There has been considerable attention to a paper by a Norwegian philosopher, Dr Anna Smajdor, in the journal Theoretical Medicine and Bioethics, outlining the case for what she calls “whole body gestational donation” (WBGD) as a form of surrogacy. This astounding paper was picked up first by Reddux, and since has received attention not just on social media but also in publications such as the Daily Mail and Cosmopolitan. The reaction is, in the main, mostly one of astonished revulsion, with a few voices as shown here (see the comments under the Daily Mail article).

The gist of Dr Smajdor’s argument is as follows: In 2000, Rosalie Ber suggested that women who have been diagnosed according to the brain death criteria, or who are in a persistent vegetative state (PVS) could be used as gestational surrogates. Yet, “surprisingly”, says Smajdor, this seems not to have been implemented anywhere in the world. Smajdor makes a few adjustments to Ber’s proposal, limiting it to women diagnosed as brain dead, and argues that with prior consent of the woman, it could provide a useful means to achieve pregnancy for those unable to carry a child to term, or, indeed, as an alternative to pregnancy for any woman, given that pregnancy is not entirely risk free. The existing system of organ donation is used to justify this, hence the description of “whole body gestational donation” which sees this as analogous to donating separate organs or body parts to save life or improve health in other individuals. Much could be said in comment on this paper but here we will simply make a few remarks…

Firstly, there are many reasons why this proposal does not seem to have been implemented, one of them being the high cost of sustaining a patient on life support, which would mean that to initiate and sustain a pregnancy until viability would be likely to involve costs in the hundreds of thousands of pounds if not more.

The high costs, plus other practical problems, does mean that this form of surrogacy may never be used in practice. But this does not imply that we should be complacent. One reason for concern is that such extreme proposals are often used rhetorically in debate. A troubling scenario is suggested. There is a general outcry. Then along comes the counter response: “We are not going to do anything so terrible! We agree this is going too far. We are proposing we do something far more reasonable!” Or perhaps, often later once the fuss has died down a bit, “We will do this, but don’t worry, we’ve listened to concerns, we’ll do it only with safeguards.”

But the proposed policy may be “far more reasonable”, may have “safeguards”, but is still nonetheless full of problems. “Not so bad”, may still be not good enough.

And a second reason for concern is that even if Smajdor’s proposal is never adopted, the ways in which she argues, including her view of childbirth, and of the human body in general and women’s bodies in particular, are firmly representative of much mainstream influential thinking in bioethics. There are many commonly used ways of arguing and of thinking about ethical problems which tend to skew towards certain “rational” sounding solutions, often favouring the use of new technologies, but which frequently present only a very limited and biased view of matters. Let’s look at just a few of the problems with Smajdor’s reasoning, problems which occur again and again in the field of bioethics.

We can start by looking at the analogy with organ donation, because it will alert us to some major problems. The argument goes by analogy:

X is really the same as Y. We accept Y. So we should accept X, in order to be consistent.

We accept organ donation. So we should accept donating the whole of one’s body, not just parts. Otherwise we are being irrational. “Those who accept brain stem death as an adequate basis for organ donation, should for consistency acknowledge its acceptability for WBGD as well”, opines Smajdor.

But Smajdor has actually shot herself in the foot by using organ donation as her model, because everything we know about organ donation confirms that human beings are not simply “rational” creatures, and the body is not merely a machine to be broken into spare parts.

Rates of organ donation are critically dependent upon sensitivity to the feelings not just of the donor but crucially of their families. Critical accounts in the media can greatly impact rates of donation, and sensitivity and empathy in explaining the situation and requesting consent of relatives is vital. Spain is often held up as having a particularly successful organ donation and transplantation system. This may be credited to its “soft opt out” system where the default position is that of consent, but critical to this is the extensive training in communication and sensitivity for those involved in requesting permission from families. Critical too, is widespread public understanding and acceptance, respect for those who opt out, and widespread agreement on the good that is being done by successful transplantation. (Remember the controversy that George Best had a liver transplant, only to continue drinking.)

How we treat the dead, including those who donate bodies, tissues or organs, is a deeply ingrained part of human culture. The very earliest signs of human civilisation show elaborate concern for proper burial. Disrespectful treatment of the dead has been used to mark disdain for enemies and criminals. But this, we now find abhorrent, showing how strong our respect for the dead is even in our “rational” and “scientific” age. We are moved to find that elephants also show respect for their dead. We cannot wave away these concerns with a few so-called “rational” arguments.

But this is precisely what Smajdor seems to do in her paper.

Smajdor acknowledges that in WBGD, the focus will move from caring for the patient, to using the patient’s body as a “repository of tissues that can be used to benefit others”. But, she says, this is just what happens anyway in organ donation.

Yes, it is. This is precisely why extreme sensitivity is needed. This is precisely why a different medical team deal with donation, not the team caring for the patient. This is precisely why, ideally, trained staff communicate with and care for the family. All this is overlooked in the name of “rational consistency”.

In the world of pure reason, truths are universal and eternal. Smajdor has no sense of time as for her it makes no difference. She recognises that in organ donation, we have to extend ventilation after brain death is diagnosed to keep the organs in a healthy state before they are removed for transplantation, and that in whole body gestational donation, this time would be extended. “But ventilating someone for two days, two weeks, or two years makes little difference except insofar as it forces us to acknowledge what we are doing before we hasten onto the next stage,” she writes.

But we are creatures who live in time, not in the abstract world of reason. Our experience of time is, well, an essential part of our lives, is woven into our entire embodied existence and development, our lives, our birth, our death.

