Surrogacy and "Procreative Tourism". What Does the Future Hold from the Ethical and Legal Perspectives?

Background and objectives: To explore the ethical and legal complexities arising from the controversial issue of surrogacy, particularly in terms of how they affect fundamental rights of children and parents. Surrogacy is a form of medically-assisted procreation (MAP) in which a woman "lends" her uterus to carry out a pregnancy on behalf of a third party. There are pathological conditions, such as uterine agenesis or hysterectomy outcomes, that may prevent prospective mothers from becoming pregnant or carry a pregnancy to term; such patients may consider finding a surrogate mother. Many issues relating to surrogacy remain unresolved, with significant disagreements and controversy within the scientific community and public opinion. There are several factors called into play and multiple parties and stakeholders whose objectives and interests need to somehow be reconciled. First and foremost, the authors contend, it is essential to prioritize and uphold the rights of children born through surrogacy and heterologous MAP. Materials and methods: To draw a parallel between Italy and the rest of the world, the legislation in force in twelve European countries was analyzed, eleven of which are part of the European Union (France, Germany, Italy, Spain, Greece, Netherlands, Belgium, Denmark, Lithuania, Czech Republic and Portugal) and three non-members of the same (United Kingdom, Ukraine and Russia), as well as that of twelve non-European countries considered exemplary (United States, Canada, Australia, India, China, Thailand, Israel, Nigeria and South Africa); in particular, legislative sources and legal databases were drawn upon, in order to draw a comparison with the Italian legislation currently in force and map out the evolution of the Italian case law on the basis of the judgments issued by Italian courts, including the Constitutional and Supreme Courts and the European Court of Human Rights (ECHR); search engines such as PubMed and Google Scholar were also used, by entering the keywords "surrogacy" and "surrogate motherhood", to find scientific articles concerning assisted reproduction techniques with a close focus on surrogacy. Results: SM is a prohibited and sanctioned practice in Italy; on the other hand, it is allowed in other countries of the world, which leads Italian couples, or couples from other countries where it is banned, to often contact foreign centers in order to undertake a MAP pathway which includes surrogacy; in addition, challenges may arise from the legal status of children born through surrogacy abroad: to date, in most countries, there is no specific legislation aimed at regulating their legal registration and parental status. Conclusion: With reference to the Italian context, despite the scientific and legal evolution on the subject, a legislative intervention aimed at filling the regulatory gaps in terms of heterologous MAP and surrogacy has not yet come to fruition. Considering the possibility of "fertility tourism", i.e., traveling to countries where the practice is legal, as indeed already happens in a relatively significant number of cases, the current legislation, although integrated by the legal interpretation, does not appear to be effective in avoiding the phenomenon of procreative tourism. Moreover, to overcome some contradictions currently present between law 40 and law 194, it would be appropriate to outline an organic and exhaustive framework of rules, which should take into account the multiplicity of interests at stake, in keeping with a fair and sustainable balance when regulating such practices.

Teeth or no teeth: exploring punitive measures for adults smoking in cars containing children in Aotearoa/New Zealand.

This viewpoint welcomes the recent announcement of the Government of Aotearoa/New Zealand to ban smoking in cars with children. However, it notes that the thorny issue of enforcement and punishment remains. Internationally there is a deficit on research on this issue. The experiences of the UK and Ireland are examined, where there was little or no enforcement of such laws, as well as a comparison with the State of Victoria in Australia, where the law was more robustly enforced. This viewpoint argues that enforcement is an important element in safeguarding the health and wellbeing of children.

April 2018 Flores Settlement Suit Challenges Unlawful Administration of Psychotropic Medication to Immigrant Children.

A lawsuit filed in April 2018 alleges unlawful administration of psychotropic medications to detained immigrant children in US custody. The suit, under jurisdiction of the Flores Settlement Agreement of 1997, alleges misuse of psychotropic medication to chemically restrain and control immigrant children and prolong their detention. This article describes the legal scope of the suit and considers significant ethically and clinically relevant questions it poses.

