Columbia University Journal of Bioethics 1 2 Fall 2008

Columbia University Journal of Bioethics And Supplement on BIOCEP Volume VI. No 1, Fall 2008

Editorial Board Faculty Editors Editors-in-Chief Dr. John D. Loike Dr. Ruth L. Fischbach Copy Editors Soo Han Cover Design: “Entwine‖ Komal Kaothari Robyn Scheinder and Dr. John D. Loike Please send your comments to Dr. John D. Loike at: [email protected] Production & Creative Directors Robyn Scheinder Jana Bassman

Web Version is available through the undergraduate page: http://www.columbia.edu/cu/ Or through http://www.bioethicscolumbia.org/

Copyright 2008 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 Sound and the Fury By Katie O‘Neill and Wei-Jen Hsieh………………………………………………..

Majority Report: DNA Data-banking As an Opt-Out System By Emilia Javorsky and Robyn Schneider………………………………………...

Could Genetic Research Interfere with Medicine? By Jorge Jara and Joanna Etra……………………………………………….

Charging You for Being You By Elisa Fung and Gabriela Vargas………………………………………….

Section II: Stem Cells and Reproductive Medicine

Altered Nuclear Transfer: A Novel Way of Developing Pluripotent Stem Cells By Sarah Eberle and Tabby Khan………………………………………………...

Secrets and Lies: Mandating Disclosure in Oocyte Donation By Tiffany Hsieh…………………………………………………………………..

Diagnosing Disability… And Keeping It by David Yin and John Tseng……………………………………………….. Section III: Neuroethics

Programmed Free Will By Elisa Fung and Lindsay Kugler…………………………………………………..

Neuroimaging for InterGender Peace By David Yin and Kathleen O‘Neill………………………………………………….

Do You Mind If I Read Your Mind? By Adela Aguirre and Alan Daboin………………………………………………

GLBT Flies: The Application of Mind Control To Sexual Preference By Viktor Gamarnik and Shu Pan…………………………………………………..

Memory Upgrades: Not Just For Your Computer By Emilia Javorsky & Wei-Jen Hsieh………………………………………………... 4 Fall 2008

TABLE OF CONTENTS (continued)

Section IV: Contemporary Issues Say No to Blow: Preventing Cocaine Addiction through Vaccination By Soo Han and Tabby Khan

Building Athletes By Yonah Heller and Jean Pierre Rabbah

Molecular Imaging and Ultrasound-assisted Drug Delivery By Ashok Ilankovan and Andrew Arnold

Bioartificial Hearts, Bioethical Issues By Esty Rajwan and Ditty Vick

One Word: ―Synthetics‖: The Ethics of Synthetic Biology By Savino Sguera and Benjamin Stern

A Dearth of Donations By VikrumThimmappa and Jocelyn Lo

A Bun in the Oven By Jennifer Gillman, Anna Plitt and Andrew Behrens

Paying For Patient Performance Viktor Gamarnik and Ben Koo

Section V: Cross-cultural Bioethics-BioCEP Sex and Education. Can they go together? By Elizabeth Edwards, Yoon Joo Kang, and Caroline Leone

Behind Their Smiles: Cosmetic Dentistry and Medical Tourism in Thailand By Mikilena Greusel and Dr. William Bloch

The Ethical Concerns of Propranolol and Memory Dampening By Donna Taraborelli, Tasha Smith, and Siwachapol Monyakul

Finding the Middle Path to Stem Cell Nirvana By Melissa Bauer and Shanshan Tang

To breach or not to breach doctor-patient confidentiality involving children with AIDS By Risa Hoshino, Janice Liu, and Sun-Chai Waleecharoenpong

Enlightenment: Just a Pill Away! By Marlon Danilewitz, Margarita Borovka, Mariangels de Planell-Saguer 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; , 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 Ethics for Biomedical Engineers (BEN4010); and all the students who contributed to this Journal. 6 Fall 2008

Introduction

In 2008, the number of articles submitted to The Journal increased almost three fold as more and more students became captivated with bioethics. Bioethical issues related to reproductive medicine, neuroethics, and genetics received high visibility 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.

This year‘s Journal volume also includes a special section on Cross-cultural bioethics with articles written by those American 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). Twenty students from various universities in the East Coast and ten Mahidol students attended this 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 their exposure to various cross-cultural humanistic values.

John D. Loike, Ph.D. Course Director for Frontiers in Bioethics and Ethics for Biomedical Engineers 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

Ruth L. Fischbach, PhD, MPE Professor of Bioethics Director, Center for Bioethics Columbia University College of Physicians and Surgeons 8 Fall 2008 I. Genetics

The Sound and the Fury By Katie O‘Neill and Wei-Jen Hsieh

Columbia University

If you were given a choice to be deaf or to in order for the device‘s electrode array to hear, which would you choose? Now, what be threaded into the scala tympani (Papsin if you had to make the decision for someone and Gordon, 2007). Three to four weeks else? later, the device is activated when a transmitter and microphone are placed over One out of every thousand children is born the ear. Since stimulation levels may shift deaf, and for the parents of these children, over time, the implant must be continuously this question is not just hypothetical (Papsin monitored throughout the patient‘s life. and Gordon, 2007). Ninety percent of deaf Moreover, implantation may cause inner ear children have hearing parents who want damage and children who undergo this their child to be ―normal‖, yet members of the deaf community contend that deafness is a normal and natural condition (National Association of the Deaf). Only recently has this issue have practical implications. Due to a new technology, the sensation of sound can be transmitted to the brain through the implantation of an electrical device.

The cochlear implant was approved by the FDA in 1985 and since then it has been successful in delivering auditory stimulation to both children and adults. However, in a study following eighty-two children for ten procedure are often at an increased risk for years after implantation, only 40% had contracting meningitis (Papsin and Gordon, speech that was intelligible to the average 2007). Furthermore, three to six percent of listener. The same study found that the time, re-implantation is necessary due to although 79% of these children could use traumatic or ―hard failure‖ which may result the telephone, more than 70% had in intracochlear changes. vocabulary scores that were below average. For the most part, cochlear implants are For these reasons, many parents believe imperfect, yet many physicians view that the implant is not worthwhile. The deafness as pathology: a disease that needs invasive procedure is performed under to be cured. Thus, pediatricians will strongly general anesthesia and calls for a small hole encourage parents to pay $40,000 to give of approximately two to three centimeters in their child the gift of sound. On the other diameter to be drilled into the patient‘s skull hand, the deaf community insists that Columbia University Journal of Bioethics 9 deafness is a natural condition and allows birthday; thus, we depend on the child‘s for the survival of a unique culture. parents to make the best decision. Moreover, deaf parents want their children to be a part of the community to which they If society were to conceptualize deafness as were born, a community whose primary a disease, do parents even have the right to language is American Sign Language. choose for their child to be deaf? As the technology is now, there are many The media often describes deafness in a complications with cochlear implants. negative light, portraying deaf children and However, if technology improves so that this adults as ―handicapped‖ or ―second-class procedure becomes common practice, citizens‖ in need of being ―fixed‖ with should the child have the right to hear cochlear implants. Yet for those of us who regardless of his parents‘ opinions? are accustomed to hearing, can we form an Although it is currently very expensive, pre- objective opinion about a life without sound? implantation genetic diagnosis suggests that as a society we could theoretically wipe out We, as hearers, have come to rely on our deafness by screening embryos. Should this ears for cues about the world in which we become as routine for families with a history live. We derive pleasure from live concerts, of deafness as it is with other genetic films with fantastic soundtracks, and our diseases? This is the logic that threatens the favorite childhood deaf community. Christmas carols. For those who are As musicians, it is deaf, a silent life is i m p o s s i b l e t o just as valid as one imagine a life with sound. without music. Yet, Beethoven, one of the greatest c o m p o s e r s o f classical music, was completely deaf when he wrote some of his most prolific works, including the well- known Symphony No. 9. Thus, even for a musician, deafness is not an impediment to profound genius. References:

To hear or not to hear, that is the question. National Association of the Deaf: http:// But, in choosing the fate of a child, who gets www.nad.org/site/apps/s/content.asp? to make the ultimate decision? In a society c=foINKQMBF&b=3930755&ct=166093. which values individual freedom, shouldn‘t the child be allowed to decide for himself? Papsin BC, Gordon KA. Cochlear implants Scientific literature suggests that cochlear for children with severe-to-profound hearing implants are most successful if the loss. New England Journal of Medicine, Dec procedure is done before the child‘s first 6, 2007: 2380. 10 Fall 2008

Majority Report: DNA Data-banking As an Opt-Out System By Emilia Javorsky and Robyn Schneider

Columbia University

It is the stuff of science fiction novels and crime scene DNA can be excluded. dystopian futures in 2007 a man was convicted of a crime he committed over 30 Although this system is more successful years ago. The local police, unable to than eyewitness evidence, it is neither large obtain a warrant for his arrest based on nor successful enough. Restricting the existing evidence, followed their suspect information contained within the databank to until he spat on the sidewalk and then reflect only those with previous convictions collected the saliva for a DNA profile. is an unethical and skewed use of this valuable technology, unfairly singling out a DNA evidence has now surpassed portion of the population with a message of fingerprinting as the most mistrust. We believe that scientifically accurate marker crimes and multiple of guilt. Evidence is offences could be more examined based on Short successfully and ethically Tandem Repeat (STR) prevented, rather than technology, which evaluates merely solved, were the specific regions within the United States to enact an DNA. The FBI currently uses opt-out system and require a standard set of 13 specific all citizens to submit their STR regions for CODIS, their DNA information to a Combined DNA Index national databank. System. The odds that two individuals share the same set The national databank of STR DNA regions is would contain number- approximately one in a billion. coded sequences of 13 STR regions and would be However, the under the DNA fingerprint act used only for direct identification against a of 2005 and its January 2006 Amendment, known DNA sample from a crime scene. the FBI‘s CODIS databank only contains DNA would be collected upon issue of an select DNA information from convicted identification card through a government or criminals, those arrested on suspicion of a state office, or, for minors, during a doctor‘s crime, and any non-US citizen who is visit for school vaccinations. Ethically detained under federal authorities. And speaking, the DNA would not be analyzed to thus, reliance on DNA evidence has largely reveal genetic traits, such as predisposition prevented racial profiling as well as wrongful for diseases, partial/familial matches, imprisonment. Retroactively, those who are ethnicity, or certain behaviors, and would wrongfully imprisoned can be exonerated only be run on a computer to rule out guilt in and those whose DNA evidence does not fit a criminal case. If a match occurs, the Columbia University Journal of Bioethics 11 corresponding ID number would be overturned. submitted by the forensic lab to a government office that deals with this According to the American Constitution information, relaying it to the appropriate Society for Law and Policy, over 30% of court system as pertinent evidence. If an crimes are committed by repeat offenders. individual does not wish to have their DNA To follow this logic, if offenders were caught submitted to this databank for whatever using DNA evidence on their first infraction, reason, that individual would need to be a the crime rate would decrease by 30% from U.S, citizen who has not been convicted of a this alone. And that‘s not counting the previous misdemeanor or felony. If this would-be criminals who, knowing that their individual is later convicted, he or she will be information is already in the system, would required under law to submit DNA to the be hesitant to commit a crime. system. DNA will be retained in the databank 25 years post-mortem. In fact, Great Britain requires submission of DNA to a national databank upon arrest, and The term ―national DNA databank‖ conjures this law has proved successful, netting 116 visions of surrendering one‘s civil liberties to DNA matches from 11,000 cold cases in an all-powerful government able to punish 2005-2006. without trial, but that could not be farther Concerns about widespread DNA data- from the truth. Imagine taking part in a banking center primarily upon the transfer of police lineup, at the mercy of a distraught sensitive health information obtained from victim‘s unreliable eyewitness testimony. DNA samples to employers or health Now imagine going to the grocery store, insurance providers. However, in our unknowingly followed by cops who are on proposed system, the DNA would not be the lookout for a stray hair or other tested for sensitive health information and abandoned piece of your DNA that they can would only serve coded data for criminal profile if there is not enough evidence to cases, acting as a sophisticated fingerprint. obtain a warrant. With a national databank, As to Fourth Amendment rights, this system these situations would be as obsolete as the would not constitute an unlawful search or notion of guilty until proven innocent. Under seizure, as we are not searching people our system, while you went about your daily specifically but matching markers on their routine, a number-coded sample of your nuclear DNA, i.e. their genotypes, which is DNA could be checked by computer analogous to the criminal justice system‘s program against known DNA from the crime matching of phenotypic characteristics. scene, with only a one in a billion chance it With the spotlight these days on DNA would match erroneously. databanking and its infringement upon civil liberties, we must stop and consider the In contrast, eyewitness misidentification is alternative: that if we don‘t willingly the single greatest cause of wrongful submitour DNA, it could be unwittingly convictions nationwide, contributing obtained, which is a much more severe misleading data to over 75% of convictions encroachment of our constitutional rights that are later overturned by DNA testing. and privileges. Thus, with the proposed system, common limitations of the current criminal justice system, such as racial profiling and false or coerced confessions, can be instantly 12 Fall 2008

Could Genetic Research Interfere with Medicine? By Jorge Jara and Joanna Etra

Columbia University

Could it become medically beneficial not to with this new information come several medicate? Based on a recent study, it bioethical issues as to how to properly treat seems that in certain situations, that may patients with heart disease, specifically just be the case. those for whom beta-blockers are ineffective. Identifying the genetic mutation Heart disease is one of the leading causes involved in the rate of success in prescribed of death in the United States. Still, there are beta-blockers could potentially give many drugs available to treat the condition, physicians the ability to discontinue use of and patients with heart disease are often the drugs on these patients, eliminating any prescribed multiple drugs to try and control negative side effects. The possible side it. One of the drugs most commonly used for effects of most beta-blockers (and for that heart disease is a beta-blocking drug – a matter, many medications) are plenty – drug that blocks the beta-receptors in the heart that responds to epinephrine. In effect, the drug disables the heart‘s increase in strength and strain in response to stimuli, saving heart power and energy in those with heart disease (Pritchett and Redfield,2002). However, one study found that altered genetic characteristics present in approximately 40% of African Americans and 2% of Caucasians renders beta-blocker drugs ineffective. The genetic alteration is such that the individual produces its own form of a ―beta-blocker drug,‖ naturally producing and evoking the same result as would be derived from taking medication beta-blockers (http://www.nature.com/nm/ nausea, diarrhea, bronchospasm, fatigue, journal/vaop/ncurrent/). hallucinations, insomnia, clinical depression, erectile dysfunction, among others, along The discovery of this particular gene with negative drug interactions (http:// alteration has answered many questions for www.cvpharmacology.com/cardioinhibitory/ researchers and physicians about the beta-bloc). differences in effects of drugs on patients with similar conditions. From the results of The implications of this study are vast and this particular study, it is shown that there is somewhat disconcerting. In terms of medical a clear link between genetics and the ethics, healthcare providers must now outcome of patient drug treatment. However, determine whether or not to treat all patients Columbia University Journal of Bioethics 13 with a drug effective on only some. studies would likely show many drugs as Bioethically, the implications are quite less universally effective. This research complicated. In the expectation that a would then reduce the market base of the physician, in following with his pledge to ―do pharmaceutical companies, as it could be no harm,‖ must scan for the particular gene determined explicitly for whom these drugs alteration, comes a new standard level for are of no use. Since it is not in the interest of patient care in reference to heart failure. If the pharmaceutical industry to conduct the best form of healthcare can only be studies whose results would lower their provided with inclusion of genetic screening, profit margin, the funding of such studies to it would seem that this information should be better healthcare would be difficult. How included in the future in the usual treatment should a physician assess whether the beta plan. Yet, genetic mapping and screening blocker is working on a specific patient? remains an extremely expensive procedure typically not covered by health insurance. Lastly, were the practice of genetic Since this gene is primarily found in the screening to be routinely included in African-American community is there ethnic treatment for heart failure or any other bioethical issues elicited? Therefore, if the medication process, the issue of privacy expectation of proper treatment expands to would offer another consideration. To screen the point of genetically testing for these for the gene involved in the result of protective factors, policy needs to be medicated beta-blockers, private genetic implemented to enforce this treatment‘s information would need to be gathered and coverage by health insurance. Since not analyzed. Though consent forms and covering a procedure established as privacy forms could easily be erected to standard care for a condition would result in reconcile a patient‘s particular desires and a severe discrepancy between healthcare rights in relation to privacy, screening for for those of able means and those unable to genetic specificities has many possible afford it, the question of cost absorption obstacles. If in the screening process accountability remains. another genetic mutation or notable disorder were to be discovered, a slew of medical Though the discovery of the possible and bioethical problems would arise as to inefficacy of beta-blockers as treatment for how to proceed. For instance, would the heart disease is great, what may be a larger researchers then have the moral or ethical and more significant result of the study is its obligation to alert these patients of the application to other drugs and their potential diseases facing them? Also, the respective usefulness. With the myriad of idea that an ―immunity‖ to a commonly used drugs available with different rates of medicine is traceable leads to the possibility success in patients harboring similar of required testing. Since such a gene conditions, it would seem that studies should alteration may increase one‘s risk for heart be conducted to determine possible genetic failure or other complications, could links associated with the specific success employers – or worse, health insurance rates of these drugs. However, these studies companies – mandate genetic screening as would be extremely costly, so much so that part of their hiring process or policy the government would likely have trouble decision? In addition, because of the privacy absorbing the cost. Yet, it is unlikely to and quality of life implications from expect the pharmaceutical industry to screening, could patients abstain from sponsor such studies, as results of the screening and continue taking beta- 14 Fall 2008 blockers, possibly only to their detriment? greatly reduced and healthcare in our Furthermore, with the gathering of this data, country would greatly improve, enabling a new policy must be implemented outlining genetics to more easily be considered in the the storage of such information as well as its treatment of patients. usage in studies and other works published to protect the privacy of the individuals Pritchett AM, Redfield MM (2002). "Beta- involved. blockers: new standard therapy for heart failure". Mayo Clin. Proc. 77 (8): 839–45; As with many ethical matters, there is no quiz 845–6, unambiguous and comprehensive solution to the specific issue. However, in the interest of improving healthcare and ensuring not to medicate patients to only negative effects, the screening for the gene effecting beta- blockers must be included in routine treatments for those patients suffering from heart disease. As the discovery of the gene‘s presence can prevent the patient from further enduring the side effects of an operatively useless medicine, it could also prove useful in the diagnosis and treatment of offspring of that individual patient. Further, the data collected should be collected and stored as part of the ongoing statistical information gathered on patients by organizations such as the National Center for Health Statistics, and it should be used to conduct longitudinal studies to determine associations with aspects of health and living. Though HIPAA regulations lend some solution to the issue of privacy in healthcare, further developments in technology and policy would need to be assumed to enable the keeping and tracking of genetic information without the possibility of infringement upon human rights. The most difficult issue remains to be the continued conduction of studies to find genetic linkage to medication efficacy. Though a clear-cut route to these studies is yet unavailable, a possible solution to lower costs all around is the funding of such studies by those companies that complete the genetic testing procedures. As the results of such studies is likely to prove profitable to their particular field, the limits of such studies would be Columbia University Journal of Bioethics 15

Charging You for Being You

By Elisa Fung and Gabriela Vargas

Columbia University

The man sitting on your left eyes your wrist diagnostic test involving the gene. In these with an eerie smirk on his face. The woman cases, however, it is important to recognize on your right points at your mouth. He is not the difference between discovery and looking at your new Rolex watch, and she is invention. While the former is simply making not pointing out spinach between your teeth. something known, the latter is defined by The man owns your wrist; the woman owns original thought and for this reason should your two front teeth. Who else owns another be allowed to be patented. part of you, and whose parts can you own? Patenting a particular DNA sequence The field of biotechnology undoubtedly inevitably gives one human being partial advocates the need to protect intellectual ownership of another human being. DNA is property and spur scientific advancement. a naturally occurring phenomenon that is This has contributed to many medical common to all human life. More specifically, breakthroughs, yet it has also taken an individuals share 99.9% of the same DNA unexpected turn. The allure of financial sequences. This allows each person to own profits and personal recognition has only 0.1% of himself or herself. Thus for transformed the motivation behind the sometone to have exclusive rights to a common practice of patenting. Once aimed certain gene is as unfounded as to spread scientific knowledge for the copyrighting the individual letters of the betterment of society, patents now serve as alphabet, as our ACTG‘s and our ABC‘s an impediment to this purpose in certain arethe fundamental building blocks of cases. Thousands have filed gene patent humans and novels, respectively. Just as applications for specific DNA sequences as authors are recognized for the originality of they try to stake their claim in the realm of their works through copyright privileges, genetics. DNA patenting should only provide compensation for the discernment of Human DNA patenting has emerged as a innovative ideas regarding genes. However, major issue faced with an assortment of patents have been issued for decades and public scrutiny. In the U.S., DNA patents this is not the case.Patenting human DNA are currently issued to those who determine sequences is essentially allowing ownership at least one specific function of a DNA and commercialization of the basic building sequence which facilitates the sharing of block of human nature. Making the human knowledge on a universal level. The patent body a subject of property right objectifies holders are then entitled to licensing rights individuals and violates the underlying for the entire gene, and thus sole control human rights to life and liberty. over the production and marketing of any 16 Fall 2008

Ownership of genes not only stands in the However, it sacrificed the rights of an way of human rights, but also detracts from individual to ownership of his own body. scientific advancement due to the appeal of This effort should be seriously considered to capitalism. A study from the Center of prevent any downstream consequences in Bioethics at both Stanford University and the the future. Who knows, kids may have no University of Pennsylvania found that 53% choice but to pay patent holders for of clinical laboratories decided against inheriting their parents‘ genes. developing new clinical genetic tests because of a patent or license. The decision to initiate or continue genetic research is associated with increased financial burden. This elevated spending, however, does not provide direct scientific benefits. It simply gives them permission to conduct their research. If research is nonetheless successfully completed and it revolutionizes the standard of medical care, it ultimately places a strain on the cost of healthcare. The increased costs of conducting research translate into increased treatment costs, which exacerbate the already large price tags of healthcare for most patients. While there is obvious interest in patents from the corporate world because of the potentially large monetary profits it would rake in, a line mustbe drawn between what can be done and what should be done for the improvement of society.

