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Babies for sale: market ethics and the new reproductive technologies.

INTRODUCTION

Both historically and currently, there are several markets in which humans and human components are exchanged for money or other economically valued resources. In the past, persons were sold into slavery (Bullough and Bullough 1987) and women in the United States were considered chattel property of their husbands until the 20th century (Dworkin 1981). Laqueur (1983) writes that a thriving market in human cadavers and body parts for medical dissection existed in both France and England from the 1970s through the 1840s. Currently, four markets exist in which human components are exchanged for economic compensation concurrent with altruistic donations of the same components: human blood, human organs, surrogate motherhood, and human reproductive cells. Strong ethical and consumer policy issues have been raised by each of these markets. The ethical arguments already put forward for two--blood and human organs--will be reviewed and a possible model of exchange presented which can account for these concerns. This will be followed by a detailed application of the model in the most recent market for the commercial exchange of human components: new reproductive technologies.

The purpose is to explore the normative and ethical foundations upon which human markets are currently based and to extend these to a consideration of the consumer policy issues that will affect the burgeoning growth in novel reproductive markets. In particular, the sacred and profane aspects of using reproductive technologies to alleviate childlessness will be addressed, as well as their relevance to more traditional approaches to infertility, such as adoption.

Markets for Human Blood

In his seminal book, The Gift Relationship, Titmuss (1970) describes in detail the ethical and economic underprintings of two markets for human blood--that based upon the altruistic gesture of providing one's blood for transfusion (usually) to strangers and the other based upon selling one's blood to a commercial blood bank. Titmuss strongly advocates the enforcement of altruism as the only mechanism for meeting the medical demand for blood, arguing that the presence of a commercial blood supply acts to devalue the human gift of blood. To Titmuss, the value of enforced altruism in a society greatly exceeds the economic benefit for some members of that society who would choose to sell their blood. In essence, his argument rests upon maintaining a distinction between sacred products (such as blood) and profane products (such as automobiles). Sacred products, he proposes, must only be given to others, never sold, because the presence of a commercial market in sacred products could destroy the presence of altruistic donations of these same products, i.e., why should someone give away that which can be sold?

In rebuttal to Titmuss' position, Hough (1978) argues that there is nothing inherently unique about blood as a commodity. In his view, people sell other aspects of themselves (e.g., cognitive abilities, physical effort), hence why should human tissues and organs be exempt from commercialization? Hough maintains that "by assigning a price to blood, and efficient allocation of blood resources within the medical industry can be maintained" (1978, 27). He further proposes that the concurrent existence of a commercial market for blood will not necessarily inhibit altruistic donations. Rather, he argues, the decline in such donations may simply reflect the breakdown of communal ties in modern society.

The ethical arguments regarding transfers of human blood largely are reiterated within discussions of policy issues surrounding markets for human organs, but additional issues arise. There are essentially two sources for transplantable human organs: cadavers and living donors. The major source, cadavers, presents some ethical problems in that, first a reliable means of establishing death prior to organ deterioration must be agreed upon; and second, the family ofthe deceased must agree to permit the organs to be harvested for transplantation (Simmons, Klein, and Simmons 1977). The second issue, as Thukral and Cummins (1987) note, could be better dealt with by attending to the emotional needs of the deceased person' family. Rather than being viewed as an organ source, the deceased person's family should be viewed as a donor, an altruistic giver providing life to another. In this type of transfer, the sanctity of the deceased person's body is maintained by transferring a vital component to another so that the recipient may continue to live. In essence, the donor is reborn or resurrected through the continuing life of the recipient. As Calne writes, such sacred-for-sacred transfers are socially condoned: "If the organs of a dead person can save the life and prevent the suffering of another human being, this is surely a good thing. The objective . . . is to . . . return to a useful and happy life a man, woman or child who otherwise would die" (1970, 1).

An overriding ethical concern in human organ markets, as in human blood markets, is whether or not to sanction commercial exchanges (Macdonald and Valentin 1988; Simmons, Klein, and Simmons 1977; Thukral and Cummins 1987). Currently, there are over 70 times as many persons waiting for heart, liver, and kidney transplant as there are organs available (Macdonald and Valentin 1988; Thukral and Cummins 1987). However, commercialization of these markets has been legally prohibited in the United States, largely due to cultural norms which circumscribe sacred-for-profane exchanges (Macdonald and Valentin 1988; Thukral and Cummins 1987).

As Macdonald and Valentin observe, these issues "are rooted largely in diverse cultural, religious, and personal values, [hence] they are ethical rather than empirical in nature. Nevertheless, . . . forums in which moral and ethical issues are discussed serve the public interest by providing vehicles for discovering, clarifying, and reexamining the premises within the contexts of various value structures" (1988, 132). The purpose here is to organize the ethical and moral issues surrounding the exchange of human components using a theoretical structure derived from anthropology (e.g., Douglas 1966; Hyde 1983; Leach 1967) and expanded upon in recent consumer behavior ethnographic inquiries (e.g., Belk, Sherry, and Wallendorf 1989; Belk and Wallendorf 1990; Belk, Wallendorf, and Sherry 1988). This structure is the sacred/profane dialectic.

SACRED AND PROFANE EXCHANGES

At the center of ethical discussions regarding the exchange of human components lies an important societal distinction between those entities deemed sacred and those deemed profane. Sacred resources, entities, or products are culturally viewed as "above" or "outside" the commercial or economic sphere. They are "set apart" from the realm of profane commerce (Belk, Sherry, and Wallendorf 1989; Belk, Wallendorf, and Sherry 1988; Csikszentmihalyi and Rochberg-Halton 1981). Several of the researchers cited view blood and human body parts as typifying sacred products (Calne 1970; Kinsley 1989; Thukral and Cummins 1987; titmuss 1970). Conversely, profane resources would include those for which the above attributes are lacking; that is, those resources deemed common, unexalted, and readily marketable (Belk, Sherry, and Wallendorf 1989; Belk, Wallendorf, and Sherry 1988).

Virtually any product or service could conceivably be either sacred or profane. For example, even a mass-produced child's doll may become sacred to the child who loves it; analogously, even religion may be profaned by ministers who seek only to materially enrich themselves. However, societal norms generally serve a sorting function which effectively labels goods and services as to their appropriate role as sacred and profane entities. Within anthropology, Douglas (1966), Hyde (1983), and Leach (1967) write extensively about the significance of the sorting function which concepts such as sacred and profane serve.

Douglas in Purity and Danger (1966) writes persuasively of the cultural importance of identifying and classifying objects, peoples, places, and events as sacred and profane. Although in various cultures, different entities will be placed into the sacred and profane categories, the designations themselves act to enforce important societal boundaries. As Douglas states, "Holiness requires that [entities] shall conform to the class to which they belong. And holiness requires that different classes of things shall not be confused. . . . It therefore involves correct definition, discrimination and order" (1966, 53).

This reasoning suggests that transfers of sacred-for-sacred would be socially acceptable, as would exchanges of profane-for-profane, because, essentially, entities within the same cultural meaning category are being exchanged. Transferring entities across categories is generally considered culturally taboo, because it creates disorder (Douglas 1966) and introduces ambiguity into the schema of cultural meaning (Leach 1967). As Douglas notes, cultural notions of pollution and inappropriateness are reactions "which condemn any object or idea likely to confuse or contradict cherished classifications" (1966, 37). Thus, a basic cultural repugnance to the exchange of blood and human organs for money would appear to stem from the fact that such exchanges violate the taboo separating the sacred from the profane. Blood and vital organs are culturally seen as appropriately transferred to another only out of love or generosity. Conversely, money (1) is usually seen as appropriate for obtaining those entities which are similarly viewed as profane, e.g. automobiles, detergent, lawn mowers.

