Introduction

1In 1978, Louise Brown was born, the world’s first test-tube baby. That was a historical turning point. For the first time in the history of mankind, a child was conceived outside its mother’s womb. It was a sensation that produced heated debates and endless controversies, among the public and in politics, the media and science. Time and again, the issue was: Should this method be allowed or prohibited? Was it progress or was it a sacrilege?

2Today, just a few decades later, in vitro fertilization (IVF) has long since become an everyday occurrence. Meanwhile, we have gotten used to reproductive medicine presenting us with ever more options. We have gotten used to headlines such as: “Indian Surrogate Bears Twins for Norwegian Couple” or “The Market for Human Eggs Goes Global.”

3In what follows I will focus on the emergence of fertility tourism and a global fertility market. To this aim, I will explore both the “demand side” and the “supply side” of such markets, and I will proceed in three steps:

1. The first part, dealing with the demand side, discusses the changing attitude towards IVF, the question being: How come that the opposition, so widespread in the beginning, gave way to broad acceptance within a few years? Here I will look at the moral debates in respect to IVF, the sound of many divergent voices and widely differing conclusions.
2. The second part, again dealing with the demand side, points to the growing acceptance of diverse forms of personal and family life in recent years. Here I will suggest that with the expanding range of lifestyles came a rapid growth in the number of hopeful parents-to-be.
3. The third part, moving to the supply side, deals with the question: Why did reproductive technologies go global and why do parents-to-be go global? In this context, I will bring in results from a small empirical study I conducted recently. It explores the websites of fertility clinics worldwide, and it finds that such services are designed in special ways so as to attract clients from abroad.

Moral issues: contested territory

4When the biological foundations of mankind become subject to direct intervention, a universe of new options and possibilities opens up. Where previously there was destiny, we are now able increasingly to decide which biological features we want and to shape and select them—for ourselves and for our children.

5We can easily see that such options are of major importance. They touch deep into our personal lives, and they shape the future of society. For this reason, within very little time IVF and similar technologies became subject to on-going social battles, a contested territory where widely differing factions asserted their respective interests, ideas, and values. Many states passed laws so as to retain some control over the options offered by reproductive medicine. In a similar vein, the representatives of various religious denominations came up with public statements, issuing decrees on how to use or not to use the new options. Last but not least, representatives of science, lobby groups, and health organizations joined the debate, pronouncing their support or misgivings in respect to reproductive technology.

Old traditions, new options

6Yet there is a basic problem common to all debates of this kind. Since medical technology has opened up radically new options, time-honored values, established norms and traditions are ages apart from that technology. There is always a gap, a gulf. Long and complicated interpretations are needed to bridge that gulf. For this reason, most of the debates follow similar lines. Time and again, they are based on rhetoric of highly sophisticated turns and artistic definitions. By many varieties of elaborated reasoning, they try to master the new questions that have come up so suddenly. For instance:

• Is in vitro fertilization a procedure for creating life, a way to counter the suffering of childless couples, and therefore worthy of social support and active promotion?
• Or is it a procedure that offends our notions of human dignity that sanctions risky manipulations, and has unpredictable consequences?
• Is embryo screening a form of eugenics, or is it a legitimate and efficacious way of preventing serious hereditary diseases?
• Or, is it permissible in certain circumstances but not in others, and who defines those circumstances?

7One thing is certain: Established authorities will never provide definite and unambiguous answers to these questions, regardless of whether we look at the Koran, the Ten Commandments or the Basic Law for the Federal Republic of Germany. As their fundamental principles come in highly general terms, these institutions leave room for very divergent interpretations. And because of this, the ongoing debates are full of controversial conclusions. For instance:

• When Gerhard Schröder was Chancellor of Germany and uppermost representative of the country’s political power, he spoke out clearly in favor of embryo research, stressing its potential for innovation. At the very same time, Jürgen Habermas, world-famous philosopher and one of the outstanding intellectuals in Germany, took the opposite view. He warned against an instrumental view of the embryo and any kind of research not recognizing the dignity of human life.
• When Gordon Brown was British Prime Minister, he praised some new lines of stem-cell research as beneficial and indispensable for progress. Yet in Germany these very lines were taboo, forbidden by the Embryo Protection Act.
• In a similar vein, leading representatives of Shiite Muslims have declared that egg donation is permissible, while the most notorious institutions of Sunni Islam have ruled that it is not.

8Given these conflicting views, it is not surprising that ordinary people be perplexed. The to-and-fro of argument and counter-argument renders all points of view suspect; each helps to undermine the other. Caught in-between, many people come up with the conclusion, first, that the subject matter is confusing; and second, that no one has a monopoly of the truth. But then, it follows that if all the opposing views seem to be well founded, how can we formulate policies that will be generally accepted?

