Surrogacy: the ethical and emotional questions

“My sister said she would carry the baby for me.”

She said it quietly, almost apologetically, as if confessing to something forbidden. Behind her were years of trying, several rounds of treatment and, finally, a conversation with her doctor after which it was clear she would not be able to carry a child herself. Her sister’s offer came over Sunday lunch, somewhere between the coffee and clearing the table. Since then she had been unable to think of anything else. Not because she knew what she wanted. But because suddenly there was a possibility for which she had no map at all.

Surrogacy is one of those subjects on which everyone has an opinion, yet very few people have ever actually lived with it. In public it is discussed as a legal or ethical problem, in magazines as a story about celebrities. When the question turns up in real life — in a couple, in a family, between friends — it is first of all something else: a stream of feelings that are hard to sort out, and relationships that shift as a result. That is what I would like to write about here.

What it actually means

In surrogacy, a woman carries a pregnancy and gives birth to a child for another person or couple, who will raise the child. There are two main forms. In so-called gestational surrogacy, the surrogate is not genetically related to the child — the embryo is created from the gametes of the intended parents or of donors. In traditional surrogacy, the surrogate is also the child’s genetic mother. The difference is not merely technical: people experience it differently, and the law treats it differently too.

Legal arrangements vary enormously from country to country — from an outright ban to systems that allow payment. This is why some couples go abroad. If you are considering this, speak to a lawyer who knows the field about the legal consequences, especially the recognition of parenthood and the child’s documents once you return home, and to a gynaecologist about the medical questions, before you sign anything. I will not go into those questions here, because they are not my field. My field is what happens inside people and between them along the way.

What we know about families formed this way

The longest and most systematic research on these families has been carried out by developmental psychologist Susan Golombok and her colleagues at the University of Cambridge. In a study published in 2004, they compared 42 families created through surrogacy with families created through egg donation and with families with naturally conceived children. In the first year, relationships between parents and children in surrogacy families were at least as warm as in the others — in some respects parents even showed greater emotional involvement.

The researchers kept visiting the same families for years afterwards. The children were developing well, most parents had told them early on how they came into the world, and the children later described that story without any particular drama. Research on surrogates led by Vasanti Jadva found that most women who had carried a child for others did not experience lasting psychological difficulties as a result, although some found the weeks after handing over the baby hard.

These are important findings, but they have limits. The samples are small, mostly from the United Kingdom, where surrogacy is altruistic and relatively well regulated. They say little about countries where it is commercial and where surrogates are in a far more difficult position. They describe averages, not any individual family. And they do not answer the question of whether it is right — only the question of how people who chose this path fare afterwards.

Before the question even arises

Hardly anyone sets out on the road to a child thinking about surrogacy. People arrive at it by a long detour: after years of trying, after losses, after treatments that did not work, or after a diagnosis that made pregnancy impossible or dangerous. I wrote about everything treatment brings with it in Assisted reproduction and its emotional cost.

That is why surrogacy almost always carries grieving within it. Not necessarily for a child — a child may still be possible — but for the pregnancy. For not feeling the first kicks, for not carrying yourself what for so long seemed a given. For the image of yourself as a woman whose body does what she asks of it. The people around you almost never recognise this grief, because the solution seems within reach. What it is like to carry a loss others cannot see is the subject of The grief nobody acknowledges: miscarriage, divorce, losing a job.

When there is no room to feel this grief, it tends to move elsewhere: into a need to control the surrogate, into mistrust, into a sense that the whole thing is somehow “foreign”. So one of the first questions worth asking yourself is simply this: have I been able to say goodbye to the pregnancy that will not happen — or at least begin to?

An ethical question that cannot be sidestepped

Surrogacy is one of the most contested issues in modern reproductive medicine, and not without reason. It brings together questions about the body, money, power and the rights of the child. Serious, well-meaning people arrive at very different answers.

Those who support surrogacy stress that women have the right to make decisions about their own bodies — including whether to carry a child for someone else. They point out that for some people it is the only route to a child they are genetically related to, that many surrogates choose this out of a deep wish to help, and that well-regulated arrangements protect everyone better than bans that send people abroad.

