November 3rd, 2007 08:30 EST
The Ethical Issues of Uterine Transplantation: Debunking the Controversy
Doctors in the U.S. are preparing to do the world’s second uterine transplant at New York Domestic Hospital. Led by Dr. Giuseppe Del Priore, NYDH’s transplant research team began its search for potential organ donors and recipients late last year, nearly 7 years after the first transplant was completed.
In Saudi Arabia, at King Fahad Hospital and Research Center in Jeddah, a 26-year-old woman received the uterus of a 46-year-old woman who had had a hysterectomy due to painful ovarian cysts. The recipient had lost her uterus at the age of 20, due to severe post-cesarean bleeding.
Although the procedure itself was considered a success, the uterus had to be removed from the woman after 90 days due to severe, life-threatening clotting in the major vessels leading to the uterus. While the uterus was in her body, however, she did have 3 menstrual periods, which doctors considered a sign of success.
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“Organ transplantation is not generally controversial in itself – even when not life-saving – and fertility treatment is not either,” comments Dr. Mark Greene, a professor of bio and medical ethics. “Put them together and we have an instance of a kind of procedure that is justifiable being used for a purpose that is justifiable, and it is hard to see why there might suddenly be genuine cause for hysteria.”
Combining key issues in the abortion and infertility treatment debate, the concept of this non-life saving, temporary transplant challenges the most accepted purpose of organ transplantation, fetal rights, and a couple’s right to reproduction.
But, as Greene highlights, nothing – not the high risks, doubtful benefits, and risks to the health of future children – in the case of uterine transplantation is new.
One central ethical problem concerns the effects of anti-rejection (or immunosuppressant) medications on a developing fetus, which has been an issue since the birth of the first baby by a mother with an organ transplant 48 years ago.
Anti-rejection medications are taken by a patient after they receive a transplanted organ to suppress the body’s immune response to foreign tissue and bodies. Without the drugs, the body’s immune system would attack the foreign organ and destroy it because the body would perceive the organ to be a threat, much like a virus.
Because these drugs must repress the immune system those patients on anti-rejection medications are at risk of catching severe cases of pneumonia, influenza, and even common colds that can kill them, because their immune system is extremely weak in its suppressed state.
As these medications must be taken for life – or until the transplanted organ is removed, as in this case – and are very powerful and dangerous even for normal, relatively healthy, adults, many bioethicists have raised the question of how such medications will affect a developing child.
Although there has been limited research into the effect of immunosuppressant drugs on developing fetuses, transplantation history does provide some information. According to the New England Journal of Medicine, more than 14,000 successful births have been reported by women with transplanted organs worldwide since transplantations the first transplant in 1954. The short-term effects on these children seem to be minimal, if non-existent; but it is only now that the opportunity to collect data on the long-term effects of immunosuppressants has arisen. This data will be key in understanding the total risk a woman takes when conceiving a child while taking anti-rejection drugs.
It is currently known that the risk of congenital malformations associated with such immunosuppressant drugs as calcineurin inhibitors, azathioprine, and prednisone (a steroid) are probably low. Animal studies, however, have suggested that there may be a problem, particularly with the calcineurin inhibitors, of autoimmune disease in children who are exposed in utero to such medications. As for other agents, such as rapamycin and mycophenolate mofetil, their effects are still unknown.
“This would currently be a highly speculative experimental procedure with the unknown risks of potentially serious problems for both mother and child,” Greene says.
Acknowledging such a possibility of grave effects, the question becomes whether or not it is morally wrong for a woman to elect for a uterine transplant and then subject her child to such harsh medications without his or her consent. It should be duly noted that this is not a case where a child could be born via in vitro fertilization (IVF) or transplant; rather it is a choice between being born via transplant and not being born at all.
Another central issue to the ethical debate is whether or not a couple has a right to reproduce, a complicated matter that has been prevalent since the introduction of infertility treatments. Sallie Tilsdale, a hysterectomy patient, and adoptive mother, challenges the idea of a right to reproduce in her article “Infertile Couples Should Pursue Adoption, Not Reproductive Technologies.” Tilsdale raises the question of whether or not the children already born and without a home, starving in another country, or orphaned, lack rights – do they not have a right to a family? Instead of this right to reproduce, she redefines it as a right to be a parent. Whether that happens through adoption or IVF is up to a couple’s decisions; but they must bear in mind Tilsdale’s central question: “Do you want to be pregnant, or do you want a child?”
The final big issue concerning uterine transplantation revolves around the feasibility of the procedure, which becomes an ethically problematic matter with any experimental procedure. Although some claim that that, as well as the procedure’s safety, was established back in 2000 in Saudi Arabia, others, like Dr. Thomas Murray, president of the Hastings Center for Bioethics, raise serious doubts.
The procedure has been tested on only a limited number of animals, including one rhesus monkey. A successful pregnancy post-transplantation has only been achieved in mice, which occurred 5 years ago in Sweden, at Gothenburg University. With the lack of information in certain areas and successful animal research, it is not yet time to proceed with this type of transplantation.