Eth­i­cal con­cerns about uterus trans­plants

Sev­eral in­fer­tile women have given birth with wombs re­ceived from ei­ther the liv­ing or dead

The Irish Times - Tuesday - Health - - Health | Lifestyle - Ge­orge Win­ter

In The Whole Woman, Ger­maine Greer writes of sur­ro­gacy: “. . . if pre­par­ing a womb to har­bour the prog­eny of strangers is morally ac­cept­able to us, we must have to some ex­tent ac­cepted the idea of the womb’s be­ing an im­per­sonal con­tainer”.

The ad­vent of uterus trans­plan­ta­tion (UTx) may re­in­force for some this no­tion of the womb as “an im­per­sonal con­tainer”.

In Septem­ber 2014, the first live birth fol­low­ing UTx was re­ported from Swe­den by Prof Mats Brännström and col­leagues. The re­cip­i­ent had Mayer-Rok­i­tan­sky-Küster-Hauser (MRKH) syn­drome – she was born with­out a vi­able womb – and the donor was a 61-year-old friend. Since then, there have been at least 12 suc­cess­ful births world­wide fol­low­ing UTx.

UTx ad­dresses ab­so­lute uter­ine fac­tor in­fer­til­ity (AUFI), which af­fects about one in 500 women, with causes in­clud­ing hys­terec­tomy for ma­lig­nancy or be­nign dis­ease, or the con­gen­i­tally ac­quired MRKH syn­drome, af­fect­ing one in 5,000 women. The al­ter­na­tive for women with AUFI is adop­tion or sur­ro­gacy.

The UTx pro­ce­dure be­gins with in-vitro fer­til­i­sa­tion, us­ing the re­cip­i­ent’s egg and her part­ner’s sperm; the sub­se­quent em­bryo is frozen; a uterus – from a liv­ing or dead donor – is trans­planted; the em­bryo is thawed and im­planted; and fol­low­ing preg­nancy and de­liv­ery by Cae­sarean sec­tion, a hys­terec­tomy is per­formed, ob­vi­at­ing the need for life­long im­muno­sup­pres­sive ther­apy.

Writ­ing in the Oc­to­ber, 2018 is­sue of Cur­rent Opin­ion in Or­gan Trans­plan­ta­tion, Prof Brännström em­pha­sises that UTx “is still at the ex­per­i­men­tal stage and new UTx cases should be within reg­is­tered tri­als and with data ac­cu­mu­lated in an in­ter­na­tional registry, to col­lect data and re­sults to fur­ther op­ti­mise the pro­ce­dure con­cern­ing ef­fi­ciency and safety”.

Prof Brännström lists sev­eral tech­ni­cal chal­lenges, but are eth­i­cal con­cerns im­por­tant?

The “Eth­i­cal Con­sid­er­a­tions” sec­tion of the Womb Trans­plant UK web­site im­plies that any so­ci­etal mis­giv­ings on the ac­cept­abil­ity of UTx will be ig­nored: “Ul­ti­mately, the de­ci­sion to go for­ward will de­pend on the judg­ment of the re­searchers, the par­tic­i­pat­ing in­sti­tu­tion, and most im­por­tantly, the pa­tient to whom the trans­plant will be of­fered.”

Hardly an un­bi­ased trio.

What eth­i­cal dilem­mas might arise?

If a trans­planted uterus were to jeop­ar­dise a re­cip­i­ent’s life, it could be re­moved; but what if it con­tains a vi­able foe­tus? And there is de­bate over liv­ing ver­sus de­ceased do­na­tion, with Span­ish and Ja­panese teams favour­ing the Swedish “live” model, and French, Bel­gian and UK re­searchers pre­fer­ring de­ceased donors. Writ­ing in the jour­nal Bioethics, Dr Ni­cola Wil­liams cites the view of the In­ter­na­tional Fed­er­a­tion of Gy­nae­col­ogy and Ob­stet­rics that “the re­trieval of a uterus from a liv­ing donor ne­ces­si­tates a rel­a­tively ma­jor surgery with its own risk of com­pli­ca­tions [and] con­sti­tutes rea­son enough to deem the pro­ce­dure eth­i­cally in­ap­pro­pri­ate”.

Also, how much would a child be en­ti­tled to know about the donor from whose uterus he or she is­sued, and – ir­re­spec­tive of whether the donor had been dead or alive – would the in­fant be the child of the donor or the re­cip­i­ent?

Given the fact of adop­tion show­ing that one can mother and love a child with­out hav­ing given birth to it, Lisa Belkin, writ­ing in the Huff­in­g­ton Post en­ti­tles her piece, “Giv­ing Birth With A Bor­rowed Womb Is Not What Makes You A Mother”, and won­ders if UTx is worth the ab­dom­i­nal surg­eries in each donor-re­cip­i­ent pair, the sub­se­quent Cae­sarean sec­tion, and fi­nally, the surgery to re­move the

uterus af­ter birth.

Gen­der iden­tity

Fur­ther, at a time when gen­der iden­tity is hotly de­bated, it is con­ceiv­able that men who have un­der­gone sex re­as­sign­ment surgery might con­tem­plate UTx. When philoso­pher Prof Ti­mothy F Mur­phy con­sid­ered this in the jour­nal Bioethics , he ar­gued not only that “so­cial

mean­ings of sexed bod­ies do not re­main con­stant”, but that if trans­gen­der women are con­ferred the same moral sta­tus as women, “[I]t is not sim­ply ‘friv­o­lous’ for transwomen to as­sert any in­ter­est in ges­ta­tion. Ges­ta­tion can play a key role in ex­press­ing and con­sol­i­dat­ing a fe­male iden­tity.”

Coun­ter­ing this is Ger­maine Greer’s (to me con­vinc­ing) view in The Whole Woman that “women should not au­to­mat­i­cally ac­cept all those who do not wish to be male as be­ing ex-gra­tia fe­males”, as­sert­ing that “if uterus-and-ovaries trans­plants were made manda­tory for wannabe women they would dis­ap­pear overnight”.

Do women who lack a uterus have a right to a Utx? My un­der­stand­ing is that a right can only be con­ferred by law, which in turn de­rives from an es­tab­lished moral prin­ci­ple.

But to what ex­tent can a moral prin­ci­ple be de­rived from a “need” or a “want”? I ask this be­cause of a ques­tion on the womb­trans­plan­ web­site ask­ing: “Why The Need For Womb Trans­plants?” Is a no-doubt gen­uine want for a child the same as a need? It is an im­por­tant dis­tinc­tion since many ba­sic needs that we share – wa­ter, nu­tri­tion, shel­ter etc – of­ten gen­er­ate a right. The risk of not dis­tin­guish­ing a want from a need is that those women lack­ing a womb may as­sert a right to a UTx when what they have is a sincerely-held want. In my view, elid­ing the terms “want” and “need” adds con­fu­sion to a de­bate that needs clar­ity.

But where cut­ting-edge med­i­cal sci­ence is con­cerned, med­i­cal sci­en­tists of­ten pay lip ser­vice to the ques­tion of ethics, leav­ing so­ci­ety to pick up the pieces.

The ad­vent of uterus trans­plan­ta­tion (UTx) may re­in­force for some the no­tion of the womb as “an im­per­sonal con­tainer”, in the words of Ger­maine Greer (be­low)

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