Threats to autonomy in uterus provision

By J. Y. Lee.

In my recent extended essay published in JME, I argued that transitioning transgender men and cisgender women who do not wish to gestate should not be excluded from opportunities to autonomously provide their uterus in service of uterus transplantations (UTx).

My argument was motivated by the fact that it is the norm to elicit a certain group in particular for uterus donations: mothers, understood here as multiparous cisgender women. The fact that they are recruited reveals an underlying ethic which problematically singles out mothers (especially the mothers of recipients) as the only agents who might plausibly autonomously donate their uterus to another.

All things being equal, we cannot just assume without argument that those with an eligible uterus who are not mothers couldn’t also autonomously donate their uterus if they so wished (at least, we cannot assume this merely on the basis of them not being mothers). To assert otherwise, in my view, commits one to an implausible view about the autonomy of adults who have a uterus but not children. What threats to decision-making about the uterus are this latter group thought to face that mothers don’t? It seems to me that the decision-making conditions for people who already do not wish to have or use their uterus are, prima facie, more favourable than for those whose primary motive to donate is to benefit a close relative.

I already considered whether the possibility of regret (over permanently giving up gestational ability) might constitute a relevant threat to the would-be donor’s autonomy. While I acknowledge that this may well explain discomfort around my proposal to include potential donors who have not already had children, I concluded that the mere possibility of regret is not by itself a barrier to autonomous decision-making about uterus donation. And it is not as if the presence of regret would nullify autonomy retrospectively either; claiming that the decisions we regret are non-autonomous merely by virtue of regret would be nonsense.

This takes me to a criticism I received from someone via social media since the publication of my article. This critic claimed that my suggestion to include transmen in uterus donor recruitment (in the same way that mothers are already included) was objectionable because it is tantamount to endorsement of organ ‘harvesting’ from the mentally ill. This critic asserts that transmen inherently suffer from gender dysphoria, a condition they characterize as a mental illness. Because gender dysphoria is a mental illness, this critic claims, it manifests only illegitimate wishes on part of transmen to undertake voluntary hysterectomy of the sort involved in uterus provision. I take the critic to be saying that it would be morally wrong to respect such wishes as autonomous.

Autonomy is a rather nebulous concept; it can admit of degrees and be difficult to achieve in any ‘pure’ sense. Indeed, bioethicists including myself have doubted whether the offering of assisted reproductive technologies (ART) as empowering choices for women can really advance their autonomy under the patriarchy. As such, I do not necessarily think it a bad thing to raise skeptical questions about autonomy in various social contexts. Indeed, the disparity between the right of autonomy that is presumed of those who have already had children, versus those who have not, is precisely what motivates my worries about uterus donor recruitment.

But I do wonder about the source of wrongness for uterus provision in the case that the potential donor is said to have gender dysphoria, or any other ‘mental illness,’ provided that they will (like all other donors) undertake the necessary psychological evaluation prior to the decision. What are the reasons to problematize the positive default assumption that all persons should be treated autonomously? Is the worry that donors who suffer from mental health issues circumvent safeguards of informed consent by default? Are there features of their condition which inherently interfere with genuine understanding about the risks of transplant hysterectomy? Is it that the desire to undergo a hysterectomy has an illegitimate cause in the case of gender dysphoria? Should such persons not be treated legally competent to make such decisions? While these are important questions to be navigated on an individual basis should reasons arise to do so, such suspicions in general seem to me less about descriptive fact as about making a normative judgment of decision-making deemed appropriate for the ‘mentally ill’ – whoever that may be. The same logics of suspicion about autonomy have been used, after all, to prevent or heighten the threshold for access to gender-affirming surgery for trans people.

A medically burdensome process like UTx, which involves multiple surgeries for the recipient (allotransplantation, C-section, hysterectomy) and the donor (donor hysterectomy), obviously warrants ethical caution. These are not decisions to take lightly, and perhaps the difficulty of volunteering for such procedures should be proportional to the risks. I certainly don’t want to suggest that a radical transplant hysterectomy should be expected of trans persons as part of their gender-affirming care – this type of pressure might indeed amount to the kind of coercion inconsistent with individual autonomy in general.

At the same time, for all the criticisms that the concept of autonomy invites in the context of ART, I believe there is a sense in which respect for autonomy can entail progress. Part of improving (reproductive) autonomy conditions for all must involve acceptance of the fact people with different life projects and viewpoints can and should be permitted to have non-normative preferences about what to do with their bodies. This includes decisions about how to use (or not use) organs like the uterus, which is traditionally coded as teleological to the reproductive fate of a feminine existence. If it is not shocking to most that someone who has already had children might want to (and can) give away their uterus, however, neither should the suggestion that the same could be desired even by those who have never undergone pregnancy.

This is why I will stand by my position that we should resist being selective about who we grant the right of autonomous choice in context, and that we should refrain from acting paternalistically over those who have not ‘used’ their reproductive organs to have children. To ensure that ART is not simply a realm in which oppressive traditions and norms are reinforced, we must make space for the disruptive risks and imprudence that the right of autonomy allows.


Author: J. Y. Lee

Affiliations: University of Copenhagen

Competing interests: None declared

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