We need to talk about the artificial womb

This week, researchers based at the University of Technology in Eindhoven announced they had received Horizon 2020 funding to build their artificial womb prototype (see this week's news article). This follows the news, in 2017 (see BioNews 898) and again in 2019, of successful animal testing of artificial womb prototypes, named the Biobag and the EVE Platform, in the USA and Australia. This latest development towards the artificial womb improves the prospects of the technology coming to fruition. The race to develop the artificial womb is on!

Artificial womb technology is sought after as a means of circumventing the inherent limitations and problems of neonatal intensive care. Around one in 13 pregnancies in the UK are delivered prematurely, and a significant number of preterm babies require intensive care. The prospects for premature neonates have improved over the last few decades thanks to developments in mechanical ventilation and substances that help babies' lungs better receive oxygen. However, babies born at or below 24 weeks are still unlikely to survive, and those born before 26 weeks are at risk of serious long-term health problems.

Neonatal intensive care only supports babies that are born functionally mature enough to withstand ventilation, so intensive care appears to have reached a natural limit at 22 weeks. Before this point a fetus usually has not developed solid lungs, so they cannot be assisted. There are also common complications associated with the interventions given in intensive care – in particular damage to the babies' lungs from ventilation and infections from feeding tubes. 

The artificial womb marks a shift in approach to treating preterms: away from intrusive attempts to provide mechanical assistance to a preterm struggling to sustain itself and towards attempting to support development by continuing gestation extra uterum. The devices being created endeavour to better mimic the environment of the uterus by sealing the preterm in amniotic fluid, administering essential nutrients through a cannula emulating an umbilical cord and using an oxygenator to assist the preterm in maintaining its own heartbeat. By providing the conditions for gestation, the preterm is able to continue growing and maturing as if the pregnancy had not ended.

It is thought that this approach could almost eliminate deaths due to prematurity (because they are not subject to the same constraints of lung maturity), and prevent the occurrence of the long-term health problems caused by common complications in neonatal intensive care. The artificial womb is also a welcome development to avoid parent(s) experiencing the devastation that often results from preterm birth. In addition, the technology could also save the lives (and health) of pregnant people by taking over gestation if pregnancy becomes dangerous. 

In the future, artificial wombs could enable gestation to become a reproductive choice, by potentially allowing people to choose how long they want to be pregnant for. It might even come to be seen as an alternative fertility treatment, alongside uterus transplants and surrogacy, for persons unable to carry a full pregnancy. At this point these benefits are all speculative – but it is easy to see why scientists are so keen to develop this technology. 

The Biobag team, based in the US, anticipate that their artificial womb device might be ready for human testing in just 5 years' time. The Eindhoven researchers suggest they might have a prototype ready for use in hospitals in the same time frame. With researchers working so quickly and with the potential consequences of the artificial womb so broad and unknown, we need to think carefully now about the legal and ethical implications of the technology in advance of its development. These problems and questions it raises are both intricate and wide-ranging. 

For example, what kind of human entity is the subject of the artificial womb? It is more similar (in behaviour, features and the extent of its dependency) to a fetus than a newborn (that has to adapt to the external environment and take on some of the burden of sustaining itself). I have argued the subject of an artificial womb is a unique entity; we have never known a human entity undergoing the process of gestation extra uterum before. I've termed it a 'gestateling.' The law (at least in England and Wales) treats a fetus and a newborn very differently, so determining the recognition and legal protections that are, or should be, afforded to a gestateling, are complicated questions in need of an answer. 
 
There are also other pressing issues related to the clinical translation of these devices from concept, design and animal experiments to a replacement for neonatal intensive care in clinics. How and when might it be ethical to test these devices on humans? Is it more ethical to test it on preterms so premature they have no chance of surviving in intensive care, or only those more mature that we know (based on clinical data in intensive care) to have some chance of survival? There are also uncertainties associated with the potential long-term consequences of being partially gestated by machine compared to a person. 

What is most interesting about the recent announcements from Eindhoven, especially in comparison to the ongoing experiments in the USA and Australia, is the focus they seem to be placing on 'uterine experience' in developing their prototype. Professor Guid Oei and his team are not just interested in successfully emulating the processes involved in gestation, but also some of the relational aspects. Professor Oei emphasises that their artificial womb will not just be a 'plastic bag' but an environment in which the gestateling can 'feel, and see, and smell, and hear the same sounds as when they are in the womb…' Whether the relationship between a pregnant person and their fetus is even something that can be artificially replicated remains to be seen. 

One thing that is clear, however, is that practical questions about a functioning and experimental artificial womb, once thought to be entirely hypothetical, are very deserving of our attention.