Columbia University Journal of Bioethics 1 2 Fall 2007
Columbia University Journal of Bioethics And Supplement on BIOCEP Volume VI. No 1, Fall 2007
Editorial Board Faculty Editors Editors-in-Chief Dr. John D. Loike Ashley Pandolfi Dr. Ruth L. Fischbach Michael Peluso Cover Design: “Entwine‖ Copy Editors Dana Balitzer, Kim Atiyeh, Soo Han, Dr. John D. Loike Ashley Pandolfi, Ben Stern, Please send your comments Kathryn Vreeland, to Dr. John D. Loike Alisha Sachchathep, at: [email protected] Zahrah Taufique, Diana Zhou
Web Version is available through the undergraduate page: http://www.columbia.edu/cu/ Or through http://www.bioethicscolumbia.org/
Copyright 2007 by: Columbia University Center for Bioethics NO PART OF THIS JOURNAL MAY BE COPIED OR USED WITHOUT PERMISSION. All views in the articles reflect those of the authors only. Columbia University Journal of Bioethics 3
TABLE OF CONTENTS
Acknowledgements ...... 5
Introductions by Dr. John Loike and Dr. Ruth Fischbach ...... …………………………………..…….6-7
Section I: Genetics
The Twist about Gene Patenting Elizabeth Cedars Kimberly Atiyeh ...... 8-11
Athletics and Stem Cells Dana Balitzer Mikilena Greusel.…………………...... 12-14
Generation XY Mikilena Greusel Benjamin Stern………………….……….15-16
Section II: Reproductive Medicine
Full Stop: The End-of-Line for Periods? Kimberly Atiyeh Benjamin Stern……………………….….17-20 Prevalence of Birth Defects in ART Infants Emily Jordan Mary Colavita……………………..…...... 21-26 A Not So Normal Request Heidi Emrani……………………..……....27-30
Ethical Issues in Oocyte Donation Professor Laura Bothwell.………….…..31-33
Fetal Reduction Aina Fuller……………………..……..…..34-39 e-BABY: Your Source for Designer Babies Frontiers in Bioethics Class of 2007……………………..…..….40-41
Section III: Neuroethics
A New Drug Boosts Up Cognitive Capabilities Amanda Harris Elizabeth Cedars……………………..….42-45
Taking an (Incomplete) Trip Down Memory Lane Matt Nguyen Sophia Lin………………………………..46-48 Images of Immorality Michael Peluso Gabriella Rothberger………………….. 49-53
4 Fall 2007
TABLE OF CONTENTS (continued)
Section IV: Contemporary Issues
Silent Continent, Silent Spring: DDT Matthew Nguyen Michael Peluso………………………..….…54-55 Organs for Sale Raymond Raad……………………..….…...56-57
Does Your Food Wear Designer Genes? Alison O‘Neill Nikki Learned………………..…………..…..58-61
Teen Obesity Operations Rob Deiches Nikki Learned…………….……………...….62-64
Animal Use In Medical Research Dana Balitzer Laura Rusky……………...……………...….65-67
Redefining Disease Rob Deiches Adil Ahmed……….………………….…..….68-71 Navigating the Maise Maze Ashley Pandolfi Alex Port …………….……………..…..…...72-74 Supplemental Section: BIOCEP
BIOCEP: Cross Cultural Education in Bioethics Dr. John D. Loike……………………..………..75
Luxurious Resort & Your Perfect Baby Ashley Pandolfi Shanshan Tang…………………...…….…76-78
Family Planning in Thailand Patcharapol Jitramontree………...……….79-81
Ethical Stances in Post-Menopausal Pregnancy Chatchanit Arif ………….………..…..…...82-84
Bone Marrow Transfer and Stem Cells Krysten Chin Lulan Wang………..……………..…..…... 85-88 The Balancing Act: Cultural Attitudes Towards Kathryn Vreeland Human Embryonic Stem Cell Research Tina Lo…………………………..………….89-92
Alternative East Meets Conventional West Rajiv Agarwal, Sanhajutha Amnajhankij, and Zahrah Taufique…………….…….….93-97 To Treat or Not to Treat? Michael Peluso Yoon Joo Kang ...……..………….……...98-100 Medical Tourism Jonathan Sury Prakaikaew Montriwat …………...... …101-104 GMOs: an International Issue Alisha Sachchathep Dana Balitzer…………………….……....105-109 Columbia University Journal of Bioethics 5
Acknowledgements
Columbia University Journal of Bioethics would like to acknowledge the following individuals and organizations for their advice and support to help publish this journal: Dr. Deborah Mowshowitz, Director of Undergraduate Programs; Marilyn Castaldi, Chief Communications Officer of the Department of External Relations; Anna Sobkowski, Director of Science Communications of the Department of External Relations; Dr. Ruth Fischbach, Director of the Center for Bioethics, Columbia University College of Physicians and Surgeons; Ms. Jana Bassman, Center for Bioethics, Dr. John D. Loike, course director for Topics in Biology: Frontiers in Bioethics (W3995); and all the students and guest faculty who contributed to this Journal. 6 Fall 2007
Introduction
In the spring of 2007, bioethical issues related to reproductive medicine, brain imaging, and genetic testing were publicized in both the public press and in scholarly journals. The authors of papers published in this Journal have voiced their opinions and proposed innovative insights and solutions in response to these issues. These student contributors are aspiring scientists, physicians, lawyers, and philosophers whose thoughts and opinions are the heartbeat of this Journal. These students will emerge as the front line of scientific and medical discovery. Their future innovative research and ability to communicate science to the public will elicit and inspire bioethical debates. Furthermore, they will become essential players in helping society resolve many bioethical dilemmas. In addition, this year we have included guest faculty from Columbia University to write for our Journal.
This year‘s Journal volume includes a special supplement from Columbia University students and students from Mahidol University in Bangkok, Thailand, who participated in an innovative cross-cultural educational program called Bioethical Cross-cultural Educational Program (BIOCEP). Seventeen CU students and ten Mahidol students attended a special two week program in Bangkok, Thailand exchanging ideas and learning how culture and religion influence bioethical dilemmas. Their articles reflect some of the lessons derived from this program. Specifically, students were exposed to various cross-cultural humanistic values that impact how bioethical conflicts are discussed and resolved.
John D. Loike, Ph.D. Course Director– Frontiers in Bioethics, Co-Director of Graduate Studies, Department of Physiology, Director of Special Projects, Center for Bioethics, Columbia University College of Physicians and Surgeons
Columbia University Journal of Bioethics 7
Preface
With the Fall 2007 edition of the Columbia University Journal of Bioethics, we have reached new heights. Besides the edition almost doubling in page length compared to our former years, the diversity of ethical dilemmas, research questions, and policy implications contained in these pages has increased exponentially. And in terms of diversity of authors, one faculty member has been added to the mix of undergraduate, graduate, and medical students. But most impressive of all, is the representation of student-authors from Mahidol University in Bangkok, Thailand who join with their Columbia counterparts to challenge us with their serious thinking from a varied global perspective.
The authors who have submitted the articles in this Journal have distinguished themselves with a panoply of insights and perspectives that is astonishing. To whet your appetite, take these provocative questions that they pose for reflection: Why could sex selection prove to be a threat to humanity? Does patenting genes influence the pursuit of scientific knowledge? How do you respond when friends ask you to be the egg donor for their child? What about athletes banking their stem cells to replace injured or worn out joints? What does pre-implantation genetic diagnosis imply about the status of the disabled? Is it ethical for individuals to benefit from increased capabilities because of a drug-induced chemical surge? In the future, when children ask ―Where do babies come from?‖ will we say ―Ordered with every option from the e-BABY designer Web site‖? Should we disregard cultural and religious influences on the practice of healthcare to establish one global art of medicine?
We are in an era where breathtaking advances in emergent technologies call for careful and dispassionate consideration. The bioethical questions found here are going to be some of the most critical facing our society in the future. They will need to be resolved by the best minds available. The authors of these remarkable articles have already demonstrated their brilliance by focusing our attention onto these profound and complex issues and explicating both their promises and their perils. In times to come, these are the minds that we will rely on as new discoveries stretch the limits of our knowledge and boundaries of our imagination. Fortunately, we can be assured that the authors of these articles are the concerned, sensible, and prepared leaders of tomorrow. As they pursue their careers, I trust that they will remain accountable and uphold the Bioethics mantra: It is not what you can do, rather it is what you should do.
Ruth L. Fischbach, PhD, MPE Professor of Bioethics Director, Center for Bioethics Columbia University College of Physicians and Surgeons 8 Fall 2007 I. Genetics
The Twist About Gene Patenting: How the Plan to Push Research Forward is Holding it Back By Elizabeth Cedars and Kimberly Atiyeh
In a recent New York Times op-ed described well enough so that a professional piece by Michael Crichton entitled Patenting can use it for the designated purpose. Life, the sub-headline stated that ―one-fifth Among other things, raw and natural goods of the genes in your body are privately are generally not admissible for patents. owned, and the results have been Since genes are incontrovertibly found in disastrous‖ (Crichton, 2007). What followed nature, patents on genes were not legal, was an elaboration of the most shocking until the 1980 Supreme Court ruling of negative consequences of gene patenting. Diamond v. Chakrabarty. Chakrabarty had While such sensational ―gene-hyping‖ modified a bacterial gene, and succeeded in stories are attention-grabbing, the truth is patenting it since it was not naturally found. that, like most issues in bioethics, there are This decision opened the door to the multiple factors that patenting of other must be considered genes; they were and evaluated before no longer con- an outright endorse- sidered exclusively ment or condemnation a part of nature. of the practice of gene Instead, a patent patenting can be could be granted given. After looking at for engineered the reasons gene genes. In an patents were first application for a granted and whether patent on a gene, they still achieve those the scientist must aims, it becomes clear fulfill not only the that gene patenting is a procedure that above general criteria for the patent, but should be abandoned, but not because of must address other issues such as: any immorality in the practice. Rather, the 1) identifying novel genetic sequences, practice should be stopped because the 2) specifying the sequence‘s product, consequences of patenting genes today 3) specifying how the product functions in actually inhibit the attainment of the noble nature and therefore its use, and goals toward which they were conceived. 4) enabling one skilled in the field to use the Patents are granted by the U.S. Department sequence for its stated purpose (Human of Commerce to the first person to invent a Genome Program, 2007). product or technique, so long as the Once a patent has been granted, invention is useful, novel, non-obvious, and the inventor is given sole use of the product Columbia University Journal of Bioethics 9 for twenty years. Any scientist who wishes The arguments in favor of gene to study the gene must pay for the right to do patenting therefore stem mostly from so. Anyone who studies the gene or part of economic considerations and interest in the gene without paying, whether developing new biotechnologies. However, intentionally or unintentionally, is subject to such arguments do not seem to have firm penalty by law. Since the Supreme Court grounding; economic interests are not ruling, genetic patenting has become necessarily in the best interest of society, increasingly popular. There were 1,175 and the genes or sequences being studied patents on human genes between 1981 and are frequently patented with little 1995, and the number of ―DNA-based‖ patents exceeded 25,000 in the year 2000. The desire to develop the biotechnology industry was likely a factor in the flood of patents granted, since large amounts of both public and private funds were being invested in the field by the early 1990s (Williams- Jones, 2007). As of 2005, 63% of patents on human genes were licensed to private companies (Jensen, 2007). Supporters of gene patents have pointed out that the patenting of genes has several benefits. Because information that is patented must be revealed, patenting genes leads to disclosure of discoveries. New information about a gene will be made public, preventing secrecy and ensuring that everyone has access to the data. Since data are available to everyone and since it is illegal to study patented material, redundant research is prevented, and research is understanding of what they do and then pushed into new, uninvestigated areas. abandoned so that researchers can identify Economic incentive will also force research new genes for patenting (Abate, 2000). into new areas, since the patenting of Also, although theoretically the system aims discoveries provides monetary for less secrecy amongst researchers, compensation through the fact that others sharing of information becomes monetarily cannot utilize discoveries without payment. costly, leading to less collaboration to avoid The compensation researchers gain is economic loss. While the patents are made incentive for them to invest resources in their public for researchers, they only become efforts, and the income from gene patents available once the patent has been granted. can be used to further their research. Until then, they are strictly confidential. Additionally, since inventors are granted Considering that there are over three million monopolies on the genes that they isolate, in genetic patent applications that have been theory, researchers will be less secretive filed, genetic research is risky. If a patent is about discoveries, which can lead to granted while research is being done on that additional and more effective collaboration particular sequence, scientists face and flow of information. injunctions or monetary penalties and 10 Fall 2007 potential setbacks to scientific advancement brought on by newer technology renders (Williams-Jones, 2007). Other economic that economic motivation superfluous. The losses are incurred when scientists must not difficult part of genetic research is not so only pay for patent licensing but they also much isolating genes as it is finding useful must invest in determining which patents and creative applications. This change in apply. Inefficiencies such as patent stacking what scientific advancement really means occur when multiple patents involve two has not been reflected by a change in identical or similar sequences of DNA in patenting laws. Current patenting practices multiple forms. One of the strongest that reward the quick identification of a gene arguments opposing gene patenting is that rather than investigations into its function researchers are rewarded for the wrong result in placing the economic reward above thing. They are given economic incentive the knowledge itself. A more appropriate primarily for isolating sequences, which is a patenting law would no longer protect the relatively routine procedure, rather than for DNA sequences that are now relatively easy the development of applications from the to isolate, but instead protect the use of sequence or the determination of the applications invented or discovered by function and significance of the gene. scientists. Instead of encouraging creativity in Additionally, one of the initial goals applications, patents cause economic of gene patents was to ensure that inefficiencies and hinder progress toward an information would be shared immediately. end product that will benefit humankind. Since the first issuing of gene patents, the Therefore, while the initial reason for number of applications for patents has these patent laws may be to focus on the misusage of nature that occurs in the patenting of a natural component of life, there are clearly many practical arguments against the patenting of genes. Examining these practical arguments further will help to clarify why the practice of gene patenting should be abandoned. The initial intentions of genetic patenting were valiant in their efforts to protect and reward those who dedicate tremendous efforts to isolate or modify a gene. It is hard to argue against rewarding researchers for their discoveries and against grown exponentially. The sharing of the aim to make patented information public. information can more easily be facilitated by However, it has been nearly three decades publication, due to the slow nature of the since the first ruling allowing genetic patent application process. The timeline patenting. When the first patents were given from discovery to granted patent is on the for genes, the process of discovering and order of years. Though in the 1980‘s characterizing DNA sequences was much patents may have made discoveries more more time-consuming and labor-intensive visible and useful to the scientific than it is today. The economic reward of community, this function has been patenting was therefore a needed impetus. obliterated. The delay between patent The faster pace of gene characterization application and patent that protects scientific Columbia University Journal of Bioethics 11 advances under a cloak of confidentiality 2000. now just adds another set of inefficiencies the system. Further, at a time when so Crichton, M. "Patenting Life." New York Times many genes have been identified, the goal 13 February 2007. 21 Feb. 2007. of research should be to understand their Jensen, K., F. Murray. ―Intellectual Property function, their role in disease, and how they Landscape of the Human Genome.‖ Science, can be utilized rather than to push investi- 310: 239-240, 2005. gation into broader areas. Rather than lim- iting genetic research through patents, re- The Human Genome Program of the U.S. De- sources and efforts should be spent in col- partment of Energy Offices of Science. ―Human laborative efforts to study genes of interest. Genome Project Information.‖ 28 Feb 2007. While the aims of establishing the practice Aug 2006.
References
Abate, T. ―Call it the Gene Rush: Patent Stakes Run High.‖ San Francisco Chronicle, April 25, 12 Fall 2007
Need a Knee? Athletics and Stem Cells
By Dana Balitzer and Mikilena Greusel
The research staff at the Hospital for technology is already being implemented in Special Surgery in New York City predicts equine orthopedics to treat race horses that within 3-5 years, stem cell replacement (Hirschler, 2007). therapy will be utilized for tissue If put to regulated use, stem cell regeneration (Pennington, 2007). Although replacement technology will eliminate the there have been incredible scientific need for many risky orthopedic surgeries advances in the study of stem cells for such as torn or damaged rotator cuffs that these purposes, several technological are common in aging adults. This barriers still remain between current studies technology could greatly improve the and actual implantation. Yet, many people quality of life for elderly patients who are at may question the moral implications of higher risk for surgical complications and possibly invisible forms of sports-doping would offer a less painful recovery. Aside that could create all new standards for from general medical conditions, stem cell athletic ability. Because of its moral therapy would provide a means by which implications and additional risks to society, professional athletes could work past the stem-cell replacement therapy needs to be current age of athletic retirement, as carefully monitored and guidelines should injuries and wear and tear will be readily be established for its application in clinical healed. Athletes, after storing their stem settings. cells in an appropriate bank, or using Stem cell therapy could have umbilical stem cells after pregnancy, would astounding consequences in sports, have the greatest insurance policy for their medicine, and general orthopedics. As careers – an almost endless supply of such, the proposed procedure has ample healthy cells to not only mimic, but support in the medical and athletic completely replace and improve their worn, communities and would allow a means of used, and damaged tissue (Pennington, therapy for common injuries in tissues that 2007). The source of stem cells always do not normally regenerate—for example, presents ethical challenges in the the spinal cord. But debilitating spinal cord development of stem cell technology. Some injuries could potentially be remedied by oppose the technology because of their using stem cells to replace damaged cells. own moral beliefs surrounding the use of In animal models of spinal injury, implanted fetal tissue. Others, like athletes, may be neural stem cells have been shown to tempted to have children for the sole improve motor capability (Bagaria et al., purpose of providing a compatible source 2006). In different areas of the body, of stem cells: the placenta (Pennington, mesenchymal stem cells differentiate into 2007). Parents may also be impelled to cartilage and bone, and may improve store away their children's stem cells in procedures such as bone grafting and case of injury years later – they may even cartilage repair (Bagaria, et al., 2006). Such do so in hopes of fostering the next Tiger Columbia University Journal of Bioethics 13
Woods or Steffi Graf. cancerous tissues can be controlled. One Apart from all of the fetal tissue paper suggests that the stem cells could be controversy, stem cells can be derived engineered to "express a suicide gene, through various areas of the adult body as which render[s] the cells susceptible to a well. Although mature cells can be isolated particular drug" (Vats, et al., 2004). Yet, it from the same donor for re-implantation, may be many years until athletes reap the "they are not the best source of cells for proposed benefits of stem cell replacement tissue repair" since these differentiated technology. Even though scientists have cells "have low proliferative potential" (Vats, yet to fully differentiate and successfully 2004). Bone marrow provides perhaps the use stem cells for therapy, they remain best source of adult stem cells. optimistic for the future. Mesenchymal cells, derived from bone Apart from technological barriers, marrow, also have the potential "to stem cell therapy also poses other moral dilemmas. The procedure would be very expensive and so would not be immediately available to all patients – most likely only to high-profile athletes. If these pro-athletes can all be reconstructed after injury, how might professional sports be affected? Misuse of this technology could extend far beyond the realm of therapy. Taken to the extreme, the process would allow individuals to store sufficient cells to provide for enough surgeries, procedures, or whatever else would be necessary to maintain their youth. With advancements in plastic surgery and cosmetics, people who can afford costly operations are already differentiate into … cartilage, bone, fat and presenting stretched skin, artificial joints, muscle‖ (Vats, et al., 2004). Some chemically injected faces, and enhanced researchers suggest that "bone marrow breasts or other body parts. In our society, stem cells can be isolated from both the elderly yearn for procedures that pediatric and adult populations, and correct or delay aging. Stem cell potentially utilized for therapeutic replacement therapy, for these individuals, interventions" (Maher, et al., 2006). would only perpetuate their quest for But even using bone marrow as a eternal youth – presumably, it would allow source of stem cells has potential them to run, walk, and dance like they did downfalls. It is unclear that bone marrow in their thirties. But cheating death and extraction would yield enough cells at a creating sixty-year-old recharged bodies high enough concentration to be effective may complicate and disturb the natural therapeutically (Bagaria, et al., 2006). order of life as we know it. Stem cells are Obtaining these cells would require a major not plastic, fake, or cloned cells. They could surgical procedure. In addition, both adult represent a dangerous link to newborn stem cells and embryonic stem cells could cells, to a fresh start, or a blind quest for also potentially form tumors. Scientists Ponce de Leon‘s fountain of youth. have proposed that the risk of unwanted or The expense of the surgery also 14 Fall 2007
raises ethical issues of class discrimination. would be essential in regulating the new Going one step further, the surgery would therapies. only be available in economically stable Stem cells have an incredible countries and therefore cause a skew in potential to revolutionize the field of international athletic advantages. In orthopedics and sports medicine. Enhancing addition, this technology could potentially the motility of handicapped patients would be abused by athletes who want unnatural ensure a priceless improvement in their strength, capacities, and durability. Such quality of life. All new technologies have the abuse by athletes would be extremely potential to be abused, and it is our social difficult, if not impossible, to track, since the responsibility to set ethical guidelines so that cells can be derived from their own tissue. those who truly need to utilize this Obviously, the dangers that stem cell technology can reap its benefits. replacement therapy generates need to be curbed by strict regulations. Even before the References technology is introduced to the medical community for use, the ethics must be taken Bagaria V., Patil N., et. al. Stem cells in into consideration so that guidelines can be orthopedics: Current concepts and possible future applications. Indian J Med Sci 60:162- set. Who will be allowed to use stem cell 169,2006. replacement therapy? What criteria will be set for a patient to qualify for the treatment? Hirschler, B. Horses lead humans in stem cells Will athletes or athletic companies be able to race, Scientific American April 25, 2007. buy rights to its use? Where will the technology be made available? Maher S.A., Hidaka C., Cunningham M.E., Despite its many barriers, it is likely Rodeo SA. Specialty update: What's new in that stem cell therapy technology can orthopaedic research. J. Bone and Joint Surgery, resolve the moral dilemmas it poses. 88:2314-2321, 2006.
Insurance companies can be encouraged to Pennington, B. For Athletes, the Next Fountain of cover the costs, to reduce the chance of the Youth? New York Times, March 29, 2007. technology exclusive availability to wealthy patients. The cost of this technology will Vats, A., Tolley, N.S., et al. The stem cell in most likely be reduced, once the process orthopaedic surgery. J Bone Joint Surg Br has been further developed and 86:159-164, 2004. industrialized. Strict guidelines for the use of stem cell technology should be created to avoid scandals in competitive athletics. Such technology could only be used as a prescribed treatment, not one that can be bought without need. In addition, it may not be possible to monitor the usage of stem cells, even those derived from the same individual, should guidelines for use be set. The creation of technology to track illegal usage of stem cell therapy in athletes (studies are currently underway to track the metabolic changes that would possibly signal the presence of implanted stem cells) Columbia University Journal of Bioethics 15
Generation XY
By Mikilena Greusel and Benjamin Stern
Attention men: if you want to have a selection, therefore, has been practiced and male child, tie off – even remove – your left deemed a safe procedure. However, even testicle, wait for the rising tide of the waxing though the technology itself is not moon, recite a chant during intercourse dangerous, it may prove to be a threat to while you lie on your left side, wear boots humanity. and hang your underpants on the right side Forget the ultrasound and of the bed. If you are a woman, you must amniocentesis – even before conception, adhere to a specific diet, climax first only the color of the nursery can be chosen during the second round of intercourse, and immediately. But watch out, one pink lie on a bed facing in a north-south direction. bedroom down the hall may lead to a whole Many ancient cultures used these obscure floor of pink bedrooms, or a whole street of rituals and relied on natural phenomena to blue. Imagine your neighbors trying to line increase their chances of conceiving male up unborn suitors for your potentially heirs. Notably, there are not nearly as many beautiful daughter, or perhaps a little-league suggestions to improve the chances of a team for your future all-star. female conception. Fortunately for today‘s There are some benefits to this new couples, gone are the days of testicle technology, such as limiting the risk of amputation; science has matured past these certain inherited sex-linked genetic occult practices into a new generation of diseases. However, widespread use of gender selection. gender selection poses many dangers to Sex selection has been possible for society. Concerns about misogyny, sexism, decades using selective abortion, and for and gender stereotypes are already spurring many years using embryos generated for in debate. After decades—if not centuries—of vitro fertilization. Each embryo‘s DNA can be struggle, as women and men finally tested and only those matching a specific approach equal footing both socially and gender implanted in the uterus. However, a economically, these issues would threaten much simpler and seemingly benign years of progress. In societies where women technique is now available. Each sperm have achieved or are nearing equal rights, carries either an X or a Y sex chromosome. regression is a distinct possibility. In cultures If a sperm containing an X chromosome where women‘s rights are negligible or just fertilizes an egg, the fetus will be female. beginning to emerge, gender selection Correspondingly, a Y-carrying sperm would perpetuate continued male produces a male. Because the X dominance and oppression. chromosome is larger than the Y, male and In Asia, where overpopulation is female generating sperm can be separated reaching alarming levels, ―gendercide‖ has by size and inserted using standard artificial already become a reality. In China, where insemination techniques. This technology is there is a one-child policy and a strong cheaper and safer than in vitro fertilization cultural preference for male children, there and is already common for livestock are approximately 120 boys born for every breeding. Sex selection, using sperm hundred girls according to a January 2007 16 Fall 2007 brief in The New York Times. Similar ratios Throughout human history, evolu- appear in Vietnam and Taiwan. In India the tion has maintained the balance of the sex ratio is 113 boys for every hundred girls, sexes. Human psychology, culture and with observed ratios in some areas as society emerged and developed in this staggering as 156 to 100. The Chinese biological state of affairs; tinkering with such government is attempting to reduce the a fundamental and cogent force will set the occurrence of sex-selective abortions, but stage for economic, political, and social disturbing numbers of female fetuses are disaster. Before we get ready to put away still being aborted. Chinese physicians, in an our lunar charts and begin to purchase do-it- effort to limit the rate of female abortions yourself sperm sorting kits, we must while adhering to population controls, are consider the severe global dangers of banning their medical staff from disclosing gender selection. the gender of embryos before birth. With new sex-selection technology, however, the issue of selective abortion may soon be moot. Freely accessible sperm sorting will only increase the rate of male births, further skewing the gender population. According to a New York Times report from July 2004, social anthropologists and political scientists believe that this will produce a generation of permanently single men, large populations of which are a strong predictor of militancy and increased warfare. Even ―equitable‖ sex selection presents societal risks. First of all, the technique is not perfect: the rate at which girls are conceived ―by mistake‖ is higher than the opposite case. Even if parents select boys and girls at equal rates, a skewed population could result. Further- more, selected children may be seen as commodities in a newly commercialized reproduction market. Girls, viewed by some cultures as disappointments, may eventually be seen as second choices or gendered castoffs. Parents who elect not to partake in sex selection, or those who cannot afford it, may project their own disappointment on their children. Finally, families that choose male children are increasing the overall risk of sex-linked diseases. Because of this fact, and because boys are more accident-prone, insurance companies may refuse to cover the procedure for male children. Columbia University Journal of Bioethics 17 II. Reproductive Medicine
Full Stop: The End-of-Line for Periods?