DNA patenting is unethical due to a lack of respect for humankind. It objectifies humans as property. Less obvious but equally significant effects exist on healthcare; the average citizen‘s common dilemma of treatment versus cost worsens. In the growing field of genetic biotechnology, it is vital that proper regulation is set to protect scientific property without exploiting individuals. This will prevent repetition of cases such as the famous Moore v. Regents of the University of California. Despite his cell lines were commercialized after treatment for leukemia, he retained no rights to the profits. In this particular case gene patenting had the positive effect of providing many people with cancer treatments. Columbia University Journal of Bioethics 17

II. Stem Cells and Reproductive Biology

Secrets and Lies: Mandating Disclosure in Oocyte Donation By Tiffany Hsieh

Columbia University College of Physicians and Surgions

Although conception with egg donation has federal or state level that either prohibits or been available for over 20 years, it still enforces anonymous donation, with fertility remains a largely unregulated process. One centers and egg donation agencies drawing aspect of assisted reproduction using donor up their own contracts and eggs that is receiving increased attention is guidelines. Furthermore, there is no whether parents should disclose to their legislation that addresses the issue of children the facts of their conception: what information disclosure. In 2002, the Ethics are the consequences of learning that one Committee of the American Society for has an anonymous genetic parent? Reproduction Medicine encouraged disclosure from parents to children about the Anonymity, in which both donor and use of donor gametes in their conception, recipient couple consent to the process but and recommended that fertility clinics and are mutually unknown and unidentifiable, programs maintain permanent records of has largely accompanied both sperm and donor screening and selection data, donor egg donation. In recent years, however, the examinations, and clinical outcomes as a tendency to maintaining strict secrecy is future medical source for offspring (Ethics shifting, with more parents telling children Committee of the American Society for Re- about the method of their conception and (in productive Medicine, 2004). Whether cases of non-anonymous donation), anonymous or not, relationships between establishing relationships with the donors, parents, and the child must be donor. Several European countries agreed on prior to the procedure—but is this (Sweden, Austria, Switzerland, and the fair to the child conceived from the donor Netherlands) have begun to ban anonymous egg, who cannot contribute to this decision? gamete donation. In 2005, the UK Government determined that children born Anonymity has its benefits from both a from egg donation have the same right to pragmatic and legal standpoint. It frees know their biological parent as adopted donors and recipients from entanglement in children on reaching the age of 18; issues of custody and liability, especially legislation was then changed requiring any since parental rights are interpreted donor of gametes or embryos to agree to the differently from state to state. Furthermore, disclosure of their identity to any adult it also protects a booming and extremely offspring. lucrative industry from scandals and lawsuits resulting from these same issues. As a The United States has no legislation on a result, anonymity allows the fertility industry 18 Fall 2008 to escape accountability, not only for as ―anonymous,‖ the fact that almost half important information such as the donor‘s had seen a photograph seems to render this health background, but also for personal concept moot. Whether or not the parents characteristics reported by the donor, from choose to disclose this information and the educational background to test scores, few nature of the conception to their children is of which are independently verified. left to their own discretion. Additionally, some argue that anonymity is a more compassionate approach for a couple Yet this only reinforces tendencies toward struggling with infertility, since creating a secrecy, especially since the nature of egg donation makes it easy to conceal the method of conception—the child is genetically related to the father, and the mother acts as the gestational parent. (Nevertheless, for privacy to remain a choice, the matching of donor and recipient blood types and physical characteristics is important.) Furthermore, the donor is often untraceable or unknown (which would obviously change if all donation were made non-anonymous), and some argue that this means there is little value to disclosing information to the child. However, many couples disclose to family members and close friends; attempting to keep the same information from the child creates the very real threat of accidental disclosure, whether from a third personal relationship between the donor, party or a genetic test. recipient, and child has the potential to give the donor an unwanted investment in the In one UK study, half of recipient parents family. surveyed did not intend to tell their child about the way he was conceived. The non The GIVF donation procedure is not disclosing parents were concerned with ―anonymous‖ per se: GIVF allows recipients potential negative consequences of to browse an extensive donor database, one disclosure, such as stigma surrounding the that details everything from the donor‘s eye donation process, loss of privacy, and hair color to her personality type. One psychological harm, concern that donors recent study surveyed 62 sets of oocyte might try to find the child (and vice versa) or donation parents from fertility programs claim parental rights, confusion regarding across the country and found that over 90% maternal identity, and disruption of family of both partners knew their donor‘s age, relationships. They believed that they were ethnicity, hair color, eye color, height, acting in the child‘s best interest by weight, education, and medical history. 80% withholding information regarding the knew the donor‘s blood type and 45% had donation process. There is no denying that seen a photograph. Even though the paternalism is necessary for the sake of a majority of recipients described their donors child‘s well-being, but parental responsibility Columbia University Journal of Bioethics 19 also dictates that the child‘s right to the truth they will not believe that their mother‘s about his conception and genetic genetic history is their own—a false background be honored. Since this assumption that may lead to misdiagnoses, constitutes an integral part of the child‘s unknowingly foregoing critical medical care, personal identity, such information falls or undergoing unnecessary treatment. What outside the boundaries of the parental right children don‘t know can‘t hurt them—unless to privacy. By bringing these children into it can. the world, parents have the moral obligation to tell them where (and who) they came It is important to note that guaranteeing from. children access to their genetic heritage is distinct from guaranteeing them knowledge As genetic testing plays an increasingly of the method of their conception. In the case of egg donation, these two issues are inextricably linked. Gamete donation in the UK, without knowledge of the nature of one‘s conception, one cannot proceed to secure identifying information; most children simply assume that they are genetically related to their parents. Neither the child‘s parents nor any state body is required by law to inform the child about the circumstances of conception. As the child has no legal right to be told the truth about his conception, this implies that he has a large role in the diagnosis and treatment of moral right to be told and his parents have a disease and in reproductive decisions, the moral duty to disclose. In practice, this child has a medical need to know his genetic means that a child‘s legal right to information history. Separating genetic from gestational depends on his parent‘s inconsistent motherhood means that children may be fulfillment of this moral duty. With non- deceived about their genetic anonymous donation, leaving the duty of background. Does a patient‘s autonomy, in disclosure to the parents implicitly gives this case the right to choose not to tell one‘s priority to the parent‘s right to privacy. child the truth, take precedence over the possible harm done to that child if he goes But this right to privacy regarding the nature through life conveying a false medical of the child‘s conception does not extend to history? Another related problem arising the child. Here, the parents‘ interests from the use of anonymous egg donation is conflict with the child‘s fundamental right to the possibility that children may have know his biological origins (in this case, his several half siblings they do not genetic identity and the identity of the egg know. Patients have the reproductive donor). By withholding information and freedom to procreate with unknown eggs, thereby having their child grow up assuming but children also have the right to avoid that his social parents are his genetic inadvertent consanguinity. Although parents, parents who do not inform their children conceived using donor eggs may be children are being indirectly unable to access the specific genetic dishonest. Furthermore, nondisclosure information of the donor, with disclosure implies that there is some shame 20 Fall 2008 surrounding this truth, which undoubtedly the ASRM Ethics Committee harms family relationships in multiple recommendations. Additionally, information ways. Parents‘ privacy concerns and the concerning disclosure should be included as intended benefits for the parents and child part of the counseling that couples receive are outweighed by the negative during their fertility treatment. Parents consequences of keeping family secrets, should be encouraged to inform their and also by the child‘s medical need for children about the use of donor gametes, information about his origin. Nondisclosure and disclose the medical history of the the child is being used as a means to the gamete donor in situations that concern the parents‘ end of having a ―normal‖ family. In child's own health. Offering peer and this way it neglects a child‘s rights to professional support and guidance to autonomy and to information about himself. parents will assist them with disclosure, both initially and after their children are born. An essential part of good practice should be openness with children about their genetic Conception with egg donation calls origins, and their moral right to this into question the very definition of information should be reflected parenthood. As the use of oocyte donation legally. (Frith, 2001) The most obvious increases, so do concerns about its solution is to institute a method to ensure psychological and social impact on families that all donor offspring know the true nature and children. It also remains to be seen of their conception. Frith (2001) proposes a how attitudes towards disclosure and non- model in which children conceived with anonymous donation will change as the donor eggs can be provided with a birth growing acceptance of assisted reproductive certificate that records the details of their technologies gradually removes some of the ―social‖ parents, as well as a donor social stigma surrounding infertility. certificate that records the details of their gamete donor. Making all egg donation non References: -anonymous would necessitate radical policy changes within the current system, in which Ethics Committee of the American Society medical practices, legal requirements, and for Reproductive Medicine. Informing control and supervision all vary widely. Just offspring of their conception by gamete as importantly, it would carry tremendous donation. Fertil Steril. 2004 Sep;82 Suppl legal and medical import, since information 1:S212-6. disclosure not only affects parents and their children, but donors and health care providers as well. If the US is not yet ready Frith L. Beneath the rhetoric: the role of to follow in the footsteps of the 2005 UK rights in the practice of non-anonymous legislation and create a donor registry, gamete donation. Bioethics. 2001, 5-6:473- children should, at the very least, be allowed 84. access to as much information about donors as was given to their parents.

To this end, regulations should include standardized requirements for the collection and maintenance of records by fertility centers and egg donation agencies, as per Columbia University Journal of Bioethics 21

Altered Nuclear Transfer: A Novel Way of Developing Pluripotent Stem Cells

by Sarah Eberle and Tabby Khan

Columbia University

Embryonic stem cell (ESC) research has access to the DNA. However, only ESC- generated widespread controversy across associated transcription factors, not factors various social, religious and geographical associated with zygote formation, are factions due to the destruction of embryos expressed in the oocyte. When fusion that is inherent in the process. For this occurs, the factors are directly transferred to reason, some type of ESC substitute that the somatic nucleus, which is subsequently retains their remarkable pluripotent reprogrammed. In ANT-GD, gene deletion, properties while circumventing these ethical rather than activation (such as that used in and moral issues must be generated. A new ANT-OAR) is used to prevent the expression technology, altered nuclear transfer (ANT), of genes involved in the development of a has recently been proposed as a way to zygote. Condic argues that life begins at generate pluripotent stem cells with trophoblast formation; trophoblast cells embryonic stem cell-like qualities without the induce the production of the amnion, chorion creation or destruction of an embryo. This and placenta, and if trophoblast formation is noteworthy development represents a inhibited, implantation does not occur. The potentially ground-breaking step towards transcription factor Cdx2 controls avoiding many of the prominent bioethical trophoblast formation. In ANT-GD, Cdx2 is issues relating to stem cell research. removed from the somatic cell. This cell is then fused to the oocyte, and clusters of ANT attempts to answer the following cells—rather than distinct masses with question: ―Is it possible to generate cells global organization—form. Condic argues with the properties of embryonic stem cells that global organization and coordinated from something that is not an communication between cells necessarily embryo?‖ (Condic 2008). ANT addresses and sufficiently constitute and embryo. If one this question in two ways; a scientists must of these two criteria is not met, a mass of first generate stem cells, and then test for cells cannot be described as an embryo. the absence of embryonic qualities. In order This combination of ANT-OAR and ANT-GD to generate the cells, two steps are prevent embryo formation because the involved—ANT-OAR, which involves oocyte- transcription factors that encourage assisted reprogramming, and ANT-GD, pluripotency are inhibited at the same time which involves gene deletion. In ANT-OAR, that transcription factors that encourage the oocyte is altered to express transcription trophoblast formation and global factors that are key in development of organization are inhibited. Thus, an embryo pluripotent cells and epigenetic is not formed in ANT. modifications of the genome are altered to allow these transcription factors greater ANT bypasses many of the bioethical 22 Fall 2008 concerns that have impeded upon the prospect for gene therapy through Despite the fact that ANT does not create embryonic stem cell research. Although or destroy embryos, this method still raised advances have been made in stem cell several bioethical issues. The point at research over the past several years, all which life begins is still unavoidably procedures currently available for obtaining controversial. Fertilization still occurs in Ant embryonic stem cells destroy embryos. The because somatic cell nucleus fuses with an act of destroying a human embryo oocyte. Thus, ANT does not resolve generates significant controversy because bioethical issues for individuals who believe many people feel that destroying an that life begins at fertilization rather than embryo‘s potential for life is unethical on implantation; ANT still creates an embryo multiple social, spiritual, and moral levels. for the purpose of destroying it later. Irregardless of whether or not the embryo implants, it is still a potential life, and so ANT remains controversial.

In addition to the question of when life begins, an issue arises in the way this research defines life. The researchers base life on purely one transcription event. The deactivation of Cdx2 is just another mode of attempting to circumvent the bioethical issues inherent in ESC research. Multiple Little testing on human ESCs has been other transcription factors can play a role in permitted by the United States government embryogenesis, so how can we possibly due to widespread outcry against this define life through the actions of just one? It technology. These regulations have is true that in cells in which this transcription prompted research involving non- factor is deactivated, trophoblasts do not embryonic stem cells. Although non- form, but again, there are events prior to embryonic stem cells have shown promise this that could also be construed as the in research, these treatments ―do not live beginning of life. up to the expectation of . . . ‗stem cell cures‘ that the public has been promised ANT allows scientists to ―play God,‖ which from embryonic stem cells‖ (Condic 2008). causes further bioethical discrepancy. This Additionally, cells from non-embryonic technology essentially reverses the normal sources ―cannot stand in for the properties course of development—it transforms an and therapeutic potential of ESCs‖ (Condic already differentiated cell into a cell that 2008). One method, the derivation of non- serves as a precursor to various cell types. pluripotent stem cells from adults, bypasses This anomaly discounts the natural the use of embryonic stem cells. properties of cells; normally, cells do not go Unfortunately, this method has limited through life in this manner. In the process therapeutic potential. Adult stem cells of deactivating and activating various cannot differentiate into all types of cells transcription factors, important qualities of a and thus, they do not have the same cell could be altered. While it is known, for reconstructive and therapeutic value of example, that Cdx2 plays a role in embryonic or ANT-derived stem cells. trophoblast formation, the total functions of Columbia University Journal of Bioethics 23 the transcription factor are unknown. For unnatural cell manipulation cannot be instance, the transcription factor could play completely resolved; however, all scientific another role in non-embryonic cells essential research involves some degree of to their survival. By knocking out the manipulation and ―playing God.‖ The only transcription factor, the scientists might alter way to somewhat resolve this issue is to is more than just development. further research about mechanisms of imparting pluripotency; scientists should Cost is also a significant factor in this examine different epigenetic modifications research. The motivation behind ANT is to and transcription factors that lead to this generate stem cells with ESC-like qualities process. Understanding the exact to fulfill the hypothetical promises proposed mechanisms behind the process will help by ESC. Due to government limitations, the researchers be more conscious of their total therapeutic value of ESC has not been research. The last major issue to address is conclusively proven. Lack of conclusive that of cost. To prevent wasting grant ESC research makes it difficult to money, the government could initially successfully gauge how much more provide money to only a few labs to do such therapeutic value ANT will have over research; if it appears that this research already existing adult stem cell therapies. does have tremendous therapeutic The tremendous amount of grant money potential, then more money can be pumped necessary to fund ANT could ultimately in. To ameliorate some allocation issues, result in therapies equal to those that the government could fund therapies for currently exist. If ANT does produce those who cannot afford it in the form of impressive therapeutic results, the extreme clinical trials. As a novel therapy, ANT costs of the process will create an allocation would need to be tested in humans as much problem. Who should receive this therapy— as possible before it becomes more widely people who can afford the procedure or the available. people who need it the most? This issue is inherent to all types of stem cell research, ANT provides an interesting alternative to and ANT does not correct for it. using embryos. By avoiding the use of embryos, the government may become more In conclusion, ANT does resolve several of receptive to funding stem cell research. the bioethical issues generated by Perhaps the key to effective and ethical gene traditional embryonic stem cell research, but therapy does not lie in stem cells, but rather, it incurs a controversy of its own. Many of in some mechanism that has yet to be these bioethical dilemmas must be resolved discovered. In the meantime, however, to make this process marketable to the further research on ANT could resolve the public. It is impossible to resolve the current questions about the efficacy of ANT‘s question of when life begins because success in gene therapy. various groups of people answer it differently. If ANT could be altered to References: bypass the fertilization event altogether, it might appeal to a broader constituency. This Condic, ML. ―Alternative sources of issue could be involved by conducting pluripotent stem cells: altered nuclear further research to develop a somatic cell transfer.‖ Cell Proliferation, 2008. 41: 7-19. capable of de-differentiating without the assistance of an oocyte. The issue of 24 Fall 2008

Diagnosing Disability… And Keeping It

by David Yin and John Tseng

Columbia University

Genetic engineering is most often negatively perceived to be a disability, and critics have associated with the societal harms it could accused such parents of harming their create: discrimination, entrenchment of children, and such doctors of violating the economic disparity, and a terrifying Hippocratic Oath to ―do no harm‖. Defenders movement toward a homogenous super- of the practice have argued that deafness race. Issues of individual rights rarely come holds cultural value among the deaf, that the into play because the traits engendered disability only occurs where auditory and would be almost visual communication universally considered contact, but that this b e n e f i c i a l . W h o ―contact zone‖ dissolves wouldn‘t want Einstein‘s in a deaf household intelligence, Michael where not hearing is the Phelps‘s Olympic norm, and even, a prowess, and the good blessing. Others have looks of Jude Law or cited the fact that the Uma Thurman? Who family might actually be wouldn‘t want a healthy happier when they can child over one that share experiences and might suffer from Tay- capacities. Sachs or cystic fibrosis? Much of the dispute centers on the goodness In recent years, of the trait, but we would however, there have argue that this is been controversial immaterial in so far as reports of negative this trait is not given or selection taking place— created, but merely parents choosing to selected for. Most can ―impair‖ their children agree that deaf parents with ―disabilities‖ such who attempted to deafen as deafness or dwarfism—that bring up a child after birth would likely be prosecuted issues of individual rights and possible for child abuse. The parents would be government intervention. The social bias making an active choice for their child that is against this selection is clear. In a 2006 New likely against both the child‘s preferences York Times article, it was reported that most and interests, and where parental decisions doctors found requests for negative impact their children in significant negative selection unacceptable. Deafness was ways, we say the government may step in to Columbia University Journal of Bioethics 25 protect the rights of the children. Opponents deaf couple is choosing a baby to adopt, of parents choosing deafness seem to and can choose between a deaf baby and a structure their arguments on similar lines: baby with normal hearing. Now it is clear parents should do what is best for their that neither baby has a greater right to be children; parents should not create chosen for adoption, nor that society does disabilities for their children. A quick not prefer one or the other. The parents may inspection of the actual scientific process exercise their own preferences in choosing used in selection, however, dismisses the which child is best suited to them, taking into premise of that analysis. account hearing, but also all of the other traits that we might find disturbing if The pertinent technological method in genetically ―engineered‖: hair color, eye embryo screening and selection is pre- color, sociability, or intelligence. Returning to implantation genetic diagnosis (PGD). It our genetic choice, the deaf parents are now should be noted that this procedure is choosing between two embryos, two already commonly used for couples to select potential babies. One will develop into a against disadvantageous traits like Tay- deaf child, and the other will hear normally, Sachs or cystic fibrosis, with little uproar. but both have an equal ―preference‖ to be These tests reveal the genetic composition chosen, to be born and to live. The parents of each embryo created, and the information are not choosing a trait that would be gathered can be used to choose which against their child‘s interest, because both embryo will be implanted in a woman for potential children have the same interest in further development into a baby. By studying being born. Now the parents are choosing the genes of the embryo, scientists can between two equally moral decisions, and, determine the likely traits the resultant adult like the adoption example, their own wishes person will have, such as deafness or can be used to make the final call. normal hearing. This is not to say that the question of The methodology of PGD clarifies some of whether or not parents should choose a the underlying assumptions in this ethical disability is completely resolved. There are dilemma. First, each embryo is naturally other arguments that this commodifies occurring, usually as a result of sperm or children, and lets parents impose eggs donated from the prospective parents, incapacities because it is in their best and fertilized using conventional IVF interest, and not the child‘s, or that ex ante techniques. If the donor couple had naturally the child that is born is the same, and that conceived, any of the embryos could have even if scientifically distinct, are still morally been potentially created, and so the chance indistinct. However, it is clear that, as in all for a deaf baby or normal baby would also bioethical debates, there must be an naturally occur. Second, no person is understanding of the fundamental actually harmed, there is simply selection techniques involved before conclusions can between the several embryos that are be formulated. In this dilemma, the created. elucidation of the technology showed that no individual rights (those of the children) are Understanding the actual procedure enables actually violated; there is simply parental us to create an alternate analogy from the selection between equally deserving but deaf parents actively creating deafness in unfortunately competing rights claims. their child. Imagine a scenario where our 26 Fall 2008

