ARTICLE

 

The Universal Declaration of Bioethics and Human Rights - a provisional perspective on surrogacy introduction

 

 

R Rheeder

ThD; Faculty of Theology, North-West University, Potchefstroom, North-West Province, South Africa

Correspondence

 

 

---

ABSTRACT

BACKGOUND: Surrogacy is a contentious reproductive technology that has garnered significant global attention, particularly following Pope Francis' 2024 condemnation of it and his advocacy for a universal ban, amid its rising prevalence in high-income regions driven by factors such as advancing parental age and the reproductive aspirations of single men, same-sex couples, and transgender individuals. This article evaluates surrogacy through the framework of the Universal Declaration of Bioethics and Human Rights (UDBHR), a 2005 UNESCO-adopted document establishing 15 universal bioethical principles to guide discussions on medicine, life sciences, and associated technologies, emphasising its role in fostering global ethical discourse grounded in human rights
OBJECTIVE: The primary objective is to assess the ethical dimensions of surrogacy by applying the principles of the UDBHR, determining whether the declaration adopts a neutral stance, merely offers procedural guidelines, or provides a substantive ethical judgment on the practice. This provisional analysis posits a central theoretical argument that the UDBHR creates an ethical paradox by simultaneously legitimising surrogacy through procedural mechanisms while posing significant moral challenges to its acceptability, with the study confined to evaluative purposes without extending to policy recommendations
METHOD: The methodology employed is evaluative, critically examining surrogacy against the UDBHR's standards to gauge its ethical soundness, incorporating an interpretive analysis of how the declaration's principles intersect with surrogacy's ethical, legal and social facets. The approach begins with an explication of surrogacy's types, processes, reasons, costs and controversies, followed by a principle-by-principle discussion under the UDBHR, drawing on limited existing literature such as the 2019 International Bioethics Committee (IBC ) Report, while maintaining a focus solely on ethical assessment
RESULTS: The evaluation identifies a dual nature within the UDBHR: certain articles offer procedural support that implicitly endorses surrogacy when conducted ethically, aligning it with benefits like parenthood fulfillment and social responsibility. Conversely, other articles highlight substantive concerns, including maternal health risks, embryo commodification, child rights violations, exploitation of vulnerable women, and long-term impacts on offspring, thereby questioning surrogacy's moral foundation
CONCLUSION: The UDBHR manifests an inherent ethical paradox regarding surrogacy, providing procedural legitimacy through guidelines that facilitate its practice while simultaneously challenging its ethical viability via principles that underscore risks to dignity, vulnerability, equality and future well-being. Consequently, the analysis concludes that surrogacy, in its current form, encounters fundamental ethical obstacles under the UDBHR, necessitating further research and stringent international regulations to potentially align it with the declaration's comprehensive ethical imperatives, particularly in safeguarding women, embryos and children

Keywords: Surrogacy, global bioethics, UDBHR, ethical paradox, reproductive technology, vulnerability, human embryo.

---

 

 

Surrogacy remains a controversial modern reproductive technology that is continually in the news. The latest controversy emerged after Pope Francis, during his 2024 annual address (8 January 2024) to the global ambassadors of the Vatican, referred to surrogacy as 'deplorable'and 'a grave violation of the dignity of the woman and the child. In the same speech, he called for the universal ban of the technology. ^[1,2]

It also appears that the practice of surrogacy is increasing worldwide, and the debate continues between countries that reject and allow surrogacy.^[3] Surrogacy is particularly on the rise in high-income regions such as Europe and Australia owing to the increasing age of potential commissioning parents, and the desire of single men and same-sex couples and transgender persons to have children.^[4]

As this technology is constantly under scrutiny, and especially because the Pope has made a universal call and this technology is a global phenomenon, it may be prudent to address this technology from a global bioethical perspective. The purpose of this article is to examine the phenomenon of surrogacy through the lens of the principles found in the Universal Declaration of Bioethics and Human Rights (UDBHR). This study uses these global principles to evaluate surrogacy by determining whether the UDBHR remains neutral, merely outlining procedural rules for surrogacy, or if it provides a judgment on the ethicality of the practice. In 2005, the UDBHR was unanimously adopted by all member states of the United Nations Educational, Scientific and Cultural Organisation (UNESCO).

The latter agreement endowed the non-binding declaration with both symbolic significance while also making it a compelling force, establishing a moral imperative for member states. For the first time, the international community pledged to uphold 15 universal bioethical principles, marking a groundbreaking commitment to ethical standards in this field. The declaration's innovative power lies in its moral demand on states to adhere to these principles. The significance of the UDBHR is further highlighted by several factors: (i) unlike earlier declarations, such as the Helsinki Declaration for example, which were drafted solely by professional bodies such as the World Medical Association, the UDBHR was a collective effort by states; (ii) it anchors global bioethics firmly within the framework of human rights; (iii) it expands the scope of bioethical principles from the traditional four developed by Beauchamp and Childress to a comprehensive list of 15; (iv) it extends its focus beyond individual concerns to include social and environmental considerations; and (v) it represents not merely the international spread of bioethics from one nation to another but also led to a true globalisation of bioethical discourse among nations.