By Kim Atiyeh and Benjamin Stern
More than any other method of causing estrogen and progesterone levels to contraception, ―the pill‘ helped bring about fall. This hormonal drop makes the uterine the sexual revolution. When introduced, oral lining slough off, producing the menstrual contraceptives gave women unprecedented flow. freedom, including the ability to control their Birth control pills work by halting the own reproductive processes and decide ovarian cycle at the very highest level of when or when not to have children. Though control: the brain. Because the pills contain its use as a primary form of birth control has artificial hormones similar to estrogen and waxed and waned over the years because of sexually transmitted infections (STIs), it is widely used in many countries, including the United States. The pill works by preventing ovulation, but normally allows menstruation on a monthly basis. Now, modern society is facing the advent of a new type of pill, Lybrel, one that could give women even more control over their own bodies and sexuality by eliminating menses. There are actually two monthly cycles experienced by women: ovulation and the menstrual cycle. Eggs come from structures called follicles in ovaries. Ovulation is controlled by follicle-stimulating hormone and leutenizing hormone (FSH and LH) released from the pituitary gland in progesterone, the body ―thinks‖ it‘s at the response to gonadotropin-releasing stage of the ovarian cycle where both hormone (GnRH) from the hypothalamus. estrogen and progesterone levels are high: FSH causes an ovarian follicle to prepare to after ovulation, but before menstruation. release an egg. In response, this follicle With high perceived levels of estrogen and releases estrogen, which causes the uterine progesterone, the hypothalamus does not lining to thicken. A spike in LH triggers release GnRH, so the pituitary is never ovulation and a change in the follicle known stimulated to release FSH and LH. As a as leutenization. In addition to the continued result, ovulation never occurs. Normally, release of estrogen, this leutenized follicle hormone-containing pills are taken for 21 then releases progesterone, which prepares days and then replaced by a hormone-free the uterine lining for implantation of a placebo pill. This allows the uterine lining, fertilized egg. If a fertilized egg does not which had thickened only slightly in implant, the leutenized follicle is degraded, response to the artificial hormones, to be 18 Fall 2007 period, though most of the usual symptoms cycle could be dangerous. Supporters of the accompany this form of menstruation (Mayo new pill counter that what is unnatural is the Clinic Staff, 2005). number of periods women in modern Though traditionally indicated with societies have. Women in developed nations this monthly regimen of active and placebo are having far fewer children than in past pills, contraceptive pills need not be taken in generations, the average age of first menses this manner. If estrogen and progesterone has gone down, and the average age of levels never decrease—that is, the placebos motherhood has risen. All these factors are eliminated—bleeding will generally not mean women are having many more periods occur (some women experience spotting). than their ancestors just a few generations Though this fact has been clear for decades, ago (Silidker, 2007). Of course, this does not only recently have pharmaceutical mean eliminating menses is safe, but it does companies formulated a regimen for mean the number of periods that women anything but monthly bleeding. Already on now experience is unprecedented. the market is Barr Pharmaceuticals‘ Undoubtedly, one of the most Seasonale, which allows women to have promising indications for Lybrel is the periods every three months. The uterine elimination of the many physically and lining does not build up past a critical emotionally uncomfortable effects, including amount, and bleeding experienced by severe pain, cramping, fatigue, and women is the same as with a normal ―pill emotional swings associated with menses period‖ (Palo Alto Medical Foundation, 2007). (Mayo Clinic Staff, 2007). Lybrel would Now, Wyeth Pharmaceuticals of Madison, eliminate the annoyances of restricting their NJ has gained FDA approval of Lybrel, the clothes since a period can mean a woman first non-cyclic oral contraceptive indicated cannot wear any light colored pants, skirts, for continuous use without any placebo or dresses. Many women simply cannot phase. In clinical trials, women used the pill function during menses and are physically for 18 months. Bleeding was halted entirely and/or emotionally crippled for as many as in 71% of the women. When treatment was seven days of the month. For these women, halted, 99% of women had a period within menstruation may not be seen as a symbol three months (Wyeth Pharmaceuticals, 2007). of womanhood and health but rather the The risks are similar to those of traditional opposite—an oppressive and chronic illness. oral contraceptives, including nausea at the Simply put, treating the cause of PMS will beginning of treatment, blood clots, stroke, eliminate its symptoms, a feat that for some and heart attack. As with the traditional pill, would mean more than just convenience—it Lybrel is expected to reduce the risk of would mean new freedom. ovarian and uterine cancer (Canadian Cancer Getting rid of the period would have Society, 2007). secondary medical benefits as well. Understandably, the elimination of a Eliminating PMS will decrease reliance on natural cycle worries many. No drug comes diuretics, anti-inflammatories, opiates, and without health risks and ethical ramifications. other drugs to treat symptoms. There would Currently, no studies longer than two years be no risk of toxic shock syndrome from have been undertaken, so the true long-term tampons and a lowered risk of rashes and effects of Lybrel are unknown. The urinary tract infections from pads. Indeed, cautionary position is that naturally, a these personal items products would rarely woman‘s hormone level in her body is meant be necessary. As insurance covers the cost to cycle regularly, and interfering with that of birth control but not hygiene products Columbia University Journal of Bioethics 19 and over-the-counter remedies, women complications such as tubal pregnancies would end up saving money. when a woman becomes pregnant while on Not having a period would mean the pill (Mayo Clinic Staff, 2005). As noted simple convenience: no emergency trips to earlier, current studies indicate that even the restroom, clothes fitting more after ceasing treatment with Lybrel, it takes consistently because of less water retention, as long as three months to resume normal and a personal life unshackled from a menstruation, during which time pregnancy prohibitive monthly cycle. can occur. To address this issue, Lybrel and The benefits don‘t end with physical similar drugs should be packaged with a convenience and better health. Lybrel and pregnancy test, covered by insurance, for its future equivalents could have routine self-tests. tremendous implications on how women The pills‘ packaging itself brings up function in society. Some might see another important issue. Current birth eliminating menstruation as a chance for control pills come in monthly packages, and women to become more competitive with each woman has in her possession only a men in all areas of life. Academic testing, few months‘ worth of pills. To save money, athletic performance, and musical ability pharmaceutical companies might choose to would be unencumbered by PMS. Job sell the new pill in bulk. This creates a performance might also get a boost if greater risk of redistribution and abuse as a monthly personal days are eliminated. secondhand, unprescribed ―morning-after‖ Women might even be viewed by men in the treatment in which a pregnant woman workplace as more reliable and rational knowingly overdoses to medically abort her decision-makers with the stabilization of child. This risk can be mitigated by limiting hormonal levels. Lack of physical symptoms the frequency of refills and advising women and a more stable mood could enhance a about their options should they become woman‘s ability to balance her career and pregnant. her personal life, as well as improve all- The societal impact of the new pill around parenting ability if she chooses to may be far-reaching. The issue of women‘s have children. equality is currently a hotbed of controversy. One serious medical and ethical On one hand, there is pressure for women concern is that the absence of a period is to have equal treatment, equal opportunity, traditionally used as a clear indicator that a and equal pay. On the other hand, there is a woman is pregnant. With the ability to turn push for men to be more accepting of off their periods, women simultaneously lose women‘s issues – for example by granting this important indicator. As with traditional maternity leave and providing day care. birth control, ovulation can occur if a woman Menstruation is a phenomenon unique to skips her pill for just a few days. Normally, if women and one that has always been this happens and a pregnancy results, she closely identified with womanhood. A will not have her period during the placebo woman who rejects menstruation, according week—allowing her to investigate into her to some, would be rejecting her body and health and make informed decisions. her feminine identity. But if women‘s However, with the new pill, it may be much differences are to be embraced, how can longer before a woman finds out if she is society keep pushing to eliminate them? pregnant. Continued use of hormones Similar issues arose when the birth control during an unwanted pregnancy can be pill first became available. Women were harmful, and there is a higher incidence of given more power over their own bodies. 20 Fall 2007
They were sexually liberated, able to enjoy sex without the risk of pregnancy—no longer Mayo Clinic Staff. ―Premenstrual Syndrome.‖ forced to settle down in order to express Mayo Foundation for Medical Education and their sexuality. Women‘s newfound sexual Research. 2006.
References
Canadian Cancer Society. ―The Birth Control Pill and Cancer.‖ 2006.
Mayo Clinic Staff. ―Birth Control Pill FAQ.‖ Mayo Foundation for Medical Education. 2005. http:// www.mayoclinic.com/health/birth-control-pill/ WO00098 Columbia University Journal of Bioethics 21
Prevalence of Birth Defects in ART Infants
By Emily Jordan and Mary Colavita
In 2006, 1% of all American babies were convulsions, long hospital stays, infections, born via assisted reproductive technologies tumors, asthma, sleep disturbances, con- (ARTs). During the same year in Sweden, genital malformations, cancers, urogenital 2% of the infant population was born defects, diseases of the skin and through using IVF alone (Schimmel, 2006). subcutaneous tissue, respiratory system With such a high usage of these procedures, diseases, conditions involving the eyes and especially IVF, it is important to understand ears, heart malformations, muscoskeletal the medical implications that ART's may anomalies, and other disorders that may involve. show up at birth or later in life (Schieve, There are a multitude of unknown risks 2005; Källén, 2005). According to a principal for both the offspring produced via any ART study performed in Western Australia and the women who use them. Women who between 1993 and 1997, 26 of the 301 receive in-vitro fertilization, and those that infants conceived with ICSI and 75 of the receive intracytoplasmic sperm injection, 837 infants conceived with in vitro (ICSI) are prescribed hormone-based drugs fertilization had a major birth defect that enhance ovulation and promote a diagnosed by one year of age, as compared nurturing environment for embryo with the 168 of the 4000 naturally conceived development. Some ART researchers claim infants. As a result, infants conceived via that this hormone treatment increases the IVF or ICSI were twice as more likely to patient‘s risk for ovarian and breast cancer; have a major birth defect (as defined above) however, this hypothesis has not yet been than were naturally conceived infants supported by research because assisted (Hansen, 2002). reproductive technologies are still in their Some critics claim that these major birth formative years (Powell, 2003). defects were more evident in ART children, Since the birth of Louise Brown, the first since they were under closer surveillance IVF baby, in 1978, a long list of possible than were the naturally conceived children, defects resulting from IVF has been but more recent research has elucidated compiled. Over the past five years, evidence trends in ART children that should not be has emerged that suggests increased risk of taken lightly. birth defects, low birth weight (even in Our paper explores relevant research to singleton babies), genetic disorders, and get an overview of the concerns and risks, possibly even cancer in children born though many studies attempting to expose through IVF and ICSI. the risks of IVF contradict each other, or ―Birth defects‖ are defined as: have come up with statistically insignificant ―abnormalities that are probably of prenatal data due to small subject pools and short origin, including structural, chromosomal, durations. For example, a Taiwanese study and genetic defects‖ (Hansen, 2002). in Developmental Psychology showed that Various studies have tentatively linked IVF there were fewer behavioral problems in IVF and ICSI to increased risk of mental children, and a Finnish study in Pediatrics retardation, upper limb defects, cerebral showed an increased risk of behavioral palsy, epilepsy, behavioral problems, problems (Golombok,1999). 22 Fall 2007
The association between IVF and an preterm birth (Källén, 2005). increased risk of birth defects is Currently, more than 20% of total ART controversial. Early studies suggesting that pregnancies result in multiple births. This IVF was safe with respect to birth defects can be attributed to ART treatments are difficult to interpret owing to small size, (Finnstroem, www.who.int/reproductive- lack of appropriate controls, and inconsistent health/infertility/23.pdf). A study in Sweden methods for detecting birth defects in the showed that of all ART children born in treated and control groups‖ (Olson, 2005). Sweden from 1982-1998 (2% of all children), Unfortunately, there are few American the risk of preterm birth and low birth weight studies that explore the IVF connection to increased after ART pregnancies, and birth defects because of policy constraints in correlated with the high occurrence of the United States that prevent funding multiple births (www.who.int/reproductive- allocation to these areas. Thus, we will rely health/infertility/report_content.htm). The on data from other nations and focus on the study also showed an increased risk of most statistically sound studies available. perinatal mortality in ART babies for the However, because of the small amount of same reason. available data, it is difficult to draw One study at the University of Iowa conclusions at present (Finnstroem, showed no difference in birth defects of www.who.int/reproductive-health/ twins, but showed that in higher-order infertility/23.pdf). multiple births there was an increased risk for defects in IVF babies, as well as in Birth Defects Resulting From Multiple Births
One of the most widespread potential causes of birth defects in IVF babies is multiple ovulation induction. In most IVF procedures, multiple embryos are injected into potential mothers to ensure that at least one embryo is transferred successfully. This, of course, increases the risk of multiple pregnancies (Wennerholm, 2000). Other singleton IVF babies (Olson, 2005). These risks associated with this practice, include three separate studies in three separate preterm delivery, low birth-weight, and even nations all concur that multiple pregnancies miscarriage (Wennerholm, 2000). A study in are a risk to the health of IVF children. late 2006 showed that a total of 35% of IVF This conclusion was contradicted by a children and 2.2% of control children were 2006 study in Israel, which showed that multiple births, and the health of multiple when data was adjusted for many similar births was worse than that of singletons confounding variables there was no (Staessen, 2004). This problem is increased rate of neonatal mortality or potentially dangerous. Preterm and multiple morbidity in IVF infants (Schimmel, 2006). births are known risk factors for brain Yet, a similar study from 2006 focusing on damage, causing cerebral palsy, epilepsy, data from Finland found, in contrast, that, and behavioral problems. These babies are ―Adjustment for mothers‘ background at an increased risk for other problems, such characteristics did not change the results…. as infections and convulsions, separate from the indicators of perinatal health showed Columbia University Journal of Bioethics 23 much worse health of IVF children, which referred to as an ―epigenetic defect,‖ which was explained partly by plurality.‖ The involves a loss of methylation of the paper also found that for multiple births ―… maternal allele. This alters gene regulation the total mortality rate up to the age of 2 (Gosden, 2003). years was twofold higher among IVF A 2003 Lancet article reported that children, compared with control children…‖ Beckwith-Wiedemann syndrome occurs in and that these deaths were caused mainly approximately one out of 15,000 births, and by malformations (Staessen, 2004). that there is a significant 4.2 fold increase in Thus, despite sporadic and sometimes the risk of Beckwith-Wiedemann syndrome contradictory research, even studies that associated with ARTs in Western countries carefully take possible confounding (Gosden). variables into account uncovered statistically significant increased risks for IVF children. Risks Associated with ICSI (Schieve, 2005). While many health problems of IVF children can be linked to With respect to ICSI, some studies multiple births, disease and increased suggest that a man‘s sperm defects can morbidity have also been linked to increased manifest themselves in his offspring by instances of specific diseases in IVF affecting kidney function. Some observers children (Staessen, 2004). Of the birth wonder if the injection of the sperm into the defects that are associated with ARTs, there egg might damage the egg‘s mechanisms are a number of chromosomal disorders that for cell division and that it bypasses natural have higher incidence in IVF and ICSI selection. Furthermore, by circumventing children. Approximately fifty genes are natural selection, ICSI can pass infertility differentiated according to their origin, and problems to the next generation, and that these imprinted genes have significant roles the defects that cause male infertility are just in development and tumor suppression. For part of a vaster spectrum of genetic and example, Dutch investigators report that developmental abnormalities that can be retinoblastoma, an inheritable tumor of the carried by defective sperm (Powell, 2003). eye, is more frequent in ART children than Such is the case with hypospadias, a those who are naturally conceived (Powell, condition in which the male‘s urethra opens 2003). under the surface of the penis. This is The imprinting disorders, Angelman suggested to result from progestin exposure syndrome and Beckwith-Wiedemann during organogenesis. Because this syndrome, are also more prevalent in ART condition is more common in ICSI males, children. Patients with Angelman syndrome rather than IVF males, and because both often display severe mental retardation, therapies use progestin and progesterone motor defects, and lack of speech that is therapy, there is stronger evidence to linked with the maternal allele UBE3A on suggest that it is a condition related directly chromosome 15. Patients with Beckwith- to paternal ―subfertility,‖ since ICSI involves Wiedemann syndrome have abnormalities at direct insertion of the sperm into the egg chromosome 11p 15. They display organ (Wennerholm, 2000). overgrowth and abdominal wall defects, in addition to an increased risk of tumors. Pre-implantation Genetic Angelman and Beckwith-Wiedemann Diagnosis (PGD) syndrome are both associated with imprinted gene clusters, and what is often Various forms of prenatal diagnosis, 24 Fall 2007 such as chorionic villus sampling and pattern between PGD and decreased birth amniocentesis, have been used to length or weight, birth defects, or frequency determine potential genetic fetus of small gestational age infants (Strom, abnormalities at as early as ten to thirteen 2000). Some researchers question the weeks of gestation. One form of genetic validity of these studies, since its subjects testing, referred to as PGD, involves the are not randomly assigned to the screening, removal and genetic analysis of one cell and since there is no strong control group: from the embryo at the 8-cell stage. In ―They‘re really picking and choosing who theory, this process better enables a they‘re looking at and what they‘re writing patient‘s decision to selectively implant about‖ (Goldman, 2007). healthy embryos. In 1990, PGD was first A strongly controlled study performed on reported for screening male embryos that women ages 37 and older in Belgium seems might carry a specific sex-linked disorder. to offset Munne and Verlinsky‘s findings. Since then, however, patients and scientists In the Belgium study, Staessen found have become concerned that PGD is being that women who had PGD gave birth to overused and that it may, in fact, not fewer offspring than the control group increase the number of healthy babies. (Staessen, 2004). Since half of all human Perhaps even removing a single cell might embryos exhibit a combination of impair an embryo and negatively impact the chromosomally normal and abnormal cells, health of potential offspring (Goldman, 2007). perhaps good embryos are being Often, PGD is used to test for unnecessarily discarded after being aneuploidy, or abnormal chromosome identified as faulty during PGD (Goldman, counts. With increasing age, such defects 2007). One-third of embryos that were rise rapidly in female eggs, and in turn, abnormal on the third day of development, embryos with aneuploidy are believed to be appeared normal when viewed on the fifth more likely to miscarry or produce offspring day (Goldman, 2007). with birth defects. PGD is applied with the Of the children that have already been intent to reduce miscarriage rates by born after having had the PGD procedure, allowing doctors to transfer fewer healthier thousands have displayed no obvious health embryos. More than two-thirds of several problems. It is important to note, however, thousand PGD procedures in the United that the oldest of the PGD babies are in their States test for aneuploidy, and there is teens, and the less obvious effects of the evidence that such screening can reduce procedure may not be apparent until later in the proportion of pregnancies lost in women life. Clearly, more research needs to be with recurring miscarriage. One study done. showed a drop from eighty-seven percent to seventeen percent in miscarriage rate, using Conclusions PGD (Munné, 2005). Similarly, Yury Verlinsky, a leader in PGD, found that the This paper aimed to illustrate the current miscarriage rate fell from sixty-eight to debates involving IVF and birth defects. twenty-eight percent with PGD, with an Despite contradictory and limited evidence, increase in the number of ―take home as well as intense political complications, babies‖ (Goldman, 2007). In Verlinsky‘s many researchers agree that there is some 1999 analysis of the effects of PGD on risk of birth defects associated with IVF, neonatal outcome of 103 infants who whether in the form of specific diseases and underwent PGD, there was no correlation or genetic problems, or as the result of multiple Columbia University Journal of Bioethics 25 progress despite these risks, and according resulting from IVF. to one researcher, ―…IVF is associated with Improved precision and accuracy in an increase in birth defects but the effect is the collection of information, research small. Findings to date are not likely to projects, and studies on all ART attempts, dissuade many couples from pursuing both nationally and internationally, would infertility treatments‖ (Olson, 2005). So, advance our knowledge of ART. explaining the relation of IVF and birth Organization of this data by country, state, defects faces certain urgency. ART procedure, biological/environmental There are efforts that have been risk factor, and birth defect would efficiently, suggested that could immediately reduce yet concisely afford prospective parents and the risks IVF poses for child health. medical professionals a vaster knowledge of Reducing the number of transferred ART results. Data collection would be most embryos is one very obvious solution efficient in the form of a longitudinal study, (Staessen, 2004). A law in Sweden limiting wherein subject sets would be observed implantations to two embryos at one time repeatedly, through adulthood. This successfully reduced birth defects and information would be available to the public, multiple births in the last ten years, a critical and it thereby, would allow couples and period, as IVF was gaining popularity medical professionals to make more (Finnstroem). However, additional studies informed decisions based on this should also explore the effect of IVF widespread data. specifically on singleton babies as well as the long-term health implications for all IVF References babies. In terms of PGD, researchers at Yale Finnstroem, O. ―Outcome of Multiple Pregnancy note that 85 percent of embryos transferred Following ART: The Effect on the Child.‖ in IVF do not lead to live births. This fact Goldman, B. ―The First Cut.‖ Nature, 445:479- highlights the need to improve methods for 480, 2007. identifying viable embryos. Recent data on success of embryos tested via PGD is Golombok, S., C. Murray, P. Brinsden, H. inconclusive, since the many studies that Abdalla. ―Social versus Biological Parenting: indicate that a decrease in miscarriage rate Family Functioning and the Socioemotional does not account for the decreased number Developmental Development of Children of ―take home babies‖ (Goldman, 2007). Conceived by Egg or Sperm Donation.‖ Journal Further, these reports display bias, since the of Child Psycholology/Psychiatry, 40:519- 527,1999. samples studied are not necessarily randomly collected. From an ethical Gosden, R., J. Trasler, D. Lucifero, M. Faddy. standpoint, however, it is unlikely that ―Rare congenital disorders, imprinted genes, and institutional review boards would approve assisted reproductive technology.‖ The Lancet, studies that either disallowed or required 361:975-1977, 2003. PGD screening of certain embryos, since its application conditional; it cannot be Hansen, M., J.J. Kurinczuk, C. Bower, S. Webb. generalized to the entire population of ART ―The Risk of Major Birth Defects After embryos, since some are at greater risk than Intracytoplasmic Sperm Injection and In Vitro Fertilization.‖ New England Journal of Medicine, others. Nonetheless, PGD screening 346:725-730, 2002. research is needed on this topic, as well as archival information on birth defects Källén, B., O. Finnström, K. Nygren, P. Otterblad 26 Fall 2007
Olausson. ―In vitro fertilization in Sweden: child Schieve Ph.D., Laura A., Sonja A. Rasmussen morbidity including cancer risk.‖ Fertility and M.D., and Jennita Reefhuis Ph.D.. ―Risk of birth Sterility, 84: 605-610,2005. defects among children conceived with assisted reproductive technology providing an epidemi- Munné, S., S. Chen, J. Fischer, P. Colls, X. ologic context to the data.‖ Fertility and Sterility, Zheng, J. Stevens, T. Escudero, M. Oter, B. 84;1320-1324, 2005. Schoolcraft, J. Simpson. ―Preimplantation ge- netic diagnosis reduces pregnancy loss in Staessen, C., P. Platteau, E. Van Assche, et. al. women aged 35 years and older with a history of ―Comparison of blastocyst transfer with or with- recurrent miscarriages.‖ Fertility and Steril- out preimplantation genetic diagnosis for ane- ity, 84: 331-335, 2005. uploidy screening in couples with advanced ma- ternal age: a prospective randomized controlled Olson, C. K., K. M. Keppler-Noreuil, P.A. Ro- trial.‖ Human Reproduction.19:2839-2858, 2004. mitti, et. al. ―In vitro fertilization is associated with an increase in major birth defects.‖ Fertility Strom, C.M., R. Levin, S. Strom, et. al. and Sterility, 84:1308-1315, 2005. ―Neonatal Outcome of Preimplantation Genetic Diagnosis by Polar Body Removal: The First Powell, K. ―Seeds of Doubt.‖ Nature, 422: 656- 109 Infants.‖ Pediatrics, 106:650-653, 2000. 58, 2003. Wennerholm, U.B., C. Bergh, L. Hamberger, et. Schimmel, M.S., C. Hammerman, A. Lusky, B. al. ―Incidence of Congenital Malformations in Reichman. ―Very low-birth-weight-infants con- Children Born After ICSI.‖ Human Reproduc- ceived by in vitro fertilization are not at higher tion, 15: 944-948, 2000. risk for mortality and morbidity: a population- based study.‖ Fertility and Sterility, 85: 907-912, 2006.
Columbia University Journal of Bioethics 27
A Not So Normal Request
By Heidi Emrani
A not so normal request was asked of are relatively new phenomena in science me a few months ago over dinner and drinks and medicine. The various technologies with two of my best friends, Pete and Jason. began being utilized in the 1970‘s and are The conversation went from ―How‘s your now used to aid in a range of infertility pasta? It looks amazing,‖ to ―we want your cases. In the early 1980‘s, egg donation eggs.‖ My friends went on to tell me about became a viable solution for women whose how they put a lot of thought into it and that ovaries failed to function, and who, for a they would prefer me over everyone else variety of reasons, were unwilling or unable they knew to be the egg donor for their child. to achieve pregnancy through in vitro They had another close friend who had fertilization (Steinbock, 2004). Surrogacy offered to be their surrogate host but they can be used in two ways, either full or preferred to use my egg over her egg. partial. Partial surrogacy utilizes the egg of Needless to say I don‘t think anyone is the surrogate mother and the sperm of the prepared to seriously make a decision like father from the couple who will parent the that on the spot. child after its birth. Full surrogacy is when My first reaction was to want to say an egg from the parenting mother or the egg yes because I love Pete and Jason and I donor is fertilized through in vitro fertilization think they would be wonderful parents. The with the sperm of the parenting father and thought of being able to help two of my best inserted into the uterus of the surrogate host friends fulfill their dream is an unbelievable (Golombok et al., 2004). Egg donation, in feeling. I have to admit it is a huge vitro fertilization, and surrogacy have been compliment. I was a bit flattered as well; I successful means of having children despite mean, to be told that your friends love you infertility for decades, but their benefits are so much that they want your genes to be a accompanied by health risks to the parties part of their family is a huge compliment. directly involved. But after the wine wore off, I woke up the Few extensive and long term next morning thinking about what a huge studies have been done on the risks decision it is to donate my eggs. involved in assisted reproductive I wasn‘t even sure where to start, so technologies because it is a new field in I decided I needed to do more research on medicine. Although many of the risks are assisted reproductive technology in general, unknown, there are also many known health specifically egg donation, in vitro fertilization, risks that range from minor to life and surrogacy. I also realized that the threatening. Egg retrieval, whether for decision doesn‘t only affect physical aspects donation or for in vitro fertilization, can be a of my health, but also would have time consuming process with many risks. psychological impacts on my life as well as The process entails injections of daily on my family. To further complicate things, hormones that stimulate the maturation of the physical and psychological well being of several eggs. Side effects of these hormone the potential child also has to be considered. injections include mood swings, vaginal Assisted reproductive technologies dryness, hot flashes, sleep problems, 28 Fall 2007 fatigue, breast tenderness, body aches, occurrence with in vitro fertilization when headaches, and visual disturbances multiple embryos are injected into the uterus (Steinbock, 2004). In order to achieve in hopes that one will be successful (Henig, maturation of as many eggs as possible, 2003). Other than common risks involved hormones may be prescribed in excess, with all multifetal pregnancies there are also which can cause hyperstimulation. risks involved to the child specifically from in Hyperstimulation occurs when a surplus of vitro fertilization. Studies have shown that eggs reach maturation causing the body to in vitro babies are more likely to miscarry or swell with fluid (Spar, 2006). A mild case is die soon after birth, and are at high risk of mainly uncomfortable and will heal itself having low birth weights. In addition, infants after a cycle of menstruation. A severe have been found to have a range of serious case, which is the result of 1-10% of in vitro birth abnormalities. Some of these birth fertilization cycles, can be accompanied by defects are, but are not limited to, kidney failure, blood clots, fluid buildup in musculoskeletal and chromosomal defects the lungs and shock. There is a possible, (Henig, 2003). The physical risks to all but uncommon, outcome of ovary removal parties involved are dangerous and deserve or even death resulting from severe considerable thought. In addition, I can‘t hyperstimulation (Steinbock, 2004). help but think that I would feel some sort of The actual retrieval of the eggs is responsibility if the child was born with done using a needle guided by an abnormalities. In addition to physical risks ultrasound inserted into the vagina and is there are psychological risks, as well as accompanied by minimal risks of sedation questions of ethics and family that need to and infection. The procedure is reported to be well thought-out. create minor pelvic discomforts but one There are many psychological donor referred to the pain as ―feeling like consequences of egg donation with respect somebody punched you in the to the question of family. There is no stomach‖ (Steinbock, 2004). In fact, five accurate way to predict what the women are known to have died as a result psychological outcome will be for me, the of the procedure in the United Kingdom, and potential child, Pete and Jason, and all of roughly 0.5-5% have reportedly had side our families. After discussing it with Pete effects ranging from respiratory distress to and Jason I was better able to piece renal failure (Spar, 2007). The known risks together what the scenario would look like. of egg donation and in vitro fertilization They would be honest with the child about range from minor to severe, but what may how she or he were conceived. With a gay be the most frightening are the unknown couple as parents, I don‘t think it would take risks involved. The unknown health risks long before the child began to wonder how linger in the back of my mind. If I grow up to she or he were conceived from daddy and have a health consequence that may have daddy. I respect how open and honest the been caused from donating I don‘t know if I situation would be, and I can‘t imagine it would ever forgive myself for unnecessarily would be a secret, because I think the child putting my health at jeopardy. should grow up knowing exactly who she or It is also important to consider the he is and from where she or he came. health risks to the potential child. Multifetal Obviously, I am very close to Pete and pregnancies are associated with more risk Jason and I would be a part of the child‘s life than a single fetus pregnancy. And whether my egg was used or not. I would multifetal pregnancy is a common be Auntie Heidi. And I think it sounds like Columbia University Journal of Bioethics 29 great fun until the part of having to separate not sure that I ethically agree with these myself from any mother-child feelings I may procedures being performed every day while have. I don‘t know how I would react if the the risks are ultimately unknown and could child looked like me and had the same goofy be significant. I don‘t know if I would want to characteristics and man-nerisms. I think a even support the field by being a guinea pig. part of me would always wonder if I made In wanting to be part of the medical the right decision or if I community and having a strong essentially gave away my child. appreciation for the pursuit of It is a complicated situation medical knowledge, I would feel because I don‘t necessarily obligated to be a part of want children, but I have been ongoing research for the rest of known to change my mind quite my life if I donated my eggs. I often. And if I did have children, would feel a moral obligation to how would I explain why they be a lifelong lab rat, and I can have a half brother or sister honestly say it doesn‘t sound being raised completely like fun. The question of family separate from them? and ethics is one that I can‘t I also have to consider answer, and I can‘t imagine my family in this decision too. I putting that burden on a child. have an extremely tight knit family and Being a kid is not easy and culturally I was raised with a strong trying to figure out who you are and how you understanding that family relationships are a fit into the world can be an enormous critical aspect of my life. I know my mother, challenge. Pete and Jason are so loving and there is no way that I could have a ―little and nurturing that I think the child would me‖ running around somewhere without her grow up with a strong sense of belonging wanting to be a huge part of the child‘s life. and personhood. Studies have shown that What about my sister‘s children- wouldn‘t children who were born with the assistance they want to know their cousin? of reproductive technology are extremely There are so many complicated wanted children and for that reason their issues when it comes to my family‘s parents are more involved with their lives involvement that I don‘t know where to begin and the children have healthier relationships with the questions and if there is ever a with their parents than other children correct answer to any of them. I feel as if (Golombok et al., 2004). But who can the more I think about the potential situation, predict how the child will feel about the the more complicated it gets, and I am sure surrogate that carried him or her for nine there will be a lot of complications that I will months and then gave them away, or the never be able to prepare for. I‘m concerned donor who offered them up. While the with my ability to separate myself from my studies show that the children born through egg and I am not sure that I should donate assisted reproductive technologies do not my eggs unless I am 100% sure. I love Pete show any severe psychological problems, and Jason, but when it comes down to it this they are mainly focused on young children is a decision that can‘t be purely based on whom I don‘t think are really old enough to how much you love someone or want to understand where they came from. I think help. that once the child reaches their teenage Another problem that I can‘t even years the situation will be a lot different and begin to tackle are the ethical issues. I am that you can‘t predict how someone will 30 Fall 2007 react when he or she realizes he or she would be appropriate. Ethically, I am not were conceived from what might be sure where I stand on the subject and I don‘t perceived as a science experiment, think I can make a half hearted decision to especially when the child becomes aware be a part of something that could potentially that as a result they may suffer from severe cause me to live in regret for the rest of my health consequences, which are not even life. So now I know that I am not prepared known yet. I feel like the child doesn‘t have to be a part of it by donating my eggs. I a choice on how he or she came into the can‘t say that I am not disappointed, world. Would such a child grow up to because I really wanted to be able to help ethically disagree with how they were Pete and Jason since I know they will be conceived and spend his or her whole life great as parents. However, I think I would filled with resentment? There are so many be more disappointed in myself for making a possible outcomes, and in reality it could decision purely based on feelings of my work out in a perfect way where everyone is heart when my brain clearly thinks happy. But if everything doesn‘t work out, differently. the stability of someone‘s mental health is at risk. The References more and more I think about the subject, and making this decision, the more and Golombok, S., C. Murray, V. Jadva, et al. more I can‘t even wrap my mind around it. ―Created Through Surrogacy Arrangements: Parent-Child Relationships in the 1st Year of Life‖. Honestly, I can‘t even decide what to order J Dev Psychology. 40: 400-441, 2004. for lunch, and after I do order I always wish I could change my mind. I just don‘t think I Henig, R.M. ―Pandora‘s Baby‖. Scientific am capable of committing myself to American. 288: 62-67, 2003. something for the rest of my life when I am so unsure of how I feel. After researching Powledge, T.M. ― Looking at ART‖. Scientific the physical risks, I feel uneasy about American 286: 20-23, 2003. putting my body through such a process. If I knew that the physical risks of donating Spar, D. The Baby Buisness: How Money, were all known, I would feel more Science, and Politics Drive the Commerce of comfortable and I would have an easier time Conception. Harvard business School Publishing accepting what risks were involved. Corporation, 2006. Knowing that I could die, and that even if I live through it I could experience health risks Spar, Deborah. ―The Egg Trade-Making Sense later on down the road, is scary. It feels like of the Market for Human Oocytes‖. NEJM 365: 1289-1291, 2007. I am playing Russian roulette with my health, and I respect my body too much to Steinbock, B. “Payment For Egg Donation and do that. The psychological effects are Surrogacy‖. The Mount Sinai Journal of equally as scary to me because I don‘t want Medicine. 71: 255-265, 2004. to live my whole life haunted by whether or not I made the right decision. I feel like I would not only be potentially sacrificing my own psychological well being, but that of my whole family‘s as well. I have a very close family and I am not sure that anyone would know how to approach the child and what Columbia University Journal of Bioethics 31
Ethical Issues at Play in Oocyte Donation
By Laura Bothwell* *Program Director at the Center for the Study of Science and Religion (CSSR) of the Earth Institute at Columbia University
Current statistics indicate that (IVF) procedures, parents and their health roughly 10-15% of all adults experience care professionals consider numerous some form of infertility (Spar, 2006), a term ethical issues, including: which technologies that is applied when a couple has been they are ethically comfortable pursuing; unsuccessful achieving conception after whether to freeze for later use, to donate to twelve months of unprotected coitus (Zegers research or to donate to another couple the -Hochschild, et. al., 2006). According to embryos that are not implanted in the recent studies, donor eggs are used in procedure; whether to pursue pre- nearly 10% of all Assisted Reproductive implantation genetic screening for congenital Technologies cycles (American Society for diseases or other undesired traits; whether Reproductive Medicine, 2003). Egg donation to continue a pregnancy if a congenital arose as a treatment for women who are disease is detected; or whether to infertile for a variety of syndromes. Some selectively reduce a multiple pregnancy. women cannot ovulate or their ovaries have When donor eggs are used, those been damaged. In some women, LH involved face a host of additional complex (luteinising hormonal) and/or FSH (follicle and challenging decisions. Of course, if stimulating hormonal) signals have donor sperm is used, similar ethical weakened, are too low, or are not quandaries apply; however, this article shall coordinated in the appropriate temporal specifically address issues at play in oocyte sequence. donation. The process of egg donation Recipients of donor oocytes have involves the administration of daily hormone often already undergone basic to extensive injections for the donor, coordinating her fertility treatments. The process can be both menstrual cycle with that of the recipient, tim e-consuming and emotionally and priming her ovaries to release an demanding. Certain ethical questions arise abnormally large number of eggs. regarding self-care. How many cycles of Meanwhile, the recipient takes progesterone treatment are infertile women willing to pills in order to prime her womb for the pursue using donor eggs in order to birth a implantation of an embryo. This treatment child with either the genes of the father usually takes at least 3 weeks. Once the paired with those of an egg donor, or the women‘s cycles are coordinated, the donor‘s genes of sperm and egg donors selected by oocytes and follicular fluid surrounding them the couple? What potentially considerable are surgically removed from the ovaries by a costs are they willing to bear in order to needle attached to an ultrasound probe. achieve a pregnancy, and at what age will Selected eggs are then combined with the they stop trying? Many recipients of donor father‘s sperm, and a chosen number of the eggs are women or couples seeking children resulting embryos are injected into the at a later age in life. Oocyte donation allows recipient‘s womb. embryos to even be implanted in the uterus During standard In Vitro Fertilization of menopausal or postmenopausal women. 32 Fall 2007
Then, the ethics of what is asked of for use by another woman is a procedure egg donors must be seriously considered. meriting these risks to the health of the To begin, ―donation‖ is a euphemism in most donor. cases—most egg donations are in fact egg The difficult ethical questions extend sales, with an average compensation rate in beyond the egg harvesting and implantation the United States of $4,216, varying stages. If a surrogate gestational carrier is according to region or donor profile employed by the parents, adding yet another (Covington & Gibbons, 2007). Some party involved in the pregnancy, then her recipients are willing to pay up to tens of rights and relationship to the child need to thousands of dollars for eggs from women of be addressed. certain physical, academic, or religious Relationships between donors, profiles, and there is no legal limitation on parents, and the child must be agreed upon. the sum a couple may offer for eggs from a The donor may remain anonymous, but donor with specific physical and/or there are both benefits and risks involved in intellectual characteristics. Some ethicists this approach. What are the psychological are concerned that women‘s eggs are consequences when a child is told that she/ becoming commodities, or that donors may he has an anonymous genetic parent? On be compelled by money to overlook health the other hand, open relationships between risks as they decide whether or not to the recipients of the donated oocyte, the donate their eggs. donor, and/or the resulting child may be Further, the health risks associated either congenial or precarious and with egg donation are not fully known. undesirable. If the donor is not anonymous, Presently, there are no longitudinal studies it must be considered whether donors ought on potential late-onset detrimental health to be protected from any future legal or effects. Shortly after the procedure, donor financial obligations to the child. health is usually stable, sometimes involving Occasionally, parents may feel that it is most mood swings or abdominal swelling. ethical to withhold the truth of the child‘s However, some egg donors experience genetic identity, never mentioning the child‘s Ovarian Hyper Stimulation Syndrome donor parentage. However, if the child (OHSS), causing significant pain and never knows his or her true genetic bloating following hyper-ovulation. Among parentage, he or she may be susceptible to women undergoing ovarian stimulation for harm resulting from ignorance of inherited egg removal, the incidence of OHSS has health concerns or personality traits. been estimated at 20-33% for mild cases, 3- Clearly, there are a plethora of 6% for moderate cases, and 0.1-2% for complicated ethical issues at play in egg severe cases (Rizk, 2006). There is no donation. Individuals and couples who remedy for OHSS, and symptoms generally pursue this procedure, as donors or dissipate a few days after egg harvesting. recipients, are often in somewhat vulnerable However, it has been reported that five positions when they must weigh all of the women have died in the UK as a result of ethical issues involved—the recipients are severe OHSS (BBC News, 2005). The coming to terms with infertility and the pathophysiology of OHSS is poorly donors are usually young women without understood, and there is no reliable test to significant financial stability. Numerous predict which patients will develop severe external factors confound the decision- OHSS (Orvieto, 2005). So, ethically, one making process. Yet, despite the situational weighs whether retrieval of a woman‘s eggs challenges facing those involved in pursuing Columbia University Journal of Bioethics 33 egg donation, it seems that a great deal of transfer, which is the injection of the the aforementioned ethical questions belong cytoplasm of a younger donor‘s eggs into to those directly involved, rather than to the eggs of an older woman. society at large. Is it not a donor‘s personal At the core of bioethics is the choice whether or not she will accept the question of how health can be sustained and risks associated with donating her eggs? Is promoted without harm to patients or to it not a couple or woman‘s choice whether or society. People have different opinions on not to pursue all of the technologies the level of influence they wish society and available in creating a family? law to have in donor and parental child- While respecting the privacy and bearing choices. As egg donation continues freedom of individuals, a number of actions to increase, the ethical challenges and recommendations can be offered by associated with this technology must be outside parties. First, it seems that it is further discussed and debated. appropriate for clinics providing oocyte donation technologies to not only fully inform References all parties involved of all associated procedural risks for the donor, recipient, and American Society for Reproductive Medicine child, but also to provide comprehensive Assisted Reproductive Technologies: A Guide information and counseling on all of the for Patients Patient Information Series January many ethical issues involved in the 14, 2007 http://www.asrm.org/Patients/ patientbooklets/ART.pdf. completion of a procedure. Many clinics make an effort to do this, but information BBC News. Safety of egg donation 'unclear'. 30 and counseling support could be provided to June, 2005. [http://news.bbc.co.uk/2/hi/ clinics by federal or state agencies. health/4634625.stm]. (Unfortunately, at this point, whereas many countries have established government Covington, S.N. & Gibbons, W.E. What is centers that address fertility issues, such as happening to the price of eggs? Fertility and the UK‘s Human Fertilisation and Sterility 87; 1001-1004, 2007. Embryology Authority, no such body exists Orvieto, R. Can we eliminate severe ovarian in the U.S.) Second, measures protecting hyperstimulation syndrome? Human donor health and well-being could be Reproduction 20; 320–322 , 2005. implemented. Perhaps health care professionals Rizk, Botros R. M. B. Ovarian Hyperstimulation could recommend that caps be set on the Syndrome, 10, (Cambridge University Press, amount of compensation that may be Cambridge, 2006). publicly advertised, or additional counseling may be required in cases involving Spar, Debora, The Baby Business: How Money, unusually high sums of compensation. Science, and Politics Drive the Commerce of Conception, (Boston. Harvard Business School Perhaps there could be legal limits to the Press, 2006). number of times a woman may donate her eggs. Third, and most controversially, new Zegers–Hochschild , Fernando, et. al., The procedures that emerge and are deemed to International Committee Monitoring Assisted pose unacceptable levels of risk to the Reproductive Technologies (ICMART) glossary health of those involved can continue to be on ART terminology: Fertility and Sterility, 86;16- outlawed. At present in the U.S., this is the 19, 2006. case for human cloning and cytoplasmic 34 Fall 2007
Fetal Reduction: Playing it Safe?
