Since the beginning of our research we have been constantly aware of the ethical considerations surrounding womb transplantation. The ethics of womb transplantation are as fundamentally based on patient care requirements as they are in the use of any innovative surgical procedures.
Womb transplantation is not unique as an example of the ever-enlarging group of transplanted organs that are not life saving. Transplantations of these organs, including voice box, face, hand, and ovary, are now possible because the risks of transplantation have been greatly reduced. Whilst not life saving, reproductive organ transplantation is clearly done for the purpose of enhancing the patient’s quality-of-life. In other words, it certainly makes a positive and important difference in the life of a woman or couple who are unable to have a child by any other method. The balance between risk and benefit appears to be improving every year.
Interestingly, the concept of womb transplantation covers all aspects of medical ethics, the so-called four pillars: primum non nocere (non-maleficence), autonomy, beneficence and justice. Womb transplantation offers all of these four qualities to a patient suffering from Absolute Uterine Factor Infertility. Our hope is that the application of such a thorough approach which will lead to compliance with the first and most important pillar of medical ethics: primum non nocere. And most importantly, that ever-elusive life goal of eudaimonia (human flourishing), an Ancient Greek concept of the highest form of human goodness and happiness, can be attained by couples for whom the concept of family was always an impossibility.
Although the wish to have a child is not life critical, and may even appear unnecessary from the perspective of some people, others certainly consider it to be of vital importance. The general study of how hormones influence conception and fertility and the use of assisted reproductive techniques received the same criticism decades ago when they first began to be applied.
Regardless of the criticism, womb transplantation may become the only option for women who are unable to conceive for reasons such as cancers or infertility or in cultures where surrogacy is an unacceptable option for couplesowing to religious or ethical reasons. Although advances in assisted reproductive techniques have helped many infertile couples to realise their dreams, large numbers of couples currently have no alternative methods other than adoption or surrogacy. Indeed, for most of the world, including much of Western Europe, surrogacy is illegal.
Substantial research on womb transplantation has been in progress for over 15 years. The first and so far, only human uterine transplant was reported in 2000, and although premature, it certainly paved the way for further research and clinical trials in this field. In animals, successful transplants have been performed in rats, pigs, rabbits, and baboons. Successful pregnancies, albeit between animal siblings and twins, have been reported after womb transplantation in mice, sheep, dogs, and other species.
It is impossible to answer the question of how much more research must be done in animals before another attempt is made in a human because no framework, rules or criteria exist to help us make this decision. Most importantly, animal trials can not predict 100% how the process may play out when tried in a woman. However further research will allow us to meet the criteria for ethical analysis of a surgical development such as uterine transplantation: sound research foundation, adequate combination of knowledge and expertise from all fields related to the procedure, and internationally recognised proficiency in the institution in which the procedure is performed. Ultimately, the decision to go forward will depend on the judgment of the researchers, the participating institution, and most importantly, the patient to whom the transplant will be offered.
A lot of concern exists regarding the effects on the developing baby when still inside the mother of immunosuppressive drugs that would be required during the pregnancy to sustain the actual uterine transplant. These drugs prevent the body which received the transplant (known as the ‘host’) from activating its own immune system, which would normally treat the donated organ as a foreign substance, e.g. a virus, and therefore attack it. Fortunately, we now have extensive information regarding these drugs. Since 1954, over 15,000 successful births have occurred in women with other transplanted organs, and the evidence supports the safety of various immunosuppressive regimens. The question of safety for the developing baby exposed to immunosuppressive regimens has been answered by experience with over 50 years of successful pregnancies in other solid organ transplant recipients.
Other ethical issues, particularly related to the question of informed consent, must still be more fully addressed. However, in terms of surgical technique, organ preservation, achievement of pregnancies in animals, and safety of immunosuppression to the baby, there now exists justification to consider another attempt at uterine transplantation in a human.