Oocyte ethics: financial compensation for human eggs

 New ethical guidance on egg donation, following an antitrust settlement regarding price fixing.

Financial compensation of oocyte donors: an Ethics Committee opinion.  by The Ethics Committee of the American Society for Reproductive Medicine, American Society for Reproductive Medicine, Birmingham, Alabama, Fertility and Sterility® Vol. 116, No. 2, August 2021

"Financial compensation of women donating oocytes for reproductive or research purposes is justified on ethical grounds and should acknowledge the time, inconvenience, and discomfort associated with screening, ovarian stimulation, oocyte retrieval, and postretrieval recovery and not vary according to the planned use of the oocytes or the number or quality of oocytes retrieved. This document replaces the document of the same name published in 2016. (Fertil Steril
2021;116:319-25. 2021 by American Society for Reproductive Medicine.)

"ESSENTIAL POINTS:

Financial compensation of women donating oocytes for reproductive or research purposes is justified on ethical grounds.

Compensation is in accord with principles of fairness, occurring within the framework of a professional relationship.

Compensation should acknowledge the donor’s time, inconvenience, and discomfort associated with screening, ovarian stimulation, oocyte retrieval, and postretrieval recovery. Compensation should not vary according to the planned use of the oocytes (reproductive or research) or the number or quality of oocytes retrieved.

Compensation should be fair and should not be an undue enticement that negatively impacts a donor’s ability to make an informed decision about the donation process and the risks involved with donation.

All oocyte-donor recruitment programs, including agencies, egg banks, and fertility clinics, should individually adopt and implement effective processes for information disclosure and counseling in order to promote informed decision-making by prospective donors.

Treating physicians owe the same professional duties to oocyte donors as to all other patients.

Programs should ensure equitable and fair provision of services to oocyte donors.

Programs should individually adopt and disclose policies regarding coverage of an oocyte-donor’s medical costs should she experience complications associated with the oocyte retrieval process."

...

" Because the burdens of donation are similar regardless of the ultimate use of the oocytes, compensating donors of oocytes for research is also ethically justified. There has been some movement at the state level to permit compensation to research donors, which stands in contrast to the approach articulated by the National Academy of Sciences with respect to compensation for oocyte donation for stem-cell research (21). In 2009, New York became the first US state to implement a policy permitting researchers to use public funds to reimburse women who donate oocytes directly and solely for stem-cell research, not only for the woman’s outof-pocket expenses, but also for the time, burden, and discomfort associated with the donation process (22). A law enacted in California in 2019 likewise requires women who provide human oocytes for research to be compensated for their time, discomfort, and inconvenience in the same manner as other research subjects, removing a previous prohibition of compensation of research donors (11).

...

"It is ethically permissible for a program to refuse to accept a prospective oocyte donor if they become aware that a prospective oocyte recipient or recruiting agency has offered gifts or payments that the program, in the exercise of its own ethical judgment, believes compromise the donor’s free choice or are otherwise ethically inappropriate. Programs should not assume that known donors, such as family or friends, are not being financially compensated. In one study of recipients using both known and anonymous donors, 19 of 20 of the known donors had been compensated, and there were no differences in the amounts provided to known and anonymous donors (27).

...

"This report was developed under the direction of the Ethics Committee of the American Society for Reproductive Medicine (ASRM) as a service to its members and other practicing clinicians. Although it reflects appropriate management of a problem encountered in the practice of reproductive medicine, it is not intended to be the only approved standard of practice or to dictate an exclusive course of treatment. Other plans of management may be appropriate, taking into account the needs of the individual patient, available resources, and institutional or clinical practice limitations. 

**************

That last paragraph may be a bow to the antitrust settlement discussed in the post below:

Friday, May 3, 2019

Donating eggs for fertility: an update

Repugnance to high incentives, by Robert Stüber

Here's a paper that seeks to understand why some transactions are permitted when only low incentives are offered, but banned when high incentives are offered. (Donation of human eggs is one example; high payments to participate in experiments is another...)

WHY HIGH INCENTIVES CAUSE REPUGNANCE: A FRAMED FIELD EXPERIMENT* by Robert Stüber

WZB Berlin March 2021

Abstract: A key feature of markets for repugnant transactions is that certain transactions seem to raise moral concerns only when they involve high monetary incentives. Using a framed field experiment with a representative sample, I show that these preferences exist, and I investigate why people display it. Participants can permit or prevent a third party from being financially compensated for registering as a stem cell and bone marrow donor. I find that a substantial fraction of individuals permit a low payment but prevent high monetary incentives. With the help of experimental treatment variation, I show that their preference to prevent high incentive offers is caused by the desire to protect individuals with high reservation prices. Evidence from a survey experiment with ethic committees emphasizes the practical importance of this finding. These results imply that shortages in the supply of controversial goods are unlikely to be solvable by providing higher incentives. 

********

Here's a short video presentation of (an early version of) the paper by Dr Stüber.  I understand that he will be moving from the WZP to NYU Abu Dhabi in September.

Donating eggs for fertility: an update

Slate brings us up to date:

INSIDE THE QUIETLY LUCRATIVE BUSINESS OF DONATING HUMAN EGGS

"The first US child conceived from a donated egg was born in 1984. Since then, the procedure has grown into a thriving industry. Demand from aspiring parents, along with a dearth of regulations, have spawned matchmaking agencies that offer to help parents find the perfect young woman whose eggs will result in the equally perfect child.

