Beyond the sound and fury: Whole body gestational donation

Modern technology opens extraordinary new vistas and possibilities. Organs can be transferred from the dead to the living. People can be paid to gestate babies on behalf of others. Gametes can be harvested from dead and dying patients. A piece of information can be plucked out and circulated around the world at lightning speed. With these possibilities come a plethora of ethical questions.

My paper on whole-body gestational donation is designed to explore some of these questions and as some of you will have seen, it has attracted some attention in both the press and social media. It involves – hypothetically – the use of a brain-dead person's body to gestate a fetus. It would – again, hypothetically – require a relatively simple tweak to systems that already facilitate organ donation. Thus, people who wish to do so would have the opportunity to become gestational donors under specific circumstances.

This scenario evokes some disturbing images and associations. Yet this is very often the case with new developments in biomedical technology. It is easy to forget now how appalled people were at the idea of 'test tube babies'. The first surgeon to attempt a heart transplant in Japan was accused of murder. The use of anaesthesia to lessen women's pain in childbirth was viewed as an ungodly transgression of the biblical decree that women bring forth children 'in labour and sorrow'.

It is worth asking whether everything that alarms and even revolts us today will seem acceptable a few years hence. Developments in technology tend to drive changes in what is perceived as being morally acceptable. But unless we want to wait passively for these changes to sweep over us, we need to look at what the future may hold, as well as turn a critical eye on practices that have become so banal and commonplace that we scarcely notice them.

As an ethicist, it is part of my job to look squarely in the face of practices and possibilities that others might prefer to ignore. My aim in presenting the idea of whole-body gestational donation was to demonstrate that this is a logical extension of activities that are currently routine in many parts of the world. If the prospect of this is unacceptable, then we have difficult questions to answer about these related practices.

Part of my interest in this field arises from my previous work published in the Journal of Medical Ethics on the ethics of harvesting sperm from brain-dead men without their consent. Sperm can be harvested by inserting a probe into the anus and applying an electric current to force ejaculation. I have published a number of papers and articles, for example in Etica and Politica, objecting to this practice, highlighting: the lack of consent; the use of a procedure that could be construed as sexual assault or rape; the observation that the same interventions could be applied to female brain-dead patients in ways that would leave them vulnerable to the reproductive interests of others.

I investigated the history of the concept of brain death and its role in organ donation, and analysed the ways in which consent features in current approaches to organ donation. I found that there are significant inconsistencies in the way that consent for organ donation is dealt with, and a steady progression in many jurisdictions, including the UK, towards an opt-out system, whereby people will have their organs harvested by default unless they have specifically requested otherwise.

Brain death and organ donation are uncomfortable topics. Many people do not like to think about what will happen to them after their death. These questions are also subjective. Most of the men I spoke to about perimortem sperm harvesting were horrified at the idea. But some of them thought it was a wonderful thing to do, to allow their loved ones to have their babies. I should add here that currently, reproductive tissue is excluded from the organ donation programme in the UK. Where sperm has been harvested from men who are dead or dying, it has been at the request of third parties. So this kind of harvesting, though it happens, is not routine in the way that other organ retrievals are (see BioNews 1169).

Over the past years, there have also been a number of cases documented in the news where pregnant women have suffered some catastrophic event that has left them brain dead. These brain-dead women were kept on prolonged ventilation for weeks or months, until the baby could be delivered. I am aware of many more such cases that have not made it into the news. Few, if any of these women gave consent to be 'kept alive' in this way. Part of the reason for the relative frequency of such cases is that pregnancy itself can cause dangerously high blood pressure and strokes.

While I was undertaking this research, I came across a paper by Rosalie Ber in Theoretical Medicine and Bioethics – an apparently serious suggestion that the moral problems of surrogacy could be alleviated by the use of women in a persistent vegetative state as surrogates. Some of the tone and language in my paper published in Theoretical Medicine and Bioethics in November last year is an ironic response to hers. Together, these are the concerns and interests that led me to the development of the concept of whole-body gestational donation. Its function is to highlight the confluence of the various practices and assumptions I have outlined above and to show where they may lead.

My view as an ethicist is that the prospect of whole-body gestational donation is deeply disturbing. Yet discomfort alone is not enough to show that something is unethical. If it were, then many medical advances would be stopped in their tracks. So how can we sift between the layers of discomfort and repugnance in order to make clear-sighted distinctions between what is, and is not, ethically acceptable in this context?

I suggest one fairly clear answer is that - given the subjective nature of people's attitudes to their bodies after death, it is ethically unsound to make assumptions about people's wishes. Explicit informed consent should be an absolute requirement for any kind of donation. Ethically sound consent requires proper information. It requires engagement with the public that goes well beyond existing organ donation campaigns. I have spoken to medical professionals who told me that the public are not capable of making the right choices, that giving them information will simply scare them. It is better that the choice is made for them. That way, they don't have to confront these difficult decisions.

I do not believe that this is the right approach. My work is informed by the belief that we should avoid the temptation to turn away from questions that are challenging or disturbing. By ignoring them, we do not prevent unethical things from happening – we enable them, by turning a blind eye. I strongly believe that the public should be fully informed, and empowered to make their own decisions regarding organ donation.

However, responsible communication is difficult in our highly confrontational and chaotic public discourse. After my paper on whole-body gestational donation 'escaped' into the real world, it was reported on by a variety of media outlets – some with a political agenda, others with a commercial interest in provoking outrage and thereby clicks. Many of the reports were deliberately misleading – glossing over, for example, the crucial issue of consent, and giving the impression that my thought experiment was a policy proposal or even an active research project.

I became the focus of an onslaught of abuse on various social media platforms, spurred on in many cases by 'public intellectuals' who posted inflammatory comments without bothering to read or understand my paper. I was called a misogynist, a Nazi, an evil scientist, a science illiterate, a far-right extremist, a far-left extremist, and much more. Amidst this sound and fury, it seems that it is more fun to embark on a witch hunt than to grapple seriously with questions about what happens to us if and when we become brain dead.