One possible configuration of sacred and profane resource exchanges is suggested in Figure 1. In the profane sector of the configuration are commercial marketing transactions. Individuals sell profane resources they possess (i.e., marketable skills) for money. Money is then used to make a variety of commercial purchases, for example, automobiles, apparel, food. The resource exchange model suggested by Donnenworth and Foa (1974) supports this normative position of secular resources (Beach and Carter 1976).

In the sacred sector of the configuration are resource transfers based upon interpersonal bonding and/or transcendent spirituality. Included would be marital relationships (love transferred between husband and wife), friendship (love transferred between two people), and religious commitments (love transferred between an individual and a deity). Foa and Foa (1974) note that social norms usually restrict the transfer of love as a resource. Almost always, love is exchanged for love; strong sanctions exist against exchanging love for money or some other profane resource. Also included in the area of sacred resource exchange would be donations of human blood, organs, and reproductive resources such as eggs, sperm, embryos, and uteri. In this instance, a human body part (generally viewed as sacred) is given to another person to enhance, preserve, or create life (also viewed as sacred). In return the donor or donot's family receives gratitude, a form of love, from the recipient.

At the center of Figure 1 are the types of exchange that most members of society deem unacceptable. These sacred-for-profane exchanges are culturally regarded as taboo, in part, because they subvert transfers which society believes should be based on love and transform them into commercial transactions. One reason why prostitution is a negatively sanctioned exchange is because it transforms sexuality into a secular commodity purchasable for money, when it is socially deemed to be a sacred act between people in love. Slavery is a taboo form of exchange in society, because humans are viewed as sacred entities; to buy or sell them commercially transforms them into profane commodities, which is socialy unacceptable. Similarly, the commercial sale of human blood, organs, and reproductive resources violates this same taboo.

Transformative sacred-for-profane exchanges are among the most ethically challenging transactions in society, because they lie at the normative boundary between what society believes should and should not be bought and sold for money. This form of exchange will be examined more directly in a novel and increasingly important context: human reproductive markets.

BABIES AS COMMODITIES

The focus is primarily upon a specific sacred-for-profane exchange that has received little attention in consumer policy literature, yet, is growing rapidly in monetary size and societal significance. Despite prevailing cultural norms to the contrary, there are currently several markets in which human commercial transactions do occur with regularity and, at the extreme, in which people are exchanged for money. These markets are centered around the production and acquisition of babie--babies in the form of component sperm and eggs, babies in the form of fresh or frozen embryos, babies in the form of tissues and organs, and babies as full-term living infants. The purpose of this study is to explore these markets in depth, to describe their economic size and consumer composition, to examine the products that each offers, and to generate some initial guidelines toward their ethical regulation. But first, the source of demand is examined which is creating these markets: infertility.

Infertility

One of six married couples in the United States (2.4 million) is infertile, unable to conceive a child within a year. Collectively, these infertile couples spent $1 billion in 1987 on medical treatments to achieve conception (Siebel 1988). The causes of infertility include toxic environmental hazards, various forms of sexually transmitted disease, malfunctioning birth control devices (e.g., the Dalkon shield), and medical conditions such as endometriosis and hysterectomies (Budiansky 1988; Corea 1985; Gold 1985). Modern cultural norms also contribute to the current high level of infertility; many women are choosing to postpone childbearing until their mid- to late-thirties, a period in which natural fertility begins to decline dramatically (Siebel 1988).

The one-in-six ration of infertile couples represents a large and often emotionally desperate market that has increasingly turned to biotechnical entrepreneurs in novel areas of reproductive medicine in the quest for a child (Singer and Wells 1984). The popular press has reported the outcomes of some of these quests in vivid detail. The national attention given to the "Baby M" surrogate mother trials brought to the fore several legal, business, and moral issues that remain unresolved (Colen 1987; Diamond 1988; Kantrowitz 1987). Similarly, a decade earlier the birth of Louise Brown, the world's first test-tube baby, raised questions regarding the role of science in creating and controlling human life which remain unanswered (Edwards and Steptoe 1980; Otten 1988).

Often the popular press chooses to emphasize the most socially disturbing aspects of these cases, predicting the advent of genetic engineering (Robertson 1987; Singer and Wells 1984) or establishment of a "breeder class" of minority women carrying children for the affluent (Nsiah-Jefferson 1988; Rifkin 1988). (2) However, beneath this rhetoric lies a more basic, core question or relevance to consumer policy: Are there aspects of human life that should not be subject to commercial exchange?

Many voices in the medical (Robertson 1987), legal (Andrews 1988; Taub 1988), judicial (Siegel 1988), and political (Edwards 1988) arenas have put forward ideological statements regarding these questions; yet the business community and consumer policy-makers have been largely silent. In the absence of normative guidance from policy-makers, entrepreneurs have entered the field of commercial reproductive technology with few or no standards for evaluating performance or practices. There are currently sperm banks, in vitro fertilization clinics, surrogate mother clinics, and embryo transfer clinics, as well as private medical practices specializing in sex selection, fetal reduction, and surrogate fetal carriers (Andrews, 1984; Budiansky 1988; Corea 1985, Frank and Vogel 1988), the majority of which are unregulated.

It is appropriate that consumer policy-makers begin to grapple with these issues and attempt to formulate answers to these questions. In the absence of constructive guidance, commercial markets will continue to be created in virtually all products of human reproduction. If some of these markets are deemed to be wholly inappropriate or inappropriate in some social contexts, then policy-makers should take an active role in proscribing market formation and/or directing their couse of development. The newer human reproductive markets, such as in vitro fertilization and surrogate motherhood, are best understood if they are first placed in context with the traditional solution to infertility--adoption.

Adoption

Traditionally, infertile couples who desired a child obtained one through adoption. Although the adopted child was not biologically linked to the parents, the parent-child union was commonly viewed as sanctified, because the parents provided a needy infant with a home, love, and nurture (Andrews 1984). Thus the family bond was secured. In the past few decades, however, the supply of adoptable children has decreased dramatically. Observers attribute this phenomenon to a variety of social factors, among them the widespread availability of birth control and abortions, and the growing cultural acceptance of single parenthood (Wilson 1985). Concurrently, the pool of persons wishing to become adoptive parents has grown dramatically. Zelizer (1985) notes that prior to the 1920s, illegitimate and orphaned babies were commonly viewed in an instrumental, economic fashion. Often such infants were sold to "baby farms," where most perished due to a lack of adoptive parents. During the 1920-1930 period, babies were culturally redefined as sacred entities, valued for thir sentimental and emotional qualities. By the 1950s a sever shortage of adoptable infants resulted in black market prices of $10,000 (Zelizer 1985). By 1984, more than two million couples were competing for the 58,000 children placed, a ratio of 35 to one (Wilson 1985). In 1985, two million couples sought to adopt, only 22,000 were successful (Johnson 1986). Ironically, as Zelizer observes, as children's value as labor decreased (due to a shift in cultural norms against child workhouses), "their emotional worth became increasingly monetized and commercialized? (1985, 171).

