By Dr Victoria Adkins, published 29th November 2024. 

Is consensus as to the status of an entity partially subjected to artificial gestation possible? Following on from her first blog post, Dr Victoria Adkins draws upon existing debates as to how to define an artificially gestated entity and considers whether compromise may be more viable than consensus.

The development of an artificial placenta is well underway, with researchers in Philadelphia, Japan and Australia, and Belgium producing a device that seeks to improve the survival and morbidity rates of infants born prematurely. Following delivery by caesarean section, it is intended that the entity be placed into a bag of artificial amniotic fluid and have an oxygenator pump attached to its umbilical cord. The device would therefore alleviate the pressure from the lungs, which are often underdeveloped at the time of premature birth.  In addition, the device would remove many of the invasive elements of traditional neonatal intensive care which can often contribute to co-morbidities.

Whilst artificial placenta technology suggests a hopeful and exciting advancement in the care of premature infants, it raises questions as to how an entity, gestated within an artificial placenta, can and should be defined. Is the entity more akin to a fetus or a neonate? Or, alternatively, does the technology open a pathway to new definitions and news ways of understanding what it means to be born? Forthcoming publications from my own PhD study will illustrate the lack of consensus amongst healthcare professionals as to how the artificially gestated entity should be classified. This mirrors much of the debate within the literature as to whether an artificial placenta is simply an advancement of neonatal intensive care or whether it brings into being a new type of entity.  If consensus is shown to be lacking amongst a key stakeholder group, how might we go about reaching agreement within and beyond the medical profession and what considerations will allow us to get there?

Consensus and considerations

Many of the hypothetical statuses applied to the artificially gestated entity have focused on its physiological characteristics or developmental markers. Some have argued that the heartbeat of the entity qualifies as a sign of life after birth that would make the entity akin to a neonate. Others, however, argue that the entity’s lack of engagement with the social world and its lack of physiological development distinguish it from a newborn.

However, in reaching a decision as to what the artificially gestated entity is, a broader approach may be better suited. From a policy perspective, for example, we might ask what the implications, both legally and medically, may be if the entity is defined as one thing rather than another. If the entity is considered akin to a neonate, it is assumed that very little legal work will need to be done. The entity will be treated in accordance with how neonates are treated in neonatal intensive care. However, were the entity considered to align more with a fetus, particularly as it gestates within a device mimicking the in-utero environment, will the legal framework surrounding a pregnant person’s right to termination become destabilised? If, for instance, a parent with a 20-week “fetus” gestating in an artificial placenta does not have the right to discontinue artificial gestation when a genetic abnormality is detected, might a pregnant person at 20-weeks gestation also be stripped of the right to terminate their pregnancy in the same circumstances? To align an artificially gestated entity with a neonate, therefore, could be the least disruptive option that also protects the rights of pregnant individuals.

An alternative approach is to develop a new status for the entity, such as “gestateling” as proposed by Romanis. By starting afresh with the entity’s status, we could possibly curtail any ramifications for existing legislation (although the drafting of new legislation and policies will be no small task). A potential issue that may arise however is the “othering” of the resulting child or the intended parent(s). Parents may feel marginalised if told their infant is different from others and this could be confusing if artificial gestation is occurring alongside neonates being cared for in a NICU ward. The resulting child may also, later in life, feel different from their peers due to being classified as a different type of entity at the time of their birth. In addition, if a new status is applied to those partially gestated in an artificial environment, at what point does their status change to align them with other young infants- when they leave the artificial environment? Or does the status stay with them until some later developmental stage?

The existing developmental focus on the artificially gestated entity also suggests that how the entity comes to be defined will be predominantly led from a medical perspective. This may be appropriate when considering the responsibility specific healthcare professionals will undertake in treating the entity and its status may therefore derive from those responsibilities. However, as I have alluded too, a mixed consensus amongst healthcare professionals indicates that perhaps medical considerations may not be enough. It may be reasoned that parental perspectives could and should inform how the entity comes to be defined- for it is assumed they too will have responsibility for the care of the entity. Although these responsibilities may be less technical in nature, the previously pregnant person may, for example, be called upon to provide recordings of their heartbeat or to sit by the side of the artificial placenta and talk to the entity as they may do if they were gestating themselves.

The possibility that different stakeholders may have different opinions about how the artificially gestated entity should be defined suggests that a much wider consultation is needed that brings these groups together- but might this make consensus an even more unreachable goal?

Consensus and compromise

Consensus on the status of an entity that is partially gestated in an artificial placenta may not be an achievable nor a realistic ambition. It may therefore be more beneficial to seek to reach a compromise position, as was the intention of the Warnock Committee set up in 1982. The Warnock Committee was charged with considering the social, ethical and legal implications of in-vitro fertilization (‘IVF’), embryo research and surrogacy. With partial ectogestation now on the horizon, the debates arising in relation to the status of an artificially gestated entity are argued to echo the Warnock’s challenge of defining the status of the embryo. Both the advance of IVF and the continued development of an artificial placenta have created previously unimagined scenarios whereby processes, once confined to occurring within the body, can now take place externally.

The Warnock Committee were quite clear in their approach in seeking to find a compromise between the public and the scientific community, but can the same be achieved with partial ectogestation? A consultation, like that undertaken by the Warnock Committee, could certainly help garner “buy-in” from the public and unlike IVF, partial ectogestation is not yet in the clinical domain. The advantage consequently lies in proactively seeking the views of the public rather than receiving an ill-formed reaction to the application of the technology. Education and information provision may therefore be key to consensus building by ensuring everyone understands what is at the heart of the consultation- what is an artificial placenta? How does it function? What happens if it does not work? By having these questions about the technology resolved, all stakeholders may be in a better position to collectively consider how the entity comes to be defined. How an artificially gestated entity is characterised may therefore not emerge from a clear consensus, but rather from a compromise aimed at making as many people as possible comfortable with the agreed-upon status. Whether a lengthy consultation to reach this compromise can be undertaken before the technology is translated to clinical practice, however, remains to be seen.

Dr Victoria Adkins is a Lecturer in Law at University of Greenwich, and has recently completed her PhD at Royal Holloway, University of London. She would like to thank members of The Future of Human Reproduction team who contributed to a workshop discussion that led to this blog.