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The Ethics of Allocating Uterine Transplants

Published online by Cambridge University Press:  11 February 2016

MICHELLE J. BAYEFSKY  and
BENJAMIN E. BERKMAN
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Abstract:

In September 2014, a healthy male child was born in Sweden following a successful uterine transplantation (UTx). The event brought hope to many women without functional uteruses around the world. Having a child with a transplanted uterus is now possible, and as knowledge of the procedure proliferates and interest in UTx grows, it is important to begin thinking about how a scarce supply of uteruses will be allocated. This article represents a first discussion of the range of factors that must be considered in answering the allocation question. The primary issues addressed are (1) the motivation to seek treatment, (2) allocation by age, (3) child-rearing capacity, and (4) the amount of infertility treatment required. A set of eligibility and ranking criteria are presented. These criteria are not exhaustive but are intended to spark discussion about how uteruses can be allocated in a just manner.

Keywords

uterine transplantationinfertilityallocationscarce supplyeligibilitymotivationagechild-rearing capacity
Type
Breaking Bioethics
Information
Cambridge Quarterly of Healthcare Ethics , Volume 25 , Issue 3 , July 2016 , pp. 350 - 365
Copyright
Copyright © Cambridge University Press 2016. This is a work of the U.S. Government and is not subject to copyright protection in the United States. 

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References

Notes

1. Brännström, M, Johannesson, L, Bokström, H, Kvarnström, N, Mölne, J, Dahm-Kähler, P, et al. Livebirth after uterus transplantation. The Lancet 2015;385(9968):607–16.CrossRefGoogle ScholarPubMed

2. Fredericks B. First baby born to woman with transplanted womb. New York Post 2014 Oct; available at http://nypost.com/2014/10/04/first-baby-born-to-woman-with-transplanted-womb/ (last accessed 29 July 2015).

3. Gallagher J. First womb-transplant baby born. BBC News 2014 Oct; available at http://www.bbc.com/news/health-29485996 (last accessed 29 July 2015).

4. See note 1, Brännström et al. 2015.

5. Nair, A, Stega, J, Smith, JR, Del Priore, G. Uterus transplant: Evidence and ethics. Annals of the New York Academy of Sciences 2008;1127:83–91;CrossRefGoogle ScholarCatsanos, R, Rogers, W, Lotz, M. The ethics of uterus transplantation. Bioethics 2013;27(2):65–73;CrossRefGoogle ScholarCaplan, AL. Ensuring the future of uterine transplantation. Fertility and Sterility 2013;99(3):682–3;CrossRefGoogle ScholarPubMedArora, KS, Blake, V. Uterus transplantation: Ethical and regulatory challenges. Journal of Medical Ethics 2013;0:1–5;Google ScholarBenagiano, G, Landeweerd, L, Brosens, I. Medical and ethical considerations in uterus transplantation. International Journal of Gynaecology & Obstetrics 2013;123(2):173–7;CrossRefGoogle ScholarPubMedMilliez, J. Uterine transplantation: FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health. International Journal of Gynecology & Obstetrics 2009;106(3):270.CrossRefGoogle ScholarPubMed

6. See note 5, Nair et al. 2008; Del Priore, G, Stega, J, Sieunarine, K, Ungar, L, Smith, JR. Human uterus retrieval from a multi-organ donor. Obstetrics and Gynecology 2007;109(1):101–4.CrossRefGoogle ScholarPubMed

7. Priore, GD, Saso, S, Meslin, EM, Tzakis, A, Brännström, M, Clarke, A, et al. Uterine transplantation—a real possibility? The Indianapolis consensus. Human Reproduction 2013;28(2):288–91.CrossRefGoogle ScholarPubMed

8. See note 7, Priore et al. 2013.

9. Farrell, RM, Falcone, T. Uterine transplantation. Fertility and Sterility 2014;101(5):1244–5;CrossRefGoogle ScholarPubMedOlausson, M, Johannesson, L, Brattgård, D, Diaz-Garcia, C, Lundmark, C, Groth, K, et al. Ethics of uterus transplantation with live donors. Fertility and Sterility 2014;102(1):40–3;CrossRefGoogle ScholarPubMed see note 5, Catsanos et al. 2013.

