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Developing World Bioethics ISSN 1471-8731 (print); 1471-8847 (online)
doi:10.1111/dewb.12085
UTERINE TRANSPLANTATION: ETHICAL CONSIDERATIONS WITHIN MIDDLE EASTERN PERSPECTIVES ZAID ALTAWIL AND THALIA ARAWI
Keywords Uterine transplant, ethics, Middle East, religion, Arab society
ABSTRACT The field of reproductive medicine witnessed a breakthrough in September 2014 with the first successful live birth post uterine transplantation. This success represents the culmination of decades’ worth of research on infertility and reproductive medicine. This subject of infertility gathers special attention in the Middle East, as childbearing is given paramount importance in the family unit. And as with any new medical advancement, Middle Eastern people look to their religious authorities for guidance. This paper describes the various ethical quandaries related to uterine transplantation, from a perspective of the religious and societal factors that are unique to the Middle East, and embeds them within the conversation of its alternative solutions.
INTRODUCTION In a society that places paramount emphasis on reproduction and fertility, the Middle East’s perceptions surrounding adoption, surrogacy and, most immediately, uterine transplantation are topics that should be brought to the forefront of discussions in the arena of health ethics. Reproduction has been a point of fascination throughout human history: the ancient Egyptians had over 10 Gods associated with childbirth and fertility, while Greek mythology produced a plethora of deities representing reproduction. Science has also sought to analyze and understand the mystery of reproduction, and more recently, infertility. Solutions to infertility have arisen in this process: the quest began in 1931 with the failed experimental uterus transplant done on Lili Elbe,1 culminating in the first human live-birth product of an allogeneic uterine transplant in October 2014.2 This success brought forward the possibility of a routine procedure to cure infertility due to uterine factor infertility, and with it a number of ethical questions that must be answered if such a procedure would be allowed to become standard of care. 1
Lili Elbe was a transgender woman and underwent one of the first trials of sex reassignment surgery. See: N. Hoyer. 1933. Man into woman: An Authentic Record of a change of sex. Essex. 2 M. Brannstrom, et al. Livebirth after uterus transplantation. Lancet 2014.
The first modern attempts at uterine transplantation (UTx) took place first in Saudi Arabia in 20003 and then Turkey in 2011.4 While ultimately unsuccessful, the trials showcased the Middle East’s interest in infertility and its solutions. The Middle East, as a region, is decisively pronatalistic; given the complex ethnic, religious, and social dynamics present, we explain various ethical considerations behind uterine transplantation and its alternatives to infertility (surrogacy and adoption). This analysis focuses on Lebanon insofar as it can serve as a model for a wider understanding of reproductive solutions in the Middle East region.
LEBANON, A REPRESENTATION OF THE MIDDLE EAST The traditional boundaries of the Middle East extend from Egypt in the West, to Iran in the East, Yemen in the South, and Turkey in the North.5 More recent classifications extend its boundaries to include Northern African 3
W. Fageeh, et al. Transplantation of the human uterus. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 2002; 76: 245–251. 4 M.E. Akar, et al. Clinical pregnancy after uterus transplantation. Fertility and sterility 2013; 100: 1358–1363. 5 United States. Central Intelligence Agency. The world factbook. Washington, DC: Central Intelligence Agency.
Address for correspondence: Thalia Arawi, PhD. Salim El-Hoss Bioethics and Professionalism Program, American University of Beirut Faculty of Medicine and Medical Center. P.O.BOX 11-0236 Riad El-Solh 1107 2020, Beirut-Lebanon. Email: [email protected]. Conflict of interest statement: No conflicts declared Correction added on 13 July 2015, after first publication: Corresponding author has been changed from Zaid Altawil to Thalia Arawi. © 2015 John Wiley & Sons Ltd
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countries such as Libya, Algeria and Morocco as well as Eastern countries such as Pakistan and Afghanistan.6 Its major ethnicities include populations of Arab, Persian and Turkish descent. Islam is the most prevalent religion followed by Christianity (with the exception of Israel where Judaism is the majority religion).7 Lebanon is a small country on the Mediterranean, with a population of about five million people. Ethnically, the majority of the population is Arab, however the 18 recognized religious sects are representative of Lebanon’s true diversity. Lebanon’s major religions are Islam and Christianity. Within the Muslim population, the majority is divided equally between Sunni and Shiite denominations, each roughly representing 24 percent of the Lebanese population.8 This difference is more skewed when looking at the Middle East as a whole, where 90% of Muslims comprise followers of Sunni Islam, with the greater part of the remaining 10 percent belonging to the Shiite denomination.9 The majority of the Middle East’s Christians live in Egypt, with the third largest population residing in Lebanon.10 Lebanese Christians represent 30–35% of the Lebanese population, and are divided into a Maronite catholic majority, Greek Orthodox, Greek Catholic, Protestant, and others.11 The legal system in Lebanon is based on a mixed system of Ottoman legal tradition, civil law based on the French civil code, and religious laws governing the various sects.12 This is similar to other countries in the Middle East, whose laws are based on an amalgamation of civil law and religious Islamic jurisprudence (Sharia). Islamic jurisprudence is further divided between Islam’s two major sects, with differences dictating their response to newly emerging ethical issues, like that of uterine transplantation. Sunni schools of thought rely solely on Scripture and prophetic tradition with analogical deduction (Qiyas), while the Shite schools ascribe to using scripture and reason (aql) to ascertain the morality of emerging ethical issues, lending greater flexibility in interpretation. Religion is a major part of the fabric of Arabic society, with most aspects of life dictated for the most part by religious doctrine. In general, Lebanese citizens, not unlike their neighbors in the region, look to their religious authorities for guidance when considering major decisions in their life. 6 M. Ottaway & T. Carothers. 2004. The Greater Middle East Initiative: Off to a False Start. Carnegie Endowment for International Peace. 7 United States. Central Intelligence Agency. 8 Ibid. 9 2009. Mapping the Global Muslim Population. Pew Research Center. Available at: http://www.pewforum.org/2009/10/07/mapping-theglobal-muslim-population/ [Accessed 24 April 2015]. 10 M. Spomer. World Christian Database. The Charleston Advisor 2014; 15: 58–61. 11 United States. Central Intelligence Agency. 12 Ibid.
Lebanon has traditionally been a destination for medical tourism in the Middle East; with numerous hospitals and leading regional academic centers, it is considered a hub for patients seeking care within the Middle East.13 Its position makes it a key player in the introduction of medical technologies and procedures in the region. Lebanese Health policy and its public perception are heavily dependent on religious influences. Prior to drafting ethical codes in medicine, the approval of religious figures from both Christianity and Islam must be obtained or the article cannot be ratified. This is illustrated by the Lebanon’s stance on abortion, which is only permitted when two physicians agree that continuation of the pregnancy places the mother’s life at risk.14 The interplay of Lebanon’s local factors combined with its place as a regional leader in medicine positions it to influence the understanding of uterine transplantation in the Middle East. As such, a discussion about Lebanese perspectives with regards to the ethics of uterine transplantation is warranted. In reading this article, bear in mind that the authors’ purpose is not to handle the broad ethical challenges of UTx per se,15 but rather to shed light on the ethical challenges as they play out in a Middle Eastern context, specifically Lebanon.
