Navigating conflicts of reproductive rights: Unbundling parenthood and balancing competing interests.

Advances in assisted reproductive technologies can give rise to several ethical challenges. One of these challenges occurs when the reproductive desires of two individuals become incompatible and conflict. To address such conflicts, it is important to unbundle different aspects of (non)parenthood and to recognize the corresponding reproductive rights. This article starts on the premise that the six reproductive rights-the right (not) to be a gestational, genetic, and social parent-are negative rights that do not entail a right to assistance. Since terminating or continuing a pregnancy is a form of assistance, the right (not) to be a gestational parent should enjoy primacy in conflicts. However, while refusing assistance may hinder the reproductive project of another person, "prior assistance" does not entitle someone to violate a reproductive right. Therefore, our analysis provides reasons to argue that someone has a right to unilaterally use cryopreserved embryos or continue the development of an entity in an extracorporeal gestative environment (i.e., ectogestation). Although this could lead to a violation of the right not to be a genetic parent, it does not necessarily entail a violation of the right not to be a social parent.

A critical view on using "life not worth living" in the bioethics of assisted reproduction.

This paper critically engages with how life not worth living (LNWL) and cognate concepts are used in the field of beginning-of-life bioethics as the basis of arguments for morally requiring the application of preimplantation genetic diagnosis (PGD) and/or germline genome editing (GGE). It is argued that an objective conceptualization of LNWL is largely too unreliable in beginning-of-life cases for deriving decisive normative reasons that would constitute a moral duty on the part of intending parents. Subjective frameworks are found to be more suitable to determine LNWL, but they are not accessible in beginning-of-life cases because there is no subject yet. Conceptual and sociopolitical problems are additionally pointed out regarding the common usage of clear case exemplars. The paper concludes that a moral requirement for the usage of PGD and GGE cannot be derived from the conceptual base of LNWL, as strong reasons that can be reliably determined are required to limit reproductive freedom on moral grounds. Educated predictions on prospective well-being might still be useful regarding the determination of moral permissibility of PGD and/or GGE. It is suggested that due to the high significance of subjective experience in the normativity of beginning-of-life bioethics, the discipline is called to more actively realize the inclusion of people with disabilities. This regards for instance research design, citation practices, and language choices to increase the accessibility of societal debates on the reproductive ethics of genetic technologies.

Financial ''risk-sharing'' or refund programs in assisted reproduction: an Ethics Committee opinion.

Financial "risk-sharing" fee structures in assisted reproduction programs charge patients a higher initial fee that includes multiple cycles but offers a partial or complete refund if treatment fails. This opinion of the American Society for Reproductive Medicine Ethics Committee analyzes the ethical issues raised by these fee structures, including patient selection criteria, conflicts of interest, success rate transparency, and patient-informed consent. This document replaces the document of the same name, last published in 2016.

'I just think it's weird': the nature of ethical and substantive non-ethical concerns about infertility treatments among Black and White women in U.S. graduate programmes.

In the United States, Black women's use of infertility treatments is relatively low, despite elevated or similar rates of infertility compared with White women. Ethical concerns about infertility treatments have been identified as a potential sociocultural factor contributing to these treatment-seeking disparities. Despite documented differences, the substance of these ethical concerns is unclear. Clarifying the nature of these concerns contributes to our understanding of the social forces that shape the contexts of infertility care. Using an intersectional and comparative analysis of semi-structured interviews with Black or African American and White women enrolled in U.S. graduate programmes, this paper investigates the nature and substance of ethical concerns about medicalized infertility treatments. Three central themes emerged: (i) ethical concerns were not binary; (ii) ethical concerns varied by modality, but not by race, and focussed primarily on infertility treatments involving third parties; and (iii) substantive non-ethical concerns were concentrated among Black women and were driven by discomfort with or preferences against treatments involving third-parties. The paper concludes with a discussion of the implications of these findings for researchers, providers, and policymakers.