9In sum, the effect of such disagreements is to undermine the law’s claim to legitimacy. If you can argue this way or the other, how can the law prescribe which direction to follow? If firm ground is nowhere to be found, shouldn’t we be free to choose for ourselves? In this way, legal regulations begin to lose their authority.

The growing diversity of lifestyles

10“Love, marriage, baby carriage”—in the nineteen fifties and nineteen sixties that was the proper way for building a family, the dominant model was the so-called “normal family,” consisting of an adult couple with their biological children. Of course the adults would be of different sexes, i.e., man and woman; they were married and would remain married until death did them part. The wife was responsible for looking after the household and for bringing up the children; the husband for bringing in the money and dealing with the outside world.

11Those are bygone times. Take the adult couple, for instance. Not that many decades ago, gay and lesbian couples were criminalized and pursued by the law. Today they can have their partnerships officially registered in many countries, and can even marry in some. For heterosexual couples, the trend goes in the opposite direction. Many choose cohabitation and go without the blessing of the state. Or take children: Not so long ago, a child born outside marriage was a “bastard,” a social outcast, and damaging to the mother’s respectability. In contrast today, in Western countries ever more children are born out of wedlock, and increasingly they are treated as equals before the law. In short, within the space of a few years, life patterns have multiplied. Relationships that but a few decades ago were regarded deviant, today are practiced by ever more people. Much of what used to be morally condemned now passes unremarked; it has become one lifestyle among others.

12But if more and more ways of life become socially accepted, why should people who live beyond the bounds of the traditional family renounce the right to have children? If others have the right to parenthood, why not them as well? Singles, gay and lesbian couples, women in their sixties who have had their careers and would like a new start as mothers; women who want to have a child by their dead or dying partner; couples who want to choose the sex of their offspring—all of these people now stand a chance to have their wishes fulfilled, by way of reproductive medicine.

13Hans Jonas, the philosopher of technology, wrote some decades ago: “Opportunity breeds appetite.” In field of reproductive medicine we can see this growing of appetites happening today (Jonas 1985, 22). The more new medical options are being offered and the more lifestyles are being accepted, the more people flock to fertility clinics.

14And vice versa: the greater the demand, the more options are being offered. The respective clinics offer a variety of services, from IVF as standard procedure right down to the choice of the baby’s sex and to catalogues presenting sperm donors, egg donors, surrogates—complete with snapshots and biographical profile.

Fertility tourism: a global market

15When trying to make use of such offers, men and women often find themselves confronted by major obstacles, including legal and financial barriers. But as often said, one person’s obstacle is another person’s opportunity. Many of the clinics set up to help would-be parents aim at attracting foreign customers. Communication via the Internet is swift and easy; with a few mouse-clicks you are in touch with fertility clinics in Spain, Russia, or India. They have two major advantages to offer: minimal restrictions and low costs. I have studied many of such websites, analyzing the services they provide or promise. For a brief summary, the major characteristics are as follows:1

• When discussing legal requirements in the country where they are based, clinics often use positive labels such as “modern,” “enlightened,” and “liberal.” Freely translated this means: “Don’t worry about legal restrictions. We know how to deal with these.”
• Many clinics offer communication in several major languages. They emphasize the international composition of their team, from multilingual doctors to multilingual nurses and counselors. This is to say, clients need have no fear of language barriers; communication in their native tongue will be available.

16Furthermore, the services provided extend beyond medical facilities proper. Clinics frequently offer a variety of additional benefits. For instance:

• They promise comfort and attention. Catch words are “individual treatment and personal attention,” “discretion,” and “understanding.”
• They praise the tourist attractions of the region, for instance: “abundant sunshine, wonderful surroundings and extensive beaches.” Sometimes there is also reference to opportunities for great shopping and delicious dining, for arranging excursions and sightseeing.
• Many clinics have a psychologist on the team, or even a psychological department, so as to provide support and relaxation to their clients, and help them to reduce stress.
• Many clinics offer legal assistance, so that their clients don’t have to be afraid of legal complications.
• Many clinics have different versions of their services, depending on the financial situation of their clients. At the high end is the luxury service (driver and car will meet you at the airport); then the standard version; and at the bottom the economy version, providing basic service only.

