blog.bioethics.net

Mr. President, No

The President has dug himself in for a battle over embryonic stem cell research. The problem is that he is dug himself into a hole that makes no ethical sense. He is in favor of research on stem cell lines that already exist but not on frozen embryos that already exist. He allows destruction of embryos for IVF but not for research. And he talks about adoption when that is manifestly not an option for most frozen embryos which are put aside often because they don't look right.

He is a man of principle but his principles are simply incoherent. - Art Caplan

Art Caplan on Autism, Genetic Testing and Ethics

From MSNBC.com.

Bloggers: Be Afraid [of Pharma Spies] - Be Very Afraid

Financial Times reports that leading pharmaceutical companies have figured out how to "'spy' on internet conversations about medicines, and they are going to be reading blogs. Already our server logs record dozens of hits a day from pharma companies (hey, works for me - read bioethics all day long, guys!), but the new software, called "i-reputation," is on a whole new scale, raising the ire of lots of folks in the Internet community. Tough to see why pharmaceutical folks reading blogs would be problematic, since after all blogs are public, but it is easy to see what the concentrated strength of pharmaceutical companies could do to suppress something that Big Pharma doesn't want to see in blogdom.

Health bloggers have the capacity right now to operate under the radar screen of big corporations, or at least to do so to some degree, because the readership is a small and dedicated sampling of people who cannot get enough news, or who are looking for very specific information from Google (that latter group makes up roughly 75% of our readership, for example). But blogdom germinates ideas that eventually become threatening to powerful corporations and others with clout - and so the same technology that made blogs so accessible will now be reverse engineered to make blogs more vulnerable...

Jonathan Alter, My Hero

In his Newsweek column this week, Jonathan Alter, himself a cancer survivor and one who might have derived much more benefit from embryonic stem cell-based therapy than from the adult stem cell therapy he received (which was itself studied in embryos), rants against the Bush policy on stem cells. He makes the case that those who work against stem cell research in Congress will have a big hole to climb out of in the next election. And, more than any mainstream columnist so far, he identifies a new phenomenon, the "stem cell extremist," as a source of the intractable political debate:

Bioethical blowhard Leon Kass of the University of Chicago conned Bush into seeing the issue as morally complex, but the rest of the world understands that it's simple enough—reproductive cloning (to create Frankensteins), no; embryonic-stem-cell research (to cure diseases), yes. (The phrase "therapeutic cloning" should be retired.) Enshrining this basic distinction in law is a better bulwark against the "slippery slope" problem than hair-splitting limitations. Most nations understand this. Only Bush bitter-enders and the pope are in the perverse position of valuing the life of an ailing human being less than that of a tiny clump of cells no bigger than the period at the end of this sentence.

Neuroethics Movies

Science & Theology News carried a brief and not particularly enlightening description of the latest neuroethics gee-whiz conference, but attached to this report is a nice list of some recent movies that illustrate the new ethical weirdness associated with brain imaging, including this one, Being John Malcovich.

Eggs, Frozen Easy

Canadian press is reporting that the McGill Reproductive Center, having just overseen Canada's first birth of a prenancy resulting from the use of a frozen egg, has now advanced the process for freezing eggs considerably. To back up a bit, it has been terribly difficult to freeze an egg, as opposed to sperm. The consequences have been significant, and not only for women with ovarian cancer or other diseases that are treated by radical hysterectomy, but also for women who have wanted to delay procreation past the age when it would be considered safe to use one's own eggs to procreate.

The team at Montreal's McGill University is flash freezing eggs, which works. 95% of the eggs frozen in their procedure are still viable when thawed. If that works out in continuing research that the procedure is safe - and boy is that a big 'if', particularly given how little clinical research on the health of offspring is actually performed in the area of IVF - this will revolutionize reproduction for women. Women who can delay pregnancy past menopause will be able to have an entirely different experience in terms of the way in which they can structure family and career - and advantage men have had, well, forever.

Faux Ethics

Philadelphia Inquirer writes about Cecil James, 31 year-old incoming pastor at 2,500 member Bright Hope Baptist Church in Philadelphia. James succeded a congressman this past Sunday as head of the church, but no sooner did he take the reigns than colleages let out his ugly little secret: apparently James faked all of his college degrees, including a Ph.D. from Princeton in medical ethics. You'd think he might check on the fact that Princeton doesn't offer such a degree. But hey, if you're going to fake a degree, do it with some ethics.

Jeffrey Kahn Pulls No Punches on Leon Kass

Among the letters from readers in the Minneapolis Star Tribune is one from Jeff Kahn, director of the Center for Bioethics at University of Minnesota, who writes:

[Columnist Michael Kinsley is] right that Leon Kass is viewed by some as "the secretary of bioethics," but that's the problem. Prof. Kass has become more a mouthpiece for the Bush administration than a credible voice for thoughtful analysis of controversial ethical issues ... There are many in bioethics who support far greater public investment in embryonic stem cell research ... [but] It's no surprise that these are not the voices represented on the current President's Council on Bioethics, which Kass chairs ... the blame lies with an administration that won't tolerate, let alone consider, dissenting views on stem cell research policy -- a much bigger problem than the ethical noodling of Leon Kass and his cronies.

Dr. Death Down Under

He's no fun for patients, according to the Corvallis Gazette-Times, but his colleagues in Portland seem to have loved him, sending this doc, with his incredible fatality rate, on to Australia with glowing letters of recommendation:

RASPBERRIES to six former Oregon colleagues of Dr. Jayant "Jay" Patel, 56, who recently was dubbed "Dr. Death" by the Australian media because 87 of his patients have from complications in the two years that he worked as a surgeon in a Queensland hospital. But then, patients dying in droves is nothing new for Patel, whose fatality rate more resembled that of a serial killer than a surgeon.

Patel practiced in Oregon from 1989 to 2000 at Portland's Kaiser Permanente hospital, when his practice was restricted here statewide because of the high rate of complications and death among Patel's patients. The Oregon Board of Medical Examiners finally restricted Patel's practice statewide in 2000. Undaunted, Patel left Oregon, armed with six glowing letters of references from his former colleagues.

Patel moved in 2003 to Australia and sought to hand out his shingle again. The Medical Board of Queensland failed to check Patel's dismal medical history in New York and Oregon, relying heavily on the letters of recommendation from those Oregon doctors who wrote them seven months after the Oregon Board of Medical Examiners restricted Patel's practice.

The word again was proved to be more powerful than the sword and, where Patel is concerned, just as lethal.

