Sunday, 3 October 2010

Uterus transplantation: ethics and pragmatics

Today, Swedish media report (here, here, here, here, here, just to name a few) on plans of a group of researchers at the Sahlgrenska University Hospital and the University of Gothenburg, to conduct the world's first ever transplantation of a human uterus. After successful experiments on rats (and a number of other animals), the team – headed by professor Mats Brännström at the unit of obsterics and gynecology – is now working on baboons in order to secure a basis of results that could motivate a move into the actual human clinical trials. The research is held out as a prospect for certain infertile couples and an alternative to surrogacy, adoption and similar methods currently used to overcome the problems faced by this group of people.

Needless to say, the research raises a number of ethical questions, something at least partly recognized by the researchers when they write in their online presentation of the research: "We think that it is necessary to look closely into these aspects of uterine transplantation before it can be developed and used in the human". This alludes primarily to the need to secure the efficacy and safety of the method before attempting to use it clinically, which is, of course, a priority. However, already this obvious issue will undoubtedly raise more subtle issues.

One of these connect to the rather sad track record of reproductive medicine when it comes to moderating its drive towards applying new ideas and technologies in light of safety and others ethics considerations. Sterilization policies and the early history of IVF continues to be a moral backpack that needs to be carried by contemporary researchers and clinicians in reproductive medicine (just as in genetics). The critical outlook from a feminist perspective by such commentators as Christine Overall and Gene Corea, to name two of the more prominent, have pointed out the dangers of reproductive technology to transform women into mere means for the production of offspring in a social context dominated by mechanisms and cultural patterns aiming at a patriarchal control of reproduction. While the influence of this tendency is hard to argue with (the fate of women have indeed been a secondary consideration in many cases of reproductive technological advances), at the same time, there are also sides to the developments that arguably are to the benefit of women as well as other groups that are or have been systematically marginalised. In as much as individuals, couples and whatever other groupings that wish to transform themselves into a reproducing family are able to overcome oppressive socio-cultural structures, the technological advances do produce new options. The threat of these options being unduly pressed on people (especially women) or used for oppressive purposes in other ways has to be recognized, of course, but you would need to be a very hard-nosed structuralist indeed to claim that the individual can never utilize available options to their own advantage. In fact, one of the main points of the high priestess of queer theory, Judith Butler, seems to be that such utilization is one of the primary roads towards overthrowing oppressive sexual structures – social, cultural and conceptual.

Having said that, the idea behind the uterus transplantation project seems, however, to present a bit of a problem from the just outlined perspective. One of the prime rationales behind the research held out in today's press reports is that the options currently faced by women facing the sort of problems that may actualize a uterus transplantation – adoption or surrogacy – are hard, burdensome or impossible to access. In Sweden, surrogacy is not legally available (except, of course off shore) and adoption is a difficult, lengthy and costly process. In other nations, surrogacy may be available, making it possible for Swedish women with the personal and financial resources required to go there for such arrangements, but not for less fortunate women. In light of this, the researchers claim, uterus transplantation carries a liberating prospect by making available a procedure that may facilitate having children for those of these women who so wish. But what this means seems to be that the situation is exactly of the sort that the feminist critics of reproductive technology have pointed out as problematic. Women who suffer the sort of physical dysfunction we are talking about will not be in a position to freely choose uterus transplantation as the preferred solution to their problem compared to other feasible options. Rather, their freedom of choice will be heavily constrained by socio-cultural-economic factors. Put in another way: the source of the problem to be solved by uterus transplantation seems to be primarily about the oppressive effects of current legislation, economic arrangements and cultural preconceptions. It could, apparently, be solved just as well by making surrogacy and adoption more available.

But of course, such changes may not in fact be forthcoming. The rationale of the researchers may then be turned into one of simple pragmatics. They can say: "we would simply love it if the socio-economic patterns oppressing our patients were to change for the better, but until then we have reason to work on our research". The critic following the sort of lines sketched above would then have to resort to the structuralist mantra of negative feedback loops; the dogma that whatever is done to help people in oppressive circumstances will sustain the oppression. Besides being a corner impossible to get out of, such an argument would need the support of convincing empirical evidence in the area of reproduction, e.g., regarding contraceptives, legal abortion, freedom to marry and divorce, etcetera.

Thus, ethics in this area teaches us to be mindful about the effects of social structures and cultural contexts, so that we are not trapped by blind spots and prejudgments. But the presence of such structures and contexts does not by itself constitute a knock-down argument. History can teach us a great deal about that, as can ethics research and experience from other cases of reproductive technology. The worry I am nurturing rather concerns if the researchers involved have secured  access to the resources and competence needed for living up to that, which takes me back to where I began; the evaluation of risks and benefits when (a) deciding whether or not to take the step over to clinical trial, (b) conducting such a trial, (c) deciding on basis of the trial whether or not to offer to the procedure, on what conditions and to whom. And, of course, in light of what has been said, the overarching evaluation in terms of fairness and cost-benefit, whether this is where the resources for liberating and helping the group of patients concerned are best spent. Once a procedure is (ethically and medically) ready for clinical use (i.e. if not the results of the trials are too poor), this last issue will undoubtedly step forward as a primary one in critical discussion.