“From the Social Predestination Room the escalators went rumbling down into the basement, and there, in the crimson darkness, stewing warm on their cushion of peritoneum and gorged with blood-surrogate and hormones, the fetuses grew and grew or, poisoned, languished into a stunted Epsilonhood. With a faint hum and rattle the moving racks crawled imperceptibly through the weeks and the recapitulated eons to where, in the Decanting Room, the newly unbottled babies uttered their first yell of horror and amazement.” – Aldous Huxley, A Brave New World.
Last month Partridge et al. at the Children’s Hospital of Philadelphia published an article in Nature Communications called “An extra-uterine system to physiologically support the extreme premature lamb.” In other words, they used what is being described in the lay press as an “artificial womb” to extend the gestational, or in-womb, period using a system outside of the mother’s body for up to 4 weeks. This is not the first such experiment to extend gestation using an extracorporeal system, but so far it has been the most successful. As the authors describe, this system uses a pumpless oxygenator circuit which connects to the fetal lamb using an interface with the umbilical cord. The aminiotic fluid circuit is closed to the outside environment, mimicking the environment of the womb. The pumpless circuit is powered by the fetal heart.
The motivating factor behind this research is the fact that extreme prematurity is the leading cause of neonatal mortality and morbidity in the developed world. The goal is to be able to use this system to allow extremely premature newborns to continue gestational development and reduce their risk of death or of serious complications related to prematurity, including lung and brain problems. This sophisticated system would replace the incubators, ventilators, and feeding tubes that are currently in use in neonatal intensive care units (NICUs) across the country.
The authors of the paper have stated emphatically to the press that their extra-uterine gestational system is meant to be used on premature infants past the age of viability (currently 24 weeks), and that it is unlikely that a system that would start at conception would ever be feasible or successful. And yet, articles that I have read in the lay press have made all sorts of claims including that society will now start routinely growing fetuses in artificial wombs, that this could change how we think about gender and parenthood, and even that “women will become obsolete.” Online articles have brought up “ethical issues,” including the loss of the “human connection,” the “humanity” of the infant, and the blurred lines between fetus and infant.
The immediate practical ethical issues that I see as a physician relate more to the prognosis of the premature infants who use the “artificial womb.” A good intervention would provide better success rates and fewer risks of harm or death than the standard of care currently in use in the NICU. This intervention would be ethically problematic if it instead lead to the prolongation of the life and suffering of an infant who is inevitably going to die in the neonatal period. However, at this stage the “artificial womb” has not yet been used in human infants, and so far in the lamb model it has shown that the animals who survived the 4-week period had normal overall body growth, lung maturation, and brain growth.
Regardless, let us step into Gattaca for a moment and imagine that an artificial womb could replace the human mother’s womb for gestation, and that this was a common and even encouraged practice. I find it difficult to imagine that an artificial womb would be “better” than (providing more benefits and fewer risks) or equal to the average woman’s uterus and body for gestation. This is primarily because artificial interventions require us to troubleshoot logistical problems with medical solutions, which all have inherent risks. For example, the lines carrying the blood through the umbilical interface will clot, so blood thinners are required, increasing the theoretical risk of life-threatening fetal bleeding.
But let us say we got really good at creating an artificial womb, and we could replicate the human gestational environment with minimal risks. Let us imagine that this would allow anyone who so chooses to have a child with the help of an artificial womb, instead of, say, a surrogate mother. This could open more options for women with medical issues that render carrying a child dangerous or impossible for them, same-sex partners, women with demanding careers, and single men.
Some may ask, is the child “human?” And how does this change abortion politics? The child, like all zygotes who become fetuses who become babies, will be of the species Homo sapien, so he or she will be human. The controversial question in the abortion debate is, rather, whether the fetus is a Human Person, or an ethical and legal entity with all of the human and legal rights entitled to you or me.
Another controversial question in the abortion debate is, at what point do the rights of the fetus to continue its gestation outweigh the rights of the mother to decide whether to continue or terminate the pregnancy (always? never? at 12 weeks? at 24 weeks?). In most US states this point has been determined to be the age of viability, around 24 weeks, at which point the fetus, if born, could survive. It is possible that the artificial womb could change the age of viability. Furthermore, it is possible that the artificial womb could give women contemplating abortion another option past 24 weeks (for example, to birth the fetus and place the infant in an artificial womb where they will complete gestation and then be placed in the adoption system).
Though every new advance in medicine, technology, and society can and will have unforeseen and unintended consequences, the advance that is actually happening in 2017 is one that could improve the lives of premature infants and their families. Rather than looking to the future with horror and amazement, let us look at the present advancement with informed, objective, and practical eyes.