Julian Savulescu
Womb transplants are again in the news as Richard Paulson, president of the American Society for Reproductive Medicine (ASRM), said there was no reason to believe that the treatment could not work for transgender women at recent conference in Texas.
The ethical issues of performing a womb transplant for a transgender women are substantially the same as the issues facing ciswomen.
The most important ethical consideration in the UK for a womb transplant is distributive justice. Limited health care resources should not be used for womb transplants because there are more cost effective methods of assisted reproduction available. However if an individual wishes to use their own funds for such a procedure, they should be made aware of the risks (which are very significant), and the alternatives, such as surrogacy.
The best interests of the future child is another critical consideration. The moral status of the fetus is a topic of much debate. However, even if we consider abortion to be acceptable, and deny that the fetus has a moral status that accords it its own interests, in cases where the mother plans to carry the pregnancy to term, the fetus represents the future child who does of course have interests (albeit that they are to be weighed against the mother’s own interests, and that the mother is responsible for making decisions on their behalf).
Therefore, although technically possible to perform the procedure, you would need to be very confident the uterus would function normally during pregnancy. The first US transplant had to be removed because of infection. There are concerns about insufficient blood flow in pregnancy and pre-eclampsia. A lot of research would need to be done not just on the transplant procedure but on the effect in pregnancy in non-human animals before it was trialled in humans. Immunosuppressives would be necessary which are risky. A surrogate uterus would be preferable from the future child’s perspective to a transplanted uterus. Uterine transplantation represents a real risk to the fetus, and therefore the future child. We ought to (other things being equal) avoid exposing future children to unnecessary significant risks of harm.
One putative benefit might be the psychological benefit to the future mother of carrying her own pregnancy. This would have to be weighed against any harm to the child of being born in this atypical way.
Such a procedure a procedure promotes liberty and maternal psychological well-being but it is hard to justify from the perspective of distributive justice if it is using NHS health resources, or from the child’s own perspective.
The issue of womb transplants raises the issue of child-centred surrogacy, that is, surrogacy chosen because a surrogate would provide a better pregnancy for the fetus and future child than could be achieved with the social or biological mother. From the perspective of the child who will exist in the future, the surrogate uterus is likely to be a better option than a transplanted uterus. The same applies to other medical conditions where a woman must take teratogenic drugs for a medical condition. For example, phenytoin used to treat epilepsy may cause birth defects, as can warfarin used to thin blood. Women who need to take such medications for serious medical conditions should consider the use of a surrogate. (Thanks to a medical student at Deakin University for pointing this out.) This could be called surrogacy for “child-centred reasons”. This would be a form of “altruistic surrogacy” where the altruism was on the part of the future mother.
This raises the issue of choosing a surrogate when other conditions will create an unfavourable uterine environment. Alcoholism and drug addicts are obvious examples. Alcohol is a potent teratogen causing Fetal Alcohol Syndrome. If those who lack a uterus, or those on teratogenic medications should use a surrogate for child-centred reasons, then alcoholics and those addicted to teratogenic drugs who are not able to abstain for the period of pregnancy should also use a surrogate when contemplating pregnancy. If abstinence is not an option, surrogacy might be.