10. See note 5, Catsanos et al. 2013.

11. See note 9, Ollauson et al. 2014; Del Priore, G, Gudipudi, DK. Promise of uterine transplant—myth or a reality? Maturitas 2014;77(1):20–3.CrossRefGoogle ScholarPubMed

12. Orentlicher, D. Toward acceptance of uterus transplants. Hastings Center Report 2012;42(6):12–13.CrossRefGoogle ScholarPubMed

13. See note 12, Orentlicher 2012.

14. It should be noted, however, that surrogacy has its own ethical challenges and is not universally available.

15. See note 12, Orentlicher 2012, at 12.

16. Adoption and surrogacy are both known to be difficult to access, due to a combination of socioeconomic and legal limitations. The adoption process is estimated to cost from $8,000 to $40,000, and surrogacy is estimated to cost at least $60,000 in the United States. (Although the UTx procedure and follow-up care are expensive as well, once the technique is sufficiently well established, it will likely be covered by insurance companies, like other forms of transplantation.) Furthermore, a majority of states do not explicitly permit surrogacy; surrogacy contracts are legally unenforceable, or surrogacy is prohibited altogether, which creates either legal uncertainty or an insurmountable barrier for those attempting to engage in surrogacy in those states.

17. See note 5, Arora, Blake 2013.

18. OPTN/UNOS Board approves initial policies regarding limb and face transplantation. United Network for Organ Sharing Newsroom 2014 June; available at https://www.unos.org/optnunos-board-approves-initial-policies-regarding-limb-and-face-transplantation/ (last accessed 29 July 2015); Lefkowitz, A, Edwards, M, Balayla, J. The Montreal criteria for the ethical feasibility of uterine transplantation. Transplant International 2012;25(4):439–47.CrossRefGoogle Scholar

19. See note 5, Nair et al. 2008.

20. Monte L, Ellis R. Fertility of women in the United States: 2012. US Census; 2014 July; available at https://www.census.gov/content/dam/Census/library/publications/2014/demo/p20-575.pdf (last accessed 26 Mar 2015).

21. OPTN: Organ Procurement and Transplantation Network; available at http://optn.transplant.hrsa.gov/ (last accessed 26 Mar 2015).

22. Reinberg S. Donor hearts going to waste, researchers report. Consumer HealthDay 2015 Feb; available athttp://consumer.healthday.com/senior-citizen-information-31/organ-donation-news-508/donor-hearts-going-to-waste-researchers-report-696318.html (last accessed 29 July 2015).

23. Lung transplant: MedlinePlus Medical Encyclopedia. MedlinePlus; available at http://www.nlm.nih.gov/medlineplus/ency/article/003010.htm (last accessed 29 July 2015).

24. The Editorial Board. Ways to reduce the kidney shortage. New York Times 2014 Sept; available at http://www.nytimes.com/2014/09/02/opinion/ways-to-reduce-the-kidney-shortage.html?_r=1 (last accessed 29 July 2015).

25. The status of vascularized composite allograft allocation. Organ Procurement and Transplantation Network Newsroom; available at http://optn.transplant.hrsa.gov/news/the-status-of-vascularized-composite-allograft-allocation/ (last accessed 29 July 2015).

26. Membership requirements for vascularized composite allograft transplant programs. Organ Procurement and Transplantation Network; available at http://optn.transplant.hrsa.gov/media/1153/0115_10_vca_membership.pdf (last accessed 29 July 2015).

27. Mumtaz, Z, Levay, A. Ethics criteria for uterine transplants: Relevance for low-income, pronatalistic societies? Journal of Clinical Research & Bioethics 2013;01(S1):004.CrossRefGoogle Scholar

28. See note 18, Lefkowitz et al. 2012.

29. Lefkowitz, A, Edwards, M, Balayla, J. Ethical considerations in the era of the uterine transplant: An update of the Montreal Criteria for the Ethical Feasibility of Uterine Transplantation. Fertility and Sterility 2013;100(4):924–6.CrossRefGoogle Scholar

30. ASRM topic: Infertility. American Society for Reproductive Medicine; available at http://www.asrm.org/topics/detail.aspx?id=36 (last accessed 29 July 2015).

31. See note 7, Priore et al. 2013, at 290.

32. See note 1, Brännström et al. 2015.

33. See note 1, Brännström et al. 2015.

34. See note 7, Priore et al. 2013, and note 29.

35. Saso, S, Bracewell-Milnes, T, Ismail, L, Hamed, AH, Thum, MY, Ghaem-Maghami, S, et al. Psychological assessment tool for patients diagnosed with absolute uterine factor infertility and planning to undergo uterine transplantation. Journal of Obstetrics and Gynaecology 2014;34(6):504–7.CrossRefGoogle Scholar

36. See note 7, Priore et al. 2013.

37. We do not mean to imply that women who become mothers through surrogacy or adoption are any less mothers to their children, or even that they are not mothers in the exact same way as women who gestate their children with regards to many of the aspects of motherhood (e.g., responsibility and closeness). They have, however, become mothers through a different path, one that may correspond better or worse to the desires and life goals of different women.

38. How to distinguish between women who desire only to gestate and women who desire to become mothers is a difficult question. Suffice it to say that these cases will be rare.

