blog.bioethics.net

It was only a matter of time...

Ian Sample of the Guardian Unlimited reports that the technology is now here to help paralyzed individuals control artificial limbs by thought alone. Just imagine how much further we might be able to go...

Linda Glenn

Kidney For Sale: Ethicist Says, Ok Why Not

Look, if Georgetown University Press really wants us to blog this book, we will. Mark Cherry has written it and it is a bold title to say the least: Kidney for Sale by Owner.

 

(WASHINGTON) — More than 4,600 Americans die each year while waiting for organ transplants. In 2003, only 20,000 of 83,000 patients waiting for organs in the United States received them. Despite widespread consensus that organ shortage is a national tragedy, bold initiatives to address the problem—such as creating a fee-based and regulated market for organ transplantation—have been fiercely rejected by the federal government, the medical community, and many religious faithful. But why? If most Americans accept the notion that the market is the most efficient means to distribute resources, why should body parts be exempt? 

 

In Kidney for Sale by Owner, bioethicist Mark Cherry contends that the market is a legitimate means to procure and distribute human organs. Cherry carefully examines arguments against a market for body parts, made by such figures as John Locke and Immanuel Kant and Thomas Aquinas, and shows these claims to be steeped in myth, oversimplification, and bad logic. He contends that equality, liberty, altruism, social solidarity, human dignity, and, ultimately, improved health care are more successfully supported by an organ market rather than through its prohibition.

 

Rather than focus on the purported human exploitation and "moral repugnance" of selling organs, Cherry says we should focus on saving lives. Many deaths could have been prevented, and many more lives saved, were it not for the moral hand-wringing over the concept of selling human organs. Cherry boldly deconstructs the roadblocks that are standing in the way of restoring health to thousands of people.

 

"Mark Cherry's book is the definitive treatment of the bioethical and business ethics questions that have been raised about a market in organs,” says Nicholas Capaldi, Legendre-Soule Distinguished Chair in Business Ethics at Loyola University. “It is must reading for anyone interested in these issues, and it will be the basis for all future discussion of this topic."

 

Mark J. Cherry is associate professor in the Department of Philosophy at Saint Edward's University in Austin, Texas; and is coeditor with H. Tristram Engelhardt, Jr., of Allocating Scarce Medical Resources, senior associate editor of The Journal of Medicine and Philosophy, senior associate editor of Christian Bioethics, and editor-in-chief of HealthCare Ethics Committee Forum (HEC Forum).

Also due out - we found out from our comments - is James Stacey Taylor's treatment of the same problem, Stakes and Kidneys: Why markets in human body parts are morally imperative. His book garnered pretty amazing reviews too:

'James Stacey Taylor has written the most comprehensive treatment of the
problem of markets in kidneys. It is probably also the best treatment of
the subject. His arguments that a legal trade in human organs would best
solve the organ shortage are more sophisticated and compelling than any I
have seen.'
Tom L. Beauchamp, Professor of Philosophy and Senior Research Scholar,
Georgetown University, Washington DC

Dave Undis of lifesharers reports some donation statistics today:

The number of organ transplants in the United States increased 6% in
2004. That's over 27,000 lives saved. Organs from deceased donors
were up 11%, and organs from live donors were up 2%. That's the good
news.

Here's the bad news:

- Last year 43,128 people were added to the national transplant
waiting list.

- Last year 6,228 people were removed from the waiting list because
they had died. Another 1,594 were removed from the list because they
had become too sick to undergo transplant surgery.

- At the end of 2004, over 87,300 people were on the national
transplant waiting list. That's up from abou 83,900 at the end of
2003.

- updated 4/2/5

Living Will? I'm Writing A Living Threat

Robert Friedman in St. Petersburg has written a living will with teeth, in the seething satire that the Schiavo debacle demands.

The Ultimate Living Will

Robert Friedman writes in the St. Petersburg Times: Like many of you, I have been compelled by recent events to prepare a more detailed advance directive dealing with end-of-life issues. Here's what mine says:

* In the event I lapse into a persistent vegetative state, I want medical authorities to resort to extraordinary means to prolong my hellish semiexistence. Fifteen years wouldn't be long enough for me.

* I want my wife and my parents to compound their misery by engaging in a bitter and protracted feud that depletes their emotions and their bank accounts.

* I want my wife to ruin the rest of her life by maintaining an interminable vigil at my bedside. I'd be really jealous if she waited less than a decade to start dating again or otherwise rebuilding a semblance of a normal life.

* I want my case to be turned into a circus by losers and crackpots from around the country who hope to bring meaning to their empty lives by investing the same transient emotion in me that they once reserved for Laci Peterson, Chandra Levy and that little girl who got stuck in a well.

* I want those crackpots to spread vicious lies about my wife.

* I want to be placed in a hospice where protesters can gather to bring further grief and disruption to the lives of dozens of dying patients and families whose stories are sadder than my own.

* I want the people who attach themselves to my case because of their deep devotion to the sanctity of life to make death threats against any judges, elected officials or health care professionals who disagree with them.

* I want the medical geniuses and philosopher kings who populate the Florida Legislature to ignore me for more than a decade and then turn my case into a forum for weeks of politically calculated bloviation.

* I want total strangers - oily politicians, maudlin news anchors, ersatz friars and all other hangers-on - to start calling me "Bobby," as if they had known me since childhood.

* I'm not insisting on this as part of my directive, but it would be nice if Congress passed a "Bobby's Law" that applied only to me and ignored the medical needs of tens of millions of other Americans without adequate health coverage.

* Even if the "Bobby's Law" idea doesn't work out, I want Congress - especially all those self-described conservatives who claim to believe in "less government and more freedom" - to trample on the decisions of doctors, judges and other experts who actually know something about my case. And I want members of Congress to launch into an extended debate that gives them another excuse to avoid pesky issues such as national security and the economy.

* In particular, I want House Majority Leader Tom DeLay to use my case as an opportunity to divert the country's attention from the mounting political and legal troubles stemming from his slimy misbehavior.

* And I want Senate Majority Leader Bill Frist to make a mockery of his Harvard medical degree by misrepresenting the details of my case in ways that might give a boost to his 2008 presidential campaign.

* I want Frist and the rest of the world to judge my medical condition on the basis of a snippet of dated and demeaning videotape that should have remained private.

* Because I think I would retain my sense of humor even in a persistent vegetative state, I'd want President Bush - the same guy who publicly mocked Karla Faye Tucker when signing off on her death warrant as governor of Texas - to claim he was intervening in my case because it is always best "to err on the side of life."

* I want the state Department of Children and Families to step in at the last moment to take responsibility for my well-being, because nothing bad could ever happen to anyone under DCF's care.

* And because Gov. Jeb Bush is the smartest and most righteous human being on the face of the Earth, I want any and all of the aforementioned directives to be disregarded if the governor happens to disagree with them. If he says he knows what's best for me, I won't be in any position to argue.

Hilary Bok: Hurray for the Judges in the Schiavo Case

Over at Obsidian Wings, Hilary Bok closes the case against conservative critics of the judges who have ruled in umpteen Schiavo decisions. Bill Kristol, Ann Coulter, Thomas Sowell, Alan Keyes, and on and on: they are all complaining about "judicial activism" in the Schiavo case - by which they mean not only that the judges have ruled outside the scope of their decisionmaking authority, but also that "this entire case is the result of renegade judges." And she points out that the critics of the courts are basically advocating that everyone and anyone rise up against the court system right now:

William Kristol, already quoted: "Perhaps it is time, in mature reaction to this latest installment of what Hugh Hewitt has called a "robed charade," to rise up against our robed masters, and choose to govern ourselves. Call it Terri's revolution."

John Gibson, Fox News: "So Jeb, call out the troops, storm the Bastille and tell 'em I sent you."

Bill Bennett: "It is a mistake to believe that the courts have the ultimate say as to what a constitution means. (...) It is time, therefore, for Governor Bush to execute the law and protect her rights, and, in turn, he should take responsibility for his actions. Using the state police powers, Governor Bush can order the feeding tube reinserted. His defense will be that he and a majority of the Florida legislature believe the Florida Constitution requires nothing less."

Ann Coulter: "As a practical matter, courts will generally have the last word in interpreting the law because courts decide cases. But that's a pragmatic point. There is nothing in the law, the Constitution or the concept of "federalism" that mandates giving courts the last word. Other public officials, including governors and presidents, are sworn to uphold the law, too. (...) Just once, we need an elected official to stand up to a clearly incorrect ruling by a court. Any incorrect ruling will do, but my vote is for a state court that has ordered a disabled woman to be starved to death at the request of her adulterous husband."

Alan Keyes: "When time is of the essence, necessity authorizes the executive to safeguard the security of the constitution before citizens and the polity suffer irreversible damage. Terri Schiavo's survival depends on Gov. Bush's faithful execution of this responsibility, and the survival of American self-government on the willingness of all those in a like position to faithfully execute the duties of their high office."

Elizabeth Farah: "Gov. Bush, you have the right to exercise your authority to save this woman's life. You have the authority to reject a corrupt judge's corrupt decision. Remember when the pharoah issued the order that all Hebrew male infants should be killed? What did Moses' mother do? She broke the law of the civil authority. She saved the life of her son. (...) Jesus says that yes, you will have many detractors – people who will revile you for doing the right thing, but you will be rewarded greatly by God."

It really is pretty incredible to read such venomous attacks on officers of the court, although of course not so much so as Congress taking on a single medical decision in late-night session. Hilary "hilzoy" Bok shreds the stupid conservative arguments, of course, but that will be small comfort to Michael Schiavo and 280 million other Americans who have fought so hard to allow Terry Sciavo some peace.

