Is It OK to Hire a Surrogate to Bear Twins?

My husband and I want to have children, and as a gay couple, we think that surrogacy is our most realistic option. Surrogacy, however, is expensive. It could easily cost between $150,000 and $200,000 per pregnancy. We could afford two rounds, but this would deplete nearly all our savings. We are well-off, but don’t come from especially affluent backgrounds, and it took a long time to accumulate these savings. These savings, in part, are for our future retirement too.

The issue is that we would like to have two children. One option is to aim for twins in the first round. However, we know that the risk of complications is significantly higher with a twin pregnancy, and the health of our future babies and the surrogate is very important to us. Is it ethical to try to get twins, even though we could afford (though not comfortably) to lower the risk for the children and have two singletons instead? We would be devastated if we ended up with twins who have health issues. — Name Withheld

From the Ethicist:

Most twins — and their mothers — end up just fine. But you raise the right issues concerning the relative increase in risks to surrogate and children. A majority of twins are delivered preterm, which raises the likelihood of a variety of health problems, and birth defects are much more frequent than they are with singletons. Among people carrying twins, the rate of pre-eclampsia, a condition marked by hypertension, is two or three times higher than it is among those with singletons, and the severity tends to be greater, too. Carrying twins also elevates the risks for gestational diabetes (and about half of those affected will later develop Type 2 diabetes), placental abruption, anemia and postpartum hemorrhage.

As I’m sure you know, the ethical status of compensated surrogacy is itself highly contested; it’s not legally sanctioned anywhere in Western Europe. (“Surrogacy,” here, refers both to gestational surrogacy, in which the surrogate is not the biological mother of the child, and traditional surrogacy, in which she is.) My own view is that great care should be taken to avoid exploitation, but that under the right conditions, a woman should have the choice to enter into such an arrangement.

What about trying for twins? In light of the risks, the American Society for Reproductive Medicine, a professional organization that promulgates clinical and ethical guidelines for assisted reproduction, urges that measures be taken during in vitro fertilization to avoid pregnancies with two or more fetuses. Indeed, many reputable clinicians would simply decline to do what you’re contemplating, for good reason. Paying a surrogate to carry twins — intentionally creating a higher-risk pregnancy, in contravention of medical recommendations — would be wrong.

Given your concerns about cost, you should think too about the additional medical expense of monitoring a twin pregnancy and about the expenses you could incur should complications arise for the surrogate, the children or both. One large-scale study found that hospital costs for twin pregnancies were, on average, about five times higher than they were for singleton pregnancies.

A final note. You say you’d be devastated if your children had health issues. Yet whatever you do, there’s no guarantee that they won’t. When it comes to a prospective child, you’ll want to do your best — and be prepared for the worst. Parenthood gives you responsibility; it does not give you control.

Readers Respond

Last week’s question was from a reader who faced a dilemma about housing her child. She wrote: “I’m a nearly 70-year-old single mother living with an adult son of 40 who has schizoaffective disorder, which is a combination of schizophrenia and bipolar conditions. I testified at a juried trial that for over 10 years he has been averse to staying on antipsychotic meds, and that, as a result, he has been jailed, and that he has attacked me repeatedly in outbursts of rage. … He has just been released from a medication mandate. … My son is brilliant, with a genius I.Q. He’s also very loving when he’s on his meds. Off his meds, he’s a real menace and a threat to both my day-to-day peace of mind and my physical safety. But if I evict him, he’ll be homeless and destitute. I believe that it is morally wrong to put a mentally disabled person out on the streets to fend for himself. I further believe that a parent must look after her disabled child — but now that’s at the risk of my own peace of mind and safety and perhaps my life. What’s the right choice?”

In his response, the Ethicist noted: “I know that it’s often hard to persuade people to stay on their medications. To go by the research I’ve seen, perhaps half or more of patients with schizophrenia, bipolar disorder or schizoaffective disorder are ‘nonadherent.’ Many of them don’t like the side effects of drugs; some prefer being manic to being medicated. And your son’s condition may well mean that your son is in an especially poor position to see that he’s better off medicated. In a lucid moment, he might agree to try a long-acting injectable, easing adherence. That’s a form of what scholars sometimes call ‘self-binding,’ in which our present self puts constraints on our future self. So is getting a mortgage. We bind our future selves all the time. Please be clear that you’re not obliged to look after him at the risk of your life and health — and besides, if you’re incapacitated, he’ll be worse off, too. Expelling him from your home if he refuses treatment isn’t a way of punishing your son for defiance; it’s a way of protecting yourself from danger. If he ends up jailed again, he could be deemed a threat to himself and to others, and another cycle of involuntary treatment could start. Alas, your son’s keen intellect may help him secure what he wants, at the expense of what he needs.” (Reread the full question and answer here.)

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As a mom of an adult with mental illness, I second the Ethicist’s response. Setting a strong boundary to protect herself is a responsible thing for the letter writer to do. And radical acceptance of both her son’s illness and her inability to control him and his actions may release her from any guilt. It worked for me.— Rebecca

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I fully agree with the Ethicist. Too often people confuse setting personal boundaries with ultimatums. But the Ethicist’s response offers a choice that respects both the letter writer and her son’s needs. In this case, the son is able to decide whether to have a home while on medication or freedom from medication and the burden of finding his own home. He gets to weigh the options and then choose which he values more.— Joyce

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I live with a psychotic disorder myself, and I don’t believe it was appropriate for The Ethicist to assume that the son is better off on his medication. It would be best for the letter writer to consult with professionals trained to handle people living with schizoaffective disorder with gentle hands. — Lindsey

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My brother and father both were bipolar, and my brother would get violent when off his meds. My father allowed my brother to live with him, despite regular bouts of abuse that included an incident that led to my father being airlifted for emergency brain surgery. Medications for schizoaffective disorder and bipolar disorder have very significant side effects. Extreme nausea, diarrhea, impotence, and a general sense of malaise are common; no rational person would ever want to feel the way these drugs make one feel. I don’t have advice for the letter writer. But I can say that making hard decisions about behavior that is intolerable is both an art form and necessary. I had to cut off contact with my father and my brother. — Eric

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I would like to suggest the letter writer contact NAMI, or the National Alliance on Mental Illness. There she can get professional advice and help from experienced parents who have children with mental illness.— Romano

Kwame Anthony Appiah is The New York Times Magazine’s Ethicist columnist and teaches philosophy at N.Y.U. His books include “Cosmopolitanism,” “The Honor Code” and “The Lies That Bind: Rethinking Identity.” To submit a query: Send an email to ethicist@nytimes.com. More about Kwame Anthony Appiah