The Biobag: A Brave New World, Part 1
Premature infants struggle to survive in a gaseous environment, which is why scientists have for decades tried to develop an artificial wet environment for the premature infant. The recent development of the Biobag has brought that environment within reach. The Biobag has yet to be trialed with human infants, and there will be much development before such an environment can replace the entirety of pregnancy, but we can imagine its potential impact now. An artificial womb that replaces all or most of pregnancy will challenge how we view birth, and will radically undermine a central argument for abortion, which is to defend the bodily sovereignty of the pregnant woman.
In the future, we can anticipate that all pregnancies might end early, with the developing embryo placed directly into an artificial womb where the “pregnancy” will continue to term.
In 2011, Allegra Lategan was born just 22 weeks and four days after conception. To keep her warm and to protect her fragile skin, she was placed into a ziplock bag. Miraculously, she survived, but she is one of the lucky ones. Even when provided with the best available care, an infant born at 24 weeks gestation has only a 70 percent chance of survival. The chance of survival drops to around 40 percent at 23 weeks, and to just 23 percent at 22 weeks. The chances of surviving without severe or moderate impairment at 22 weeks are just five percent. In short, infants born at 24 weeks or earlier typically endure considerable medical problems, and their parents are left to reflect on whether they made the right choice in the face of their child’s suffering.
A major problem of infants born prior to 24 weeks is respiratory failure. In the womb, the lungs are ventilated with liquid, but outside the lungs must be ventilated by gas. At 24 weeks, the lungs are not ready for the transition from liquid to gas and the alveoli—the tiny air sacs of the lungs that facilitate gaseous exchange—thicken, enlarge and stiffen in the premature infant. The result is inefficient oxygen exchange, with the inevitable consequence of organ failure and death. The problem cannot be prevented with mechanical ventilation because that merely enhances gas ventilation, and it is gas ventilation that causes the immature alveoli to develop abnormally.
Realizing that the solution to maintaining life after premature delivery lies in replicating the environment of the womb, scientists are pursuing an artificial womb environment. In 2003, I was lucky enough to hear Warren Zapol speak at the 50th anniversary meeting of the Association of University Anesthesiologists (AUA) on the topic: “Scientist-Clinician: Going to Extremes.” Zapol described his early efforts with Ted Kolobow to develop the first artificial placenta, which they used to maintain the life of a premature fetal lamb outside the womb for two days, in 1969. There have been many significant advances since then, but artificially oxygenating and pumping blood through a premature infant continued to generate problems, including heart failure, infection, poor circulation and a variety of other issues largely associated with pumping the blood too quickly or too slowly. That is, until 2017.
In April of 2017, scientists at the Children’s Hospital in Philadelphia maintained premature fetal lambs outside the womb for four weeks. They achieved this by placing the fetal lambs inside a custom–designed bag, which they dubbed the Biobag. The Biobag looks like an oversized ziplock bag, but unlike the actual ziplock bag that kept Allegra Lategan alive, the Biobag replicates the size and shape of the uterus and contains an artificial amniotic fluid that completely encases the developing fetus.
In essence, the Biobag is an artificial womb that provides an entirely sterile environment, protecting the fetus from infection. The Biobag also uses an umbilical cord cannulation that enables blood flow to be maintained entirely by the beating of the fetal heart, which prevents strain on the heart by stopping the blood from pumping too quickly or too slowly. Inside the Biobags, the fetal lambs demonstrated normal development of their lungs and brains and obvious signs of maturation. Over the course of four weeks, the lambs opened their eyes, became more active, grew wool, and occupied more space in the Biobag.
The implications of the Biobag to aid premature infants and their parents are obvious. In the future, we can expect many more infants to survive at 22 weeks and even earlier, and without the enormous risk of impairment. But think beyond the implications for premature birth to the implications for pregnancy and birth more generally. In the future, we can anticipate that all pregnancies might end early, with the developing embryo placed directly into an artificial womb where the “pregnancy” will continue to term. Or maybe pregnancy will be avoided altogether, and gestation will proceed from test tube to Biobag; women will no longer need to be involved except to provide eggs, while men will provide sperm.
Such ideas are at the edges of science fiction because science is very far from being able to implement either of the scenarios I have imagined here. We can anticipate it will be many decades before science gets close to eliminating pregnancy —nevertheless, we can anticipate it and thus we can also anticipate its moral implications. Bioethicists often complain that the science rushes ahead of them; here is an opportunity for bioethics to rush ahead of the science.
On the face of it, eliminating or vastly curtailing pregnancy should be liberating for women. There will no longer be any need for women to undergo the discomfort and risks of a long gestation. If sex is entirely decoupled from pregnancy, then men and women will finally be equal in their pursuit of sexual activity, without the fear of an accidental pregnancy.