The enormous disproportion between supply and demand in the adoption marketplace, highly reminiscent of that found for organ transplantation (Macdonald and Valentin 1988; Thukral and Cummins 1987), has led to increased pressure for commercialization and entrepreneurism (Zelizer 1985). In the process, both babies and prospective adoptive parants are often transformed into profane products. The parents-as-products phenomenon is found most commonly in the public adoption agency sector of the market. These baby suppliers establish stringent socioeconomic criteria for choosing potential parents. Martin (1988) details the primary adopter attributes sought by suppliers:

The primary factor the adoption agency looks for when examining potential parents is financial stability . . . the agency would prefer that [they] by in the best financial situation possible . . . the more money and job stability you have, the better your chances are to win a baby . . . Education in our society is highly valued, [therefore] a college background is an asset in your application. The higher the degree, the better. (35, 37)

Although many natural parents would not meet these criteria, as Martin (1988) notes, it is a seller's market.

Potential adoptive parents have responded to this situation in two ways. First, they have increasingly turned to private entrepreneurs who broker infants for a fee. One form of baby brokerage is the traditional "home for unwed monthers," which continues to operate in the South and Midwest (Zelizer 1985). For a fee ($20,000 is common), prospective adoptive parents can register with the home, specifying the attributes they are seeking in an infant.

A second brokerage practice consists of entrepreneurs, often lawyers, who specialize in what are termed private adoptions. These brokerages often advertise for unwed mothers. One such operation, termed Golden Cradle, utilizes aggressive promotional tactics:

A successful automotive supplies and accessories wholesaler, [Golden Cradle founder] Richard Elgart simply applies the principles he has learned hawking care wax and seat covers . . . Elgart spends $186,000 annually pblicizing Golden Cradle; Over the years his bold black-and-yellow PREGNANT? CALL COLLECT IN CONFIDENCE signs have appeared on buses, train trestles, park benches, and even Burger King tray liners across the country. He has appeared on radio and television programs and has listed his agency in the Yellow Pages of 168 cities of 21 states and in 41 college directories. (Johnson 1986, 78)

Golden Cradle charges $9,000 to Pennsylvania residents (where it is located) and $11,000 to those from out-of-state. Advertisements for other private baby brokerages, as well as public adoption agencies are shown below, taken from the New York City Yellow Pages.

BALLESTER INTL ADOPTION * REFERRAL SVCES. Sensitive, Caring & Concerned ADOPTION EXPERT. Consultant With Social Service Agencies & Fertility Specialists. Combplete & Thorough. CONSULTATION & HOME STUDY. 205 E. 89, NYC, NY 10128. 410-3088.

DAVID KEENE LEAVITT ATTORNEY. PRACTICE LIMITED TO: INDEPENDENT ADOPTIONS. DIRECT PLACEMENTS. INTERSTATE ADOPTIONS. NO CHARGE TO CALLING PARTY. 1-800-535-5351. 9454 Wilshire Blvd. Beverly Hills, Calif. 90212.

EDNA GLADNEY HOME. REGNANT? ADOPTION IS AN OPTION. Residence program, Continuing Education Counseling, Medical Care, Confidential. A Non-Profit Non-Sectarian Agency Serving Young Women Since 1887. Toll Free Dial 1 & Then 800 433-2922. 2300 Hemphill St. Fort Worth, Texas.

Finally, prospective adoptive parents can act as their own brokers and seek to find a baby themselves. Like the agencies, they advertise listing the desirable attributes they possess as parents and hoping to persuade an unwed pregnant woman to supply her baby to them. Four such advertisements appearing in a reent issue of a university newspaper are reproduced here.

ADOPT--Happily married well-educated couple desire to give infant all the advantages of a loving home & family. Expenses paid. Call Cindy & Al collect.

ADOPTION--Happlily married couple wants so much to adopt white newborn. Will provide lots of love & security. Expenses paid, legal. Call collect.

ADOPTION--Loving couple, happily married & financially secure, seeks white new born baby for a warm, secure home, with educational opportunities. Medical expenses paid. all inquiries confidential. Call collect.

ADOPTION--We are a happily married financially secure couple who want to adopt a baby. We will give the baby love, security, lots of relatives & a comfortable home. Let us help make this difficult time easier for you. Completely legal & confidential, all expenses paid. Call Donna & Ted collect.

Just as the shortage of adoptable infants has tended to turn prospective parents into profane products who must sell themselves to adoption agencies, the resulting commercialization of the adoption market has tended to transform babies into profane commodities (Zelizer 1985). Prospective adoptive parents, especially those willing and able to pay up to $25,000 for an infant, demand an ideal product; historically and currently that perfect baby is envisioned as a healthy, white newborn with blonde hair and blue eyes (Martin 1988; Rosenblatt 1988; Zelizer 1985). Adoptive parents who are willing to accept "less" than this ideal baby consider themsleves altruistic. As one frustrated couple reported, "We never anticipated that we'd run into any difficulty. . . . After all, we aren't looking for a blue-eyed, blond baby" (Berman 1987, 101). Couples unwilling to adopt must either remain childless or turn to the new reproductive markets.

Artificial Insemination

Artificial insemination of a woman with a man's sperm is the simplest and oldest of the noval reproductive technologies. Approximately 50,000 babies per year are conceived through artificial insemination (American Baby 1988). The Ethics Committee of the American Fetility Society reports that although use of donor semen as a treatment for infertility began in the 1800s, it was not until the late 1960s that its use became widespread (1986). Briefly, in artificial insemination a woman who is able to conceive, but whose husband's sperm are not usable for conception, is inseminated by a physician using a syringe filled with semen from a donor. Semen used for artificial insemination may be fresh or frozen.

Although artificial insemination may be used by a single woman who desires a baby (Taub and Cohen 1988), it is most commonly used by married couples in which the husband is infertile. At present all state statutes governing artificial insemination require the husband to provide written consent that he permits his wife to be inseminated and is to be deemed the legal father of the child (Ethics Committee of the American Fertility Society 1986). Further, as Andrews reports,

Over half of the artificial insemination statutes are premised on the assumption that a physician or someone under a physician's supervision will perform the insemination. . . . In Georgia, performing artificial insemination without a medical license is a felony punishable by up to five years imprisonment. (1988, 280)

Andrews (1988, 281) further notes that the California Court of Appeals provided an explanation of the legal rationale requiring a physician to perform the insemination: "the physician can serve to create a formal, documented structure for the donor-recipient relationship to avoid misunderstanding between the parties" to the transaction. In other words, the physician serves as a sanctifying agent who "cleanses" the conception of direct interpersonal contact between the male sperm provider and the female recipient. Ritualistically, the physician intercedes into what would otherwise be an adulterous union between the man and the women.

