domestic issues
Opportunities for reproductive travel are often held to improve both
access and equity in access to reproductive resources, at least for some groups
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(Pennings 2002, 338). Additional advantages may include economic benefits
for destination countries, their health-care systems, and women who provide
ova or surrogacy services (Crozier and Martin 2012). However, a growing mul-
tidisciplinary body of literature (Hudson et al. 2011;Inhorn and Patrizio 2012)
has identified a range of ethical and practical concerns about reproductive
travel. Many of these concerns are equally relevant to domestic markets, and, in
some contexts, may apply to noncommercial provision or use of gametes or
surrogates. However, the cross-border socioeconomic inequalities that are typi-
cal of many transnational markets for reproductive resources render partici-
pants more vulnerable to these risks than they may be in the setting of
domestic markets, and certainly than they would be in the absence of financial
incentives for resource provision.
a. Risks for providers of reproductive resources
Relatively wealthy reproductive travelers may pay well above local prices
for reproductive care and resources in less economically developed countries.
The magnitude of financial incentives available may encourage care providers
to expose donors and surrogates to avoidable risks in the hope of maximizing
profits (Nahman 2011, 631; Deonandan et al. 2012). In turn, the latter may be
willing to incur higher risks in order to obtain significant financial incentives
(e.g., Pande 2009, 150). Although laxity of regulation and oversight of repro-
ductive care providers may exist in the absence of reproductive travelers,
foreign customers may play a significant role in stimulating and sustaining
markets. The relative invisibility of resource providers to those who purchase
gametes or surrogacy services in these markets, due to language and cultural
barriers as well as geographical and social distancing (Vora 2013, S102), may
also diminish concern for provider well-being by customers, thus increasing
their vulnerability.
Physical and psychosocial risks to providers of reproductive resources
may include inadequate medical care leading to ovarian hyperstimulation
syndrome; transfer of multiple embryos; social stigmatization; and impaired
autonomy in decision making about the pregnancy, including choices about
terminations, lifestyle during pregnancy, and interventions during labor (e.g.,
Pande 2009;Bailey 2011;Lundin 2012). Women may be exploited, for example,
where others take advantage of their poverty or lack of education in order to
obtain their agreement to an unfair contract, in which the benefits to brokers,
health-care providers, and intending parents are disproportionate to the
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economic gains of donors or surrogates (Ramskold and Posner 2013, 398). In-
creased opportunities to profit from women’s reproductive labor may encour-
age coercion by relatives or trafficking (Whittaker 2011) that might not occur
in the absence of a market.
Many of these harms relate to the underlying commodification of wom-
en’s labor and bodies and the impact of this on attitudes toward women in
the marketplace for reproductive labor. Anderson (1993) argues that the
contractual nature of surrogacy—even where it is unpaid—undermines the
bodily autonomy of women and devalues the emotional labor that surrogates
perform:
Treating women’s labor as just another commercial production process vio-
lates the precious emotional ties the mother may rightly and properly estab-
lish with her “product,”the child, and thereby violates her claims to respect
and consideration. (186)
This concern is reflected in findings from the transnational marketplace, which
Whittaker and Speier describe as disaggregating “the work of motherhood”
(2010, 377). The intrusion of market norms into the intimate relational sphere
of reproductive labor makes it difficult to avoid objectification of providers of
reproductive resources, or at least obscuration of their subjectivity.
b. Risks for children and intending parents
Children created in the transnational market may risk separation from in-
tending parents due to legal barriers to citizenship; abandonment; trafficking;
and increased barriers to tracing or identification of genetic parents across inter-
national borders (Trimmings and Beaumont 2011;Mohapatra 2012). Research
suggests that maintenance of social relationships between reproductive resource
providers and recipient families or preserving the possibility for future disclo-
sure of identity or personal information may be valuable to children, gamete
providers, and surrogates (Jadva et al. 2010,2011,2012). It is perhaps too soon
to expect research into the long-term outcomes of children produced through
reproductive travel, in particular with respect to the impact of established or
neglected relationships with resource providers. Nevertheless, potential risks
should be considered when seeking care in the transnational market.