ORGAN DONATION IN THE MIDDLE EAST Transplantation in the Middle East is a relatively new practice. The first heart transplant took place in Turkey in 1969, and renal transplantation established a foothold in the early 1970s. Iran currently dominates the transplantation leaderboard with its government-controlled transplantation program.16 Transplantation in the Middle East gained momentum in 1986 with the Amman Declaration, in which Muslim theologians accepted the concept of brain death and approved transplantation of organs from both living and
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2013. Lebanon’s leading hospitals continue to attract foreign patients Middle East Health. Dubai: Michael Hurst. Available at: http://www.middleeasthealthmag.com/cgi-bin/index.cgi?http://www .middleeasthealthmag.com/jul2013/feature4.htm [Accessed 24 April 2015]. 14 T. Arawi & A. Nassar. Prenatally diagnosed foetal malformations and termination of pregnancy: The case of lebanon. Developing world bioethics 2011; 11: 40–47;2004. Lebanese Code of Medical Ethics. Beirut, Lebanon: Syndicate of the Lebanese Order of Physicians. 15 For the broad ethical debate see R. Catsanos, et al. The ethics of uterus transplantation. Bioethics 2013; 27: 65–73. 16 M. Masri, et al. Middle East Society for Organ Transplantation (MESOT) Transplant Registry. Experimental and clinical transplantation: official journal of the Middle East Society for Organ Transplantation 2004; 2: 217.
© 2015 John Wiley & Sons Ltd
Uterine Transplant Ethics Middle East cadaveric donors.17 With the exception of Egypt, Saudi Arabia, and Iraq the Amman declaration provided an impetus for the acceptance of transplantation as a practice throughout the Middle East and was instrumental in allowing the expansion of previously established cadaveric transplantation programs in countries such as Lebanon.18 Since transplantation began in Lebanon in 1972, according to the Middle East Society for Organ Transplantation registry, over 740 kidney transplants have been performed, with 100 from cadaveric donors.19 While not as active as Iran, Lebanon’s program has potential for much expansion, especially from cadaveric donors. This is due to high rates of accidents both in Lebanon and the Middle East.20 The primary obstacles that present as roadblocks are 1) a lack of proper awareness regarding the religious acceptability of transplantation 2) a lack of the proper infrastructure to utilize fresh cadaveric organs in time. Health systems are weak, and the cost and technology required make a state of the art transplantation program a low priority (this is true for many other countries in the Middle East as well). Currently, living organ donation is the most widely practiced, usually from genetically related donors, however cadaveric donation and transplants from unrelated donors exist.21 It is worth noting that Lebanon endorses the principles of the Istanbul declaration, which emphasize the prohibition of organ trafficking and transplant tourism.22
DESCRIPTION OF UTX AND THE INCENTIVES BEHIND ITS DEVELOPMENT Uterine transplantation is a procedure that involves surgically removing the uterus from a donor, along with vascular attachments, and transplanting it into a recipient. Similar to other forms of transplantation, immunosuppressive medications must be used, although medications with teratogenic effects are discontinued some time before the initiation of embryo transfer. Theoretically, after one or two successful pregnancies have occurred, the transplanted uterus will be removed.23 17
1988. Decree No. 5, 3rd Conference of Islamic Jurists (Amman: 11-6 October 1986). In Fiqh Academy Book of Decrees. Jeddah: Figh Academy and Islamic Organization of Medicine Sciences: 34. 18 Masri, et al. 19 Ibid. 20 M. Asim, et al. Blunt traumatic injury in the Arab Middle Eastern populations. Journal of emergencies, trauma, and shock 2014; 7: 88. 21 Masri, et al. 22 S.C.o.t.I. Summit. Organ trafficking and transplant tourism and commercialism: the Declaration of Istanbul. The Lancet 2008; 372: 5–6. 23 L. Johannesson, et al. Uterus transplantation trial: 1-year outcome. Fertility and sterility 2015; 103: 199–204.
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The primary incentive behind the development of the uterine transplant was to aid women suffering from Uterine Factor Infertility. Uterine factor infertility (UFI) refers to the refractory causes of female infertility stemming from the anatomical or physiological inability of a uterus to sustain gestation. The causes of uterine factor infertility are numerous24 and can be acquired, such as in intractable post-partum hemorrhage, or congenital such as in Mayer-Rokitansky-Kuster-Hauser syndrome, better known as Mullerian agenesis. Today, uterine factor infertility affects 3–5% of the population;25 given the current state of reproductive medicine, should there exist the desire to have children, the only alternatives for women affected by UFI are surrogacy and adoption, options that may not always be viable given cultural, religious, legal, and personal concerns.26 Uterus transplantation is intended to enable the birth of a healthy child, with no direct health benefits for the recipient. In fact, after the child has been delivered to full term, removal of the uterus is recommended, so that constant immunosuppression is not required.27 By allowing women to experience gestation, however, it can be argued that there are psychological health benefits to having a child that can substantially improve the quality of their lives.28 While one might argue that this quality of life is socially constructed, it remains a fact that for many women in the Middle East, it is also viewed as a quality of life that is religiously or biologically constructed as well, and thus ingrained in the fabric of their life. The fact that social respect for women in much of the Middle East is still very much connected to their ability to give birth to a child, may very well explain why the first uterus transplantation was attempted in the Arab world.29 A 2005 study on reproductive perceptions among women in Lebanese communities cited respondents reporting the capacity to bear children as ‘both essential and desirable, because children are the basis for happiness in marital life.30’
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E. Taylor & V. Gomel. The uterus and fertility. Fertility and sterility 2008; 89: 1–16. 25 Ibid. 26 A. Lefkowitz, et al. The Montreal Criteria for the Ethical Feasibility of Uterine Transplantation. Transplant international : official journal of the European Society for Organ Transplantation 2012; 25: 439–447. 27 Johannesson, et al. 28 G. Benagiano, et al. Medical and ethical considerations in uterus transplantation. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 2013; 123: 173–177. 29 W. Fageeh, et al. Transplantation of the human uterus. Ibid.2002; 76: 245–251. 30 A. Kaddour, et al. Women’s perceptions of reproductive health in three communities around Beirut, Lebanon. Reproductive Health Matters 2005; 13: 34–42.
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UTX ALTERNATIVES IN A REGIONAL CONTEXT: SURROGACY AND ADOPTION Much of the controversy surrounding UTx stems from the availability of supposedly easier options: adoption and surrogacy. Thus an understanding and discussion of these two topics is present in this paper to provide readers with the requisite context needed to have an informed perception of UTX. Surrogacy is an arrangement in which a pregnancy is carried to term by a woman for another couple or person. Initial implantation of the embryo into the surrogate is achieved through in vitro fertilization in the surrogate mothers womb or through artificial insemination. Although technically a feasible procedure, gestational surrogacy is not without complications, especially in Middle Eastern countries. From a legal perspective, only the Islamic republic of Iran has legalized surrogacy.31 This can be due to jurisprudence primarily based on Islamic Sunni Sharia in most of the Middle Eastern region while Iran follows Shiite sharia law. As such, individuals seeking to bypass their infertility through surrogacy would have to travel abroad for the procedure, making it a less desirable option. Formal legislation regarding surrogacy is still pending, and no measures are put into place to clarify the role of the surrogate and the biological mother in the process of childbirth. For example, current legal proceedings in Iran (the only Islamic country currently permitting surrogacy) place the surrogate’s name on the child’s governmental identity documents32 rather than his biological mother. Fertility centers also attempt to bypass this legal obstacle by admitting the surrogate under the biological mother’s name. Interestingly enough, according to an Iranian executive guideline on embryo donations, donors must declare their religion to their fertility clinic. This measure is in place since Islamic law decrees that non-Muslims have no guardianship over Muslims, making sure no other religious influences (the surrogate’s) can be imposed on a Muslim child.33 Religious perspectives on the matter of surrogacy are predominantly prohibitory, with Sunni authorities in Islam deeming the procedure inadmissible by Sharia Law. The reasoning behind this being the confusion as to who the ‘real’ mother of the child is, as well as the 31 A.Z. Akhoundi MM. 2007. Surrogacy: definition, types and its necessity in treatment of infertility. In Medical, legal, Islamic jurisprudential, ethical- philosophical, sociological and psychological aspects of surrogacy. Tehran: Samt. 32 For a more thorough discussion on Surrogacy in Iran, and Islamic Jurisprudence in General see: K. Aramesh. Iran’s experience with surrogate motherhood: an Islamic view and ethical concerns. Journal of medical ethics 2009; 35: 320–322. 33 A. Pirouz & N. Mehra. Legal Issues of A Surrogacy Contract Based on Iranian Acts. Journal of Family and Reproductive Health 2011; 5: 41–50.
