The 90s was a terrifying decade. Boris Yeltsin with his finger on the button. Fortunately he was too drunk some of the time to move. The Spice Girls. And Y2K. I bought plenty of water.
Civilisation came to the brink in 1997 when Ian Wilmut managed to play God and clone a mammal, a sheep called Dolly. International chaos ensued. The German Prime Minister said it would lead to “xeroxing people.” The European Parliament beat its breast, proclaiming cloning an affront to human dignity. It proudly asserted that every human being had a right to genetic individuality (let’s conveniently forget that 1/300 live births involve clones or identical twins that lack genetic individuality).
In Roald Dahl’s short story, William and Mary, William dies of cancer. But a novel procedure allows his brain, with one eye attached, to be kept functioning in a clear plastic vat. His wife convinces William’s neurosurgeon to allow her to take William (or rather his brain and eye) home with her.
When home, Mary places William in a prominent place in the sitting room from where he can survey all her actions. He had been a domineering and controlling husband. He forbade her to have a TV and to smoke. Now, Mary purchases a TV and takes up smoking, blowing smoke in the direction of William. She will punish him for his abuse and his brain may stay alive, utterly powerless, for up to 200 years.
This story was science fiction. But yesterday, the first step to creating the brain in a vat was reported in the US. Back in July 2013, scientists reported the first organ grown from stem cells: a liver. A kidney, heart and other organs have followed. The potential of these technologies to eventually provide replacement organs is also an opportunity to sweep away complex ethical issues: most obviously in avoiding the need for organ donation, but also in enhancing the ability to test drugs on lab grown organs before testing in humans- reducing the risk of harm to research participants, hopefully some day to a negligible amount.
Now, just 2 years later, the first brain has been grown in a laboratory. The organoid has been grown for 12 weeks, the equivalent of a 5 week old foetus.
Lead researcher Professor Rene Anand, from Ohio State University in the US,
“It not only looks like the developing brain, its diverse cell types express nearly all genes like a brain.”
Julian Savulescu and William Isdale
An editorial in the Lancet earlier this month report on the first fall in UK organ transplants in a decade.
Key statistics included that “the number of people who chose or were able to donate their organs in 2014 fell, and that 224 fewer people in the UK received an organ transplant than the year before”
Amongst the factors restricting donations is family consent: “no appreciable rise has occurred in the proportion of families who gave consent to organ retrieval following the death of a relative, which continues to hover “stubbornly below 60%”.
The Lancet also points to inefficiencies in the use of those organs that are donated.
Australia’s #DonateLife week has just been completed, a week dedicated to promoting organ donation, Australia is seeking to improve its own rates, which lag behind the UK, US and other comparable nations. The government is already undertaking a review into the current organ and tissue donation and transplantation programme.
One quote from the Lancet is perhaps timely:
As Rafael Matesanz, Director of Spain’s world-leading Organización Nacional de Trasplantes, recently reminded us, we should “…never blame the population. If people donate less, it must be something we have done wrong””
William Isdale and I recently proposed Three Ethical Ways to Increase Organ Donation: no longer allowing a family veto where a patient has consented; financial incentives to consent; and non financial incentives to consent (such as higher priority as a recipient for those who are on the transplant list).
On August 25, Peter Singer, Neera Bhatia William Isdale, Julian Koplin, and myself will be participating in a public event in Melbourne, Solving the Organ Crisis Ethically, where we will critically discuss the ethics of a range of options available to increase the organ supply in Australia.
There are 1500 people waiting for an organ in Australia. Some of those will die, or become too ill to be an organ recipient, before an organ becomes available. How far should we go to address the organ shortage?
Steven Pinker has recently written an op-ed questioning the contribution of bioethics to the safe and efficient regulation of research. This has been widely misinterpreted and criticised, though Alice Dreger has written a recent accurate blog in support of Pinker. Pinker provocatively said that bioethics should get out of the way of research. This has been interpreted to mean that we should give up ethics review of research. Nobody, not me, and not Steven Pinker, thinks we should abandon ethical review of research. He actually says, ” Of course, individuals must be protected from identifiable harm, but we already have ample safeguards for the safety and informed consent of patients and research subjects.” Pinker is objecting to the unnecessary, unproductive obstruction that much bioethics represents to good research and regulation.
I largely agree with him and have said as much myself over the years. I recently wrote a piece for the anniversary issue of the JME arguing as much. I applaud him for trying to generate some self-reflection in the field.
