Uterine transplantation is not a good use of limited resources: FOR: Uterine transplantation is not a good use of limited resources-a case of distributive justice and burden of disease.

Abstract

The debate surrounding uterine transplantation (UTx) is complex and multifaceted. Although its scientific merit has recently been put in the spotlight, the social, economic and ethical considerations implicated have been largely left out of the mainstream conversation. In its current state, a principlistic analysis of UTx reveals arguments in favour of the principles of autonomy and beneficence, but it remains largely equivocal with regards to the principle of justice (Lefkowitz et al. Transpl Int 2012; 25:439–47). Successful public healthcare systems aim to abide by the principle of distributive justice, where providers seek to allocate the scarce resources at their command (operating rooms, time of physicians and nurses, medical supplies) in a just way so as to most efficiently address the needs, health and welfare of individuals and groups within the population. The aim of such an approach is to ensure maximisation of quality-adjusted life-years (Skedgel et al. Med Decis Making 2015;35:94–105). In such considerations, ‘micro-allocation at the lower level’ (Breyer, F. Health care rationing and distributive justice. Rationality, Markets and Morals 2009;27:406), particularly among individuals with rare conditions, is not prioritised unless unjust burden exists, or the population-risk of not treating such individuals is disproportionate (e.g. epidemics and quarantines). Indeed, in the setting of limited resources, the needs of the people should guide the distribution of opportunities for wellbeing, including access to care and partitioning of goods and services. Relative to a number of life-threatening conditions for which there may not be treatment alternatives, the burden of disease of uterine factor infertility, the main indication for UTx, remains comparatively low. In addition, the cost of the procedure is disproportionate in comparison to the cost of its alternatives, namely surrogacy and adoption. Said cost includes four surgeries, anti-rejection regimens, at least one cycle of in vitro fertilisation, and close monitoring for at least a year after the transplant and throughout the pregnancies. Furthermore, as it stands today, the number-needed-to-treat to reach a live birth in UTx is unknown; however, in theory it is likely to be rather high because it must take into account the success of both the transplant itself and the ensuing in vitro fertilisation cycle. Hence, a cost-effectiveness analysis is necessary before allocating limited resources to this procedure. As it has been performed at an experimental stage, where it still remains, UTx programmes are better funded by grants from private research foundations and philanthropists [Brännström et al. Lancet 2015;385(9968):607–16]. Other ethical concerns that arise in the case of UTx, notably the principles of equity, inclusion and social solidarity, reveal tensions with the use of limited resources for like-procedures. A challenge exists in finding the right balance between the social responsibility of the state and the individual rights and responsibilities of citizens. Although each person should benefit from the same care, health equity is not the same as equality in health status. Inequalities in health status between individuals are inevitable consequences of genetic differences, gaps between social and economic circumstances or personal choice of lifestyle. Such individual decisions should not drive the unequal distribution of resources for expensive interventions like UTx. Although healthcare systems may no longer be exclusively concerned with the preservation of life but rather with remedying the malfunctions of the body and enhancing quality of life (Warnock. A question of life: The Warnock report on human fertilisation and embryology. Oxford: Blackwell, 1985), the use of limited resources should be morally prioritised into the research and treatment of life-threatening diseases. Indeed, in the presence of limited resources, the management of life-enhancing conditions, such as uterine factor infertility, need not be prioritised. None declared. Completed disclosure of interests form available to view online as supporting information.■ Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.