By Aina Fuller
A 37-year old woman used IVF and implications for both sides. fertility medication, specifically GnRH- Between 1980 and 1997, the analogues and gonadotropins, in hopes that number of births involving triplets or more she would become pregnant. Her hopes soared by 400% (Chertok, 2001). This were answered nine fold when doctors told increase is directly correlated to the use of her she was pregnant with nontuplets. Her infertility drugs in conjunction with IVF. The joy soon turned to concern as doctors most common fertility drugs are relayed the health risks posed not only to gonadotropins—naturally occurring her potential children, but to herself. The hormones that the brain produces to family and doctors chose to take the route of stimulate the ovaries to produce other multifetal reduction: an outpatient procedure hormones and prepare eggs for release that involves the use of ultrasound to fatally (Kirkey, 2000). The use of multifetal inject potassium chloride into one or more of reduction becomes more highly the fetuses through the mother‘s abdomen recommended as the number of fetuses in (Women‘s Health Channel). Her pregnancy pregnancy increases. was successfully reduced to two fetuses Although ultimately it is up to the after three attempts, and the woman gave mother and her doctor, multiple fetuses that birth to healthy twins (Athanasiadis, et al., are quadruplets or higher often pose risks 2005). that make fetal reduction practical and In this case, the health risks posed appealing for all parties. Once fetal were fairly obvious to both doctor and reduction comes into play for pregnancies of patient, and fetal reduction was the logical triplets or lower as aforementioned, the next step. But what about in the case of issue becomes much more challenging. lower multiple pregnancies? In a paper The severe prematurity rate for non-reduced published recently, a study found that triplets in a 2007 study was 25%. For reduction even in smaller multiple reduced twins the rate is 4.9%. Similarly, pregnancies increases fetal viability, thereby low birth weight correlates to the number of posing a more difficult ethical question fetuses in the pregnancy. Triplets had (Cheang, 2007). With proper care and significantly lower birth weights than did their management, pregnancies up to triplets are reduced twin counterparts (Cheang, 2007). now more successful than ever. With the To successfully reduce fetuses, lack of resources, however, even these potassium chloride is usually injected into smaller multiple pregnancies pose a huge the heart of the targeted fetus between 10 risk to the mothers and infants, calling into and 12 weeks of pregnancy. The heart then question the utilization of fetal reduction. stops beating and the dead fetus is Unfortunately, not all cases of fetal and reabsorbed by the mother‘s body. A multifetal reduction result in success. There second, less common and more invasive are health risks posed to both mothers and procedure involves a transvaginal approach fetuses, whether one decides to undergo and is performed earlier in the pregnancy. fetal reduction or maintain multiple fetal The procedure is performed at about 8 to 10 pregnancy, compounding the ethical weeks via embryo aspiration or suction from Columbia University Journal of Bioethics 35 the uterus. Here, the patient must undergo risk to the other fetuses as well as the anesthesia and there is a greater risk of careful management of reduced infection. This second procedure is pregnancies until they reach term. considered more dangerous because of a Because the average age of a higher risk of spontaneous reduction and it women utilizing IVF and accompanying is too early to screen for genetic defects fertility drugs tends to be older than naturally (http://bioethicsdiscussion.blogspot.com/ pregnant mothers, genetic screening is often 200610/multiple-f etal-births -should- a routine procedure. The most common test society.html). A common theme in both is Chorionic Villus Sampling (CVS) (Chertok, these procedures is timing: timing must 2001). Although this test can be an weigh into the decision process as it is important factor in deciding which fetuses to important for the mother‘s body to have reduce, it is not the only one. To consider sufficient time to reabsorb the remains back them all evokes the ethical questions into her body without posing risk to the other inherent in this type of procedure. fetuses (Valko). Children and mothers of multifetal The Ethics of Fetal Reduction: pregnancies are at risk for a number of conditions. Firstly, children of multiple births The American College of often are more likely to suffer long-term Obstetricians and Gynecologists recom- disability when they do survive. Cerebral mends the prevention of multigestational palsy and other neurological disorders have pregnancies during the hormonal regulation, a higher occurrence among multiple birth conception, and implantation stages of babies. In about 4 to 5% of women who do fertility treatments (Chertok, 2001). undergo multifetal reduction, the pregnancy According to different doctors at the college, still results in miscarriage of all the fetuses. the patient‘s physician should not only take In addition, the mother of a multifetal into consideration health risks, but also pregnancy is at risk for pregnancy induced ethical concerns. Often, patients undergoing high blood pressure; increased incidence of multifetal reduction also undergo counseling. preeclampsia – a condition with a slue of According to one study, there is a symptoms including a sudden increase in measurable trajectory of acceptance for blood pressure, excessive weight gain, swel- most patients who undergo multifetal ling, severe headaches, visual disturbances, reduction as: (a) pre-fetal reduction: feeling and more; acute polyhydramnios or an threatened by the confirmed diagnosis of excessive amount of amniotic fluid; vaginal multifetal pregnancy, facing guilt and conflict and uterine hemorrhaging, heavy bleeding; of undergoing fetal reduction; (b) undergoing preterm labor and delivery; and a prolonged fetal reduction: getting confused due to hospitalization and surgical delivery (http:// family's concern about fetal reduction, losing bioethicsdiscussion.blogspot.com/200610/ a sense of body boundary intactness, and multiple-fetal-births -should-society.html). worrying about the safety of the remaining Although multifetal reduction significantly fetuses; (c) post-fetal reduction: grieving for reduces these risks, there are still other risks losing fetus, and returning to the course of posed to pregnancies that do undergo normal pregnancy (Chiu, 2006). multifetal reduction. Often, however, these The real problem at the ethical core risks are usually more associated with the of this controversial procedure is that neither quality of care including the prominence of the doctors nor the patients have any mistakes during the procedure that causes concrete control over how many eggs 36 Fall 2007 become fertilized after insemination. testing, such as is the case for Tay-Sachs In the United States, unlike most disease, abortion and fetal reduction are other countries, in vitro clinics are not more acceptable than in others (Johnson, susceptible to any law that regulates the 2000). number of embryonic babies that can be Often, the selection of the fetus to implanted into a womb (Valko). This has a reduce is based, not on any sort of genetic much larger political implication as IVF is a testing, but on geography (Johnson, 2000). costly treatment. Clinics with the highest For example, if a mother is carrying triplets fertility rates often attract the most patients. and she opts to reduce her pregnancy to To achieve high fertility rates, these clinics twins, the doctor will recommend choosing often err on the side of caution and implant the fetuses located on opposite sides of the upwards of 5 eggs as a sort of ―insurance policy‖ in hopes that at least one will catch and the procedure will be statistically successful (Valko). The ethically charged question that comes into play, then, is how to choose which fetuses to reduce. Already a difficult question, there are a number of obstacles posed through technology that make the decision even more trying. According to one study, in a case reviewing 4,000 cycles of fertility treatments, doctors found that blood tests and ultrasounds used to monitor egg follicles were not reliable at predicting the risk of multifetal pregnancy (Kirkey, 2000). Although genetic testing is common for women who are above the age of 35 and use their own eggs, doctors disagree on the timing of this genetic testing. According to one doctor, the safest way to undergo fetal reduction is to reduce the pregnancy first at womb to prevent competition for nutrients ten weeks, lets say to twins, and then do and to reduce the risk of miscarriage. genetic testing via CVS one week later Following this course of logic, then, (Johnson, 2000). In this safe mode, then, in the case of multigestational pregnancies the selection of the reduced fetus is really of three or higher, how does one choose left up to chance – a moral dilemma for a how many fetuses to abort? Often, because family. of the risks posed by fetal reduction, doctors Even if genetic testing identifies a will recommend reducing to twins in order to certain abnormality, what does that imply leave a margin for error in hopes that at about the status of disabled people in this least one will make it to delivery. In cases of country? By choosing not to have a severe health concerns, however, a disabled child, is one leaning toward reduction to a singleton may prove wiser eugenics and reducing the value of people since statistically, singleton pregnancies are with disabilities? In certain cases as is more successful than twins or higher documented in any pregnancy with genetic (Kirkey, 2000). Most high quality care Columbia University Journal of Bioethics 37 facilities, however, will reduce the least nothing about forcing a choice on women, amount of fetuses necessary in hopes of only that they have a choice. In the case of complying with an ethical standard. With fetal reduction, I believe it‘s important to proper management and care, the maintain this option for choice to undergo successful triplet pregnancies brought to the procedure, but this choice must be term has increased exponentially (Chertok, coupled with education and counseling. If 2001). anything, the regulation should not be What if one does not have access to imposed on the procedure itself, but on the high quality healthcare? Accessibility to IVF services provided in conjunction with it. and fertility drugs is based on a number of Without education and emotional factors that are often economically based. counseling, it will be difficult for mothers to Age does play a role in that younger women make an informed decision that will not risk encountering fertility issues often are the lives of the rest of their children. As a advised to undergo just IVF, with a success society, this is a challenging bioethical issue. rate that is 2 to 3 times more than that of From a religious perspective, natural pregnancy. In the case of older however, multifetal reduction evokes a much women, fertility treatments become more more concrete response. In one paper, the invasive with the introduction of fertility author outlines the ethical concerns for medication, genetic testing, and so on multifetal reduction in Judaism. The (http://bioethicsdiscussion.blogspot.com/20 procedure presents a challenge to Jewish 0610/multiple -fetal-births -should- law as ―there is an apparent threat to the society.html.). Often, facilities with lesser preservation of the fetuses‘ lives.‖ (Chertok, quality standards are still able to provide the 2001) In Judaism, childbearing is of utmost expensive treatment by foregoing importance, thereby justifying the utilization counseling that is strongly recommended in of certain fertility treatments such as IVF and conjunction with IVF and fertility treatments. fertility drugs. Many rabbinical authorites As part of a more successful management allow fetal reduction where there are three plan, a psychologically healthier mother fetuses or more, since it presents a real makes for a physically healthier mother and health risk to the mother. According to environment for the fetus or fetuses. In said Jewish law, a religious benchmark for the counseling sessions, there is also a forum to definition of life is forty days post review and discuss personal ethical implantation. Because multifetal reduction concerns with the procedure that might often occurs at about ten weeks, this might leave mothers distraught (Kirkey, 2001). be viewed as contrary to Jewish law and its Often with ethical discussions about guidelines to preserve life. However, there multifetal reduction, a comparison to are some religious exceptions to this rule. abortion is unavoidable. Because of the In the case of abortion, Jewish Law concerns for quality of healthcare, the states that if the woman‘s life is endangered, number of fetuses implanted, and the termination of the pregnancy is acceptable. presence of counseling, some people who Applying that to fetal reduction, then, if the are pro fetal reduction also advocate federal fetuses pose a serious health risk for the regulation of the procedure (http:// mother, fetal reduction is ethically bioethicsdiscussion.blogspot.com ) . acceptable. The mother here has authority Regulation can become invasive, forcing of life because of her status as a full human women to make a choice between babies. being. In multifetal gestation, where all the With abortion, however, the law states fetuses threaten each other resulting in 38 Fall 2007 reduced chance at survival, Jewish Law counseling of patients to take into account would consider the fetuses as each other‘s their religious or other unique lifestyle pursuers. Yet, the fetuses have equal status perspectives, could help the decision since none of them are yet a full human making process. Because the procedure of being, unlike the fetus‘ status in comparison fetal reduction is so inherently ethically to its mother. Thus, it may be understood charged, the necessity for counseling is that multifetal reduction is only permissible integral. in the event that the chance for the survival In addition, one study found that of the remaining fetus(es) is increased embryos incubated in the lab for five days as (Chertok, 2001). However, reduction or opposed to three before implantation could abortion based on gender or non-life dramatically ―lower the multiple birth rate threatening anomalies are not acceptable. while actually increasing a woman's shot at The Catholic Church employs a getting pregnant‖ (Kirkey, 2000). This much stricter stance, prohibiting the use of technique allows embryos to grow to any sort of fetal reduction technology. blastocysts, allowing physicians to more According to the church the procedure is un- carefully screen for healthier embryos that acceptable because it is a ―willful elimination are more likely to implant. This could of human life [that] cannot be justified, significantly reduce the number of embryos neither on the basis of the principle of the so implanted to two or even one, guaranteeing -called "lesser evil," nor on the basis of that a precedence in which fetal reduction would of the double effect,‖ referring to the not be required at all. projected increase in health for both mother In terms of policy, as afore- and remaining fetuses (www.all.org). The mentioned, I am a firm believer in pro- church also warns of the potential of fetal choice, allowing a women to decide for reduction to lean towards a eugenic herself what to do with her body. Again, mentality, ―where through the techniques of however, I believe this choice is not really a prenatal diagnosis, people come to measure choice unless the decision maker is fully the value of a human life solely according to informed about the consequences, both parameters of normality and physical well- positive and negative, of her decision. Of being" (www.all.org). course, the entire point of IVF and fertility Even on a religious basis, then, treatments is to provide people with the there are disagreements about the utility of potential for life and offspring where it is no fetal reduction. longer naturally available. Bearing children is a gift that comes with both good and bad A Resolution? baggage. It does not seem to make much sense to attempt to vie for the potential for Perhaps a method of resolution is to life by putting at risk both the lives of the discuss fetal reduction in consultation with potential children and the mother who the physician and a member of the clergy carries those children. Mothers must be (Chertok, 2001). Some studies have shown informed about these potential life risks so that patients undergoing counseling had a they can be responsible for both their own much higher success rate of babies carried lives and those of their offspring. to term (Women‘s Health Channel). Often, Fetal reduction is a useful hospitals that deal with high-risk technology but it should be practiced as it pregnancies will provide such counseling, was intended: as a solution to a serious but it is not standard. Thus, individualizing health risk and not a routine procedure. The Columbia University Journal of Bioethics 39 commodification of the reduction of life Chiu P.Y., Su T.J., Chen Y.C., Ko C.M., Hu Li Za poses much more charged ethical Zhi. Lived experience of multifetal pregnant implications than the reduction of life for women with fetal reduction. 53;25-33, 2006. beneficial purposes, as fetal reduction is Johnson, K. Tough Choices on Fetal Reduction, intended to be. Through education and Genetic Testing. OB/GYN News, May 15, 2000. support, it should be standard that mothers are always able to make their best, informed Kirkey, S..'Outdated' fertility drugs not worth the decisions. risk. The Ottawa Citizen SAN DIEGO. Friday 27 October 2000. References:
Athanasiadis A.P., Karavida A., Tzitzimikas S., et Valko, N.G.. Fetal Reduction: Good Medicine or al. J. Fetal reduction in a nontuplet pregnancy: Atrocity? http://www.lifeissues.net/writers/val/ technical and ethical considerations. Eur J val_02fetalreduction.html. Obstet Gynecol Reprod Biol, 120:227-9, 2005. Women‘s Health Channel. Bioethics Discussion Brambati, E. Genetics: Genetic analysis prior to Blog. http://bioethicsdiscussion.blogspot.com/20 selective fetal reduction in multiple pregnancy: 0610/multiple-fetal-births -should-society.html. technical aspects and clinical outcome. Human Reproduction, 10:818-825, 1995. ―Multiple Pregnanices: Fetal Complications.‖ http://www.womenshealthchannel.com/ Cheang C.U., Huang L.S., et al. A comparison of multiplepregnancies/risks_babies.shtml. the outcomes between twin and reduced twin pregnancies produced through assisted reproduction. Fertil Steril. 88:47-52, 2007. Chertok, I. Multifetal Pregnancy Reduction and Halakha. Early Pregnancy: Biology and Medicine. V: 201- 210, 2001.
40 Fall 2007
A New Drug Boosts up Cognitive Capabilities and the Ethical Debate on Performance Enhancers
By Amanda Harris and Elizabeth Cedars A new drug that falls under the depolarization and causing the propagation category of AMPA receptor potentiators, or of the signal, in the form of an action ―ampakines,‖ was recently discovered that potential, down the neuron‘s axon to the has the potential to heighten cognitive axon terminal (Fernandez, et al., 2006). capabilities (Fernandez, et al., 2006). The There the signal is converted from an drug works by modifying the action of AMPA electrical one to a chemical one through receptors in the brain, which respond to the neurotransmitters, which are released into neurotransmitter glutamate. Although these the synapse to bind to receptors on the next compounds may have ameliorative effects neuron. Signaling in networks of neurons for a variety of diseases and seem to work in leads to all brain functions, from memory, animal models with neuropsychiatric emotion, and decision-making to regulation diseases, their therapeutic value has yet to of autonomic processes. When these be fully established. Already acknowledged, processes do not occur in the way they though, is the effect of these types of drugs should, various diseases may result. on healthy individuals, who can abuse the AMPA receptors are able to bind medication in order to enhance their and release glutamate very quickly, and are cognitive capabilities. The discovery of a therefore primarily responsible for fast drug similar to, but potentially more potent excitatory synaptic transmission (Black, than, other ampakines raises an ethical 2005). They play an important role in Long question: Does the potential benefit out- Term Potentiation (LTP), a phenomenon weigh the already negative consequences or contributing to the plasticity of neural should researchers begin investigations into connections and therefore thought to be new treatments in order to prevent the important for learning and memory. escalation of an already dangerous Modulators of AMPA receptors have been practice? found to affect the rate at which the A recent article, published by receptors become desensitized to glutamate Fernandez, et al. (2006), details the (Lynch et al., 2006). These receptors can discovery of a class of drugs that modulates be activated for longer periods of time after a receptor of the neurotransmitter glutamate. a single release of neurotransmitters, The binding of neurotransmitters like increasing their ability to propagate a signal. glutamate to receptors on the dendrites of Drugs that modulate the transmission of neurons affects the opening and closing of AMPA‘s excitatory signals may therefore be ion channels. AMPA receptors are one of beneficial in treating diseases such as three different kinds of glutamate receptors. Alzheimer‘s and schizophrenia in which When the AMPA receptor binds glutamate, a there is impairment of cognitive functions conformational change occurs that leads to (Marenco and Weinberger, 2006). an open channel. That channel is permeable Additionally, several studies have shown to positive ions that will flow along their that modulation of AMPA receptors concentration gradient, leading to increases the expression of neurotrophins, Columbia University Journal of Bioethics 41 or growth factors in the brain, such as Brain- on one particular thing for an extended Derived Neurotrophic Factor (BDNF), which period of time. From preparatory private has been implicated in depression (O‘Neil et high schools to competitive universities, the al., 2004). This increase in BDNF may be desire to have an edge over other students responsible for the anti-depressive effects is compelling. There is an increasingly seen in rodents treated with AMPA receptor popular black market on campuses for these modulators (O‘Neil et al., 2004). Through drugs. Students frequently take medications their role in the expression of neurotrophins, to study longer, more efficiently, or to AMPA receptor modulators also have the improve their cognitive functioning while potential to be beneficial in treating taking exams. Currently, this abuse of Parkinson‘s Disease (O‘Neil et al., 2004). Adderall and other amphetamines is not at a The new class of drugs appears to scale large enough to attract political be more potent than the previously identified attention. However, if it continues to AMPA receptor modulators (Fernandez, et escalate at the present rate, it will be an al., 2006). The claim is that these new issue that university policies and even interactions will be more effective in national legislation will have to address. If generating the beneficial effects of this new, more potent drug follows in its previously discovered AMPA receptor modulators. However, no studies have yet confirmed the effect in actual neurons or in live animal models. Therefore, their actual potential as treatments for these diseases remains to be seen. While any drug that may improve treatments of debilitating diseases deserves attention and consideration, there are ethical issues associated with this particular category of drugs and a precedent of tolerance to contend with. Ampakines that modulate the activity of AMPA receptors, have been shown to enhance cognitive functioning not only in targeted diseased patients, but also in healthy individuals (Lynch et al., 2006). Is it ethical for brothers‘ footsteps, it can greatly exacerbate individuals to benefit from increased the problem. capabilities because of a drug-induced The ethical issue is deeply rooted in chemical surge? Should the moral American values. In America especially, understanding of an ―equal athletic playing there is a culture of competition that field‖ be applied to academics as well? It is permeates all aspects of one‘s leisure and illegal for professional athletes to enhance work experiences. Since competition is an their performance through the use of drugs important vehicle for evaluating a person‘s like steroids because it is not ―fair‖ to the skill, it is essential to Americans that there is other players. an equal playing field in every area. Students in America can easily Affirmative action, although now mostly acquire prescription amphetamines, like disapproved of, can be understood as the Adderall, to help them focus more concretely country‘s way of leveling the playing field 42 Fall 2007 between races for educational and legislation that regulates these cognitive employment opportunities. Need-based enhancers? How can these consequences scholarships are also an example of be prevented and still preserve the American customs that attempt to correct therapeutic benefits of these drugs? discrepancies in equality. That is why A bioethicist might approach these Americans condemn ―performance questions with two suggestions. One is to enhancers‖ so vehemently; they interfere devote resources to developing the drug so with what is perceived to be the natural that it limits the delivery to specific areas of selection process wherein the fittest the brain. Alzheimer disease seems to be survives. In addition, certain groups of characterized by abnormalities in specific people are able to obtain these drugs more regions of the brain, including the neocortex, readily, specifically wealthier people who hippocampus, and amygdale (Kandel, can afford them and who can afford the Schwartz, and Jessell, 2000). The affected psychiatrists who prescribe them. The availability of cognitive enhancers therefore also raises the possibility of creating further stratification within society, a phenomenon that is already being seen to occur with the use of expensive preparatory programs for standardized tests (Roscigno, et al., 2006). Yet, these drugs were developed for a purpose and with good intentions. Ampakines do seem to be able to treat certain diseases. However, some of these diseases are also the subject of some controversy. Diseases such as ADHD and depression are certainly real, but some experts believe they are over-diagnosed (Brower, 2004) and once a person is prescribed medication, it is easy for them to get refills, even in excess. That is why these prescription pills readily find their way to healthy hands. The problem with fixing an overly-diagnosed disease and its brain regions of Schizophrenic patients are subsequent prescription is qualifying who is less well understood, but may include the ill enough. If doctors apply stricter guidelines prefrontal cortex, hippocampus, and globus to their diagnoses, they might inadvertently pallidus (Kandel, Schwartz, and Jessell, turn away patients who actually do need the 2000). Targeting drugs to these regions medication to treat their depression or might be helpful in limiting the effects of the ADHD. It is a dangerous road that could drugs on healthy individuals and thus lead to unfortunate, preventable tragedies. rendering them useless as performance Is it worth continuing to develop these enhancers. specific kinds of drugs if this will be the The other suggestion is to approach fallout from them, or should time and money treatment of these diseases from alternative be invested in a totally different approach to pathways. The effects on AMPA receptors these illnesses? Should there be stricter ameliorate the symptoms of the diseases, Columbia University Journal of Bioethics 43 but AMPA receptor deficits are not the Marenco, S. and Weinberger, D.R., Therapeutic cause of these disorders—in many cases potential of positive AMPA receptor modulators the causes are still unknown. While AMPA in the treatment of neuropsychiatric disorders. receptor potentiators may be a good CNS Drugs, 20:173-85, 2006. treatment for the symptoms, funds should O'Neill, et al., AMPA receptor potentiators for the be used instead to support research into treatment of CNS disorders. Curr Drug Targets identifying the causes and developing cures CNS Neurol Disord, 3:181-94, 2004. rather than generating ethically ambiguous drugs. Roscigno, et al. The Myth of Meritocracy? SAT Both of these options are Preparation, College Enrollment, Class and scientifically feasible today and therefore Race in the United States Paper presented at scientists have an obligation to spend their the annual meeting of the American Sociological money and resources on the development Association, Montreal Convention Center, Montreal, Quebec, Canada, 2006.