introduction of the husband’s sperm into the surrogate resulting in a child born out of wedlock.34 Shiite scholars such as Grand Ayatollah Montazeri (of Iran) consider surrogacy admissible for legally married couples that are infertile, and regard the embryo as different from the sperm and as such see no problem with the introduction into a woman outside the couple.35 With regards to Christianity, and pertaining specifically to the Greek-orthodox denomination, there is difficulty in giving blessing to surrogacy because it deprives all three actors, the birth mom, the genetic parents and the fetus, of their prototypical role in the process. The developing relationship between the surrogate and the fetus is unjust to the genetic parents as it deprives the mother of an indispensible part of motherhood and the disruption of the bond between the surrogate and the fetus at birth is seen as both unjust towards the surrogate and the child, who would lose that intimate relationship.36 Catholicism has prohibited surrogacy, describing it as immoral in that it involves the dissociation of husband and wife, and an intrusion by a person other than the couple involved. According to the Catholic Church, surrogacy ‘betrays the spouses’ right to become a father and mother only through each other’.37 The Catholic Church maintains that it is not objectively evil to be infertile, and advocates adoption as an option for such couples that still wish to have children. Gestational surrogacy is also, as Castanos et al. put it, a risky decision.38 There are questions of who has control and decision-making rights in matters affecting the pregnancy. As far as the genetic mother can supervise the pregnancy through conditions in the surrogacy agreement, she ultimately cannot control the surrogate mother’s behavior during gestation, and would not be able to continue the pregnancy should the surrogate decide to terminate. There is also the risk of the surrogate mother developing a relationship with the fetus, owing to the intimate nature of a gestation. Such considerations are tricky in the Middle East, as there is no ethical/legal framework to tackle such issues as they arise. Current laws do not recognize the intricacy of a surrogate’s relationship with the fetus or the biological mother, nor do they differentiate between the source of the embryo (the biological parents) and its destination (the surrogate’s uterus), complicating the picture of who has decisionmaking rights in the pregnancy. 34
D. Atighetchi. 2007. Islamic bioethics : problems and perspectives. New York: Springer. 35 Aramesh, op cit note 14. 36 M. Nikolaos. The Greek Orthodox position on the ethics of assisted reproduction. Reproductive biomedicine online 2008; 17(Suppl 3): 25–33. 37 Catholic Church., et al. Compendium : Catechism of the Catholic Church. Washington, D.C.: United States Conference of Catholic Bishops. 38 Catsanos, et al, op cit note 7.
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Uterine Transplant Ethics Middle East In its current form, Lebanese law neither permits nor outlaws surrogacy outright.39 Iran’s influence as a regional Shiite authority, and their legalization of commercial surrogacy, may help explain why Lebanon is unique in the Middle East with regards to its ambiguous laws concerning gestational surrogacy. This raises concerns regarding exploitation of poor women in Iran and possibly in Lebanon, specifically where the Shiite population is concerned. Gestational surrogacy’s ambiguous legal status in Lebanon raises another important concern, and that is the possibility of child abandonment in cases where the biological parents are not satisfied with the product of the surrogate pregnancy. This is highlighted by a recent Thai case of a child with Down’s syndrome abandoned by his parents, leading to a ban on commercial surrogacy.40 With its vague laws and lack of governmental oversight on possible surrogacy practices in Lebanon, this is a very real concern. Adoption is another substitute advocated by critics of UTx, the rationale being that it is more ethically justifiable to take care of an orphan who needs parents than to selfishly subject yourself and your unborn child to unnecessary risks and possible harm. While it is true that adoption is ‘safer’ so to speak it does not come without its own difficulties. The largest barrier to adoption being normalized within Lebanon and the rest of the Middle East is the Islamic stance on the practice. In the contemporary sense,41 adoption is not permitted by Islamic law. Currently only five Muslim majority countries in the world allow it.42 It is generally not permitted because it is seen to erase natal identity, a pre-Islamic tradition that Islam sought to restrict.43 Islam does recognize and encourages a communal obligation to provide for and protect homeless and parentless children. This specific care and provision of children for the purpose of bringing them up and caring for them is not only permissible, but is considered a blessed deed, especially in the case of orphans and foundlings. However, adoption in Islam can be better compared to foster care than adoption as understood
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from a Western perspective. This ‘fostered’ child must retain his birth name, may not have legal rights to the adoptive family’s inheritance once he/she comes of age, and would not be allowed to share in the same familial informalities allowed between biological relations under Islamic law. For example, if a boy were ‘adopted’ by an Islamic family in Lebanon, by Sharia law, he would not be allowed to be in the same room alone with his adoptive mother, or family members of the opposite sex, once he reached puberty. This would be seen as breaking the rules of modesty between members of the opposite sex that are not genetically related. The adoptive mother could only overcome this obstacle by breast-feeding him before the age of two, establishing ‘milk kinship’, a practice common to the Middle East.44 This cultural reality may reinforce biological bias, as it makes the lack of a genetic link between the child and his adoptive parents both tangible and explicit. Biological bias can subsequently lead to neglect and possible abuse. Literature on the higher rates of abuse among stepparents, otherwise known as the ‘Cinderella Effect’, may allude to the difference in bonding experienced by the adoptive parents and their child.45 Furthermore, because global adoptions tend to involve older children who come from backgrounds of neglect or abuse, they require what Jonathan Pearce, the director of Adoption UK, calls therapeutic parenting. ‘Of course, this is different to raising a biological child, just as it is different to raising an adopted child 30 or 40 years ago. It’s a parenting that I think should include ongoing training – just as you have with any other demanding job,’ he says.46 Unfortunately, information on adoption within Middle Eastern populations is lacking, with no formal studies assessing the prevalence and demographics of those adopted. As such, the nature of the adopted children, their backgrounds, and their relationship to their adoptive parents cannot be properly ascertained. With these distinctions in mind, one can see how adoption can be viewed as a less attractive alternative to uterine transplantation in Middle Eastern countries.
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M. Sidahmed. 2014. Surrogacy not an option in Lebanon. The Daily Star 13 September. 40 A. Phillip. 2015. A shocking scandal led Thailand to ban surrogacy for hire. The Washington Post February 20. 41 Where the child is given full rights and responsibilities of a biological child, including the adoptive father’s name. 42 Indonesia, Malaysia, Somalia, Tunisia, and Turkey. M.W.s.S. Council. Adoption and the Care of Orphan Children: Islam and the Best Interests of the Child. The Global Muslim Women’s Shura Council Statements 2011; 4. 43 Before the emergence of Islam in the Arab peninsula, the practice of adoption closely resembled a form of enslavement where captives were stripped of their natal identity and appropriated into the captor’s clan. This served the purpose of asserting military dominance through appro¯dı¯. ¯ba priating large numbers of fighting men. S. Joseph & A. Nagˇma 2003. Encyclopedia of Women and Islamic Cultures: Family, Law and Politics. Brill: 1.
