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Uterine transplants: applaud, and then shut up

By Charles Foster

It was reported this week that 56 year old Eva Ottosson is planning to give her 25 year old daughter, Sara, the uterus in which Sara herself gestated. Sara suffers from Mayer Rokitanksy Kustner Hauser Syndrome: she was born without a uterus.

Predictably the newspapers loved it. And, equally predictably, clever people from the world’s great universities queued up to be eloquently wise about the ethics of the proposal.

But if ethics are concerned with what we should do, there was really nothing worthwhile to be said about Eva Ottosson’s altruism (bar the usual uninteresting caveats about dangerousness and resource allocation), except: ‘Fantastic’.

Of course it is possible to think of things to say. Anyone who has dabbled in philosophy or law could churn out a few thousand words of commentary. When I heard the facts I reflexively began to draft a mental essay plan. But (if one excludes insane religious objections) the bottom line is inescapable.

Two points emerge:

First: we should remind ourselves that the business of ethics is to find the right answer to problems, not to discuss the problems. Discussion is a means, not an end. Discussion is only warranted when it is necessary (as it usually is), in order to decide what should be done. We spend far too much time discussing for discussion’s sake;  discussing around rather than discussing towards the right answer. That’s fun, congenial, and stimulating, but pretty vain. It also makes for papers in our professional journals that make non-ethicists wonder why on earth money should be spent maintaining ethics departments.

Second: we need to develop a professional language of congratulation. Ethicists can contribute significantly to the case of Eva Ottosson by saying: ‘We’re ethicists, and we’ve nothing but respect.’ It’s not unprofessional to be delighted at the right result: it’s an indication that we have the concern about the right result which is the only proper justification for being in ethics at all. Let’s choke down the desire to be smart and sceptical. Let’s suppress the caveat-generating reflex. And let’s just stand and applaud.

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12 Comment on this post

  1. Charles,

    although I agree with most of this, it seems to me that you miss one important role that a bioethicist might have; that of facilitator and mediator of public reasoning (rather than participant in public debate and moral judge). I'm doing a job like this precisely on uterus transplantation in just a little bit more than an hour on the Swedish national radio. It will be me and one of the head surgeons involved, Mikael Olausson, and we will be answering questions not about what is right or wrong, but what is involved and how you can think about it. I think this is important, because a thing like this quite understandably awakens a lot of feelings and thoughts, and also reactions of weirdness or of outright moral concern (psychologically, these things are hard to distinguish, not only in bioethicists). As a bioethicist, I can help here not mainly by saying, "as long as the risk-benefit ratio's alright, there's no worry, so let the doctors get on with it", but by actually addressing concerns that people may have in more or less vague ways. Neither will it be very helpful for me to pass categorical judgement on such concerns. What is needed from me to help people think for themselves is rather that I help clarifying the concerns and put them into context (by analogous examples and historical parallels, for instance). What is more, in this particular case, there actually is one issue that is a genuinely controversial one also from a professional bioethics perspective, namely what is to be counted as a benefit here, and why. The controversy on this appeared immediately when the plans of the Gothenburg surgeons where posted at the page of the Bioethics International Facebook group, but is immediately recognisable for anyone who has familiarised him- or herself with the debate on the moral status of possible future people. Now, I have certain ideas on that topic that would mean that the potential benefit of the operation is, in fact, more substantial than what would be conceded by some of my colleagues in bioethics and moral philosophy. So, given that this particular disagreement cannot be resolved during my 5-7 minute radio appearance, I'd better reason <i>around</i> how our unreflected thoughts on such a basic ethical matter may, in fact, make a difference to what we would consider to be a sufficiently good risk-benefit ration……

  2. Christian,
    Many thanks. You're absolutely right: facilitation and mediation are important. But, again, as tools which help in the construction (or sometimes, importantly, the dissemination of knowledge about), the right solution.
    As to the question of what should be counted as a benefit: that is often controversial, and often the subject of legitimate, lengthy and technical debate. But surely not here? (subject, as I said, to the issues of dangerousness and resource allocation).
    Hope your broadcast goes well.

