The author thanks the anonymous reviewers for their valuable comments and suggestions.
1Today, adoption and assisted reproduction can be considered to be two different ways for having children, when this does not happen in the more traditional way. The choice of resorting to assisted reproduction rather than adoption is one that is extremely personal, in the sense that each person or couple decides the preference most resonant with their own thinking on becoming parents.
- 1 In Italy Assisted Reproductive Technology refers to medically assisted reproduction: the expressio (...)
2At the root of these considerations is the desire for a child. The desire to embark on a journey to have a child – through ART1 or adoption – reflects an intention, which refers to the intentionality that drives our choices, decisions and actions: this intention is developed on more than one level, the biological, as well as the psychic and existential one. After all, this desire can be read in moral terms as an opening to the other: we speak of an ethics of the “third included”, that is, when the ethic that emerges from the singularity, and from the relationship I-you, opens up to the other—the third (Malherbe 2014).
3We are, and we exist because someone decided that s/he wanted us, that s/he welcomed us, that s/he cared for us. This brings us back to what in ethics is defined as a way and a form of recognition, which also represents the way we define who we are, and what our identity is.
4In recent years, there has been a return to a closer attention to the practice of surrogacy in the ART debate. Both at European and international levels, this currently represents one of the most controversial scenarios in the practice of medically assisted reproduction.
5Surrogacy is used in response to the difficulties, or impossibility of a couple, a woman, or a man to carry a pregnancy. An important distinction in the surrogacy debate concerns genetic, or traditional surrogacy, in which a woman makes her eggs available and agrees to carry a pregnancy for someone else, often after artificial insemination, thus creating a genetic and gestational link between her and the unborn child. So-called ‘gestational surrogacy’ represents a pregnancy conducted for others by a woman who has no genetic link with the fetus and the unborn child. If, instead, a woman who carries the pregnancy is paid, the practice is considered commercial surrogacy. By contrast, “gestational surrogacy for others”, or “altruistic surrogacy” is when a woman acts as a surrogate for altruistic reasons, without compensation.
- 2 As far as Ukraine is concerned, access to the practice is provided for heterosexual couples with a (...)
- 3 The use of these techniques is allowed only to couples who are residents of the country.
- 4 The US states that have legalized this practice are Alabama, Arkansas, California, Connecticut, Il (...)
- 5 The law defines forms of protection for surrogate mothers both in terms of the conditions under wh (...)
6Not all countries approve such practices from a legal point of view. Some countries prohibit surrogacy, others permit only altruistic surrogacy, without any form of payment, while other countries actively favour the practice of maternity for payment or altruistic surrogacy, legalizing and/or regulating it. The fourth scenario is represented by those countries that do not clarify the issue, not taking a clear position on it. In Europe, the countries that have banned the practice of gestation for others, both paid and altruistic are Austria, Bulgaria, France, Germany, Italy, Norway, Portugal, Spain, Sweden and Switzerland. Altruistic surrogacy is permitted in some European countries, in particular in Belgium, the Netherlands, Denmark, Great Britain, Greece, Portugal and Ireland. Both altruistic and not-for-profit surrogacy is also allowed in Israel, Vietnam, New Zealand and some states in Australia, as well as in Canada, in Brazil and in Mexico, where the first law on altruistic surrogacy was enacted in Mexico City in 2010. Commercial surrogacy has been legalized in Russia, Ukraine,2 Uganda, Nigeria, Kenya, Thailand3 and in some states of the USA4: these countries have regulated surrogacy practices, but with few restrictions, in particular with regard to the origin of the parents, who may or may not be residents and citizens of that country. The practice of commercial surrogacy is on the rise in the United States, where it is estimated that around 1000 women per year act as surrogates (Armour 2012). India, where liberal guidelines on commercial surrogacy had been defined in 2002, sanctioned a ban on international surrogacy with the Assisted Reproductive Technology (Regulation) Bill (2014), preventing access to clinics and profit-making interventions for non-Indian couples. The recent Surrogacy (Regulation) Bill (2019) prohibits any form of commercial surrogacy and allows only altruistic surrogacy, which can be requested exclusively by Indian couples.5
7In recent years, numerous studies and research have been carried out, for example in Great Britain and Australia, from which interesting data has emerged regarding the psychological implications for women who act as surrogate mothers, and regarding the parental relationships established between them and the ‘commissioning’ parents. These studies demonstrate that women who gestatee for others often show recurrent characteristics, such as greater resilience, an ability to live without excessive anxiety during pregnancy, as well as the ability to detach from the child. For this reason, it is recommended that women who become surrogate mothers be particularly “resilient” from a psychological point of view (Pizitz, McCullaugh, Rabin 2013). With specific regard to the parental relationships thereby created, there is progressive consideration of the possibility of maintaining relationships and contacts between sponsoring parents, the child and the surrogate mother herself (Imrie, Jadva 2014). These relationships seem to become less close as the children grow up, particularly when the surrogate mothers were not known to the parents before starting the assisted reproduction process (Jadva et al. 2012).