Positive Feedback for pcemakrRUS04!!
Would *definitely* Buy From Again.
Delivery Was Just in Time.

Arizona Republic is grumpy about the recent implant of a pacemaker purchased on eBay. We say "why?" eBay offers patients more than 17,000 medical devices - many at low, low discount prices. And you know what - it's just good business. Just think - the physicians at Arizona's Advanced Cardiac Specialists can make up a lot of the money that they'd been losing from cutbacks in insurance reimbursement - especially since $411.99 (their winning bid) let them sell the pacemaker for a $5500 profit. Cardiac surgeons have to eat too.

Come to think of it, why was it that eBay stopped allowing the sale of organs?

Congress Can Heal You, Too

The only thing funnier than Jon Stewart hosting a bioethics Q&A, if anything could be funnier than that, is Michael Bassik's suggestion that people send Congress their medical problems for diagnosis:

Take a digital picture or video of your medical problem – tennis elbow, acne, runny nose, hemorrhoids, or whatever ails you - and send it to the doctor in charge of the US Senate and your health care.

Everyone, take two minutes and upload your photos to Flickr.com. "Tag" the photo "Frist." If we get critical mass, we'll send everyone's photos to Dean Rosen, the good doctor's Health Care policy director!

More lessons from Schiavo

Posted in the Op Ed section of Good Friday's Globe and Mail:

Death is the veil that those who live call life

By Linda MacDonald Glenn

End-of-life issues brought me into the field of bioethics. I lost my first husband, Jack MacDonald, to cancer in 1984. He died after a long struggle that led ultimately to the question of whether to insert a feeding tube to prolong his life. Jack's chemotherapy had caused nausea, mouth sores, and esophageal ulcers and his oncologist had ordered a feeding tube. As I sat by Jack's bedside while the surgeon discussed the procedure, my husband start to cry. "Please no more . . . let me go," he pleaded.

Stunned, I didn't know what to say. Jack took my hand, grasped it and repeatedly said, "Please no feeding tubes, no more tubes . . . no more." He paused, rested a moment, then smiled (as if he knew what I was thinking) and said, "And if you wait until I'm unconscious to put one in, I swear I will come back after I've died and haunt you for doing that." I cried and laughed at the same time and promised I would never do that to him.

I loved Jack and I did not want to let him go, but I did not want to see him suffer any more. Jack had realized the fight was over long before I did; he tried to reassure me that he wasn't frightened and that he wasn't in any pain, and I shouldn't worry. Ultimately, I honoured his wishes; but it was, without a doubt, one of the most difficult decisions of my life. A few weeks later, Jack slipped into unconsciousness and died quietly, peacefully, on Feb. 8, 1984, at 6:33 p.m.

Of course, I sympathize with Michael Schiavo and his decision to remove the feeding tube of his wife Terri, who has been in a persistent vegetative state for 15 years. Maybe, because I'm approaching the half-century mark, I seem be to facing increasingly more end-of-life issues.

At my age, I know that no one escapes this life alive. But that does not ease the grief of losing so many loved ones. What brings me comfort is the belief that the people I have loved and lost are still with us, if not in body, then in spirit. These individuals have been my teachers and have helped me learn that what we experience on Earth is part of a natural and continual evolution of our individual souls.

I believe we are born so that we can learn life's lessons and help one another to grow. When we have learned all we can on this Earth, and served our purpose, we return to God (or, if you prefer, to the Cosmos, Eternity, the Universe, the Multi-verse, Everything-ness). One of my favourite authors, Buddhist monk Thich Nhat Hanh, writes that we are afraid to die because we are afraid we will become nothing when we die. But rather than seeing death as an end to life, we should see our lives as a temporary manifestation, like a parentheses in a sentence that is eternity, or a wave that's part of the larger ocean. Death can teach us valuable lessons about impermanence and the interconnectedness of all things.

This may not provide a lot of comfort to Terri Schiavo's parents, Bob and Mary Schindler, who this week appealed to the U.S. Supreme Court to have their daughter's feeding tube reinserted. This life-and-death case has gripped us and prompted debate about end-of-life care and what the "sanctity of life" means. It has created schisms in religious communities and been the topic of heated conversation at many a dinner table. Watching the Schindlers publicly plead for intervention is heart-wrenching. I have no doubt that they love Terri, and are doing this for her sake. I am reminded, though, that in the bestseller The Road Less Traveled, M. Scott Peck defines love as "the will or willingness to extend one's self for the purpose of nurturing one's own or another's spiritual growth."

The question now is: Whose spiritual growth is being nurtured here? Traditionally, the Catholic Church, of which Terri Schiavo is a member, employs a burden-versus-benefit analysis in determining whether or not to use extraordinary measures to sustain life. Part of the reasoning behind this is the recognition that death is not the ultimate evil, but eternal damnation is. And that our purpose here on Earth is to serve God, and once we have done that, we no longer need to cling to these earthly bonds.

It is ironic that all of this is taking place during Holy Week, a time when the Christian community celebrates the triumph of eternal life over death, through the resurrection of Christ. To the devout Christian, to allow Terri to die would be to allow her to return to God. Her death does not diminish the fact the she and all of her loved ones were created as gifts from God and should be cherished as such. Regardless of her fate, the debate over whether or not Terri's wishes should be honoured has helped us realize that it is our responsibility to exercise our free will to make choices to nurture our own or another's spiritual growth. In searching for meaning and purpose in our lives, we reconnect with others and remind ourselves that ultimately, we are not alone.

Terri's case is heart-wrenching because it touches everyone, and its outcome further shapes our relationship with others and the governments to which we delegate authority.

The fundamental lesson seems clear: Decide for yourself how to manage the end of your life, and make it clear to others. Without this guidance, you are the victim or beneficiary of conflicting interests and beliefs -- or of an ad hoc consensus that may, or may not, coincide with your own wishes.

- Linda Glenn

John Paris, Jesuit Bioethicist - My Religion Has This One Wrong

John Paris does one of his typical clearheaded Q & A sessions, this time on Schiavo and with MSNBC. If you are looking for a clearheaded Catholic perspective on Schiavo, this is it. John is amazing.

Good Thing There Are Amazing Neurologist Superstars Working On Behalf of the Schindlers

Or not.

The New Living Will Form

I'm thinking that Bill Allen's proposal for a living will is maybe a good idea for me, you and everybody else with fear of the Bush administration a sense of humor.

I received this today from a member of our hospital staff with whom i have not spoken about my idea the other day.

Florida - Living Will

I, _________________________ (fill in the blank), being of sound mind

and body, unequivocally declare that in the event of a catastrophic injury,

I do not wish to be kept alive indefinitely by artificial means.

I hereby instruct my loved ones and relatives to remove all

life-support systems, once it has been determined that my brain is longer

functioning in a cognizant realm.

However, that judgment should be made only after thorough consultation

with medical experts; i.e., individuals who actually have been trained,

educated and certified as doctors.

Under no circumstances -- and I can't state this too strongly -- should

my fate be put in the hands of peckerwood politicians who couldn't pass

ninth-grade biology if their lives depended on it.

Furthermore, it is my firm hope that, when the time comes, any

discussion about terminating my medical treatment should remain private and confidential.

Living in Florida, however, I am acutely aware that the legislative and

executive branches of state government are fond of meddling in family

matters, and have little concern for the privacy and dignity of

individuals.

Therefore, I wish to make my views on this subject as clear and

unambiguous as possible. Recognizing that some politicians seem

cerebrally challenged themselves (and with no medical excuse), I'll try to keep this simple and to the point:

1. While remaining sensitive to the feelings of loved ones who might

cling to hope for my recovery, let me state that if a reasonable amount of

time passes -- say, ____ (fill in the blank) months -- and I fail to sit sit

up and ask for a cold beer, it should be presumed that I won't ever get

better.

When such a determination is reached, I hereby instruct my spouse,

children and attending physicians to pull the plug, reel in the tubes

and call it a day.

2. Under no circumstances shall the members of the Legislature enact a

special law to keep me on life-support machinery. It is my wish that

these boneheads mind their own damn business, and pay attention instead to the health, education and future of the millions of Floridians who aren't

in a permanent coma.

3. Under no circumstances shall the governor of Florida butt into this

case and order my doctors to put a feeding tube down my throat. I don't

care how many fundamentalist votes he's trying to scrounge for his

brother in 2004, it is my wish that he plays politics with someone else's life

and leaves me to die in peace.

4. I couldn't care less if a hundred religious zealots send e-mails to

legislators in which they pretend to care about me. I don't know these

people, and I certainly haven't authorized them to preach and crusade

on my behalf. They should mind their own business, too.

5. It is my heartfelt wish to expire quietly and without a public

spectacle. This is obviously impossible once elected officials become

involved. So, while recognizing the wrenching emotions that attend the prolonged death of a loved one, I hereby instruct my relatives to settle all

disagreements about my care in private or in the courts, as provided by

law.

If any of my family goes against my wishes and turns my case into a

political cause, I hereby promise to come back from the grave and make

his or her existence a living ____ (fill in the blank)

Terri Schiavo's Brain:
A Neuroethicist Clarifies Her Condition

Martha Farah, neuroscientist and neuroethicist at Penn has put together a page on Terri Schiavo at the Penn neuroethics site, which includes many references to neurological literature on PVS, and she wrote this up for us:

Recent discussions of the Terri Schiavo case have focused, understandably enough, on its legal and political dimensions.  But what propelled this case through umpteen courts and into the US Congress are the neuroethical issues it raises, and we’ve heard almost nothing about them lately.  I do not think the lack of attention to the neuroethical issues is simply because they are settled and need not be discussed further.  (Indeed, if someone has solved the mind-body problem and I missed it, email me quick!)  The issues at stake here concern the relations between conscious awareness, brain and behavior, and these are hard problems.  What gives mental life to a brain and how can we tell whether a given damaged brain supports some type of awareness?