"Donating eggs can be lucrative, with agencies paying as much as $50,000 per cycle in some cases.
...
"Ads or marketing materials targeting potential donors rarely mention the risks or common complaints. Liz Scheier donated eggs three times between 2005 and 2007, and says she was told there were no known risks associated with egg donation. Today, Scheier is a media liaison for We Are Egg Donors, a women’s health organization that works with more than 1,500 donors to promote transparency and advocate for their concerns. She says that donors nowadays hear the same line she did, delivered almost verbatim. But it’s missing one key detail. “There are no known risks because no one has looked,” she adds.
...
"Egg donation has thrived in the US in part because there are few laws regarding the transfer of unfertilized eggs for reproductive purposes, according to industry experts. They say a handful of states have policies that touch on some aspect of egg donation, generally from the perspective of the recipient.

With few regulations, the US has become a magnet for well-off wannabe parents in other countries where egg donation is regulated, or outright illegal. Egg donation is barred in China, Germany, Italy, and Norway; paying women to donate eggs is prohibited in most of Europe, as well as in Canada and other nations.
...
"In 2011, an egg donor sued ASRM [American Society for Reproductive Medicine] over the organization’s compensation guidelines, which the donor claimed were a form of illegal price-fixing; other donors later joined the case. In a 2016 settlement, ASRM agreed to eliminate its payment suggestions, pay $1.5 million in legal fees, and give the plaintiffs $5,000 each. Agencies were freer to offer donors more money.
...
"Since then, donor pay has soared, particularly for attractive, well-educated donors."


HT: Stephanie Lo

A wedding while expecting "twiblings"

The NY Times has a very 21st century wedding announcement, of two husbands who both wanted to be fathers. Read it all here and feel proud to be human:
And You Thought Your Family Was Modern

Here's the surrogacy bit:

"Dr. Luo, 40, known for his meticulous organizational skills, created a database to track the multiple agencies, fertility doctors, legal issues, egg donors and surrogates involved in fulfilling the couple’s dream of having children.

"However comprehensive, Dr. Luo’s document could not calculate the many emotional ups and downs on the San Francisco couple’s journey to parenthood.

"Yet if all goes as planned, come September, after three years, the involvement of three women, and a significant financial investment — about $300,000 — the couple will be changing diapers for two babies. A boy and a girl, conceived with eggs from the same donor, will each be tied biologically to one of the men. In today’s parlance, they’ll be “twiblings.”

“We’re living our version of our parents’ American dreams,” said Dr. Luo..."

Surrogacy laws in Europe (mostly banned) and some countries where it is allowed

EuroNews has the story (and a map):

Where in Europe is surrogacy legal?

Families Through Surrogacy provides some information about countries around the world that allow surrogacy

The table below lists issues related to surrogacy in various countries which allow it.

COUNTRY	LIMITATIONS	EGG DONORS
AUSTRALIA	Altruistic surrogacy only available. No donor or surrogate matching available. Advertising for surrogates not legal. All donors must be identified Ethics committee approval often required. Foreigners cannot access surrogacy in Australia	User groups such as www.eggdonationaustralia.com.au can provide
CANADA	Altruistic surrogacy only available. Foreigners can access surrogacy	via seperate Egg donor providers
GREECE	Heterosexual couples and single females eligible. Foreign nationals allowed to engage. Surrogate cannot be compensated beyond out-of-pocket expenses	Donors, if required, must be anonymous. Eggs/embryos/sperm are able to be shipped directly from your registered clinic.
GEORGIA	Compensated surrogacy available  to heterosexual couples, including foreigners. Legal protections in place
INDIA	Only available for Indian residents	In-country donors are anonymous however donor photos may be available other details provided: age, height, weight, previous donation history, children, blood group, education level/ occupation
ISRAEL	Altruistic surrogacy available only to heterosexual Israeli residents
KENYA	Compensated surrogacy available to locals and foreigners. No legal protection
LAOS	Compensated Surrogacy available  to foreigners. Gestation & birth occurs in Thailand. No legal protection
MEXICO	Tabasco state closed to surrogacy. Other states have no legal protections. Embryo transfer occurs in Cancun or Mexico City often	Caucasian and Latin Sperm and Egg Donors available. Possible to bring your own surrogate and /or known donor. No waiting list
NIGERIA	Altruistic and commercial surrogacy available to Nigerian heterosexual residents	Egg donors available
SOUTH AFRICA	Altruistic surrogacy available to heterosexual South African residents
THAILAND	Only available altruistically to Thai residents
UK	Altruistic surrogacy only available. Advertising for surrogates not legal foreigners cannot access surrogacy in UK
UKRAINE	Only heterosexual married couples	Caucasian, offer photos with family history, occupation/ area of study, previous donor history and physical details.
USA	Gay and heterosexual foreigners can access surrogacy here see surrogacy laws by US state	Very wide range available from donor agencies or privately

COUNTRY	APPROX COSTS($US)	DONOR & SURROGATE SCREENING	YEARS EXPERIENCE	LEGAL ISSUES
AUSTRALIA	IVF: $25,000 Expenses: $10,000 Legals & counselling: $22,000	Donor screening offered only if through an egg bank	<5 td="" years="">	Transfer of legal parentage available 4-6 months post birth if uncompensated surrogacy used domestically.
GEORGIA	IVF: $8,500 Surrogacy: $26,000 + Local egg donor add $5,000 +	according to age, genetics and lifestyle, mental and physical health	10 years	Intended Parents named on birth certificate to meet the criteria of countries such as the UK, single surrogates are available and DNA testing is available
CANADA	$90,000		>15 years	Transfer of parentage. Canadian passport available
KENYA	$50,000		<3 td="" years="">	No legal protection
UK		Surrogacy UK, COTS	>15 years	Transfer of legal parentage available
USA	IVF costs: $25,000 Surrogacy: $68,000 Other costs: $20,000	Varies by agency	30 years	Parents names on the BC as mother and father
UKRAINE	IVF: $8,500 Surrogacy: $26,000 + Local egg donor add $5,000 +	according to age, genetics and lifestyle, mental and physical health	~5 years	Intended Parents named on birth certificate to meet the criteria of countries such as the UK, single surrogates are available and DNA testing is available. No eligibility for Ukraine citizenship
GREECE	IVF: $20,100 Surrogacy: $44,000 Legals: $10,000+ Local egg donor: $1,360		10+ years	Recently opened up to foreigners Parents names on the BC as mother and father. Court case prior to IVF ensures transfer of parentage occurs before embryo transfer
MEXICO	$80,000 (incl US egg donor)	unknown	<1 td="" year="">

Two California surrogacy stories from Europe, and a (pretty sad) one from Italy via Russia

Here's a late breaking story about an Italian couple that enlisted a surrogate in Russia, had the child taken from them by Italian authorities, and has just lost their appeal to the European Court of Human Rights.

