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Whole Body Gestational Donation

photograph of pregnant belly

In her recent paper, “Whole Body Gestational Donation,” Oslo University-based ethicist Anna Smajdor proposed a thought experiment in which the bodies of brain-dead women were used as biological incubators to gestate humans from conception to birth. Her argument follows along the lines of traditional posthumous organ donation, arguing that if we’re comfortable with the regulatory and ethical systems underlying the gifting of individual body parts (hearts, kidneys, livers, eyes, etc.), then we should allow consenting women to donate their entire body to act as a deceased surrogate. And that, if we have some discomfort with the latter prospect, and we are committed to the idea of treating like for like, then perhaps there is something wrong with the more traditional form of donation. But, conversely, if we’re happy with the former, we should be satisfied with the latter.

Unsurprisingly, given the controversial subject matter, her paper blew up. Both curious and indignant responses have come from broadcasters and outlets across the spectrum, including Fox News, Cosmopolitan, BioEdge, and Women’s Health, to name just a few. Smajdor received such vitriol because of this coverage that she wrote a follow-up piece for The Progress Educational Trust, providing some context to her thoughts and defending the work, emphasizing that it was not a policy suggestion but, rather, a way of highlighting a potential inconsistency in how we understand postmortem donation.

Now, much could be written about how media outlets have covered (and, as Smajdor suggests in her response, deliberately misconstrued) her argument. Instead, however, what I want to do here is engage with the work itself. Specifically, I want to discuss the best use of donated organs.

But, before doing so, I feel it’s important to acknowledge that the prospect of women being used as tools for gestation after brain death is bleak. Rather than being taken off ventilation and allowed to die promptly (and maybe with some dignity), the idea that doctors could keep these women artificially alive simply so their reproductive organs can work to grow a fetus for a third party needing a surrogate is, on the face of it, horrifying. It, not unjustly, conjures up intense emotional discomfort for many. But, as Smajdor notes in her paper and response, simply finding something unpleasant isn’t a sufficient justification to consider it immoral or impermissible.

Many things that we now think acceptable, maybe even good, were at one point lambasted because of their seemingly clear immorality (heart transplants, for example). Ultimately, the “wisdom of repugnance,” as Leon Kass terms it, may give us reason to pause for thought but is not a good enough reason to outright disregard a proposal.

What, then, is the problem (or at least one of the problems) with Smajdor’s proposal? The answer for this article’s focus comes down to a numbers game. Specifically, how many people can the organs from a single cadaver help?

In the right conditions – that is, if the cause of death isn’t something that makes the organs unusable – a single deceased organ donor can save up to eight lives. Each kidney can be donated to a different individual, freeing them from dialysis (on average, for someone on dialysis, life expectancy is five to ten years). A single liver can be split into two and donated to two more people. Each lung can go to a different individual, helping another two people. Finally, the pancreas and the heart can help the final two persons. It is not just life-saving body parts like these that clinicians can harvest after death: corneas, skin, tendon, ligaments, blood, bone, bone marrow, and even the hands and face can be donated to those who need them. In fact, according to the U.S.’s Health Resources & Services Administration, a single deceased donor can save eight lives and help another seventy-five.

Not everyone who signs up to be a deceased donor can donate the full range of body parts. There are multiple reasons why this may be the case, from medical to social to religious. Even with this acknowledgement, however, each person who agrees to donate their organs and other biological materials does something which can fundamentally change many people’s lives for the better.

Each part of the body that is donated is a gift of immeasurable worth, one that we must think carefully about how best to use. To waste such organs or consolidate them so that they help only a tiny few is to do a great disservice to the person who, by donating their body after death, undertakes an act of immense selflessness and beneficence.

It is here that whole body gestational donation runs into a problem.

Using someone’s body for gestation means that those organs and tissues cannot be relocated and used for another purpose or help another person. Instead, the life-saving or enhancing organs and tissues will be occupied for the nine months that the donor uses their reproductive organs to grow a human. For example, you can’t harvest the heart from a brain-dead person if the cadaver already uses that heart to pump blood around the body during gestation. The same is true of other organs, which will need to remain in the body to ensure that pregnancy can occur and delivery is successful.

A potential counterargument is that not all organs are required for persons to gestate or even live. Living organ donation happens regularly and doesn’t result in that person’s untimely demise. You can donate part of your liver or pancreas, an entire kidney or lung and keep on living, albeit with some health implications. It seems theoretically possible that the same could be true for whole body gestational donation. Some organs and tissues would need to remain for the pregnancy to occur, while others could be harvested and donated to those in need. In effect, splitting the donation allocation into those required for gestation and those not.

