The Moral Imperative for Ectogenesis

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edited by Tuija Takala and Matti Häyry, welcomes contributions on the conceptual and theoretical dimensions of bioethics.

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Dissecting Bioethics
“Dissecting Bioethics,” edited by Tuija Takala and Matti Häyry,
welcomes contributions on the conceptual and theoretical dimen-
sions of bioethics.
The section is dedicated to the idea that words defined by
bioethicists and others should not be allowed to imprison people’s
actual concerns, emotions, and thoughts. Papers that expose the
many meanings of a concept, describe the different readings of a
moral doctrine, or provide an alternative angle to seemingly self-
evident issues are therefore particularly appreciated.
The themes covered in the section so far include dignity, natu-
ralness, public interest, community, disability, autonomy, parity of
reasoning, symbolic appeals, and toleration.
All submitted papers are peer reviewed. To submit a paper or to
discuss a suitable topic, contact Tuija Takala at tuija.takala@helsinki.fi.
The Moral Imperative for Ectogenesis
ANNA SMAJDOR
The United Kingdom, like many other
affluent Western societies, is appar-
ently in the grip of declining fertility.
The resultant strain on the economy
caused by an aging population is being
exacerbated by what has been charac-
terized as the selfishness of women
who delay reproduction in their ef-
forts to secure financial and social sta-
tus before getting around to starting a
family.
1
Such women may only begin
to think about having children in their
mid-30s, an age that, according to re-
search, is a predictor of “serious mor-
bidity” in pregnancy and childbirth.
2
And for many of those who try to
start families when in their 30s, their
fertility may have declined so that they
may not be able to have children at all
or may need to resort to reproductive
therapies to do so.
The obvious response to this is to per-
suade women to reproduce earlier, re-
gardless of the effect on their careers or
other interests. However, there is more
at stake than just this. In fact, women
do not necessarily have children only
to fulfill their own biological desires. So-
ciety at large may also have an interest
in reproductive matters, and it is here
that the difficulty emerges. Encourag-
ing women to curb their other interests
and aspirations in order to have chil-
dren at biologically and socially opti-
mal times reemphasizes that it is women
who take on the risks, whereas society
in general profits from these sacrifices.
This, I suggest, is a prima facie injus-
tice. Yet it is founded on a physical ne-
cessity: Babies must be gestated in
women’s bodies.
But there is an alternative approach
to this problem: Rather than putting
the onus on women to have children
at times that suit societal rather than
women’s individual interests, we could
provide technical alternatives to ges-
tation and childbirth so that women
are no longer unjustly obliged to be
Thanks to Karen Gui.
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Cambridge Quarterly of Healthcare Ethics (2007), 16, 336
–
345. Printed in the USA.
Copyright © 2007 Cambridge University Press 0963-1801/07 $20.00
DOI: 10.1017/S0963180107070405
336

the sole risk takers in reproductive
enterprises. In short, what is required
is ectogenesis: the development of ar-
tificial wombs that can sustain fetuses
to term without the need for women’s
bodies. Only by thus remedying the
natural or physical injustices involved
in the unequal gender roles of repro-
duction can we alleviate the social in-
justices that arise from them. My
argument that follows is based on work
by Justine Burley,
3
who in turn devel-
ops her position from Ronald Dwor-
kin’s views on the subject of equality
in healthcare distribution.
4
Burley’s Argument: A Right to
Fertility Treatment?
Dworkin talks of integrating health
care into other goods and regarding
all these goods in terms of distributive
justice.
5
He argues from this that nat-
ural inequalities may generate a prima
facie right to restitution. Thus, if a
person is born blind, she may be re-
garded as the victim of a prima facie
injustice that could lead to a claim for
compensation. Burley extrapolates from
this that the infertile can also claim
compensation in the form of state-
funded fertility treatment.
