Hidden from view

Possession of a womb has not always been a blessing. In the past, the woman who successfully gestated children faced an agonising labour and risk of death. Her pain was to expiate the sin of Eve in tempting Adam with that apple. The book of Genesis declares ‘I will greatly multiply your pain in childbirth, in pain shall you bring forth children yet your desire shall be for your husband’ (Genesis 3.7). John McKeown cites Martin Luther:

[W]e see how weak and sickly barren women are. And those who are fruitful are healthier cleanlier and happier and even if they bear themselves weary—or ultimately bear themselves out— that does not hurt let them bear themselves out this is the purpose for which they exist.1

For Luther, women were ‘not created for any other purpose than to serve man and be his assistant in bearing children.’1

However, even if a woman’s purpose was thought to be to gestate her husband’s children, her contribution to the creation of the child was judged by many learnt men across the ages to be simply a ‘seed bed’ for the embryo.2 Wombs were no more than a necessary medium in which the father’s seed could grow. Aristotle argued that the embryo was formed when the male seed interacted with menstrual blood. The woman nourished the seed.2 Galen disagreed, contending that women produced seeds, although ‘weaker in nature’ than the male seed. In the 17th century, anatomists examining semen under the microscope discovered sperm, originally described as ‘animalcules.’ The view (described as preformationism) grew that the fully formed child was present in the sperm.

Animalculism obviously proved inaccurate, but for those who believed that mothers only contributed an environment in which the father’s child could grow and be nurtured, the woman was in effect a ‘gestational carrier’. From this (mistaken) premise, the legal incapacities which English law imposed on married women begin to make some sort of sense.3 The marriage contract obliged a wife to make her womb available to nourish her husband’s s children. Coupled with the myth that a wife could not refuse consent to marital intercourse, perpetuated in English law until 1991,4 husbands enjoyed something akin to what we might classify today as a right to procreate, and wives a duty to provide the means by which he might do so.7

A husband’s interest in the child was magnified by the firm belief that the child was ‘his’, the product of his body; he had the strongest of interests in ensuring that no other man’s ‘animalcule’ was carried in the wife’s womb and passed off as his. He had a further strong interest in ensuring that the behaviour of the ‘gestational carrier’ did not compromise his reproductive enterprise. That sadly did not mean that all husbands acted positively to promote the health of the wife. The high rates of child mortality and at many times in history the surplus of women over men might mean that quantity in reproduction was the primary objective, to generate as many children as possible and replace ‘worn out wombs’ with fresh stock. The desire for sons and primogeniture begin to make sense. If you accepted animalculism, a son when he reproduced begat a grandson who shared your blood. Daughters will bear a child formed by her husband’s ‘animalcule’, unrelated to its maternal grandfather.

A working womb did not necessarily benefit the woman, but to be barren might have been a worse fate. From classical times, theologians and physicians declared barren women to be monstrous. In Ancient Greek myth, the grisly Gorgon queen Medusa, whose gaze turned men to stone, was said by some to be barren. The empty womb was dangerous, but so was any womb, dangerous to the woman and to others. Secreted far from public view, wombs were judged the cause of many female ills, or rather conditions styled ‘ills’ by men.

Women, learnt men declared, were defective creatures possessing weak intellectual capacity and unregulated emotions. Christian theology was supported by so-called science. The ‘scientific’ grounds for female defects were various, contradictory and changed over time. When it came to female physiology ‘medical men’, anatomists, the law, the Church et al resembled Alice in Wonderland trying ‘to believe as many as six impossible things before breakfast.’ The female body was declared to be defective compared with male perfection, yet when anatomists were able to examine the interior of female corpses, they argued that female organs could be seen as inversion of the male.5 So, it was said that the ‘neck of uterus is like the penis, and its receptacle with testicles and vessels is like the scrotum’.2 Wombs, however, were accorded dark powers not shared by the perfect male genitalia. The ‘wandering womb’ which was not fixed in its proper place but wandered around the body pressing on heart and lungs endangered the woman’s life resulting in ‘suffocation of the mother’.6 The wandering womb was described as ‘a migratory uterus prowling about the body like a wild animal pressing on the chest.7 The uterus emitted noxious fumes; not a desirable commodity. By no means all eminent physicians agreed that such a condition existed. The Trotula, a medieval compendium on women’s medicine, rejected the notion of ‘suffocation of the mother’.8 Popular opinion on science then as now influenced society, as Edward Shorter explained ‘through popular culture as well rode a visceral male fear of women’s’ magical powers’.9 Wandering wombs made a good story. A cure for wandering wombs and later hysteria recommended by some medical men was sexual intercourse—within marriage of course. Writers warned of the libidinous nature of imperfect women, seeking in sexual relations with a man to be completed. As Rawcliffe notes, male writers seemed to see no contradiction in depicting the womb as both ‘a passive empty vessel and a voracious animal’.7

