An Ethics-Informed, Comparative Analysis of Uterus Transplantation and Gestational Surrogacy for Uterine Factor Infertility in High-Income Countries

Interest in the future, clinical implementation of uterus transplantation for uterine factor infertility was recently boosted by the demonstration of proof-of-concept for deceased uterus donation/transplantation. The ethical dimensions of living and deceased uterus transplantation are explored and addressed in the paper through their comparison to the ethical elements of an existing, legal, assisted reproduction practice in some high-income countries, i.e., gestational surrogacy. A set of six ethics lenses is used in the comparative analysis: reproductive autonomy and rights, informed choice/consent, relevant critical relational theories, health equity, theoretical application of the accepted living donation standard, and comparative benefits and burdens considerations. Gestational surrogacy, as currently practiced in some high-income countries, is the assumed, theoretical base-threshold for determination of ethical acceptability in assisted reproduction practices. The analysis demonstrates that (at the present time): 1) the ethical acceptability of living uterus donation/transplantation is less than that of gestational surrogacy in high-income countries, and 2) the ethical acceptability of deceased uterus donation/transplantation is roughly equivalent to that of gestational surrogacy. This leads to the conclusion that, at the present time, only one version of uterus transplantation practice, i.e., deceased uterus transplantation, should be considered ethically acceptable for possible clinical implementation in high-income countries.