Whole Body Gestational Donation

In her recent paper, “Whole Body Gestational Donation,” Oslo University-based ethicist Anna Smajdor proposed a thought experiment in which the bodies of brain-dead women were used as biological incubators to gestate humans from conception to birth. Her argument follows along the lines of traditional posthumous organ donation, arguing that if we’re comfortable with the regulatory and ethical systems underlying the gifting of individual body parts (hearts, kidneys, livers, eyes, etc.), then we should allow consenting women to donate their entire body to act as a deceased surrogate. And that, if we have some discomfort with the latter prospect, and we are committed to the idea of treating like for like, then perhaps there is something wrong with the more traditional form of donation. But, conversely, if we’re happy with the former, we should be satisfied with the latter.

Unsurprisingly, given the controversial subject matter, her paper blew up. Both curious and indignant responses have come from broadcasters and outlets across the spectrum, including Fox News, Cosmopolitan, BioEdge, and Women’s Health, to name just a few. Smajdor received such vitriol because of this coverage that she wrote a follow-up piece for The Progress Educational Trust, providing some context to her thoughts and defending the work, emphasizing that it was not a policy suggestion but, rather, a way of highlighting a potential inconsistency in how we understand postmortem donation.

Now, much could be written about how media outlets have covered (and, as Smajdor suggests in her response, deliberately misconstrued) her argument. Instead, however, what I want to do here is engage with the work itself. Specifically, I want to discuss the best use of donated organs.

But, before doing so, I feel it’s important to acknowledge that the prospect of women being used as tools for gestation after brain death is bleak. Rather than being taken off ventilation and allowed to die promptly (and maybe with some dignity), the idea that doctors could keep these women artificially alive simply so their reproductive organs can work to grow a fetus for a third party needing a surrogate is, on the face of it, horrifying. It, not unjustly, conjures up intense emotional discomfort for many. But, as Smajdor notes in her paper and response, simply finding something unpleasant isn’t a sufficient justification to consider it immoral or impermissible.

Many things that we now think acceptable, maybe even good, were at one point lambasted because of their seemingly clear immorality (heart transplants, for example). Ultimately, the “wisdom of repugnance,” as Leon Kass terms it, may give us reason to pause for thought but is not a good enough reason to outright disregard a proposal.

What, then, is the problem (or at least one of the problems) with Smajdor’s proposal? The answer for this article’s focus comes down to a numbers game. Specifically, how many people can the organs from a single cadaver help?

In the right conditions – that is, if the cause of death isn’t something that makes the organs unusable – a single deceased organ donor can save up to eight lives. Each kidney can be donated to a different individual, freeing them from dialysis (on average, for someone on dialysis, life expectancy is five to ten years). A single liver can be split into two and donated to two more people. Each lung can go to a different individual, helping another two people. Finally, the pancreas and the heart can help the final two persons. It is not just life-saving body parts like these that clinicians can harvest after death: corneas, skin, tendon, ligaments, blood, bone, bone marrow, and even the hands and face can be donated to those who need them. In fact, according to the U.S.’s Health Resources & Services Administration, a single deceased donor can save eight lives and help another seventy-five.

Not everyone who signs up to be a deceased donor can donate the full range of body parts. There are multiple reasons why this may be the case, from medical to social to religious. Even with this acknowledgement, however, each person who agrees to donate their organs and other biological materials does something which can fundamentally change many people’s lives for the better.

Each part of the body that is donated is a gift of immeasurable worth, one that we must think carefully about how best to use. To waste such organs or consolidate them so that they help only a tiny few is to do a great disservice to the person who, by donating their body after death, undertakes an act of immense selflessness and beneficence.

It is here that whole body gestational donation runs into a problem.

Using someone’s body for gestation means that those organs and tissues cannot be relocated and used for another purpose or help another person. Instead, the life-saving or enhancing organs and tissues will be occupied for the nine months that the donor uses their reproductive organs to grow a human. For example, you can’t harvest the heart from a brain-dead person if the cadaver already uses that heart to pump blood around the body during gestation. The same is true of other organs, which will need to remain in the body to ensure that pregnancy can occur and delivery is successful.

A potential counterargument is that not all organs are required for persons to gestate or even live. Living organ donation happens regularly and doesn’t result in that person’s untimely demise. You can donate part of your liver or pancreas, an entire kidney or lung and keep on living, albeit with some health implications. It seems theoretically possible that the same could be true for whole body gestational donation. Some organs and tissues would need to remain for the pregnancy to occur, while others could be harvested and donated to those in need. In effect, splitting the donation allocation into those required for gestation and those not.

Beyond the unpleasantness of such a proposition (which, again, isn’t sufficient to rule out the proposal), there may likely be practical reasons why this isn’t possible.

As Smajdor herself notes, pregnancy isn’t a benign process. On the contrary, it carries severe dangers and puts a not-inconsiderable toll on the human body. This is as likely to be the case for the dead body as it is for the alive one.

As such, harvesting multiple organs and tissues while simultaneously expecting the brain-dead body to gestate successfully might simply be asking too much. Ultimately, the body may be unable to handle the biological load of pregnancy without relying upon the full range of life-sustaining organs.

In traditional, post-donation pregnancies, this usually doesn’t appear to be the case. For example, the U.K.’s NHS notes that “many women have had babies after donating a kidney without any impact on the pregnancy from the kidney donation.” However, we’re not talking about normal pregnancies here. The brain-dead body could be vulnerable to various complications and negative impacts because it’s dead. And while this wouldn’t be a risk to the pregnant body (after all, they’re already dead), it could jeopardize the efficacy of whole body gestational donation if it means that successful gestation is unfeasible when combined with traditional organ donation.

So then, if faced with a choice between whole body gestational donation, which could help bring one person into the world, or traditional forms of organ and tissue donation, which could save eight lives and help a further seventy-five, the latter seems like the obvious choice. This, in turn, may help us explain (or perhaps justify) our differing intuitions when it comes to the apparent equivalence of organ donation and gestational donation.