The UDBHR serves as a unique global tool for addressing bioethical issues arising from technological advancements. According to Article 1.1 of the UDBHR, the declaration addresses ethical questions in medicine, life sciences and related technologies (e.g., surrogacy) as they pertain to humans by considering their social, legal and environmental implications.^[5] The Declaration determines that a complete bioethical discussion must incorporate its principles, urging countries and scientists to integrate these into all bioethical deliberations (art. 19, 23).^[5,6] This means that the UDBHR should be used to determine whether surrogacy as a technological procedure is ethically sound.^[7]

Although the practice of surrogacy has received much attention, there is almost no discussion on the UDBHR and surrogacy, therefore necessitating this study. The only document that links surrogacy and the UDBHR is the Report of the International Bioethics Committee (IBC) on Assisted Reproductive Technologies (ART) and Parenthood (2019).^[3] Although the IBC (of UNESCO) addresses surrogacy, it does not focus exclusively on surrogacy, and there is no discourse between this reproductive practice or technology and the UDBHR, hence the inclusion of the word 'provisional' in the title of this study. The central theoretical argument is that the UDBHR simultaneously legitimises surrogacy through procedural guidelines while raising substantial ethical concerns that challenge its moral acceptability, creating an unresolved ethical paradox within its framework. The methodology outlined in the research is evaluative, aiming to assess surrogacy technology against the standards of the UDBHR. It also includes an interpretive element, analysing how UDBHR principles apply to surrogacy-related ethical, legal and social issues. The value of the research is purely to evaluate. The study explicitly limits itself to critical assessment of surrogacy against established bioethical principles without proposing policy solutions or practice recommendations, maintaining its focus solely on ethical evaluation.

To achieve the aim, this article begins by explaining the most relevant surrogacy technology and characteristics, followed by a discussion of reproductive technology as measured against the UDBHR principles. The analysis concludes with an assessment of surrogacy's ethical standing according to these principles.

 

Surrogacy explained

Types of surrogacy

Surrogacy is a reproductive arrangement in which a woman agrees, often under a legal contract, to become pregnant and give birth to a child on behalf of another person or couple, who will assume parental rights after birth; this process involves complex ethical considerations and legal frameworks that vary across jurisdictions.^[3,8] Traditional surrogacy occurs when the surrogate mother contributes genetically (her ovum) to the commissioning parents. In this case, the commissioning father or a donor can assist in fertilising the surrogate mother. This type of surrogacy does not require in vitro fertilisation (IVF) and was practiced until around 1978.^[9] Gestational surrogacy occurs when the genetic material is not provided by the surrogate mother, but rather by the commissioning mother, with fertilisation facilitated by the commissioning father or a donor.^[9] Multi-party surrogacy is when neither the surrogate mother nor the commissioning parents contribute genetically to the conception of the child, relying primarily on donors. In this way, up to five people can contribute to the creation of a baby, namely the commissioning parents (as social parents), the surrogate mother, and (two different) donors.^[3,8] Gestational and multi-party surrogacy became a reality from 1978 onwards owing to advancements in artificial reproductive technology, which made it possible to create a human embryo outside the body in a laboratory.^[3,8] A surrogate mother can be a family member, friend or person selected by a surrogacy agency or IVF clinic. There may be complete anonymity between the surrogate mother and the commissioning parents, but they can also have full contact with each other.^[4]

The surrogacy process

Fertilisation in gestational and multi-party surrogacy occurs through IVF fertilisation. Briefly, this procedure involves placing female and male gametes together in a petri dish, leading to the fertilisation of the female gamete and the formation of a human embryo. The procedure includes hormonal stimulation to extract oocytes from the ovary. Sperm can be collected from the man through ejaculation, aspiration or other surgical procedures. During each cycle, eight to 12 oocytes are retrieved and fertilised. Typically, one or two embryos are placed in the uterus. When transferring one embryo, there is a 30 per cent to 35 per cent chance of pregnancy for a woman under 35.^[3] The ethical dilemma of greatest concern within the domain of IVF pertains to the management of surplus embryos.