Intending parents who seek reproductive resources abroad may suffer
financial exploitation; intended genetic relationships may not eventuate, with
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third-party gametes or embryos used to create children instead of those of par-
ents; and parents may be unable to obtain custody or return home with their
children (Medew 2013;Trimmings and Beaumont 2011).
In addition to the direct hazards faced by participants, reproductive travel
may impair access to ART or health-care services for citizens of destination
countries, when resources are diverted to the market for foreign consumers (In-
horn 2012;Donchin 2010). Bailey (2011) also points out that the sale of repro-
ductive resources to foreign patients in countries like India occurs against a
background of gross inequities in access to obstetric care, impaired reproduc-
tive rights, and high rates of infertility and maternal mortality. Reproductive
travel may also exacerbate inequities in access to ART and reproductive re-
sources within the countries from which intending parents travel, as only those
sufficiently wealthy are able to circumvent restrictive domestic legislation or
overcome shortages of resources by purchasing care abroad. Finally, reproduc-
tive travel may negatively impact the home country of intending parents, where
costs arising from the creation of children abroad fall upon the domestic
health-care or social welfare systems (McKelvey et al. 2009;Barrington and
Janvier 2013). Where care is provided domestically, easier regulation of policy
and practice may help to minimize health risks to surrogates, gamete providers,
or children created—for example, by reducing financial barriers that may
encourage higher-risk practices, such as multiple embryo transfer (Maheshwari
et al. 2011).
4. Responding to reproductive travel
There is consensus that at least some harmful elements of the global mar-
ket can and should be addressed. Three categories of suggested regulatory or
policy responses to concerns about reproductive travel are commonly de-
scribed: prohibition, harmonization, and harm minimization.
Most authors dismiss the idea of prohibiting reproductive travel as un-
feasible or unfair. Nevertheless, Turkey and some Australian states have
introduced legislation with extraterritorial application such that citizens are
considered liable to prosecution on their return home if they engage in activ-
ities such as obtaining gametes or commissioning a surrogate overseas (Cohen
2012, 1325). A number of factors, including respect for liberty, the right to
travel, and patient autonomy and confidentiality, may preclude effective
enforcement of prohibitions (Van Hoof and Pennings 2011,2012;Culley et al.
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2013). Furthermore, in the absence of efforts to meet needs within the domestic
setting, prohibitions may increase risks to participants as they seek to conceal
illicit travel abroad—for example, through impaired continuity of care for reci-
pients of ART abroad (Mancini et al. 2011).
Harmonization refers to proposals involving the establishment of interna-
tional consensus on at least some elements of ART regulation. Setting aside the
improbability of achieving this, as even within the European Union this has
proven challenging (Van Hoof and Pennings 2012), harmonization risks
imposing the most restrictive or the most liberal of policies on a global scale.
If the policy is broad in scope and unfair or otherwise unethical, the impact
may be extremely harmful. On the other hand, if harmonization targets specific
issues, it may be possible to achieve consensus on less ethically or politically
contentious issues, such as the setting of minimum standards of care for provi-
ders of reproductive resources (Thorn et al. 2012). Partial harmonization is
unlikely, however, to resolve many of the issues of reproductive travel outlined
earlier.
a. Harm minimization
Most commentators, working from the presumption that reproductive
travel is inevitable and not inherently undesirable, focus on harm minimization
strategies. At one extreme, these include efforts to promote and facilitate repro-
ductive travel with minimal restrictions on trade designed to protect vendor
and purchaser rights, to facilitate citizenship acquisition of created children,
and to establish minimum standards of care (e.g., Chung 2006;Crozier and
Martin 2012). Practical strategies to prevent specific harms include legal mea-
sures, such as international treaties governing the rights of children born
through reproductive travel; fair trade agreements to prevent economic exploi-
tation of resource providers; and accreditation schemes that would help trav-
elers to identify clinics that meet standards of care and ethical practice (e.g.,
Humbyrd 2009;Ramskold and Posner 2013).
