Reasoning through the Problem of Uterine Transplantation
Louis Janmot (1814–1892), The Angel and the Mother (Poem of the Soul 3) 1854, (detail).
What a surprise to sit down on a commuter train and see an ad picturing a newborn baby held tightly by a woman with the tag line “overcoming infertility with a uterine transplant.” Bioethics is truly everywhere these days. One’s first emotional reaction is positive. Who would not want to make the joy of bringing a beautiful baby into the world possible? A further moment’s reflection also suggested another favorable thought. Infertility is sometimes caused by a lack of healthy functioning organs that in many cases can be treated. (The opposite approach, intentionally and directly sabotaging healthy female or male human reproductive systems to cause infertility by contraception or sterilization, is clearly unethical.)
Yes, and I would add that every pro-life person or church rejoices at the miracle of new life and the joy of parenthood. I cannot begin to describe the flood of emotion when I first held my daughter just after her birth following years of marriage in which my wife and I suffered from the inability to have children. A search through Catholic teaching on transplantation turns up no direct prohibition on this procedure. Interestingly, The New Charter for Health Care Workers, compiled by the Pontifical Council for Pastoral Assistance to Health Care Workers, does affirm the following in section 119: “Not all organs can be donated. From the ethical perspective, the brain and the gonads are ruled out as potential transplants, inasmuch as they are connected respectively with the personal and procreative identity of the person. These are organs specifically connected with the uniqueness of the person, which medicine must safeguard.” That makes sense, but the womb is clearly not categorically excluded by these criteria since its main function is to provide a safe place for preborn babies to develop.
What about the practical problems associated with obtaining a uterus for transplantation and the odds of a safe and successful procedure? Throughout most of human history this was the insurmountable problem. Today, medical science and technology are fast turning science fiction into feasible medical possibilities; hence, the ad to drum up business for uterine transplants on the train I boarded! Clearly, however, this is not a routine major surgery and is risky, with no guarantee of resulting in a “babe in arms.” The US Government Organ Procurement and Transplantation Network (OPTN) Vascularized Composite Allograft Committee reported that eight of thirty-two uterus grafts by three programs in the USA failed and only twenty-one live births eventually resulted from the thirty-two transplants. The first successful uterine transplants were done in Saudi Arabia in 2000 and Turkey in 2011. The first resulting in a live birth in 2014 took place in Sweden. As of late 2020 only about 100 have taken place worldwide. Uterine factor infertility affects many women, however, so those numbers are set to grow as more medical centers seek to do these operations.
The main ethical problem with undergoing uterus transplantation leaps out when reviewing the steps involved. The only way it has worked so far is through the use of in vitro fertilization (IVF). The Catholic Church and all those who believe that human procreation is a sacred act that should not take place in a laboratory petri dish do not accept IVF as an acceptable means to overcome infertility. The ethical bar is high for an act to be moral. We not only need good intentions and a good object but also ethical means to achieve that end. It is virtuous to want to help people in poverty, but that noble intention cannot justify robbing a bank to obtain the funds to do the good work of charity.
Theoretically, if conception and pregnancy were to take place in a morally licit way, transplanting a womb to help a woman overcome sterility could be ethically acceptable. One would also need an ethical donation of the uterus, with appropriate assessment of the risks and benefits of the procurement and transplantation surgeries and their consequences. Robust informed consent would need to be part of that process. The National Catholic Bioethics Center (NCBC) recently joined the Catholic Medical Association, the National Association of Catholic Nurses, USA, and the National Catholic Partnership on Disability to oppose “live uterus transplants and genitourinary transplants from living donors which create a disability in the donor” in a submission to OPTN on the topic of establishing membership requirements for uterus transplant programs. Since the uterus is not required to sustain an adult woman’s life, so far living donors have provided most of the transplanted wombs.
I find the issue of uterine transplantation interesting because it shows how scientific advances create promising new possibilities that still fall short of what is ethically acceptable. This can lead to various temptations. The first would be to accept the use of IVF as long as other ethical safeguards are met, a kind of ethical minimum standard that does not do justice to the dignity of the human person. Some have brought forward the terrible idea of attempting to graft a uterus into a biological male. Another temptation might be to reject scientific research in this area a priori when further advances could lead to children being brought into the world with a donor womb but conceived naturally without IVF.
A good example of ethical technological solutions when seemingly intractable medical problems arise is autographic transplantation of ovarian germinal cells. The New Charter, in section 112, points out that it is acceptable in principle for a woman to have her own ovarian germinal cells removed before aggressive radiation or chemotherapy that could otherwise harm her fertility and then have her ovarian tissue grafted back. This could allow her to cycle normally afterwards and conceive children naturally. NCBC ethicists bring this alternative up when people ask about “freezing eggs” which is an ethical problem because it is done in view of future IVF. I recommend buying the New Charter if the Church’s perspective on these and other medical issues interest you.
