February 2008
"Natural" can mean many things
Via Jim Fossett comes this op-ed by Neil Shubin in NYT about the variety of ways species have found to reproduce -- and how that should make us cautious when talking about what's "natural" in debates about cloning and other technologies. Here's a snip:
Cloning is one of many mechanisms species use to survive in a dangerous world. Indeed, the diversity of reproductive strategies seen in animals staggers the imagination. Some reptiles do not determine sexes genetically, but rely on different incubation temperatures to determine the development of males and females. Other creatures can actually switch sexes during their lifetimes, being born male and developing as females. Still others can switch sexes based on behavioral cues in the social group. There is no one way that creatures start development, grow and form sexes — there are many varied ways.
Unfortunately, humans seem to forget this fact when we find ourselves turning to nature to guide us through difficult choices, such as arguments about whether life begins at conception, or over the proper structure of the family. Or, more recently, regarding the morality of cloning. Whether we’re talking about raising bigger cattle or growing life-saving organs or trying to “live forever,” both sides like to stress their abilities to judge what is “natural.” Judging from Komodo dragons, lizards and sharks, the answer seems to be that for reproduction, almost anything goes.
And that is the point. Biology is about variation. Without variation, the world would be static and unchangeable, and species would gradually disappear as they failed to meet challenges like changing climates and environments. So as we continue our very necessary debates over ethical issues, let’s bear in mind that morality is a concept limited to our species. The natural world is a fuzzy place that doesn’t always accommodate our decidedly human need to find cut-and-dried categories.
Should you "protect" a patient from his own convictions?
This week's JAMA includes an interesting article by Dr. Bruce Campbell, a surgeon in Milwaukee. He writes about his apprehension in removing a tumor from a Jehovah's Witness. The procedure itself was relatively ordinary, but it carried the real risk of bleeding -- and the patient had, in accordance with his beliefs, forbidden Campbell from delivering a transfusion. (The article isn't open access, but NYT's Well blog helpfully clips many of the interesting sections.)
The patient ends up being fine, but Campbell was left with uncertainty about the situation:
For my part, I had spent two weeks becoming increasingly anxious that I might suddenly be called upon to “protect” this man from his own convictions. What emergency course of action might I have recommended if he had experienced a massive hemorrhage during the operation? Would I have tried to force his family to consider a lifesaving transfusion? I was still not certain.
If the patient had needed a transfusion, what should Campbell have done?
-Greg Dahlmann
Addiction through the lens of neuroscience
Newsweek's cover article this week looks at how neuroscience is prompting researchers to develop new medications and vaccines to treat addiction:
The emerging paradigm views addiction as a chronic, relapsing brain disorder to be managed with all the tools at medicine's disposal. The addict's brain is malfunctioning, as surely as the pancreas in someone with diabetes. In both cases, "lifestyle choices" may be contributing factors, but no one regards that as a reason to withhold insulin from a diabetic. "We are making unprecedented advances in understanding the biology of addiction," says David Rosenblum, a public-health professor and addiction expert at Boston University. "And that is finally starting to push the thinking from 'moral failing' to 'legitimate illness'."
In laboratories run and funded by the National Institute on Drug Abuse (NIDA), fMRI and PET scans are forcing that infuriating organ, the addicted brain, to yield up its secrets. Geneticists have found the first few (of what is likely to be many) gene variants that predispose people to addiction, helping explain why only about one person in 10 who tries an addictive drug actually becomes hooked on it. Neuroscientists are mapping the intricate network of triggers and feedback loops that are set in motion by the taste—or, for that matter, the sight or thought—of a beer or a cigarette; they have learned to identify the signal that an alcoholic is about to pour a drink even before he's aware of it himself, and trace the impulse back to its origins in the primitive midbrain. And they are learning to interrupt and control these processes at numerous points along the way. Among more than 200 compounds being developed or tested by NIDA are ones that block the intoxicating effects of drugs, including vaccines that train the body's own immune system to bar them from the brain. Other compounds have the amazing ability to intervene in the cortex in the last milliseconds before the impulse to reach for a glass translates into action. To the extent that "willpower" is a meaningful concept at all, the era of willpower-in-a-pill may be just over the horizon. "The future is clear," says Nora Volkow, the director of NIDA. "In 10 years we will be treating addiction as a disease, and that means with medicine."
Criminalizing the brain drain
By Stuart Rennie
There are many numbers around to express the inequalities in health care between developed and developing nations. In Malawi, there is one physician for about 50,000 persons; compare with Great Britain, where it is considered shocking when there are districts with only one doctor per 3500. In Zambia, there is one nurse for about 3000 patients; in the United States, studies have shown that even an increase from a 1:4 nurse/patient ratio to 1:10 can have a significant impact on surgical patient death rates, as well as job dissatisfaction and burnout. Who knows what a 1:3000 ratio does for patients and nurses. But for all the contrasting figures that can be found in the scientific literature, an unscientific anecdote stands out for me. In Kinshasa, somewhere off the Boulevard du 30 Juin, there is a small dental clinic, which I noticed was absolutely jammed full every single evening, with some patients spilling out onto the trottoir. Someone told me that there are 12 registered dentists in Kinshasa, a city with estimated population of 8 million. That struck me as terribly low, though in the meantime I have learned that according to WHO estimates (2004), the average dentist/patient ratio in Africa is 1 per 150,000.
