Transferred
Sonia Sodha in the Graun on the mindless excitement about altruistic hysterectomy:
…the UK’s first womb transplant was reported last week – transferred from an older sister who has had children to a younger sister with a rare condition that means she could not otherwise carry a pregnancy. Articles were packed with quotes from doctors heralding this as a profound development, the “dawn of a new age”, according to the chair of the British Fertility Society.
…
I couldn’t believe how little discussion there was of the risks to the woman donating her womb. Hysterectomy – the removal of a woman’s womb – is described by the NHS as a “major operation”, with all the risks that involves, only recommended if other treatment options are exhausted. I know friends who have experienced debilitating symptoms because of early menopause who have begged doctors for a hysterectomy, only to be told that no doctor would approve it because it’s major surgery that is not medically necessary.
But then again, of course, it’s only women, so does it really matter that it’s risky?
Read the medical papers and the list of risks for living womb donors is dizzying: urinary tract infections, faecal impaction, wound infection, bladder hypotonia, leg and buttock pain, anaemia, respiratory failure during anaesthesia, depression, early menopause. One in 10 donors in 45 analysed cases have required further surgery. The medical team that carried out the UK transplant have developed techniques that have reduced but certainly not eliminated these risks. How did none of this make it into the news reports?
Frankly I think the younger sister should have refused.
How do you ensure that consent is meaningfully given in light of these risks? Is it even ethical to allow an individual to take these risks to try to improve someone else’s fertility? There are parallels with altruistic surrogacy, where a woman carries and gives birth to a baby – a risky endeavour – for someone else. What about the emotional pressure, which might be self-inflicted, that means a sister or mother might feel they ought to donate a womb or offer to carry a baby?
Maybe it’s not worth worrying about. Maybe soon people will stop worrying about infertility because they’ll be so worried about bringing children into a world in flames.
I agree. “I can’t let you do that for me,” isn’t that difficult to say. It’s a sentiment that–by definition–every decent, non-psychopathic person has learned. We say it for trivial things like trying to let us have the past piece of cheesecake. You’re damn right that a woman ought to say it to the idea of having her sister’s uterus surgically transplanted into her.
You’ll have to forgive me a bit of a science fiction musing, but … Wouldn’t a means of extra-uterine gestation be a better, safer, more ethical pathway for research and development? An external, artificial womb would allow someone like this woman to become a mother without risking anyone’s health: not hers, not her sister’s, and (assuming the system worked) not the child’s. We might even imagine that such an invention, were its production and use to become inexpensive, could be used by women in general. Upon becoming pregnant, a woman could have the option of transferring the zygote/embryo/fetus to an external womb. Among other things, this would consign death during childbirth to the dustbin of history. There’s even a conservative argument to be made for it as an alternative to abortion, fer Chrissakes. And the progressive, woke, Pink News set should be on board as an alternative to surrogacy that avoids so many feminist objections.
Now, I know very little about the state of research into such a thing. I’d be quite interested to learn how far it’s come and why the focus appears to be on surgical transplantation.
Yeah. Just no. Absolutely not: it’s major, risky surgery, with horrific potential side effects. No.
The more I think about this the more bizarre and creepy it becomes. I couldn’t even imagine being able to look my sister in the eye after getting a piece of her put into myself if it wasn’t literally a matter of life and death.
I’m not entirely sure I’d be a donor for someone, even a family member, even if it were a life and death situation. It depends entirely on the surgery. Kidney or lung? I just don’t know. Maybe, maybe not. Bone marrow? Probably.
I am on a donor registry, but it just depends on the risks at the time.
I was reading about this. They don’t just take the uterus; they take the cervix and upper part of the vagina as well.
I had a radical hysterectomy in my late thirties because I had precancerous tumours on both ovaries. It has since been discovered that ‘ovarian’ cancer (from which my aunt and great-aunt died) actually originates in the Fallopian tubes, and has thus been mis-named.
I wonder if donor organs are thoroughly screened for precancerous cells before transplantation? Are the recipients regularly screened for signs of cancer?
I, too, can’t imagine receiving an organ from anyone that wasn’t life-saving. Well, in my case, even if it was. There are too few donor organs available, of all kinds, to be giving one to someone like me. I would, however, willingly donate anything I can; but, given my genetic problems, I very much doubt that they’ll be wanted. Besides, I’d almost certainly have to stop taking all my meds first; and then I’d probably be donating post mortem and the ethics of living donation wouldn’t apply.
