Ethics around womb transplantation

Ethics is about communication. As with any conversation, views about values enter into existing debate, and these influence further discussion. This is true when looking back on our ethical discussion of womb transplantation.

A BioNews article tapped into the discourse surrounding uterine transplantations performed for nine women in Sweden. All have received organs from live, genetically related, human donors, possibly all mothers and sisters. These are part of an ongoing investigation by a team in Gothenburg led by a Swedish obstetrical surgeon, Mats Brännström. The article reported that one of these patients is preparing to become pregnant having received a donor egg, conjoining this technique with IVF and the transfer and implant of the embryo.

Technical problems make it difficult to imagine this procedure could bring success: that is, the delivery of a healthy child. Although pregnancy has occurred after uterine transplant, no child has been born via a donated uterus. Previously, the uterus had been successfully transplanted from a cadaver: a surgical success. However, no pregnancy followed. But in animal studies, the procedure has resulted in successful transplantation, pregnancy and birth, suggesting that a life-giving and sustaining womb may be possible.

These results promote an open discussion which would have been unimaginable years ago. As a National Post article pointed out, Arthur Shafer from the University of Manitoba saw a difference between the 'moral panic' reflected in the discourse surrounding the first test-tube baby, and what he characterised as a more limited reaction with uterine transplantation. He also suggested also that today's view is less that it is an 'unnatural' procedure but more that it is technically challenging.

Professor Outi Hovatta from Karolinska Institutet, an international advocate for addressing the problem of infertility, and also a colleague of Brännström's, shared with me some interesting thoughts about the matter. She leaves to Brännström the challenges of the surgical technique but notes that the strategy employed in these nine cases - accepting a live donor's as opposed to a cadaver's organ - has strengths and weaknesses. For example, although the uterus can be transplanted, the supporting network providing blood supply could not, bringing risk of failure of the organ.

The 'usual suspects' of popular ethics principles come up in this conversation, as expected - autonomy, beneficence and maleficence. But, like the bright colors of a primary palette, while these terms may at first evoke clear and separable meaning, and seemingly ease the task of fitting the circumstances of the case to some formula, such as 'utility = benefit > risk'. In the end, the colours are mixed. For example, with heart transplantation, high risks were deemed acceptable in high-benefit situations (in other words: to save a life). Here, it is not the saving of a life, rather, as Professor Hovatta said, but the quality of life of the mother. The giving of life to the unborn baby is a speculation, a mystery yet unveiled.

Another way that the discussion has shifted is in the matter of who expresses consent. With donor and recipient involved, it is necessary that each provide consent while understanding what the procedure is and what its risks and benefits are, as well as what future consequences may be found.

Again, note that the future child would be born into this situation. How will the child experience his parent, not just biologically, but psychologically? The physical and emotional bond would naturally be with the mother, or, perhaps, the donor, reflecting on her 'new pregnancy', which does not exist, though she is part of it. But then don’t we all make ourselves out to be characters that don’t exist?

Apologies to W. Bion for my tattered recollection, but perhaps it was he who once said that there is not such a thing as a group mind, only the aggregate of individual aims. So, I must consider my own part in the discourse. I must admit, when I first thought about womb transplantation I, indeed, imagined the transfer of a formless organ. It wasn’t the iconic heart, or a 'bean-shaped kidney', after all. These I have held more as objects, popularly admired and familiar in shape. Other than a drawing, I did not recall seeing a 'womb', and seeing a film of it being carried during the surgical procedure from donor to recipient; it seemed to have less form. Well, my wife corrected me — the uterus is hardly formless, and is factually perhaps more the shape of a heart than the heart is, which brings us back to the benefit. The woman who desires a womb in order that a child be born, is not saving a life, but is co-creating a life, providing the vessel for life.