The maximum number of embryos is created, but only one or two are placed in the uterus during a cycle. The remaining embryos can be frozen for future use by the parents, donated or destroyed.^[10]

Reasons for choosing surrogacy

Surrogacy can occur for altruistic or financial (commercial) reasons. Altruistic surrogacy is undertaken out of compassion or solidarity with the other person's need.^[8] In some countries where altruistic surrogacy is permitted, the act is completely free of charge, or the surrogate mother is compensated for specific pregnancy-related expenses such as healthcare but may not receive any (extra) payment for the process itself. However, the majority of surrogate mothers participate in the process for commercial reasons. Commercial surrogacy usually means a surrogate mother is paid beyond just her medical expenses. They are often mothers who still have dependents in their household. Some women consider it a job, with the surrogacy agency as their 'employer.'^[4,11]

A commissioning parent or parents consider this technology owing to infertility resulting from a lack of a uterus or uterine abnormalities. It is the only way for a woman who was born without a uterus or whose uterus was removed for medical reasons to conceive her genetically own child.^[4] Some women are also unable to complete a pregnancy owing to recurrent miscarriages or failed IVF treatments, and can only become genetic mothers through the use of a surrogate.^[3,8] Surrogacy is recognised as a vital means of enabling parenthood for those facing significant reproductive challenges.^[12] This technology is also considered by single men or same-sex male couples. It is also the only way for these individuals to become genetic parents. There are also examples of single women who have not used their own ova or carried the child themselves, who have become parents through surrogacy.^[13] Female couples may consider this technology for medical reasons. ^[3,4,8]

Costs and compensation in surrogacy

The costs associated with surrogacy vary between different countries and it is an expensive process.^[8] The complete process of surrogacy in the USA can cost as much as $200 000. Programmes include $20 000 to $80 000 for medical expenses, $3 000 to $15 000 for legal fees, $6 000 to $54 000 for surrogate recruitment programmes, and between $20 000 to $55 000 for surrogate compensation. In low-income countries, the costs associated with the process are usually half of that in the USA, making surrogacy tourism attractive.^[4,14] The surrogate mother is usually paid an additional amount for a multiple pregnancy.^[4,15]

There is a debate about whether clear differences exist between commercial and altruistic surrogacy. Surrogacy often involves significant medical expenses, including healthcare costs and time off work due to pregnancy (sick leave). Some argue that commissioning parents can structure a large financial payment to the altruistic surrogate by covering these expenses generously. Instead of a straight salary, the altruistic surrogate receives much higher than normal reimbursements for things such as doctor visits and maternity leave. In this way, the total amount that the altruistic surrogate receives might be similar in commercial and altruistic arrangements, blurring the lines between the two. Because of this potential for structured payments, some believe the clear distinction between commercial and altruistic surrogacy is becoming difficult to maintain.^[4,16] A monetary compensation is actually a win-win situation for both parties because the surrogate mother receives good financial care and the commissioning parents receive their desired child.^[17] The monetary compensation or payment of the surrogate mother leads to a certain contradiction. On the one hand, during altruistic surrogacy, the minimal payment may be seen as compensation for the effort, but it can also be interpreted as exploitation. On the other hand, during commercial surrogacy, a good payment for services rendered may be considered fair, but it can also be seen as the commercialisation and commodification of the surrogate mother's child. Although multiple empirical studies have documented the exploitation of surrogate mothers, the charge of child commodification remains a normative critique or theoretical objection, lacking empirical substantiation.^[4,15]

Challenges and controversies in surrogacy

During the process of surrogacy, complex ethical and legal issues can arise, such as what happens if the child is born with disabilities and no one wants the child, or what happens if the surrogate mother becomes emotionally attached to the child.^[8] In both cases, a written agreement is drafted between the commissioning parent(s) and the surrogate mother, outlining the intentions of both parties, duties, the nature of the compensation, and payments, as well as the decision-making process in unforeseen circumstances.^[4]

 

Surrogacy: A global perspective

This discussion examines surrogacy through the lens of relevant principles found in the UDBHR. The aim is to determine whether the UDBHR remains neutral by merely providing procedural guidelines for conducting surrogacy or if it offers a judgment on the ethicality of the practice.

Human dignity and human rights

Article 3.1 of the UDBHR states: 'Human dignity, human rights, and fundamental freedoms are to be fully respected.' Some argue that surrogacy undermines human dignity by using the woman (the surrogate mother) as a means to others' ends, thus treating her as less than human.^[9,18] Specifically, commercial surrogacy is viewed as commodifying the female body and the child, affecting their dignity. ^[4] However, in the case of altruistic surrogacy, it can be an expression of the surrogate's autonomy and personal choice, reinforcing her dignity. When a woman chooses to become a surrogate out of altruism, she exercises her autonomy, making a significant decision about her body and life. This act can be a source of profound personal satisfaction and self-fulfillment, aligning with respect for human dignity. Regarding commercial surrogacy, some argue it can be seen as a legitimate form of labour, where compensation is for the service and effort involved rather than for the body itself. The surrogate is compensated for her time, physical and emotional labour, and associated risks, not selling her body or the baby. This perspective upholds the surrogate's dignity by emphasising her autonomy and contribution.^[7] As for the child, concerns about commodification are countered by the intent and ethical framework guiding surrogacy agreements. The primary motivation is to create a family, not to trade or profit from the sale of children. Properly regulated surrogacy includes legal and ethical oversight to protect all parties, especially the child. Therefore, despite existing concerns, Article 3 does not provide a convincing basis for ethical condemnation of surrogacy practices, as surrogacy arrangements can be compatible with human dignity when conducted according to ethical standards and principles.

