Surrogacy: When Is It Ethical and Who Can Count on It.

According to Vox: Your Mileage May Vary is a column of advice that provides a unique platform for contemplating moral dilemmas. It is based on the concept of value pluralism, which asserts that each of us has several values that are equally important, but often contradict each other.

Reader Situation

I am a thirty-year-old woman who wants to have a child, but I have a condition that complicates (but does not make impossible) pregnancy. This will make pregnancy more uncomfortable and physically devastating than for many other women. Although it won't result in permanent disability, the consequences will be sufficient that I would strongly prefer not to be pregnant.

I can afford a surrogate through a reputable agency. But surrogacy is considered ambiguous and often ethically questionable. Long ago, I knew someone who said she enjoyed being pregnant and helping others through the process, so perhaps theoretically someone might consciously choose to be a surrogate without financial coercion? But even if that were ethical, I’m afraid my friends and family would judge me. There is a belief that there is something wrong, unnatural, or selfish about wanting to have a biological child but not wanting my body to become a vessel for it.

Furthermore, I’m not alone in finding pregnancy difficult. My situation may be worse than average, but overall pregnancy is an unpleasant process, so I can’t claim it is exclusively bad for me to justify the desire to pay for the use of another woman’s body. I would like your help with this issue.

Your Response

Dear whom it may concern, There are indeed several ethical questions regarding surrogacy worth considering, and some of them, in my opinion, you should not ponder further—let's start with the latter.

You already noted that there is a cultural stigma attached to refusing to make your body a vessel for carrying a child—it is considered 'wrong' or 'unnatural for women.' But this idea is absolutely absurd. The notion of a 'proper' way to be a woman is a patriarchal construct; anyone who tells you that you are 'abnormal' for hating pregnancy reflects sexist expectations that women’s bodies should be available for reproductive labor.

So if your anxiety about condemnation from others relates to this, please don’t dwell on it any longer. But of course, there are real moral issues that surrogacy raises.

I believe that surrogacy can be ethically justified in certain situations. First of all, surrogacy is not a one-dimensional phenomenon. Commercial surrogacy (when you pay someone to carry a child) is significantly different from altruistic surrogacy (the free version where a surrogate carries a child out of love). Finding an altruistic surrogate is not easy—after all, pregnancy is a dangerous business—but I agree with your intuitive sense that if you are able to find someone who voluntarily agrees to do it, then choosing that option will help avoid many problems of commercialization or exploitation.

Key Takeaways

• Unethical areas of surrogacy thrive in countries like Georgia, Ukraine, and Cyprus. However, there is a moral difference between hiring a surrogate in these countries and in the USA.
• When someone can become pregnant but does not want to for psychological reasons, their case is often deemed 'elective.' However, mental health needs can also be a legitimate medical need.
• 'Epistemic injustice' refers to the wrongful treatment of someone as a knower. People who claim to understand their mental health needs, which make pregnancy risky, are often not taken seriously, but the situation is beginning to change.

However, within commercial surrogacy, there is another distinction—where the surrogate lives. There is a moral difference between hiring a surrogate in developed countries and hiring in countries like the USA. For instance, in Georgia, it is known that surrogacy agencies recruit women from shelters for victims of domestic violence—some see surrogacy as their only way to achieve financial freedom. Ukraine, Cyprus, and several other countries are also known for their ethical issues surrounding the surrogacy industry.

Yet American surrogates are usually not impoverished; they are typically middle-class women with husbands and children who have other economic opportunities. The best surrogacy agencies monitor poor women at risk of exploitation. This empirical context means that the likelihood of exploitation in the USA is lower (though not zero) compared to international surrogacy.

Another reason I believe surrogacy is ethically justified is that for many people, the desire to have children, including those who wish to be biologically related to them, is a need rather than simply a want.

Many opponents of surrogacy argue that no one has a 'right' to a biological child, so if you cannot or do not want to be pregnant—that is your problem. These opponents are correct in asserting that no one has an absolute right to give birth to a child—otherwise the state would be obligated to provide surrogates, egg, and sperm donors, regardless of their willingness to participate! But people can still have a qualified right—that is one we generally recognize but which may be restricted to protect the interests of others.

As for those who physically cannot create a biological child—when they have a medical justification, I believe that the qualified right to a child means that surrogacy can be ethical, provided certain criteria are met, such as informed consent.