The harm minimization approach is imperfect. Successful implementa-
tion requires an ad hoc strategic approach to specific issues, with agreement to
be sought on each of these from a culturally, socioeconomically diverse number
of nation-states. The process of negotiating agreements is likely to be lengthy,
and abstentions by some nations with a large market share may undermine the
impact of partial consensus. Most importantly, harm minimization neglects the
problems within domestic systems that drive the transnational market: many
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people may prefer to access reproductive care in their own country. Although
an understandable strategy at the international level, the harm minimization
approach allows individual nations to avoid responsibility for domestic prac-
tices and for the cross-border impact of domestic policy.
b. Regulated national markets
Regulated markets have long been advocated as a remedy for “transplant
tourism”(e.g., Matas et al. 2008), and commentators (e.g., Millibank 2013) have
recently proposed introducing payments for ova providers and surrogates par-
tially to discourage harmful reproductive travel. The rationale for regulated mar-
kets is simple: introduction of payments for reproductive resources is expected
to enhance supplies, thus enabling countries to better meet domestic needs
and minimizing demand for travel. The recent increase in “compensation”
for egg providers in the United Kingdom (Wilkinson 2013) and the introduc-
tion of legislation permitting payment in Israel (Gruenbaum et al. 2011) are
not explicitly designed to discourage reproductive travel, nor are they described
as regulated market systems; however, these changes follow years of national
debate concerning ova shortages and rising numbers of outgoing reproductive
travelers.
There are some intuitively appealing elements of regulated market propo-
sals: in particular, they imply recognition of responsibility for meeting needs
within the domestic setting, and acknowledge the potentially harmful impact of
domestic activities on foreign communities. However, their success depends on
meeting four key requirements. First, market regulation must be sufficient to
prevent at least the major concerns about transnational trade, without being so
restrictive that those with unmet needs will continue to travel abroad in signifi-
cant numbers. Second, countries must be capable of enforcing regulation effec-
tively. Third, the financial incentives offered must sufficiently increase supplies
to meet needs. Fourth, payments must not in themselves be sufficiently harmful
or unethical to warrant market prohibition.
The challenge of defining standards of care for providers and recipients of
reproductive resources is compounded by such issues as provider anonymity
and eligibility criteria for parenthood. However, these regulatory questions
apply to any system offering ART, regardless of whether providers are paid. Of
note, simply regulating provider care in a national market will not resolve exist-
ing inequities in access to resources, unless allocation and access criteria are re-
vised in the process of market regulation. Although market advocates may
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support the introduction of public subsidies for ART (if these are not already in
place), markets are not renowned for promoting equitable participation. Con-
cerns have recently been expressed about the cost of accessing ART in Austra-
lia, where market norms dominate despite public funding programs (Medew
and Baker 2013). Paying for reproductive resources may well encourage the
adoption or further development of commodificatory attitudes toward prac-
tices surrounding infertility treatment. This could lead to greater economic in-
equities in access to ART through reliance on market mechanisms of exchange.
Determining a “fair”price for gametes and surrogacy services that the market
will tolerate may also prove difficult. Should providers of resources be paid
regardless of whether a successful pregnancy results? Will extra incentives be
justifiable for providers possessing desirable or rare attributes, such as a specific
ethnic or religious heritage, proven success as a surrogate, and so on?
With respect to the efficacy of hypothetical market regulations, such as
the enforcement of safety standards, transparency in practice, and fair prices
for reproductive resources, there are good reasons to be skeptical. There is
widespread evidence of poor enforcement of regulations in both the market
and nonmarket settings (e.g., Motluk 2010;Gurmankin 2001;Keehn et al.
2012;Janwalkar 2012;Luk and Petrozza 2008;Watson 2011). A major hurdle
to effective regulation will involve the establishment and maintenance of
data collection systems, such as provider and recipient registries, that monitor
practices and outcomes (e.g., Schneider 2008;Cahn 2009). The failure of
many current markets to establish and transparently audit regulations govern-
ing standards of care and data collection, especially concerning the provision
and use of reproductive resources, suggests that the burden of regulation will
fall heavily upon the state.
Given the evidence from existing markets, it is plausible to assume that
the use of financial incentives may increase supplies of some resources in some
countries, at least temporarily. The efficacy of incentives will depend not only
on the amounts offered but also on the societal extent of economic disadvan-
tage, the availability of alternative employment opportunities for women, and
whether nonfinancial disincentives to provide resources are also addressed.
