"Despicable," Pope Francis called it recently during his annual address to the world’s ambassadors to the Vatican, urging for a global ban "to prohibit this practice universally." What is this atrocious act, this thing that a year before he'd also called "inhuman and increasingly widespread?" It's surrogacy, or the practice in which someone with a uterus agrees to gestate and deliver a baby on the behalf of other parents.
For those familiar with Catholic dogma, it's not exactly a bombshell that the head of the church should affirm opposition to this particular reproductive advancement. (The Vatican also nixes in vitro fertilization.) But the harsh words, in which the pontiff warned against turning a fetus into "an object of trafficking," struck like a fresh slap.
“There are people all over the world who have lovingly built families through surrogacy," Barbara Collura, president and CEO of RESOLVE: The National Infertility Association, told USA Today in January, "and may feel the pope has discounted their family and the way they’ve chosen to build it."
Once a more shadowy process, surrogacy has gained greater visibility in the past several years, thanks to high profile families who've opted for surrogacy, like Kanye West and Kim Kardashian, Neil Patrick Harris and David Burtka and Chrissy Teigen and John Legend, who in 2020 lost their son Jack in the 20th week of gestation. "Our hearts, and our home, are officially full," Teigen wrote last year after welcoming baby Wren, thanks to their "incredible, loving, compassionate" surrogate.
There are two types of surrogacy — gestational, in which both the egg and sperm come from donors (who may or may not be the intended parents) or traditional, in which the surrogate's eggs are used. The Journal Fertility and Sterility estimates that "Between 1999 and 2013, there were 30,927 surrogate pregnancies in the United States," a number that has risen significantly in the decade since. A surrogate may carry a child altruistically — say, for a family member or other loved one — or may receive compensation. And it's the notion of money changing hands that makes some people uncomfortable.
That unease can be a positive, if it assures appropriate checks and balances so that everyone is protected in a complex dynamic involving payment, bodies and bringing a new human (or more) into the world. Compensated surrogacy is banned in several countries including Canada, Spain, France and Taiwan. In Cambodia in 2020, 32 surrogates were found guilty of human trafficking, a case that drew the ire of human rights advocates. As Al Jazeera reported when they were first arrested in 2018, "Many surrogates come from poor families, where work in the garment and light manufacturing industries brings in a minimum wage of $170 a month."
In the U.S., regulations vary from state to state. New York, for example, passed in 2021 the Child-Parent Security Act to require licensure for surrogacy organizations, protect surrogates and establish legal rights for parents-to-be.
Without appropriate and thoughtful systems in place, things can go wrong in a variety of ways. In a 2022 feature in Fortune, one former surrogate who endured a life-threatening ectopic pregnancy said, "Surrogacy is a for-profit business. No one’s going to tell you that there’s a possibility you could die." In 2023, U.S. News and World Report estimated the total cost of surrogacy as between $100,000 to $225,000, with surrogate base compensation ranging between $30,000 to $70,000.
Writing in Newsday in January, NYU professor of bioethics Arthur Caplan and NYU professor of obstetrics and gynecology Gwendolyn Quinn acknowledged that "Monitoring commercial surrogacy or pregnancy for hire in poor nations needs improvement. Regulations in wealthy nations need to be upgraded as well," but went on to note that "Surrogates are participating in an efficacious, medically safe process, and thus give one of the most priceless gifts one person can give another. This is true whether they are fairly compensated or, as the Pope’s condemnation unfortunately ignores, are doing so altruistically, as sisters, mothers or friends."
And that's what, in his well-meaning but ignorant of both law and biology way, Pope Francis fails to consider — the intention behind any given act of surrogacy, and the competence of its execution. Can surrogacy be exploitive or transactional or at least bureaucratic? Sure, and so can marriage. So can work. So can adoption, which the 87 year-old pontiff, who says that "A child is always a gift and never the basis of a commercial contract," doesn't have any issue with.
What surrogacy (and marriage and work and adoption) have going for them in a great many cases are a sincere, human desire for love and connection. "The thing that we can do that serves surrogate intended parents and the children born through surrogacy the most is by continually centering that this is really a kinship," says Adrienne Black, founder and CEO of Heart to Hands Surrogacy in Eugene, OR, and a retired surrogate herself, "and that this child is here by love and choice. All these people came together to make that happen. Yes, these other pieces are important. Compensation is important. Making sure the intended parents' parenting rights are respected are important. But if we really come back to the place that we are all humans choosing to create this life, with love and intention, those things also tend to fall into play."
For Black, assuring that outcome means a thorough vetting on all sides, including reviewing medical records and conducting interviews, as well as making sure the surrogate "has access to the resources so that she can become informed about decision making on medical care, and the social impact and her own ethics and morals. We have to make sure that she's very well prepared," she says, "with a full understanding before she commits to any of this process."
Intended parents are similarly screened to assess whether they are "prepared to bring this child into their life through surrogacy." Black says, "We do really have to look at how have we created that foundation of safety in each party before we even look at introducing them and talking about legal contracts between them. It starts with a foundation of stability."
Amira Hasenbush, a surrogacy lawyer in Los Angeles and the chair of the Legal Advisory Committee for a nonprofit called Men Having Babies, adds an additional perspective. "Compensation in and of itself does not make a surrogacy unethical, in my opinion. Surrogates spend significant amounts of time and energy undergoing screening, going to medical appointments and going through insurance and legal paperwork in order to help the intended parents. They defer travel, ask other family members to pitch in when they are under more physical stress, and take on real medical risk in order to help another family."
"We don't consider it unethical to pay firefighters or soldiers," she continues. "Surrogates are also using their bodies to help others, and in my opinion, an expectation that they should do so for free carries very strong overtones of sexism and paternalism. While women are perfectly capable of determining whether they want to put the stress and risk on their bodies, there is nothing unreasonable about requesting reasonable recompense for doing so."
The need for clear and ethical standards across all lines of surrogacy, especially in places of great financial inequity, is obvious. That's a systemic issue — not a moral failing in the families who want to welcome a child, or the women who freely and thoughtfully opt to become surrogates.
And it's definitely not any commentary at all on the children whose path into this world was made possible by surrogacy. "I think the first thing we need to remind all of ourselves is, this is this child's creation story. It's not just an embryo that gets put in a uterus, and then we have a baby. And when surrogates and intended parents come into this, they have to be able to balance and support that relationship so that we can do this really magical, beautiful thing together."