6
However, there is a potential diffi-
culty her e that Burley observes, namely,
that having children could be re-
garded as being merely an expensive
taste. On Burley’s reading of Dwor-
kin, those tastes that we cultivate do
not necessarily constitute grounds for
compensation, but where expensive
tastes have been acquired involun-
tarily, the claim for compensation could
still stand. Here she cites Dworkin’s
stipulation that if people’s tastes are
related to their conception of the “good
life,” then restitution is not necessarily
warranted. If individuals could be of-
fered the means of removing or reliev-
ing the desire or taste for X in a way
that did not encompass the provision
of X, but they chose to retain the de-
sire, they would not be eligible for
compensation. So someone addicted
to truffles and caviar could not de-
mand compensation if she character-
ized the possession of this desire as
being something desirable in itself.
The desire for children tends to be
characterized by its high place in
people’s priorities, as Burley notes.
7
Generally, if infertile people long for
children, they do not want to receive
treatment aimed at removing the de-
sire or healing the emotional pain of
childlessness: They want provision of
children themselves or at least the
wherewithal to generate them. Bur-
ley’s reading of Dworkin so far indi-
cates that state funding for fertility
treatment is not justified.
However, Burley then moves on to
consider the problem from a different
angle: We have established that the de-
sire for children is likely to be intri-
cately tied up with people’s conception
of the good life and as such cannot be
regarded as a handicap of which suf-
ferers have a right to be relieved. This
means that people who do have chil-
dren and who find that their finances
are adversely affected have no claim to
restitution despite the fact that their im-
personal resource holdings may be ad-
versely affected. This is not simply
because they have chosen to have chil-
dren, but more specifically because their
choice to do so is intrinsically connected
with their ethical beliefs and their as-
sumptions about what constitutes a good
life. If a deficit is to merit compensa-
tion, it must be possible to construe it
as a limitation upon the possibility of
one’s pursuit of the good life.
But people who cannot have chil-
dren do not choose their infertility,
nor do they construe childlessness as
part of their conception of the good
life. Individuals may be infertile
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through no fault or choice of their
own, but through mere brute luck.
Therefore, when compared with fer-
tile people, the personal resource hold-
ings deficit of the infertile may merit
compensation.
8
Thus, for Burley, fer-
tility treatments can be fitted into
Dworkin’s framework as a form of re-
distributive justice, based on redress-
ing the deficit in personal resource
holdings that may result from no
voluntary choice of the individual con-
cerned and that may inhibit that per-
son’s capacity to pursue her life goals.
So far, Burley’s argument doesn’t
prove anything more thanaprimafacie
entitlement: The question of where to
place fertility treatments in the fund-
ing hierarchy remains. There are many
prima facie claimants for funding, but
only limited resources. Dworkin rec-
ommends a quasi “veil of igno-
rance”
9
approach, in which people
would choose which handicaps to
make provision for, without necessar-
ily knowing which handicaps they
would suffer from. Only those condi-
tions that the aggregate have chosen
to insure against would be compen-
sated. Burley suggests that in this kind
of scenario, the social and economic
weight given to reproduction is so
pervasive that “[i]t is plausible to in-
sist that individuals in the aggregate
would stipulate infertility as one hand-
icap they were particularly concerned
to receive compensation for.”
10
Applying the Burley/Dworkin
Argument to “Natural” Fertility
As we have seen, natural inequalities
can be argued to constitute prima facie
grounds for restitution. In what fol-
lows I bring these arguments to bear
on my own contention: The fact that
women have to gestate and give birth
in order to have children, whereas men
do not, is a prima facie injustice that
should be addressed by the develop-
ment of ectogenesis.
At this point, it seems clear that
there may be a problem: Natural in-
equalities are frequently beyond our
power to remedy. If we cannot make
the blind see, increase someone’s IQ,
or relieve women of the burden of
gestation and childbirth, then surely it
follows that we cannot have any moral
obligation to do these things. An act
cannot be a duty unless we can be
sensibly be commanded to perform it
(ought implies can).
11
Accordingly, our
responsibilities in terms of redistribu-
tion of natural goods are circum-
scribed by what is feasible.
12
However, this seems short-sighted in
the context of our rapidly moving tech-
nological achievements. If the only ar-
gument against someone’s having a
need met is that no one can meet that
need, perhaps resources should be di-
verted toward being able to meet that
need. That is to say, in some circum-
stances, perhaps ought implies ought to
be able to. Kant’s point, of course, holds
when to fulfill a duty would be a logical
impossibility. However, many things
that are currently impossible (e.g., ec-
togenesis) are merely contingently so.
