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.

Legal considerations in reproductive medicine.

Legal issues affect reproductive medical practice throughout the entire world. The breadth and depth of this interrelationship extend far beyond the scope of one series of articles in Views and Reviews. Given this limitation, we have chosen to present five topics, all different, but illustrative of key concepts that influence our practice of reproductive medicine. Our hope is that this "medical-legal sampler" will both inform and provoke thoughtful consideration of the ways we can best and most responsibly practice and serve our patients.

Gestational age limits for abortion and cross-border reproductive care in Europe: a mixed-methods study.

OBJECTIVES: Little is known about the experiences of women who travel within Europe for abortion care from countries with relatively liberal laws. This paper aims to assess the primary reasons for travel among a sample of women who travelled from European countries with relatively liberal abortion laws to obtain abortion care mainly in the UK and the Netherlands. DESIGN: Multi-country, 5-year mixed methods study on barriers to legal abortion and travel for abortion. SETTING: UK, the Netherlands and Spain. POPULATION OR SAMPLE: We present quantitative data from 204 surveys, and qualitative data from 30 in-depth interviews with pregnant people who travelled to the UK, the Netherlands and Spain from countries where abortion is legal on broad grounds within specific gestational age (GA) limits. METHODS: Mixed-methods. MAIN OUTCOME MEASURES: GA when presenting at abortion clinic, primary reason for abortion-related travel. RESULTS: Study participants overwhelmingly reported travelling for abortion because they had exceeded GA limits in their country of residence. Participants also reported numerous delays and barriers to receiving care. CONCLUSIONS: Our findings highlight the need for policies that support access to abortion throughout pregnancy and illustrate that early access to it is necessary but not sufficient to meet people's reproductive health needs. FUNDING: This study is funded by the European Research Council (ERC). TWEETABLE ABSTRACT: This study shows that GA limits drive women from EU countries where abortion is legal to seek abortions abroad.

Análisis ético y jurídico del turismo médico en Colombia. Riesgos en la instrumentalización comunicativa / Ethical and legal analysis of medical tourism in Colombia. Risks in communicative instrumentalization

En un contexto globalizado, donde el mundo convencional se expande a lo virtual, se desarrolla un análisis ético y jurídico del turismo médico en Colombia mediante la identificación de riesgos potenciales en la instrumentalización comunicativa. La oferta y demanda de cirugía estética acompañada del marketing, como un reflejo del deseo, lo bello y el maquillaje, promueven tensiones éticas latentes. La incertidumbre jurídica que gravita alrededor del flujo transfronterizo e indeterminación de los distintos sistemas jurídicos exterioriza varios frentes susceptibles de abordaje y que a su vez se erigen como desafíos. El trasfondo de las reflexiones que se divisan hace imprescindible reivindicar prerrogativas fundamentales, inherentes a los seres humanos, que parecen desvanecerse ante inserciones cada vez más frecuentes y penetrantes provenientes de realidades construidas y enraizadas en el vaivén de los precios (AU)

In a globalized context, where the conventional world expands into the virtual, an ethical and legal analysis of medical tourism in Colombia is developed through identifying potential risks via communicative instrumentalization. The supply and demand for cosmetic surgery along with the associated marketing, as it reflects on desire, beauty, and makeup, promote latent ethical tensions. The legal uncertainty that gravitates around the cross-border flow and the indeterminacy within the different legal systems externalizes on several fronts that should be addressed and which in turn pose challenges. The background of the reflections that can be seen make it essential to claim fundamental prerogatives, inherent to humanity, which seem to vanish when presented with the frequent and penetrating insertions coming from realities built and rooted in the fluctuations of prices (AU)