8For all involved parties, the potential benefits and risks arising from the use of assisted reproduction have been highlighted and studied by learned societies of reproductive medicine, gynecology and obstetrics, foetal medicine, and neonatology (Burrell, Edozien 2014). Moreover, some phenomenological studies reflect, from a bodily and lived point of view, on the specificity and relevance of the relationships established between mother, father and child, during pregnancy and at birth (Bornemark, Smith 2016).
- 6 See the research carried out by Debora Spar (Spar 2006) in the USA on the subject.
- 7 I am referring here to the survey conducted within the Committee on Social Affairs, Health and Sus (...)
9The “baby business” and the market for reproduction and parenting represents a key issue for ART and has been the subject of numerous studies6. At local and global levels, the impact these practices can have in terms of fairness and justice is the subject of international debate, as exemplified by the discussion within the Council of Europe on whether or not to permit practices that allow and encourage the gestation of a child by another woman when the couple or woman is unable to carry it out.7
- 8 It is estimated that infertility affects 7 million American couples: infertility affects many Indi (...)
- 9 The author highlights the dynamics of global injustice that are remarked by assisted reproduction (...)
- 10 The cost of ART in the USA today is as high as $250,000 when interventions are performed in the mo (...)
10The growing practice of so-called transnational surrogacy, which in particular leads to the movement of couples and individuals from wealthier countries to countries with developing economies, is raising complex issues of justice on a global scale. This new “procreative tourism” has brought many US couples and those of other nationalities to countries such as India, where surrogacy had been legalized with costs amounting about half or even a third of what the same couples would have to pay in their home countries (Frankford et al. 2015).8 What emerges from the studies carried out particularly concerns complex gender dynamics, an imbalance bargaining power and lack of genuine legal protection for surrogate mothers. These practices involve women who generally have a low level of schooling, are poor, and often come from rural backgrounds. It is important to understand what dynamics are triggered from multiple view points, considering the clinical risks for women, the impact from a psychological and relational point of view, as well as to their personal life and their past family dynamics. With regard to commercial dynamics and the elements of potential inequities that are thus triggered, the discussion is currently very heated. At the political level, and on an international scale, a consideration of global justice has even raised the possibility of a universal “ban” of these practices (Saravanan 2015).9 In economic terms, for example, the cost of a child obtained through assisted reproduction in the United States can be very high, compared to the costs that these interventions carry in other countries of the world.10
11How much can the use of paid practices in relation to assisted reproduction change the way we perceive the body and its value, the transmission of life and perhaps even parenting?
12In the contexts that have legalized this practice, as the United States, it has been observed over the years that the substantial investment that couples have to make in order to have a child with assisted reproduction techniques leads to a frequent recourse in speech and language to the idea of “ownership”, of ownership with respect to the child, which is also very present when we speak of “own” children, in the sense of children biologically generated by the couple: this language, on the other hand, seems less strong in situations where adoption is used (Brakman, Scholz 2006).
13One observation, which emerged in the debate, concerns the fact that disembodying, in a literal sense, the gametes and the fertilization itself from the body, we move in the direction of a sort of “objectification” of life, so to speak, or at least of some of its elements, essential, moreover: for this reason it is possible to consider these forms of life as “bio-objects”. Today, these themes deal not only with bioethics and biolaw, but also with biopolitics, which studies the policies of life considering the economic value that is thus recognized and attributed to it (Rose 2007).
14From this point of view, possible forms of control and containment of costs can help not only to guarantee forms of greater equity, but also to maintain a sort of “naturalness” of assisted reproduction interventions, avoiding falling into too much or exclusively commercial logic and instead bringing back to the forefront the most proper meaning of such interventions, that is, that of an aid that medicine can offer with respect to reproduction (Del Savio, Cavaliere 2016).
15These scenarios generate new problems both on a local and international scale, and on a global level, and the economic and commercial component must be controlled, precisely because in fact the “objects” in question are very special: they are “prerequisites” necessary for the biological and genetic transmission of life, and what derives from them is then a subject, therefore the symbolic meaning associated with them is very relevant.
16Alongside the problems of justice and the anthropological ones, related to the meaning associated to life and its transmission, there are aspects of parental relations that are thus established.