Those who are critical of surrogacy warn that wherever money is involved, there is a serious risk of exploiting poorer women. They ask whether a pregnancy — and with it a child — can be the subject of a contract. They point to the unequal power between the surrogate and the intended parents, and to the pressure a sister or friend may feel within a family when someone she loves asks her for something this big. Some also raise the question of the child, who had no say.

I do not think my task here is to take a side. As a therapist in training, it seems more important to me that people making this decision know both sides — including the arguments they do not like. Anyone who knows only one side may later find themselves facing questions they were not prepared for. And anyone who pushes their doubts away because “now is not the time” will most likely meet them later, when the child is already here.

When the surrogate is someone you know

When I talk with people about this subject, it seems to me that it is hardest when the surrogate is not a stranger but a sister, a friend or a cousin. On paper this looks like the best option: the trust is already there, the motives are clear, the child will have someone close who carried them. In reality, all the old patterns of the relationship move into the arrangement.

Relational family therapy, in which I am training, starts from the idea that we bring the emotional atmosphere of the relationships we grew up in into every new relationship. Christian Gostečnik writes about how unresolved family dynamics repeat themselves — not because anyone wants them to, but because they are all we know. If one sister was always the one who gives and the other the one who receives, that division will show itself in full force during a pregnancy. If there was a quiet rivalry between them, it may surface at the first scan.

The questions that open up are very concrete. How much is the intended mother allowed to know about what her sister eats and drinks? May she come to the check-ups? What if the sister changes her mind during the pregnancy? What if, after the birth, she needs more contact than the intended mother can give? And how will the sister’s partner, her children and both sets of parents see all this?

A short scene (composite, not a real person) shows how quickly such a conversation can become tangled:

“I want to help you. I really do. I just don’t know how I’ll feel watching you breastfeed him.”
“Then I won’t. I can bottle-feed him, if that makes it easier for you.”
“You see, that’s it. You’re already adapting to me. As if I owe you something I have to give you exactly right.”
“I’ll owe you for the rest of my life. How could I ever repay you?”

In these few sentences there is everything: gratitude that can turn into debt, accommodation that can grow into quiet resentment, and fear that the relationship will never be quite the same again. None of this means the arrangement is a bad one. It does mean that it needs far more conversation than people usually expect.

The surrogate’s voice

In public debate the surrogate often disappears — she becomes either “the solution” or “the victim”, and rarely a person with her own story. Research that asked women who had carried children for others about their experiences paints a more varied picture. Many speak of pride and of a sense of having done something meaningful. Some describe difficult weeks after the birth, when body and feelings had not yet caught up with the fact that the baby was not with them. For many, contact with the family later on mattered — not as a mother, but as a special kind of bond.

Research by Sarah Imrie and Vasanti Jadva found that even years later most surrogates spoke positively about the experience and that their relationship with the family they had carried for was important to them. But here too: these were women in a regulated, altruistic setting. Where a surrogate carries a child out of hardship, the stories are often different.

If you are the one considering carrying for someone, your questions matter just as much as the intended parents’. What is drawing me to this? Whose voice do I hear when I tell myself I ought to? How will it affect my children and my partner? And what will I need afterwards?

The child and the story of their beginning

A question parents often push to later is what they will tell the child. Research on families formed with donated gametes or surrogacy is fairly consistent: children who hear their story early, as something ordinary, accept it much more easily than those who find out later or by chance. I wrote about what origins mean for a child’s identity in Donor conception: what it means for a child’s identity.

In surrogacy the story is especially concrete: there is a woman who carried the child. Sooner or later the child will wonder who she is and why she did it. Parents who are at peace with this will find it easier to answer than those who feel shame, jealousy or a fear that the child will not be “fully theirs”.

So the story of the child’s beginning is worth telling yourself first. How do I tell it? As a story of failure, or as the story of the path by which they came to us? Children pick up very precisely on the emotional tone in which parents speak about things — sometimes more than on the words themselves.