Beyond the unpleasantness of such a proposition (which, again, isn’t sufficient to rule out the proposal), there may likely be practical reasons why this isn’t possible.

As Smajdor herself notes, pregnancy isn’t a benign process. On the contrary, it carries severe dangers and puts a not-inconsiderable toll on the human body. This is as likely to be the case for the dead body as it is for the alive one.

As such, harvesting multiple organs and tissues while simultaneously expecting the brain-dead body to gestate successfully might simply be asking too much. Ultimately, the body may be unable to handle the biological load of pregnancy without relying upon the full range of life-sustaining organs.

In traditional, post-donation pregnancies, this usually doesn’t appear to be the case. For example, the U.K.’s NHS notes that “many women have had babies after donating a kidney without any impact on the pregnancy from the kidney donation.” However, we’re not talking about normal pregnancies here. The brain-dead body could be vulnerable to various complications and negative impacts because it’s dead. And while this wouldn’t be a risk to the pregnant body (after all, they’re already dead), it could jeopardize the efficacy of whole body gestational donation if it means that successful gestation is unfeasible when combined with traditional organ donation.

So then, if faced with a choice between whole body gestational donation, which could help bring one person into the world, or traditional forms of organ and tissue donation, which could save eight lives and help a further seventy-five, the latter seems like the obvious choice. This, in turn, may help us explain (or perhaps justify) our differing intuitions when it comes to the apparent equivalence of organ donation and gestational donation.

Procreative Autonomy and Climate Change

photograph of father walking with daughter in the water on the beach

This article has a set of discussion questions tailored for classroom use. Click here to download them. To see a full list of articles with discussion questions and other resources, visit our “Educational Resources” page.

From record-setting wildfires raging the Amazon to rising sea levels and melting ice caps, the devastating effects of climate change are becoming ever more apparent. Scientific data maintains that much of the rise in average global temperature is a direct result of human activities that emit heat-trapping greenhouse gases. The effects of climate change that we are currently facing are a consequence of a one-degree Celsius increase in average global temperature when compared to pre-industrial times. At this rate, we will experience up to a 4°C increase in average warming by 2100, which will only exacerbate and magnify the already rampant environmental degradation.

Fortunately, this future is avoidable as long as mitigating measures are rapidly implemented at the individual, community, and national levels. Recent analysis suggests that if immediate changes to halt climate change are made, carbon emissions can be lessened within 12 years, which will keep the rise in average temperature to 1.5°C above pre-industrial levels. Given that our actions now are crucial to the future of the biosphere and consequently the future of all people, climate-conscious individuals recognize the urgent need for change.

Even though scientific consensus asserts the existence of climate change, to global warming and climate change skeptics, this is still a point of contention. But to the rest, the numerous impacts of climate change can raise valid concerns over the sustainability of natural resources, and the kind of dystopian reality future generations will be grappling with in their lifetime if we do not act now.

A contentious resolution that has been proposed is factoring in climate change when deciding whether or not to have children and how many, if at all. Climate change has forced people to contemplate the ethics of having children in a consistently warming and thereby deteriorating world. Curtailing the population means the environment will suffer a reduced impact due to human activities, which will translate to a higher standard of living for the remaining population in terms of an increase in per capita availability of natural resources. Earlier this year, Rep. Alexandria Ocasio-Cortez faced criticism from conservatives following her Instagram live stream in which she pondered, “Basically, there’s a scientific consensus that the lives of children are going to be very difficult. And it does lead, I think, young people to have a legitimate question: Is it okay to still have children?”

For BirthStrikers, the answer is decidedly tough but evident. UK-based environmental activist Blythe Pepino set up BirthStrike, a voluntary organization for people who have made the decision to not have children given the inevitable environmental deterioration looming in the future. Pepino maintains that BirthStrike does not aim to dissuade people from bearing children but to instead spotlight the exigency of the ecological crisis. BirthStrikers are a part of a growing movement of people who have made this decision and the movement continues to gain momentum as conversations regarding the ethics of bearing children are fostered in groups of climate-conscious people.

On the other hand, some are quick to dismiss the notion of limiting procreation due to climate change as absurd, such as Republican Sen. Mike Lee of Utah who in March, stated that the solution to climate change is having more babies. On the Senate floor, Lee shared his solution in a presentation, declaring that, “More babies will mean forward-looking adults, the sort we need to tackle long-term large-scale problems.”

Tyler Cowen, a professor of economics at George Mason University echoes Lee’s thoughts on climate change and bearing children. Cowen argues that having more children and increasing the population of a nation would also increase the chances of nation coming up with innovative solutions to climate change. Cowen states, “If progress on climate change is at all possible, someone will need to contribute to it,” and goes on to explain that the most promising people who will do so is our potential children, especially if we are climate-conscious.

