Global Currents article

Producing Motherhood? Uterus Transplantation for Infertility

Children hold hands with their mother in Dago, Indonesia. Photo Credit: Ikhlasul Amal, 2010.

One of the main findings of the Science and the Human Person working group (the larger project to which these essays contribute) is that the discursive traditions of Islam and Catholicism offer valuable insights, but not a full account, of the human person. One of the project’s podcasts (in which I was honored to participate) described debates among Islamic jurists on the permissibility of organ donation. Herein I will weave together these threads, albeit partially, by outlining fundamental questions raised by the science and practice of uterine transplantation. I will further suggest that to better conceptualize, and eventually furnish, ethical guidelines that attend to the bioethics of uterine transplantation a multidisciplinary model is required, one where secular and religious bioethicists partner with social and medical scientists.

Procedurally, uterine transplantation involves removing the uterus from a living individual, or from an individual who fulfills the neurological criteria for death, and grafting this organ into a willing female recipient. Uterus transplantation, like limb and face transplantation, is part of the growing area of research into vascular composite allografts where multiple tissues types are transplanted as one functional unit. Uterus transplantation is unique in that it is a temporary measure; once the transplanted uterus fulfills its function in the donor it is removed and discarded. As with all organ transplants, the viability of the organ depends on a myriad of factors including the condition of the uterus when it is removed from the donor, the medical status of the recipient, the immunological compatibility between the donor and the recipient, the surgical technique utilized, and the efficacy of the immunosuppressive drugs the recipient takes to forestall organ rejection. In order for the donor’s sacrifice, the surgeon’s labor, and the recipient’s daily ministrations to be ethically justified, the ends of the procedure must be righteous and likely to be attained, while the risks and side effects relatively minimal. Accordingly, over the past decade, uterine transplantation has become an increasingly viable procedure with acceptable risk-to-benefit ratios, and the success of carrying to term and delivering an infant via a transplanted uterus increasingly probable. This biomedical advancement births bioethics questions both old and new.

For one, uterine transplantation forces clinicians and ethicists to (re-)examine the ambiguous line between therapy and enhancement; is this purported therapy restoring bodily function, adding a new physiologic capacity, or something in between? Uterus transplantation is an experimental procedure/emerging therapy for women with absolute uterine infertility (AUFI). AUFI refers to the inability to bear children because women either (i) lack a uterus (congenitally or because of surgical removal due to disease), or (ii) have a uterine abnormality that prevents embryo implantation and/or gestation to term. For these women, uterus transplantation holds the possibility of (re-)gaining the ability to gestate and birth a child. If uterus transplantation is judged to be a clinical therapy, then AUFI is termed a disease. To consider the therapy vs. enhancement question ethicists must delve into both the medical and the social bases upon which AUFI becomes a disease and uterus transplantation its treatment, as well as the implications thereof.

As noted above, women with AUFI are not all the same. Some cannot bear children for they were born without a uterus or without one that permits gestation. For this group uterus transplantation is technically not restorative because their bodies innately did not have the capacities theoretically offered by a transplanted uterus. Rather, in these cases uterus transplant offers an opportunity to rectify the body’s perceived deficiency by allowing for childbirth. This fix is based on patient desire, as well as on social expectations of womanhood and cultural notions of the normative body being one that contains reproductive capacity. Certainly, social scientific data will attest to the fact that some women with AUFI, as well as those unable to bear children for other reasons, experience profound loss. This sense of missing out on an essential part of life motivates their seeking procedures like uterus transplant. Yet this sense of something missing does not fully support a claim of uterus transplantation as restorative. It certainly adds meaning, value, and enhances perceived flourishing, but it does not restore an innate ability for someone suffering from AUFI. In one way it is more akin to enhancement in that it provides women without a uterus the chance of having a child of their own, much like a prosthetic extremity allows congenital amputees to gain a limb. The extremity adds a capacity, enhances functioning, but does not replace something that was lost, for the extremity was either not there or not fully formed or functional in the first place. The other group with AUFI, those who have had to undergo uterus removal due to disease are, arguably, different because they lost a capacity their bodies previously contained. For them uterus transplantation may be deemed restorative.