Frank and Vogel describe the process whereby artificial insemination is cleansed of the sexual intimacy normally attached to conception and transformed instead into a sanctified exchange: [3]

In a kind of silent, institutionalized ceremony, mediated by the medical community, a man and a woman who will never meet . . . produce a bably who will probably never know its biological father. . . . The man, separated from his contribution except for a three digit number . . . can detach himself and not think about the fact that he may pass his son or daughter on the street someday. Because of this same detachment, sanctioned by the scientific community, the mother has only to think about his hair or eye color and hope it is the same as her husband's. (1988, 21-22)

To obtain semen, many couples use the services of a commercial sperm bank; there are about 30 sperm banks in the United States (Frank and Vogel 1988). Sperm banks often seek medical school students as donors, because they are young, healthy, white, well-educated, and intelligent--desirable attributes in a sperm product (Frank and Vogel 1988). Consumers who want truly high quality semen can visit the Repository for Germinal Choice, a sperm bank in Escondido, California, founded by millionaire Robert Graham in 1979. His aim is to generate higher intelligence by using the genes of men of proven genius. graham prefers sperm from Nobel Laureates in the physical snces, but he has recently begun accepting semen from other academics and top leaders in business (Noble 1987).

Sperm donors used by the Repository for Germinal Choice are unpaid volunteers; however, most donors to commercial banks are paid. Noble (1987) reports that the average reimbursement is $50 to $75. Frank and Vogel (1988) report that beyond the financial incentive for selling sperm, donors are motivated by a mixture of rationales, among them being altruism, a sexual thrill, and wanting to procreate their genes.

Although sperm donors are fulfilling an important demand on behalf of infertile couples who could not otherwise have a child, they may do so at some cost to themselves and to our cultural conception of the sanctity of the family. as Noble notes, "Not everything is supposed to be sold in our society. . . . Love is not, and under most social codes neither are human beings or bodies" (1987, 39). The sperm donor sells a part of himself that perhaps should never be given up except in a sacred bonding. When one sells oneself, even to create life, what has one become? This same question can be considered from a woman's perspective in the form of surrogate motherhood.

Surrogate Motherhood

A surrogate mother is defined by the Ethics Committee of the American Fertility Society as

a woman who is artificially inseminated with the sperm of a man who is not her husband; she carries the pregnancy and then turns the resulting child over to the man to rear. In almost all instances, the man has chosen to use a surrogate because his wife is infertile. After the birth, the wife will adopt the child. The primary reason for the use of this technology is to produce a child who is genetically linked to the father. (1986, 62)

Although surrogate motherhood is often depicted in the press (Keane 1981) as the converse of artificial insemination, in fact it differs in several important respects. First, it represents a significantly greater physiological and emotional commitment on the part of the surrogate mother. The surrogate mother not only provides genetic material, her egg, but also gestates and gives birth to the child. Because of these latter contributions, she is paid a substantially larger fee for her services (usually $8,000-$12,000). Further, because under normal circumstances a baby is legally presumed to belong to the woman who gives birth to it, the surrogate mother must sign a contract prior to conception abdicating her possession of the child and agreeing to surrender it upon birth to the man with whose sperm she was impregnate (Keane 1981).

Because of the commercial aspects of surrogacy technology and because it involves the intentional conception of a child who will be given up by its natural mother in return for money, this treatment for infertility has raised substantial ethical controversy. Undoubtedly the most vivid exemplar was the "Baby M" case, which involved two sets of parents, William and Elizabeth Stern and Richard and MAry Beth Whitehead, fighting over possession of one baby (Colen 1987; Diamond 1988; Fleming 1987; kantrowitz 1987; Orth 1987; Whitehead 1986). Reviewing this case, as presented in the popular press from 1986 to 1988, will help to highlight the consumer policy issues involved.

An article in Time notes that the contract in which the Sterns agreed to pay Mary Beth Whitehead to have a child fathered by Mr. Stern raised several issues relating to the sacred/profane exchange dilemma: "Is a womb a rentable space? Should the use of a surrogate mother be a legitimate option for couples who cannot have children? Or is it an odious trade in babies?" (Lacayo 1986, 36). The article also introduced several socioeconomic distinctions between the parties to the exchange. In a subsequent article in People, Mary Beth raised the issue of exploitation of the poor by the rich: "You cannot contract to sell a baby. If they legalize this contract, they may soon start bringing in poor women from other countries just to be breeders (like me)" (Whitehead 1986, 52).

A later article in Time elevates the sacred/profane exchange controversy to more abstract, but insightful terms:

The second half of the 20th century has been full of uneasy trade-offs and Faustian bargains. One after another, life's most intimate and privileged matters--sexual relations, birth, and death--have been delivered to the unsanctified ground of science and commerce. . . . If a society legitimates surrogacy, what has it done? Has it imperiled its most venerable bonds of kinship and the bond between mother and child? Has it opened the way to a dismal baby industry? (Lacayo 1987, 56)

Simultaneously, a piece in Newsweek (Kantrowitz 1987) makes it clear that a valuable product was at stake in the controversy: a blond, blue-eyed little girl.

In April 1987, Judge Sorkow rendered his decision, awarding custody of Melissa to the Sterns. "At birth, mother and father have equal rights to the child . . . the biological father pays the surrogate for her willingness to be impregnated and carry his child to term," wrote Sorkow. "At birth the father does not purchase the child. It is his own, biologically, genetically related child. He cannot purchase what is already his" (Colen 1987, 64). an editorial in time counters,

Are there any ethical limits on what one person may pay another to do? It is a question that rarely rises in the world of normal commerce, even in the modern service economy (of which the contract drawn between William Stern and Mary Beth Whitehead may stand as the oddest example). . . . The emotions that were being traded have a soul-like sanctity in the sense that they belong to the mysteries of the species and are commonly shared. . . . Whatever Stern and Whitehead thought their pact was about, they were trafficking in goods too elusive to package and too universal for personal property. What you do not own, you cannot sell. (Rosenblatt 1988, 88)

Whitehead's lawyers carried her case to the New Jersey Supreme Court, which handed down its decision in February 1988. The court held that the surrogacy contract violated a legal prohibition against paying money for adoption: "the use of money for this purpose--and we have no doubt whatsoever that the money is being paid to obtain an adoption and not, as the Sterns argue, for the personal services of Mary Beth Whitehead--is illegal and perhaps criminal. . . . There are, in short, values that society deems more important than granting to wealth whatever it can buy, be it labor, love, or life? (Thom 1988, 74). Despite this ruling, the Court awarded custody of Melissa to the Sterns on the grounds that it was in the best interests of the child to reside with her father and his wife. The justices also found no illegality in allowing women to volunteer as surrogates, providing the agreement allowed the mothers to change their minds about foregoing parental rights (Siegel 1988).

The Stern-Whitehead case was important in that it established some legal precents for consumer policy decisions in a heretofore largely unregulated human market. Over the past decade 2,000 infertile couples have contracted with women to bear them babies for a fee averaging $10,000 (Kantrowitz 1990). The vast majority of these transactions are arranged by surrogate parenting clinics, at least nine of which advertise regularly in local or national newspapers (Overhold 1988, 165).

