Nature nurtures debate on namesake

Josh Carter, over at the Bioethics.com blog, comments on the editorial in the April 10th issue of Nature, (subscription only. Joe quoted some but let me know if you need the full text) which uses news of a transgendered (but not transexual) pregnant and bearded woman to ask the age-old question, what is "natural" and whether "natural" is better than "un-natural."

What do you want to bet that the author prefers "natural" fibers for his clothes and "organic," when it comes to groceries? We know that the editorial board has opinions on the good and bad, since the cover of the April 3 issue in front of me has the headline, "Carbon emissions: it's worse than you thought."

Even though the question couldn't have been asked quite this way in the past, Nature asks one of the oldest philosophical questions. Unfortunately, they ask in a juvenile manner. In fact, they beg the question by stating that the approved purpose is to "enhance the human condition."

(As I commented on the Bioethics.com blog) The “natural” uses of medicine and science seek to discover and use our discoveries to encourage, enhance, and/or return to optimal what Aristotle called the “telos,” the “what it is meant to be.” For instance, a splint reduces pain and holds the limb in physiological position as it heals. Hip replacements, glasses and hearing aids aren't normally intended to give you the ability to jump higher or stronger, see with the sight of an eagle or hear a pin drop in the next county -- they are used in an attempt to return your functioning to "normal."

The most active debates in science today are actually discussions about the “nature” of the thing we are studying or manipulating. Is global climate change causing the Earth to heat up more than is “natural,” is it man-made (due to those carbon emissions), or cyclical, etc. Should there be regulation on abortions to for sex-selection or to choose for deafness? Who gets the resources to be the Six MillionTrillion Dollar Woman and why not allow men and women to demand that their limbs be cut off or that their faces be botoxed and surgeried into a human caricature that scares children?

Again, we see the problem with setting up the ethics hierarchy so that "autonomy" trumps "non-maleficence." "I want" ethics over "First, do no harm."

Is there good in the telos, or is there any standard for dividing funding and power in science and medicine? If there aren’t good and bad uses of science and medicine, then “Anything goes,” if you can get the financing, the power, or the ability to do it.

Human-DNA-in-cow-egg embryo created in UK

Scientists in the UK report that they have created an embryo using the transfer of human nuclear DNA from an embryonic human cell into the oocyte of a cow that has had the nucleus removed. These embryos are the "hybrids" or "cybrids" that we've been discussing for the last few years.

From the Guardian:

Apparently these researchers have achieved some success - but by using the nucleus from a very early embryonic cell, which might be easier to reprogramme than an adult cell. At the moment it is impossible to assess the significance of this report until we know more details of what has been achieved ... the results have been repeated and, importantly, they have been reviewed by independent researchers in the usual way."

Josephine Quintavalle, of the pressure group Comment on Reproductive Ethics, said the research should not worry those opposed to hybrid embryos because the Newcastle work did not seem convincing. "The embryos didn't survive, they were created from embryonic stem cells rather than adult tissue, and there's a lot of question marks over the research."

But she added: "What it has done is wake up the public to this reality, that while parliament is getting in a tizz about this, while the whole country is up in arms discussing it, the HFEA is already issuing licences."

Supposedly, if the technique is perfected to allow the embryos to survive longer, these embryos will allow the study of the early embryo and production of embryonic stem cells in order to learn more about and find cures for diseases like diabetes and Parkinson's.

However, even if the embryos are disorganized and fail early, or if they are destroyed at day 5 or 6 or whenever, the ethical determination as to whether they are "human" or "bovine" has not been cleared up. We won't know what they are until several labs and several trials successfully create these embryos.

If the embryos appear to divide in an organized manner, producing human proteins and the differentiation necessary to create human embryonic stem cells, then they are essentially human embryos. This is a case of the old if it walks like a duck, quacks like a duck, etc., logic.

Since the stated intention is to destroy the embryo, and we don't know whether they are human or not, those of us who find the killing of humans, even at the earliest stages will also hold that it is inherently unethical to even begin the process.

A discussion about the discussions about the announcement can be read at one of Nature.com's blogs, "The Great Beyond."

From the thread, "UK hybrid embryo: in perspective - April 02, 2008,"

New Scientist has attacked the group for announcing the achievement through the media rather than through a scientific publication. The Independent focuses on the ethical debate. Not many organisations outside the UK gave it any coverage at all, and those that did may have been under the impression that it was a world first, not mentioning previous achievements in the field (eg. Life Scientist, Australia).

Abortion and risk to the health of later babies

New analysis of old data published in the January 2008 issue of the Journal of Epidemiological Community Health (free abstract) has confirmed the association between induced abortions and later premature birth and low birth weight babies. Babies born prematurely and/or weighing less that normal are much more likely to die in the first month or have severe health problems like lung disease or brain damage.

However, the focus of the original research is based on self-reported information from over 45,500 moms who gave birth from 1959 to 1966 and the records don't tell us whether the mothers had spontaneous abortions (miscarriages) and induced intentional abortions. The authors do find that increased numbers of miscarriages or abortions increase the risk of low birth weight at full term and of premature birth:

Compared with women with no history of abortion, women who had one, two and three or more previous abortions were 2.8 (95% CI 2.48 to 3.07), 4.6 (95% CI 3.94 to 5.46) and 9.5 (95% CI 7.72 to 11.67)times more likely to have LBW, respectively. The risk for PB was also 1.7 (95% CI 1.52 to 1.83), 2.0 (95% CI 1.73 to 2.37) and 3.0 (95% CI 2.47 to 3.70) times higher for women with a history of one, two and three or more
previous abortions, respectively.

The new information from the JECH is nearly 50 years old and can't distinguish between miscarriages and induced abortions, so it doesn't really tell us much about the risk from today's elective abortions or give proof that induced abortion is risker than miscarriage. I'm afraid that that is the emphasis of media reports like those in Time and Medical News Today. (Although they don't note the surprising result that the study found no association between smoking and premature birth, although there was a significant association between smoking and low birth weight.)