I am certainly not suggesting that clinical therapies must be restorative in order to be ethically justified; there are many genetic therapies and surgical procedures that seek to rectify abnormalities in structure, function, and phenotype that are part and parcel of ethical medical practice. Rather, ethicists (be they secular or religious scholars) must appreciate the ways in which uterus transplant and AUFI makes visible the ways in which social expectations and ideas about the normative body interact with the ethical ends of medicine. A host of bioethical questions arise when uterus transplantation is considered as a social practice: Is the fact that some women with AUFI suffer and are desirous of a solution sufficient enough justification to categorize it as a disease that demands medical remedy? Or does the fact that gestating and birthing is perceived to enhance the flourishing of some women sufficient grounding to make it part of routine medical practice? At present uterus transplantation is a procedure undertaken by willfully consenting adults, but if we could perform it on children with less complications and better success would it be ethically justified? On a related note, would medicine deem women who are born without a uterus diseased at birth or do they become diseased only because the need for a child arises later in life? Is either group, the child or the adult, somehow physiologically deviant due to no fault of their own, therefore making it medicine’s task to graft reproductive capacity upon them?

AUFI illustrates how all diseases are socio-culturally constructed; some have physiological or functional correlates (e.g. coronary artery disease), while others are thus classified because they are deviations from social norms (e.g. idiopathic short stature). Women with AUFI fit into both categories in that they are deemed to have a physiological or functional “disability” based on a “missing” function, and accordingly uterus transplant blurs the line between treatment and enhancement. There is no doubt that women with AUFI suffer considerably because they cannot have offspring. Although uterus transplantation may offer a solution to this suffering there are other potential “therapies” to not having children, such as adoption or gestational surrogacy. The appeal of uterus transplantation may be strong, and the procedure may be ethically justified, but it is also carries greater risk than these alternatives. In this case, as in others, ethicists need to fully consider the social forces that turn atypical anatomy or physiology into malady, and difference into disorder. Scholars may find interesting parallels to draw upon in the deaf community where some opt to not have their deafness (or that of their children) “remedied” because they do not see deafness as a disease and reject such stigmatization.

As religious bioethicists weigh in on the ethics of uterus transplant they need to examine conceptions of the normative body from the lens of tradition. For example, both Islam and Christianity have versions of an imago Dei doctrine. Does this notion offer insight into distinctions between therapy and enhancement when it comes to reconfiguring the body by adding a uterus?  When building out conceptions of the normative body based on scriptural indicants, both traditions must confront the issue that in some narrations womankind was generated from the first man. What sort of normativity can be attached to the uterus, an organ only present in female bodies? Similarly, both traditions speak to the value of procreation with scriptural texts that command the faithful to “be fruitful and multiply.” Does this directive envisage women without a uterus as being removed from God’s bounty out of wisdom, or can it ground uterus transplantation as a meritorious deed because of a desire to fulfill this teaching? In addition to these new wrinkles, uterus transplantation livens up “older” debates about organ transplantation in religious traditions. Although organ transplantation is generally permitted by Muslim scholars when it is life-saving, uterus transplantation is not technically life-saving for the individual recipient. Would the fact that it allows for a future generation to exist which would not have otherwise accord it life-saving status or does it have a different merit? Islamic scholars debate organ transplantation’s ethico-legal permissibility because it can, arguably, detract from the honor, dignity, and inviolability accorded to the human being as God’s creation because it reduces the human beings into a mix of interchangeable parts. Does uterine transplantation change this stance appreciably?

Continuing on to other social constructions, uterus transplantation necessarily implicates notions of motherhood. The transplanted uterus, if all goes well, would allow a woman to gestate and give birth to a baby. By definition, it would then appear, that uterus transplantation generates a child-parent relationship. Yet it has always been the case that motherhood is constructed upon social as well as biological foundations. Biomedical advancements have made the biological linkages between offspring and potential parents all the more varied, and uterus transplantation adds to this complexity. At one level, the link between a parent and a child is based on shared DNA, the propagation of these building blocks of life from one organism to another links one generation of a species to another. The DNA provides data on one’s origin and ancestry, generates one’s phenotypic and physiological profiles, and speaks to one’s probabilities for disease and longevity. DNA science has replaced “older” methods of evaluating the linkage between offspring and parents. For example, in the Prophet Muhammad’s time, the science of physiognomy was practiced to certify links between progeny and progenitors; today DNA science has supplanted this practice. Yet, modern biomedicine can now offer multiple other biological claims to parenthood as the chain from progenitor to progeny can be further subdivided. Nowadays the ovum and the sperm cell (either with or without the nuclei that contain the cell’s DNA) can be donated from people other than those who desire a child, and the womb within which the fused zygote is gestated can either be hired from a third party or, in the case of uterine transplant, come from a donor.

