Another challenge to be faced by bioethics in the decades ahead is the downstream consequences of falling birth rates.
Once fertility begins to fall, it keeps falling to levels which once seemed (sorry) inconceivable. The replacement birth rate is 2.1 children per woman. But in South Korea, parts of Spain, and Russia it has fallen below 1.3. At that rate, population begins to decline fairly rapidly. A small population could have big political consequences.
This worries the leaders of Iran. The birth rate in Iran has fallen more swiftly than anywhere else in the world – from 6.4 in 1986 to a current low of 1.8. When they look into their crystal ball, they see a weak and depopulated nation.
This is why the Supreme Leader, Ayatollah Ali Khamenei, recently released a 14-point plan to reverse decades of propaganda for small families and double his country’s population to 150 million. His proposals include: increasing the birth rate to more than 2.3; lowering the age of marriage; an Islamic-Iranian lifestyle and opposing undesirable aspects of the Western lifestyle; and providing treatment for both male and female infertility.
A bill is already being drafted to ban abortions and sterilisations. Government support for family planning and contraceptives has already been discontinued. A program offering free vasectomies has been terminated.
For Westerners like me, the social policy and politics of a theocratic country like Iran are quite mysterious. But if its rulers are as impatient and stubborn as the media makes them out to be, they may try to impose pro-natal policies, lest they drift into geopolitical irrelevance. Today most bioethics deals with issues relating to having fewer children. What happens when women are pressured into having more children? What dilemmas will bioethicists face then?
I wonder if the next frontier in the practical side of bioethics will be elder care. With the number and proportion of over-65s growing everywhere, opportunities for abusing defenceless elderly are multiplying.
Take the scandal in Mississippi over its June 3 Republican Senate primary. The incumbent is 76-year-old Thad Cochran, a 36-year veteran of the Senate with a thatch of white hair. In the eyes of Tea Party Republicans the Senator is extremely liberal. And extremely old. Money is pouring into the state to knock Cochran off his perch and replace him with a 41-year-old breath of fresh air, Chris McDaniel, a state senator.
However, some of Mr McDaniel’s supporters have been too eager to prove just how decrepit Senator Cochran is. A pro-McDaniel blogger, Clayton Kelly, entered a nursing home where Senator Cochran’s bed-ridden wife Rose, who suffers from dementia, is being cared for. He took photos of her, added them to a video, and posted it on the internet. The message: an old liberal guy with a ailing wife shouldn’t represent the great state of Mississippi. The strategy has backfired. Senator Cochran is holding his own after the invasion of his wife’s privacy. Mr Kelly has been charged with "exploiting a vulnerable adult". Two other men have also been arrested.
Mr McDaniel has been reduced to complaining that Senator Cochran is exploiting a “sick individual” (ie, Kelly) for electoral advantage. Since this is precisely what Kelly did to Mrs Cochran, it’s hard to see how this will get traction with voters. The breath of fresh air has been tainted by a burp from the sewer.
Another week of mud-slinging in American electioneering. For media junkies, it’s very entertaining and will soon be forgotten. But it may foreshadow a society where the elderly are routinely discriminated against, exploited, vilified and abused. Geriatric bioethics will be a growth area.
First, a couple of self-referential issues. We have changed our commenting software to Disqus, a popular and robust add-on which is used on many big websites. It works much the same as the old system, but is easier for the moderators. The transition was relatively smooth, but I fear that a couple of comments might have been lost. I apologise if they were yours.
We have launched our six-monthly BioEdge appeal for donations. You still have a month left, so don’t panic! We do not have a big institutional donor backing us, so please think about it.
As for other matters, our stories this week cover a wide range of topics, from doctor-cide in Syria, to animal rights, to prenatal testing for autism.
But one item in my background reading that I found riveting was the blog of Rudy Rupak Acharya, the founder of a leading medical tourism company in California called Planet Hospital. Although he claimed to be a broker for procedures ranging from teeth whitening to hip replacements, surrogacy was a major part of his business.