As inconstitucionalidades da Resolução CFM nº 2294/2021 sobre a utilização das técnicas de reprodução assistida / The unconstitutionalities of Resolution CFM nº 2294/2021 on the use of assisted reproduction techniques

O Conselho Federal de Medicina acaba de editar a Resolução nº 2.294/2021, publicada em 15 de junho de 2021, que aponta normas para a utilização das técnicas de reprodução assistida. Apesar de o propósito ser o aperfeiçoamento das práticas e a observância aos princípios éticos e bioéticos para trazer maior segurança e eficácia a tratamentos e procedimentos médicos, repete inconstitucionalidades das normatizações pretéritas e impõe mais restrições ao sonho das pessoas de ter filhos. Desse modo, mais do que avanços, o novo regramento provoca um retrocesso que não se coaduna com a garantia constitucional e legal que assegura o livre planejamento familiar.(AU)

The Brazilian Federal Council of Medicine has just edited the Resolution nº 2.294/2021, published on June 15, 2021, which sets out rules for the use of assisted reproduction techniques. Although the purpose is to improve practices and observe ethical and bioethical principles to bring greater safety and efficacy to medical treatments and procedures, it repeats the unconstitutionalities of past regulations and imposes more restrictions on people's dreams of having children. In this way, more than advances, the new regulation provokes a setback that is not consistent with the constitutional and legal guarantees of free family planning.(AU)

Restricted access to assisted reproductive technology and fertility preservation: legal and ethical issues.

Access to assisted reproductive technology (ART) and fertility preservation remains restricted in middle and low income countries. We sought to review the status of ART and fertility preservation in Brazil, considering social indicators and legislative issues that may hinder the universal access to these services. Although the Brazilian Constitution expressly provides the right to health, and ordinary law ensures the state is obliged to support family planning, access to services related to ART and fertility preservation is neither easy nor egalitarian in Brazil. Only a handful of public hospitals provide free ART, and their capacity far from meets demand. Health insurance does not cover ART, and the cost of private care is unaffordable to most people. Brazilian law supports, but does not command, the state provision of ART and fertility preservation to guarantee the right to family planning; therefore, the availability of state-funded treatments is still scarce, reinforcing social disparities. Economic projections suggest that including ART in the Brazilian health system is affordable and may actually become profitable to the state in the long term, not to mention the ethical imperative of recognizing infertility as a disease, with no reason to be excluded from a health system that claims to be 'universal'.

Recent Judgement of the Italian Judiciary about medical assisted procreation (MAP): is informed consent valid after parents separation?

ABSTRACT: Law No 40/2004 regulates in Italy the matter of medically assisted procreation (MAP). Recently, the Tribunal of Capua Vetere expressed its position on the subject of informed consent in a case of MAP. In the specific case, a couple entered the preliminary stages of the PMA procedures, carrying out the fertilization of the ovum and the embryo production. Afterwards, the couple separated and the man denied consent to the continuation of the MAP. The woman, willing to proceed with the implantation, the woman made an urgent judicial appeal, obtaining the judge's permission to transfer the embryo to the uterus. This paper analyses the different bioethical positions on MAP's informed consent. In fact, on the one hand, the paper highlight what is set out in Law 219/2017 which provides for the possibility of the patient to revoke at any time the consent to the treatment given. On the other hand, it should be noted that Law 40/2004, willing to protect the embryo, establishes the irrevocability of the position of parental consent after fertilization. The judgment in question seems to favour this latter position, placing itself in the protection of the cryopreserved embryo and recall-ing the principle of entrustment following the fertilization of the egg. Nevertheless, the matter is controversial a consistent amount of legal developments are expected to arise in the next future.

Disparities in access to effective treatment for infertility in the United States: an Ethics Committee opinion.

In the United States, economic, racial, ethnic, geographic, and other disparities prevent access to fertility treatment and affect treatment outcomes. This opinion examines the factors that contribute to these disparities, proposes actions to address them, and replaces the document of the same name, last published in 2015.