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UTX AND ARAB SOCIETY In 2013, Lefkowtiz et al updated the Montreal criteria to determine the ethical feasibility of uterine 44
P. Parkes. Milk kinship in Islam. Substance, structure, history*. Social Anthropology 2005; 13: 307–329. 45 G.A. Tooley, et al. Generalising the Cinderella Effect to unintentional childhood fatalities. Evolution and Human Behavior 2006; 27: 224–230. 46 K. Hilpern. 2007. A Different Kind of Love. Available at: http:// www.theguardian.com/lifestyle/2007/dec/15/familyandrelationships .family [Accessed 24 April 2015].
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Figure 1. Revised Montreal Criteria for the Ethical Feasibility of Uterine Transplantation.48 transplantation.47 They suggested specific criteria for the recipient, donor and institution to fulfill if they are to be considered candidates for uterine transplantation (Figure 1). In the context of Arab/Lebanese society specific attention must be paid to parts 1.d and 1.g that state that a woman’s decision to undertake uterine transplantation must be rational and that she must responsible enough to consent and not under coercion. Due to the structure of the Lebanese family unit, these two articles of the Montreal criteria are problematic.
Infertility is not just an obstacle to be tackled by the husband and wife; in many cases extended family members (for example both mothers-in-law) are involved and the decision to undergo fertility treatments is tackled as a group effort.49 As such, the decision is no longer solely governed by the person undergoing the procedure, and there arises the risk that she might be coerced into having surgery done, be it directly or indirectly.50 Even if the subject were to be dealt without the presence of other family members, her consent is still in question knowing the pressures she is surely to have faced at home. These influences on reproductive and personal autonomy are not specific to uterine transplantation alone but are a common theme in pro-natalistic societies. As previously discussed by Mumtaz and Levay,51 the Montreal criteria may be difficult to apply in such situations, as a myriad of factors contribute to decision making and informed consent. The implications of family coercion in culturally pro-natalistic societies may have far reaching effects even outside the context of UTx and the Montreal criteria, extending into the complex interactions between women in the Middle East and the patriarchal society to which they belong. Regardless of cultural acceptance, one can argue that societal and familial coercion into undergoing a surgical procedure falls into the realm of violation of human rights and reproductive autonomy. Another problem that presents itself in the context of a pro-natalistic society is gender selection. As mentioned earlier, it is not just having a child that is central to the family unit; it is having a male child as well that is of paramount importance. The first-born male is central to the identity of the Arabic family, as is evident by how parents in Arab societies are referred to using the prefix abu- or im- (father-of and mother-of, respectively) followed by the name of the first-born son. A number of ethical questions arise from this paradigm: what happens if the product of the uterine transplant is not a male? Will termination of pregnancy be considered? Will the woman or her marital family pressure the attending physicians to impregnate the transplanted uterus repeatedly even if it is detrimental to the young woman’s well being? Or will they simply use sex-selection technology to ensure only male embryos are created during in-vitro fertilization, an issue with ethical ramifications. A big concern turns out to be that UTx technology can become one more vehicle for the practice of sex selective pregnancies and abortions for families to ensure they have a male child and
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Kaddour, et al. Directly by coercion into undergoing the procedure; indirectly through a fear of abandonment. 51 Z. Mumtaz & A. Levay. Ethics criteria for uterine transplants: relevance for low-income, pronatalistic societies. J Clinic Res Bioeth S 2012; 1: 2. 50
47
A. Lefkowitz, et al. Ethical considerations in the era of the uterine transplant: an update of the Montreal Criteria for the Ethical Feasibility of Uterine Transplantation. Fertility and sterility 2013; 100: 924–926. 48 Ibid.
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Uterine Transplant Ethics Middle East heir.52 While many of these questions could ostensibly be raised with surrogacy as well, given Utx’s more recent entrance into the conversation surrounding pregnancy alternatives, they are worth re-emphasizing here.
EXPLOITATION: UTERINE DONATION Provided uterine transplantation becomes a standard procedure that can be safely carried out, one must also be wary of the consequences of such a technology being brought to Lebanon. Current trials are being conducted with deceased donors and live relatives, and the possibility exists that uteri in the future may be ‘donated’ from living, but unrelated individuals. It is possible that women who are not good candidates53 for UTx may seek alternative methods to obtain their uteri, alternatives that may not always be legal, such as reversion to black market procurement. In Lebanon, this point bears particular consideration because the country has a history of organ trafficking, in part due to the fact that voluntary donation in Lebanese society is still a tough concept to sell (for example of 800 road deaths in Lebanon in 2008, zero organs were harvested for donation).54 This reality has been augmented recently with the onset of the Syrian crisis. Refugee families desperate for sources of income have resorted to selling their organs to make ends meet. The media has extensively covered the illegal sale of organs in Lebanon and the gangs that run them.55 These reports have since been denounced by the Lebanese ministry of Health as unfounded, however it is very conceivable that impoverished families, especially refugees that have found themselves in a dire financial situation, may resort to selling
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their or their daughters’ uteri in order to be able to survive. If uterine transplantation has the potential to become another vehicle for human exploitation in Lebanon, the question of whether it is morally justifiable to bring this technology to our region, knowing full well that legal and social frameworks protecting individuals from these forms of trafficking are at present absent in Lebanon, is one worth posing.56
CONCLUSION Uterine transplantation presents a promising solution to uterine factor infertility. Despite its debatable ethical merits, it represents a pioneering step in the field of reproductive medicine, and perhaps a better alternative to its regional counter-parts. With regards to its acceptance as a solution to Uterine Factor Infertility in the Middleeastern region, further obstacles must be crossed. Religious acceptance is key, and while Islamic acceptance is discernible, Christian authorities remain apprehensive. The looming specter of human exploitation is more worrisome, and perhaps, unfortunately a challenge that will not be dealt with in the very near future. Deciding to undergo a uterine transplantation or not is, at least for the moment, more of a social decision than a medical one in most countries in the Middle East, and how Middle Eastern women will view themselves and their roles is an important issue to ponder
Acknowledgements The authors would like to thank Kristina Tester, for her instrumental help in writing this manuscript.
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Z. Mumtaz, et al. Understanding the impact of gendered roles on the experiences of infertility amongst men and women in Punjab. Reproductive health 2013; 10: 3. 53 Suitable candidates should be of fairly low age, and in good health. See: M. Brännström, et al. Uterus transplantation: animal research and human possibilities. Fertility and sterility 2012; 97: 1269–1276. 54 T.I.o.H.M.a.S. Protection. 2012. National Health Statistics Report in Lebanon. Beirut: Saint-Joseph University. 55 U. Putz. 2013. Lebanese Black Market: Syrian Refugees Sell Organs to Survive. Speigel Online. Available at: http://www.spiegel.de/ international/world/organ-trade-thrives-among-desperate-syrianrefugees-in-lebanon-a-933228.html [Accessed 24 April 2015]; H. Johansen. 2014. Lebanon’s black market in refugee organs. Middle East Monitor. Available at: https://www.middleeastmonitor.com/blogs/ lifestyle/9067-lebanons-black-market-in-refugee-organs [Accessed 24 April 2015].
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Biographies Zaid Altawil is a recent medical graduate of the American University of Beirut and currently a post-doctoral research fellow at the Division of Global Health and Human Rights, Department of emergency medicine at Massachusetts General Hospital. Thalia Arawi, PhD is the Founding Director of the Salim El-Hoss Bioethics & Professionalism Program at the American University Beirut Faculty of Medicine and Medical Center. Dr. Arawi is also the Clinical Bioethicist at AUBMC and the Vice Chair of the Medical Center Ethics Committee there. She is also member of several international bioethics associations and societies. 56
Putz, op cit note 59.