I’m guessing the focus on transplants is because it’s old technology; innovating is hard and you need that VC/grant money to try anything so radical. Uterine replicators absolutely should be something advanced civilizations should be looking into; you end up with a more productive work force, narrow the gender pay gap, remove the complications of pregnancy, better enable screening for defects and gene manipulation, etc, etc…
Here’s a highly speculative article from Fertility and Sterility “Inklings” that was shared on X with me as “proof of concept by experts.” A “first” on the horizon: the expansion of uterus transplantation to transgender women and the section on potential organ rejection is, to my mind, full of hand-waving away the risks. But here’s the intro:
Bizarrely, there is a discussion of whether or not a man should go through an orchiectomy prior to a uterine transplant because the continued production of androgen would lead to masculination of any femaile fetus that is being subjected to this experimentation.
C’mon, really? You’ve got gender dysphoria so bad you simply must have a pregnancy, but you would have to be convinced to give up your bollocks? I would thiink they would already be in a jar on the mantle by this time.
#1 Nullius in Verba
“You’ll have to forgive me a bit of a science fiction musing, but … Wouldn’t a means of extra-uterine gestation be a better, safer, more ethical pathway for research and development? ”
See the SF of Lois McMaster Bujold, where the benefits and abuses of such technology are often major plot points. In the stories this tech is called the ‘uterine replicator’.
OK, I’m going to wade in here, because medical ethics is notionally my professional field; I have friends and colleagues who are academic medical ethicists and lawyers, and they’ve been asking this kind of question since UTx was mooted as something that might be considered in the UK – so we’re talking about something in the region of 8 to 10 years now. And I’m also going to wade in because I’m a bit drunk. Apologies in advance.
Guess what?
Richard Smith, the surgeon heading the project, has been utterly open with them. He’s been involved with their projects, and they with his.
So, pace Sodha’s concerns… yeah. They’ve all been considered in quite some depth, and for a long time. I know of several people who’ve got PhDs out of this kind of stuff – hell, I even supervised one of them, and about a decade ago I supervised the PhD of someone who’s been working on transplantation ethics professionally since. I owe my own career to another significant player, who two decades ago lent me his office for a year while he was on sabbatical and I was on the dole.
Bluntly, and though I hate to descend into credentialism, UTx and transplantation isn’t one of my own interests, but I know a lot of the ethicists and lawyers whose interest it is, and who have been in one way or another involved in this. I’m mates with a lot of them, and am on at least nodding terms with almost all. They will not have been slack in their considerations.
Are the moral defences of UTx watertight? I doubt it. But I can’t think of a single significant medical intervention that couldn’t attract perfectly coherent objections from perfectly sane people. Foreclosing every single one of them is not the standard we set for any other procedure, though, and so I’m buggered if I can see why it’d be the right standard to set for this one. The ethical scrutiny has been painstaking.
Enzyme, I’ve no problem with credentialism used wisely. I do expert evidence work in my field so I have to support it really. I do wish more experts would recognise that being an expert on ‘X’ does not make one an expert on ‘Y adjacent to X’.
Anyway, genuine question for you. I can accept that ethicists have looked at UTx and concluded that there are no category ending objections to it. With UTx, and other procedures for that matter, surely that is not the end of the ethics considerations though? Life is full of edge cases and scenarios that no prior analysis can identify. Surely there must be case specific ethics consideration before picking up a scalpel?
Are we talking about transplantation, or donation? For women, or for men?
Is that directed at me or Enzyme? For my part I could envisage ethical considerations arising from all of those. From the outside it’s just not clear what the depth and breadth of consideration is and whether specific individual cases are given any ethical review or just happen under a prior umbrella approval.
As it stands, nobody is seriously talking about transplanting a uterus into a man at the moment. That is to say: a few people have raised it as a notional possibility, and there’s an arguable point about whether equalities law might, on paper, require considering men as recipients; but it’s a looooong way off the agenda, and even if we’re considering men as recipients, that consideration would be pretty quickly dealt with. This is for all kinds of reasons, not the least of which is that the rationale for UTx is to facilitate pregnancy – that’s the whole point – and that’s well over the horizon. But the other thing is that absolute uterine factor infertility is clearly pathological – as the result of some kind of birth defect – or the result of pathology – as after, say, uterine cancer. Being male is not pathological, so the medical rationale simply isn’t there.
Also, we’re talking about uterine transplant here, not ovarian; male pregnancy would clearly involve getting the egg from somewhere as well, or else a much bigger operation involving ovarian transplants. But I’m not aware of there having been any discussion at all of ovarian transplantation. Either way, though, it’s a much more complicated thing.
Donation – again under the incipient UK system – would be from live donors, and each donor would have to satisfy a fairly hefty list of conditions; it’s not a million miles away from living-donor kidney donation or liver-lobe donation in this sense. So there’s a combination of umbrella and individual considerations in play.
I’m not sure what the edge-cases you have in mind would be.
Rob @ 13 – Enzyme, I guess – I’m not clear on what the wading in is objecting to. Maybe it’s to Sodha saying we need to think about this? Because ethicists and lawyers are thinking about it?