ECHR rules in surrogate case--Court overrules its previous verdict
 "(ANSA) - Strasbourg, January 24 - The European Court of Human Rights said in a ruling Tuesday that Italy had not breached the rights of a couple after taking away a child born to a surrogate mother in Russia with whom they had no biological ties. The child was taken away from the couple after they returned from Russia following DNA testing showed that neither the man or the woman were its biological parent, even though a Russian birth certificate put them as parents.
    Tuesday's ruling overrides a previous decision made by the Strasbourg court in January 2015. "The Court considered that the contested measures had pursued the legitimate aims of preventing disorder and protecting the rights and freedoms of others," the ECHR said. "On this last point, it regarded as legitimate the Italian authorities' wish to reaffirm the State's exclusive competence to recognise a legal parent-child relationship - and this solely in the case of a biological tie or lawful adoption - with a view to protecting children".
    The child has been adopted by another family."

"PARADISO-CAMPANELLI VERSUS ITALY"
Surrogate motherhood: stopped by the European Court for Human Rights. The Chambre supports the Italian Court
"(Strasbourg) “The Court rules that the relationship between the applicants and the child is not part of family life”: this has been ruled by the Grande Chambre of the European Court of Human Rights, issued today about “Paradiso-Campanelli versus Italy”. The case is about an Italian couple living in the province of Campobasso, who went to Russia in 2011: through a private organisation, the married couple had had a child from a “surrogate mother” who has no biological relationship with the couple. Under Russian law, the couple could record the child as their own child, but, once back in Italy, the Court refused to record the child as the couple’s child and, after finding there was no biological relationship, it ruled that the child should be taken away from the applicants (the child was about eight months old back then) and then adopted by a different family. Today’s ruling overturns a ruling issued by the Court in January 2015: it claimed that taking the child away from the first couple breached article no. 8 of the Convention on Human Rights (right to private and family life), regardless of the child’s interest. The new ruling states, instead, that the Italian Court had actually ruled in the child’s interest and also stopped surrogate motherhood."

HT: Dorothea Kuebler
**************************
Here are two earlier stories, set in England and Italy, from the blog Above the Law. about surrogacy as a repugnant transaction (at home) and the resulting fertility tourism (to California):

1."British aristocrats, the Viscountess and Viscount Weymouth... welcomed their second son on December 30, 2016. In what is likely a first for the British aristocracy, the child was born via surrogate.

The baby boy is the second grandson of the 7^th Marquess of Bath. I’ll just assume this is kind of a big deal in England. Lady Weymouth suffers from medical complications that made a second pregnancy too dangerous. So the couple turned to a California surrogate. To their credit, they are reportedly* sharing their story to help remove some of the stigma associated with surrogacy. Welcome and all hail the Right Honourable Henry Thynn. No typo. Honorable is spelled that way on purpose."

*They explain the differences between surrogacy in California and Britain as follows:

"Ceawlin explains that the US state has the most advanced legal system for the procedure. 
For example, it allows money to be exchanged, while Britain insists no more than expenses can be paid to the woman who will carry the child.
‘Obviously, we would have preferred to do it closer to home, but the legal system in Britain has not evolved with medical technology, so any contract with a surrogate is not binding,’ he says. 
‘Even if the baby is 100 per cent yours (ie the sperm and egg) the surrogate still has the right to keep the baby. California has the most evolved legal system in the world [for surrogacy].’ 

2. "Italy Is Not A Great Place To Be Gay. The parents of the twins are a gay Italian couple. While the U.S. made the move to permit gay marriage in 2015, Italy still denies same-sex couples the right to marry. Italy also denies gay couples the right to adopt children. Italian same-sex couples can’t even adopt their own family members through kinship adoptions. And, unsurprisingly, there is no same-sex step-parent adoption since gays can’t marry in the first place.

Having limited family-building options, the couple turned to an egg donor and California surrogate to conceive their children, and complete the family they dreamed of. Two embryos were transferred to the same surrogate. One was a donor egg fertilized with sperm from dad 1; the second was a donor egg, but this time fertilized with sperm from dad 2. The twins are biologically half-siblings with the same birthday. The conditions for an Arnold Schwarzenegger/Danny DeVito situation probably couldn’t have been set any higher.

This Is What Partial A Victory Looks Like. The fathers returned from the United States to Italy with their twins in tow. But the Italian government initially refused to recognize the children as (1) sons of the fathers, and 2) eligible for Italian citizenship. The fathers’ appealed, and were able to obtain what many consider a victory.

The court determined that despite the children being born to a gay couple (strike 1), using donor eggs (strike 2 – donating eggs and/or sperm is illegal in Italy) and to a surrogate (strike 3 – surrogacy is also illegal in Italy), it would be in the children’s best interest for Italy to recognize the parent-child relationship. The court awarded parental rights of each individual twin to the genetically related father."  

(NB: the two twins aren't legally related in Italy...)

