It’s got Nobel Prize written all over it. The scientific innovation, CRISPR, which enables accurate ‘editing’ of DNA (compared to current techniques where a viral vector introduces the DNA at random), has had one team member “jumping out of my skin with excitement”. Still at basic science level, it has already been hailed as a potential new treatment for Huntington’s Disease, HIV and other disorders. It is apparently so easy to use that Professor Mello, who was involved in the project, has said, “a total novice in my lab got it to work”.
One possible application that has been suggested is ‘correcting’ the germline: changing the genetics of sperm, eggs and embryos, to eliminate diseases not just in individuals, but in future generations. The designer baby is in production.
A tragic case was recently reported of a man who died following botched care via the NHS’ telephone helpline. Suffering from blood poisoning, a series of errors, mis-recording and failure to listen meant that he was told simply to take the remedy ‘Gaviscon’. He died shortly afterwards. This was rightly widely reported in the press as a major failing of the health system. Many such catastrophic errors in medicine are reported in the press, and wherever possible safeguards put in place to prevent their re-occurrence.
However, we seem to accept deaths that occur not through medical mistakes but through what I will call moral mistakes. For example, each day 3 people die on the waiting list to receive organ transplants. Many of those could be saved if all those eligible and consenting to give organs did so. But instead, organs are withheld even when those who have opted in to organ donation die, because their families decide against it. Others are withheld because we have failed to introduce an opt out system of consent, meaning that those who simply never got around to signing up are excluded from bringing life to another person.
This is just one example of how mistakes in medical ethics can kill people. There are many more.
Winchester Lectures: Kamm’s Trolleyology and Is There a Morally Relevant Difference Between Killing and Letting Die?
The Winchester Visiting Lecturerships were established in 1995 for the purpose of inviting visiting lecturers in the fields of International Relations, History, Philosophy, Religion, Theology or Law. We are grateful to the committee for this opportunity to bring Professor Frances Kamm to Oxford for this series of two lectures October 21 – 22, 2013.
Over the series, Frances Kamm considered a kaleidoscope of cases in which one innocent person must be killed to prevent 5 innocent people being killed. She argued in some situations, killing one is permissible to prevent 5 other people being killed, yet in other cases it is impermissible to kill one to save 5. Or so go her intuitions. She points to what she finds are morally relevant considerations that distinguish permissible from impermissible killing.
The most straight forward case of impermissible killing, and the one in which she and many others have a clear intuitions, is Transplant.
In Transplant, a doctor contemplates killing one innocent person and harvesting his/her organs to save 5 people with organ failure. This is John Harris’ survival lottery.
But this is a dirty example. Transplant imports many intutions. For example, that doctors should not kill their patients, that those with organ failure are old while the healthy donor is young, that those with organ failure are somehow responsible for their illness, that this will lead to a slippery slope of more widespread killings, that this will induce widespread terror at the prospect of being chosen, etc, etc
A better version of Transplant is Epidemic.
Press Release: British Medical Journal Head to Head: Should athletes be allowed to use performance enhancing drugs?
Stories about illegal doping in sport are a regular occurrence. On bmj.com today, experts debate whether athletes should be allowed to use performance enhancing drugs.
Professor of ethics Julian Savulescu, from the University of Oxford, argues that rather than banning performance enhancing drugs we should regulate their use.
He points out that, since Ben Johnson in 1988, only 10 men have ever run under 9.8 seconds – and only two (including Usain Bolt) are currently untainted by doping. “The zero tolerance ban on doping has failed,” he says. “It is time for a different approach.”
He argues that regulation could improve safety and says “we should assess each substance on an individual basis” and “set enforceable, fair, and safe physiological limits.”
He acknowledges that, if a substance came to dominate or corrupt performance, there would be good reason to ban it. But says, if a substance allows safer, faster recovery from training or injury, “then it does not corrupt sport or remove essential human contribution.”
And he dismisses the argument that allowing elite athletes to take drugs under medical supervision will encourage children and amateurs to imitate their heroes, pointing out that amateur doping “is already happening in an unsupervised manner.”