  3. Dmitri Pisartchik

    Charles, thank you for an interesting post.

    I would, however, challenge your assertion that "if ethics are concerned with what we should do, there was really nothing worthwhile to be said about Eva Ottosson’s altruism (bar the usual uninteresting caveats about dangerousness and resource allocation), except: ‘Fantastic’."

    While I do not share this line of thinking personally, there is an interesting and worthwhile argument that could be developed condemning this apparent act of altruism by virtue of it being a directed donation of an organ. Should people be allowed to pick and choose the recipients of their donated organs? To say 'Fantastic' in response to the case described we would have to answer 'Yes' to this question, but its not immediately clear that that is the correct answer. Directed donation is not an issue that enjoys that kind of consensus in the field of bioethics. Although I do think that this donation is a good thing (I wouldn't go as far as calling it fantastic) I am also aware that my position will have to be defended from criticism and supported by argument.

    I dare say, that commenting on this case with this lens in place is not all an "uninteresting caveat" but rather a part of an important and worthwhile discussion about the role and extent of altruism in organ donation.

    1. Dmitri,
      Many thanks.
      While I agree that the issue of whether you should be able to choose the recipient of one of your organs is a very serious ethical issue indeed, it wasn't an issue here. There aren't women crying out for uterine transplants. Yet, at any rate.

  4. I do agree wholeheartedly with Charles' encouragement to stop discussing for the sheer sake of discussing (something which I occasionally find exasperating, both in seminars with students and now and then with colleagues). Many of the issues raised in connection with the planned uterine transplant remind me of those I encountered when reading about the surrogate who was carrying her own grandson in the US fairly recently, and in both instances, I struggle to identify where the problems might be (over and beyond possibly a social risk in the surrogacy arrangement).

    Reproductive choices, including the choice to opt for innovative medical assistance, are usually very difficult ones and have great significance for those who are faced with having to make them. Ethicists worth their salt will not 'problematise' these issues and choices, but provide clear and helpful guidance. All too often (most recently in relation to organ transplantation in Germany) I have to read experts' opinions on the moral dimension of the issue in broadsheets or hear them in interviews, and their views simply boil down to "it's problematic" or "one could decide either way".

    If my thoughts are useless at the bedside, I ought to ensure that I address them at the kind of people who can make them useful by means of discourse and refinement. And not at those who are in need of guidance.

    1. Nils,
      Many thanks. Yes, ethicists are not true stakeholders in many, if not most, ethical debates.

  5. Charles,

    actually, you may be surprised how often I encounter doubts about to what extent facilitating that a child comes into existence is a benefit. Strangely enough, the same people who express such doubts also often (if not always) voice concerns regarding the expected well-being of the child. My standing thing is usually to point out the tension between these two opinions: if you want to acknowledge suboptimal results in terms of well-being in reproduction, you need to entertain a view of the value of potential people that allows for the emergence of new people to count as a benefit. Had no time to do that today, though, alas. 😛

  6. Anthony Drinkwater

    I applaud your article : 'nuff said. Or "Wovon man nicht sprechen kann, darüber muss man schweigen"

  7. I found the following article by Natalie Wolchover interesting.
    Yahoo! News Beta UnveiledExperience the newly designed site and learn more here.Woman to Receive Uterus Transplant From Mom. Will It Work?
    ShareretweetEmailPrintNatalie Wolchover, Life's Little Mysteries Staff Writer Natalie Wolchover, Life's Little Mysteries Staff Writer – Wed Jun 15, 1:29 pm ET
    A Swedish woman may soon become the first person ever to carry a baby in the very womb from which she was born. Sara Ottosson, a 25-year-old who, like 1 in 5,000 women, was born without a uterus, has been shortlisted for an experimental uterus transplant surgery. Sara's would-be womb donor is Eva Ottosson, her mother.

    "I've had two daughters, so it's served me well," Eva Ottosson told the press, referring to her uterus. "[Sara] needs it more than me."