However, the authors review results from other studies which do make distinctions between the mothers who had previous induced abortions and those who had miscarriages. Those studies do show an association between induced intentional abortions and low birth weight, term low birth weight, and premature birth. Instead of the 300 to 900% risk over full term live birth, most found at least a small 1.1 to 1.4 (10% to 40%) increased risk after one intentional induced abortion and up to 3 times the risk after 2. While there is also a risk after miscarriage, miscarriage can't be helped. The variables which can be changed - not those that can't be - are matters for public health policy.

And fewer of our children will have to die for it.

New Stem Cells Questions and Answers

A reader posts some questions that I'll try to answer. (Thanks, Janet!)

The most important thing to remember is that the new iPS cells appear to be like embryonic stem cells, but they can be made without killing anyone and they can be made to match the patient.


"Does this new procedure use any cells from the unborn to induce pluripotency in the adult skin cell thus creating a stem cell?"

Both labs in the news actually showed their final process using adult cells that did not require the death of any human individual at any age.

However, one of the groups (Thomson's, from Wisconsin) proved that the process is possible by using embryonic stem cells and fetal cells from abortions, while the other group (Yamanaka's, from Japan) used mouse cells for the basic science before using adult skin cells.

"If it does, then it cannot be considered an ADULT stem cell. So, it seems there would need be a third category of stem cells.

"If it does not use cells from the unborn, then could the iPS be considered an ADULT stem cell? It would be simpler to explain. Or because it is not a stem cell to begin with but is induced to become an ADULT stem cell, do we still need a third category for stem cells.

"I think that if the cells that are reprogrammed came from tissues after birth, they are adult stem cells, and the research using them is "adult stem cell research." (or non-destructive stem cell research resulting in induced pluripotent stem cells.)"

It can get complicated, and you do have to read "the fine print" in the reports to figure out the source.

I've always thought of the two groups as divided into

1. Destructive Research - that depends on the intentional destruction of individual human beings at any age is unethical vs.
2. Non-destructive Research - ethical research methods that do not intentionially cause injury to human beings.

For simplicity, most people call the first "embryonic" and the others "adult."

For instance, umbilical and amniotic fluid cells are ethical, non-destructive stem cells that are technically "fetal stem cells."

In contrast,
1. "embryonic" means the cells came from embryos - in humans that's up to 8 weeks gestation.

2. Most of the "fetal cells" used in research come from harvesting the bodies of children who are aborted, between the age of 8 weeks and term. These are sold as tissue cultures by commercial labs. Some of the cultures have been cultivated for 20 or 30 years and the genes and growth habits have been studied and they can be counted on to do what they are supposed to do.

3. Sometimes the "fetal" tissues are harvested after a natural miscarriage. These are considered ethical. (I don't think there are any commercially available standard tissue cultures from miscarriages.)

"I realize this is very basic and elementary to the posts that you get from doctors and other scientists but I believe that we must have clear definitions BASED ACCORDING TO WHERE THE STEM CELLS COME FROM to educate the voter and to keep the issues clear so that legislation isn't passed to support this new procedure with wording that would allow funding to inadvertently go to human embryonic stem cell research and human cloning."

Usually name is based on where the cells came from, but if the cells acted like the very early embryo - if they were truly "totipotent" like the zygote which is able to make both the body and the placenta - then research on them would be unethical.

The problem with "therapeutic" cloning, for instance, is that it would create a new human embryo that is capable of self-directed, organized development.

Even if he or she will be killed or die naturally in a few days, it's not right to create human beings with the intention of destroying them or using them for the benefit of others and to their own harm.

"Irregardless of the media and the bloggers who support human embryonic stem cell research and human cloning, most Americans do not believe in the Communist philosophy that the end justifies the means. No matter what our vocation or business, we draw the line when the means are immoral. We expect other Americans to do the same, including scientists and researchers. Destroying one human being to help another is clearly immoral and we should not have to fund it. We will vote accordingly."

I agree. We believe that "self-" should always be part of "sacrifice."

"George Bush and the Catholic Church hold us in thrall"

That's what Terry over at the Womens Bioethics Project Blog says. Terry has a big problem with the breakthrough in stem cell research that so many of us are thrilled with, and says,

It is amazing to see how the Catholic Church and George Bush can hold us all in thrall regarding human embryonic stem cell research. Because of the opposition to deriving stem cells from human embryos which destroys the embryo, eminent scientists are now reduced to attempting to find stem cell alternatives and have done so - by creating induced pluripotent stem cell lines derived from human somatic cells, an advance (?) which is being heralded today in the NY Times. In other words, we can regress human skin cells to an embryonic state by introducing retroviruses including c-Myc (cancer cells) to do so. The only problem with this is that it also creates tertomas which are nasty little creatures - effectively a germ cell tumor which may contain hair, teeth, bones, eyeballs, torsos and hands. Yuk, as Leon Kass would say. Here's an idea: instead of trying to create human embryonic stem cells from someone's nose or foreskin, let us do the research on embryos as nature intended.

Really Terry? "As nature intended?"" Nature intended for us to "use the original container," when it came to embryos.


Most of the basic research was done in mice - look at the history of Yamanaka & Takahashi's research, along with the reports published by Jaenisch this summer.

And Terry's way off on the teratomasas draw back: the *ability* to form teratomas in immune-deficient mice is one of the tests necessary if a researcher wants to prove that the cells are embryonic-like or pluripotent stem cells. (As opposed to multipotent - the fact that his cells did not make teratomas was one criticism of Atala's amniotic stem cell work. Gearhart was specific about the pressure he and others placed on Atala, so I expect to hear more about that in the future.)

