Artificial Womb Brings Tough Choices, But Who Tests It?

Arthur L. Caplan, PhD


November 13, 2023

This transcript has been edited for clarity.

Hi. I'm Art Caplan. I'm at the Division of Medical Ethics at the NYU Grossman School of Medicine.

Some of you may have heard that not too long ago, there was a hearing convened by the FDA on an amazing technology: the artificial womb. The FDA convened a hearing to listen to what scientists thought about whether it is time to try the artificial womb to save the life of an extremely premature infant. It's something that I think we all need to be thinking about because whether it gets approved this year or next year, it's a technology that is on the way.

Doctors and scientists have been working hard to try and develop some sort of system where you could take a premature infant and allow it to live even though it doesn't have lungs. The current limit on prematurity is that fetuses born before, let's say, 20-23 weeks simply don't have lungs. Remember, we all began birth as little mermaids and mermen swimming around in amniotic fluid inside a mom's womb.

Fetuses need to have chemicals that could support their breathing. If you could come up with an artificial solution and get it into the right delivery system, say some sort of a bag that could contain the fetus, much like the womb does, then you'd be able to extend efforts to save the lives of preemies beyond, let's say, 23 or 24 weeks.

Remember the old line in the Roe v Wade abortion decision before it was overturned later and recently by the current Supreme Court in the Dobbs decision? They took it from experts that fetal viability was 24 or 25 weeks. Well, this technology is going to extend, potentially, viability to younger fetal ages.

That is going to raise a host of questions both in terms of how to introduce this technology into ob/gyn and public policy decisions about how to manage it relative to the abortion debate. The appearance of this technology is going to raise a slew of ethical issues as we try to introduce it into obstetrics and for our ongoing debate about abortion in the US.

In terms of using the technology, the key ethical issue is that you're going to have to decide who goes first to test it. Remember, you can't just have a natural birth of a premature infant unless you've got the artificial womb nearby. At least to begin with, you're talking about C-sections that are planned, knowing that somebody is very likely to have a premature infant. Then, the technology and the delivery can be coordinated so that a premature infant could be put directly into the artificial womb.

Trying to decide who goes first in terms of prematurity raises many questions about fairness and justice in terms of eligibility. There are women who are known, as you're monitoring them, to have fetuses that appear to be in trouble. Maybe they should be selected as the first individuals offered the chance at the artificial womb. There are women who abuse substances and are at high risk for prematurity. Maybe they would agree to have their fetus removed via C-section and put into this technology if they are very, very high risk. There are other genetic conditions and medical conditions that put women at high risk for an early delivery as well.

Sorting through who goes first is going to be tough. We can't promise that the technology will allow a baby to be produced that's healthy. When you put it in the artificial womb, it can only stay there for a short period of time, long enough, hopefully, that it matures its lungs, and then you move it to a neonatal ICU.

There's a large amount of technology and high costs. Who's paying for all this? Really, you're talking about women who can both access the artificial womb and a neonatal unit. I'm going to say that certainly, it is going to favor better off, richer, and more informed people who have good obstetrical care to begin with. I think there's going to be a disadvantage in the introduction of the technology against people who are poor or uninsured, given all the steps that are going to be required.

Obviously, women are going to have to be told that this is a gigantic experiment. I assume many of them would be willing to take the chance if they knew their child was going to be premature and die, which is the fate of babies without lungs. This means that we better be sure the science is sound. That's what the FDA is wrestling with, but it's also something that has to be wrestled with at each institution that agrees to try this for the first time.

Let's say it works, and the technology is disseminated. We're going to have some interesting questions come up, such as when fetal viability really begins. Some states are passing laws that say no abortions after 6 weeks. Some are saying no abortions after 15 weeks. Others are saying no abortions after viability, but viability would be shifted if we had a technology that let you go after a premature infant who is 17 weeks, 18 weeks, or maybe even 15 weeks at some point.

Will that and should that shape our decisions about how to permit abortions and allow women to make decisions about what they want to do if they're facing prematurity and a threat to the health of their infant and maybe creating an infant that would have disabilities or not necessarily be healthy?

It's already the case in many states where those decisions are being taken away from women. Using a technology like this, it seems that the case is strong to allow that choice to be made by the woman. She's the patient. She's the one who's going to have to make decisions about the care of this fetus and what happens to it if things look like they're not going well.

It's going to be hard to emphasize her rights given the climate that we see that I don't think is going to change much in the future in many states, which basically say, "We're taking the decision away from you. You're going to have to have this baby, and you're going to have to use this technology." I don't support those stances, but I think it's something that we can begin to introduce into the debate now.

The artificial womb, overall, maybe is not quite ready yet for prime time. Let's test it and see what will happen. I'm all for that. Down the road, there will be tough choices in front of us about access, informed consent, and how will this reshape thinking about the huge ethical controversy that has beset America, which is abortion.

I'm Art Caplan at the Division of Medical Ethics at the NYU Grossman School of Medicine. Thank you for watching.

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