HSS4331 – Introduction to International Health Theory

Nov 24, 2008 – Medical (Reproductive) Tourism

Upcoming Events

• Wednesday Nov 26, 6:30pm, UC Terminus – “Hunger Banquet” featuring Prof Paul Haslem. $5 in advance (from International House) or $6 at the door

• Thursday Nov 27, 6pm, UC Terminus - Student Refugee Program Awareness Night – free of charge and there will be pizza.

• Monday Nov 24, 5-7pm, RGN Amph A, Dr Jane Philpott on “Canadians engaging in global health”

All are eligible for your summaries

Today….

• We’re going to talk a little bit about some of the work I currently do

• Some of it is coordination with Assisted Human Reproduction Canada (AHRC)– But nothing I say or present today should

necessarily be considered the position of AHRC

In General….

• What is “medical tourism”?

1. The act of (typically Western) medical professionals doing abroad to do “good work”, but in reality functioning as gawking tourists

2. The act of (typically Westerners) going abroad (to typically developing countries) to seek medical care.

The First Type

• The act of (typically Western) medical professionals doing abroad to do “good work”, but in reality functioning as gawking tourists– The danger of every international health project– Whom does it really benefit?– “cowboy” global medicine– Sustainable?

The Second Type

• The act of (typically Westerners) going abroad (to typically developing countries) to seek medical care.– Growing in popularity– Often tied to other tourist activities– Negative downstream consequences may not be immediately obvious

EXAMPPLE: Reproductive medical tourism

Terminology

• Infertility:– One year of unprotected sex without conceiving a

child– Includes both “sterile” and “subfertile” people– Sterile:

• Will never conceive without medical assistance

– Subfertile:• May still conceive without medical assistance

Infertility

– About 15% of couples will be defined as “infertile”– But this only accounts for those who actually seek

services; likely an underestimate

-1990 estimate: >1 billion women worldwide are affected by “infertility”

-only covers those of reproductive age who have been “diagnoses”

**On the increase in Western nations**

Why Is Infertility On The Rise?

• People waiting till later in life to have kids• Obesity and diabetes are on the rise• Environmental contaminants may be affecting hormone levels

Terminology

• Assisted Human Reproduction (AHR)– Anything involving helping infertile people

become fertile

• Assisted Reproductive Technologies (ART)– Technologies related to AHR– Some define it only as technologies involving

embryo formation outside the body

IUI

• Intra-uterine insemination• Artificial presentation of sperm into the

vaginal canal– “turkey baster method”

IVF

• In Vitro Fertilization• Creation of embryo in a dish, and returning it

to the womb• “test tube babies”• Considered the vanguard ART technology

ICSI

• Intra cytoplasmic sperm injection• Done in conjunction with IVF• Grab a sperm and force it into an egg• Used when sperm just can’t get the job done by

themselves

Gamete Donation

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

• Egg donation– Very invasive– Expensive procedure– Hard to find donors

Surrogacy

• A surrogate mother is a woman who agrees to gestate and give birth to a baby for someone else

• Scenarios:– Surrogate receives sperm via IUI and uses her own egg– Surrogate donates egg, embryo created via IVF (with

or without ICSI)– Another egg is used, embryo created via IVF (with or

without ICSI)

Statistics

• Canada:– about 6500 IVF embryo transfers per year

• USA:– About 120,000 IVF procedures per year

• UK:– About 35,000 IVF procedures per year

• Europe:– About 300,000 IVF procedures per year

Costs• One attempt at IVF costs $8000-$16000• ICSI costs extra

• Donated sperm costs $200-$600 (from US centre)• Donated egg costs $500-$20000 (from US source)

• Surrogate services cost ~$50,000 or more

The Law

• 1993: Royal Commission on New Reproductive Technologies

• 2004: Assisted Human Reproduction Act

• 2006: Assisted Human Reproduction Canada

• 2009: rules spelled out in the Act begin to be enforced

Canada’s Act

• Human cloning prohibited• Sex selection prohibited• In vitro gene alteration prohibited• Transplanting non-human gametes or embryos

into a human is prohibited• Transplanting human gametes/embryos into a

non-human for the purposes of creating a human• Create chimeras/hybrids

Canada’s Act

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

• etc

The Law

• Laws in different countries vary dramatically• In the US, it varies from state to state• In Australia, only one state has clear

regulations• In UK, rules are well defined and monitored• In Israel, it’s the wild wild west• Etc.

So….

• Let’s say you’re an infertile couple in Canada who wish to:– Select sex of your baby– Pay for a surrogate mother– Pay for a sperm or egg donor– Pay less for a baby

What do you do?

