Uterine transplant raises hopes — and thorny ethical questions

The nation’s first uterus transplant, performed last week at the Cleveland Clinic, raised the hopes of infertile women who could use the procedure to get pregnant. But it also sparked an intense debate about the ethics of the risky, expensive — and entirely elective — surgery.

That debate starts with a simple question: Why do it?

Transplanting a uterus from a cadaver could give thousands of women with damaged or missing wombs their only chance to become pregnant. But many of those women could have children genetically related to them by other means, such as paying a surrogate to carry an embryo created through in vitro fertilization.

“It sounds exciting, but you might say ‘Why are we going through all of this?’” said Arthur Caplan, professor of bioethics at the New York University School of Medicine. “We have other options that are safer for the fetus and the would-be mom. I’m not ready to say ‘Don’t do it,’ but you have to really proceed with caution here.”

At the same time, it’s not right to dismiss the concept out of hand just because it’s an elective surgery, other ethicists say.

“For a woman who feels like pregnancy means so much to them … I don’t know if we can be flip and say, ‘Well, you can have a kid another way,’” said Nanette Elster, assistant professor at the Neiswanger Institute for Bioethics at Loyola University Chicago. “Do we want to be paternalistic and say, ‘Hey, that’s too much risk to you’ when pregnancy may mean everything to her?”

For many women, carrying a child through pregnancy is tremendously important, said Lisa Campo-Engelstein, associate professor at the Center for Biomedical Ethics, Education, and Research at Albany Medical College.

“In our society pregnancy is the ultimate marker of femininity. If you’re able to give birth, you’re a ‘true’ — quote-unquote — woman,” Campo-Engelstein said.

“In the US, reproductive care is often seen as not real medical care,” she added. “It’s troubling when we get a lot of ethicists coming in authoritatively and saying ‘Women don’t need this; it’s not important’ without listening to women’s voices.”

Ethicists point out, too, that hiring a surrogate is not a perfect solution for women with uterine-factor infertility.

It can be risky for the fetus since there is no guarantee a surrogate will act in the child’s best interest in terms of diet, lifestyle, or following medical advice. And surrogacy can raise its own tricky ethical questions, since poor women are much more likely to assume the physical risks of carrying a pregnancy to term for a fee.

Women who choose a uterine transplant face steep challenges.

The process requires three surgeries: The transplantation itself; a caesarian section to deliver the baby, and then a final surgery to remove the uterus after childbirth so the recipient doesn’t need to continue taking powerful drugs to prevent her body from rejecting the organ.

Any surgery carries risk of infection and complications, but transplant surgeries include the additional risk of organ rejection and the medical complexities that come with those immunosuppressant drugs.

Swedish surgeons at the University of Gothenburg were the first to transplant a uterus successfully enough that the patient could carry a fetus. The first such patient gave birth in October 2014.

A Cleveland Clinic spokeswoman would not comment on the cost of the surgery in the United States, but medical ethicists said future patients could easily pay more than $100,000 for a transplant. Assuming insurance companies balk at paying for the procedure, that would put uterus transplants only within reach of the affluent.

There’s another wrinkle: Prospective organ donors might not feel comfortable having their wombs harvested after their death to carry another woman’s child. That could deter some people from becoming donors.

“The technical term in bioethics is the ‘ick’ or ‘yuk’ factor,” Campo-Engelstein said.

Donors have similar hesitation about giving away other intimate parts of themselves, as in face transplants — also pioneered by the Cleveland Clinic.

“What’s really going on is we think that the face and the uterus are somewhat different than the kidney,” Campo-Engelstein said. “People might be hesitant to donate, but I think that hesitancy can be avoided if people are educated that they can choose to donate whatever they want.”

The American fertility industry is a final source of concern for ethicists, who fear that clinics might in the future offer the procedure to anyone willing to pay for it, without screening candidates to make sure they’re appropriate for the surgeries — and perhaps without adequately training the surgeons.

Caplan suggested that the medical community should commit to tracking a small number of uterine transplant patients and their babies through the first years of the children’s life to better gauge the risks to everyone involved.

Elster agreed: “Taking this one step at a time — not jumping in and completely doing that belly flop, but dipping your toe and seeing what’s happening — might be the way to go.”