If the danger of the womb was not enough, its monthly function testified further to the evidence of female defect. Menstruating women were ‘venomous during the time of their flowers and so dangerous that they poison beasts with their glance and little children in their cots.’ Should a man have intercourse with a menstruating woman, a child conceived might interalia be born leprous or blind, hunch backed or malformed.’ Any child born in defiance of such a taboo ‘would bear some mark of ignominy, if only red hair’.7

Once human dissection showed plainly that wombs were not apt literally to suffocate or wander around the body, Victorian doctors recast the womb as the cause of hysteria.10 The womb disordered the female brain. We hear a great deal about ‘baby brain’ today and cognitive impairment in the menopause. It has been reported that women having a heart attack with exactly the same symptoms as men are often sent home told they are suffering from panic or stress11—hysteria by any other name?

Arcane beliefs about the womb, which underpinned laws adverse to women and especially pregnant women, no longer hold sway. The womb is no longer mysterious and yet misogynistic attitudes, which define women by their biology, persist. Look at contemporary social media abuse of female MPs. See how some US states have passed regressive laws on abortion, contra to Constitutional Rights, to police every woman’s womb.8 As we now examine, technological advances, while potentially benefiting women, might also invite opportunities to interfere with female autonomy, increasing the potential for conflict between the interests of women and fetal welfare and the continued pathologisation of aspects of female physiology.

A view into the womb

The previous section outlined the ways in which the ‘inaccessibility’ of the womb was a source of rampant speculation about women and their pregnancies. Twentieth century advances in medical technology have drastically changed how we engage with women and the fetus during pregnancy, though as we will demonstrate, these have not necessarily quashed some of the backward thinking about needing to control gestation. X-ray technology initially allowed obstetricians to diagnose potential health problems prenatally, and the later development of obstetric ultrasound provided a safer way of gaining insight into fetal health, ultimately becoming a routine part of prenatal care. In the second half of the century, various forms of prenatal testing and treatment procedures were pioneered, including complex prenatal surgeries for conditions like spina bifida.12 Many of these relatively recent developments are now used routinely, and some previously experimental and risky procedures have been made safer and less invasive, allowing their gradual introduction into healthcare.13 These developments have placed the fetus firmly at the centre of the gestation process. Some worry that this shifts the maternal–fetal relationship to be potentially adversarial and may also lead to the woman’s interests being side lined.14 Douglas explains that ‘the perception of childbearing as primarily, rather than coincidentally, a health matter has led to an increasingly more difficult dilemma for health professionals. Who is their patient, the mother or the fetus?… But in the event of a conflict of interests who should take priority?’.15 Technology has arguably oriented the focus away from the pregnant person towards gathering as much information as possible about the fetus, potentially becoming a form of coercive control. Douglas concludes that ‘the main focus of attention these days [with all of contemporary obstetric technology] has moved away from the pregnant women and towards the fetus within her… [and this] enables supervision to be maintained over the woman and to some extent her lifestyle’.15

Developments in fetal medicine, from heart rate monitoring to three-dimensional imaging and prenatal surgery, have made the journey from zygote to child, once hidden from view, accessible not only to pregnant women, but also their families, doctors and society. We are increasingly afforded a ‘view into the womb,’ leading to the perception of the fetus as a distinct being. Taylor notes that ultrasound has had the effect of bringing fetuses ‘to life’ in that ‘it necessarily involves making visible the invisible and unmasking what has been hidden and obscured, [and] inevitably draws us into a rhetoric and politics of vision.’16 The fetus appears as something that can be watched and ‘interacted with’.17 Technology has afforded the means ‘to monitor, to control and possibly intervene.’18

