Blameless Excuses and Uterus Transplants


I still plan to offer several more reflections on Between the World and Me, but I also feel compelled to offer some commentary and framing to two articles on transplants that appeared last week: the first uterus transplant in the USA and the news that desensitizing kidney recipients could allow for unmatched kidney donation. I’ll take them in theological order: the first shall be last and the last shall be first.

Desensitizing kidney recipients in layman’s terms means to make their immune systems less hostile to the transplanted kidney prior to transplantation. The upshot is that a desensitized patient could receive a kidney from a donor who is not a very good match. (If you want to know more about matching donor and recipient, read the article linked above.) The NYT headline above shouts the good news that now there is a method of desensitizing that allows a person in need of a kidney to receive one from ANY donor. That is great scientific and medical progress! And yet, like with any progress, there is also a cost, and this time the cost is social.

For the most part, this advancement is in fact good news—more people awaiting kidneys will be able to receive kidneys, and one’s position on the list will be a better indicator of how much longer one has to wait than the rarity of one’s blood type or HLA type. The social cost I refer to shows itself in living kidney donation. As you may know, a person can live with one kidney, and therefore some people choose to donate one of their kidneys to a family member or friend in need, and sometimes even to a stranger or acquaintance. But what happens when a family encourages one of its members to donate to another? What if the power dynamics in the family coerce a young member to donate to an older member, a child to a parent, or an abused member to an abuser? Well, traditionally, transplant teams have helped these individuals navigate the power asymmetry by giving them a “blameless excuse.” Transplant teams don’t want to coerce donors into donating, and they don’t want to operate on coerced donors—donating an organ must be a voluntary act.* Most often, the blameless excuse is that the potential donor doesn’t match the recipient. The blood type isn’t right, the HLA typing is too far off, or some such. This new medical advancement in transplantation has just made the most common versions of the blameless excuse for potential kidney donors more difficult to offer.

Of course, there are other forms of the blameless excuse: anatomical mismatch, not healthy enough to donate, but a family might be suspicious if their Division I collegiate athlete was deemed too unhealthy to donate a kidney. The beauty of the “doesn’t match” blameless excuse is that it is a kind of knowledge that’s inaccessible to the general public. Blood was drawn and it went to a far away lab somewhere in Hospitalistan where magic was performed and the potential donor was deemed to either match or not. This all happened behind closed doors and the news was delivered by someone wearing a white coat who read the information off of a ‘results screen’ that was indecipherable to the laity. Not being able to see the results and assess them for oneself is an essential element of the blameless excuse. In the future, to protect the integrity of living organ donation, the transplant teams are going to have to be more creative.**

While the desensitizing advancement in kidney transplantation highlights the potential coercion in the family system, it seems that the family itself is now an object that can be medically created with the prospect of uterus transplants. Of course, reproduction has been medicalized previously through insemination, IVF, and other assistance therapies. But a uterus transplant is pretty extreme. You’d have to want to give birth to a baby very badly to undergo the transplant surgery and take the anti-rejection drug regimen. But ‘giving birth’ isn’t even part of the plan. The patient who received the uterus would not be able to conceive naturally or give birth naturally—she would have to use IVF and have a C-section. The uterus would only be stable enough to support the growth of the fetus. The medical resources in terms of research, lab time, and highly-trained-doctors’ hours that went into this project is astounding. How is it ethical to prioritize the reproduction of specific individuals? Where is the greater good or the public good in this project? Should medicine be used to fuel or fund narcissism? This returns us to a question that has been asked about IVF and LGBT adoption: Is being a parent a right? And to extend that question: How extensively should medical resources be used to promote or protect that right, if it exists?

I could talk about this all day and come to no conclusion, but I also want to touch on a feature of the article that I found rather novel: the patient and the doctor invoke God as an explanatory feature of her medical narrative. When a donor was found for her so quickly, the doctor “considered it an act of God,” and the patient said that “she [had] been praying that God would allow [her] the opportunity to experience pregnancy….” I don’t want to dwell too much on the personalized theology that is required to think God has favored your own wishes for health or a sports victory; that would be yet another blog post. But I do want to point out that the doctor and the patient have both suggested that her infertility is a theological problem, though they have different ways of intervening to solve it. The doctor’s invocation of God obscures and renders unknowable the entire listing process for getting an organ transplant, though I do take his statement to really focus on the lack of waiting for the uterus that was required. It could also be read to argue that the immediate availability of the uterus is some kind of divine permission to proceed. But prior to this permission, the doctor had worked very hard (as had many others) to put the process in motion. He was doing the work to get her ready for a transplant for months in advance, so where is God in this exactly?

The patient’s invocation of God is more interesting. She prayed—a different intervention than the doctor’s—that God would allow her to experience pregnancy. It should be noted that she and her husband had already adopted three children, so she was already a parent, but she had not created life herself. Moreover, her infertility disallowed her husband from creating life. Theologically, some readings of Genesis 1 put forward that being made in the image of God means having the ability to create. The more conservative readings usually argue that the kind of creation that is required is procreation, the creation of life. More liberal readings will argue that being a creator in the artistic and technological sense are also ways of imaging God. Potentially, if she could not create life, then she could not image God. So she used all the technologies at her disposal to overcome that limitation. A theological problem became a medical problem with a medical solution. I would argue that a theological problem deserves a theological solution, and that would be to see her infertility (limitation) as an invitation to think about how she does create and image God in the world. More importantly, as a society, we should think about how many medical resources we want to throw at solving theological problems.


*The potential donor has a different set of doctors than the potential recipient, so there is no conflict of interest—the doctors represent the needs and desires of their individual patients.

**One of my surgeon colleagues mentioned that her team only offers the statement, “X is not a donor,” without a more specific excuse, in line with HIPAA. That is laudatory, but also a vague and unsatisfying answer to families, which leads them to continue to ask about the specifics. It was, in fact, in the context of working with this team that I learned about the “blameless excuse,” which can be given to the potential donor who then offers it up to the family as the reason he or she cannot donate. You can imagine how this happens: the potential donor asks, “what am I going to tell my family?” and the doctor might offer up suggestions, including that “you aren’t a match.” The doctor has not violated HIPAA because she is talking to her patient, but the patient may disclose this blameless excuse to the family later.