- 11 The authors observe that the experience of adoption and that of the mother and adoptive parents te (...)
17All these experiences seem to have a common trait, that of being bodily experiences and bringing the maternal body in particular to the center of the discussion. In the debate on adoptions and in the reading of motherhood, the strength of what has been defined as the “biological paradigm”, which “unduly influences the way we conceive, speak and consequently behave in relation to the different forms that the maternal body assumes” (Brakman, Scholz 2006, p. 57),11 emerges clearly. The biological paradigm also seems to be central in the approach to assisted reproduction.
- 12 A notion of this kind brings attention back to the particularity of experience, which always inevi (...)
18In the phenomenological tradition and in the debate of feminist philosophy the value of embodiment and bodily condition is highlighted, and it is emphasized that “maternity relationships are physical relationships, but they cannot be reduced to them” (Brakman, Scholz 2006, p. 69): in this tradition and in this debate, the concept of body and embodiment are considered to go beyond the simple organic condition, which remains anyway their main condition of possibility. Considering this concept of corporeity, lived experiences and relationships play an important role in helping to shape personal, moral and social identity. With the notion of “bodily motherhood”, are emphasized the “physical relationships of the subjective body-lived more than the genetic and biological links” (Brakman, Scholz 2006, p. 65).12 Rebecca Kukla noted that we can find “bodily motherhood” in “women who seek conception, women who are pregnant and giving birth, adoptive mothers, birth mothers who give their children for adoption, women who donate and ‘adopt’ gametes, and women who care for babies and children” (Kukla 2006, p. vii).
- 13 “The activity of mothering, which accompanies a child in becoming a particular social person, is a (...)
19In an alternative or complementary model to the biological and genetic paradigm, more focused on nurturing, and community, on the importance of physical relationships and even more on their social and symbolic value, motherhood, fatherhood and parenthood can be read as a kind of “community event”. The very act of raising a child is read as something that goes beyond a simple “natural” act.13 If this applies to adoption practices and situations, can we extend the model to assisted reproduction and gestation practices for others?
20When we consider a maternity carried out for solidarity purposes, this extended and “community” parental model can present some interesting characteristics, by analogy with that of adoption, at least in terms of the “community” involved and responsible for bringing a child into the world, seeing it born and raising it. The commercial dimension extended to these practices – as in the cases of surrogacy for payment – seems to change their characteristics and condition introducing different logics in the process of reproduction, however already complex in itself in biological, psychological, moral, social and symbolic terms.
- 14 See Committee on Social Affairs, Health and Sustainable Development of the Parliamentary Assembly, (...)
21In fact, the problem of interpersonal dynamics that are created in motherhood for others, between the surrogate and/or gestational mother and the unborn child and between these and those who will become the social parents of the child, remains open. It is not by chance, perhaps, that in the debate on surrogacy the notion of the best interest of the child has been taken up again, in order to highlight how – among the many subjects and actors involved in the articulated process of medically assisted reproduction – a special attention and preventive legal protection must be reserved to the unborn child.14
22What else can suggest an enhancement of bodily relationships and their meaning with respect to the definition of identity? Even when we have not lived the experience of being mothers or fathers, we have lived the other experience, that of being children, of having been generated. And on this we could ask ourselves what is the relationship we have with those who gave birth to us and how much their way of wanting us, of welcoming us, of accompanying us or not, could have influenced who we are, how we are and where we are going in the challenging and complex path of our lives.
23It is always a corporeal relationship that has brought us into the world. And care is corporeal, never disembodied, because it deals with the body, the flesh, the life, not in the abstract but in concrete, entering in relationship with it, touching it, manipulating it, and this helps to define the relationship we have with it (Mortari 2015).
24Our body represents our space in the world and this has a determining value with respect to how we perceive ourselves and how we relate to ourselves, to others and to reality. The body keeps memory in many ways. We are, we remain embodied existences: our existence, the choices and events that have designed it seem to be impressed not only in our consciousness and our memory, but also in our flesh, in our being a body, in our somatic reality. From there they then pass to the memory and emerge in the conscious and unconscious, in experiences and relationships, in events and feelings. Also for this reason, with the body we understand.
