BIOMEDICAL ETHICS

What ends will or should the new technology serve?

What values should guide society’s adjustments?

By what standards should the assessment agencies assess?

What do we mean by the betterment of humanity?

What is a good person?

What is a good life?

What is a good community?

“THE NEW BIOLOGY”

1. Control of Death

2. Control of Life

3. Control of Human (genetic) Potential

4. Control of Human Achievement

Kass, Leon. (1971). The New Biology: What Price Relieving Man’s Estate? Science, 174(4011):779-788

“…we may be rapidly acquiring the power to modify and control the capacities and activities of men by direct intervention and manipulation of their bodies and minds.”

Kass, Leon. (1971). The New Biology: What Price Relieving Man’s Estate? Science,174(4011):779-88

[p. 779]

“THE NEW BIOLOGY”

“Biomedical technology may make it possible to change the inherent capacity for choice itself…humans can for the first time recreate themselves.””

Kass, Leon. (1971). The New Biology: What Price Relieving Man’s Estate? Science,174(4011):779-88

[p. 780]

“THE NEW BIOLOGY”

CONTROL OF DEATH

Heroic Medicine / Euthanasia

Infant Mortality

Organ Transplants / Stem Cells

Infectious Disease

Degeneration / Aging

What is Death ?

“The permanent end of all life functions in an organism or part of an organism”

“Cessation of all vital functions without the capability of resuscitation”

“The absence of life”

“The irreversible loss of all brain function”

CONTROL OF DEATH

HEROIC MEDICINE

Karen Ann Quinlan1975; mixed alcohol & tranquilizers; passed out; aspirated vomit

“persistent vegetative state”

Parents fought to remove life support

After removing support, she lived another 10 years

Terry Schindler-Schiavo1990; K deficiency; coma

Woke a few weeks late in a “locked state”

Receives food and water via gastic feeding tube

In 1998 Terri’s husband asked to have the food tube removed; parents fought; still pending

HEROIC MEDICINE

EUTHANASIA

0

10

20

30

40

50

60

70

80

90

Fundamentalists ModerateProtestants

LiberalProtestants

Catholics

Strong Moderate Minimal

[NORC, 1977-94; General Social Surveys Combined]

Per

cen

t A

ffir

mat

ive

Res

po

nse

s (%

)

40

50

60

70

80

90

0-11 yrs SomeCollege

4+ yearsCollege

HS graduate

Per

cen

t A

ffir

mat

ive

Res

po

nse

s (%

)

Strong

Moderate

Minimal

None

[NORC, 1977-94; General Social Surveys Combined]

EUTHANASIA

INFANT MORTALITY

YEARWHITE BLACK

Male Female Male Female

2001 6.2 5.1 15.5 12.5

1995 7.0 5.6 16.3 13.9

1990 8.5 6.6 19.6 16.2

1985 10.4 7.9 20.8 17.2

1980 12.1 9.5 24.2 20.2

US Infant Mortality by ‘Race’

[National Center for Health Statistics, 2001]

Which organs?

• Kidney• Heart• Liver• Lung• Pancreas• Intestine• Cornea• Skin• Bone• Bone Marrow

ORGAN TRANSPLANTS

Survival Rates --

98% kidney95% liver85% heart79% pancreas70% small intestine70% multi-organ65% lungs65% heart/lungs

ORGAN TRANSPLANTS

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 ‘00 ‘01

Patients on wait list at end of year Number of transplants

# of

pat

ient

s

[OPTN, December 31, 2002]

ORGAN TRANSPLANTS

UK Organ Donors[as of Dec 31, 2002]

< 0.30

0.30 - <0.60

0.60 - <0.70

0.70 - <0.80

0.80 - <0.90

0.90 - <1.0≥ 1.0

Registrants (millions)

[NHS, December 31, 2002]

ORGAN TRANSPLANTS

ORGAN TRANSPLANTS

Who Gets the Transplants ??

• Young, white, boys

• Wealthy individuals

• Shortage of available organs = lucrative black market trade

• Cycle of transplant access = rich to poor; black to brown to white; female to male

ORGAN TRANSPLANTS

Suggested Solutions• Education programs to elicit more donors

• Regulated transplant centers

• Use organs from executed prisoners

• Mandatory donation

• Futures market -- financial incentive donor’s kin

• Non-human sources

ORGAN TRANSPLANTS

FETAL TISSUES

Inner Stem Cell Mass

In Vitro Fertilized EggBlastocyst Stage

Undifferentiated CellsSpecialized Cells

neural cellsblood cells

muscle cells

• Undifferentiated cells that can be easily manipulated

• Cannot become a fetus

TreatableDisorders

Limb Amputations

Spinal Cord Injuries

Burns

Neurological Disorders

Heart Disease

Diabetes

• Understand human growth and development

• Pharmacology

• Restore any cell type

FETAL TISSUES

Spinal cord injuries Parkinson’s Alzheimer’s

FETAL TISSUES

INFECTIOUS DISEASE

1950 1960 1970 1980 1990 2000

Diphtheria 3.83 0.51 0.21 >0.005 >0.005 >0.005

Mumps - - 55.55 3.86 2.17 0.13

Measles 211.01 245.42 23.23 5.96 11.17 0.03

TB - 30.83 18.28 12.25 10.33 6.01

Syphilis 146.02 68.78 45.26 30.51 54.52 11.23

Gonorrhea 192.50 145.40 297.22 445.10 277.45 129.04

Infectious Disease Rates, US

[CDC Control & Prevention, (2001). Summary of notable diseases, Morbidity and Mortality Weekly, 50(53)]

