When Having a Baby Means Someone Else Carries It

A woman in her 30s sits in a fertility clinic, facing an impossible choice. She wants a biological child, but a health condition would make pregnancy unusually difficult and "physically disfiguring." She can afford surrogacy through a reputable agency, but the moral weight of asking another woman to carry her child feels crushing. "There's such a stigma around it," she writes to an advice columnist. "I fear being judged by friends and family."

Her dilemma captures a tension at the heart of modern reproduction: When medical technology makes the impossible possible, how do we navigate the ethics of outsourcing one of humanity's most intimate experiences?

The Surrogacy Spectrum

Surrogacy isn't a monolith. The ethical landscape shifts dramatically depending on the circumstances. Altruistic surrogacy — where someone volunteers to carry a child without payment — sidesteps most concerns about commodification. But finding someone willing to undergo pregnancy's risks as "a literal labor of love" is rare.

Commercial surrogacy operates in a more complex moral space. In countries like Georgia, Ukraine, and Cyprus, agencies have been documented recruiting at domestic violence shelters, where women see surrogacy as their only escape from abuse. The $50 billion global fertility industry thrives on such desperation.

But American surrogacy tells a different story. Most surrogates are middle-class white women with families of their own. Reputable agencies actively screen out low-income candidates to avoid coercion. The economic context matters: a woman with multiple options choosing surrogacy faces different ethical considerations than one with none.

Medical vs. Elective: A Blurring Line

The medical establishment traditionally divides surrogacy into two categories: medically indicated (when pregnancy is impossible) and elective (when it's unwanted). But this binary is cracking under scrutiny.

Consider the transgender man who could physically carry a pregnancy but knows it would trigger severe gender dysphoria. Or the woman terrified of childbirth after her best friend died in delivery. Are these "elective" cases, or do psychological needs constitute medical ones?

Philosopher Miranda Fricker's concept of "epistemic injustice" — wronging someone in their capacity as a knower — applies here. When society dismisses someone's assessment of their own mental health needs, it commits a specific form of harm. Medical professionals are slowly recognizing that mental health is just as legitimate as physical health.

The Justice Question

Even when surrogacy involves consenting adults with economic alternatives, questions of fairness persist. If pregnancy would be uncomfortable for you but not uniquely harmful, is it just to transfer those risks to another woman?

This isn't just about autonomy — the libertarian principle that consenting adults should be free to make contracts. It's about justice: the deeper question of what we owe each other in a world of unequal burdens.

The woman seeking advice acknowledges this tension: "I don't think I can claim it would be so uniquely bad for me that I'm justified in wanting to pay to use someone else's body." Her self-doubt reflects a broader cultural uncertainty about when personal desires justify involving others in intimate labor.

Global Inequalities, Local Choices

The ethics of surrogacy can't be separated from global economic realities. A New York Times Magazine investigation revealed Ukrainian surrogates living in basement facilities, unable to leave, their phones confiscated. These women weren't making informed choices — they were trapped by circumstances.

Yet dismissing all surrogacy as exploitative ignores the agency of women who genuinely choose it. Some American surrogates describe pregnancy as a service they're uniquely positioned to provide, finding meaning in helping others build families.

The challenge lies in distinguishing genuine choice from constrained options. Economic inequality doesn't automatically negate consent, but it does demand careful scrutiny of the conditions under which decisions are made.