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bioethics
Developing World Bioethics ISSN 1471-8731 (print); 1471-8847 (online)
doi:10.1111/dewb.12085
UTERINE TRANSPLANTATION: ETHICAL CONSIDERATIONS WITHIN MIDDLE EASTERN PERSPECTIVES ZAID ALTAWIL AND THALIA ARAWI
Keywords Uterine transplant, ethics, Middle East, religion, Arab society
ABSTRACT The field of reproductive medicine witnessed a breakthrough in September 2014 with the first successful live birth post uterine transplantation. This success represents the culmination of decades’ worth of research on infertility and reproductive medicine. This subject of infertility gathers special attention in the Middle East, as childbearing is given paramount importance in the family unit. And as with any new medical advancement, Middle Eastern people look to their religious authorities for guidance. This paper describes the various ethical quandaries related to uterine transplantation, from a perspective of the religious and societal factors that are unique to the Middle East, and embeds them within the conversation of its alternative solutions.
INTRODUCTION In a society that places paramount emphasis on reproduction and fertility, the Middle East’s perceptions surrounding adoption, surrogacy and, most immediately, uterine transplantation are topics that should be brought to the forefront of discussions in the arena of health ethics. Reproduction has been a point of fascination throughout human history: the ancient Egyptians had over 10 Gods associated with childbirth and fertility, while Greek mythology produced a plethora of deities representing reproduction. Science has also sought to analyze and understand the mystery of reproduction, and more recently, infertility. Solutions to infertility have arisen in this process: the quest began in 1931 with the failed experimental uterus transplant done on Lili Elbe,1 culminating in the first human live-birth product of an allogeneic uterine transplant in October 2014.2 This success brought forward the possibility of a routine procedure to cure infertility due to uterine factor infertility, and with it a number of ethical questions that must be answered if such a procedure would be allowed to become standard of care. 1
Lili Elbe was a transgender woman and underwent one of the first trials of sex reassignment surgery. See: N. Hoyer. 1933. Man into woman: An Authentic Record of a change of sex. Essex. 2 M. Brannstrom, et al. Livebirth after uterus transplantation. Lancet 2014.
The first modern attempts at uterine transplantation (UTx) took place first in Saudi Arabia in 20003 and then Turkey in 2011.4 While ultimately unsuccessful, the trials showcased the Middle East’s interest in infertility and its solutions. The Middle East, as a region, is decisively pronatalistic; given the complex ethnic, religious, and social dynamics present, we explain various ethical considerations behind uterine transplantation and its alternatives to infertility (surrogacy and adoption). This analysis focuses on Lebanon insofar as it can serve as a model for a wider understanding of reproductive solutions in the Middle East region.
LEBANON, A REPRESENTATION OF THE MIDDLE EAST The traditional boundaries of the Middle East extend from Egypt in the West, to Iran in the East, Yemen in the South, and Turkey in the North.5 More recent classifications extend its boundaries to include Northern African 3
W. Fageeh, et al. Transplantation of the human uterus. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 2002; 76: 245–251. 4 M.E. Akar, et al. Clinical pregnancy after uterus transplantation. Fertility and sterility 2013; 100: 1358–1363. 5 United States. Central Intelligence Agency. The world factbook. Washington, DC: Central Intelligence Agency.
Address for correspondence: Thalia Arawi, PhD. Salim El-Hoss Bioethics and Professionalism Program, American University of Beirut Faculty of Medicine and Medical Center. P.O.BOX 11-0236 Riad El-Solh 1107 2020, Beirut-Lebanon. Email: [email protected]. Conflict of interest statement: No conflicts declared Correction added on 13 July 2015, after first publication: Corresponding author has been changed from Zaid Altawil to Thalia Arawi. © 2015 John Wiley & Sons Ltd
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countries such as Libya, Algeria and Morocco as well as Eastern countries such as Pakistan and Afghanistan.6 Its major ethnicities include populations of Arab, Persian and Turkish descent. Islam is the most prevalent religion followed by Christianity (with the exception of Israel where Judaism is the majority religion).7 Lebanon is a small country on the Mediterranean, with a population of about five million people. Ethnically, the majority of the population is Arab, however the 18 recognized religious sects are representative of Lebanon’s true diversity. Lebanon’s major religions are Islam and Christianity. Within the Muslim population, the majority is divided equally between Sunni and Shiite denominations, each roughly representing 24 percent of the Lebanese population.8 This difference is more skewed when looking at the Middle East as a whole, where 90% of Muslims comprise followers of Sunni Islam, with the greater part of the remaining 10 percent belonging to the Shiite denomination.9 The majority of the Middle East’s Christians live in Egypt, with the third largest population residing in Lebanon.10 Lebanese Christians represent 30–35% of the Lebanese population, and are divided into a Maronite catholic majority, Greek Orthodox, Greek Catholic, Protestant, and others.11 The legal system in Lebanon is based on a mixed system of Ottoman legal tradition, civil law based on the French civil code, and religious laws governing the various sects.12 This is similar to other countries in the Middle East, whose laws are based on an amalgamation of civil law and religious Islamic jurisprudence (Sharia). Islamic jurisprudence is further divided between Islam’s two major sects, with differences dictating their response to newly emerging ethical issues, like that of uterine transplantation. Sunni schools of thought rely solely on Scripture and prophetic tradition with analogical deduction (Qiyas), while the Shite schools ascribe to using scripture and reason (aql) to ascertain the morality of emerging ethical issues, lending greater flexibility in interpretation. Religion is a major part of the fabric of Arabic society, with most aspects of life dictated for the most part by religious doctrine. In general, Lebanese citizens, not unlike their neighbors in the region, look to their religious authorities for guidance when considering major decisions in their life. 6 M. Ottaway & T. Carothers. 2004. The Greater Middle East Initiative: Off to a False Start. Carnegie Endowment for International Peace. 7 United States. Central Intelligence Agency. 8 Ibid. 9 2009. Mapping the Global Muslim Population. Pew Research Center. Available at: http://www.pewforum.org/2009/10/07/mapping-theglobal-muslim-population/ [Accessed 24 April 2015]. 10 M. Spomer. World Christian Database. The Charleston Advisor 2014; 15: 58–61. 11 United States. Central Intelligence Agency. 12 Ibid.
Lebanon has traditionally been a destination for medical tourism in the Middle East; with numerous hospitals and leading regional academic centers, it is considered a hub for patients seeking care within the Middle East.13 Its position makes it a key player in the introduction of medical technologies and procedures in the region. Lebanese Health policy and its public perception are heavily dependent on religious influences. Prior to drafting ethical codes in medicine, the approval of religious figures from both Christianity and Islam must be obtained or the article cannot be ratified. This is illustrated by the Lebanon’s stance on abortion, which is only permitted when two physicians agree that continuation of the pregnancy places the mother’s life at risk.14 The interplay of Lebanon’s local factors combined with its place as a regional leader in medicine positions it to influence the understanding of uterine transplantation in the Middle East. As such, a discussion about Lebanese perspectives with regards to the ethics of uterine transplantation is warranted. In reading this article, bear in mind that the authors’ purpose is not to handle the broad ethical challenges of UTx per se,15 but rather to shed light on the ethical challenges as they play out in a Middle Eastern context, specifically Lebanon.
