Ethical Considerations for Recipients and Fetuses

From the perspective of recipients, UTx is clearly more risky than either adoption or gestational surrogacy. Unlike in many other transplants, the risks involved in the surgery itself and the prolonged use of antirejection medications cannot be weighed against the benefit of saving a life, as the function being restored is reproductive not vital. Some bioethicists argue this means the threshold for justification of the procedure should be higher than for other transplants,Footnote ¹² especially in cases where gestational surrogacy is available as a safer alternative.Footnote ¹³ Kavita Arora and Valarie Blake remind us that for many women with AUFI simply having a child is not enough; they wish to be “visibly pregnant, emotionally pregnant, and seen as pregnant by society,” a desire that surrogacy does not accommodate.Footnote ¹⁴ Adoption also fails to provide this experience. These authors note that in a pronatalist society, even morning sickness and pregnancy weight gain can be highly valued symbols.Footnote ¹⁵ However, while UTx certainly provides a closer approximation of natural reproduction, given the fact a transplanted uterus would not have nervous innervation, the sensations of pregnancy would be quite different. Thus, Bayefsky and Berkman claim that unless fully informed, prospective recipients may “overrate” how similar the experiences would be, and women “might feel alienated from the transplanted organ” due to this lack of innervation.Footnote ¹⁶

Much of the ethical debate surrounding UTx focuses on the need for informed consent from recipients. Arthur Caplan et al. claim women are “willing, even eager” to take the risks associated with experimental UTx for the chance to experience pregnancy,Footnote ¹⁷ which we argue is likely influenced by pronatalistic social pressure. Pronatalist dogma prioritizes childbearing as a social duty for women even when significant obstacles must be overcome to achieve reproductive success, as in the case of infertility.Footnote ¹⁸ While this pressure exists for all women in society, regardless of fertility status, a desire to avoid the stigma of infertility might leave women with AUFI particularly vulnerable to its influence. Zubia Mumtaz and Adrienne Levay further claim that in some low-income pronatalistic societies where womens’ value is still significantly determined by childbearing capacity, a truly noncoerced decision to pursue UTx might be impossible.Footnote ¹⁹ Using Pakistani women as an example, these authors note that fertility treatment decisions are often made by mothers-in-law, rather than the women themselves, and that failure to produce sufficient offspring leaves these women susceptible to “physical, mental, and emotional abuse,” social discrimination, and psychological distress.Footnote ²⁰

The risks of stigma, discrimination, and psychological distress are also morally significant beyond the challenge they pose to informed consent. Being subjected to social and interpersonal pressures to undergo UTx would be harmful even if these pressures are not so great that they altogether override the possibility of obtaining informed consent.Footnote ²¹ For those who experience these pressures, deciding not to pursue UTx would come at a cost. In some contexts, merely having the option of undergoing UTx may therefore be harmful, especially insofar as there are few alternative means of overcoming AUFI. Even assuming it is possible to obtain informed consent for UTx, at least in some circumstances or to a standard that is equivalent to other reproductive decisions, there are still a number of ethical considerations that warrant special attention. One is the need to create comprehensive allocation protocols for the transplant organs, as existing methods are not suited to UTx. Arora and Blake note prioritization on the basis of “sickest first, best prognosis or quality of life assessments” are not relevant in the case of UTx, as all potential recipients would be expected to maintain the organ for a similar length of time, and “nobody is more or less infertile than the next.”Footnote ²²