En un context globalitzat, on el món convencional s'expandeix al virtual, es desenvolupa una anàlisi ètica i jurídica del turisme mèdic a Colòmbia mitjançant la identificació de riscos potencials en la instrumentalització comunicativa. L'oferta i demanda de cirurgia estètica acompanyada del màrqueting, com un reflex del desig, el bell i el maquillatge, promouen tensions ètiques latents. La incertesa jurídica que gravita al voltant del flux transfronterer i indeterminació dels diferents sistemes jurídics exterioritza diversos fronts susceptibles d'abordatge i que al seu torn s'erigeixen com a desafiaments. El rerefons de les reflexions que s'albiren fa imprescindible reivindicar prerrogatives fonamentals, inherents als éssers humans, que semblen esvair-se davant insercions cada vegada més freqüents i penetrants provinents de realitats construïdes i arrelades en el vaivé dels preus (AU)

Medical Tourism and the Best Interests of the Critically ill Child in the Era of Healthcare Globalisation.

In this article, we examine emerging challenges to medical law arising from healthcare globalisation concerning disputes between parents and healthcare professionals in the care and treatment of critically ill children. We explore a series of issues emerging in English case law concerning children's medical treatment that are signs of increasing globalisation. We argue that these interrelated issues present distinct challenges to healthcare economics, clinical practice, and the operation of the law. First, social media leverages the emotive aspects of cases; secondly, the Internet provides unfiltered information about novel treatments and access to crowdfunding to pay for them. Finally, the removal of barriers to global trade and travel allows child medical tourism to emerge as the nexus of these issues. These aspects of globalisation have implications for medicine and the law, yet child medical tourism has been little examined. We argue that it affects a range of interests, including children's rights, parents' rights as consumers, and the interests of society in communalised healthcare. Identifying putative solutions and a research agenda around these issues is important. While cases involving critically ill children are complex and emotionally fraught, the interconnectedness of these issues requires the law to engage and respond coherently to the impacts of healthcare globalisation.

The Charlie Gard Case, and the Ethics of Obstructing International Transfer of Seriously Ill Children.

In 2017, the court case over medical treatment of UK infant, Charlie Gard, reached global attention. In this article, I will analyze one of the more distinctive elements of the case. The UK courts concluded that treatment of Charlie Gard was not in his best interests and that it would be permissible to withdraw life-sustaining treatment. However, in addition, the court ruled that Charlie should not be transferred overseas for the treatment that his parents sought, even though specialists in Italy and the US were willing to provide that treatment. Is it ethical to prevent parents from pursuing life-prolonging treatment overseas for their children? If so, when is it ethical to do this? I will outline arguments in defense of obstructing transfer in some situations. I will argue, however, that this is only justified if there is good reason to think that the proposed treatment would cause harm.

A review of policies and programmes for human organ and tissue donations and transplantations, WHO African Region.

Several resolutions, endorsed by the World Health Assembly and the United Nations General Assembly, articulate the need to improve the availability, quality and safety of organ and tissue donation and transplantation, as well as to prevent and combat trafficking in human organs. Here we assessed the implementation of these resolutions pertaining to organ and tissue donations and transplantations by sending out a questionnaire to all 47 countries in the World Health Organization African Region. From 33 countries that provided data, we identified several obstacles and challenges. Compared to other regions, there are very limited data on organ donation and transplantation. Most countries are lacking legal and regulatory frameworks, since they did not yet establish a specific or comprehensive legislation covering donation and transplantation of human organs and tissues. Countries also have a poor national capacity to perform organ and tissue transplantations and the organization and management of national programmes are weak. Funding, both from domestic and external sources, is insufficient to implement effective transplantations programmes and patients have inadequate financial protection. To address these challenges, we propose that countries and partners should develop and implement policies, strategies, plans and regulatory frameworks for all aspects of organ and tissue donations and transplantations, including fighting against organ trafficking and transplant tourism. Where donation and transplantation programmes exist, stakeholders should develop the skills of human resources, adopt technical standards and quality management procedures to improve donation and transplantation of human organs and tissues.

