Reproductive (Medical) Tourism
HSS 2121 April 1, 2009
Raywat Deonandan, PhD
ray@deonandan.com
Assistant Professor, Health Sciences, University of Ottawa
Former Chief Scientific Advisor, Assisted Human Reproduction Canada
You can download this presentation at:
classes.deonandan.com
We are going to talk about:
-Medical tourism (what is it?)
-Reproductive tourism (what is it?)
-The ethics of the above (what is ethics?)
• The words, expletives, guttural moans and
occasional odours coming out of my mouth do
not necessarily reflect the opinion of Assisted
Human Reproduction Canada
In General….
• What is “medical tourism”?
1. The act of (typically Western) medical professionals doing
abroad to do “good work”, but in reality functioning as gawking
tourists
2. The act of (typically Westerners) going abroad (to typically
developing countries) to seek medical care.
The First Type
• The act of (typically Western) medical professionals doing
abroad to do “good work”, but in reality functioning as
gawking tourists
–
–
–
–
The danger of every international health project
Whom does it really benefit?
“cowboy” global medicine
Sustainable?
The Second Type
• The act of (typically Westerners) going abroad (to typically
developing countries) to seek medical care.
– Growing in popularity
– Often tied to other tourist activities
– Negative downstream consequences may not be immediately obvious
EXAMPLE: Reproductive medical tourism
Summary of the Ethical Issues
Summary of the Ethical Issues
•
•
•
•
•
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Misdirection of financial resources – those who seek services abroad deny their resources
(i.e., outgoing funds) to their home community
Misdirection of medical resources – those who provide services to “tourists” are denying
their services to their home community
Implications of insufficiency – the act of seeking services abroad implies that services are
insufficient, in quantity, type, timing or affordability, in the home community
Criminality – if service seeking abroad is done to avoid laws at home, should the international
community consider this criminal behavior? Is the provision of services therefore the
abetting of such criminal behavior?
Quality control – if the health and welfare of “tourists” is a concern, how do we control for
the quality and validity of medical services provided outside of one’s administrative
jurisdiction?
Robustness of informed consent – are “tourists” provided with adequate and accurate
representation of actual risks and probable success rates? Brokers may misrepresent facts.
The above may apply to all types of medical tourism
We will revisit those
ethical issues when we
discuss the specific
case of Reproductive
Tourism
In 4…3….2…1….
Terminology
• Infertility:
– One year of unprotected sex without conceiving a
child
– Includes both “sterile” and “subfertile” people
– Sterile:
• Will never conceive without medical assistance
– Subfertile:
• May still conceive without medical assistance
Infertility
– About 15% of couples will be defined as “infertile”
– But this only accounts for those who actually seek
services; likely an underestimate
-1990 estimate: >1 billion women worldwide are
affected by “infertility”
-only covers those of reproductive age who have
been “diagnoses”
**On the increase in Western nations**
Why Is Infertility On The Rise?
• People waiting till later in life to have kids
• Obesity and diabetes are on the rise
• Environmental contaminants may be affecting hormone levels
The Available Infertility Services
•
•
•
•
•
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Fertility drugs
IUI
IVF
ICSI
Gamete donation
Surrogacy
Fertility Drugs
IUI
• Intra-uterine insemination
• Artificial presentation of sperm into the
vaginal canal
– “turkey baster method”
IVF
• In Vitro Fertilization
• Creation of embryo in a dish, and returning it
to the womb
• “test tube babies”
• Considered the vanguard ART technology
Louise Brown,
Born July 25, 1978
The OctoMom!
My Hallowe’en
costume next year
Denny’s Octomom special:
14 eggs, no sausage, and
the guy at the next table
pays for it.