What might be liberating for some, however, could be oppressive for others. Some women and couples might wish to be pregnant—to experience a new life growing within and to bond in their relationship during that time. If the Biobag were perceived as a safer environment for the gestating fetus, then such a choice might be viewed as morally problematic. Such a scenario is highly feasible, given contemporary concern about the fetus being exceptionally vulnerable to the eating, drinking, working and other lifestyle habits of pregnant women. Such danger to the fetus often is exaggerated, but it encourages a view of the womb as a risky container for future infants, with the Biobag as a potentially safer alternative.
Use of the Biobag might also undermine mother-infant bonding. Birth is nothing if not intense, for both mother and infant. The pain, the release of cortisol, the extremes of emotion kick–start an extended period of togetherness between the mother and infant. A caesarean birth avoids some, but not all, of these extremes, extremes that opening a Biobag might not present at all.
The Biobag will, however, overcome the invisibility of pregnancy. Although the development of ultrasound allows visualization of the developing fetus, this visualization is indirect and intermittent. Assuming the Biobag is transparent—which will presumably be necessary to facilitate monitoring—then parents will have unparalleled and continuous visual access to the developing fetus. As a clearly and obviously separate physical entity from the woman, the fetus is available to both parents for interaction, to be empathized with, communicated about and bonded with directly.
The complete separation of a woman from a developing fetus also undermines a central justification for abortion. As Ann Furedi explained in her Moral Case for Abortion:
“Control over one’s body is an essential part of being an individual with needs and rights. It is one of the most important legacies of our political traditions and, however one feels about the status and value of the fetus, it seems bizarre that this fundamental right should be withdrawn from women during pregnancy.”
During pregnancy, the fetus is inextricably intertwined with the woman’s physiology. There is nothing that can be done to the fetus without directly involving the woman and, therefore, without her express consent. Similarly, because the woman is providing necessary life support to the fetus with her own body, she is morally and legally able to withdraw that life support. Nobody should be forced to use their own body as life support for another being against their will, and so, the woman is legally and morally entitled to withdraw that life support via an abortion.
The introduction of the Biobag, however, entirely negates the argument for abortion as necessary to liberate a woman from an unwanted bodily imposition. In the Biobag, the fetus is an entirely separate entity and not at all reliant on another person’s body for its continuing survival. Under these circumstances, “aborting” the fetus would involve withdrawing the life support provided by the Biobag, and that withdrawal will likely be managed via a series of laws that will no longer place control entirely in the hands of the putative mother.
Once a fetus is inside the Biobag, then the decision to have a baby will have been taken. In the case in which gestation occurs from test tube to a Biobag, the decision will have been made even before placing the fetus in the Biobag. When the Biobag takes over pregnancy at a certain point, then the decision is made, as the fetus is separated from the woman, which is essentially an early birth. From that point forwards, the mother (and father) are free to walk away from the fetus in a similar way to how parents are currently able to walk away from their offspring. In reality, of course, that is not very free at all. Abandoning a child is fraught with moral and legal difficulties, as perhaps it should be. Abandoning a fetus in the Biobag will not fundamentally alter those moral and legal difficulties, but merely bring them forward in time.
The Biobag will also create new difficulties associated with the management of the Biobag until such time as the fetus is removed and the baby delivered. An obvious difficulty will be what to do when development goes wrong and the fetus progresses abnormally. Under current abortion law, the woman would be allowed to terminate the pregnancy on the basis that it is her body and it is the woman who will have to bear the consequences of continuing the pregnancy. As noted, however, the Biobag critically undermines that argument and it seems unlikely that the putative mother would be allowed to unilaterally mandate the withdrawal of the Biobag’s support. That decision will more likely involve the wishes of the father, the judgment of the supporting medical team and laws and regulations governing when putative parents and medical teams might decide to continue or withdraw the life support provided by the Biobag.
In short, use of the Biobag to support the lives of wanted infants born prematurely is morally uncomplicated. The prevention of grief and trauma for the parents of these infants provides a straightforward moral justification. The use of the Biobag to obviate the need for normal pregnancy looks on the surface to be equally uncomplicated. Such use liberates women from the burden and dangers of pregnancy. That liberation, however, may be felt as oppressive by women who want to experience pregnancy. Use of the Biobag will also have a dramatic impact on the process of having a child, and how this may affect parent-child bonding is difficult to anticipate.
Finally, the Biobag will essentially bring birth forward, or help to eliminate, birth, which will undermine a central argument for abortion—the maintenance of bodily autonomy by a pregnant woman. Especially for women, therefore, the Biobag will timelock the decision to have a child in a way that normal pregnancy currently does not. That timelocking may be experienced as a lack of autonomy and choice by women to continue their progress towards motherhood, and may invite state and other regulatory concerns into her life that are currently held in check by the realities of pregnancy being inextricably bound up with her bodily autonomy. Although these scenarios are currently science fiction, they are worth grappling with now before they get closer to being science fact.