title: Informed consent in medical decision-making in commercial gestational surrogacy: a mixed methods study in New Delhi, India.
abstract: OBJECTIVE
  To investigate ethical issues in informed consent for decisions regarding embryo transfer and fetal reduction in commercial gestational surrogacy.
  
  
  METHODS
  Mixed methods study employing observations, an interview-guide and semi-structured interviews.
  
  
  METHODS
  Fertility clinics and agencies in Delhi, India, between December 2011 and December 2012.
  
  
  METHODS
  Doctors providing conceptive technologies to commissioning couples and carrying out surrogacy procedures; surrogate mothers; agents functioning as links for surrogacy.
  
  
  METHODS
  Interviews using semi-structured interview guides were carried out among 20 doctors in 18 fertility clinics, five agents from four agencies and 14 surrogate mothers. Surrogate mothers were interviewed both individually and in the presence of doctors and agents. Data on socio-economic context and experiences among and between various actors in the surrogacy process were coded to identify categories of ethical concern. Numerical and grounded theory-oriented analyses were used.
  
  
  METHODS
  Informed consent, number of embryos transferred, fetal reduction, conflict of interest among the involved parties.
  
  
  RESULTS
  None of the 14 surrogate mothers were able to explain the risks involved in embryo transfer and fetal reduction. The majority of the doctors took unilateral decisions about embryo transfer and fetal reduction. The commissioning parents were usually only indirectly involved. In the qualitative analysis, difficulties in explaining procedures, autonomy, self-payment of fertility treatment and conflicts of interest were the main themes.
  
  
  CONCLUSIONS
  Clinical procedural decisions were primarily made by the doctors. Surrogate mothers were not adequately informed. There is a need for regulation on decision-making procedures to safeguard the interests of surrogate mothers.
authors.affiliation: Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark.
authors.forename: Malene
authors.initials: M
authors.lastname: Tanderup
authors.forename: Sunita
authors.initials: S
authors.lastname: Reddy
authors.forename: Tulsi
authors.initials: T
authors.lastname: Patel
authors.forename: Birgitte Bruun
authors.initials: BB
authors.lastname: Nielsen
mesh_terms: D000328:Adult; D016265:Conflict of Interest; D003657:Decision Making; D004624:Embryo Transfer; D005260:Female; D066296:Grounded Theory; D006801:Humans; D007194:India; D007258:Informed Consent / Q000941:ethics* / Q000523:psychology; D007407:Interviews as Topic; D011247:Pregnancy; D018607:Pregnancy Reduction, Multifetal; D012959:Socioeconomic Factors; D013533:Gestational Carriers / Q000523:psychology*; D055815:Young Adult
keywords: Assisted reproduction; commercial gestational surrogacy; decision-making; embryo transfer; fetal reduction; informed consent