ORGAN DONATION IN THE MIDDLE EAST Transplantation in the Middle East is a relatively new practice. The first heart transplant took place in Turkey in 1969, and renal transplantation established a foothold in the early 1970s. Iran currently dominates the transplantation leaderboard with its government-controlled transplantation program.16 Transplantation in the Middle East gained momentum in 1986 with the Amman Declaration, in which Muslim theologians accepted the concept of brain death and approved transplantation of organs from both living and
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2013. Lebanon’s leading hospitals continue to attract foreign patients Middle East Health. Dubai: Michael Hurst. Available at: http://www.middleeasthealthmag.com/cgi-bin/index.cgi?http://www .middleeasthealthmag.com/jul2013/feature4.htm [Accessed 24 April 2015]. 14 T. Arawi & A. Nassar. Prenatally diagnosed foetal malformations and termination of pregnancy: The case of lebanon. Developing world bioethics 2011; 11: 40–47;2004. Lebanese Code of Medical Ethics. Beirut, Lebanon: Syndicate of the Lebanese Order of Physicians. 15 For the broad ethical debate see R. Catsanos, et al. The ethics of uterus transplantation. Bioethics 2013; 27: 65–73. 16 M. Masri, et al. Middle East Society for Organ Transplantation (MESOT) Transplant Registry. Experimental and clinical transplantation: official journal of the Middle East Society for Organ Transplantation 2004; 2: 217.
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Uterine Transplant Ethics Middle East cadaveric donors.17 With the exception of Egypt, Saudi Arabia, and Iraq the Amman declaration provided an impetus for the acceptance of transplantation as a practice throughout the Middle East and was instrumental in allowing the expansion of previously established cadaveric transplantation programs in countries such as Lebanon.18 Since transplantation began in Lebanon in 1972, according to the Middle East Society for Organ Transplantation registry, over 740 kidney transplants have been performed, with 100 from cadaveric donors.19 While not as active as Iran, Lebanon’s program has potential for much expansion, especially from cadaveric donors. This is due to high rates of accidents both in Lebanon and the Middle East.20 The primary obstacles that present as roadblocks are 1) a lack of proper awareness regarding the religious acceptability of transplantation 2) a lack of the proper infrastructure to utilize fresh cadaveric organs in time. Health systems are weak, and the cost and technology required make a state of the art transplantation program a low priority (this is true for many other countries in the Middle East as well). Currently, living organ donation is the most widely practiced, usually from genetically related donors, however cadaveric donation and transplants from unrelated donors exist.21 It is worth noting that Lebanon endorses the principles of the Istanbul declaration, which emphasize the prohibition of organ trafficking and transplant tourism.22
DESCRIPTION OF UTX AND THE INCENTIVES BEHIND ITS DEVELOPMENT Uterine transplantation is a procedure that involves surgically removing the uterus from a donor, along with vascular attachments, and transplanting it into a recipient. Similar to other forms of transplantation, immunosuppressive medications must be used, although medications with teratogenic effects are discontinued some time before the initiation of embryo transfer. Theoretically, after one or two successful pregnancies have occurred, the transplanted uterus will be removed.23 17
1988. Decree No. 5, 3rd Conference of Islamic Jurists (Amman: 11-6 October 1986). In Fiqh Academy Book of Decrees. Jeddah: Figh Academy and Islamic Organization of Medicine Sciences: 34. 18 Masri, et al. 19 Ibid. 20 M. Asim, et al. Blunt traumatic injury in the Arab Middle Eastern populations. Journal of emergencies, trauma, and shock 2014; 7: 88. 21 Masri, et al. 22 S.C.o.t.I. Summit. Organ trafficking and transplant tourism and commercialism: the Declaration of Istanbul. The Lancet 2008; 372: 5–6. 23 L. Johannesson, et al. Uterus transplantation trial: 1-year outcome. Fertility and sterility 2015; 103: 199–204.
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The primary incentive behind the development of the uterine transplant was to aid women suffering from Uterine Factor Infertility. Uterine factor infertility (UFI) refers to the refractory causes of female infertility stemming from the anatomical or physiological inability of a uterus to sustain gestation. The causes of uterine factor infertility are numerous24 and can be acquired, such as in intractable post-partum hemorrhage, or congenital such as in Mayer-Rokitansky-Kuster-Hauser syndrome, better known as Mullerian agenesis. Today, uterine factor infertility affects 3–5% of the population;25 given the current state of reproductive medicine, should there exist the desire to have children, the only alternatives for women affected by UFI are surrogacy and adoption, options that may not always be viable given cultural, religious, legal, and personal concerns.26 Uterus transplantation is intended to enable the birth of a healthy child, with no direct health benefits for the recipient. In fact, after the child has been delivered to full term, removal of the uterus is recommended, so that constant immunosuppression is not required.27 By allowing women to experience gestation, however, it can be argued that there are psychological health benefits to having a child that can substantially improve the quality of their lives.28 While one might argue that this quality of life is socially constructed, it remains a fact that for many women in the Middle East, it is also viewed as a quality of life that is religiously or biologically constructed as well, and thus ingrained in the fabric of their life. The fact that social respect for women in much of the Middle East is still very much connected to their ability to give birth to a child, may very well explain why the first uterus transplantation was attempted in the Arab world.29 A 2005 study on reproductive perceptions among women in Lebanese communities cited respondents reporting the capacity to bear children as ‘both essential and desirable, because children are the basis for happiness in marital life.30’
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E. Taylor & V. Gomel. The uterus and fertility. Fertility and sterility 2008; 89: 1–16. 25 Ibid. 26 A. Lefkowitz, et al. The Montreal Criteria for the Ethical Feasibility of Uterine Transplantation. Transplant international : official journal of the European Society for Organ Transplantation 2012; 25: 439–447. 27 Johannesson, et al. 28 G. Benagiano, et al. Medical and ethical considerations in uterus transplantation. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 2013; 123: 173–177. 29 W. Fageeh, et al. Transplantation of the human uterus. Ibid.2002; 76: 245–251. 30 A. Kaddour, et al. Women’s perceptions of reproductive health in three communities around Beirut, Lebanon. Reproductive Health Matters 2005; 13: 34–42.
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UTX ALTERNATIVES IN A REGIONAL CONTEXT: SURROGACY AND ADOPTION Much of the controversy surrounding UTx stems from the availability of supposedly easier options: adoption and surrogacy. Thus an understanding and discussion of these two topics is present in this paper to provide readers with the requisite context needed to have an informed perception of UTX. Surrogacy is an arrangement in which a pregnancy is carried to term by a woman for another couple or person. Initial implantation of the embryo into the surrogate is achieved through in vitro fertilization in the surrogate mothers womb or through artificial insemination. Although technically a feasible procedure, gestational surrogacy is not without complications, especially in Middle Eastern countries. From a legal perspective, only the Islamic republic of Iran has legalized surrogacy.31 This can be due to jurisprudence primarily based on Islamic Sunni Sharia in most of the Middle Eastern region while Iran follows Shiite sharia law. As such, individuals seeking to bypass their infertility through surrogacy would have to travel abroad for the procedure, making it a less desirable option. Formal legislation regarding surrogacy is still pending, and no measures are put into place to clarify the role of the surrogate and the biological mother in the process of childbirth. For example, current legal proceedings in Iran (the only Islamic country currently permitting surrogacy) place the surrogate’s name on the child’s governmental identity documents32 rather than his biological mother. Fertility centers also attempt to bypass this legal obstacle by admitting the surrogate under the biological mother’s name. Interestingly enough, according to an Iranian executive guideline on embryo donations, donors must declare their religion to their fertility clinic. This measure is in place since Islamic law decrees that non-Muslims have no guardianship over Muslims, making sure no other religious influences (the surrogate’s) can be imposed on a Muslim child.33 Religious perspectives on the matter of surrogacy are predominantly prohibitory, with Sunni authorities in Islam deeming the procedure inadmissible by Sharia Law. The reasoning behind this being the confusion as to who the ‘real’ mother of the child is, as well as the 31 A.Z. Akhoundi MM. 2007. Surrogacy: definition, types and its necessity in treatment of infertility. In Medical, legal, Islamic jurisprudential, ethical- philosophical, sociological and psychological aspects of surrogacy. Tehran: Samt. 32 For a more thorough discussion on Surrogacy in Iran, and Islamic Jurisprudence in General see: K. Aramesh. Iran’s experience with surrogate motherhood: an Islamic view and ethical concerns. Journal of medical ethics 2009; 35: 320–322. 33 A. Pirouz & N. Mehra. Legal Issues of A Surrogacy Contract Based on Iranian Acts. Journal of Family and Reproductive Health 2011; 5: 41–50.