III. Contemporary Issues

Say No to Blow: Preventing Cocaine Addiction

through Vaccination

By Soo Han and Tabby Khan

Columbia University

While the United Nations‘ anti-drugs chief by inducing the immune system to form Antonio Maria Costa recently condemned antibodies that attack cocaine. The antibody both British supermodel Kate Moss and binds to cocaine, forming a complex that is Grammy-winning artist Amy Winehouse for too big to cross the blood-brain barrier, glamorizing the use of cocaine, he failed to preventing the drug from reaching the condemn the millions of reward center of the brain. people around the world who This essentially eliminates are also addicted to the the high that cocaine users drug. According to the feel upon taking the drug. United States‘ Office of National Drug Control Policy, It is important to note, the number of chronic however, that this is not a cocaine users in the United preventive vaccine; it is States alone is 3.6 million. In necessary that cocaine is addition to this number, present in the bloodstream 11.2% of all people above in order for the antibodies to the age of 12 have reported have something to which at least one instance of they can successfully bind. cocaine use; due to the This means that while the addictive nature of the drug, drug prevents the user from up to 75% of these users will getting ―high,‖ it does not become addicted, and only prevent addiction. 25% of people who try to quit will be able to Addiction, as defined by the NIDA, refers to do so without help. ―a chronic brain disease that causes compulsive drug seeking and use‖. This At this point in time, there is no ―magic vaccine, rather than eliminating the desire to bullet‖ that can cure cocaine addiction. Most take the drug, suppresses the ―pleasurable cocaine users are forced to enter feeling‖ that users feel upon administration rehabilitation clinics in order to fight their of the drug. Currently, while this vaccine addictions. Recently, scientists developed a has the potential to prevent relapse and vaccine for cocaine addiction that could wean people off of the drug, it is unable to enter the market by 2010. This vaccine acts prevent the onset of cocaine addiction. In Columbia University Journal of Bioethics 27 addition to conducting clinical trials on the addicted, family history or not. By only effectiveness of this current vaccine, vaccinating those teenagers whose families scientists are in the process of developing have a history of cocaine abuse or other another vaccine that will prevent the cocaine addictive behavior, we are leaving an entire addiction before it starts. While the current segment of the population at risk. vaccine targets the dopamine receptors in the reward centers of the brain, a preventive The development of a vaccine for cocaine is vaccine could act by enhancing dopamine a noble and groundbreaking advance in reuptake in these rewards centers, pharmaceutical research, but it does give essentially eliminating the effects of the rise to many ethical and social questions. If drug. Kosten believes his we are to place our faith vaccine could potentially be completely behind such a used to ―vaccinate high risk vaccine, we are diminishing the teens until they mature to an value of rehabilitation and age of better decision- social intervention programs making‖. that have shown to help over fifty million people combat Kosten‘s suggestion brings addiction in the past. Many about many ethical questions former addicts who have seen regarding the use of the success in overcoming their cocaine vaccine. It is not addiction through such possible to vaccinate programs see vaccines as a everyone against cocaine ―crutch‖ rather than a means to addiction, so how exactly are true sobriety. A vaccine is not we supposed to determine a cure for addiction, but rather who falls into a high-risk a quick-fix that requires group? According to a study conducted in persistent administration to work properly. If 1993, cocaine addiction exists across all we tout this addiction vaccine as a cure-all, racial, economic, and ethnic strata. There is much as we do for vaccines for diseases no way to label one cultural group as any such as polio and measles, we are more ―at-risk‖ than another group. essentially condoning drug use and Therefore, will it be necessary to turn to dismissing it as ―not a big deal anymore.‖ genetics in order to decide to whom to America has a drug problem, and a quick fix allocate the vaccine? For example, children vaccine is no way to solve it. For now, we and teenagers with a history of addiction in should just stick to going to rehab. their family are more vulnerable to addiction. Basing vaccine allocation on purely genetic Referneces: history, however, has a great deal of risks. It is dangerous to discount the influence of Orson FM, Kinsey BM, Singh RA, Wu Y, epigenetic and social factors in drug Gardner T, Kosten TR. Substance abuse addiction. Even if a teen has no history of vaccines. Ann N Y Acad Sci. 2008, drug abuse, peer pressure has been shown 1141:257-69 to have a significant impact on one‘s ability to try drugs. Because of the highly addictive nature of cocaine, it is entirely possible that a teenager who tries it once will become 28 Fall 2008

Building Athletes

By Yonah Heller and Jean Pierre Rabbah

Columbia University

Is Tiger Woods, the world‘s top-ranked (blurred vision). The LASIK operation is golfer, a cheater? Two thoughts performed in two stages, beginning with the immediately pop into the reader‘s head. The creation of a corneal tissue flap and followed first reaction is ―Oh no…not another athlete by laser modification of the cornea itself. juiced up on steroids,‖ followed by ―Really? The flap is resected through the use of a Tiger Woods? ‖. Steroid use is at the metal blade called a microkeratome. forefront of issues regarding unfair Leaving a hinge at one side, the flap is competitive advantages in sports. It has folded back, exposing the middle of the become the epitome of athletic wrongdoing, cornea, called the stroma. An ultraviolet a notion bolstered by the recent disclosure laser is used to remodel the cornea, and of the Mitchell Report, which investigated athin layer of stroma (middle of the cornea) the use of steroids and performance- tissue is vaporized with the laser in a finely enhancing drugs in Major League Baseball, controlled manner. The flap is restored and and concluded that steroid use tarnishes the remains in position by itself. integrity of the sport by giving the user an unfair and illegal competitive advantage. The general purpose of this procedure is to But where does the moral line of competitive reduce or eliminate reliance on glasses or advantage begin and end? With rapidly corrective lenses. However, Many athletes emerging biotechnology, ―athletic have undergone this surgery to improve engineering‖ is becoming an increasingly their vision--including Tiger Woods, NBA viable prospect. Not only is it possible to player Lebron James, and baseball player improve athletic prowess through the Greg Maddux. Woods claims that the ingestion of performance- enhancing procedure has enabled him to perform the substances, but technology involving daunting task of ―reading the greens‖ more prostheses, body modifications, and, in the effectively. Few professional athletes would future, perhaps even genetic modification admit that they have undergone a voluntary may all produce an ―improved‖ athlete. At medical procedure for the primary purpose what point is the use of these technologies of gaining competitive advantage. However, considered cheating? it is reasonable to assume that if a competitive advantage may be gained It is currently possible to improve one‘s through such a relatively non-invasive vision to ―normal‖ 20/20, or even to an procedure, its popularity will increase among enhanced visual acuity of 20/15 or 20/10 both professional athletes and those who through LASIK, or Laser-Assisted In Situ aspire to professional status. If such a Keratomileusis, procedure. This procedure procedure improves the patient‘s ability to is performed to correct refractive errors, see the ball, or the greens, or the basket, whether myopic (nearsightedness), what prevents him/her from choosing to hyperopic (farsightedness), or astigmatic undergo this surgery? Columbia University Journal of Bioethics 29

Another medical treatment that has athletes throw harder, shoot the basketball reportedly provided athletes with a better, or hit the golf ball more accurately competitive advantage is the ―Tommy John‖ post-surgery encourage children to believe surgery, or ulnar collateral ligament (UCL) that unnaturally modifying one‘s body is reconstruction. After injuring the UCL in the acceptable? inside of the elbow, most sufferers experience pain and joint instability. In order There is no clear answer to this question. to stabilize the joint, a tendon from the Standards of acceptable and unacceptable forearm is harvested and tunneled through means and methods modification need to be the ulna and humerus. Due to the continual developed. With the various emerging tensile stress experienced in their elbows, biotechnologies, we must be vigilant in this injury is very common in baseball monitoring their intended uses, in order to players, especially pitchers. Most pitchers prevent athletes and those who emulate perform as well as they did before the them from putting themselves at risk. procedure, and some pitchers perform even better post surgery. Kerry Wood of the So, is Tiger Woods a cheater? Not today. Chicago Cubs said, ―I hit my top speed (in pitch velocity) after the surgery." Is this a fair way for an athlete to gain a competitive edge?

The question arises as to why the use of steroids and other performance-enhancing substances is considered ―tampering‖ while the Tommy John surgery is not. And what about more ―benign‖ enhancements, such as swimmers shaving their bodies to become more hydrodynamic, or wrestlers dieting to ―make weight,‖ or even gymnasts employing ports psychologists? All these methods create a physical advantage over the natural (unadulterated) athlete.

Perhaps the health risk of a procedure is the issue. In contrast to shaving one‘s chest, which has few health implications, (aside from potential razor burn), one might argue that steroid use is maligned because of the myriad associated health risks, and that allowing their use sends the message to young people that taking them is acceptable. However, there are many health risks involved in surgery as well, including pain, anesthesia complications, infection, and countless others pertaining to the particular surgery. Furthermore, doesn‘t seeing 30 Fall 2008

Molecular Imaging and Ultrasound-assisted Drug Delivery

By Ashok Ilankovan and Andrew Arnold

Columbia University

The history of ultrasound is strongly correlated with discoveries related to sound. In 1822, Swiss physicist Daniel Colladen cal- culated the speed of sound. In 1877, Lord Rayleigh published his treatise The Theory of Sound. It clearly described the fundamental physics behind sound waves. A few years later, the Curie brothers discovered the piezo-electric effect, providing the breakthrough for voltage-based generation of sound waves and the detection of subsequent echoes. The next few decades saw developments in SONAR systems for underwater navigation. In 1942, Karl Theo- dore Dussik became the first scientist to employ ultrasound for medical diagnosis. In Fig. 1: Diagnosis of a breast malignancy 1953, Wild and Reid published the first two -dimensional clinical ultrasound images, ultrasound beams, and digital encoding of shown to Fig.1. Within a few years, ultra- ultrasound echo-pulses, have allowed for sound was used in various imaging appli- improvement of the quality and detail of cations. The first ultrasound system to im- ultrasound images, as shown in Fig. 2. age a fetus was implemented in 1961. Furthermore, by using the concept of the Ultrasound is most commonly known for its Doppler Effect and ultrasound‘s ability to use in imaging of the fetus during pregnan- detect frequency shifts, engineers are able cies. However, it is used for many other to develop ultrasound systems that display purposes. Currently, it uses are mostly di- flow properties of blood. Hence, echocardi- agnostic. However, a lot of research is be- ography also incorporates imaging of the ing conducted for its use in therapy. One of direction of flow of blood through its major uses is echocardiography, which involves the use of ultrasound to image the heart valves, allowing echocardiologists to heart and its blood flow. Initially, the field of determine if heart valves are functioning echocardiography involved the two dimen- appropriately. Currently, the main therapeu- sional static images of the heart. However, tic application is ultrasound‘s use in physio- developments in ultrasound technology therapy. The thermal energy generated have allowed for 3D and real-time imaging from ultrasound is used to stimulate muscle of the heart. Overall, improvements in relaxation. Research is being conducted on transducer design, control in focusing of the its ultrasound‘s use for thermal ablation to Columbia University Journal of Bioethics 31 destroy cancerous cells and other dis- trast imaging receives the second harmonic eases. from the response through filtration of the fundamental frequency and generates an Ultrasound uses high frequency sound as image with a much higher signal to noise the basis for ultrasound imaging and ther- ratio than conventional ultrasound imaging. apy. Exposure of ultrasound to body has Current microbubbles are capable of pass- shown no side effects; a major benefit over ing through the smallest capillaries in the body, preventing the obstruction of blood flow. However, larger microbubbles allow for better contrast imaging. Hence, it is important to find a balance between the safety of the microbubble size and its ability to improve imaging. Microbubbles must also be durable, so they can reach the site of imaging and endure the energy imparted by the ultrasounds acoustic field. In order to allow for stability, the microbubble is filled with heavy gases, since they have a low solubility and high persistence. ―The preferred gases include fluorinated gases such as sulphur hexafluoride, octafluoropropane, or Fig. 2: (a) An image generated through conven- decafluorobutane, which are innocuous and tional ultrasound. (b) An image generated exhibit, low solubility in aqueous media.‖2 through digitally encoded ultrasound. Note, The shell of the microbubble is designed to X-ray, CT, or PET imaging. In addition, it is be elastic to prevent breaking and to pro- a relatively low-cost imaging solution; a ma- mote resonance. jor benefit over MRI imaging. Hence, ultrasound imaging is a non-invasive, low-cost, Contrast imaging has allowed of various real-time capable imaging modality. lesions in the body; primarily those that show contrast enhancement patterns. Many of the most important recent techno- Therefore, in Europe they are commonly logical achievements in the US imaging in- used as a means of ruling out the existence dustry were prompted by the advent of mi- of certain lesions. Furthermore, ultrasound crobubble contrast agents, which led to can be used for monitoring the blood supply revolutionary innovation in the form of con- to tumors. Finally, contrast agents have al- trasts specific imaging modes‖. Contrast lowed for detailed imaging of the perfusion specific imaging significantly improves the of the kidney, allowing for improved detec- detail observed in ultrasound images, allow- tion of prostate cancer in clinical tests. ing for the possibility of imaging at the molecular level. Contrast imaging relies on the A number of pathologies result in the injection of microbubbles into the patient‘s upregulation of specific receptors. This pro- blood circulation. These microbubbles reso- vides the possibility for designing microbub- nate when in contact with the ultrasound‘s bles that are capable of targeting these re- acoustic field and provide a non-linear receptors, allowing for imaging of the pathol- sponse. Hence, the microbubbles provide ogy. Recent scientific studies have de- an echo that has multiple harmonics. Con- signed microbubbles with specific antibod- 32 Fall 2008

ies bound to their shell allowing for targeting. Targeting microbubbles can open up One of the largest ethical issues surrounding possibilities for detection of inflammation, microbubbles is that it could manipulate the volumetric reconstruction of a tumor, and genes of the patient by injecting DNA or a the detection of smaller lesions. Essentially, virus into the system via the microbubbles. targeted contrast agents can improve the The microbubbles would be sent to targeted specificity of imaging beyond the improve- tissues and initiate the release of DNA or a ments provided by free flowing contrast virus, as described in the previous section agents. When applied to therapy, microbub- on drug delivery, to help rectify the problem. bles could be used for drug delivery. Essen- This raises many ethical issues, including a tially, this would involve containing the drug physician breaking the Hippocratic Oath. Is within delivery systems, such as lyposomes injecting a virus into someone‘s body ―doing and micelles. Then the microbubbles can be no harm‖? Is it unethical to manipulate a ruptured at the location of the pathology. patients DNA? Considering that current The ruptured microbubble causes pores to medical science cannot address the long be opened in the membrane of the drug de- term effects of gene manipulation, there is a livery system and the membranes of cells at great debate over the use of gene manipula- the site of pathology, allowing for localized tion in humans. Some argue that it is playing drug delivery. This technique is known as god and that manipulating human DNA is sonoporation. It is important to note that unethical, while others wave it in as the cure microbubbles can be destroyed with ultra- of the future. While these debates rage on, sound in the range of diagnostic imaging. it is important to realize that scientists are Hence, the acoustic field created for drug not sure of the long lasting effects and that it delivery will provide no damage to the body. will take a few more years of research be- In addition, the pores opened by sonopora- fore it would be close to testing on humans.3 tion are seen to close a few seconds after Once it is testable in humans, it will be the opening. The goal of such techniques would FDA‘s choice as to whether using gene ma- be to focus therapies to tumor sites. If drug nipulation is reasonable for the public delivery becomes a feasible modality, it sphere or not. Hence, this example provides could be improved with targeted microbub- a possible controversial use of ultrasound- bles. assisted delivery systems.

Microbubbles, though a potential solution for The FDA will also have to decide if the sub- many diseases, has many ethical issues stances being injected are safe. Many ethi- surrounding both its delivery methods and cal issues surround the use of the targeting its availability. The delivery methods raise mechanism of microbubbles and their ef- ethical issues regarding use of viruses and fects on the body. The rupturing of micro- DNA manipulation, targeting the correct site, bubbles opens pores on the cell mem- and release point for the drug. Other ethical branes, and thus, has a direct effect on cell issues surround the availability of microbub- physiology. Hence, a physician must en- bles, as they may be expensive and have sure that the microbubbles are going to be possible negative side effects. However, broken down in the right spot so that the despite all of these ethical issues, the po- medication takes effect in the right area, tential of microbubbles-based ultrasound but also that other cells are not unneces- offers hope for many people who need gene sarily affected by sonoporation. In addition, and cancer therapy. the biological effects of sonoporation must Columbia University Journal of Bioethics 33 be seriously analyzed through clinical trials. as a treatment, would still be in the thou- In addition, the delivery of potentially harm- sands of dollars. Unfortunately, when ap- ful drugs to sites of pathology open a whole proximately 45 million Americans don‘t have new dimension of ethical concerns. If a mi- health insurance, it seems very unlikely that crobubble containing a cytotoxic substance everyone will get an equal opportunity to to help combat cancer is released in the have microbubble therapy if they need it. wrong spot, it could be potentially fatal to Also, current medical science doesn‘t under- the patient. This means that the microbub- stand the possible negative side effects, bles must target the precise location of pa- which can lead to disaster for a family that is thology and the ultrasound must be specifi- not well off and now has to take care of a cally focused, because permanent damage family member who is incapacitated. can occur from the smallest error. Also, Though microbubbles are still not ready for there are issues human testing, it is important to notice the with how to inject possible issues that may arise from such a someone. Is it technology and to be prepared for worst safe to let micro- case scenarios. bubbles flow through a pa- There are also ethical issues that concern tients blood- nanotechnology that apply to microbubbles. stream to get to Microbubbles greatly enhance the images the target loca- that ultrasound gives; however, is it always tion or should the necessary to inject microbubbles for these bubbles be ap- images. Considering the risks mentioned plied as close as possible to the infected above, it is plausible that for some ultra- site? If the drug is released at the wrong sounds, the level of detail created by the point, the procedure is potentially fatal; how- microbubbles in unnecessary. This leads to ever, it isn‘t always possible to inject micro- an ethical issue about when is the use of bubbles directly into the targeted area. This microbubbles appropriate. A pregnant leads to a conundrum, since the medication woman probably doesn‘t need microbub- needs to get into the body, but it could be bles for her ultrasound where as trying to potentially fatal if released in the wrong find evidence of heart disease in a middle spot. However, the risks are dropping rap- age man may necessitate the use of micro- idly as modern science has found it possible bubbles.5 This leads to issues over the to target areas of the body easily without standards of practice such as when micro- having the microbubbles break prematurely bubbles should be used and how much risk (Tsuitsui). All that needs to be worried is involved. Currently, Contrast Enhanced about now is the human error in targeting. UltraSound (CEUS) is used for identifying cancers, inflammatory diseases, and blood Humans, as a species, tend to create many perfusion in organs. In these cases, the risk ethical issues out of societal issues. One of of not finding one of these problems is the ethical issues that plagues the use of greater than the risks of using microbub- microbubbles is the socio-economic benefits bles. Standards and applications are really that will be reaped only by those who can risk optimizations in which physicians tries afford the cost of a new technology. Though to way the risks of using microbubbles for a it will be much more cost effective for finding more enhanced image versus the risks of heart disease early (UNMC), microbubbles, the issue that the microbubbles would be 34 Fall 2008 trying to enhance. A pregnant woman that in rare cases, certain people show an doesn‘t really need to see the finer details allergic reaction to microbubbles6. If this is of the fetus but a doctor may seriously the case, it is important for a doctor to be need to consider enhancing the image of a ready for a patient to suffer from an allergic middle age mans heart to see the develop- reaction. ment of heart disease. Stopping heart disease from developing inside a person is As microbubbles begin to evolve into a po- worth the risks of microbubbles causing tential medical treatment, many of the issues potential problems. discussed previously require answers. Cur- rently, institutions from the U.S.A, U.K, and Though many ethical issues surround mi- Australia believe that there are five basic crobubbles, their potential use in medical solutions to help minimize the risks of using technology are boundless. Though the use microbubbles. These include scanning at of microbubbles may come at a risk to the lower mechanical indices, scanning at patient, very few things in life do not involve higher frequencies, reducing total acoustic some form of risk. The concern is if the po- exposure time, reducing contrast agent tential benefits out way the risks. Since dose, and adjusting the timing of cardiac scientists cannot be sure of the side effects triggering.6 Since this is a very recent tech- or potential negative impacts, it is hard to nology, more research needs to be done determine; however, the potential benefits before determining exactly what steps need make microbubbles an almost necessary to be done to solve some of the dilemmas medical technology to research. Despite mentioned. However, a plausible solution for the fact that microbubbles rupture cell walls the time being, though possibly a little un- and can potentially cause damage to the ethical, is family history and screenings. body, it offers options for fighting cancer, Though it may be unethical to discriminate finding heart disease early, and delivering due to someone‘s family history, the effects medications to specifically targeted areas. of microbubbles is still widely unknown; As technology improves, hopefully micro- therefore, the use of CEUS should be re- bubbles will become useful form of treat- served for people with family histories of ment for those who truly need it. heart disease and cancers, thus limiting the risk of damaging a person who is perfectly The potential risks of modern microbubble healthy. If a person potentially has a chronic technology can be impeded through many disease and it runs in the family, it is worth different methods. First, physicians should the risk to have microbubbles injected; how- not use microbubbles Konofagou, Elisa. ever, if your family history shows no sign of ―History of Diagnostic Ultrasound.‖ Lecture a chronic disease, it might not be worth us- 1: Introduction: Diagnostic Ultrasound Imag- ing microbubble for the sharper image. ing. Department of Biomedical Engineering, Columbia University: 2008. on areas where References: damage to microvasculature could be potentially very harmful. This would include the Barnett, Stanley B. et al. ―Recommendations eyes, brain, or a fetus. Second, the use of on the Safe Use of Ultrasound Agents.‖ Ul- electrocardiograms will help physicians trasound in Medicine and Biology. World monitor how a patient‘s heart is doing as Federation of Ultrasound in Medicine and CEUS can cause disturbances in cardiac Biology. Volume 33, Number 2: 2007. rhythm. Finally, there has been evidence Columbia University Journal of Bioethics 35

Blomley, Martin. ―Which US Microbubble Contrast Agent is best for gene therapy?‖ Radiology. Volume 229, Number 2: Novem- ber 2003.

Schneider, Michel. ―Molecular Imaging and Ultrasound-assisted Drug Delivery.‖ Journal of Endourology. Mary Ann Liebert, Inc. Vol- ume 22, Number 4: April 2008.

Tsuitsui, Jeane et al. ―The use of microbubbles to target drug delivery.‖ Cardiovascular Ultrasound. Volume 2, Number 23: Novem- ber, 2004.

UNMC. ―Microscopic bubbles unlock key to detecting heart disease early.‖ University of Nebraska Medical Center: February 10, 2005.