The cost of implementing regulations will likely contribute to higher costs for
those accessing resources within the domestic market. Poorer individuals and
couples may still be priced out of their local systems and driven to seek cheaper
care in foreign markets, as evidenced by outgoing reproductive travel from the
United States to India, and from India to Dubai (Inhorn 2012).
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The fourth and final claim that advocates must defend is that a regulated
market will eliminate or substantially reduce the ethical concerns raised in
the transnational market setting. Setting aside concerns about physical or psy-
chological harm to vendors of reproductive resources, which regulations gov-
erning standards of care and safety are intended to address, more intangible
but no less significant concerns about vendor autonomy, exploitation, and
inappropriate commodification may persist in the regulated market setting.
Earlier we discussed these concerns briefly, and they have been examined
extensively elsewhere (e.g., Bailey 2011;White 2006;Steinbock 2004;Hol-
land 2001;Tieu 2009). We touch here only on some concerns specificto
autonomy.
Although careful regulation may help to promote vendor autonomy by
ensuring procedures for obtaining informed consent are followed, the existence
of financial incentives may increase the risk of women being coerced, not by
the incentive offer itself but by others in a position of power over them, where
legal markets provide additional opportunities for profit. Greater transparency
in a regulated market may help to avoid the perils of human trafficking for
reproductive resources; however, expanding the range of earning options avail-
able to the poor is not always desirable, even where such extremes of harm are
preventable (see Rippon 2014). Regulated markets may expose the poor to
additional legal or social pressures to sell reproductive resources, as some ob-
servers have already noted (Palattiyil et al. 2010, 691). At best, regulated
national market proposals offer only limited theoretical advantages in compari-
son to unregulated transnational markets, in the form of more effective harm
minimization.
Donchin argues that commonly proposed solutions to the problem of
reproductive travel are flawed due to their shared “presumption that injustices
tied to prevailing open market arrangements apply only to individual parties
and do not extend to social institutions”(2010, 331). She advocates a “social
connection model”of transnational responsibility that would foster a coordi-
nated approach to addressing the issues and would also target the socioeco-
nomic situation of women who have no choice but to sell their reproductive
resources in the transnational market (332). In the next section, we outline the
National Self-Sufficiency Model, which more explicitly locates responsibility
within societies, and promotes a holistic response to the multifactorial chal-
lenge of meeting needs for reproductive resources.
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5. National self-sufficiency in reproductive resources
The self-sufficiency model aims to establish (usually national) governance
of efforts to meet needs for particular human biological materials or medical
products of human origin, and is motivated by practical and ethical concerns.
First and foremost, it situates the challenge of meeting needs within the scope
of societal responsibility, and in the global context. The goal of meeting needs
for resources domestically is framed in contrast, if not in opposition, to the al-
ternatives of outsourcing donations or creating national markets. Given genu-
ine commitment to this goal, efforts will be made to meet needs, and to prevent
them where possible, not merely to discourage or prevent outgoing travel or
cross-border trade in human biological materials.
a. The ethical framework of the self-sufficiency model
Although policies governing the procurement, use, and distribution of
human biological materials in various countries are often supported by ethical
declarations or guidelines, these are rarely tied explicitly to the goal of self-
sufficiency. The role that ethical principles may play in informing strategic
efforts is neglected: ethics seemingly constrains, through prohibitions and
warnings, rather than facilitates progress toward self-sufficiency. Unsurpris-
ingly, practical strategies to increase supplies of resources may be detached
from the moorings of morality, with developed policies checked against ethical
frameworks to ensure compliance, rather than being inspired by and intimately
connected with them. To pursue self-sufficiency successfully, this approach to
policy making must be inverted. As the Aristotelian roots of the term would
suggest,
8
self-sufficiency must begin with a community of individuals uniting
in pursuit of a common goal, recognizing that its achievement depends on
shared commitment to securing the requirements for human flourishing.