39. See note 27, Mumtaz, Levay 2013.

40. A complete analysis of what kinds of pressure constitute undue or illegitimate pressure to undergo UTx is beyond the scope of this article. See Millum (2014) for a full discussion of undue third-party pressure in a medical context. (Millum, J. Consent under pressure: The puzzle of third party coercion. Ethical Theory and Moral Practice 2013;17(1):113–27.CrossRefGoogle ScholarPubMed)

41. Cousineau, TM, Domar, AD. Psychological impact of infertility. Best Practice & Research Clinical Obstetrics & Gynaecology 2007;21(2):293–308.CrossRefGoogle Scholar

42. See note 5, Catsanos et al. 2013.

43. Rumsey, N. Psychological aspects of face transplantation: Read the small print carefully. American Journal of Bioethics 2004;4(3):22–5.CrossRefGoogle Scholar

44. See note 35, Saso et al. 2014.

45. Policy 12: Allocation of vascularized composite allografts (VCA). Organ Procurement and Transplantation Network; 2015 May; available at http://optn.transplant.hrsa.gov/ContentDocuments/OPTN_Policies.pdf#nameddest=Policy_12 (last accessed 29 July 2015).

46. Policy 10: Allocation of lungs. Organ Procurement and Transplantation Network; 2015 May; available at http://optn.transplant.hrsa.gov/ContentDocuments/OPTN_Policies.pdf#nameddest=Policy_10 (last accessed 29 July 2015).

47. Policy 6: Allocation of hearts and heart-lungs. Organ Procurement and Transplantation Network; 2015 May; available at http://optn.transplant.hrsa.gov/ContentDocuments/OPTN_Policies.pdf#nameddest=Policy_06 (last accessed 29 July 2015).

48. Policy 8: Allocation of kidneys. Organ Procurement and Transplantation Network; 2015 May; available at http://optn.transplant.hrsa.gov/ContentDocuments/OPTN_Policies.pdf#nameddest=Policy_08 (last accessed 29 July 2015).

49. The new Kidney Allocation System (KAS) frequently asked questions. Organ Procurement and Transplantation Network; available at http://optn.transplant.hrsa.gov/ContentDocuments/KAS_FAQs.pdf (last accessed 29 July 2015).

50. Amaral, S, Reese, PP. Children first in kidney allocation: The right thing to do. Transplant International 2014;27(6):530–2.CrossRefGoogle Scholar

51. Williams, A. Intergenerational equity: An exploration of the “fair innings” argument. Health Economics 1997;6(2):117–32.3.0.CO;2-B>CrossRefGoogle Scholar

52. See note 50, Amaral 2014, at 530.

53. “Ethical Principles of Pediatric Organ Allocation.” Organ Procurement and Transplantation Network: available at http://optn.transplant.hrsa.gov/resources/ethics/ethical-principles-of-pediatric-organ-allocation/ (last accessed 15 Nov 2015).

54. Daniels, N. Global aging and intergenerational inequity. In: Daniels, N. Just Health: Meeting Health Needs Fairly. Cambridge: Cambridge University Press; 2007:161–90.CrossRefGoogle Scholar

55. See note 53, “Ethical Principles of Pediatric Organ Allocation.”

56. Daniels, N. The prudential life-span account of justice across generations. In: Daniels, N. Justice and Justification. Cambridge: Cambridge University Press; 1996:269.CrossRefGoogle Scholar

57. Women of childbearing age who are malnourished. World Health Organization; available at http://www.who.int/ceh/indicators/malnourishedwomen.pdf (last accessed 29 July 2015).

58. O’Grady K. Early puberty for girls: The new “normal” and why we need to be concerned. National Women’s Health Network; 2009 Oct; available at https://nwhn.org/early-puberty-girls-new-%E2%80%9Cnormal%E2%80%9D-and-why-we-need-be-concerned (last accessed 29 July 2015).

59. Menopause. National Institute on Aging; 2011 July; available at https://www.nia.nih.gov/health/publication/menopause (last accessed 29 July 2015).

60. See note 20, Monte, Ellis 2014.

61. IVF. NHS Choices; 2015 Jan; http://www.nhs.uk/Conditions/IVF/Pages/Introduction.aspx (last accessed 29 July 2015).

62. Insurance coverage for infertility laws. National Conference of State Legislatures; available at http://www.ncsl.org/research/health/insurance-coverage-for-infertility-laws.aspx (last accessed 29 July 2015).

63. Heffner, LJ. Advanced maternal age—how old is too old? New England Journal of Medicine 2004;351(19):1927–9.CrossRefGoogle Scholar

64. Maria del Carmen Bousada de Lara was diagnosed with cancer within a year of giving birth and tragically passed away in 2009.