Indeed, for families of those who donate organs, the time their relative spends on ventilation, and the harvesting of organs, does make a significant difference. The manner in which the family can say goodbye changes. This is not to be dismissed, and the generosity of families who willingly agree to this for the sake of others should be acknowledged. Smajdor seems to think that the issue can be resolved into overcoming our “distaste” for sustaining brain-dead patients for long periods. The “discomfort” here, she suggests, “relates to the liminal state between life and death that brain-dead patients occupy”, as if overcoming this discomfort is akin to, say, overcoming squeamishness at having to pull a splinter out of someone else’s fingernail.

For the rest of the human race, these “liminal states” are the stages of transition between life and death which form critical points of significance and meaning. The recognition of their significance is an integral part of our humanity. Neither at the start, nor at the end of life, does Smajdor understand the importance of how we respond to our embodied existence.

Furthermore, Smajdor has a pick and mix approach to evidence. She bends over backwards to examine the minutiae of the scarce empirical evidence regarding gestation in women who are diagnosed as brain dead while pregnant, speculating optimistically about what might be possible, and observing for example that “there is no known upper physiological limit to the prolongation of somatic function in the absence of brainstem function”. But this simply means we have virtually no evidence, because it’s never been done. Yet Smajdor uses it to imply we could carry on keeping the body going indefinitely. She seems to grasp at any shred of evidence that WBGD can be done. Yet at the same time, any arguments against it are dismissed as mere “distaste”.

The body is seen as a robotic resource, as a machine. The use of reason in this paper shows an instrumental rationality which understands the human body as simply part of the material universe, one more resource to be exploited and used, and as in need of improvement. The fact that even normal pregnancies are not risk free is used as an argument to justify using WBGD for any pregnancy, not simply in cases where an individual or couple cannot otherwise carry and birth a baby. But this is one place where Smajdor’s “rationality”, her mathematical calculation approach to ethics, comes apart – mysteriously, she never explains how eggs are extracted from a woman’s body, because that would remind us of the not inconsiderable risks of egg donation. Oddly as I have often noticed in much bioethics and discussions of technology ethics, it so often seems to be risks that occur in the natural course of life which are counted; risks caused by technology itself are either ignored, or it is assumed that improvements in technology can eliminate them.

Pregnancy, no; injecting a woman with massive amounts of hormones and other drugs to induce ovulation and egg extraction, yes.

The last comment for now concerns the child. Smajdor’s arguments address the physical health and safety of the foetus as it may develop within the womb of a woman who is brain-dead. Naturally physical health is extremely important. But again, she reduces the human being to nothing more than a biological, material creature. If a woman has become simply a “bio” version of a gestation machine, if she is brain dead, the baby born in such circumstances emerges from a static, unconscious and unfeeling mother. What emotional and psychological issues might this bring?

Children now often see their own ultrasounds from when they were in the womb. Recent celebrity same-sex male couples have shown off such ultrasounds, strangely isolated images, the mother entirely absent. The woman who bore a child in its first months from conception to birth is notable by her absence. What lack might such children grow to feel when they finally understand their origins? And what lack might a child feel who is born of a brain-dead donor, kept alive on ventilation for the entire period of gestation?

In surrogacy from WBGD, this is not parallel with those thankfully rare cases where a pregnant woman suffers some calamity and the pregnancy is sustained after a diagnosis of brain death to produce a child that she had wanted as her own. For in cases of WBGD surrogacy, under this scheme of technical rationality, a scheme which treats bodies as bits and pieces, and as machines to be exploited, the brain-dead woman is used as if she simply as an incubator or useful storage unit.

Of course she is never that. There are intimate biological links between a woman and the child she carries, even in the absence of any genetic relatedness. Fine-tuned adjustments to the mother’s physiology occur. Communication between mother and child takes place on many different levels. Free foetal DNA enters the maternal bloodstream. Stem cells from the foetus can help repair the mother. The growing child will recognise sounds, the mother’s voice, different tastes, the pace of the mother’s gait.

The consent of the woman to WBGD does nothing to remove these facts of human development or their significance. To focus on consent as a means of resolving ethical problems is again to see the question in terms of an abstract rationality, not in terms of the grounded biological reality and connectedness to each other which forms the underpinning of our mortal existence, which frames our moral compass.

In some jurisdictions, the families of those who donate organs may be sent anonymous “thank you” cards, or be updated anonymously about the welfare of those who received their relative’s organs. This is often a source of comfort, but must be handled with sympathy and sensitivity as families may feel their loved one “lives on” in others. With whole body gestational donation, these relatives will have waited months and months to bury their relative. What of their feelings about the child?

At birth, the child will be removed from the womb, and, presumably, the ventilation will be switched off. Will Smajdor and her bioethical colleagues tell us that concern for this is based on “irrational” feelings about the “liminal” states at the start of life, on “disgust” which we must overcome?

Arguments are sometimes presented as more rational, the more they abstract from reality they become; the more “emotional” the response the more it is dismissed or belittled. Good luck bringing up a baby on such a regime of pure reason.

Will it be left to the rest of us to explain that, no, human beings are not simply biological creatures to be manufactured to order; the dead are not simply vessels to be used to satisfy the desires of others for children. We need to explain to these “bioethicists” that, as significant as a child’s birth day is, so is their journey from inside the womb of great significance, and not just to the child but to the mother; just as the journey we all take out of this life is significant, and not just to the individual, but to all who love and care for us.

 ~ Paula Boddington is a moral philosopher. Paula has published on a wide variety of topics including the ethics of organ donation and transplantation, clinical genetics and genomics, and the ethics of new technologies.