References
Black, MD. Therapeutic potential of positive AMPA modulators and their relationship to AMPA receptor subunits. A review of preclinical data. Psychopharmacology (Berl), 179:154-63, 2005.
Brower, V. Analyze This. EMBO Rep 4:1022– 1024, 2003.
Fernandez, et al., A novel class of AMPA receptor allosteric modulators. Part 1: design, synthesis, and SAR of 3-aryl-4-cyano-5- substituted-heteroaryl-2-carboxylic acid derivatives. Bioorg Med Chem Lett, 16:5057-61, 2006.
Kandel E.R., Schwartz J.H., Jessell T.M. Principles of Neural Science, 4th ed. p.1153 (McGraw-Hill, New York, 2000).
Lynch, et. al., Ampakines and the threefold path to cognitive enhancement. Trends Neurosci, 29:554-62, 2006.
44 Fall 2007
Taking an (Incomplete) Trip Down Memory Lane
By Sophia Lin and Matt Nguyen
If you were presented with the 0/31/the-neurobiology-of-fear). opportunity to erase a particular frightful What remain unknown are whether memory without affecting other memories, recollection of a fear memory also causes would you take it? Joseph LeDoux of the synaptic potentiation in the lateral amygdala, Center for Neural Science at New York and whether interference of reconsolidation University studied the phenomenon of is reconciled through a reduction in deleting one precise memory in the brain, potentiation at reactivated synapses (Doyere and its potential effects on the future of et al., 2007). The experiment involved two psychiatry. This paper examines the different conditioned stimuli: a pure 1-kHz specifics of his experiments, their ethical tone and a complex frequency-modulated implications, and possible resolutions. sound. These two stimuli were paired with When memories are newly formed, the same aversive unconditioned stimulus, they are vulnerable to disruption for a period and then the rats were subjected to an intra- of time before being stored in the long-term lateral amygdale infusion of either vehicle or state of mind. During reconsolidation, a U0126, a pharmacological agent which process is evoked when the memory is causes amnesia. The rats were then placed retrieved, providing the opportunity to mold in a reactivation trial with one of the the memory before storage once more. This conditioned stimuli while the other process may potentially be utilized to treat conditioned stimulus was not reactivated. psychiatric disorders and pathological Shortly after retrieval, the rats were tested conditions including drug addiction, phobias, for memory retention of both stimuli as well paranoia, or post-traumatic stress disorder as one day later to test for long-term (Doyere et al., 2007). However, the memory. knowledge regarding the selective process Both the vehicle and U0126 group of reconsolidation is still very limited. displayed similar levels of freezing to the Research on reconsolidation has centered reactivated conditioned stimulus during upon Pavlovian fear conditioning based on a reactivation and to both reactivated and non- method for manipulating associative reactivated conditioned stimulus during the learning. Fear arousal from conditioning short-term memory test. However, there was induces synaptic potentiation at lateral impairment during the long term memory amygdale synapses (Doyere et al., 2007). test for the reactivated conditioned stimulus The amygdala, a small, almond-shaped part in the drug-treated (U0126) group. This of the brain, is a part of the limbic system signifies that the effect of U0126 on memory and attached to the anterior of the is selective to the reactivated conditioned hippocampus. It is involved in encoding and stimulus. Consequently, despite sharing the consolidating memories relating to fearful same aversive outcome, two associated experiences and receives its core memories can be independently contributions from the visual, auditory, and consolidated. The fearful memory is erased, somatosensory cortices while distributing rather than only breaking the connection responses to the hypothalamus (see between memory and its fear-induced http:neurophilosophy.wordpress.com/2006/1 response (Smith, 2007). Columbia University Journal of Bioethics 45
For the reactivated conditioned someone is crippled by a terrible memory, it stimulus, the level of potentiation in the could be a blessing for them to forget. It lateral amygdale during the short-term seems that this technology would be a memory test differed between the pure tone worthwhile pursuit if a large group of people and frequency modulated stimuli. Retrieval could benefit from it. Those with drug itself can produce plastic changes in the addictions or phobias are also a large group lateral amygdala independent of alterations who would possibly be given relief by this in afferent processing in the thalamus technology. Yet even in these possible (Doyere et al., 2007). This experiment instances of use there are ethical questions. illustrates the selective effects of retrieval Is it ever ethical to erase memories? and reconsolidation, where the retrieval Memory is a key to self-identity. Someone activates two different actions. One creates who has undergone experiences in his or potentiation, which may reflect mechanisms her life is indelibly affected by them, for of updating new memories, while the other better or worse. Deciding to destroy a process renders the modifications memory is not a light decision to undertake. connected with initial learning labile. The psychological problems that could be Therefore, there is a de-consolidation of the helped from this technology already have fear memory trace in the lateral amygdala, existing treatments which do not have to possibly erasing the initial encoded resort to pharmaceutically altering the brain. plasticity. During the renewal of fear There is a possibility that such a technology memories, these discoveries form the would be over prescribed, used in a way that neurophysiologic groundings for content- would lessen regard for human experience. limited modifications. If experiences were always treated as While these findings are though they could be erased later, how experimentally sound, the scientists do not would that affect people‘s perception of the specify to what extent the particular fears world and how they act in it? If it is possible, can be erased. Additionally, these tests are the ability to edit one‘s mind in this powerful only conclusive in rats, and have not yet way would be unprecedented. It is shown promise on humans. The study fails important to note, however, that there is to focus on inhibiting the molecule precedent in this kind of desire. People responsible for the synaptic strengthening, a have used many substances and methods part of the memory process. to try to forget things for time immemorial, There is still much research to be from the lotus plants of The Odyssey to done. If this technology is ever able to work alcohol. If individuals have the right to in humans, there are important ethical control what is in their mind, shouldn‘t they issues to consider. The ability to erase have the right to delete things as they wish? memories, even if they are fearful ones, is a This is a question that has been at the heart powerful tool in altering minds. Is there ever of many debates of the individual against the a time when it is appropriate to do this to a proclamations of society and government, human being? Easing the suffering of such as with the war on drugs and someone with post-traumatic stress disorder prohibition. This technology would simply (PTSD) is an appealing goal and perhaps be a new arena for this longstanding conflict. the most notable way this technology could There are also ethical questions be applied in a positive manner. The world about how this technology could be used by is being torn by war and every day man- organizations such as the government. made and natural disasters affect people. If Soldiers could be medicated and be made to 46 Fall 2007 forget atrocities committed or seen - and thorough. It would also be worthwhile to then they could be sent out again to the next think of how governments would use this conflict zone. Intelligence agencies could technology if it were highly developed; we use the technology to erase the memories of should be informed and alert citizens who those who witness clandestine activities or would elect trustworthy people. Technology carry out secret missions. Criminals could per se is morally neutral, it is how people erase the memory of a witness, or erase use technology that creates moral their own memory of committing a crime. dilemmas. These possibilities reveal how much potential for malevolence could come from References such a technology. It also exposes the societal and cultural influences that play into Doyère, V, J. Dbiec, M.H. Monfils, G.E. Schafe, the use of technology. Ruminations on J.E. LeDoux. Synapse-specific reconsolidation of distinct fear memories in the lateral amygdale. memory erasure have been in culture and Nature Neuroscience - 10: 414 - 416, 2007. society for a long time. There are even films in popular culture like Total Recall, Memento Smith, K. Wipe out a single memory:Drug can and The Eternal Sunshine of a Spotless clear away one fearful memory while leaving Mind, which have explored ideas about another intact. www.nature.com/ memory loss and deletion. news/2007/070305/full/070305-17.html. The benefits of this technology seems at first, to be outweighed by the risks. But in reality this technology could lead in a dangerous direction. When technology could have the potential for so much abuse, it must be pursued very carefully. Regardless, this type of research could be very useful in learning more about memory and the brain. Many still unenvisioned benefits could arise from this study. Many technologies we have now could be used for supposedly terrible ends but have been tightly regulated. That is why a possible solution would probably stem from observing the use of technologies in other areas such as reproduction. Cloning technology, for example, is restricted by laws that prevent the creation of humans. It is too early to say what kind of treatments could come out of this research, and it remains to be seen whether treatments could be so dramatically effective as to allow the sort of uses mentioned above. Regardless, it would be best if these treatments were carefully used and regulated. Screening processes and psychological profiles would have to be very Columbia University Journal of Bioethics 47
Images of Immorality: Brain Structure Studies Implicate Specific Regions in Immoral Behavior
By Michael Peluso and Gabriella Rothberger
Imagine sitting on a jury and hearing negative decisions and increased likelihood the following case: of engaging in these actions if they are thought to fulfill a utilitarian goal. For A waiter in a local restaurant is example, patients with VMPC lesions are charged with poisoning and killing a more likely to take the life of a loved one if customer. He claims that the customer they think that it will save a group of people revealed to him that he was infected with with whom they are unacquainted. The HIV and desired to spread the virus to as VMPC is crucial in emotional many people as possible before he died. responsiveness; damage often results in Evidence in the case suggests that the significantly diminished social emotions waiter, knowing that the customer had a including guilt and compassion. Individuals severe allergy to poppy seeds, placed with damage to this area are predisposed to these seeds in his customer’s soup in make decisions that would be viewed as response to what he heard. The customer morally ―wrong‖ by our legal system and ate the soup, began to convulse, and died society, and that this predisposition directly at his table. The waiter was accused of results from damage to this particular area murder. of the brain (Koenigs et al., 2007). Initially used as a means of Although you believe that the identifying damaged brain regions and in waiter should be found guilty, the defense linking specific brain areas to particular calls a key expert who presents some objective behaviors, fMRI may now be interesting neurobiological data. The employed to determine the moral perceptive accused has a lesion in a particular brain ability of an individual. Dr. Joy Hirsch, the region that regulates emotional behavior director of Columbia University‘s fMRI and morality. Now, you need to make a research program, includes this types of decision: does the damage to this region studies as the new ―Neuros‖ of modern preclude you from rendering a guilty society – including NeuroViolence, verdict? Or should the accused face the NeuroDecision-Making, and NeuroLaw. same consequences despite the fact that Increasingly, our society looks for he may have been neurobiologically explanations of more and more behaviors in predisposed to commit his crime? the structure and the function of the brain. The work of Koenigs et al., (2007) By taking a brain image of this particular illustrates that damage to the ventromedial area, researchers may conclude that there prefrontal cortex (VMPC), an area of the exists a predisposition to a lack of moral brain implicated in social emotions, results in behavior and, more disturbingly, attribute it the generation of overly utilitarian judgments to the structure of a particular region of the with regard to moral dilemmas. This brain. unusual behavior is indicated by a In their study, Koenigs et al., (2007) decreased aversion to emotionally salient, patients with an without lesions in VMPC 48 Fall 2007 were presented with hypothetical situations and those that did not. The measurement that were non-moral, moral but emotionally used to distinguish between the situations impersonal, or moral and emotionally centered on the emotional reaction to the personal. Emotionally personal moral scenarios of an independent group of ten dilemmas were either low-conflict or high- neurologically normal subjects. This is not a conflict. The researchers collected the large group of people and can hardly be responses of participants and analyzed viewed as representative. Perhaps if the them based upon whether the patients had a categorization of the situations had been VMPC lesion. They found that in high- different, the results would not have had conflict personal scenarios (which included statistical significance. raping, poisoning, and killing others,) a Furthermore, it is difficult to speak of significantly greater proportion of the VMPC statistical significance when the sample size group endorsed the action than either of patients with lesions is confined to six comparison group. subjects. A much larger sample is required These results suggest that to drawn any conclusions. In addition, the individuals with damage to the VMPC make researchers conducted neuroanatomical emotionally-charged moral judgments analysis through fMRI for the VMPC patients according to a different code than healthy but used CT data for other subjects, raising individuals. With the ease of brain imaging some issues of consistency. And the in the twenty-first century, it would be very categories of stimuli used are actually quite simple to adopt this technology to perform subjective – are low-conflict and high-conflict brain scans of suspects in crimes of an situations really the same for different emotionally personal and salient nature. people? Their statistical analysis of logistic The technology could be used in the regression and estimating equations was argument for the acquittal of these suspects strong, but although differences in VMPC because they possess a physiological activity were statistically significant, only six limitation that prevents them from making subjects were used in this study and twenty- proper moral judgments. Conversely, this one personal moral scenarios, many of technology could be used to argue for the which were highly-specific and unlikely to immediate incarceration or, at the very least, ever occur in an individual‘s life. More monitoring of people found to have damage appropriate and relevant scenarios would to this particular brain region. The results of have enhanced the study significantly. If this study could also be applied to testing these data were ever to be applied on the qualifications for law enforcement officers, larger scale discussed in this paper, civil servants, and members of the armed mapping would need to be done on forces, as these individuals must not be scenarios judged to be germane to the morally incapacitated when it comes to specific case. making sound judgments upon which millions of lives rest. Ethical Issues This study cleverly demonstrates the influence of the VMPC in mediating The main ethical issue that results moral decisions using MRI technology and from this study is the propriety of using self-report of subjects‘ reactions to different imaging technology in a way in which an scenarios. Still, the significant findings hinge individual can be implicated or exonerated. on the distinction between those decisions The fact that certain brain activities correlate that constituted having personal significance with certain types of behavior is well known. Columbia University Journal of Bioethics 49
This research indicates that a specific area action to which they are predisposed. This is involved in a particular type of morality has both positive and negative and, presumably, damage to or poor consequences – our justice system would development of this region will compromise be more objective in only punishing those the ability to engage in that type of moral individuals who engage in violent actions to decision making. While previous studies which they are not predisposed, and this have indicated that the prefrontal cortex and increases fairness by not punishing limbic system are implicated in utilitarian individuals who are not in control of their thinking, this work specifically predicts that actions. But if they don‘t have control over utilitarian ideals will be pursued even if that violent actions, what is to be done with pursuit requires a high-conflict, emotionally individuals with damage to the VMPC? If salient act. Thus, murder, rape, and acquitted, they are likely to engage in such violence may be viewed as reasonable activities again. But if institutionalized, it is means to a perceived noble end; as long as unlikely that they will ever be able to live the goal benefits more people than its normal lives. They will have to live with the pursuit hurts, damage to the VMPC makes stigma of being VMPC-damaged, and the any action morally justifiable. knowledge of this stigma may exacerbate It is difficult to really align activation their condition. And because these of brain areas with coherent or specific individuals are otherwise unaffected by the thoughts or behaviors. Different people think damage to the VMPC, is it fair to prevent differently and behave differently in given them from living everyday lives just because situations despite the fact that they may of a predisposition to a very limited range of exhibit activity in identical brain regions. Our violent activities that would arise out of thoughts and behaviors are complex situations which they may never face? responses to the totality of inclinations and These ethical concerns describe experiences our lives afford us. Therefore, circumstances in which an individual has although the study links brain activity in the already engaged in some sort of violent VMPC with moral reasoning, we cannot be behavior. However, there are two slippery certain what the differences in actual slopes created by the application of this new thought processes are between individuals understanding of the VMPC. First, at what with or without these lesions, nor can we point do we limit the study of brain areas conclude what behaviors will result. and their implication in our actions? What if This technology brings to light the we continue to pursue the identification of shortcomings of the idea of free will in our regions that may explain all different types of actions. Can a pathological condition in immoral behavior, not just ones limited to which the VMPC is damaged absolve a specific utilitarian situations? The person from accusations of violent behavior, implications of identifying brain regions as there would be a discrete neurological attributed to the range of immoral behavior basis to that behavior? Could innate are many, as is the risk of individuals criminal behavior as a result of VMPC claiming damage to these regions to damage prevent charges from being brought exonerate them from the guilt of their against a rapist or murderer? It is possible actions. A person might claim that a to imagine a system in which individuals do difference in the shape of his prefrontal not have to serve prison time because it cortex, attributable to natural variation within would be biological or neurological populations, predisposes him to a behavior discrimination to sentence them for an even if it is not so. And if studies do not 50 Fall 2007
e-BABY: Your Source for Designer babies
By Class of 2007– Frontiers in Bioethics Dr. John D. Loike, Course Director
For around $45, high-end toymaker technologies to artificially select for non- F.A.O. Schwarz will make a life-like doll to disease based traits is unethical. your specifications. As advertised on their Parents could use genetic website, ―You can choose from skin, eye, technology to select their children‘s physical and hair color… to recreate someone you characteristics by generating a variety of know.‖ While customized dolls are an embryos and choosing one with the desired expensive luxury in the toy world, there is characteristics. Applying these technologies burgeoning potential for an even pricier to select or to genetically alter physical medical technology that would allow wealthy characteristics interferes in the natural clients to design the features of their own evolution of the species and the beauty of real children. human diversity. Secondly, it reduces Modern society supports technology children to the level of toys: custom-made such as in-vitro fertilization, pre-implantation playthings to be had for a price. If we are to genetic diagnosis, and prenatal genetic have any respect for human life, we must testing as a positive way for families to avoid appreciate the wide variety of physical the transmission of debilitating genetic appearances that are prevalent across our diseases such as Tay-Sachs disease, species. Thirdly, it makes the dangerous Down‘s syndrome, and hemophilia. In such assumption that the superficial preferences cases, parental selection of children‘s of the parents will be the best for the child. genetic traits is not only moral, but should be There is no way to predict how parents will encouraged to ensure that these diseases then treat their ―product‖ and how that are not passed on. relationship will affect the child. Finally, the The issue of selecting babies with manipulation of the human genome also has genes that regulate physical characteristics, the potential to create a further stratification such as height, raises bioethical concerns. between classes. Far from unifying mankind While only 14.5% of people in the United and directing our genetic predispositions States are over six feet tall, 58% of Fortune away from disease and disability, these 500 CEO men are over six feet. Research technologies could create an unprecedented has shown that for every inch of height, a divide between social and cultural groups. person makes an additional $800 more a New technologies in the area of year in salary. Furthermore, statistics show genetic engineering are progressing rapidly that society correlates height with and could be applied to designing babies by intelligence, power, ability to provide, and altering the genetic makeup of the embryo. leadership skills – characteristics that For example, germ-line gene therapy goes undoubtedly would make many people‘s beyond pre-implantation genetic diagnosis lives better. If we were able to isolate a and involves the addition of new genes to gene for height, wouldn‘t we want to select cells so that any trait could be theoretically for it? Yet we believe the choice to apply expressed in a genetically-tailored child. In Columbia University Journal of Bioethics 51 reality, there are limitations to this fertilization has facilitated the birth of technology. The addition of new genes to millions of healthy children from couples an embryo does not necessarily mean that with infertility problems. Yet, we are any trait can be expressed since both witnessing the commercialization of this genetics and the environment influence the technology through centers that allow physical characteristics of an individual. ―customers‖ to choose sperm or egg from Parents must understand that genetic potential donors, based on the donor‘s engineering only provides a child with intelligence, physical characteristics, certain genetic propensities and not appearance, and personality. Applying all necessarily the expression of the desired these technologies to select for ―superficial‖ trait. Our genes interact in specific ways physical characteristics is dangerous and and exhibit multiple effects on an organism. immoral. In the future, when our children Genes also must be added at specific sites, ask ―Where do babies come from?‖ we and the random addition of genes may be sincerely hope the answer will not be that dangerous. As a result, using this they are ―the top of the line designer technology to eliminate the natural babies,‖ ordered with every option from the interaction of genes might elicit terrible e-BABY website. diseases or disorders that were not anticipated. Therefore, germ-line therapy should be used exclusively for treating disease. Assisted human reproduction has been highly successful, in part, because new technologies focus on aiding the disabled and treating disease. In vitro 52 Fall 2007 exist to confirm or deny this, can the person that does not mean they are not competent be held responsible? enough to be aware of societal norms and Secondly, this research forces us to modify their decisions as such. consider the possibility of the use of brain These studies do not analyze the scanning for pre-diagnosing an inclination relationship between the VMPC and other toward immorality. Could our legal system brain regions that may modify its thought devise a method that screens individuals for processes, and as such, we may not be able damage to brain regions like the VMPC and to reduce moral actions to just one area of then institutionalizes them because they the brain – they may be the result of pose a risk to those around them? It is easy interactions of global brain circuitry. Thus, to imagine organizations whose employees the evidence provided in this paper is not are often in emotionally salient, high-conflict conclusive enough to justify the idea that an situations initiating screening tests to individual‘s actions are unqualifiedly determine the compatibility of potential determined by just one region, and it workers through an analysis of neural therefore cannot be argued that these activity in certain brain regions. All of these individuals are unable to modify the are possibilities that result from the decisions made by the VMPC with a working application of the technology in this paper; it knowledge of acceptable societal norms. represents a slippery slope, at the bottom of Additionally one can argue that regardless of which are societies like those in 1984 and being able to personally feel moral emotion, Minority Report. All semblances of privacy as long as the individual has functioning and individual property would be sacrificed brain regions involved in rational thought, he in the name of society as medical records should be held responsible for his actions. are exploited for these purposes. Murder is a crime, and the law still maintains this fact, despite its possible social utility. Resolution The most straightforward resolution of the ethical dilemmas posed by this paper A possible resolution of these issues is the rejection of the technology in would be based on doctor-patient situations in which it would be used for any confidentiality and the guarantee that legal purposes. In the past, technologies medical records like those indicating that initially appeared to be detrimental to damage to brain areas associated with the survival or integrity of humanity have moral activity will not be made available to provided us with inestimably valuable potential employers or in any situation in knowledge of the functions and processes of which they are not subpoenaed in court. the human mind, brain and body. Still, legal However, a more important strongholds around such technologies are question is whether evidence from studies of required to ensure that we do not veer from brain regions that are associated with the path of knowledge. morality should be admissible in court at all. In all clinical studies, subjects are At present, individuals can be exonerated if required to give their consent that they are they demonstrate that they were not aware of the aims of the study and the competent to make an appropriate decision procedures they will undergo. But in cases at the time that they committed a crime. But like this, does the subject really know (can this situation is fundamentally different – they really know?) what the implications of individuals are predisposed to engaging in a their participation will be? It is hard to certain type of moral decision making, but predict how the public would react to Columbia University Journal of Bioethics 53 findings which demonstrate that these References individuals are lacking in moral cognition. Will brain lesions in this region or altered Hirsch J. Your conscious and unconscious brain: capacity for moral and empathetic feelings from brain to mind and beyond. Lecture, Kavli Institute of Brain Science, Columbia University, be considered a clinical condition or a 2007. W3005, Neurobiology II: Neural Circuits. disease? Can or should such a condition be cured? What will life be like for an individual Koenigs M, Young L, Adolphs R, Tranel D, with this particular brain lesion? We have to Cushman F, Hauser M, and Damasio A. Damage consider the effects that participating in to the prefrontal cortex increases utilitarian moral these studies will have on the subjects. If judgements. Nature 446: 908-911, 2007. we cannot assure participants that they will benefit from participation, we should at least Loike JD. 2007. Chapter 10: Neuroethics. be able to ensure that they will not have to Bioethics Digital Textbook, Columbia University. face any adverse responses or Mill JS. On Liberty. 1869. On Liberty. circumstances as a result. Any participants
54 Fall 2007
Silent Continent, Silent Spring: DDT as a Bioethical Obligation
By Matthew Nguyen and Michael Peluso
Southwestern Uganda is inhabited mere $3 which that is usually unaffordable by some of the most unfortunate people in by most Ugandans, can save your life from the world. Living on less than $1 a day, they malaria! struggle to survive in the face of infertile On a continent where 90% of the land, starvation, and the threat of violence one million malaria-related deaths in the from the Democratic Republic of Congo. world occur each year, remarkably little has But the biggest killer is not malnutrition, gone into combating the disease. New Congolese rebels, or even the ubiquitous technologies are not necessary to reduce HIV – it is a microscopic protozoan that the risk of malaria in Africa. Dichloro- causes malaria. News reports claimed that Diphenyl-Trichloroethane (DDT), over a Idi Amin was responsible for 500,000 deaths century old, has the potential to help in in his eight-year reign as President of alleviating this critical health issue as a cost- Uganda. During that same period it can be effective and potent way to fight mosquitoes. estimated that mosquito-borne malaria Nevertheless, DDT‘s many negative caused sixteen times— over 7 million—as associations in the West, stemming mostly many casualties worldwide. A far cry from from research and observation in the 1950s the summertime pests in the United States, and 1960s of the effects of high these infected mosquitoes in sub-Saharan concentrations of the chemical, have Africa are harbingers of death. prevented its use in places like Uganda, as Malaria is the most common donor governments and international diagnosis made at the Bwindi Community agencies have refused to fund programs in Health Centre (BCHC), the only clinic that which it plays a fundamental role. serves the Bakiga and Batwa populations in Last fall, the World Health southwestern Uganda. Malaria is the Organization announced support for a new biggest killer of patients, incurs the largest policy of indoor DDT spraying in both drug and blood costs, occupies the most epidemic and non-epidemic areas. Under laboratory time, and causes the staff to lose the guidelines, the WHO calls for spraying in days of work and family members. Yet, areas of high malaria transmission, including foreigners, mostly wealthy tourists on gorilla- in Africa. While scientists, health workers, tracking expeditions, know little of the and policymakers heralded this decision as problem. While on a hike through the a breakthrough, it does not represent a Impenetrable Forest, visitors, like myself significant change from the last 40 years of (Michael Peluso) are generally informed restrictions, as the utilization of DDT in a that using a bed net is unnecessary public health capacity was never limited because there is no risk for contracting legally. Instead, it faced financial and malaria at such a high altitude. That night, ideological obstacles. Now, the funding that one of us (MP) got bitten, and three days wealthy nations and organizations have later, diagnosed with malaria. For about $3 been resistant to provide since the 1970s, proper treatment was obtained-In Uganda, a may start to trickle in for use in areas where Columbia University Journal of Bioethics 55 governments cannot afford comprehensive the scientific and political communities of the DDT programs. We can only hope so, as West: researchers have the responsibility of the provision of DDT to the regions that continuing to study DDT and its applications, need it the most is not just a political, and the political community is obligated to economic, or social issue: it is a bioethical assist financially and administratively with one. the implementation of these programs. Bioethical debates over DDT focus According to doctors at BCHC, ―prevention on the balance between saving human lives is so much better than cure.‖ The logic is and the polluting the environment. While irrefutable: malaria is a terrible disease; Rachel Carlson‘s work (1962) provided DDT could prevent the death of millions valuable insight into the dangers of chemical cheaply, safely, and effectively. It is time to agents and their effects on wildlife, the use move beyond the perceptions of a ―Silent of DDT for public health requires far lower Spring‖ when the cries of so many dying are concentrations how much lower than for left unheeded. It seems incongruous to agricultural use. And with 500 million screen embryos to eliminate genetic infections and 1 million deaths each year disorders as done in many Western from malaria, it is hard to deny that a lack of countries when millions of people in effective DDT programs contributes to a developing countries are falling victim to a tremendous amount of avoidable human disease caused by simply improvable suffering. The WHO decision signals a environmental conditions. realization that DDT has not been used to its full potential in the developing world, even References though it was largely responsible for the eradication of malarial mosquitoes in much Carson, Rachel. Silent Spring. Boston: Houghton Mifflin Co., 1962. of the western hemisphere and Europe during the 1900s. Unlike stem cell research or cloning, DDT is not a new technology. Consequently, insufficient attention has been devoted to it. When so many lives are at stake, it is imperative to look not only to newly developed technologies, but also to older ones that may have not reached their full potential. While the WHO initiative represents a step in the right direction, simply stating support for a program is not enough to solve a problem. Countries around the world can help ensure that adequate DDT programs are instituted internationally. This obligation is held by both 56 Fall 2007
Organs for Sale
By Raymond Raad
Nearly 100,000 people in the US are gain from the exchange. Joan would get a waiting for organs to save their lives, but chance at life, which she obviously most will never get them. About 12,000 of considers more valuable than these will die in the next year alone, while $15,000. Claire would gain both an only 6,000 will get another chance at opportunity to save a life, and whatever she life. What is especially tragic is that a chooses to do with her money. This act is solution does exist - but it is banned by the not immoral for two reasons. First it is pro- federal government. life for both Joan and Claire. Joan gets an The solution is to create a market on opportunity to live longer, and Claire can use human organs. However, the National her new money on any number of Organ Transplant Act, passed in 1984 and commodities to improve her life. Second, if sponsored by Sen. Al Gore, makes it illegal these two individuals have made their for individuals to sell organs whether they choices to participate in the exchange, then come from live donors or cadavers. Thus, a respect for privacy requires that no one all organ donations must be self- gets in their ways. sacrificial. Naturally, as a result of this ban, So why do so many people consider a huge shortage of organs has developed. this immoral? Primarily due to two subtle People who needed transplants errors in moral thinking. The first should be able to pay for them as part of the is exemplified by questions like these: Why transplantation costs, and receive them at doesn't Claire just donate her kidney for the moment that they are needed. Many of free? After all, doesn't money taint the today's most morbid diseases, from end donation process? stage kidney disease to liver cancer would These questions may seem be like high blood pressure -- diseases to reasonable, but only on a superficial level. live with rather than die from. The decision to donate a kidney is a Many influential people speaking on remarkable display of virtue because this issue, including doctors and ethicists, it shows that a person values human consider such a market doable but consider life. Kidney donation also involves it to be immoral. In the face of such a moral undergoing the risks of surgery such as belief, no number of logical arguments can bleeding and infection, and a 6-week be effective, and for good reason. No recovery time. If the doctors and nurses one can accept a practical solution when it involved get paid, why should the donor requires selling one's soul. undergo all this trouble for free? Not only But is an organ market truly does Claire deserve compensation, but it is immoral? Suppose that there are two profoundly disrespectful to remove an organ people: Joan and Claire. Joan needs a from her body and not offer her anything in kidney to live and has agreed to buy one return. Compensating the donor doesn't from Claire for $15,000. Claire is in full compromise her virtues; it reinforces agreement, but would not be willing to them. A donor who is paid is likely to leave donate her kidney for free. Both stand to the surgery satisfied both with herself and Columbia University Journal of Bioethics 57 her contribution. In fact, the effect of not Claire's choices. Instead of going to college compensating the donor may be viewed as to become more successful, Claire would punishing her for her virtues -- and it may have to continue to live in poverty. In cause even the most caring of donors to contrast, an organ market would provide her regret her decision. with more opportunities to climb the Further, it is important here that we socioeconomic ladder and achieve distinguish between two questions that are happiness, while also allowing her to make a easily confused: contribution to another human life. Those who want to help the poor should stop (1) Is it right for Claire to sell her organs for opposing organ markets; the real problem is money? poverty, not the organ market. (2) Is the government justified in It is important that we challenge and punishing her if she does? dispel this popular notion of an organ market being immoral, both because it is wrong and The trouble with many anti-market because this belief has many negative positions is that they do not separate these effects. Its widespread acceptance is two questions -- and, in fact, they assume leading to tens of thousands of deaths each that the second is a corollary of the year due to organ shortages in the United first. Nothing could be further from the States alone. When our code of morality truth. Whether Claire should sell her kidney leads to death of patients, it is time that we or not, is a private autonomous decision for question this code. her to make. No one has the right to impose Thankfully there has been some his view on her. She may elicit the opinions limited progress in this area recently: several of family members, doctors, and ethicists, ethicists and doctors have become less anti- but only if she so chooses. When the market. Yet at best they are willing to government bans her from selling her concede that the buying and selling of kidney, it is imposing itself on her life and organs is "not necessarily immoral" -- hardly violating her right of privacy in a matter of a whole-hearted or whole-minded utmost importance. endorsement. If patients are going to have The second type of moral error is any chance to live, then we must make it believing that an organ market will somehow clear that an organ market is not just morally exploit the poor by forcing them to give up permissible but highly moral because it is their organs. To think about this clearly, let's the only system that is compatible with go back to our above example. This time, human life and human choice. assume that Joan is rich while Claire is a poor woman who needs the money to attend college. It very well may be an injustice that Claire is poor, but given that she is, there is nothing about this exchange that is forceful or unjust. If Claire has decided that she would rather have the college education than her kidney, then she will likely be better off after the exchange. Poor people when properly educated can make their own decisions just like everyone else. The only effect of the ban is to limit 58 Fall 2007
Does your Food Wear Designer Genes?