36 Fall 2008

Bioartificial Hearts, Bioethical Issues

By Esty Rajwan and Ditty Vick

Columbia University

Each year, cardiovascular diseases top the cadaveric rat hearts and removed their DNA list of the most serious health problems and intracellular structural proteins. The around the globe, with 22 million people decellularized rat heart was then mounted in living with heart failure. Heart a bioreactor and seeded with freshly isolated transplantation remains the most effective neonatal cardiac cells through intramural treatment and for many, the only chance of injection. The researchers concluded that survival. In the United States, there are given enough maturation time to reestablish between 60,000 and 100,000 people who its vascular architecture, an organ could benefit from a new heart. Due to an processed in this way could be acutely limited supply, only 2,300-2,400 transplantable, in part or in entirety, for end transplants are performed each year, stage heart failure. This decellularization meaning that about 70% of patients in need procedure (leaving an acellular scaffold with of heart transplants cannot get them and die perfusable vascular architecture, competent because of the limited availability of donor acellular valves, and intact chamber hearts (AMA, 2008). geometry) was also successfully applied in this study to a porcine heart, indicating that The lack of supply of transplantable hearts is the technology could also be scaled to not, however, the only obstacle facing hearts of human size and complexity. transplant recipients. Those who do receive donated organs face aggressive medical Further study and improvements of this treatments that might have harmful side technology might lead to its application to effects, to keep their bodies from rejecting human trials and potential solve the the transplanted organs. problems of immunological rejection and obtaining sufficient organs. Bioartificial Several attempts have been made to hearts would be obtained from cadavers and engineer an artificial heart. Most could be reseeded with a patient‘s own cells, approaches have been limited by the thereby eliminating immune system rejection inability to create the geometry necessary to complications. The potential to apply this support the high oxygen and energy technology to humans appears real demands of cardiomyocytes in areas deeper especially since this technology has been than the surface tissue (Eschenhagen and used to create a human trachea that was Zimmermann, 2005). Cadaverous hearts transplanted into a woman (Webster, 1998). have been recently used to overcome this problem (Ott, et al., 2008). With this There are three bioethical concerns related technology the organ from the ―donor‖ is not to this new technology. First, would transplanted directly into the recipient. obtaining human hearts using this Rather, it is decellularized and reseeded technology create inappropriate issues with with endothelial cells and cardiomyocytes. respect to organ donation and the selling of In their study, the scientists collected 140 organs. Second, what bioethical issues are Columbia University Journal of Bioethics 37 related to the use of animal hearts to form might, with the advent of bioartifical heart the architecture of these bioartificial organs. technology in humans, come from foreign Lastly, what are the bio-legal issues that countries where there might be less might emerge using this technology. oversight than in America. It is possible that an underground market might develop in The scarcity of donor hearts in the current which the poor are forced to sell the corpses system is partially due to very limited criteria of their family members in order to make for who might be considered as an eligible money. It is also possible that the bodies of heart transplant donor. In addition to strict prisoners might be used for this sort of requirements of age of donor, ischemic time organ donation, without any consideration of (the time between interruption of circulation the ―donor‘s‖ desire. to the organ and reestablishment of circulation), size of donor, medical history of One way to bypass some of these issues is the donor, and conditions of the donor heart, use animal hearts as donors. Generally, in most countries a patient must be rendered when bioethicists think about brain dead in order for his heart to be xenotransplantation, the transplantation from harvested (Wittwer and Wahlers, 2008). As one species to another, one of the main of now, the donor (before his death) must issues of concern is the possibility of have given explicit approval for organ unwittingly spreading animal diseases to the donation in order for the organs to be human recipients, such as porcine removed. This decision to be a ―card- endrocrine retroviruses (PERVs). If the carrying‖ organ donor is necessary in the animal-donated cadaveric hearts are current system of organ donation because completely decellularized however, this there is little time available between the issue becomes irrelevant, the assumption moment of death and the time that the organ being that the acellular matrix will not retain is harvested. There is little time to contact animal diseases that could be transmitted to family members to get approval for organ a human recipient. New screening tests harvest if the potential donor does not carry would substantiate that the acellular hearts identification of his desire to donate his were in fact, viral free. However, there are organs. However, this would be different if still bioethical issues of concern. First of all, the donor‘s heart would be useful with a high some people think that xenotransplantation ischemic time (and we assume here that the is an unethical process because it is technology described in the study at hand ―unnatural‖ or against their cultural and could be applied to hearts with high religious ideals. Although many medical ischemic times). A new bioethical question processes are ―unnatural‖ and are generally arises: Can a family decide to donate a not considered to be unethical, medicine family member‘s heart even if that person must accept that some people will find the did not consider the possibility of becoming possibility of a xenograft to be anathematic an organ donor during his lifetime? If the to their values because they do not want person has no immediate family members, their bodies or the bodies of their loved ones might someone else close to him or her also to be part animal. There is the possibility make this decision for the potential donor? that animal-based bioartificial hearts will be less expensive to obtain, and therefore there The possibility of using hearts with large will be a division along the lines of class for ischemic times becomes an even bigger who receives a human-based heart and who issue when we consider that these hearts received an animal-based heart. If we 38 Fall 2008 assume that a human-based heart would be medical history of the donors and recipients preferred over an animal-based heart, we‘d and the locations of both donors and have a class divide of health that seems recipients. It could also take into account a unethical because the wealthy would be donor‘s preferences about the destination of able to obtain better treatment. their heart, such as if they wished their organ to go to a recipient with children or to If this technology becomes clinically a recipient for whom it is predicted that the approved there will emerge three sources organ will extend life by a certain number of for heart transplants. They are: (1) hearts years. obtained from human donors and transplanted immediately after the death (2) One might think that it would be easy for a bioartificial hearts engineered from human potential recipient to put in all the ―right cadaveric hearts, and (3) bioartificial hearts answers‖ that will move him to the top of the engineered from animal cadaveric hearts. waitlist for an organ. But these ―right Although information describing how the answers‖ would not exist because the waitlist system works currently is not readily algorithm would take into account so many available, the American Heart Association different factors contributing to the match states that ―Donor organs are given between donor and recipient. Even with this according to the severity of the illness or complex system, however, no transplantable status level of the patient, size and blood heart is likely to be perfect. The key issue, group compatibility, and the length of time as has been mentioned repeatedly in the spent on the waitlist‖ (Jurt, et al., 2002). bioethical literature, is to always respect autonomy. This translates in practical terms We suggest the implementation of a more to an upholding of the importance of complicated algorithm than the one implied transparency of information and informed by this sentence. We propose an algorithm consent, so that any potential recipient of a that would match any heart (of the first, heart transplant knows and approves of second, or third type) to a donor based on exactly what he‘s getting in to or actually, he the factors already in place, but also other knows exactly what is getting into him. factors having to do with the bioethical preferences of the particular donors and recipients. For example, a recipient might References: decide he doesn‘t want an animal‘s heart, and he would be able to input this ―Heart Disease and Stroke Statistics.‖ information into the database. Also, patients American Heart Association, American might be able to input the amount of risk Stroke Association. 2008 Update At-a- they‘d be willing to take if a heart of a certain Glance. non-ideal profile would become available. Although the scientific data is not yet available to compare the efficacy of the Eschenhagen, T. & Zimmermann, W.H. three different types of hearts, we assume Engineering myocardial tissue. Circ. Res. there would be differences and patients 97, 1220-1231 (2005). would be able to determine their comfort in taking a certain risk for a potential benefit for Jurt, U., K. Delgado, K. Malhotra, H. Bishop, these non-ideal organs.1 This complex and H. Ross, Heart Transplant: What to algorithm would also take into account the Expect. Circulation 106, 1750-1752 (2002). Columbia University Journal of Bioethics 39

Ott, Harold C., Mattheisen, Thomas S., etc. Perfusion-decellularized matrix: using nature‘s platform to engineer a bioartificial heart. Nature Medicine 14, 213-221. (January 2008).

Webster NR. Animal Tissues into Humans. Br J Anaesth 80, 281-282, 1998.

Wittwer, Thorsten and Thorsten Wahlers. Marginal donor grafts in heart transplantion: lessons learned from 25 years of experience. Transplant International 21, 113 -125 (2008).

1The idea that less-than-ideal donor hearts should be accepted and used has been suggested in recent literature (Wittwer T, Wahlers T. Transpl Int. 2008;21:113-25. Epub 2007). The authors suggest that the potential benefits of using non-ideal hearts are likely to far outweigh the risks associated with using these hearts in transplantations. atients could then decide, on a numerical scale, how willing they are to take the risks associated with less-than- ideal hearts.

40 Fall 2008

A Dearth of Donations

By VikrumThimmappa and Jocelyn Lo

Columbia University

In 2008, for the first time in United States illegally fill the void in organ supply. history, a physician was charged with overprescribing drugs to a patient. Dr. Perhaps it is time to authorize the Roozrokh didn‘t just overprescribe Ruben questionable sale of organs. The questions Navarro; he expedited Navarro‘s death in that arise then are whether this is ethical order to recover his salvageable organs for and if permitting the sale and purchase of transplantations. organs in the U.S. would transform organs into just another commodity. This is only the beginning of the ethical tensions arising in response to the There would certainly be benefits to this increasingly limited number of organ policy. On a societal level, the supply of donations. Physicians, patients, and their organs from those persuaded by financial families are now questioning how and where incentives would theoretically increase, to procure these organs since the supply while individually, donors could turn a profit has not proportionally increased with the from items obtained free of charge at demand. birth. In addition, black market transactions of organs would decline, since these goods One possible solution to prevent other would be available through legal physicians from acting like Dr. Roozrokh is avenues. Even crimes related to organ to legalize the sale of organs. Currently in thievery would wane since making the sale the United States, it is illegal to purchase of organs legal would reduce their price in and/or sell organs according to the National the market. Hopefully, situations like the Organ Transplant Act of 1984, and organs recent kidney racket in India, where a are only available as donations from doctor solicited poor individuals with promise the living or the recently deceased. Already of work then stole and sold their kidneys, will evident by the surge of black market no longer have reason to occur. transactions in organ sales and transplant tourism, these populations are being forced Conversely, while neglecting the practical to pursue alternate, illegal limitations of legalizing organ purchases routes. Illustrating the desperation of from deceased individuals‘ families, this patients in need of organs and system has ethical implications and businessmen in need of money, reports consequences that are enough to suspecting Chinese authorities of selling highlight its inadequacies. By executed prisoners‘ organs without their or placing financial value on deceased family their families‘ consent, blazed through the members' organs, cultural and religious media in mid 2007. Opportunistic values are called into question. True, the individuals and groups have stepped up to body no longer serves a practical purpose Columbia University Journal of Bioethics 41 after a person's death, but the issue of donation system, which currently relies on distinguishing betweena person‘s body and the consent of donors before their deaths or a person‘s identity emerges. their families after the fact, to that of presumed consent. Spain and Austria On a more fundamental level, families must have already effectively enacted versions of consider whether the sentimental value of a this presumed consent system to raise family member‘s body can be translated into organ supply. Currently, the U.S. registered monetary gain. This is where the difference 21.4 organ donors per million while Spain lies between selling and donating an organ. boasts 35.1 organ donors per million as the Selling an organ transforms the act of saving highest of any country. It is time for the U.S. a person‘s life into one of personal to enact the same policy. benefit. One consequence of organ selling is the donor‘s concern about pre-mortem Instead of sending out renewed drivers' patient care. In extreme circumstances, like licenses with donor card forms that indicate that involving Dr. Roozrokh, patients' well- an individual is willing to donate organs, the being and care could be neglected, since forms should request the explicit dissent of through the patient's anticipated death, a organ donations. In this case, as opposed commodity would become available. to the former, explicit dissent opens the possibility for those on-the-fence or Although increased dona-tions because indifferent individuals to contribute their of financial benefits could theoretically organs, thereby increasing the organ supply increase the organ supply by encouraging but also creating an additional purpose for unethical medical action, organs would still their passing--to save another person‘s life. most likely come from those who need the money most urgently. The financially disadvantaged would inevitably be exploited. Legalization would catalyze the struggle to balance the need for organs to save patients‘ lives and the manipulation of desperate individuals willing to sell their organs to the highest bidder. This would undoubtedly result in a steady stream of transplantable organs flowing to the rich.

Although there are benefits to legalizing the sale of organs, the negative conclusions drawn from an ethical perspective clearly overshadow this system's practicality as a means to increase the supply of organs in the U.S. Do we really want a society in which organs are primarily given to those with the greatest ability to pay? Other options need to be examined.

Undoubtedly, the U.S. should revamp its 42 Fall 2008

A Bun in the Oven

By Jennifer Gillman, Anna Plitt and Andrew Behrens

Columbia University

t‘s 3 AM and your child is asleep. But necessary to understand the effects on the something is happening in the world: this developing fetuses. At birth, a premature child is being developed in a laboratory. infant‘s brain is not sufficiently wired, and Years ago, a child born prematurely at 26 therefore the rest of its development weeks was not expected to survive, or would depends on the environment in the NICU. survive only with severe lifelong illness. Generally, research shows that extremely Attempting to save these babies was an act low gestational age infants are more prone of heroism. Now, with new improvements in to brain injury and lung diseases. neonatal technology, many of these infants Furthermore, the NICU has been shown to can be stabilized and sent home after put these preemies at a higher risk of neuro- months of treatment. As research in developmental disorders. Until these neonatal technology continues, investigators artificial wombs become fully developed, are also examining how to grow embryos children maintained in them may survive but and fetuses outside of the womb – will this will face serious medical challenges. be this seen as an act of triumph, or are the ethical implications too much of a burden on Our bodies have evolved in such a way that our society? the intrauterine environment provides the perfect conditions for embryologic and fetal It has been predicted that growing a full development. Sigmund Freud called the baby in an artificial womb will be made womb the ―stimulus barrier,‖ because it is possible in just a few years. Nine years where the fetus can develop undisturbed. ago,Yosinori Kuwabara designed a tank, The stress of a typical NICU or an artificial filled with amniotic fluid and equipped with womb works against the intricate and an umbilical cord, to develop a 20-week old delicate development of the human body, goat fetus for additional 21 weeks (to full while the architecture of the mother‘s womb term). Furthermore, Dr. Hung-Ching Liu provides the perfect conditions to sustain showed that human embryos would attachto life. If this womb is replaced with a highly a uterus-like chamber lined with human irregular and variable NICU environment cells. The artificial uterus was simply a mold before 37 weeks of gestation, the preemie of collagen plastered with endometrial tissue experiences shock. to prompt the embryo attachment. Currently, she intends to continue her research up to The natural womb goes beyond assisting the 14-day limit placed on growing human the physical development of the child. The embryos in laboratories. child‘s regulation of emotional behavior begins in the mother‘s uterus and continues With emerging technologies that aim to after birth for full term babies. Disrupting this simulate a uterine-like environment, it is bonding time leads to disorganized Columbia University Journal of Bioethics 43

behavior. When the child is in the womb, it reproduce? If not, will women have to becomes familiar with the mother‘s acquiesce to surgery to withdraw the fetus? heartbeat, and later learns the sound of her The problem would then snowball into the voice. Thus, if we were to have a child question of how to support these children in develop completely outside of the mother‘s our already crowded foster care facilities. womb, there could be the psychological consequences due to the absence of this On a more positive note, if regulated mother-child bond. appropriately, this kind of technology could become the sequel to in vitro fertilization and Frank Duffy, a physician at the Children‘s in vitro implantation. If this technology is Hospital of Boston states, ―In the early days proven to be safe, the responsible of neonatology, just having these babies application would be towards women who survive was a miracle. Now it‘s more or less wouldn‘t be able to otherwise conceive a expected that these ‗miracle babies‘ will child. Also, it is very likely that if this survive. We have to help these babies to be procedure is approved, it will be very comparable to full term infants. That goal is expensive, and artificial wombs will not within our grasps.‖ It is more important to become the norm. improve on the outcomes of the children that we know will survive, as opposed to Assuming that the reproductive assistance funneling money and resources towards method would be the most practical usage technologies that will most likely lead to of artificial wombs, the major ethical priority more underdeveloped children. Researchers would once again focus on the well being often get ahead of themselves, and that is a and development of the child. This is an great path towards innovation, however, we issue that is relevant today, and work is must first develop environments that are being done to improve the environment of safe enough to promote the normal the NICU to promote the child‘s neurological development of premature babies. as well as physical development. This seemingly small step is the key that justifies Nevertheless, even though it sounds like opening the door to the realm of artificial science fiction, we may one day see the use wombs. of these artificial wombs in our local hospitals, and we will be left to deal with the ethical consequences. Artificial wombs could one day be considered another alternative to abortion. While the abortion issue looks at the woman‘s right over her own body, the artificial womb takes the woman‘s body out of the picture; these fetuses could be born extremely prematurely and raised instead of being aborted. However, with the ―birth‖ of this baby comes the birth of many social dilemmas. Would this technology make abortions illegal once and for all, eliminating the choice of abortion for the prospect of transferring the fetus to an artificial womb? That is - do we have the right not to 44 Fall 2008

Paying For Patient Performance

Viktor Gamarnik and Ben Koo

Columbia University

As a highly regarded endocrinologist, one physicians have expressed their concern day you are rather puzzled to discover that about the P4P reimbursement model‘s your reimbursement rates have just been dependency on patient outcomes, as it is a lowered because several of your patients in commonly held belief that a doctor ought to the diabetes chronic care program that you take the role of a healer, not an enforcer. By run have been presenting with consistently measuring patient performance standards, worsening symptoms. You also know that the P4P model will effectively punish amongst all your patients, these are the physicians for their non-compliant patients. ones who have most often disregarded your Inevitably, this will lead to the rejection of medical orders. This is a possible scenario non-compliant patients by physicians; if under the recently emerging health physicians‘ incomes and reputations are insurance movement known as Pay for dependent on how many non-compliant Performance (P4P). The main objective of patients they have, such patients will soon this new medical reimbursement system is find that the quality healthcare at the very to reward physicians, hospitals, and other core of P4P programs is impossible to find. healthcare providers for the quality and efficiency of their treatment. P4P is an We believe the P4P paradigm has alternative plan to mainstream enormous potential for raising the overall reimbursement fee-for-service models, such quality of healthcare available to every as Medicare, which have been showing patient. However, this system cannot be deteriorating healthcare quality and implemented under the presumption that decreasing emphasis on effective patient patient improvement is solely a function of treatments. There are currently over a the physician‘s input. Our solution relies on hundred different voluntary pilot P4P the establishment of a more secure programs; by using rewards as incentives, relationship between physicians and many have shown evidence-based insurance providers. Such a system may be increases in both the quality and efficiency achieved by a variety of means, including of patient health care. The American College the enforcement of harsher punishments for of Physicians (ACP) stated that the insurance fraud activities. Most importantly, ―adoption of appropriate quality the institution of a more honest affiliation improvement strategies, if done right, will between the financers and actual providers result in higher quality patient care leading of healthcare will allow the focus on to increased physician and patient performance to shift toward the patient. satisfaction.‖ However, the illustration above When an insurer detects a case of a patient reveals one glaring problem in the P4P with a deteriorating condition, the first model: physicians are held wholly course of action will be to assess the responsible not only for their performance, situation with the physician. If there is but for the actions of their patients. Many sufficient reason to believe that the patient‘s Columbia University Journal of Bioethics 45 condition is worsening due to a voluntary the insurance providers but participating non-compliance issue, a closer investigation physicians and, most importantly, patients. of patient behavior will be warranted. Finally, In addition to the already proven positive if non-compliance is verified, oversight then effects on overall healthcare quality, our becomes the insurer‘s responsibility. For model will encourage greater patient example, the patient‘s premiums may be compliance, ultimately leading to decreased increased, and in extreme cases patients long-term costs. may be presented with the possibility of losing coverage altogether. Though such methods of enforcement may seem contrary to common notions, the rationale is clear: a patient who refuses necessary and proper treatment for a condition presents the insurer with unacceptable risk, and a guarantee of increasing expenditures in the future. The crucial feature of this system is that physicians become key participants (as opposed to sole victims) of the performance assessment process. As such, they are responsible for ensuring the distinctions between non-compliance: an elderly Alzheimer‘s patient who frequently forgets to take medications ought not to be punished; a young diabetic patient who avoids insulin injections and blood sugar monitoring for cosmetic or social purposes, however, does present an increased and highly avoidable risk to the insurer, and as such, ought to face the prospect of increased premiums unless behavior is altered. Under this system, insurers will retain the ability to objectively assess physician performance without alienating doctors from the process with the presupposition of wrongdoing. At the same time, physicians will embrace this type of P4P approach because it will provide them with a positive reason to ensure patient compliance (e.g. maintaining the patient‘s ability to pay for treatment), as opposed to the negative prospect of losing income. Patients too will be far more likely to respond to the tangible prospect of increased costs.

We therefore believe that our modified P4P reimbursement model will benefit not only 46 Fall 2008

One Word: ―Synthetics‖ The Ethics of Synthetic Biology

By Savino Sguera and Benjamin Stern

Columiba. Univeristy

It will soon be possible to design and synthesize the bacterial genome, Gibson‘s construct a live organism without a team divided it into 101 parts, each progenitor. The science of ―synthetic overlapping by 80 base pairs for joining biology‖ has existed since the early days of later. These were synthesized and joined genetic engineering, but the synthesis of together in vitro to form plasmids of novel organisms without a genetic ancestor approximately 144 kilobases in length. Then, of any kind represents a qualitative advance the plasmids underwent recombination in over previous work. The philosophical and engineered yeast, which can accommodate ethical issues raised by synthetic biology up to 2 megabases of extra genetic material. suggest an imperative to set clear guidelines The native M. genitalium genome was for the investigation and application of the modified to include a few genetic markers science. With the recent synthesis of and an additional gene that prevents viruses, and soon bacteria, the power in the adhesion to mammalian cells (incorporating hands of individuals who can wield it for the safety recommendations proposed by good or evil. Rather than simply implore Alisomar conferences of the 1970s). Though scientists and engineers to ―do no evil,‖ we no bacterium was generated from this must take active precautions to regulate synthetic genome, the next logical step is synthetic biology. Philosophers, ethicists, sure to happen soon (if it has not already). and religious figures should be included in the discussion about the synthesis of The applications of synthetic biology are organisms so that the technology can be limited only by the extent to which science used for the betterment of humankind and chooses to pursue them. Engineered our planet. bacteria could, among other things, produce life-saving drugs at relatively little expense, In January 2008, Daniel Gibson, Craig remove carbon dioxide from the Venter, and others (Gibson et al., 2008) atmosphere, process toxic pollutants, and reported the first successful fabrication of a capture solar energy. Conversely, the bacterial genome, that of the Mycoplasma potential evil is rivaled only by nuclear genitalium. Though this species possesses weapons: the engineering of infectious the smallest known bacterial genome, the diseases or even a ―superbug‖: a virus or accomplishment represents a landmark in bacterium that is fatal, easily transmitted, synthetic biology. Previously, the longest and resistant to known drugs. After decades DNA sequence synthesized was 32 of debate and speculation about the kilobases long. However, the M. genitalium plausibility of engineering an organism, genome, the shortest of any bacterial Pandora‘s Box has been opened. The genome, is over 500 kilobases. To abundance of concerns throughout the Columbia University Journal of Bioethics 47 philosophical spectrum has prompted many adhere: life is greater than the sum of its individuals to demand a broader public parts. Most religions go further to claim that awareness of the implications of this new an unquantifiable force governs the creation biology. (IDEA League Summer school, and sustenance of life; synthetic creation is August 2007). hence seen to be ―playing God.‖