What appalled me was how crass making babies becomes when profit supplants romance. What’s love got to do with it anyway? Here’s the raucous, pitchman voice of Rudy:
In Mexico, we have actually managed to make the costs as cheap as India when you take air, hotel, and visas into consideration. I am saddened to see this latest crap circus [a ban on gay surrogacy] come blazing out of the poop shoot of Indian bureaucracy because it ruined the plans of so many people …
A word to our competitors. Be decent and build your own opportunity but do not try to leach off of us. We have signed exclusives with our clinic already while you were trying to figure out what hit you…
We here at PlanetHospital.com will provide you with the impeccable service that many of our clients praise us for and use our experience to guide you. We will also provide you with options in Mexico, Thailand and Panama. We understand what you need and what you are looking for and it is our pleasure to make it happen stress free, and we will even throw in a free pizza for you …
I think that Margaret Atwood could make a novel out of Rudy’s blog posts without much effort at all. Oh, and by the way, Rudy’s company has been forced into involuntary bankruptcy, with an alleged US$1 million owing to his creditors, many of them couples seeking to acquire children. No more free pizzas, guys.
As the 50s recede into the rear-view mirror, for many people they become suffused with a nostalgic glow. But they had at least one defect: doctors were quite careless about this all this annoying informed consent stuff, especially when their patients were young, indigent or military.
This week we have highlighted experiments on children in a psychiatric hospital in Vienna. Doctors deliberately infected them with malaria which affected them for years afterwards. This is relatively minor compared with the infamous Tuskegee syphilis experiments in the US, which ran from 1932 to 1972, in which researchers withheld treatment from black sharecroppers.
If you have the stomach for it, there is a Wikipedia article listing many more stomach-churning experiments in the 1940s, 50s and 60s. (Yes, I know, Wikipedia is not reliable, but its lists are useful.)
We recognise that these experiments were exploitative, but at the time, doctors and scientists often just shrugged their shoulders and got on with the job. In hindsight it is easy to say that they were blind to the ethical dimensions of their work.
But what of us? Are there aspects of today’s medicine which seem acceptable and ethical which will be condemned as debased and immoral by our grandchildren? Or have we entered a golden age of moral perfection? Any ideas?
I was bowled over when I read about a family in Utah whose life was turned upside down after using a home genetics kit (see below). They discovered that John Branum was not the biological father of Annie Branum. Instead the biological father was Tom Lippert, a disgraced lawyer working at a fertility clinic linked to the University of Utah where Pamela Branum had artificial insemination in 1991.
“Disgraced” is a polite way of saying that Lippert died of alcoholism and that he had served two years of a six-year sentence for the lurid kidnapping of a coed in 1975. He tried to brainwash her into falling in love with him. In short, he was both kinky and a fruitcake.
It turns out that Mr Lippert not only prepared, labelled and shipped "samples" around the country, he had also been a frequent donor at the clinic. Behind his desk were photos of the clinic’s “success stories”. Mrs Branum now suspects that it could have been his bragging board. Why not? Mr Lippert was a very, very strange man.
However, a committee has produced a report for the University of Utah which says that it would be unethical to attempt to notify couples of Tom Lippert’s possible handiwork. It would upset people too much, it is unlikely to uncover more wrong-doing, it is very difficult, a dog ate the paperwork, it would breach privacy agreements, it’s not the University’s fault anyway, no one has been hurt, things are different nowadays and so on.
These arguments don’t convince the Branums and they don’t convince me. IVF must be the only industry in the world which can get away with excuses like that after catastrophic systemic failure. The one essential thing IVF clinics promise is the right baby. But they won’t test to ensure delivery. And if they fail, they will refuse to investigate the scope of the disaster for fear of hurting people’s feelings. If General Motors could play by those rules, would it be in bankruptcy court now?
Good on the Washington Post! It certainly takes a principled stand in its editorial on stem cell research. Not even its potential for curing dread diseases is sufficient reason to cross a bright line, it argues. “The creation of human embryos specifically for research that will destroy them is unconscionable. The government has no business funding it.”