South Korea Spends More on One Stem Cell Researcher than the U.S. Federal Government Spends on All Stem Cell Research

The AP reports that "The South Korean government provides $2 million in pure research funds to Hwang's team, and $24.4 million in facility assistance for stem cell and related research." By comparison, the US government's total FY 2004 investment in human embryonic stem cell research was $24 million!!! - Art Caplan

Grey Areas Are Difficult for Mr. Cohen

Eric Cohen is so paralyzed at the prospect of human cloning that he seems unable to fathom the possiblity of banning cloning for reproduction while allowing it for research. One wonders if he is also unable to distinguish driving under the speed limit from exceeding it or allowing participation by children in minimally risky research but not very risky research. Mr. Cohen is worried about the effects of ideology on the thinking of the pro stem cell research side but his intellectual palpitations over human cloning seem to have rendered him incoherent. - Art Caplan

House of Representatives Votes to Reverse Bush Ban on Stem Cell Research

New York Times writes:

The House of Representatives voted today to ease restrictions on federal financing for embryonic stem cell research ... The 238-to-194 vote in favor, far short of the 290 needed to override a presidential veto, sends the issue to the Senate, where an identical measure is pending.

Stem cell research has considerable support in the Senate as well. Its chief sponsor is Senator Arlen Specter, Republican of Pennsylvania, who heads the Senate subcommittee that controls federal financing for medical research ... The House's action, and the likelihood of approval in the Senate as well, sets the stage for the first veto to be cast by President Bush, who reiterated his opposition this afternoon to the current legislation.

Hours before the House vote, Mr. Bush said that despite the potential for medical breakthroughs, that the use of human embryos in the studies was too high a cost to pay.

In 2001, President Bush prohibited federal financing of research on embryonic stem cells, except work on the limited number of cell lines developed before his decision.

Representative James R. Langevin, a Rhode Island Democrat, who was paralyzed at age 16 after a gun accidentally discharged in a police station and severed his spinal cord, said he supported the embryonic stem cell legislation despite opposing abortion.

"My life as a quadriplegic is certainly filled with challenges and obstacles," he said. "It's motivated me to help create a culture that values and protects life from its beginning to its end. For me, being pro-life also means fighting for policies that will eliminate pain and suffering and help people enjoy longer, healthier lives and to me, support for embryonic stem cell research is entirely consistent with that position."

President Bush, Ethicist

The President has put his dizzying ethical analysis to work again. He has spoken again to the press about his absolute opposition to the destruction of any human life that happens to have been created after August of 2001 outside of Iraq. Bloomberg reports that the President is not talking about the problems associated with the total contamination of every single line made available by his 2001 measure, nor is he explicitly explaining how he can argue so strongly against the destruction of any human life when in fact those lines also resulted from intentional destruction of human life.

Perhaps he could clarify whether or not NIH should fund research using lines of embryonic stem cells that were made from destruction that occured in other countries that he couldn't control. Why would that be problematic, after all, if the only problem is funding 'the destruction' of human life? Never mind those details - its semantics.

The important thing is that the President is very very much behind life. It should absolutely, positively be allowed to sit frozen, dying in freezers. It should absolutely be thrown away. Support life! Save the embryos! They have a right to live out their lives as freezer cubes and at the bottom of a trash can!!

Cardinal Commits Metaphor Slaughter

The dogmatists thoughtful folks who oppose any research of any kind using embryonic stem cells have marshalled their most aggressive rhetoric for the big battle in the House of Representatives, and the poor metaphors they are invoking are groaning under the weight. Take for example this column in today's USA Today by Cardinal William Keeler, which features the following fatuous prose:

How does it show respect to treat human lives as mere crops for harvesting?

... government-funded researchers would reach in and destroy these young lives before that can happen...

The fixation on destroying embryos has diverted resources away from more promising therapies, and therefore ill serves suffering patients as well as embryonic human beings.

Leaving the embryonic citizens in their little freezer rods means that they will continue to degenerate, day by day, in what amounts (on the Cardinal's terms) to a protracted abortion. So that isn't in any sense saving them - to save them we'll need to make sure that they are removed from the freezer and used in that most immoral ritual IVF, which means they'll need to be gestated by someone, so, by the way, Cardinal, would you care to adopt an embryo? No? Perhaps you could direct, or at least ask, some of your staff or supporters to carry and bear these poor embyros? No?

The hypocrisy in play in the debate about the ethics of stem cell research is truly incredible, and getting worse by the minute.

Add to List of Places I am Not Welcome: Indiana

A killer's request to give his liver to his sister has been denied, according to the Indianapolis Star. I recommended that the courts delay execution to determine whether or not the organ might save his sister's life. But Indiana residents are livid that the matter is on the table at all:

The Parole Board's hearing Friday in an auditorium at the Indiana Government Center drew about 75 spectators and seven television news cameras, including at least two national affiliates.

Hutslar's loved ones expressed outrage that a murderer has received so much attention.

Sharon Barker, Hutslar's granddaughter, reminded board members that her grandmother suffered 30 broken bones when she died.

"I just don't understand the viciousness of this," Barker said, noting that the fire Johnson set destroyed most of Hutslar's photographs and heirlooms.

-Art Caplan

NPR : Bioethics and Child Testing

Marjorie Speers of the AAHRPP, which provides the standards for accrediting human research protection programs, talks with Jennifer Ludden of All Things Considered about the problems of safety and ethics in drug studies on kids.

The HIV Foster Children Case: Mark Kline Speaks Out in Toledo

toledoblade.com carried a surprising editorial from Dr. Kline, professor of pediatrics at Baylor College of Medicine and director of the Baylor International Pediatric AIDS Initiative, in which he responds to the angry editorial from that Toledo paper.

Well, It Worked with Schiavo: The President Prepares the Nation for a Stem Cell Crisis

President Bush, who many believed would feel more free to move to the center on stem cell research in his final term in office, has planted his feet squarely in the middle of the right wing on stem cell research. In the face of moderate Republican support for the research, the President spent the morning (we noted) with the Catholic conference and has now begun to lobby Congress directly:

"I made it very clear to the Congress that the use of federal money, taxpayers' money to promote science which destroys life in order to save life is _ I'm against that. And therefore, if the bill does that, I will veto it."

It makes a great deal of sense as a package: the President's man in the Senate is fighting hard to get a conservative package of judges confirmed - virtually every one of whom has spoken or written against abortion, stem cell research or both - and he devoted an enormous amount of time and energy to the Schiavo matter.

In both cases the President is creating an image of himself as strong on moral matters - and has adopted language about "erring on the side of life" that while spoken about Schiavo has telegraphed his strong support for the Kass agenda.

There are all sorts of reasons one might conjecture for the President's newfound vigor on stem cell research.

First, there isn't much at stake. The energy in stem cell research is in the states now, not the Federal government, and anyone who believes that the Fed is going to become a major player in stem cell research is delusional. So the President gets to appear to fight against stem cell research for the religious right, while quietly allowing the pharma and biotech business, and many wealthy constituents, to advance that research as much as they like from places like, say, California, which is about to invest more money in stem cell research per annum than most of the rest of the world combined. It is a bit like Pres Bush Sr.'s fight for extreme sentences for marijuana use in Federal courts - you can appear to be tough on crime by pushing a ridiculously steep penalty for lighting up a joint, but it won't hurt you in the long term because there are almost no cases of smoking marijuana that will ever see a Federal court.

