So many times the old adage about the personal being political rings true, and perhaps never so much as when control over the most intimate aspects of our lives are at stake. Reproduction occupies this deeply intimate ground, as witnessed in the ferocity surrounding the abortion debate. Reproductive technologies encompass everything from birth control -- something we often take for granted as even counting as technology because we've become accustomed to its existence -- to emergency contraception to abortion to the other side of fertility control, which is the treatment of infertility. In all cases, what counts as going too far and what is seen as detrimental to society at large is vastly different to different people.

As with other politically, economically and emotionally charged issues, one problem society faces is how difficult it is to even discuss the potential choices and repercussions of those choices. It's even hard to figure out how to step back and get a good view of the landscape we might hope to examine and consider, much less discuss or manipulate. Having written about these issues -- and struggled with huge familial fallout for the way I did so -- I feel particularly awed by Debora Spar's book, The Baby Business: How Money, Science, and Politics Drive the Commerce of Conception, for her contribution. She has framed these issues in ways that offer a clear view across a confusingly dense landscape. Reading her book provided not only smart insights into economics, but also offered a sense of how conversations are possible, ones that can be compassionate, significant, incisive and comprehensive.

Spar delves into the issue of how we're making and obtaining babies at the turn of the twenty-first century. Opting out of the political debate, she relies upon her professional training -- she's an economist -- to examine these highly charged and terrifically complex issues. Spar's central point is that now that reproductive technologies are available, commerce and conception are inextricably linked. To acknowledge and examine this market is an essential step for anyone to forge a more clear understanding of the issues surrounding use of advanced reproductive technologies. By placing her focus upon the costs, she lays out the parameters of the debate in cooler terms than most authors or researchers currently chronicling brave new realm of baby making are able to finesse. The book covers the breadth of potential avenues to parenthood, including fertility treatments involving sperm and egg donation, technologies such as in vitro fertilization (IVF) and preimplantation genetic diagnosis (PGD), surrogates, and international adoption.

As Spar writes in her preface:

As people -- as parents -- we don't like to think of children as economic objects. They are products, we insist, of love, not money; of an intimate creation that exists far beyond the reach of any market impulse. And yet, over the past thirty years, advances in reproductive medicine have indeed created a market for babies, a market in which parents choose traits, clinics woo clients, and specialized providers earn millions of dollars a year. In this market, moreover, commerce often runs without many rules.

Without denying the intricacy of the moral and legal and social and political issues raised by new reproductive technologies, the author first places the drive to have babies into an historic context, reminding readers that references to infertility were in evidence as early as in Genesis, when Jacob's wife found herself unable to conceive and sent her husband to the maid, later adopting the child of that union as her own. Spar characterizes the desire for babies as infinite, something that cannot be curbed. Buying into that premise isn't hard once you give even a passing glance at the numbers. As she describes, "Quietly, doctors began to see the field of reproduction not only as a cutting edge of medicine but also as a distinctly profitable endeavor -- expanding, unregulated, and catering to a population that seemed ever eager to pay. Between 1995 and 1998, the number of in vitro procedures performed in the United States rose by 37 percent, from roughly 59,000 to roughly 81,000. During the same period, the number of fertility clinics rose from 281 to 360."

Not only do people want babies because they want babies in an amorphous way, but some people want specific babies to save the lives of their gravely ill children. Spar writes of two families desperate to produce genetically specific children, the family of Henry Strongin Goldberg and of Molly Nash. Both children were born with a condition that causes bone marrow failure called Fanconi anemia; for both children, getting the precisely correct match for a bone marrow transplant was their only hope. While Molly Nash's mother was able to birth a baby with a favorable match, Henry Strongin Goldberg's mother -- after nine IVF attempts -- produced a child whose marrow did not end up a compatible match and the ill boy died. As Spar points out, two concerns arise from such situations. One is the cost: about $18,000 for the IVF process plus $3,500 for the diagnostic testing (PGD). Obviously, this means not every family would even be able to try to save their child at all. Another is how to draw a line: saving the life of a critically ill child is one extreme, but a slippery slope lies just beyond that circumstance. Dr. Jeffrey Steinberg, who runs a California infertility clinic, is quoted as saying, "'We've had emails and phone calls requesting specific traits.'" Spar points out that the eggs of an Ivy League educated, attractive young woman can fetch as much as $50,000. The fear of designer babies is not, she argues, unwarranted.

The Baby Business examines the economics of surrogates, first outlining the narrative arc from Baby M and women donating not only womb space but their eggs to the ability today, thanks to more sophisticated technologies, for a gestational surrogate to essentially "rent out" her uterus. With surrogates as with all technologies, one of the book's real strengths is that Spar reports upon the global market. In doing so, she notes which countries are willing to pursue certain avenues to creating children and which aren't. She looks at how different countries try to regulate technologies, and how others -- like ours in large part -- don't. Potential inequities between those who can purchase the opportunity to engage a surrogate and the women offering the service -- depending upon country of origin, often young and easily exploited -- exist and, Spar argues, must be acknowledged. This market, she urges, "... needs rules that establish how motherhood is transferred from one woman to another; rules that protect all these mothers along the way; and rules that define whether surrogacy is a privilege, a prerogative, or a prohibited activity."

Spar also explores what is almost a flip side to reproductive technologies, which is adoption. She writes, "As with the more mechanical forms of reproduction, adoption carries an often hefty price tag, ranging from virtually nothing -- the cost of adopting a teenager from the U.S. foster system -- to more than $35,000, the fully loaded cost for a healthy white Russian infant." Placing adoption squarely into the framework of this area of commerce -- conception -- is a savvy move, one that broadens the debate and offers a lot more information about how markets and governments and individuals can look at these issues, because adoption has a longer, active history than reproductive technologies do thus far. The interplay between control of reproduction and adoption is linked in critical ways.

By examining the economics globally with such attention to detail, along with offering analogies that contextualize the questions about regulation -- such as how our country deals with such medical issues like organ donation and hip replacements -- Spar reveals how a landscape that exists, often without acknowledgement, can become more visible. Focusing upon the issues, the questions, the potential choices offer a starting point for intelligent conversations, ones less fueled by simplistic or knee-jerk politics, and clearly these conversations must occur. As Spar ably observes of the possibilities that we are grappling with: "We can plunge into the market that desire has created, imagining how we can shape our children and secure our children without destroying ourselves." Having synthesized a great deal of pertinent information, she's laid the groundwork for many of these necessary discussions. This book is truly a must-read.

mmo : june 2006