The Ethics of Uterus Transplantation
Organised by Lancaster University and King's College London
15-16 September 2016, Lancaster University
This symposium was organised to facilitate in-depth discussion as well as international and interdisciplinary collaboration between academics and clinicians with an interest in uterus transplantation (UTx), which would allow women who lack a functioning uterus to become pregnant and gestate their own offspring.
Given the recent successful trial of UTx in Sweden, which has so far resulted in five live births, the symposium began with a session focussing on 'The Swedish Experience'. Dr Randa Akouri, a member of the Swedish uterus transplantation team, summarised their results so far and outlined plans for research in the coming years. She also tackled questions from the audience on the technical and ethical issues raised by the procedure. These included questions regarding the choice in Sweden to use living uterus donors, the extent to which this decision 'fits' with the Swedish unwillingness to permit surrogacy, and whether the benefits of UTx truly outweigh the harms it poses to uterus recipients.
Dr Lisa Guntram then explored how medical professionals in the Swedish trial have justified the development of uterus transplantation. She noted three key themes often reproduced in physician's accounts of the development of UTx – equality for women with absolute uterine factor infertility (AUFI), the impact of the procedure on the quality of the lives of such women, and the 'biological drive' or 'instinct' to reproduce. This resulted in a lively debate on the proper aims and limits of medical treatment, whether AUFI should be considered a disease, and the first of many discussions regarding the question of whether gestation should be considered valuable.
The question of alternatives to uterus transplants for women with AUFI, such as surrogacy, adoption, and ectogenesis (gestating the fetus outside the body in an artificial uterus) were then explored by Dr Mianna Lotz and Dr Natasha Hammond-Browning. They noted that such options are not exact equivalents to UTx as none provide the opportunity for gestation. However, they argued that, despite this, there may be good reasons to reconsider whether UTx should be preferred by women who want to experience pregnancy and birth. Dr Lotz suggested that although many women have a strong desire for this experience, those who seek to develop or provide UTx must think carefully about the extent to which its availability may reinforce damaging essentialist and pro-natalist views regarding the importance of genetic and gestational parenthood. This could also deter couples from adopting, which not only satisfies an adult's desire to become a parent but also fulfils the serious and morally weighty needs of children to grow up in a stable and loving environment. Dr Hammond-Browning then looked at the risks and harms of UTx for donors and recipients and the extent to which, as a result of the highly medicalised nature of a UTx pregnancy and its occurrence in an enervated uterus, uterus transplantation could really be seen to cater to the desire of women to experience pregnancy. She suggested that given the inability of UTx to deliver a 'normal' pregnancy experience, it may well be preferable for women with AUFI to choose ectogenesis over UTx, if and when it becomes available, in order to reduce harms and risks of harms to both donors and recipients.
Discussions regarding alternatives, social pressures and the high value many women with AUFI place on gestation continued into the third and final session of the first day. Dr Emily McTernan explored the value of gestation and the question of whether uterus transplantation should be seen as a response to a medical need or is more aptly characterised as enabling people to pursue a particular and often (but not always) valued life project.
The second day began, as did the first, with short presentations from medical professionals engaged in UTx research. Mr J Richard Smith and Dr Benjamin Jones of the UK uterus transplantation team outlined their plans for their upcoming trial in 2017, which will use deceased donors. They also explained the inclusion and exclusion criteria for both donors and recipients in the UK trial as well as the points system used to rank potential candidates for the UK trial. This generated a great deal of discussion. One of the major themes which emerged was that of justice and fairness in the selection criteria for recipients. Should, for example, only women with a long-term partner and who have not yet become parents through adoption or surrogacy arrangements be admitted into the trial, as the criteria require? Concerns regarding donor consent also emerged. Given the relatively unknown status of UTx, many deceased donors may not have considered donating their uterus despite having signed the donor register.
The final two sessions focused on questions which might arise after trials for uterus transplantation have been completed. Dr Amel Alghrani looked at the legal and regulatory challenges which might be posed by the availability of UTx in the UK, such as the question of how UK law might regulate uterus transplants, given that it is both a form of transplantation (which falls under the remit of the Human Tissue Authority) and also requires the use of assisted reproductive technologies like IVF (which are regulated by the Human Fertilisation and Embryology Authority). She also examined the question of whether transgender women might be able to access uterus transplants under the Gender Recognition Act 2004 and articles 8, 12 and 14 of the European Convention on Human Rights.
Professor Lars Sandman and Dr Valarie Blake then explored the question of funding, through both private and socialised health-insurance systems. Professor Sandman suggested that – although uterus transplants are the kind of technology that could be funded within socialised healthcare systems, given that other forms of assisted reproductive technologies are systematically funded – UTx may not be considered important enough to qualify for funding, given resource constraints and competing priorities. Dr Blake then looked to the barriers to funding likely to arise in the US context. She noted that although the US healthcare system is one of the most expensive in the world it is also one of the least equitable.
The event closed with a summary from Professor Ruth Chadwick, who elegantly drew together and discussed a number of key themes which emerged of the course of the symposium. She also drew the attention of participants to one area of debate that had been largely absent from discussion over the two days – the welfare of the children created as a result of uterus transplantation trials – who not only face risks in terms of their physical health but, as a result of public and media interest may, like the first IVF babies, face psychological burdens.
The questions, issues and themes that emerged throughout this stimulating and thought provoking symposium have important implications not only for ethics and policy discussions concerning uterus transplantation specifically, but also ongoing debates in both the fields of reproductive and transplantation ethics.
This symposium took place as part of a Wellcome Trust funded research programme entitled 'The Donation and Transfer of Human Reproductive Materials'. It is linked with an open call for papers for a special issue of Bioethics entitled 'The Ethics of Uterus Transplantation', which will be guest edited by Professor Rosamund Scott, Professor Stephen Wilkinson and Dr Nicola Williams. The closing date for submissions is the 31 March 2017.