Surrogacy Research Articles

Surrogacy and the significance of gestation: Implications for law and policy.

Gestational surrogacy is ethically complex, generating very different responses in law and policy worldwide. This paper argues that contemporary surrogacy law and policy, across many jurisdictions, fail to give sufficient attention to the significance of the relationship between the child and the gestational surrogate. This failure risks repeating the mistakes of historical, discreditedapproaches to adoption and donor-assisted conception. This paper argues that proper recognition of the significance of gestation must be an organising principle in surrogacy law and policy. The paper begins by pointing to examples of surrogacy law and practice where the role of the gestator is unacceptably minimised, most notably the framing of the surrogate as a mere 'carrier'.It goes on to examine the nature of gestation, including consideration of contemporary scholarship on the metaphysics of pregnancyand emerging work in epigenetics, and argues that current evidence supports the view that the gestational relationship must be taken more seriously than it currently is. The paper then draws analogies with parenthood in donor-assisted conception and adoption to argue that approaches to parental status in novel family formations that fail to promote transparency and seek to deny the truth of familial relationships are doomed to fail. The paper concludes by suggesting some implications for law and policy that flow from placing sufficient emphasis on the gestational role. The overarching thesis of this paper is that gestational surrogacy is ethically permissible when these fundamental requirements are adhered to, and that surrogacy law should proceed on this basis.

Kontribusi Maqāshid al-Syarī’ah dalam Pengembangan Bioetika Islam

Advancements in medicine and biology have brought significant changes in medical practices, giving rise to new ethical issues such as surrogate motherhood and egg or sperm donation. In such cases, bioethics is essential. However, the prevailing bioethics is predominantly Western, diverging from Islamic ethical principles, thus potentially leading to different ethical conclusions. Hence, Islamic bioethics needs to be introduced and developed. One instrument used in this development is maqāshid al-Syarī’ah. This article aims to examine the contribution of maqasid al-shariah in the development of Islamic bioethics. Employing a literature review method, the article explores literature on Islamic bioethics and maqāshid al-Syarī’ah. The study's findings suggest that maqāshid can bridge Islamic principles with existing realities, enabling Islamic bioethics to address contemporary bioethical issues without compromising Islamic values.

Особенности рассмотрения дел по обязанию произвести государственную регистрацию рождения ребенка, рожденного суррогатной матерью

An integral part of the cases arising from the legal relations of surrogate motherhood considered by the court are cases on the obligation to make state registration of the birth of a child born by a surrogate mother. The article examines the peculiarities of the consideration of cases of this category in court, numerous examples from judicial practice are given. The authors consider it expedient to change the jurisdiction of these cases and justify that cases on making an act record of the birth of a child from a surrogate mother should be considered as soon as possible and are subject to immediate execution.

LAW AND ECONOMICS IN SURROGACY MARKETS

The concept of reproductive justice can offer a framework for complex and nuanced analyses of surrogacy, taking into account the agency of surrogates and potential vulnerability of intended parents. When we define surrogacy contracts, we mean the situation in which the fertilized egg of a married couple is inserted into the uterus of a surrogate mother and carried to term by a woman who has no genetic connection with the fetus. Surrogacy contracts offer a way to supply a genetic connection that adoption contracts cannot provide. This paper argues that surrogacy with heavy regulation is a step forward into the future because it incorporates the best legal solution to custody disputes while also attaining the most economically efficient solution. This paper argues the same about surrogacy markets becoming a standard and prudent practice because calling babies a Pareto-efficient exchange that benefits everyone at the expense of no one. Surrogacy can be an excellent option for a set of biological parents who desire a child but cannot carry a pregnancy for health reasons, with potential framework for the psychological and sociological effects of mental health and abortion. The status of surrogacy agencies within the United States allows for heavy legal and economic regulation of surrogacy markets. When the law of contracts and property are incorporated into surrogacy markets, it is easier and more “efficient” for couples to make bargains with surrogate gestational carriers.

Intimate strangers: Commercial surrogacy in Russia and Ukraine and the making of truth By VeronikaSiegl, Ithaca, NY: Cornell University Press, 2023. 306 pp.

Intimate strangers: Commercial surrogacy in Russia and Ukraine and the making of truth By VeronikaSiegl, Ithaca, NY: Cornell University Press, 2023. 306 pp.

