Promise of pregnancy raises series of what-ifs

Arthur Caplan, Ph.D. • E-mail

A team of physicians in New York City has announced that they intend to conduct the first uterus transplant in the United States. For women born without a uterus, or who have had their uterus removed due to illness, this procedure offers the hope that they will be able to bear children. 

It is hard to argue that there is any "in principle" reason why surgeons should not attempt uterus transplants. There are women who could benefit from the procedure and the technical skill to undertake the procedure is rapidly evolving. Despite the adoption options and the fact that American women can, in most states, use a surrogate mother, the fact is that many women want to bear their own biological children. The risks involved in trying a brand-new form of surgery are not going to discourage some women from signing on as subjects.

There is a need. There are people willing to take the risk. And the skills necessary to do a uterine transplant are emerging at many transplant centers. So, what is the problem with the proposed surgery?

There are three major issues. 

First, little research has been done on animals. No animal has given birth to a healthy offspring or even given birth at all post a uterus transplant. If, instead of a surgical innovation, the doctors involved were talking about a new drug treatment to give to infertile women, no one would let them try without showing that it was safe and had some efficacy in animals. 

The fact that the surgery involves no new drugs or medical devices does not mean the surgeons are not morally obligated to prove they can make it work in a mouse, rat, pig or goat before rounding up desperate women as experimental subjects.

Second, the uterus to be transplanted will have to come from a deceased woman.  The New York doctors say they will use someone who has signed a donor card and whose family is OK with the donation. But is this really enough? Few American women ever thought that their uterus might be donated if they signed a donor card. The uterus is not seen by many women in the same light as a kidney or a liver. The transplant team would be on firmer moral ground if they used a donated uterus from a woman who explicitly consented to donate that organ prior to her death and who made it very clear that she and her family renounced any and all claims to a relationship with any child that might result.

Lastly, it is very likely the first uterus transplant will fail. The surgical team says that this is not a problem since they can take the uterus out if things go wrong. 

But what if that uterus contains a fetus?  What if the mother says she is willing to die to give birth to that fetus? What if the father or the mother say they want the uterus removed even if there is a fetus present if things are not going as planned? The doctors have not said as much as they need to about what their "exit" strategy will be if, sadly, the surgery does not go as planned.

Transplanting the uterus, or for that matter, fallopian tubes, ovaries, testes, and other reproductive organs may bring great benefit to many.  But since there are two subjects involved — the would-be mom and her would-be child — any transplant team that proposes trying this novel surgery had better be sure it has done all that it can to ensure a good outcome. It isn’t clear that the New York group has yet met that standard.

Arthur Caplan, Ph.D., is director of the Center for Bioethics at the University of Pennsylvania.