Embryonic stem cells have always had all the problems that Terry mentions - including the retrovirus manipulation in many cases, look up "first transplantable lung cells" from the Houston, Texas Stem cell researchers here and here - in addition to the ethical problem of requiring the destruction of human embryos and the necessity to consider buying or bartering for oocytes.

Embryonic stem cells have the same concerns about the ability to reliably direct the cells toward the desired cell line, about the lack of regulation inherent in the primitive cells in culture, and ensuring that a more primitive cell - a future tumor - was not transplanted with the derived, less plastic cells.

One huge advantage that the new process offers that has never been achieved before, is the ability to make patient specific cells for everyone, not just the elite few who can afford to buy the oocytes.

The viruses used are strongly "silenced" or suppressed in the culture conditions used to direct development and are well known - the research to remove them from the DNA is not predicted to be all that hard. But that shouldn't really be a problem form long: between the two researchers and the information coming out of other labs, I wouldn't be surprised if we are able to skip the transfection in a year or two.

In the meantime, Wilmut has announced that the science is driving him to abandon embryonic research and cloning (especially using animal oocytes and human nuclear DNA to form a cimera), Yamanaka and Thomson are getting ready to patent and sell their cell lines for drug research and basic science, as well as anticipating future transplants.

Court upholds Texas Prenatal Protection Act

In 2003, the Texas Legislature passed a Prenatal Protection Act, which named the unborn children of Texas individuals from fertilization to natural death. Texas law also calls the "individual" a "person." With the world the way it is after Roe versus Wade, and because most of us have compassion for a woman who believes she doesn't have a real choice, we had to make exceptions for the decisions of the mother, including abortion and - even when the child is not in her womb - for those she empowers, such as doctors and techs at in vitro fertilization clinics.

However, the law in Texas protects a woman and her child against some one else taking the life of her child against her wishes. We will also punish the murderer when we can't protect them.

Today, the Sixth Texas Court of Appeals upheld the conviction of a man for killing his pregnant girlfriend under our Prenatal Protection Act.

The man was dating two women when one became pregnant. He told the other woman that he would "take care of it," and then shot the mother of his child 3 times with a shotgun, once in the face.The jury determined that he knew the woman was pregnant and that he intended to kill them both. He was convicted of capital murder and sentenced to life imprisonment.

The Court decision plainly states:
"By expressly defining capital murder such that one of the victims may be any unborn child from fertilization throughout all stages of gestation, the statute leaves no ambiguity as to what conduct is proscribed. In particular, the plain language of the statute prohibits the intentional or knowing killing of any unborn human, regardless of age. No ordinary person reading the statute would have any doubt as to whether it encompasses victims at all stages of gestation."

We know that violence often begins when a woman is pregnant and that 25% to 30% of deaths during pregnancy are due to homicide, usually at the hands of the father of the child.

I hope that this Court opinion and the original law will save lives. I wish for a day when no one is in danger of being intentionally killed by someone else, much less a loved one. And I hope that the publicity about this law will cause everyone - the person about to get behind the wheel after drinking as well as the abusive husband or boyfriend, to consider the risk of harming a mother too dangerous to even think about.

I believe we are much more likely to overturn Roe now than we have been at any time since 1973, while still ending up with restrictions in at least as many States as we had then. And I believe that the reason why this is so is because more than half of our citizens are unhappy with elective intentional abortion on demand as it is practiced in too many States today.

I also believe that a pro-life Congress could restrict the Courts from interfering with the States' legislative actions on abortion tomorrow, on the grounds that it's obvious that the unborn are persons.

For one thing, we have 4-D ultrasounds now and babies born as young as 20 weeks go home healthy.
In addition, many minds were changed - are still being changed - by the debate over partial birth abortion.


However, the reality is that there is zero chance of getting a Human Life Amendment through the Senate, much less getting 2/3 of the States to ratify it if the States themselves are not already doing it. (Please read up on how the 13th and 14th were ratified: the Legislators from the Southern States were not allowed to participate.)

Far too many men and women think of abortion as insurance against their bad decisions, rather than one more (awful) bad decision.

There are still too many people who think rape and incest are appropriate reasons in themselves for an abortion. They haven't heard how many women decide to carry their children to term after rape or considered the very real humanity of the unborn child, who shouldn't be punished for his father's crime.

But we do have a chance at returning the choice to the States where the majority would restrict abortion except to save the life of the mother. And each person that we teach to think of the unborn child as a person, the closer we get to ending elective intentional abortion.

On the power of Naming (iPS and Art Caplan's Off the Wall Question)

Art Caplan, Ph.D., is one of the pseudoeditors over at the Journal of American Bioethics blog, bioethics.net and a founding member of the "Progressive Bioethics Initiative," along with Robin Alta Charo, the subject of one of yesterday's posts. Dr. Caplan writes a regular "Breaking Bioethics" column for MSNBC.

Art took the liberty of renaming the induced pluripotent stem cells (iPS) that were such big news yesterday. He calls them "panacea cells."

I wondered why so many people were calling iPS cells "embryonic stem cells," when cells with similar markers derived from umbilical cord blood were called "embryonic-like stem cells."

Obviously, these are not technically "embryonic," they are reprogrammed adult stem cells. Technically, all research on iPS cells derived from fibroblasts (a cell found in the skin and many organs that regenerates the connective tissue) should be thought of as research on "adult stem cells."

However, Art asks the oddest questions in his opinion piece:

Lastly, some may wonder if a reprogrammed panacea cell acts like an embryo, should it then be classified as a human embryo?

True, a reprogrammed cell cannot implant in the womb but it can do everything else an embryo does. Is this form of genetic engineering a solution to the issue of avoiding human embryo destruction or merely a new route to a similar destination?

iPC's do not "act like an embryo. They cannot "do everything that an embryo does."

