Artificial Womb Brings Tough Choices, But Who Tests It?

The artificial womb that is being developed could potentially save very premature infants, but testing it raises many issues.

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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.