* Cases per 100,000

Infectious Disease Rates

• same trends to not appear in all segments of US society

• same trends to not appear worldwide

• increased virulence of once ‘conquered’ diseases

• emerging pathogens

INFECTIOUS DISEASE

DEGENERATION

Worldwide Life Expectancy Rates (in yrs)

Andorra 83.49 Mozambique 31.30

Macau 81.87 Botswana 32.36

San Marino 81.43 Zambia 35.25

Japan 80.93 Lesotho 36.94

Singapore 80.42 Angola 36.96

* US life expectancy = 78.16 years** UK life expectancy = 77.14 years

[CDC, December 31, 2003]

Right to Die

Stem Cell Research

Health Care Benefits

Cost of Medical Care

Eldercare

SchiavoKevorkianUK Standards

Ronald ReganChristopher ReevesMichael J. Fox

Socio-economic divideChanging demographicNational Health Care ?

2/3 $$ last monthRationed careUtah plan

Changing demographicFrom kids to parentsIsolation

CONTROL OF DEATH

“Test-Tube Babies”

• In vitro fertilization

• 1978; Edwards & Steptoe

• Baby Louise Brown

• Common practice today especially for older women

• Not sanctioned by the Catholic church

CONTROL OF LIFE

Hormone injected

Recovered eggs

Suction device

Nutrient solution

Sperm sample

Fertilization of egg

Blastocyst

Insertion of embryo into uterus

Pregnant mother

CONTROL OF LIFE

• What to do with cast off cells?

• What are the legal rights of embryos?

• When used, what are the rights of the surrogate mother? Who are the surrogates?

• Who’s responsible for a defective baby?

CONTROL OF LIFE

HUMAN POTENTIAL

• 6% of consultations with doctors are related to genetic disorders

• 26% of all institutional beds are occupied by patients with genetic disorders

• 8.5% of all infant deaths are the result of a single gene defect

• Over 600 single gene defects are known, another 800 suspected

• On average, we all carry 6-8 defective genes

Negative Eugenics

• Ultrasound

• Chorionic villi testing

-- identify & eliminate unwanted genetic traits

• Amniocentesis

• Genetic counseling

• Sterilization

HUMAN POTENTIAL

Ultrasound• uses sound waves • detects visible defects

handheld transducer

HUMAN POTENTIAL

Amniocentesis

• Combined w/ultrasound

• fetal waste products

HUMAN POTENTIAL

Chorionic Villi Testing

• Microscopic projections lining the outermost layer of the embryonic sac

• same genetic material as fetus

• sampled at 10-12 weeks gestation

• fast turnaround time

HUMAN POTENTIAL

Genetic Counseling

HUMAN POTENTIAL

Sterilization

Carrie Buck case

HUMAN POTENTIAL

Positive Eugenics

HUMAN POTENTIAL

Cryobanks

HUMAN POTENTIAL

HUMAN ACHIEVEMENT

Neurological, psychological and physiological manipulation

• Mood altering & enhancing medications

• Cosmetic endrochronology

Valium• diazepam

• addictive potential high - 2 wks

• birth defects -’floppy child’ syndrome

• ‘for relief of psychic tension and its somatic symptoms’

• females outnumber users 2.5 to 1

HUMAN ACHIEVEMENT

Valium• most widely prescribed drug

worldwide in the 60s & 70s

• prescribed for anxiety, depression, insomnia, and anxiety

• caused depression, anxiety, and insomnia

• marketed to our desire for a ‘good life’

HUMAN ACHIEVEMENT

Growth Hormone

Growth Hormone• given to normal but small kids

• add 6” height, 50% muscle mass

• recombinant DNA technology

HUMAN ACHIEVEMENT

AdrenalCortex

Thyroid

Testis

OvaryBone

UterineMuscles

MammaryGlands

KidneyTubules

Hypothalamus

Pituitary

Adrenocortotropic Hormone

ThyroidStimulating

Hormone

Gonadotro

pic H

ormone

Go

nad

otr

op

ic H

orm

on

e

Gro

wth

Ho

rmo

ne

Oxytocin

Oxytocin & Prolactin

Antidiurectic

Hormone

HUMAN ACHIEVEMENT

BIOMEDICAL ETHICS

Derek Roberts

Peter Singer

Rational or Rationed Medicine ?

• Should everyone have access to care, regardless of ailment ?

• Control of infertility, increase in life expectancy, reduction in infant mortality , reduced infectious disease = diminished limits on population growth

Derek Roberts

Peter Singer

Rational or Rationed Medicine ?

• increases at 6X the rate of inflation per year

• $4,700 per person per year paid for health care

• High deductibles for families - $2,000

• Racial divide in access, regardless of income

BIOMEDICAL ETHICS

Derek Roberts

Peter Singer

Rational or Rationed Medicine ?

0 = costs nothing, gives back alot

3 = costs a little, gives back some

7 = society sustains them beyond what they pay back

10 = costs from the start, not possible to pay back

BIOMEDICAL ETHICS

What ends will or should the new technology serve?

What values should guide society’s adjustments?

By what standards should the assessment agencies assess?

What do we mean by the betterment of humanity?

What is a good person?

What is a good life?

What is a good community?

BIOMEDICAL ETHICS