Friday, March 11, 2016

Ethics and uterus transplants

Guest post by @UtilityKnife1

It’s easy to be negative. Given that the return in clinical outcomes relative to cost is too often poor for any clinical innovation (e.g., robotic surgery, home uterine monitoring, bone marrow transplants for breast cancer, etc.), it is a reasonable bet anything new in medicine is lemon. Innovation and technology within health care account for significant portions of per capita growth in health spending among Americans over the last 50 years. In some cases this spending has resulted in real improvements in health outcomes but this is not the case in many settings. So what about spending to transplant a uterus?

Uterine transplant is not new. The procedure has been done in animals, has even resulted in live births among humans, and is not conceptually complicated. A donor uterus including the cervix is sutured to the top of the vagina, and the blood supply is hooked up. Since there is no nervous input into the transplant, it will not contract in any sort of coordinated way and delivery of any fetus must be via cesarean section. Similarly, fetal movements will not be felt in the same way. Any “experience” of pregnancy from a transplanted uterus is thus not totally natural (note the recent patient who underwent uterus transplantation at The Cleveland Clinic said “experiencing” pregnancy was an important reason behind her decision to pursue this surgery).

The reason to perform a uterine transplant is most easy to understand in those settings where a woman is born without a uterus (although in these cases they should have ovaries). Getting pregnant with a transplanted uterus requires in vitro fertilization. The organ recipient will have to take anti-rejection drugs, and when pregnancy is no longer desired, the uterus should be removed to avoid prolonged exposure to these drugs. None of this is an ordinary part of the pregnancy experience to say nothing of the implications for the fetus.

Is any of this worth the cost? Is this ethical? These days the question of ethics can’t be answered. Across pluralistic worldviews (e.g. Judeo-Christian, Atheism, etc.), there cannot be an agreed morality beside perhaps respect for persons. Although within some common content-full moralities, uterine transplant is not endorsed.

Some ethicists have likened uterine transplant to other non-life sustaining transplants such as hand and face transplantation. That seems a stretch given the day-to-day implications of a distorted face or no hands relative to the more silent matter of uterine factor infertility. I am not belittling the impact of infertility but there are alternatives—albeit unreasonably complicated ones—and if the “experience” of pregnancy is the driver of this health need, a worrisome precedent is endorsed. Also how much of the “authentic” experience must be experienced to warrant the cost to pursue it?

I would like to experience being smarter or running faster or whatever. How far should we go with this? We are not all equal except in the sense Jefferson spoke of, and that gets thorny across our varied worldviews?

So that brings us back to the money. While there are all kinds of good ethical reasons to pursue health care reform in the U.S., the factors that motivated the current changes, at least on the local level, were not the problems with justice but money. Doctors and hospitals are changing because they are following the money.

The moral medium across plural worldviews is money, and thus the question of whether or not uterine transplant is appropriate will be best understood, like it or not, in terms of cost. Surrogacy and adoption are not cheap, and the cost is borne exclusively by the party seeking a child. Uterine transplant is not going to be cheap any time soon, if ever, but the cost (if covered by insurance) would be borne by the community. Perhaps the community should not bear that cost. The city of Cleveland absorbed some cost because the dollars spent to perform that now ill-fated procedure possibly could have been used on more high-value care.

Incidentally, one reason for any of the three UNESCO-approved U.S. sites to perform uterine transplantation could be related to money as raising a hospital’s profile usually results in improved market share. If the dollars are there and the patient can pay her full way for IVF, transplant, pregnancy, and hysterectomy, does that settle the matter? I’ll wait for the upcoming brain transplant to sort that one out.

@UtilityKnife1 is an academic gynecologist


William Reichert said...

Increasingly, the United States health care system has been compared unfavorably with other countries. Both in terms of cost
and in terms of outcome. And the metrics for outcome rely
very heavily on two things: infant mortality and length of life.
If this critique is accepted and if it is desirable to improve
our world ranking then we must insist that progress in medicine
contributes to the metrics being measured.
I would suspect that uterine transplants will not contribute to
this idea of "progress'. Costs will go up. Possibly the infant mortality rate will be negatively affected. Life expectancy of the US population will not rise as a result of this procedure.
Our standing in the world of health care systems will be therefore negatively affected. This is a political reality that needs to be considered because political realities can have consequences.

UtilityKnife said...

It is impossible to separate the effects of personal income, education, use of medical care and health. The 4 variables are so tightly linked that using any adult-based health metrics unravel along these associations. Infant mortality rates are the preferred metric to estimate a populations health because these variables should have less impact. Its not perfect.

The US has the most medicalized folks in the world - note the recent report citing even retail clinics have not reduced health spend b/c folks use these for stuff they would have previously taken care of by themselves. A uterine transplant could be along the same lines - pursuing medical care for an indistinct outcome that already has redress. Recall that the enthusiasm for physician-assisted suicide waned among patients once pain management was more aggressively addressed in this population. Should not the same be true to the extent we address the problems of surrogacy or adoption?

Michel Accad said...

I enjoyed the post.

One comment: I agree (roughly) that "The moral medium across plural worldviews is money," but that entails that the money is spent by the user. Put the cost of the uterine transplant (or any other cost) on the shoulders of the collectivity (tax payer, insurance premium payer, etc...), and that beneficial effect of money goes out the window.

UtilityKnife said...

To a hospital who are the buyers and who are the suppliers of their product? Perspective is everything. On a community level uterine transplant makes little sense. How can the spend be justified when other community tasks (e.g. schools, infrastructure, etc) would render better health outcomes? Indeed, money is spent by the user and in this case the Cleveland Clinic used its margin to perform this procedure; they could have spent it on other care needs with better health returns. As a non-profit they have to spend their margin on something and from a marketing perspective this was a enticing option. Margin and mission...its hard to tell the difference at times.

Old Fool said...

It was interesting to note how quickly The Cleveland Clinic held a press conference announcing the uterine transplant. The poor lady looked like she had just left the recovery room, before being posed in front of the cameras. I think this says much about the priorities of the parties here. I think she must have been coached about that "experience" business. Most women would rather avoid the unpleasantness of the experience. I can tell you from personal experience that it's not all that much fun!

Skeptical Scalpel said...

Thanks for commenting. I agree the publicity was a bit too soon as subsequent events showed.

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