However, an important boundary remains in the form of the pregnant woman, whose consent is essential for any kind of intervention to be performed: ‘literally, if not conceptually, the pregnant woman incorporates the foetus, so direct medical access to the fetal patient is as remote as ever’.19 Laws in many countries appear to recognise the interests of the pregnant woman as primary, and the fetus is usually not considered a being with its own rights and interests.20 Respecting the autonomy of the pregnant patient is given ethical primacy even by those who would accept a limited notion of fetal patienthood.21 Yet it is necessary to be vigilant as personal and social perceptions of fetal status and interests have and are likely to continue to evolve, even as legal and ethical codes maintain the autonomy of the pregnant woman as central.22 The medicalisation of pregnancy has already led to a change in how women perceive their responsibilities to the unborn child,23 24 and technological developments, such as more sophisticated prenatal imaging or pregnancy apps monitoring fetal well-being, could further encourage this thinking. Empirical studies of pregnant women preparing for prenatal therapy suggest that the fetus is commonly seen by them as a distinct entity with its own needs and interests.25 Further technological development may increase the potential for tension between the perceived interests of the woman and her fetus. Consequently, it is important to interrogate the ways in which we imagine the maternal–fetal relationship as technology increases access to the womb.

There is an urgent need to avoid perceptions of the womb as a site of conflict, in order to ensure that pregnant women’s bodies are not treated as a dangerous environment for the fetus, rather than an essential part of the maternal–fetal unit. Pregnant women’s interests and autonomous choices must not be erased and ignored in favour of promoting fetal well-being, and the conflict view of the maternal–fetal unit seems to play a crucial role in this framing. In the next two sections, we present the notion of maternal–fetal conflict as it is often used in the ethical and legal literature, and demonstrate why this notion is unsubstantiated, incoherent and possibly dangerous, and should therefore be rejected.

Reviewing conflict

Maternal–fetal conflict is said to occur when a pregnant woman behaves in ways that may be harmful to the fetus, such as drinking excessive alcohol or refusing a caesarean that is medically indicated.26 27 This is seen in definitions like: ‘maternal–fetal conflict has been defined as the situation in which the intent or actions of the pregnant woman do not coincide with the needs, interests, or rights of her fetus as perceived by her obstetric caregivers’.28 This posits the main ethical dilemma for doctors as being how to balance the interests of the pregnant woman in having her autonomy respected and the fetus in having its ‘interests’ or welfare protected, leading back to the problematic issue of recognising the fetus as a separate patient.

Sometimes it is not the pregnant woman who is considered to be the ‘perpetrator’ of the conflict—her well-being might be jeopardised by interventions aimed at ensuring the well-being of the fetus29—for example, more invasive maternal–fetal surgeries that may present long-term risks to the woman’s health and well-being, and sometimes caesareans performed for fetal benefit. The definition above more clearly paints the pregnant woman and fetus as adversaries, rather than acknowledging that the well-being of the fetus ultimately depends on respecting the autonomy of the pregnant woman, who is usually the one most invested in ensuring good outcomes for the future child.30 31 However, any conception of clashing interests rests on the assumption that pregnancy involves two separate parties, between whom conflict might occur, rather than a necessarily interdependent biological unit. We argue instead that this interdependence must be taken as a starting point when examining ethical issues in prenatal care and application of reproductive technology.

The notion of ‘maternal–fetal conflict’ is so pervasive it is often the starting point of discussions related to ethical issues in pregnancy. Bioethical discussion often takes this framework, and examples of conflict, as the default assumption32 33 or a problem to be addressed,34 thus generating the false perception that such conflict is widespread. Medical research also adopts this terminology at times, which inevitably frames the presentation and discussion of findings.35 36 Most notably, maternal–fetal conflict is arguably one of the key concepts in the area of obstetric ethics,21 37 38 including a large body of work on balancing the doctor’s obligations towards the pregnant woman and those owed to the fetus.39–41 Some have suggested that the difference of opinion between medical professionals and pregnant woman about what to do in a particular situation is the true source of conflict: the term ‘maternal–fetal conflict’ ‘misdirects attention away from the conflict that needs to be addressed: namely the conflict between the pregnant woman and others (such as child welfare agencies, physicians and other healthcare providers) who believe they know best how to protect the fetus’.26 42 This is reminiscent of the imagery conjured by pre-Victorian doctors treating the female body as an innate source of danger. We can see echoes of suspicion and mistrust towards women where risk is calculated by doctors who seem to be advocating for the fetus, as if the default assumption is that women’s behaviour will somehow endanger it.

