Pregnancy, pain and pathology: a reply to Smajdor and Räsänen.

In their recent paper 'Is pregnancy a disease?', Anna Smajdor and Joona Räsänen argue in the affirmative, highlighting features shared by both pregnancy and paradigmatic diseases. In particular, they point to the harmful symptoms and side effects of pregnancy, and the provision of medical treatment to both pregnant patients and those aiming to avoid pregnancy. They consider both subjectivist and objectivist approaches taken by philosophers of health in defining disease, and point out that neither approach convincingly excludes pregnancy. Finally, they present a normative case for treating pregnancy as a disease, suggesting that this attitude could promote preventive provision of contraception and abortion, and encourage respect for (and better treatment of) patients' suffering during pregnancy. In this response, I challenge various parts of Smajdor and Räsänen's argument, and cast doubt on the normative benefits of their approach.

Surrogacy and the Fiction of Medical Necessity.

A number of countries and states prohibit surrogacy except in cases of "medical necessity" or for those with specific medical conditions. Healthcare providers in some countries have similar policies restricting the provision of clinical assistance in surrogacy. This paper argues that surrogacy is never medically necessary in any ordinary understanding of this term. The author aims to show first that surrogacy per se is a socio-legal intervention and not a medical one and, second, that the intervention in question does not treat, prevent, or mitigate any actual or potential harm to health. Legal regulations and healthcare-provider policies of this kind therefore codify a fiction-one which both obscures the socio-legal motivations for surrogacy and inhibits critical examination of those motivations while mobilizing normative connotations of appeals to medical need. The persisting distinction, in law and in moral discourse, between "social" and "medical" surrogacy, is unjustified.

Phenomenological Interview and Gender Dysphoria: A Third Pathway for Diagnosis and Treatment.

Gender dysphoria (GD) is marked by an incongruence between a person's biological sex at birth, and their felt gender (or gender identity). There is continuing debate regarding the benefits and drawbacks of physiological treatment of GD in children, a pathway, beginning with endocrine treatment to suppress puberty. Currently, the main alternative to physiological treatment consists of the so-called "wait-and-see" approach, which often includes counseling or other psychotherapeutic treatment. In this paper, we argue in favor of a "third pathway" for the diagnosis and treatment of GD in youths. To make our case, we draw on a recent development in bioethics: the phenomenological approach. Scholars such as Slatman and Svenaeus have argued that the extent to which the body can (or should be) manipulated or reconstructed through medical intervention is not only determined by consideration of ethical frameworks and social and legal norms. Rather, we must also take account of patients' personal experience of their body, the personal and social values associated with it, and their understanding of its situation in their life: their narrative identities. We apply this phenomenological approach to medicine and nursing to the diagnosis and treatment of GD in youth. In particular, we discuss Zahavi and Martiny's conception of the phenomenological interview, in order to show that narrative techniques can assist in the process of gender identification and in the treatment of youth presenting with GD. We focus on two case studies that highlight the relevance of a narrative-based interview in relations between patients, HCPs, and family, to expose the influence of social ideologies on how young people presenting with GD experience their bodies and gender.

Why-UD? Assessing the requirement to trial an intrauterine device as a condition for elective sterilisation in female patients.

Some National Health Service healthcare boards in the UK will approve a request for female sterilisation only if the patient first accepts a trial period of 1 year with an intrauterine device (IUD), a form of long-acting reversible contraception. In this article, I argue that this requirement is not justified by appeal to any of (or any combination of) promotion of informed consent, paternalistic concerns regarding patient regret in later life and health service budgetary considerations. Informed consent and patient autonomy may be promoted by a mandatory waiting period, but the concomitant imposition of an IUD trial during this period cannot be justified on these grounds. As long as elective vasectomy is offered by the healthcare system, elective female sterilisation should be accessible under reasonably similar-even if not identical-conditions.

Double-donor surrogacy and the intention to parent.

