HSS4331 Introduction to International Health Theory

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Reproductive (Medical) Tourism HSS 2121
April 1, 2009
Raywat Deonandan, PhD
ray_at_deonandan.com Assistant Professor,
Health Sciences, University of Ottawa Former
Chief Scientific Advisor, Assisted Human
Reproduction Canada
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You can download this presentation at
classes.deonandan.com
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We are going to talk about -Medical tourism
(what is it?) -Reproductive tourism (what is
it?) -The ethics of the above (what is ethics?)
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• The words, expletives, guttural moans and
  occasional odours coming out of my mouth do not
  necessarily reflect the opinion of Assisted Human
  Reproduction Canada

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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.
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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?

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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
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Summary of the Ethical Issues
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Summary of the 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 ones 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
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We will revisit those ethical issues when we
discuss the specific case of Reproductive
Tourism In 43.21.
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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

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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

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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

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The Available Infertility Services

• Fertility drugs
• IUI
• IVF
• ICSI
• Gamete donation
• Surrogacy

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Fertility Drugs
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IUI

• Intra-uterine insemination
• Artificial presentation of sperm into the vaginal
  canal
• turkey baster method

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IVF

• In Vitro Fertilization
• Creation of embryo in a dish, and returning it to
  the womb
• test tube babies
• Considered the vanguard ART technology

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Louise Brown, Born July 25, 1978
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The OctoMom!
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My Halloween costume next year
Dennys Octomom special 14 eggs, no sausage, and
the guy at the next table pays for it.
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ICSI

• Intra cytoplasmic sperm injection
• Done in conjunction with IVF
• Grab a sperm and force it into an egg
• Used when sperm just cant get the job done by
  themselves

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Sperm Donation

• Relatively simple
• Donors are usually friends or family
• Anonymous donors are rare and in demand

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Egg donation

• Very invasive
• Expensive procedure
• Hard to find donors

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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)

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Other Technologies

• PGD pre-implantation genetic diagnosis
• IVM in vitro maturation
• flash freezing of eggs
• Hybrids and cybrids

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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

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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

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Canadas Assisted Human Reproduction Act (2004)

• 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

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Canadas Act

• No payment for surrogacy
• No paid brokerage for surrogacy
• No payment for gametes
• No paid brokerage for gametes
• etc

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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, its the wild wild west
• Etc.

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So.

• Lets say youre 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?
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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

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Reproductive Tourism

• The phenomenon of going abroad to seek
  reproductive technologies
• Might be considered a form of Medical Tourism

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South Asia

• Currently, parts of the USA are the most popular
  destinations for reproductive tourists
• But India is fast becoming an important
  destination

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India

• Surrogate mother in India costs
• 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

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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

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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

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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.
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• 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

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So, Whats The Problem?

• From an international health/development point of
  view, what are the issues?

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The Issues

• Protection for couples travelling abroad
• Protection for women selling services in poor
  countries

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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?

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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

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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 ones body, as client and
  doctor have a vested interest in the surrogates
  nutrition and activities

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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

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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

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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)

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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

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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 clients country?
• Does she have the 2 year leeway in the UK?

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Cross Border Reproductive Care

• Why is this the preferred terminology?

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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 ones 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.

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• Are there additional ethical issues that apply
  specifically to reproductive tourism?

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• 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 husbands
• Quality of care surrogates 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?

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• Limits of care While the surrogates 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?

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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

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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

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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

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Quotes