Reframing conflict

The prevalent framing of pregnancy as a site of conflict in medicine, ethics and law has been challenged, especially by authors writing from a feminist standpoint. Bowden argues that the pervasive maternal–fetal conflict conceptualisation of pregnancy is both innately problematic and empirically unfounded.30 She explains that this model ‘presents the interests of the pregnant woman as conflicting with those of the future child and therefore, the pregnant woman as a threat to her future child rather than the person who is most invested in its welfare’.30 This can lead to the ignoring of women’s autonomous choices as well as the erosion of trust between pregnant women and medical professionals, likely leading to further negative outcomes. In this section, we demonstrate that there are conceptual, outcome-based, and political and social reasons why framing pregnancy as a site of conflict is both unfounded and harmful, and must be abandoned.

First, the notion of maternal–fetal conflict is arguably conceptually unsound. This has been explored extensively within bioethical and philosophical literature. There are metaphysical arguments about the status of the pregnant woman positing that it is mistaken to consider a pregnancy as involving two distinct entities.58 59 Some argue that considering the fetus as a part of the pregnant woman59 or considering the fetus-pregnant woman as a unit/dyad view19 is more accurate. Some of these authors do not attempt to draw any normative claims from such argumentation.59 Still, their conclusions could be used as support for the idea that the pregnant woman and the fetus are intertwined such that the concept of there being separate interests cannot make sense.

The terminology around this concept is also highly suggestive and value-laden. Using the term ‘conflict’ perpetuates the problematic assumption that ethical dilemmas in pregnancy are a matter of clashing rights between the woman and the fetus,26 when it is not determined in either ethics or law that fetal rights are a coherent concept.20 60 Also, the ‘maternal’ in maternal–fetal conflict implies that the pregnant woman already has parental responsibilities towards the fetus while it is still in the womb, which may then conflict with her other desires and actions. This is also (rightfully) contested,26 with some authors arguing that fetuses cannot be the proper object of parental responsibilities.61

Second, the outcomes for maternal and fetal health are worse when women are perceived as a potential threat to their own pregnancy. As the fetus is increasingly visualised and subject to clinical recognition as a ‘patient’, and even some legal recognition,13 this strengthens the perception that there is a need to interfere with the choices women can make about their pregnancies, either by failing to disclose information (as in Montgomery55) or in the framing of childbirth as an emergency when this may not necessarily be appropriate.62 However, empirical studies have demonstrated that fetal outcomes are better when women are enabled to take a more directive role in their own care.30 63 64 Respecting women’s autonomy is important in allowing them, the people most familiar with their own body, underlying health needs and values, to make the decisions they feel best promote their own and their fetus’s welfare.

The notion of conflict is deeply rooted in a historical tradition of thinking about women and wombs. The origins of our social and medical attitudes can be found in early mistaken beliefs about procreation and the mother’s gestational role. These ideas however, when applied in medical practice, encourage dysfunctional relationships between clinicians and pregnant women, as observed in forced caesarean cases where doctors often seek court approval in cases involving women with mental health conditions.65 The presentation of a woman’s health interests and personal well-being as detrimental to her fetus can also dissuade some, particularly vulnerable women, from accessing prenatal care.30 66 Pregnant women are more likely to engage in prenatal care when they do not fear legal consequences67 or being made to feel judged by care providers.30 There is substantial evidence that outcomes are better for both woman and fetus when pregnant women are engaged and receive routine prenatal care,68 69 so to guarantee this autonomy in pregnancy must be protected. Furthermore, as Bowden observes, women choosing pregnancy are almost always invested in the outcome and so treating women as a source of danger is usually spurious.30

Finally, there are significant political and social ramifications of the framing of the womb as a hostile environment. Some of these are already evident in practice. A worrying trend of prosecuting ‘pregnancy-related offences’ in some US states under so-called ‘fetal protection laws’ shows a perception of women as dangerous, leading to apprehension and all the consequences of life after imprisonment. These cases involve an over-representation of poor women/women of colour, showing how certain groups are disproportionately affected by conflict framing, depending on the overall political context.70 Such thinking also encourages the view of women as ‘dangerous creatures’ that threaten a man’s procreative interests, again echoing the themes evident in the historical background provided earlier in this paper. Furthermore, we have demonstrated that it is not constructive, nor pertinent to the achievement of the best clinical outcomes, to routinely place blame at women’s feet for failing in gestation when there are other factors that need to be addressed. There are broader socioeconomic factors that are more responsible for poor prenatal outcomes, including access to care, than any individual women’s behaviour.