Second, the President is able to drown out the incredible accusations of ethics violations (or accusations of overreaching on Schiavo) by his most senior lieutenants in Congress. And he is able to give those under fire an opportunity to speak out in public on ethics, or at least to be associated with the battle for 'innocence' and 'the vulnerable' twice in as many months. Tom DeLay is particularly interested in stem cells, all of a sudden, and that might be the most telling evidence of the Bush strategy in that regard. This is a particularly useful strategy in Western and Southern states, where concern about ethics in Congress is growing, but where the operative rule about gay marriage, abortion and euthanasia is "the enemy of my enemy is my friend."

Third, and most obviously, the President appears hell-bent on suppressing the growth of a moderate, conciliatory block of Republicans in the House and Senate. He knew what he was facing with Sen. Specter and Sen. Orrin Hatch, whose views on science politics have been fairly stable for years, but who do plenty of work for the Republican party when called. But one can see how he'd grow tired in recent weeks of watching Republicans line up one after another, in the states and in Congress, to support bills that in their view are more in line with the will of the public - the same public that bombarded Republicans' offices with complaints about the Schiavo debacle. The President needs to be tough on collaborations that take the form of Clinton/Gingrich.

And perhaps there is a basic philosophical orientation in the administration that comes from conviction: as Obi-Wan reminded us, Sith Lords can only see the world in terms of absolutes.

Either way, buckle your seat belts for a week that will see the President of the United States make the strongest statement against science to be made by the leader of a superpower since the Popes of the 12th century.

Caplan in MSNBC on the Korean Experiment

Writes Art:

The critics of cloning embryos for research would have you fear the Korean breakthrough by gravely intoning that cloned people are next. But, it is not really there worry because if it were the solution — a ban on reproductive cloning is readily at hand. No, the critics are really arguing is that it is just plain immoral to make and destroy a cloned embryo from cells taken from your skin, tongue or the lining of your mouth that might, if stem cell research is allowed to go forward, help cure you of Parkinsonism, spinal cord injury, diabetes or the damage done by a heart attack. That view, if allowed to prevail, means that you can look forward to a lot more announcements from South Korea and other countries and a lot fewer cures for you and your family. And where is the ethics in that?

White House Uses Korean Experiments as Excuse to Telegraph their Forthcoming Veto on H.R. 810

The incredible cloning threat - more looming and dangerous than weapons of mass destruction, according to then Cardinal Ratzinger, has the President angry enough today to issue a statement about the Korean experiments from Science, which we blogged yesterday. Writes the AP:

President Bush on Friday said he would veto legislation that would loosen restrictions on embryonic stem cell research and expressed deep concern about human cloning research in South Korea. ''I'm very concerned about cloning,'' the president said. ''I worry about a world in which cloning becomes accepted.''

There is a strong message here from the President, symbolically it will be of great importance to the Catholic community, whom he is addressing with this message:

Bush, in his fifth year in office, has not yet exercised his first veto. The White House also promised a veto this week of a highway bill if it exceeded the administration's spending limits.

Bush began the day at the National Catholic Prayer Breakfast where he was cheered for urging people to ''pray that America uses the gift of freedom to build a culture of life.''

The remark was a public reaffirmation of his position on sensitive issues such as abortion and stem cell research.

Bush recalled the legacy of the late Pope John Paul II and said, ''The best way to honor this great champion of human freedom is to continue to build a culture of life where the strong protect the weak.''

New stem cell research sparks debate

In this San Jose Mercury News op ed you can see why, in my view, some journalists (including Gina Kolata) have missed the boat. - David Magnus

Abdallah S. Daar, Laureate of the Avicenna Prize for Ethics in Science 2005

Abdallah S. Daar has been chosen as Laureate of the Avicenna Prize for Ethics in Science. This upon the recommendation of a jury which met on 22 March 2005 in Bangkok, Thailand. This Prize is intended to reward the activities of groups and individuals in the field of ethics of science.

Dr Daar, from the Sultanate of Oman, previously held the Chair of Surgery at Sultan Qaboos University, Sultanate of Oman. He is currently Professor of Public Health Sciences and of Surgery at the University of Toronto, where he is also Director of the Program in Applied Ethics and Biotechnology and Co-Director of the Canadian Program on Genomics and Global Health at the University of Toronto Joint Centre for Bioethics, and Director of Ethics and Policy at the McLaughlin Centre for Molecular Medicine.

His significant contribution to research in the ethics of science and technology does not only cover a wide range of topics, but engages in depth with issues at the crossing point of science and ethics, technology and society. The impressive breadth of his numerous publications in the area of biomedical ethics is evident from the scope of themes that he covers, ranging from more traditional issues such as living donor transplantation to newer concerns such as the use of stem cells, genomics and xenotransplantation.

The Prize owes its name to the renowned 11th-century physician and philosopher of medieval Islam Abu Ali al-Husain Ibn Abdallah Ibn Sina (980-1038), known in Europe as Avicenna. This Prize, awarded once every two years, consists of a gold medal of Avicenna along with a certificate, the sum of $10,000, and a one-week academic visit to the Islamic Republic of Iran.

The jury of the Prize comprised Pilar Armanet Armanet (Chile), newly appointed Chairperson of UNESCO's World Commission on the Ethics of Science and Technology (COMEST), Johan Hattingh, Rapporteur of COMEST, and Song Sang-yong, also a member COMEST.

In approving the Statutes of the Avicenna Prize for Ethics in Science, the Executive Board of UNESCO recalled that the "promotion of principles and ethical norms to guide scientific progress, technological development and social transformations" are among the objectives of the Medium Term Strategy of UNESCO (2002-2007). The Executive Board also stressed that "the creation of the Prize will contribute in a significant way to the reinforcement of international awareness and sensitivity and to demonstrate the importance of ethics in the field of science."

- Art Caplan

Stem Cells from Cloning: Better, Faster, and from 6 Year-olds and Incredibly Charitable Young Women

This week's Science, just out, discusses work just completed by Woo Suk Hwang, Shin Yong Moon and colleagues at Seoul National University. They did several interesting things. This team, a year ago, published in the same journal their successful cloning of a human embryo.

In this publication they indicate that they have been able to produce cloned human embryos much more efficiently, which means fewer oocytes (eggs) are required to produce an embryo healthy enough that its cells can be harvested to produce "lines" of stem cells. They were able to do so because they used younger egg donors, which they discovered result in more healthy embryos than older donors. And they were able to grow embryonic stem cells without destroying the embryo manually. Instead they put the developing embryo (is it really an embryo? film at 11) atop a bed of mouse feeder cells, and for some reason the embryo just dissolved (naturally?) into a mass of stem cells.