Benefit and harm

Article 4 of the UDBHR states: 'In applying and advancing scientific knowledge, medical practice, and associated technologies, direct and indirect benefits to patients, research participants, and other affected individuals should be maximised, and any possible harm to such individuals should be minimised.'Surrogacy provides significant benefits by fulfilling the parental dreams of commissioning parents, offering a pathway to parenthood for those unable to conceive naturally, including infertile couples, single individuals, and same-sex couples. Surrogacy allows them to maintain a biological connection with the child, which is crucial for many.^[4] Surrogate mothers can experience deep satisfaction from helping others become parents. In commercial surrogacy, financial compensation can improve the surrogate's quality of life, supporting her and her family's future opportunities.^[9]

Potential harm includes emotional challenges for commissioning parents, such as anxiety and societal stigma. However, research shows they generally have positive experiences with minimal reports of fear, stress or ethical discomfort.^[4,13] For surrogate mothers, risk and possible harm include typical pregnancy complications, the effects of hormonal treatments, and psychological challenges. A study published in the Annals of Internal Medicine^[19] found that surrogate pregnancies, specifically gestational surrogacy, have a higher rate of complications compared with natural pregnancies and those achieved through IVF. The study included 863 017 women and found that 7.8 per cent of surrogate mothers experienced severe maternal complications, such as postpartum haemorrhage, severe pre-eclampsia, and serious postpartum infections. This rate was more than three times higher than for natural pregnancies and almost twice as high as for IVF pregnancies. The study also noted that surrogate mothers were more likely to give birth prematurely. The researchers suggested that the genetic difference between the surrogate and the baby might affect the immune response during pregnancy, potentially leading to these complications. The research raises ethical questions about the practice of surrogacy, especially in countries where commercial surrogacy is allowed.^[19] Multiple pregnancies increase risks for both surrogate and child, but insisting on singleembryo transfer can mitigate these risks.^[3,4] Studies indicate that with proper support and healthcare, surrogates generally have positive experiences, especially in high-income countries.^[4,20] Therefore, given that the potential harms of surrogacy, particularly the significantly higher rate of severe maternal complications, outweigh the benefits, Article 4 of the UDBHR cannot currently approve the practice, as it mandates maximising benefits and minimising harm.

Autonomy and individual responsibility

Article 5 of the UDBHR emphasises: 'The autonomy of persons to make decisions, while taking responsibility for those decisions and respecting the autonomy of others, is to be respected.'Commissioning parents exercise their autonomy by choosing surrogacy to fulfill their desire for children, an aspect of personal family life. They should have the freedom to make informed decisions about the process. The surrogate's autonomy is respected when her decision to carry a pregnancy for someone else is made freely and without coercion. Her autonomy includes decisions about her healthcare during pregnancy within the agreed contractual framework. Both parties should engage in open communication and mutual respect to ensure their autonomies are respected.^[12] Article 5 supports surrogacy by emphasising the importance of autonomous, informed decisions and ethical responsibility for both commissioning parents and surrogate mothers.

Consent

Article 6.1 of the UDBHR states: 'Any preventive, diagnostic, and therapeutic medical intervention is only to be carried out with the prior, free, and informed consent of the person concerned, based on adequate information.' The principle of informed consent applies to surrogacy under Article 1 of the UDBHR, which covers 'medicine, life sciences, and associated technologies' for humans, even though surrogacy isn't strictly preventive, diagnostic or therapeutic.^[5] Ensuring informed consent in surrogacy involves providing the commissioning parents and the surrogate with detailed information about all medical procedures, risks and potential psychological impacts. Consent must be voluntary and explicit, and can be withdrawn at any time without disadvantage, aligning with Article 6.1.^[21] Surrogacy cannot be rejected based on informed consent issues because these can be addressed through thorough laws, education and support, ensuring that surrogate mothers fully understand and consent to the process.

Persons without the capacity to consent

Article 7a of the UDBHR states: 'In accordance with domestic law, special protection is to be given to persons who do not have the capacity to consent: authorisation for research and medical practice should be obtained in accordance with the best interest of the person concerned.' Article 17 of the UDBHR emphasises that the well-being and rights of future children must also be considered and protected. ^[5] It is essential to ensure that all legal frameworks protect the rights of future children born through surrogacy, although research on the best interests of such children is limited.^[7] Some question whether surrogacy serves the best interest of the child, arguing that it intentionally disrupts biological connections, which may conflict with the child's rights as outlined in Article 16 of the UDBHR, emphasising the importance of the natural family unit.^[3] The UN Convention on the Rights of the Child (Article 3) underscores that the best interest of the child must be the primary consideration in all decisions affecting them.^[22] Both altruistic and commercial surrogacy arrangements may disregard the child's right to be conceived through natural means and to participate in a traditional family unit. After reflecting on Article 7, if this argument - which is broadly supported - is valid, surrogacy raises ethical concerns about the child's right to natural conception and thus calls its ethical acceptability into question.

