The Royal Hospital for Women Foundation in Sydney recently held a fundraising event which featured doctors from the Hospital speaking of a successful uterine transplant to a woman they had performed in January 2023.

When asked whether they would transplant a uterus to a transwoman (a biological man) to allow her to carry a child, they did not rule it out. Uterine transplants to biological men are another complex ethical issue raised in the context of reproductive technologies.

Let’s start with the easiest case, which is the one in the Royal Hospital’s example. A young woman loses her uterus from complications of childbirth. Her mother is the uterine donor. The mother’s motivation is her love and compassion for her daughter and the donation is altruistic and no money, profit or commercialism is involved. Provided all other criteria for an ethical organ donation and transplant are fulfilled – for example, acceptable risk, informed consent from all involved, no coercion, and so on – I believe most people would agree this intervention is ethical and legal.

Whether that is also true for transwomen seeking a uterine transplant is not clear, however, because it does not fall within the same parameters. The website of the Royal Hospital for Women Foundation regarding its involvement in reproductive technologies, in general, summarises that well: “Help make the impossible possible”. This possibility of a uterus transplant to a biological man raises many complex ethical issues, including when is it unethical to use medical technologies to achieve what is impossible in Nature. That is an increasingly relevant and important question in bioethics.

My first thought on hearing of this event was a flashback memory to 1988 and the 57th Annual Couchiching Conference, “Biological Engineering: Blessing or Curse?”, held over a residential weekend at Geneva Park, Ontario, Canada. I was the featured speaker and my keynote address was titled “Biotechnology: Doing the Unthinkable” and my closing remarks “Going to Peace on Nature”.

It was a warm summer afternoon and I was the first speaker after Sunday lunch, so I anticipated a sleepy audience. I decided to wake them up by addressing the question, “Should men be helped to become pregnant?”. Unknown to me there was a journalist in the audience. On Monday morning, a Canadian newspaper (from memory the Ottawa Citizen) had a short front-page article, “Ethicist says men could have babies.”

That day when I arrived at my office at McGill University in Montreal, I received several phone calls from men saying they were interested in knowing whom they could contact to explore this possibility. I asked one of them, a heterosexual married man with five children, why he wanted to do this. He replied, “Because I’ve always envied my wife being able to carry our child and I’d like to have that experience.” Most women who contacted me said the men who wanted to become pregnant must be mad to want to take on that burden. We know that hypothetical decision making, which it was at the time, can be very different from facing the real situation, which is now our reality.

So let’s have a look at the ethics of this.

The best interests of the child

First, in all reproductive technology decision-making, we must place the child and their rights and “best interests” at the centre of the decision-making and they must take priority. This often does not happen because the fertility industry, which is predicted to generate over US$46 billion revenue annually by 2030, cannot market to a yet-to-be-conceived child, but only to the adults who want a child. This results in the would-be-parents’ interests being central and the future child’s interests, if considered at all, secondary at best.

We sometimes operationalise the requirement of placing the future child at the centre of the decision-making through a doctrine called “anticipated consent”. If the child were here now is it reasonably certain they would consent to their coming into existence in this way? If that is not reasonably certain, ethically the procedure should not be undertaken.

The doctrine of the child’s anticipated consent is important. My experience with Australians born from anonymous sperm donation when that was still legal was that they would not have consented. One of them, Joanna Rose (now Dr Rose) was giving evidence to an official enquiry (I can’t recall whether it was a parliamentary committee or another official enquiry).

An enquiry member – a man - confronted her aggressively saying, “I don’t know what you are complaining about, if it hadn’t been for that anonymous donation you wouldn’t be here causing a fuss.” My heart sank. How could one reply to that? She left a long pause then said, “If I were the outcome of rape, I’d be glad to be alive, but that doesn’t mean I approve of rape.” Brilliant.

Repairing nature

We can also make a distinction, which not everyone agrees helps us ethically, between using medical technology to repair nature when it fails – as in the case of the young Sydney woman – with using it to do what is impossible in Nature, a biological man being pregnant. The former is much more likely to be ethical than the latter. This could allow us to justify, ethically, helping biological women with a uterine transplant, but not biological men, without being accused of wrongful discrimination.

Just because a doctor carries out a procedure does not mean that it is necessarily medical treatment. My contention is that uterine transplantation is medical treatment for a biological woman with a defective uterus, but not for a biological man. We are more likely to have claims or even rights to necessary medical treatments, than to non-therapeutic interventions.

If the uterine recipient were a biological man, more ethical issues are raised. For instance, if “she” were a transwoman, would “her” sperm be used to fertilise donor ova? If so, she would be both the mother and the father of the child. The law in many jurisdictions defines the mother of a child as the woman who gives birth to it. This is the reason that in some jurisdictions surrogate motherhood was legislated as an exception to this presumption.

Here is another example of an ethical issue: what if the uterus donor were a transgender man (a biological women) having gender realignment/transition surgery and asks that “her” uterus be donated to a transgender woman?

Currently, an alternative possibility for gestating human babies is on the horizon. Exogenesis, the use of artificial uteruses, so no human would be involved in gestating the child. This has already been achieved in the laboratory with lambs. As the renowned Australian scientist Alan Trounson said to me when Dolly the cloned sheep‘s existence was announced, “What we can do in one mammal we can do in other mammals. The crossover time from animals to humans is usually around seven years.” The relevant and urgent ethical question is always not “Can we?”, but “Should we?” implement all the possibilities new science opens up?