Gestational carrier cycles: embryology trends, national guideline compliance, and resultant perinatal outcomes in the United States, 2014–2020

The increased use of gestational carriers has expanded family-building opportunities for people and couples unable to carry pregnancies on their own. National American Society of Reproductive Medicine guidelines for gestational carriers have changed over time to reflect advances in reproductive technology and mounting evidence supporting the medical benefits associated with singleton gestations. Assess changes in gestational carrier cycle practice patterns and resultant pregnancy outcomes in the United States in relation to changing national American Society of Reproductive Medicine guidelines, which changed in 2013 and2017. This retrospective study used data from the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System and included all cycles that were reported from 2014-2020 involving an embryo transfer to a gestational carrier. Binomial regression models evaluated trends in preimplantation genetic testing for aneuploidy, American Society of Reproductive Medicine guideline adherence, number of embryos transferred, and pregnancy outcomes over time. Of the 40,177 gestational carrier transfer cycles from 2014-2020, there was a significant increase in frozen-thawed cycles (41.3% increase), use of assisted hatching (53.4% increase), intracytoplasmic sperm injection (50.0% increase), and preimplantation genetic testing for aneuploidy (155.7% increase). The likelihood of preimplantation genetic testing for aneuploidy was higher in 2020 than in 2014 for autologous oocyte transfers to gestational carriers, both for those aged ≥38 years (adjusted relative risk, 2.38 [95% confidence interval, 2.11-2.70]) and than those aged <38 years (adjusted relative risk, 2.85 [95% confidence interval, 2.58-3.15]). As preimplantation genetic testing for aneuploidy usage increased, single embryo transfer rose for both autologous (adjusted relative risk, 2.22 [95% confidence interval, 1.94-2.50]) and donor cycles (relative risk, 1.91 [95% confidence interval, 1.81-2.02]). This shift toward single embryo transfer corresponded with a decrease in multiple embryo transfer by 79.2% and subsequent decreases in multiple gestations by 68.8% in donor and 73.6% in autologous oocyte cycles from 2014-2020. Gestational carrier cycles remained highly adherent to changing American Society of Reproductive Medicine guidelines throughout the study period. Among live births, there was a 19.4% and 7.9% increase in term deliveries among donor and autologous oocyte cycles, respectively, from 2014 to2020. Practice patterns have drastically changed throughout the study period, with major increases in the use of preimplantation genetic testing for aneuploidy, intracytoplasmic sperm injection, assisted hatching, and frozen transfers. In response to changing American Society of Reproductive Medicine guidelines, the use of multiple embryo transfers has decreased for gestational carrier cycles with subsequent decreases in multiple gestations and miscarriages and slight increases in live birth rates.

Humoral Immunity across the SARS-CoV-2 Spike after Sputnik V (Gam-COVID-Vac) Vaccination.

SARS-CoV-2 vaccines have contributed to attenuating the burden of the COVID-19 pandemic by promoting the development of effective immune responses, thus reducing the spread and severity of the pandemic. A clinical trial with the Sputnik-V vaccine was conducted in Venezuela from December 2020 to July 2021. The aim of this study was to explore the antibody reactivity of vaccinated individuals towards different regions of the spike protein (S). Neutralizing antibody (NAb) activity was assessed using a commercial surrogate assay, detecting NAbs against the receptor-binding domain (RBD), and a plaque reduction neutralization test. NAb levels were correlated with the reactivity of the antibodies to the spike regions over time. The presence of Abs against nucleoprotein was also determined to rule out the effect of exposure to the virus during the clinical trial in the serological response. A high serological reactivity was observed to S and specifically to S1 and the RBD. S2, although recognized with lower intensity by vaccinated individuals, was the subunit exhibiting the highest cross-reactivity in prepandemic sera. This study is in agreement with the high efficacy reported for the Sputnik V vaccine and shows that this vaccine is able to induce an immunity lasting for at least 180 days. The dissection of the Ab reactivity to different regions of S allowed us to identify the relevance of epitopes outside the RBD that are able to induce NAbs. This research may contribute to the understanding of vaccine immunity against SARS-CoV-2, which could contribute to the design of future vaccine strategies.