In terms of safety issues, in addition to the risks of anesthesia and surgery, UTx provides diagnostic challenges regarding graft rejection. Liza Johannesson and Stina Järvholm note that the uterus has no distinctive blood marker that might indicate organ rejection, unlike the pancreas, liver, or kidneys.Footnote ²³ This is particularly problematic when considering significant organ damage could occur before rejection is clinically detected, and if the transplant organ needed to be removed after a pregnancy had been initiated this might entail loss of fetal life. Other valid concerns for maternal and fetal well-being relate to the increased blood flow through the uterine arteries needed in pregnancy, increasing the risk of blood clots, preeclampsia, and placental ischemia.Footnote ²⁴ Whether children who were gestated in a transplanted uterus should be informed of this fact is another ethical consideration that mimics existing IVF, donor insemination, and adoption cases.Footnote ²⁵ Additionally, Caplan et al. claim that incidental fetal exposure to antirejection medication—for example, for a liver transplant patient who later becomes pregnant—is not morally equivalent to the deliberate exposure entailed in UTx, where the use of the drugs is “solely for the purpose of carrying a pregnancy.”Footnote ²⁶ Finally, it is worth noting that risk–benefit analyses of UTx have disregarded the impact of long-term immunosuppression on recipients under the assumption that the transplanted uterus would be removed, and with it the need for antirejection drugs.Footnote ²⁷ As such an intervention would require the voluntary consent of the recipient, this outcome cannot be assumed in every case.

Regardless of the significant risks to UTx recipients, the demands of reproductive liberty provide strong support for the conclusion that women with AUFI should be free to pursue UTx in contexts where it is available. The contrary position might inadvertently cast high-risk natural pregnancies as morally impermissible, by implying that levels of reproductive autonomy should be graded by severity of risk. When comparing potential harm to fetuses gestated in transplanted wombs with the alternative of nonexistence, there is similarly a presumption in favor of UTx.Footnote ²⁸ However, a hypothetical right to pursue a future treatment if it becomes widely available does not suggest that it should be adopted as an appropriate treatment for AUFI. That UTx does not actually cure AUFI so much as circumvent it, and pregnancies in a transplanted uterus are not equivalent to those within a native womb, indicates to us that further research needs to be conducted to develop safer, more satisfactory fertility solutions for women with AUFI. (While not the focus of this paper, these arguments also bear relevance for other noncurative treatments and transplant types.) Due to concerns with ethically obtaining suitable organs for transplant, we argue UTx should not become normalized as the treatment for AUFI. To demonstrate this point, we will now outline some of the issues surrounding cadaveric and live uterus donation, before discussing the moral superiority of alternatives, such as bioengineered wombs and ectogenesis.

Cadaveric Donation as Postmortem Surrogacy

Due to the risks associated with being a live organ donor, fertility clinics embarking on UTx in the United Kingdom initially forbade using live donors, and the Cleveland Clinic in the USA has still opted exclusively for cadaveric donations.Footnote ²⁹ In 2016, Nicola Williams noted that while at that time all of the successful live births following UTx had been the result of live donors, some scientists working in the area believed the opportunity to harvest more extensive vasculature from deceased donors would in time decrease the risk of thrombosis and necrosis, such as was seen in the Saudi case.Footnote ³⁰ The Cleveland clinic has since achieved live births from cadaveric donated uteruses, with the first in 2019.Footnote ³¹ However, the issue of increased ischemic time for a cadaveric donation and the associated increase in graft rejection rates remain a problem.Footnote ³²

Beyond the technical constraints, the use of cadaveric donation for UTx carries various ethical concerns. Many of these concerns directly relate to the fact UTx is not lifesaving and involves a reproductive organ. As George Agich notes:

While a comparison can, and often is, drawn between UTx and face and hand transplants (neither of which constitute “efforts to save lives that are in immediate danger”), Arora and Blake note these transplant surgeries are still very rare, and hospitals have typically required special consent procedures from donor families in recognition of the difference between saving a life and improving the quality of that life through transplantation.Footnote ³⁴ Further relevant differences can be seen between potentially saving a woman’s life and providing a means for her to gestate future offspring.

Caplan et al. claim that women who have currently signed donor cards have done so with implicit knowledge that their reproductive organs were not among those to be harvested, suggesting that transplant teams would “be on firmer moral ground” if they only considered cases where women had explicitly consented to their uterus being donated.Footnote ³⁵ However, this stipulation would severely limit the number of organs available for transplant, especially considering the requirements of quality, matching, timing, and other transplant criteria.

