Soon we might not need wombs to birth babies

• An astonishing new book explores an idea that is simultaneously dystopian and wondrous

It is an incontrovertible fact that every human that has lived has been born from a person. So it is both a dystopian and wondrous idea that in the near future babies may be gestated entirely in artificial wombs.

In an astonishing new book,

Eve: The Disobedient Future of Birth, Canadian postdoctoral researcher Claire Horn points out that the concept is not a chasm from what already happens when prematurely born neonates are nurtured first to survival and then to health in hospitals’ incubators.

Incubators were trialled with some success as far back as the 1880s by French physician Stéphane Tarnier, and by the turn of the 20th century they could keep 38-week gestated infants alive (a full-term pregnancy is 40 weeks). Now, modern medicine and medical technologies can assist babies as premature as 24 weeks, and the threshold is now considered 22 weeks, albeit with high mortality rates and a strong likelihood of serious health issues for those who survive.

Advances in embryo research are also contributing to a contraction of the duration a foetus needs to be in utero.

I’m old enough to remember the huge 1978 “test-tube baby” news story of the first person born through in vitro fertilisation (IVF) conception. Louise Brown’s miracle birth was an inflection point along the path to technology-assisted human procreation. In less than two generations IVF has become a well-understood option for couples unable to conceive naturally.

A total 8-million people have since been born through IVF, and perspectives and interpretations of “natural” are stretching. As Oxford University philosophy professor William MacAskill elucidates in his book

What We Owe the Future, scientific advances are often the catalyst for changes in society’s outlook and norms. Though moral paradigms can get locked in, even for centuries, they can and do shift.

In 2016 Cambridge University embryologists successfully grew a human embryo in a laboratory to 13 days, and only stopped the experiment at that point not to breach the 14-day rule imposed by the International Society for Stem Cell Research (ISSCR). The Rockefeller University in the US replicated the achievement, leading the ISSCR to reshape its guideline to case-by-case considerations in 2021.

“These respective developments in neonatology and embryology have brought us to an unprecedented moment,” Horn writes.

She estimates that we are no more than a decade away from an artificial womb that will be able to sustain a foetus from 20 weeks. Embryos can be grown and maintained in laboratories to at least two weeks, so the maths means that soon, from conception to the 40-week birth norm, babies will feasibly spend less time in utero than ex utero.

One day, not too far off, the laboratory and the neonatal ward “will meet in the middle, and we will have achieved full ectogenesis: external gestation”, she believes.

This sentence distils the cleverness of Eve as the book’s title, referencing the biblicalorigin story to annotate a new 21st century watershed in how humans are brought to life. Science is being disobedient, but progress marches on regardless.

Many ethical considerations spin out from this. Is ectogenesis a good thing? Readers who may recoil from the very idea should know one of the book’s strengths is that Horn writes with a mixture of awe, sensitivity towards the beliefs of others, uncommon sense and insightful perspectives. Befitting her career as a legal scholar, she incorporates the history of advancements, information about current experiments and trials, statistics, legal frameworks and landmark cases in law to build rational arguments for her positions.

These positions vary, or, rather, she passes on unequivocal conclusions. This is to her credit; putting herself in others’ shoes helps readers weigh the quandaries in this most fraught of fields — the intimate intersection of human biology, beliefs, scientific possibilities and ethics.

Thus, we understand that the medical scientists conducting ghoulish experiments on animal foetuses are motivated by aiming to help humans; that 1960s’ Stanford University obstetrics professor Robert Goodlin — who removed 10-18 week-old foetuses in abortions and then attempted to keep them alive without always informing the mothers — had good intentions but acted unethically and was subjected to a US Senate subcommittee investigation in 1974.

Admirably, Horn addresses the wider implications of this field of progress. Which mothers would be able to rely on the medical marvels that will sustain premature babies? Which parents could have access to cutting-edge IVF options? Would the medical profession be guaranteed to be free of biases, even unconscious ones, that may curtail the new paradigm of reproductive rights in their application to people who identify differently along the gender continuum?

EMPATHY PERMEATES

So, Horn reminds us to pay attention to more basic issues too. Referencing the 1990s’ medical sociologist Dorothy Roberts, she points out that IVF, artificial wombs and other reproductive technologies should not be framed as “new reproductive choices”, or women’s “further liberation”. Claiming they advance individual freedom without rectifying social inequalities would mean that these developments are “operating like blinders that obscure issues of social power”.

Her empathy permeates even when she writes dispassionately about research technicalities or governance protocols, because she always returns to the mothers and the infants and unborn who are on the precipice of living or dying.

Often, she writes as if thinking aloud, noting that how we react to moral dilemmas, however heartfelt, is very different to when the dilemma is our own. About Goodlin’s work, for example, if it had led to successfully reducing the number of weeks a premature baby needed to be in utero, and she was faced with a life or death choice regarding her own early-stage pregnancy, wouldn’t she be grateful for at least the chance to save her baby?

This is not an academic musing. We learn that she authored Eve during her own pregnancy, and a particularly moving passage is when she describes it as “an entirely new way of moving through your life”. Pregnancy is a “relational encounter, a constant feedback loop between pregnant person and foetus”, and while acknowledging this is precisely why some women find the idea of an artificial womb so compelling, for her something ephemeral, spiritual and crucial in the way a life comes into the world would be lost.

Ultimately, this is a book about feelings. As medical science and technology advances, if we wish to shape a future which balances what is possible with ethical considerations — what is right, at least to most of humankind — we need more empathetic thinkers such as Horn.

[HORN] ALWAYS RETURNS TO THE MOTHERS AND THE INFANTS AND UNBORN WHO ARE ON THE PRECIPICE OF LIVING OR DYING