Until recently, a patient’s behavior was the one source of evidence we could use to infer their mental state.  Now functional neuroimaging has been brought into the mix.  Both sources of evidence are trickier to interpret than they appear at first.

Some observers of Terri Schiavo find her behavior indicative of conscious awareness and intentionality.  One observer, writing on the website terrisfight.org wrote: “I was pleasantly surprised to observe Terri’s purposeful and varied behaviors... I never imagined Terri would be so active, curious, and purposeful. She watched people intently, obviously was attempting to communicate with each one in various ways and with various facial expressions and sounds.”  For me, watching Terri Schiavo in the website videos, it was difficult not feel I was seeing a person interacting with others and aware of her surroundings.

However, clinical and experimental neuroscience have taught us some surprising things about the range of behaviors that can emerge from a decorticate brain.  Such behaviors include orienting with eye and head movements toward sights and sounds, generating facial expressions, and producing nonverbal vocalizations that have meaning for us, if not the person producing them, such as cries and laughter.  In light of this, we must interpret the behavior seen in the videos cautiously and with a measure of skepticism.

The most natural interpretation for the behaviors we see on the video is not the only interpretation.  For example, when a dozing Terri is loudly ordered to “open your eyes!” and does so, does that mean she understood what was said?  Or would she have done the same thing if roused with an equally loud order to “open your mouth!” or “stand on your head!”

Humans are hardwired to interpret the behavior of others in terms of mental states.  In the psychology literature this tendency is part of a suite of abilities termed “Theory of Mind” (ToM) and in most situations we apply our ToM automatically, without weighing alternative reasons for the behavior.  For a particularly striking demonstration of this fact about ourselves, consider the typical response to the robot Kismet.  Kismet is part of a research effort at the MIT Artificial Intelligence Lab to design machines that interact socially with humans.  Kismet has been programmed to gaze at humans who approach it, orient to salient objects moving within its field of view, pull back avoidantly if an object is thrust forward at it, and so on.  People attribute all manner of cognitive and emotional states to this robot on the basis of a fairly small set of simple behaviors, and have been known to become quite attached to it.  And this is a contraption made of metal and plastic, not a human being!  My point is emphatically not to liken Terry Schiavo to Kismet, but rather to suggest a similarity in our reactions to the woman and the robot.

Recent functional brain imaging results have added a new twist to the debate over Terri Schiavo and the treatment of persistent vegetative state (PVS) more generally.  Brain imaging is potentially helpful in understanding the mental life of neurological patients.  Behavior is an imperfect measure of cognitive state in anyone, but especially in neurological patients whose verbal and motor systems may be damaged or disconnected from cognitive systems. Brain imaging offers seemingly more direct access to the workings of cognitive areas of the brain.  However, at this point in the development of functional brain imaging, the meaning of different patterns of brain activity is not well understood.

A much publicized article in the journal Neurology used fMRI to document cortical responses to speech in patients who were in a minimally conscious state (MCS).  This result, reported on the front page of the New York Times, was seized upon by some as evidence that Terri Schiavo may retain more awareness than her behavior suggests.  There are two problems with this conclusion.

The first problem is that the patients in this study were in a MCS, not a PVS.  What is known about brain activity in PVS?  A few studies have shown that the primary sensory cortices of PVS patients respond to touch and sound but higher-level cortices associated with cognition are not reliably activated.  However, one PVS patient imaged with PET showed more cortical activation in response to a story told by his mother than to nonsense words.

The second problem is that brain activation, even activation that discriminates between meaningful stimulation and nonsense, does not imply awareness.  The cognitive neuroscience literature contains a number of studies in which people’s awareness of stimuli was manipulated while brain activity was measured.  In studies with healthy normal participants, awareness of visual stimuli was eliminated by the use of brief, subliminal presentations.  In studies with neurological patients, a phenomenon called “extinction” was used to control awareness of the stimuli; visual stimuli on one side of space are extinguished (not consciously perceived) when another stimulus is presented simultaneously on the other side of space.  These studies have shown that stimuli can activate relevant regions of cortex even when people are unaware of the stimulus.  This is consistent with the idea that the brain activity underlying perception is graded, ranging from nonexistent to the levels of activity observed in normal conscious perception, and that conscious awareness of external events accompanies only the higher end of that range.

The bottom line is that we have two windows through which to look for an answer to the question of conscious awareness in brain-damaged patients, and while neither is crystal clear, both are useful.  The first is extended behavioral observation (as opposed to snippets of video), undertaken with an awareness of our susceptibility to the “Kismet” phenomenon.  The other is functional neuroimaging, interpreted cautiously and with an awareness of how much remains to be learned about activation-cognition correlations in damaged brains.

Dahlia Lathwick Indicts the Palm Sunday Compromise

An emerging consensus holds that even with New England Journal of Medicine's rush publication of Schiavo articles by George Annas and Tim Quill, the standout commentary on what happened here -- geez, what did happen here? am I dreaming?? -- is by Dahlia Lathwick, senior editor of the online magazine Slate, who offers a scathing indictment of Congress's sudden interest in the Schiavo case. She pointedly questions the motives behind the Palm Sunday Compromise, particularly the rush to trample centuries of federalist traditions in the pursuit of a self-proclaimed "culture of life".

There's also a nice interview of Dahlia Lathwick by Alex Chadwick, discussing many of the legal particulars of the Schiavo case.
- Sean Philpott (senior scientist at New York Wadsworth Institute)[thanks Bob Baker (Union)]

Forget Canada.
I'm Moving to California.

L.A. Times reports on the California Medical Association's vote this week in which 449 of 450 physician deligates voted to express "emergency outrage" at Bush administration maneuvering on the Schiavo case - an in particular to condemn the legislation he signed allowing Terri Schiavo's parents to request of a Federal court that Ms. Schiavo's feeding tube be reinserted.

As We Await the Opinions of the 11th Circuit Court on Schiavo...

It is worth remembering Justice Scalia's concurring opinion in the Cruzan case.  I don't think the President or his allies in Congress can expect much sympathy from the highest court.

JUSTICE SCALIA, concurring. The various opinions in this case portray quite clearly the difficult, indeed agonizing, questions that are presented by the constantly increasing power of science to keep the human body alive for longer than any reasonable person would want to inhabit it. The States have begun to grapple with these problems through legislation. I am concerned, from the tenor of today's opinions, that we are poised to confuse that  enterprise as successfully as we have confused the enterprise of legislating concerning abortion -- requiring it to be conducted against a background of federal constitutional imperatives that are unknown because they are being newly crafted from Term to Term. That would be a great misfortune.

While I agree with the Court's analysis today, and therefore join in its opinion, I would have preferred that we announce, clearly and promptly, that the federal courts have no business in this field; that American law has always accorded the State the power to prevent, by force if necessary, suicide -- including suicide by refusing to take appropriate measures necessary to preserve one's life; that the point at which life becomes "worthless," and the point at which the means necessary to preserve it become "extraordinary" or "inappropriate," are neither set forth in the Constitution nor known to the nine Justices of this Court any better than they are known to nine people picked at random from the Kansas City telephone directory; and hence, that even when it is demonstrated by clear and convincing evidence that a patient no longer wishes certain measures to be taken to preserve his or her life, it is up to the citizens of Missouri to decide, through their elected representatives, whether that wish will be honored. It is quite impossible (because the Constitution says nothing about the matter) that those citizens will decide upon a line less lawful than the one we would choose; and it is unlikely (because we know no more about "life and death" than they do) that they will decide upon a line less reasonable.

- Art Caplan

Plus, We Hear that You Have Friends in High Places Down Here

St. Petersburg Times had an interview with Michael Schiavo, who put his request to President Bush point blank:

"Come down, President Bush," Schiavo said in a telephone interview. "Come talk to me. Meet my wife. Talk to my wife and see if you get an answer. Ask her to lift her arm to shake your hand. She won't do it."

Schiavo Decision: Read It

Read the order direct from the U Pitt law center as PDF here.

Federal Judge Denies TRO in Schiavo

U.S. District Judge James Whittemore denied a request by Schiavo's parents to re-insert the feeding tube that had been withdrawn Friday. The judge stated in his ruling that the "plaintiffs have not established a substantial likelihood of the success of the merits of their case." Next stop: 11th Circuit Court of Appeals in Georgia -- Linda Glenn

Schiavo Means?

A few thoughts about what, other than reform of laws about euthanasia, might come from this incredible climax to the Schiavo case:

Living Wills May Not Work, but I'm Getting One - There couldn't be a more salient test of the question as to what it might mean if I do not write down "I prefer not to be held hostage by fears about a feeding tube for more than a decade, please." I've argued in several papers that living wills are a mistake and are unlikely to work, and others have found enough empirical evidence to cast doubt on the idea that advance directives make much difference in the care that patients receive. But tell that to Michael Schiavo. Today it is awfully clear that no matter what I and other critics of living wills might have believed about how well they work, they do at least make it easier to avoid the Schiavo level of confusion and wrangling. I have opined over and over again that living wills are too litigious. Um, ok, I was wrong. All around the country people will now begin thinking very seriously about writing down their wishes about feeding tubes and respirators. It is as John Danforth said when he pushed for the Patient Self-determination Act in the first place: young people "should get a Miranda warning" about what can happen if they do not talk to others about health care preferences.