By Alison O’Neill and Nikki Learned
The use of biotechnology to improve the production of new red blood cells. Folate the color, taste, nutrition and production of is commonly found in leafy green vegetables food began in ancient times, when farmers as well as in citrus fruits. A typical adult first cross-bred different plant strains and should consume approximately 400 μg of realized that they could produce varieties folate per day, while pregnant and nursing with the optimal characteristics of both of the women need up to 600 μg daily. Folate original plants. Today, our knowledge about deficiency has been implicated in a variety biology and genetics is indubitably more of birth defects, as well as in anemia and advanced, and our tools to harness that even cancer. The United States currently knowledge are increasingly more requires that grain products be fortified with sophisticated, yet the two central goals of folate in order to increase intake by the bioengineering food remain the same: population, but there are no such nutrition and economics. Researchers hope requirements in most underdeveloped that by designing foods that have superior countries where many of these health nutritional value, increased resistance to conditions are prevalent. Moreover, the pesticides, and a variety of other positive addition of synthetic folic acid (the current characteristics, many health and food method of grain product fortification) has shortage problems can be alleviated. raised concerns regarding its safety. Current techniques in food bioengineering Therefore, the introduction of folate into a vary from basic hybridization of different common food product such as tomatoes crop strains to the insertion of new genes could provide benefits both here and into a plant‘s genome. Although the creation abroad. of improved food products has resulted in In order to increase the amount of many positive benefits over the years and folate in tomatoes, researchers crossed two still has great potential, there are drawbacks strains of tomatoes that had greatly to the use of technology in crop increased quantities of the precursors in the manipulation, which have possibly unethical plant‘s production of folate. The vitamin is implications. composed of one molecule each of Recently, a group of researchers at pteridine, p-aminobenzoate (PABA), and the University of Florida bioengineered a glutamate. A previous team of scientists tomato strain with up to 25 times as much engineered a tomato strain that folate as the control tomatoes. Folate, the overexpressed GTP cyclohydrase I, the anion form of folic acid, is a water-soluble B enzyme that catalyzes the first step in the vitamin that helps to produce and maintain pteridine synthesis reaction. Although levels new cells, as it is essential in the production of pteridine greatly increased, folate levels of DNA and RNA. As a result of its role in only increased 2- to 4-fold. It was cell division, folate is especially important determined that this was a result of during periods of rapid cell generation, such decreased levels of PABA and thus, a new as pregnancy. Additionally, it is essential in strain was engineered to have Columbia University Journal of Bioethics 59 overexpression of aminodeoxychorismate However, these areas are also those that synthase, which catalyzes the first step of would benefit from having increased folate in PABA synthesis. When the two strains were their diet. This raises the question of which crossed, the resulting offspring tomatoes is worse: folate insufficiency or malaria? contained over 25 times as much folate as Excess folate could interfere with other the control tomatoes. The levels of folate in drugs as well, but these would not be the tomatoes are high enough to provide identified until something goes wrong. daily folate intake for an average adult in The biofortification of foods has the less than one serving. potential to exacerbate the obesity epidemic While there are many advantages to the folate biofortification introduced by de la Garza and his research team, there are also potential downfalls relating to this specific technology and that of genetically engineering foods, in general, which need to be examined. The possibility of having the daily requirement of a vitamin or nutrient available in a single tomato, for example, can be dangerous especially if the bioforticated food product is a staple of one‘s diet. The consumption of three tomatoes would lead to three times the daily intake of folate. For the general public the consumption of excess folate proves harmless, but there are two population groups that could potentially suffer, the elderly and those on anti-malaria treatments. High levels of folate can mask the symptoms of Vitamin B12 deficiency. Considering that 20-25% of the elderly have low or borderline present in the United States. By condensing B12 stores and B12 malabsorption, the the daily requirement of vitamins and elderly have an increased risk of living with nutrients into one tomato, the motivation to undiagnosed Vitamin B12 deficiency, which eat fruits and vegetables could decrease. ultimately leads to demyelination and nerve We eat fruits and vegetables because of the cell death. (www.fda.gov/oc/history/ nutrition they provide, but if their health makinghistory/folicacid.html). Should the benefits were condensed into one fruit or elderly be confronted with that increased vegetable, would we choose to eat them? risk? Excess folate has also been shown to The future applications of this technology interfere with anti-malaria drugs, and in one could lead to fruits and vegetables that study, doubled the drugs‘ failure rate (http:// contain the daily requirement of many news.bbc.co.uk/2/hi/health/6067450.stm). If vitamins and minerals. This could the consumption of these tomatoes was detrimentally affect people‘s eating habits. It unregulated in areas such as Sub-Saharan is reasonable to hypothesize that a section Africa where malaria is a serious threat, the of the population would use these super anti-malaria treatment would be less nutritious genetically engineered foods as an effective and would lead to more deaths. excuse to eat less nutritious and higher 60 Fall 2007 calorie foods. could drastically improve health and nutrition Genetically engineered foods also in humans, does our commitment to affect the environment they are grown in as improving conditions for people supersede well as the surrounding animal population. our obligation to protect other species? While the potential for this genetically Alternatively, if the use of genetically engineered tomato to harm the soil and modified foods reduces the need for surrounding animals may seem low, a look pesticides and other products harmful to the at a past example of genetically engineered environment, should we actively pursue corn illustrates the potential dangers. In the those strains even if they have negligible case of the StarLink bioengineered corn, nutritional benefits for humans? there were studies that showed that the The second overarching ethical consumption of the corn‘s pollen by issue is whether or not people have the right monarch butterfly caterpillars led to their to know the exact content of food death (www.news.cornell.edu/releases/ purchases. It can be argued that food May99/Butterflies.bpf.html). In addition, it bioengineered for nutritional purposes is a was intended only to be used for cattle form of treatment addressing a medical consumption but was somehow leaked into condition. As an example, the new tomato the human food supply. StarLink corn, which strain could be considered a medical was only approved for animal consumption, treatment for folate deficiency, and a patient, was genetically engineered to contain a in this case the food consumer, always has gene whose protein product is toxic to moths a right to know exactly what treatment he or that destroy crops and decrease corn yield. she is receiving. Also, it is worth However, that same protein product caused acknowledging that many people simply many people who consumed traces of the have an aversion to food that is not corn to have anaphylactic allergic reactions considered ―natural.‖ Whether or not their upon ingestion. Additionally, while StarLink concerns are scientifically valid, it is corn has negative consequences for reasonable that they should have the choice butterflies, it also has positive effects on the to avoid eating something that they find environment because it reduces the need for distasteful. Additionally, there are several the pesticides that will kill the corn-devouring religious concerns associated with moths. bioengineered food. A common critique is The ethical issues associated with that manipulating the genome of plants the use of bioengineered foods can be either by transferring genes from one partitioned into two main concerns. One has species to another or simply introducing new been touched upon already in this paper: characteristics, interferes with the how do we weigh the environmental effects uniqueness of species and violates God‘s of the use of biotechnology in food handiwork. Another issue is that dietary production? As has been demonstrated, restrictions prescribed by many religions GMOs can have both positive and negative require that the practitioner be vigilant about effects on the environment, and thus it is the content of food consumed. Although essential to analyze the potential decisions such as whether or not a ramifications of the introduction of a new practicing Catholic can eat a vegetable that crop strain. The issues require us to define contains part of an animal genome on a our responsibility to other species in a Friday during Lent should obviously be left variety of ways. For example, if a new food to the observer and the Church to decide, it strain is harmful to an animal population, but is important for them to have the information Columbia University Journal of Bioethics 61 necessary to make an informed decision. of this burgeoning technology without As a solution to these complex overstepping ethical boundaries. issues, we propose an educational campaign to demystify bioengineered food References as well as the creation of a committee to create guidelines for the labeling of food Diaz de la Garza, Rocio I, et al. Folate items. The education/labeling program will biofortification of tomato fruit. PNAS, 104;4218- 4222, 2007. be modeled after the recent campaign to help the public understand the nutrition facts of their food. By combining mandatory labeling of food with an understanding of the meaning underlying the labels, people will be able to make informed decisions about what they consume based on health, personal preference, and religious persuasion. Additionally, regulations regarding the manufacture of GMOs must be put into place. Any farm producing food for human consumption, whether it engages in the production of bioengineered crops or not, must regularly test the composition of their products in order to ensure that they can accurately label their products. Essentially, the goal is to eliminate the public perception of GMOs as ―bad‖ or ―unhealthy‖ and truly help people understand the composition of substances that they ingest. Once this level of understanding is achieved, any choices that they make are wholly dependent upon their own personal preferences and free will to decide what and what not to eat. Furthermore, the creation of a database of the genetically engineered foods being produced and where they are sold is essential. This will allow healthcare practitioners to recognize possible negative effects, such as an undesirable reaction between a compound and a vaccine. If the doctor is aware that folate-enhanced tomatoes are being consumed in a particular area, for example, she can advise his patients receiving the malaria vaccine to reduce their tomato consumption. Through both education as well as careful regulation of GMOs, we can begin to reap the benefits 62 Fall 2007
Teen Obesity Operations: ―Big Concerns for Big Kids‖
By Rob Deiches and Nikki Learned
The Associated Press recently restrictive bands or staples. This creates a published an article addressing the rise in small pouch at the top of the stomach, which the frequency of teen obesity operations in receives all of the food deposited from the the United States. The article cited findings esophagus. Because the pouch is much published in a recent study prepared by smaller than the entire stomach, the researchers at the Robert Wood Johnson functional volume of the stomach is greatly Medical School in New Brunswick, N.J., and reduced. The pouch fills with food more the Cincinnati Children‘s Hospital. The quickly and encourages feeling ―full‖ more research indicated that between 1996 and quickly. In addition, a very narrow opening 2003, an estimated 2,744 children between is created at the base of the pouch, which the ages of 12 and 19 underwent some form delays the emptying of the stomach, and of obesity-related, or ―bariatric‖ surgery. The thus reduces the sensations of hunger rate almost tripled between 2000 and 2003, between meals. In other words, you eat less reaching a shocking 771 surgeries in the at mealtime and spend more time not eating final year of analysis. If adolescent surgery between meals. The net effect: you are rates continue to climb at these speeds, eating less overall and therefore lose weight. experts predict that more than 1000 In gastric bypass, an even more adolescents may undergo surgery this year. extreme procedure, the small intestine is It is important to note that the study does not address the causes of obesity, the types of surgery performed, or the severity of the obesity of patients who underwent surgery. Nonetheless, those are startling numbers - too many young people are going under the knife during what are supposed to be their healthiest years. Perhaps these statistics are not great cause for concern; perhaps these are all routine, minimally invasive procedures that do not carry great risk. Sadly, this is not the case. As it turns out, bariatric surgeries are anything but routine, fundamentally altering the way surgically cut within the duodenum, the the body processes and metabolizes intestinal segment which normally is the first ingested food. There are two main types of to receive digested food from the stomach bariatric surgeries: banding, or stapling and is responsible for the majority of nutrient procedures, and gastric bypass. In banding absorption into the body. Surgeons then procedures, the stomach is partitioned into create another volume-restricting pouch two smaller sections via the installation of from the stomach tissue, and create a Columbia University Journal of Bioethics 63 functional pathway from the pouch to the shortened small intestine, thus bypassing a portion of the duodenum, and reducing overall nutrient absorption by an amount proportional to the amount of bypassed duodenum tissue. Here, physicians literally impair the body‘s ability to absorb fuel, so it becomes substantially easier to encourage your body to break down its fat stores for energy. As might be expected, both of these procedures involve significant risks and side effects including infection, hemorrhaging and other common risks associated with abdominal surgery, like leakage of corrosive digestive fluids into the abdominal cavity and nutritional deficiencies. It‘s not all bad news though: almost all of the aforementioned surgeries go well, with mortality rates of zero for the government has largely overlooked in children, and 0.2% for adults. Rates of medical decision-making process legislation. complication in children are also lower than Children and adolescents thus face a risk of that of adults. And it works. Bariatric exploitation by impatient parents or surgery has been shown to be the most overzealous physicians. And who is going successful way to treat obesity and promote to pay for these expensive ordeals, which fat loss. include significant operating room time, an But can we truly justify making average 3.2 day hospital stay for the decision to have our next generation adolescents, and extensive post-operative undergo major surgery so early in life? check-ups and diet and lifestyle planning These procedures are serious, life-long sessions with doctors and nurses? commitments, and are irreversible without These are tough issues to face. additional surgery. As we continue to It is important to take a step back for a embrace the quickest, easiest solutions to moment and consider the larger picture. modern medical problems for our children Bariatric surgery is certainly reserved only and ourselves, we really must make for the most extreme, morbid obesity cases significant strides in developing safe when alternative means of treatment have standards and practices, specifically for been exhausted; it is used only as a last bariatric procedures. At what point does resort measure. Also, in 2002, over 16% of surgery become a viable treatment option to American adolescents were considered overweight patients, and what roles should overweight or obese. That means there are doctors and parents play in making or hundreds of thousands of overweight kids helping to make the decision to undergo this (another issue we won‘t directly address type of surgery? Yes, the technology is here) who aren‘t getting their stomachs there, but should we use it? stapled. So really, the most important These questions are particularly question we need to answer is, why and relevant for children and adolescents, whom how are these few children getting the 64 Fall 2007 surgery reaching the point that an invasive development of the condition and it‘s never operation is the best option to treat their too early to start cultivating healthy habits. condition? Beyond that, we must take greater The general sentiment in the responsibility for our youths‘ awareness of medical community about the causes of and access to alternatives to fast food and morbid obesity is ambiguous; in the minds of video games, and make a more sincere some, the condition is the result of physical effort to be aware of the day-to-day food or mental disease, while to others, a lack of and activity choices they make. We will self-control and responsibility is the need to develop objective medical legislation underlying cause of this gratuitous body fat. that tells us in what cases surgery should While our genetic predispositions are the even be considered as a potential treatment. primary determinates of our metabolisms, Eventually, we will have to encourage an and while it is tempting to use our effort on the part of restaurants and food grandparents as genetic scapegoats for all suppliers to limit the fat and caloric content of our tendencies toward disease, it is clear of their food (no trans fats is a good start), from the ubiquitous weight loss and exercise and campaign for healthier foods in schools. product advertisements we face today that In the end, the most important our behaviors and actions can also have thing is the health, individuality, and well significant impacts on our bodies. And it being of the children. As long as we supply doesn‘t cost a dime for a child to get up and sufficient opportunity and education to go for a walk around the block. ensure that adolescents have the capability The first step in the path towards and know-how to lead healthy lives, the a satisfactory solution is to more effectively most important thing we can do is be target and educate children who are at risk supportive, emphasize positive choices, and of becoming morbidly obese about the encourage our young people to think ahead damage their physical condition is doing to when they choose what to eat, or what their bodies. As with many diseases, early activities to pursue. lifestyle changes may be the cheapest, safest, and healthiest way to prevent the Columbia University Journal of Bioethics 65 Animal Use In Medical Research: A Look at Various Religious Attitudes Toward Animal Testing
By Dana Balitzer and Laura Rusky
The ethical dilemma of using animals render animal experimentation animals for research continues to reemerge, useless. Christian anti-evolutionist/ brought to attention by various organizations creationists propose that all animals belong which question the legitimacy as well as to one category and humans to another, with necessity of using animals for research. In a little relation between them. These world where many base morality on religion, Christians cite biblical scriptures such as, these beliefs and science must meet a ―all flesh is not the same; men have one kind common ground. Many religions do not of flesh, animals have another‖(www.all- advocate the abolishment of animal creatures.org/clct/art-antest.html). They con- research, yet still demand that society clude that using animal research to further carefully consider, on a case by case basis, medical understanding is flawed because when there is a need to sacrifice animal the knowledge obtained is irrelevant to lives. helping us better understand humans. Jewish, Christian and Islamic Similar views are expressed by animal arguments regarding animal research research oppositionists from the Jewish and overlap considerably. All share the belief Islamic faiths (www.islamicconcern.com/vivi- that animals were created and are loved by section.asp and http://www.jewishveg.com/ God. Various groups interpret this belief as a schwartz/position-paper.html). reason in itself to abolish animal Yet similar arguments about the experimentation. Some Christians argue that fundamental differences between humans the teachings of Jesus mandate care for those ―weak‖ or ―lesser‖ then oneself and therefore humans have a God given responsibility to protect animals (www.all- creatures.org/clct/art-antest.html). A Muslim scholar, Al-Hafiz BA Masri, states, ―According to the spirit and the overall teachings of Islam, causing avoidable pain and suffering to the defenseless and innocent creatures of God is not justifiable under any circumstances. No advantages and no urgency in human needs would justify the kind of calculated violence which is being done these days to a n im a ls ‖ ( www.islamicconcern.com/ vivisection.asp). Many followers of Judaism and Christianity agree. Other abolitionists believe that innate differences between humans and 66 Fall 2007 and animals are used in support of animal suffering.‖ (www.fbresearch.org/education/ research. A verse from the New Testament religions.htm). Animal experimentation is not supporting this reads, ―A man is worth many expressly outlawed, but must be justified by sparrows, but not one sparrow can die a real human need. unnoticed in God‘s world.‖(www.fbre- Eastern religions are known for their search.org/education/religions.htm). Many reverence of animals. Hindus and Buddhists Christians contend that Christianity values both believe that animals have souls and the lives of humans over the lives of animals emotions, and consider the lives of all and thus if sacrificing animal lives can animals sacred. This is exemplified in the potentially save human lives, it is fact that both religions consist largely of acceptable. Some Muslims also condone vegetarian followers. A key concept of medical experimentation to support medical Buddhism is the elevation of suffering in all advances (www.islamonline.net/iol-english/ living beings. Buddhism emphasizes that dowalia/techng - 2 0 0 0 - A u g u s t - 22/ killing must only occur out of necessity, techng7.asp). Of key importance to these however different interpretations what Muslims is the intent behind research. qualifies as ―necessity‖ can lead to different Qur‘anic scholar Al Hafiz B A Masri states ethical conclusions. Buddhist bioethicist, that ―any kind of medical treatment of Damien Keown, states, "in general I see animals and experiments on them becomes little justification for experimentation on ethical and legal or unethical and illegal animals from a Buddhist perspective. If we according to the intention of the person who think animals have a right to life then it's does it.‖(www.fbresearch.org/education/ difficult to justify fatality-causing religions.htm). experiments, regardless of the benefits Jewish belief also considers human which may (or may not) follow, or the fact life to be of higher worth then animal life, that those conducting the experiments do so thereby justifying the use of animals in from the highest motives." (www.ahimsa.net/ medical research (www.jewishveg.com/ jbe/jbe043.html). schwartz/position-paper.html). Jewish law The Dalai Lama, leader of the dictates that "It is forbidden, according to the Tibetan Buddhist Sect and considered by Law of the Holy Torah, to inflict pain upon followers to be an incarnation of any living creatures. On the contrary, it is embodiment of Buddha‘s compassion, our duty to relieve the pain of any however, disagrees with these scholar‘s creatures." (www.jewishveg.com/schwartz/ interpretations. In a talk given at the Society faq_animals.html). for Neuroscience‘s annual international Proponents of animal research from convention in 2005, he said, "I encourage all three western religions state provisions the minimum use of experiments on under which the research must be animals, the absolute minimum amount of conducted. A leading Judaic scholar, Rabbi pain. Only perform highly necessary Rayner, states ―… would regard any experiments, and as little pain as possible." experimentation on animals as ethically It is his belief that animal research is a permissible provided (a) that it is done in necessity ―to bring greater benefit to a great such a way as to cause the least possible number of sentinel beings‖ (www.- suffering to the animals and (b) that there is pharyngula.org/index/weblog/comments/ real basis for the hope that such dalai_lama_at_the_society_for neuro- experimentation may lead to the saving of science/). human life or the relief of human According to the Hindu faith, the Columbia University Journal of Bioethics 67 atman or soul can be reincarnated into animals. One scholar explains how "Hindus see animals as beings like humans but with souls in different karmic form.‖ Due to the belief that souls that reside within humans and animals are of equal value, many Hindus oppose animal experimentation. Others recognize the potential benefit animal experimentation can provide to mankind. As with Buddhism, individual Hindu sects and followers often have diverging views on the balance between these karmic consequences and the value animal experimentation could provide to human life (http://www.ethnicityonline.net/ hindu_staff_issues.htm). Analysis of how animal experimentation is viewed in five major world religions, Judaism, Christianity, Islam, Buddhism, and Hinduism, reveals immense similarities in each. Great respect for animal life as well enormous value of human life is expressed in each. Animal experimentation is either expressly outlawed or tightly regulated from the perspectives of various religions. It is arguable that modern technologies have not advanced enough to entirely replace animal experimentation. However, it is important to balance the value of each study to improving the quality of human life, and to never frivolously disregard the moral implications of animal sacrifice.
68 Fall 2007
Redefining Disease
By Rob Deiches and Adil Ahmed
High-throughput chip-based matrix- part of the regulatory mechanism for blood assisted laser desorption/ionization time-of- sugar by controlling pancreatic hormone flight mass spectrometry (MALDI-TOF MS) release. Subjects who carried a specific is a technique that allows researchers to polymorphism in the GAD2 gene exhibited analyze and compare biological lower blood-sugar levels during fasting, ―in- macromolecules, such as large pieces of between-meal‖ times and had lower Body chromosomal DNA and whole protein Mass Index values, while subjects with subunits. The technology works by higher BMI values exhibited the gene less shattering a sample of molecules with a frequently (Boesgaard, TW, et al, 2007). In laser and determining the sizes of the other words, the Danish researchers found a resulting fragments by ionizing them and ―skinny‖ gene, or at the very least, a gene measuring how fast they fly toward an which seems to promote healthier body electric source. The bigger pieces move weight in its carriers. more slowly, the slower pieces more quickly, Findings like these represent the tip and a computer reads how many pieces of of the proverbial iceberg in proteomics each size show up for a given sample. research because they help bridge gaps Because bonds between different atoms between genetic information, protein have different strengths, each molecule production, and phenotype expression. In shatters in a specific way based on its years to come, scientists hope information chemical structure, and thus produces a obtained from assays like the MALDI-TOF characteristic pattern of fragment sizes. MS process will allow us to build a genetic This fragmentation data can be collected, lexicon, a roadmap which will allow physical and the resulting mass spectra can be and emotional characteristics and catalogued, allowing researchers to make a predispositions to be accurately predicted database of signature patterns which can be from genetic information, and vice-versa. used to identify unknown proteins or genes. Armed with this kind of knowledge, we could This is a fast and accurate spectral analysis screen people for disease risks to help them technique for high-throughput processes, yet take precautionary measures early on in life, sensitive and gentle enough to be used and even go so far as to screen developing effectively to look at whole proteins. embryos for genetic predispositions to Recently, scientists at the Steno diseases. The incidence of obesity, Diabetes Center in Copenhagen used diabetes, cardiovascular disease, cancer, MALDI-TOF MS to compare similarities and drug addiction, and possibly even criminal differences in genetic information from 5,857 behavior could be drastically reduced by middle-aged white subjects. They looked at filtering out ―bad seeds,‖ and making sure the GAD2 gene which codes for a protein that only the more disease-free genes are enzyme involved in the production of allowed to be passed to future generations. gamma-aminobutyric acid, a chemical But why stop at that? What if we messenger which has been shown to be were to isolate a gene for intelligence and Columbia University Journal of Bioethics 69 greater learning aptitude, or perhaps a gene to work to make themselves attractive to for sexual preference, or athletic ability? potential mates, given that they would be Why could we not screen embryos for the able to choose the characteristics of their presence of these genes as well, ensuring offspring anyway? What effects might that that all members of the next generation will have for certain industries, like those for have the ―strongest‖ possible genetic perfume or designer clothing, and for social predisposition? This potential future is not institutions like dating and marriage? Would pure science fiction; it is likely that one day parents feel the same connection with their we will be able to screen embyos for children, knowing that they did not share all predispositions to all sorts of phenotypes, of the same genetic information? What and perhaps even add or subtract desired would this do to the institutions of family and genes. Humanity has already witnessed lineage? analogous scenarios in our domestication of These questions are interesting, but plants and animals, through which we have the answers are unclear. We can be sure, unknowingly selected specific genes to however, that society would face significant design the most successful profile. We have practical issues upon the introduction of also already made significant strides in human genetic engineering. For instance, human genetic screening processes. how would the non-engineered‘s relative Researchers can now perform genetic physical ―shortcomings‖ affect daily life? screening to measure susceptibility to Consider this example: there are currently approximately 1400 different diseases, about 1 million public school students in many of which can be detected during the New York City, each of whom falls prenatal or even pre-pregnancy periods somewhere in a wide spectrum of (www.genetests.org). It is important to think intellectual ability (http://schools.nyc.gov/ about what a society capable of such offices/stats/default.htm). The standard pub- science will look like - we may be able to lic school curriculum is a compromise literally build a genetically superior human between limited resources and a need to be being, taking the best genes we as a appropriate for the majority of students. species have to offer and combining them to What might happen if, over the course of a create the most successful child, with the few years, genetically engineered students, greatest possible potential. In other words, with much stronger intellectual abilities, we might be able to perform ―rational‖ suddenly became a majority in classrooms? selection, and shorten the Darwinian time The old curriculum would not allow these frame from hundreds of years to only a few students to achieve their potential, and it generations. would likely be made more advanced to Certainly, this technology would accommodate the new ―average student.‖ raise many religious and moral questions, This new curriculum, however, would now like what would it mean to be human if we be too advanced for many non-engineered were able to change ourselves at will, or, students, and thus more students would given that many people believe humans struggle. New classes might have to be were made in the image of God, is it right to developed just for these struggling students, tamper with God‘s design? Let us assume, providing a greater strain on resources, and however, for the sake of discussion, that these students might find themselves public opinion permitted the use of human labeled as ―learning impaired‖ in relation to genetic engineering. What would society their more capable, engineered peers. look like? Would people feel less obligated Another case: in New Jersey, the 70 Fall 2007 current minimum vision score one can have change accordingly. Eventually, today‘s to still be legally permitted to operate a car is definition of normal might become 20/50 vision in at least one eye with or with- tomorrow‘s description of disease. out corrective lenses (www.state.nj.us/mvc/ It is interesting to consider the Licenses/VisionTest.htm). This standard emotions individuals would experience in was developed as a safe compromise the wake of these altered definitions of between statistical factors such as the disease. Would the non-engineered feel average drivers‘ reaction times, speed limits, proud of their ―natural‖ origins, or would they and vehicle braking distances. What would feel inferior to their engineered peers, and happen if, over a few decades, the majority feel compelled to adopt pharmaceutical or of drivers suddenly became genetically technological enhancements, just to keep engineered individuals with nearly up? What might be the psychological instantaneous reaction times, and 20/10 or effects of such a practice? A paper sheds 20/5 vision capabilities? Speed limits would some light on this question in its analysis of likely increase, and the minimum vision the psychological and stigmatizing effects of score would change accordingly, perhaps antipsychotic medication for people with dropping to 20/30 or maybe even 20/20. mental illness. Citing extensive survey data, Suddenly, many people who used to be the report found that patients who took considered healthy might be considered antipsychotic drugs as treatment for handicapped, as society makes schizophrenia felt significantly more accommodations for new needs and stigmatized than patients who suffered from characteristics of the average driver. diabetes and took corrective medication In each of these scenarios, how (Sajatovic et al., 2007). Nearly half of the should those unable to meet the new social subject pool reported aversion specifically to benchmarks be accommodated? Should the medication because it invited more they be encouraged to seek pharmaceutical frequent criticism from family and friends, or prosthetic enhancements? Who would and also often correlated with a devaluation pay for those procedures? Should the social of the patient and the patient‗s family. It is benchmarks remain at their original levels clear from studies like these that having to and should efficiency be reduced, just to rely on treatments just to maintain normal accommodate the less capable? In other, social competencies can be extraordinarily more extreme circumstances, would the non challenging. In an analysis of the social -engineered be entitled to disability benefits? value of genetic enhancement technology, it Cases like this raise a significant question: will be important to consider the less how would the condition of the genetic obvious personal and emotional costs such ―underclass‖ differ from many of the disabled a technology would introduce. and diseased states we have defined in If our understanding of human today‘s society, like ADD, myopia, or mental biology ever does reach the point where retardation? These diseases are often human beings can be literally designed, can characterized through a relative comparison, the technology be introduced in a way that in that the afflicted individuals have a lower will prevent genetic class stratification, and average potential for productivity in society thus will not require a thorough revision of than the average healthy citizen. Thus, if certain social institutions? We believe it the average citizen becomes more can, but the process will require significant productive and more capable, the collaboration between policymakers and benchmarks for these diseases must scientists. We will need to develop Columbia University Journal of Bioethics 71 extremely strict regulatory guidelines References explaining what kinds of genetic screens and manipulations can be performed. The Boesgaard, TW, et al. "A -243A-->G use of genetic replacement or engineering polymorphism upstream of the gene encoding GAD65 associates with lower levels of body technology should be limited such that only mass index and glycaemia in a population-based a small proportion of a gamete‘s DNA can sample of 5857 middle-aged White subjects." be changed. This would likely decrease the Diabetic Medicine 24: 702-706, 2007. risk of problems associated with large-scale restructuring of the genome, but more "GeneTests." University of Washington. 1 May importantly, it would also prevent ability 2007 www.genetests.org. enhancement from occurring too rapidly, thus preventing significant distinction in "Licensing Tests." State of New Jersey Motor ability between the genetically engineered Vehicle Commission. New Jersey Motor Vehicle Commission. 1 May 2007 http://www.state.nj.us/ and the non-enhanced individuals in society, mvc/Licenses/VisionTest.htm. and therefore allowing many social practices to continue unchanged. In addition, in order "NYC Department of Education Statistical to prevent potential genetic profiling or Summaries." Official School Register. 31 October prejudice, individuals should only be given 2006. NYC Department of Education. <(http:// access to their own genetic information, and schools.nyc.gov/offices/stats/default.htm>. genetic screening of gametes should only be performed at the request of the donor. Sajatovic, Martha, et al. "Is antipsychotic Finally, we must educate the public about medication stigmatizing for people with mental illness?" International Review of Psychiatry, genetic engineering technology‗s strong 19:107-112, 2007. basis in natural biological processes like recombination, to ensure that humans born from engineered gametes will not need to suffer from stigma, and will be treated much the same as the non-engineered. If strong, decisive measures like these are not taken, there is a high probability that the introduction of this technology would result in too rapid development of human abilities, increased strain on public infrastructure resources, increased class stratification, and significant tensions between newly defined social groups. If we start discussing these potential problems now, we can minimize their damaging effects in the future, which will allow us to take greater advantage of the disease-fighting potential of genetic engineering technology.