"It Could Have Been Much Worse. While this was not a complete victory, it was a step forward for Italy. In prior cases, an Italian court has denied parentage to both parents — or even taken away a surrogate-born child from the parents and made the child a ward of the state! In an infamous case from 2014, an infertile couple in their 50s — who had been turned down for adoption three times — turned to surrogacy. They paid a Ukrainian surrogate €25,000 to carry a child conceived with donated genetic material. When they brought the child back to Italy, the government refused to register the child as theirs and charged them with fraud. Sadly, the court went further, ruling that the child, whose genetic and surrogate parents were unknown, was a “child of no one.” Despite even an Italian prosecutor advising that the child be allowed to stay with the intended parents, the court ruled that the child must become a ward of the state and put up for adoption. Heartbreaking.

Europe’s Anti-Surrogate Tendencies. Italy is not an anomaly. Most of Western Europe (including France, Spain, and Germany, among others) bans surrogacy. This has led to a number of troubling cases when Europeans go elsewhere for surrogacy and then try to bring their children home. In France, for instance, several surrogacy cases have involved French courts denying parental rights. But couples have had success appealing to the European Court of Human Rights. There, a child’s right to his or her parents has prevailed over French domestic law."

**************************

Caps on payment to egg donors abolished in antitrust settlement

Kim Krawiec has the news at the Faculty Lounge:  below is her post

Egg Donors Get Pay Limits Axed With Antitrust Settlement

From Law360:

Egg Donors Get Pay Limits Axed With Antitrust Settlement

By Kelly Knaub

Law360, New York (February 1, 2016, 7:01 PM ET) -- A class of human-egg donors who allege the American Society for Reproductive Medicine violated antitrust laws by capping compensation to donors asked a California federal court Friday to approve a settlement requiring the organization to remove the compensation guideline, calling the agreement an “excellent resolution” of the case.

Under the proposed settlement, ASRM will remove language stipulating that “[t]otal payments to donors in excess of $5,000 require justification and sums above $10,000 are not appropriate,” effectively benefiting all women who donate eggs in the future.

. . .

In addition, ASRM will pay a total of $1.5 million under the agreement to compensate the plaintiffs’ counsel for fees and costs incurred in in the litigation, as well as up to $150,000 to cover the costs of notice to the class.

They could have saved that $1.5 million dollars in legal fees if they had listened to me about this back in 2009.  :-)

Related posts:

The NY Times Weighs In On Egg Donor Price Fixing

If You Want A Market, Have A Market . . . Otherwise

“Feeble Even By Normal Litigation Standards”

Egg Donor Antitrust Suit In Today’s WSJ

Sunny Samaritans’ Suit Survives

ASRM Seeks Dismissal of Egg Donor Suit

Kamakahi v. ASRM et al. — Updates

Politics And Profits in The Egg Business (When Sunny Samaritans Sue, IV)

When Sunny Samaritans Sue, Part III

When Sunny Samaritans Sue, Continued

When Sunny Samaritans Sue

The Value of Smart Eggs

Posted by Kim Krawiec at 03:24 PM in Reproductive Markets, Taboo Trades | Permalink

Is it unethical to pay more than $10,000 for human egg donation? (An antitrust suit...)

The NY Times has the story: Egg Donors Challenge Pay Rates, Saying They Shortchange Women

"In a federal lawsuit, a group of women are challenging industry guidelines that say it is “inappropriate” to pay a woman more than $10,000 for her eggs. The women say the $10,000 limit amounts to illegal price-fixing, and point out that there is no price restriction on the sale of human sperm. A federal judge has certified the claim as a class action, which will most likely go to trial next year.
...
"While many other countries limit egg donation and the compensation that is allowed, egg donation is essentially unregulated in the United States. But in 2000, the American Society for Reproductive Medicine established the guidelines for how much women should be paid. They say that compensation over $5,000 requires “justification,” and that more than $10,000 is “beyond what is appropriate.” The amounts have never been adjusted.

The society argues that capping the price ensures that low-income young women are not drawn to donate by a huge payout without considering how it may affect their lives.

“If the compensation became too high, there is a concern that it might be incentive for donors to lie about their medical history,” said Tripp Monts, a lawyer representing the society. “And it could induce young women to donate without thinking too far down the road.”

Do pricing guidelines for human eggs violate antitrust laws?

The WSJ has the story:
Putting a Price on a Human Egg
Lawsuit claims price guidelines used by fertility clinics artificially suppress the amount women can get for their eggs

"How much is a human egg worth? The question is at the heart of a federal lawsuit brought by two women who provided eggs to couples struggling with infertility.

The women claim the price guidelines adopted by fertility clinics nationwide have artificially suppressed the amount they can get for their eggs, in violation of federal antitrust laws.

The industry groups behind the price guidance—which discourages payments above $10,000 per egg-donation cycle—say caps are needed to prevent coercion and exploitation in the egg-donation process.

But the plaintiffs say the guidelines amount to an illegal conspiracy to set prices in violation of antitrust laws. The conspiracy, they argue in court papers, has deprived women nationwide a free market in which to sell their eggs, and enabled fertility clinics to “reap anticompetitive profits for themselves.”

“It’s naked, illegal price-fixing,” said Michael McLellan, a lawyer for the women.
...

...
"Other egg donors say a robust market depends on compensation. “I helped couples achieve their dreams, and in return they helped me go to law school, buy an apartment, pursue my dreams when I was in my 20s,” said Gina-Marie Madow, a four-time egg donor now working as a lawyer at Circle Egg Donation, a Boston-based egg-donation agency. Ms. Madow said $10,000 “feels like the right amount for women to get” for a cycle but didn’t understand the reason behind the price cap. “I just don’t think the [organizations have] done a good job explaining why it exists,” she said.

The price caps might also guard against worries that women might pay more for eggs from mothers of certain ethnic or racial backgrounds, or with such traits as physical beauty or high intelligence. Such a market exists, largely through a small number of agencies that cater to couples willing to pay a premium.