In the Future, it Will Be Tough to Get a Majority of Legislators to Agree to Support Choices by Individuals About Health Care - The scene on the House floor as the debate persisted about Schiavo is staggering. Those who fought for the sanctity of marriage now fight against the importance of a husband's choice. Those who fought for the importance of the 10th amendment and states rights more generally are suddenly desperately fighting against a state's rule of law. The body that made it possible for Cruzan's case to become the Patient Self Determination Act is now deciding that expressed views about dying just don't matter. Why? Because Democrats do not want to run for office against campaign commercials that feature Terri Schiavo dying.

Systemic End of Life Care Is Now Officially Less Important than Jack Kevorkian and Terri Schiavo and Tom DeLay's Own Ethics Problems - Ask yourself when was the last time that President Bush and the Congress undertook anything like a midnight effort - including a flight to get the President from Texas to D.C. during a vacation - on behalf of healthcare. Give up? Never. Just think what could happen if Congress worked this hard or spent this much of our tax money to discuss and vote quickly on reform of managed care. It could never happen - but why? Because the battle over Terri Schiavo is illuminated by a single, vulnerable woman. If Democrats could manage to make a symbol out of a young woman dying of a curable chronic disease because she has no insurance, we might have 40 million fewer uninsured people in the nation today. And the lesson doesn't end there: this case is sucking the life out of the end of life care debate. Just as Kevorkian turned the nation's attention away from the problems that made his services seem desirable, the Schiavo case turns our attention away from dozens of critical questions about the funding of hospice and a dozen other issues.

Compassion for the Dying Schiavo and Her Family Ought Not Be Lost - There is no question in my mind that the Schiavo case illustrates wanton, callous political maneuvering on the part of some. It is equally clear to me that Congress has no business working on this case in this way - interfering in the lives of those who are touched by such tragedy as they make private decisions. But it should not be lost that many who have begun to fight in this matter as it has been quickly escalated have deep compassion for the Schiavos, and that such compassion comes from a vital sense that death and suffering must be understood and respected - and that love for life is important and beautiful. Somewhere in the middle is the opportunity to take this case and use it to move quickly to reform of national policies. I hope that happens. That will of course come as no comfort to the mother of baby Sun in Houston.

People Struggle Most Against the Worst Odds - There is no question about Terri Schiavo's condition. She is never ever going to awaken, no, to be more blunt, her brain is utterly destroyed and there is nothing of what was Terri Schiavo remaining in her but the simple functioning stem that causes her other organs to continue to function at the most basic level. That much is clear. All that remains of Terri Schiavo is her dignity and the symbolic meaning of her body. So why does anyone fight to keep her in this condition rather than discontinuing a treatment that everyone agrees is not therapeutic? What does it mean to fight against the impossible in this case? Republicans fighting against this measure have tried desperately to avoid discussion of what might re-grow Ms. Schiavo's brain, because God forbid they say what the man who offered Mr. Schiavo $1 million to keep Terri Schiavo said: stem cells. No, there is nothing here for them to point to but miracle. And it should be noted that pushing for a miracle against impossible scientific odds is a critical part of the American culture in an era in which physicians often feel that they must offer treatments that they do not believe are therapeutic. The idea that patients and others have a right to request things whether or not they work is being reinforced right now.
- Glenn McGee

You Need a Living Will

This is the location to find information about a living will - which after the Schiavo case you may really want to consider having. An advance directive aimed at ensuring that your doctors and significant others know what treatments you would, or would not, want has suddenly become the most important tool one could have in the event that there is any difference between your views and your family's views about end of life care. Country simple: if you would want a feeding tube removed were you in persistent vegetative state, and you think that it is enough that you told your family as much, think again and get a living will. Your state's information is above.

Warning: not guaranteed to protect you against the combined legislative force of a majority of congress.

Schiavo: A Constitutional law perspective

Kathy Cerminara, law professor at Nova Southeastern University, has been analyzing much of the legislation coming out on the Schiavo case; I look forward to hearing what she has to say about the Congressional legislation. Interesting enough, at least two "right to die" cases have been decided by the federal courts: Gray v. Romeo, 697 F. Supp. 580, ; 1988 U.S. Dist. LEXIS 11580, where the court held upheld Marcia Gray's right to self-determination and her right to refuse medical treatment, as expressed through her husband, as surrogate and Tune v. Walter Reed Army Medical Hosp., 602 F. Supp. 1452, 1454 (D.D.C. 1985). In Tune, the court ordered, in accordance with the patient's wishes, the removal of her life-support system, although such an action would likely result in her immediate death. So, being in Federal Court certainly doesn't automatically equal a victory for the Schindlers. The federal district judge has three issues to decide initially: First, the request for a temporary restraining order (TRO) to reinstate the feeding tube; second, the constitutionality of the bill approved by Congress, and third, whether on not any of Terri Schiavos's constitutional rights have been violated. For the judge to grant a TRO, he has to weigh and balance four criteria: (1) an ascertainable claim for relief (that is, a right of the Plaintiff which is in need of protection), (2) a likelihood of success on the merits of the claim, (3) irreparable harm and damage which will occur if the TRO is not granted, and (4) No adequate remedy at law (that is, no way of calculating money damages). The Court may also balance the hardships to the parties if the TRO is granted, and at any public policy or public interest involved in the controversy. A hearing has been scheduled for 3pm today, we'll see what the federal judge does with this. -- Linda MacDonald Glenn

The Fate of Terri Schiavo
Has Already Been Decided

What Congress and the President are trying to do has already been done--by the Florida legislature and by the President's brother Jeb who is the governor there. The Supreme Court of Florida quickly rejected Bush's and the legislature's attempt to intervene with what was known as "Terri's Law". There is every reason to predict that the same fate awaits Tom Delay, Bill Frist, James Sensenbrenner and George Bush.

First, state courts control the handling of end of life care issues not the Federal courts. Second, the facts in this case have been litigated forever and there is no reason to think any Federal judge will find any flaws with the due process according Terri's parents and siblings as they have fought against her husband. Third, Congress is trying to pass a law for 'one' and that is unlikely to be seen as constitutional. Fourth, the Schiavo case is essential a domestic dispute. Federal courts hate to get involved in these. Fifth, and perhaps most importantly, the trial court judge shows no inclination to be bullied. He has already told Congress to pound sand when it issued subpoenas requiring Terri Schiavo to testify in Washington. He may well do the same in response to any Congressional legislation.
- Arthur Caplan

The Ethics of Sucking Blood from Private Parts

Forward Newspaper reports on the "harassment campaign" against prominent Orthodox rabbi and medical ethicist Rabbi Moshe Tendler, a bioethics expert and Talmud instructor at Yeshiva University, who

was criticized by ultra-Orthodox leaders and newspapers after he was quoted in the press as saying that the practice of metzitzah b'peh, or oral suction of the circumcision wound, should be conducted with a sterile tube. In many ultra-Orthodox circles, especially within certain Hasidic sects, the ritual is performed by having the mohel suck blood from the wound with his lips directly on the baby's penis.

Tendler spoke out against the practice following reports last month that a Jewish infant had died of herpes and that several other babies had contracted the virus after being circumcised by mohel Rabbi Yitzchok Fischer, who practiced direct oral suction. Tendler co-authored an article in the August 2004 issue of the medical journal Pediatrics, which asserted that the risks of herpes infection should outweigh any ritual benefits of using direct oral suction.

In recent weeks, ultra-Orthodox newspapers have condemned Tendler and accused him of reporting Fisher to health officials — a claim that Tendler vehemently denies.

Syndiated Columnist Kate Scannell on Lying to Insurance Companies

Kate Scannell is a great columnist - she does her homework and writes with verve about social issues. And she reads AJOB; that alone makes her cool. So we were incredibly proud to read her most recent column, based entirely on the new articles in our journal about lying to insurance companies. She even did her own little "mini-study" to confirm the findings of the authors:

In an article published in the current issue of The American Journal of Bioethics, researchers examined the willingness of the public and physicians to support deception of insurance companies for the purpose of obtaining health care services. The researchers asked over 1,600 physicians and 700 public members (drawn from a pool of prospective jurors) what the doctor should do in similar scenarios.

The researchers found that 26 percent of the public sample and 11 percent of surveyed physicians chose deception of the insurance company as the proper response.

Mine is an informal and unscientific poll, but I had the opportunity to ask 22 physicians about their response to the study's findings. No one was surprised that some physicians and public citizens supported deception of insurance companies in the service of obtaining necessary patient care, but all were surprised that the reported percentages were so low. Nearly everyone believed that the majority of physicians at some time or   other had "stretched the truth"or "coaxed a patient" or "caved in to a patient's demands" to misrepresent facts in order to satisfy the insurance company's pre-qualification criteria for obtaining costly drugs or tests.

In both circumstances, health care costs may be driven upwards if patients are inadequately treated or diagnosed, and if doctors and patients spend too much time making requests and appeals to insurance companies. Additionally, the medical profession may find its reputation undermined when an insurance company administrator   can trump doctors' medical decision-making and determine what constitutes necessary medical care.

Information Under the Skin:
the European Union Worries

EUROPA reports on the EU European Union Ethics in Science and New Technologies (EGE) opinion on the ethics of implanting information and communication technologies (ICT):

"The idea of placing ICT devices “under our skin” in order not just to repair but even to enhance human capabilities gives rise to science fiction visions with threat and/or benefit characteristics. However, in some cases, the implantation of microchips with the potential for individual and social forms of control is already taking place.

