Angel Petropanagos outlines some of the many medical risks and ethical challenges of uterine transplantation, including the challenges with obtaining informed consent and the harms to women as a group.
Earlier this year, Dr. Mats Brännström and his research team released a 6-month report for phase one of their uterine transplantation clinical trial. The researchers transplanted uteri from live-donors (mostly mothers of recipients) into nine women with uterine-factor infertility. Seven uterine transplants were successful. According to the researchers, phase two of the uterine transplantation trial has now begun and five transplant recipients are undergoing in vitro fertilization (IVF) in the hope of achieving a pregnancy.
On the surface, uterine transplantation seems like a good idea. It could help to alleviate some of the suffering associated with infertility and satisfy some women’s desires to experience pregnancy. However, uterine transplantation raises a number of medical and ethical issues that make use of the procedure morally problematic.
First, there are serious medical risks for the recipients, donors, and potential offspring. Uterine recipients, like other organ recipients, risk organ rejection as well as immunosuppressant drug-related side-effects, such as cancer. Donors must undergo a radical hysterectomy that requires the removal of large amounts of blood vessels that surround the uterus. A radical hysterectomy may decrease donor quality of life and cause them psychological harm. Potential offspring are at risk because of possible insufficient blood flow to the uterus as a side-effect of uterine transplantation. This, along with organ transplant complications, such as infection or rejection, could result in fetal injury or death. More generally, given the experimental nature of uterine transplantation, there may be additional medical complications and long-term health risks for recipients, donors, or offspring.
Second, it is difficult to secure fully informed patient consent for recipients and for donors. Insofar as the risks and benefits of uterine transplantation followed by IVF are unknown or uncertain, recipients may not be able to make a fully informed decision. Also, recipients’ strong desires to experience pregnancy and have a biological connection with their offspring might compel some women to agree to risky procedures. Indeed, the desire for offspring makes therapeutic misconception a serious concern for uterine transplantation research. Donors, who are usually mothers or blood-relatives of recipients, may feel pressure to donate because of their relationship with the recipient and because of the pervasive social expectation that women behave altruistically. In addition, some donors may have a personal interest in the birth of children following uterine transplantation. For example, mothers who donate to their daughters may wish for their daughters to experience pregnancy and also hope for the birth of biologically-related grandchildren. Uncertainties about uterine transplantation risks and benefits, social pressures, and desires for children make it challenging to secure informed patient consent.
Finally, uterine transplantation reinforces the patriarchal ideals that both womanhood and motherhood are grounded in the experiences of pregnancy. Such ideals are evident in the claims of uterine transplantation recipients who have said that menstruation made them feel like “real women”. Defining womanhood in terms of potential fertility is problematic, in part, because it harms women who are not fertile, have not experienced pregnancy, and are not mothers. Furthermore, the pursuit of pregnancy and motherhood can lead to the fragmentation and exploitation of women’s bodies.
In the case of uterine transplantation, women attempting to achieve a pregnancy and produce biological offspring must rely on the womb (and sometimes the eggs) of other women. Often, the bodies of poorer women are fragmented in order to help satisfy the reproductive desires of wealthy women. Like other reproductive technologies – such as surrogacy, IVF, and fertility preservation – uterine transplantation promotes both biological and genetic motherhood (or, at the very least, the perception of such) and privileges biological family-building. Arguably, the availability of uterine transplantation raises concerns about uterus selling on the black market and presents yet another mechanism for the exploitation of women. Such social norms concerning womanhood and reproduction are harmful to all women, not just those seeking to be uterine recipients or donors.
Although there are many concerns with uterine transplantation, there are ways to address the challenges. To begin with, improving adoption and surrogacy laws could help some women to choose these (arguably less medically or ethically risky) family-building practices instead of uterine transplantation. Also, insofar as obtaining uteri from live donors is risky for the donors, researchers could use cadaver or 3D printed uteri (but, unfortunately, these solutions raise other ethical challenges and do little to address the ethical concerns involving recipient women, potential offspring and women as a group). Most importantly, however, rigid social norms around womanhood and motherhood must be challenged. In the absence of oppressive social ideologies, it is possible that decision-making about uterine transplantation would be less ethically troubling or that uterine transplantation would fail to be an attractive reproductive option for women.
As uterine transplantation research continues to push the boundaries of organ transplantation and assisted reproduction, researchers should pause and consider the pressing ethical issues that characterize uterine transplantation.
Angel Petropanagos has her Ph.D. in philosophy from Western University, with a specialization in feminist bioethics. @APetropanagos