New research published in The American Journal of Bioethics highlights the ethics of the use of deceased vs living donors in uterus transplantation.
Absolute uterine factor infertility affects approximately 1.5 million women worldwide. For almost 2 decades, researchers have been working to understand the implications of living vs deceased donors in uterus transplants.
The first live birth after a uterus transplant was achieved in Sweden in 2014, followed by 4 more births, all from uteri provided by living donors. In the United States, the first successful trial with living uterus donors took place in 2017 at Baylor University Medical Center, and the Cleveland Clinic is currently conducting a trial with deceased donors. Other institutions are developing their own trials with both living and deceased donors. As data accumulate from various studies, the unique challenges and benefits of both deceased and live donors are emerging.
Researchers from Case Western Reserve University and the Cleveland Clinic Lerner College of Medicine focused on moral justification and consent to donation of the organs, as well as some of the challenges and complexities resulting from uterus donation.
Moral justification for the procedure is somewhat controversial because of the risk posed to a live donor — in effect, a healthy person who becomes a patient. However, people may choose to become donors based on perceived psychological benefits, especially if they are a family member of the recipient. In the case of deceased donors, there is the question of whether uterus donation is justified since it is not considered a lifesaving procedure. Other quality-of-life donations have been permitted in the past, and uterus transplants can be justified as generally beneficial for the recipient’s psychological and emotional health.
In examining the role of consent in uterus donation, the investigators pointed out that in the United States, the uterus is not an organ included in the general donor agreement. As such, donors with uteri may never even have considered that uterus donation could be a possibility and thus cannot have given their consent. It has also been determined that procurement of nonvital organs such as the uterus should occur only after vital organs have been procured, and must not prevent the harvesting of lifesaving organs. Living donors are able to give consent as well as accept any risk to their own health and any emotional or psychological effects that may follow donation. Currently, it is difficult to determine the full extent of these risks given the limited number of surgeries that have been performed to date.
Researchers also addressed some of the nuances particular to uterus transplant, such as donor rights. It has been determined that once the transplant has occurred, donors and their families have no right to the uterus, which becomes the property of the recipient. After it has been used and removed, the uterus is considered medical waste. Donors and families of donors must also recognize that they have no parental rights regarding any children born from the donation, according to the Uniform Parentage Act of 2000. In addition, family members who serve as donors should know that donation does not promise a future relationship with any resulting children.
Based on the various benefits and challenges of uterus donation, the investigators concluded that deceased uterus donation is justified by the principle of beneficence, and living donation is justified by the psychological and emotional benefits to the donor. There are risks involved for living donors, and those risks should be fully understood by donors before a decision is made. Additionally, donors should acknowledge that by donating a uterus they relinquish their rights to any resulting children. Because uterus transplantation is a relatively new area in medicine, the researchers advocate for creation of an international registry to monitor the procedure and its outcomes as various institutions take part.
Bruno B, Arora KS. Uterus transplantation: the ethics of using deceased versus living donors. Am J Bioeth. 2018;18(7):6-15.