Respect for human vulnerability and personal integrity

Article 8 of the UDBHR emphasises the protection of human vulnerability and personal integrity in the context of advancing scientific knowledge and medical practice. In surrogacy, this principle applies to two key vulnerable groups: economically disadvantaged surrogate mothers and human embryos.^[9,23] The additional vulnerability of surrogate mothers, particularly those from economically disadvantaged backgrounds, is a significant concern. These women may be coerced by poverty into surrogacy, lacking other viable income options. In developing countries, women are often exploited by intermediaries or agencies, who profit disproportionately from their labour.^[4,7,15,24] Despite the need for strict regulations and oversight to ensure fair compensation and informed consent, these safeguards are generally lacking in many surrogacy arrangements, leaving vulnerable women at risk of exploitation.^[7,9]

However, the most profound ethical concern in surrogacy relates to the vulnerability of the human embryo. Some countries and individuals view the human embryo as possessing the status of a person.^[7] Recent biological knowledge suggests that development from fertilisation to birth is a continuous, uninterrupted process with no qualitative leaps. There is no substantial ontological modification between conception and birth that would justify denying the fetus full human status from conception.^[25,26] Since the fetus's being remains essentially unchanged from conception to birth, it must be recognised as a full human person from the moment of conception and afforded moral protection accordingly.

The IVF process, integral to many surrogacy arrangements, involves multiple stages that pose risks to the human embryo. These include ovarian stimulation, egg retrieval, fertilisation and embryo culture. Collectively, these IVF-related manipulations - while indispensable for assisted reproduction - introduce mechanical, chemical and environmental stresses that can compromise embryo health, developmental trajectory, and long-term outcomes. Embryos are graded based on specific biological criteria (embryonical eugenics), with those deemed insufficient often discarded. This selection process raises significant ethical concerns, as it involves making life-or-death decisions about human embryos.^[25,26] Human embryos are extremely fragile and susceptible to environmental influences, genetic abnormalities, and developmental disruptions. Their viability in artificial environments such as IVF labs depends heavily on precise control of conditions. Ethically, embryos are highly vulnerable because they have no agency or ability to make decisions for themselves, leaving them at the mercy of others' choices.^[25,26]

Given these considerations, Article 8 of the UDBHR presents a strong argument against surrogacy. The practice not only potentially exploits vulnerable women but also raises profound ethical issues regarding the treatment of human embryos. If we accept the premise that human embryos possess the status of persons, then the common practices in surrogacy and IVF - including embryo selection and discarding - become ethically untenable. This makes surrogacy a profoundly questionable practice from the perspective of protecting human vulnerability and personal integrity.

Privacy and confidentiality

UDBHR Article 9 emphasises the importance of respecting individuals' privacy and confidentiality, particularly in situations involving personal and medical information.^[5] In the context of surrogacy, this means ensuring that sensitive information shared between surrogate mothers and intended parents is protected from unauthorised access. Recent studies have highlighted the need for robust confidentiality measures, including secure storage and limited access to surrogacy agreements and medical rCcords.^[4] However, the question of whether anonymity should be maintained between surrogate mothers and commissioning parents remains a topic of debate. While some countries mandate anonymity, others encourage open communication and even argue that donor-conceived children have a right to know their genetic origins.^[27,28] From a bioethical perspective, it is essential to strike a balance between respecting individuals' privacy and promoting transparency and accountability in surrogacy arrangements. By implementing appropriate measures to manage privacy concerns, it is possible to mitigate potential risks and ensure that surrogacy is practised in a responsible and ethical manner. Article 9 cannot be used as a compelling basis for denouncing surrogacy, as privacy concerns can be managed through appropriate measures.

Equality, discrimination, and stigmatisation

Articles 10 and 11 of the UDBHR emphasise equality, justice and nondiscrimination in healthcare, including surrogacy.^[29,30] Surrogacy is a vital option for infertile couples, single parents and same-sex couples,

but high costs create inequity.^[4,7] Surrogate mothers worldwide should receive equal compensation, but disparities persist, raising concerns about justice. Economically disadvantaged individuals face a dilemma: exclusion could exacerbate marginalisation, while inclusion without safeguards could lead to exploitation.^[9] Articles 10 and 11 support procedural fairness and equal access in surrogacy, rather than opposing the practice itself. They promote ethical practices and protect the rights and well-being of all parties involved in surrogacy.^[7]