Regulating surrogacy intermediaries: a comparative analysis of regulatory approaches and implications in the Chinese context

Abstract This article addresses the significant research gap concerning the regulation of surrogacy intermediaries in China’s rapidly growing surrogacy market. Employing a ‘law in context’ perspective, it explores the question of how to effectively regulate surrogacy intermediaries in the Chinese context. Situated within China’s unique socio-cultural landscape, where procreation carries profound significance, the study navigates the complexities of surrogacy regulation, including ethical dilemmas, rights infringements and regulatory ambiguities. The article advocates for the regulation of surrogacy in China to prevent possible exploitation, referencing three international models: prohibiting commercial surrogacy, governing non-profit surrogacy organisations and imposing duties on for-profit surrogacy agents. The aim is to construct a robust, context-sensitive regulatory framework for surrogacy in China, focusing on identifying suitable intermediaries and defining the scope of effective regulatory oversight.

U.S. Gestational Carrier Embryo Transfer Trends, 2014–2020 [ID 2683526

INTRODUCTION: Multiple embryo transfers (METs) are common among gestational carriers (GCs) despite increased obstetric risks of multiple gestations and strong recommendations from American Society for Reproductive Medicine (ASRM) for single-embryo transfers. This study assessed GC embryo transfer trends from 2014–2020 to evaluate compliance with national guidelines. METHODS: This retrospective, population-based cohort study used data from the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System. All cycles from 2014 to 2020 involving an embryo transfer to a GC were analyzed. The number of GC embryo transfers, use of preimplantation genetic testing (PGT), and outcome (singleton versus multiple gestation) were assessed. Poisson and linear regression models evaluated trends in number and proportion of cycles over time. Institutional review board approval was obtained. RESULTS: Of the 40,177 GC transfer cycles from 2014 to 2020, 11,081 (27.6%) involved transfer of two or more embryos. Both the number (n=2,001 in 2014; n=814 in 2020) and proportion of METs (56.6% of all transfers in 2014; 11.8% in 2020) (P&lt;.05 for both) decreased. The use of PGT among MET GC cycles increased from 23.9% in 2014 to 61.4% in 2020. Among live births, there was a 71.0% reduction in the proportion of multiple gestations from 2014 (25.5%) to 2020 (7.4%) (P&lt;.05). Among double-embryo transfers, the majority were performed at the blastocyst stage with an increase from 2014 (76.7%) to 2020 (88.1%) (P&lt;.05). CONCLUSION: With increased use of PGT and extended blastocyst culture, MET and subsequent multiple gestation pregnancies have decreased amongst U.S. GCs. These trends suggest increased compliance with ASRM national guidelines.

Accomplishment of canine cloning through in vitro matured oocytes: a pioneering milestone.

The in vitro maturation (IVM) rate of canine oocytes remains low compared to other mammals due to their unique reproductive characteristics. This study aimed to explore the effect of hormone supplementation during the IVM of canine immature oocytes on nuclear maturation and subsequently assess its potential application in canine somatic cell nuclear transfer (SCNT). Immature oocytes were collected and cultured in an IVM medium supplemented with hormones (follicle-stimulating hormone [FSH] and progesterone [P4]) or without hormones (control) for 24 hours. The maturation rates of oocytes in the hormone-treated group (94.92 ± 3.15%) were significantly higher than those in the control group (61.01 ± 4.23%). Both in vitro and in vivo matured oocytes underwent NT to evaluate their utility, and the fusion rates were higher in the in vitro matured group than those in the vivo matured group, not significant between in vivo and in vitro matured group (73.28% and 82.35%, respectively). As a result, 14 fused embryos from the in vitro matured group were transferred into two surrogates, with one surrogate achieving a successful pregnancy and delivering four puppies. Whereas in the in vivo matured group, 85 fused embryos were transferred to 8 surrogate mothers, leading to three surrogates becoming pregnant and delivering one, four, and two puppies. The pregnancy rates were not significant between both groups (50% and 37.50%), but the number of offspring exhibited a significant difference (28.57% and 8.23%). In conclusion, we achieved a remarkable milestone by successfully producing cloned puppies using in vitro matured oocytes, underscoring the feasibility of canine cloning from in vitro recovered oocytes. It is important to note that this study focused only on immature oocytes after ovulation and only during the estrus stage. Further research targeting other stages of the estrous cycle could potentially enhance canine cloning efficiency.

