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A question of ethics

Facts are in flux. For example, this is what Del Priore and Gudipudic wrote in Maturitas (2014, 77: 20-23) in their consideration of the future of uterus transplantation (UTx): “Despite dozens of animal experiments and a few animal births, no human birth has occurred to allow any definitive conclusions.” Their paper was accepted on 19 October 2013. On 5 October 2014, in Sweden, the first live birth following Utx occurred and was reported by Brännström et al in The Lancet (2015; 385: 607-616). In August 2016 Brännström et al, writing in Fertility and Sterility (2016, 106: 261-266), described “the first report of a live birth after mother-to-daughter UTx, and it also represents the second birth ever after human UTx”.

More recently, in a piece entitled Womb transplantation offers hope to women who wish to get pregnant, Catherine Shanahan in the Irish Examiner (18 November 2016) considered that “the possibility of womb transplant [sic] moved closer to these shores, thanks to the pioneering work of J Richard Smith, consultant gynaecological surgeon at the Imperial College London”.

Mr Smith is associated with www.wombtransplantuk.org (WTUK), whose website states: “Since the beginning of our research we have been constantly aware of the ethical considerations surrounding womb transplantation.” But one wonders what this ‘constant awareness’ has yielded in terms of ethical misgivings. In addressing the fact that Brännström et al used live uterus donors in Sweden, Mr Smith told the Irish Examiner: “The donors are altruistic donors and there is nothing unethical about this at all − it’s a perfectly reasonable thing to do − but they are at risk of major surgical complications.”

Three things arise from this. First, such is Mr Smith’s reported assertion that “there is nothing unethical about this at all” (my emphasis) that I almost hesitate to ask whether the infant resulting from a live donor UTx is the child of the donor or recipient, or is it irrelevant? Second, if an unforeseen circumstance meant that the transplanted uterus posed a life-threatening challenge to the recipient, presumably it could simply be removed, but what if the uterus contained a viable foetus? Third, surely Mr Smith’s warning that donors undergoing a procedure that is not life-saving “are at risk of major surgical complications” prompts deliberation on a physician’s duty to “first, do no harm”?

According to Mr Smith, a proposed British series of UTx will use uteri taken from cadavers who are heart-beating and brain-dead. This raises, inter alia, the question of how much a child would be entitled to know about the cadaver’s transplanted uterus from which he or she issued.

According to WTUK, “any woman diagnosed with Absolute Uterine/Womb Factor Infertility between the ages of 18 and 36 would potentially be eligible for a womb transplant when it becomes a safe option in the human setting”. But in this unfolding era of transgender individuals and their associated rights, should men who have undergone sex-reassignment surgery be entitled to go the whole reproductive hog and receive Utxs? In Assisted gestation and transgender women in Bioethics (2015, 29: 389-397), Murphy argues not only that “social meanings of sexed bodies do not remain constant”, but that if transgender women are conferred the same moral status as women, it is “not simply ‘frivolous’ for transwomen to assert any interest in gestation. Gestation can play a key role in expressing and consolidating a female identity.”

But in her book The Whole Woman (1999) Germaine Greer contends that “women should not automatically accept all those who do not wish to be male as being ex gratia females”, arguing that “if uterus-and-ovaries transplants were made mandatory for wannabe women they would disappear overnight”.

There are several issues to be debated, but it seems that establishing the technical feasibility of UTx takes priority over ethical concerns. Thus, the ‘Ethical Considerations’ section of the WTUK website states: “Ultimately, the decision to go forward will depend on the judgment of the researchers, the participating institution, and most importantly, the patient to whom the transplant will be offered.” By comparison, one may infer, any reservations of society at large are inconsequential. And in the same section, while it is acknowledged on the one hand that “other ethical issues, particularly related to the question of informed consent, must still be more fully addressed”, they are somewhat discarded in the next sentence: “However, in terms of surgical technique, organ preservation … [etc.] … there now exists justification to consider another attempt at uterine transplantation in a human.”

These examples demonstrate the uncertain relationship between medical science and the community which it purports to serve. I don’t oppose UTx, but I deplore the seeming scant regard given to its associated ethical issues.

In a speech on Armistice Day, 1948, American General Omar Bradley said: “The world has achieved brilliance without wisdom, power without conscience. Ours is a world of nuclear giants and ethical infants.”

It’s time we grew up.

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