This research is likely to reframe the stem cell debate entirely. First, it suggests that it will be possible to really do research soon on the production of "personalized" lines of stem cells, derived from the sick person and for the purpose of implantation into the same person. In fact, the researchers produced an embryo from the skin cell of a young boy (6) with a degenerative disease that couldn't be treated with a direct infusion of stem cells - but that might be treated by genetically altering the first cell of that cloned embryo, resulting in healthy cells that are still genetically very similar to the child who would receive them.

Now, clearly, it wasn't such a wise idea for these folks to start with a six year-old - you can't get consent to do therapeutic cloning on a six year-old - but the experiment is telling.

A big issue here is that NAS guidelines on stem cell research (scroll down to Jon Moreno's picture) suggest that it is a mistake to pay egg donors for their donation for stem cell research. The effect of that here would be huge - young women who will donate their eggs without compensation given the risks associate with egg donation. Frankly, there just won't be egg donation without payment.

New Breakthrough in Stem Cell Research Raises Ethical Issues

Today Science released the early publication of a major breakthrough in stem cell research. The South Korean researchers who last year created the first human stem cell through the use of somatic nuclear transfer have now made a tremendous leap forward. They have increased the efficiency of the use of cloning to produce stem cells by about 16 fold. This brings us much closer to the day when clinical trials with matched cells chosen to avoid rejection will take place. It is a major step forward.

We can soon expect to hear worries that this research takes us closer to human reproductive cloning. Such concerns are misguided. There are many steps between the creation of fertilized (or fused) embryo and a baby—succeeding in improving efficiency to the blastocyst stage is impressive, but it gets scientists no where near the stage where reproductive cloning could be successfully carried out. Moreover, it is not clear that the techniques used to get to that stage are compatible with future development, since they are created to make it easier to derive stem cells (they are two dimensional). In short, there is no reason to believe that any of the 11 blastocysts that have been produced could ever have become babies, even researchers had wanted to produce them. And these researchers (including one scientist from the U.S.) have been clear that they would regard human reproductive cloning as unsafe, unethical, and illegal.

This does not mean there are no ethical issues in this research. Indeed there are several new challenges that it provides. Science was concerned enough about those issues that they have taken the unusual step of publishing the informed consent and IRB documents governing the research online. In addition, Mildred Cho and I were given the opportunity to address some of the concerns and challenges in a policy forum piece that has also just been published. An op ed summary of these issues will be coming out Friday in the San Jose Mercury News.

- David Magnus

Brazil Would Rather Have No U.S. AIDS Money than Have Faith-based Restrictions

Blogs our man Stuart Rennie: As mentioned in an earlier post, the Bush Administration attaches faith-based strings to its international AIDS funding. Countries burdened with HIV/AIDS are better placed to receive support if they promise to tackle the epidemic in ways that do not offend delicate neo-conservative sensibilities.

The Administration is opposed to needle exchange programs in US funded AIDS programs in Eastern Europe, Russia, China and South East Asia, and back in February, it announced a new requirement that all US government funded AIDS organizations (both home and abroad) must sign a declaration condemning commercial sex work. Organizations working in unapproved ways with intravenous drug users or sex workers are seen as ‘promoting’ drugs and prostitution, and funded accordingly.

The Brazilian government has read the fine print, and they want out of the program. Toward the beginning of May, it was announced that Brazil has rejected $40 million in AIDS funding in order to send a message to Washington and the world. The director of Brazil’s HIV/AIDS program, Pedro Chequer, has a polite way of putting it:

I would like to confirm that Brazil has taken this decision in order to preserve its autonomy on issues related to national policies on HIV/AIDS as well as ethical and human rights principles."

One might argue that this decision by the Brazilian government is ethically questionable itself, i.e. what if the loss of $40 million results in increased HIV/AIDS-related morbidity and mortality? Does the government in this case have an obligation to swallow its pride, and accept the money, in order to protect some of its citizens?

On the other hand, the Brazilian government’s decision was not top-down: it apparently had non-governmental and grassroots support. And they could always argue that they do not really need $40 million in ideologically tainted (and potentially counterproductive) support anyway. Among low- and middle-income countries, Brazil is one of the success stories in the global struggle against HIV/AIDS.

But not every country has the human rights tradition, the social justice activism, the wherewithal, and frankly, the balls to do what Brazil did this week. It will be interesting to see which other countries are ready, willing and able to follow suit. - Stuart Rennie

Tranplant Discrimination Against those with HIV

American Journal of Transplantation (June '05) includes a fascinating study by Sydney Halpern and others at Penn in which a study of 347 surgeons revealed that there is some discrimination against those with HIV in terms of who gets an organ, and the reasons don't make sense in clinical terms.

The 347 surgeons (56.1%) returning completed questionnaires believed that HCV- and HIV-infected patients have similar post-transplant survival (p = 0.9), but that both groups fare worse than HBV-infected patients (p < 0.00001 for both comparisons). Most transplant surgeons considered HBV- and HCV- infected patients to be appropriate transplantation candidates (p = 1.0 for this comparison), whereas one-third considered HIV-infected patients to be appropriate candidates (p < 0.00001 when compared with HBV- or HCV- infected patients). That surgeons are generally willing to transplant HCV- infected patients but not HIV-infected patients, and yet believe these groups will have similar post-transplant survival, suggests that survival estimates alone do not explain surgeons' choices. HIV-infected patients should have equal access to organs unless or until evidence emerges that they fare substantially worse than other potential recipients.

[thanks Sean Philpott]

The Full Employment Act for Stem Cell Research

Well it's out, at last, the first Request for Applications (RFA) for money from the California Institute for Regenerative Medicine, abbreviated WYD - Who's Your Daddy CIRM and pronounced "SERM." This thing is a monster - $1.25 million a year proposals are being invited for institutions, each one of which could support up to 16 new scholars in stem cell research. And $800,000 and $500,000 for smaller programs. And that's just the start of it - these are just the grants to pay for training new people to work in the field. The big bucks are going to be in support of actual research initiatives. Places like Stanford for example are going to leverage this money to build new buildings for regenerative medicine. This program has been coming since Californians passed Proposition 71, the $3 billion stem cell initiative. But when you actually look at the thing, it is just a huge amount of money that will go to a select number of institutions.

Is there ethics money? Well, sort of. The programs "will be required to offer at least one course in stem cell biology and disease and a course in the social, legal and ethical implications of stem cell research." And there is a mandate that CIRM "seeks institutions that will promote interaction among trainees from different fields, especially those trained in basic science and clinical medicine." But there's no gigantic ethics pot here, so the money for bioethics and stem cell research, which everybody thinks ought to be front burner, will require that the big schools in California think intelligently about how important it can be for them to include a real ethics program in their applications for stem cell money. And that is going to require that some of us fly out there and sell that idea to UCLA and other places that have virtually no bioethics right now. And you know, it's such a long flight...