Embryonic stem cells harvested by disaggregating (destroying) an embryo at the blastocyst stage do not have the ability to "act like and embryo," once they are removed from the embryo itself. At least by the third or fourth division (and possibly from the first cell division), the cells are differentiated into cells that will become either trophoblast (the future placenta) or Inner Cell Mass (the body proper of the embryonic individual).


These cells do not demonstrate the abilities that the zygote or early, pre-blastocyst stage cells do. There is no mention in either article of the development of trophoblast cells - the cells that become the placenta - or of any organization that gives them the appearance of an embryo in the petri dish.

The only purpose that these questions serve is as segue to Art's final points in favor of continued research into cloned human embryos and embryonic stem cells derived from human embryos:

My view is that genetically altering body cells creates something that does not have the same moral standing as what is made from a sperm and an egg. That is why I favor continued work to create cloned human embryos as well.

I'm afraid that Dr. Caplan is confused or he is deliberately attempting to mislead his readers in support of a philosophical agenda, not science or ethics.

Limits on "I want" ethics

While we're all waiting for the announcement that Shinya Yamanaka's lab has or has not published on human embryonic-like stem cells dedifferentiated from adult stem cells . . . (The press releases hit while I was writing this post.)


Wesley Smith's blog, Secondhand Smoke has a good discussion titled, " Just Because Someone Wants Something, Does That Mean Doctors Should Do It?," that goes along with the conscience and limits on science debates that seems to be the theme of this blog over the last couple of weeks.


The limits should probably be based on the individuals' right to life and liberty as in, "Is it permissible for a person to infringe on his own rights?" and "Does the desired event risk life and liberty of others?" These themes are what I consider the basis for "First, do no harm."

There are questions that need to be asked.

1. Nothing should be allowed that is designed to intentionally kill a human being. (The Nuremberg Code says "except, perhaps, in those experiments where the experimental physicians also serve as subjects,” but I don't believe that even doctors are allowed to infringe our own right to life and liberty.)

2. Will society be asked act to make special accommodations for the the intentionally mutilated (or the obese, the smoker, the Jehovah's Witness or vaccine denier, etc.)? (How much of my life, liberty and property do you claim?)

3. Will the rights of certain individuals be infringed upon by a demand for an action from someone else that is repugnant to the one being forced to act? (Traditional ethics that society may restrain, but not compel, action except in limited situations such as parents' duty to their children, doctors' and lawyers' duties to their patients and clients. )

Christian Medical Association on Right to Conscience

If the scientist or doctor is driven by curiosity (and a desire for her own set of money making patents?) or because "it's legal" and patients want it, where do we draw the line between preference, opinion and conscience?

We've been discussing the significance of ethics and conscience at here at LifeEthics.org, the Women's Bioethics Blog and Bioethics.net (The latter two "bioethics" sites, emphasize laws and science at all cost, almost to the point of dismissing ethics and, especially conscience, at all. The subject is also the theme of posts at Bioethics.com, the blog of the Center for Bioethics and Human Dignity.

Now, the weekly email newsletter of the Christian Medical and Dental Association has dedicated an issue to the subject, in light of the statement (opinion?) on conscience from the The American College of Obstetricians and Gynecologists. There are links to the statement, itself, and rebuttals by Dr. Robert Orr, and Dr. Edmund Pellegrino.

Truth or Dare?

blog.bioethics.net notes that there may be a change in the direction of stem cell research, with Ian Wilmut's announcement that he and his lab won't be focusing on cloning or embryonic stem cell research.

Blogger Greg Dahlman states that if there is a change, it's because the science, and not the ethics, is driving that research.

Forget for a moment that we're discussing nascent humans and whether or not they are "life."

Imagine instead that we're discussing global warming and I say that I've invented a machine that will eventually turn sewage into clean water and unlimited energy for everyone, but the cost is a definite increase in the mean global temperature. The benefits of cleaning our water and the environment, along with the energy to grow crops and build homes all over the world are obvious. But the polar caps will probably melt and we'll have to use some of that energy to move water across new deserts and abandon lowlands.

Now, imagine that there are two ways to approach the development of the machine, one might be faster while also speeding warming, but the other is much, much less efficient and slower and we just might be able to avoid half of the warming.

Will we debate whether science or ethics is driving the research?

Dolly's Dad: Cloning, embryos and eggs not needed

10 years after the world learned about the cloning of Dolly the sheep, the scientist responsible for her birth announces that cloning is passe'.

Just after the announcement that a US lab has managed the first confirmed cloning of primate (monkeys, not human) embryos using adult cell donor DNA, Ian Wilmut made statements to the UK press that he's abandoning the cloning track for research using something like Japan's Yamanaka's process of dedifferentiation or reprogrammed adult cells to produce stem cells. (He's also selling the paperback version of his latest book.)

This approach, he says, represents, the future for stem cell research, rather than the nuclear transfer method that his large team used more than a decade ago at the Roslin Institute, near Edinburgh, to create Dolly.

Last year, at the American Society of Bioethics and Humanities Conference, the top ‘ethicists’ were nearly in a panic over these techniques. They evidently put pressure on Yamanaka to and criticize his own research. Then, 3 other labs proofed the technique and the Yamanaka’s lab advanced a step or two. Gearhart and Moreno were still scoffing last month, when they spoke at the National Academies of Sciences museum during the ASBH conference.


I’m afraid that too many labs and too many PhD candidates and sponsors have all their eggs in the cloning basket for the issue to fade decently. Talk about being left behind — all US research centers, such as the California Institute of Regenerative Medicine — will be negated if they insist on following the dead end trail of cloning and unethical destructive embryonic stem cell research.

The Yamanaka technique involves reprogramming adult fibroblasts - skin precursors - to a primitive, embryonic stem cell state. The stem cells are not quite 'totipotent" from what we can tell -- they aren't capable of forming new embryos. But they are capable of forming "all the cells of the body," at least with manipulation in the proper environment.