De nombreuses résolutions approuvées par l'Assemblée mondiale de la Santé et l'Assemblée générale des Nations Unies ont souligné le besoin d'améliorer la disponibilité, la qualité et la sécurité des dons et de transplantations d'organes et de tissus humains, de même que celui d'assurer la prévention et la lutte contre le trafic d'organes. Dans ce document, nous avons étudié la mise en œuvre de ces résolutions relatives aux dons et transplantations d'organes et de tissus, par le biais d'un questionnaire envoyé aux 47 pays appartenant à la région Afrique de l'Organisation mondiale de la Santé. Nous avons identifié de nombreux obstacles et défis dans les 33 pays qui nous ont transmis des données. Par rapport à d'autres régions, il existe très peu d'informations à ce propos. La plupart des pays ne possèdent pas de cadres juridiques et réglementaires car ils n'ont pas encore établi de législation spécifique ou exhaustive couvrant les dons et transplantations d'organes et de tissus. Certains manquent également de moyens au niveau national pour réaliser des greffes d'organes et de tissus, tandis que leur organisation et leur gestion des programmes nationaux sont inadaptées. Tant les fonds provenant de l'intérieur que ceux fournis par l'extérieur ne permettent pas d'instaurer des programmes de transplantation efficaces. Enfin, les patients ne bénéficient pas d'une protection financière suffisante. Afin de pouvoir relever ces défis, nous proposons que ces pays et leurs partenaires développent et appliquent des politiques, stratégies, projets et règles pour tous les aspects liés aux dons et transplantations d'organes et de tissus, y compris la lutte contre le trafic d'organes et le tourisme de la transplantation. Et là où des programmes de dons et de transplantations existent, les intervenants devraient acquérir des compétences en ressources humaines, mais aussi adopter des normes techniques et des procédures de gestion de la qualité afin d'optimiser les dons et transplantations d'organes et de tissus.

Diversas resoluciones que la Asamblea Mundial de la Salud y la Asamblea General de las Naciones Unidas aprobaron articulan la necesidad de mejorar la disponibilidad, la calidad y la seguridad de la donación y el trasplante de tejidos y órganos, así como de prevenir y combatir el tráfico de órganos humanos. En el presente documento se evalúa la implementación de estas resoluciones relacionadas con la donación y el trasplante de tejidos y órganos por medio del envío de un cuestionario a los 47 países de la Región de África de la Organización Mundial de la Salud. De los 33 países que suministraron los datos, se identificaron varios obstáculos y desafíos. En comparación con otras regiones, existen muy pocos datos sobre la donación y el trasplante de órganos. La mayoría de los países carecen de marcos normativos y legales, ya que todavía no han establecido una legislación específica o integral que aborde la donación y el trasplante de tejidos y órganos humanos. Los países también tienen una capacidad nacional deficiente para realizar los trasplantes de tejidos y órganos, además de que la organización y la gestión de los programas nacionales son débiles. El financiamiento, tanto de fuentes nacionales como internacionales, es insuficiente para implementar programas de trasplantes efectivos y los pacientes tienen una protección financiera inadecuada. Para hacer frente a estos desafíos, se propone que los países y los socios elaboren e implementen políticas, estrategias, programas y marcos normativos de todos los aspectos de la donación y el trasplante de tejidos y órganos, incluida la lucha contra el tráfico de órganos y el turismo de trasplantes. Cuando existan programas de donación y trasplante, las partes interesadas deberían desarrollar las habilidades de los recursos humanos y adoptar estándares técnicos y procedimientos de gestión de calidad para mejorar la donación y el trasplante de tejidos y órganos humanos.

Legal and ethical issues in cross-border gestational surrogacy.

This article aims to identify the main legal and ethical issues around international surrogacy. Owing to the legal diversity and ethical background of such a globalized practice, a review of the key existing literature on these two matters has been identified and analyzed. The article also identifies and analyzes the most significant legal solutions provided by supranational jurisdictions when dealing with cases of international surrogacy. The scope of the article includes the efforts to reach a minimum legal framework at the international level, with the aim not to standardize but to provide common legal solutions to those travelling abroad to have a child by means of surrogacy.

Assessing the Potential Impact of the Declaration of Istanbul 2008 on Internet Reporting of Human Organ Transplantation-Related Crimes Using Interrupted Time Series Analysis and Meta-Analysis Approaches.

