Practical Ethics

When the heart stops: harvesting organs from the newly (nearly) dead

In the New England Journal of Medicine yesterday, doctors from Denver reported on three controversial cases of heart transplantation from newborn infants. These cases are striking for several reasons. They were examples of so-called ‘donation after cardiac death’ (DCD), an increasingly frequent source of organs for transplantation, but done very rarely in newborns. They are controversial because the transplanted organs were hearts that were ‘restarted’ in recipients after they had stopped in the donor. Transplant surgeons waited only a relatively short period after the donor’s heart had stopped (75 seconds) before starting the organ retrieval process. These transplants raise serious questions about the diagnosis and definition of death.

The point of death

The Guardian yesterday reported the death of the man who had been so tragically shot in Antigua, with his wife, three weeks after their wedding. It began like this:

"Ben Mullany, the newlywed who was shot on honeymoon in Antigua in an attack that killed his wife, Catherine, died in hospital in Wales yesterday after his life support machine was switched off.  The 31-year-old trainee physiotherapist, who had suffered a fractured skull and had a bullet lodged in the back of his head, was flown back to Britain while in a coma on Saturday. Tests carried out when his condition stabilised after the 24-hour journey established he was brain dead." 

This is a familiar way of describing such happenings, even among clinical professionals.   Brain death is pronounced, so the life support machine is switched off, and the patient dies.   The clear implication is that brain death is not death.  The machine is still keeping the patient alive, and it is switching off the machine that causes real death. 

Reproductive science: is there something we're missing?

Thirty years after the first test-tube baby, Nature asks various experts for their views on what the next thirty years of reproductive medicine will bring. Some of the more startling predictions are:

• No more infertility, with both children and 100-year-olds able to have children
• Embryos created from stem cells, increasing the ease of embryo research and genetic engineering of children
• … with the resulting greater availability of embryos making it easier to create cloned humans
• Artificial wombs, enabling babies to develop outside the mother’s body
• … which, some worry, could become compulsory as an alternative to abortion, or to avoid premature birth or fetal alcohol syndrome
• ‘Genetic cassettes’ implanted in embryos to counteract the effects of inherited diseases
• Increase in litigation following evidence that IVF babies may later suffer adverse effects from the environment in which they were grown as embryos

Testing alternative therapies

The journal Science is today reporting on a controversial plan by the US National Institute of Mental Health (NIMH) to test an alternative treatment for autism on children. The treatment, known as chelation therapy, involves the use of drugs that remove heavy metals from the blood. It's based on a the theory - unsupported by conventional science - that mercury in vaccines triggers autism.

Chelation therapy is widely used, but its benefits and effects are not well understood. The NIMH have therefore argued that there is a "public health imperative" to test the drug. But opponents claim that any such study would be unethical, since the quality of the trial is likely to be poor, and any results - especially negative ones - would be unlikely to alter the behaviour of parents who support the therapy.

Is there a duty to execute prisoners humanely?

An article published this week in PLoS Medicine discusses the ethics of research on US lethal objection protocols. The authors conclude:

While lethal injection and the death penalty present a host of ethical questions, the specific, pressing issue now faced by 36 US states, the federal government, and the 3,350 prisoners on death row is the movement to amend lethal injection protocols to comport with Eighth Amendment requirements and to minimize the potential for pain and suffering, in itself a commendable goal. As jurists demand lethal injection protocol changes, however, corrections officials, governors, and their medical collaborators are left in a legal and ethical quandary. In order to comply with the law and carry out their duties, they are employing the tools and methods of biomedical inquiry without its ethical safeguards. Given the current guidelines for human experimentation, it is difficult to conceive of circumstances in which lethal injection research activities could be carried out in a fashion consistent with these ethical norms, and yet those engaged in such research would seem to be required to do so.

This passage raises many questions. Is is the movement to amend lethal injection protocols really the pressing issue? Can a movement to execute prisoners more humanely really be commendable? But let's focus on the authors main claim: namely that the states in question face a legal and ethical quandary since, (i) they are under "duties", as well as legal requirements, to execute more humanely, but (ii) they cannot do so without breaching the ethical and legal requirements.

