Womb Transplants in Sweden

A team of surgeons in Sweden have transplanted donated uteruses into 9 women who were born without them, or who had lost them to cervical cancer. The aim is to permit the women to bear their own children. From the story:

"The transplant operations did not connect the women's uteruses to their fallopian tubes, so they are unable to get pregnant naturally. But all who received a womb have their own ovaries and can make eggs. Before the operation, they had some removed to create embryos through in-vitro fertilization. The embryos were then frozen and doctors plan to transfer them into the new wombs, allowing the women to carry their own biological children."

There are several ethics issues here, clearly. First, there's the danger to the donors of the uteruses. Doctors said they preferred live uterus donors to dead donors because they could be certain, with live donors, that the uteruses were functioning properly and didn't have any problems like HPV infection. But the uterine donation is a major surgery--more dangerous than a hysterectomy, since it involves removal not only of the uterus but also of surrounding blood-vessel needed to keep the uterus alive in the donee. The procedure thus subjects donors to serious risk for the sake of a donation that isn't lifesaving.

Perhaps more troubling is the question of how the pregnancies will proceed. Will the developing fetuses be affected by the anti-rejection drugs the women are taking? What happens if rejection occurs part-way through a pregnancy? Will the uteruses be strong enough to carry the fetuses to term safely? Will placental formation and blood flow be sufficient to ensure the fetuses are healthy? At what stage and for what reasons will pregnancies be terminated?

If pregnancy is achieved, doctors plan to remove the uteruses to prevent the women's having to take anti-rejection drugs for life. (The drugs can have serious side-effects.) Two earlier attempts at human uterine transplantation (using uteruses from dead donors) failed: one in 2000 in Saudi Arabia, which had to be abandoned when a blod clot formed; and another in Turkey last year, in which the pregnancy failed at 2 months. Uterine transplants have been done in mice, sheep and baboons, but the baboon transplants did not result in pregnancy.

An American team announced its intention to perform a uterine transplant some years ago, raising some ethical issues, but no such procedure has yet been performed in the US.  

NSW, Australia Considers Eliminating Organ Donor Family Veto

A new discussion paper from the New South Wales (Australia) Ministry of Health raises the possibility of eliminating the veto-power over organ donation that families of potential organ donors currently hold. NSW has the largest donor registry in Oz, but that hasn't translated into high transplantation numbers, largely because 45% of families choose to veto the harvesting of organs from their loved ones who'd signed up to be organ donors. This article summarizes some responses to the proposal. Transplant Australia, Kidney Health Australia and the Australian Medical Association all line up in favor of the change, but, interestingly, a spokesman for transplant lobby group ShareLife opposed the move, arguing that it could undermine people's willingness to sign up to be donors, and pointing out that the countries with the most successful transplant programs (Spain, Portugal, Croatia) all respect the wishes of the family. What matters isn't the legal regime, but the quality of communication with the families.

The discussion paper also raises the possibility of moving from the current opt-in system to a "presumed consent" system where patients would have to opt out of donation, but it does so only formally, noting (correctly) there's little international evidence in favor of making that move. Finally the paper suggests scrapping the NSW Roads and Maritime Services donor register and transferring its content to Medicare's national register.

Ninth Circuit Approves Bone Marrow Payment

The US Ninth Circuit Court of Appeals has determined that the federal ban on selling organs does not apply to bone-marrow donors who use modern marrow-donation technology. The once-painful procedure has now been replaced by a procedure resembling blood donation. Instead of removing actual marrow from the donor's bone, physicians now remove marrow precursor cells from the donor's blood--and the National Organ Transplant Act does not restrict payments for blood donation. The holding permits MoreMarrowDonors, a California nonprofit, to move forward with a program to offer $3000 scholarships, housing allowances or charitable donations as inducements to bone marrow donors.

Deadish Donors

BioEdge is reporting on a proposal made this summer in AJOB, and repeated this year at the ASBH meeting, to do away with the dead donor rule. The basic argument is that 1) the legal definition of "brain death"--total cessation of all upper-brain and brain-stem function--seldom applies to people we term "brain dead," because there's typically a little bit of residual functioning left; and the cardiac-death criteria depend, often, upon a decision being made not to revive someone who, in other circumstances, might be considered revivable (e.g., someone whose heart stopped 90 seconds ago). So, given that we're already harvesting organs from people who are only problematically "dead" according to our current, flawed, definitions, why not just tell the truth, do away with the dead donor rule, and substitute a regime of honesty about the complexity of death, and informed consent? The difficulty, of course, is with the politics and public understanding of the rule. No matter what kind of public education you attempt to do, if you were to announce the end of the dead-donor rule, a certain segment of the population would flee from being organ donors because of fear that they'd be "killed" for their organs.

Note: Harvard's Bob Truog has been making very similar arguments against the dead donor rule for years.

Black Market Kidney Conviction in US

A man pled guilty yesterday to multiple counts of illegal trafficking in human kidneys. This is the first conviction under federal law banning the sale of human organs. The defendant took payments of $120,000 or more for each of three kidneys which he purchased from donors in Israel for $10,000 each. He was caught in a government sting operation, attempting to sell an organ to a federal agent. His attorneys argued that the resultant transplants worked, relieving the American buyers from the burdens of kidney disease and dialysis; that the organ recipients had sought him out and not vice-versa; that the donors in each case were aware of what they were doing; and that the surgeries were conducted by reputable and skilled transplant surgeons in well-known (but unnamed) American hospitals. The money, they argued, was used for "expenses associated with the procedures"--though it's not clear from the coverage what that's supposed to mean. Federal prosecutors were rightly unimpressed, noting that black-market organ sales pose a public health danger, and are also unfair, since they result in preferential allocation of organs to the rich (and corrupt).

Another approach to organ donation...

Nuffield on Bodily Donation

The Nuffield Council on Bioethics has posted a new report on donation of human bodies and body parts for medicine and research. It covers a wide range of topics: live and cadaveric organ donation for transplant, gamete donation for reproduction, use of healthy volunteers in first-in-human trials, blood and cord blood, tissue donation, and more. It's a huge and far-reaching report, and I haven't had time to read it deeply, yet, but it appears that the most controversial of its recommendations is to create a pilot program under which women would be paid for donating eggs for research.