introduction of the husband’s sperm into the surrogate resulting in a child born out of wedlock.34 Shiite scholars such as Grand Ayatollah Montazeri (of Iran) consider surrogacy admissible for legally married couples that are infertile, and regard the embryo as different from the sperm and as such see no problem with the introduction into a woman outside the couple.35 With regards to Christianity, and pertaining specifically to the Greek-orthodox denomination, there is difficulty in giving blessing to surrogacy because it deprives all three actors, the birth mom, the genetic parents and the fetus, of their prototypical role in the process. The developing relationship between the surrogate and the fetus is unjust to the genetic parents as it deprives the mother of an indispensible part of motherhood and the disruption of the bond between the surrogate and the fetus at birth is seen as both unjust towards the surrogate and the child, who would lose that intimate relationship.36 Catholicism has prohibited surrogacy, describing it as immoral in that it involves the dissociation of husband and wife, and an intrusion by a person other than the couple involved. According to the Catholic Church, surrogacy ‘betrays the spouses’ right to become a father and mother only through each other’.37 The Catholic Church maintains that it is not objectively evil to be infertile, and advocates adoption as an option for such couples that still wish to have children. Gestational surrogacy is also, as Castanos et al. put it, a risky decision.38 There are questions of who has control and decision-making rights in matters affecting the pregnancy. As far as the genetic mother can supervise the pregnancy through conditions in the surrogacy agreement, she ultimately cannot control the surrogate mother’s behavior during gestation, and would not be able to continue the pregnancy should the surrogate decide to terminate. There is also the risk of the surrogate mother developing a relationship with the fetus, owing to the intimate nature of a gestation. Such considerations are tricky in the Middle East, as there is no ethical/legal framework to tackle such issues as they arise. Current laws do not recognize the intricacy of a surrogate’s relationship with the fetus or the biological mother, nor do they differentiate between the source of the embryo (the biological parents) and its destination (the surrogate’s uterus), complicating the picture of who has decisionmaking rights in the pregnancy. 34
D. Atighetchi. 2007. Islamic bioethics : problems and perspectives. New York: Springer. 35 Aramesh, op cit note 14. 36 M. Nikolaos. The Greek Orthodox position on the ethics of assisted reproduction. Reproductive biomedicine online 2008; 17(Suppl 3): 25–33. 37 Catholic Church., et al. Compendium : Catechism of the Catholic Church. Washington, D.C.: United States Conference of Catholic Bishops. 38 Catsanos, et al, op cit note 7.
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Uterine Transplant Ethics Middle East In its current form, Lebanese law neither permits nor outlaws surrogacy outright.39 Iran’s influence as a regional Shiite authority, and their legalization of commercial surrogacy, may help explain why Lebanon is unique in the Middle East with regards to its ambiguous laws concerning gestational surrogacy. This raises concerns regarding exploitation of poor women in Iran and possibly in Lebanon, specifically where the Shiite population is concerned. Gestational surrogacy’s ambiguous legal status in Lebanon raises another important concern, and that is the possibility of child abandonment in cases where the biological parents are not satisfied with the product of the surrogate pregnancy. This is highlighted by a recent Thai case of a child with Down’s syndrome abandoned by his parents, leading to a ban on commercial surrogacy.40 With its vague laws and lack of governmental oversight on possible surrogacy practices in Lebanon, this is a very real concern. Adoption is another substitute advocated by critics of UTx, the rationale being that it is more ethically justifiable to take care of an orphan who needs parents than to selfishly subject yourself and your unborn child to unnecessary risks and possible harm. While it is true that adoption is ‘safer’ so to speak it does not come without its own difficulties. The largest barrier to adoption being normalized within Lebanon and the rest of the Middle East is the Islamic stance on the practice. In the contemporary sense,41 adoption is not permitted by Islamic law. Currently only five Muslim majority countries in the world allow it.42 It is generally not permitted because it is seen to erase natal identity, a pre-Islamic tradition that Islam sought to restrict.43 Islam does recognize and encourages a communal obligation to provide for and protect homeless and parentless children. This specific care and provision of children for the purpose of bringing them up and caring for them is not only permissible, but is considered a blessed deed, especially in the case of orphans and foundlings. However, adoption in Islam can be better compared to foster care than adoption as understood
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from a Western perspective. This ‘fostered’ child must retain his birth name, may not have legal rights to the adoptive family’s inheritance once he/she comes of age, and would not be allowed to share in the same familial informalities allowed between biological relations under Islamic law. For example, if a boy were ‘adopted’ by an Islamic family in Lebanon, by Sharia law, he would not be allowed to be in the same room alone with his adoptive mother, or family members of the opposite sex, once he reached puberty. This would be seen as breaking the rules of modesty between members of the opposite sex that are not genetically related. The adoptive mother could only overcome this obstacle by breast-feeding him before the age of two, establishing ‘milk kinship’, a practice common to the Middle East.44 This cultural reality may reinforce biological bias, as it makes the lack of a genetic link between the child and his adoptive parents both tangible and explicit. Biological bias can subsequently lead to neglect and possible abuse. Literature on the higher rates of abuse among stepparents, otherwise known as the ‘Cinderella Effect’, may allude to the difference in bonding experienced by the adoptive parents and their child.45 Furthermore, because global adoptions tend to involve older children who come from backgrounds of neglect or abuse, they require what Jonathan Pearce, the director of Adoption UK, calls therapeutic parenting. ‘Of course, this is different to raising a biological child, just as it is different to raising an adopted child 30 or 40 years ago. It’s a parenting that I think should include ongoing training – just as you have with any other demanding job,’ he says.46 Unfortunately, information on adoption within Middle Eastern populations is lacking, with no formal studies assessing the prevalence and demographics of those adopted. As such, the nature of the adopted children, their backgrounds, and their relationship to their adoptive parents cannot be properly ascertained. With these distinctions in mind, one can see how adoption can be viewed as a less attractive alternative to uterine transplantation in Middle Eastern countries.
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M. Sidahmed. 2014. Surrogacy not an option in Lebanon. The Daily Star 13 September. 40 A. Phillip. 2015. A shocking scandal led Thailand to ban surrogacy for hire. The Washington Post February 20. 41 Where the child is given full rights and responsibilities of a biological child, including the adoptive father’s name. 42 Indonesia, Malaysia, Somalia, Tunisia, and Turkey. M.W.s.S. Council. Adoption and the Care of Orphan Children: Islam and the Best Interests of the Child. The Global Muslim Women’s Shura Council Statements 2011; 4. 43 Before the emergence of Islam in the Arab peninsula, the practice of adoption closely resembled a form of enslavement where captives were stripped of their natal identity and appropriated into the captor’s clan. This served the purpose of asserting military dominance through appro¯dı¯. ¯ba priating large numbers of fighting men. S. Joseph & A. Nagˇma 2003. Encyclopedia of Women and Islamic Cultures: Family, Law and Politics. Brill: 1.