BACKGROUND: A severe shortage in donor organs is the major driver for organ transplantation-related crimes. The Declaration of Istanbul 2008 (DOI) was created to stop such crimes. We investigated the impact of DOI on Internet reporting of transplantation-related crimes. METHODS: We conducted Google Advanced Searches to collect data on "kidney trade," "kidney sale," "organ trafficking," and "transplant tourism" in 15 original participant and 10 nonparticipant countries, 6 years prior through 8 years after the promulgation of DOI. The data were normalized for population and transformed to a logarithmic scale. Interrupted time series analysis (ITSA) was applied to estimate the changes in slopes of the outcome variables before and after DOI, and then the overall intervention impact was calculated by meta-analysis. RESULTS: The combined results indicated that the overall impact of DOI on the reporting of "organ trafficking" and "transplant tourism" was statistically negative (reporting reduced significantly) as intended but on "kidney sale" and "kidney trade" was statistically positive (reporting increased significantly), and the increase was higher in the nonparticipant countries compared to the participant countries. The rate of reporting on "transplant tourism" declined in the participant countries more pronouncedly than in the nonparticipant countries. CONCLUSIONS: DOI has a positive impact on the reporting of "organ trafficking" and "transplant tourism" but not on the reporting of "kidney sale" and "kidney trade." The increased reporting of "kidney sale" and "kidney trade" can be indicative of an impact of DOI on public awareness and increased reporting of the residual transplantation-related crimes.

The implementation of European Union (EU) rules on cross-border care: moving towards convergence?

This article studies the implementation of the European Union (EU)'s Patients' Rights Directive in Germany and Norway. The objective of the Directive was to allow EU member states to have a say in the regulatory work, ensure predictability and uniformity in the application of EU rules on cross-border care, and enhance a move towards EU harmonisation in this area. So far, the implementation processes in Norway and Germany have mixed results regarding the likelihood of achieving uniformity and harmonisation. Although the Directive has had convergent effects on certain areas of cross-border care, such as setting up National Contact Points and providing patients with the basic right to treatment abroad, implementation also shows divergent patterns. In both countries, adapting to EU rules has strengthened patients' rights to choose freely among health-service providers in a wider European health-service market. However, due to legal discretion and country-specific institutions within which the new rules are applied, divergent patterns prevail.

Review of inbound medical tourism and legal details of obtaining a visa for treatment of head and neck cancer.

BACKGROUND: We aim to provide a review of inbound medical tourism and the legal process of obtaining a visa for medical/surgical treatment for the patients with head and neck cancer. METHODS: We reviewed current statistics and the medical and legal literature regarding inbound medical tourism and the process of obtaining a visa for patients traveling to the United States for medical treatment. To illustrate this process, we present a case of an advanced-staged and disfiguring facial polymorphous high-grade adenocarcinoma in a previously healthy 29-year-old woman from Liberia. RESULTS: This report provides a synopsis of available statistical data on inbound medical tourism and the legal aspects of obtaining a visa for patients seeking medical care from abroad. CONCLUSIONS: Medical tourists traveling to the United States for treatment of head and neck pathologies face considerable barriers in obtaining prompt care, leading to a possible increased disease burden and difficulty in rendering oncologic treatment.

Liver Transplant in Colombia.

Liver transplantation began in Colombia in 1979. It is one of the most active countries in this field in Latin America but has faced problems with the regulation and appropriate management of solid organ transplantations, including transplant tourism, which is a worldwide problem. There is a well-structured donation and transplant network regulated by the government in all the stages of the process. In 2017, the country was ranked fourth for the number of liver transplantations (LTs) performed in Latin America, after Brazil, Argentina, and Uruguay, with a rate of 5.6 LTs per million population. Current regulatory bodies were created to coordinate and provide transparency and equality to transplant recipients. This article describes the evolution, government commissions, assignation criteria, and current status of LT in Colombia.