“Over time the rules of the sport have evolved,” he says. “They must evolve as humans and their technology evolve and the rules begin to create more problems than they solve. It is time to rethink the absolute ban and instead to pick limits that are safe and enforceable.”
But hospital doctors, Leon Creaney and Anna Vondy believe this would lead to escalating use and call for tougher enforcement.
“The argument against doping in sport is moral, not medical,” they write.
“Athletes who wanted to live a healthy existence would be pushed out altogether. Soon, the only competition that would matter would be the one to develop the most powerful drugs, and athletic opponents would enter into an exchange of ever escalating doses to stay ahead of each other.”
They warn that, in some nations, “we might see a return of the state sponsored doping programmes of the 70s and 80s” and say without the anti-doping programme “the use of performance enhancing drugs would expand exponentially and filter deeper into our society.”
Legitimising performance enhancing drugs in elite and professional sport would also change the message sport sends to society, they add. “Would a bioengineered athlete be able to inspire in the same way?”
They dismiss the argument that because we will never be able to catch every cheat, we should give up trying, saying the answer is “to make the anti-doping system more effective.”
If testing was ubiquitous, they say, “it would be virtually impossible to evade detection, and the equilibrium would be reset in favour of not cheating.”
And if a first offence led to a lifetime ban, “the risks involved would become much greater, such that fewer people would take the gamble of getting caught in the first place,” they conclude.
Professor Julian Savulescu, Uehiro Chair in Practical Ethics & Director, Oxford Centre for Neuroethics, University of Oxford, UK
Tel: +44 (0)1865 286 888
Leon Creaney, Trauma and Orthopaedics, University Hospital Birmingham, UK
“Electroceuticals”, or therapies utilising electricity, are nothing new and range from the widely accepted defibrillator/ pace makers to the more controversial electric shock therapies like ECT sometimes employed to treat severe depression.
But a recent article in Nature argues that these are just a small, crude sample of what electroceuticals may be able to offer in the future. Universities and pharmaceutical companies are researching a wide range of therapies based around electrical stimulation, promising benefits (in the long term) as diverse as mind-controlled prosthetic limbs to a treatment for anorexia. Transcranial Electric Stimulation (TES) is delivering some promising results in depression and treatment of learning disabilities.
Not only is the research potential there, but it appears that the funding is too. Nature report that GlaxoSmithKline are funding 40 researchers to pursue research in this area, amongst other initiatives to kick start electroceutical development. And earlier this year, the US invested $110 million from 2014’s budget for the “Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative”. At the same time, over in Europe, work has commenced on a 10 year, billion pound ‘Human Brain Project, bringing together 135 institutions to try to map parts of the human brain via computer simulations.
We may be starting out on the track for the “holy grail” of neuroscience: strategic control of single neuronal activity. This is, apparently, one of GSK’s goals.
With that level of control, we could finally reach the realms of science fiction: where the mind and therefore the person is under external control. Freedom might be annihilated.
We would face confronting questions over authenticity and identity. There would be alienation between the pre-existing person and their subsequent brain activity.
Burgess’ A Clockwork Orange is a graphic illustration of a common objection to enhancement, the erosion of freedom. TES at present does not appear to represent a major threat to freedom, but it is one of a family of technologies that could one day be used for effective mind control.
Scientists in America have found a way to reduce crime amongst some high risk groups by 30-40%. It involves a simulation of crime scenes where the victim is a hologram representing the potential criminal in question, followed by discussion with a trained therapist. The experience causes the subject to feel greater empathy and reduces violent crime. We should introduce this therapy now, as a matter of priority.
There is no such therapy, sadly. But there is something which promises the same effects in some groups. Ritalin. A Swedish study found that taking ADHD medication significantly reduced the criminality rate amongst those with ADHD: by 32% in men, and 41% in women. ADHD has itself been associated with an increase in criminality.
Some people will argue that this is a therapy for ADHD, not an enhancement. But ADHD is not a disease like cancer – it is likely a variant of normal functioning involving lower levels of impulse control and attention.
Ritalin, Adderall, Modafenil are all taken by thousands of professionals and students to enhance performance, in a similar way to caffeine. The film Limitless was loosely based on modafenil (in fact, Modafenil doesn’t appear to have such a dangerous side effect profile as is portrayed in the film, though there are as yet no long term studies of normal people). Ongoing research into Alzheimers disease and other impairments will lead to other drugs which enhance normal cognition.