We're going to hear more and more dispute about the "proper" name for the cells -- disputes over whether they are actually stem cells. And a huge amount of discussion about the dangers from the viral transfection that is used to add the genes that turn on stemness.


We will be expected to forget that

1. No one has been able to clone a human embryo in spite of thousands of eggs used in Hwang's scam alone,

2. That 13,000 monkey eggs were used in the latest attempt to clone primates, that the published study relates an efficiency of 0.7% success, and the authors aren't quite sure why they were successful where other labs weren't,

3. The fact that true embryonic stem cells are short lived in the body and difficult to control (reports actually criticized the embryonic like stem cells from dedifferentiation for making tumors in mice - although that is one of the properties that defines embryonic stem cells)

4. That transfection with plasmids and specialized virus particles is an established technique of gene therapy,

5. and that the production of stem cell lines toward the end-stage adult cells has used viral transfection as well.

Even though he spouts the proper mumbo jumbo about the "moral status of the human embryo" (and that a person is someone capable of valuing herself - with the gradual acquisition and loss connected with functional capability), don't be surprised if Wilmut is, himself, negated and Watsoned because of his disloyalty to the cloning and embryo-destructive catechism. (James Watson's non-PC comments from last month cost him his lab, although he's been saying the same things for years.)


Now, if only the US, and especially the Texas, research Powers That Be will pay attention and learn.

Give me liberty or give me condoms!

Where are the condom squads who go around making sure that every grocery store, drug store, and 24 hour convenience store stocks latex condoms and the appropriate lubricants, "at all times"? Condoms are a much more basic public health issue than Plan B, which only works (when it works) for about 5 days in the woman's cycle.

Siricou Raven is keeping the conversation alive as to whether or not pharmacists should be forced to stock and dispense all legal medicines. She asks,

What is the difference between a pharmacist refusing to distribute contraception because it offends his own morality, and one refusing to dispense HIV medication because it offends his own morality?

Treating disease has never been controversial. Have you ever heard of a doctor or pharmacist who refuses to treat syphilis, gonorrhea or chlamydia? Have you noticed any that have ceased doing Pap smears since we learned that abnormal Paps are due to a Sexually Transmitted Disease, Human Papilloma Viruses that are only transmitted by sexual contact?

(I do know a pulmonologist - a lung specialist - who will not take on patients who smoke. I could draw all sorts of parallels between sex and smoking, but I'll leave that to you.)

At issue is the very basic question is that of the "unalienable" individual right to liberty, expressed as following the conscience.

As Judge Lawrence wrote in the Injunction, the Washinton State law is very clear on the right to conscience and freedom to practice religion.

There is no reason to carve out contraception and "reproductive health" (a Newspeak term, if I ever heard one) as a special, protected class of medicines, devices and procedures.

For that matter, why on earth would any woman who doesn't want to become pregnant have sex without two or more contraceptives in hand/body before the act itself and/or know her fertile periods? If men didn't have the back up insurance of abortion, I'd bet they would be more careful, too. (Rape is an Emergency Room issue - the ER doc and SANE nurse can dispense and counsel on fertility risk, right along with prophylaxis for STD's).

While I'm ranting:

Ethics lesson 1: Life trumps liberty, since pretty much everything else depends on being alive.

Ethics lesson 2: The only reason the State should force action from a citizen is in cases of life and death. Each law that is enforced puts the citizen's life and liberty at risk, since the enforcement will involve the real and virtual guns of the State. There is a long history of recognizing the relationship between the right to own property and the right to liberty. If the State may take the property or restrict the livelihood of a person, the person is at risk of prison or hunger and is not free.

Ethics lesson 3: People who will do acts that they believe morally wrong for any reason other than to save lives (to stay out of jail, keep their jobs or avoid controversy) are either unethical people or insane. And I'm not too sure about the people who would force them, either.

Government Health: Intervention, Restrictions, and Penalties

What do Massachusetts and Great Britain have in common? Mandated health coverage.

Today is the last day that citizens of the State of Massachusetts may buy health insurance or risk penalties on their State income tax.

The BBC News from Britain reports that the Nuffield Council on Bioethics proposes that the government do more to protect the people from themselves and their choices:

The government should intervene more with public health measures Government ministers should shrug off media accusations that they are running a nanny state and introduce tougher public health measures, experts say.

The Nuffield Council on Bioethics said the time had come to consider a whole host of interventions in the UK after the introduction of a smoking ban.

Its proposes raising alcohol prices, restricting pub opening hours and better food labelling to fight obesity.

The government said it was taking steps to protect public health.

The report by the panel of experts, which include scientists, lawyers and philosophers, said there was a balance to be struck between individual freedom and wider public protection.

*****
"But the government has a duty to look after the health of everyone and sometimes that means guiding or restricting our choices." (emphasis mine, BBN)

Of course, the UK doesn't have our Declaration of Independence, with its insistence that each of us is endowed with the inalienable right to life, liberty and pursuit of happiness and that the government receives its power from the consent of the governed. Massachusetts ought to know better.

However, I'm afraid that the bioethicists and bureaucrats go to the same schools.

While I appreciate that the Massachusetts plan calls for each person or family to buy individual health insurance if they don't have it through their employer, and I recognize that people would be healthier if they follow the recommendations of the UK bioethicists, I would prefer a tax deduction for compliance, rather than a penalty. Rewards seem to work better than punishments for behavior that other people decide is "for your own good."

The statement from Lord John Krebs about restrictions for the common good, however, is the most worrisome. Remember that some in the public health community believe that in times of crisis, the community interests must trump those of individuals due to the scarcity of resource and public funding of relief and rescue. (Never mind that the courts are paid for by community funds, also have limited resources and yet, no one would dare suggest suspension of individual rights in criminal cases.)