25It is curious to reread today, in the light of the new ways that fertilization, conception and reproduction as a whole have taken on, the very beautiful pages of a book by the body historian Barbara Duden (Duden 1987): Duden has reconstructed the history of the perception of pregnancy, of its initial signs, studying the archive of Dr. Storch, a German doctor who in 1730 had decided to record the descriptions with which her young patients spoke of strange symptoms perceived before addressing him. From these colorful images the signs and “symptoms” of pregnancies in progress emerged little by little. In her book on genetics and maternal bodily experience (Duden 2002), Barbara Duden observed that perhaps we lack today – in the age of ultrasound scans and such relevant visual images – the ability to reconnect “head and womb”, to listen to our bodies, for what they tell us, and thus to collect the signs that speak to us of something new, of something that has begun and that in this uncertain beginning does not always represent a positive moment of pleasure, because it is accompanied by discomfort, effusions and new moods. Yet this remains a beginning and comes from each woman and each man charged with those personal and interpersonal, social and cultural complex meanings with which we paint our ideas and representations of giving life, giving birth and coming to the world.
26As Martin Buber wrote: “… in the mythical Hebrew language it is said that in the womb man knows the universe, and forgets it at birth. And this bond remains imprinted on him, as a mysterious image of desire” (Buber 1993, p. 77). Once again, and also in a reflection that draws on other philosophical and religious traditions, the value and essential function that desire has for human existence re-emerges.
- 15 Relational autonomy, or autonomy in relation, refers to the recognition of the essentially relatio (...)
- 16 The notion of relational autonomy highlights the dynamics relevant to our moral development and ou (...)
27In the bioethical debate the value of relationality has been emphasized, as a characteristic trait of the person for what defines his moral autonomy, subjectivity and social identity. An original, but not isolated, contribution has come in this sense from feminist philosophies, which have revisited the notion of autonomy in a relational sense:15 criticizing the most widespread conception of autonomy – the one adopted in the bioethical debate starting from the approach of principlism – these authors have highlighted its limits, represented primarily by excessive individualism, abstraction from reality and the atomistic vision of the individual that would underlie it. In an alternative conception, the moral autonomy of the subject is built from his being and being in relation with himself, with others and with the world: the subject and the person are thus defined in their moral identity also through the body, living in time and living in relation. This is why the notion of relational and reciprocal autonomy has been taken up again in the bioethical debate. It seems to be precisely the relationships and relational dynamics within which we grow and form those that are at the basis of even our most significant moral behaviors, ranging from our attitudes to care, our sense of justice to the ability to manage these dynamics in the complexity of situations, but especially of relationships with others.16
- 17 Every person, according to these authors, is defined by her embodiment and her relationality, that (...)
- 18 Duden observed that the fetus has become a very marked “discursive object” since biomedical techno (...)
- 19 Rebecca Kukla notes that motherhood and maternity represent a very rich and fertile ground not onl (...)
28This relational dimension also characterizes and concerns the fetus and the unborn child (McLeod, Baylis 2006).17 The fetus in its development is conditioned – again, at least until now – by an essential relationality with the mother, with her body, with her corporeity:18 it has been observed in this regard that there are no embryos without mothers and that life is never given in the abstract, but always in concrete form, that is, in the form of the living, taken individually and as a human species (Mahowald 2005; Duden 1991). The fetus grows, develops and enters into a form of “recognition” starting from this original relationship that could be even only “gestational”. Hilde Lindemann Nelson wrote that the decision to “sustain a pregnancy also represents an exercise in moral action” (Lindemann Nelson 2009, p. 48): the choice of the mother highlights this condition of always being a moral agent and this moral trait takes on even more particular importance when morality is read by highlighting the value of corporeity and relationality. The experience reflects the fact that “those of us who are mothers know that our bodies will always be maternal bodies and that the profound moral and phenomenological transformation that awaits our motherhood continues throughout life” (Kukla 2006, p. ix).19
29Lindemann Nelson writes: “If we take seriously the feminist emphasis on the relational nature of the human self, we must abandon the idea that pregnancy is essentially a private problem (in which the woman is not responsible to anyone other than herself) … as and if she experiences her pregnancy it cannot be a morally indifferent problem for at least someone else” (Lindemann Nelson 2009, p. 46).
30In the consideration of relational dynamics, another important figure remains to be analyzed, namely that of the father, in the role that he assumes today in the light of the new practices of reproduction and also socially new ways of becoming parents (Recalcati 2011).
- 20 The studies conducted in this area still seem to be rather limited, while their contribution may b (...)
31The experiences of women who have decided to become surrogate mothers have been analyzed through some qualitative research, aimed at capturing the emotional components and experiences of surrogate mothers (Taebi et al. 2020; Jadva 2020).20 The different contexts and cultures in which these practices take shape always seem to play an important role, both for the couple and the surrogate mother, since where a situation is very precarious, from a social and economic point of view, the choice to carry out a surrogacy can be dictated by necessity and the consequences can sometimes be more complex in psychological and relational terms, in the community of reference and also within the family of these women (Theran et al. 2014; Lamba et al. 2018).