    Sara, like all women whose wombs are missing, dysfunctional or were cancerous and had to be removed at a young age, cannot naturally conceive and give birth to a child. Like many others, Sara is so desperate to do so that she has volunteered for a completely unproven surgery — one that has never before worked in humans — in which her mother's uterus will be transplanted into her abdomen. It will then be implanted with one of Sara's own eggs, fertilized in vitro. After delivering the baby nine months later, Sara will go back under the knife to have the borrowed uterus removed.

    A previous attempt at uterus transplantation was made in 2000 in Saudi Arabia, but the recipient's body rejected the foreign organ, and it had to be removed four months into her pregnancy. Now, a team led by Mats Brannstrom, a Swedish surgeon, thinks that enough research has since been done to try the procedure again. Sara hopes the team will choose her for their first attempt.

    Edwin Ramirez, a gynecologist at Antelope Valley Hospital in Lancaster, Cali., who leads a group that also hopes to transplant a uterus within the next two years, told Life's Little Mysteries what makes the surgery so unique, and why a mother-daughter donor-recipient team provides the best shot for pulling it off.

    Will it work?

    "A uterus transplant is complex in the sense that the pelvis is more vascular than other parts of the body — it has more blood vessels — so the risk of bleeding during uterus removal is higher than with other organs," Ramirez said. He and his colleagues are developing a protocol for the organ removal procedure by operating on sheep and monkeys.

    Another issue is organ rejection: When you receive an organ transplant, your immune system treats the foreign organ as an invading enemy and tries to break it down. Organ recipients must stay on a regimen of "immunosuppressive" drugs for the rest of their lives to stifle this natural response. Sometimes, though, the drugs don't work — and they didn't work for the patient involved in the previous uterus transplant attempt.

    Furthermore, immunosuppressive drugs have side effects (such as weakening the immune system's response to real infections and illnesses) which could be dangerous to both mother and fetus during pregnancy. An appropriate drug regimen thus needs to be designed specifically for uterus transplantation recipients.

    Despite these complications, uterus transplantation is less complex overall than heart or liver transplantation, Ramirez noted; the procedure has simply been slower to develop because it isn't life-saving. "It's a little different than your traditional organ transplantation because we're dealing with a nonvital organ. It's more of a life-improving procedure," he said. [Read: Uterus Transplant: Q&A with Surgeon's Collaborator]

    World's best mom

    The mother of the recipient makes the ideal donor, Ramirez explained. The mother of an adult daughter is most likely in her late 50s or early 60s, past menopause, and is no longer in need of her uterus. "You're performing an operation on a female that really doesn't need to have her uterus removed, but she's doing it to benefit her daughter," he said.

    Old age is no issue when it comes to the uterus: It can be brought back to full functionality at any point. "The uterus will always be functioning. If you give it estrogen, it's going to respond. If you prepare the uterus, it should work perfectly fine in the recipient," Ramirez said.

    Only a mother-daughter pair who share the same blood type would be considered for surgery, Ramirez explained, because this lowers the chance of organ rejection. Having 50 percent of the same genes also means the mother-daughter pair might share similarly positioned blood vessels, he said, making it easier for surgeons to lock the transplanted organ into place in the daughter.

    In short, he said, "If we can transplant a uterus into the recipient who actually was born out of that uterus there's less chance of rejection."

    Medical competition

    Ramirez and Brannstrom are colleagues who have worked together on uterus transplantation research in the past, Ramirez said, but now they lead separate teams, both of which would like to be the first to transplant a womb.

    "From a personal standpoint, I feel that I know Brannstrom fairly well and I think he's making this public because he sees that our group is advancing fast," Ramirez said. "He doesn't want to be behind in research."

    Ramirez said Brannstrom may well be ready to do the surgery within a year, but that his group is nearly ready, too. "We already have our patients screened and ready to go. Do I feel like I can do it tomorrow? Yes. But I'm a perfectionist," Ramirez said.

    Brannstrom could not be reached for comment.

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