Andrew Culliford, whose story is featured in the Daily Mail, is one of the estimated 7 in 100,000 people living with Motor Neuron disease, a progressive degenerative disease which attacks muscles, leaving those affected eventually unable even to breathe unassisted. For Andrew, a young father who has a severe form of the disease, it means a two to five year life expectancy.
The US introduced a mandatory pre-approval process for pharmaceutical drugs after over 100 people were killed by an untested drug formulation . Today, each drug must go through a series of strictly controlled trials, including Phase 1 tests on healthy volunteers, followed by Phases 2 and 3 which test the drug and dosages on smaller and then larger patient groups. The process is estimated to cost $500 million per drug and to take 8 – 12 years.
The process is designed to ensure the efficacy of drugs has been scientifically demonstrated to a very degree of confidence, and to ensure that patient safety is sufficiently protected. In many ways it has been a triumph of science and regulation.
But it has been a failure for one small group of patients: those with rare, imminently lethal diseases, for whom there are no existing good treatments. Those who will die in less than 8 years. It is these patients who are asking to have access to untested medicines, and to avoid placebo controlled trials, where half the participants are given no drug at all. Les has proposed innovative methods of patient recording data. I have discussed this proposal previously on this blog , and in a joint paper with Les Halpin and clinicians.
On Monday, London will see the world’s first artificial meat burger cooked and tasted, by Professor Mark Post of Maastricht University.
Artificial meat stops cruelty to animals, is better for the environment, could be safer and more efficient, and even healthier. We have a moral obligation to support this kind of research. It gets the ethical two thumbs up.
The development of artificial meat is a triumph for both science and ethics. Current meat production involves inflicting significant suffering on animals. It also causes environmental damage (see the FAO report, Livestock’s Long Shadow) and is hugely inefficient because limited food resources have used to keep a large animal alive. Intensive farming of chickens and pigs is also a breeding ground for the emergence of new strains of flu, causing pandemics that could kill tens of millions. Artificial meat production will almost entirely avoid these issues.
Ethical veganism will become a much more palatable option, as one could avoid eating real meat without sacrificing an integral part of many people’s diet. Indeed, this may be a watershed moment for animal welfare – if artificial meat manages to catch on and take over a large portion of the market, many fewer animals will be cruelly raised and slaughtered through factory farming, a key goal of movements like PETA (who have, incidentally, wholly endorsed and promoted the development of artificial meat).
Of course, such large-scale beneficial effects will only be realized under three conditions: the artificial meat must be safe, cheap and tasty. The safety of Mark Post’s concoction is as yet unknown, but may well be the easiest condition to satisfy. In fact, it could become more safer as meat production could be laboratory controlled and reduce risks of emergent pandemics from flu passing from animals to humans. If he is correct and the meat is identical at the cellular level to actual meat, it should be no less dangerous – though further tests are undoubtedly needed before it could be offered to the public at large. As for cost, previous estimates put Post’s burger at around £250,000, obviously prohibitive for mainstream consumption. Just as the cost of genetic sequencing has fallen precipitously over the years, we can expect artificial meat prices to fall as more efficient means of production are developed. It remains to be seen whether artificial meat can ever be made more efficiently and cheaply than real meat, however. Finally, one of the most important tests of Monday’s event is whether the artificial meat will actually be palatable. It may be that the meat is only suitable simulating ground up meat and mixed with other ingredients to add texture and flavour – but then again, outlets like McDonald’s have made a mint producing widely-enjoyed meat out of an infamous ‘pink sludge’ that is quite disgusting on its own. Indeed, of all potential adopters, the fast-food industry – which relies on efficiency and artificiality much more than aesthetics or ‘all-natural’ ingredients – seems like the most likely outlet for artificial meat.
Perhaps the future of the fast food industry is ethical meat, instead of the unethical meat. Consumers would be hard pressed to tell the difference between an artificial Big Mac and the current one.