ICSI
•
•
•
•
Intra cytoplasmic sperm injection
Done in conjunction with IVF
Grab a sperm and force it into an egg
Used when sperm just can’t get the job
done by themselves
Sperm Donation
– Relatively simple
– Donors are usually friends or family
– Anonymous donors are rare and in demand
Egg donation
– Very invasive
– Expensive procedure
– Hard to find donors
Surrogacy
• A surrogate mother is a woman who agrees to
gestate and give birth to a baby for someone
else
• Scenarios:
– Surrogate receives sperm via IUI and uses her own
egg
– Surrogate donates egg, embryo created via IVF
(with or without ICSI)
– Another egg is used, embryo created via IVF (with
or without ICSI)
Other Technologies
• PGD – pre-implantation genetic diagnosis
• IVM – in vitro maturation
• “flash freezing” of eggs
• Hybrids and cybrids
Statistics
• Canada:
– about 6500 IVF embryo transfers per year
• USA:
– About 120,000 IVF procedures per year
• UK:
– About 35,000 IVF procedures per year
• Europe:
– About 300,000 IVF procedures per year
Costs
• One attempt at IVF costs $8000-$16000
• ICSI costs extra
• Donated sperm costs $200-$600 (from US centre)
• Donated egg costs $500-$20000 (from US source)
• Surrogate services cost ~$50,000 or more
Canada’s Assisted Human
Reproduction Act (2004)
•
•
•
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Human cloning prohibited
Sex selection prohibited
In vitro gene alteration prohibited
Transplanting non-human gametes or
embryos into a human is prohibited
• Transplanting human gametes/embryos into a
non-human for the purposes of creating a
human
• Create chimeras/hybrids
Canada’s Act
•
•
•
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No payment for surrogacy
No paid brokerage for surrogacy
No payment for gametes
No paid brokerage for gametes
• etc
The Law
• Laws in different countries vary dramatically
• In the US, it varies from state to state
• In Australia, only one state has clear
regulations
• In UK, rules are well defined and monitored
• In Israel, it’s the wild wild west
• Etc.
So….
• Let’s say you’re an infertile couple in Canada
who wish to:
– Select sex of your baby
– Pay for a surrogate mother
– Pay for a sperm or egg donor
– Pay less for a baby
What do you do?
You Go Abroad
• Example
– In Virginia Mason medical centre in Seattle, 33%
of patients are Canadian, most seeking to buy
donor eggs
– In India, “reproductive tourism” is a $450 million
industry
Reproductive Tourism
• The phenomenon of going abroad to seek
reproductive technologies
• Might be considered a form of Medical
Tourism
South Asia
• Currently, parts of the USA are the most
popular destinations for “reproductive
tourists”
• But India is fast becoming an important
destination
India
• Surrogate mother in India costs <$5000
• Plethora of doctors, all English-speaking
• Case study:
– A British couple in 2006 spent 60,000 pounds on
IVF in the UK without success, so they went to
India and paid $3,300 for a surrogate mother
Why India?
• Cost of IVF is 1/50th compared to USA
• Generally believed that Indian women smoke
and drink less (foetal health)
• Enormous NRI community, who are now
wealthy and infertile
• Very few (in any) laws
• Open acceptance of sex selection techniques
Why India?
• In India, infertility is seen as a curse, so many
surrogates report that they are doing
charitable work by providing a child for an
infertile couple
Nine of the 45 surrogates available at the Akanksha clinic in Anand, India,
where at least one Western woman visits every day seeking a surrogate.
• Akanksha clinic
– Among the most famous in the industry
– Surrogates are cloistered in secret locations
• Clearly, there is some civil discontent
– Surrogates rent their wombs for food, healthcare
and cash amounting to about $6000
• A fortune for many of them; quite affordable for us
So, What’s The Problem?
• From an international health/development
point of view, what are the issues?
The Issues
1. Protection for couples travelling abroad
2. Protection for women selling services in poor
countries
The Issues
• Couples are bypassing the laws of their own
countries; should they be prosecuted?
• Informed consent… how informed are these
women?
• Choice…. In many places, how can we
guarantee that women are not being forced to
participate?
More Issues
• India is popular also because of its familial
laws:
– In UK, a surrogate mother can change her mind
and claim the baby as her own any time within the
first 2 years of life
– In India, the surrogate loses all rights to the baby
at the point of delivery
More Issues
• Is remuneration fair? Should surrogates be
paid global market rates?
• Social stigma of carrying the child of a man
who is not your husband
• Loss of control of one’s body, as “client” and
doctor have a vested interest in the
surrogate’s nutrition and activities
Even More Issues
• Must protect vulnerable infertile Westerners
from being fleeced by dishonest doctors and
surrogates
• In instances of extreme poverty, is there really
such a thing as choice for a surrogate?
– Compare to instances of “choice” for an
impoverished woman who “chooses” prostitution
Even More Issues!