“It’s a concern about eugenics, that women will pay more for eggs from an Ivy League grad,” said John Robertson, a professor of law and bioethics at the University of Texas.

Kimberly Krawiec, a law professor at Duke University who has studied the egg-donor industry, played down such concerns, adding that mothers-to-be generally aren’t looking to build a genetically superior child. Ms. Krawiec said she had little issue with couples paying more for eggs from women with, say, high SAT scores. “Fertile people have been screening for beauty and intelligence for years and years,” she said. “It’s called dating.”

Egg donation in Israel at a new, higher price

Egg donors to be compensated with NIS 19,000

"The Knesset's Labor, Welfare and Health Committee approved raising compensation sum to egg donors to NIS 19,000 ($5200) due to lack of donors.

"Since the bill to allow women to donate eggs in Israel was approved over a year and a half ago, only seven women had donated eggs, and were given NIS 10,000 ($2800). The Health Ministry requested to raise the compensation total in order to increase the number of donors due to severe shortage of eggs."

Repugnant markets involving altruistic motivations

Kim Krawiec follows up on Kieran Healy's work on markets for organs, and how the distinction between gift giving and buying and selling isn't so clear.

Krawiec writes (I quote at length, but not the whole thing):

"...I agree with Kieran that financial incentives for human organs are more likely to win social acceptance if they resemble the gift-based allocation systems that have already gained social legitimacy. And the oocyte market – a clearly market-based system with the trappings of gift, including the language of donation -- is a good example of this phenomenon. 

In fact, as I’ve discussed before, this disconnect between market realities and gift narrative is an important feature of many taboo trades.  By normalizing otherwise jarring transactions, gift narratives may facilitate markets that otherwise would stagnate under the weight of social disapproval. For those, like me, who believe there is social value in enabling the infertile to reproduce or those dying from kidney failure to live – and, by corollary, allowing those who consider themselves better off by the receipt of compensation in exchange for an egg or kidney – to do so, this is a good thing. 

At the same time, though, the oocyte market example also illustrates the costs of denying market realities in favor of the pretense of gift exchange -- gifts in name only: 

(1) Legal misfit

Gift-based exchange regimes are typically governed by a different set of legal rules than are market-based exchange regimes.  We tend to recognize, for example, the possibilities for opposing interests and opportunistic behavior in a regime of market-based exchange.  And many legal rules governing market-based regimes are designed with these considerations in mind. In contrast, we often assume (incorrectly, especially when the gift is one in name only) an absence of opportunism and an alignment of interests in the case of gift-based exchange. 

(2) Social stereotypes

I do not know if, or how, this would play out in organ markets, but it has for some time concerned me with respect to reproductive markets, especially the oocyte and surrogacy markets.  Scholars have long noted the presumption that many services provided by women, including reproductive and domestic labor, should be provided altruistically, despite their high economic value.  Says Mary Anne Case, for example:

Much of what women have market power over, such as their sexual and reproductive services, they have long been expected not to commodify at all. Even when monetary compensation is allowed, it is often kept low and female providers are expected to be interested in rewards other than money.

The continued insistence that egg donors are, and should be, motivated primarily by altruism and the desire to help others, rather than by the desire for monetary compensation, threatens to reinforce gendered notions that the market activities of women are driven in large part by altruism and that women as a group are uninterested in reaping the full gains of trade from the provision of their goods and services. 

The comparison to sperm markets is especially telling. The insistence on the altruistic motivations of egg donors is in stark contrast to the presumed motivations of sperm donors, who are recruited through materials that ask, “Why not get paid for it?” and advertise, “your sperm can earn!” 

...

In the end, gifts in name only represent a trade-off.  On the one hand, the language of donation coupled with the realities of market-based exchange has the capacity to legitimate otherwise troubling exchanges, facilitating life-saving operations and parenthood for the infertile.  At the same time, gift-in-name-only exchange has consequences for the social, legal, and market structure of these industries, and for the consumers, producers, and others, including the public-at-large, affected by them."

Ad for custom egg donor

An ad in the Harvard Crimson (the student newspaper) reflects some of the fast-changing world of same-sex marriage and the market for reproductive services, with a mixed-race married gay couple looking for a Caucasian-Chinese mixed race egg donor. I infer that the market for surrogate wombs may also be involved.

**************

(This also reminds me of the work Kim Krawiec has been doing on the American Society for Reproductive Medicine’s guidelines for compensating oocyte donors. ("Total payments to donors in excess of $5,000 require justification and sums above $10,000 are not appropriate.")

Kim's recent blog posts on the subject are here, here, here and here, and her paper is here: Krawiec, Kimberly D., Sunny Samaritans and Egomaniacs: Price-Fixing in the Gamete Market (May 23, 2009). Law and Contemporary Problems, Vol. 72, No. 3, 2009; UNC Legal Studies Research Paper No. 1356012. Available at SSRN: http://ssrn.com/abstract=1356012

Outsourcing reproduction

The WSJ has an article on Assembling the Global Baby
"With an international network of surrogate mothers and egg and sperm donors, a new industry is emerging to produce children on the cheap and outside the reach of restrictive laws."

"In a hospital room on the Greek island of Crete with views of a sapphire sea lapping at ancient fortress walls, a Bulgarian woman plans to deliver a baby whose biological mother is an anonymous European egg donor, whose father is Italian, and whose birth is being orchestrated from Los Angeles.

"She won't be keeping the child. The parents-to-be—an infertile Italian woman and her husband (who provided the sperm)—will take custody of the baby this summer, on the day of birth.

"The birth mother is Katia Antonova, a surrogate. She emigrated to Greece from Bulgaria and is a waitress with a husband and three children of her own. She will use the money from her surrogacy to send at least one of her own children to university.