The use of cadaveric donation in UTx to create a child also brings with it concerns regarding the donor family’s potential relationship with that child. In some ways, UTx could be viewed as a form of postmortem surrogacy, and thus the ethical concerns surrounding gestational surrogacy bear some relevance to this debate. Marilyn Bartucci’s study of donor families’ attitude toward donation in the late 1980s indicated families were “looking for some type of immortality for their loved one,” believing they somehow “lived on” through the life of the transplant recipient.Footnote ³⁶ Sensationalist media coverage of donor families bonding with recipients or experiencing unusual phenomena as a result of the transplanted organ seem to perpetuate the idea that the donor somehow cheats death through donation. Although this may be comforting for family members and not necessarily problematic in the case of nonreproductive organs, an NBC news report in 2013 highlights that donor families often conceive of the donated organ as still belonging to their loved one. Two mothers who met the recipients of their children’s hearts described the experiences as follows:

It is not unreasonable to suggest that the families of UTx donors might feel a similar connection to the uterus of their loved one, and that much like in the case of some children of gestational surrogates, may feel as if they share some bond with the resultant offspring. David Orentlicher claims UTx is the only way for a woman with AUFI to avoid “shar[ing] her parenthood with another woman,” as is seen in gestational surrogacyFootnote ³⁸; however, this might not preclude the donor’s family from feeling a sense of entitlement to the fruits of the donated womb, so to speak. While it is impossible to speculate on how this novel transplant arrangement might be perceived by donor families, it is worth considering the potential implications of confused familial ties before embracing this procedure.

Although many of the ethical criticisms that apply to gestational surrogacy are clearly not relevant in the context of UTx using a cadaver organ—including shifting the risk of pregnancy-related morbidity and mortality onto another woman—other concerns remain. For example, arguments that surrogacy risks instrumentalizing women’s reproductive abilities and perpetuating pronatalist views of the role of women as mothers in society (which are often raised in discussions of surrogacy)Footnote ³⁹ may, with some modification, also apply to UTx. At the same time, it is worth noting that although the burdens of surrogacy are different from the burdens of uterus donation, uterus donation is not without its burdens. As John Robertson argues:

Whether there would be a consequential increase in the psychological burden of making organ donation decisions in the absence of a clear directive regarding reproductive organs is yet to be seen; however, the possibility warrants closer examination. At least intuitively there seems to be a morally relevant difference between donating someone’s reproductive versus nonreproductive organs, especially if donor families feel some responsibility for providing not the means to save an existing life, but that which is required to create new lives. The above quote also relates to our next key argument that live uterus donation represents a significant burden on donors.

Live Donation as Archetypal Maternal Altruism

Being a live donor for UTx carries similar clinical risks as other forms of live donation, including blood clots, hemorrhage, adverse anesthetic events, and infection, with no concomitant health benefit for the donor. When compared to a standard hysterectomy, the risks might be further exacerbated by the need to harvest additional vasculature to achieve transplant success.Footnote ⁴¹ For postmenopausal donors, the use of hormone therapy prior to surgery also increases the risk of blood clots forming pre and postoperatively.Footnote ⁴² Olausson et al. note that while there are no available data on the risks of hysterectomy among healthy patients, large data sets yield rates of injury for those undergoing the procedure for benign uterine disease at 1–2% for bladder injury, 0.1–0.5% for ureter injury, and 0.1–1% for intestinal injury.Footnote ⁴³ Even in the absence of these negative outcomes, Williams notes:

Nevertheless, there are various reasons why live donation for UTx is more likely to be successful—as has previously been the case with kidney transplantation—including the fact that the surgery can be timed such that both patients can be prepared for the operation.Footnote ⁴⁵

