Who should give away their uterus?

By J. Y. Lee.

Uterus transplantation (UTx) is an experimental surgery which can enable women with absolute uterine factor infertility (AUFI) to receive a healthy uterus and experience a pregnancy. Since the first successful live birth via UTx in 2014 (Gothenburg, Sweden), more than 40 live births via UTx have taken place.

While UTx is an exciting surgical innovation in many ways, it is accompanied by risks to both the recipient and donor. The risks are especially pronounced for live donors, for whom a transplant hysterectomy would not only be medically unnecessary, but highly burdensome (and much more invasive than a standard hysterectomy). And unlike recipients, for whom receiving a uterus may be life-enhancing, there are no comparable benefits to donors for giving away their uterus. It should be noted that giving away one’s uterus in context implies giving up one’s ability to get pregnant permanently after the fact. Indeed, such considerations are precisely why some have argued that it is ethically preferable, in context, to use deceased donors rather than live donors.

There are, however, logistical challenges associated with UTx using deceased donors, on top of a shortage of suitable uteri. It is therefore likely that, at least for the time being, live donors will continue to be recruited for UTx. Under what circumstances, then, is it morally appropriate to ask a potential donor for their uterus? This is the question I explore in my latest article at JME.

Firstly, I examined existing donor eligibility criteria (in Europe and the US) to canvass how live donors are, in practice, recruited. While donors are carefully vetted in any case, the majority of UTx trials to date require that donors under a certain age be multiparous (that is, they must already have had children) and/or related to the recipient (e.g. be the recipient’s own mother). This may not, on the face of it, seem particularly unusual or objectionable. It may even seem obvious to some. After all, organ donation between family members is commonplace. Furthermore, the criterion of multiparity is not unusual in the assistive reproductive context: having prior children is also often a condition of becoming a surrogate.

In my view, however, the notion that uterus donors should necessarily be multiparous and/or be related to the recipient is highly problematic. The requirement that otherwise eligible live donors should have previously given birth implies, by default, that women should not make decisions about giving away their uterus unless they have already ‘used’ it to have their own children. Here, the possibility of later regret over sterility is catastrophized relative to other risks, such as surgical complications from the transplant hysterectomy. Furthermore, the expectation that the live donor be related to the recipient places such persons under objectionable pressure to ‘gift’ their uterus to a family member. Interestingly, these norms together reinforce the notion that if anyone should give away their uterus, it is ideally someone’s mother, if not the recipient’s own: a woman who has both already fulfilled the expected duty to bear her own children, and has (allegedly) proved in so doing that her uterus is up to the task.[1]

Under such logics, mothers in general – often the mothers of recipients – are likely to be targeted and oversubscribed in UTx. Someone who is perceived to have completed childbearing, I suppose, is treated as no longer being in ‘need’ of their uterus, and perhaps ‘safe’ from experiencing regret over giving away their uterus. Besides the fact that such logics are oppressive to women, other plausibly eligible groups who may be interested in participating are also explicitly excluded or simply neglected – like nulliparous (childfree) women or transgender men. Thus, I argue in my article that those who have a functional uterus but who may not necessarily want it (for whatever reason), ought to be equally considered as potential uterus donors. This is especially important since many such individuals plausibly possess an independent interest and motivation in not gestating or having a uterus (rather than simply to benefit somebody else). If they are, further, willing to provide their uterus to someone who does wish for one, it seems like a recipient-donor match could be made which is more ethically palatable than those simply taken as a given in UTx, like mother-to-daughter pairings.

I should clarify, however, that my point is not to say that these groups (or anyone in general, for that matter) should sign up to be uterus donors just because they may be medically eligible and willing to do so. As I emphasize in my essay, there are plenty of reasons which speak against providing one’s uterus, irrespective of whether one particularly wants to keep theirs or not. Allowing that it may be both possible and permissible for a potential donor to autonomously agree to provide their uterus, however, my goal is to show there is room to improve existing parameters of donor recruitment by reflecting on whose uterus is (not) being solicited for UTx and why. The mothers of recipients should not be taken for granted as natural uterus donors; on the flip side, those who may want to give away their uterus without having ever ‘used’ it should be considered in earnest.

While my view constitutes a critique of existing practices around live uterus donor recruitment, my recommendation to make eligibility conditions more inclusive in this way is entirely consistent with the fact that UTx is largely celebrated as a medical innovation. It would be a hypocrisy, after all, to offer UTx to potential recipients in the first place, or even to claim that UTx should become more routine, without simultaneously appreciating the fact that there must correspondingly be enough donors willing to relinquish their uterus as well.

 

[1] It should be noted that I refer here to cisgender women because they make up the current majority of uterus donors. Of course – as I also write in my extended essay – this may well change if measures are taken to recruit transgender men, for example.

 

Paper: Who should provide the uterus? The ethics of live donor recruitment for uterus transplantation

Author: J. Y. Lee

Affiliations: University of Copenhagen

Competing interests: None declared

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