The Cutest Babies Money Can Buy

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BOOK REVIEW

By ABBY LIPPMAN

TITLE: The Baby Business: How money, science, and politics drive the commerce of conception
AUTHOR: Debora L. Spar
PUBLISHER: Harvard Business School Press, 2006
299 pages (including endnotes, acknowledgments, and index)
US $26.95

It’s probably a toss up whether more money is spent in the USA on preventing pregnancy or on creating children. Exactly how and where this $3 billion (US) changes hands annually in the production of what Deborah Spar calls "a good that is inherently good…..children for people who want them" is detailed in her book, "The Baby Business."

Unlike others who have examined reproductive technologies (e.g., donor insemination, in vitro fertilization [IVF], surrogacy, egg "donation,") on ethical, social, or health grounds, Spar uses a different lens. Claiming to set aside the intractable moral issues inherent in all these practices, as well as in adoption, Spar explores their use and marketing as evidence of why the US government needs to play a "more active role in regulating the baby business."

As might be expected from a professor of business administration at Harvard, Spar’s "The Baby Business" is primarily a small-l liberal call for some order in this market where babies, and the cells from which they arise, are increasingly commodified and commercialized. Spar builds a case for some regulation not so much to protect directly the health and well-being of the women and children who are the stock-in-trade for this market, but to ensure it functions most efficiently to "manufacture embryos that turn into babies" accessible to all who want them.

Spar documents in detail the current commercial, market-driven, unregulated baby business as it exists in the USA and the ripples it creates elsewhere. She underlines how the option(s) chosen for its regulation will vary according to whether it is pregnancies, children, or something else that is to be distributed fairly through this marketplace. And she lays out different ways of viewing this business, grounding these approaches in her claim that this commerce, whose end product is "a child to raise," is unlike all others.

One major difference is the potentially endless demand (for eggs, embryos and "surrogate" mothers, etc.), a demand constrained primarily in the US by prices that limit availability to this "material" to only to the wealthiest who alone can pay out-of-pocket for these "luxury" purchases not covered by insurers, public or private. Noting that science puts some limits on the "supply side," Spar reminds us that these are nevertheless quite elastic: each approach to meeting some specific demand in turn creates yet another new market.

For example, an experimental procedure, egg-freezing, first offered prior to cancer chemotherapy for selected women who might want to bear children later in their lives, almost overnight became an entrepreneurial opportunity. Egg banks now post internet ads promoting their storage facilities to young women who don’t want to interrupt their careers for childbearing until their 40s or 50s.

Besides its unusual supply/demand relationships, other special features of the baby business also lead Spar to argue for government intervention. "Normal" market mechanisms don’t apply when, in selling their assisted reproductive services, failure is, paradoxically, more lucrative than "success": repeated attempts at IVF when no baby is born are more profitable for clinicians than is creating a pregnancy on the first go. Relevant, too, is the global nature of the commerce: those who can’t get women’s eggs where they live can locate a "donor" on the internet. If surrogacy is against the law in one country, it can be arranged "offshore" – with the contracting couple coming home from a holiday holding a newly born infant in their arms.

But, rather than propose any one (or more) policy/regulatory model specifically to address all this, Spar calls for "an intense political debate" from which she envisions consensus regulations emerging -- and offers some principles with which to guide this debate.

It’s hard to carp at Spar’s quite Canadian ("let’s have a public discussion") solution to these vexed problems. After all, from 1989-1993, Canadians went through a multi-million dollar Royal Commission on new reproductive technologies, with this followed by several long difficult years of talk and consultation as Parliament debated multiple draft bills until finally passing, in March 2004, the Assisted Human Reproduction Act. Politicians and citizens here mostly accepted several of Spar’s guiding principles for regulation (i.e., assured access to information about the risks, benefits, and costs of the various interventions; some enforceable set of laws; possible limits on individual choice), but two years later, we have yet to see regulations or the Agency to refine and enforce them in action. Given the advanced state of the baby business in the US, to say nothing of irreconcilable differences about the "status of the embryo" or of the absence of publicly-funded health insurance, it’s not easy to see any public discussion there arriving at consensus on policy proposals, their urgency notwithstanding.

Thus, while "The Baby Business" is an eye-opener about the nasty undersides of the "commerce of conception," Spar doesn’t get down to details about what to do. Further, by not assessing the pros and cons of what other countries (Canada, the UK, even China) have done to impose some control on the (in)fertility industry, she offers no insights into what the US could do differently (better?) in face of a continually growing, cross-border trade. And even if she had, the question remains: will it really matter? Without considering how to manage the "reproductive tourism" developing as differences in regulatory regimes between countries lead individuals to go elsewhere to purchase what is forbidden or unavailable at home, it is hard to estimate the impact of national legislation in any one jurisdiction. To avoid the worst hazards accruing to the most vulnerable and the most marginalized women, those who will provide, or help produce, the "raw materials" of the "goods" sought – "happy, healthy children" for others -- some international, or at least supranational, control is essential.

Spar gives readers a more realistic picture of assisted reproduction than is provided by newspaper photos of some very pregnant 63 year old woman or of rosy-cheeked infant triplets. And learning the details of how postmenopausal pregnancies and multiple births are made – and bought – should begin to rally support for getting this industry under some control. But for control to be truly respectful of women, and women’s lives, we need also to understand the causes of infertility (why is there such an increasing demand for outside assistance in making babies in the first place?) and not only the profits made by circumventing it. Good policy development must also deal with the current disjunction between the excessive societal attention to and investment in reproductive technologies and the meager and decreasing efforts to improve the social and economic conditions that will let women have – or keep -- the children they want when they want them.

As a society, we tend to become galvanized when the "fix" is technological, yet too willingly turn away, and cut services, when the intervention addresses root causes. Moreover, we seem to care very much about how children are created, but much less so about creating the conditions to allow children to thrive. Spar seems to consider these "moral," not "business" matters, and omits them from her analysis. We don’t have this luxury. Fashioning regulatory policies that will control the market without controlling or coercing women, requires expanding Spar’s vivid picture of a (sometimes quite ugly) profit-driven world of sellers, buyers, and brokers of eggs, sperm, embryos, bodies, and babies. It means acknowledging the inherent social, ethical, political, and cultural issues that make this boundary field between medicine and industry so troubling to everyone. Most importantly, it means we must start investing in the well-being of women and children, not their acquisition.

A version of this article first appeared in the Globe and Mail, May 27, 2006