'Equality-enhancing potential of novel forms of assisted gestation: Perspectives of reproductive rights advocates' by Elizabeth Chloe Romanis in (2023)
Bioethics comments
Novel forms of assisted gestation—uterus transplantation and artificial placentas—are highly anticipated in the ethico-legal literature for their capacity to enhance reproductive autonomy. There are also, however, significant challenges anticipated in the development of novel forms of assisted gestation. While there is a normative exploration of these challenges in the literature, there has not yet, to my knowledge, been empirical research undertaken to explore what reproductive rights organisations and advocates identify as potential benefits and challenges. This perspective is invaluable. These organisations/individuals have an awareness not only of the needs of individuals but also of the political landscape in which regulatory decisions are made and which individuals navigate when seeking reproductive assistance. In this study, data was generated from two semi-structured focus groups (n = 11). Reflective thematic analysis was used to examine the views raised by study participants in these focus groups. This paper explores two of the themes constructed in the data. First, the equality-enhancing potential of assisted gestation exploring the multifaceted ways in which assisted gestation has structural benefits for marginalised groups. Second, realising the equality-enhancing potential of assisted gestation explores the intersecting barriers to access to reproductive technologies and how they may impede the benefits of these technologies in practice. These results can enhance conceptual understanding of the importance of novel forms of assisted gestation and ensure that attention is paid to practical barriers in further normative research.
For people unable to gestate, whether for biological, social or psychosocial reasons, assisted gestation affords them the opportunity to become biological parents. Assisted gestation has long existed in surrogacy. However, novel reproductive technologies that make possible different forms of assisted gestation are on the horizon and are highly anticipated for the specific experiences they could afford people who cannot gestate. This article reports results from an empirical research project seeking the views of reproductive rights advocates in Great Britain about the benefits and limitations of novel forms of assisted gestation.
Uterus transplantation (UTx) presents the possibility of enabling those without a uterus of their own (whether they were born without it or have had a hysterectomy) to gestate—experiencing pregnancy and birth. Since the first report of a live birth from a successful UTx in Sweden in 2014, approximately one hundred transplants have been successfully performed worldwide. While the procedure is not yet widely available and is yet to be performed in the United Kingdom (at the time of writing), it is described as an ‘emerging therapy that is transitioning from an experimental phase to an established clinical practice’. To date, the transplant has only been performed on people with physiology assigned female at birth (AFAB). However, one team of research surgeons have concluded that despite being challenging ‘there is no overwhelming clinical argument against performing UTx’ on a person with physiology assigned male at birth.
A more futuristic endeavour is the artificial placenta, capable of facilitating gestation outside of the body (‘ectogestation’). Speculation about the possibility of gestation outside the body has increased since the publication of successful animal studies demonstrating proof of concept in 2017. There are now more teams working on the prospect, and promising results of animal testing continue to be published worldwide. These devices all have a similar design—a sealed system of warm amniotic fluid (in which the subject is located), with a cannula acting as an umbilical cord to deliver oxygen and nutrients and remove waste, and a pumpless oxygenator circuit. Researchers have indicated that they hope to begin testing on human subjects in the immediate future. Equity financing for clinical translation was secured in 2022 by the team working in Philadelphia. These devices are being designed specifically as a means of improving outcomes from extremely premature birth. Artificial placentas have the potential means of enhancing reproductive decision-making by ‘taking over’ gestation for people undertaking dangerous pregnancies. The technology, in its current iteration, can facilitate only partial ectogestation (since the technology is reliant on the subject having foetal physiology). In the future, artificial placentas might have further choice-enhancing potential by offering the ability to make decisions about what degree of bodily gestational labour individuals are willing to undergo in becoming a parent in a broader range of circumstances, for example, by enabling people to opt out of performing a complete gestation, or, even of undertaking gestation at all.
There is a growing body of normative ethical literature that explores the benefits and potential limitations of both UTx and artificial placentas; however, this literature can be considered somewhat disjointed. These technologies are most often explored in isolation and while it is important that we consider what is different about each technology, considering forms of assisted gestation collectively can help us see the implications of arguments made about novel technologies in their broader context. Moreover, considering the genus of assisted gestation (and thus several technologies encompassed within it) can improve our conceptual understanding of the technologies. While these technologies work in different ways, there are some obvious synergies in their potential uses to aid people who cannot gestate, and they might be thought of as alternative options to address an inability to gestate by potential service-users. Thus, in this study, multiple forms of assisted gestation were considered. The study sought to ascertain the views of reproductive rights advocates about novel forms of assisted gestation—UTx and artificial placentas—drawing together experiences and reflections connected to each.
To my knowledge, before this study, there had been no empirical research conducted exploring reproductive rights advocates’ perspectives on novel forms of assisted gestation. Empirical research with individuals working with or for reproductive rights organisations is key because they have an awareness of the experiences of different people who cannot gestate or who have experienced difficulties during gestation and birth and of the political landscape. Their insights are consequently invaluable in highlighting how individuals may want to access and use novel technologies, as well as some of the challenges they may face. This article reports results from a focus group study exploring these perspectives that was analysed using a reflexive thematic analysis approach. These results have utility in helping enhance the understanding of why assisted gestation is important, and what the potential access barriers are for individuals, in further normative research.