b. Social solidarity as an ethical foundation for self-sufficiency
The concept of self-sufficiency is reflected in contemporary accounts of
solidarity, referred to as “shared practices reflecting a collective commitment to
carry ‘costs’(financial, social, emotional, or otherwise) to assist others”(Prainsack
and Buyx 2012, 346; emphasis in the original). The value of framing blood and
organ donation as societal concerns requiring collective efforts is increasingly
recognized (e.g., Martin 2013, 52). Gestational surrogacy and gamete provision
are practices that may involve a variety of complex, novel, and peculiarly
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intimate relationships, all of which engage with a fundamental social bond of
human lives: that of parent and child. Yet these practices are customarily treated
as private, individual concerns, in which observation or intervention by society
or the state is often considered inappropriate. Resituating infertility, and the use
of reproductive resources, within a framework of community and solidarity will
require a significant paradigm shift. However, such a move will enable policy
makers to better address not only the social and ethical concerns we emphasize
in this paper, but also the more practical concerns that clearly fall within the
scope of public governance, such as issues of public funding for ART, vigilance
and surveillance of safety and quality of reproductive resources, and legislation
governing parental and child rights in the context of gestational surrogacy and
third-party gamete conception.
The exclusion of society from reproductive concerns may be motivated
by the desire to protect reproductive privacy, but the transnational marketplace
appears to facilitate disconnection rather than fostering intimacy in reproduc-
tive relationships. The relationships formed between intending parents and the
gamete providers or surrogates who enable the creation of their children are
often tenuous or contested (e.g., Vora 2009, 270–72; Pande 2011). Indeed,
such are the anxieties surrounding parental rights and the risk that donors or
surrogates may undermine those of intending parents that payment for surro-
gates is even advocated on the grounds it will help to disrupt any maternal
feelings on the part of the surrogate (Ramskold and Posner 2013, 399).
The transnational care setting is especially conducive to relationship disrup-
tion, with language and cultural barriers, geographical distance, and, often,
donor anonymity combining—or conspiring—to prevent, weaken, and eventu-
ally disrupt any connections between participants (Vora 2013, S102; Saravanan
2013).
Negotiating the challenges of parental, genetic, and gestational relation-
ships in ART is necessary if societies are to progress toward self-sufficiency.
Establishing relationships in the immediate term and facilitating future relation-
ships if and when they become desirable or necessary is likely to be beneficial for
all participants, if these relationships are formed within the context of a legal,
medical, and social system that provides appropriate psychosocial support and
clarity on legal obligations and rights, which help to foster trust (e.g., Golombok
et al. 2013). The promotion of solidarity, at both the personal and societal levels,
will encourage recognition of the vulnerability of all participants in ART
through enhanced understanding of their varied experiences, facilitating the
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adoption of protective measures. Promoting solidarity will also help to encour-
age participation in opportunities to help meet needs—for example, through
donation of resources.
The self-sufficiency model resituates reproductive resources in a frame-
work of mutual care and relatedness consistent with feminist bioethics. In
transnational reproductive travel, efforts to establish or sustain a relational
account of surrogacy, for example, struggle to compete with neoliberal dis-
course (e.g., Kroløkke and Pant 2012). Within the self-sufficiency model, the
social context of procurement and use of reproductive resources is recognized,
and relationships in the personal and public spheres are nurtured, consistent
with an ethics of care (e.g., Parks 2010) and a relational understanding of
bioethics. Baylis et al. (2008, 205), for example, argue that
[the] pursuit of public goods for health, for the benefit of us all requires
trust, collective responsibility and accountability. As such, concrete expres-
sions of relational solidarity in the context of public health ethics are to be
found in our accepting of responsibility for ourselves and our actions, in
our willingness to be held accountable for others (especially the weakest and
most disadvantaged in society), and in our awareness of mutual vulnerabil-
ity and interdependence.
c. Justice, reciprocity, and efforts to meet needs
A society that adopts the goal of self-sufficiency must begin by acknowl-
edging the extent and diversity of needs for reproductive resources. Infertility is
rarely spoken of as a public health issue, despite the fact it affects roughly 9 per-
cent of heterosexual couples of procreative age seeking to create children (Boi-
vin et al. 2007, 1506), and an untold number of singles and LGBTQ couples for
whom “structural”infertility (Daar 2008, 24) impedes the achievement of pro-
creative goals. The extent of needs for reproductive resources in any country,
represented by individuals or couples for whom the timely receipt of donor
gamete(s) and/or gestational surrogacy services represents the best method of
creating a child, is unknown.