"The man bringing together this disparate group is Rudy Rupak, chief executive of PlanetHospital.com LLC, a California company that searches the globe to find the components for its business line. The business, in this case, is creating babies.

"Mr. Rupak is a pioneer in a controversial field at the crossroads of reproductive technology and international adoption. Prospective parents put off by the rigor of traditional adoptions are bypassing that system by producing babies of their own—often using an egg donor from one country, a sperm donor from another, and a surrogate who will deliver in a third country to make what some industry participants call "a world baby."

"They turn to PlanetHospital and a handful of other companies. "We take care of all aspects of the process, like a concierge service," says Mr. Rupak, a 41-year-old Canadian.
...
"PlanetHospital's most affordable package, the "India bundle," buys an egg donor, four embryo transfers into four separate surrogate mothers, room and board for the surrogate, and a car and driver for the parents-to-be when they travel to India to pick up the baby.

"Pricier packages add services like splitting eggs from the same donor to fertilize with different sperm, so children of gay couples can share a genetic mother. In Panama, twins cost an extra $5,000; for another $6,500 you can choose a child's gender.
...
"Greek surrogacy is regulated by a 2005 law, but the business takes advantage of a legal loophole. Surrogate mothers are not supposed to act for profit. However, they can accept money for pregnancy-related expenses. Typically, the expenses are set at up to $50,000.

"The judge never asks" about the money, says Maria Kouloumprakis, a surrogacy lawyer in Greece. Ms. Kouloumprakis calls the situation "an emptiness in the law."

"Egg donors often come from the U.S. or Eastern European countries since white parents tend to prefer fair-skinned children. Those countries allow donor anonymity. Parents on tighter budgets might opt for a donor from India or Latin America. Sperm is often provided by the fathers-to-be, though it's also available from a network of sperm banks in the U.S. and Europe.
...
"Many factors drive surrogacy's global spread. China and other big adoption destinations have toughened their rules in recent years. Some developed countries, including Japan, Spain, Germany, Italy and France, outlaw or severely restrict surrogacy at home. The United Kingdom prohibits surrogacy for pay, and in 2005 banned donor anonymity. Some U.S. states prohibit surrogacy for pay, and in recent years some have outlawed gay adoption.
...
"[In India, a] couple made payments as the pregnancy progressed, with the final amount due at birth. Of the $35,000, PlanetHospital keeps around $3,600. Another $5,000 goes to the egg donor, plus another $3,000 or so for travel expenses. The surrogate gets $8,000. The rest, around $15,000, is paid to the clinic.
...
"No country has become a greater magnet for the business than India, which made surrogacy legal in 2002. It has an ample supply of inexpensive surrogates and egg donors. There is little regulation beyond guidelines that set age limits for surrogates and prohibit a woman from acting as a surrogate more than three times.
...
"Surrogacy's complexity can give rise to extraordinarily difficult decisions, such as whether or not to abort. This can happen because clinics sometimes implant multiple embryos into multiple surrogates to improve the odds: If one miscarries, there are still viable pregnancies. However, if several implants successfully lead to pregnancy, clients face ending up with not just one or two children, but many."

And here is the PlanetHospital website--they are involved in all sorts of "medical tourism," not just reproductive services.

The market for human eggs

Here's a multifaceted article on the global market for human eggs and fertility treatment, with medical tourists flowing from countries with more restrictive laws to those with few or none: Unpacking The Global Human Egg Trade

"According to a 2010 study by the European Society of Human Reproduction and Embryology, nearly 25,000 egg donations are performed in Europe for fertility tourists every year. More than 50% of those surveyed traveled abroad in order to circumvent legal regulations at home. The Cypriot government estimates that, each year, 1 in 50 women on the island between the ages of 18 and 30 sells her eggs. One NGO analyst says that among the island's Eastern European immigrants, the rate may reach 1 in 4, and some women give up their eggs several times in a year. By comparison, only 1 of every 14,000 eligible American women donates.


"Donation is described as an altruistic act, which means no payments," says Savvas Koundouros, a Cypriot embryologist, as he draws heavily on a cigarette. "It sounds strange to all of us that a person would receive so many injections over weeks and then undergo general anesthesia just because they are kind people." Koundouros has impregnated more women than Genghis Khan -- and thanks to a system that does not in any way rely on altruism, he plans to seed many, many more. He recently invested more than 1 million euros in a state-of-the-art IVF clinic in the resort city of Limassol.
...
"Peter Singer, the Ira V. Decamp professor of bioethics at Princeton, doesn't necessarily have a problem with the sale of eggs. "I don't think that trading replaceable human body parts is in principle worse than trading human labor, which we do all the time, of course. There are similar problems of exploitation when companies go offshore, but the trade-off is that this helps the poor to earn a living," he says. "That's not to say that there are no problems at all -- obviously, there can be -- and that is why doing it openly, in a regulated and supervised manner, would be better than a black market." Note that he says "would be."


"While the clinics of Cyprus sometimes feel like frontier outposts, the ones in Spain can seem like established fortresses. Spain has been the top destination for European fertility tourists since the mid-1980s. At Barcelona's Institut Marquès, a 14th-century carriage house in one of the poshest parts of town, you can understand why....