Anyway, anybody with half a brain out there in bioethics has to be scheming to build a bioethics proposal for one of these big center grants - because that could result in the biggest program in the nation in bioethics quite quickly. Oh yeah and that would serve the public interest.

Living Wills Save Money? Dude, Did You Really Say That Out Loud?

Experts Dispute Remark That Living Wills Save Money, leads the Washington Post in a story about HHS Secretary Mike Leavitt, who made the incredible blunder of claiming that living wills for senior citizens could "reduce Medicare's skyrocketing health care costs." Why? Duh, he replied, because the old people will die faster. Reasons for Leavitt's conclusions were left vague.

Leavitt is proposing that physicians who bill Medicare must include a discussion of the directives in their consultations with patients. And nobody disputes that such a discussion is a good idea, or even that it might "work" in terms of getting patients' wishes on the table. But the question of whether living wills actually change outcomes in hospitals is still very much alive. There is data, but it isn't conclusive. More to the point, whether or not living wills save money would depend entirely on what people actually say in their living wills - and nothing will scare aging folks more than the idea that the government wants them to sign living wills because that way they'll die less expensively. Even if it were true - which it very likely is not - it speaks volumes about how difficult it has been to discuss advance directives in public policy without pushing hot buttons.

Fisk University Opens Bioethics Program

One of the nation's oldest historically black colleges, Fisk University in Nashville, has announced that it will be starting a bioethics program. The sponsor, Dollar General Corporation leader Cal Turner, seems to love ethics, having paid already for an endowed chair across the way at Vanderbilt. Thankfully he keeps using his own name for this stuff rather than that of his company - can you imagine 'the Dollar General Professor of Ethics'? Anyway Turner bought a building for the Center at Fisk.

The effort should attract some talent to Fisk in bioethics - and in turn help further to foster new energy in bioethics, and to diversify its populations and its interests. Bioethics remains incredibly homogenous in terms of its ethnic composition, something nobody wants but nobody seems to know how to solve.
Update: Jonathan Moreno reminds me that Fisk President Hazel was the Department of Energy cabinet secretary who brought the radiation experiments matter to President Clinton's attention, and specifically suggested that Presidential Advisory Commission to investigate.

The Foreskin Battle

Circumcision is one of those ethical nests that just doesn't get any less contentious no matter what the evidence.

Years of data suggesting that male circumcision is without significant clinical advantage, and carries a number of disadvantages for males, have persuaded none of the proponents of the procedure, including both religious and medical advocates.

University of Maryland's student paper, which (apparently) isn't written by the sort of chimpanzees that typically author news pieces for university papers, does a nice job in its chronicle of the "day in the life" of advocates in the ethics of circumcision, if that's the sort of mood you're in.

The Real Story is How She Didn't Get Killed

Ok maybe that is overstatement. But taking on a company as big as Astra Zeneca with an accusation like this one reported in Forbes is, um, dangerous:

A Georgetown University doctor is alleging that an education firm working with drug giant AstraZeneca tried to ghostwrite an article in a medical journal.

Adriane Fugh-Berman, an associate professor of alternative medicine at Georgetown, charges that she was approached by a medical education firm, Mold, United Kingdom-based Rx Communications, to write an article on the potential of medicinal herbs and dietary supplements to interact with a commonly used blood thinner, Coumadin.

"They sent me a completed manuscript with my name on it," Fugh-Berman says, "and I hadn't actually agreed to write anything."

At the time, AstraZeneca (nyse: AZN - news - people ) was developing its own experimental blood thinner, Exanta. The drug was eventually rejected by the U.S. Food and Drug Association. But Coumadin's capacity to interact with everything from spinach to supplements was expected to be a major selling point for the new drug. Later, Fugh-Berman says, she was asked to review a paper for a medical journal, and it was the same ghostwritten paper she had previously been offered to pass off as her own.

It is, whether true in this case, a practice that is rapidly becoming commonplace. Or at least that is what our ghostwriters told us to say.

Nobody Does More Clinical Ethics

Or at least nobody compares themselves to a bicycle wheel as clearly as the bioethics program at University of Toronto, led by Peter Singer and for some time now based on a programmatic dedication to ethics consultation in the various hospitals affiliated in some way with the school. As a strategy for growth, clinical and research ethics has really boosted the bioethics programs that have adopted it. And this piece about the "hub/spokes" model really explains how they are doing it and where you can read more about it. These Toronto guys are really innovative, as we discussed when Singer and colleagues put out a killer report on developing world bioethics. Clinical ethics makes it all possible - and this is the roadmap or rather bicycle trail toward it.

Jeremy Sugarman: Research Ethics Costs Money

Jeremy Sugarman keeps doing the research everybody else wishes they had thought to do. In the April 28th New England Journal of Medicine, Sugarman and others examined data from a number of major medical centers to assess the cost of IRBs. The operating costs "ranged from $171,014 to $4,705,333, with a median cost of $741,920," and that means that "institutions and policy-makers need to recognize the important role of the IRBs in protecting research participants so that they are not shortchanged." More important, the bigger the place, the cheaper the review - $400 for high-volume medical centers versus $600 for low volume spots.

What Sugarman doesn't say but is interesting nonetheless is that the median cost of $742K/yr for an IRB is about double the median support level for a bioethics program in an academic medical center. Lots of bioethics folks who are struggling for cash might want to consider annexing their IRB...

Who is Elias Zerhouni, Really?

The answer is complicated: he's a man who came to the U.S. 30 years ago with $300 in his pocket. He's a former Johns Hopkins adminstrator and scientist with a history of running programs well. He's a leading radiological scientist whose profile in basic science was not his calling card, but who developed a number of key technologies and even started businesses. And he is the lightning-rod at the center of science and government in his role as director of the National Institutes of health, presenting proposed ethics rules that have angered many in the NIH including, notably, Zeke Emanuel, head of its ethics program.

In this Baltimore Sun piece, the profile of Zerhouni is interesting - pointing to his ambivalence about the ethics rules, his skillfulness in managing both sides of the stem cell controversies, and his bearing as NIH head - what he's like in the office, and what he doesn't do as director.

An Illustration of Inequity

The second part of a series in the Times discusses what role social class plays in health care in the United States. Reading this comparison of the way three different heart-attack patients were treated illustrates not only social class differences, but gender inequities as well. But in this cases illustrated, all of the patients at least had one form or another of health insurance. And what of the plight of the uninsured souls -- I guess their fate is either too grim to explore or not worth mentioning ? It is extremely frustrating to watch the public vote in leaders who place more emphasis on such things as fighting gay marriage, inserting creationism in and taking evolution out of textbooks, and keeping condoms or birth control out of sex education and keeping feeding tubes in patients in persistent vegetative states against their will. What will it take to awaken people to their obligation to their brothers and sisters of basic health care? Where's the "justice for all?" -- Linda Glenn

The One Egg at a Time Bill

Representative Napier of Kentucky has proposed 05RS HB145, a bill that would crimalize any IVF procedure that produces more than one egg per, uh, well he hasn't worked that part out yet exactly.