Non-therapeutic male genital cutting and harm: Law, policy and evidence from U.K. hospitals.

Female genital cutting (FGC) is generally understood as a gendered harm, abusive cultural practice and human rights violation. By contrast, male genital cutting (MGC) is held to be minimally invasive, an expression of religious identity and a legitimate parental choice. Yet scholars increasingly problematize this dichotomy, arguing that male and female genital cutting can occasion comparable levels of harm. In 2015 this academic critique received judicial endorsement, with Sir James Munby's acknowledgement that all genital cutting can cause 'significant harm'. This article investigates the harm occasioned by MGC. It is informed by a Freedom of Information (FoI) study which provides some empirical evidence of the nature and frequency of physical harm caused by MGC in U.K. hospitals. While acknowledging the challenges and limitations of FoI research, we outline important lessons that this preliminary study contains for medical ethics, law and policy. It provides some empirical evidence to support claims regarding the risks which accompany the procedure and the obligation of health professionals to disclose them, and reveals the paucity of measures in place to ensure that harms are recorded, disclosed and monitored.

The German debate on male circumcision and Habermas' model of post-secularity.

This paper considers Habermas' model of a post-secular political order in the light of the debate on male circumcision that arose in Germany after a court ruled that male circumcision was an unjustifiable act of bodily harm. Central to this model is the idea that religious reasons can only become effective in central legal institutions when they are translated into secular reasons. My paper demonstrates that there are two distinguishable readings of this proviso. On the one hand, there is a broad reading according to which it is only necessary to reach a conclusion that is in line with the democratic principle stating that all citizens can be regarded as co-legislators even if non-generalizable value orientations might then shape the interpretation of fundamental rights (in the case of circumcision, the right to bodily integrity). On the other hand, a truly secular (narrow) reading would avoid the inclusion of non-generalizable value orientations. The debate on circumcision demonstrates that these two interpretations lead to different and conflicting modes of justification. The broad reading allows for a justification of male circumcision, whereas the narrow reading makes such a justification unlikely. In addition, the filtering function of the proviso is weakened in a broad reading.

Not a matter of parental choice but of social justice obligation: Children are owed measles vaccination.

This article presents arguments that reframe the discussion on vaccination ethics. The correct starting point for discussions on vaccination ethics is not what society owes parents, but rather what society owes children. Drawing on the justice theory of Powers and Faden, two conclusions are defended by presenting and defending a set of arguments. First, a just society is obligated to protect its children against serious vaccine-preventable diseases such as measles through adequate levels of vaccination. Second, this obligation of the just society rests on identifiable individuals and institutions: parents, healthcare professionals, government, and vaccine producers have important obligations in this regard. This removes vaccination out of the realm of individual or parental discretion, and situates it in the realm of societal obligation. Children are owed vaccination, society is obligated to provide it. If parents cannot or will not provide it, society ought to respond.

The Harm Principle Cannot Replace the Best Interest Standard: Problems With Using the Harm Principle for Medical Decision Making for Children.

For many years the prevailing paradigm for medical decision making for children has been the best interest standard. Recently, some authors have proposed that Mill's "harm principle" should be used to mediate or to replace the best interest standard. This article critically examines the harm principle movement and identifies serious defects within the project of using Mill's harm principle for medical decision making for children. While the harm principle proponents successfully highlight some difficulties in present-day use of the best interest standard, the use of the harm principle suffers substantial normative and conceptual problems. A medical decision-making framework for children is suggested, grounded in the four principles. It draws on the best interest standard, incorporates concepts of harm, and provides two questions that can act as guide and limit in medical decision making for children.

When Parents Refuse: Resolving Entrenched Disagreements Between Parents and Clinicians in Situations of Uncertainty and Complexity.