The intimate relation between bodily and psychic functions is basic to our personal identity. Neurosciences are developing very quickly. The brain implants developed to alleviate tremors in Parkinson’s disease are only one example. They show that ICT implants may influence the nervous system and particularly the brain and thus human identity as a species as well as individual subjectivity and autonomy.

These are the essential reasons why ICT implants in the human body have large and important ethical consequences. Not surprisingly, the respect for human dignity has been the fundamental basis of EGE discussions of where the limits should be drawn for different applications of ICT implants."

Elizabeth Blackburn, Fired by President Bush from Bioethics Commission, Awarded Franklin Medal

Elizabeth Blackburn is a great scientist, the only stem cell biologist who served on the Presidents Council on Bioethics under Leon Kass, and those who watched as she was dismissed from the Council were appalled - particularly at the assertion by Kass in newspapers that Blackburn was dismissed not for her politics but because she did not participate in the panel's discussions. If you followed the scandal you know that Blackburn was in fact very active in the discussions, by email, but that at the heart of the matter was the question of how to cast her contributions as a scientist to the public debate.

Benjamin Franklin would have loved Elizabeth Blackburn, and no doubt it is that fact - as well as her basic science acumen - that insipred the judges at the Franklin Institute in Philadelphia to award her the Benjamin Franklin medal, which has been awarded to truly outstanding scientists since 1824.

Blackburn, an Australian who is now a U.S. citizen and a professor at the University of California, San Francisco, was one of 18 people chosen in 2001 to serve on the President's Council on Bioethics. She researched developments in embryonic stem cells and told her fellow council members that the field held great promise in the health-care field.

The use of such cells from human embryos is opposed by abortion opponents. Blackburn and another scientist were replaced in 2004 with three people who held more conservative views.

The panel chairman said her removal was not related to politics, but Blackburn disagrees. She wrote of her experience in a two-page column in the New England Journal of Medicine, and said she received positive calls and letters from around the world.

'People don't like the idea that science policy is not being based on evidence,' she said yesterday."

Jersey Loves Stem Cell Research

A Hart Research survey pegs support for a $250 million state bond initiative for stem cell research at 83%. Unless New York steps up to the plate with the huge Silver proposal, adoption of the New Jersey proposal would make New Jersey the second most generous place in the world to locate stem cell research programs.

RIP: Brown University Bioethics

Brown University was never really known as a place to learn bioethics as a profession.

But what Brown was known for in bioethics was its great research and writing, and a kind of leadership in bioethics that allowed it to create the very first "bioethics major" for those who are not yet ready to learn a profession - undergraduates. It was a brilliant concept - teach undergraduates about medicine, philosophy, the social sciences, and so many other things through the filter of ethical issues in biomedical science. And it worked. It was started by Dan Brock, a philosopher and bioethics pioneer who retired from Brown several years ago, taking positions first at NIH, then Harvard.

Brown couldn't get its act together to hire Brock's replacement. It had, instead, a very public implosion in bioethics, in fact, as the Brown philosophy department displayed the nearsightedness that has become typical of philosophy departments, declining to hire any among a pool of strong applicants for Brock's job because none of them were "good enough philosophers." It was the sort of decision that has characterized the past decade in philosophy, a ten year period that has seen the more-or-less total demise of the public role of academic philosophy.

So bioethics at Brown - easily one of the school's best-known areas of accomplishment - essentially died, and with it that incredible bioethics major, which Brown has announced will now die. The bioethics major wasn't just a precedent that a number of other schools would eventually follow, although it did establish that an interdisciplinary undergraduate program in bioethics might make educational sense. What it really represented was the pinnacle of Brown's greatness as an undergraduate institution - back when Brown was a top-10 school in the late 80s. It was a fabulous example of how the Brown "design your own major" program both attracted good students with good motivations and also taught them to combine science and humanities.

So, just like that, Brown disappears from bioethics. R.I.P.

Now Here's a Foundation for Bioethics: I Saw it on Star Trek!

From the Baltimore Sun, a story you have to read to believe: Loyola College (MD) professor Diana Schaub, advisor to President Bush, argues that cloning and stem cell research are bad because she saw it on Star Trek.

The show has "left me receptive to the view that mortality is, if not precisely a good thing, then at least the necessary foundation of other very good things," she wrote in an article last year. "There is something misguided about the attempt to overcome mortality."

Her interest in mortality and Star Trek could be regarded as the quirks of an academic if not for her position on the President's Council on Bioethics, a 18-member panel that advises Bush on some of the most polarizing subjects in society.

Yes, the President digs deep for ethical advice.
- Art Caplan

Linda Glenn: Why the Schiavo Case is Personal

End of life issues are what brought me into the field of bioethics. I lost my first husband, Jack MacDonald, to cancer in 1984. He died after a long struggle with leukemia. I’ve written about his life and his death in an article in the journal Healing Ministry: Three Lives, Three Deaths, Three Journeys: Explorations on Dying Well, September/October 2001. What I didn’t write in that article was our discussion about a feeding tube. Jack’s chemotherapy had caused nausea, mouth sores, and esophageal ulcers. His oncologist had ordered a feeding tube (a jpeg) and the surgeon was discussing the procedure with him and I at the bedside and my husband start to cry. He pleaded, “please no more…let me go.” The surgeon, a kindly old gentleman, left the room for us to talk. Stunned, I didn’t know what to say. Jack took my hand, grasped it and repeatedly said, “Please no feeding tubes, no more tubes… no more.” He paused, rested a moment, then smiled (as if he knew what I was thinking) and said, “And if you wait until I’m unconscious to put one in, I swear I will come back after I‘ve died and haunt you for doing that.” I cried and laughed at the same time and promised that I would never do that to him. After a while, I stepped into the hallway, where the kindly old surgeon was waiting for me. This was the same surgeon who had put in Jack’s Hickman catheter months earlier and he wanted to tell me that he understood and supported Jack’s decision, and that at this point, death was a friend to be welcomed. I loved Jack, I did not want to let him go; but I did not want to see him suffer anymore. Jack had realized the fight was over long before I did; he tried to reassure me that he wasn’t frightened and that he wasn’t in any pain, that I shouldn't worry. Ultimately, I honored his wishes; but it was, without a doubt, one of the most difficult decisions of my life. A few weeks later, Jack slipped into unconsciousness and died quietly, peacefully, without struggle on February 8, 1984, at 6:33 p.m. So, as you can imagine, I sympathize with Michael Schiavo. One of the more disturbing aspects of the political rhetoric is the hyperbole of the politicians and the Schindlers (Terri's parents) talking about how Michael is intent on “starving” Terri to death, as if she were a person who was totally healthy and fully functional. Is it possible that none of these persons have ever witnessed a hospice death? And hospice organizations have explained time and time again that someone at the end-of-life doesn’t experience thirst and hunger in the same fashion that healthy individuals do. The language the politicians and the Schindlers are using is intended to provoke and inflame. What also puzzles me is that these devout Christians seem to be ignoring the fact that, according to the Christian doctrine, death is not the ultimate evil, but eternal damnation is; to allow Terri to die would be to allow her to join with God in eternal life. Perhaps the Schindlers and the politicians don’t really believe in an afterlife? But this case is no longer about Terri’s wishes, or her husband attempting to honor her wishes, or a family dispute. It has become a political battle reflecting the torn state of the nation, about "being right and looking good" and who has control. --- Linda MacDonald Glenn

Majikthise : Lies Terri Schiavo's Parents Told Me

Majikthise rants on the Schiavo case, with her usual rigor and clarity - what a great blog. This post by the way did thousands and thousands and thousands of visits today - more than either the MSNBC or CNN top line Schiavo stories. More evidence that the cutting edge in bioethics-related journalism and commentary is quickly transitioning to blogs - people just want better, more incisive, full discussion, no matter their political affiliation.

Nope, the President's Bioethics Council Isn't Lobbying for Policy At All

Word today that Yuval Levin, the smart and very effective Executive Director of the President's Council on Bioethics, will now be Associate Director of the Domestic Policy Council. In the White House.

The neocons' new "bioethics legislative agenda" fell so flat that republicans rebuked it and democrats have now called for a formal congressional inquiry into the conduct of the Chair, Leon Kass. As we predicted, it looks like the neocons are now at least gesturing toward an executive White House bioethics policy agenda.

Peggy Noonan on Schiavo in Wall Street Journal

OpinionJournal columnist Peggy Noonan[thanks Jon Eisenberg] writes:

The supporters of Terri Schiavo's right to continue living have fought for her heroically, through the courts and through the legislatures. They're still fighting. They really mean it. And they have memories.

On the other side of this debate, one would assume there is an equally
well organized and passionate group of organizations deeply committed to
removing Terri Schiavo's feeding tube. But that's not true. There's just
about no one on the other side. Or rather there is one person, a
disaffected husband who insists Terri once told him she didn't want to
be kept alive by extraordinary measures.

He has fought the battle to kill her with a determination that at this
point seems not single-minded or passionate but strange. His former
wife's parents and family are eager to care for her and do care for her,
every day. He doesn't have to do a thing. His wife is not kept alive by
extraordinary measures--she breathes on her own, is not on a respirator.
All she needs to continue existing--and to continue being alive so that
life can produce whatever miracle it may produce--is a feeding tube.

It doesn't seem a lot.

So politically this is a struggle between many serious people who really
mean it and one, just one, strange-o. And the few bearded and
depressed-looking academics he's drawn to his side.

Caplan on MSNBC on Schiavo

Writes Art Caplan on MSNBC.com:

We have now reached the endgame in the case of Terri Schiavo. Her husband, Michael, remains unwavering in his view that she would not want to live in the state she is in. Despite the fact that he has been made the target of an incredible organized campaign of vilification, slander and just plain nastiness, he remains unmoved. Even a pathetic effort to bribe him into changing his mind with the offer of $1 million did not budge him.

