Imagine receiving someone else’s uterus – a healthy, functioning womb – through a cutting-edge surgical transplant.
Now imagine that very organ, perhaps one donated by your own mother, which carried you as a baby, becoming the place where your own child begins to grow.
For some reproductive advances like these start and end in the realm of what might be possible – ideas to discuss, possibilities to consider, but not something that could ever be part of their own story.
But for others, this type of procedure has already changed their life.
First successfully trialled in Sweden in 2013, uterine transplantation has emerged as a ground-breaking development in reproductive medicine, offering hope to women living with uterine factor infertility, a condition in which the uterus is absent or non-functional, or as an option for those who have lost their fertility following cancer treatments such as chemotherapy.
Such a ground-breaking procedure requires stringent ethical guidelines and poses difficult questions for reproductive medical teams, researchers, donors and recipients.
It’s in this space that philosophers like Associate Professor Lotz, a member of an international ethics committee on uterus transplantation, is using her expertise to help shape the ethical conversations surrounding this procedure.
She notes that while the procedure is life-changing it is also invasive, carrying significant risks for all the parties involved.
“It is a major operative intervention for both donor and recipient, followed by immunosuppression to prevent organ rejection,” explains Associate Professor Lotz.
“Recipients must undergo IVF to achieve pregnancy, deliver via caesarean section, and, crucially, have the transplanted uterus removed after a limited period, often around five years or after one or two pregnancies, to minimise the long-term risks associated with immunosuppressive drugs.”
Associate Professor Lotz, is using her expertise to help shape the ethical conversations surrounding this procedure. Image: Ian Waldie /getty.com
Complications are not uncommon, particularly for donors, and can include urinary tract infections, urinary tract dysfunction and, as with any surgery, there is the potential for serious risks.
Associate Professor Lotz says these shouldn’t deter donors or their recipients from the transplant procedure but must be clearly explained to ensure informed consent.
That consent can become more complex as potential donors weigh not only the medical risks, but the experiences of those who have undergone the procedure before them. Lotz says donor testimony is increasingly playing a crucial role in shaping the decisions of future participants, creating subtle but emotionally complex ethical considerations.
This is especially relevant when the potential donor is the recipient’s mother. Mothers are often considered good candidates for donation, in part because they have typically passed childbearing age.
Yet the closeness of the mother–daughter relationship can also muddy the waters, with pressure from deep-rooted cultural expectations of the ‘selfless mother’.
“Traditionally, mothers and the norms around what it is to be a mother can be seen as this represent an ideal of a self-sacrificing figure, who is expected to do anything and everything for their child,” explains Associate Professor Lotz.
“Those norms are still very strong and may leave some women vulnerable if their daughter asks them to donate their uterus, and if the daughter has no one else to go to. Even without daughter’s intending to have this effect, mothers can feel a sense of pressure and obligation – there are a lot of complex feelings to navigate.”
Even when these risks are successfully navigated, other ethical complexities can emerge after surgery, particularly in how donors recount, or sometimes minimise, their own experiences.
“When it comes to sharing the realities of their experience, the mothers involved in the procedure might feel a need to downplay or suppress the extent of how the surgery has affected them, particularly, for uncomfortable long-term side effects such as incontinence.”
For this reason, Associate Professor Lotz emphasises the need for greater scope for anonymous donor testimony, allowing potential donors to better understand other women’s experiences before making their own decision.
“If we have anonymous patient experience websites and vehicles for women to describe what exactly they went through so that potential donors can access them, they can also make a more informed decision and will be able to weigh up the risks.”
In addition to this measure, and to support goals of equality and non-discrimination, Associate Professor Lotz also argues that current protocols that guide donor selection – which restrict the diversity of candidates - require a broader rethink.
“We should be aware of what the particular vulnerabilities for mothers are, and do what we can do to create alternatives for women who want a uterus so that they don't necessarily have to approach their mothers,” explains Associate Professor Lotz.
“Myself and other ethicists have argued that where possible, it should be open to trans men and also younger women to donate their uteruses, which currently isn't allowed on most protocols.”
“Requirements of ‘bring your own donor’ should also be abandoned on the protocols, allowing ‘non-directed’ donation to become more commonplace.”
Beyond living donation, Lotz is an advocate for working towards expansion of deceased donation models for uterus transplantation, given that this is proving to be a medically viable alternative to living donation.
However, drawing the ethical lines is often nuanced and continues to be an evolving challenge as technology advances.
More broadly and in more extreme cases, Philosophers may no longer imagining simple pregnancy inside a medically transplanted uterus carried by a healthy mother, but examining ethical problems like, ‘what could happen if a women’s body is kept functioning on life support?’
But perhaps, for now, the ethical questions surrounding reproductive technology are much simpler: how do we close the gaps that exist between those who have to imagine this type of technology and those who can afford to make it a reality?
‘“We need to think about assisted reproductive procedures that aren’t just for the wealthy and privileged, but are accessible to everyone who may desire to use them,” explains Associate Professor Lotz.
“For me, autonomy is extremely important – that is, ensuring people have the information they need and can make an informed choice, freely deciding what it is they want to do.”
Top image: Ian Waldie/ getty.com