When shared decision making breaks down and parents and medical providers have developed entrenched and conflicting views, ethical frameworks are needed to find a way forward. This article reviews the evolution of thought about the best interest standard and then discusses the advantages of the harm principle (HP) and the zone of parental discretion (ZPD). Applying these frameworks to parental refusals in situations of complexity and uncertainty presents challenges that necessitate concrete substeps to analyze the big picture and identify key questions. I outline and defend a new decision-making tool that includes three parts: identifying the nature of the disagreement, checklists for key elements of the HP and ZPD, and a "think list" of specific questions designed to enhance use of the HP and ZPD in clinical decision making. These tools together will assist those embroiled in complex disagreements to disentangle the issues to find a path to resolution.

Elective Abandonment: A Male Counterpart to Abortion.

Two of the most influential arguments in favour of the permissibility of abortion were put forward in the latter half of the twentieth century by Judith Jarvis Thomson and Mary Anne Warren. The implications of these arguments for unwilling putative fathers have largely not been considered. Some have argued that Thomson's defence of abortion might allow a man under certain circumstances to terminate his parental responsibilities and rights. To my knowledge, nobody has considered the implications of Warren's argument for men. I will consider the implications of both arguments for men. I will argue that if they are successful defences of abortion then they are also successful in justifying a male counterpart to abortion which I label 'elective abandonment'. I will not be defending or attacking these arguments as defences of abortion, but will defend the claim that they apply as well to elective abandonment as they do to abortion.

Ethical Issues in Conducting Research With Children and Families Affected by Disasters.

PURPOSE OF REVIEW: We review topical evidence on ethical issues in conducting disaster research with children and families affected by natural disasters, with an emphasis on analyzing specific vulnerabilities associated with children and families affected by disasters, identifying significant findings and trends of ethical guidelines and approaches, and discussing key observations into ethical research in a disaster setting. RECENT FINDINGS: Current evidence indicates that there is a wide range of research methods for child disaster studies. Vulnerability as a concept in child disaster studies is more prevalent with several scholars underscoring the need for an ethical approach to disaster research. Current disaster research evidence suggests that there is specifically an interest in conducting disaster research with children and families. With the increase in investigations, it is strongly recommended that investigators adhere to ethical standards in research practice when conducting research with vulnerable populations (e.g., children) within a postdisaster context.

Damaging the Future: The Health Rights of Children and the Issue of Short-Termism; Issues Facing Australian Bioethicists.

This article considers recent ethical topics in Australia relating to the health rights of children in the contexts of (1) detention centers, (2) vaccination, and (3) procreative liberty, within a wider framework of discussion of the competing rights of society, parents, the child, and future generations.

The Default Position: Optimizing Pediatric Participation in Medical Decision Making.

Inclusion of children in medical decision making, to the extent of their ability and interest in doing so, should be the default position, ensuring that children are routinely given a voice. However, optimizing the involvement of children in their health care decisions remains challenging for clinicians. Missing from the literature is a stepwise approach to assessing when and how a child should be included in medical decision making. We propose a systematic approach for doing so, and we apply this approach in a discussion of two challenging clinical cases. The approach is informed by a literature review, and is anchored by case studies of teenagers' refusal of clinical care, regulatory requirements for research assent, and the accepted approach to involving cognitively impaired adults in medical decisions.

Genome editing and assisted reproduction: curing embryos, society or prospective parents?

This paper explores the ethics of introducing genome-editing technologies as a new reproductive option. In particular, it focuses on whether genome editing can be considered a morally valuable alternative to preimplantation genetic diagnosis (PGD). Two arguments against the use of genome editing in reproduction are analysed, namely safety concerns and germline modification. These arguments are then contrasted with arguments in favour of genome editing, in particular with the argument of the child's welfare and the argument of parental reproductive autonomy. In addition to these two arguments, genome editing could be considered as a worthy alternative to PGD as it may not be subjected to some of the moral critiques moved against this technology. Even if these arguments offer sound reasons in favour of introducing genome editing as a new reproductive option, I conclude that these benefits should be balanced against other considerations. More specifically, I maintain that concerns regarding the equality of access to assisted reproduction and the allocation of scarce resources should be addressed prior to the adoption of genome editing as a new reproductive option.