Of utmost concern is the security of These ethical issues should be addressed in biosynthesis technology from malicious an organized and timely way. First, the interests. Can humankind create a more scientific community should strive to reach a virulent and dangerous life-form than nature consensus on the proper design, already has? The development of pathogens engineering, production, and use of for the purpose of bioweaponry could synthetic organisms. Scientists, ethicists, conceivably occur without bound with the religious leaders, and jurists should be use of widely-available protein components convened in a conference similar to as the science improves. Asilomar in 1975. The goals of the conference should be far-reaching and Some have looked beyond these immediate address the future possibilities of synthetic risks to the possibility of negative impacts on biology, notably the complete design of nature. The introduction of a new organism higher forms of life—including humans. whose existence is not the result of common However, the conference should also focus evolution can significantly affect not only the on the technologies that will appear in the natural environment but the natural gene coming decade. Here are our pool as well. Synthetic and traditional recommendations for some of the measures bacteria can interact to compete for nutrients to be considered, with specific attention to or even exchange genetic material; there bacteria. are as of yet no means to predict the specifics and magnitude of the resultant To address the possibility of uncontrolled environmental changes. reproduction and infection, all bacteria engineered from scratch should include The arrival of engineered bacteria has multiple suicide pathways for use as an renewed the debate in the scientific ―abort‖ system. Each pathway would be community regarding the definition of life. (A activated by an existing compound not found simple distinction between ―natural‖ and in most natural environments, but known to ―artificial‖ life becomes blurred when be generally safe to other organisms speaking of extant life forms recreated from (alternatively, a novel engineered compound proteins). Synthetic biology also raises could be used). The multiplicity of pathways questions to which scientific inquiry may reduces the chance of adaptation to the never provide a definite answer. This is true abort system. The abort toxins would be because, contrary to the beliefs of most of used to kill off bacteria in the event of the world‘s population, conventional science unwanted escape, unforeseen behavior, or is based almost entirely upon reductionist simply when they are no longer needed for methods. That is, it holds that a system can industrial or environmental purposes. be completely accounted for through study of its constituent parts. This belief Before synthetic bacteria are constructed, contradicts the doctrines (religious or each should be simulated in a computer otherwise) to which a majority of humans program that uses the latest artificial 48 Fall 2008 intelligence methods to model interactions of prohibitively expensive at first, but the genes. This will require the use of powerful concept represents a new way of assessing computers and the development of robust the impact of technology. If we are to craft algorithms, but is feasible on the bacterial new forms of life, we must take care that our scale. The simulation, of course, should creations will not detrimentally alter the screen for harmful effects. balance of our environment. Even with the best intentions, computer models, in vitro Next, after the bacteria are cultured and studies, and animal testing, we are likely to constructed, they should undergo DNA encounter unforeseen consequences should microarray analysis3 for a full genome-wide a truly novel life form enter the picture. assessment of expression levels. A range of stimuli should be applied to cultured bacteria While humans built ―from the dust of the to predict their response in a variety of earth‖ are still far off, engineered bacteria are environments. This will generate an right around the corner. Those engaged in ―expression profile‖ for the bacteria across policy debate should keep in mind the far- the stimuli. Each expression profile should reaching possibilities of synthetic biology, but then be compared to the expression profiles should still pay close attention to the of existing strains of bacteria with known technologies that will appear soon. Setting mutations. After this assessment animal environmentally conscious, ethical, and clear testing should be conducted to assess the guidelines for the use of synthetic bacteria bacteria‘s effects on various animals, will set a precedent for those who will face including mammals. future issues. If we set forth principles and connect them directly with policy, we can set If for some reason a toxic strain of synthetic a precedent for future generations and help bacteria is necessary for an industrial ensure technologies are used in a safe and application, the facilities in which that strain ethical way. will be cultured should follow strict safety and containment protocols. Toxic bacteria should have an additional abort pathway: they will References: be engineered to be susceptible to several known antibiotics. Gibson DG, Benders GA, Andrews- Inevitably, there will be biological designs Pfannkoch C, Denisova EA, Baden-Tillson sufficiently different from known organisms H, Zaveri J, Stockwell TB, Brownley A, that their behavior outside the laboratory Thomas DW, Algire MA, Merryman C, cannot be predicted. To address this Young L, Noskov VN, Glass JI, Venter JC, concern, we propose building a series of Hutchison CA 3rd, Smith HO. ―biosphere‖ testing centers funded by the Complete chemical synthesis, assembly, government and an industry consortium. and cloning of a Mycoplasma genitalium Each center will harbor a wide range of genome. ecological environments and animal species. Science. 2008 Feb 29;319(5867):1215-20. The bacteria should be released into the hermetically-sealed environment and the IDEA League Summer school, Synthetics: results carefully surveyed. Each experiment the ethics of Synthetic Biology‖ August would be terminated by release of the ―abort‖ 2007, The Netherlands. toxin. These ―in-terra” experiments may be Columbia University Journal of Bioethics 49

A Revised View on Scientific Fraud By Anshu Das and KrishnKhanna

Columbia University

The recent breakthrough in deriving scientific community has skyrocketed. Yet, embryonic stem cells from skin cells, at times, the value of this information seems reminded us of another ―breakthrough‖ in to falter. Publications are arising which may stem cell research that shocked the world. In not only be of little practical use, but may 2004, Professor Hwang Woo-Suk of Seoul even be completely false. National University claimed to have cloned the first embryonic human stem cell Yet while scientific fraud smudges academic (Saunders and Savulescu, 2008). integrity and ethics, to say that its impacts are only injurious would be incorrect.A silver As pre-med students, Hwang was our idol. lining does exist around this dark cloud of However, our memory of him ends tragically, scientific negligence. In one word: hype. when in 2005, the university found that he had fabricated his results. Our hero was Lets take an example outside of the world of convicted of violating bioethical law. hard science and look at the hoaxes surrounding the infamous Bigfoot. The And yet, as new stem cell developments footprints that fooled millions were revealed appear, we cannot help but continue to as a hoax in 2002. The hoax made most idolize our embezzling role model. However, skeptics ever more skeptical. But when it is this such a bad thing? Regardless of the was still considered legitimate, the hype it lack of truth behind his studies, Hwang created excited both adventurous hikers and shook the scientific community just as much rogue researchers alike. as transforming these skin cells did. And that is what a researcher aims to do: It was this hype that was responsible for discover something that will grab people‘s placing the field of cryptozoology on the attention to his/her work, so the field can map. By bringing this subject into the thrive on. mainstream, new species, whose existences were rumored, were finally discovered. Even Manufactured data and fraudulent research the attention given to the search for the is, undoubtedly, a slap in the scientific missing link between ape and man can be community's face. So why would something partially attributed to the public interest in like this happen? There is an interesting Sasquatch. analogy between economics and scientific research. The basic concept of supply and Public interest is necessary for the scientific demand is such that with an increase in community, and crucial to any scientific supply, the value of a commodity decreases. field‘s survival. When the masses become In the case of research, the commodity is captivated bya new discovery, the research information. With the advent of the Internet, in the field shifts into overdrive. In the field of the amount of information accessible to the stem cell research, this is manifested in 50 Fall 2008 numerous ways. Scientists and the public both harbored distrust towards the world of research. But In the fervor of excitement, grants are won this doubt dissipated very quickly, and the and funding is no longer a hurdle. More same fervor surrounding stem cell research researchers begin working on similar is present in the air today. For the sake of projects and the field startsto prosper. the developments and the excitement Newer discoveries are made. And, in the Hwang initiated in the field of stem cell end, it is the public who benefits from the research, doesn‘t he at least deserve some results of new technology. credit?

But the politics of the issue are brought into His fraud, like many others before his, the limelight as well. Politicians are by no intrigued and inspired those inside and means experts on stem cell research. Rarely outside of the scientific community. But are they impacted by minor developments in when the truth is revealed, the same the science of cloning. Instead, they want to falsifications smash the listeners back down see the very tangible applications of the new to reality. And it is our crushed fantasies that research. we generally remember. Seldom are the moment of epiphany, and the feeling of That is exactly what Hwang‘s ―discoveries‖ hope, and the vision of future potential taken showed them. It is these types of leaps and into account. bounds that cause the lawmakers to shift their attitude towards this controversial but In the case of Professor Hwang, the potentially life saving research. And it is rejuvenating energy his false publications these types of breakthroughs materialize the brought to the field are still quite visible. His research‘s future potential. lab stated that they hoped he would return. A number of lawmakers have pledged their Call it a fiasco, but when Professor Hwang ongoing support, regardless of their party published his radical claims, the scientific affiliation. And from the general public, over community was ecstatic. Professor Hwang‘s 700 women volunteered to donate their eggs breakthrough changed the way the masses to his lab so that his study could continue. looked at stem cells. Up until then, cloning had taken place only with cows and sheep, And if you count us, he will surely have at but the creation of a human embryonic stem least two supporters on this side of the cell meant that a human clone was no world. He had the audacity to give the field longer science fiction. of stem cell research the boost it needed to bring about the developments we see today. But such news was too good to be true. In He may not have shown that human cloning late 2005, the university determined that is possible, but he at least inspired us to Hwang‘s results were fabricated. He was believe that it could be. found guilty for embezzlement and bioethics law violations. His title was stripped and his papers retracted. References:

Did he deserve it? Through the lens of Saunders R, Savulescu J. Research ethics and academic integrity: absolutely. Sure, the lessons from Hwanggate: what can we learn from scientific community was embarrassed. the Korean cloning fraud? J Med Ethics. 2008 Columbia University Journal of Bioethics 51

IV. Neuroethics

Programmed Free Will

Elisa Fung and Lindsay Kugler

Columnbia University

In the movie Minority Report, the U.S. had that there was a significant time delay developed a precrime police unit to predict between a peak in the fMRI reading and crimes before they happened. Through the when the letter the subject recorded was use of advanced technology, genetically flashed on the screen. This indicates that altered humans were thought to flawlessly the decision was made in the brain (shown predict a criminal‘s actions before they were by the fMRI peak) before the subject was carried out and so they were arrested before conscious that they were going to make a they could do anything. In this movie, crime decision (indicated by the letter). This was virtually eliminated. Although this research implies that technology can be movie was based on science fiction, there is used to predict someone‘s actions before he potential for a precrime unit to come to even knows that he will make a decision to fruition. act. Perhaps with more investigation, earlier brain activity (more than ten seconds before Research has shown that brain signals can the decision is made) can be imaged to be detected through a ―readiness potential‖ predict the actions of the individual. in the prefrontal and parietal cortex up to ten seconds before a subject actually makes a This research is new and exciting, however decision to act (Soon et al., 2008). Through there are some issues of concern. It can be the use of the emerging technology of fMRI, useful in very select cases, but generally its the supplementary motor area (SMA), which use is detrimental. For instance, society is known to be involved in motor could benefit from further development of preparation, can be imaged. Corresponding this technology for use in spying on terrorist changes in peaks on the fMRI image are activity and preventing unnecessary visible during the process of decision- fatalities. This technology may have been making. In Soon‘s experiment, subjects able to prevent the September 11th tragedy, were asked to push either a left or right given that an fMRI image of the terrorist‘s button whenever they felt the urge to do so. brain could have been obtained at airport While they were deciding, a screen flashed security. However, its use should be a random letter every half second. Subjects regulated because it can be easily abused. were asked to record which letter they saw For example, if police were to use it to make directly before deciding when they were arrests, the so-called criminal would not going to press a button. Results showed know what he would be arrested for 52 Fall 2008 because he would not be aware that he Soon‘s research challenges this would have committed a crime in the future. fundamental moment. The whole issue of People could be arrested for their thoughts faith is refuted by the research because the and not their actions. Everyone has brain decides before the individual decides. inappropriate thoughts, at times, but most of Faith is no longer a personal decision, but these thoughts are not acted upon. an anatomical signal. According to the religious communities, faith cannot be If a convicted criminal‘s ―readiness potential‖ proven; it is not a result of neuron activation were shown on the fMRI, then current but a conscious choice. technology would not even know what that decision would be. The peak does not show Conscious choice is also important in what the decision is, just that a decision was anyone‘s mental health. Soon stated ―the made. According to impression that we are Soon‘s research, if the able to freely choose present technology were between different possible used, predictions of a courses of action is decision made between fundamental to our mental two choices would only be life.‖ The ability to make accurate 60% of the time. decisions separates These results are only humans from being as slightly better than if automated as robots. random selection had The knowledge that occurred. This accuracy people make their own level would only decrease decisions is not only vital as the decision becomes to their sanity but also to more complicated and their ambitions. If people more choices are cannot claim ownership to available. As Soon their own thoughts, it continues with his removes the need for research, society must be motivation and ready for the ramifications encouragement because that will result from his the brain will fire and findings. actions will be done according to the connections of the brain. For example, The lack of free will, which is implied by students will no longer feel the need to push these findings, will cause the religious for the greatest achievement possible. They community to question their choice in faith. will have the mentality that there is a set From the Christian perspective, there is a level that they can reach because their brain moment of re-birth, meaning that an has decided what level of accomplishment it individual ―makes a decision to follow can reach, and it cannot be altered by their Christ‖. This moment is currently defined as persevering attitude. In the long run, this will the time when God reaches into the lead to a society that will settle for less than individual‘s life, not necessarily when the its potential. anatomy of his brain decides his faith. The individual is thought to play an active role in Despite these ramifications, this research deciding when to let God into his life, yet could be valuable to the scientific Columbia University Journal of Bioethics 53 community. The more scientists know about may be a more accurate projection of the the brain and its processes, the greater the action that is later taken. While accuracy potential for better understanding. may improve, this peak will appear much Specifically, this research could be used to closer to the time of action, and so there is understand and possibly find a cure for not enough time to act upon the given data. complications in the brain, such as This means that the technology could not be Parkinson‘s Disease, Alzheimer‘s, or even used to convict future criminals, simply minor injuries that affect the SMA region. because there is not enough time to act. As Despite the potential gain from this for the religious and mental health effects, technology, there may be too many adverse the ability to refute the ―readiness potential‖ consequences to promote further indicates there is a personal choice and we investigation if the current research is are not simply programmed to follow the applied to public society. If the research is commands of our brain signals. This means purely used for the advancement of the that an individual can choose to ―make the m e d ic a l a n d decision for scientific Christ‖ or community, then i n c l u d e continuing this motivation in his research will be final decision to beneficial. act. Free will does, in fact, Although Soon‘s play a role in the research seems final instant like it thoroughly b e f o r e a n analyzes the individual does decision process, something. there are several additional factors Decisions may that need to be change due to considered. His external factors research does not in mere seconds take into account before an action that people can is made. For change their e x a m p l e , a minds during that driver‘s brain ten-second frame may signal for a between the lane change due ―readiness to slow traffic, potential‖ and the however, his time of action. consciousness Within these ten decides when it seconds, the is safe to act conscious will of the individual could decide upon this impulse. When driving, the not to act out what the ―readiness potential‖ environment rapidly changes, and so a predicts. If an fMRI is taken in the region decision cannot be made ten seconds that shows conscious decisions, then there before an action is taken. In general, 54 Fall 2008 decisions are made with outside influence up to the moment of action. The information from initial brain signals does not suffice to conclude that a particular action will take place.

Soon‘s research has sparked controversy in the cognitive science field. His preliminary results show potential for advanced knowledge about the brain, however, more definitive results are necessary for practice in the public sector. As previously mentioned, the use of this technology would not be well received by society. There is a reason why the audience of Minority Report was routing for Tom Cruise‘s character to fight against the precrime unit and what it stood for. Americans pride themselves on their right to freedom and liberty, which means their choices are not restricted by something they cannot control. However, if they were told that their choices were not their own, the foundation of America would be challenged.

Reference:

Soon CS, Brass M, Heinze HJ, Haynes JD. Unconscious determinants of free decisions in the human brain. Nat Neurosis' 2008 May 11(5):543-5

Columbia University Journal of Bioethics 55

Neuroimaging for InterGender Peace

By David Yin and Kathleen O‘Neill

Columbia University

Neurotechnology has been used to _r=1&scp=1&sq=separating % 20girls % measure brain activity in order to 20and % 20boys % 20into % 20different % understand the relationship between brain 20classrooms&st=cse). In 1995, there were function and behavior. Neuroimaging only two single-sex public schools; today techniques trace different proxies there are 49, most of which opened in the hypothesized to be correlated with past three years. The number of gender- increased mental activation. Positron segregated schools is even higher. One emission tomography (PET) allows expert estimated the number at 360, up scientists to visualize the accumulation of from only a dozen in 2002. This change is radioisotope-tagged molecules (e.g. the result of an increasing awareness or glucose). Functional magnetic resonance acceptance on the part of educators that imaging (fMRI) measures the localized girls and boys learn differently, a increase of cerebral blood flow. Other phenomenon long-observed by teachers techniques measure electrical activity, but only in the past decade buttressed by magnetic fields, and oxygen absorption. scientific explanations. Girls generally use Although neuroimaging can be used to more cortical areas of their brains for verbal investigate brain activity of humans in and emotive functioning, while boys use general, it can also be used to measure more cortical areas for spatial and differences between brains of different mechanical functioning. Reduced groups—across genders, races, and ages. concentrations in serotonin and oxycontin How and why groups are different are in male brains make boys more likely to be questions of interest to social groups as physically impulsive and less likely to sit still well as neuroethicists who must consider and empathize with friends. the ethical problems created by their research. Here we discuss ethical This separation of boys and girls into dilemmas related to the use of separate classrooms to promote better neuroimaging to uncover behavioral or learning for each group is fraught with both cognitive differences between men and practical and ethical problems. On a women in the areas of education and practical level, it is not clear that this is sexuality. actually the best way in which to group children; gender is a very crude delineation A March 2008 New York Times article of talents. In most studies, there is only one reported on the growing trend in American standard deviation between the differential public schools of separating girls and boys measurements of boys and girls, which into different classrooms suggests that in any school there will be a http://www.nytimes.com/2008/03/02/ number of boys that would have learned magazine/02sex3-t.html? better in a girls‘ classroom and vice versa. 56 Fall 2008

It would be less convenient to administer handicapped by chance is not different and personal MRIs or learning tests to each negative, but different and positive. For individual student, but those would be better historically disadvantaged minorities we have indicators of differences than sex. There is affirmative action, for paraplegics we have also the problem of pigeonholing children into wheelchair ramps, and for autistic children jobs or careers at an early age. If the there are special classrooms. If there are implication of the research is that girls should differences between men and women, the take more humanities classes and boys only type of discrimination justified is one that should take more science and math classes, benefits the lacking. Boys should never be the schools are essentially guiding their deprived of language arts to focus on math, wards into particular life paths without but instead taught language arts in a better considering the personal interests or wishes way. In sum, differential treatment inside and of the children themselves. outside the classroom based on scientific discovery should exist only to dissipate and From a legal and moral perspective, gender- compensate for inherent differences, not to segregated schools are reminiscent of the exacerbate them or to artificially raise race-segregated schools of recent past. barriers to opportunity. American law forbids different educational policies promulgated on the basis of sex. Is it The second area to explore is female different if the separation of boys and girls is sexuality (Kenneth et al., 2008; Georgiadis et done out of scientific belief and benevolent al., 2006). It was not too long ago that people intent, rather than likely racist or sexist bias? thought that women did not have orgasms, Could different brain development justify and most women were not worried if they did other types of segregation in society not orgasm. Today much of this has changed (American Psychiatric Association, 2007)? and studies have scientifically proven the To resolve this question we present two existence of the female orgasm, as well as thought experiments. If neuroimaging and localized arousal and orgasm in the female genetics prove James Watson‘s claim that brain. Moreover, medicine has suggested certain races were less intelligent than that any woman should be able to achieve others, would that be a justification for orgasm. This opens up new doors for unequal allocation of resources in school for medicine and science to enter a woman‘s the ‗smarter‘ races versus the ‗dumber‘ definition of her own sexuality. If all women races? Imagine that some individuals were should be able to achieve orgasm, does expelled from school for being ―anti-social‖ every woman have a right to her orgasm? If a but modern science revealed that they woman can‘t achieve orgasm, is it not longer actually had some neurological difference her fault or her partner‘s fault, but merely a related to autism, should they still be rejected medical condition that can and should be for poor behavior? treated? By attempting to better understand the causes and complexities of female There are other social-ethical considerations. orgasm, this part of sex becomes something First, it would exclude outliers; the intelligent that could soon be controlled by science. members of an unintelligent group would be left behind. Second, it would constitute unfair Critical to this discussion is one question: punishment. Society does not and should not what is natural sex? In order to have sex punish for something out of someone‘s (the kind that allows for procreation), a man control. Ethical treatment of individuals must orgasm. Therefore, it is safe to say that Columbia University Journal of Bioethics 57 orgasm for men in sex is natural. It is clear female orgasmic disorder as a ―persistent or that normally, many women do not achieve recurrent delay in, or absence of, orgasm orgasm, and in fact no not need to orgasm following a normal sexual excitement to get pregnant. Does this mean that her sex phase.‖ Orgasm medicines will be in that instance was not correct? Since developed out of market forces, and health science has already found some answers to insurance companies will no doubt cover the genesis of a female orgasm, should it those medicines because of the same also define what is ‗normal‘ for a woman? market forces as well as political and cultural For some women, achieving orgasm is pressures. As scientific knowledge about the difficult, verging on the impossible. Without nature of female orgasm increases, we the easy standard for men, how can predict female orgasmic disorder will be scientists determine this natural state for more commonly accepted and medications women? Neuroimaging is being used to treating it will be more widespread. study female orgasms. As the women were stimulated, brain activity rose in one sensory That there are cognitive, emotional, and part of the brain, called the primary behavioral differences between men and somatosensory cortex, but fell in the women has long been accepted as fact and amygdala and hippocampus, areas involved summarized in the phrase, ―men are from in alertness and anxiety. During orgasm, Mars, women are from Venus.‖ activity fell in many more areas of the brain, Neuroimaging technology has given society a including the prefrontal cortex, compared new way of exploring just what causes those with the resting state. Understanding the differences in the brain. The practice of areas of the brain involved in female selectively imaging male and female brains orgasms will lead to developing better for differences has the potential for justifying medications for treating the absence of unequal and unfair practices, but it also has orgasm. While men currently have Viagra for the potential to increase our ability to rectify erectile dysfunction, drugs based on long-standing biological inequalities. The targeted neurotransmitters will soon create a standard for utilizing information about group sister industry for women. Would such a pill differences should always be to increase be considered as equally important or as opportunities for a previously left behind valid a medication that should be covered by group, and never to rationalize harm. health insurance? Erectile dysfunction is defined as a medical condition—a diseased References: state for a man. In a woman, however, inability to achieve orgasm is certainly not American Psychiatric Association. Accessed conceptualized in the same way—yet. January 1, 2007.