Perspektif Islam terhadap Program Bayi Tabung: Etika, Hukum, dan Hak Waris

Fertilization (IVF) program, especially in the context of ethics, law and inheritance rights. By exploring religious texts and the views of ulama, this research discusses ethical considerations related to the use of artificial reproductive technology in Islam as well as legal interpretations related to its implementation. Apart from that, this research also reviews how Islamic inheritance law regulates the position of children born through IVF. The research method used is the qualitative descriptive method which allows researchers to describe phenomena or research topics in depth, without requiring quantitative measurements. The results of this research show that several ulama' consider the IVF program to be controversial because it is considered to violate natural law or Sunnatullah and is associated with the practice of adultery. However, fatwas from the MUI and NU guide the halalness of the IVF procedure by taking into account religious values ​​and the needs of married couples. In Indonesia, the implementation of this program is regulated by Undang-Undang Nomor 36 Tahun 2009 concerning Health and the MUI fatwa which allows the use of sperm and ovum from legal husband and wife couples. The legal status of children resulting from IVF refers to the Civil Code and Law Number 1 of 1974, with legal recognition depending on the use of donor sperm and surrogate mother. Children born through IVF using the husband's sperm are considered legitimate children with inheritance rights, while inheritance laws for children using donor sperm and surrogate mothers require further consideration.

Motherhood and attitudes towards motherhood in women with Mayer-Rokitansky-Küster-Hauser syndrome.

The aim of the study was to find out what proportion of women with MRKHS have decided to become mothers and have children or would like to have children and consider various options for motherhood. Additionally, the survey aimed at identifying factors that might influence the women's decisions and opinions regarding adoption, gestational surrogacy (GS) and uterus transplantation (UTx). The study group consisted of 100 adult women with MRKHS who filled out questionnaires consisting of 56 questions. The survey was self-administered and anonymous. Most of the study participants were under 30, lived in large cities ( > 150 000 inhabitants) and declared to be heterosexuals in a steady relationship (p < 0.05). While 11 participants had children, 66 out of 89 childless women (74%) expressed a desire for motherhood, but as many as 80 surveyed women have felt pressured to have children. The number of participants for whom a biological relationship with offspring was significant and insignificant respectively equaled (p = 1.000). The majority of the study participants supported the process of legalizing GS in Poland (95 vs 4) yet would opt for commercial rather than altruistic GS (64 vs 31) (p < 0.05). Most respondents stated that UTx is consistent with their faith and conscience (91 vs 4) and found UTx ethical (88 vs 4) (p < 0.0001). The majority of Polish women with MRKHS express the need to become a mother, but only one in ten has a child. The women's interest in biological motherhood is significant.

Mild obesity does not affect perinatal outcome in gestational carrier cycles.

Does BMI of gestational carriers (GCs) affect perinatal outcomes after embryo transfer? Overweight and class I obesity in GCs does not affect the rate of good perinatal outcomes. The use of GCs is increasing, but uniform guidance regarding optimal BMI for GCs is lacking. Women with obesity who conceive without fertility treatment or through autologous or donor in vitro fertilization are at higher risk of adverse maternal and fetal outcomes, but data on obesity in GCs are very limited. We performed a retrospective cohort study of 1121 GC cycles from January 2015 to December 2020 at US Fertility, the largest national partnership of fertility practices in the USA. All GC cycles performed at a large network of fertility practices were reviewed. Same-sex partners undergoing co-IVF were excluded. The primary outcome was good perinatal outcome from the first embryo transfer, defined as a singleton live birth at ≥37 weeks of gestation with birth weight between 2500 and 4000 g. Secondary outcome measures included frequencies of live birth, clinical pregnancy, miscarriage, full-term birth, low birth weight, large for gestational age, and cesarean delivery. A generalized linear model (log-binomial) was used for each to compare outcomes across BMI groups using normal BMI (20-24.9 kg/m2) as the reference group. Risk ratios and 95% CIs were estimated for each category group relative to normal BMI. We identified 1121 cycles in which GCs underwent first embryo transfer, of which 263 (23.5%) were in GCs with BMI >30. Demographics and reproductive history for GCs did not differ by BMI groups. The age of intended parents, use of frozen eggs, and fresh embryo transfers were higher with increasing BMI group. There were no statistically significant associations between BMI and good perinatal outcomes, live birth, clinical pregnancy, biochemical, spontaneous abortion, or low birth weight. However, among live births, higher BMI was significantly associated with birth by cesarean (P = 0.015) and large for gestational age infants (P = 0.023). This was a retrospective study, and there may be unmeasured confounders. The number of patients with BMI <20 or ≥35 was small, limiting the power for these groups. We were not able to assess all maternal and fetal outcomes. In this study, we did not identify any significant impact of BMI on the chances of having a good perinatal outcome. Prior research studies have been inconsistent and this is the largest study to date. No external funding was received for this work. The authors do not have any conflicts of interest to declare. N/A.