He says he loves his wife and will do whatever it takes to end an existence that he believes she would not want to endure. He thinks that she would want her feeding tube stopped and that she would wish to die rather than remain bed-bound in a nursing home in a permanent vegetative state for the rest of her days

The Schindler parents and their other children remain equally convinced that Michael is wrong.  They say that Terri would want to live, that she is not as brain-damaged as Michael contends, and that there is still hope for her recovery despite the fact that she has failed to show any real improvement in 16 years. They argue that there are still more treatments to be tried and that as a Catholic Terri would want to honor recent Papal teachings that feeding tubes should not be removed from those in permanent vegetative states.

Congress, or at least the pro-life constituency in the House and Senate, are doing their best to halt Schiavo's death. Last-minute bills invoking habeas corpus, a legal doctrine that has historically only been used for those held in federal custody, along with incredibly zany and inappropriate subpoenas to doctors and nurses requiring that Terri Schiavo be brought to Washington, show a level of grandstanding that is normally reserved for issues such as the use of steroids by major-league baseball players. 

So now that this miserable case is moving toward a resolution, what can be said about who is right and who is wrong? And what is the likely legacy of the battle over the fate of Terri Schiavo?

Ever since the New Jersey Supreme Court allowed a respirator to be removed from Karen Ann Quinlan and the U.S. Supreme Court declared that feeding tubes are medical treatments just like respirators, heart-lung machines, dialysis and antibiotics, it has been crystal clear in U.S. law and medical ethics that those who cannot speak can have their feeding tubes stopped.  The authority to make that decision has fallen to those closest to the person who cannot make their own views known. First come husbands or wives, then adult children, then parents and other relatives.

That is why Michael Schiavo, despite all the hatred that is now directed against him, has the right to decide his wife’s fate. The decision about Terri’s life does not belong to the U.S. Congress, President Bush, Rep. Tom Delay of Texas, Florida Governor Jeb Bush, the Florida Legislature, clerics in Rome, self-proclaimed disability activists, Operation Rescue founder Randall Terry, conservative commentators, bioethicists or Terri’s parents. The decision is Michael’s and Michael’s alone.

Remember the recent debate about gay marriage and the sanctity of the bond between husband and wife? Nearly all of those now trying to push their views forward about what should be done with Terri Schiavo told us that marriage is a sacred trust between a man and a woman. Well, if that is what marriage means then it is very clear who should be making the medical decisions for Terri — her husband.

But, isn’t it true that tough questions have been raised about whether he has her best interests at heart? They have. But, these charges against Michael Schiavo have been heard in court again and again and again. And no court has found them persuasive.

Has there really been careful review of this case? Is Terri really unable to think or feel or sense? Will she never recover? The flurry of activity in Washington and Tallahassee might make you think there has not. But that is not so.

There have been at least 11 applications to the Florida Court of Appeal in this case resulting in four published decisions; four applications to the Florida Supreme Court with one published decision (Bush v. Schiavo); three lawsuits in federal district court; three applications to the U.S. Supreme Court and nearly untold motions in the trial court. This has got to be the most extensively litigated "right-to-die" case in U.S. history. No one looking at what has gone on in the courts in this case could possibly deny that all parties have had ample opportunity for objective and independent review by earnest and prudent judges of the facts and trial court orders.

The time has come
So, it is clear that the time has come to let Terri die. Not because everyone who is brain damaged should be allowed to die. Not because her quality of life is too poor for anyone to think it meaningful to go on. Not even because she costs a lot of money to continue to care for. Simply because her husband who loves her and has stuck by her for more than 15 years says she would not want to live the way she is living.

If Terri is allowed to starve to death what next? Undoubtedly there will be efforts to pass laws to prohibit feeding tubes from being taken away from others like Terri in the future. And there may even be efforts made to push right-to-die cases out of state courts and into federal courts. These are bad ideas.

We have had a consensus in this country that you have a right to refuse any and all medical care that you might not want. Christian Scientists do not have to accept medical care nor do Jehovah’s Witnesses need to accept blood transfusions or fundamentalist Protestants who would rather pray than get chemotherapy. Those who are disabled and cannot communicate have the exact same rights. Their closest family members have the power to speak for them.

The state courts of this country have the power to review termination of treatment cases and have done so with compassion, skill and wisdom for many years. Those who would change a system that has worked — and worked well for the millions of Americans who face the most difficult of medical decisions — should think very hard about whether Sen. Bill Frist, DeLay, Sen. Hillary Clinton, Bush, Sen. John Kerry or the governor of your state needs to be consulted before you and your doctor can decide that it is time to stop life-prolonging medical care.

Cali legislators' power grab on stem cells

Last November, California voters overwhelmingly approved Prop. 71, which created the California Institute for Regenerative Medicine to fund stem cell research on a large scale. The initiative created an oversight committee that was to be made up of various stakeholders who were to be appointed by elected officials as well as representatives from the leading public academic institutions in the state. The result is a committee that includes representatives for a variety of disease advocacy groups, scientists, and a small representation from the biotech industry. This committee has been charged with creating rules and regulations for many aspects of this research, and many of the members of the Independent Citizens Oversight Committee (ICOC) have established track records of thoughtful deliberation on the topics that must be addressed.

One of the key features of Prop. 71 was the way that it insulated the funding and management of CIRM from external oversight or control by the California state legislature. For obvious reasons, when dealing with the tough issues that must be faced—how do we ensure adequate protection and consent for women who donate their oocytes for research, what kind of intellectual property rules should be developed so that we can create incentives for private funding of the development of therapies, without making treatments unaffordable, and at the same time bring a return on investment to California – these issues are best left to a group like the ICOC with assistance from experts (such as the working group that is to be created under terms of Prop. 71). The last thing we would want is for these issues to become fodder for political gamesmanship in the legislature.

Unsurprisingly, the state legislature is unhappy with the fact that they are not relevant to an important undertaking within the state. State Sen. Deborah Ortiz (possibly motivated by a desire for higher public office) has abandoned her long standing support of stem cell research and is attempting to subvert the expressed will of the people. She is partnering with a conservative opponent of stem cell research to try to enact a constitutional amendment that would allow the state to mandate precisely the sort of oversight that the ICOC is already in the process of developing. This may very well have a large amount of support in the legislature. For the most part, this seems to be simply a desire to be allowed to put their stamp on the efforts of the CIRM. Rather than give the ICOC a chance to see if the actual protections are adequate, Ortiz and her colleagues are trying to rush in so that they can have their fingerprints on the rules and regulations that are likely to be enacted anyway.

The one exception is legislation that is being proposed that would make it illegal for women to voluntarily serve as oocyte donors for the expressed purposes of research (since in practice these women take drugs to superovulate to produce a sufficient number of eggs). It is worth noting that women routinely do this in IVF, and in fact, there is nothing to prohibit women from continuing to produce eggs as surrogates for other people trying to reproduce. Apparently Ortiz believes that assisting reproductively challenged individuals is sufficiently important that women should be allowed to make this decision, but research is not important enough to allow anyone to expose themselves to risk.

This issue highlights the difficulty of turning these matters over to a legislature that fundamentally lacks knowledge or insight into the research process or into the details of the practice of medicine. The citizens of California wisely chose to pass a measure that had built in measures for oversight and public accountability—the fact that the legislature is left out is a poor reason to undo the will the people. - David Magnus

House Passes "Incapacitated Persons Legal Protection Act"

Last night, the House passed HR 1332. The bill undermines a consensus formed over six decades of jurisprudence and ethical reflection establishing the right of individuals or their surrogates to refuse medical treatment, and will erode the power of the States to adjudicate on such decisions where there is conflict. [more] - Dominic Sisti

Jews vs. Catholics on the Stem Cell Debate

'Oy Vitae' is the title for this William Saletan piece about religion and stem cell research. Saletan is doing a series of "I watched the bioethicist" pieces, most recently in the form of a bunch of adoring pieces about the Kass commission, which we blogged some time ago. In the current piece, also in Slate, he takes a travel diary approach to reviewing what he sees at a bioethics conference in Rome.

Tuesday, March 8

It turns out that Catholic faith in reason cuts both ways. It can dispel the yuck factor but can just as easily override our sense of goodness. That's the inadvertent lesson of Pacholczyk's morning presentation on women who "adopt"—i.e., implant and carry to term—IVF embryos. He asserts that such adoptions are intrinsically evil. I stare at him in disbelief, but he makes a case. Procreation is unitary; therefore, just as it's wrong to have sex without openness to pregnancy, it's wrong to get pregnant without sex. What if a woman has hired a clinic to cultivate IVF embryos and is on the table ready to have them implanted? Pacholczyk says she should "stop the train of evil"—get up and leave the clinic. The embryos must be left in limbo because they can't be "licitly" implanted.

Stem Cell Research in Russia:
The Wild, Wild, Wild East

Moscow Times and Seattle Times spend some time this week on the surreal efforts in Russia to capitalize on stem cell mania among Russians and countless others around the world - all of whom are rushing to Russia to get 'treatments' from stem cell 'labs'. The Moscow Times piece starts in labs that aim at literal immortality - cryo facilities - and moves to an incredibly popular cosmetic adult stem cell procedure, and then concludes with an evaluation of embryonic stem cell work in Russia:

[Gennady Sukhikh] wears an expensive suit, complete with cuff links. He heads a laboratory where one piece of equipment with an unpronounceable name costs $150,000. He has two of them. When I was in Pushchino, the scientists there suggested I ask Sukhikh where he keeps his homogenizer — something like a meat grinder that minces human embryos. So I ask, where’s the homogenizer. The professor says that those are all lies, and starts talking about the laboratory’s scientific achievements. And there certainly are achievements: the 18-22 week-old embryos that Sukhikh works with have differentiated stem cells, meaning that they come from organs that are already formed. Retina cells can treat eye diseases, heart cells can be used to treat heart diseases, etc. The results are amazing, but not a single foreign magazine is willing to publish them, because, Sukhikh says, there is a strict ban in the West against using any aborted materials for clinical tests. It’s called bioethics. Then again, where Sukhikh gets 18-22 week-old embryos in a country where abortions after 12 weeks are illegal is also unclear.