Respect for cultural diversity and pluralism

Article 12 of the UDBHR underscores respect for cultural diversity and pluralism, stipulating that such respect must not violate human dignity, human rights and fundamental freedoms.^[5] Culture encompasses a society's distinctive spiritual, material, intellectual and emotional features, with pluralism and diversity essential for social cohesion. However, cultural practices cannot justify discrimination or violate fundamental human rights, necessitating a balance between cultural values and individual rights. Religion significantly influences cultural and ethical debates surrounding surrogacy.^[4] Some religions reject surrogacy based on beliefs about parenthood, reproduction, the female body, and embryo status, often restricting reproduction to heterosexual marriage.^[9,12] Conversely, some religions, such as Buddhism, view infertility as a curse and accept surrogacy as a compassionate solution.^[7,31] This highlights the diverse religious perspectives on the practice. Crucially, Article 12 prioritises human dignity and rights over cultural considerations. While a woman may choose surrogacy based on religious or cultural beliefs, she must not be coerced and must provide informed consent, a fundamental human right superseding cultural norms.^[8] This ensures ethical surrogacy practices that respect the autonomy and rights of all involved. Therefore, Article 12, while procedurally relevant, cannot convincingly condemn surrogacy when conducted ethically and with respect for individual rights. It emphasises the need to navigate cultural diversity while upholding universal human rights standards.

Solidarity and cooperation

Article 13 of the UDBHR promotes solidarity and cooperation, urging joint efforts towards common goals, especially in bioethics and human rights.^[32] This principle encourages working together for the greater good, despite modern challenges. Individual solidarity, as defined by the UDBHR, involves personal responsibility and supportive actions based on shared humanity.^[33] It emphasises empathy, compassion and acting for others' welfare. Both altruistic and commercial surrogacy can be considered forms of solidarity. Altruistic surrogacy is clearly motivated by empathy and a desire to help. While commercial surrogacy involves financial compensation, this does not negate the presence of solidarity. Payment can be viewed as recognising the significant physical, emotional and psychological commitment undertaken by the surrogate. Similar to compensated research participants or non-governmental organisation workers, financial remuneration does not preclude acting in solidarity with others. Crucially, ethical guidelines and legal frameworks must protect surrogates from exploitation and coercion, prioritising their health, rights and well-being. Informed consent is paramount.^[33] In my view, Article 13's emphasis on solidarity and cooperation provides a compelling argument for surrogacy as a valid way to assist those facing infertility.

Social responsibility and health

Article 14 of the UDBHR asserts the responsibility of the state and society to promote health, a fundamental human right and human good encompassing physical, mental and social well-being. ^[5] Surrogacy can contribute to this broad definition of health. For individuals unable to conceive naturally, surrogacy offers a path to parenthood, promoting physical health by avoiding pregnancy-related risks for the intended mother. It also addresses the psychological distress and social stigma associated with infertility, fostering mental and social well-being through family creation. Ethically conducted surrogacy, with informed consent and respect for all parties,^[7] aligns with health as a human good. Article 14 provides a strong basis for accepting surrogacy. It highlights the societal responsibility to ensure the highest attainable standard of health.^[34] In regulated contexts protecting all parties' rights, especially the surrogate's, surrogacy can be a vital tool in fulfilling this responsibility. By positioning health as both a right and a social good, Article 14 supports broad interpretations of health services, potentially including reproductive technologies such as surrogacy to address diverse health needs. However, ethical considerations and robust regulations are essential to prevent exploitation and ensure responsible implementation.

Sharing of benefits

Article 15 of the UDBHR emphasises sharing the benefits of scientific research with society, especially developing countries,^[5] providing an ethical framework for surrogacy. This principle, rooted in justice and solidarity,^[35] suggests that surrogacy, as a medical application, should share its benefits among all parties involved. Intended parents gain parenthood, while surrogates receive fair compensation and support. Surrogacy extends the principle of universal access to scientific advancements, offering a path to parenthood for those facing infertility. It can bridge gaps between regions with advanced medical technologies and those without, providing significant financial opportunities for surrogates in developing countries. Additionally, surrogacy's demand for quality healthcare can improve healthcare standards, distributing scientific benefits more broadly. Article 15 of the UDBHR supports surrogacy by advocating for the equitable sharing of scientific research benefits, making it an ethical framework to promote health and economic benefits inclusively.

Protecting future generations

Article 16 of the UDBHR emphasises considering the impact of life sciences on future generations, including their genetic constitution.^[5] While surrogacy raises potential challenges for children born through this method, these concerns can be addressed through responsible practices. Prenatal health is crucial. Surrogate mothers should receive counseling and support to promote healthy habits, including vaccinations, avoiding teratogens, and abstaining from harmful substances.^[4,9] Open communication within families formed through surrogacy is essential for the child's emotional well-being.^[4,37]

Multiple pregnancies, a risk with some surrogacy procedures, pose increased risks of perinatal complications and neurological problems. ^[3,7] However, single embryo transfer, combined with high-quality freezing programmes, mitigates this risk.^[7] The aforementioned study observed that surrogate mothers demonstrated a higher incidence of premature delivery compared with non-surrogate pregnancies.^[19] Premature birth, occurring before 37 weeks of gestation, can cause various immediate and long-term health problems for the child, including respiratory issues, temperature instability, feeding difficulties, infections, jaundice, chronic diseases, neurodevelopmental impairments, vision and hearing problems, growth issues, and psychosocial challenges.^[37] Protecting children's identities and origins is crucial to prevent stigmatisation.^[4] Article 16 of the UDBHR raises ethical challenges to surrogacy by highlighting the potential impact on future generations, including the increased risk of premature birth and associated health problems, which necessitates careful consideration of the child's well-being.