Surrogacy: An important pathway to parenthood. A call for international standardization

This comprehensive review examines the multifaceted landscape of surrogacy, a revolutionary treatment for infertility. The study examines historical origins, shifting trends, medical considerations, psychological implications, legal complexities, international variations, and ethical dilemmas surrounding surrogacy. With the advent of assisted reproductive technology, gestational surrogacy allows intended parents a genetic connection to their child. Medical facets encompass indications for gestational surrogacy, drawing attention to maternal health risks and infertility factors. Evidence indicates that medical outcomes are comparable to conventional pregnancies, suggesting a viable reproductive solution for intended parents. Due to the complex nature of surrogacy psychological and emotional vulnerability is inevitable; yet studies underscore positive psychological well-being and satisfaction among gestational carriers (GCs), intended parents (IPs) and children. Surrogacy also has many religious dimensions, as each religion has its own perspective on the distinctive process of creating life and its outcomes, such as, the determination of the child's mother according to their beliefs. Legal considerations emerge as a fundamental aspect, with differing regulations globally. The review emphasizes the significance of comprehensive agreements to safeguard the rights and responsibilities of surrogates and IPs. The unique surrogacy laws in Israel serve as a noteworthy example, reflecting a progressive approach that provides a promising template to establish crucial international guidelines on surrogacy. The absence of international consensus necessitates attention from the global community to address key concerns, including the well-being of GCs, legal recognition for IPs, and the child's best interests, with the goal of establishing a universal standard of care in the field.

La regulación de la maternidad subrogada y su impacto en los derechos reproductivos en el Perú

The objective of this study was to analyze the impact of the regulation of surrogate motherhood as a way to strengthen reproductive rights in Cercado de Lima, 2022. For which, at the level of methodology, it was of qualitative approach, basic type, with a design based on grounded theory and phenomenological and case study method. Interview guide instruments were used to interview six lawyers who are experts in family and genetic law and their responses were processed through Atlas ti Vs. 23. Finally, it was concluded that the study on the regulation of surrogacy in Lima in 2022, most of the participants supported the regulation to strengthen reproductive rights, which will allow greater development of those who decide to become parents through other alternative mechanisms of assisted reproduction.

Prawo do tożsamości dziecka urodzonego w drodze surogacji

The following article examines the right to identity of children born through surrogacy. It is a review of international law, the jurisprudence of the European Court of Human Rights (in particular, Mennesson v. France, Labassee v. France, Paradiso and Campanelli v. Italy, A.M. v. Norway), Polish state law, jurisprudence and legal literature, the purpose of which is to establish: what is the right to identity, what is its scope and elements, and what is the current standard of protection of the child’s identity. The article also addresses the conflict between the right to identity of a child born as a result of a surrogate pregnancy, in the context of the right to know one’s origin, and the right to privacy of gamete donors who wish to preserve their anonymity.

Legal regulation of the implementation and protection of the rights of participants in surrogate motherhood legal relations in the conditions of war in Ukraine