Ultimately, whether or not health insurance http://www.psychnet-uk.com/dsm_iv/_misc/ can cover drugs for a female orgasm will not complete_tables.htm depend on the scientific definition of biologically natural sex, which seems to Kenneth R. Maravilla MD, Claire C. Yang invite the same flawed anthropological MD (2008) Magnetic Resonance Imaging surveys as a quest to find the natural and the Female Sexual Response: Overview number of menstrual cycles. It will simply of Techniques, Results, and Future depend on a cultural definition of what is Directions. Journal of Sexual Medicine. natural. The DSM-IV, for example, defines Published article online: 11-Apr-2008. 58 Fall 2008

Georgiadis JR, Kortekaas R, Kuipers R, Nieuwenburg A, Pruim J, Reinders AA, Holstege G. Regional cerebral blood flow changes associated with clitorally induced orgasm in healthy women. Eur J Neurosci. 2006 Dec;24(11):3305-16. American Psychiatric Association. Diagnostic and Statistical Manual - Text Revision (DSM-IV-TR™, 2000)

Columbia University Journal of Bioethics 59

Do You Mind If I Read Your Mind?

Adela Aguirre and Alan Daboin

Columbia University

If you ask people what special power they brain in order to describe responses evoked wish they could have, you will surely come by natural images. Two volunteers were across this answer: ―I‘d like to read minds.‖ used and, with varying degrees of Now imagine what you could do with such a surprisingly high accuracy, the pictures they power. You would be able to know what were looking at from a specific set were people think about you, what will be on the recognized simply from the brain signals. exam the following day, as well as what The experiment demonstrated that another person‘s real intentions are. But if successful identification can be drawn from mind-reading is not under your control, it can a set of 120 images and they also used a easily become your worst nightmare. And more general visual decoder to assess believe it or not, these dreams and fears performance for larger sets. Results indicate may soon become an integral part of your in one volunteer that accuracy barely grandchildren‘s lives. Dr. Jack Gallant‘s declined from 92% to 82% when the set of team of researchers have begun the first images was increased from 120 to 1000 steps that may ultimately culminate in real (about eightfold). As such, this new study is mind-reading technology (Kay et al., 2008). a frontier in neuroscience which may They claim that science is at a stage where potentially lead to the reconstruction of a we can reasonably detect what somebody is picture of a person‘s visual experience from looking at by interpreting their brain signals. measurements of brain activity alone. This calls for analysis, both in terms of Eventually this may lead to more complex looking at potential benefits it brings as well and accurate mind-reading. as in becoming aware of the bioethical ramifications that may stem from the What are the benefits derived from this technology as it becomes more advanced in study. Learning about how pictures interact the upcoming decades. with the brain and recognizing where they come from it is possible that we may learn a Functional magnetic resonance imaging, or lot more about the mysteries behind fMRI, studies were carried out to decode dreaming. And, more practically, we may certain neurological activities in the visual become better able to make diagnoses in cortex of the brain. A decoding method the brains of people with mental diseases by based on quantitative receptive-field models comparing how their brains operate that characterize the relationship between compared to normal and healthy people in visual stimuli and fMRI activity in early visual the same activities. Or, it might become areas was used. These models were used possible for paraplegics to make use of the to decode orientation, position (spatial technology by picturing images which a frequencies) and object categories in the computer would be able to recognize via 60 Fall 2008 fMRI so that they ―may be one day able to their own purposes, will we value virtues like operate machines by remote control.‖ honesty and sincerity, or will they lose their Clearly then, it looks like this could be very worth? One can argue, no doubt, that less promising if developed well. people will lie, but what matters is whether it will be out of a sense of goodness or fear. The bioethical issues concerning this There would still be a lingering doubt, and emerging technology are both complex and good people may bear the brunt of it. This, numerous. First of all, the ability to detect an of course, would be resolved if mind-reading image that an individual has seen from a set were to develop to the extent that we would of images is very valuable information. An know why somebody is thinking as they are, individual‘s privacy of mind and thought may but this surely sounds like something for the soon be invaded and used for purposes that next millennium. might not be in the best interest of the subject. And how will we determine who will As for relationships between friends and have the access to this information? Will it couples, there may be more interesting be open to everybody or a select and things to imagine. For instance, once Apple privileged few? And if knowing an has an fMRiPOD available for purchase, we individual‘s personal may have a hard time experiences via making friends at all. measurements of With processes where brain activity may we weed out those reveal information that are uninteresting about behavioral or unusual, we may tendencies, think we are speeding intelligence standards, up the process of and possibly even friend-searching, but past traumatic and we may end up emotional events that depriving ourselves of have occurred in their those friendships we lives—how will we use often have for no such information in obvious reasons. court and hiring Furthermore, you have employees or to wonder who wants accepting students? It to be friends with is interesting to consider how much of each people who will read their minds. Then quality somebody will have to possess in again, it may also become the standard way order to be accepted for something, and of operating. But what will it mean to be a how many well-qualified people will be left friend? To share secrets or private thoughts out from good opportunities because a brain will surely not play a role anymore, and scanner says so. probably everyone will be ―trustworthy‖ by then. As for couples, there will be similar And, of course, we must also consider how issues. How will issues of trust between the state of interpersonal relationships will couples be solved, and how high will divorce be in the future. If mind-reading software rates go once a spouse‘s mind can be read? were to become a sort of open-source These ponderings only hint at the complexity technology that anybody can fix or alter for that will arise in an era when mind-reading Columbia University Journal of Bioethics 61 becomes accessible. very beneficial for clinical medicine. The challenge, however, will be finding a way to Another issue looming over this technology convince people and companies that the deals with the issue of how well we know negatives will outweigh the positives if how the brain system actually works. technologies like these are abused. Because our level of knowledge is quite limited and the field of neuroscience is In sum, with the advent of new technologies constantly growing, scientists may be there always comes some degree of conveniently simplifying the mechanisms uncertainty and risk. This is especially the used by the brain and yielding linear case when dealing with technologies that explanations for their experimental results. concern brain activity and the possibilities of Although consistent correlations can be privacy-destroying techniques such as mind- found via this new use of fMRI technology, reading. As we can clearly see, we risk the possibility of excluding alternate neuroscience is at the forefront of this, and reasons for patterns that have been there may soon come the day when discovered. A more holistic way in needed to humanity undergoes a revolution of a type account for the way the body responds to its never seen before. It will extend to just environment since factors such as race, about everything, and the adjustments we class and other socioeconomic issues may make will have to be considerable. It should be responsible for visual experiences and be no wonder, then, that subjects like trends. Furthermore, because the potential neuroethics are becoming ever more of abuse of personal information can ensue, popular, as we become ready to face the it would be unlawful to base any kind of incredible implications on everything once conclusion regarding a person‘s ability on we understand the enigma that is the human their experimental results. So we must set brain. up some neuro-policies dealing with References: technologies like the ones that will emerge from Dr. Gallant‘s study. Kay KN, Naselaris T, Prenger RJ, Gallant JL.Identifying natural images from human Some solutions to the problems that can brain activity.Nature. 2008;452:352-5. arise from this are in fact associated with limiting, but not prohibiting its use. A possible source of regulation can come from the federal government. However, since this kind of federal oversight may lead to a stunt progression in the experiments for political reasons, a private non-profit intellectual and scientific organization can be placed in charge (maybe, quite fittingly, a think tank). Additionally, ensuring the technology does not diffuse easily in order to avoid societal problems is a first necessity. Furthermore, encouraging the makers of this new neuroscientific application to place a significantly higher degree of focus on its possibilities for therapeutic value might be 62 Fall 2008

GLBT Flies: The Application of Mind Control To Sexual Preference

Viktor Gamarnik and Shu Pan

Columbia University

Can the biology of Drosophila be applied, Going one step further, the authors utilized ethically, to human beings? In 2008, Clyne the recorded songs of she-male flypods to and Miesenbock sought to characterize the prompt mating in mute (de-winged) males basis for the mandatory behavioral display and virgin females. They found that while (in the form of a courtship song) that the induced female songs did not lead to precedes successful copulation in copulation, recordings obtained from Drosophila. They found subtle differences induced she-males were sufficiently between male and female central nervous convincing. The most striking conclusion systems, which could result in the male-only arising from these observations was that display of courtship song (a low-frequency both males and females possess almost single-sided wing vibration). Two genes, identical circuitry, and the differences are fruitless (fru) and doublesex (dsx), are dictated merely by the presence or absence implicated in development of sex traits. of a command signal pathway. Moreover, the authors felt that two potentially interrelated explanations were These findings exhibit a potential paradigm plausible: 1) gender specific gene shift in the way neuropsychological research expression resulting in differences in is conducted. Namely, scientists may no neuronal circuitry, or 2) both males and longer be required to rely merely on females possessing the song circuitry, with observations of wild-type and abnormal the necessary command signals being outward behaviors, but may be able to present only in the males. The authurs of induce arbitrary behavioral patterns at will by this paper 1 developed optogenic exerting control at the genetic and sensory technology to address these issues. This levels. Such techniques are clearly much technique relies on the co-expression of light more subtle and elegant than elucidation of -activated ion channels and P2X2 ATP trained responses to stimuli. To the layman receptors in neurons which express the fru observer, videos of the Drosophila gene. Selective depolarization of fru- experiments appear to be Hollywood-style expressing neurons is then achieved by mind-control: flashes of light produce injecting a ―caged‖ ATP molecule into the arbitrary behaviors, even in subjects who do cervical stalk and stimulating the system not normally exhibit nor are even aware of with UV light, which photolyses the ATP having such abilities (Cleveland Clinic cage, activating the system. This Foundation, ―A Pacemaker for the Brain,‖ configuration was then used to induce http://www.clevelandclinic.org/health/health- courtship songs in male, female, and she- info/docs/1900/1937.asp). male flypods (flies with the brain excised who still retain the ventral thoracic ganglia). More importantly, there is ample reason to Columbia University Journal of Bioethics 63 assume that this type of neural pathway is technology. Aside from its obvious uses as conserved in higher species. Courtship an invaluable tool in the field of behaviors are displayed across all varieties neuroscience, the technology has other of animals, and there are remarkable potentials, some being ethically similarities even across different species. questionable. Because sexual reproduction is the fundamental method of maintaining a life As mentioned before, a good portion of the form for multiple generations, it is quite population still hold dear the notion that reasonable to postulate that such neuronal homosexuality is a deviation from the norm. pathways evolved at an early stage, and Making numerous arguments against have since been conserved to some extent, homosexuality as being unnatural, such even in organisms such as humans. Though individuals have referenced sources as far human courtship rituals are far more ranging as religious texts to even the complex, the facility of courtship and Darwinian model of evolution, to support reproduction is so fundamental that we are their claims. The technology, as developed compelled to wonder if at least some types by Clyne and Miesenböck, may still be in its of similar neural pathways are at work. If infant stages, but its principles nevertheless such is the case, the notions of sexual apply to more complex, mammalian preference in humans may need to be organisms. In the not too distant future, such reexamined: perhaps humans too possess methodology may become a modern day male and female circuits, and differences in brain washing technique. Overzealous behavior and preference arise simply from parents who believe their children to exhibit variations in which command signals are homosexual tendencies could potentially present. A male‘s preference for female selectively activate, and in other cases mates may be due to activation of the selectively repress, the neural pathways for ―traditional male‖ or suppression of same-sex attraction. Even without the ―traditional female‖ neural circuits. Similarly, genetic technology to choose a child‘s homosexual or transgender behaviors may sexual orientation (which, given the complex not arise from ―abnormal‖ genetics (as is nature of sexuality in general may never commonly believed), but might simply result come to fruition), the ability to repeatedly from under/ overstimulation of certain stimulate specific neural pathways could pathways. The discoveries and especially accomplish the same goal. Today, deep the methodologies presented by Clyne and brain stimulation (DBS, commonly called Miesenböck (2008), as well as the recent ―brain pacemakers‖) is being used to treat advancement of such techniques in higher diseases such as Parkinson‘s, clinical animals (e.g. mice), raise concerns about depression, and epilepsy. Even though the potential applications in humans. technology is still in experimental stages, there is already discussion of non-disease The manipulation of ion channels to the applications, such as enhancement of extent of behavioral mapping and optogenic emotions. It is not difficult to see how such ‗mind-control‘ may someday be extended to technology can transition into the realm of human subjects, perhaps even falling prey sexual preference modification. In essence, to misuse and exploitation. Given the if the correct neuronal pathways are immense similarity in the underlying identified, children could readily be framework for sexuality, one should consider reprogrammed to display ―normal‖ the possible ramifications for this heterosexual—or if the parent so chooses, 64 Fall 2008 homosexual behaviors. Since the command Morelle R., ―Flies get ‗mind-control sex signals are given directly to neuronal swap‘,‖ BBC News 18 April 2008, http:// pathways, the recipient of such a procedure news.bbc.co.uk/2/hi/science/ may not even be aware of the external nature/7350403.stm. command signals, let alone rationalize their subsequent actions. Cleveland Clinic Foundation, ―A Pacemaker for the Brain,‖ http://www.clevelandclinic.org/ Obvious restrictions must be instated for health/health-info/docs/1900/1937.asp. such a technology. With the exception of scientific research, such a technology should not gain approval for use in higher mammals. Responsible use aside, the underlying mentality regarding sexuality must be re-evaluated. Contrary to popular belief, homosexuality may prove to not be an aberration of nature. As seen in the aforementioned results, males, females, and even transgender organisms have mechanistically functional circuitry for producing the specific behavioral patterns. Perhaps humans are no different in this regard. The heterosexual phenomena of male preference for female (or vice versa) may purely be the result of selective activation and/or repression of ingrained neural pathways. If such pathways are present in both sexes, then one can reasonably infer that any one individual is fully capable of exhibiting heterosexual, as well as homosexual tendencies. Through this biological perspective, homosexuality is no longer viewed as a physical defect from the so-called ―wild-type‖ sexuality. As such, sexual preferences varying from the male- female majority may be a valid product of continued evolution. Especially in a scenario of dwindling resources, homosexuality acts as a deterrent to overpopulation and benefits survival on a species level.

References

Clyne J.D., Miesenböck G., ―Sex-specific control and tuning of the pattern generator for courtship song in Drosophila Columbia University Journal of Bioethics 65

Memory Upgrades: Not Just For Your Computer

Emilia Javorsky & Wei-Jen Hsieh

Columbia University

Scientists are beginning to identify genes and can only be portrayed in a qualitative that contribute to the manifestation of fashion with vague descriptors such as memory. The identification of such genes ―barely detectable‖, ―normal‖, ―strong could provide a genetic epidemiology of expression‖. cognitive dysfunction as well as diagnostic tools to indentify individuals carrying In contrast to this subjective methodology, different allelic forms of these genes. gene chip technology can provide a more Ultimately, these new genes may become quantitative analysis of gene expression. targets for the discovery of drugs to Tully hopes that this new technology will ameliorate various forms of cognitive provide confirmatory information, gene-by- dysfunction. Timothy Tully is interested in gene, as to which transcripts are involved the genetic basis of with memory. Its memory and hopes that potential to yield ―exact his recently patented coordinated ―gene chip technology‖ transcriptional response will allow him to identify to different stimuli the genes expressed across all gene during transcription- transcripts‖ is extremely dependent memory informative (Tully et al, (long term memory) 2008). In particular, the formation, specifically coordinated effect that a candidate memory gene transcript has on genes (CMGs) and memory begets many candidate plasticity genes (CPGs) (Tully et novel questions regarding the way in which al., 2007,2008). memories are processed and stored in the brain. One advantage to gene chip Previously, Tully has taken a molecular technology is that given a large sample size, biologist‘s approach to identifying memory it is possible to quantify gene expression genes (Tully et al, 2007). His work relies on using a signal transformation algorithm; Western analysis and immunohistochemistry thus, helping to improve the statistical to detect the proteins produced by specific reliability and validity of one‘s results. An genes involved in memory cascades. By increased sample size, or larger ―n‖, can generating dsRNA-based transgenes (UAS- allow memory researchers to look at the dsNR1 and UAS-dsNR2), Tully attempts to entire organism‘s genome under the same identify which NMDARs are required during experimental conditions. This removes the memory formation. Yet, there are many subjective components that arise in implicit flaws with the techniques of Western techniques such as Western blotting, blotting. His results are merely ―suggestive‖ immunoprecipitation and in - s it u 66 Fall 2008 hybridization. Similarly, this technology and developing therapies for memory makes it is easier to replicate one‘s results related disorders and disabilities, the with a higher degree of specificity and possibility of selecting for ―superior‖ memory accuracy. alleles is disconcerting.

Though Tully is utilizing mouse and By researching memory genes you embark Drosophila models, most genes in these on the slippery slope of eugenics. If this model systems have been shown to have new technology is coupled with emerging human homologs. There is a growing reproductive techniques such as PGD, then knowledge that ―mammalian homologs can it becomes possible to select for embryos be functionally substituted in Drosophila for with superior memory alleles. Genetic its fly homolog [and in such] the present selection artificially accelerates Darwinian discovery directly implicates the evolution; thus, upsetting the natural order. corresponding mammalian homologs‖ (Tully But this isn't just another ―designer baby‖ et al, 2008). As a result, there are many issue. An improved memory capacity allows ethical dilemmas that can potentially arise if an individual to be more efficient, perceptive this technique is successfully replicated in and enhances cognitive faculties. By humans. selecting for a genotype associated with improved memory function, there is a risk of With any new technology, there is always creating a demographic of intellectually and the risk of exploitation. It is the potential for ultimately economically elite. therapeutic application that often troubles ethicists. A gene chip technology that could Inarguably, an enhanced memory would be screen for enhanced memory genes extremely advantageous for one's personal suggests that treatments to improve memory endeavors. Just think, how often have you function may be possible in the near future. wished you had a photographic memory? Though memory enhancing therapies could For professions that require substantial prove invaluable for patients with memory cognitive demands, genetic profiling may be disorders such as Alzheimer's disease and used to selectively hire candidates. Parkinson's disease, there is the possibility Employers could screen for individuals that these treatments could be abused by possessing a greater capacity to remember individuals without any memory pathologies. and recall, which would result in a pool of If the therapies were shown to improve employees with the capacity to consistently memory function in both patients and outperform their peers. Using this logic, it is controls, individuals with a normal memory possible that one's genetic profile could be capacity could use the therapies to enhance used to discriminate and determine their cognitive performance. Memory employment opportunities. enhancing therapies would be invaluable for professions with high cognitive demands; Memory is a hallmark of individuality. To however, these benefits would only be lose sole possession of one's memory reaped by those who can afford them, processes strips us of what differentiates the further propagating the expansion of the human experience. The use of gene chip achievement gap. As a result, the members technology to examine the genes involved in of the highest economic echelon will also long term memory pose a threat to an become the intellectual elite. Though there individual's autonomy. If it is eventually may be obvious benefits to understanding possible to correlate specific CMG's and Columbia University Journal of Bioethics 67

CPG's to types of events or experiences, must be tightly regulated. The prospect of then it may be possible to look at the profile artificially enhancing our learning capacity of gene activation to make inferences about seems attractive; however, there may be one's experiences. With such unexpected detrimental effects. Our current advancements in biotechnology, it would social paradigm views learning as then be possible for science to bridge the advantageous and adaptive, however recent gap of cognitive isolation and some of your research questions this theory. A recently most intimate and precious memories could published paper by T.J. Kawecki (2008) be revealed in a mosaic of fluorescent dots. examines the costs of increased learning capacity in Drosophila and remarks that The polemic is two-fold. We need to ―populations selected for improved learning separate diagnostic tools from enhancement lived on average 15% shorter than the procedures. Selecting for superior memory corresponding unselected control alleles through PGD encompasses the latter populations.‖ The findings of Kawecki‘s and should not be conflated with screening research highlight the physical toll of for life-threatening pathologies. On the increased cognitive capacity, suggesting other hand, memory enhancing drugs raise that a delicate equilibrium exists between an ethical debate with economic physiological well being and the ability to implications. Today, one can either improve learn. With the advent of memory alertness and mental concentration by enhancement, we risk upsetting the balance purchasing a cup of coffee from a corner which could ultimately contribute to our early kiosk or one can choose to take prescription demise. enhancers such as Ritalin or Adderall. While many will argue that taking expensive References: prescription medications to enhance performance is unethical, very few Kawecki, TJ. Learning Ability and individuals will oppose the consumption of a Longevity: A Symmetrical Evolutionary daily cup of Joe. What if Ritalin, like coffee, Trade-Off in Drosophila. Evolution only cost a dollar a day—would it still be problematic? If there was a memory Tully, T. et al. Specific requirement of NMDA enhancing pill that was as cost-effective as receptors for long-term memory caffeine, it is doubtful that there would be an consolidation in Drosophila ellipsoid body. ethical debate. Thus, the question becomes Nature Neuroscience 10, 1579 (Dec. 2007). an issue of access. By allowing all individuals equal opportunities to medical Tully, T. et al. Specific requirement of NMDA treatments, one removes the socio- receptors for long-term memory economic barriers which limit our modern consolidation in Drosophila ellipsoid body. health care system. Nature Neuroscience 10, 1579 (Dec. 2007).