Unfortunately, that was in 1994 (October 2). Almost exactly 20 years later, the Post took a very different line. An editorial this week argued: “As long as scientists do not cross ethical lines much farther from where they are now … researchers should have the flexibility to go in whichever direction is scientifically useful.”
As Emerson once said, “a foolish inconsistency is the hobgoblin of little minds.” No one can blame the Post for recalibrating its positions with the years. But a 180-degree turn is a different matter.
The 1994 editorial warned of the “slippery slope”. Anyone who denies that this lacks force as an argument should read both editorials carefully. Twenty years ago, the “deeply alarmed” Post said that creating embryos for experimentation was “flat wrong”. Now it says that “Some ethical worries are reasonable, but they are not enough reason to hold back this research.”
What is very discouraging in this comparison is not so much the change in the Post’s position as its decline in moral sophistication. Back in 1994, it recognised that serious ethical issues were involved. The issue could not be decided simply by acquiescing to scientists’ demands. Now its position is essentially that the only thing that matters is financial and scientific success. Is this really progress?
I just finished reading the obituary of an American scholar of Persian studies – who had nothing whatsoever to do with bioethics, as far as I know. What caught my eye was the fact that he spoke fluent Russian, German, Arabic, Persian, Pashto, French, Uzbek, and Turkish, as well as being able to cipher out ancient languages like Avestan, Pahlavi and Sogdian. Pretty good for a boy from Birmingham, Alabama.
Being a polyglot would be a big help in reporting on bioethics. Unfortunately, the only languages your editor is fluent in are English, American, Kiwi and Australian. Developments in countries where English is not the lingua franca are underreported. Google Translate is a treacherous guide -- traduttore, traditore, as they say in Italian. So, for the most part, we are stuck with reporting what happens in English-speaking countries, even if significant developments occur elsewhere.
Perhaps that is why this week’s lead story has flown under the radar, even though it did appear in the English-language Journal of Critical Care. It seems, as far as I understand it, that intensive care doctors in Belgium have decided (decreed may be a better word) that it is acceptable medical practice to euthanase their patients, even if they are not suffering, even if they are not elderly, even if their relatives have not requested it, even if they have not requested it and even if it is not legal.
The lead author, Dr Jean-Louis Vincent, of the Free University of Brussels, attempted to justify this policy in a leading Belgian newspaper, Le Soir, in February but the news must have ground to a halt at the language barrier.
I do hope that critical care physicians in other countries protest this development. Surely it cannot be good for their specialty. How many Belgians will trust their mother’s doctor when she is seriously ill if he has the power to decide whether she lives or dies?
An administrative note: BioEdge will not be published next week because of the Easter holiday.
After a month of false leads and dashed hopes, it is time to question whether the search for the lost Malaysian Airlines flight 370 is worthwhile. This is the question posed by Glenn Cohen, a professor at Harvard Law School, recently.
Cohen is being deliberately provocative, but since the cost of the search will probably run into hundreds of millions of dollars, it’s a utilitarian question worth pondering. He points out that US$100 million (a very conservative estimate of the cost) could save 52,192 life years if the same amount were spent on vaccinating children.
No governments have asked this question; they are blindly determined to find the plane and learn the fate of the 239 people on board. Cohen lists a few of the reasons why: to learn what went wrong to prevent future incidents, to bring closure for relatives, and to satisfy the voyeuristic instincts of media consumers.
To these should be added: ingratiating themselves with China (most of the passengers were Chinese) and promoting regional cooperation in a dangerous area of the world.
Cohen says that this may just be an example of our bias toward identifiable lives over “statistical lives”, a point often made by Peter Singer. There is certainly more than a germ of truth in this, but something tells me that there is more to it.
Ultimately, the only excuse for the existence of governments is defending the common good. A government which is indifferent to the welfare and emotional needs of its citizens will not last. Disaster victims have been treated so abominably in the recent past in China that the new President, Xi Jinping, is probably desperate to portray himself as a defender of his restless citizens’ rights. His government’s stability may depend on it. That may be the strongest reason for continuing the search.