Moving innovation to practice: an Ethics Committee opinion.

The introduction of new strategies, tests, and procedures into clinical practice raises challenging ethical issues involving evaluation of evidence, balancing benefits and harms, supporting patient autonomy, avoiding conflict of interest, and promoting advances in health-care. The purpose of this document is to assist reproductive health practitioners as they introduce new interventions into the clinical care that they provide to patients. This document replaces the previously published document of the same name, last published in 2016.

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.

Assisted reproductive technology, justice and autonomy in an era of COVID-19.

Fertility services were significantly curtailed or suspended as an initial response to the coronavirus (COVID-19) pandemic earlier this year, following guidance from European Society for Human Reproduction and Embryology (ESHRE) and the American Society for Reproductive Medicine (ASRM) as well as a General Direction (GD0014) issued by the Human Fertilisation and Embryo Authority (HFEA). It is difficult to argue with triage of medical care and resources in the face of anticipated overwhelming demand, but this situation resulted in considerable distress, as shown by a change.org petition opposing ASRM recommendations, which has gathered over 21,000 signatures to date. Although halting assisted reproductive technology (ART) as the pandemic unfolded was ethical because public health goals superseded individual patient autonomy, the fertility sector now faces a greater challenge balancing ethical considerations in an era characterized by the ongoing threat of COVID-19. This article discusses justice and autonomy in the context of ART, potential conflicts and resolutions.

Aspectos éticos y legales de los test de portadores de mutaciones recesivas en tratamientos de reproducción humana asistida con gametos donados / Ethical and legal aspects of recessive mutation carrier testing in assisted human reproduction treatments with donated gametes

La contribución de donantes, necesaria en numerosos tratamientos de reproducción asistida, exige la aplicación de protocolos que garanticen la compatibilidad y seguridad en la selección y aplicación de dichas donaciones. Este trabajo analiza algunos aspectos relacionados con los avances tecnológicos que permiten detectar mutaciones para enfermedades recesivas, abriendo la posibilidad a la comparación genética (matching) entre donantes y receptores, reduciendo los riesgos de enfermedades transmisibles a la descendencia. Observando los límites que plantea esta tecnología, especialmente, el marco jurídico que rige la obligatoriedad o no de su utilización, así como la intervención de la autonomía del paciente receptor de dichos gametos. Poniendo de manifiesto la importancia del abordaje interdisciplinar y normativo ante la expansión de estos avances en reproducción asistida (AU)

The contribution of donors, which is necessary in many assisted reproduction treatments, requires the application of protocols that guarantee compatibility and safety in the selection and application of such donations. This paper analyses some aspects related to the technological advances that allow to detect mutations for recessive diseases, opening up the possibility of genetic comparison (matching) between donors and recipients, reducing the risks of transmissible diseases to offspring. Observing the limits posed by this technology, in particular, the legal framework governing whether or not its use is obligatory, as well as the intervention of the autonomy of the patient receiving these gametes. Highlighting the importance of an interdisciplinary and regulatory approach to the expansion of these advances in assisted reproduction (AU)

La contribució de donants, necessària en nombrosos tractaments de reproducció assistida, exigeix l'aplicació de protocols que garanteixin la compatibilitat i seguretat en la selecció i aplicació d'aquestes donacions. Aquest article analitza alguns aspectes relacionats amb els avanços tecnològics que permeten detectar mutacions per a malalties recessives, obrint la possibilitat a la comparació genètica (matching) entre donants i receptors, reduint els riscos de malalties transmissibles a la descendència. Observant els límits que planteja aquesta tecnologia, especialment, el marc jurídic que regeix l'obligatorietat o no de la seva utilització, així com la intervenció de l'autonomia del pacient receptor d'aquests gàmetes. Posant de manifest la importància de l'abordatge interdisciplinari i normatiu davant l'expansió d'aquests avanços en reproducció assistida (AU)