Prospective surrogates are screened to determine if they are physically and psychologically sound and asked several questions to determine other attributes they possess which would make them attractive to a contracting infertile couple (Keane 1981). Once accepted by the clinic, a prospective surrogate is interviewed by couples who might desire to purchase her services. It i at this stage that the prospective surrogate most resembles a product-for-sale. One journalist describes the scene at Keane's Dearborn, MI< surrogacy center as follows:

His comfortable two-story offices were full of prospective surrogate mothers, . . . and infertile couples who had come to check out the candidates. The well-groomed couples . . . were each assigned a private office, through which the surrogates were rotated to proffer their fertility. . . . I watched them come and go, the surrogates, young women dressed to please. . . . "Just look at her," said one young man smiling at his pretty young girlfriend and their eight-month-old child, "Her stomach was that flat the day she left the hospital. . . . I'll take care of her when she's pregnant again, but the baby means absolutely nothing. It's like watching someone's car for nine months. We're in it for the money; it's a business--that's they was we look at it." (Fleming 1987, 35)

Once the deal is struck, the contracting couple agrees to pay the surrogate a fee that ranges from $8,000 to $12,000 and to provide for her medical expenses, which usually come to $5,000. The couple also pays a fee to the agency arranging the transaction of from $4,000 to $12,000 (verhold 1988). There is money to be made in the surrogacy business; Noel Keane's surrogacy agency grossed $600,000 in 1986 (Fleming 1987).

Despite the commercialism described, there is another side to surrogacy. Contrary to the negative publicity and torn emotions engendered by the "Babby M" trials, over 500 children have been born as a result of surrogacy and only a handful have experienced contested custody; the vast majority of transactions have gone smoothly with satisfied parties on both sides of the exchange (Overhold 1988). Thus, most participants have ended up happy, and 500 children have experienced a life that otherwise would never have occurred (Ethics Committee of the American Fertility Society 1986).

The reasons for happiness on the part of the infertile couple are obvious. Through surrogacy they have obtained something that otherwise would have been impossible--a child who is in part genetically theirs. And for the majority of surrogate mothers, the experience has been rewarding beyond, and often in spite of, its financial aspects. Overhold summarizes the results from several studies and identifies the primary motivations for surrogates as being altruism, a need to feel good about themselves or make a special contribution to society; guilt over past abortions; personal experiences as adoptive children; and the need to reenact their own childhood abandonment (1988). Other cite the surrogate's desire to create life, to re-experience pregnancy and childbirth, to gain a feeling of self-fulfillment and accomplishment, and to help others attain a family (Frank and Vogel 1988; Keane 1981).

If both consumers and producers are satisfied with the exchange, why then does it bother so many others? The most often cited rationale for aversion to the notion of surrogacy is that it commercializes an event--conception and birth--that is widely regarded in Western culture as sacred (Frank 1985). The exchange of money for a baby is repugnant to many because it seems to reduce a sacred child to a profane commodity (Rifkin 1988).

In Vitro Fertilization

In vitro fertilization (IVF) was developed originally by the research team of Robert Edwards and Patrick Steptoe in England. Through this procedure the world's first "test-tube" baby, Louise Brown, was bor in 1978 (Edwards and Steptoe 1980). During 1988, 2,734 babies were born in the United States through IVF, almost eight per day (Jolidon 1989). IVF helps overcome one of the primary causes of female infertility--blocked or missing fallopian tubes. Mature eggs are placed in a petri dish containing a culture medium designed to mimic the environment of the uterus. Sperm provided by the women's husband, which have been concentrated to a high potency, are mixed in with the eggs. Ideally, the eggs are fertilized and become embryos. Up to six embryos are then transferred to the woman's uterus using a catheter. If all goes well, one or more of the embryos will successfully implant itself in the uterine wall and grow to term; a normal baby, or babies, will be born nine months later (Fleming 1989; Silberner 1985; Singer and Wells 1984). A recent modification of IVF, termed gamete interfallopian transfer, or GIFT, harvests the eggs, mixes them with concentrated sperm from the husband and replaces the mixture, prior to fertilization, into the uterus (Siebel 1988).

The controversy surrounding in vitro fertilization centers on two issues, both of direct concern to consumer policy. The first concerns the large cost, averaging over $5,000 per attempt which serves to restrict its availability to affluent couples, and the low success rate of the procedure. The second concerns the view that IVF manufactures babies; that, in essence, IVF clinics functions as conception factories in which human fetuses are grown in laboratories (Orth 1987; Thom 1988). Recent technological developments which permit fertilized embryos to be frozen and stored for later implantation in their mothers or possibly even provided to another woman for implantation, have fueled the image of IVF as the doorway to a brave new world of technologically produced humans (Cowley 1989; Gubernick 1987; Seligmann 1989). Each of these issues will be examined.

Costs and capitalism in IVF

The cost of the in vitro fertilization procedure is high, and the success rate is low (Jolidon 1989; Otten 1988; Raymond 1988). At the Jones IVF Clinic in Norfolk, VA, the premier IVF clinic in the country, only 60 women out of 100 who start in a given cycle will have eggs successfully retrieved. Only 15 of these women will have a positive early pregnancy test. If those 15, at least five will miscarry, leaving only ten women who will give birth to a live baby (Otten 1988). The overally "take-home baby rate" per egg retrieval (i.e., women who actually complete the egg retrieval stage) was 8.9 percent in 1986 (Raymond 1988).

Despite this low success rate, infertile couples who have no other alternative to obtain a genetically related child continue to pursue IVF. The Office of Technology Assessment reported that in 1987, 14,000 IVF attempts were made, with the average couple spending $22,000--a total of $66 million (Otten 1988). given the size of this lucrative market, IVF clinics are opening at a rapid rate (Edwards 1988). Currently, there are 160 IVF clinics in the United States; about one-fourth are privately funded by venture capitalists. The majority have yet to produce a single baby (Jolidon 1989; Raymond 1988). Several have begun to venture into advertising and public relations efforts to publicize their services (Blakeslee 1987; Cosco 1988).

The high cost of IVF makes it virtually unavailable to minority women. Feminists, such as Laurie Nsiah-Jefferson (1988), point out that this results in discrimination against most infertile minority women and all infertile women of low-to-moderate socioeconomic status (SES). She observes that these infertile women desire children as much as their more affluent, white counterparts. Recognizing this, the American Fertilty Society Ethics Committee recommended that insurance policies cover the cost of IVF procedures so that they can be utilized by consumers on a nondiscriminatory basis (Ethics Committee of the American Fertility Society 1986).

Babies as technological products

A second criticism of IVF is that it transforms the sacred miracle of human conception into a profane laboratory procedure; babies are transformed to products manufactured by doctors (Frank and Vogel 1988). Even the Ethics Committee of the American Fertility Society recognizes this possibility; in their 1986 report they write, "[IVF] separates procreation from sexual union, life-giving from love-making. The assumption is that for the good of the child and the couple, the child should be conceived in an act of sexual lovemaking. [Further] the use of IVF . . . tends to medicalize other basic human problems" (335). Frank and Vogel state this same proposition more directly,

The miracle of life does seem to lose some of its meaning when lovemaking is replaced by a medical procedure, when people become reduced to laboratory animals, and sperm and egg become just raw materials that scientists mix in petri dishes according to a formula. (1988, 251-252) [4]

With the transfer of conception from the couple's sexual union to the scientist's laboratory comes an intriguing transfer of power: The sacred role of life-giver becomes transferred from a theistic source to humans--from god to doctors. One woman desribes her visit to a fertility specialist, who she hoped would "give me a baby.... We were waiting for him to play God and give us an instant cure" (Tilton and Moore 1985, 15). Another woman, who had undergone IVF treatment and was given photographs of her fertilized embryos at the two-cell, four-cell, and eight-cell stages of growth says, "It takes your breath away to think that they can do that. It's like being offered a forbidden glimpse of the Divine" (Tilton and Moore 1985, 86).