Laws, conscience, medicine and bloggers

In contrast to the hype that you might read on blogs and in the press, the Federal District Court judge in Washington has upheld the law of that State. The basic right to not be forced into action that one considers unethical or immoral - the right to liberty - was upheld first, by the Washington State Legislature and affirmed by the Court.

According to the Seattle Times article, there will be a trial next year and the "rules were meant as a compromise after long, contentious hearings and intervention by Gov. Christine Gregoire, who threatened to replace members of the Board of Pharmacy who didn't vote to protect women's rights." (Emphasis mine, BBN.)

The judge ruled in favor of State Law and overturned regulations passed by the Washington State Board of Pharmacy which were changed in July of this year to require that "pharmacies must maintain at all times a representative assortment of drugs in order to meet the pharmaceutical needs of its patients." The plaintiffs, two individual pharmacists and a corporate pharmacy were asking to be allowed to follow their previous practices "refuse and refer."

The Court's ruling is posted here at the Seattle Times website, which also has a fairly good review of the case to this point, here. (I've saved copies of each, so let me know if they disappear).

Judge Ronald B. Leighton issued an injunction that delays the force of the regulation, since it appears that the regulation violates laws passed by the Washington State legislature to protect the rights of individuals:

"As a part of the Health Care Access Act, the legislature expressed the recognition “that every individual possesses a fundamental right to exercise their religious beliefs and conscience.” RCW 70.47.160(1). The Legislature further acknowledged that “in developing public policy, conflicting religious and moral beliefs must be respected.” RCW 70.47.160(1). Accordingly, the Legislature provided that “no individual health care provider, religiously sponsored health carrier, or health care facility may be required by law or contract in any circumstances to participate in the provision of or payment for a specific service if they object to so doing for reason of conscience or religion.” RCW 70.47.160(2)(a). No person may be discriminated against in employment or professional privileges because of such objections. RCW 70.47.160(2)(a). The right of conscience, however, is not intended to result in a patient being denied timely access to any service included in the basic health plan. RCW 70.47.160(2)(b).

"An identical right of conscience was included within the Insurance Reform Act adopted by the Legislature in 1995. RCW 48.43.065."

(emphasis in italics are mine, BBN)


The regulation itself was poorly written.

The phrase "at all times" is a big problem. Would that mean that all pharmacies must change their hours so that they are open or on call 24/7? As to the phrase, "representative assortment," that might mean different things to different people. The wording open to the widest interpretation, however, is the phrase, "pharmaceutical needs of its patients." (Let's forget that pharmacies don't have patients, pharmacists do.)

The "pharmaceutical needs" of patients is wide open to interpretation, especially in the case of Plan B. I've covered the evidence (here) that indicates that Plan B only works to prevent ovulation and fertilization the 5 days or so of the month before and the day of ovulation and the lack of evidence that it acts in any way as an abortifacient. Unfortunately, this isn't acknowledged in the court's ruling or by any of the other parties in the case.

I depend on pharmacists to evaluate the prescriptions I write for my patients. They have often helped me by catching and refusing to fill scripts because they knew about drug interactions, allergies, and fraudulent prescriptions when I didn't. I would like for them to notify me if they refuse to fill my scripts, but their professional judgment is the very thing we physicians and patients are depending on, isn't it? If we force them to do what they believe to be wrong, the only pharmacists we'll be left with will be people who will do wrong because they were "only doing their job." (Where have we heard that before?)


There's an especially over-wrought emotional discussion over at the Women's Bioethics Project blog. No posts are published without the permission of the author, who evidently has some pretty strong feelings involved. I added to the intensity of the silliness and self-righteousness with my comments, I'm afraid. (So far, they haven't posted my remarks from 12 hours ago about cigarettes as a legitimate treatment for priapism [an old remedy - no longer advised - that was actually used as late as the '80's], prescribing of wine as a relaxant, and the fact that I make it a policy not to prescribe medications until they are on the market long enough to be proven by lots of other doctors' patients.)


As Mick Jagger sang, "You can't always get what you want. . . but you can try sometimes to get what you need."

(edit - typos fixed at 5:30 PM CST 11/14/07)

Human dignity: What it is

Whether it's a genetic result of evolution or the way we are designed by a Creator, even very young children seem to have a sense that it's important to understand that there are consequences to infringing rights of other people before they can express "That's not fair!."

My attempt a couple of days ago to discuss the foundations of conservative philosophy and human dignity is not nearly so elegant as this one from Professor Francis Beckwith, associate professor of philosophy and church-state studies at Baylor University:

It is the view that human beings have intrinsic dignity by nature that is not a consequence of their size, level of development, environment or dependency.

and

"We don’t become less intrinsically valuable because others think it is in their interest to destroy us.

The Professor's letter addressed the controversy over abortion in Waco, Texas the home of Baylor. It might also give the editors of the American Journal of Bioethics a better understanding the base of the conservative philosophy and human dignity.

Admittedly, the result can be risky for people, individually and in groups. This is where government comes in and why it's vital to educate the public about the nature of rights as endowed to each human individual from the beginning of life until death. The danger comes from other people who discriminate between which human individuals fit into artificial categories smaller than the species category. The re-defining and discrimination - and the distraction by adding adjectives and qualifiers - is the beginning of the infringement of rights, whether the categories are according to physical or political power, race, status, location, development or function.

Thanks, to Jivin' Jehosaphat for the link to the Beckwith editorial in the Waco Tribune-Herald.

Conservative vs. Progressive (no adjectives)

Once again, we're reminded about the great gulf between perception and reality (just look at the repetition of the names of authors whose ethics comments are published in the "mainstream" science and bioethics journals and explore the political and religious viewpoints of those authors and editors), between the idea that all humans are people possessing rights endowed by "their Creator," and the difference between exercising those rights and the restrictions and privileges afforded by government. And we see another example of projection, re-definition to attack pro-life conservatives.