This definition of needs is arguably problematic, in that its scope is
extremely broad, and it allows for a subjective interpretation of the optimal
method for achieving one’s procreative desires. In contrast, although rationing
considerations continue to influence the definition of needs for organ trans-
plantation, quantification of true needs for organs is estimable through
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epidemiological assessments of end-stage organ failure within populations
(e.g., Gilbertson et al. 2005). We believe a broad definition of needs for repro-
ductive resources is necessary to allow all members of society to engage in
meaningful dialogue regarding procreative goals, and strategies that will help to
achieve them. Such a definition respects the fulfillment of procreative or par-
enting goals as a fundamental capability of human lives, and enables a more
transparent examination of resource allocation practices and policies and ef-
forts to prioritize or discriminate between needs more equitably.
Recognition of needs is not synonymous with recognition of procreative
rights. The implications of a hypothetical procreative right have been debated
elsewhere (e.g., Dillard 2007); suffice to say that few societies are likely to
endorse an unlimited claim upon the resources that may be required to secure
a child for all those with infertility—even in cases of “medical”infertility. As
noted earlier, there is considerable work to be done on the issue of just alloca-
tion of reproductive resources, and allocation criteria may vary among commu-
nities. The unique burdens and benefits that may arise from creation of kinship
bonds through provision of gametes or surrogacy services may justify greater
partiality in allocation criteria in some societies than would be considered
acceptable in allocation of other biological materials—for example, through di-
rected donations aiming to support the maintenance of relationships between
donors and recipient families.
Efforts to meet needs for reproductive resources equitably should be mir-
rored by efforts to achieve equity in donation of resources within society.
Equity in the distribution of donations is sometimes implicit in documents
contrasting self-sufficiency in biological materials with cross-border trade. If
the burdens of donation are to fall within the responsibility of a community, in
order to avoid the injustice associated with foreign outsourcing, surely that
community must seek to share the burdens fairly among its members. The
removal of barriers to donation within the community assists in promoting
equity and may also enhance access to scarce resources for particular groups
within society who might otherwise be disadvantaged through lower represen-
tation among the donor population. This is particularly relevant if directed
donation of reproductive resources is heavily influenced by sociocultural or
ethnic factors, as evidence from the marketplace suggests (e.g., Almeling 2007).
Preserving the prohibition of payment for provision of biological materi-
als, which has historically been tied to the pursuit of self-sufficiency (Keown
1997), is also necessary if equity in donation is to be achieved. Although the
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requirement for voluntary, nonremunerated donation of blood or organs
is usually linked to concerns about recipient safety and exploitation of donors,
or the concerns of commodification discussed earlier, the Council of Europe
(1990) explicitly tied the prohibition to concerns about equity in its early advo-
cacy of self-sufficiency in plasma. The Council cited as one reason for the pro-
hibition “social justice reasons, in order to ensure participation in donation by
all social strata of the population, irrespective of economic status”(2).
The removal of disincentives, including financial barriers, regarding
donation of reproductive resources will foster social justice and equity in dona-
tion, and, we repeat, should not be confused with financial incentives. Simply
removing disincentives may increase the availability of reproductive resources
in some societies. Motivation of donation is nevertheless an important concern
for communities pursuing self-sufficiency. If meeting needs is a shared goal
and responsibility, to what extent should community members be expected to
contribute the resources required to achieve this?
d. Donation expectations
Obligations to donate reproductive resources are likely to be more limited
than those arguably associated with donation of blood or organs (e.g., Snelling
2012;Hester 2006). The latter needs are more prevalent than those for reproduc-
tive resources, with the possible exception of specific social communities suffer-
ing high rates of infertility. The statistic promoted by the Australian Red Cross
Blood Service (2012), for example, which notes that one in three Australians will
have need of a therapeutic blood product yet only one in thirty donates blood, is
less readily translatable to donation and use of reproductive resources.