The Jone Infertility Clinic implicitly understands the attributions of sacredness directed towards it by the infertile couples whose babies it helps to create. A picture in the clinic waiting room depicts a baby in a crib with a teddy bear. The caption reads: "They say babies are made in Heaven,... but we know better" (Gold 1985).

Extensions of IVF

Since the first IVF baby was born in 1978, a multitude of extensions and applications have been made of the basic IVF technology (Fleming 1989; Thom 1988). One is the cryopreservation of embryos; this procedure involves taking excess embryos created during an IVF cycle and preserving them for future implantation, should the current attempt fail, by cryogenically stabilizing them in liquid nitrogen (i.e., keeping them at hyper-low temperatures). To date, more than two dozen babies have been born through this technique (Breu and Feldinger 1986). The additional consumer policy issue cryopreservation raises, of course, is what rights, if any, do embryos have and whose property are they (Robertson 1987)? In other words, are frozen embryos people or possessions (Jolidon 1989; Seligmann 1989)?

Normally, IVF embryos are reimplanted in their mother. However, they may also be implanted in a surrogate carrier. A surrogate carrier is a woman who, for a fee of around $10,000, agrees to carry a couple's embryos to term in her own womb (Ethics Committee of the American Fertility Society 1986). A surrogate carrier differs from a surrogate mother in that she is not genetically related to the child she is carrying. The use of a surrogate carrier makes it possible for a woman who has intact ovaries, but whose uterus

has been removed or is malformed, to have a genetically related child with her husband. It essence, the couple "rent" the womb of the surrogate carrier. A popular culture article (Johnson 1987) reports the total cost of one such transaction as $32,000. Recently, yet another court case began over custody of an unborn child who is genetically the product of a married couple, but is being carried by a surrogate with whom the couple contracted for a $10,000 fee (Kantrowitz 1990). The outcome of this case could set a significant precedent regarding the genetic versus uterine basis of maternity.

A third extension of IVF is the use of egg donors. For example, a woman whose uterus is intact, but whose ovaries have been removed, is able to carry a baby, although she cannot conceive one. Through IVF technology, an egg obtained from another woman can be fertilized with the husband's sperm and the resulting embryo implanted in her uterus. Although the baby is genetically unrelated to the woman carrying it, it is genetically linked to her husband, and together they are able to experience pregnancy and birth of a child (Ethics Committee of the American Fertility Society 1986). Egg donors are paid from $500 to $1,200 (versus $50 for a typical sperm donation) because of the surgical risk involved in retrieving eggs (Brozan 1988). At present, demand for human eggs greatly exceeds supply. Hence, just as in the markets for human organs and adoptable infants, some entrepreneurs are attempting to set up banks in which eggs can be purchased (New Scientist 1988). The Cleveland Fertility Clinic permits couples to select eggs based on donor attributes such as hair color, eye color, height, body build, and educational attainment. Donors are required to sign an agreement stating that they relinquish ownership of the egg (Frank and Vogel 1988, 122), in essence, relinquishing genetic claim to the child.

Fetal Tissue

Thus far this paper has described how babies, embryos, wombs, sperms, and eggs are bought and sold in the infertility marketplace. The ethical justification in each of these instances is that a couple wants a child, and is willing to go to physical, emotional, and financial extremes to obtain one. There is another way in which babies are being used as products, however, which closely resembles the markets for human organs. Consider the following excerpts from medical news reports:

Pioneering surgery by doctors in Mexico has shown that fetal-tissue transplants can replace damaged nerve cells in victims of Parkinson's disease--a neurological disorder that eventually causes death. Transplants of insulin-producing cells from fetuses have shown promise in treating diabetes, as well. (Budiansky 1988)

A brain-dead baby was taken off life-support machines Saturday after no recipients could be found for his organs, but another baby, born without a brain stem, was on a respirator today in hopes of saving her organs for transplant. Last October, a brain-dead anencephalic girl was flown from Canada to Loma Linda University Medical Center where her heart was successfully transplanted into the chest of a newborn. (The New York Times 1988)

A woman, on Ted Koppel's "Night Line" television show last January, declared she wanted to get pregnant for the sole purpose of aborting the fetus so that its tissue could be used to treat her father [who had Parkinson's disease]. (Budiansky 1988)

These excerpts raise the concerns of Titmuss (1970) that a society in which the human reproductive process can be technologically manipulated in order to create children, may also come to view babies as a set of components (e.g., insulin-producing cells, livers, hearts) that can be utilized to benefit other children and adults. The underlying metaphor is if babies can be manufactured from bits and pieces of human tissue, they can also be broken down again into bits and pieces of human tissue.

CULTURAL NORMS AND SACRED/PROFANE EXCHANGE

As many sources suggest, human life is considered sacred in our culture (Andrews 1988; Bazell 1988; Belk 1988; Belk, Wallendorf, and Sherry 1988), and the creation of human life is considered the most sacred act in which a couple can engage (Lacayo 1987; Orth 1987; Rifkin 1988). Several commented explicitly on the sanctity of the fetus and the sanctified role of the mother.

Birth and children have traditionally functioned as symbols of promise, continuity, and renewal. And the fetus . . . serves even more dramatically as a symbol of innocence and hope. . . . It has become a symbol of nature; a token of people's reverence for the universe, for natural processes and for creation itself. (Gallagher 1988, 166)

Bearing children is a woman's . . . most awe-inspiring power. It makes her a natural force and part of the rhythm of things. . . . Like the plant, . . . Mother Earth, . . . .the fertile women is a powerful creature. (Frank and Vogel 1988, 255-256)

Prior to the new technologies for engineering human reproduction, conception was viewed as an uncontrollable natural force, the miracle of life, as many of the present texts termed it (Rifkin 1988; Rosenblatt 1988; Tilton, Tilton and Moore 1985). Similarly, prior to novel medical technologies for prolonging life and eradicating disease, death was also viewed as an uncontrollable, natural event. Secularization -- the ability of humans to control natural processes through technology -- has altered society's views of life and death. Through technology, people can now assist the creation of life and prevent or at least stave off death.

Several ethicists view any technological intervention into the sanctity of life and death as harmful. Rifkin (quoted in Frank and Vogel 1988) states:

Those things we can't control, we tend to regard as sacred. . . . As parts of nature come under our control, we desacralize them, turning them into mere utilities. In other words, the part of the [life] process that cannot be anticipated and manipulated remains in the realm of the sacred; the part that can be anticipated and made to serve human ends becomes profane. . . . It is also true that familiarity breeds contempt or indifference. As we gain control over things, they lose their fascination for us. What was once the object of our respect becomes mundane appendage. (254)

As much as society values the secular power technology provides to manipulate life and death, society also fears it. Society fears that once the sacred mystery has been removed, once children have become commercialized, life itself will become less valued -- less sacred (Frank 1985; Titmuss 1970). And yet these technologies, and resulting markets in life and death, are here to stay. As Einstein said, "That which is learned, cannot be unlearned." What rules can be used to decide which transactions are acceptable and which are not? For what purposes should society permit money and other profane resources to be exchanged to create life, and for what purposes should such exchanges be forbidden? The norms which emerge from a cross section of the texts examined (which purportedly represent current cultural values on this topic) (5) may be categorized into two groups: technological intervention and commercialization.

Technological Intervention

The first group deals with technological intervention into the life and death process. The norms representative of this category are:

(1) Technology may be used to remedy flaws in nature in order to create or prolong life.

