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When I renewed my driver's license, I was asked if I wanted to remain an organ donor. These days, women who agree to be organ donors may not anticipate a new type of donation: their uterus.
Some women have absolute factor infertility due to cancer treatment or to being born without a uterus. Medical researchers have tried for years to solve this understandably grievous problem, their efforts culminating in the only presently feasible solution: a uterus transplant.
The technology is still very new. The first "womb transplant baby" was born less than two years ago, in late 2014, in Sweden. The birth of baby Vincent followed years of failures in animal trials, but since then, three more babies in the Swedish trial have been born.
One year after Vincent's birth, the U.K. announced that ten women would receive uterus transplants in a clinical trial there, with the first birth expected in late 2017. Unlike the Swedish women, who received wombs from living donors, the women in the U.K. trial will receive uteruses from "brain-dead" donors.1 And in the U.S., despite some initial reticence, Cleveland Clinic surgeons recently announced similar plans to perform uterus transplants using deceased-donor organs.2
Is this something to celebrate, a case of the barren woman becoming the joyful mother of children? Or is it another instance of medical technology run amok to satisfy women's desires to gestate and give birth to a child?
A Wide Range of Concerns
Uterus transplantation raises a complex series of ethical questions encompassing the four major principles of Western bioethics: autonomy, non-maleficence (do no harm), beneficence, and justice. These ethical questions span the areas of research ethics, organ transplant ethics, and reproductive ethics, and in addition, there are questions concerning the psychological as well as physical impact such transplants will have on the donor, recipient, and future child. And for Christians, there are moral and theological aspects to consider related to children and infertility, bringing third parties into the marital relationship, God's providence, and the stewardship of resources.
More than a decade ago, a uterus transplant (UTx) was performed in Saudi Arabia, using a living donor. In 2013, an attempt was made in Turkey using an organ from a heart-beating, brain-dead donor. Both attempts failed, and the first one, not based on results from animal trials, violated the standard for ensuring safety and effectiveness before attempting human trials. In subsequent animal trials, either the subjects did not survive, the transplant was not successful, pregnancy did not occur, or a pregnancy occurred but was terminated. -Nonetheless, researchers pressed on, and to date, eleven women have received UTx. This history shows that when researchers are rushing to be the "first in the world" to accomplish UTx, they are tempted to ignore apparent conflicts of interest and to take dangerous shortcuts.
Concerns for the Recipient
A related concern is the question of fully informed consent. Did the women receiving transplants see themselves as patients or as research subjects? Were they aware of the failure of animal trials? In their desperation to have a child, were they willing to "try anything"? As the history of IVF illustrates, couples pursuing infertility treatment will say yes to almost anything they can afford. At least the risks of IVF are fairly well identified, even if they still have not been adequately studied, but UTx research is identifying risks case by case.
Moreover, thus far, these high-risk procedures have been performed on young, healthy women, who did not need the transplant to save their lives. Further, the transplant is "ephemeral," meaning that the uterus must be removed after a maximum of two pregnancies, so that the recipient may avoid a lifetime of taking anti-rejection drugs. Vincent's mother has already had her transplanted womb removed, due to the high risks of that one pregnancy and her doctors' fears that a second pregnancy would be even riskier.3
Yet another complicating aspect of attempting pregnancy via a womb transplant is the necessity of IVF. Although the recipient must have functioning ovaries, at this time pregnancy is only being attempted using embryos created and frozen prior to the transplant. There is some risk to harvesting eggs. Moreover, some embryos will die during freezing, others during thawing, and "excess" embryos may be discarded. The certainty of embryonic deaths is unacceptable for Christians.
Concerns for the Donor
Donors, too, sustain serious risks. A living donor not only undergoes all the risks of major surgery, but she has to have more tissue removed (arteries and veins) than if she were having a typical hysterectomy. There is no published data about the risks of elective hysterectomies.
In the case of a deceased donor, it must be clear that she or her family intended to include her uterus among the retrievable organs, because some—perhaps many—women regard the uterus as being different in kind from, say, a heart or a kidney. Additionally, prompt removal of the uterus from the donor is preferable, to avoid the "major systemic inflammatory changes" that occur at death and would degrade the quality of the organ. This raises concerns about potential over-hastiness to remove a uterus before the donor is truly dead, concerns that have already arisen in other organ retrieval scenarios.
Psychological implications for a living womb donor—usually the mother, other relative, or close friend of the recipient—may be different from those for a kidney donor. The donor might feel particularly close to the "miracle baby" that is born; she may also be devastated by a transplant or pregnancy failure. Her altruism is praiseworthy, but there is also the danger that other family members may exert subtle coercion. At the very least, the involvement of a close relative sets up the possibility of future conflict and awkward social dynamics.
Concerns for the Child
Most tellingly, little attention is being paid in medical, ethical, or popular discussions to the impact on the child who is gestated in a transplanted womb. For some children, the womb in which they grow in their mother's body will be the same womb in which their mother herself grew. Of course, it has not yet been possible to study the psychological effects on children, but at the very least, serious thought should be given to their well-being. Or does the good of potentially being able to bring forth a life (as opposed to the good of a life already in existence) trump all other concerns? If that is the position taken, then multiple ethical and theological goods will be sacrificed on the altar of one potential good, gestating a child of one's own.
There are also numerous physical risks that could affect the child, such as miscarriage or induced abortion, preeclampsia, hypertension, diabetes, mandatory C-section delivery (to avoid stressing the uterus), prematurity, and low birth weight. Vincent's birth was induced at 31 weeks and 5 days, due to maternal health risks.
A final ethical issue concerns the massive diversion of sophisticated medical technology and human expertise that UTx involves. Costs have been estimated to be in excess of $500,000,4 which I suggest is an unconscionable waste of resources to expend so that a woman may pursue having "a child of one's own" and the experience of pregnancy.
Infertility illustrates the sin and brokenness that mars all of creation. We cannot explain why some couples are unable to bear biological children. Yet, attempts must be made to understand this sorrowful situation within the context of God's providence, his purposefulness, and his good and gracious will, as well as his intent for just and fair use of natural resources. This posture will, however, put us radically at odds with those who are avid about pursuing the promises of uterus transplantation despite the serious risks and extravagant costs. The ethical and theological concerns require deeper exploration, and until they can be resolved, a preliminary conclusion for Christians should be to put this tempting technology in the category of "do not touch." •
For a more extensive treatment of this topic, see Paige C. Cunningham, "'Womb Transplant Babies': A Preliminary Exploration of Recent Biomedical Advances," Dignitas, vol. 22, no. 4 (2014).
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