A womb with a view: the ethical dilemma of ectogenesis

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any people, be it for biological or social reasons, are not able to have a child without some sort of medical intervention. According to the UK NHS, one in seven couples who would normally be able to conceive will face difficulty in doing so.

While these fertility issues may arise from physiological problems in one or both partners, it is often the woman or partner with a uterus who bears the physical brunt of invasive fertility treatments like IVF. But rapidly advancing scientific developments around the world are opening the door to the possibility of artificial gestation.

Growing a baby outside of the womb is known as ectogenesis, and we already see a form of it in medical practice today. When premature babies are transferred to an incubator to continue their development in a neonatal unit, that’s partial ectogenesis.

But the concept of an artificial womb is something else altogether, something that could extend the period a foetus could be gestated outside of the body, and may even render the human womb obsolete.

Artificial wombs could provide a way for women who cannot carry their own child, gay male couples and single men to have biological children without the need for a surrogate. They could also boost the survival rates of extremely premature infants, even those born before the current viability window of around 22 to 24 weeks – just one factor that sets in motion a number of ethical questions about whether the artificial womb is something we should even be attempting at all.

Medical scientist Dr Nauf AlBendar says: “To this day, the morbidity and mortality rates for premature babies born before approximately 28 weeks gestation remains high. Therefore, the primary motive for artificial ‘womb’ technologies is to revolutionise treatment while providing a chance for severely premature babies to better develop their lungs and other important organs before being brought into the world.”

Recently, experiments led by Dr Jacob Hanna were carried out at the Weizmann Institute of Science in Israel to observe how the gestation process starts in mammals and understand how genetic mutations and environmental conditions may affect growing a foetus. But the work also raises questions about whether it might be possible to culture human foetuses outside of the womb.

Embryos were removed from the uteruses of mice at five days of gestation and grown for six more days in an artificial womb, bringing them around halfway to full development. They were placed in glass vials inside incubators, filled with a nutrient-rich fluid.

These vials were attached to a slowly spinning wheel to prevent the embryos from attaching to the wall, where they would become deformed and die. The incubators were also connected to a ventilation machine providing oxygen and carbon dioxide to the embryos.

At day 11 of development, the embryos in the artificial womb were found to be identical to those in the wombs of living mice. However, they had become too large to survive without a blood supply, and the nutrient solution that fed them through diffusion was no longer sufficient.

Combatting this is the next hurdle for the Weizmann researchers, but their work has already progressed beyond what they described in the paper. In an interview, Hanna has described taking fertilised eggs from female mice just after fertilisation, rather than five days later, and growing them in the artificial uterus for 11 full days.

These researchers aren’t the only ones to have developed an artificial womb. A team of clinicians at the Children’s Hospital of Philadelphia have developed the Biobag, a way to gestate sheep foetuses taken from their mother’s wombs by caesarean between 120 and 140 days gestation, an age equivalent to 23 to 24 weeks in humans.

The bag replaces the placenta with an oxygenator plugged into the lamb’s umbilical cord, filled with an amniotic fluid replacement which the lamb breathes and swallows.

Meanwhile, the Women & Infants Research Foundation in Western Australia has developed the Ex-Vivo Uterine Environment (EVE), which operates on similar principles but has been carried out using slightly younger lambs.

While the Weizmann research is being carried out to explore fundamental questions about the earliest stages of foetal development, the Biobag and EVE have both been developed with the express intention of improving outcomes for preemies.

AlBendar says: “These technologies are not yet ready for human use, but there are some daunting questions that we should ask ourselves before the first artificial womb baby comes to life, especially if these technologies will be used in multiple environments and not solely as an emergency life support in neonatal intensive care units.”

The impact artificial wombs could have on abortion laws is one of the most significant ethical quandaries arising from their potential development. In the UK, abortions can take place within the first 24 weeks of pregnancy. After this point, terminations may only be carried out if continuing the pregnancy constitutes a serious threat to the pregnant person’s life or in cases of serious foetal disability.