We have either chosen not to focus re-
search in these areas or are still strug-
gling to find answers to the problem.
As long as there is no logical impos-
sibility, we are not exempted from our
moral duties simply by the fact that
we do not yet have a way of solving
the problem.
In fact, although the possibility of in-
cubating babies in artificial wombs (ec-
togenesis) has long been regarded as the
province of science fiction, it no longer
seems incredible that within the fore-
seeable future, babies could be ges-
tated without the need for a woman’s
body. Ectopic pregnancies show that the
development and survival of a fetus out-
side the uterus is possible,
13
and ad-
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Dissecting Bioethics
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vances in neonatal care have meant that
the number of weeks’ gestation neces-
sary for a baby’s survival are diminish-
ing steadily.
14
Meanwhile, at the other
end of the spectrum, laboratory tech-
niques have enabled scientists to create
and cultivate embryos in vitro for up to
2 weeks before implantation. Restric-
tions on this timeframe have been due
to legal and ethical cutoff points rather
than technical problems. Thus, the win-
dow of time required for pregnancy is
shrinking and could feasibly become
redundant.
Therefore, arguments such as those I
am making based on the Burley/
Dworkin angle cannot be dismissed on
the grounds that they are beyond our
current capabilities. If there is a prima
facie injustice involved in reproduc-
tion, then it would seem that there could
indeed be a prima facie moral duty to
consider the possibility of alleviating it.
But this seems to leave us with a
problem. If natural inequalities can con-
stitute prima facie grounds for restitu-
tion, and current impossibility does not
rule out a duty to channel resources in
particular areas, we might find our-
selves compelled to pour funds into re-
search to raise IQs or enhance people’s
memories or other physical or mental
attributes. Negative interventions might
also be claimed: If there are some peo-
ple who are “naturally” deaf, I could
demand to become deaf too, since
Dworkin’s theory
—
on which I am
basing my argument
—
avoids draw-
ing barriers and boundaries between
therapeutic interventions and enhance-
ments or stipulating any objective
benchmark as to what should be re-
garded as desirable.
I think this can be answered by em-
phasizing that all we have tried to es-
tablish at this stage is a prima facie right
to restitution. Although it might be sur-
prising if some of the kinds of interven-
tion I’ve mentioned, such as elective
deafening, were prioritized beyond the
prima facie stage, it does not seem in-
herently problematic that these possi-
bilities share with ectogenesis a place
at the merely prima facie stage of mer-
iting attention. We must simply be sure
that there is an effective means by which
competing claims can be judged.
To progress the claim for restitution
beyond the prima facie stage, we need
to consider the “veil of ignorance”-
type scenario as described above, where
individuals make judgments based on
which disabilities they would provide
for, without knowing in advance
whether they would suffer from these
disabilities. Although Dworkin rejects
explicitly using criteria such as well-
being or suffering to distinguish objec-
tively between claims, he leaves it open
as to what criteria the individual might
use in his/her analysis of the options
from behind the veil of ignorance and
how these considerations might affect
the aggregate outcome.
So what would motivate people’s
judgments in these conditions? The
probability of having a particular con-
dition is thought by Burley to be a
significant factor. Burley also assumes
that social proclivities, such as the de-
sire for genetically related offspring,
would be a motivating factor.
15
I want
to add my own ingredient to this spec-
ulative mix, namely, the association of
the condition with pain and suffering.
16
Gestation and childbirth, it seems
to me, are very likely to be associ-
ated with pain and suffering in a way
some other conditions might not be.
Moreover, a susceptibility to these pr ob-
lems afflicts around 50% of the popu-
lation (assuming that in this particular
veil of ignorance scenario, the individ-
ual does not know which gender they
will be). Thus, on these two grounds
alone, I would suggest that choos-
ing
—
if the choice was open
—
a tech-
nological alternative to gestation and
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childbirth from behind the veil of ig-
norance would be entirely plausible.