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UTX AND ARAB SOCIETY In 2013, Lefkowtiz et al updated the Montreal criteria to determine the ethical feasibility of uterine 44
P. Parkes. Milk kinship in Islam. Substance, structure, history*. Social Anthropology 2005; 13: 307–329. 45 G.A. Tooley, et al. Generalising the Cinderella Effect to unintentional childhood fatalities. Evolution and Human Behavior 2006; 27: 224–230. 46 K. Hilpern. 2007. A Different Kind of Love. Available at: http:// www.theguardian.com/lifestyle/2007/dec/15/familyandrelationships .family [Accessed 24 April 2015].
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Figure 1. Revised Montreal Criteria for the Ethical Feasibility of Uterine Transplantation.48 transplantation.47 They suggested specific criteria for the recipient, donor and institution to fulfill if they are to be considered candidates for uterine transplantation (Figure 1). In the context of Arab/Lebanese society specific attention must be paid to parts 1.d and 1.g that state that a woman’s decision to undertake uterine transplantation must be rational and that she must responsible enough to consent and not under coercion. Due to the structure of the Lebanese family unit, these two articles of the Montreal criteria are problematic.
Infertility is not just an obstacle to be tackled by the husband and wife; in many cases extended family members (for example both mothers-in-law) are involved and the decision to undergo fertility treatments is tackled as a group effort.49 As such, the decision is no longer solely governed by the person undergoing the procedure, and there arises the risk that she might be coerced into having surgery done, be it directly or indirectly.50 Even if the subject were to be dealt without the presence of other family members, her consent is still in question knowing the pressures she is surely to have faced at home. These influences on reproductive and personal autonomy are not specific to uterine transplantation alone but are a common theme in pro-natalistic societies. As previously discussed by Mumtaz and Levay,51 the Montreal criteria may be difficult to apply in such situations, as a myriad of factors contribute to decision making and informed consent. The implications of family coercion in culturally pro-natalistic societies may have far reaching effects even outside the context of UTx and the Montreal criteria, extending into the complex interactions between women in the Middle East and the patriarchal society to which they belong. Regardless of cultural acceptance, one can argue that societal and familial coercion into undergoing a surgical procedure falls into the realm of violation of human rights and reproductive autonomy. Another problem that presents itself in the context of a pro-natalistic society is gender selection. As mentioned earlier, it is not just having a child that is central to the family unit; it is having a male child as well that is of paramount importance. The first-born male is central to the identity of the Arabic family, as is evident by how parents in Arab societies are referred to using the prefix abu- or im- (father-of and mother-of, respectively) followed by the name of the first-born son. A number of ethical questions arise from this paradigm: what happens if the product of the uterine transplant is not a male? Will termination of pregnancy be considered? Will the woman or her marital family pressure the attending physicians to impregnate the transplanted uterus repeatedly even if it is detrimental to the young woman’s well being? Or will they simply use sex-selection technology to ensure only male embryos are created during in-vitro fertilization, an issue with ethical ramifications. A big concern turns out to be that UTx technology can become one more vehicle for the practice of sex selective pregnancies and abortions for families to ensure they have a male child and
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Kaddour, et al. Directly by coercion into undergoing the procedure; indirectly through a fear of abandonment. 51 Z. Mumtaz & A. Levay. Ethics criteria for uterine transplants: relevance for low-income, pronatalistic societies. J Clinic Res Bioeth S 2012; 1: 2. 50
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A. Lefkowitz, et al. Ethical considerations in the era of the uterine transplant: an update of the Montreal Criteria for the Ethical Feasibility of Uterine Transplantation. Fertility and sterility 2013; 100: 924–926. 48 Ibid.
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Uterine Transplant Ethics Middle East heir.52 While many of these questions could ostensibly be raised with surrogacy as well, given Utx’s more recent entrance into the conversation surrounding pregnancy alternatives, they are worth re-emphasizing here.
EXPLOITATION: UTERINE DONATION Provided uterine transplantation becomes a standard procedure that can be safely carried out, one must also be wary of the consequences of such a technology being brought to Lebanon. Current trials are being conducted with deceased donors and live relatives, and the possibility exists that uteri in the future may be ‘donated’ from living, but unrelated individuals. It is possible that women who are not good candidates53 for UTx may seek alternative methods to obtain their uteri, alternatives that may not always be legal, such as reversion to black market procurement. In Lebanon, this point bears particular consideration because the country has a history of organ trafficking, in part due to the fact that voluntary donation in Lebanese society is still a tough concept to sell (for example of 800 road deaths in Lebanon in 2008, zero organs were harvested for donation).54 This reality has been augmented recently with the onset of the Syrian crisis. Refugee families desperate for sources of income have resorted to selling their organs to make ends meet. The media has extensively covered the illegal sale of organs in Lebanon and the gangs that run them.55 These reports have since been denounced by the Lebanese ministry of Health as unfounded, however it is very conceivable that impoverished families, especially refugees that have found themselves in a dire financial situation, may resort to selling
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their or their daughters’ uteri in order to be able to survive. If uterine transplantation has the potential to become another vehicle for human exploitation in Lebanon, the question of whether it is morally justifiable to bring this technology to our region, knowing full well that legal and social frameworks protecting individuals from these forms of trafficking are at present absent in Lebanon, is one worth posing.56
CONCLUSION Uterine transplantation presents a promising solution to uterine factor infertility. Despite its debatable ethical merits, it represents a pioneering step in the field of reproductive medicine, and perhaps a better alternative to its regional counter-parts. With regards to its acceptance as a solution to Uterine Factor Infertility in the Middleeastern region, further obstacles must be crossed. Religious acceptance is key, and while Islamic acceptance is discernible, Christian authorities remain apprehensive. The looming specter of human exploitation is more worrisome, and perhaps, unfortunately a challenge that will not be dealt with in the very near future. Deciding to undergo a uterine transplantation or not is, at least for the moment, more of a social decision than a medical one in most countries in the Middle East, and how Middle Eastern women will view themselves and their roles is an important issue to ponder
Acknowledgements The authors would like to thank Kristina Tester, for her instrumental help in writing this manuscript.
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Z. Mumtaz, et al. Understanding the impact of gendered roles on the experiences of infertility amongst men and women in Punjab. Reproductive health 2013; 10: 3. 53 Suitable candidates should be of fairly low age, and in good health. See: M. Brännström, et al. Uterus transplantation: animal research and human possibilities. Fertility and sterility 2012; 97: 1269–1276. 54 T.I.o.H.M.a.S. Protection. 2012. National Health Statistics Report in Lebanon. Beirut: Saint-Joseph University. 55 U. Putz. 2013. Lebanese Black Market: Syrian Refugees Sell Organs to Survive. Speigel Online. Available at: http://www.spiegel.de/ international/world/organ-trade-thrives-among-desperate-syrianrefugees-in-lebanon-a-933228.html [Accessed 24 April 2015]; H. Johansen. 2014. Lebanon’s black market in refugee organs. Middle East Monitor. Available at: https://www.middleeastmonitor.com/blogs/ lifestyle/9067-lebanons-black-market-in-refugee-organs [Accessed 24 April 2015].
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Biographies Zaid Altawil is a recent medical graduate of the American University of Beirut and currently a post-doctoral research fellow at the Division of Global Health and Human Rights, Department of emergency medicine at Massachusetts General Hospital. Thalia Arawi, PhD is the Founding Director of the Salim El-Hoss Bioethics & Professionalism Program at the American University Beirut Faculty of Medicine and Medical Center. Dr. Arawi is also the Clinical Bioethicist at AUBMC and the Vice Chair of the Medical Center Ethics Committee there. She is also member of several international bioethics associations and societies. 56
Putz, op cit note 59.