This time limit has been influenced partially by the fact that certain foetal abnormalities are not evident or do not develop until the 20 to22-week mark, but also by the fact that babies born before the 24-week mark have very low chances of survival outside the womb.

Artificial wombs like the Biobag and EVE could change all this, by allowing babies born this prematurely – and maybe even earlier – to continue developing outside of their mother inside an artificial uterus.

The legal abortion limit in the UK was brought down from 28 weeks to 24 in 1990 because advances in neonatal care meant foetuses born in this window had become more likely to live. 

If artificial wombs are ever able to help even smaller babies to survive, this could mean the legal limit on natal abortion is cut yet again, something which could have a profound impact on a pregnant person’s right to choose. 

If a foetus is viable outside of a person’s womb inside of an artificial one, then does the foetus’ right to life trump that of a pregnant person’s right not to become a parent?

As well as potential alterations to the termination time window, ectogenesis could change who makes the final decision about ending a pregnancy. 

Bioethicist Dr John Loike says: “There is going to be a difference with respect to who has a say.

One could argue that if a woman is carrying a child, she may have more of a say than her partner. On the other hand, if both parties are gestating an embryo or foetus in an artificial placenta, maybe it should be a more equal say and each partner should have an equal share in making that determination.”

Abortion legislation isn’t the only thing complicated by the ethics of ectogenesis. Fertility treatments like IVF and IUI can be prohibitively expensive, and access to them via public health providers like the NHS varies wildly between geographical territories. This has already led to a fertility wealth gap, which could be further complicated by throwing ectogenesis into the mix.

“There are certain technologies where we know the price is going to go down,” says Loike. “Gene sequencing fifteen years ago cost a billion dollars. It’s now going to be a few hundred. But the cost of fertility treatment is not going to drop, it’s a service thing.

Theoretically, you’d love to have government insurance policies cover this, but you need the money to do that. Who’s going to pay, where’s the money going to come from? It’s not the ethical question, it’s a more financial question.”

But ectogenesis could also render the controversial practice of commercial surrogacy obsolete. Financially and socially vulnerable women can become targets for commercial surrogacy, and there have been reports of surrogate mothers being treated poorly by surrogacy agencies.

If an artificial uterus were to become an option, even if only for those with the means to pay, then the demand for surrogacy could dry up, freeing vulnerable people from potential exploitation.

Some bioethicists argue that we have a moral imperative to pursue ectogenesis. Dr Anna Smajdor from the University of Oslo says that ectogenesis would allow reproductive labour to be redistributed more fairly in society, allowing women and people who can get pregnant to bypass the physical turmoil of the process, and is therefore something which should be practised in a just society if it proves physically feasible.

Yet, others argue the exact opposite – that ectogenesis would not liberate women, but further subjugate them. In the journal Bioethics, Dr Zelijka Duturovic from the Institute for Social Sciences in Belgrade writes: “Making pregnancy an optional route to motherhood would make women's life trajectory more similar to men's and thus put pressure on women to compete with men on the ground shaped by men's preferences.

“Despite being a treasured experience of many women today, bearing children could become the luxury of the few, the province of the very poor and a choice working women will pay a high price for as women who choose pregnancy become stigmatised as self-indulgent or unprofessional and penalised for it in the workplace.”

Full ectogenesis is unlikely to exist for decades, but artificial wombs appear set to arrive far sooner. When they do arrive, it’s important that public health bodies world-over are prepared for the incumbent legal and ethical regulations they will need to put in place.

Loike says: “I think we have the capacity and the intelligence to make good decisions. In 1978 when the first test tube baby was born, there was a volcanic eruption of press about designer babies, people using the technology to select for gender or hair colour.

“Yet, out of the eight million IVF babies now born, there’s no record of anyone trying to create a designer baby. There is, I believe, a certain moral character in society. Not always, but sometimes there is. I’m hoping that moral character continues.”