Bioethics

Is It Immoral for Men to Gestate? Transgender* Women?

Recent advances in uterus transplantation will soon make this possible

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Schwarzenegger Pregnant
Junior

The first child ever successfully gestated in a transplanted uterus and brought safely to term was born in Sweden in September. The healthy baby boy's 36-year-old mother had been born without a uterus. The transplanted organ was donated by a 61-year-old family friend who had herself given birth to two children.

Eggs were extracted from the woman's intact ovaries and fertilized in vitro using her male partner's sperm. This produced eleven embryos that were then frozen. A year after the transplant, physicians installed a single embryo in the woman's new womb which resulted in the pregnancy that led to the birth of the baby boy.

The Swedish woman who gave birth last year is one of nine women into whom researchers transplanted donated uteruses in 2013. Two of the recipients had to have their transplants removed due to infections and blood clots. There's no news of any pregnancies so far from the other recipients.

As it happens, there are other human beings who are born without uteruses: males and transgender women. Is there any reason—biological or ethical—why they should not be considered as possible uterus transplant candidates? With regard to biology, it is already quite common to successfully transplant solid organs such as kidneys, livers, and hearts between different sex donors and recipients now.

More research will be doubtlessly be required, but there do not seem to be any insuperable physiological barriers to figuring out how best to connect up the proper blood supply to the donated organs and manage relevant hormonal issues in men and transgendered recipients. In the case of transgender women, they will already be following a supplemental hormone regimen. The supply of organs could be quite large since post-menopausal women can be donors.

So are there any moral reasons why men and transgender women should not be permitted to gestate? One handy ethical rule of thumb with regard to deploying a novel reproductive technology is that it should be about as risky as conventional procreation. As a reference point, note that in the United States about 3 percent of babies are born with a major structural or genetic birth defect. The Swedish infant got a near perfect APGAR score, demonstrating that it is possible to safely bring a baby to term in a transplanted womb.

In the December 2014 issue of Bioethics, University of Illinois College of Medicine bioethicist Timothy Murphy asks if uterus transplantation becomes routine and effective, "would there be any morally significant reason why men or transgender women should not be eligible for the same opportunity for gestation?" He concludes in his article, "Assisted Gestation and Transgender Women," that the answer is no. 

Murphy is mainly arguing against Australian bioethicist Robert Sparrow who asserts, "Because pregnancy is not a reasonable expectation in men, men who wish to become pregnant are not capable of establishing that this desire should be granted the same moral weight as women's desires to become pregnant." Both philosophers are fixated on the question of whether the state is obliged by the interests of some of its citizens in giving birth by means of the assisted gestation to pay for research and the medical provision of the technology. Murphy thinks that the answer is "yes," but he is wrong. Sparrow is wrong for different reasons. He thinks that the answer is "yes" for women, but "no" for men. It should be "no" for both.

Setting public health conundrums aside, one citizen does not, in general, have a moral claim on the money and time of another citizen merely to benefit himself and his interests. Thus there is no moral justification for the public funding of assisted gestation research and treatments for either men or women. 

Sparrow goes badly astray when he claims that "no negative right to male pregnancy exists." As conventionally defined, a negative right is a right to be free to hold and practice a belief, to pursue an action, or enjoy a state of affairs without outside interference. Sparrow rather convolutedly comes to his perplexing conclusion largely because he thinks that male pregnancy will only be possible if there is a corresponding positive right requiring that the government pay for the development of assisted gestation technologies applicable to men. Women have a positive right to research funding and treatments, but men do not. Since Sparrow believes that assisted gestation for men will necessarily not be developed without government funding then it doesn't matter if male pregnancy is outlawed. Thus one cannot have a negative right to do something that in fact one cannot do. This evidently passes for sophisticated philosophical reasoning nowadays.

Murphy is, however, right when he notes that Sparrow's "analysis of assisted gestation would not cut at all against privately-funded research, since private parties are, in general, free to spend their money according to their own lights. It is therefore entirely possible that private funders could support and bring to successful completion a program of assisted gestation research for men and transgender women." This point is bolstered by the fact that privately-funded research is largely responsible for most of the advances in assisted reproduction made during the past four decades.

Assuming that uterus transplants can be made to work in men and transgender women who would be happy to pay for the surgery and follow up treatments themselves, are there any ethical reasons that they should be denied the joys and pains of pregnancy and childbirth? The 2013 update to the authoritative Montreal Criteria for the Ethical Feasibility of Uterine Transplantation suggests that given the current concerns over safety and efficacy, it is premature to offer uterus transplants to men and transgender women now. However, the update acknowledges that this is likely to change and observes that "there does not seem to be a prima facie ethical reason to reject the idea of performing uterine transplant on a male or trans patient."

In support of this judgment, the authors of the update point out that the principle of autonomy is not sex-specific. They argue that a man or trans patient who wants to bear a child does not have a lesser moral claim to that desire than do women. The Montreal Criteria update makes this intriguing analogy: "A male who identifies as a woman, for example, arguably has UFI [born without a uterus], no functionally different than a woman who is born female with UFI." The authors then observe that "such a person's right to self-governance of her reproductive potential ought to be equal to her genetically female peers and should be respected." If it is moral to offer this technology to a genetic female without a uterus, why would it be immoral to provide it to a genetic male without uterus? The answer is that it wouldn't be.

"All people, however sexed in body, have interests one way or another about whether to have children and about how to have them," observes Murphy. "Not only do those interests vary widely, the interests will in some measure be artifacts of the technologies available."

Murphy is right. People's procreative decisions are increasingly made in the context of proliferating reproductive technologies. Technologies that now enable people to pursue their interests in how and when to have children include contraceptive pills and injections, gamete donation, artificial insemination, in vitro fertilization, freezing eggs, sperm, and embryos for later use, surrogacy, intracytoplasmic sperm injection, cytoplasmic transfer of mitochondria into eggs, pre-implantation genetic diagnosis, and freezing ovarian tissue. All of these technologies were once widely considered to be ethically problematic, but are now accepted as moral by most people.

Novel reproductive technologies over the horizon are cloning, the generation of sperm and eggs from somatic cells, tissue engineering to grow new uteruses, editing the genomes of embryos prior to implantation, and artificial wombs. Sometime later in this century it will be possible to transform skin cells taken from a single person into both eggs and sperm. In vitro fertilization could combine those gametes to generate an embryo that might then be gestated in an artificial womb. By that time people will regard uterus transplantation as the technological equivalent of bear skins and stone axes.

For the foreseeable future the vast majority of people will continue to pursue their interests in having children in the conventional way. It's fun and a lot cheaper.

Ultimately, uterus transplantation will be a niche reproductive technology sought by very few people who have been born lacking that organ—be they genetic females or genetic males. There is no moral reason to deny the option of uterus transplantation to those who have an interest in using it and are willing to pay for it. In other words, individuals do have the negative right to pursue assisted gestation.

Disclosure: I am a cisgender male with no current interest in gestating.

*Correction: Changed from "transgendered" to "transgender" to conform to AP style.