Assisted reproduction often involves biological contributions by third parties such as egg/sperm donors, mitochondrial DNA donors, and surrogate mothers. However, these arrangements are also characterised by a biological relationship between the child and at least one intending parent. For example, one or both intending parents might use their own eggs/sperm in surrogacy, or an intending mother might conceive using donor sperm or gestate a donor embryo. What happens when this relationship is absent, as in the case of 'double-donor surrogacy' arrangements (DDS)? Here, a child is conceived using both donor eggs and sperm, carried by a surrogate, and raised by the commissioning parents. In this paper, I critically examine proposals to allow DDS in the United Kingdom, and the intentionalist justification for treating this practice distinctly (morally and legally speaking) from private adoption. I argue that the intentionalist approach cannot plausibly justify such a distinction and that other approaches to moral parenthood are also unlikely to succeed.

Defending two dilemmas.

Ashley's response to our recent paper argues that a fuller appreciation of the available clinical data, of the rights of children to autonomy, and of the primary purpose of gender-affirming endocrine treatment supports the rejection of both the pathway and consent dilemmas for the treatment of gender dysphoria, as raised in this journal. In this response, we highlight certain misrepresentations of our argument, and defend our conclusions against Ashley's main objections.

Two dilemmas for medical ethics in the treatment of gender dysphoria in youth.

Both the diagnosis and medical treatment of gender dysphoria (GD)-particularly in children and adolescents-have been the subject of significant controversy in recent years. In this paper, we outline the means by which GD is diagnosed in children and adolescents, the currently available treatment options, and the bioethical issues these currently raise. In particular, we argue that the families and healthcare providers of children presenting with GD currently face two main ethical dilemmas in decision making regarding treatment: the pathway dilemma and the consent dilemma.

Moving forwards: A problem for full ectogenesis.

Most existing literature on the ethics of full ectogenesis has proceeded under the presupposition that science will at some point produce sophisticated technologies for full-term gestation (from embryo to infant) outside the human womb, delivering neonate health outcomes comparable with (or even superior to) biological gestation. However, the development of this technology-as opposed to the support systems currently being advanced-would require human subject experiments in embryo-onwards development using ectogenic prototypes. Literature on ectogenic research ethics has so far focused on 'backwards' development of partial ectogenesis: incubation and ectogestation technologies that would allow the support of earlier and earlier neonates and foetuses. However, little has been said about the ethics of 'forwards' development of (partial or full) ectogenesis, involving the development of embryos and foetuses in prototype environments. Such a prototype might allow us to produce a gestateling or live neonate from a human embryo, but with poorer expected development and health outcomes than from biological gestation; it might also produce only gestatelings (healthy or otherwise) before the technology was developed to a stage where full-term gestation was achievable. This paper explicates some of the ethical issues that this raises for the development of 'full' ectogenesis, and presents prima facie reasons to consider this research problematic and therefore to require extensive further argument in its defence.

A lost cause? Fundamental problems for causal theories of parenthood.

In this paper, I offer a critique of (actual and possible) causal theories of parenthood. I do not offer a competing account of who incurs parental obligations and why; rather, I aim to show that there are fundamental problems for any account of who acquires parental obligations and why by appeal to causal responsibility for a child's existence. I outline and justify three criteria that any plausible causal account of parental obligation must meet, and demonstrate that attempting to fulfil all three criteria simultaneously will give rise to one or both of two potentially insurmountable dilemmas.

La enseñanza de la Historia de Cuba: un reto para la Universidad Médica / The teaching of the History of Cuba: a challenge for the Medical University

Introducción: la enseñanza de la Historia de Cuba ha constituido una prioridad para la revolución cubana, una premisa para el sostén ideológico de la misma, una condición básica para defender la unidad de nuestro pueblo. De tal modo que incluida en todos los niveles de enseñanza en nuestro país va garantizando que nuestros niños y jóvenes la incorporen desde edades tempranas, primero a través de nociones y representaciones y luego a través de sus leyes y regularidades, por lo que la Historia de Cuba como ninguna otra disciplina tiene esta ventaja. Objetivo: profundizar en la influencia de los medios de información y su repercusión negativa en la enseñanza de la Historia de Cuba en la universidad médica. Método: se realizó una revisión exhaustiva de varios temas históricos relacionados con los programas de Historia de Cuba que se imparten en nuestra enseñanza que están ubicados en sitios digitales como Wikipedia que es uno de los más utilizados por nuestros estudiantes. Desarrollo: se escogió como sitio para el análisis el sitio digital Wikipedia y se tomaron como muestra 10 hechos históricos de los que tratamos en nuestras clases, y de ellos ninguno trata adecuadamente. Conclusiones: el uso de los sitios digitales no puede ser ni la primera, ni la única opción que utilicen nuestros estudiantes, para la preparación en las asignaturas de Historia de Cuba aunque en ocasiones parezca más fácil(AU)