When the two of you are not in the same place

It rarely happens that both partners arrive at surrogacy at the same time and with the same feeling. Often one sees hope, while the other sees questions that frighten them. One is already researching countries and agencies, the other would rather wait or think about adoption. Or the difference may run deeper: one longs for a genetically related child, while to the other this matters less.

At that point it is very easy for the couple to split into the one who “wants it” and the one who is “holding back”. In reality both are carrying important parts of the same decision. The one holding back often puts into words doubts the other also feels but does not dare to hear. I wrote about what it is like when one is ready and the other is not in When one of you is ready and the other isn’t: ambivalence in a couple. The same dynamic shows up here.

When the conversation always ends in an argument or in silence, it helps to begin it differently — not with “are we doing this or not”, but with what each of you is afraid of. You will find some suggestions on how to approach such a conversation in How to start a difficult conversation with your partner: the first three minutes decide.

An exercise: separating your voice from the others

When a decision is this big and this surrounded by opinions, you can lose track of what you yourself think. This exercise will not make the decision for you, but it helps you hear. You need paper and half an hour of quiet.

1. Write down all the voices you hear. Your mother, your partner, your sister, your doctor, the articles you have read, religious or ethical convictions. Next to each, write in one sentence what it is telling you.
2. Next to each voice, note what you feel. Relief, guilt, anger, hope, shame? Don’t judge, just notice.
3. Find your own voice. On a fresh sheet write: “When no one is watching, I wish …” and keep going without stopping for at least five minutes. You may find several wishes in you at once that contradict each other — that is ambivalence, and with decisions like this it is to be expected.
4. Write down one ethical question that won’t leave you alone. Not in order to solve it, but so that you stop pushing it away.
5. Choose one person you will talk to about what you have written. Ideally someone with no stake of their own in the decision. The questions before a big decision can help here too.

You can repeat the exercise a few weeks later. Often some voices will have grown quieter and others clearer.

Where this perspective falls short

This whole piece is about feelings and relationships. That is an important part, but not the only one. Surrogacy is also a legal and medical question, and no amount of reflecting on your own feelings can replace good legal advice or a conversation with a gynaecologist. Deciding purely on the basis of how you feel, without knowing the legal consequences, would be unwise.

Nor does therapy answer the ethical question. It can help you understand why a particular argument unsettles you so much, or notice that you are deciding out of fear. But it cannot tell you whether surrogacy is right. That is a question of your values, and sometimes of your faith or worldview.

And finally: reflection has its limits. Some people get so lost in the questions that thinking becomes a way of avoiding the decision. If you feel you are going round in circles, Decision paralysis: when thinking it over becomes a way of avoiding may help. Sometimes the healthiest thing is to set yourself a deadline and then decide with everything you know at that point — even if it means choosing a different path.

What talking to a therapist can offer

People considering surrogacy rarely come to therapy because of the decision itself. More often they come because they are exhausted after years of trying, because they can no longer hear each other as a couple, or because an offer within the family has opened old wounds. Therapy has room for all of this — for grief that had no place elsewhere, for anger that feels ungrateful, for doubts that cannot be spoken in front of a sister who is willing to carry.

In marriage and family therapy, which I am learning, we are interested not only in the individual but in the whole system in which a decision takes shape. Who will be involved? What does the decision mean for each of them? Which stories from earlier generations wake up along the way? This does not make the decision easier, but it can make it more your own. I also work with English-speaking clients, in person in Ljubljana.

What to remember

• Behind surrogacy there is almost always grief for a pregnancy that others rarely recognise.
• Research on families in a regulated, altruistic setting suggests that children and parents mostly do well — but it does not answer the ethical question.
• The ethical question has serious arguments on both sides; it is worth knowing the ones you don’t like as well.
• When the surrogate is a sister or a friend, old relationship patterns move into the arrangement — they need to be talked about before the pregnancy begins.
• Legal and medical questions belong with a lawyer and a gynaecologist; the emotional and relational ones deserve their own space.