When it Snows Embryos

Darby Penney pointed me to this RFP (request for grant submissions) from the U.S. Department of Health and Human Services, for public awareness campaigns on Embryo Adoption. It is an honest-to-goodness save the embryos campaign and it will provoke all sorts of interesting legal critique. Perhaps the current administration has successfully used the newly implemented laws protecting fetuses in order to move strongly now in the direction of promoting 'rescue' for embryos.

Or maybe now that the language of "adoption" has been so clearly embraced, by many folks on both sides of the political aisle, as a way of describing embryos (which absent adoption would by definition then be "aborted" - a huge shift in language for how we would discuss what happens in IVF), we will all be volunteering to raise these embryos.

I will believe that this phenomenon has traction, though, only when I start to see pro-life advocates pregnant with excess embryos.

Israeli Guinea Pigs

Salon.com describes the effort of a medical ethicist in Israel to uncover some incredible violations of human rights in medical research. The stories are amazing and have provoked a massive response from the Israeli government:

At one hospital, staff pierced children's eardrums to apply an experimental medication yet to be approved in any country. At another, patients with senile dementia had their thumbprints applied to consent forms for experimental drugs.

... [State comptroller Eliezer] Goldberg said two women died from infections, but their deaths were not reported to the ministry, nor was a legally required investigation committee set up. The comptroller said that in some cases the deaths of patients who were part of clinical trials were not immediately reported, which undermined attempts to establish whether the experiments were to blame.

Michel believes some doctors bowed to incentives from pharmaceutical firms to test experimental drugs. "I don't have to explain the enormous power of the pharmaceutical industry to direct research according to its priorities," he said.

Goldberg described how one researcher was also the medical director of a company that initiated the clinical trial he was responsible for.

[thanks Sean Philpott]

Caplan & Magnus at National Press Club

They will not use chairs or wear make up, but Art and David will in fact prove that they make a good tag team. The action starts at 9:00 a.m. Friday May 13th at National Press Club on F Street, and the subject is the implications of the Schiavo case.

Israel Recognizes Right to Stop Life Support

Ynet news reports that there has been an official recognition by a Tel Aviv court that terminal patients have a right to request and receive discontinuation from life support. - Art Caplan

The Latest Rumbling in the Blogosphere: Questions About Ethics

Adam Cohen grumbles (correctly) about the hypocrisy of a blogosphere dedicated to exposing ethical shenanigans in the major media that is itself subject to little or no scrutiny. In his editorial he discussed issues with the key blogs, those read by roughly a hundred times more readers than the one you are reading. Reading his editorial though inspired me to inquire as to how many blogs are explicitly dedicated to ethics. Which of course turned out to be an impossibly non-specific Google search as 'blog +ethics' (anybody have any idea how to turn up an answer??), but it did yield 2.5 million results. 'ethics blog' yields 606, and 'ethics blog' +medicine yields 60. No idea what that means but as best I can tell not much. [thanks Wayne Shelton].

Living Wills R Us

Put It In Writing, says the American Hospital Association, and according to their recent update to member hospitals,

The AHA's "Put It In Writing" Web site has attracted more than 11,830 individual visitors since it went online Monday, with visitors staying more than eight minutes on average. The wallet card was downloaded more than 4,150 times, and the brochure more than 3,550 times. Hospitals are encouraged to include on their Web sites a link to the site, which contains resources to help people put their wishes about end-of-life care into advance directives.

The wallet cards really are a new kind of push. Also on the AHA page: links to bar association sites on myths about advance directives and about how to plan for healthcare at the end of life. [thanks John Morley (AMC)]

Brain Enhancement Update: A Memory & Attention Deficit Compound that Helps Everyone?

New Scientist tells us about a new set of pharmacological compounds called ampakines, that may enhance memory and mental performance with causing the jitteriness of traditional stimulants. Identified as potential treatment for ADD, memory loss, and even Alzheimer's disease, the substances also appear to have a uniform effect on normal subjects in the trials. Ampakines are in clinical trials in the U.K. now. Art Caplan "Stimulating your brain with a reminder on a handheld digital device doesn’t seem that different to me from stimulating your brain with a drug." - Linda Glenn

New York: Still, Quietly, the Nation's Stem Cell Leader

Mount Sinai School of Medicine's announcement that it has established the Black Family Stem Cell Institute marks another milestone along a path that is more or less invisible in the public debate. While attention focuses on the incredible amount of money that the state has ponied up in California for the science of stem cells, most have missed the fact that there are many more stem cell researchers and labs in New York than in any other state, including Massachusetts and California. And, unlike Massachusetts, which is supposedly bleeding scientists to California at an alarming rate, New York's stem cell community is, albeit anxiously, growing.

There's still no question that San Francisco, should it get the headquarters for the $3 billion California agency, would become the critically important location for stem cell research someday. Why then are most New Yorkers staying, so far? It could be the talent - key people with Nobel prizes in the field have very happy homes near Columbia University. But these big guns are being courted by California:

“They feel the venture-capital money will be easier there,” [a prominent NYC researcher] says. His colleagues are also being courted. Lorenz Studer at Memorial Sloan-Kettering Cancer Center—perhaps the city’s most accomplished Parkinson’s researcher working with human embryonic stem cells—says he’s gotten feelers from Stanford and the Burnham Institute in San Diego. California also has come calling for Mount Sinai’s Gordon Keller, who is using human embryonic stem cells to work toward treating blood diseases. “I have gotten some e-mails, yes, from San Diego,” Keller says. “Just, Would you be interested in coming to look? Certainly. I’m going out there to give some seminars anyway. How can you not go?” Since Proposition 71 passed, doctors say the medical centers have been abuzz about who might stay and who might go. Some say the measure even played a role in one departure before Election Day: Arnold Kriegstein, a researcher who led Columbia’s neural stem-cell initiative for eleven years, packed up his lab in August and left for the University of California at San Francisco...

[But] New York has been the epicenter of more than its share of medical breakthroughs: chemo and radiation, blood transfusions, X-rays, aids therapies. For all that, the accomplishments of our scientists rarely command the spotlight. Maybe it’s just the city’s cacophony of braying interests: New York is the capital of so many things—finance, advertising, fashion, the media—that Big Medicine gets lost in the shuffle. But despite their lack of glamour, the hospitals, medical schools, and research centers are the largest employers in New York; the hospitals alone generate at least $1 billion a year in tax revenue. And it’s not just the size of the industry, it’s the quality. In the past six years, five Nobel Prizes have been awarded to New York scientists. Medicine here is in many respects what the city does best; sensational hospitals feel like a New York entitlement—not something that could slip away at any moment. And that is true of its key stem cell players: Columbia, NYU, Memorial Sloan-Kettering, Mount Sinai, Weill-Cornell, Rockefeller, and Yeshiva’s Albert Einstein College of Medicine.