72 Fall 2007
Navigating the Maize Maze: How to Avoid Toxic Corn
By Ashley Pandolfi and Alex Port
Every day, almost 16,000 people die the year 2000, over 14 million acres of from hunger-related causes (Black, et al., United States maize were treated with 2003). Biotechnology offers a solution. chemical insecticides for this major pest. Genetically modified organisms (GMOs), The corn root worm is estimated to cost the such as corn, increase productivity and maize industry in the United States one eliminate plant pests and diseases. Corn, billion dollars per year due to pesticide costs one of the GMO industry‘s principal targets, and crop damage. is vital to the global food supply and is GM foods, like MON863, have been grown commercially in over 100 countries around since the 1990s, with the principal with a combined harvest of 705 million ones being derived from plants; soybean, metric tons. It is grown primarily for its maize, canola and cottonseed oil. Such kernel, which is refined into human and alterations improve the health of the plant animal feed, medical products and industrial and potentially benefit farmers; farmers use goods. Refined maize products are fewer inputs to grow their crops, eliminating abundant internationally in processed foods the need for pesticides, herbicides, or such as breakfast cereals, dairy goods, and chemicals to prevent disease. Genetic chewing gum although around 80% of maize modifications can also increase yields, in the United States and Canada is used as increase nutritional content or raise levels or animal feed. quality of starch, proteins, or oils. GMOs are a promising step in the This is not the first time MON863 elimination of hunger, but campaigners has been tested. Before it was put on the against GMOs have said for years that market, field trials in the United States genetic modification technology is unproven indicated that MON863 was not different and potentially dangerous. Their arguments from other maize varieties in terms of have mostly gone unsubstantiated—until agronomic characteristics, aside from now. A recent study, showed that rats fed resistance to corn root worm. Additionally, on a globally available version of genetically reproductive characteristics such as pollen modified maize developed liver and kidney production, viability and dispersal were toxicity, and concluded that the particular unchanged in MON863. Gene exchange strain of GM corn, MON863, is not safe for between MON863 and maize relatives was consumption (Seralini, et al., 2007). determined to be negligible in managed MON863, the corn in question, is a ecosystems, with no potential for transfer to form of maize genetically modified to make it wild species in Canada and the United resistant to corn rootworm, Diabrotica States. virgifera, a major pest of maize in the US The MON863 transgenic maize maize-growing belt. The larvae feed on faced even tougher scrutiny before it could maize roots, causing nutrient and water be approved by the European Union. As a depletion and making harvesting difficult. In result, Monsanto conducted a 90-day rat- Columbia University Journal of Bioethics 73 feeding study that, according to the safe for consumption. However, genetically- Monsanto Company‘s claims, demonstrates modified plants that have been engineered that MON863 is safe for consumption. to produce pesticides are not subject to the Following the Monsanto study, MON863 has same rigorous toxin testing. It is generally been authorized by the European Union for assumed that the toxins produced by the use in animal feed since 2005 and for GMOs will not affect mammal consumers. human consumption since January 2006. On the contrary, the high incidence of Nevertheless, the results of the initial studies hepatorenal toxicity found in rats fed on remain contentious, and a German appeals MON863 indicates that the insecticidal court forced Monsanto to allow public toxins being produced by the altered maize access to the data. This led the Committee do, in fact, affect mammals. Long term for Independent Information and Research exposure to altered maize can cause on Genetic Engineering in Paris to toxification of the liver and kidney, which independently reassess Monsanto‘s may lead to either organ failure or tumors. findings. According to the abstract of this As such, MON863 cannot be considered study: safe for mammalian consumption until more extensive studies have been conducted. Appropriate statistics were added, such This provides an ethical dilemma, as as a multivariate analysis of the growth MON863, which may cause liver and kidney curves, and for biochemical parameters toxification, is a widely propagated strain of comparisons between GMO-treated rats maize throughout North America, New and the controls fed with an equivalent Zealand, Australia and Europe. If this normal diet, and separately with six particular strain was prohibited while further reference diets with different tests were conducted, the global supply of compositions. corn would be greatly reduced, sending the price of maize skyrocketing. In addition to The findings of this reassessment being consumed directly, corn comprises a are startling: of the rats that were fed the substantial percentage of animal feed, and altered maize, the males saw a 3.3% weight any shortage in maize would have a decrease, and females saw a 3.7% weight cascade effect on the prices and availability increase marked by hepatorenal toxicity in of meat and dairy products as well. On one both. The males were affected primarily in hand, it is unethical to knowingly feed the kidney, leading to changes in urine consumers a product that may be concentrations and weight loss indicative of carcinogenic, yet on the other hand, it is renal toxicity. Females were primarily unethical to create a global food shortage affected in the liver, and showed decreased simply because a strain may be dangerous. plasma protein levels in comparison with Additionally, the dilemma is double edged: control females. GM corn allows for increased production Unsurprisingly, the liver and the that directly benefits the poorest consumers, kidney, the main organs of detoxification, conversely any action taken regarding the were disrupted by consumption of the GMO- saleability of such maize will directly affect maize. The transgenic modification causes those lower socioeconomic strata. Wealthier the cells of the maize to produce an consumers can afford to purchase more insecticidal toxin. Ordinarily, agricultural expensive organic foods, and will be largely pesticides are subjected to extensive toxicity unaffected by either the risk of cancer from tests in mammals before they are deemed GM products or an increase in global corn 74 Fall 2007 prices, but poorer consumers would be hit sufficient testing regulations. Until MON863 hard by both prospects. Therefore, it is can be deemed safe for consumption, no necessary to act both quickly and cautiously new MON863 corn should be planted or in order to reach a positive solution. produced. After current harvests, MON863 We therefore propose a solution that corn should be replaced with either a benign will preserve the current global corn supply variation of MON863 that has been while preventing the entrance of unhealthy adequately tested or with a non-genetically- corn to the market in the future. MON863 modified strain of corn. GM corn currently in production cannot be immediately taken off the market because of References the detrimental effect such action would have on the global corn supply. However, it Black, R., S. S. Morris, J, Bryce. "Where and is unethical to allow a potentially toxic strain Why Are 10 Million Children Dying Every Year?" The Lancet, 361;2226-2234, 2003. of corn to be used for human consumption.
As such, we recommend that MON863 corn Seralini, G.E., D. Cellier, et. al. “New Analysis of currently in production be reallocated to a Rat Feeding Study with a Genetically Modified industrial uses such as the production of Maize Reveals Signs of Hepatorenal Toxicity.‖ ethanol, cardboard, textiles, and adhesives. Archives of Environmental Contamination and Major crops of corn grown throughout the Toxicology 52:596-602, 2007. world are currently under contracts for use in particular industries such as human consumption, industrial products, or animal feed. Reorganization of these contracts would undoubtedly take time and careful examination; however, reallocation of MON863 corn to industrial uses would also save human lives by preventing human consumption of toxic corn and by saving the global food supply. Furthermore, it is also necessary to establish globally applicable mandatory testing regulations for GM foods. These regulations must be specific for different GM modifications so that GM foods such as the MON863 strain of corn are tested as pesticide-related modifications rather than under less strict general GM regulations. As the GMO industry progresses, GMO testing regulations must remain current with different avenues of genetic modification to prevent strains such as MON863 from heading to market without adequate analysis. GM foods, such as corn, are a promising step toward the elimination of hunger. Development of GMO products should be allowed to continue, under Columbia University Journal of Bioethics 75
Supplemental Section: BIOCEP Cross Cultural Education in Bioethics By Dr. John D. Loike
Under the leadership of President Lee infections (SARS, avian flu, malaria), the Bollinger, Columbia University has integration of Western and Eastern developed its global perspective, presence, medicine, medical tourism, stem cell and identity. BIOCEP is a prototype for research, abortion, public health, HIV, interscholastic cooperation designed to genetic testing, and reproductive medicine. align students with modern international BIOCEP‘s interdisciplinary workshop aims issues in the area of bioethics. In this to enrich students‘ cross-cultural educational enrichment summer workshop, awareness and analytical skills concerning Columbia University students spend two the ways different religions and cultures weeks at Mahidol University with Mahidol work to resolve complex issues in medical University students engaged in lectures, ethics. discussions, and on-site professional visits The first BIOCEP program in 2007 had 17 Columbia University students and 10 students from Mahidol University. In addition to participating in an educational program, the Columbia students served as global goodwill ambassadors for Columbia University. BIOCEP represents an ideal opportunity for students to experience bioethics and public health issues in other countries and to view, on site, the impact of diverse cultures on global public health education and delivery. The outcome of this innovative program goes beyond classical classroom-based education. It fosters experience in real-life situations, creative thinking and conflict resolution, all of which are essential components to cultivate the next generation of leaders emerging from related to the challenges of bioethics. Columbia University. This comprehensive workshop is based The following BIOCEP special on the extensive experience of Columbia supplement contains articles written in University‘s faculty in the areas of bioethics partnership between Thai and Columbia and public health education. The workshop students comparing and contrasting how focuses on how different cultures, religions, differences in Thai and American culture and governments respond to and resolve and religion influence bioethical challenges. bioethical challenges including: emerging 76 Fall 2007
Buy One Get One Free: Luxurious Resort & Your Perfect Baby
By Ashley Pandolfi and Shanshan Tang
Sitting on a beautiful beach, sipping who have the genetic makeup necessary to a coconut smoothie, you flip through a be compatible donors for a sick child. At the magazine snipping out the most same time, however, future parents could mesmerizing eyes, delicate nose and use the technology to select embryos for luscious lips. The next day, you will head off their perfect baby – whether it be a blue- to the finest medical facility in the country, eyed blondie or a stunning brunette. and for less than you would pay for a new To perform PGD, one cell is washing machine, you will walk out pregnant removed from an 8 cell embryo around three with your perfect baby. days after it is fertilized by the parents‘ egg Combining medical tourism with and sperm in the laboratory. The removal honeymoon quality vacations, Thailand is does not damage the further development of climbing the market on medical tech- the embryo, and the chosen embryo(s) can nologies, including pre-implantation genetic then be implanted into the woman for diagnosis, or PGD. Offering affordability development into a fetus. An important and highly personal service, Thailand is factor that differentiates America from enticing foreign clientele and keeping up as Thailand is the metaphysical origin of PGD technology progresses. diseases. Buddhism, the predominant Though the technique sounds religion in Thailand, has firm stances toward fascinating at first, and medical tourism genetic testing. Revolving around a principle plays an important role in Thailand‘s growing of karma, that each individual is born as a economy, the lack of limitations on PGD in being that has accumulated experiences Thailand, and in America, could be over previous lifetimes, genetically modifying dangerous. Without restrictions, tech- a fetus would be condemned. Eliminating nologies such as PGD and prenatal genetic embryos with serious conditions may be testing enable parents to make decisions frowned upon as alteration of beings with that could affect gender balance, disease poor karma, and an action against nature burdens, and genetic diversity. Thailand and the being that holds that karma. and America should regulate these Through suffering, and perhaps benevolent processes, within their unique conceptions deeds in this lifetime, the person could have of human life and disease, while maintaining been able to raise his or her karma, working certain reproductive freedoms. Using PGD, towards a better lifetime in the future – a parents can try to avoid having a child with a chance forever denied to tossed-out debilitating genetic disease such as cystic embryos. fibrosis, Duchenne muscular dystrophy, and American views on PGD are based even late-onset diseases such as in a wide array of religious influences and Alzheimer‘s Disease and breast cancer. political divisions and vary widely across One might also use PGD to screen potential America‘s diverse population. For those embryos in order to create "savior siblings" who regard human life as acquiring full Columbia University Journal of Bioethics 77 moral status at conception, the use of PGD decision of whether or not to abort their to deliberately create more embryos than child. United States law allows abortion into will ever become children is ethically the second trimester without designating problematic. This view is common amongst reasons for performing the abortion. In many followers of Christian religions and contrast, abortion is illegal in Thailand with politically conservative Americans. More exceptions on rape cases and serious health liberal Americans often argue that risks for the mother. In the last few reproductive choices are private decisions a decades, however, Thailand has embarked woman makes with her partner, their on a campaign to eliminate thalassemia, a physicians, and their faith. serious genetic disease characterized by Currently, there is significant anemia and physical abnormalities. In order support in both the United States and to reduce the rates of thalassemia, Thai Thailand for using the procedure to prevent physicians use prenatal genetic testing to implanting embryos with early onset, life- test fetuses and recommend the abortion of threatening diseases. But when it comes to affected fetuses. Pre-implantation genetic choosing children with a less debilitating testing might offer families a better option – condition, or a late-onset disease such as preventing having an affected child while Alzheimer‘s, a lack of legal regulations relieving the need to undergo an abortion in leaves clinics in both countries making case- order to do so. by-case decisions on just how far they will One of the most dividing factors go with PGD. between the two countries and what might The Thai Medical Council merely ultimately impact a family‘s decision to ―advises‖ against techniques such as PGD, undergo PGD is cost. In the United States, leaving physicians to set their own moral a round of PGD, including IVF, can cost over boundaries on case decisions. Similarly, in 15,000 dollars. This barrier to affordability, the United States, while a number of some critics fear, could make pre- medical boards recommend limiting the implantation diagnosis the first significant technique to early-onset serious diseases, step toward a genetic class divide in which many clinics will test for late-onset diseases the wealthy will become more genetically and allow sex selection. Because of U.S. pure than the poor. Whereas only the bans on federal support for embryo research wealthy Americans can afford PGD and heated political division over abortion, procedures in the United States, many PGD has developed mostly in the private Americans and Thais are more willing to pay sector where it has been free of government 4,000 to 6,000 dollars in Thailand for the regulation and oversight. Decisions about exact same procedures. By appealing to the ethical uses of PGD remain at the foreign wallets, Thailand has increased discretion of private physicians. medical tourism, offering foreigners not only When it comes to abortion, PGD PGD but also inviting beaches and the technology might actually alleviate some mouthwatering Thai cuisine during their ethical concerns. Pre-implantation genetic stay— quite a package! testing, in contrast to prenatal genetic Clearly, Thailand and America must testing, skips the need for an abortion by approach the ethics and regulation of PGD testing the embryos before they are even from their unique perspectives, incorporating implanted. In prenatal genetic testing, cultural and religious perspectives as well as already developing fetuses are tested for economics. Although economics ideally diseases leaving parents with the difficult should not play a factor in decisions about 78 Fall 2007 reproductive choices and the regulation of reproductive technologies, in reality it is References likely to have a significant impact. As a developing nation, PGD technology is new "Designer Babies." BEEP BioEthics Education Project.
Columbia University Journal of Bioethics 79
Thailand‘s government support for Family Planning
By Patcharapol (Pat) Jitramontree
In contrast to America‘s casual- everyone. Indeed, condoms were ness in addressing overpopulation through everywhere: bus stations, schools, parks, government control, Thailand has met the malls, clubs, pubs, movie theaters, and even problem head on with tremendous success. in the ever-so-prevalent traffic jams. The turning point was 1971, when the Thai Anywhere there was a crowd, there were government willingly worked with the going to be condoms. Obviously, the Population and Community Development primetime of condom distribution was on Association (PDA), the largest non- holidays. For example, cops were given governmental organization of Thailand, in boxes of condoms to hand out on New carrying out a national population policy. Year‘s Eve during the world famous Within 15 years, Thailand lowered the total campaign called the Cops and Rubbers fertility rate (TFR) of 3.2, (which is Campaign (ibid). considerably high in comparison to the Apart from the promotion for replacement rate of 2.1) to a significantly condom use, the government wisely lower rate of 1.6 (Frazer, 1996). introduced other forms of contraception, Furthermore, subsequent outcomes were and, more importantly, made them doubling per capita income and achieving accessible to the public, including the poor, economic security amongst individual who make up the majority of the Thai families, therefore improving Thai‘s quality of population. For example, Thailand was the life (ibid). first to allow the injectable contraception The Thai government achieved Depo-Provera (DMPA) and remains the success in family planning by doing two world‘s largest user. Operating room nurses things: promoting use of contraception and were trained to do simplified methods of incorporating economic development with female sterilization (Africa, 2000). Non- family planning. scalpel vasectomies were available free of If one could describe Thailand‘s charge at various festivals as well as on the contraceptive campaign with three words, King‘s birthday, in an effort to instill the they would most likely be hilarious, perception of contraception as a celebratory provocative, and effective. The campaign trend. In other words, contraception was was led by the famous former economist promoted as something everyone was and public relations mastermind Meechai getting into for the good of it, like the Viravaidya. Meechai took public education of introduction of the iPod. contraception to the limits, with programs In fact, sterilization, even more than such as the condom balloon blowing condoms, has become the main contest, whereby local authorities competed contraception used by Thais. Also, use of in popping condom balloons by blowing contraception amongst married couples them up. Once the people were more aware incredibly increased from 15 to 70 percent of condoms and their benefits, Meechai by 1996 (Frazer, 1996). Given the success made sure condoms were available to of family planning in Thailand, the same 80 Fall 2007 result could not be achieved if America were ‗produce workers‘ by having more children to adopt the same family planning program. without consideration of the feasibility of This is because Thailand‘s strategy is supporting the family size. One of the unique to its own problems, which are challenges was changing this perspective by completely different from America in many providing alternative income sources. The aspects. For example, the underlying story Thai government came up with a creative behind the success in Thailand was the animal loaning program reducing debt and integration of family planning with social poverty amongst farmers. Instead of leaving economics. By doing so, the government farmers with no choice other than borrowing made it clear that they were not coercing money from high interest local money Thais to have fewer children. They were lenders who were relentless in tiding them encouraging families to prepare adequately through, the government and the PDA for desired family size. The Thai government provided them with this alternative whereby launched several programs along with the they borrowed ‗workers‘ (animals) and promotion for use of contraception, which returned them, while keeping their profits. In another program, priority of giving out large amounts of loans was given to families who practiced family planning. ―Members of the loan fund received shares and dividends on the basis of the contraceptive method used; more effective methods had higher values. As the level of contraceptive prevalence within a village increased, so did the total amount of the loan fund‖ (Frazer, 1996). These two loan systems helped relieve the burden of debt, and thus reduced the feeling of need to have many children to help them work to increase profits. One ethical concern of population control arises within its general concept of were aimed to improve families‘ economic restricting individual rights versus protecting development as a part of the family planning the community. From a Thai‘s perspective, program. the government‘s national population policy There is a famous preaching for was very appropriate considering the socio- Thais which is ―Thailand‘s backbone is rice economical impact overpopulation would farmers.‖ This teaches Thais to value food have on a developing country such as and, more relevantly, to respect Thailand. Thais dutifully sacrificed individual poor farmers regardless of their wealth. rights for the good of the community, Indeed, Thailand‘s main support seems to perhaps due to an increased understanding be rice farmers as they make up 80% of the of the economical impacts of having too Thai population (Overpopulation, 2007). many children. The government‘s strategy to Amongst farming families, it was understood influence motives for family planning with that the more farmer hands they had, the economic incentives is distinctively milder more the families could produce crops and than China‘s One Child Policy (International, therefore make, and possibly even increase, 2002). Thai people were ‗highly profit. Thus, farmers felt the need to recommended‘ to consider family planning, Columbia University Journal of Bioethics 81 but not coerced by any means. Buddhists, differently. Furthermore, the implications of who make up over 90% of the population an overpopulation problem are much more (Overpopulation, 2007), had no problems amplified in the perception of a developing with the new idea. Besides, a Buddhist nation like Thailand as opposed to a scripture says, having ―many children makes developed country such as the United you poor.‖ Contraception is viewed as States. religiously acceptable as long as it does not kill an ―embodied soul,‖ which generally References refers to embryos. Sterilization has interestingly received little criticism. Africa, F. Thailand in Laws and Policies Affecting Furthermore, the government made it clear Their Reproductive Lives. Women of the World. Pg 169-204, 2000. http:// that the national population control is aimed ww.reproductiverights.org/pdf/Thailand.pdf. at tackling Thailand‘s most prevalent problem: poverty. By doing so, the Frazer, E. Thailand: A Family planning Success government made the impression that they Story. 1996. http://www.context.org/ICLIB/IC31/ were less focused on forcing families to Frazer.htm. have fewer kids, but were more concerned about making sure a family can afford and International Family Planning Programs: accommodate the family size. Many Thais Criticisms and Responses Population Matters. see the government‘s plan of incorporating 2002. http://www.rand.org/pubs/research_briefs/ RB5063/index1.html. social economics with family planning killing two birds with one stone. Therefore, there Overpopulation. From Wikipedia, the Free are really no considerable ethical violations Encyclopedia. 2007. http://en.wikipedia.org/wiki/ by the population control of Thailand. Overpopulation. I think that the fact that family planning in Thailand has worked considerably well without resistance is in itself telling of the ethical concern amongst the population on the topic. While in the United States the public may respond otherwise, Thais, 94.4% of which are Buddhists, support the policy (Overpopulation, 2007). The general explanation for this is perhaps the fact that Thailand is more of a community-oriented society than the United States, which values individual rights more. Accordingly, a national population policy is naturally perceived as acceptable to most Thais while Americans may feel 82 Fall 2007
Ethical Stances in Post-Menopausal Pregnancy
By Chatchanit (Farah) Arif
The controversial issue of post- life. menopausal pregnancy is at the fore-front of In assessing the Islamic point of bioethical debate. Ethicists in favor of post- view on post-menopausal pregnancies, it is menopausal pregnancy, as well as critics of important to discuss the Muslim concept of the idea, base their perspectives on religious purity of the child. Artificial insemination and beliefs, social sciences, and medical in vitro fertilization are allowed, only if the science. This paper specifically focuses on sperm and the egg are of the husband and the Islamic perspective on post-menopausal wife (Gatrad A., 2001). Hence, post- pregnancy and evaluates the positions of menopausal pregnancy can be practiced if both proponents and critics basing their the couple uses their own cryopreserved arguments on the social and medical embryo or, if possible, their own sperm and sciences. eggs (Gamal, 2005). It is absolutely It is essential to review the basic forbidden for any couples to use donated tenants of Islam before discussing the eggs, sperm or embryos. Since at present it viewpoints of Muslims on post-menopausal is possible to cryopreserve embryos, pregnancy. Islam is a monotheistic religion originating with the teachings of the Prophet Muhammad (Pbuh), believed to be the final prophet sent by God. Believers of Islam read and follow the word of God which is compiled in a holy book called the Qur‘an. The words and deeds of the Prophet Muhammad (Pbuh) are incorporated into an Islamic scripture called Sunnah. Together, the Qur‘an and the Sunnah are the fundamental textual sources for the Islamic faith. In this fast growing world, new technologies are being invented and implemented on a daily basis. In order to parents can decide to have another child combat issues related to the advancing later in life even if a wife is beyond methods, Ijtihad, the Islamic process of menopausal period. Nevertheless, Islamic making legal decisions by interpretation of ethics demand caring for the health of the the Qur‘an and the Sunnah, is used (Gatrad, woman. The health of the woman must be 2001). The Qur‘an, Sunnah, and Ijtihad are protected not only for her own life, but for the three main sources for Islam‘s divine the benefit of her children who need a full code of conduct called Shari‘ah, which is set of parents to guide them through their used widely in many Muslim countries mid-adolescence (Gamal, 2005). Further- (Gatrad, 2001). Shari‘ah is a sacred law for more, the decision to initiate post- Muslims and deals with all aspects of human menopausal pregnancy must be based on Columbia University Journal of Bioethics 83 many factors including: the maintenance of One of the critics against post-menopausal a child‘s genetic parentage, the pressing pregnancy is Dr. Eike-Henner Kluge who nature of the circumstances, the safety to denies the practice of assisted reproduction both mother and child and, finally, insuring in older age women. He asserts that it is that the parents will not abandon their inherent in female biological development responsibilities to their children that pre-pubescent girls and post- (Gamal, 2005). menopausal women are not able to Aside from religious perspectives, reproduce (Jennifer, 1996). Kluge realizes there are many ethical and biological that many post-menopausal women merely concerns regarding whether it is appropriate want to have a child to make up for their for old age women to use technology for the opportunity loss earlier, and that there is no purpose of reproducing beyond natural evidence showing that children of old age childbearing age. Although today the tech- parents are being harmed based on the age nologies are advanced enough to practice of parents alone. Nevertheless, Kluge points such unnatural processes, there are also out that post-menopausal pregnancy is not many ethical points of view as to how far only unsuitable biologically but it also gives they should be allowed. rise to social and moral incapacity for Ethicists in favor of post- motherhood (Jennifer, 1996). menopausal pregnancy often state that one Another argument against post- should respect the rights of women to menopausal pregnancy is that nature has decide to be a mother at any age, even past limited human beings and their capability to menopause. There should be no age reproduce (The Ethics Committee, 2004). discrimination to who can be a parent as long as she is physically and emotionally ready to do so. There are no concrete rules to what age a mother should be or to who is too old to be a mother. In Islam, proper parents should be the ones who can bring up their child in a safe environment providing enough love and care. They should be economically stable in order to raise a child in a safe and nurturing manner. How would Islam view a post- menopausal woman who requests pregnancy because she lost her only child or Practices that try to extend the limits of she never had a child before? Islam will reproduction are said to be unnatural (The support such a woman only if it is confirmed Ethics Committee, 2004). The Ethics by a doctor that she is healthy enough to Committee of the American Society for practice post-menopausal pregnancy, but a Reproductive Medicine stated that parenting mother can only do so with her own eggs needs both physical and emotional and her husband‘s sperm or their own involvement which can be stressful, and old cryopreserved embryo. If they have not met age parents might not meet the need of a the requirements, Islam would not permit growing child and might not maintain a long post-menopausal pregnancy. parental relationship. Given this point, it is There are also those who oppose true to say that there are many tasks for the idea of post-menopausal pregnancy. parents involved in raising a child; from 84 Fall 2007 getting up several times in the middle of the The Ethics Committee of the American Society night to running around and playing with for Reproductive Medicine. Oocyte donation to them when they are young. It may be postmenopausal women. Fertility and Sterility, difficult for older parents to do these tasks 82; S254-S255,2004, effectively. Although some families might have baby sitters who are ready to help take care of a child, it is not going to be a real parent-child relationship if all the major works are being done by someone else. In conclusion, post-menopausal pregnancy is a sensitive issue which has no definite conclusion to say whether it is right or wrong within Islamic law. Although this controversial issue might be considered wrong by various points of view, with valid arguments and reasons this procedure might be adaptable to a certain extent. For instance, in Islam, if the couple‘s cryopreserved embryo (or egg or sperm) is used and if the mother is physically fit to undergo the procedure, it is acceptable. Also in ethical points, if a post-menopausal mother has weighed her options and has decided to use the technology, she has a right to do so. Therefore, Islam would support the principle of autonomy allowing one‘s own personal decision in deciding what is best for oneself.
References
Anne, Z. S., & Richard J. P. Motherhood after age 50: an evaluation of parenting stress and physical functioning. Fertility and Sterility, 87;1327- 1332, 2007.
Gatrad, A. R., & Sheikh A. Medical ethics and Islam: principle and practice. BMJ , 84;72-75, 2001.