(2) Technology should not be used to destroy life in order to prolong life, and

(3) Technology should not be used to manipulate nature, in order to create more socially desirable forms of human life.

These norms may be translated into specific consumer policies.

The first norm advocates the use of technology to remedy natural defects, so long as the outcome is creating or prolonging life. Thus, treatments for infertility including artificial insemination, surrogate mothers, surrogate carriers, IVF, donor eggs, and donor embryos would be acceptable. These technologies, collectively, assist couples who have a natural defect (i.e., infertility) and who greatly desire to overcome this defect and obtain a child. A desired child and a completed family are formed simultaneously; thus the outcome would be socially sanctioned. A conditional assumption is that the resources provided by the third parties necessary to create a child (e.g., sperm, egg, gestation) are obtained without coercion and do not negatively affect the quality of life of these third parties (Frank 1985; Kinsley 1989; Simmons, Klein, and Simmons 1977; Titmuss 1970).

These technological norms for reproductive markets closely resemble those now prevailing in human blood and organ markets, that is, technological intervention in the form of blood transfusions and organ transplants are ethically acceptable if they prolong or permit normal life without damaging the life of another. In support of this normative stance the Ethics Committee of the American Fertility Society states "The conclusion of the Committee in most of the [infertility treatment] scenarios is that the alleviation of infertility provides a sufficient rationale for treatment" (1986, 18). Similarly, a discussion among several medical ethicists published in Harper's reaches the conclusion that "therapy connotes taking away the negatives. . . . The sentiment here is that it's acceptable to take away the negatives" (Lapham et al. 1987, 47).

A second application of this norm would be to permit use of organs and other tissues from fatally defective infants and fetuses to prolong life in other infants and adults. Thus, the organs of infants born anencephalic who are doomed to die may be used to give life to other infants who could live if their defects were corrected with these organs. Similarly, adults and children suffering from Parkinson's disease and diabetes could ethically be treated with tissues from miscarried fetuses. It may also be ethical to treat such defects with tissues from aborted fetuses. This latter instance, however, raises the issue of whether it is moral to utilize purposely destroyed life to remedy a natural defect, such as diabetes. One panel of ethicists (Lapham et al. 1987) did view this form of exchange as ethical, so long as the person responsible for the death of the fetus (i.e., the abortion) did not benefit from the death (e.g., received no remuneration, was not a recipient of the fetal tissue).

This latter example leads directly to the second norm: Secular technology should not be used to destroy life in order to create or prolong life. This norm would forbid the purposeful destruction of embryos or abortion of fetuses in order to provide organs or tissues for use in prolonging life in others. Such actions are viewed in the cultural texts examined as unethical because they destroy one life in order to enhance another. Because all lives are deemed equally sacred, such exchanges are not justified. Thus, instances such as the woman who wished to conceive and abort a fetus in order to treat her father's Parkinson's disease would be unacceptable. Even more unjustified would be the purposeful creation of embryos or fetuses for use as sources of organs and tissues.

Finally, the third norm suggests that technology should not be used to manipulate natural selection in order to create more socially desired forms of human life. In essence, this norm forbids use of technology for the purpose of selecting among normal natural states, i.e., the application of genetic engineering and eugenic science to humans (Cowley 1989; Elmer-Dewitt 1989). The availability of donor sperm, donor eggs, genetic screening, and chromosomal manipulation technologies may lead some prospective parents to attempt to engineer the traits possessed by their child. Thus, products such as those offered by ProCare, which markets a "Gender Chocies" kit ($49.95) intended to help parents select the sex of their child prior to conception, would be deemed unethical (Frank and Vogel 1988).

In keeping with this norm, the Ethics Committee of the American Fertility Society recommends that "the use of . . . [infertility treatments] for nonmedical reasons, such as to produce a 'superbaby,' is ethically unacceptable" (1986, 18). Similarly, the Harper's medical ethics panel concludes that "it's not acceptable to put inthe positive; that's engineering" (Lapham et al. 1987, 47). Using technology to add socially desired traits (e.g., blonde hair, high I.Q.) reduces the child from a sacred entity valued for its life to a consumer good valued for its gender, eye color, hair color, physique, or intelligence.

Thus, secular technologies or marketing applications which create, enhance, or prolong human life without concurrently destroying or damaging other human life are currently viewed as morally acceptable. Secular technologies which destroy human life, even to prolong or enhance other human life, or which artificially select one natural state of human life over another (e.g., a blue-eyed boy over a browneyed girl) are morally unacceptable and should be discouraged.

A second category of ethical proposals concerns whether human reproductive markets should be commercialized or not. That is, technology aside, should persons be allowed to buy and sell components essential to the creation of life, or in the case of infant adoptions, actual human beings? Kopytoff (1986, 69) argues that such transactions necessarily transform the entities being exchanged into common or profaned materials, that is, into commodities. The commoditization of human materials "such as labor, intellect, or creativity, or more recently, human organs, female reproductive capacity and ova" is, in his view, "a perennial moral concern in Western thought" (84), and is likely to remain a troubling realm for exchange because "the difference between persons and things is particularly difficult to define, defying all attempts at drawing a simple line where there is a natural continuum" (86).

Currently, the human reproductive arena, like that for human blood and organs, is in a state of disarray; the markets display a mixture of altruistic (sacred) and commercial (profane) transactions. Surrogate mothers operate on both a voluntary and fee basis; similarly human eggs, sperm, and embryos may be given altruistically to others or sold. Human infants may be obtained from nonprofit public agencies or for-profit private adoption services.

As described, the demand in all these reproductive markets (as in those for blood and organs) greatly exceeds the voluntary supply. Hence, nonaltruistic, commercial markets have sprung up to provide alternative sources of supply. Two ethical issues arise directly from the establishment of these commercial markets. The first is, does the act of commercializing human reproductive markets, itself, desanctify the human lives involved and therefore serve as such a source of moral disruption in society that it should be proscribed entirely? And second, if such markets are permitted, how can they be made more economically equitable for all who may desire to enter them; that is, can mechanisms be developed which would limit or even eliminate bias based upon the socioeconomic status of the participants?

Titmuss (1970) would argue strongly that the very presence of commercial reproductive markets poses a threat to altruistic reproductive markets, i.e., that the act of paying one person for reproductive components will necessarily inhibit others from giving away those same components. However, research by Overhold (1988) suggests that some surrogate mothers are motivated almost solely by the desire to make an altruistic gesture. Many of these women wish to make amends for past reproductive sins they feel they have committed or are genuinely moved by the helplessness of infertile couples. For this group of providers, then, payment would actually reduce the value of their actions to themselves (Kopytoff 1986; Zelizer 1985). The same would seem to hold true for voluntary providers of eggs, sperm, and embryos, as well as for some unmarried women wishing to place their infants for adoption (Zelizer 1985).