This week we’ve tried to give the gist of one of the most surprising arguments I’ve come across in a long time. Bioethicist Inmaculada De Melo-Martín contends in most recent issue of The Hastings Center Report that a ban on sperm and egg donor anonymity is misguided, unnecessary, socially harmful and “morally problematic”: in short, unethical. (Read all about it here.)
It’s quite a thought-provoking paper. IVF clinics defend donor anonymity on pragmatic grounds: unless donors are guaranteed anonymity, they are unlikely to donate. But I’ve never read a robust ethical defence.
Melo-Martín’s central idea is that we construct our own lives; we are not condemned to act out a genetic script. So what can possibly be the problem if you are “a genetic orphan”? We have plenty of other resources – family, friends, society -- with which to build an identity. There is a germ of truth in this in this repudiation of genetic determinism. I may have a gene which predisposes me to like chocolate, but this does not condemn me to eke out a pitiable existence as a chocoholic.
But there's something more to this than meets the eye. The debate over donor anonymity hinges on the most fundamental issue in contemporary bioethics: what is the body for, anyway? Are we simply spirits “fastened to a dying animal”, as W.B. Yeats wrote in “Sailing to Byzantium”? In that case, our burdensome bodies are of no great ethical significance. I think that Melo-Martín belongs to this school of thought. It’s a kind of revival of Platonic dualism.
The more common sense Aristotelian view is that persons are somehow body and spirit, neither one nor the other, but both simultaneously. It’s difficult to explain, but it corresponds to our experience. We do write our own script in life, but our genes are just as fundamental to our life experience. Without knowing our mother and father, we feel incomplete or at least we feel that something is lacking. In other words, our bodies are not something that we possess, but are an integral part of who we are. This week's story on surrogacy exemplifies this approach.
The dialogue between Platonism and Aristotelianism has been going on for about 24 centuries, so it’s unlikely to be solved soon. But it’s not merely an academic bunfight. As the controversy over donor anonymity shows, it continues to affect vital contemporary issues.
One of America’s leading bioethicists, Thomas H. Murray, of The Hastings Center, has called for a national debate on so-called “mitochondrial transfer” (see below). This is a highly controversial technique for allowing parents who might pass on a genetic disease due to defective mitochondria. It is being studied in both the US and the UK.
What I have realised in the few news stories I have written on this topic is that its ethical assessment depends on how the technique is framed.
This begins with its name. Is it really just transferring 1% of genetic material to an embryo – which the name implies? If so, perhaps it’s not a big deal – although, as I recall, 1% or so is the difference between us and chimpanzees. Or is it really a transfer of the 99% of genetic material which resides in the nucleus to a new cell membrane? (See below). That sounds a bit more serious, doesn’t it?
Then there are the benefits. The child, conceived through IVF, is supposed to have healthy mitochondria and will be free from the genetic disease passed on by its mother. That frames the mitochondria as interchangeable computer chips. But is that true?
In one of the stories below US biologist Maureen Condic challenges this assumption. She says that there are dangers in this technique. What if some of the old mitochondria remains in the cell and clashes with the new mitochondria? Plus, the DNA in the nucleus and the DNA in the mitochondria are supposed to be a perfect match. What guarantee is there that they will function properly? Is it possible that the technique might create a new genetic disease?
I don’t know the answers to these issues, but I do know that these difficulties do not fit within the frame of the scientists who are boosting it. They confidently dismiss warnings about “three-parent embryos” but they speak very vaguely about the risks to the child’s health inherent in “mitochondrial transfer”. At its best this is hype; at its worst it is cynical manipulation of public ignorance.
The scientists are playing with fire. As science communication expert Matthew Nisbet points out, “As in the case of climate change, each time a scientific claim is proven false or inaccurate; it risks further alienating publics already distrustful of the science and scientists.”