Gamal, I. S., & F.R.C.O.G., & F.R.C.S. Religious perspectives of ethical issues in ART. Middle East Fertility Society Journal, 10; 185-190, 2005.
Jennifer, A. P. A closer look at reproductive technology and postmenopausal motherhood. Canadial Medical Association, 154;1189-1191, 1996. Columbia University Journal of Bioethics 85
Bone marrow Transfer and Stem Cells
By Krysten Chin and Lulan Wang
As nature has dictated for centuries, countries that lack the resources to conduct the conception of human beings occurs their own research; however, many when the sperm from the male and the egg countries face their own ethical issues as it from the female unite within the fallopian relates specifically to their culture. The tube after the act of sexual intercourse. religious and cultural perspectives in Religion and culture have played very Thailand greatly differ from those of the important roles in providing guidelines as to United States of America. About 90% of the with whom and when people should have people living in Thailand are Buddhist and children, usually with a spouse and when therefore religion plays a large role in how they are able to take on the responsibility of the country is run and how the rules and raising a child. The increased demands for regulations are made. Although Buddhism is assisted reproductive procedures such as in an exceptionally compassionate religion, the vitro fertilization (IVF), gamete intrafallopian people of Thailand are very traditional and transfer (GIFT), and surrogacy have pushed resistant to certain changes. With the large scientists even harder to uncover more number of people in the United States, it is options in order to give hope to couples who always difficult to reach one conclusion on are infertile. It has now become feasible that ethical matters but there are many people in the near future, sperm may be created who have a liberal approach to life. Through from bone marrow stem cells. This activist organizations and numerous people information gives rise to many ethical issues willing to speak and act out for certain around the world concerning the possibility causes, the government is constantly being of children being born into many different challenged and laws are slowly but surely family situations that could be considered as changing. Even if the U.S.A and Thailand far from ‗ideal family life‘ as possible. Given have similar laws, they may have them that sperm could be created from the bone because of different reasons. marrow stem cells of either a woman or a Discoveries in bone marrow stem man, it is conceivable that there might not cell research have opened another doorway even be a need for the male to take part in in reproductive medicine. Bone marrow is the wonderful process of creating a child. the soft tissue found in the hollow interior of The fact that two women in a homosexual bones and it contains two types of stem relationship may have their own biological cells. There are hematopoietic stem cells child without the use of a donor sperm has which produce leukocytes, erythrocytes and sparked a very controversial issue. Is it blood platelets, and mesenchymal stem ethical to allow two people of the same sex cells which have the capability to to have a child using gametes formed from differentiate into many other types of cells their own bone marrow stem cells? when given sufficient and necessary The spread of medical knowledge stimulation for a specific cell type. around the world has been immensely Mesenchymal stem cells are the cells that beneficial to the smaller developing are being used in medical research. It was 86 Fall 2007 recently discovered that the germ cell couples that it would not be possible for progenitors found in bone marrow stem cells them to have a biological child between contain some genetic markers which could them without the use of a female? Lastly, be coaxed into differentiating into full fledged even if this procedure is legalized only for gametes. What is interesting is that the the use by infertile men, like every other law research so far shows that spermatozoa that is in place, wouldn‘t there be those who may be produced outside of the testis, but disobey the law and provide this procedure so far the stem cells only help to replenish for those who want it for illegal reasons? the ovaries, not create new oocytes How could the government efficiently control independently of the ovaries. What also the utilization of creating gametes from bone needs to be acknowledged is that the stem marrow stem cells? cells taken from a female‘s bone marrow In the United States of America, can only produce X-chromosome sperm, since the social movements of the gay therefore only creating female (XX) babies. community in the 1970‘s, there has been a It would be impossible for a lesbian couple very slow acceptance of the rights and to have a biological son (XY) from both equality of homosexuals. Presently there are mothers. Although the creation of only ten states that allow civil unions or functioning gametes cannot be achieved just domestic partnerships between two people yet, because it may be a reality within the of the same sex and only one state, being next decade or so, a plethora of ethical Massachusetts, which allows for marriage issues arise from the possible uses and between same-sex couples. It is even abuses of such a technology. harder for same-sex couples to adopt The ethical concerns arising from children. It is allowed only in a handful of the creation of spermatozoa to be used by states and only few more allow for the homosexual couples in the United States of adoption by one person and then the other America differ from Thailand. Of course applying for joint rights over the child after there are many advantages of ‗making‘ the adoption process is completed. This sperm such as helping infertile men to method however is extremely complicated provide sperm for the conception of their and expensive and only the most vigilant of own biological child, but there will be even couples fight for that opportunity. In vitro more ethical dilemmas that scientists, fertilization is another route that same-sex doctors, the government and the general couples take but it is still very complicated public must face when dealing with all the for both people to obtain parental rights. other possible uses of this ground breaking So in light of the many troubles that procedure. One must take into consideration homosexuals still have with equal rights for the current perspectives on the homosexual marriage and adoption, we reach the family lifestyle as it pertains to gay marriage question of if it is even ethical for same-sex and adoption, as well as the questions and couples, whether in the future they can be possible issues that the child will have to legally married or not, to be given the option deal with throughout her life. Going even of using bone marrow stem cells to produce further is the issue that only female babies a child. In the U.S.A. there are widely could be produced from a lesbian couple so varying opinions about every topic under the how fair would it be only make girl babies? sun because of the great number of people, Because a woman is unquestionably religions and region specific cultures so it needed for the conception and birth of a would not be fair to generalize what a child, wouldn‘t it create an argument by male ‗typical American‘ would say. The union of Columbia University Journal of Bioethics 87 the egg and sperm outside of the uterus like question is whether or not is any objection of in IVF does not occur naturally but it does the Buddhism against same-sex marriage? not change the fact that a man and a woman The answer is ''no.'' need to be involved for the creation of that In fact there is neither support nor child. Creating sperm from a female is denial of marriage between the same definitely out of the norm. It seems as genders. This is because Buddhism is most absurd as a male human being becoming concerned with whether an action is helpful, pregnant and giving birth! That for sure will based on good intentions, and free of harm. never happen, even if for some bizarre This differs from the positions taken by reason it becomes scientifically possible. Christian faith groups. They often evaluate a Which man in their right mind would chose specific action itself, based on whether it is to become pregnant!? Anyway, as it is good or evil according to a system of already argued that homosexuality is morality derived from that group's ‗unnatural,‘ just the introduction of such a interpretation of the Bible. Homosexuality, procedure is raising moral concerns among whether it is between men or between doctors. women, is not improper in itself. What is Since the research so far shows that improper is the use of organs already only female babies may be produced by defined as inappropriate for sexual contact. female couples and an oocyte cannot The Buddha posted himself simply as the mature without an ovary, these stem cell one who shows the way. He did not insist procedures may not be easily accepted. The that he had any right to enforce on others obvious inequality of what they should do. However the third opportunities for gay Precept of Buddhism deals with sexual couples may either misconduct, under the law of karma which is lessen the interest or being followed by greater majority in heighten the Thailand. The law of karma basically says anticipation of further that all living creatures are responsible for discoveries. For their actions and the effects of their actions, example, using syn- so if an individual committed a sin, then he thetic biology it may or she will have to repay for it in the future. be physically possible Even the Dalai Lama, who is the leader of to insert a Y- the Tibetan people and is revered by chromosome in a millions of Buddhists worldwide, sperm or develop commented "From a Buddhist point of view techniques to allow lesbian and gay sex is generally considered an oocyte to develop without an actual sexual misconduct." For all these reasons it ovary. is unlikely that Buddhists will easily approve Despite strong protests by the a law to allow gay marriage. Catholic Church in the European Union, In Thailand, the ideas of Spain has turned into the third country in the homosexual behaviors and acts are more EU that recognizes the rights of homosexual commonly accepted as a form of couples. In a Buddhist culture like Thailand, entertainment for the general public; where over 95% of the population are homosexuality has nowadays become a Buddhist, many Thai people are pondering fashion eventuating in youngsters forming whether the law could be applied in the circles at various schools and universities country as Theravada Buddhism. The fighting over their lovers of the same gender. 88 Fall 2007
In addition, many other homosexual groups References often include university graduates, office workers, and students, promote behaviours Heidi Hardman (28 Jul 2005) Stem cells in bone that may contradict conservative Buddhist marrow replenish mouse ovaries,http:// www.medicalnewstoday.com/articles/28210.php. culture and Thai traditions. This trend though has been rather exaggerated in the Jean-Pierre Predagne (n.d.)THAI FAMILY http:// media. Although the Constitution has www.thaiworldview.com/family.htm. provided same-sex groups with rights as personal rights, the Cultural Department Jessica Ruvinsky (June 28, 2007) Babies from cannot accept it and has been standing on Bone Marrow and Another potential use for stem the opposite side and would most probably cells: procreation. h t t p : / / disregard any homosexual pregnancy. discovermagazine.com/2007/jul/babies-from-bone- Thai family is about thankfulness marrow. and respect. Thus family values are especially essential in Thai ethnicity ever METTANANDO BHIKKHU, (July 13, 2005), Religion and same-sex marriage, http:// since Thailand was named. Precisely, even www.buddhistchannel.tv/index.php? the Thai language contains multiple id=00000000008,00000001429,0,0,1,0. vocabularies to show their politeness. On the other hand, homosexual marriage Somtrakul (Jun 4, 2004) Cultural Ministry Irate creates an unusual family structure which is Over Gay Civil Servants, Blaming TV Media as a unfamiliar to the Thai society. Additionally, Distributing Source. http://www.utopia-asia.com/ it‘s hard to imagine a child having parents of unews/article_2004_06_4_034037.htm. the same gender. Therefore allowing bone marrow stem cell transfer will neither create WebMD Medical News, (Oct.12, 2005), http:// www.religioustolerance.org/hom_budd.htm. a general acceptance by the public nor support from the family relatives. Studies have shown that children growing up with same-sex parents do not necessarily have differences in self-esteem, gender identity, or emotional problems from children growing up with heterosexual parents. Yet, a child raised by same-sex parents may create a different cultural burden. Conclusively, Thailand and America are culturally and ethnically very different, but when it comes to certain issues with regards to a new way of living or to a new perception of life and family, the social acceptance is slow and gradual.
Columbia University Journal of Bioethics 89
The Balancing Act: Cultural Attitudes Towards Human Embryonic Stem Cell Research
By Kathryn Vreeland and Tina Lo
Many fundamental ethical tenets embryo‘s right to life versus the needs of the span religious and cultural divides. A mother, as with abortion. There are many society must uphold the right to life for its other ethical concerns related to questions survival, for example, especially since life over the true research potential, availability can be taken away as easily as it was of alternative therapeutic options, and the created. This becomes particularly clear in potential costs and benefits to wider society. current debates over the morality of One strong argument in favor of embryonic embryonic stem cell research. Unlike stem cell research is that it is efficient. techniques for harvesting adult and umbilical Current techniques utilize embryos that have cord blood stem cells, the current process been fertilized through in-vitro fertilization for obtaining embryonic stem cells requires (IVF), but were not used and will therefore what some consider the violation of our most be frozen or destroyed. On one hand, it is basic moral precept. This article examines practical to use these leftovers for the response to an ethically ambiguous harvesting hES cells, making use of a medical advancement from two strong, yet resource that would otherwise be wasted or distinct cultures. In Thailand, Buddhism accumulate storage costs. On the other greatly influences public opinion and the hand, if society accepts this sacrifice of government‘s reserved response, while in embryos, to what degree should the creation the United States, diversity fuels action both of embryos specifically for research for and against the use and research of purposes be allowed, if at all? Furthermore, human embryonic stem cells. as scientists discover in greater detail the Globally, the stem cell debate has conditions required to utilize ES cells‘ not been confined to the scientific pluripotency, novel techniques could community. Future therapies in develop for harvesting hES cells without regenerative medicine and tissue destroying the embryo. replacement proposed by researchers, coupled with current treatments for cancers, Thai Perspective diabetes, Parkinson‘s, and genetic diseases by non-embryonic stem cells, have made Buddhism strongly influences Thai the average person aware of the vast culture and exists as a foundation for potential applications for human embryonic medical ethics, as the majority of Thai stem cells (hES cells). However, despite people practice the religion. Buddhism having ethically motivated stances on places great importance on the principle of abortion, the general population lacks a ahimsa, or non-harming. As in most nuanced scientific understanding and is religions, do not kill or cause others to suffer often unclear on the various points disputed. is an essential tenet, but it is important to Ethical concerns are not limited to the note that monks do not teach that Buddhism 90 Fall 2007 is an absolutist Council of Thai- religion with stead- land imposes fast rules. Guide- controls to lines exist for maintain medical negotiating the gray ethics. This is areas of life, and a especially true in person‘s karma is regards to g e n e r a l l y advertising for influenced by his or clinical use of her intention. Thus, a d u l t a n d it may be ac- umbilical cord ceptable for a blood stem cells scientist to kill an to treat disease embryo for the despite sufficient purpose of treating supporting data. illness, but unac- Y e t , t h e ceptable for the same person to kill the government sector has lacked in-house same embryo for selfish reasons, such as expertise for making an informed decision termination of an unwanted pregnancy. In on embryonic stem cell research. Thailand, aborting an unborn child is Consequently, the Food and Drug staunchly illegal, but not the killing of a Administration (FDA) does not recognize it fertilized egg. Abortion is permitted when and provides no standard to compare the the mother‘s health is at risk, or in the case stem cell quality and the safety of potential of rape, but society generally feels that the treatments. Dr. Suradej Hongeng, a scientist baby has the right to a traditional family and professor at Ramathibodi Hospital in upbringing. Buddhism emphasizes the Bangkok, feels that some federal stance is needs of society over personal desires, and better than none, even if it opposes another life enhances the community, while research. Without guidelines, individual abortion drains resources and mandates the scientists are hesitant to break into the field doctor and family act unethically. In this and impose personal beliefs on the larger regard, one may argue that Buddhist community. teachings embrace science for the greater good, and the Thai people should uphold American Perspective embryonic stem cell research because the controversial embryo termination is intended On June 30, 2007, in a press to be an altruistic sacrifice, not murder. release defending his veto of a bill already Although researchers in Thailand passed by the United States Congress and have slowly become involved in human House of Representatives, President Bush embryonic stem cell research, and currently stated: ―My Administration has sought to work with animal embryonic stem cells, no understand the dilemmas of stem cell government policy exists to prevent or research not as a choice between science regulate the medical community. Public and ethics, but as a challenge to advance officials recognize the potential for this medicine while meeting our solemn research, but feel it has been unveiled too obligation to defend human life.‖ Though rapidly for the ethics that mold regulations to abortion may be legal in the United States, have a chance to catch up. The Medical both pro-life and pro-choice Americans Columbia University Journal of Bioethics 91 strongly vocalize their beliefs, often centered be sacrificed, even for the greater good. around the precise point when a person Many citizens are slowly coming to should be recognized. Democracy understand and accept the importance of encourages diversity of opinion, as do stem cell research, and applaud the state of multiple religions and a plethora of cultures California for its significant financial backing. influencing citizens, so it is to be expected IVF was at first controversial, but when the that this melting pot disagree on medical technology became commercially applicable ethics. and helpful for many families, ethical Two concurrent events necessitated uneasiness diminished. Scientists argue regulation of federal funding for research that embryonic stem cell research will follow involving human embryos. In 1969, a similar path and strive to increase the scientists created life by performing the first number of experts in the field. Federal human in vitro fertilization, and in 1973, Roe support is essential not only for financial versus Wade terminated life by legalizing reasons, but also to decrease the paperwork abortion. Americans value personal created by legal issues and to generate freedom, thus a woman‘s right to make large-scale quality control. In addition, the ethical decisions governing her own body. efficacy of the few cell lines currently But with in vitro human embryos, as the available for distribution is minimal, as they entire voting population does not agree on lack broad genetic diversity and may when life begins, the government cannot deteriorate with age. force all taxpayers to support a possibly unethical practice. In 1999, the Clinton Conclusion Administration attempted to modify regulations after the National Bioethics An ethical contradiction exists in the Advisory Commission deemed it ethical to fact that abortion in Thailand is not legal, yet derive stem cells from leftover embryos for embryonic stem cell research has been research benefiting society, as spares were carried out unregulated, and comparably, consciously made during IVF, but Congress that the United States government does not would not agree to fund any research that fund embryonic stem cell research, but resulted in the destruction of a human legalized abortion over thirty years ago. embryo. And so today, as scientists extol American policy makers will continue to the wondrous potential of hES cell research strive for a balance in legislation until to change the field of medicine, Americans enough citizens favor crossing the line, most remain divided on the line between life and likely influenced by a prominent discovery, death, and federal funding is provided only and dissenters will protest until a loved one for research on hES cells derived from the can benefit from the research. Recently, the cell lines of previously destroyed embryos, Thai government created a committee of where the crucial decision has already been medical professionals to draw up regulations made. on human stem cell research and its clinical Capitalism, a tenet of American applications. They understand the demand ideology, upholds the efficiency argument for direction, and hope to formulate an that embryos leftover from IVF procedures official ethical standard in accordance with should be used for a better purpose. Some cultural beliefs to govern current and future Americans believe this to be ―ethically stem cell discoveries. Buddhism has helped permissible if not a moral imperative,‖ while many Thai people decide when, if ever, life others stand firm that no potential life should may be sacrificed, and American ethics 92 Fall 2007 support opinions as varied as the Kiatpongsan, Sorapop, Pruksananonda. population. Fundamentally, both societies "International Trends in Bioethics for ES cell agree that the value of life cannot be Research." J Med Assoc Thai Vol. 89 No. 9 compromised by technology, but pervading (2006): 1542-1544. culture influences the way in which the two Mehlman, Maxwell J. "The Ethics of Embryonic governments regulate and interpret ethical Stem Cell Research." The Doctor Will See You conduct in medicine. Globalization has Now November 2005 2 Oct 2007
Columbia University Journal of Bioethics 93
―Alternative‖ East Meets ―Conventional‖ West: The Medical Dichotomy
By Rajiv Agarwal, Sanhajutha Amnajhankij, and Zahrah Taufique
―Medicine‖ is traditionally considered scientifically provide a cure. Moreover, a to be the art of restoring the human body to second issue that arises when discussing a ―healthy‖ state, in which its practice brings the multiplicity of medicine is whether we each patient‘s condition a step closer to the should have one universal approach in order ideal, arguably Platonic, human form. Based to further galvanize international discussion on the Hippocratic definition of medicine as and collaboration on advancements within ―to do away with the sufferings of the sick the healthcare domain. It is commonly [and] to lessen the violence of their thought that having one standard practice of diseases,‖ medicine should maintain a dual medical care will most likely enable us to emphasis on curing patients of their sickness achieve universal access to medicines and and easing their corporal and mental pain will also facilitate in providing an equitable (Jones, 1981). However, upon analyzing this standard of healthcare. Yet, is this really conception from a global perspective, possible? Should we disregard cultural and differences in culture and religion tend to religious influences on the practice of introduce alternative approaches to medicine healthcare in order to establish one global which - though they may preserve art of medicine? Hippocratic standardized concepts - can First, it is important to highlight what reprioritize and shift the art‘s primary we mean by medicine driven by culture and concern from providing a cure to offering religion, as ―health is a product of social, palliative comfort. That is to say, non- economic, political, and religious social Western medical practice that is grounded structures that are themselves shaped and on religious and spiritual underpinnings constituted culturally‖ (Adams, 2004). affects not only how medicine is practiced Specifically, medical practice in Southeast but also questions the fundamental objective Asia is largely influenced by societal norms of the art itself. and Buddhist cultural foundations. In fact, As regional and cultural differences ―the Buddhist Order was very solicitous for revolutionize our understanding of medicine, the bodily health of its members and the the problem that seems to quickly surface is Buddha is reported to have said, on one whether we can trust these alternative occasion: ‗He who would care for me should methods that lack scientific proof to be care for the sick‘ (de Bary, 1972). According efficacious and beneficial for the patient. to one of the precepts of Theravada Some may argue that any modicum of Buddhism, one must always act with recovery is not due to the usage of such non mindfulness and use one‘s thoughts as a -conventional medicine but is rather the gateway to higher truths - ―a monk… [must result of the body‘s natural healing process. be] always strenuous, self-possessed, and If this is the case, one may question whether collected in mind‖ in order to achieve clarity it is even appropriate to call these non- and utter freedom to make cognitive conventional methods a subcategory of decisions (de Bary, 1972). As Buddhist ―medicine‖ since it merely provides a source monk Phra Chainarong stated: ―The goal is of psychological comfort and cannot not to control your mind, but rather to not be 94 Fall 2007 controlled by your mind.‖ Therefore, the herb can be particularly useful for treating notion of mindfulness enables one to have a specific diseases. In Thailand, the better awareness of both one‘s inner self government encourages people to learn and surroundings, and is essential for the about the value of herbs in order to utilize path to enlightenment or nirvana. In their therapeutic benefits and to preserve the conjunction with the fundamental principle to tradition of herb usage for future not harm others or oneself, the Buddhist generations. Clearly, government advocacy emphasis on mindfulness and regard for the for medicinal herbs further adds to the human being thereby contributes to legitimacy of using such non-conventional alternative non-Western medical practice in methods of treatment. Furthermore, in Southeast Asian countries. contrast to the difficulty in obtaining certain One of the most important drugs or medications, herbs such as ginger, applications of Buddhist principles to the garlic or lemon are easy to find. It is medical realm is the practice of meditation. commonly thought that ginger helps in curing Meditation allows an individual to cleanse his constipation, garlic helps in removal of or her mind of all emotional attachment, parasitic worms, and lemon helps to reduce compulsions, and inhibitions to consequently bruises and swollenness (Health arrive at a lucid state. Although meditation Department, 2001). In China, Japan and cannot rectify chemical imbalances or India, herbal remedies are composed of molecular infections, it still enables one to dried and powdered whole herbs or herb control pain levels and heightened emotions extracts in liquid or tablet forms; China even that inevitably affect one‘s mental health. considers herbs as a backbone for its The art of meditation can therefore assist in medical knowledge. While the funding for overcoming periods of depression or anxiety research on herbal medicine may not be to better an individual‘s psychological state. equivalent to that for conventional Moreover, at the Golden Jubilee Medical medications, there is still ongoing research Center in Thailand, Buddhist monks are on a number of herbs like Silybum myrtillus invited to educate patients and staff (milk thistle), Ginkgo biloba (ginkgo), and members monthly, serving as spiritual Echinacea (purple cornflower). For example, instructors to improve patients‘ mental European researchers have shown that condition. However, one may argue that Echinacea helps to stimulate the immune while this ―eastern‖ method of healing proves system by increasing the number of the to be valuable for the mind, it also threatens immune system cells and developing cells in to mislead patients into believing that they bone marrow and lymphatic tissue. are cured of their sickness due to the power Echinacea also speeds up the release of of psychological comfort. Again, this immuno-competent cells into the circulatory reemphasizes the main skepticism behind system and inhibits the enzyme the use of alternative medicine for treatment, hyaluronidase. This inhibition helps in since it seems to only improve the healing wounds by accelerating the psychological wellbeing of an individual formation of new tissue (NIH Report, 1995). without actually restoring the body to a Acupuncture is another fascinating healthier state. case study when it comes to alternative Along with the importance of medical care, as more Americans are achieving a collected mind as a source of adopting acupuncture as a valid treatment medical comfort, herbs have been used as for many of their health problems. It is medicine for nearly 60,000 years, as each unusual that people who are culturally Columbia University Journal of Bioethics 95 accustomed to depending on conventional Center by Dr. Visal Kantaratanakul, the methods of medical treatment should so basic principles of alternative medicine readily embrace this form of alternative include a primary focus on the person as a medicine; there has not been much research whole being, prevention of illness, done on acupuncture, and many of the individualized treatments, treatments that results procured from studies on this subject are aimed at the causes of illness rather still remain inconclusive, warranting further than the downstream symptoms, and most study (Carpenter, 2006). Despite the lack of importantly, treatments that are designed to scientific research about the effectiveness of support the natural healing processes of the the procedure, many people in the United human body. States view acupuncture as ―a therapeutic The exercise of a holistic approach technique which can be applied legitimately for treatment, emphasis on preventative without regard for its theoretical medicine, and reliance on natural curative justification,‖ (Yoshida,1998). In fact, most of efforts of the body itself therefore collectively the States in America have acupuncture add to the attraction of using alternative boards which serve to standardize the procedures in medicine. For this reason, it is acupuncture practice and ensure that not difficult to find signs of the popularity of patients receive treatment from practitioners alternative medicine in our society today. For who have received a certain level of training. example, the number of Yoga studios has This clearly demonstrates the acceptance of drastically increased, fashion and health this originally Chinese treatment into the magazines frequently advertise the benefits American medical system. of alternative medicine for stress relief, Thus, in spite of its lack of scientific fitness and weight control, and treatments evidence, alternative medicine – such as such as acupuncture are commonly used to that which originates from Buddhist concepts alleviate muscle aches, joint problems and – has recently gained much attention and migraines among other ailments. Even the popularity in the western world; people have growing number of people turning to organic started turning to forms of treatment such as products and herbs to improve their general yoga, massage therapy, homeopathic health indicates that the ideology behind remedies and meditation to alleviate medical most alternative medicines methods has problems, be it physical or psychological. trickled its way into our culture. In fact, Not only have people started using alternative medicine has become so alternative medicines to treat already prominent in western civilization that the existing problems, but our society has United States of America invests nearly two become cognizant of the merit in prevention million dollars each year to the National of illness as a more effective way to lead a Center for Complementary and Alternative healthy life, as Hippocrates remarked that ―it Medicine, in order to stimulate research on is necessary to inquire into the cause why the efficacy of using alternative medicines such symptoms come to men‖ in sickness (Janeviriya, 2003). (Jones, 1972). This philosophy stems But if there is no scientific evidence directly from ancient medicine and is further to support alternative medicine, then how do supported by Buddhist values, which we explain the current phenomenon of the focuses on supporting the body‘s immune increasing interest in using non-conventional system by keeping one‘s mind and body methods? Below are a few reasons that healthy throughout a person‘s life. As explain why people may prefer to use mentioned at the Golden Jubilee Medical alternative medicine over conventional 96 Fall 2007 procedures: throughout the world. Some patients are simply unsatisfied Perhaps then the original question with conventional treatment. Most people should not be whether we should disregard prefer to be responsible for their own health, cultural and religious influences on medical so they feel that alternative medicine can practice to create one universal brand of give them freedom to make decisions on healthcare, but instead why proponents for their own health. conventional ―westernized‖ medicine have Because some of the alternative so much distrust for alternative methods. methods have been practiced for thousands According to medical anthropologist of years, people maintain a high level of trust Vincanne Adams: for similar alternative treatments like Another reason culture is often acupuncture and herbal remedy. People overlooked in analyses of health equity from Southeast Asia are already stems from the materialist biases of western accustomed to the idea of the non- medical science itself. That is, western conventional medicine since they grew up medical models tend to prioritize the physical with the influence of cultural beliefs. and material contours of health and health Some patients feel that with the inequality and to treat cultural phenomena alternative treatment, there will be no as extraneous. Typically, the cultural chemical accumulation in their bodies, thus dimensions of health and healing are they feel safer to use this method. The relegated to the realm of psychology or, patients feel that alternative treatment is the more commonly, to the realm of ‗placebo‘ or simplest and most natural method of ‗belief‘. Most often these dimensions are treatment. seen as ‗ineffable‘ and external to real Given that there is no credible medical effects of pathologies (284). support of alternative medicine, one may In other words, western physicians begin to question the kind of people who who oppose alternative medicine attribute all would use these alternative methods for ―success‖ of non-conventional practices to treatment. Critics of alternative medicine the psychological comfort that patients feel may erroneously believe that only people when they ―think‖ they are cured of their who are not scientifically enlightened would illness. Advocates of western medicine use alternative medicine. But in fact, most of believe that ―even when they derive no people who use alternative medicine are objective benefits, devotees who have a educated and take a greater interest in strong psychological investment in questioning the power of conventional alternative medicine can convince medicine, especially when it does not themselves that they have been provide beneficial results for the human helped‖ (Beyerstein, 1999). Accordingly, are body. Furthermore, according to BBC news, we truly justified in valorizing ―the secular those in poor health, those who have over the religious‖ form of medicine or is this physical symptoms, with no actual physical a paradigm of our bias for westernized causes, and those who see themselves as medicine over the alternative methods of spiritual or environmental friendly also use treatment that are grounded on religious and alternative medicine. cultural principles? (Jones, 1972). Therefore, though alternative One way to resolve this problem is medicine may not have enough scientific through the use of complimentary alternative evidence to support its legitimacy, it has medicine or CAM - that is, alternative fulfilled the needs of many groups of people medicine that is integrated with western Columbia University Journal of Bioethics 97 conventional treatment to increase the to assist in the curing process, it positive effect on patients. There are only nevertheless provides a considerable source very few people who actually ignore the of mental and bodily comfort in times where conventional treatment and fully rely on the the very notion of ―falling ill‖ exacerbates a alternative treatment alone. Studies have patient‘s state of distress. shown that about 80% of people who use alternative medicine also use the References conventional medicine, and are satisfied Adams, V. ―Equity of the Ineffable: Cultural and Political with the combined effect (// Constraints on Ethnomedicine as a Health Problem in news.bbc.co.uk/2/hi/health/426005.stm). Contemporary Tibet,‖ Public Health, Ethics, and Equity. Moreover, a majority of physicians find CAM Editedby Sudhir Anand, Fabienne Peter, and Amartya acceptable as long as it is used in Sen, (New York: Oxford University Press, 2004). conjunction with traditional western medicine Beyerstein, B.L. ―Psychology and Alternative Medicine and does not act as a replacement for Social and Judgmental Biases That Make Inert conventional methods (Snyderman, 2002). Treatments Seem to Work,‖ The Scientific Rev of Thus, while alternative medicine may be Alternative Med, 3;16-29,1999. derived from cultural and religious values, its Carpenter, R. J. ―The acute effect of acupuncture on combined usage with mainstream medicine autonomic modulation‖ Columbia University Lecture, garners some level of respect and Teachers College. 2006. legitimacy. And this integrated or ―east De Bary, W.T. The Buddhist Tradition in India, China, meets west‖ form may serve as the only and Japan. (New York: Vintage Books, Random House, possible mechanism to ―globalize‖ medicine Inc. 1972). without discriminating against influences caused by culture. Health Department. สมุนไพรใช้เป็นยา[herb as medicine]. Even though the placebo effect and 2001. Sri Muang Publish: Bangkok. lack of scientific evidence contribute to the Janeviriya, N. 2003. การแพทย์ทางเลือกไปถึงไหนแล้ว. [http:www.elib dubious nature of alternative medicine, we -online.com/doctors46/general_alternative001.html. are not justified in mandating one universal medicine that favours conventional and Jones, W.H.S. ―Ancient Medicine,‖ Hippocrates with an westernized forms of treatment. Patients English Translation, 1; 12-63. (Cambridge: Harvard University Press, 1972). must still retain their ability to freely choose the method of healthcare that they are most Jones, W.H.S. ―The Art,‖ Hippocrates with an English comfortable with, regardless if different Translation, Vol.II. 190-217. (Cambridge: Harvard countries trust different medical practices; University Press, 1981). medicine should never jeopardize patient NIH Report, ―Alternative Medicine: Expanding Medicals autonomy. Therefore, as religions like Horizons.‖ (DIANE publishing company, 1995). Buddhism have affected healthcare in Southeast Asia, it is not proper to completely Snyderman, Ralph and Andrew T. Weil. ―Integrative medicine: bringing medicine back to its roots‖ Archives discount these ―non-scientific‖ and non- of Internal Medicine, Vol 162, No.4. 2002. Western methods. Instead of focusing on the conflict between western and alternative Yoshida, Motoko. ―The Conceptual Foundation of medicine, we should remember that the Physician‘s Use of Acupuncture: A study of New York State‖ Columbia University, 1998. main goal of any physician should be to improve the patients‘ condition both through cure and by comfort. And though alternative and cultural medicine has not been proven 98 Fall 2007