Pregnancy Is Barbaric
There has been a conceptual failure in
medical and social and ethical terms
to address the pathological nature of
gestation and childbirth and to tackle
the health problems it poses from a
justice perspective. Here, I want briefly
to highlight some of the risks in-
volved in pregnancy and childbirth. I
want to suggest that the desire of
women to be able to reproduce as men
do, without risking their physical and
mental health, economic and social
well-being, and
—
crucially
—
their bodily
integrity, can be defended against
charges of being mere whim, prefer-
ence, or expensive taste. The effects of
gestation and childbirth on women’s
health alone mean that the claim of
women to be relieved from this means
of reproduction can be firmly located
within a recognizably health-oriented
need.
17
Fifteen percent of all pregnant women
develop potentially life-threatening
complications.
18
Over the years 2000
–
2002, the overall maternal mortality
rate in the United Kingdom was 13.1
maternal deaths per 100,000 materni-
ties.
19
Pregnant women are likely to
suffer health problems including back
pain, exhaustion, bowel problems, and
urinary incontinence extending for 6
months after delivery and beyond.
20
The prevalence in particular of fecal
incontinence following childbirth is
something that has only just begun to
be recognized, and it has been sug-
gested that for this reason alone, “nat-
ural” birth should be something for
which women give informed consent
based on a full understanding of these
risks.
21
Morbidity associated with child-
birth has been systematically neglect-
ed.
22
Perhaps for this reason, research
shows that mothers experiencing their
first childbirth find the event worse than
they had expected.
23
Where women are
aware of the risks involved, this can
increase fear of childbirth.
24
Fear it-
self can raise the likelihood of their
having caesarean sections due to com-
plications arising from tension and
trauma at the time of birth.
25
Caesar-
eans, of course, entail all the usual
risks of major surgery.
Despite the known dangers associ-
ated with caesareans, more and more
women choose this option with all the
attendant risks.
26
They are often casti-
gated for this (“too posh to push”
27
).
But no one likes having major surgery;
the fact that some women are tempted
by the possibility of this procedure
can be taken to demonstrate that “nat-
ural” childbirth is a fearsome pros-
pect. As Shulamith Firestone said,
“pregnancy is barbaric.”
28
Put simply, however much modern
medicine can do to improve outcomes
in pregnancy and childbirth, it cannot
remedy the fact that these processes
impose risks on women that far ex-
ceed the risks of normal day-to-day
living. The health-related consequences
of childbirth and labor also permeate
into women’s ability to function as
mothers and as members of society. A
difficult labor increases the chances of
posttraumatic stress syndrome
29
; in-
continence and back pain may keep
women out of work or severely re-
strict their employment options and
thus impair their financial well-being.
The final point to make here is the
well-known one that, for expectant
mothers, the fact of encompassing an-
other life in their bodies often takes a
serious toll on their autonomy. Preg-
nant women are routinely expected to
subsume their appetites and desires
into those that would be in keeping
with the well-being of the fetus. Not
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only this, but their abilities and rights
to make decisions about their medical
care are at risk of being overridden in
favor of the interests of the unborn
child. Respect for one’s bodily integ-
rity, something that most men may
take for granted at least in a medical
setting, is by no means assured for
women even in societies that pride
themselves on concern for ethics and
autonomy. Women are still sterilized
against their will and undergo forced
abortions and forced caesareans.
30
Voluntary Risk
One could, of course, argue that in
these days of modern contraception,
women aren’t forced to have children.
It is a choice that women make. If they
choose to accept the risks involved,
they can have no claim to restitution.
Burley neatly illustrates the idea of
choice and risk in an analogy that I
borrow here.
31
Suppose two people go
bungee jumping, knowing that this is
a sport that entails a certain degree of
risk. One of the jumpers suffers de-
tached retinas; the other is unscathed.
Burley states that the injured bungee
jumper does not have a claim to com-
pensation, because she voluntarily un-
derwent the same risks as the other
jumper. In fact, it is a case of option
luck as opposed to brute luck.
