Ethical considerations in uterus transplantation

Abstract

Uterus transplantation offers a novel treatment option for women with uterine factor infertility. While currently in the early clinical research phase, uterus transplantation will likely provide an alternative to adoption or gestational surrogacy, which is not permitted in some parts of the world. It uniquely allows for women with uterine factor infertility to experience the gestational component of motherhood and also to potentially share a genetic link with the offspring. Clinical research on uterus transplantation has been in process since the 1960s, and the first human live birth following transplant was reported in 2014. However, given the rapid clinical advancement, it is important to review the medical safety of the procedure and ethical dilemmas for the donor, recipient, and resulting child as well as the regulatory landscape that will ultimately guide clinical adoption. Given that uterus transplantation brings together the challenges of both assisted reproductive technology as well as organ transplantation as the world's first ephemeral transplant, it is important to discuss the ethical, legal, and social implications prior to moving from research to widespread clinical practice. Keywords: ethics, regulation, infertility Ethical considerations in uterus transplantationOrgan transplantation has been performed since the early 20th century for a variety of reasons, including restoring function, saving life, and extending lives. Organ transplantation raises its own ethical considerations, including the use of cadaveric or living donors, allocation of scarce resources, use of medical and other criteria to determine eligibility, and informed consent.1-3 Improving the quality of a patient's life, rather than saving life itself, is a more recent goal and achievement of organ transplant (eg, hand, corneal, and face transplants) that presents further ethical considerations.1,3 For example, it is unclear how much risk is justified in the face of interventions aimed at improving quality of life rather than saving life. Uterus transplantation raises these same issues along with novel ones. For example, it is the first organ transplant with the goal being reproduction. Also, uterus transplantation is the first ephemeral organ transplant, or a transplant designed specifically for a short term, rather than the anticipated long-term nature of a transplanted liver or kidney, for example.As a transplant with reproduction as its goal, it necessarily raises ethical questions about technological aid of reproduction, including the rights of any reproductive donors, the interests of the child, commodification of women's bodies, the interests and goals of the mother, and the role of the state in regulating women's bodies and reproduction.

The Future of Uterus Transplantation: Cost, Regulations, and Outcomes

“…6 Thus, the determination of listing priority will be based on waiting time but if there are reasons that particular patients or groups of patients are disadvantaged by waiting time alone, there may need to be additional prioritization criteria. 6 For example, highly sensitized recipients may match with a small number of potential donors so, as with kidney recipients, these patients may need to be prioritized over unsensitized recipients when a matched donor is identified. In the future, the allocation of uterus grafts will likely have to be adjusted to account for factors beyond waiting time when these factors are associated with inequity in the allocation system.…”

“…24 Donation between family members carries concerns on both the donor and recipient sides of UTx donation. 6,24 The potential donor may feel internal pressure to donate, especially if the potential donor is the recipient's mother and feels responsible for the recipient's AUFI. The potential donor may also be externally pressured by the potential recipient or other family members and feel obligated to donate so that they can fulfill a family desire for the potential recipient to have children.…”

“…22 The ILDA is meant to be a trained individual, separated from any evaluation of the UTx recipient, that confirms that all parts of the UTx evaluation process are understood by the donor, the donor understands the risks, benefits, and alternatives to donation of their uterus, and that the donor has been adequately assessed before donation. 6,18 Nondirected living donation, where the recipient and donor do not know each other before UTx, carries its own challenges with informed consent and allocation. 24,25 Nondirected donors do not necessarily gain the same benefit of seeing the results of their donation in the outcomes of the recipient as they do not know their recipients.…”

“…4 It is this distinction that presents many unique challenges in UTx. 5,6 In this paper we discuss future directions in UTx including cost, registries for tracking UTx outcomes, and allocation of uterus grafts. We will conclude with a discussion of how UTx recipient criteria may evolve as we gain more experience performing UTx.…”

“…Given that UTx is in its infancy in comparison to other solid organ transplants, there are many issues specific to UTx that still need to be addressed 3. UTx is considered to be “life-enhancing” and not “life-saving.”4 It is this distinction that presents many unique challenges in UTx 5,6. In this paper we discuss future directions in UTx including cost, registries for tracking UTx outcomes, and allocation of uterus grafts.…”