Some might object that artificial meat is unnatural. So it should be avoided. True, the meat would be grown in a lab rather than a farm. But what value does naturalness have, on its own? Natural meat often relies on the confinement and slaughter of animals, which many have noted is morally wrong – and in fact, the factory farms where most meat is produced are hardly ‘natural’ environments. In factory farming, they more resemble hideous torture chambers where animals eat their own faeces. Moreover, we are perfectly content to introduce numerous artificial elements into all aspects of our lives – phones replace natural communication, cars replace natural transport, factories replace natural craftsmanship, houses replace natural abodes, and so on. Part of human development is to improve upon the natural state of the world, and artificial meat is just another such development. It is not only inevitable, but should be encouraged and welcomed with open arms.
There is one ethical downside to creating artificial meat. Many animals would not come into existence who would have lived and many farmers might lose their livelihoods. The solution maybe to combine artificial meat production with controls on farming to ensure animals that are brought into existence for farming purposes only have happy, worthwhile lives and are slaughtered in humane ways.
We hope the creation of artificial meat will prompt a thoughtful debate on the ethics of food production and eating.
Doctoral Candidate in Philosophy
University of Oxford
Professor of Practical Ethics
30 July. This blog is an extended version of the post ‘Vaccines: All or Nothing’ (posted 29 July).
A vaccine which would protect children from Meningitis B has been rejected by the Joint Committee on Vaccination and Immunisation (JCVI) as not cost effective, despite the fact the cost is not yet known.
The Department of Health’s director of immunization explained:
“This is a very difficult situation where we have a new vaccine against meningitis B but we lack important evidence. We need to know how well it will protect, how long it will protect and if it will stop the bacteria from spreading from person to person.
“We need to work with the scientific community and the manufacturer to find ways to resolve these uncertainties so that we can come to a clear answer.”
A call for more research is a standard answer to many dilemmas in healthcare, though perhaps one which is easy to ignore. As far as we know there are no current plans to ensure that this research takes place but the vaccine has already been found to be safe, and according to the BBC, “tests have suggested the vaccine is effective against 73% of the different strains of the disease”.
Resource allocation is an inevitable part of any health care system, and perhaps especially so in the NHS. Whilst we would like to provide all available treatments, prioritizing according to effectiveness and cost is necessary, though the exact method of calculating this (currently Quality Adjusted Life Years, or QALYs) is of course under intense debate and scrutiny.
In the meantime, children continue to suffer avoidable, lifelong disability due to infection with Meningitis B. I argue with Lach de Crespigny in a forthcoming paper on homebirth that actions (or failures to act) taken today which cause harm in the future are as wrong as if that harm were realized today. The plight of these children and adolescents should not be ignored.
Put simply, if you could prevent a child from getting brain damage, now or in the future, at little cost to you, you ought to perform that act.
One possible way forward would be to allow parents to pay for the vaccination of their child, at whatever price the company sets, just as holiday vaccinations can be provided by the NHS at a cost to the patient. Vaccinated children could be monitored and their data recorded. Not only would this generate the data that would establish how high up funding agendas this vaccine should be, but some individual children would be prevented from suffering this deadly and debilitating disease. To increase take up, the company would be under market pressure to keep the price as low as possible.
The second fastest runner of all time, USA’s Tyson Gay, has reportedly tested positive for a banned substance, along with the Jamaican sprinters Asafa Powell, and Sherone Simpson making for shocked headlines across the world.
But this is just one high profile story amongst a recent rash of news stories across sports and across countries. In athletics, 24 Turkish athletes are confirmed to have tested positive this year; Australian Rules Football is still reeling from the ongoing Essendon scandal; and over in the United States, inquiries into an anti ageing laboratory said to supply human growth hormone to top baseball players are ongoing. Whilst the 100th Tour de France is so far untainted by positive tests, cycling doping cases have continued this year with two Giro D’Italia riders testing positive.
Still there is a sense that we are just seeing the tip of the iceberg. Chris Froome, now tested at the end of each stage as the yellow jersey, has been relentlessly hounded over whether his recent impressive performances are due to doping.
1. The Failure of Zero Tolerance
We don’t know which individuals are doping and which are not. One thing we do know is that the zero tolerance ban on doping has failed.