To Treat or Not to Treat? Cross-Cultural Perspectives on Denial of Treatment
By YoonJoo Kang and Michael Peluso
A 40-year-old Burmese man community. According to doctors at Siriraj crosses the politically unstable border Hospital in Bangkok, the well-being of this between Burma and Thailand, and makes community, which begins with the family and his way into northern Thailand. He arrives at extends to all those who interact with the a Thai clinic in the mountains presenting patient, is often taken into account by Thai symptoms such as fever, chills, night doctors when weighing their options for sweats, weight loss, chronic fatigue, and treatment. An analysis of the two blood in his sputum. A chest X-ray indicates perspectives on the above scenario brings that he has tuberculosis, but due to the to light key ideological differences between difficulty of culturing the bacterium that the cultures, providing insight into cross- causes the disease, sensitivity results may cultural inconsistencies in medical ethics. not be available for two months. To make matters worse, the clinic is running low on The American Perspective drugs and has only a two-month supply of first-line drugs—isoniazid, rifampicin, and An American perspective on issues pyrazinamide. Therefore, he will need to of treatment involving tuberculosis would return to the clinic to continue his treatment likely be rooted in the individualism of the once they run out. With the instability at the medical system and a strict interpretation of border and his need to provide for a family the Hippocratic Oath. While Thai medicine back home, the physician is unsure whether appears to focus on the effects on the the patient will ever return to the clinic again. community of treating or not treating a Should the physician supply the drugs and patient, American medicine would likely risk creating a resistant strain in his never turn a patient away. Of course, community if he does not return, or should tuberculosis prevalence in the United States the physician deny treatment and send him is incredibly low, and thus the risk of home sick, with a 50% chance of spreading any type of TB, drug resistant or succumbing to the disease? not, is substantial. In Thailand, where the While the standards of medical care prevalence of TB is, according to several in the United States and Thailand are doctors at Ramathibodi Hospital, quite comparable, the American and Thai medical widespread, it is advantageous to endeavor systems may make different determinations to focus on maintaining sensitivity in the regarding the obligation of the physician to bacteria, as widespread TB is far better and the patient and to his community. In general, easier to treat than widespread multi-drug the focus on the individual and his privacy is resistant TB (MDRTB). prevalent in the American philosophy of An ethical argument in favor of medicine, whereas the Thai philosophy, treating all cases of TB, regardless of the grounded in the principles in Buddhism, patient‘s apparent ability or inability to stresses the importance of the individual‘s complete the course of treatment, is position in relation to the broader grounded within the very act of becoming a Columbia University Journal of Bioethics 99 doctor. The unstated prescription of the prevent its development in the first place. Hippocratic Oath, ―first, do no harm‖ This is because, as mentioned before, TB is necessitates the prescription of drugs to all much easier to treat than MDRTB. Second TB patients, as an attempt must be made to line drugs needed for treating MDRTB are provide adequate medical care. It is not the expensive, and they are considered ‗orphan responsibility of the doctor to assess drugs‘ since they are off patented and face whether a patient is capable of taking the exceedingly low demand from the drugs, nor is it within his authority to deny manufacturer‘s perspective. If, by denying treatment on his own assumption that the treatment, the risk of development and patient is incapable. The spread of MDRTB can be onus falls instead on the reduced, it will be patient, who is given by favorable to do so. the doctor the resources Yes, doctors necessary for complete should not deny treatment treatment, to take based on the assumption responsibility for his own that the patient will most disease and health. probably not return. Nowhere in the Oath are However, lack of finance doctors given the responsibilities of judges – and distance from the patient‘s residence to they are merely healers who must do their the health facilities were the most common work with only the interest of the individual reasons reported by the patients for non- patient in mind. In American medicine, the adherence to treatment. Under the patient is the primary concern, and his role Hippocratic Oath, doctors are not meant to in the community is secondary. bear the burden of being judges as to The reasons for being unable to whether or not a patient should be treated; a complete treatment in the United States are doctor must simply issue the required also quite different from those in Thailand, treatment. Nevertheless, the rights and and this may explain the discrepancies in welfare of the community must be the philosophy of treatment. Since access considered as well. Should the physician, to medical care and drugs for treatment is aware of the repercussions of his actions, consistently satisfactory throughout the US, help a community to be free of malicious the most likely reason behind treatment diseases? With respect to the failure is human error on the part of the aforementioned case: the illegal immigrant physician (who could misdiagnose or carries a TB that night lead to MDRTB if he incorrectly prescribe drugs) or the patient does not complete his treatment. In this (who may make a conscious decision to situation, a typical Thai doctor would deny discontinue treatment even if the treatment the patient treatment due to his Buddhist is consistently available). teachings. Traditionally, Buddhist teachings The Thai Perspective emphasize upon the concept of karma. Karma is the idea that ones actions, which The subject of drug resistant and can be good or bad, come back to one MDRTB has been an area of growing based on his or her merit. If one does concern among epidemiologists, clinicians something with good intentions, for the and public health workers in countless greater and common good, then one does nations. The primary aim in its control is to not cause negative karma as one is thinking 100 Fall 2007 for the good of his community. Under this of karma, good intentions, and insignificance given discipline, the doctor would believe of physical death that denial of treatment is that as he is saving more people from acceptable. MDRTB by sacrificing the life of a single patient. It would be a justified course of Conclusion action. As medical practices within Thailand It is ironic that in spite of the are evolving, Thai practitioners are faced introduction of effective chemotherapy fifty with more and more ethical predicaments. years ago, tuberculosis is still capable of Generally, Thais refer to Asian medical causing as many as two million deaths a models, which are heavily influenced by year. Despite the fact that we now have a Animist, as well as Chinese Taoist and more in depth understanding of the disease, Buddhist beliefs. Historically, these models the treatment of the disease can still be were available to and performed by problematic. The right to refuse treatment Shamans and healing specialists along with and the risk poised by individuals, whose Buddhist monks. Then in the 19th century, untreated disease poses a risk to others, is Thailand was introduced to the western one of the many critical issues discussed by medical model as it came with the western many. world‘s colonization of the east. While The widespread problem of Thailand was making efforts to modernize its tuberculosis has not been addressed by the nation and avoid western imperialism, medical organizations adequately, albeit its acceptance of the western medical model magnitude. The fact that education in a became more recognized. This was society is strongly related to the health in the influenced by the involvement of Christian society must be addressed in order to come missionaries and thus, by the mid-20th up with a solution. In order for the problem century, western medicine was the dominant to be resolved, the government must medical model. develop information, education and The western model, which is based communication for the people of their on the cause and effect concept, was alien country. Along with this, the problems linked to traditional Thai beliefs. Buddhists believe with access to medical treatment must be that human beings consist of physical, eradicated. It is, however, very important to mental, emotional and spiritual elements. realize that even with the finest treatment for These four aspects are then believed to be MDRTB, the problems related to it may still linked with a person‘s external environment. persist and so the effective use of first like When one is said to be healthy, all the drugs is needed to remove the problem from forces mentioned are in harmony, whereas the root. disease suggests that disharmony prevails, averting one from living holistically. In addition, a person‘s physical body is treated as a vessel in which the spiritual elements are contained during the process of shifting from one life to another. Therefore, when a person dies, he or she does not really ‗die‘ but rather move on to another life. In other words, death is not considered to be an issue. It is in these very Buddhist concepts Columbia University Journal of Bioethics 101
Medical Tourism: The Unspoken Risk Benefit Ratio
By Jonathan Sury and Prakaikaew (Gail) Montriwat
If you could take a vacation to an Hospital, one of the leading hospitals in exotic location and come home 30 pounds Bangkok, up to 60% of patients are lighter, two bra sizes larger, and look ten foreigners (Medical Tourism, 2007). years younger, wouldn‘t you jump at the According to Cochrane (2006), Bumrungrad chance? For a fraction of the price, Hospital has treated more than 400,000 thousands of foreigners travel to countries patients coming from over 150 countries like Thailand each year to undergo popular during the past year. This unprecedented cosmetic procedures such as nose jobs, number of international patients surpasses tummy tucks and breast enhancements. any other hospital in the world (Vacation, The industry of medical tourism is 2005). In 2006, Yanhee Hospital, another expanding at a rapid pace as its appeal is institution that caters to foreigners, treated continuously glamorized. Advertisers 457 patients from the United States, making promote the concept of going abroad for the U.S. the top country of origin of medical treatments, like travel agents international patients (Sumritvanitcha, promote spring break. They prioritize the 2007). After its appeal to international affordability of the endeavour, while patients and subsequent expansion, the stressing the vacation as a bonus. While hospital was renamed Yanhee International globalization has provided a forum for Hospital (Yanhee, 2007) .Breast aug - cultural exchange, it has also facilitated the mentation, one of the most often sought out production of medical tourism. In a world procedures performed at Yanhee Hospital, where consumerism is increasingly costs $2600 U.S. dollars, whereas the same prevalent, medical care is now viewed like procedure performed in the United States an a la carte menu. would cost nearly five to ten times as much Several ethical debates exist and (Berger, 2007). Considering price alone, the many people question the legitimacy of the calculations are compelling. After factoring industry as a whole. Of concern are issues in airfare and additional vacation expenses, of health equity, economic implications, the prospects of medical tourism remain resource allocation, consumer protection favourable. It is still remarkably cheaper for and cultural maintenance. On the contrary, Americans to travel to Thailand for cosmetic however, there are various consequential surgery than to have it done at home. benefits and explanations for its validity. In Although the lower cost is a the midst of such constructive cultural persuasive incentive to choose medical exchange, medical tourism has been treatment in Thailand, the attraction also lies applauded while the relevant ethical in the additional services offered to foreign concerns are set aside. Thailand has patients, such as transportation become an exceptional destination for arrangements, private VIP rooms in hotel- foreigners in need of essential medical like atmospheres, spa-like amenities and treatments, as well as those seeking elective international cuisine (Bompey, 2006). medical procedures. At Bumrungrad Yanhee Hospital prides itself on excellent 102 Fall 2007 service, demonstrated by their high nurse to offered to foreign patients and Thai patients, patient ratio, and their Thai hospitality. the latter are not always able to pay for the Representing their institution are same procedures. The allocation and exceedingly attractive staff dressed in affordability of medical resources is elaborate attire, emphasizing the highly increasingly inequitable. Despite the valued concept of beauty. Lining almost difference in the monetary value between every wall are mirrors that accentuate flaws, the two countries, what international patients creating a sense of vanity and necessity for declare as cheap service is still considered perfection. In bathrooms, posters of before quite unaffordable to many Thai clients. and after pictures advertise what could be Many rural areas in Thailand lack easily attainable. modern medical equipment and the fewer Medical tourism is often driven by number of physicians available in these various failures in health care systems. Forty clinics are often lacking experience. As the -five million Americans are currently best doctors and medical staff are serving uninsured in the U.S, yet some of these medical tourists, their attention is diverted to people have been able to seek out an these foreigners and the quality of care to alternative route of obtaining treatments, by locals often suffers as a result. Although the engaging in cheap medical care in income generated from medical tourism is developing countries (Newsroom, 2007). ultimately beneficial, only the wealthy Thai Likewise, the impetus for the hospitals citizens and international patients who travel participating is most often determined by to Thailand for services are able to reap the their economic state. Driven by the financial benefits. This exchange further delineates crisis in the late 1990‘s, when Thai hospitals the social classes in Thailand. were in need of revenue, medical tourism Despite the primary attraction of generated substantial amounts of money for travelling to countries like Thailand for the country (Bombardieri, 2002). inexpensive medical treatments, many Bumrungrad Hospital generates 50% of the foreigners question the quality of the health hospital's revenue from foreign patients facility and the physician. Oftentimes, (Sloane, 2004). Money from international appropriate certifications are difficult to patients has provided several improvements locate. For international patients receiving for these hospitals, in both the quality of treatment overseas there is also a lack of technology and quantity of resources. The consumer protection in the sense that, for economies of countries like Thailand have covered parties, insurance will not pay for profited from such exchange; however, the these services. In the event of malpractice health care systems in countries like the suits, initiating action is complicated. ―When United States, where many of these patients considering any overseas treatment it is come from, have remained stagnant. important to understand that any legal While the industry of medical disputes concerning your care will be tourism has aided the economic system in decided in the country of treatment, not your Thailand, the provisions available to country of citizenship‖ (International, 2007). foreigners are often unattainable to the In an effort to avoid such situations, Yanhee country‘s own citizens. Prioritizing the Hospital in Bangkok offers a satisfaction interests of foreigners over its own citizens guaranteed policy whereby a second raises issues of justice and health equity. surgery is offered for free if the patient is not Although there is a two-tiered system, where fulfilled and a full refund can be obtained if a price difference exists between services the patient is still not satisfied at that time. Columbia University Journal of Bioethics 103
Yanhee Hospital boasts that they have had institution and promote their mission ―no malpractice suits from international (Sumritvanitcha, 2007). patients‖ thus far (Sumritvanitcha, 2007). Religion has continuously Bumrungrad Hospital also provides all intersected with medicine and often creates patients in Thailand a controversy. In Thailand, Buddhists believe similar protection plan in the importance of abstaining from under the Patient Bill beautification. While Buddhism is of Rights which has widespread, only a small portion of people in been enforced by the Thailand actually practice, therefore the Kingdom‘s medical presence of beauty pageants and Council (International, advertisements on cosmetic surgeries are 2007). Patients may becoming more acceptable. Cultural complain directly to the Medical Council, exchange between countries has also Ministry of Public Health and Thai Consumer facilitated and influenced their openness to Protection police, which have the power to obtaining such surgeries. revoke the licenses of offending While many opponents of medical practitioners. Now, not only Yanhee and tourism fear its implementation will have Bumrungrad hospital are being accredited adverse effects on the countries involved, for its institution but many other private the industry has been operational for many hospitals in Thailand are applying for years now. Its performance has benefited all accreditation from the Joint Commission of the players involved, by providing International, the global arm of the institution services to the uninsured, and by providing that accredits most U.S. hospitals as well income to the participating hospitals. As the (Kher, 2006). healthcare exchange continues, cultural In Thailand, beauty has become a exchange is also amplified. More and more widespread obsession, which is attainable countries all over the world have become via plastic surgery. While cosmetic surgeries involved as the vision of the endeavour were once considered taboo, current Thai becomes universally advantageous. It is culture stipulates more covert measures, by important to question whether this exchange seeking such procedures in moderation, to has an expiration date and will there be a avoid scrutiny by the mainstream society. detrimental time when health care in Yanhee Hospital is known as one of the best countries such as the United States will be hospitals for cosmetic surgery in Thailand. highly recognized as insufficient to its own They aim to live up to their motto of ―Beauty people. Not only is it important to consider can be yours at Yanhee Hospital!‖ and make such consequences that are now fracturing this promise not only to international health care systems accountability in the patients, but to Thais as well. Yanhee United States, but also punishments that hospital has continued to attract various could derive from the country providing foreigners, from all around the world. As the medical tourism itself should as well be number of foreigners has increased, Thai remarked upon. Thailand must further be people have become more open to the idea conscious of its own unjust access to health of undergoing these medical procedures care towards its own citizens before such themselves. Yanhee Hospital also promotes inequity becomes too far established in the their concept of beauty by holding an annual future. Therefore, at times tampering with beauty pageant, in order to identify an both countries medical care makes it harder appropriate person to help represent their to maintain and preserve one‘s culture with 104 Fall 2007 such prevalent exchange. For the time International Visitors. 2007. being, despite the numerous ethical issues BumrugradInternational Hospital. http:// that arise in such an endeavour, medical www.bumrungrad.com/overseas-medical-care/ tourism is considered functional and Bumrungrad-International.aspx. Kher, U., 2006. Outsourcing Your Heart. Time In seemingly beneficial. Partnership with CNN. 21 May., pp 1-5. http:// www.time.com/time/magazine/ References article/0,9171,1196429-1,00.html.
Becker, C., 2004. The Best Care Money Can Medical Tourism In Thailand. 2007. Thai Buy? Modern Health Care Magazine, Global Websites. http://www.thaiwebsites .com/medical- Care Solutions. 9 August.http:// tourism-thailand.asp. www.hospital2000.com/english/ news_modern_health_2.asp. Pricing. 2007. Yanhee International Hospital. http://www.yanhee.net/eng/srv/srv_val_btc.asp. Berger, G., 2007. Health Care Overseas – Is Medical Tourism Right For You?. Ezine Articles. Sumritvanitcha, S., 2007. Medical Tourism http://ezinearticles.com/?Health-Care-Overseas-- Lecture. Yanhee Hospital. Bangkok, Thailand. -Is-Medical-Tourism-Right-for-You?&id=711952. Sept. 10.
Bombardieri, M., 2002. A Dose Of The Good Life Vacation, Adventure And Surgery?, 2005. In Bangkok: Thai Hospitals lure ‗medical tourists‘ Elective Surgeries By World-Class Doctors At with low-cost care and hotel-like service. San Third-World Prices. MMV, CBS Worldwide Inc. Francisco Chronical. http://sfgate.com/cgi-bin/ http://www.cbsnews.com/ article.cgi?f=/chronicle/archive/2002/12/15/ stories/2005/04/21/60minutes/main689998.shtml. TR51858.DTL.
Bompey, N., 2006. Thailand Attracts Patients For Sex Changes, Other Surgery, Global Journalism. http://archive.wn.com/2006/11/22/1400/ norwayglobe/.
Cochrane, J., 2006. Asian Hotspots of Medical Tourism: (Indian, Singapore, Malaysia and Thailand). ―Medical Meccas,‖ Newsweek International.30 October., http:// www.healthmedicaltourism.org/ Resources/October_2006_Articles Asian_Hotspots_of_ Medical_Tourism%3A_%28India% 2C_Singapore 2C_Malaysia _and_Thailand%29/.
Income Stable, Poverty Up, Numbers of Americans With and Without Health Insurance Rise, Census Bureau Reports. 2007. Newsroom. U.S. Census Bureau. http:// www.census.gov/Press-Release/ www/releases/archives/ income_wealth/002484.html.
Columbia University Journal of Bioethics 105
GMOs: an International Issue
By Alisha Sachchathep and Dana Balitzer
Starfire Red™, Electric Green™, manipulating life forms. Some of these and Sunburst Orange™ sound like very ethical concerns include health issues, the exciting colors, and one would generally lack of long-term studies, and even the perceive that they were used in coloring possibility of new viral creation. Other candies, or perhaps in certain toys, or even concerns have to do with the environment, on t-shirts. However, children shopping for the unfeasibility of predicting the effects of new pets will definitely be surprised to know introducing new species, whether to label that it gets better; they can actually buy fish foods as GMOs, and the high costs of in those colors. Glofish®, a genetically GMOs because of their patents. modified organism (GMO) is gaining In Thailand, farmers do not currently popularity among customers who are grow GMOs, but the government has a captivated with the idea of having their generally optimistic impression of GMO aquarium filled with glowing fish. But is this technology. The Thai government is ethical? Are all types of GMOs ethical? currently researching many GMO projects. Where do we draw the line? In addition, local Thai stores and markets In this paper, the different ethical contain GMO products because the country concerns of GMOs are going to be does not prohibit the import of GMO analyzed, and those of the Thai and products. GMO products in Thailand mainly American population will be compared and come from China, the second largest contrasted, in order to look at the variation of producer of GMOs after the United States of viewpoints among two very different America. Hence, politically, Thailand is not cultures. against the import of GMOs, and intensive By definition, GMOs are organisms research could mean that Thailand may one that have had their genetic material altered day grow GMO crops. via recombinant DNA technology. The use In South East Asia and Thailand in of such organisms has endless possibilities particular, there are a few major GMO in fields such as pharmaceuticals, agricultural projects currently in agriculture, and medicine. Examples of development, such as the development of a GMOs include Golden rice, genetically pest and disease resistant papaya. Perhaps modified papaya, pesticide resistant plants, one of the most well known examples of insecticide sweet corn and long lasting GMOs in South East Asia is that of Golden tomatoes. Rice, which is engineered to produce beta- In many situations, GMOs have carotene for vitamin A deficiency. In turned out to be helpful and carry with them Thailand and throughout South East Asia, many different advantages, especially in the vitamin A deficiency is still a major cause for agricultural field. However, GMOs also concern. Some have noted that GMO carry with them a lot of economical, social technology is in fact not necessary to and environmental concerns . At the end of resolve this issue, as other organic crops the day, it boils down to the bioethics of such as the sweet potato have naturally high 106 Fall 2007 amounts of Vitamin A. In addition, others rights over these new species. have criticized the use of Golden Rice in a In addition to these concerns, it is country such as Thailand, where the amount very difficult to ascertain the view of the Thai of rice consumption is so high that rice public on the issue of genetically modified containing large amounts of beta-carotene organisms. When speaking of social will, can in fact result in an excess amount of one must consider that in the case of Vitamin A consumption. Thailand, a large percentage of the Thai The consequences of GMO usage population is not educated enough to be in Thailand are complex. The use of GMO concerned or aware of GMOs, including technology has the enormous potential to farmers. Although GMO crops are very increase crop production and prevalent in the markets and stores, these consequentially increase food availability products are not currently labeled. So it is throughout Asia. For example, one source hard to predict the reaction of these farmers estimated that transgenic rice can increase if the government ever starts encouraging production to up to 25 percent from current the farming of GMO crops. Among those numbers (James and Krattiger, 1999) . As who are aware of the use of GMOs, many the world‘s largest rice exporter, Thailand are apprehensive. However, the fact that could easily benefit from such increased imported GMO products, some of which are crop yields. In addition, high-nutrition crops labeled, are still being sold in local stores engineered similarly to Golden Rice could indicate that there is room in the Thai market potentially solve many public health issues for GMOs. Thai society may currently and malnutrition in Thailand. accept GMOs, but this acceptance may However, many non-government stem from an overall lack of awareness. officials and others disagree regarding how Indeed, due to the high percentage GMO technology may affect Thailand of Buddhists in Thailand, it may be very economically and politically. Thailand has a possible that the Thai public would object unique agricultural niche within the more strongly to GMO technology if there international markets as a producer of were an increased awareness. In Buddhist organic crops. It is possible that the belief, all acts must be performed out of introduction of GMO technology may in fact compassion, never greed. With these result in a loss of this economic niche. principles in mind, it is reasonable to Thailand would be forced to compete with assume that the Thai population would be international agricultural superpowers and more accepting of GMO technology if they would no longer have the same unique were convinced that its usage would have crops to offer to the markets. truly altruistic applications. However, the Even greater causes for concern in greed of large corporations and international Thailand are the issues of global justice and competitions would not be viable motivations patent rights. Due to the complex nature of in the eyes of many Buddhists. international relations and trade The political stance of America, on agreements, it is very difficult to guarantee the other hand, is totally in support of the that Thailand would indeed benefit use of GMOs, domestically, and economically from the introduction of GMO internationally. Around 65% of the products technology. Many have argued that the available in American supermarkets contain introduction of GMO crops would not benefit some amount of genetically modified poor Thai farmers, but rather the ingredients. For a government to allow such international companies who hold the patent a high percentage of a certain type of Columbia University Journal of Bioethics 107 product in its country definitely shows that it show that many Americans are actually is totally in support of that product and unaware of the level of prevalence of GM probably does not believe in the harms that food in their own markets. Funded by the so many other people are worried about. United States Department of Agriculture The government has also had a number of (USDA) under its Initiative for Future disagreements with other countries with Agriculture and Food Systems program, regards to labeling GMOs. These have been Rutgers University's Food Policy Institute mainly clashes of opinions with the EU and conducted public opinion surveys (Hallman, its member countries. Hebden, Aquino, Cuite, & Lang, 2003; Existing EU regulations require the Hallman, Hebden, Cuite, Aquino, & Lang, labeling of certain GM food products 2004) that found Americans are generally containing more than 1% of GM material. uninformed about GM food and largely This clearly shows that the EU is absolutely unaware of its presence in the food system for the labeling of any GM product and and their own diets. Fewer than half of the wants its people completely informed of the respondents in the latest Food Policy presence of any GM material in their food. Institute (Hallman et al., 2004) study realized According to a recent MORI Poll conducted that foods containing GM ingredients are April 18 - 22, 2002 and commissioned by available in supermarkets and fewer than Greenpeace UK, public opposition to GM one in three believed they had personally food is widespread in the EU. Of particular consumed GM foods. Surprisingly, results interest, 76% of respondents said the indicate that Americans are generally not labeling of all food with GM ingredients adequately informed about GM food and its should be made compulsory. The United availability within the American food States of America, on the other hand has industry. They are a population that might indicated it has concerns with the growing of heard of GMOs, might have seen some move toward such restrictions on market commercials here and there, but from a entry. Many speculate that this is probably a holistic point of view do not have a very result of concern of public fear, which would sufficient knowledge of the use of GM crops technically result in lower sales of GM in their own country. Perhaps this is another products. reason that allows such a relaxed approach On the level of social will in towards GM products within the American America, it can be easily said that society. Americans have a far more relaxed Another perspective that also has a approach towards GMOs, possibly because strong effect on the way that people think of the encouragement of their government. and act, is the religious perspective. In 1994, the first genetically modified crop, a America is a diverse country consisting of tomato, came on the market in USA. people belonging to many different faiths. Americans have consumed GMOs for the Judaism, Christianity, and Islam are the longest period of time and because there major religions of Americans of faith. In have not been any incidents that show the Christianity one can see, a lot of different scientific link between consuming GMOs views, so it is hard to draw a line that and adverse health effects, most Americans indicates exactly what the religion as a are now convinced that GMOs are safe. whole actually thinks of GMOs. With all that However, what they are forgetting is the fact said, evidence does show that, to an extent, that long term effects cannot be predicted, Christians believe that using GMOs for and must be further examined. Reports increased production was against God‘s will. 108 Fall 2007
Those were the words of Pope John Paul II. forbidden foods. For example, swine DNA in Others have tried to show through scriptures soy could make the soy product haram. This that we should not interfere with the genes issue is still the subject of some debate of life forms . For instance, in Genesis 1: among scholars and certifying organizations. "God saw that it was good…God saw Basically, except for the use of pig‘s genetic everything that God had made, and indeed, material, other forms of GM food are it was very good." Scholars argue that every accepted and consumed by Muslims without creature and species has an intrinsic value any religious concerns. and hence we need to respect their Looking at all three religions, and uniqueness and the way that they naturally keeping in mind that a lot of American breed, by not tampering with their genes. people are not strictly Christian, Jewish, or Other Christian parties still argue that the Islam, and many of them are also agnostic use of GMOs is not beyond the limit of or atheistic, this basically explains why human action. Despite the Pope‘s (year Americans have such a relaxed approach 2000) denouncement, the Catholic Church towards GMOs. officially confirmed they were not against the The use of genetically modified use of biotechnology, only advocating organisms as agricultural crops has created prudence and regulation. heated debate in almost every country which Aside from the health risks and has been exposed to the technology. As potential risks of GMO to the environment, exhibited in the relative attitudes of the Jewish law has to consider whether GMOs United States and Thailand towards GMOs, are Kosher. For thousands of years, Jews the issues reflect the cultural attitudes as have adhered to strict food laws based on well the political-economical situations of the instructions found in Bible. At the each respective country. As the world moment, many Kosher organizations are continues to develop as an international indeed certifying genetically modified food marketplace, policymakers and citizens alike as being Kosher. However, this comes with in every country must respect the cultures of many opposing viewpoints within the Jewish other nations and must consider the community as well. A lot of Jews are arguing ramifications that this technology may have that GMOs should be prohibited because of on the future. health or environmental risks. Once again it can be noticed that even within one religious References belief, it is hard to place a certain bar that strictly decides the status of GMOs. Factsheet. http://pewagbiotech.org/resources/ The next religion whose opinion factsheets/display.php3?FactsheetID=2. needs to be addressed for analyzing Hallman, W.K., Hebden, W.C., Aquino, H.L., opinions within America is Islam. So are Cuite, C.L, & Lang, J.T. (2003). Public GMOs halal? Yes, today's biotechnology perceptions of genetically modified foods: A products are approved as halal. According national study of American knowledge and to the Islamic Jurisprudence Council (IJC), opinion. New Brunswick, NJ: Food Policy foods derived from biotechnology-improved Institute, Cook College, Rutgers, The State (GMO) crops are halal - fit for consumption University of New Jersey. by Muslims. Some scholars have suggested that foods derived from biotechnology- Hallman, W.K., Hebden, W.C., Cuite, C.L., improved crops could possibly become Aquino, H.L., and Lang, J.T. (2004) Americans and GM Food: Knowledge, Opinion and Interest haram (non-halal) if they contain DNA from Columbia University Journal of Bioethics 109 in 2004. www.foodpolicyinstitute.org/docs/ reports/NationalStudy2004.pdf. GMOs Halal http://www.agbioworld.org/biotech- Globalpolicy. www.globalpolicy.org/socecon/ info/religion/index.html. trade/gmos/index.htm. Crops percentage www.greenpeace.org/raw/ EU Labeling www.thunderlake.com/gmos.html. content/international/press/reports/ge-crops- increasingly-isolat.pdf. Pope www.biotech-info.net/Pope_view.html. American unawareness www.choicesmaga Catholic church http://www.agbioworld.org/ zine.org/2005-4/GMOs/2005-4-05.htm. biotech-info/religion/catholic.html.
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