However, Lee and Cowen’s reasoning does not account for the series of carbon footprints our descendants will be producing which will collectively continue to add to the problem we are aiming to solve. Lee and Cowen also fail to address scientific data that deals with decisions made at the individual level, with recent research pointing to having children being detrimental to the environment given its already fragile state. Researchers calculated that having one less child would result in a family in an industrialized nation conserving 58.6 tons of carbon dioxide each year, which is much more efficient than other proposed solutions to limiting carbon dioxide production such as giving up cars (saving 2.4 tons) and flying (saving 1.6 tons per transatlantic flight).

Discussing the prospect of not having children as a legitimate solution to climate change gives rise to other ethical concerns such as our right to bear children and the innate value of procreation. Procreative autonomy is one of many forms of autonomy people can employ to govern their lives and an extension of one’s right to liberty. In the context of human reproduction, exercising procreative autonomy means having total freedom in their choices regarding bearing children and, ultimately, retaining dominion over one’s body. Implementing policies to curb procreation interferes with individual procreative autonomy. While this value is of great significance, we might wonder whether whatever right we might have to it is absolute. If every individual possesses an inherent right to bear children, does this right also mean that an individual should have as many children as they want without any regard for the environmental consequences of their decision?

The instinct theory of human procreation states that all animals including humans have an inherent and fundamental desire to procreate, which is why almost all animals reproduce. This theory goes on to explain that if humans do not procreate, having left their purpose unfulfilled, will be unhappy. This theory is not without its flaws – the notion of an intrinsic desire for progeny lacks supporting empirical data. The urge to procreate is not universal amongst humans – people have and still choose not to experience parenthood simply because that is not what they want. In this light, the procreation-instinct theory comes across as an oversimplification of human nature.

If population growth is to be regulated to resolve climate change, can governmental restrictions on the number of children one can bear ever be justified? Sarah Conley, a philosophy professor at Bowdoin College argues it can indeed be justified in her 2005 journal article, The Right to Procreation: Merits and Demerits. Conley explains that if procreative autonomy is considered a right or an extension of the freedom to live life on our own terms, then restricting the number of children one can have would be an encroachment of this right. But Conley also notes that, “Imposing one’s children on an overpopulated world is also a kind of interference […] in the lives of others in that world. Whose desire should trump?” Comparing the significance of different people’s rights, Conley points out how one person’s right to something can outweigh another person’s right to something else, and how the more basic a right is, the more difficult it would be to supersede. Even though it would be repressive for a government to regulate the number of children one can bear, it may be even more repressive to rob others of the right to basic needs of life by contributing to overpopulation, which would deplete finite natural resources. Hence, Conley believes that governmental restrictions on childbearing is ethically admissible because unlimited procreation would impinge on others’ fundamental rights even more so than governmental limitations on procreation would interfere with one’s procreative autonomy.

Regardless of where one stands on this issue, decisions about bearing children remain deeply personal. While all people have the right to bear children, the fact is that overpopulation and the resulting increase in human activities are contributing to climate change. Whether you regard the climate impact of having a child an important consideration or not, taking action to remedy climate change is becoming ever more pressing and contemplating the ethical concerns climate change presents can serve as a driver to help us arrive at an equitable solution.

“Free Birth” and the Politics of Childbearing

Black and white photograph of a midwife holding a baby

Last month, a woman using the pseudonym ‘Lisa’ shared on Facebook that her infant daughter had died: ”Journey Moon was born a sleeping angel on Oct. 7 at 8 lbs 13 oz. She passed due to a massive urinary tract infection I had… I’m laying in the hospital writing this and get to go home tomorrow. We will be having Journey cremated.”

Lisa had a post-term pregnancy, lasting forty-two weeks. She experienced complications throughout a six-day labor on her desert property, including an inability to urinate due to her UTI. Attended only by her husband, Lisa did not seek medical support until long after her water broke, and she was concerned by the appearance of an unusual, odorous liquid. After a complicated delivery requiring a vacuum and anesthesiologist, Lisa gave birth to her stillborn child.

Why undertake a six-day labor without seeking medical support? The answer lies with Lisa’s newfound community.  Lisa had joined a 6000-strong Facebook group of women under the aegis of the Free Birth Society. Founded by Emilee Saldaya and Yolande Clark, the Free Birth Society advocates for ‘autonomy’ in giving birth. ‘Autonomy’ in Free Birth parlance appears to be code for ‘isolation’ as much as for individual control.  The website advocates for “wild” birth, as contrasted against “unnecessary interference with this physiological design.”  