Regular readers of this blog will be familiar with my argument for legalising doping in sport, aiming to focus resources on harm reduction rather than zero tolerance. Key safeguards in this approach are (1) doping carried out under the supervision of a doctor, and (2 ) checks on athletes to ensure they maintain normal physiological ranges of relevant parameters.
Many commentators consider this approach unrealistic. But as the world’s elite riders commence the Tour de France 2015, it appears that they will be riding under something very close to that vision.
In March this year, the Cycling Independent Reform Commission published a report into current doping practices. It concludes that doping is still prevalent, with estimates from those in the sport ranging from 20 – 90% of athletes participating in doping.
However, two mechanisms within anti – doping policy, the Athlete Biological Passport, and the Therapeutic Use Exemption, appear to be functioning effectively as regulators on doping behaviour: enhancing its safety and limiting its impact, without preventing its use outright.
Authors: William Isdale & Julian Savulescu
Last week the Federal Government announced that there would be a review of Australia’s tissue and organ transplantation systems. The impetus for the review appears to be continually disappointing donation rates, despite the adoption of a national reform agenda in 2008.
Since 2008 there has been an increase from 12.1 dpmp (donations per million population) to a peak of 16.9 in 2013 – but the dip last year (to 16.1) indicates that new policies need to be considered if rates are to be substantially increased.
Australia’s donation levels remain considerably below world’s best practice, even after adjusting for rates and types of mortality. At least twenty countries achieve better donation rates than Australia, including comparable countries like Belgium (29.9), USA (25.9), France (25.5) and the UK (20.8).
The review will focus in particular on the role of the national Organ and Tissue Authority, which helps coordinate donation services. However, many of the key policy settings are in the hands of state and territory governments.
It is time to go beyond improving the mechanisms for implementing existing laws, and to consider more fundamental changes to organ procurement in Australia.
How to Be Free: Objectification and the Noumenal World An Impression of Neil Levy’s First Leverhulme Lecture
When I was a medical student and doctor, there were a few legendary teachers at the Alfred Hospital. The greatest of these was a general physician called Y Lim. He was the Sherlock Holmes of bedside clinicians. He would take groups of medical students to see a patient and diagnose the patient “from the end of the bed”, just by observing carefully the paraphenalia around the patient’s bed, the medication and the movement of the side of their chest.
He was highly sought after as tutorials with Y Lim spelt success in the clinical examinations. I never had him but my friends in the year before did. At the end of their last tutorial, just before the final examinations, they asked him, “Y Lim, how do we do well in the short and long cases? How can we become a doctor?”
Y Lim replied, “Look like a doctor. Talk like a doctor.”
Three Ordinary Agents
Consider the following 3 people (philosophers call them “agents” because they do stuff, like secret agents do stuff secretly). They are all based on real life characters.
Julian Savulescu discusses the ethics of mitochondrial transfer
Imagine that there was a law which prevented 150 children a year suffering from a life threatening liver or kidney failure from receiving a transplant. This would be unethical. But this is precisely the current state of affairs for around 150 children every year in the UK suffering from mitochondrial disease, or mitochondrial failure.
From an ethical perspective, mitochondrial transfer is most accurately described as a form of transplantation, or “micro-organ” transplantation.
An elegant example of biopsychosocial (BPS) impacts on our health has been reported today.
It has long been reported that chronic stress reduces fertility: it reduces libidos, reduces the likelihood of a pregnancy, and increases the risk of miscarriage.
Scientists from the University of Berkeley have shown that blocking the gene for a hormone – called gonadotropin inhibitory hormone (GnIH) removes the impact of the stress on fertility levels in rats, and restored a normal rate of pregnancy.
If this translates to humans, it could have major impact. According to the University of Berkeley press release:
“Stress is thought to be a major contributor to today’s high levels of infertility: Approximately three-quarters of healthy couples under 30 have trouble conceiving within three months of first trying, while 15 percent are unable to conceive after a year.”
The BPS model explores causal interaction between the biological, psychological, and social factors in illness (usually in the context of understanding mental illness). This might be one of the more simple biopsychosocial interactions. Kenneth Kendler’s fascinating Loebel Lecture series unpicked some complex interactions (video and audio available on the Oxford Loebel Lectures and Research Programme website).
But it raises an interesting ethical question, and one that frequently arises in the enhancement debate. Should we take a biological solution, when an environmental solution is available?