By Dr Zoe Bolton and Professor Stephen Wilkinson, published 16th June 2023

Claire Horn’s book Eve: The Disobedient Future of Birth takes as its starting point the idea that, in the near future, advances in artificial womb technology (AWT) will make it possible for babies to be grown outside the human body for the first time. Citing recent scientific developments, such as the work of researchers from the US, Australia and Japan who have developed biotechnologies that are able to sustain the life of extremely premature lamb fetuses in an artificial womb environment, Horn argues that the possibility of conception and gestation taking place wholly outside of the human body is ‘closer than ever before’.

AWT is an exciting and controversial topic and, over the course of Eve, Horn uses potential future developments in this technology as a lens through which to consider issues such as eugenics, health inequality, abortion and gender inequality. In doing so, she raises some urgent questions about the possible use and misuse of AWT: Could it be adopted for eugenic ends by those in power? Who would have access to it? Could AWT pose a threat to abortion rights? Might artificial wombs be used to reduce gender inequality in reproductive labour? These, and other pertinent questions, are explored throughout the book in a series of well-researched chapters, drawing on a wide range of scientific, historical, legal and academic sources.

“Horn writes well for a general audience and presents complicated ideas and concepts in an accessible way.”

Published by the Wellcome Collection, Eve is aimed at a general reader and this is reflected in the content and style of the book. Horn uses the opening chapter to offer a brief overview of the historical and current scientific developments in biotechnologies. This overview, which provides a useful context for non-expert readers, effectively establishes both the timeliness of the book and Horn’s overarching aim for the subsequent chapters which examine ‘how our society needs to change before the introduction of artificial womb technology’. This is an ambitious aim for such a complex and divisive subject but Horn writes well for a general audience and presents complicated ideas and concepts in an accessible way.

In ‘Chapter 2: An Artificial Foster Mother’, Horn’s comparative discussion of attitudes to neonatal research and embryo research offers a concise account of advancements in both fields. This is an interesting chapter, and Horn convincingly argues that for full ectogenesis (where the entire gestational process takes place outside the human body) to become a reality the research into AWT and embryology needs to ‘meet in the middle’: embryo research needs to be extended to allow in vitro embryo development for as long as possible, and the threshold for sustaining extremely preterm fetuses in artificial wombs needs be lowered. Horn ends the chapter by raising the question of what the consequences of trialling this entirely new form of gestation might be were it to become a scientific possibility.

Looking to the past, ‘Chapter 3: Ectogenesis for a Brave New World’ explores that question in more detail. Drawing initially on J B S Haldane’s 1923 paper, Daedalus, or, Science and the Future, where the term ‘ectogenesis’ was first coined, Horn argues that the legacy of artificial wombs is inextricably entangled with eugenics. This claim is expanded on over the course of the chapter as Horn demonstrates, in impressive detail, the harms that have been caused by eugenics policies and practices in the UK, US and Canada (and beyond) right up to the present day.

“The chapter would perhaps have been more balanced, and the argument more nuanced, if oppositional voices had been given more space”.

Horn is undoubtedly right to raise the question of whether we have yet built a world where we can be confident that artificial wombs will not be used to coercive ends. However, as she acknowledges, there have been significant attempts to fight against eugenic practices to get reproductive justice for underrepresented groups, and the chapter would perhaps have been more balanced, and the argument more nuanced, if those oppositional voices had been given more space. It is notable, for example, that Bertrand Russell’s 1924 response to Haldane’s Daedalus, Icarus or the Future of Science, does not receive a mention. This feels like an odd omission given that Russell was one of the first to take issue with Haldane’s eugenicist thesis.

The next chapter, ‘Mother Machine’, focuses on reproductive health inequalities. As Horn notes, the reproductive technologies currently in development are labour-intensive and costly making it likely that AWT will only be available in already well-resourced environments. The chapter carefully documents examples of global, structural reproductive health inequalities which are statistically far more likely to impact those living in developing countries, indigenous people and people of colour. The figures are indisputable and Horn questions whether investment in expensive innovations, like artificial wombs, is really justified given existing levels of global health inequality. It is this line of thought that leads Horn to assert that for AWT to be of benefit it is first necessary to ‘confront health inequity and to secure reproductive care for all’.

These are noble aims but, given the timescales for the likely introduction of AWT, do feel somewhat idealised. If we are just decades away from the introduction of AWT, as Horn suggests elsewhere in Eve, how probable is it that global health inequalities will have been eradicated and that equitable reproductive care will be a reality? Arguably, the more pressing question is how we deal with the inevitable introduction of these technologies in unjust societies. Horn does offer some more grounded solutions to this problem suggesting for example that, as the technology evolves, researchers could make it a priority to create an artificial womb prototype that could function in places with limited infrastructure for neonatal care.

“Horn raises the important question of whether, rather than offering a solution, artificial wombs might actually threaten abortion rights”.

Chapter 5 moves to abortion and to the idea that AWT might offer a ‘solution to the abortion debate. Turning this idea on its head, Horn raises the important question of whether, rather than offering a solution, artificial wombs might actually threaten abortion rights. This is one of the strongest chapters in the book. It draws on an impressive range of research and offers an excellent account of Roe v. Wade that is easily understandable to the general reader. Horn is a passionate advocate for abortion rights and argues that we should not see abortion as a ‘problem’ to be solved by technology but rather as an indication that it is time to ‘decriminalise, destigmatise and improve access to safe, free and culturally sensitive abortion care’.

The final chapter in the book, ‘The Tyranny of Biology’, turns to feminist perspectives on AWT and to the question of whether artificial wombs might offer a solution to gender inequality in reproductive labour. Starting with Shulamith Firestone’s revolutionary manifesto The Dialectic of Sex (1970), Horn also references the work of modern commentators Anna Smajdor and Evie Kendal. Horn agrees with Smajdor and Kendal that the physical risks of pregnancy have a negative impact on women, but she does not support their view that AWT is a viable solution. Horn sees the problem as one of ‘sexism and medical paternalism’ and not of reproductive biology.

Horn’s proposed solution is ‘a substantive undoing of the medical, legal and social practices that undermine the pregnancies and parenthood of people of all genders’. Again, there is a touch of idealism here as it is unlikely that there will be a wholesale undoing of those practices before AWT is introduced. Perhaps, instead, there is a middle ground that could have been considered in the book. Neither Smajdor nor Kendal think AWT will solve all of the structural inequalities in society but, if AWT has the potential to save some women from dying from complications in childbirth, why should the technology not be used to this end in the future? Surely, it is possible both for AWT to be utilised to prevent unnecessary deaths in childbirth, particularly in high-risk groups, and for feminists continue to fight the social inequalities that underlie current medical, legal and social practices?

“In a sense then this book is not primarily about AWT. Instead, AWT is used as a means of grounding a rigorously researched account of other key contemporary reproductive issues”.

Horn writes in the introductory chapter of Eve that the book ‘starts from the premise that artificial wombs will only be as innovative as the social context in which they arrive’. In a sense then this book is not primarily about AWT. Instead, AWT is used as a means of grounding a rigorously researched account of other key contemporary reproductive issues. The book addresses vital and interesting questions. However, where it arguably falls short is in not offering realistic shorter-term policy solutions, particularly given that, scientifically, we are already on the road to AWT. While the book offers a clear and committed set of moral and political views (many of which we share) it could have been strengthened by offering more sympathetic and detailed expositions of opposing positions. Having said all that, it is an informative read and a good starting point for a reader interested in human reproduction who wants to familiarise themselves with current issues and debates.

A version of this book review was first published in BioNews.