On February 24, 2022, a full-scale war is taking place on the territory of Ukraine. Millions of people lost their homes and jobs. Children, as the most vulnerable category of the population, were particularly affected. Thousands of children were left without parental care, and some were not handed over to their legal parents at all. These events necessitated the study of the chosen research topic. The article is devoted to the rights of children who became victims of martial law on the territory of Ukraine as a result of the attack of the Russian Federation. The article shows the number of children affected by the war. The general principles of protection of children’s rights, defined by the international legislation are considered. An example of international experience in the protection of children in martial law is given. Particular attention is paid to the protection of the rights of children born to surrogate mothers during hostility in Ukraine. Problems of realization of the rights of participants of the specified legal relations are defined. It has been established that the fulfillment of the terms of the contract by the surrogate mother does not guarantee the protection of the interests of the child. The problems of the procedure of registration and documentation of the birth of children are mentioned. The provisions of the Family Code of Ukraine and other special legislation on the legal regulation of the procedure for registration of the birth of a child have been studied. It is noted that in conditions of martial law in the occupied territories, and in cities where hostilities continue, registration is impossible. Changes in the national legislation, introduction for the period of martial law in the field of the specified questions are considered. The author examines the possibility of adopting children born to surrogate mothers, as well as those left without care or evacuated to other countries. Conclusions were made about the impossibility of adopting these children under the accelerated procedure. Emphasis is placed on the need to comply with the adoption procedure established by national law. At the same time, it was noted about the need to strengthen the work of consulates in order to register children who are temporarily in another state. It is proposed in Ukraine to create appropriate registers of potential parents who apply to Ukrainian medical institutions for the birth of children from surrogate mothers. In order to record information about newborns and facilitate the search for biological parents of their own children, it is proposed to use the application “Diia”. In addition to these conclusions, the author stressed the need for Ukraine to ratify the Rome Statute.

A View of Civil Law and Islamic Law on the Practice of Surrogate Mother

IVF is one of the modern methods that can help legal couples obtain children. Both Indonesian Civil Law and Islamic Law allow this practice. Still, it must be carried out based on the provisions, namely by involving couples who are legal in the eyes of the law. IVF carried out through surrogate motherhood is prohibited by both positive law and Islamic law because its existence can disrupt lineage. Children born from this practice are not considered legitimate due to confusion and ambiguity during the process. This research is a normative juridical literature study that is processed based on primary and secondary legal sources consisting of primary, secondary, tertiary legal materials, and non-legal materials with the aim of: 1) Understand how Indonesian civil law and Islamic law view the issue of surrogate mothers; and 2) Knowing how the guardianship status of IVF children born through surrogacy practices. It was found that both Positive Law and Islamic Law prohibit the practice of IVF with surrogate mothers because it results in legal confusion for the child. This research is expected to contribute to further research, especially research that raises the theme of IVF.

A Re-Examination of Human Cloning through Islamic Ethical Lens

Human cloning is one of the controversial topics in the present generation. Accommodating natural development, social changes and needs, Islam has left no aspect of human endeavours unregulated, including human cloning. However, emerging issues about human cloning signal little or no proper understanding of the concept by the Muslims leading to flagrant Islamic disavowal; hence, the need to re-examine the concept from Muslim’s perspectives. Drawing from Maqāṣid Sharīʿah principles, including the rule of necessity for self-preservation and respect for human beings, this paper seeks to assess permissibility or otherwise of human cloning through the ethical lens of Islamic jurists. The paper argues that if human cloning could not be prohibited as such, it could still be opposed because it engenders various harmful consequences, which include family disorder, chaos in the clone's family relationships, physical and mental diseases for clones and suffering of egg donors and surrogate mothers. However, human cloning for biomedical research and exploitation of stem cells from cloned embryos at the blastocyst stage for therapeutic purposes would be acceptable. The paper concludes that there is no ethical impediment to taking adventure in human cloning, whose probable benefit outweighs possible harm.

Public Reason, Bioethics, and Public Policy: A Seductive Delusion or Ambitious Aspiration?

Can Rawlsian public reason sufficiently justify public policies that regulate or restrain controversial medical and technological interventions in bioethics (and the broader social world), such as abortion, physician aid-in-dying, CRISPER-cas9 gene editing of embryos, surrogate mothers, pre-implantation genetic diagnosis of eight-cell embryos, and so on? The first part of this essay briefly explicates the central concepts that define Rawlsian political liberalism. The latter half of this essay then demonstrates how a commitment to Rawlsian public reason can ameliorate (not completely resolve) many of the policy disagreements related to bioethically controversial medical interventions today. The goal of public reason is to reduce the size of the disagreement by eliminating features of the disagreement that violate the norms of public reason. The norms of public reason are those norms that are politically necessary to preserve the liberal, pluralistic, democratic character of this society. What remains is reasonable disagreement to be addressed through normal democratic deliberative processes. Specific issues addressed from a public reason perspective include personal responsibility for excessive health costs, the utility of a metaphysical definition of death for organ transplantation, and the moral status of excess embryos generated through IVF and/or their use in medical research.