In 1992, the author JG Ballard was invited by Zone magazine to supply a glossary for the 20th century, and defined science fiction as ‘the body's dream of becoming a machine’ (Ballard, 1996). This might appear to have little relevance to midwifery, but the fast‑developing relationship between premature infants and machines may yield life‑saving advances, as well as ethical challenges.
Globally, 0.4% of infants are born before 28 weeks; yet despite this modest percentage, ‘extreme prematurity remains the leading cause of infant morbidity and mortality even in developed countries’ (De Bie et al, 2021). To reduce the mortality and morbidity of extremely premature infants, a fundamental shift in therapy was needed: to delay pulmonary gas exchange by treating these infants as fetuses not neonates (De Bie et al, 2021). Such an approach preserves normal organ maturation, especially lung development, and ‘constitutes the foundational rationale for artificial placenta and womb technology’ (De Bie et al, 2021).
Work on developing an artificial womb began in 1958 when researchers ‘cannulated the umbilical vessels of seven previable human fetuses in a warmed perfusion chamber and connected these to a spiral, Plexiglas, film oxygenator, prolonging their life up to 12 hours’ (De Bie et al, 2021). However, it is apparent that Aldous Huxley's imaginative response to the evolving disciplines of science and technology in Brave New World, first published in 1932, was prescient, with artificial placenta and womb technology being evoked. For example, in chapter 1, while showing a group of students around the Central London Hatchery and Conditioning Centre, Mr Foster ‘described the artificial maternal circulation installed in every bottle at metres 112; showed them the reservoir of blood‑surrogate, the centrifugal pump that kept the liquid moving over the placenta and drove it through the synthetic lung and waste product filter’ (Huxley, 1988).
The importance of the lung mentioned by Huxley is underlined by Shah and Mychaliska (2023), who note that extremely premature infants are typically ‘born between the canalicular and saccular stages of lung development when surfactant production is limited, and the lungs are not sufficiently developed for gas ventilation. As such, lung immaturity is foundational for many of the complications of prematurity’.
As of 2023, there is one artificial placenta system in development at the University of Michigan, and two artificial wombs in development at the University of Pennsylvania and, jointly, at the University of Western Australia and Tohoku University, Japan. Features common to both systems are: ‘1) extracorporeal circulation designed for [extremely premature infants]; 2) maintenance of fetal circulation; 3) vascular access entirely or partly through the umbilical vessels; 4) fluid‑filled lungs; 5) specialised environment for organ protection and ongoing development’ (Shah and Mychaliska, 2023).
As ever, when new medical technologies appear on the horizon, the issue of ethics trails in their wake. For example, Kukora et al (2023), acknowledge that with artificial placenta and womb technologies progressing toward clinical testing in humans, ‘currently, no recommendations exist comparing these approaches to guide study design and optimal enrolment eligibility adhering to principles of research ethics’.
One of the ethical challenges cited by Kukora et al (2023) relates to caesarean sections. Where it was considered that the artificial womb needed cannulation during a controlled ex utero intrapartum procedure, necessitating maternal general anaesthesia to provide the fetus/neonate with stable placental support, ‘more recently, however, the cannulation procedure has been optimised to allow caesarean delivery. As such, participation in a clinical trial of this technology would dictate this mode of delivery for patients who otherwise could have been vaginally delivered’ (Kukora et al, 2023). Electing for a caesarean ‘at this gestational age is a serious consideration when the survival of her infant is uncertain’ (Kukora et al, 2023).
In their wide‑ranging appraisal of the ethical issues raised by artificial placenta and womb technologies, Romanis et al (2024) considered accessibility and the potential for unfair distribution: ‘disadvantaged persons are more likely to be those on whom the technology is tested (because structural health inequalities mean they are more likely to experience premature birth) and then the least likely to be able to access it if/when it becomes offered more routinely in jurisdictions like the USA without [being] free at the point of access’. Romanis et al (2024) argue that there is a bearing on the concept of justice, a central tenet of medical ethics, and they make a subtle distinction between equality and equity in healthcare, noting that not all healthcare users are the same and therefore do not have equal need ‘and thus should not always be treated the same to ensure fairness: equity instead recognises that all individuals are not the same and do not have the same needs, and as such affording equal resources to all people may perpetuate existing unfairness’.
‘…not all healthcare users are the same and therefore do not have equal need’
It seems that, medical scientific progress and midwifery will have to eventually address the ethical issues derived from a technology first mooted by Huxley (1988) in a work of fiction.