17Furthermore, time and again we find services centered on the hopedfor child: All will be done to ensure the baby’s health and well-being. In a nutshell: The clients may expect a quality baby. For instance:

• According to what the clinics’ websites say, sperm donors, egg donors, and surrogate mothers are chosen with utmost care, and only the best will be accepted. The criteria include the donors’ health, medical history, family status; and also psychological stability, intelligence and education, appearance and ethnic origins.
• With surrogates, their health, diet and lifestyle are regularly monitored during pregnancy. Such measures are meant to make sure that the surrogate will provide the optimal prenatal environment for the embryo.

18By offering such services, infertility treatment has grown into an international business with high growth rates. Clients follow characteristic paths and destinations, depending on their respective wishes and their financial situation: Germans travel to Turkey, Egyptians to the Lebanon, the Dutch go to Belgium, and Americans to Romania. German women have the eggs of Spanish women implanted in them, American women have eggs sent from Italy or Greece, Lebanese women make use of eggs donated by American women. Lesbians go to Denmark for Danish sperm.

India: “rent a womb”2

19Last but not least, hopeful parents-to-be travel to India. India is a deeply divided nation, with a tiny group of very rich people at the top, a small but expanding middle class in between, and many millions of poor at the bottom, men and women who have no access to education, decent jobs or adequate health-care. For this reason, ever increasing numbers of women—often illiterate, often from rural areas, often in desperate need of money—are willing to serve the rapidly growing fertility industry, for instance as surrogates. In recent years, India has even been named the world capital of surrogate motherhood, the slogan being: “Rent a Womb.” For the nine months of pregnancy, a surrogate is paid usually $5,000 to $7,000. In exchange, the women have to submit to a strict regime. The contracts frequently stipulate that they should live in clinic dormitories, follow a strict diet, abstain from sexual intercourse with their husband, and leave their own children in the care of others. Corresponding rules for protecting the surrogates’ rights scarcely exist.

20To those promoting surrogacy, surrogacy is a fair deal. Indeed, it is a win-win situation: to one woman, the baby; to the other, the money. So both get what they want.

21Yet such a view overlooks some fundamental characteristics of surrogacy. It willfully ignores the unbalanced distribution of rights and risks involved (for instance the health risks for the surrogate). It ignores that surrogacy is based on a hierarchy of power, a hierarchy of nation, color, and race. In a nutshell: that it is built on global inequality.

The medical profession and commercial enterprise

22When medical practice is turned into a commercial enterprise, its rules change. Priority is not given to the ethics of the medical profession, but to the principles of making money: maximizing profits. Conception, pregnancy, and birth are no more the outcome of a sexual act between a man and a woman, an act that often comes with some emotional bond. Instead, they are now a technical operation, to be performed by experts, suppliers, and contractors.

23In the context of this booming new market of fertility tourism, serving the wishes of parents-to-be becomes a carefully calculated deal, a business contract. It is a commercially organized transaction, built on market strategies, and designed by PR agencies. They know the tricks of the trade: how to downplay the risks and inflate the success rates of medical interventions, how to build trust with the parents-to-be and raise their hopes, how to touch their hearts and feed their need for love—for instance by presenting picture galleries of babies, all charming of course, or telling stories praising the bliss and never-ending joys of parenthood.

24Furthermore, some contracts come with regulations covering every detail, with special rules in case of unexpected events and outcomes. For instance: if the commissioning couple goes through a divorce or dies, what should be done with the embryos? If the child growing inside the womb should have some physical deficiency, or if there will be triplets instead of one baby, will the commissioning couple then be obliged to follow the deal and accept responsibility for the children? Or could they claim that the outcome is different from what they had ordered, and therefore they have a right to reject it?

25The basic problem is obvious. The commercial production of children is no business like other business. Even with high-tech reproductive technology, nature still plays a major part, and nature cannot be controlled totally. Accidents happen. What then?

Conclusions

26In the field of reproductive technology, rapid advancement combines with enormous potential. Time and again, we are heading for major questions and confronting major dilemmas. For instance, how can we do justice to those men and women to whom reproductive technology means the only chance of ever having a child of their own? How can we recognize their pain and their longing, and at the same time recognize the rights of the other parties involved, for instance the future well-being of the child, or the health and autonomy of the surrogate mother? How can we do justice to one group without injuring the rights of the others? And how can we deal with the issue of global inequality, with the hierarchy of color, nation, race that is a hidden part of fertility tourism?

27Seen like this, fertility tourism demonstrates a classic feature of modernity, namely: the close intertwining of risks and opportunities. British sociologist Anthony Giddens has outlined the dilemmas lying in wait here: “The ‘end of nature’ opens up many new issues for consideration… The capability of adopting freely chosen lifestyles, a fundamental benefit generated by a post-traditional order, stands in tension… with a variety of moral dilemmas. No one should underestimate how difficult it will be to deal with these” (Giddens 1991, 231).