We argue that the above considerations show we must ‘move away from presenting the needs of a developing fetus as being in conflict with those of the pregnant woman’.30 One way to do this is by adopting a more holistic view, which regard the pregnant woman and the fetus as ‘an inseparable whole whose well-being needs to be fostered before, during and after the pregnancy’.28 Focusing on this maternal–fetal ‘dyad’19 as an interdependent biological unit is a better approach to providing ethical prenatal care than trying to balance the distinct interests of two (seemingly opposed) parties, especially since the fetus is fully dependent on the pregnant woman for its health and survival.19 This also ensures that women are affirmed as persons, with their autonomy and bodily integrity respected. Rejecting the notion of ‘conflict’ reduces the risk of stigmatising pregnant women for a multitude of decisions about their gestation, from diet to childbirth. As future reproductive technologies emerge, it is particularly important that we reframe thinking about pregnancy to determine appropriate ethical and legal parameters for their use.

Womb with a view

One of the most anticipated developments in assisted reproduction is ‘assisted gestation’; the ‘artificial womb.’ Ectogestation58 is the process of gestation undertaken ex utero in a device attempting to emulate the conditions of the human womb. Complete ectogestation is the growing of babies entirely from scratch in an artificial womb; partial ectogestation is the use of ‘artificial womb’ devices to facilitate the continued gestation of human entities that are removed from a woman’s womb prematurely. Recent animal experiments with artificial womb prototypes have demonstrated it is possible to facilitate partial ectogestation in lambs,71–73 fuelling speculation about the development of this technology and its impact.

Artificial wombs are often heralded as a source of potential liberation for women. Simonstein and Mashiach-Eizenberg explain that ‘reproductive hazards have traditionally been viewed as women’s fate, and therefore, have been taken for granted’.74 Firestone,75 Kendal76 and Smajdor77 echo concerns about the physical burdens of gestation and pregnancy being placed exclusively on female people and posit that entirely removing gestation from the body offers women, finally, equal opportunity. Smajdor explains that with complete ectogestation available, women would be able to ‘reproduce as men do, without risking their physical and mental health, economic and social well-being, and crucially—their bodily integrity’.77 Partial ectogestation has also been advocated as beneficial for women as a way of alleviating some of the burdens of pregnancy by offering, for example, an alternative if pregnancy is dangerous (or potentially undesirable) in the later stages.78 The problem with the arguments about how ectogestation might assist women in taking more control of their reproduction is that they are often advanced in a vacuum, seemingly ignorant of contemporary sociolegal conditions and importantly, women’s histories. Some of our concerns about the capacity of the technology to liberate women of the burdens placed exclusively on the female body are shared by other feminist scholars.79–81 Vallerdu and Boix assert that ‘medical practices have historically maintained a form of male control over women, and that reproductive technologies have been oriented towards the male help in detriment of women’s welfare’82 and thus the introduction of ectogestation would likely be no different.

In this section, we place the (potential) development of the artificial womb into historical and contemporary context by demonstrating how prevailing narratives of maternal–fetal conflict—if not addressed—will limit the capacity of technology capable of ectogestation from benefiting women and pregnant people. First, artificial wombs might escalate the pathologisation of gestation, and second, they might fuel excessive control over natural pregnancy by creating a ‘narrative of alternative.’ The purpose of this examination is not to advocate that we should ban research into ectogestation, because we see the potential benefits it will bring. Rather we seek to contextualise any potential development in the prevailing and enduring norms about pregnancy to illuminate the concerns that should be considered before ectogestation is used in humans. While this investigation is inevitably speculative, it helps highlight some of the contemporary concerns about harmful conceptualisations of maternal–fetal conflict.