 

Summary

The UDBHR presents a profound ethical paradox in its approach to surrogacy. On one side stands the declaration's procedural architecture - Articles 5, 6, 9, 12, 13 and 15 - which implicitly legitimises surrogacy by establishing guidelines for its implementation, tacitly acknowledging its potential benefits as a pathway to parenthood and its connection to Article 14's vision of social responsibility and health. On the opposing side stands a formidable array of substantive ethical principles within the same declaration that fundamentally challenge surrogacy's moral acceptability: Articles 3, 8 and 10 raise alarm about human dignity, vulnerability and equality; Article 4 confronts the documented higher rates of severe maternal complications for surrogates; Article 8 questions the ethical status of embryos potentially reduced to commodities; and Article 16 expresses concern for future children who cannot consent to their creation circumstances.

This tension creates an unresolved ethical contradiction within the UDBHR framework - it simultaneously provides procedural legitimacy to surrogacy while raising substantive ethical concerns that challenge whether surrogacy can ever be fully reconciled with the declaration's core principles. This analysis suggests that despite procedural accommodations, surrogacy as currently practised faces fundamental ethical barriers that require rigorous addressing through further research and robust international regulations before it can be deemed genuinely compatible with the UDBHR's comprehensive ethical vision, particularly regarding the protection of vulnerable participants - women, embryos and future children.

Declaration. None.

Acknowledgements. None.

Author contributions. Sole author.

Funding. No funding occurred in the development of this article.

Conflicts of interest. None.

 

References

1. Williams ME. Pope Francis isn't completely wrong about surrogacy. Salon; 2024. https://www.salon.com/2024/02/04/pope-francis-isnt-completely-about-surrogacy/ (accessed 5 February 2024).

2. Cook M. Pope Francis continues to wage war on surrogacy. BioEdge; 2024. https://bioedge.org/beginning-of-life-issues/surrogacy/pope-francis-continues-to-wage-war-on-surrogacy/ (accessed 5 February 2024).

3. IBC. Report ofthe IBC on assisted reproductive technologies (Art) and parenthood. SHS/IBC-26/19/2 REV. Paris, 20 December 2019 (accessed 18 November 2020).

4. Brandão P, Garrido N. Commercial surrogacy: An overview. Rev Bras Ginecol Obstet 2022;44(12):1141-1145.         [ Links ]

5. UNESCO. Universal Declaration on Bioethics and Human Rights; 2006. https://www.unesco.org/en/legal-affairs/universal-declaration-bioethics-and-human-rights?hub=387 (accessed 13 November 2013).

6. Ten Have H. Respect for cultural diversity and pluralism. In: Tham J, Kwan KM, Garcia A, editors. Religious perspectives on bioethics and human rights. Cham, Switzerland: Springer International Publishing; 2017.         [ Links ]

7. Van den Akker OBA. Surrogate motherhood families. Cham, Switzerland: Palgrave Macmillan; 2017.         [ Links ]

8. Ten Have H, Patrão Neves M. Surrogate motherhood. In: Dictionary of global bioethics. Cham, Switzerland: Springer Nature; 2021:991-992.         [ Links ]

9. Stehr E. International surrogacy contract regulation: National governments' and international bodies' misguided quests to prevent exploitation. Hastings Int'l Comp L Rev 2012;35:253.         [ Links ]

10. Ten Have H, Patrão Neves M. In vitro fertilisation. In: Dictionary of global bioethics. Cham, Switzerland: Springer Nature; 2021:623-624.         [ Links ]

11. Attawet J, Wang A, Sullivan E. 'Womb for work' experiences of Thai women and gestational surrogacy practice in Thailand. Hum Fertil (Camb) 2022;25(5):912-923.         [ Links ]

12. Ten Have H, Patrão Neves M. Assisted reproductive technology. In: Dictionary of global bioethics. Cham, Switzerland: Springer Nature; 2021:137.         [ Links ]

13. Golboni F, Jalali A, Dinmohammadi M, et al. Iranian model of decision making to use surrogacy: A grounded theory study. Health Care Women Int 2020;41(7):853-865.         [ Links ]

14. Luk J, Petrozza JC. Evaluation of compliance and range of fees among American Society for Reproductive Medicine-listed egg donor and surrogacy agencies. J Reprod Med 2008;53(11):847-852.         [ Links ]

15. Blazier J, Janssens R. Regulating the international surrogacy market: The ethics of commercial surrogacy in the Netherlands and India. Med Health Care Philos 2020;23(4):621-630.         [ Links ]