You Go Abroad

• Example– In Virginia Mason medical centre in Seattle, 33%

of patients are Canadian, most seeking to buy donor eggs

– In India, “reproductive tourism” is a $450 million industry

-> Reproductive Tourism

South Asia

• Currently, parts of the USA are the most popular destinations for “reproductive tourists”

• But India is fast becoming an important destination

India

• Surrogate mother in India costs <$5000• Plethora of doctors, all English-speaking

• Case study:– A British couple in 2006 spent 60,000 pounds on

IVF in the UK without success, so they went to India and paid $3,300 for a surrogate mother

So, What’s The Problem?

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

The Issues

1. Protection for couples travelling abroad

2. Protection for women selling services in poor countries

The Issues

• Couples are bypassing the laws of their own countries; should they be prosecuted?

• Informed consent… how informed are these women?

• Choice…. In many places, how can we guarantee that women are not being forced to participate?

More Issues

• India is popular also because of its familial laws:– In UK, a surrogate mother can change her mind

and claim the baby as her own any time within the first 2 years of life

– In India, the surrogate loses all rights to the baby at the point of delivery

More Issues

• Is remuneration fair? Should surrogates be paid global market rates?

• Social stigma of carrying the child of a man who is not your husband

• Loss of control of one’s body, as “client” and doctor have a vested interest in the surrogate’s nutrition and activities

Even More Issues

• Must protect vulnerable infertile Westerners from being fleeced by dishonest doctors and surrogates

• In instances of extreme poverty, is there really such a thing as choice for a surrogate?– Compare to instances of “choice” for an

impoverished woman who “chooses” prostitution

Even More Issues!

• What kind of health follow-up are surrogates given?– Are they given post natal care, especially after the

baby has been given up?

• What reproductive effects do surrogates suffer from?– Giving birth is dangerous– Potential for surrogate to become infertile

Legal Issues

• A child born to a surrogate mother in India… what are the legal steps to get it into the country of the “client”?– Formal adoption procedures?

• Can a surrogate mother in India benefit from parental laws of the client’s country?– Does she have the 2 year leeway in the UK?

“Cross Border Reproductive Care”

• Why is this the preferred terminology?

What Needs to Be Done?

• What do you think?

Summary of the Ethical Issues• Misdirection of financial resources – those who seek services abroad deny their resources

(i.e., outgoing funds) to their home community• Misdirection of medical resources – those who provide services to “tourists” are denying

their services to their home community• Implications of insufficiency – the act of seeking services abroad implies that services are

insufficient, in quantity, type, timing or affordability, in the home community• Criminality – if service seeking abroad is done to avoid laws at home, should the international

community consider this criminal behavior? Is the provision of services therefore the abetting of such criminal behavior?

• Quality control – if the health and welfare of “tourists” is a concern, how do we control for the quality and validity of medical services provided outside of one’s administrative jurisdiction?

• Robustness of informed consent – are “tourists” provided with adequate and accurate representation of actual risks and probable success rates? Brokers may misrepresent facts.

The above may apply to all types of medical tourism

• The following issues are particularly relevant to the seeking of surrogate services in the developing world:

– Robustness of informed consent – this issue, as it pertains to the surrogate, is quite separate from that pertaining to the tourist. Social downstream impacts must also be communicated (eg, is a conservative society ready for a woman to carry baby for two gay men; will husband respond well to wife carrying the baby of another man; specific religions –eg, Muslim- concerns)

– Custody rights – rights vary from country to country. To what extent is the industry affecting the drafting of custody rights legislation?

– Cultural appropriateness – see (a): economic attraction of the industry may bring it to societies presently unprepared for some of the implications, eg gay parents, single mothers, carrying a child that is not your husband’s

– Quality of care – surrogate’s physical health is maintained, but only to the extent that it benefits her pregnancy. What of social and mental health? What of her removal from care-giving milieu of her own community? If clinic provides her diet, does she still cook for her family?

– Limits of care – While the surrogate’s medical health is of prime importance during pregnancy, does this care end upon birth of the child? Is there an investment in post-partum care? To what extent does economics affect this trend? (Eg, a regular surrogate should be maintained in good health due to her ability to perform again.)

– Remuneration – one reason tourists seek service is reduced cost abroad. But while remuneration for the surrogate is likely above what she would otherwise earn, it is likely below global market rates.

– Abortion – selective reduction is a common occurrence in ART. Is surrogate aware and culturally responsive to this likelihood?

– Medical advocacy – clinician responds to needs of the tourist. Is it a conflict of interest to also be care-giver to the surrogate?

What We Are Doing

• Step 1 – bring together ART regulatory bodies from key nations

• Step 2 – agree that these are issues worth considering

• Step 3 – Collect data!• Step 4 – to be determined

Achievable Goal

• Establishment of international body to:– Monitor extent of reproductive tourism– Set forth international guidelines for appropriate

ART/AHR care– Monitor quality control for doctors offering

services to international clients– Monitor rights abuses of local women offering

their reproductive tissue and services