Beyond the physical risks to live donors, Robertson considers the psychological issues that would need to be addressed to ensure “the donor does not believe that she is ‘the mother’ of the child” gestated in her donated organ.Footnote ⁴⁶ He also notes that especially in cases where the intended mother has eschewed gestational surrogacy in favor of UTx from a live donor, that she must be cognizant of the substantial burden this has imposed and “the obligations of reciprocity which that would entail.”Footnote ⁴⁷ This might include agreeing to support a relationship between the donor and any children gestated following UTx. Other psychological risks to donors include possible problems with sexuality and gender identity postdonation, based on current knowledge regarding hysterectomy patients.Footnote ⁴⁸ Such considerations form part of the cost–benefit analysis each donor–recipient pair would need to calculate before embarking on such an endeavor, requiring realistic expectations on both sides of the rates of transplant success.Footnote ⁴⁹

One major ethical dilemma surrounding live donation for UTx is the potential for a commercial market to arise, where disadvantaged women are coerced into donating their uterus for money. Ostensibly such a market should be simple enough to ban by limiting to altruistic donation; however, the parallel case of live kidney donation demonstrates that even when commercial donation is illegal, poor and vulnerable individuals will still be targeted to sell their organs.Footnote ⁵⁰ Thus, Mumtaz and Levay claim transnational uterus donation has the potential to “encroach on women’s human rights in places where they already have little decision-making power or rights,” such as low-income countries.Footnote ⁵¹ Of course, much as the practice of illegal kidney trafficking has not led us to block all forms of kidney transplantation, the possibility of an exploitative trade in uteruses may not by itself be sufficient to block UTx outright. However, as we argue below, the burdens associated with this procedure may constitute an unreasonable demand on any woman, regardless of whether any monetary incentive is provided.

There is a well-documented gender imbalance in living organ donation. Using kidney donation as an example, although many more women than men opt to become living organ donors, they are less likely to receive a kidney. It is both more common for wives to donate a kidney to their husband than it is for husbands to donate a kidney to their wife, and more common for mothers to donate to a son or daughter than for fathers to do the same.Footnote ⁵² Although the reasons for this discrepancy are not fully understood, they likely include the greater likelihood that women will view donation as a parental or spousal duty, that women are more susceptible to pressure to donate, and/or that broader structural inequalities between men and women render donation less disadvantageous for women than for men (because, e.g., women are more likely to receive a lower salary and/or have a more flexible schedule than men).Footnote ⁵³ The fact that women are already vulnerable to pressures to become live organ donors makes it particularly difficult to obtain voluntary consent in the context of an organ that only women can provide, and that mothers in particular are well-positioned to donate. As first-degree relatives are more likely to provide a match for transplant, and mothers are expected to have completed childbearing by the age their daughters might be seeking UTx, it is reasonable to assume mothers will be among the most common live donors. The perceived demands of “parental duty” and the broader impact of pronatalist dogma may exert a strong influence on the decision to become a uterus donor, and in so doing would arguably impede live donors’ ability to make noncoerced decisions.

In the Swedish trial, eight of the nine donors were mothers or close genetic relatives (e.g., sisters) of the recipient, with the ninth case being a close friend.Footnote ⁵⁴ Concerns that women may seek UTx due to “an internalized stereotype that a woman is not whole unless she bears and rears her own child”Footnote ⁵⁵ go some way toward explaining why a mother might feel particularly compelled to donate their uterus to their daughter, especially in cases where she was born without a uterus. That mothers might blame themselves for their daughters’ structural infertility creates another source of pressure complicating the decision to donate. Janice Raymond claims that while men are often socialized to be able to rationalize self-interest, women, and particularly mothers, are painted as the “archetypal altruists,” paragons of self-sacrifice who are expected to put the needs of their children above all else.Footnote ⁵⁶ In the face of such enculturation a genuinely free choice to donate a uterus to a daughter with AUFI might be difficult to achieve.

Live donor uterus transplantation is therefore ethically fraught. This is not to say that the use of living donors is ethically unjustifiable; we leave this question open. We are defending the more modest claim that there are strong moral reasons to continue to investigate alternative means of treating AUFI, despite the therapeutic potential of UTx.