So it could be talent or location that is preventing a massive brain drain to California. And there is the other reason ... Just as Dr. Keller was preparing to leave NYC to discuss "feelers" with folks out there, Mount Sinai figured out how to keep him: with an endowed institute that allows him to stay in New York. New York will find a way to raise enough stem cell money to compete with California, but it will take time. "Harold Varmus says Memorial Sloan-Kettering is financing the work of scientists like Lorenz Studer with donations. And Gerald Fischbach says Columbia will set aside at least 10,000 square feet of space for stem-cell research. “We’re not going to get sidelined,” Fischbach says. “I won’t let that happen. We’re gonna make a huge effort to raise private funds for embryonic stem cells.”

Ultimately though the big ticket is still the New York legislature in Albany, which is now sitting on the hold button. So, quietly, the nerve center for stem cell research quietly awaits a verdict from the people who will ultimately decide whether the key state for stem cell research is on the east or west coast.

[updated]The list of core science advisors to the California initiative from outside the state has just been named, and 5 of 8 of them are New York folks: "Ali Brivanlou, a 45-year-old developmental biologist at Rockefeller University in New York, considered one of the up-and-comers of his field; Alexandra Joyner, a developmental biologist at New York University; blood-disease expert Stuart Orkin of Harvard University; Lou Gehrig's disease expert and neurologist Jeffrey Rothstein of Johns Hopkins University; Pablo Rubenstein, founder of an umbilical-cord-blood program at the New York Blood Center; George Yancopoulis, a respected researcher of neurological disorders at Regeneron Pharmaceuticals Inc. in Tarrytown, N.Y.; and Alan Trounson, a well-known stem cell expert in Australia."

Culture of Life Foundation Attacks National Academy of Sciences' Guidelines. Kass Commission on Bioethics is ... Silent

National Academies Guidelines for stem cell research are ethically irresponsible, says Austin Ruse of the Culture of Life Foundation. His position is a familiar one, but has not been made with regard to NAS guidelines.

"These guidelines are both inadequate and disingenuous," Ruse said. "The members of the Academies are attempting to give the appearance that they are offering thoughtful and temperate solutions. The reality is that their belief in the total acceptability of destroying human life in its most vulnerable stage for the purposes of scientific research prohibits them from producing an ethically acceptable set of principles. If there was any question that these members are not offering a truly moderate solution, the fact that they refuse to call for a ban on the creation of animal-human hybrids should remove any doubt."

Much more interesting, to date the President's Commission on Bioethics has been silent on the guidelines. That fact is remarkable in part because the guidelines come from the nation's official science body, but also because they are so directly in conflict with the stated views of Leon Kass and with the stated position of the PCB.

The Starvation Act

Well you knew it was coming. But at last the Model Starvation and Dehydration of Persons with Disabilities Prevention Act has come. National Right to Life posted the actual proposed law complete with [fill in your state here] generic language.

Enhancement and Ugliness

Maureen Dowd examines the somewhat interesting finding out this week concerning what happens to 'ugly' babies in grocery stores, focusing on the questions of enhancement and parenthood.

Texas Thinks Hard about Stem Cell Research

I would not have believed Texas could even consider state funding for embryonic stem cell research until I read this in the Dallas Morning News:

One of the most important questions facing legislators in Austin this session is how to treat research that involves embryonic stem cells, which many scientists believe can help cure diseases such as juvenile diabetes and Parkinson's, as well as spinal cord injuries and other debilitating conditions. Such research is in addition to ongoing research using adult stem cells, which are much more limited in supply.

President Bush has limited federal funds for research using embryonic stem cells. Some Texas legislators want to go further, making such research a felony. At the other end of the spectrum, a joint resolution invites voters to amend the state Constitution to create a stem cell research institute.

In the middle are bills that outlaw the use of stem cells to clone human beings but allow their use in research designed "to develop regenerative or reparative medical therapies or treatments." Researchers would have to comply with strictures to be established by a commission composed of doctors, scientists, bioethicists, legal experts and religious leaders. The panel's members would be appointed by the executive commissioner of the state Department of Health and Human Services.

That is a morally defensible policy that we believe is both ethical and smart. Under no circumstances do we condone replicating human individuals through cloning, but it does not follow that the state should ban carefully controlled research that might lead to cures for some of mankind's most destructive diseases. We urge the appropriate committees to pass legislation by GOP Rep. Beverly Woolley and Democratic Sen. Eliot Shapleigh permitting privately financed embryonic stem cell research.

The important thing which will put Texas ahead of the federal government and most other states is to confront the ethical issues and establish a sound regulatory framework. Some people equate the destruction of any embryo, no matter how early in its development, with the loss of human life. But our society is in the mainstream in having accepted that some embryos will be sacrificed in procedures such as in vitro fertilization, which make other lives possible.

"Most Western industrialized countries share a view that embryos in petri dishes are neither persons nor mere property," according to a report by the Hastings Center, one of the nation's oldest think tanks on bioethics issues. The fundamental question to be asked, the authors suggest, is: "Will a given technique or manner or purpose of embryo research express appropriate respect for these entities?"

We believe Texans can be proud of an approach that seeks to answer that question in a rigorous way in the name of improving the health and well-being of generations to come.

Message from the Heart

Guest blogger Linda Glenn:

An article in the Washington Post this morning reminds that heart disease kills more women than anything else. It is six times more deadly than breast cancer and more deadly for women than it is for men. And yet it is still under-recognized, under-studied, under-treated and under-funded, making women the another vulnerable population. Part of the problem is that screening tests designed originally for men often miss heart problems in women; these tests often need to be combined with other diagnostic tools such as an echocardiogram and a nuclear scan. Women need to educate themselves and bring to the attention of their health care providers that this is a serious problem that warrants further study.

- Linda Glenn

There’s a Healer Abroad, at a Clinic Near You

Stuart Rennie, our man in North Carolina, is very angry about a new IOM plan for a kind of new Peace Corps:

The brain drain of qualified health care personnel from the developing world to more privileged countries is well-documented, devastating and an issue of fierce debate. The migration of physicians, nurses and other health workers to greener pastures further weakens many developing world health care systems already lacking material resources and overburdened by the HIV/AIDS pandemic, tuberculosis, malaria, and diarrhea.