• What kind of health follow-up are surrogates
given?
– Are they given post natal care, especially after the
baby has been given up?
• What reproductive effects do surrogates suffer
from?
– Giving birth is dangerous
– Potential for surrogate to become infertile
Disease Issues
• Reproduction is a vector
• Fluid associated with donated eggs and sperm may
be infected with HIV, Hep C, etc... Maybe even Mad
Cow Disease (unlikely)
Cases
• Despite dramatic shortages of “altruistically
donated” sperm in the Western world, a gay
man in New Zealand was not permitted to
donate because he was from a high risk group
for HIV
• Currently a case in the USA of an egg donor
with Tay-Sachs disease; she has already
produced 3 children
Legal Issues
• A child born to a surrogate mother in India…
what are the legal steps to get it into the
country of the “client”?
– Formal adoption procedures?
• Can a surrogate mother in India benefit from
parental laws of the client’s country?
– Does she have the 2 year leeway in the UK?
“Cross Border Reproductive Care”
• Why is this the preferred terminology?
Reminder of Ethical Issues
• Misdirection of financial resources – those who seek services abroad deny
their resources (i.e., outgoing funds) to their home community
• Misdirection of medical resources – those who provide services to
“tourists” are denying their services to their home community
• Implications of insufficiency – the act of seeking services abroad implies
that services are insufficient, in quantity, type, timing or affordability, in
the home community
• Criminality – if service seeking abroad is done to avoid laws at home,
should the international community consider this criminal behavior? Is the
provision of services therefore the abetting of such criminal behavior?
• Quality control – if the health and welfare of “tourists” is a concern, how
do we control for the quality and validity of medical services provided
outside of one’s administrative jurisdiction?
• Robustness of informed consent – are “tourists” provided with adequate
and accurate representation of actual risks and probable success rates?
Brokers may misrepresent facts.
Are there additional ethical issues that apply
specifically to reproductive tourism?
– Robustness of informed consent – this issue, as it pertains to the
surrogate, is quite separate from that pertaining to the tourist. Social
downstream impacts must also be communicated (eg, is a
conservative society ready for a woman to carry baby for two gay men;
will husband respond well to wife carrying the baby of another man;
specific religions –eg, Muslim- concerns)
– Custody rights – rights vary from country to country. To what extent is
the industry affecting the drafting of custody rights legislation?
– Cultural appropriateness – see (a): economic attraction of the industry
may bring it to societies presently unprepared for some of the
implications, eg gay parents, single mothers, carrying a child that is not
your husband’s
– Quality of care – surrogate’s physical health is maintained, but only to
the extent that it benefits her pregnancy. What of social and mental
health? What of her removal from care-giving milieu of her own
community? If clinic provides her diet, does she still cook for her
family?
– Limits of care – While the surrogate’s medical health is of prime
importance during pregnancy, does this care end upon birth of the
child? Is there an investment in post-partum care? To what extent
does economics affect this trend? (Eg, a regular surrogate should be
maintained in good health due to her ability to perform again.)
– Remuneration – one reason tourists seek service is reduced cost
abroad. But while remuneration for the surrogate is likely above what
she would otherwise earn, it is likely below global market rates.
– Abortion – selective reduction is a common occurrence in ART. Is
surrogate aware and culturally responsive to this likelihood?
– Medical advocacy – clinician responds to needs of the tourist. Is it a
conflict of interest to also be care-giver to the surrogate?
What We Are Doing
• Step 1 – bring together ART regulatory bodies
from key nations
• Step 2 – agree that these are issues worth
considering
• Step 3 – Collect data!
• Step 4 – to be determined
Achievable Goal
• Establishment of international body to:
– Monitor extent of reproductive tourism
– Set forth international guidelines for appropriate
ART/AHR care
– Monitor quality control for doctors offering
services to international clients
– Monitor rights abuses of local women offering
their reproductive tissue and services
Conclusions
• Reproductive freedom is a complex concept
– Is reproductive tourism a win-win scenario,
wherein the provider of a biological function is
amply rewarded for sharing her gifts with the
inferitle?
– Is reproductive tourism exploitative, wherein the
bodies of poor women are commodified for use
by rich Westerners?
– The best we can hope for right now is to maximize
informed consent and empowerment of choice
Quotes