Ethical and regulatory debates on gestational surrogacy highlight risks of exploitation and lack of coordinationNew ethical debates shape the future of gestational surrogacy

Gestational surrogacy has become an increasingly important pathway to parenthood for individuals and couples who cannot otherwise achieve or safely sustain pregnancy, yet its expansion has intensified longstanding ethical and regulatory controversy. Drawing on an extensive review of the literature summarized in Supplementary Table 1, this narrative review synthesizes contemporary ethical arguments and regulatory debates concerning gestational surrogacy. The analysis focuses on the tension between reproductive autonomy and concerns regarding exploitation, commodification, structural inequality, and the welfare of children. This synthesis identifies a growing challenge to the traditional binary distinction between commercial and altruistic surrogacy: payment alone does not determine whether an arrangement is exploitative, while altruistic models may also involve coercive pressures arising from familial obligations, social expectations, or economic dependence. At the same time, the child's interests, including secure legal parentage, citizenship, knowledge of origins, and recognition of the gestational relationship, have moved closer to the center of ethical analysis. Regulatory approaches remain highly heterogeneous, ranging from permissive commercial systems to altruistic-only models and complete prohibition. Against a broadly regulationist academic and professional literature, recent political initiatives, most notably the 2023 Casablanca Declaration and increasingly critical European parliamentary discourse, have strengthened an abolitionist framing of surrogacy as a threat to human dignity and a potential form of reproductive exploitation. We argue that the contemporary debate has therefore reached a moral crossroads: the central question is no longer simply whether surrogacy should be commercial or altruistic, but whether exploitation is intrinsic to gestational surrogacy or contingent on the conditions under which it is practiced. A coherent future framework should protect gestational carriers and children while respecting reproductive autonomy, and should address the transnational nature of surrogacy through stronger regulatory coordination.