Though the idea of memory enhancing drugs is frightening, understanding the way memory works is essential to the progression of science. While research concerning the genetic basis of memory should not be limited, the translation of laboratory findings to clinical applications 68 Fall 2008

V. Cross-cultural Bioethics: BioCEP

Sex. Education. Can they go together? Ethical Dilemmas Facing Sexual Education in Thailand and the United States

By Elizabeth Edwards*, Yoon Joo Kang** and Caroline Leone*

*Columbia University and **Mahidol University International College

Talking about sex makes people when trying to hide sexual activity from uncomfortable. Talking about sex with parents. teenagers makes people even more uncomfortable. However, many people feel Let’s Talk About Sex—in the United States that if children and teenagers are not educated about sex they cannot learn how What should be taught? One of the more to keep themselves safe and healthy. common answers in sexually conservative countries, like the United States, is Sexual education has been a fiercely abstinence. A 2004 poll by NPR (NPR, contested issue ever since the discovery of 2004) found that fifteen percent of sexually transmitted infections and the Americans believe that schools should teach beginning of the women‘s rights movement. only about abstinence from sexual The biggest questions have always been intercourse and should not provide what should be taught, where it should be information on contraception. Abstinence- taught, and to whom it should be taught. only sex ed relies on the reality that These same questions are asked all over abstinence is the only completely fool-proof the world but responses can be astoundingly method of birth control and STI prevention. different depending on religious persuasion, However, the teaching of abstinence-only past experiences and cultural norms. sex ed in schools in the United States has proven woefully ineffective. An increase in One current challenge is who should teach teen pregnancy rates has been shown within sex education. Should sex education be the schools that teach abstinence-only sex responsibility of parents, teachers, religious education (Guttmacher Institute, 2006). Is leaders, peers or the media. But with the abstinence really working? Since rapidly increasing rates of HIV and STI‘s that abstinence-only sex ed teaches that one have been seen in the last two decades, it is should refrain from sexual activity, an paramount that young people are able to abstinence-only method of sex education make informed sexual decisions that may could not possibly teach young people about help keep both themselves and their healthy sexual habits such as contraception- partners healthy. Gone are the days when use, the importance of communication in teenagers can worry solely about pregnancy sexual relationships, and sex as part of Columbia University Journal of Bioethics 69 normal (albeit unique) human relationships. gradually, beginning with basic topics at a Even in schools that teach more than just young age and progressing to coverage of abstinence, sex ed in the U.S. is still quite the more complicated and controversial conservative. In 2002, one-third of teens in topics as children mature. the U.S. said they had never received any formal instruction about contraception Let’s talk about sex—in Thailand (Guttmacher Institute, 2006). If schools in the U.S. are not even teaching about Young adults in Thailand are no different contraception, one can hardly expect them from their peers in any other country in their to discuss more controversial sexual issues curiosity and eagerness to learn about sex. such as the morning after pill, abortion, However, because the word ―sex‖ is still homosexuality, S&M and masturbation. regarded as a dirty word in Thailand, no one Because there is no clear consensus on ever talks openly about it among adults, let what is right and what is wrong these issues alone with kids. There seems to be little or make people especially uncomfortable, and no explanation as to why the topic is taboo as a result they are often completely other than outdated traditions, worried neglected in sexual education courses. parents, conservative teachers and self- righteous do-gooders that lament Thailand‘s Who should be taught? Most people believe cultural degradation and blame permissive that sex education should be taught to young Western influences for young people‘s people at some point, but there is continual rise in ―loose sexual behavior.‖ controversy over what age is appropriate to The common Thai approach, ―no begin sexual education. A more liberal belief sex please; we‘re Buddhists‖, parallels is that children should be taught about the abstinence-only sex education in the U.S.; birds and the bees as early as elementary both make teenagers‘ eyes glaze over. Thais school. Research has shown that many perpetuate a system of modesty because of students in the U.S. feel that they were not the long-standing tradition of keeping one‘s taught even general information early personal life private. Many Thais fear that enough to protect themselves against things sex education will send the wrong message like pregnancy and STI‘s when they became to youth, prompting promiscuity and pre- sexually active (http://www.urban.org/ marital sex. In modern Thai culture, publications/900037.html). Many parents however, such excuses are antiquated and fear that teaching young children about sex ignore the fact that the majority of teenagers before they are even interested in it will only are sexually active. Limited knowledge of cause curiosity and will leave the door open safe sex behavior due to lack of formal sex for unsafe experimentation. The reality, education is contributing to the resurgence however, is that children in the U.S. are of the HIV/AIDS epidemic and the rising teen exposed to sex by our widely sexed media, pregnancy and abortion rates in Thailand. even if the exposure is as minimal as Can sex ed fix this? billboards and commercials. Even young children need to begin to understand how When attempting to answer the question of they came to be and to understand what should be taught in sexual education in appropriate sexual behaviors in the event Thailand, the answers are similar to those in that this information is being withheld at the United States. From the point of view of home. A reasonable and rational argument nearly anyone concerned with public health is that sex education should be taught and individual safety, all children deserve to 70 Fall 2008 be informed. In Thailand, it is especially because they are told to. Pregnancy occurs important for people to have correct the same way in Thailand as it does in the information about HIV and abortion due to United States, and can be prevented using the problems the country is facing regarding the same contraceptive methods. No matter these issues. For many reasons, including the language, talking about sex keeps the popularity of the sex-trade, the lack of people healthy, keeps their partners healthy, education, and lack of resources, the HIV keeps their children healthy and keeps a rate has begun rising once again population healthy. Talking about sex is (Kittimunkong, 2008). In order to combat the healthy. rising HIV rate, education efforts should be aimed at people before they become References exposed. Additionally, because abortion is legal in only two circumstances in Thailand, NPR.Org. National Public Radio, Sex it is a key issue that should be addressed in Education in America.‖ . 2004. sex education classes. Women may only get . pregnancy was a result of a rape or if the mother‘s health is in danger. Because Guttmacher Institute. 2006. Facts on Sex under most circumstances abortion is not an Education in the United States.‖ < h t t p : / / option in Thailand, youth need to understand www.guttmacher.org/pubs/ how to prevent pregnancy. Because of the fb_sexEd2006.html> issues relating to HIV and abortion in Thailand, sex education should be targeted at young people, before they begin blindly experimenting.

In a country that doesn‘t talk about sex the issue of sex education is quite challenging. Although a liberal method of sex education seems counter-intuitive to a sexually modest country, trends seem to show that a lack of education is causing some of the country‘s most devastating problems.

Let’s talk about sex. No, really!

Although Thailand and the United States are very different countries with different religions, cultures and morals, youth in both countries face very similar issues when it comes to sex. Although sex education should always respect individual cultures, cultural differences do not change the fact that sex is a universal behavior. No one is immune to sexually transmitted infections. Not all teens will abstain from sex just Columbia University Journal of Bioethics 71

Behind Their Smiles: Cosmetic Dentistry and Medical Tourism in Thailand

By: Mikilena Greusel* and Dr. William Bloch**

*Columbia University and **Mahidol University International College

Would you buy used dentures off the street? Bangkok is located in a hospital specializing How about braces from a man in a tent? In in alternative medicine. At Jubilee hospital, Thailand, where dental care is provided by where Chinese alternative medicine is government insurance plans, these are studied, practiced and perfected, there is an common practices. However, international entire wing dedicated to dental care that is dental reconstructive surgeries are booming empty. Just a block away from the hospital in Bangkok, making it a capital for Eastern is a market where dentures are sold in medical tourism. As progress continues in makeshift glass cases – one can only this developing world, the ethics of medical assume they were either sold by someone tourism and cosmetic versus necessary who needed the money or donated by dental care must be explored in Thailand. families of the deceased. These fixtures will not fit properly in the mouths of those who How is it that a nation regarded on an need them; they may be contaminated to the international scale as a center for point of causing infection; they may even be reconstructive medical procedures is stolen property. It is shocking to consider reduced to taking dental care into the hands that the people who purchase these of street vendors? According to the dentures could just walk a short distance to healthcare professionals at Siriraj Hospital in Jubilee hospital‘s empty dental clinic for Bangkok, Thailand, the rampant lack of treatment – where insurance pays for at dental care throughout the country is due to least part of the charge. In Thailand, this is the continually decreasing ratio of dentists to just not done. Why waste money on a set of patients. In 2004, when the last survey was professionally crafted dentures when you taken, there were 14,000 patients per dentist could save the cash? If a tooth aches, why in Thailand. Even though Siriraj Hospital fix it? There are others, just pull it out. contains the Faculty of Medicine of Mahidol University, one of Bangkok‘s most In addition, Thai dentists often treat patients prestigious higher education centers, that without measuring the patient‘s blood ratio has continued to grow over the past pressure or taking diagnostic x-rays. By four years, resulting in a critical lack of taking the patient‘s blood pressure, the dental care among the Thai populace. dentist is screening for high blood pressure. The procedure costs nothing and can save The gap in dental care in Thailand has lives, as dentists see many patients that become so extreme due to financial realities have never been screened for hypertension. that it has forced many Thais to seek Also, dental x-rays are invaluable in oral alternative forms of dental treatment. diagnosis and treatment planning. Thai Ironically, the largest dental clinic in dentist generally have x-ray facilities, yet x- 72 Fall 2008 rays are not always taken before dental from eyelid reductions and jaw procedures, treatment. This means that much dental the most prominent facial marker of ethnic treatment is rendered without complete identity is the nose. Because of this, Asian diagnostic information, as x-rays allow the men and women – especially those in the dentist to see what is present below the gum professional circuit – are going under the line, between the teeth and in the jawbones. knife to erase their ethnic features in hopes This radiographic information can be used of looking American, European, German… for early detection of serious conditions such pretty much any ethnicity that is Western as oral carcinoma. and not Asian. Yes, this is a cultural preference, perhaps even a fad, but it For the disadvantaged Thai citizens, who cannot be ignored. unfortunately comprise the majority of the nation‘s population, dental care is a luxury. On some flights to Thailand part of the on- For those who can afford dental procedures, board entertainment includes a brief they elect to have unnecessary documentary describing Thai culture. This reconstructive surgeries so that they can video details the fear among Thai‘s that their appear more ―Western‖ looking. Among the customs and culture are being forgotten and many hospitals in Bangkok, Yanhee hospital left behind as Thailand progresses. One stands apart from the others in its must ask, in a country that is afraid of international appeal. The advertising morphing into something without a directors of Yanhee hospital are proud to remembered cultural past, why is it so inform visitors that their hospital attracts popular to elect painful, involved procedures more Koreans than any other for jaw line to eliminate distinct Thai facial reduction surgeries. Even though Yanhee characteristics? What will be the hospital, ―a convergence of Health and consequences within Thai culture and Beauty‖, is a fully functional healthcare society if people continue to pursue these facility with various dental procedures listed body-altering, image-altering and culture- on their brochure, the hospital is mainly a altering treatments? If left unchecked, the plastic surgery/oral & maxillofacial center for cultural ramifications of this trend will be personal beautification. The Yanhee vision catastrophic. is, ―To be at the forefront of the health care industry in Asia, to gain international You are born with your identity and no recognition for its quality of service matter how you change your body, who you particularly for beauty and for other medical are inside will forever be intact. However, services, as well.‖ Among the forgotten changing the face of a culture goes beyond ‗other medical services‘ is much needed personal modification. To escape confused dental care for patients – not only for those generations of Asian children who do not seeking cosmetic alterations. see their ancestry reflected in the faces of their parents, ethical guidelines must be The most common oral & maxillofacial explored and set so that the option of procedure (what they dub ―Aesthetic cosmetic dentistry does not go too far. Dentistry‖) performed at Yanhee hospital is Instead of nose jobs and jaw line rhinoplasty, or a nose job. In today‘s world procedures, Thai people need proper market, the ideal image of physical prosthetic care, they need more dentists perfection, according to Asian people, is to and, most importantly, they need to maintain have a Western physique. In Asia, apart the true expression of their identity. Columbia University Journal of Bioethics 73

The Ethical Concerns of Propranolol and

Memory Dampening

Donna Taraborelli, Tasha Smith**, Siwachapol Monyakul***

*University of Pennsylvania, **Columbia University and ***Mahidol University

Psychopharmaceuticals are currently being memory by making a person less likely to tested that could allow victims of traumatic develop the emotionally-charged memories experiences to cope better by fading their associated with traumatic experience memory. The potential for drugs such as (McGaugh, 2003). Propranolol is shown to propranolol to relieve people of tragic work best if given to a person within six memories and make bad experiences toler- hours of the traumatic event occurring. Not able is the subject of much debate. only does propranolol remove the emo- Should we have the right to choose what tional aspect of the memory, it may also drugs we want to use in order to alter the cause a person to forget factual information way our minds work? Or is it unethical to regarding an incident. Propranolol may erase our memories, undermining our true dampen positive memories as well as identity as a person by doing so? This pa- negative ones. per will explore the ethical concerns of using memory dampening drugs for the treat- Post-traumatic stress disorder is a severe ment of Post-Traumatic Stress Disorder and ongoing emotional reaction to an ex- (PTSD), as well as compare Western argu- treme psychological trauma. The emo- ments to Buddhist philosophy on the topic. tional reaction to the trauma is so great that psychological defenses are incapable of Propranolol is currently approved by the coping. Most people who experience a FDA and mainly used to treat hypertension, psychological trauma do not go on to de- as well as a host of other conditions such velop PTSD. The emotional effect from the as migraine prophylaxis and myocardial trauma usually subsides after several infarction. It is also able to cross the blood- months. PTSD is thought to be primarily brain barrier and get to where stress hor- an anxiety disorder and is different than mones are causing chaos in the brain. Ex- normal grief and adjustment after traumatic perimentally, propranolol is being used to events. It may also be closely related to treat post-traumatic stress disorder be- panic attack disorder. About 20 percent of cause it has been shown to fade memo- people who are exposed to severe, even ries. It is common for a particular drug to repetitive traumatic events develop PTSD. be approved to treat one problem and used Most people recover from the acute stress ―off-label‖ to treat other conditions that reactions following the event after a few have shown to benefit from it. weeks (Pittman, 2006).

Several scientists are conducting experi- Memories, whether good or bad, do not ments that suggest propranolol may blunt form instantly after an event but solidify 74 Fall 2008 over time. Traumatic memory does not Another criticism of memory dampening is behave like other memories. It is very ac- that it would dehumanize people by giving tive and does not decay and its the major us too much control over our life experi- purpose of memory is to predict the future . ences. ―We are not free to decide every- However, there is good reason that memo- thing that happens to us; some experi- ries are not indelible since the ability to for- ences, both great joys and terrible misfor- get is also an important human characteris- tunes, simply befall us. These experiences tic (McGaugh, 2003). become part of who we are,‖ part of our lives ―as truthfully lived‖ (Kolber, 2006). One criticism on the use of memory damp- Living truthfully is what we as individuals ening drugs is that they will somehow dam- make of it. Taking medication to help with age the psychological well-being of people a disorder is not being untruthful, it is part or degrade the quality of their lives. For of our truth. When overcome with trauma, example, Meilaender says that it is better helping ourselves by taking medication is to struggle through our traumatic experi- acknowledging truthfully that we are over- ences with the help of others and to fit whelmed and need help coping. Pro- them into a coherent story within the scope pranolol will not make a painful experience of our lives (President‘s Council for Bio- non-existent; it will give someone a chance ethics, 2003). This may be the brave or to overcome a hurdle they otherwise could romantic way of describing how we should not. It could also help a person overcome overcome the difficulties thrown at us in a traumatic experience faster, rather than life, but for people who have PTSD, it is spending years in therapy and missing a easier said than done. Some people are significant amount of time being a better able to cope with trauma and it does not spouse, parent, or friend to those around overtake their identity and ruin their lives. them. They are able to deal with the traumatic experience over time with the natural sup- Research done on propranolol has demon- port systems we can set in place, such as strated that some factual memory may be social support from loved ones or psycho- distorted after taking the drug. However, if therapy. Others develop PTSD and have a a person were to develop PTSD after a much harder time functioning in life after traumatic experience, a consequence of the experience. the disorder is memory loss. Additionally, we hardly ever remember events exactly It may be problematic if we medicate our- the way they occurred. Memories fade selves after mildly traumatic experiences over time and actually may be distorted and do not attempt to deal with situations each time we think about them and go over that could be considered natural parts of scenarios in our minds. Certain details life, such as broken hearts or the death of a may change slightly as we recount the loved one. People have developed ade- situation and then a new version of the quate coping skills without being victims of event stored. It is unlikely the experience devastating car crashes or violent crimes. will be remembered completely different There will be some of those people who than what actually happened, but there is a are able to recover from such experiences good chance that over time certain details over time and with the help of therapy and slip away or alter slightly (Kolber, 2006). then there will be people who are unable to cope and need the help of medication. It is also worthwhile to consider the use of Columbia University Journal of Bioethics 75 memory dampening drugs from alternative keep it as a reminder not to make the same perspectives, such as from Buddhist phi- mistake again. losophy. In Buddhism, all living things are composed of three different structures (Tri Under the control of medication, patients Gaya). The first structure is the unstable may feel they are getting better and relief structure (Anijjata). Since life has a begin- from their suffering. If patients stop taking ning and an end, nothing in this world is medication, however, it is likely that the stable. All living things that we see, touch, pain and suffering will come back to them. and hear are composed of both happiness A drug like propranolol may block the neu- and sadness at the same time. Based on rotransmitters that cause people to suffer this teaching, when an individual encoun- emotionally, but it may not provide resolu- ters an incident that causes distress we tion to the problem. Drugs are usually cre- should remember that these incidents will ated to provide cures for problems, but in not last forever. Therefore, the individual using those drugs we are not dealing with will not always suffer. the underlying cause of the suffering.

The second structure is the suffering body References (Tuk Kata). Buddha teaches that an individual will suffer when they live with things Lemonick, M.D. The Flavor of Memories. which are disliked. Suffering also occurs Time Magazine: Mind and Body Special Is- when things beloved are lost. (Auppayehi sue. Januay29, 2007; pages 102 – 104. Sumpayoko Tukko Piyehi Vippayoko Tukko). One suffers because of the desire Kolber, A.J. (2006). Therapeutic Forgetting: to hold on to the things we love and the The Legal and Ethical Implications of Mem- struggle to rid ourselves of the things we ory Dampening. Vanderbilt Law Review, dislike. An individual must face both with- 59:5, 1561-1626. out exception. Loss and gain are the nature of life and suffering occurs because an in- Marchione, Marilynn. A pill to fade traumatic dividual cannot accept this truth. The third memories? Doctors are working o it. January and last structure is the eternal body 14, 2006. www.signonsandiego.com/news/ (Anatta). In Buddhism, eternal means emp- science/20060114-0917-traumapill.html tiness. One should know that the only thing that is eternal is the truth that everything McGaugh, J.L. Memory and Emotion. Pub- will be gone in the end. Good and bad will lished by Columbia University Press, United exist in concert until the end of time. Kingdom, 2003;McGaugh, J.L. (2006) Make Mild Moments Memorable: add a little From these three structures, Buddha arousal. Trends in Cognitive Sciences, 10:8, taught that suffering comes from within us. 345-347. Nothing causes us to suffer if we do not allow it. A person who suffers from a bad Pitman RK. Combat effects on mental health: incident can be healed by understanding the more things change, the more they re- the three truths that Buddha taught. In Bud- main the same.Arch Gen Psychiatry. 2006 dhism, the idea is not to get rid of suffering, Feb;63(2):127-8. but rather learn how to live with suffering in a way that will not affect us. We should not try to forget the past, but instead we should 76 Fall 2008

President‘s Council for Bioethicsr. Beyond Therapy: Biotechnology and the Pursuit of Happiness. A Report from the President‘s Council for Bioethics. January 2003.

Columbia University Journal of Bioethics 77

Finding the Middle Path to Stem Cell Nirvana

Melissa Bauer* and Shanshan Tang**

*Columbia University and **Mahidol University International College

On opposite sides of the globe, the Land of ranks. Supplying funds to local, provincial Smiles and Land of Opportunity showcase and national institutions, China is in a highly the extremes in stem cell research advantageous position for streamlining their regulation while facing similar bioethical funds into those facilities that produce the dilemmas. In the public hospitals of Thailand most promising results (Liao et al., 2007). many scientists are frustrated by the lack of Greater involvement in the Thai government regulation on stem cell research. Although will allow stem cell research to flourish many of these facilities possess the domestically and on the global scale, placing technological capacity for highly advanced Thailand on par with the research giants of stem cell research, the lack of regulations the West. instilled extreme hesitation among the Thai scientific community to progress with such Unlike many western powers, the United studies. Currently, embryonic stem cell and States is experiencing a deceleration in the reproductive cloning research projects are progress of stem cell and reproductive not conducted at public institutions. This cloning research. However, this effect is an opened the door for a mass influx of foreign outcome of over-regulation by the private companies to hire researchers at government rather than a result of lacking Thai private hospitals. Dr. Suradej Hongeng regulatory measures. Multiple bills have of Ramathibodi Hospital of Bangkok been proposed in the United States expressed an urgent need for the Thai Congress to charge individuals who engage government to establish regulatory in reproductive cloning with a ten million legislation of stem cell and cloning research dollar fine and with up to ten years in prison. to allow for publicly funded Thai hospitals to Public funds for embryonic stem cell contribute to the advancement of science in research are also limited by major these fields as allowed in other Asian regulations mandated by the federal countries. government ((New York and Stem Cell Research, 2008). First, embryos derived In the highly competitive and rapidly before 9:00 P.M. on August 9, 2001 and developing Asian markets, the stifling of which are no longer needed for reproductive scientific creativity and advancement sets purposes may be used for research after Thailand behind many of its neighbors. In informed consent. Second, there should be China, for example, research on both no financial inducements in obtaining the embryonic and adult stem cells is supported embryos from donors. This suffocating by the Chinese Ministry of Science and legislation created a situation similar to that Technology which aims to launch the found in Thailand. Although not as prevalent country to the forefront of the research as in Thailand, due to the greater financial 78 Fall 2008 burden of conducting research in western million individuals inflicted with countries, there still exists a significant cardiovascular disease and over 40 million increase in the American business sector for people with osteoporosis may be treated funding research centered at private using this technology (SNAP, 2008). Without institutions. A revision of the excessive a reassessment of the ethical implications of regulations on federally funded stem cell banning stem cell research, American research and cloning projects will jumpstart creativity in this field will continue to be American ingenuity and assist the United strangled by excessive regulation. States in reclaiming its leading role among industrialized A promising countries in this advancement for scientific field. establishing guidelines for S t e m c e l l s t e m c e l l research will research in unlikely offer any Thailand is the cures to diseases S t e m C e l l in the near future. Network – Asia- However, it may Pacific (SNAP). offer treatments C r e a t e d i n for millions of September of people worldwide 2007, this suffering from a organization aims variety of to create a ailments. In framework for T h a i l a n d , conducting researchers hope that stem cell therapies research in these in these frontiers focusing may be used to treat Thalassemia, referring on patient needs, research interests, to a group of inherited hematological business sector priorities and research disorders. There are approximately 500,000 regulation and funding. Member countries clinical patients in the country and 30-40% include some of the rising powerhouses of of Thais are carriers for this genetic disorder scientific advancement including China, (Mahidol Report, 2008). Ethical guidelines South Korea, Japan, Taiwan, Singapore and on stem cell research will encourage Thai Australia. Although a promising scientists to experiment with these therapies collaboration, SNAP is still in its infancy and to lead to improvements in the quality of life it will be many more years before Thailand in the Thai population. will see significant regulations evolve from this body. As in Thailand, many Americans will benefit from the advancements in stem cell In the United States, both the House of research. With the variety and incidence of Representatives and the Senate passed bills chronic diseases skyrocketing in the US to change the country‘s policy regarding population, American researchers are publicly funded stem cell research (). The House of many illnesses. As of 2005, 5 million Representatives, in 2005, voted in favor of Americans with Alzheimer's disease, 60 federally funded research with surplus Columbia University Journal of Bioethics 79 frozen embryos (.). One year Mahidol Report: "Thalassemia Research later, the Senate passed three different bills Center." Mahidol University. 12 Aug. 2008 in support of legalizing federal money . over from in vitro fertilization. Although SNAP- "Stem Cell Network Asia Pacfic." President Bush vetoed these proposals, the SNAP - Stem Cell Network Asia Pacfic. 12 efforts to lift limitations of stem cell and Aug. 2008 . by politicians at the national level.