"In 2007, the U.K. banned payments to egg donors. In 2009, the Institut Marquès opened a satellite office in London, offering full-service, pregnancy-guaranteed packages for as little as $37,000 for three IVF cycles. The stream of foreign customers has become so steady that the clinic no longer waits for patients to sign on before tracking down appropriate donors. Instead, it keeps a bull pen of women on hormones, ready to give up their eggs. "Sometimes we will lose the eggs if we can't find a customer, but it's a trade-off," says embryologist Josep Oliveras. "This way, we can guarantee a steady supply."
...
"Perhaps more than any other company, Elite IVF has transformed baby-making into a globalized, industrialized process. For Sher, outsourcing is simply the inevitable outcome of the science that allowed procreation to move out of the bedroom and into the lab. Like the Petra Clinic and the Institut Marquès, Elite IVF offers clients cheaper access to eggs and a full suite of fertility treatments; unlike those more-localized operations, Elite operates worldwide, with offices and partner clinics in Britain, Canada, Cyprus, Israel, Mexico, Romania, and the U.S. Sher plans to expand soon to Turkey, taking advantage of new bans on egg donation there.


"Sher sees the regulatory and price differentials in eggs as an opportunity to reduce the cost of raw materials, pass the savings on to his customers, and offer them virtually any fertility service that they can't get at home. Want sex selection, which is illegal in most countries? A Mexican clinic can help you. Too old for IVF in the U.S.? Cyprus is the answer.

"Today, Elite IVF's network of clinics, egg sellers, and surrogate moms produces between 200 and 400 children per year, helping create families like Aron and Shatzky's. And it's just going to get more complicated. "The future is designer babies," says Sher. He describes an offer he once received from an investor interested in partnering with Elite IVF. "Surrogates in Asia would carry the eggs of superdonors from America -- models with high SAT scores and prestigious degrees who would be paid $100,000 for their eggs. Those babies could sell for $1 million each -- first to his friends, then to the rest of the world."

"Sher declined the offer, but says it is only a matter of time before someone moves in that direction. At that point, maybe governments will get more involved. McGee, the bioethicist, predicts that "we will soon begin to recognize the danger of an ant-trail model of reproduction whereby strangers without any responsibility to each other and clinicians able to vanish in a puff of smoke meet in a transaction that culminates in humanity's ultimate act: creation."

HT to MR

Egg shortage in Britain

Desperate hunt for donor eggs forces couples to seek IVF abroad, the Telegraph reports.

"Waiting lists for fertility treatment involving donated eggs have risen in this country since laws were changed to prevent women from donating anonymously.

"Now research shows the national shortage is the main reason couples go abroad for fertility treatment, with almost half of British "fertility tourists" going to Spain, where anonymity is allowed, and donors receive generous compensation.
"The study for the Economic and Social Research Council found that women who left Britain for IVF treatment were most likely to do so in search of a donor eggs, after encountering long waits in this country. "...
"Almost half of the women went to Spain thanks to policies which pay women up to 1000 euros to donate eggs, while remaining anonymous.
"Next was the Czech Republic, which also allows anonymous donation, and more generous payments than this country, where clinics are only allowed to provide £250 to those who donate eggs.
"Others went to the United States, South Africa, Barbados, Russia and Ukraine."...
"Research collaborator Dr Allan Pacey, a fertility expert from Sheffield University, said the findings of the research suggested more should be done to encourage egg donation in this country, including more generous compensation payments for those who underwent the procedure.
"Since legislation was passed in 2004 ending donor anonymity, the number of egg donors fell for three years, only rising marginally in 2008, the last year for which figures are held, when 1,084 eggs were donated.
"Experts believe more than double that number of donations would be required to meet current demand.
"Dr Pacey said he believed the shortage of donors in Britain was more to do with the small amount of compensation women were given rather than the lack of anonymity.
"Egg donation is a pretty horrendous thing to go through, so I think you could easily argue that £250 [the limit set in Britain] is not sufficient," he said.
"Regulators are currently reviewing the rules they set in 2006 which set the current limits.
"Prof Lisa Jardine, the chairman of the Human Fertilisation and Embryology Authority, has said that a rise in payment levels could encourage more women to donate eggs, meaning fewer infertile women would feel forced to seek treatment abroad."

More on payments for egg donors

Payment Offers to Egg Donors Prompt Scrutiny
" a study in the most recent issue of The Hastings Center Report, a leading bioethics journal, found that the compensation being touted in ads aimed at young women often exceeded industry guidelines. The study is the latest development in a long-running debate over how much — or even whether — egg donors should be paid. "...
"Last fall, California adopted a law requiring egg donor advertisements to include specific warnings about health risks. The state already bans the sale of eggs for research purposes, in accordance with guidelines issued by the National Academy of Sciences.
In contrast, New York’s Empire State Stem Cell Board decided last year that state research money could be used to pay women up to $10,000 for donating eggs."
Kim Krawiec over at Faculty lounge has an update on the extra problems facing egg donation in Israel: What Religion Is Your Egg?

Surrogacy, payments, and parental rights in Britain

Couples who pay surrogate mothers could lose right to raise the child: High court could refuse recognition to people who flout law by paying disproportionate fees to a surrogate mother overseas.

"Childless couples who acquire a baby using a surrogate mother abroad risk not being recognised as its parents in Britain if they flout British law by paying fees, fertility lawyers have warned.
Such payments, which can be as high as £30,000, could lead to those who have made them being refused permission by the high court to become the child's legal parents, specialist solicitors say.
The Human Fertilisation and Embryology Act 1990 allows couples entering into deals with a surrogate mother overseas to pay her only what is allowed here – "expenses reasonably incurred", such as compensation for time off work, medical bills and living expenses."
...
""The risk couples face if they pay a disproportionate amount in expenses is that the high court may refuse to authorise those expenses. That could result in the parental order application failing and in turn they would have no status as parents under English law," said John Randle, a leading surrogacy lawyer."
...
"International surrogacy is hugely controversial. "It's unethical and exploitative because the trade is all one-way," said Breedagh Hughes, a Royal College of Midwives spokeswoman, on the ethics of childbirth. "It reduces babies to the level of commodities." "