In the professor’s laboratory, a rejuvenation therapy course using fetal cells costs about $8,000. There are 15 shots all at once: intravenously, into the muscle tissue, and under the skin of the stomach. By the way, if you dial the stem cell hotline, after a couple of questions you will be redirected to Sukhikh’s laboratory.

Any clinic using stem cells [in Russia] is acting illegally. Up to this point, the Health Ministry has not issued a single license to use stem cells, only for storage. Doctors say that thanks to stem cell therapy people can now start living up to 120 — without clinical tests we have to take their word for it.

Schiavo Resources: Timeline

Jeff Spike, Steven Haidar, Kathy Cerminara, Ken Goodman and others in bioethics in Florida put together some outstanding resources on the Sciavo case - including this timeline that is really, really useful - pretty much the best thing out there for nailing down what happened when. Their collection of links on Sciavo isn't half bad either.

Baby Sun to be Taken Off Life Support Today

Shiela Otto at Albany Med let us know that the AP/NYT is reporting that Baby Sun, who has a rare genetic disorder that caused his lungs and chest to be too small "to support life," is the subject of what appears to be a final ruling from a Houston judge. He ruled that the injunction preventing physicians from discontinuing Sun Hudson's life support will stand, and that at 2 P.M. today the life support at Texas Children's Hospital is to be discontinued.

Congressional Call for Inquiry into the Kass Matter

This was released today, again requiring little comment:

Bioethics Leader's Role In Setting Agenda Questioned

A member of Congress yesterday requested that the inspector general of the Department of Health and Human Services investigate Leon R. Kass, chairman of President Bush's Council on Bioethics. At issue is whether Kass acted inappropriately by helping to lead an effort to craft a legislative "agenda" for Congress that would place new restrictions on embryo research and other areas of reproductive science.

In the letter, Rep. Diana DeGette (D-Colo.) expressed concern that Kass may have misrepresented his private views as those of the council and that the council's resources may have been used in the effort. The effort brings "a cloud of suspicion" on the bioethics council, she wrote.

Kass said he has been very clear with people that his work for the new "bioethics agenda" for Congress -- still in its early stages -- is independent of his work for the council. "No council resources or council time was used," he said yesterday.

The inspector general typically takes two weeks to decide whether to take on a congressional request, a spokeswoman said.

Free Sex Sells

The Sun Times reports on a new study out in Fertility and Sterility, in which Tarun Jain and colleagues discuss a survey study that amounts to a poll of patients concerning whether or not they would choose the sex of their baby through preimplantation sex selection - if it were free. 41% said yes, and half of those said that they would use the procedure even if it were not free.

Vatican Clarification: Removing a Feeding Tube is "a Pitiless Way to Kill"

Miami Herald reports today that "Monsignor Elio Sgreccia, the Vatican's chief bioethicist, said in an interview with Vatican Radio that removing Schiavo's feeding tube would be equivalent to euthanasia," and that "while the Holy See's Pontifical Academy for Life rarely gets involved in individual cases, Schiavo's case bears on larger issues. 'Silence in this case would be interpreted as approval.'" This is not a new position for the pontiff, who as recently as last year reaffirmed that while extraordinary means of care to sustain life are not necessary, no one should be deprived of food and water. But it is an extraordinary move for the Vatican to position itself on the Schiavo case so directly, and will no doubt create an even more heated debate among American Catholics. [thanks Art Caplan]

ABC, or D?
The Case of Uganda

Uganda holds a unique place in the history of the AIDS epidemic in sub-Saharan Africa. Uganda was the first African country in which the AIDS threat was immediately recognized at the highest political levels, the first in which civil society was genuinely mobilized in the fight against HIV/AIDS, and one of the very few countries in sub-Saharan Africa in which the spread of the epidemic seems to be slowing down.

Part of the Ugandan success story has been attributed to what has become known as the ABC approach to AIDS prevention: Abstinence is best, Being faithful to your partner is second best, and when all else fails, use a Condom. Over the years, the ABC approach has not been without its critics in both developed and developing countries. Some have objected that promoting abstinence is simply unrealistic given the universal human appeal of sex. Others have pointed out that ‘be faithful’ is an especially unhelpful prevention message for women with unfaithful male partners. But opponents of ABC were often stopped cold in their tracks with the very mention of … Uganda. The facts seemed to speak for themselves: Uganda strongly promoted ABC, and the adult HIV prevalence rates dropped from a peak of 18% in 1995 to around 5% in 2001.

The ABC (or at least the AB of ABC) approach has strongly appealed to conservative tastes among US government officials and influential religious groups, and many US-funded AIDS prevention programs around the world are roughly based on the Ugandan model. The approach seems to merge conservative views about the sanctity of marriage and sexual temperance with sound public health policy. The case of Uganda has been predictably invoked by conservatives to argue that the promotion of ABC prevention programs abroad is justified by scientific study and actual outcomes, and is not simply the imposition of a puritan sexual morality.

This use of Uganda as poster child has recently been challenged. A study presented at last month’s CROI conference in Boston indicated that the drop in HIV prevalence in Uganda was not due to A, B, or C, but rather a combination of C and D, where D stands for Death. Maria J. Wawer, a physician at Columbia University’s Mailman School of Public Health, presented data that suggested the rate of HIV prevalence between 1993 and 2004 in Uganda has declined due to increased condom use and the deaths of HIV positive persons, rather than abstinent and faithful behaviors. While HIV prevalence decreased, the Ugandans studied were not more abstinent or faithful than before. To the contrary, the percentage of men reporting one or more sexual partner rose during this period, the percentage of non-sexually active young men between 15-19 years old fell, and the median age for first sexual intercourse for both sexes declined. So much for A and B.

As access to AIDS treatment in Uganda increases, the Grim Reaper will stop holding down the HIV prevalence rates. Besides death, the recent Columbia University study suggests that the most effective way to reduce transmission of HIV is what many have said all along: promotion of condom use.

Only time will tell how conservative backers of AIDS prevention programs in the developing world will respond to this news about their beloved ABC approach. Will there finally be a ‘pro-life’ embrace of the condom?
Link, More, and Still More. - Stuart Rennie

Schiavo Goes to Congress

Whatever ones views about the Schiavo case this is a very very bad attempt to find an answer.  Habeus Corpus is not the right legal doctrine for figuring out what to do with incapacitated persons in private hospitals, nursing homes or hospices. Hearings have now been scheduled - next week - by the slowest body in the world, which is moving fast to consider measures aimed at 'saving' Terri Schiavo through just that doctrine. We have the proposed bill, and this is the planned hearing:

 

MEETING NOTICE

 

 

Subject: Legislative Hearing on H.R. 1151, "To amend title 28, United States Code, to provide the protections of habeas corpus for certain incapacitated individuals whose life is in jeopardy, and for other purposes."

 

Date: Wednesday, March 16, 2005

 

Time: 2:00 p.m.

 

Location:  2141 Rayburn House Office Building

 

By Direction of the Chairman

If you want to see the proposed legislation in PDF form just email us. - McGee/Caplan

Oregon's Odometer

Robert Baker (Union) passed on the update from the State of Oregon on the past year's experiences with its Death with Dignity Act. From the Report:

Seventh Year Stats on DWD Law Released Today

Today, the Oregon Department of Human Services (DHS) released its
seventh annual report on the Death with Dignity law. The DHS, an
independent, non-partisan state agency, is responsible for monitoring
and enforcing compliance with the Oregon law. The report provides a
summary of the experiences of patients and physicians who
participated in the law during its seventh year of implementation
(January 1, 2004 - December 31, 2004).

The report's findings include:

1. 37 individuals availed themselves of the law in 2003
(approximately 12/10,000 total deaths in Oregon last year);

2. All the individuals were covered by health insurance;

3. 89% were enrolled in hospice care;

4. Those choosing Death with Dignity were well-educated (51% with
college degrees) and cited loss of autonomy, decreasing ability to
engage in enjoyable activities and loss of dignity as their primary
end-of-life concerns;

5. 97% were able to die at home;

6. Cancer was the most common diagnosis.

For the seventh consecutive year, data continues to demonstrate that
the law works as intended. Despite the care with which the law has been implemented and the
peace of mind it has provided to those at the end of life, the Oregon
Death with Dignity law remains under attack.

On February 22, 2005, the U.S. Supreme Court granted the Department
of Justice's request for a hearing in Gonzales v. Oregon, No. 04-623
(formerly Oregon v. Ashcroft; Alberto Gonzales succeeded John
Ashcroft as U.S. Attorney General in February 2005).
The Court will likely hear the case in this fall. The Death with
Dignity law remains in effect.

Schiavo's Highest Bidder

CNN/Reuters reports that a random California businessman has offered Michael Schiavo, husband of Terri Schiavo, $1 million,

'...to relinquish his custodial rights to Terri's parents in an effort to keep the hope for Terri alive,' Herring told a Los Angeles news conference. 'After viewing video of Terri on television, I came to the belief that there was hope for her ... I have seen miraculous recoveries occur through the use of stem cells in patients suffering a variety of conditions,' Herring said.