16. Van Beers B, Bosch. A revolution by stealth: A legal-ethical analysis of the rise of preconception authorisation of surrogacy agreements. New Bioeth 2020;26(4):351-371.         [ Links ]

17. Gunnarsson Payne J, Korolczuk E, Mezinska S. Surrogacy relationships: A critical interpretative review. Ups J Med Sci 2020;125(2):183-191.         [ Links ]

18. Andorno R. Article 3: Human dignity and human rights. In: Have H, Jean M, editors. The UNESCO Universal Declaration on Bioethics and Human Rights: Background, principles and application. Paris: UNESCO Publishing; 2009:91-98.         [ Links ]

19. Velez MP, Ivanova M, Shellenberger J, Pudwell J, Ray JG. Severe maternal and neonatal morbidity among gestational carriers: A cohort study; 2024. https://www.acpjournals.org/doi/abs/10.7326/M24-0417 (accessed 30 September 2024).

20. Yee S, Hemalal S, Librach CL. 'Not my child to give away':A qualitative analysis of gestational surrogates' experiences. Women Birth 2020;33(3):e256-e265.         [ Links ]

21. Ten Have H, Patrão Neves M. Consent, informed consent. In: Dictionary of Global Bioethics. Cham, Switzerland: Springer Nature; 2021;351-352.         [ Links ]

22. United Nations. Convention on the Rights of the Child; 1989. https://www.ohchr.org/en/instruments-mechanisms/instruments/convention-rights-child (accessed 6 June 2024).

23. Ten Have H, Patrão Neves M. Vulnerability. In: Dictionary of global bioethics. Cham, Switzerland: Springer Nature;2021:1043.         [ Links ]

24. Trowse P, Cooper D. The agony and the ecstasy: Sacrifice and pain for financial gain: Have Indian surrogate mothers been exploited by their intended parents in commercial surrogacy arrangements? J Law M Ed 2018;25(2):388-407.         [ Links ]

25. Condic M. A scientific view of when life begins. Arlington, USA: Charlotte Lozier Institute; 2014. https://lozierinstitute.org/a-scientific-view-of-when-life-begins/ (accessed 12 August 2024).         [ Links ]

26. Duhart PDR. The status of the human embryo: An interdisciplinary (bioethical) analysis of reality. Med y ética 2023;34. https://www.scielo.org.mx/scielo.php?pid=S2594-21662023000400895&script=sci_arttext&tlng=en#aff2 (accessed 25 September 2024).

27. Ishii T, de Miguel Beriain I. Shifting to a model of donor conception that entails a communication agreement among the parents, donor, and offspring. BMC Med Ethics 2022;23(1):18.         [ Links ]

28. Harper JC, Kennett D, Reisel D. The end of donor anonymity: How genetic testing is likely to drive anonymous gamete donation out of business. Hum Reprod 2016;31:1135-1140.         [ Links ]

29. D'empaire G. Article 10: equality, justice and equity. In: Have HT, Jean M, editors. The UNESCO Universal Declaration on Bioethics and Human Rights: Background, principles and application. Paris: UNESCO Publishing; 2009.         [ Links ]

30. Ten Have H, Patrão Neves M. Vulnerability. In: Dictionary of Global Bioethics. Cham, Switzerland: Springer Nature; 2021:1043.         [ Links ]

31. Deonandan R. Thoughts on the ethics of gestational surrogacy: Perspectives from religions, Western liberalism, and comparisons with adoption. J Assist Reprod Genet 2020;37(2):269-279.         [ Links ]

32. Elungu A. Article 13: Solidarity and cooperation. In: Have H, Jean M, editors. The UNESCO Universal Declaration on Bioethics and Human Rights: Background, principles and application. Paris: UNESCO Publishing; 2009: 211-217.         [ Links ]

33. Fayemi AK, Chimakonam AE. Global justice in the context of transnational surrogacy: An African bioethical perspective. Theor Med Bioeth 2022;43(2):75-93.         [ Links ]

34. Martínez-Palomo A. Article 14: Scial responsibility and health. In: Have H, Jean M, editors. The UNESCO Universal Declaration on Bioethics and Human Rights: Background, principles and application. Paris: UNESCO Publishing; 2009: 219-230.         [ Links ]

35. Ten Have H, Patrão Neves M. Benefit sharing. In: Dictionary of Global Bioethics. Cham, Switzerland: Springer Nature; 2021: 153-154.         [ Links ]

36. Sifris A. The family courts and parentage of children conceived through overseas commercial surrogacy arrangements: A child-centred approach. J Law Med 2015;23(2):396-412.         [ Links ]

37. Pravia CI, Benny M. Long-term consequences of prematurity. Cleve Clin J Med 2020;87:759-767.         [ Links ]

 

 

Correspondence:
R Rheeder
riaan.rheeder@nwu.ac.za

Received 11 October 2024
Accepted 3 July 2025