Pregnancy
Surrogacy and Medical Decision-Making: What You Need to Know
Thoughtful planning in surrogacy helps protect everyone involved.
Posted May 6, 2025 Reviewed by Kaja Perina
Key points
- Medical decisions in surrogacy are rarely black-and-white—clarity requires planning, not guessing.
- Contracts can’t predict every scenario—flexibility and open dialogue are essential.
- Use a two-part framework: Surrogate’s health vs. decisions that impact the future child.
- Talk through these two categories before you begin treatment.
According to the Society for Assisted Reproductive Technology (SART), embryo transfers to gestational carriers increased by 146% between 2014 and 2017. This surge reflects several social changes: the federal legalization of same-sex marriage in 2015, increased utilization of the internet to share information and experiences, and the diminishing stigma surrounding infertility treatment.
As a result, more people — including those in same-sex relationships, those facing medical diagnoses like cancer, individuals with structural uterine issues or unexplained infertility, and those who could not discontinue critical medications — sought out surrogacy as a path to parenthood.
As the only therapist invited to testify before the State Senate Judiciary Committee to legalize compensated surrogacy in New York, I have witnessed firsthand that surrogacy remains misunderstood and, to some, controversial. Some still believe surrogacy harms women and should not be legal. However, this perception does not reflect the reality. The American Society for Reproductive Medicine (ASRM) has developed strong ethical guidelines that create a safe and supportive framework for both intended parents and gestational carriers, ensuring appropriate medical and mental health safeguards are in place.
Even with these protections, many intended parents feel overwhelmed when navigating the process — from selecting an agency to building a relationship with their gestational carrier and understanding how to approach critical medical decisions. At a 2021 American Society for Reproductive Medicine symposium, I shared key insights from my decades of experience, including the importance of preparing for medical testing and pregnancy termination decisions in advance.
Medical Decision-Making: Why It Matters
Your surrogacy contract will likely include many difficult "what if" scenarios — situations that feel uncomfortable to think about. Like a warning label on medication, most problems outlined will never occur. Yet, if an unexpected situation does arise, careful preparation can make all the difference.
When complicated medical situations arise — such as considering termination or a potentially risky medical procedure — intended parents often seek second and third opinions. Meanwhile, the pregnancy continues, and the longer decisions are delayed, the more emotionally charged and complicated they become.
Rather than avoiding discussing these possibilities, it is critical to use a thoughtful framework to prepare:
Two Key Challenges with Contracts:
- Medical problems are rarely black and white.
Doctors usually don’t tell you exactly what to do. Instead, they share information, risks, and probabilities. Decision-making happens in a landscape of uncertainty. - Contracts can’t anticipate every scenario.
Even the most detailed legal agreements can’t cover every possible complication or outcome.
You may be advised to group issues into "medical" versus "cosmetic" or "life-threatening" versus "non-life-threatening" categories. Unfortunately, this rarely captures the full complexity. Many issues involve varying degrees of emotional strain, financial burden, physical discomfort, and long-term consequences for both the child and the family.
A More Helpful Framework
A more productive approach is to think about medical testing and termination decisions in two broad categories:
- Category 1: Protecting the Surrogate’s Health and Life
If a complication arises that threatens the surrogate’s life or physical health, she (and her partner, if applicable) must retain the right to make the decision that best protects her safety and well-being. - Category 2: The Parent’s Decision
If the issue concerns only the embryo or fetus, the intended parent(s) should be the ones to make the decision. It is important to remember: it is the parent(s) who will need to raise this child or suffer the potential traumatic experiences or financial hardship involved. Their ability to make an informed decision is crucial.
This framework helps uncover true expectations early in the process. If a surrogate feels that, for emotional or religious reasons, she must participate in decisions concerning the fetus — even when her own health is not at risk — intended parents must know this before moving forward and must carefully consider whether they are willing to accept this plan.
How Often Do These Issues Arise?
Thankfully, such conflicts are rare. The guidelines and screening processes are designed to set surrogacy journeys up for success. However, rare does not mean impossible. And if you are one of the few facing an unexpected and difficult situation, statistics offer little comfort.
Taking the time to have these conversations in advance — even when they are uncomfortable — protects everyone involved and helps ensure your path to parenthood remains as joyful and smooth as possible.