Schiavo's case has inspired some new lows in public behavior, and offering a public bribe to encourage someone to abandon his wife has to be a watershed. But given the politics of the donor, you have to wonder whether, if these magic stem cells imagined by the donor - cells capable of generating a new brain based only on the DNA of cells long ago dead in Ms. Schiavo's brain - came from embryos, would he still be offering the money?

Update: Mr. Schiavo did not accept the prize money. This has got to be annoying to the legion of people out there who have described Mr. Schiavo's efforts as merely a matter of convenience - a description that no doubt motivated the big bribe in the first place.

Whatever You Are Doing,
You Are in the Wrong Field

Forbes doesn't even have to make the point explicit. The numbers speak for themselves:

If you caught Nell Minow's musings on Forbes Radio as to why CEOs are paid so much money, Pfizer (nyse:  PFE -  news  - people  ) Chief Executive Henry McKinnell's 72% pay increase last year may not leave you overly flummoxed. McKinnell's impressive haul of $16.6 million was made up of a base salary of $2.2 million, a healthy bonus of $3.9 million, plus a restricted stock award of $4.3 million. Sharp-minded number-jugglers will notice that these figures don't quite $16.6 million make. Well, throw in $5.81 million in common stock as part of an incentive program, and $307,454 in retirement savings, and all becomes clear. McKinnell's 2004 salary dwarfs his 2003 earnings of $9.7 million. With seemingly bathetic timing, the New York-based pharmaceutical manufacturer will hold an analysts meeting next month to discuss how to reduce costs by $2 billion, as many of the company's major drugs are losing patent protection over the next few years.

- Art Caplan

The Kass Agenda: "Bioethics for the Second Term"

Well, finally we got our hands on the heretofore unpublished document, "Bioethics for the Second Term: Legislative Recommendations," written by Chair of the President's Council for Bioethics Leon Kass and distributed to Congress this week in a lobbying push led by Kass himself. It contains the grand plan for all sorts of bans and restrictions of science to be enacted by the U.S. Congress, and has been unabashedly promoted by Kass - who says that he is not acting as Presidential Council Chair during his lobbying efforts.

The agenda is sweeping, conservative, and odd enough that it has angered Republicans in Congress more than Democrats; the latter are beside themselves with joy at watching the right wing rip the Kass document to shreds for being too liberal. Democrats should not be too giddy - much of what is here could be pushed through the executive branch and left to the courts and states to reject.

Behold, the Plan:

Bioethics for the Second Term: Legislative Recommendations

Track One: Defense of Human Life

• Prohibit the creation (by whatever means) of any human embryo solely for
research, in which the embryo will be harmed or destroyed.

Track Two: Defense of Human Dignity

• Prohibit the transfer, for any purpose, of any human embryo (produced ex
vivo, by whatever means) into the body of any member of a non-human
species.

• Prohibit the production of a hybrid human-animal embryo by fertilization
of human egg by animal sperm or of animal egg by human sperm.

• Prohibit the transfer of a human embryo (produced ex vivo) to a woman’s
uterus for any purpose other than to attempt to produce a live-born child.

• Prohibit attempts to conceive a child by:
(1) Any means other than the union of egg and sperm.
(2) Using gametes obtained from a human fetus or derived from human
embryonic stem cells.
(3) Fusing blastomeres from two or more embryos
(a) Operationally, in each case the prohibited act comprises the creation
ex vivo of any such human embryo with the intent to transfer it to a
woman’s body to initiate a pregnancy.
(b) Nothing in this law shall be construed to prohibit or interfere with
efforts, on the part of someone not violating provision (a), to adopt or
rescue such an embryo by transferring it to a woman’s uterus in an attempt
to bring it to birth.
(c) Any child conceived by these prohibited means shall, at whatever stage
of its development, be regarded and treated under the federal law no
differently than a child conceived naturally, enjoying equally all rights
and protections accorded to a child conceived naturally at the same stage
of development

• Prohibit the buying, selling, and patenting of human organisms at any
stage of development.

In this and the subsequent provisions, it will be necessary to offer a
definition of “human embryo.”

In this provision, it will be necessary to define “fertilization” in such
a way as to exclude from this statutory prohibition the current practice,
in assisted reproduction clinics, of testing the capacity of human sperm by
seeing if they can penetrate oocytes taken from hamsters. No union of
sperm and egg nuclei occurs; thus no embryo is formed.

It will be important here to define who will be seen as violating this
prohibition: suggest that this include at least those (1) who plan or do
the act, (2) who advertise themselves as offering this service for this
purpose, and (3) who own a company whose employees engage in such a
practice or that profits from it.

A Bioethics Agenda for the President’s Second Term

This purpose of this memo is to outline a bold and plausible “offensive”
bioethics agenda for the second term.

What we seek to achieve

New biotechnologies challenging human freedom, equality, and dignity are
arriving at an accelerating pace, especially in the domains of assisted
reproduction and genetic manipulation. And yet there are currently no
boundaries or protections in federal law to help us confront the challenges
they pose. Three aims, above all, guide the effort to establish
boundaries:

1. To defend the dignity of human procreation, of parents, children, and
families, from certain dehumanizing practices now becoming possible through
new biotechnologies.

2. To defend nascent human life from exploitative and destructive
practices, and to prevent the treatment of the unborn as a mere resource
for research.

3. To advance responsible scientific research within these clear ethical
bounds.

Efforts to achieve these aims in the first term, and results

• Cloning: Sought to combine the first two aims by prohibiting a practice
that both deforms human procreation and creates human embryos for research:

human cloning. Backed a total ban of all human cloning, which passed the
House but failed to reach a vote in the Senate for two consecutive
Congresses. Appears unlikely to succeed in the next Congress as well.
o Meanwhile, South Koreans successfully cloned human embryos; British HFEA

authorizes human cloning-for-research; Harvard scientists get permission to
do human cloning-for-research; a right to do such research is
constitutionalized in California and endorsed in several other states. We
did not get the preferred convention passed at the United Nations. We have
lost much ground.

• Stem cell research: Allowed federal funding for ESC research on lines
existing as of August 9, 2001. Got no credit from scientists, physicians,
and patient groups for doing so. Got nothing in exchange for this
permission (e.g. limits on other noxious practices). No control over embryo
research in the private sector. Have successfully defended the policy to
this point, but are purely playing defense for a policy that gives no
permanent benefit: the next Democratic administration will overturn the
policy, and the field will be left with no moral limitations anywhere.

• Other Biotechnical Areas: No activity whatsoever. Radical techniques of
human reproduction and genetic manipulation proceed unscrutinized and
unregulated.

Summary: We have played defense to support a funding policy that touches
but a tiny fraction of the brave-new-world issues we must address. If it
is clear that the cloning ban does not have the votes, we must pursue
another strategy to address our concerns. It is time to broaden our
approach and to go on offense.

Diagnosis

One key reason the effort to ban cloning has not succeeded is that it is
too narrowly focused and insufficiently ambitious; it limits our political
coalition and deforms our arguments. It sought to prevent only the cloning
of children, and not other troubling new methods of baby-making, and to
prohibit the exploitative creation and destruction for research only of
cloned embryos, rather than all human embryos. It was thought that the
combination of these two partial steps around the technique of cloning
might strengthen our position, but it has turned out only to confuse the
underlying issues, and to detract from the force of either concern seen in
full. The debate degenerated into an argument about terminology, rather
than placing cloning in the larger and more disconcerting contexts of
threats to the dignity of procreation and threats to nascent life. Our
response to the failure of the cloning ban, therefore, must not be to pull
back, but to move more aggressively on these two fronts, properly and
individually understood.

The second term agenda
To make progress, we must return to our principles and think fresh about
how best to protect the dignity of procreation and family, how best to
defend nascent life, and how best to advance scientific research within
moral bounds. We propose a three-track approach that takes these three aims
as its starting point, and seeks to pursue them each aggressively.

1. On the Dignity of Human Procreation: Seek legislative protections of
the dignity of human procreation, banning the following degrading and
dehumanizing practices (more than just cloning):

• Transfer of a human embryo into the body of an animal, for research (or
other) purposes

• Production of hybrid human-animal embryo (human egg with animal sperm, or
vice versa)

• Transfer of a human embryo to a woman’s uterus for any purpose other than

to produce a child (no pregnancies for research or organ farming)
• Attempts to conceive a child by means other than the union of egg and
sperm, derived only from adults (no cloning, no using eggs and sperm
derived from fetuses or embryos, etc.)

• Buying, selling, and patenting of human organisms at any stage of
development

2. On the Protection of Human Life: Seek a legislative ban on creation of
any human embryo solely for research and destruction (not just by cloning,
but also by IVF)

3. On Advancing Stem Cell Research within Moral Bounds: Continue to defend the current stem cell funding policy, but offer encouragement and support through the NIH for efforts to find new ways to derive human pluripotent
stem cells without destroying or harming human embryos. These might include deriving stem cells from (a) dead embryos, (b) artificial
non-embryo-but-embryo-like artifacts, (c) non-destructive embryo biopsy,
(d) reprogrammed adult somatic cells.

Summary: Taken together, these offer a strong and coherent bioethics
agenda for the second Bush term. They target squarely the three key moral
aims, with each track designed to be pursued independently and to be
difficult to oppose in its own terms. They allow us to respond to the
inability to pass the cloning ban not by yielding ground, but by seizing
the initiative and raising our ambitions while still defending the existing
funding policy.

We have today an administration and a Congress as friendly to human life