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Uterus Transplants. Ethical?

At the beginning of December, Baylor University Medical Center at Dallas announced [1] that a female recipient of a new uterus transplant procedure had successfully delivered a full term baby.  This was the first time this had taken place in the U.S., but not the first time absolutely.  Sweden boasts of four live births since 2014 from seven uterus transplant recipients.

An estimated [2] 15% of women of childbearing age suffer from absolute uterine infertility (AUI), which means their uterus is either non-functioning or non-existent.  Up till now, fertility specialists have told them that if they want a child they should either adopt or do surrogacy.  The Baylor team is hoping their success will open a third option, at least for wealthy women, who have $500,000 to pay for the expensive procedure.

The treatment took place in six phases.  During the first phase, the recipient underwent in vitro fertilization (IVF).  Her ovaries were stimulated with powerful drugs, eggs were harvested and fertilized with a partner’s sperm, and multiple embryos were created and frozen.  Phase two was the transplant.  The uterus with the cervix was removed from a living donor and transplanted into the recipient.  In phase three, which took about a year, the recipient’s body was flooded with immunosuppressant drugs to prevent tissue rejection, and the status of the transplant was monitered.  In phase four, the embryos were thawed and one was transferred into the recipient’s uterus.  During phase five the recipient gestated and delivered the baby.  In phase six, she had a hysterectomy to avoid the long-term risk of tissue rejection from the transplanted uterus.

Ethical Evaluation

The Baylor procedure was ethically problematic for at least two reasons.  First, it required IVF.  The transplant team determined that only women who could gestate their own biological babies were eligible for the procedure.  Because the operation did not include transplanting or reconnecting the fallopian tubes, Baylor required the recipients to undergo IVF using their own eggs.  Since IVF creates children through a technological procedure, it unjustly denies them their rights to be conceived by a mother and father through an act of marital love and violates the procreative good of marriage—and in the U.S. it almost always also includes killing human beings through the eugenic screening and destruction of “unfit” embryos (although no details of the Baylor IVF procedure were released).

Second, from the scant reporting, it appears that the woman who donated her uterus did so from dual motives.  Time reported [3]: “she and her husband had already decided they were not going to have any more children, and she wanted to offer someone else a shot at motherhood.”  She apparently chose to kill two birds with one stone, undergo a permanent sterilization procedure in order not to have any more children, and donate the uterus she had removed by hysterectomy to an AUI patient.  The Catechism of the Catholic Church, quoting Humanae Vitae, teaches that “every action which, whether in anticipation of the conjugal act, or its accomplishments, or in the development of its natural consequences, proposes, whether as an end or a means, to render procreation impossible” is contraceptive and hence immoral (no. 2370).  This includes elective hysterectomy for sterilization purposes (no. 2399).

Ever Morally Legitimate?

If uterus transplants did not involve IVF or elective sterilization, could they be consistent with the goods of marriage?  Let’s look at each question individually.

First, must women use IVF to conceive their own children?  If women suffering from AUI, who still have functioning ovaries, could receive not simply a uterus and cervix but also functioning and attached fallopian tubes (perhaps one day from tubes created [4] using one’s own adult stem cells [5]), then a successful transplant may be the occasion for facilitating fertilization as a result of marital intercourse.  The 1987 bioethics instruction from the Congregation for the Doctrine of the Faith, Donum Vitae, teaches as a moral principle that technological procedures that “assist” the martial conjugal act to reach its proper finalities can be licit, while those that “substitute” for it (e.g., IVF) are not.  Uterus transplants that facilitate martial intercourse would fall under those that “assist” the conjugal act.  This, of course, implies that recipients are married or about to get married.

Second, if transplants were received from deceased donors, then the problem of elective sterilization would be removed.

Whether or not these two alternatives are surgically possible are medical and not ethical questions.  If at present they are not possible, then conscientious researchers should certainly explore how to make them possible.

One final ethical question.  The procedure requires that otherwise healthy women undergo multiple surgeries, including an eventual hysterectomy.  Are these justifiable in light of the benefits to be achieved?  Assessing this question fully can only be done in the light of the medical facts bearing upon each person asking the question.  But in principle, the benefit for a formerly absolutely-sterile couple of becoming able to engage in fruitful marital intercourse is very great.  Therefore, unless some grave harm is threatened in the individual case which would cause the spouses to compromise on some existing duties, then it very well may be licit to accept the risks posed by multiple surgeries, including the therapeutically-indicated hysterectomy after a child has been brought to term.

It might even be possible [6] one day using induced pluripotent stem cells (iPSCs) to grow a uterus in vitro using a patient’s own cells that would not be subject to the same rejection problems as foreign tissue transplants.