The Moral Superiority of Alternatives to UTx

As outlined above, there are ethical issues surrounding both cadaveric and live donation that we argue cannot readily be met. Of course, careful regulation may be able to mitigate these issues. However, it is worth noting that the more aggressively UTx is restricted in order to mitigate these concerns, the more likely it becomes that the organ supply might dwindle to the point where UTx is only available to a rare few, if at all.

Pursuing UTx on any major level would require us to consider how the goal of minimizing relevant ethical concerns should be balanced against the goal of ensuring a sufficient supply of transplantable uteruses. (If the supply of uteruses is scarce, resource allocation dilemmas would also arise.) However, this issue is secondary to the main objective of this article, which is to establish that UTx is a potentially dangerous distraction from the development of alternative treatments for AUFI. Even Dr. Mats Brännström, team leader of the Swedish uterine transplant trial, believes that bioengineering wombs using stem cells would be a superior treatment for AUFI, reducing or eliminating many of the risks associated with uterine transplant for both the donor and recipient.Footnote ⁵⁷ Using an artificially created womb built from patients’ own cells also means fetuses would not be exposed to antirejection medications and women may feel as if they are experiencing a more genuine pregnancy, less alienated from an organ built from “self” tissue than one that was “foreign.” There would also be no need to remove the organ after use, which may have a positive impact on sexual identity for women with AUFI, who could justifiably desire an intact uterus for reasons of bodily integrity separate from reproduction.Footnote ⁵⁸ Ariel Lefkowitz et al. note both desires might also arise in transgender women, whose claims to treatment for AUFI may be deemed equivalent to other women, as “The principle of autonomy is not sex-specific.”Footnote ⁵⁹ A bioengineered womb would allow women to control maternal lifestyle influences on fetal development—one of the major benefits Brännström sees to UTxFootnote ⁶⁰—while also avoiding potentially harmful exposure to antirejection medication.

On the surface, it may appear as if allowing UTx to develop into the preferred method of treatment for AUFI is not harmful to anyone, even considering the reality of scarce transplant resources. It might also be thought that UTx is ethically preferable to surrogacy (and in particular transnational commercial surrogacy), which is at present the main means by which women with AUFI can achieve genetic motherhood. Nevertheless, UTx does not cure AUFI in the way a bioengineered womb might, and if IVF is any indication, once a method of circumventing infertility to promote childbearing is achieved, the motivation to find genuine cures for the underlying condition deteriorates. Thus, by allowing a small number of women to take advantage of UTx, not only would we be promoting the likely exploitation of donors, both domestically and internationally, but also potentially derailing research into more beneficial treatments focused on women’s health and wellbeing, rather than solely the goal of producing offspring. A future bioengineered womb could satisfy a woman’s desire to become a mother, genetically, gestationally, and socially, at much lower risk than that which is provided through UTx, as graft rejection issues could be avoided, and with no harm to third parties.

For those women who are less concerned with gestational motherhood, the potential for artificial gestation, or ectogenesis, might also be an appealing alternative to pregnancy. This option might prove valuable for women with AUFI, transgender women, or any woman who wishes to have genetically related offspring without being pregnant or engaging a surrogate. As ectogenesis would eliminate the risks of pregnancy-related morbidity and mortality from mothers and surrogates and would not depend on exploiting maternal altruism to procure scarce organs through invasive surgery for transplantation, we argue this gestational alternative would be morally superior for women with AUFI. Although there are many ethical issues surrounding the potential development and regulation of ectogenesis services that would need to be addressed before the technology could be released, for the purposes of our argument, the central defense for investing in this technology as a reproductive option for women with AUFI revolves around the fact that all other means of gestating children involve significant risks and burdens to women, rather than objects. UTx merely represents an extreme example of these risks, to intended mothers and uterus donors, and is a procedure whose normalization in fertility care we argue can still be prevented. Thus, while respecting reproductive liberty might demand that UTx be tolerated to a degree, we maintain that this should only be permitted if it does not serve to impede progress toward other treatments, such as bioengineering and ectogenesis.