In my argument, pregnancy is the
bungee jump. Granted, women do often
voluntarily make the choice to jump and
thus assume the risks involved. How-
ever, the prima facie injustice involved
lies in the fact that when men decide to
jump
—
or to have a genetically related
child
—
they are able to do so without
assuming any of these risks that affect
women in similar situations. When a
man wishes to have offspring, he is able
to do so without risking his bodily in-
tegrity, his health, or his privacy. Thus,
in terms of personal resource holdings,
women are systematically at a disad-
vantage. In the context of reproduc-
tion, men and women are not like the
two bungee jumpers in Burley’s anal-
ogy: The choices and risks open to them
are vastly unequal.
Applicability of the Argument to
Men or Surrogates
Just as some women might wish to be
free of the burdens of childbirth and ges-
tation, so some men might long to be
able to experience these things. I con-
cede that if there were men who wished
to gestate and give birth, the lack of this
capacity could be regarded by such men
as a deficit in their personal resource
holdings. Such men, according to my
argument, would also have a prima facie
right to restitution. However, just as
women would have to rely on other fac-
tors to advance their cause beyond a
mere prima facie right, so would men
in these circumstances.
There is another possibility to con-
sider here. In fact, a woman does not
always necessarily have to gestate and
give birth in order to have genetically
related children. A less technologically
pleasing solution is currently at hand:
surrogacy. If those women who do not
wish to give birth could routinely del-
egate the task to those who do, the
injustices I’ve been describing would
seemingly evaporate. Just as a man
can currently use his wife or partner
as a surrogate to carry his child, rather
than carrying it in his own body, so in
this new arrangement, his wife or part-
ner would also be able to avail herself
of a surrogate.
However, this scenario is unlikely to
be appealing. Apart from the difficulty
of ensuring that sufficient surrogates
would offer themselves, without veer-
ing into coercion, it simply seems to re-
frame the problem in a narrower context.
Part of the objection about the current
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reproductive situation is that a subset
of individuals in society (women) is, in
effect, obliged to act as surrogates for
men. If we simply reduce the number
of that subset, without addressing the
inherent inequality (namely, that it has
to be women who are the surrogates,
rather than men), we come no closer to
solving the injustice.
Effects on the Child
There is, of course, a fundamental eth-
ical consideration to be addressed in
relation to the question of ectogenesis:
What effect would it have on the child?
It might be argued that “ecto-children”
would lack some essential bond with
their mothers that other children have.
At the very least, it would seem ex-
tremely technically demanding to en-
sure that an artificial womb provided
all the nutrients necessary for the well-
being of the child. And what about
the effect on the mother/child relation-
ship? Surely this would be fractured
by the removal of the physical bond
between them.
With regard to the safety of ecto-
genesis, I assume for the purpose of
this argument, that sufficient research
would need to be carried out to estab-
lish this. However, the difficulties of
mother/child bonding still remain. I
want to make two points in response
to this possible obstacle. First, those
who suppose that the mother’s bond
is entirely dependent on her physical
gestation of her child do a huge dis-
service to all the step- and adoptive
parents who love their children dearly.
More importantly, they sweep away
any possibility of claiming that fathers
can love their children as much as
mothers do. Of course I don’t claim
that fathers always do love their chil-
dren as much as mothers, but I think
it self-evident that they can.
Conversely, mothers’ physical con-
nection with their babies does not guar-
antee a secure and unconditional flow
of motherly love. Plenty of women
fail to bond with their naturally born
children. Arguably, the traumatic pro-
cesses of birth are partly implicated in
this: Postpartum depression (which af-
fects 13% of women who have given
birth) may cause the mother to reject
her child or to refuse to nurture it, all
of which have a negative effect on the
child’s subsequent development.
32
Another point to make here is that,
in the current age of prenatal testing
and diagnosis, the phenomenon of the
“tentative pregnancy” has been well-
documented.
33
That is to say, women
undergoing prenatal tests speak of a
need to re-form bonds with their fe-
tuses after receiving test results. There
are also considerations related to the
development of visualization tech-
niques during pregnancy: For many
couples, being able to “see” the baby
on screen is a highly significant mo-
ment. This is not connected with the
knowledge that the baby is inside,
which has been evident all along, but
is tied up with the idea that the baby
looks like something, that it can be
seen despite being inside the mother.