This week, a panel convened by the Institute of Medicine has announced a bold new plan to tackle the brain drain problem -- or rather -- a plan to address the problem only in so far as it threatens to undermine the $15 billion President's Emergency Plan for AIDS Relief (PEPFAR). Unpretentiously entitled “Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS”, the proposed program is described as a ‘Peace Corps for Health’ where American health professionals do stints in the 15 developing world countries targeted by PEPFAR. Any illusions about the altruistic motives of prospective participants are swiftly deflated by the press release:

". . . the plan envisions about 1,000 people from various health fields receiving fellowships to work abroad for at least one year for $35,000. While the stipend would be less than what a person's regular job pays, the program would be designed to make motivated people believe they can afford to interrupt their career for such work. Ideally, the fellowships would expand their skills and marketability. "I think this gives them [the employees] some leverage that they never had before," said Andre-Jacques Neusy, the director of the Center for Global Health at New York University School of Medicine."

You seem to get a cynical message – emanating from the Institute of Medicine – that only the prospect of future self-enrichment will motivate your average health care professional to heal the impoverished sick. But there are more carrots where they came from:

"A third component would provide money to newly trained physicians, nurses and other health professionals to pay back school loans. One year of work in an approved overseas AIDS program would earn $25,000 in loan repayment."

Interestingly, the unveiling of the Institute’s plan comes the same week as a news item in the British Medical Journal entitled “Developed world is robbing African countries of health staff.” [link] Here we are reminded that countries like the US, UK and Canada have been actively recruiting the manpower of developing world health systems for years. According to Richard Cooper of the Health Policy Institute at the Medical College of Wisconsin, up to 22% of doctors in the US, a total of 170,000, were born and trained abroad, some of them from countries like Ghana, which now has only 1500 doctors serving a population of 20 million people. Alas, Ghana is not one of the lucky PEPFAR countries slated to receive the inexperienced doctors up to their ears in debt benefits of ‘Healers Abroad.’

It is not clear how Healers Abroad can address the deeper geopolitical and economic causes of the brain drain or how importing foreign health professionals (at zero cost to ministries of health in developing countries) won’t make it worse. Those interested can access the Institute of Medicine’s document here.

Thus endeth the rant. - Stuart Rennie [thanks Lara Vaz]

William Frist Did Not Kill Kenny on South Park

Frank Rich at the Times watches South Park, and the publication of the new book South Park Conservatives by Brian Anderson spurs Rich to analyze the problem of being a "cool" conservative. Republicans look at Jon Stewart and others who have catalyzed a thoroughly hip new liberal media, and ask themselves ... what can we latch onto to be cool? The answer, Anderson hypothesized when he sent his book off to press a year or so ago, is South Park. It pokes fun at all sorts of liberal excesses, and has been awfully cool doing so.

So what does this have to do with bioethics? Rich points out that during the months that Anderson's book has been gestating at its publisher, South Park has made a shift, leaving conservatives in an awkward position. Why? Because South Park turned on the Republicans over the Schiavo case:

In the March 30 episode, Kenny, a kid whose periodic death is a "South Park" ritual, lands in a hospital in a "persistent vegetative state" and is fed through a tube. The last page of his living will is missing. Demonstrators and media hordes descend. Though heavenly angels decree that "God intended Kenny to die" rather than be "kept alive artificially," they are thwarted by Satan, whose demonic aide advises him to "do what we always do - use the Republicans." Soon demagogic Republican politicians are spewing sound bites ("Removing the feeding tube is murder") scripted in Hell. But as in the Schiavo case, they don't prevail. Kenny is allowed to die in peace once his missing final wish is found: "If I should ever be in a vegetative state and kept alive on life support, please for the love of God don't ever show me in that condition on national television."

This remarkably prescient scenario, first broadcast on the eve of Terri Schiavo's death, anticipated just how far the zeitgeist would swing in the month after the right's overreach in her case. A USA Today poll a week later found that Americans by 55 to 40 percent believe that "Republicans, traditionally the party of limited government, are 'trying to use the federal government to interfere with the private lives of most Americans' on moral values." In other words, what Hillary Clinton's overreaching big-government health care plan did to the Democrats a decade ago is the whammy the Schiavo case has inflicted on the G.O.P. today.

[thanks Wayne Shelton]

In Praise of Zero Grazing

Bloggeth Stuart Rennie:

The Terri Schiavo case painfully demonstrated how bioethics has become a flashpoint for culture wars between conservatives and liberals. But more excruciating still is how these culture wars are increasingly being exported abroad. As Helen Epstein describes in “God and the Fight Against AIDS" in last week’s New York Review of Books , unseemly conflicts between secular and evangelical Christian AIDS organizations over US government contracts to tackle HIV prevention in the developing world threaten to fuel the pandemic.

As Epstein observes, up to 2000, evangelical Christian groups went out of their way to stigmatize persons living with HIV/AIDS. After a fellow evangelical took office in the White House, however, religious groups began to see spiritual prospects (and large sums of money) in HIV/AIDS patients where they once saw only the workings of Satan. As Franklin Graham (son of Billy) put it, “AIDS has created an evangelical opportunity for the body of Christ unlike any in history.”

Speaking of which: $1 billion of the $15 billion to be devoted to AIDS treatment and care in developing countries by the US government is earmarked for HIV prevention through abstinence-only-until-marriage programs. Sensitive to the accusation that such programs are based on religious moralizing rather than scientifically proven effectiveness, evangelical groups typically cite the case of Uganda, where a dramatic drop in HIV prevalence rates during the 1990’s is claimed to have been due to abstinence policies and programs. If nothing else, these claims are music to the ears of the First Lady of Uganda, Janet Museveni, herself an evangelical Christian. However, almost on a monthly basis, hefty reports emerge that claim abstinence was not the cause of the decline in HIV prevalence in Uganda, and that current abstinence-only HIV prevention programs in Uganda or elsewhere will be a public health disaster. Last month, it was Human Rights Watch’s turn.

Epstein has an interesting take on the debate. In her view, what drove the decline of HIV in Uganda in the 1990’s was not abstinence or the increased use of condoms, but the then-established HIV prevention policy of ‘Zero Grazing.’ Many persons in Uganda, especially in rural areas, practice polygamy. Men may have many wives as they can economically support. The basic message of Zero Grazing was: those in polygamous relationships should be faithful to their (many) lifelong partners, and not engage in casual sex. If all men sleep only with their different wives, and the women only sleep with their husbands, HIV would not spread. This policy did not involve the promotion of abstinence or condom use: it promoted faithfulness, albeit faithfulness within a network of polygamous relationships. And according to Epstein, it was a culturally responsive policy seemed to work in 1990’s Uganda.

What are the chances of reviving ‘zero grazing’? Not great: certainly the present US administration would be loath to support any policy premised on an acceptance of polygamy. And as Epstein notes, while abstinence and condom programs are supported by multimillion dollar bureaucracies, zero grazing has no backers. So the ignorant armies will continue to clash at night for the foreseeable future.