Good news stories can feel few and far between these days. The pace of progress means they are often medical; there’s always new life-saving and life-changing treatments on the horizon.
Perhaps that explains the breathy excitement with which the UK’s first womb transplant was reported last week – transferred from an older sister who has had children to a younger sister with a rare condition that means she could not otherwise carry a pregnancy. Articles were packed with quotes from doctors heralding this as a profound development, the “dawn of a new age”, according to the chair of the British Fertility Society.
I enjoy a happy story enough that I initially bought it. But I soon felt a gnawing sense of unease about the superficiality of the coverage, and its failure to flag any of the pressing ethical questions it raises.
I couldn’t believe how little discussion there was of the risks to the woman donating her womb. Hysterectomy – the removal of a woman’s womb – is described by the NHS as a “major operation”, with all the risks that involves, only recommended if other treatment options are exhausted. I know friends who have experienced debilitating symptoms because of early menopause who have begged doctors for a hysterectomy, only to be told that no doctor would approve it because it’s major surgery that is not medically necessary. There are plenty of cases of women of childbearing age saying they were refused a hysterectomy in case they changed their minds about having children. Whatever the social or medical reasons for refusal, it indicates how reluctant doctors generally are to direct women towards surgery they think unnecessary.
Read the medical papers and the list of risks for living womb donors is dizzying: urinary tract infections, faecal impaction, wound infection, bladder hypotonia, leg and buttock pain, anaemia, respiratory failure during anaesthesia, depression, early menopause. One in 10 donors in 45 analysed cases have required further surgery. The medical team that carried out the UK transplant have developed techniques that have reduced but certainly not eliminated these risks. How did none of this make it into the news reports?
Other types of living organ donation also carry risks. But with kidney or liver donation, you are donating to save someone’s life. In the case of a womb, you are donating a major organ as a fertility treatment. There is no guarantee of success: it carries the same risks of rejection as other transplants, and the IVF treatment might not be successful. The recipient will have to undergo at least three major surgeries – the implantation, a C-section if she becomes pregnant, and the removal of the uterus after a maximum of five years to reduce the considerable health risks of immunosuppressant medication (considered “relatively safe” for the foetus). In just over a quarter of 45 cases, the transplant didn’t work. There have been around 100 successful transplants worldwide, resulting in about 50 live births.
How do you ensure that consent is meaningfully given in light of these risks? Is it even ethical to allow an individual to take these risks to try to improve someone else’s fertility? There are parallels with altruistic surrogacy, where a woman carries and gives birth to a baby – a risky endeavour – for someone else. What about the emotional pressure, which might be self-inflicted, that means a sister or mother might feel they ought to donate a womb or offer to carry a baby?
Living organ donation is regulated by the Human Tissue Authority and so both sisters in this case were interviewed by one of its independent assessors to confirm consent has been given and no payment has changed hands. But these processes are fallible; indeed, they have failed to catch victims of organ trafficking. Were this transplant to become more common, it is entirely conceivable that some donors could end up being coerced in the UK; let alone what might happen in countries where organ trafficking is rife.
Using a womb from a recently deceased donor might be ethically preferable, but less effective; though I imagine some women might feel quite differently about their reproductive system being donated to aid someone else’s fertility treatment than life-saving organ donation. (It is important to note that uterine transplant is classed as “novel” and so is not covered by the UK organ donor register; a womb would not be removed for donation from a deceased woman without the explicit consent of her family.)
Medical infertility can be a horrible thing to go through. I have many friends who have experienced it. I know what it is like to want your own children and to realise this might be unachievable for medical, social or financial reasons. I think it is terrible that the NHS does not offer more routine fertility treatment where it could make a difference, not only because it would help people fulfil their aspirations to become parents but also because it’s a no-brainer in a society where falling birthrates will mean either much higher taxes or much worse public services in the decades to come.
But womb transplants seem to me to cross an ethical boundary: a pursual of having children regardless of the costs or risks. There is no inalienable right to carry a baby or to have a genetic child that society must meet at any ethical or financial cost. Absolute uterine infertility is thought to affect around one in 500 women, so is a relatively uncommon cause of medical fertility; of course, these women are allowed to experience profound sadness at the fact they will never carry a baby. But it could never be financially appropriate for the NHS to fund these expensive transplants when rationing means so many women go without more basic fertility treatments; and the risks mean that living donation should not even be on the table in the first place.
Just as it was wrong for the government to hand our ethical framework on surrogacy over to lawyers, these big ethical calls must not be left to medical professionals, whose well-meaning bias leans towards seeing a problem, then fixing it, regardless of the wider ethical implications. Just because something is medically possible and desired by individuals – like sex selection of embryos – does not mean we should do it.
There remains so much societal pressure on women to see the essence of womanhood as giving birth to their own children; it makes coming to terms with not being able to do this even harder. But coming to terms with it is, sadly, what some women need to be supported to do: womb transplants are not the answer.
