Uterus transplantation trials: is deceased donation morally preferable?

In recent
years there has been much research on the feasibility of human uterus, or womb, transplantation (UTx). Five pregnancies and three live births have now been recorded from trials in Sweden and Turkey, and more trials are being prepared worldwide. Should research prove fruitful, UTx would allow those who are unable to gestate and birth their own children a much-desired opportunity to become not only social mothers (through adoption or traditional surrogacy arrangements), or genetic and social mothers (through gestational surrogacy) but mothers in all three senses.

Like many experimental transplantation procedures (e.g. face, hand, corneal and larynx transplants) UTx falls firmly into the camp of the quality-of-life transplant — undertaken in order to enrich rather than save lives. However, unlike most of these — where one would be both unlikely to find a willing living donor or an ethics committee willing to sanction such a donation — wombs for transplantation can be and have been obtained from both the living and deceased. Indeed, of the 11 procedures performed worldwide so far, ten have used living donors.

Some, however, have suggested that the use of living donors in UTx research is morally problematic. Unlike deceased donation, living donation necessarily causes some physical harm to the donor and includes a small but not insignificant risk of long-term morbidity and mortality, as well as generating concerns regarding donor consent and the possibility of regret. The International Federation of Gynecology and Obstetrics (FIGO), for example, held in its 2009 guidelines on
UTx
:

'The donated uterus, if removed from a living donor necessitates a relatively major surgery with its own risk of complications … Given the known hazards to live donors, the procedure is considered ethically inappropriate.' (1)

Was FIGO's assertion too quick? The use of living organ donors has been permitted since the dawn of the transplantation era and is now so commonplace that over half of the kidneys transplanted in the UK in 2013-14 were from live donors. Healthy volunteers are also routinely subjected to small risks of significant harms in clinical research, and few hold that such practices should be subject to blanket moral condemnation. Instead, it is generally suggested that such harms and risks may be justified by appeals to either or
both:

a) The value of respect for individual autonomy
b) The benefits donation produces for donors, recipients and other stakeholders

Might not the same considerations justify living donation in this case?

Should one take an autonomy-based approach, there seems little reason to suggest living donors should not be used in UTx trials, provided adequate mechanisms are in place to ensure valid consent is obtained. Living womb donors do not offer to subject themselves to anything like the risks associated with already accepted living-donation practices, such as partial liver and lung transplants. Thus, if consent may be provided in such cases, it would be bizarre to suggest that it may not be provided in
far-less risky cases.

Should one take a harms—benefit analysis approach, it is clear that the harms risked by living donation in UTx are much smaller than those risked in other contexts, so their use should be permissible provided there are good reasons underlying such a choice.

In other transplantation contexts, appeals are often made to organ shortage. Without the use of living donors, many potential organ recipients will die as demand for organs such as kidneys and livers far outstrips supply. However, the small-scale nature of the trials and the leisurely pace at which UTx can be performed (given that although distressing, an inability to gestate is not life-limiting) makes it unlikely that an appeal to shortage can be made in this case.

Appeals, however, can and have been made to the suggestion that the use of living donors is likely to prove more successful than the use of deceased donors. The Swedish and Japanese research teams, for example, claim that the use of both related and unrelated live donors is liable to lead to better patient outcomes and long-term graft survival rates due to factors such as better tissue matching, reductions in warm ischemia time, and the negative effects of brain death on organ quality. Given the experimental nature of the procedure, however, such benefits remain uncertain. Research teams preferring the use of deceased donors claim, conversely, that the uterus for transplantation is actually best retrieved from the deceased. Some teams based in the US, UK and Turkey suggest that, despite the benefits mentioned above, long-term survival of the uterine graft is unnecessary given that it is designed to be temporary (removed after one or two pregnancies), and longer lengths of vasculature can be obtained from the deceased, lessening the chance of complications and rejection in recipients.

So, is it ethically appropriate to use living donors in UTx trials? On views privileging individual autonomy, the answer is a resounding yes, provided that valid consent from donors is obtained. On a harms—benefit approach the answer is similar. Given that there are good reasons to claim that the use of living donors may prove more efficacious, research into this possibility — using both living and deceased donors — does seem justifiable provided researchers use minimally invasive methods of retrieval.

Of course, this is not to say that, once trials are completed, the use of living donors will still prove justifiable. Should it be the case that there is both no shortage of deceased donor uteruses and that the use of living donors is no more likely (or only slightly more likely) to prove successful, those who hold that living donation requires a favourable harm—benefit ratio may claim, with good reason, that only deceased donors should be used.