Figurine of woman with two infants. Photo credit: Nadia Carol, 2008.

Thus the couple desiring a child can legally claim to be rightful parents of an infant they have no DNA or gestational link to. Perhaps there is no ethical issue with such a claim because adoption provides some precedent. Adoption, in ancient times as well as today, has always been a practice that privileged social over biological bonds where accepting a child into one’s home and rearing them created a parent-child relationship. Contemporary biomedicine seems to have innovated beyond this older method with egg, sperm, embryo, and uterus donation. However it is likely that couples who have children via the method of egg and sperm donation plus gestational surrogacy would not consider themselves to be adoptive parents. Technically, however, they are not biological parents either. Is a new category of parenthood needed to cover this situation? Returning to the matter of uterus transplantation, the same question arises: does the act of gestation ground kinship ties and accompanying ethical claims? Gestational surrogacy arrangements, where they are legal, may provide some precedent, but these are also not without their controversies. Would the uterus donor be able to claim parental rights? Or in the case that the donated uterus was deficient in some way would the gestated child be able to make claims of the “right not to be born” against both the uterus donor and the recipient since the functional issue arose only after the uterus was transplanted into the new body?

A further complication, at least for Muslim thinkers, is that the womb and gestation are particularly significant in Islamic theology. One of God’s names is derived from the Arabic root for the womb; and Muslims are warned not to sever the ties of the womb lest it sever God’s mercy from the individual. Similarly the Qur’an emphatically declares that the “true” mother is the individual who birthed (and gestated) the child. Rearing is an important function but not one that grounds parental rights in this world or the next in the Qur’anic paradigm. As such a uterus donor’s ethico-legal claims of parentage would be harder to dismiss. Moreover, another analogy may be drawn from within the tradition. According to Islamic law, milk maids have parental rights, and some thinkers argued gestational mothers should be treated similarly. Does a uterus donor mother need to be added to the mix? Even if Muslims were to not seek uterus transplantation as a remedy the question is nevertheless pertinent to Muslims and Islamic law. With opt-out policies of organ transplantation gaining momentum in multiple countries, it is possible that a deceased Muslim women’s uterus may be used for transplantation purposes in the future. What would the relationship be between the child born to the recipient of that uterus and the children of the donor? Would kinship ties ensue, and the prohibition of marriage amongst siblings be invoked?

Having marked out several important bioethical questions uterus transplantation gives rise to, and noting how these questions have religious dimensions, I would like to close by discussing, in broad strokes, how social science and religious tradition might work together jointly to address these questions. In my view the project of defining terms such as motherhood and distinguishing between enhancement and restoration is a task religion can take up. Religious texts and scriptural teachings provide theologies and ontologies that provide frameworks upon which to build out such conceptions. At the same time, it is important to note that religious interpretations are not neutral; the way a text is read, understood, and explicated is contextually-dependent. These contexts go back, as well as carry forth, into time and make a tradition lived and always evolving. Hence when the religious frameworks are brought to address contemporary questions, their historicity and weddedness to social contexts must be acknowledged, and the frameworks revised as needed. Moreover, the experiences of motherhood, how notions of motherhood play out in society, and how patients invoke conceptions of restoration and enhancement in seeking healthcare are all topics of social scientific research. Even if the individuals studied are religious actors, their decision-making is also shaped by a myriad of other cultural, political, and social forces. Consequently social science has much to offer religious bioethics; it helps to clarify human experiences, understandings, and contexts, both historical and contemporary.

Scholars on this forum have grappled with the many ways in which biomedical advancements spur the reexamination of religious doctrine and teaching and also have forecast how religious theologies can give fuller meaning to the discoveries of biomedicine. They have further commented on how this bilateral exchange is framed by larger social, political, and economic forces. Attending to the pressing bioethical questions of uterus transplantation requires scholars from all three disciplines—religion, medicine, and social science—to come together in trialogue.

Aasim Padela
Dr. Padela is an emergency medicine physician, health services researcher, and bioethicist whose scholarship focuses on the intersection of community health, religious tradition, and bioethics. He is Director of the Program on Medicine and Religion at the University of Chicago.