Thus, it is unlikely that these altruistic providers would be driven from the market by the presence of for-fee providers, as they are seeking a sacred form of exchange. On the other hand, it is clear that there are insufficient numbers of altruistic providers to meet the demand in the various reproductive markets. As even Titmuss (1970) acknowledges, and Hough (1978) advocates, the supply/demand imbalance may be rectified through the presence of commercial markets. By putting a monetary value on the components of human life, the primary ethical reservation to permitting such markets has been that they profane or desacralize all life (Frank 1985; Kopytoff 1986; Thukral and Cummins 1987; Titmuss 1970). Although on the surface, this proposition would appear to be certainly true, on closer examination it may in fact be false. In Titmuss' (1970) view, human life, as a sacred entity, must be kept separate from the arena of commerce; to put a price on life inherently profanes it. However, commercial markets in human blood, organs, and reproductive components do not so much put a price on life, as they permit the expenditure of economic resources to enhance, prolong, or create life. And, in fact, there are many commercial markets which meet these needs without ethical opposition. For example, few would dispute monetary expenditures on health insurance, medical care, exercise equipment, and nourishing food for oneself or one's family. In fact, the absence of such expenditures might be taken as a sign of moral laxity.

The infertile consumers who enter the reproductive markets described, e.g., in vitro fertilization, have a common sacred goal in mind--they want to become parents to a baby. To foreclose them from achieving this goal and forming that most sanctified of human units--a family--because a fee must be paid to attract a supplier seems a greater blow to communal values than does the money paid. Hence, this paper advocates the presence of commercial markets in the reproductive arena as a necessary means for satisfying demand for a sanctified goal.

However, with advocacy must also come greater societal responsibility for the equitable functioning of these markets (Forbes 1987). At present commercial markets are largely available only to those with middle or upper socioeconomic status. Few infertile minority or working-class couples have the financial resources to obtain advanced treatment or to purchase reproductive components necessary for them to have a child. Thus, this paper advocates the approach described by some researchers in the area of organ transplantation (Brams 1977; Caplan 1984; Koop 1983), i.e., governmental administration of a common fund from which childless couples could draw resources to pay for the treatment and reproductive components they need. In essence, childlessness would be viewed as a communally shared problem for which communally gathered funds would be made available. Such a solution would also have the effect of increasing the sacredness of the commercial reproductive markets, by making the elimination of childlessness a common social goal, instead of a competitive, economic bidding process.

Such an approach would be consistent with the reasoning of Forbes regarding appropriate rationales for consumer policy intervention. As he notes,

Actions to alter wealth, income or consumption distributions are based on various concepts of justice and equity that are held within a particular society. . . . They are based on widely accepted beliefs that there are basic human needs to be met and that . . . consumption of some goods and services are the basic right of all members of the particular jurisdiction. The goals of policies under this rationale include . . . providing basic services . . . to those who cannot pay for them, or cannot acquire sufficient quantities of them in market transactions. (1987, 276-277)

In the author's view, treating infertility would represent a socially condoned extension of basic health care benefits now available.

CONCLUSIONS

The issues discussed and the reproductive markets described are complex and emotionally wrenching. Yet they are points upon which sound, ethical consumer policy must be formulated. As a social scientist and a human being, one must take responsibility for evaluating the social benefit and harm these various reproductive transactions offer.

Although the discussion has attempted to put forward these issues dispassionately and has offered preliminary ethical guidelines and policy suggestions for their resolution, it is important to keep in mind the all-too-human desires and tragedies they represent. In reaching judgments as to which exchanges in reproductive markets are acceptable and which are not, one must never lose sight of real people, real parents, and real children whose needs, happiness, and even existence are at stake.

The present analysis has proposed that human reproductive markets are analogous to those for human blood and organs, in that they may be understood as representing sacred and profane aspects of cultural meaning. This inquiry has explored in depth the nature of both altruistic/sacred and commercial/profane exchanges in reproductive markets. It has concluded that although sacred-for-profane exchanges, as for example paying a surrogate to carry the child of an infertile couple, are morally troublesome, such exchanges can be ethically construed as positive, if they serve the larger sacred goal of creating families.

To achieve this socially beneficial end, it is recommended that basic public health services be extended to include governmentally funded infertility treatment, which would provide equal access to reproductive technologies for consumers who are unable to procure these desired services in a competitive economic market. It is also advocated that the commercial sector of these same reproductive markets continue to operate in order to insure adequate supply to meet the demand of infertile couples desiring a child. It is anticipated that the aultruistic sector of these markets will continue to function, with sacred-for-sacred donations of reproductive resources (e.g., sperm, eggs, embryos, uterine surrogacy) continuing to be made by persons who wish to engage in this form of exchange.

Several ethical guidelines have been presented that apply to all three of the reproductive market sectors described, i.e., governmental supported, commercial, altruistic. These may be summarized as follows: the novel reproductive technologies now (and becoming) available are to be directed toward remedying flaws in nature (e.g., infertility) in order to prolong or create life. However, it is unacceptable to destroy one human life in order to prolong another human life. Further, the novel reproductive technologies should not be used to manipulate nature in pursuit of more socially desirable forms of human life (i.e., eugenics is morally unacceptable).

These ethical guidelines and consumer policy suggestions are intended to serve as a constructive starting point for the negotiation of a national policy on reproductive markets. Public debate and governmental response to these issues are highly desirable in order to more quickly and effectively serve the many couples whose hope for a child lies in their resolution.

(1) It should be noted that the model presented suggests a somewhat narrow conception of money as signifying solely a profane entity in Western culture. While money is often classified as a commercial/profane resource (e.g., Foa and Foa 1974), researchers using a sociological (Zelizer 1989) and anthropological (Belk and Wallendorf 1990) perspective have documented instances in which money may be used to signify communal/sacred bonds. For example, money gained through inheritance or given as a gift to loved ones may serve as a sacred entity and be treated differently than money exchanged in commercial transactions (e.g., Belk and Wallendorf 1990).

(2) Several sources have also questioned the morality of commercial markets in human blood and body parts on the grounds that poor consumers are unfairly discriminated against both as donors and as recipients. Calne (1970), for example, argues against use of selection panels for ranking potential organ transplat recipients on the grounds that "invidious and prejudicial" decisions discriminating against the poor will result. Similarly, Simmons, Klein, and Simmons argue that such boards "would reject the unemployed, the worker whose job is less important, the person who has few family ties or obligations, and the man with a history of deviance of any sort" (1977, 11). Further, they argue that commercializing organ transplant markets may result in turning the poor into organ pools for the rich, a possibility also noted by Frank (1985), Kinsley (1989), Macdonald and Valentin (1988), and Titmuss (1970).

(3) As a reviewer observed, the deification of the scientific community in modern culture permits doctors and other scientific practitioners to serve as priests in such cleansing rituals (Belk, Sherry, and Wallendorf 1989). However, societal members may still feel somewhat uncomfortable about the sanctity of such ceremonies, because they are not sanctioned by God or nature, which are seen as having even higher sacred Power (Berman 1981).

(4) As one reviewer noted, this bears a strong resemblance to arguments now being put forward by animal rights activists.

(5) See especially: Andrews 1988; Bazell 1988; Calne 1970; Corea 1985 Edwards and Steptoe 1980; Ethics Committee of the American Fertility Society 1986; Fleming 1987; Frank and Vogel 1988; Kantrowitz 1987; Lacayo 1986, 1987; Lapham et all. 1987; Orth 1987; Overhold 1988; Rifkin 1988; Rosenblatt 1988; Simmons, Klein and Simmons 1977; Singer and Wells 19884; Taub and Cohen 1988; Thom 1988; Titmuss 1970.

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Elizabeth C. Hirschman is Professor of Marketing, School of Business, Rutgers University, New Brunswick, NJ.
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Date:Dec 22, 1991
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