(Go ahead and read the Declaration of Independence (Here's another text version). I believe it's a good primer for understanding conservativism.)

The latest American Journal of Bioethics includes a silly little target article, "Biotechnology and the New Right: Neoconservatism's Red Menace," (the abstract is free, the rest is behind a pay-wall. Let me know if you want to read it) by Jonathan Moreno, Ph.D. and Sam Berger. Both "progressives" are mouth pieces a Senior Fellow and a (former?) Research Assistant at the Progressive Bioethics Initiative. The PBI is an off-shoot of the "Center for American Progress," a far-left think-tank started by John Podesta.

Moreno and Berger look at the fathers of some men that opponents have named "neocons," and build upon the argument that

"Although the neoconservative movement has come to dominate American conservatism, this movement has its origins in the old Marxist Left. . . . By not acknowledging and embracing their intellectual roots, neoconservatives are left with a deeply ambivalent and often confused view of biotechnology and the society that gives rise to it."

The "Open Peer Commentary" pieces are written by volunteers who review and argue the target article. Remember the Womens Bioethics Project and their "God's Bioethics" expose'? (Read more about that here and here.) The Commentary "Responding to Neocon Critiques of Biotechnology: A Progressive Agenda" (sorry, another pay-to-read) by Kathryn M. Hinsch, and Robin N. Fiore, Ph.D., of the Women's Bioethics Project should offend conservatives of all ages and progressives as well.

In order to overcome what they see as impediments to their goal of ". . . attempting to construct a coherent consensus “progressive view” that could be acceptable to the wide range of extant progressive views (plural)," (sic) they suggest that Progressives work on the following problems:

1) Widespread scientific illiteracy permits the substitution of rhetoric about vague but disquieting threats to human nature, engenders distrust of the scientific enterprise and its products, and sanctions relativism with respect to non-scientific and pseudoscientific explanations and justifications for empirical claims. For example, neocons have successfully exploited the public’s lack of understanding with respect to the differences between therapeutic and reproductive cloning in order to pursue a ban on all forms of embryo research.

2) Social arrangements structured by historical gender, race and class inequities continue to appropriate women’s sexuality, their reproductive capacities, and their labor. Progressives as well as conservatives often neglect analyses of (current and potential) distributions of power and privilege. For example, neither conservatives nor progressives address caregiving in ways that acknowledge the increasing dependence on uncompensated care
by women in families and the impact of caregiving burdens on women’s own well-being. The President’s Council on Bioethics issued a lengthy report that finally concludes with a recommendation (sigh) that yet another commission be appointed to study this issue (President’s Council on Bioethics 2005).

3) Progressives are identified as being more concerned with social justice and conservatives as more concerned with human dignity — 45 million uninsured Americans rebut both propositions. On questions of access, disparities in healthcare and medical entrepreneurship,
progressives have failed to distinguish themselves. Conservatives offer a dystopian vision of a future gerontocracy and blame ill health on the personal irresponsibility of the medically least well off. Mainstream bioethicists have offered arguments from“justice” about individuals’ duty to refuse expensive medical interventions
after a “fair” share of normal life expectancy, but have been unable or unwilling to specify a “fair” profit margin for entrepreneurial healthcare systems and insurers.

4) Moreno and Berger (2007) suggest that the neocon attempts to ban whole sectors of biotechnological research and commercialization — particularly those that implicate reproduction — stem from neocon’s understanding of “people” (scare quotes added for emphasis) as too weak, imperfect, and immoral to make certain weighty decisions. This view of moral agency has, of course, been routinely applied to women and other infantilized social actors, particularly with respect to individual decisions regarding sexuality and reproduction. In Gonzalez v. Carhart, the Supreme Court of the United States justified upholding the ban on late-term abortion in part by invoking gender stereotypes and claiming that women needed to be protected from poor decision-making. As Justice Ginsberg pointed out in her dissenting opinion, this decision could have been accomplished by strengthening informed consent rather than depriving women of the right to autonomous choice. Conservatives are now attempting to limit forms of medical progress that have implications for the moral agency of previously privileged social actors. For example, Francis Fukuyama and Leon Kass, both members of the President’s Council on Bioethics, support legislation that would criminalize the prescription or utilization of treatments developed (anywhere in the world) from cloning technology.
A progressive alternative to technology embargoes and diminished moral scope might focus on developing programs to enhance technological information literacy, critical thinking and decision-making skills and supports, as well as broadening opportunities for community participation. Such efforts may nourish solidarity and ground more substantive forms of autonomy.
5) The patenting of drugs, devices and other medical technologies both stimulates innovation and deprives the medically indigent, creating special interest wealth at the expense of life and health. In contrast, Benjamin Franklin refused a patent on his design for an improved wood stove, preferring that all people benefit from it.
Ultimately, progressives must engage the difficult problem of ensuring that the benefits of the new biology and medical advances are distributed as broadly as fairly as possible.

Both the Progressives and the Women would do well to consider what it means to believe that the right to "life, liberty and pursuit of happiness" are endowed on all humans, rather than legislated and regulated. So many of the misconceptions outlined above are answered anew by this simple philosophy. No matter who your father was.

Note: Post was edited 11/2/07, because of an error in Ms. Hinsch's name.

I forgot (a note on memory and humanity)

I know that you may not be able to tell, but I'm trying to make my blog posts shorter. So, I left some quotes out of this morning's post on memory. However, this quote from the Time Magazine article, "The Ethics of Erasing a Bad Memory" by Dr. Scott Haig, on human-ness needs to be repeated:

Much of what we read about brain science in the media today would have us believe that we're nothing more, really, than very fancy machines. And surely what we're learning about the physical brain is exciting and powerful — but thinking honestly, it remains so limited. We can trace the brain pathway of a drug "high," we can call it pleasure, but that tells us nothing about what so many people choose instead — deeper things that somehow beat out mere pleasure as the reasons for doing what we do. Those comforts — of ultimate meaning, virtue, peace and joy — have little to do with molecules.