Appeals to reciprocity may be more easily made within some social com-
munities. For example, individuals and couples suffering structural infertility
may engage in a mutual exchange of resources, so that structural barriers to
procreation—for example, the absence of a sexual partner of the opposite sex—
may be overcome. Pennings’s (2007) proposed gamete mirror exchange, in
which partners or even relatives of individuals in need of gametes could donate
their own gametes in exchange for a third party’s gametes, may replicate the
success of domino chains and paired exchanges used to facilitate donation and
transplantation of kidneys.
However, the additional burdens of female reproductive labor mean that
such reciprocal exchanges may involve inevitable inequalities in the distribution
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of burdens, if not benefits of donation. The nature of female reproductive labor
and the incalculable potential costs of genetic or gestational parenthood (Crozier
and Martin 2012, 49) suggest that donation of reproductive resources will
remain an exceptional act, rather than a societal expectation. Rather than limit-
ing the relevance of the self-sufficiency concept, with its solidaristic foundations,
we believe this makes it all the more necessary for use in policy making in the
reproductive field.
e. Meeting needs for reproductive resources
Just as persons with organ failure or anemia might have their therapeutic
needs met using alternatives to transplants or transfusions, intending parents
may achieve their goals of parenting without using reproductive resources:
with options including adoption, fostering, and other informal opportunities
for parenting. Alternatives to creating children through ART may be limited
due to financial and regulatory barriers (e.g., Kamarck et al. 2012) and lack of
children available for adoption (e.g., Cuthbert et al. 2010). Furthermore, foster-
ing or adoption may not fulfill parenting goals for couples or individuals who
wish to create a child using their own genetic material(s), or who wish to carry
a child using provided gametes.
Unfortunately, socially dominant conceptions of traditional families or
parenting may exclude some individuals or couples from accessing these op-
tions, reinforcing the barriers to parenthood associated with “structural”infer-
tility. Such exclusions should be addressed within the self-sufficiency
framework as equity in the allocation of reproductive resources and in access to
ART is pursued. Needs for reproductive resources may also be reduced through
strategies to prevent infertility. Strategies may include: public health interven-
tions (Macaluso et al. 2010); improved access to fertility preservation treat-
ments for young people undergoing oncology treatment (Levine et al. 2010), or
women who anticipate delayed reproduction (van Loendersloot et al. 2011);
and social policy interventions to facilitate earlier reproduction and to engage
with socioculturally constructed procreative goals. Education campaigns to
raise awareness of infertility and its varied etiology, and of opportunities for
prevention, will play an important role in minimizing needs (see Hammarberg
et al. 2013;Wyndham et al. 2012;Lemoine and Ravitsky 2013, 6–7). Recogni-
tion and engagement with social and cultural norms that may play a role
in shaping expectations and desires for children are also critical (Greil et al.
2011).
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6. Achieving self-sufficiency—a call for innovation
Progress toward self-sufficiency will depend on innovation and a coordi-
nated, multifaceted approach to the complex issue of meeting needs for repro-
ductive resources. The practical elements recognized as essential for progress in
meeting needs for blood or organs are equally relevant to reproductive re-
sources. These may be summarized as the POLIS model: public health, for the
prevention and treatment of needs; organization, with a national authority tak-
ing responsibility for oversight and coordination of various strategic elements
and infrastructure; legislation, to protect the interests of intending parents,
donors, and children; information, through the systematic and transparent col-
lection of data to inform policy and practice through quality and safety evalua-
tion; and societal engagement, through debate and education, to encourage
solidarity and enfranchise all members of the community in opportunities to
donate or receive resources when needed.