Free Birth rejects both obstetrics and midwifery, instead offering coaching packages ranging from $98 USD to $899 with titles such as ”Conscious Conception” and “Radical Birth Keeper.” Membership in the now-defunct Facebook group (to which Lisa belonged) was free. However, strict norms were enforced, which included immediate deletion of comments from users who advised medical assistance when complications arose. This self-regulated online community encouraged Lisa to continue the ‘free-birth’ process throughout the agony of her six days.

The Free Birth Society capitalizes on deep cultural issues around childbirth. The history of medicine does not shine with respect to women’s autonomy. J. Marion Sims, lauded as the father of modern gynecology, performed unanaesthetized operations on nonconsenting slave women. Obstetrics is still fraught when it comes to respecting the autonomy and consent of childbearing individuals. One of the most infamous recent cases was of Caroline Malatesta, whose crowning infant was forced back into her vagina by a nurse for six minutes, resulting in irreparable nerve damage and PTSD. A 2012 study found that the strongest predictor of PTSD from giving birth was conflict with care providers. Often, obstetrics practices can mirror patriarchal paradigms.

In light of these factors, it is easy to see the appeal of a movement that emphasizes women’s control over their own birthing process. Saldaya and Clark offer a vision of birth-positivity, describing it as the “most profound experience of ecstasy, love, power and beauty in our human experience.” Their website seems suffused with joy and even suggests giving birth “naturally” confers esoteric wisdom (Clark speaks of the “deep and hidden truths” of a “secret society”). This emphasis on the subjective experience and knowledge of women who give birth is appealing, as it addresses gaps commonly experienced by obstetric patients. But Free Birth goes further than other critiques, to the extent that it eschews even midwives and doulas who traditionally served as advocates for women-centered birthing paradigms.

Free Birth’s complete rejection of conventional and alternative care providers could be also read in light of an undercurrent of mistrust of experts that runs broader in American culture. On the Free Birth website, there are contradictions reminiscent of other alternative discourses, such as anti-vaccine movement. Multiple references are made to “physiology” and “evidence-based birth” in the abstract, but physiological accounts and citations of specific studies are notably absent.

Saldaya and Clark do not simply encourage women to inform themselves, arm themselves with options, celebrate childbirth, and campaign for better patient-doctor obstetric experiences. Free Birth altogether rejects professional support and knowledge (apart from workshops in ‘Free Birth’) in favor of a sort of mysticism. The claim is that once all interference is removed, the body knows what to do.  

This corporeal yet mystical task of ‘unlearning’ suggests the exploitation of a third cultural trend – the sanctimony of the “mommy wars.” In a world where every reproductive choice a woman makes is weighted by juggling impossibly burdensome roles, Free Birth proposes solo childbirth as one more achievement badge of ‘natural’ motherhood to which women should aspire.

The appeal of the Free Birth Society derives from deep-seated problems around women’s reproductive autonomy. It is understandable why women would be attracted to de-emphasizing the medicalization of childbirth, and to reclaiming its celebration. Unfortunately, as Lisa’s example shows, this desire does not change the fact that childbirth remains a risk in “nature.”

Do women deserve better maternal care around the world? Indubitably, both in the developed world, and especially in developing countries, where for some women, ‘natural’ childbirth is perforce and not an Instagrammable lifestyle. But women also deserve better than Saldaya and Clark’s “secret society.”  While identifying some serious issues, Saldaya and Clark have accepted and reinforced the marginalization which leads women to a radical dichotomy.  A meaningful childbirth and a healthy, living mother and child should not be treated as mutually exclusive outcomes.

Women deserve social transformation that harnesses scientific knowledge, political voice, individual autonomy, subjective experience, and ethics. Instead of alienating women from crucial maternal health support, we need concerted efforts between pregnant individuals, medical care providers, midwives, and society at large to improve knowledge of and adherence to maternity care that respects women’s autonomy.

Womb Transplantation: A Procedure in Need of Defense?

A woman viewing an ultrasound

Baylor Medical Center in Dallas recently announced a first in the US: a woman gave birth to a baby from a transplanted uterus. The procedure currently has a staggering price tag: $200,000 to $250,000.  It’s cheaper to hire a gestational surrogate to carry a baby, though still very expensive.  So it seems uterus transplantation forces women to defend their desire to give birth, as opposed to leaving the birthing to someone else.  But then, hiring a surrogate is much more expensive than adopting.  So perhaps the woman who opts for a uterus transplant also has to defend her determination to procreate instead of adopting.  In an Axios article on the “complicated ethics of uterus transplantation,” the fact that adoption is not pursued by the transplant patient is one of the main issues raised.

Continue reading “Womb Transplantation: A Procedure in Need of Defense?”