"Jonathan, a 32-year-old nurse, tells how he and his civil partner, Colin, 33, a financier, spent $150,000 (£98,000) on surrogacy to become the parents of Harriet, who was born in California last year. They live in London.
"We began discussing having a child in 2006, when we were deciding to become civil partners. I was feeling broody, and had always wanted to have my own biological child. We opted to pursue surrogacy in California because we would get legal custody there of the child before it was born and the surrogate would have no legal relationship to the baby.
"My sperm was introduced to eggs left by an egg donor: they were fertilised in an IVF clinic in Los Angeles and two of the embryos were implanted into the surrogate. She simply carried the child for nine months.
An agency in LA found both the egg donor and the surrogate. We never met the egg donor or knew who she was, but knew her medical history, results of her genetic tests, what she looked like and so on. We did meet and get on well with the surrogate, who was called Jennifer. She had two daughters of her own and had been a surrogate once before. There was no coercion. We had a contract, and Jennifer specified things in that like that she wanted back massages and a big hotel room for her family to stay in when she was giving birth.
Agencies in California quote a price of $100,000 to $150,000 to do everything relating to a child. The whole process wasn't too difficult, and cost us about $150,000. We paid the embryologist $60,000, though that included the harvesting of the donor's eggs, the IVF and the transfer of the embryos into the surrogate. It was $40,000 for the surrogate and $10,000 for the egg donor, plus $10,000 to the agency, who supplied the donor and the surrogate. Then there was $10,000 for our lawyer, $5,000 for the medical and psychological screening and another $5,000 for medication for both the donor and the surrogate, to ensure they were in cycle at the same time.
"Bringing Harriet into the UK nine months later was incredibly difficult, though, and we engaged lawyers to help us. She had to come in as an immigrant on a US passport on a six-month tourist visa. When we later filled in a form to get her British citizenship, we put 'not known' in the section headed 'mother'. She now has dual nationality and is legally ours under Californian law. If we do apply, it could be an issue that we paid well over the 'reasonable expenses' limit – that is, we paid a fee. That's illegal in this country, but allowed under Californian law.
"We shouldn't have to seek a parental order. She was conceived and born in California as our child, and her birth certificate says who her parents are, so the courts here should respect Californian law.
Having to apply for a parental order, where there'd be an assessment of Harriet's welfare and Colin would have to prove that he's no danger to her, is an inequity. Anybody else can go out, get drunk, get pregnant, bring up a child appallingly and face no intervention or legal barriers.
I resent people saying that British couples who resort to surrogacy are buying babies abroad. We didn't buy Harriet: she's not picked off a shelf. She's not a 'designer baby'.
We had our own child and had a great team to help us. All we did was rent a woman to carry her. We paid for the services of an embryologist and an incubator who walks and makes good babies – but we didn't buy a baby. She's my daughter biologically, and she's our baby.
A lot of heterosexual couples in the UK spend a lot of money having many cycles of IVF at £5,000 a time – is that not buying a baby?" "

HT: Nick Feltovich

Egg donor compensation

Study hard. The Globe reports: Yes, top students reap rich rewards, even as egg donors
Would-be parents want high scorers

"The Harvard Crimson was one of three college newspapers that ran an identical classified ad seeking a woman who fit a narrow profile: younger than 29 with a GPA over 3.5 and an SAT score over 1,400. The lucky candidate stood to collect $35,000 if she donated her eggs for harvesting.

The ad was one of 105 college newspaper ads examined by a Georgia Institute of Technology researcher who issued a report yesterday that appeared to confirm the long-held suspicion that couples who are unable to have children of their own are willing to pay more for reproductive help from someone smart. The analysis showed that higher payments offered to egg donors correlated with higher SAT scores.
“Holding all else equal, an increase of 100 SAT points in the score of a typical incoming student increased the compensation offered to oocyte donors at that college or university by $2,350,’’ wrote researcher Aaron D. Levine.
The paper, published in the March-April issue of the Hastings Center Report, examined ads in 63 student newspapers in spring 2006 and was billed as the first national cross-sectional sample of ads for egg donors. "
...
"Concerned about eggs being treated as commodities, and worried that big financial rewards could entice women to ignore the risks of the rigorous procedures required for harvesting, the American Society for Reproductive Medicine discourages compensation based on donors’ personal characteristics. The society also discourages any payments over $10,000.
Levine’s paper points out, however, that no outside regulator enforces those guidelines and that they are often ignored.
Of the advertisements Levine examined, nearly one-quarter offered donors more than $10,000, and about one-quarter of the ads listed specific requirements, such as appearance or ethnicity, also in violation of guidelines that discourage greater payment for particular personal characteristics."
...
"The issue of the report containing Levine’s analysis also offers a counterperspective from John A. Robertson, who chaired the ethics committee of the American Society of Reproductive Medicine. He casts doubt on the notion that it is an ethical problem to pay more for eggs from a woman with a particular ethnic background or high IQ. “After all, we allow individuals to choose their mates and sperm donors on the basis of such characteristics,’ Robertson wrote. “Why not choose egg donors similarly?’’ "

See also The Value of Smart Eggs from The Faculty Lounge by Kim Krawiec.
"In his response accompanying the report, John Robertson (Texas, law) questions whether there are really any ethical problems raised by the study – after all, Levine finds compliance with the ASRM guidelines in at least half the advertisements in his sample. I would argue, however, that Levine’s study highlights a serious ethical issue, though it is not infertile couples or the agencies working on their behalf whose behavior is ethically troubling. It is ASRM’s paternalistic and misguided attempts to control oocyte donor compensation through the same type of professional guidelines that courts have rejected when employed by engineers, lawyers, dentists, and doctors that should raise an ethical red flag."

And here is the Hastings Center Report: Self-Regulation, Compensation, and the Ethical Recruitment of Oocyte Donors by Aaron D. Levine