65. Caplan AL, Patrizio P. Are you ever too old to have a baby? Older women and infertility services. Medscape: Seminars in Reproductive Medicine 2010; available at http://www.medscape.com/viewarticle/726675 (last accessed 29 July 2015); Smajdor, A. The ethics of IVF over 40. Maturitas 2011;69(1):37–40;CrossRefGoogle ScholarFriese, C, Becker, G, Nachtigall, RD. Rethinking the biological clock: Eleventh-hour moms, miracle moms and meanings of age-related infertility. Social Science & Medicine 2006;63(6):1550–60;CrossRefGoogle ScholarPubMedSteiner, AZ, Paulson, RJ. Motherhood after age 50: An evaluation of parenting stress and physical functioning. Fertility and Sterility 2007;87(6):1327–32;CrossRefGoogle ScholarPubMedSauer, MV. The impact of age on reproductive potential: Lessons learned from oocyte donation. Maturitas 1998;30(2):221–5.CrossRefGoogle Scholar

66. Grossman, LC, Kort, DH, Sauer, MV. Managing assisted reproduction in women over the age of 50 years: A clinical update. Expert Review of Obstetrics & Gynecology 2014;7(6):525–33.CrossRefGoogle Scholar

67. Jolly, M, Sebire, N, Harris, J, Robinson, S, Regan, L. The risks associated with pregnancy in women aged 35 years or older. Human Reproduction 2000;15(11):2433–7.CrossRefGoogle ScholarPubMed

68. See note 63, Steiner, Paulson 2007.

69. See note 63, Caplan, Patrizio 2010.

70. See note 63, Smajdor 2011.

71. The Practice Committee of the American Society for Reproductive Medicine and the Practice Committee of the Society for Assisted Reproductive Technology. Recommendations for gamete and embryo donation: A committee opinion. Fertility and Sterility 2013;99(1):47–62.e1.CrossRefGoogle ScholarPubMed

72. As is mentioned in a later section, women at the top of this age range will, in practice, likely receive somewhat lower priority on the basis of their being less likely to achieve a successful pregnancy despite access to available fertility treatments.

73. Benzies, KM. Advanced maternal age: Are decisions about the timing of child-bearing a failure to understand the risks? Canadian Medical Association Journal 2008;178(2):183–4.CrossRefGoogle ScholarPubMed

74. Hoffman, SD, Maynard, RA. Kids Having Kids: Economic Costs and Social Consequences of Teen Pregnancy. The Urban Institute, Washington, DC; 2008.Google Scholar

75. Hoffman SD. By the numbers: The public costs of teen childbearing. The National Campaign to Prevent Teen Pregnancy; 2006 Oct; available at https://thenationalcampaign.org/sites/default/files/resource-primary-download/btn_national_report.pdf (last accessed 29 July 2015).

76. New York State Consolidated Laws, Domestic Relations Chapter 14, Article 7, Titles 1–4.

77. District of Columbia Code (1999), Title 16 Particular Actions, Proceedings and Matters, Chapter 3, Sections 16-301 to 16-315.

78. The Ethics Committee of the American Society for Reproductive Medicine. Child-rearing ability and the provision of fertility services: A committee opinion. Fertility and Sterility 2013;100(1):50.CrossRefGoogle Scholar

79. HFEA Code of Practice: Guidance Note 8. Welfare of the child (version 2.0). Human Fertilisation and Embryology Authority; available at http://www.hfea.gov.uk/5473.html (last accessed 29 July 2015).

80. The Ethics Committee of the American Society for Reproductive Medicine. Access to fertility treatment by gays, lesbians, and unmarried persons: A committee opinion. Fertility and Sterility 2013;100(6):1524.CrossRefGoogle ScholarPubMed

81. OPTN/UNOS Ethics Committee. Ethical principles in the allocation of human organs. Organ Procurement and Transplantation Network Newsroom; 2015 June; available at http://optn.transplant.hrsa.gov/resources/ethics/ethical-principles-in-the-allocation-of-human-organs/ (last accessed 29 July 2015).

82. See note 60, Insurance coverage for infertility laws 2015.

83. Uffalussy JG. The cost of IVF: 4 things I learned while battling infertility. Forbes; 2014 Feb; http://www.forbes.com/sites/learnvest/2014/02/06/the-cost-of-ivf-4-things-i-learned-while-battling-infertility/ (last accessed 29 July 2015).

84. If we took into account ability to afford the treatments needed to become pregnant, we would be advantaging wealthier women who could afford all the treatments they need. Instead, we should develop a mechanism for obtaining low-interest loans for women in need of additional care. It is also possible that, in the future, the procedure will be covered by health insurance.

85. Thoracic Organ Transplantation Committee. Proposal to revise the lung allocation score (LAS) system. OPTN/UNOS 2012 Oct: 1–112.