Daniel Callahan Young Writer's Prize Winner

Congratulations to Michelle Bayefsky on winning the first Daniel Callahan Young Writer's Prize! Michelle will be receiving the prize award of $500 and a copy of Daniel Callahan's autobiography, In Search of the Good: A Life in Bioethics. Thank you to the finalist judges, Daniel Callahan, Michael Gusmano, and Laura Haupt (their bios can be found here). 

Uterine Transplant: Where, If Anywhere, Should We Draw the Line?
By Michelle Bayefsky

In October 2014, researchers from the University of Gothenburg in Sweden reported the first case of a live birth following a uterine transplant. The uterus was transplanted from a postmenopausal woman into a 36 year-old woman born without a uterus. At nearly 32 weeks of pregnancy, she gave birth to a male child with normal birth weight for gestational age and excellent APGAR scores.[1]

The birth of this child represents a tremendous breakthrough in the treatment of infertility. There are many causes of female infertility, including damaged fallopian tubes, premature menopause and endometrial (uterine tissue) abnormalities. Corresponding treatments include in vitro fertilization, use of donor eggs, and use of a gestational surrogate. Uterine transplantation could obviate the need for gestational surrogates for patients with uterine infertility, allowing these mothers-to-be to carry their own pregnancies and potentially precipitating a decline of the controversial practice of surrogacy.

But why stop there? If uterine transplantation is a treatment for absolute uterine infertility, trans-women also have this condition, and so do all men. In this essay, I will explore whether and where to draw the line for those who should be eligible for a uterine transplant.

It is not yet possible for individuals with XY sex chromosomes to gestate a child. However, the desire for transgender women to carry a pregnancy is present,[2] and at least one bioethicist, Timothy Murphy, has begun to think about the prospect of uterine transplants into trans-women.[3] Murphy correctly focuses on state funding, since the hands-off regulatory attitude towards reproductive medicine in the United States[4] makes it unlikely that transgender uterine transplants would be banned outright. The debate about the appropriateness of transgender uterine transplants will therefore center on the need to prioritize limited healthcare resources.[5]

There are two central questions at stake. First, is there such a thing as a right to a uterine transplant? Second, is there a reason to distinguish between cis-women, trans-women, and men with regards to their claims to a uterine transplant, whether or not rights are at stake? If so, the state could be justified in prioritizing the needs of cis-women over trans-women over men who desire to gestate a child.

Uteruses are a scarce resource, and the state cannot ensure uteruses to all those who might lack and strongly desire them. It is therefore difficult to claim that people have a right to a uterine transplant, though they may have a right to fair access to an established supply of uteruses, should one come to exist. The scarcity issue is compounded by the fact that uteruses, like other organs, exist within other people’s bodies. Unless a sufficient number of uteruses are supplied via donation, claiming a right to a uterine transplant would be claiming a right to someone else’s body part. One could conceive of body parts as public goods, but such a view would violate our closely held beliefs about bodily autonomy. Since the state cannot forcibly redistribute organs, the right to a uterus can only be a right in an abstract sense. Nevertheless, the relative strength of claims to this abstract right can be used to determine what constitutes fair access to the limited supply of uteruses. Who, if anyone, should be prioritized?

Answering this question requires that we carefully examine our notions of infertility and instincts about childbearing. Intuitively, we might think there are reasons to differentiate among cis-women, trans-women, and men based on physical features and what it means to be “infertile.” For instance, it may be tempting to argue that cis-women without uteruses are infertile because they lack the typical reproductive organs of an XX-woman, while trans-women and men are fertile because they can still use sperm to ‘father’ children in the classic XY manner. However, all three categories are fertile in terms of their gametic capacity to reproduce but infertile with regards to the capacity to gestate.

One might also attempt to argue that women, whether cis or trans, have a stronger claim to the experience of carrying a child because it is typically a woman’s experience and part of being female. However, many women choose not to have children and are not lesser women because of it. Furthermore, arguments about childbearing based on assumptions about what it means to be a woman risk unjustly imposing societal norms and expectations on women, both cis and trans.

It may seem that distinctions among the three groups most plausibly rely on assertions relating to the prospective happiness of the transplant recipient. It is possible that cis-women have greater childbearing expectations, and would be most anguished by the inability to carry a pregnancy and should thus be given highest priority. Similarly, trans-women, who identify as the sex that typically bears children, may be more anguished than a self-identifying man. It is easy to imagine, though, a trans-woman who has always longed to gestate a child, or even a man with a very strong desire to carry a child, who would suffer deeply if they could not obtain a uterine transplant – even more than some cis-women without functional uteruses. Thus psychological impact could not reliably be used to distinguish among the three groups.

Ultimately, a priori distinctions could most reasonably be made on the basis of differential resource expenditure. If uterine transplantation is significantly easier, more successful or less expensive in a cis-woman, or a trans-woman who has undergone hormone therapy, this justifies prioritizing these groups the same way recipients are prioritized in the donation of other organs.[6]

Realistically, given the general lack of coverage for fertility services in the United States,[7] it is unlikely that either cis or trans-gender uterine transplants will be funded in the near future.

However, if uterine transplants do receive public funding and transplants into XY women and men are equally successful and no more economically burdensome than transplants into XX women, trans-women, as well as men with a profound desire to gestate, should be equally eligible to receive a uterine transplant.

Michelle Bayefsky is a first-year pre-doctoral fellow in the Department of Bioethics for the National Institutes of Health. She graduated from Yale University in 2014 with a B.A. in Ethics, Politics and Economics. She worked as a research assistant for two consecutive directors of the Yale Interdisciplinary Center for Bioethics. She also founded and served as Editor-in-Chief of the Yale Bioethics Journal. Michelle currently investigates ethical challenges posed by innovations in genetic technology, issues related to the regulation of genetic testing, and questions that arise at the intersection of genetics and reproductive medicine.
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[1] Brännström, M., L. Johannesson, et al. (2014). "Livebirth after uterus transplantation." The Lancet.

[2] Mott, Stephanie. "Trans-Uterus." The Huffington Post. TheHuffingtonPost.com, 21 Jan. 2014. Web. 14 Nov. 2014.

[3] Murphy, Timothy. "The Ethics of Helping Transgender Men and Women Have Children." Perspectives in Biology and Medicine 53.1 (2010): 46-60.

[4] Leigh, Suzanne. "Reproductive 'tourism'" USA Today - Health and Behavior. USATODAY.com, 02 May 2005. Web. 19 Sept. 2014; Williams, Benjamin. "Screening for Children: Choice and Chance in the “Wild West” of Reproductive Medicine." George Washington Law Review 79.4 (2011): 1305-342.

[5] Murphy, Timothy. "Uterus Transplants for Transgender Women?" Weblog post. Ethics and Choices about Children. Timothyfmurphy.blogspot.com, 27 Apr. 2014. Web. 14 Nov. 2014.

[6] The use of cost-effectiveness arguments in prioritizing organ transplantation is itself controversial (see, for example, Dan Brock, “Ethical Issues in the Use of Cost Effectiveness Analysis for the Prioritisation of Health Care Resources”), but I cannot explore this issue here.

[7] "State Laws Related To Insurance Coverage for Infertility Treatment." Insurance Coverage for Infertility Laws. National Conference of State Legislatures, Jun. 2014. Web. 12 Nov. 2014.