Doctors, faith and helping the poor

The Chicago Tribune published an article on a study concerning doctors who help the poor. I haven't read the actual article, yet, but I wonder how the "poor" are defined and question the definition of "religiosity" vs. spiritual.

For one thing, I'm not sure how, as a Family Physician, I would separate my patients into poor and not-so-poor. Currently, I work for other doctors, but their patients seem similar to the ones I cared for when I had my own practice, although the trend is away from Medicaid, which pays very little compared to Medicare and private insurance. (Medicaid pays less than the office overhead for the time it takes to see the patient.)

There seems to be a fair mix in the patients that come to our practices through the hospital call lists because they don't have a doctor. Also, I frequently hear that this patient or that has an agreement with the doc to pay what and when she or he can. I'm also reminded by the staff that the patient is "self-pay." These patients are "coded" or charged as little as we legally can without committing the felony offense of insurance or Medicare fraud. (The law says we can't charge less than we would charge a Medicare patient and we can't charge a "discounted" rate without risking charges of fraud. There is a little bit of lee-way, however, in calculating the risk, history necessary, etc.)

The study, based on a mail survey of more than 1,100 American physicians, found that 31 percent of doctors who described themselves as religious reported that they serve primarily poor or uninsured communities, compared with 35 percent of doctors who had no religious affiliation.

Those two figures were statistically equal, but other comparisons showed that doctors were more likely to treat underserved populations if they considered themselves highly spiritual, felt that their religious beliefs influenced their medical practice, or said they were raised in a family that encouraged service to the poor.

How do you determine "religious" if not by those who "considered themselves highly spiritual, felt that their religious beliefs influenced their medical practice?"

BTW, I've been away while studying for and taking my every-7-years American Board of Family Physicians National Boards. I won't know the results until mid-September, but at least there's no dead lines looming ahead of me for a while. Yeay!!!

Ethics, embryos, and e-rants

Kevin T Keith (His often profane blog, Sufficient Scruples, focusing on why it's wrong to be religious, pro-life or pro-abstinence is here) wonders (in 1700+ words) how scientists ever began to speak in terms of "ethical" and "unethical" about sources of stem cells at the Women's Bioethics Blog:

To emphasize that: the search for "ethical" stem cells has no importance whatsoever, other than the fact that it responds to objections raised by a certain segment of the religious right and grounded on their religous (sic)beliefs. There is no need for them otherwise, and they are less desirable therapeutically than the already-available alternative of actual embryonic stem cells. Such lines of research, and the diversion of time and resources they represent, have no point unless that religious objection is demonstrated to be a compelling moral claim.(Italics in the original)

Let's forget that embryos require that oocytes be harvested from women, risking their health or that embryonic stem cells from embryos created by in vitro fertilization can never be "patient-specific" until and if human cloning is perfected. Let's forget growing evidence that the differentiation of stem cells is dependent on local factors and conditions - the 'niche' in which the cells are found. And, along with Kevin, we can forget that there are in fact people who object to the destruction of human embryos without a religious objection.

Let's look at the question of applying the concept of ethics to research.

Kevin obviously has very strong feelings that there is a right side and a wrong in determining whether or not destructive embryonic research is "ethical."

Isn't the act of determining one position right and others find that position wrong making "ethical" or "moral" decisions?

"Should Science Speak to Faith?"

That free Scientific American issue also contains a dialog between two scientists on faith, religion and the scientific community. Laurence M. Krauss and Richard Dawkins discuss their different views on engaging in "seducing" people of faith. ("Teaching is seduction." "No one appreciates a dishonest seducer.")

Gentlemen, the main point you should understand is that those of us of faith believe that science lets us understand what is - not what we should do or why.

Oh, well, at least you agree that there's a difference between right and wrong. We can begin our conversation, from this common ground.

More equal or less?

A self-defined troll, Siricou Raven, asks,

Merely being human genetically isn't enough - so what do humans have that makes them protected over all other species? And when do they aquire whatever this is?

SR, I don't have to weigh, measure and evaluate - you do. You are the one asserting that "being human genetically isn't enough."

Why isn't being human enough?

The problem is more that you find it necessary to justify killing some humans and so you are the one looking for that something that makes some humans less "protected over other species." A more precise way to phrase your premise would be,

"[W]hat do humans have that makes them protected" - from other humans - "over other species," -- while still protecting yourself?

I, on the other hand, follow long-standing philosophic tradition that all humans have the right not to be killed, and the slightly less common tradition that every member of our species is human-enough to be protected from deliberate killing and enslavement. (As I say, "We're the only species having this conversation.")

I believe that anyone can come to the same conclusion - with a little study of biology, logic, history, and even some imagination.

The biology is self-evident. Follow the embryology, anatomy and physiology. The one-celled embryo is the same entity as the rational adult. Our repetitive discussions about "why" and "when" are simply more proof of the continuity, rather than any discrete discontinuities.

It goes against logic to proclaim that "Some of us are more equal than others."

And it requires a lot of energy to defend your philosophy. Energy used up in defining, renaming, listing characteristics and measurements. Then, you need convoluted laws, an army or police force trained to discriminate and protect the "special" people.

If you want to skip logic and efficiency, study the subject of human rights from a historical perspective: Historically, the more inclusive a society, the more freedom for all. Societies that discriminate spend too much energy protecting the special people and their "right" to kill and enslave others.

Even the societies with historical caste systems, where the discrimination is internalized all along the spectrum of human-ness, exposure to ideas about human rights - or the birth of a William Wilberforce, Susan B. Anthony, Ghandi or Martin Luther King, Jr. - weakens former "protections" for the privileged. Society changes. (Far too often, after a period of violence betwee