A paradigm shift is required, which must relocate infertility in the public,
relational sphere, and reconsider the widespread commodification of ART and
reproductive resources. Advocates of regulated markets will likely be skeptical
of our proposal’s feasibility, yet, despite the obvious influence of financial in-
centives on supplies of gametes and surrogacy services, it would be unwise to
conclude that such incentives are necessary, let alone sufficient, to meet societal
needs for these resources. Studies of actual providers and surrogates—both
paid and unpaid—cite various motivating factors, including a strong emphasis
on altruistic or solidaristic motivations (Purewal and van den Akker 2009c;
van den Akker 2003). There have been few studies of general public attitudes
toward donation and surrogacy (e.g., Purewal and van den Akker 2009a,
2009b;Poote and van den Akker 2009), which, compounded by a lack of public
awareness of the extent of infertility and needs for reproductive resources, pre-
sumably contributes to the current poor rates of unpaid provision through lack
of promotional and educational campaigns informed by knowledge of these at-
titudes. Novel strategies to promote donation might include, for example, the
creation of new opportunities to share resources, such as donating “surplus”
embryos or gametes that have been procured for personal use and would other-
wise be discarded (e.g., Nachtigall et al. 2009;Mertes et al. 2012).
Successfully implementing the self-sufficiency framework with respect to
reproductive resources in any society will require a complete overhaul of poli-
cies and practices concerning procurement, use, and distribution of gametes
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and surrogacy services. The process must begin with public debate about issues
surrounding infertility, ART, and the procurement of resources, as well as
transnational reproductive travel. Change, innovation, and successful efforts to
meet needs effectively and ethically within the domestic setting will take con-
siderable time and public investment. Different societies may choose to priori-
tize particular strategies and adopt unique pathways to self-sufficiency, taking
into consideration their own resource constraints, current practices, and socio-
cultural values. Regardless of the anticipated diversity in such approaches, the
self-sufficiency framework and its central ethos will lay the foundations for a
more responsible, socially integrated approach to the hazards of transnational
trade and the problem of unmet needs for reproductive resources. It represents
a novel approach to issues that have traditionally been fragmented and rele-
gated to the private market sphere, one that offers rich opportunities for explo-
ration—for example, through the lens of feminist bioethics or Aristotelian
ethics—and one that may finally lay the foundations for a united, collaborative
approach to the global and local challenges of meeting needs for all human bio-
logical materials.
Notes
1. We agree with Downie and Baylis (2013, 225) that the term donor is often
misleading—for example, where providers of gametes or surrogacy services receive
remuneration exceeding the costs they may incur, as such payment (commonly
described as compensation) represents a financial incentive and commodifies the repro-
ductive labor and/or resources in question. Thus, we use the term “provider”to refer
to men or women from whom gametes are obtained for use by another individual or
couple, regardless of whether they are genuine donors or vendors.
2. For simplicity, we use the term “surrogate”or “surrogacy”to refer to both
“gestational”and “traditional”surrogacy, and do not engage with issues that may be
specific to traditional or “genetic and gestational”surrogacy.
3. We use the term “intending parent(s)”to refer to individuals or couples who
plan to create a child using ART and provided oocytes, sperm, and/or surrogacy ser-
vices.
4. We focus primarily on the use of ova and surrogacy services: first, because the
ease of transferring sperm internationally makes it easier for individuals in some coun-
tries simply to import sperm rather than traveling abroad to obtain it, although donor
sperm are still frequently used by those traveling abroad to access reproductive services
(Pennings 2010;Shenfield et al. 2010); second, because the nature of female reproductive
labor involved in provision of ova or surrogacy services creates additional burdens for
providers, such as increased risks to health.
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5. One exception is France, where national monitoring of ART enables collation
of data. In 2009, the Agence de la Biomédicine reported 1,673 couples were wait-listed at
French clinics for donor eggs, with 328 women undergoing pick-up for egg donation—
enabling 641 IVF attempts (Agence de la Biomédicine 2012a, 2).
6. New Zealand is a notable exception (Gillett et al. 2012).
7. In countries such as the United Kingdom, patients may subsidize the costs of ac-
cessing ART by “sharing”some of the ova procured during their own treatment with
other patients, in return for discounted treatment fees (Blyth and Golding 2008). Some
gametes may of course be shared without such financial incentives.
8. Aristotle discusses autarkeia (self-sufficiency) in the context of the polis
(city state) at length in The Politics (1996). He describes states as heterogenous commu-
nities in which individuals come together in pursuit of common needs and shared goals:
“not a mere aggregate of persons, but, as we say, a union of them sufficing for the pur-
poses of life”(177; 1328b).
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