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Sunday, March 20, 2016

Uterus transplants and other interventions extending capabilities to those not born with them

The Cleveland clinic's most recent attempt to do a cadaveric uterine transplant did not meet with the desired endpoint. The uterus had to be removed because complications (Link). This was brought to my attention in a blog piece from the MD Whistleblower (Link). He raises some interesting questions but I think his questions should also touch upon implications in a much broader clinical and ethical realm. The circumstances of the transplant were the patient who received the transplant was born without a womb. As it turns out, there are many humans who are born without wombs, approximately half  to be specific.

The Cleveland Clinic experiment seems like a bad idea at multiple levels. It is not as if no other options existed for this specific person. For the transplanted womb option to work, they had to go through the in vitro fertilization anyway meaning those eggs could have been implanted in a surrogate who did not need to take a host of immunosuppressive drugs for the entirety of the pregnancy. Frankly, I do not see how any IRB could approve this protocol. It places the person getting the uterus at great risk and places an unborn child at great risk, all of which is completely unnecessary for generating a child. Yes, it is a clinical trial but I simply cannot see how these types of risks can be justified. It appears to be reckless in my opinion.

The ability or inability to carry a child because of having or not having a uterus is one of basically an infinite set of human functional differences which exist because of inborn or acquired differences. The question I want to pose is what portion of these differences constitute fair game for correction via some sort of medical intervention? What sort of interventions should we strive to develop and which ones of these should be the target of investment of public dollars? As we move inexorably toward a world which defines access and payment for health care as a universal right, what of the inevitable desires of people to use the health care system to enhance functionality beyond what they were born with? Does that too represent an inherent human right?

Think of all the differences in inborn or acquired traits which could become fair game. I am not so tall and always thought it would be great to be taller, much taller. The fact that I am "vertically challenged" likely has had all sorts of impact on what success and failures I have encountered in life. Simple physical attractiveness (perhaps not so simple) has huge functional implications which has major impact on where people end up in the world. At his point height and physical attractiveness are already amenable to some form of rectification. Imagine all of the possibilities for enhancements that other interventions could impact.

Should this be within the realm of heath care delivery? We already have bleed through in terms of training and missions. Physicians trained in plastic surgery and increasingly other fields such as dermatology, are trained as physicians but have moved into realms very distinct from taking care of people with actual illness and sickness. Once we validate the mission to take people who are not sick by any typical definition of disease, and push the mission to create functionality that people were not born with, we are doing something very different. Before we open this Pandora's Box, we should be very intentional about understanding where it will take us.