Your situation is more complex, as you do not have an impossibility to get pregnant—the reason is that for certain reasons, you do not want to. Typically, your case is referred to as 'elective surrogacy.' Some professionals refuse to arrange surrogacy if they consider it elective rather than medically justified.

But doctors increasingly recognize that the line between 'medically justified' and 'elective' is not so clear. While elective surrogacy is often associated with vanity—bringing to mind a celebrity who does not want to be pregnant out of fear of ruining their figure—not everyone who turns to elective surrogacy does so for cosmetic reasons.

What if someone could become pregnant but the fear of childbirth is so great due to a traumatic experience—say, the death of a close friend during childbirth? And what about those who are transgender and physically can carry a pregnancy but know it would trigger such gender dysphoria that it could cause serious psychological harm? Shouldn't the need for mental health be considered a medical necessity?

These ideas are not hypothetical—real people have testified to them—but they are often overlooked as medical needs. I suspect these individuals have experienced what contemporary philosopher Miranda Fricker calls 'epistemic injustice.'

Epistemic injustice refers to the 'wrongful treatment of someone as a knower.' When society denies someone the right to assess their life experience or disdains an important part of that experience due to a lack of our collective interpretive resources, this can be an example of epistemic injustice. I believe those who find themselves in between medical categories often risk receiving such treatment, and I do not wish that to happen to you.

So I want to acknowledge that I do not know what condition you are referring to when you say that you have a condition that 'makes pregnancy more uncomfortable and physically devastating than for many pregnant women.' Since I do not know the details, I would advise you to ask yourself: How much more uncomfortable is it? How much more devastating is it? What consequences of this discomfort or devastation will affect your overall well-being?

Only you can truly attempt to answer the last question, as the same consequences can affect different people in various ways, depending on how well we are prepared financially, socially, psychologically, and even spiritually.

When you think about the risks to your health, try asking yourself: Is that risk for you greater than the risk for an average healthy woman, so that you would feel comfortable shifting the risks of pregnancy and childbirth onto her?

Some may say this question does not matter. They argue that the only thing that matters in this case is autonomy—yours and the potential surrogate's—and if you both agree to a surrogacy agreement and she is not under financial duress, then that is sufficient!

But there may be one more important value that may be at stake: fairness.

As far as I can judge, your case exists in a gray area—surrogacy is not clearly 'medically justified' or 'elective' based on the information you provided. If you ask yourself, 'Is there a significant risk that carrying a child would seriously harm me?' and the answer is 'Yes!'—then some doctors might argue that surrogacy is medically justified. But if your answer is, 'Well... no, not really,' then you might be closer to the 'elective' side of the spectrum. And in that case, it is wise to question whether it is fair to ask another woman to take on significant risks of pregnancy and childbirth.

You wrote about pregnancy: 'I do not think I can claim that it would be so uniquely bad for me that I am justified in wanting to pay for the use of another woman's body.' This suggests that you currently see yourself as closer to the elective camp. I urge you to give yourself the opportunity to really explore this with friendly and honest self-reflection. If honesty indicates that you do not consider it justified to put someone else's body at risk in a situation where she would otherwise not be doing so, perhaps you have your answer.

However, if you are risking psychological harm to yourself as you feel it is not 'considered' a real need, please know that mental health is just as medically legitimate as physical health. If you discuss the option of surrogacy with a medical professional, please consult several to avoid the risk of being categorized in a way that does not reflect you.

Ultimately, perhaps none of us can be the ideal interpreter even for ourselves. But you are the primary interpreter—with all the authority and responsibility that entails.

What I'm Reading

• This disturbing story in the New York Times Magazine about the global fertility industry raises why I consider partnering with a surrogacy agency in countries like Georgia to be unethical. These surrogates do not have the ability to provide informed consent.
• “Does cognitive dissonance really exist?” asked Sheila Law in The New Yorker recently. Now I feel cognitive dissonance about all those times I thought I felt cognitive dissonance!
• Don't miss “I’m Kenyan. I Don’t Write Like ChatGPT. ChatGPT Writes Like Me.” This essay by Marcus Olanga explaining why his writing is often confused with mixed AI text is both wondrous and frustrating. It turns out that trying not to write in an English style shaped by colonial heritage is only possible with great difficulty.