The ethics of womb donation and transplantation

Last month news broke of an experimental womb transplantation surgery planned for early next year. With it came the possibility of women with an absent or non-functioning uterus carrying a child to term (1).

One of the hopeful donors - Eva Ottosson, who hopes to act as a donor to her daughter Sara - is based in Britain. Online comments, written in response to UK newspaper articles, reveal that there are many so-called ethical objections to the procedure. But are these justified?

There are, predictably, concerns about the 'rightness' of having Eva's granddaughter carried in the same womb as her daughter. It's hard to discern the ethical argument here, other than the 'yuk factor'. There are no concerns about family relationships and genetic history as no DNA is exchanged.

The usual ethical debates about surrogacy are not valid either. Although the womb was originally Eva's, the child would be carried inside her daughter. Sara would be the child's mother having begotten, gestated and planned to raise he or she.

The question of maternity, legal or otherwise, is not under debate (although see (2) for further discussion). The womb doesn't knowingly and autonomously care for the growing embryo, despite some people giving it an almost mystical or anthropomorphic status. Ethical concerns over maternity and family relationships should receive little weight in this case

But this transplant is being performed to improve quality of life, not to save life. While this is a reasonable concern, this point has been addressed countless times before when discussing other reproductive technologies or face transplants. There is already a precedent for allowing surgical interventions that merely enhance life.

The medical and physiological dangers of this complex experimental procedure provide, perhaps, the only real ethical concerns (3). At present, with only animal cases to base the procedure upon, the risks for humans are undetermined. As in all transplant surgeries, the recipient would have to take immunosuppressant drugs. Whether the womb would avoid rejection and function responsively in situ is unknown. The previous attempt at womb transplantation in 2000 was unsuccessful - the womb had to be removed due to uterine necrosis.

There are unknown risks to the (unconsenting) embryo too. An IVF embryo would be transferred once the womb is transplanted. There are no studies - even in animals- investigating how a transplanted womb acts during a successful pregnancy: will it be appropriately sensitive to circulating hormones, neural and chemical signals, and allow a healthy pregnancy to come to term?

Given the exquisitely-orchestrated physiological process of pregnancy this should give pause for thought. Further, Caplan et al (2007) (4) discuss the therapeutic misconceptions surrounding the donors/recipients of first surgeries: 'they need to be frequently and emphatically reminded that [they]…are subjects in a research study, not patients getting a new treatment. It is unlikely that they will benefit by delivering a baby'. It is unclear from news reports and interviews that this carefully delineation exists in this case.

The ethical concerns over this radical new surgery for the donor and recipient boil down to unknown risks. This should not trouble us anymore than other experimental surgeries: they are adults capable of informed consent. More worrying are the ethical concerns of using the womb for carrying a child with all the incumbent unknown risks and consequences.

We might (in the words of Charles Foster in his ethics blog (5)) 'applaud' the announcement of this procedure. But we must also carefully balance one person's right to participate in an experiment to bear their own child with our consideration of the vulnerable, but silent, unconsenting child.