References

Lunt N, Smith R, Exworthy M Medical Tourism: Treatments, Markets and Health System Implications: A scoping review.Paris: OECD; 2011

Mulligan A. The right to travel for abortion services: a case study in Irish ‘cross-border reproductive care’. Eur J Health Law. 2015; 22:239-66

Pennings G. Reproductive tourism as moral pluralism in motion. J Med Ethics. 2002; 28:337-41

Pennings G. Legal harmonization and reproductive tourism in Europe. Hum Reprod. 2004; 19:(12)2689-94

Salama M, Isachenko V, Isachenko E Cross border reproductive care (CBRC): a growing global phenomenon with multidimensional implications (a systematic and critical review). J Assist Reprod Genet. 2018; 35:1277-88

Shalev C, Moreno A, Eyal H Ethics and regulation of inter-country medically assisted reproduction: a call for action. Isr J Health Policy Res.. 2016; 5

Thorn P, Wischmann T, Blyth E. Cross-border reproductive services − suggestions for ethically based minimum standards of care in Europe. J Psychosom Obst Gyn.. 2012; 33:(1)1-6

Reproductive tourism

02 December 2018
Volume 26 · Issue 12

Abstract

Travelling abroad to access procedures such as IVF, genetic diagnosis and sex selection are becoming increasingly common—bringing with them a host of ethical quandaries. George Winter explores

Although travelling abroad for the sake of one's health is centuries old—Lourdes, for instance, or ‘taking the waters’ in spas—the concept of so-called ‘medical tourism’ has increased in popularity in recent years. Lunt et al (2011: 2) define medical tourism as ‘when consumers elect to travel across international borders with the intention of receiving some form of medical treatment … [it] most commonly includes dental care, cosmetic surgery, elective surgery and fertility treatment.’

Missing from the list is abortion, as exemplified by many Irish women who travelled across international borders to obtain terminations that were illegal in their home country (Mulligan, 2015) until the referendum in June this year.

Fertility treatment belongs to a category that has been variously described as ‘reproductive tourism’, ‘transnational reproduction’, ‘reprotravel’ and ‘cross-border reproductive care’ (CBRC). The most common fertility treatments associated with CBRC are in vitro fertilisation (IVF); intracytoplasmic sperm injection; sperm, egg or embryo donation; commercial surrogacy; pre-implantation genetic diagnosis; sex selection and fertility preservation (Salama et al, 2018). Legal constraints, expense in home countries, privacy issues and cultural familiarity are some of the factors helping to drive the popularity of CBRC (Salama et al, 2018).

Shalev et al (2016) have shown that while CBRC is a multi-billion-dollar business, it also has severe regulatory shortcomings. The authors called for a system of international governance that addresses some of the challenges, such as surrogacy practices that involve multiple provider countries: ‘The intended parents from country A might transact with an egg provider from country B, who travels to a clinic in country C, where the egg is fertilised and implanted in a surrogate mother from provider country D’ (Shalev et al, 2016: 2). This in turn raises questions over the legal and nationality statuses of children; an ethic of care that confers both rights and responsibilities on the adults involved, combined with a focus on the wellbeing and rights of subsequent children.

Others, however, argue that CBRC is the inevitable outcome of uneven regulation, and that patients can hardly be blamed if they cross national frontiers in search of a pragmatic solution to a reproductive problem. Pennings (2002: 3) asserts that when ethical conflicts occur, tolerance should be exercised in the form of respect for the moral autonomy of the minority, and that ‘the state refrains from taking active measures (such as restrictions on the freedom of movement of, and criminal charges against, offenders) to prevent citizens from seeking medical care in a state that holds a policy that better accords with their moral insights.’

Yet, my inference from the analysis by Thorn et al (2012) is that the assertion of one's autonomy and society's tolerance of it, in the context of CBRC, will still leave concerns to be addressed. These include, as Thorn et al (2012) note, the hyperstimulation of oocyte donors to harvest large numbers of eggs; intended parents for whom IVF has failed risking multiple pregnancies abroad; the extent to which oocyte donors or surrogates can access free medical follow-up to obviate possible complications; and if donors and surrogates remain anonymous, children are unable to discover information in relation to their biological and/or gestational roots.

Yet despite these, and other, misgivings, Pennings (2004: 2689) not only believes that CBRC ‘is a safety valve that reduces moral conflict’, but also that Europe-wide legislation should be avoided if possible, with regulation ‘of these private ethical matters' left to national parliaments. In the context of Brexit, some may consider this approach to be fraught with difficulties.

CBRC may see midwives being quizzed by prospective parents on the pros and cons of this increasingly widespread aspect of human reproduction. In the absence of due consideration being given to the ethics of CBRC at the outset, it seems that busy midwives may have to contend with issues that were not originally thought to be within their remit.