A review of surrogate motherhood regulation in south American countries: pointing to a need for an international legal framework.

BACKGROUND: Advances in science and technology coupled with globalization are changing access to and utilization of reproductive health services. This includes the transnational phenomenon of families who use surrogate mothers to reproduce, with forms of altruistic and commercial surrogacy becoming more commonplace. Simultaneously, changes in law, regulation, and policy are necessary to protect surrogates, intended parents, and resulting children. These developments have been slow to adapt to challenges inherent to surrogacy arrangements, most specifically in low-and middle-income countries, including in South American countries. METHODS: We conducted an interdisciplinary non-systematic literature review and legal analysis of existing and pending policy, laws, and regulations related to commercial surrogacy arrangements in Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Paraguay, Peru, Uruguay, and Venezuela. The review focused on articles that discussed topics of domestic and international law, policy, regulation, and governance related to commercial surrogacy. We queried PubMed, JSTOR, and Google Scholar for Spanish and English-language articles limited to those published between 2000 and 2016. RESULTS: Our literature and legal review found a wide variance in how different countries address the issue, including two (Brazil and Uruguay) that have issued guidance attempting to clarify the legality of commercial surrogacy, others who have introduced surrogacy-specific legislation, and a final group with no specific legal mechanisms in place. Our extracted legal case studies also indicate that courts have a hard time interpreting existing law and its applicability to surrogacy. The influence of Catholicism also played a role in the adoption of surrogacy and other advanced reproductive technology (ART)-related legislation. CONCLUSIONS: Changes in global infertility rates, the emergence of new family structures, and advancement of ART are factors that will influence future development of legal frameworks addressing surrogacy in South America. Despite a growing transnational market for commercial surrogacy in many of the countries examined, the current patchwork of policy does little to clarify what forms of surrogacy are legally permissible, nor do they adequately protect surrogates, intended parents, or the children themselves. This points to an urgent need for regional legal and policy harmonization specifically designed to align with public health and human rights principles.

What is the Responsibility of Australian Medical Professionals Whose Patients Travel Abroad for Assisted Reproduction?

Australian medical professionals whose patients undertake assisted reproductive treatment abroad face a conflict: to try to provide optimal and on-going care for their patient at the same time as ensuring compliance with Australian legal, ethical, and professional rules which proscribe as unsafe or unethical key aspects of such treatment. A major suggestion from literature on medical travel is that risks to the patient can be mitigated through the involvement of the local professional. However, the force of legal regulation and ethical guidance in Australia strenuously directs clinicians away from involvement in overseas reproductive treatment. This article reports on 37 interviews with Australians travelling abroad for surrogacy, egg donation, and embryo donation, reflecting on patients' experiences with Australian medical professionals both before and after they travelled. Patient reports demonstrate a fragmented and bewildering medical landscape in Australia, in which the ability to access domestic care and expertise varied markedly depending upon the kind of treatment patients were seeking abroad, and the mode of practice of the Australian doctor. Doctors practicing within licensed IVF clinics were notably more constrained than those outside such a setting. Patients seeking egg donation were offered information and received a wide range of diagnostic and preparatory treatments, while those seeking surrogacy were shunned, chided and offered limited (and sometimes covert) assistance. While recent changes to national ethical guidance improve clarity on information giving, the ethical and legal propriety of Australian medical professionals providing diagnostic or preparatory treatment for cross border reproduction remains uncertain.

Surrogacy and the ECtHR: Reflections on Paradiso and Campanelli v Italy.

This case note analyses the recent judgment of the European Court of Human Rights in Paradiso and Campanelli v Italy and examines its implications for cross-border surrogacy in Europe. It is argued that this judgment is highly significant, because it sets new standards in terms of the concept of family life under Article 8 of the European Convention on Human Rights. This judgment, it is argued, only appears to bring a halt to the (seemingly) backdoor legitimacy of commercial surrogacy established by the findings of the Second Section and previous judgments of the Court. Finally, this case note critiques the Grand Chamber's findings and examines its likely impact on the problem of cross-border surrogacy.