32In the case of gestational surrogacies, the motivations of these choices generally correspond to those of making an altruistic gesture and facing a different maternity, but also to the possibility of having a different body image of oneself: in the case of commercial surrogacy, the motivations seem to mix intrinsic elements, such as altruism, with extrinsic elements, such as the compensation that can be obtained (Ferolino et al. 2020). What emerges from studies conducted on women who have carried out pregnancy for others in the form of an altruistic surrogacy is that the difficulties have been experienced especially in the early stages and that they are mostly overcome over time, in physical terms but especially with regard to their psychological condition; starting from the same studies it seems that children born using this practice are children who do not suffer psychological or existential repercussions different from those who encounter children born in the most traditional ways, since the complex behavioral dynamics seem to be comparable and they can be addressed in a similar way (Zadeh et al. 2018). As far as their story is concerned, it seems important to privilege a form of early storytelling to these children of the way they were born, explaining to them what happened and allowing them to confront their own story, to become aware of it and make it part of their own story. What the children seem to be looking for are mainly explanations of the motivations that led these people to give their availability as donors or gestational mothers, but sometimes they also look for forms of relationship with surrogate mothers, as well as with donors: the search for their biological parents and gestational mother seems to involve fewer difficulties where the children present a situation of stability towards their parents and their family. Parents, for their part, seem to exercise and live towards these children very dedicated forms of care, which are also explained in light of the difficulties that these parents may have experienced and lived in trying to have children. What emerges in any case in multiple studies is the importance of thinking about and organizing accompaniment and counseling for women who became surrogate mothers before, during and after pregnancy, so as to support them also with regard to the experiences that this kind of pregnancy and the need to take distance from the child can arouse in them. It also seems very significant the relationship that can be established between the parents and the gestational mother, because good communication helps to deal differently with the stages and dynamics of pregnancy and the following ones (Yee, Librach 2019; Yee et al. 2020).
- 21 According to the author, this need for reciprocity and equality concerns both relationships and in (...)
33The conceptual elements relevant in this reflection seem to be in particular the body and corporeity, relationships and emotions, which can be considered as pre-political dynamics and which define the subjective identity of the person and his moral subjectivity, profiling a condition and a reality of relational autonomy. Also for this reason, when we talk about ethical issues related to reproduction, we could observe that the real “challenge” begins when we become mothers and fathers, when we “meet” the other and open ourselves to the novelty that s/he can bring, to the “beyond” that s/he can represent, to the “surprise” that s/he can offer (Malherbe 2014, pp. 163-167). In the reflection on assisted procreation and the use of surrogacy, reference has been made to the relevance of relationships and the importance of composing different relationships, in a dynamic of reciprocity and responsibility, recovering the concept of ethics formulated in the phenomenological field by Emmanuel Lévinas, who understands ethics as that component of mutual responsibility that unites human beings (Krause 2018).21 It is possible to consider today a way of becoming parents that involves the intervention of another person, to carry the pregnancy forward, considering that this process takes place in a more communitarian way, as is also the case with adoptions (Gunnarsson Payne 2018). The dynamics of solidarity is also considered in the field of transplantation, when donations are made between living human beings: in this case, too, the psychological dynamics and experiences of the people involved are very complex and delicate and require dedicated forms of accompaniment. In analogy with these two situations, that of adoption and that of transplantation between living persons, also with regard to forms of surrogacy, it can be said that the solidarity dynamic seems to allow more relevant forms of recognition and respect and better protect the freedom and dignity of the different persons involved.
34In the analyses and reflections dedicated to the birth rate, the decline of births, the value and meaning of life, one can look at these new practices with a critical eye, that is, willing to see and collect the value and possible limits of these interventions, to try to reduce and correct them, in perspective. Medicine works from the inside out to its own limits, because knowledge expands, techniques improve and therefore we move in the direction of a refinement of interventions: societies and cultures – for their part – contribute to re-read and redefine their moral parameters of reference.
35In her book The human condition, Hannah Arendt wrote:
“The miracle that saves the world, the realm of human affairs from its normal, ‘natural’ ruin is ultimately the fact of natality, in which the faculty of action is ontologically rooted. It is, in other words, the birth of new man and the new beginning, the action they are capable of by virtue of being born. Only the full experience of this capacity can bestow upon human affairs faith and hope, those two essential characteristics of human existence …” (Arendt 1958, p. 247).
36The numerous questions that remain open call to the possibility of considering new ways of formation and of transmitting life, they call to our ability to maintain a high attention to the symbolic meanings that these practices invest: that remembers the opportunity to exercise a form of moral creativity, in order to identify ways of intervention and scenarios that can protect and respect the different subjects involved in them.
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