34
Physical gestation of a child is thus
neither necessary nor sufficient for the
development of a loving parental bond.
The permutations of childrearing in
our society are diverse, and it seems
highly dubious to locate some kind of
mystic essence of parenthood in ges-
tation and childbirth if neither of these
things can be directly associated with
the development of the loving bond
or with benefits to the child.
Arguing for Prioritization
To return to the argument in favor of
ectogenesis: I have suggested that there
are prima facie grounds for women to
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Dissecting Bioethics
342

be relieved of the natural inequalities
involved in reproduction and have at-
tempted to deal briefly with some of
the more obvious objections to this
claim. In this final section, I want to
address the major difficulty: where to
locate ectogenesis in a competing hi-
erarchy of claims for state assistance.
As suggested by the Dworkin/Burley
model, a version of the veil of igno-
rance is required, in which individu-
als make decisions based on their
preferences and their judgments of the
likelihood of being afflicted by certain
disorders, and the aggregate of these
choices receives priority in funding.
I’ve emphasized that Dworkin’s ap-
proach does not require that anything
be objectively definable as a disease,
disability, or disorder, so the fact that
gestation and childbirth are “natural”
for women is not in itself an argument
against their appearance in the list of
contenders for restitution.
Burley’s argument in favor of the
provision of state-funded artificial re-
productive technologies rests heavily
on her assumption that this veil of
ignorance test would yield a result
that prioritized fertility treatments. I
think that this assumption is hasty.
Burley does not discuss the relation-
ship between fertility treatments and
remedies for other natural inequali-
ties, and I see no reason to suppose
that it would necessarily be prioritized
in the way she assumes. Infertility as
a condition is not necessarily associ-
ated with suffering in the way that
say, appendicitis is. Only a subset of
those who are infertile will actually
wish to reproduce. For those who do
not, they might never even realize that
they lacked the capacity.
In theory at least, there might be
greater scope for ectogenesis to be pri-
oritized due in part to the pain and
trauma that even the best-managed
childbirth entails. There is also the fact,
as I’ve pointed out, that susceptibility
to this trauma affects around 50% of
the population
—
considerably more than
Burley’s 1 in 10 couples who may suf-
fer from infertility. But our society
would need to undergo a major con-
ceptual shift for sufficient numbers to
regard female fertility per se as some-
thing that merits compensation. For
this reason, I suspect that the veil of
ignorance test would be unlikely to
work if embarked on now. However,
if women
—
and men
—
feel that there
is a genuine justice issue here, it re-
mains with them to convince the skep-
tical masses of this fact.
The democratic nature of the
Dworkin/Burley argument that I’ve
borrowed here requires more than ab-
stract theorizing: People need to be
persuaded. Probably the “yuck factor”
will be too strong for it to prevail as
yet. But just as it was thought absurd
that women should vote or ride horses
astride, so it may come to seem ab-
surd that they were chained to the
degrading and dangerous processes of
pregnancy and childbirth simply be-
cause of our inability to get our heads
round the possibility of an alternative.
I would like to close with an imag-
inary scenario: You, the reader, from
behind the veil of ignorance, are asked
whether you would prefer to be born
into society A, where women bear all
the risks and burdens of gestation and
childbirth, as they do now, or society
B, where ectogenesis has been per-
fected and is routinely used. You do
not know whether you will be born as
a man or a woman. Which would you
choose?
Notes
1. Foggo D, Rogers L. Fertility experts urge
end to “selfish” late motherhood. The Sun-
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day Times 2006 Jul 9; Templeton SK. Late
motherhood “as big a problem” as teenage
mums. The Sunday Times 2006:Aug 13.
2. Hebert PR, Reed G, Entman SS, Mitchel EF
Jr, Berg C, Griffin MR. Serious maternal
morbidity after childbirth: Prolonged hospi-
tal stays and readmissions. Obstetrics and
Gynecology 1999;94(6):942
–
7.
3. Burley JC. The price of eggs: Who should
bear the cost of fertility treatments? In: Har-
ris J, Holm S, eds. The Future of Human
Reproduction. Oxford: Clarendon Press; 1998:
127
–
49.
4. Dworkin R. The foundations of liberal equal-
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