Legislative and research communities must agree on a policy to regulate the private sector‘s involvement in these research disciplines. This will protect the public from ethically controversial treatments. Also, immediate efforts must be made to educate the public on the current expectations and benefits of stem cell and reproductive cloning therapies. The coupling of revised legislation and education will boost scientific creativity in both Thailand and the United States and assist civilians in clarifying the potential of such technologies‘ impact on their own health and quality of life.

References:

Liao, Lianming, Lingsong Li, and Robert C. Zhao. "Stem Cell Research in China." Philosophical Transactions of The Royal Society 362 (2007): 1107-112.

New York and Stem Cell Research"New York and Stem Cell Research: a Scientific, Policy and Economic." New York and Stem Cell Research: a Scientific, Policy and Economic. Jan. 2006. 12 Aug. 2008

80 Fall 2008

To breach or not to breach doctor-patient confidentiality involving children with AIDS

By Risa Hoshino*, Janice Liu*, and Sun-Chai Waleecharoen- pong**

*Columbia University, ** Mahidol University International College

AIDS has infected more than one million ners‘ health. The doctor asks for their per- Thai citizens and has killed more than mission to disclose his diagnosis for the sake 460,000 people since the beginning of its of others‘ safety but the parents refuse. epidemic during the 1980‘s. However, with Should the doctor breach the doctor-patient Thailand‘s anti-AIDS campaign, the number confidentiality oath or abide by it under all of new infections has dramatically fallen circumstances (Weiner et al., 2004)? since 1991. The country used creative and persistent ways to educate the Thai people In both Thai and American law, the parents about preventing the spread of this debilitat- have full control of the confidentiality of their ing disease. In its initial phase, non- children‘s medical records. They can legally governmental organizations (NGO‘s) such hide any medical information from their chil- as the Red Cross and Population and Com- dren whenever they feel it is necessary. munity Development Association (PDA) Several factors have been associated with tackled AIDS by educating people about the the parents‘ decision not to disclose the HIV prevention of AIDS such as handing out diagnosis to their child. Among the top rea- condoms at brothels and promoting HIV sons were that the child is not old enough or education in schools. By 2003, there were ready, the child would not keep the diagnosis only 19,000 new HIV cases, much lower private, or that the child will be subject to os- than the original 143,000 at its peak. tracism from the community and family. An- other reason is the fear that the children will But the war has just begun. Instead of a con- become angry with the parents for transmit- tinued progress, the number of new HIV posi- ting AIDS to them. tive cases in Thailand has increased significantly and is currently the leading cause of However, even though the parents may have death among young adults. Precautionary concerns about the child‘s well-being when measure to slash AIDS in Thailand must be not being told their status, there may still be re-instituted. psychological damage to the child if the status is not revealed. Clinical reports have A Thai couple brings their thirteen year boy indicated positive outcomes associated with with AIDS to the doctor for a check-up. How- disclosure including the promotion of trust, ever, the parents have never disclosed his improved adherence, enhanced access to diagnosis to the child. During the visit, the support services, open family communica- doctor finds that he is old enough to start tion, and better long-term health and emo- having sexual intercourse and believes that tional well-being in children (Wiener et al, not telling him will endanger his sexual part- 2004). Parents who disclose the diagnosis to Columbia University Journal of Bioethics 81 their children believe in a child‘s right to know bad karma can cancel each other out, but is their health status and that their child will rather two separate columns where a tally of learn the diagnosis elsewhere. In addition, each category is kept. If we look at the point the parents fear the child would get involved of view from the karma effect, it is considered in sexual activities without protection and bad karma to go against the will of parents hope that disclosure will lead to improved which we consider to be the supreme figure. health care or improved medication adher- The Buddhist monk, Phra Chainarong, be- ence. These children may also endanger lieves that one should act according to what other people‘s lives if they are not told their one believes will have the least harm and the status and perform unprotected sexual inter- most benefits to the individual and to society. course with their partners. Should the doctor- If the doctor believes that more harm will be patient confidentiality oath be observed in all caused if the parents do not inform their chil- circumstances or can they be overridden in dren of their status, then there will be more situations where public safety is threatened? good karma and less bad karma in telling the Both Thai and American cultures and values child (both come into play). Though both are employed to explore the conundrum of karmas still exist in the decision, the intention whether to disclose diagnosis information to behind the action determines the significance children against the caregiver‘s will when it of each. In addition to karmic effects, Bud- endangers societal safety. dhism also teaches people to ―know all truths‖. If children are not told their HIV Thailand Perspective status, they will never know all truths and will not reach nirvana in this life. This goes In Thai culture, all decisions are at least influ- against Buddhist principles and is therefore enced by, if not based on, the teachings of another reason to inform the child of his or Buddha for hundreds of years. According to her state. sutra, Buddha said that parents have three roles in caring for their children: First, parents Even though the law favors the parents in are birth givers. They are the one who tend making the final decision for their child, the to their children‘s grown both physically and law is not as strict because of the Buddhism mentally, while providing love, passion and theme of community unity. Even though par- care to their children. Second, parents are ents may not want to tell their child, the doc- the first teachers of their children. Parents tors and parents have the mutual respect and are obliged to teach their children all basic cultural backgrounds to be able to make de- needs to survive and also help develop their cisions together without the doctor being out children thoughts and characters. Lastly, par- of his or her place. Even though disobeying ents are ―Phra Orrahun‖ or ―Buddhist saint.‖ the parents wishes is against Buddhist teach- Parents have to love their children consis- ings, going against the Buddhist principle of tently and unconditionally. Hence, in Thai ―do no harm‖ is even more, in a western culture, parents have the final say in making sense, sinful. Community plays a large role in decisions for their child. They can choose to decision making of the people. By not telling tell or not to tell their children about their HIV infected children about their disease, once status. the child has reached an age of increased sexual activity, their ignorance may cause In Buddhism, each action has a karmic effect other innocent people in the community to that follows, whether it is good or bad. Karma also be infected. Hence, with the Buddhist is not a point system where good karma and perspective to do no harm and a communal 82 Fall 2008 sense of responsibility, doctors may have the tors Get Sued, 2001), creating a more cau- right to go against the will of infected chil- tious atmosphere between doctors and pa- dren‘s parents if they believe it is better for tients. This increases the potential for a di- the community. With the knowledge in the chotomy between opinions of doctors and hand of the children, they will be more cau- parents when it comes to making decision for tious of their actions, possibly inhibiting fur- the child, instead of integration between the ther increase to the already escalated num- two as Thai culture supports. ber of HIV infections in Thailand. Doctors are trained from the very beginning to never breech doctor-patient confidentiality. American Perspec- With such a heavy em- tive phasis on that confidentiality and the high per- In the United States, centage of lawsuits individualism domi- threatening in the back- nates American cul- ground, doctors face ture, shifting from a one of the most contro- political concept to a versial medical issues personal lifestyle. In where they must decide modern day America, between their moral individualism has values and respecting now become a cul- the individualism of their tural mindset that patients. span issues like the This controversy is also freedom of speech, to imbedded in the issue intrinsic values of of pediatric disclosure of everyday life. HIV. Having HIV is considered to be taboo, This concept governs where parents and chil- almost every aspect dren have become so- of society, including cial pariahs once the healthcare. In the information has been medical field, the law released to the public. It gives individuals the is then understandable right to make healthcare-related decisions for if parents of an HIV positive child refuse to themselves, as long as he or she has the disclose this information to him or her, with mental capacity to do so and is at least at the the hopes that the child will be able to live out legal age of 18. This means that parents of a normal childhood. However, if an HIV posi- minors have absolute control in making medi- tive child is at an age where he or she is cal decisions for their child, despite sugges- sexually active, and the parents still refuse to tions from the doctor. Nowadays, more and tell the child of his or her status for fear of more Americans are practicing their individ- social ostracism, does the doctor compro- ual rights in court cases, including medical mise his trained values for moral ones? lawsuits. Studies show that an estimated Should the physician overstep his boundaries 25% of all doctors in the United States get in disclosing such information for the sake of sued on an annual basis (When Good Doc- protecting the community? American law Columbia University Journal of Bioethics 83 strictly prohibits doctors from releasing such information, then they should have the right information without the consent of the par- to override the parents in this decision. Even ents because individual rights favor the legal though there are less occurrences of HIV/ guardians. But has individualism finally over- AIDS infection among the United States stepped its own boundaries? population, adopting an attitude of social and communal responsibility will further efforts in Conclusion the fight against AIDS.

Thailand has taken more control over its growing statistics in terms of educating the public and HIV prevention programs because of the higher incidences of HIV infection spreading across the country. However, an important part of its success is due to its Buddhist-integrated culture of having communal responsibilities. The culture incorporates the idea that one should act according to what one thinks will do the least harm to people. A policy that gives Thai doctors the right to disclose information to the HIV infected children about their status once they reach the age of twelve will benefit the community, and follow the cultural philosophy. Some ethicists may promote an earlier age to inform the child of his or her status. How- ever, a study shows that early disclosure of diagnosis to the child may not necessarily be better than at an older age. Of 40 HIV- infected adolescents and young adults, the investigators found no relationship between timing of disclosure and psychological adjustment, social support, or the adolescent‘s own decision to disclose his or her HIV status to others (Wiener et al, 2004). But whether or not the disclosure comes at an early or late age, the process must still be gradual for the child. The disclosure must be carried out in a sensitive fashion through counseling. References: Wiener LS, Battles HB, Heilman N.Public The Thai perspective on this issue uses a disclosure of a child's HIV infection: impact more communal approach versus the more on children and families. individualistic attitude of American culture. It AIDS Patient Care STDS. 2000 Sep;14 better serves the needs of the community (9):485-97. while performing the least harm to the most number of individuals. If the doctors feel that it would be more harmful to hold back the 84 Fall 2008

Enlightenment: Just a Pill Away!

Marlon Danilewitz*, Margarita Borovka**, and Mariangels de Planell-Saguer***

*Yeshiva University, ** Columbia University, *** University of Pennsylvania

Oek the monk began his rigorous Buddhist sires. By achieving Nirvana one has in fact training when he was eight years old. Mov- achieved an existence free from suffering, ing to a Buddhist temple with other monks, and pain. Furthermore, suffering is per- he dedicated the bulk of his daily hours to ceived to be the result of desire and lust. studying the words of the Buddha and The path to access Nirvana is also of prime meditating to undergo personal growth and importance. Meditation and introspection improvement. Finally after forty years of complemented with the study of some of training and tremendous personal sacrifice the seminal Buddhist texts including the and perseverance, Oek achieved enlight- Sutra, the words and teachings of the Bud- enment, a state without desire and lust, dha, are the avenue that with work, dedica- free from suffering. Barney, an American tion, maturity, growth, and time will aid one businessman and financial trader was the in attaining enlightenment. Alternatively, envy of all of his colleagues. His prowess Western society achieved its nascence in on Wall Street stemmed from his superior Greece and has incorporated many of the intelligence and creativity. Notwithstanding Greek values such as happiness, beauty, his natural endowments, Barney desired to speed, and strength. It could be argued be better, smarter, and happier. One day, that they were a culture of desire. All of he decided to visit his psychiatrist to pro- these notions have been compounded with cure some cognitive and mood enhancing the advent of capitalism and the rise of drugs. After only a few days of ingesting competition and primacy of the result over these powerful pharmaceuticals, Barney the process. emerged a smarter and happier man. While both of these stories are entirely ficti- The enhancement of normal neurocogni- tious, there is a common sentiment that is tive function by pharmacological means is reflective of Buddhist culture, and Western no longer terrain of fiction, but has become society. a fact of everyday life for many people in our society. For the most part, these drugs One of the more well known Buddhist ideas are used ethically to treat neurological and concerns the topic of enlightenment, or psychiatric illnesses, including Alzheimer‘s, Nirvana. Nirvana is the highest stage of ADD, strokes, dementias associated with existence in Buddhism and is defined as a Parkinson‘s disease and schizophrenia. state of cessation of all desires, or empti- However, psychopharmacology is also in- ness. It is a point of satisfaction, and com- creasingly being used for ―enhancement‖ placency, where one becomes at peace purposes. Such drugs, known as cognition with things and no longer experiences de- enhancers, work on the neural processes Columbia University Journal of Bioethics 85 that underlie mental activities including at- their ability to focus, concentrate and en- tention, perception, memory, language, hance their memory. Surveys of college planning and decision-making, by altering students have found that 4 to 16 percent of the balance of the chemical neurotransmit- respondents say that they have used ters involved in these processes. stimulants or other prescription drugs to improve their academic performance. In some school districts in the United A critical question is how to differentiate States the proportion of boys taking meth- treatment from enhancement. However, as ylphenidate, usually prescribed to treat at- today‘s technologies for treatment are be- tention deficit-hyperactivity disorder ing introduced into a bitterly competitive (ADHD), exceeds the highest estimates of society, they become necessary requisites the incidence of ADHD, implying that at for the general public who believes that least a part of the normal childhood boister- improvement is a moral obligation. Imagine ousness and distractibility are being tar- a scenario in the future, when you‘re apply- geted for pharmacological intervention. ing for a job, and the employer says, ―Sure, Similarly, the spike in the usage of pre- you‘ve got the talent for this, but we require scription stimulants (such as methypheni- you to take Adderall.‖ Our analysis will fo- date and dextroamphetamine) as study cus on cognitive and mood enhancing aids by high school and college students, drugs and the ethical questions that have with no prior history of ADHD, has drawn been raised concerning their use and pro- public attention. The market for nutritional spective use in Western society, and socie- supplements, which is estimated to be in ties rooted in Buddhism. the billions of dollars worth of sales, signals that society is eager and waiting for the rise Western Perspective drugs that promise cognitive enhancement. The reference to the first ten years of the Another growing phenomenon pertains to new millennium by some as the ―decade of the off-label use of existing drugs such as the mind‖ is in part a reflection of the trend Ritalin (methylphenidate) and Provigil of enhancement of cognition and mood (Modafinil) by people who want to ‗pep up‘. through the prescription and use of brain Provigil has been shown to improve one‘s stimulants (Rose, 2006). Protestant work working memory, allowing individuals to ethic and the source of self-fulfillment, remember an extra digit (most people can propagates the desire to do work in a better hold seven random digits in their memory way, with or without the use of un- but have difficulty with eight). It has also prescribed prescription drugs. Americans been able to improve individual‘s test tak- feel driven to work harder and are ashamed ing performance, and ability to plan. These if they are not working. They generally work positive effects has elicited the interest of more hours and take fewer vacations than normal people into using these drugs to workers in other advanced economies. stave off fatigue, boost exam performance Therefore, if drugs like Ritalin or Prozac al- and aid recovery from the effects of long- low one to do work in a faster, better, more distance flights. Furthermore, an informal efficient way, and to do so enthusiastically, study in Nature found among 1,400 of its then their effects may help to understand readers that one in five said they had taken more clearly the experimentation with Ritalin, Provigil or beta blockers (drugs that ―cosmetic psychopharmacology‖ in Ameri- can have an anti-anxiety effect) to bolster can culture. 86 Fall 2008

respective markets. In other words, capital- Americans also place importance on acquir- ist society will create any markets necessary ing the happiness they see idolized around to make a profit (Persaud, 2006). However, them in popular culture. The media portrays with the advent of these drugs and their ha- leisurely and worry-free lifestyles as the bitual use, people will lose their emotions norm. However, if one is unhappythen is and critical elements by undermining the there something wrong? Are all people human element of trying. They will also limit mandated to feel self-satisfied and nostalgic what it means to be human to one personal- at all times? If not, have they failed? In the ity type – the extroverted, confident, daring United States, not only has happiness be- individual. While the effects appear worth- come a right, but a duty, and one that while to try these medications, it is important should be pursued aggressively. Interest- to think about the long-term effects they will ingly enough, ―Life, liberty, and the pursuit of bring about in future generations. happiness " is one of the most famous phrases in the United States Declaration of One of the most immediate effects of en- Independence. These three aspects are hancement drugs, however, will be an in- listed among the inalienable rights of man. creased gap between the rich and the poor. However, this ethic can be oppressive to the While enhancement technology will provide average American, who encounters prob- supposed benefits for some, it will also be- lems at work, fights with his/her spouse, and come a disabling force for those who cannot experiences a financial crisis (Elliott, 1998). afford it. The number of people in this coun- Enhancement drugs appear to be the easy try perceived as impaired will increase be- way out of their conundrums. However, it is cause the definition of what it means to be important to note that these pills allow peo- disabled will change. In fact, a new under- ple to pursue happiness on an individual class could be created – ―the unen- basis, rather than on a collective one. Indi- hanced‖ (Wolbring, 2006). As a society, we vidualism is another aspect of American must think about the consequences of culture, which may explain why enhance- reaching a higher level of cognition through ment medications have become so popular. external means, especially at the cost of The transformation of the ―pursuit of happi- losing our interconnectedness and human- ness‖ from a right to a duty engenders the ity. mental pressure to search for joy and find it by any means available and to do so in the Buddhist Perspective privacy of one‘s home. If being happy is a duty, then mood and cognition-enhancing Buddhism voices many ethical concerns drugs are the road to eternal bliss, as long regarding the potential use of Ampakines, as the prescription does not run out. Or at Prozac and other pharmaceuticals that can least, they are a temporary shortcut to the bolster one‘s cognitive capabilities, and happiness that Americans seek. brighten one‘s mood. The Buddhist notion of Karma, the belief of cause and effect The convergence of enhancement technol- whereby bad actions merit suffering and ogy and capitalism creates the markets nec- good actions result in happiness, poses a essary to convince the American people that number of ethical concerns to the use of they possess defects, while a free market enhancement drugs in a normal population. society encourages a competition for the In particular, with the advent of pharmaceu- most successful improvement within these ticals of this nature which have the unique Columbia University Journal of Bioethics 87 ability to alter one‘s own natural cognitive endowments and temperament/personality, Another concern championed by Buddhism an argument has arisen among Buddhists is the belief that the root of suffering lies in concerning how to react to these miracle desire. If the aim of a Buddhist existence is drugs. The more traditional approach main- to achieve a state of Nirvana and the eradi- tains that these drugs interfere with one‘s cation of suffering, desire must first be extin- karmic destiny, and as a result, should not guished (Bodhi, 2000). Thus it would seem be used. The alternative approach, does not that intention for taking enhancement aiding perceive these drugs to tamper with one‘s drugs so as to increase one‘s cognitive abili- karmic fate, as they fall within the normal ties and to manipulate one‘s personality and and acceptable realm of permissible ac- enjoy more happiness would in fact further tions. It could be understood that the devel- delay one from attaining the enlightened opment and possibility to use these types of state of Nirvana. pharmaceuticals are a part of one‘s karmic balance and as such, are intended to be The potential of achieving enlightenment, utilized. Nirvana, applies equally to every single human being. Buddhism does not discriminate Similarly, Buddhism places a tremendous between creed, sex, race, religion, or finan- value on the individual and the primacy of cial status; enlightenment is within the grasp his own actions and work in achieving Nir- of everyone. Although, one can argue that vana. The key to fulfilling our need for hap- the level of one‘s cognitive faculties can ei- piness lies ―within, not outside us. This ther increase or decrease one‘s chances of means that all we need right here, inside, attaining enlightenment, the journey towards without looking to external things‖ (Tsering, spiritual completeness is not subject to 2005). This would suggest that despite Pro- fierce competition between individuals but is zac‘s potential to increase one‘s self es- rather a self directed mission, void of rivalry. teem, truncate one‘s bouts with depression As such, the social inequalities that are glar- and gird one with a greater sense of inde- ingly apparent in the intense competition to pendence and extraversion, because the get ahead in America, and which have the impetus for this change was external to the potential to be further exacerbated by the self this type of development, it is inappro- rise of cognitive and mood enhancement priate for Buddhists. drugs, are not a part of the Buddhist path to Nirvana. This sentiment is echoed by the words of the Buddha ―He who fills his lamp with water Conclusion will not dispel the darkness, and he who tries to light a fire with rotten wood will fail. The concept of enlightenment, striving to be And how can anyone be free from self by better, exists in both cultures. For example, leading a wretched life, if he does not suc- American society thrives on a work ethic ceed in quenching the fires of lust, if he still that has been maturing for over three centu- hankers after either worldly or heavenly ries-the journey to achieve supremacy first. pleasures. But he in whom self has become As Gregory Stock has said, ―Future genera- extinct is free from lust; he will desire neither tions will not want to remain ‗natural‘ if that worldly nor heavenly pleasures, and the sat- means living at the whim of advanced crea- isfaction of his natural wants will not defile tures to whom they would be little more than him‖(Carus,1974). intriguing relics from an abandoned 88 Fall 2008

past‖ (Franklin, 2006). Similarly, enlighten- Better Humans? The Politics of Human En- ment is the state that Buddhists strive for: hancement and Life Extension. Ed. Paul ―This, bhikkhus, is that middle way awak- Miller, James Wilsdon. London: Demos, ened to by the Tathagata, which gives rise 2006. 129. to vision, which give rise to knowledge, which leads to peace, to direct knowledge, Rose, Steven. ―Brain Gain‖. Better Hu- to enlightenment, to nibbana‖. It is interest- mans? The Politics of Human Enhance- ing to note that both societies are deter- ment and Life Extension. Ed. Paul Miller, mined in achieving a greater goal; however, James Wilsdon. London: Demos, 2006. 69- their means are in stark contrast to each 70. other. Tsering, Geshe G. The Four Noble Truths: References: The Foundation of Buddhist Thought Vol- ume 1. Boston: Wisdom Publications, 2005. Bodhi, Bhikku. The Connected Discourses of the Buddha. Boston: Wisdom Publications, Wolbring, Gregot. ―The unenhanced under- 2000. class‖. Better Humans? The Politics of Hu- man Enhancement and Life Extension. Ed. Carus, Paul. The Gospel of Buddha. United Paul Miller, James Wilsdon. London: Kingdom: Alcove Press Ltd, 1974. Demos, 2006. 126.

Elliott, Carl. ―The Tyranny of Happiness: Eth- ics and Cosmetic Psychopharmacology‖. En- hancing Human Traits. Ed. Erik Parens. Washington, D.C.: Georgetown University Press, 1998. 184-187.

Franklin, Sarah. ―Better by design?‖ Better Humans? The Politics of Human Enhance- ment and Life Extension. Ed. Paul Miller, James Wilsdon. London: Demos, 2006. 89.

Persaud, Raj. ―Does Smarter mean happier?‖ Columbia University Journal of Bioethics 89