Introduction: the teaching of the History of Cuba has been a priority for the Cuban revolution, a premise for its ideological support, a basic condition to defend the unity of our people in such a way that it is included in all levels of education in our country and guarantees that our children and young sters incorporate it since their early ages, first through notions and representations and then through its laws and regularities, that is why the history of Cuba, like no other discipline, has this advantage. Objective: to deep into the influence of the media and its negative impact on the teaching of the History of Cuba at the Medical University. Method: it was performed an exhaustive analysis of several historical issues related to the programs of Cuban History that are taught in our schools and located on digital sites like Wikipedia, which is one of the mostly used by our students. Development: for the analysis it was chosen the Wikipedia digital site and the sample included 10 Historical facts from the ones discussed in our classes, and none of them is properly treated. Conclusions: the use of digital sites can not be the first or the only option to be used by our students for their preparation in the History of Cuba even though sometimes it seems to be easier(EU)

Valores humanistas: encargo de la sociedad cubana a la Universidad Médica del siglo XXI / Humanist values. Assignment of the Cuban society to the Medical University of the 21st century

La personalidad profesional que exige la sociedad no nace con el ser humano, sino es una consecuencia de la experiencia histórico-social y de los motivos profesionales, donde el papel del profesor y un trabajo individual con el estudiante contribuyen a su desarrollo integral. Nuestro objetivo fue abordar desde un marco teórico y metodológico el fortalecimiento de los valores humanistas como encargo de la sociedad cubana a la universidad médica del siglo XXI, para lo que se realizó una investigación del tipo exploratorio. Apoyados en el método teórico empírico de revisión documental se realizó una profunda revisión de la bibliografía, lo que permitió por métodos teóricos modelar un marco teórico del tema, utilizando los métodos análisis-síntesis e inducción deducción, transitando por toda la evolución histórica de la universidad, los principales elementos desde la óptica del proceso docente y su enfoque psicológico, hasta arribar a las conclusiones de que los valores son formaciones motivacionales del desarrollo humano, en el que tenemos responsabilidad los docentes desde las actividades curriculares y extracurriculares, en el contexto de la formación profesional del estudiante universitario por la trascendencia social positiva, al regular y orientar la actitud de estos hacia el crecimiento humanista y el perfeccionamiento humano, por lo que cada profesor de las ciencias médicas debe contribuir a su fortalecimiento en la juventud por ser la etapa para la fijación interna de valores socialmente positivos en forma de convicciones personales(AU)

The professional personality which society requires does not born with the human being, but is a consequence of the historical-social experience and professional reasons, where the role of the teacher and individual work with students contribute to their overall development. Our goal was to approach from a theoretical and methodological framework the strengthening of humanist values as the assignment of cuban society for the Medical University of the 21st century, for which it was performed an investigation of exploratory type. Supported by the theoretical empirical method of documentary review it was performed a bibliographic revision, which allowed, by means of theoretical methods, the creation of a theoretical framework of the topic, supported by the analysis-synthesis and induction deduction methods, transiting across the historical evolution of the University, the main elements from the perspective of the teaching process and its psychological approah, to finally conclude that values are motivational formations of human development, in which all teachers have responsibilities from the curricular and extracurricular activities, in the context of vocational training of University students by the positive social significance to regulate and guide the attitude of these humanist growth and human development. That is the reason why every professor of medical sciences must contribute to his strengthening in the youth because this is the stage for internal fixation of socially positive values in the way of personal convictions(EU)