What’s the big deal with ‘whole body gestational donation’? On defending bioethics

By J. Y. Lee.

Over the past week, a flurry of articles on the internet (for example: 1, 2, 3) sensationalized the contents of a journal article published by philosopher Anna Smadjor, on what she calls  “Whole body gestational donation” – with discussants on social media largely condemning the proposed concept, and implying that “bioethics” itself is a corrupt field rife with repugnant ideas.

Smajdor’s work builds upon on an earlier paper by Rosalie Ber, who suggested that one way to avoid moral issues raised by gestational surrogacy might be to use female patients in a persistent vegetative state (PVS) – who had given prior consent – as surrogates. While Ber did not articulate a term for this concept, Anna Smajdor names this idea whole body gestational donation (WBGD).

Smajdor points out, quite plausibly, that just as some people would be prepared to donate parts of their bodies for organ donation, some may also plausibly be prepared to donate their whole bodies for gestational purposes. She suggests that states and health services – wherever organ donation is legal – might adapt their policies so as to allow for WBGD, as one option among other organ donation options. This means that people, just as they may elect and consent to donate some of their organs in case of their eventual death, might likewise consent to donate their whole bodies for gestational purposes in advance – or so her claim goes. On this framework, WBGD could theoretically be enacted in eligible brain-stem dead patients. WBGD would of course be “qualitatively different in that entails ventilation over an extended period,” in addition to the fact that it is not life-saving in the way people often understand organ donation to be. Rather, WBGD is proposed as a potential way to benefit aspiring mothers (or parents) who wish to avoid the risks and burdens of gestating with their own bodies.

Make no mistake – many ethical issues warrant continued discussion in this case. Smajdor fully acknowledges that “prolonging ventilation and somatic survival in brain-dead patients is undoubtedly a disturbing prospect,” given that WGBD would make salient the way a patient’s body can be completely instrumentalized for other people’s benefit. However, she believes – rightly so – that many of the ethical concerns which might follow WBGD have a similar structure to the concerns raised for other areas of reproductive medicine and organ donation. Thus, the fact that WBGD is riddled with various (though, in the end, standard) ethical concerns – like many other areas of medical practice – is obviously not itself a reason to shy away from raising the idea.

While I make no comment as to whether WBGD is a good idea overall, or whether it is something that I believe people in general might (or should) somehow come to accept morally, much of the reaction to Smajdor’s work, and the accompanying reaction to bioethics as a field, strikes me as misconstrued. One online article claims that “the body, even in death, still demands respect, and Smajdor’s proposal is not only disrespectful, but also dehumanizing and exploitative.” These are certainly ongoing concerns echoed in both the realms of organ donation as well as surrogacy, where ongoing bioethical debate offer rationales from different sides. Yet debates about what is or isn’t dignified, respect-worthy, exploitative, and so forth, are by no means settled. Smajdor’s justificatory scheme for WBGD is no different to the justificatory schemes that might be used in support of allowing commercial surrogacy, for instance. I myself have written critically about the objectionable ways that people overtly moralize commercial surrogacy (and in an accompanying JME blog post).

In fact, I can think of many other hard ethical cases up for debate which have not seemed to stir up the same condemnatory responses online. For example, many women with AUFI (absolute uterine factor infertility) find it acceptable to gestate their own child by receiving a uterus donation from living relatives (like one’s mother, aunt, or sister) or unrelated strangers willing to give up their uterus. This is despite the fact that a uterus transplant is not a ‘life-saving’ organ transplant, despite medical risks to both donor and recipient being widely acknowledged, and in spite of adoption and surrogacy being possible alternatives. The moral consensus when it comes to uterus transplantation, however, seems to be one of general excitement and continued endeavours to innovate. This is evidenced by the fact that, since the world’s first live birth via uterus transplantation in Gothenburg (Sweden) in 2014, research teams around the world have followed in Sweden’s footsteps. In the past couple years alone, many new countries have sought approval over their own uterus transplantation clinical trials – for example, in Australia and Japan. News headlines on this topic suggest that uterus transplants are ‘an amazing gift’, a stark contrast to the reaction borne by Smajdor’s suggestion to make it possible for people to donate their whole bodies for gestational purposes, despite there being clear parallels in terms of potential ethical worries.

While I am not suggesting that uterus donation is morally equivalent to whole body gestational donation, plausibly we might recognize that similar ethical concerns apply in both cases: we can question the conditions under which consent to be a donor/recipient for such a procedure might be legitimately given, we might anticipate the serious harms that might befall either party, contemplate the potential for emotional coercion and exploitation, and so on and so forth. Is it really, on balance, morally better to allow living uterus donors to undertake a risky, medically non-necessary, and non-life-saving procedure for people who wish to gestate, than to allow people to donate their bodies for gestational purposes in the event of their brain stem death? Of course, we might in the end find that the standard conditions proposed for uterus donation turns out to be more ethically acceptable on the whole relative to WBGD. But even if this were the case, such a result still does not speak in favour of taking the view that WBGD is a uniquely abhorrent or reprehensible proposal.

To point out another example, an article written by Didde B. Andersen in 2021 on vital organ donation makes a philosophical case for a radically permissive type of organ donation. Andersen argues that people – even people who are not imminently dying for other reasons – ought to be permitted to become living, vital organ donors. She says this may be permissible even when the donor risks incurring “non-trivial and irreversible harm (as is the case when he or she is not about to die for other reasons),” focusing on scenarios where the potential donors may voluntarily and autonomously wish to sacrifice themselves for others.

She calls this concept living vital organ donation (LVOD). Andersen’s LVOD is, in many ways, much more radical than Smajdor’s WBGD; for one, in the case of LVOD we are talking about patients who would still be alive at the time of donation but who would be killed in the process of the sacrifice. I think what the existence of this literature shows, however, is that bioethics, while it may sometimes be a platform for ideas we personally find repugnant, indeed remains an important field precisely because it is poised to debate a range of ethically difficult and complex matters. While some of these topics – and the mere fact of them put up for discussion in the first place – may strike many as completely alien to individual moral sensibility or gut instinct, it seems entirely reasonable, as well as valuable, for us to continue talking about issues for which people’s autonomy and welfare are at stake, and to reflect on why exactly we ought to approve or disapprove morally of both ongoing and prospective medical practices.

Author: J. Y. Lee

Affiliations: University of Copenhagen

Competing interests: None declared

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