The authors devote most of their attention to the second claim, (ii), but arguably (i) is more problematic.

Brain Boosting and Cheating in Exams: Four Responses

A report by the Academy of Medical Sciences looking at different aspects of drug use and mental health has identified a growing trend for off-label use of drugs intended for the treatment of diseases including narcolepsy, ADHD and Alzheimer’s. The use of such drugs by a healthy individual can improve memory, alertness and concentration. While the report does not condemn the practice, it raises a number of potential concerns over safety, and fairness. Professor Les Iversen, report co-author, highlighted concerns that the use of enhancement in exams would unfairly advantage wealthier students, and suggested that the use of such drugs could be considered cheating. The report recommends that legislation is prepared to tackle the misuse of such drugs, including the potential for urine testing in schools and universities.

Below are responses from Julian Savulescu, Nick Bostrom, Anders Sandberg and Mark Sheehan on the effects of cognitive enhancing drugs, and the issue of cheating

The New Law on Admixed Embryos and the Genetic Heritage of the Living Kingdom

Scientists in the US recently created a fluorescent human embryo. This was achieved by inserting a gene for green fluorescent protein. This shows that it is possible to successfully transfer a gene from a non-human animal to a human and for that gene to express its function. Other animal studies have shown that such gene transfer is both safe and effective, creating super animals, such as mice with colour-vision derived from human genes transferred.

Humane Evolution

Professor John Harris wonders Who’s afraid of a synthetic human? in the Times. He argues we should support the Human Fertilisation and Embryology Bill because it will help us develop effective therapies and enhance ourselves. Science is about bettering our lot, after all. In particular, he says, synthetic biology may help us avoid going extinct due to our vulnerabilities and instead enable us to choose (or become) our successors as a species.

Many people become confused by the possibility of a posthuman future. The traditional view of the future is a stark one: either humanity extinct, or humans roughly as they are today. The posthuman options would be that we either change ourselves so radically that the resulting species is so  fundamentally different from humanity that we would regard it as something entirely new, or that we create some kind of independent beings that continue our culture even as traditional humanity retires from the forefront (hopefully as proud parents of the new beings). The range of possible options within these scenarios is endless, inviting equally endless and loud speculation. That tends to distract from the key message of Harris’ essay: we are leaving the realm of natural evolution and entering what he calls a realm of enhancement evolution.

The Ethics of 'Human Admixed Embryos': Concerns and Responses

By Loane Skene, Professor of Law, University of Melbourne and Julian Savulescu,  Uehiro Chair in Practical Ethics and Director Uehiro Centre for Practical Ethics, University of Oxford

The Human Fertilisation and Embryology Authority (HFEA) Bill, currently before the UK Parliament, will, if passed, permit HFEA to license the creation for research of embryos that combine human and animal genetic material (called, in the Bill, ‘human admixed embryos’). These embryos include cybrids which are formed by inserting the nucleus of a human body cell into an animal egg that has had its nucleus removed. Cybrids would produce embryonic stem cells that are 99.9% human. The Bill would also permit other types of embryos to be formed from human and animal genetic material that would be up to half animal. This post explains why scientists want to create human admixed embryos. It then outlines some ethical concerns about the creation of these embryos and responses that may be made to those concerns.

The Choice to Have Artificial Blood: Less than the Best?

Controversy has erupted around whether experiments to test artificial blood should stop. Experimental blood substitutes raised the risk of heart attack and death, yet U.S. regulators allowed human testing to continue despite warning signs, says a scathing new report.

Blood substitutes, or artificial blood, could be stored for years without refrigeration, and be used in battlefield situations. It would carry no risk risk of infection with hepatitis or HIV. It would be an acceptable alternative to Jehovah’s Witnesses who refuse life saving blood transfusions.
In a new report, researchers pooled data from 16 separate studies of five different blood substitutes, involving over 3,700 patients. Researchers found a 30 percent higher risk of death overall for patients who received transfusions using the blood substitutes. The risk of heart attack was nearly tripled in the groups receiving blood substitutes.

“Experts speculate that hemoglobin in the blood substitutes scavenges nitric oxide from the blood, causing blood vessels to constrict and sticky platelets to build up. That increases the risk of heart attacks.”