Nevertheless, the industrialized world regards itself as having serious doctor, nursing and dental shortages, and part of the solution to the crisis currently involves recruiting from… the developing world. You don't need a fully articulated theory of justice to see a deep problem here.
One more bit of info to drop in your online dating profile
From a New York Times piece on the reasons the HPV vaccine would -- or would not -- be given to boys:
Baruch Fischhoff, a professor of decision sciences at Carnegie Mellon, thinks that older boys may see a mix of benefits in Gardasil. “Being able to say to a girl, casually, that you had the shots, boys might think, ‘If I can slip that into the conversation, it makes me less of a risk and seem like more of a humanitarian,’ ” Dr. Fischhoff said. “So the self-interested and altruistic motives could actually support each other.”
-Greg Dahlmann
Earlier on blog.bioethics.net:
+ Men and HPV
The mirror world
Here in the US it's pretty much a given that you will be required to foot at least some of the bill for your health care. To some people this arrangement isn't just a matter of scare resources, it's actually a feature of the system because it bring market pressure to bear on the system. It's really just a question of how much people should be asked to pay.
Over in the UK, they're having almost the exact opposite debate. The question there is: should people be allowed to put up their own money for medical treatment and still get help from the National Health Service. From a story in the New York Times:
Created 60 years ago as a cornerstone of the British welfare state, the National Health Service is devoted to the principle of free medical care for everyone. But recently it has been wrestling with a problem its founders never anticipated: how to handle patients with complex illnesses who want to pay for parts of their treatment while receiving the rest free from the health service.
Although the government is reluctant to discuss the issue, hopscotching back and forth between private and public care has long been standard here for those who can afford it. But a few recent cases have exposed fundamental contradictions between policy and practice in the system, and tested its founding philosophy to its very limits.
One such case was Debbie Hirst’s. Her breast cancer had metastasized, and the health service would not provide her with Avastin, a drug that is widely used in the United States and Europe to keep such cancers at bay. So, with her oncologist’s support, she decided last year to try to pay the $120,000 cost herself, while continuing with the rest of her publicly financed treatment.
By December, she had raised $20,000 and was preparing to sell her house to raise more. But then the government, which had tacitly allowed such arrangements before, put its foot down. Mrs. Hirst heard the news from her doctor.
“He looked at me and said: ‘I’m so sorry, Debbie. I’ve had my wrists slapped from the people upstairs, and I can no longer offer you that service,’ ” Mrs. Hirst said in an interview.
“I said, ‘Where does that leave me?’ He said, ‘If you pay for Avastin, you’ll have to pay for everything’ ” — in other words, for all her cancer treatment, far more than she could afford.
Officials said that allowing Mrs. Hirst and others like her to pay for extra drugs to supplement government care would violate the philosophy of the health service by giving richer patients an unfair advantage over poorer ones.
Patients “cannot, in one episode of treatment, be treated on the N.H.S. and then allowed, as part of the same episode and the same treatment, to pay money for more drugs,” the health secretary, Alan Johnson, told Parliament.
“That way lies the end of the founding principles of the N.H.S.,” Mr. Johnson said.
-Greg Dahlmann
Where exactly are the corpses for the "Bodies" exhibit coming from?
It seems the company behind "Bodies... The Exhibition," one of the two most popular traveling exhibitions of plastinated corpses, isn't very sure, beyond the fact that they come from China. ABC reported last week that there's evidence the bodies may in fact have belonged to executed prisoners. Here's the company's response to ABC:
Arnie Geller, the chairman of Premier Exhibitions, told ABC News he was appalled at the allegations that some of the bodies from his Chinese suppliers might be those of executed prisoners.
He said his own medical staff had seen no such evidence and that his suppliers have assured him that "these are all legitimate, unclaimed bodies that have gone through Dalian Medical University."
"If these can actually be attributed to even the people that we're doing business with, we would have to do something about that immediately," Geller said.
The ABC report has apparently prompted New York's attorney general, Andrew Cuomo, to open an investigation into the exhibit.
And what about that other plastinated bodies exhibition? Gunther von Hagens, the guy behind "Body Worlds" says he's stopped using bodies from China.
Back to "Bodies... the Exhibition," why the outrage against using executed prisoners? It's not like the exhibit has said it has a whole stack of consent forms for its bodies. According to the company, the corpses were "unclaimed," which sounds like a code word for "we didn't have to bother with consent because there was no one around to complain." So, are we really concerned about the the prisoners and their lack of consent? Or are we just motivated by our own unease about the act of execution?
-Greg Dahlmann
(story via Art Caplan)
screengrab: ABC
Previously in AJOB:
+ Gunther von Hagens' BODY WORLDS: Selling Beautiful Education
Earlier on blog.bioethics.net:
+ Not-so-exquisite corpses
Possibly a step towards solving the iPS cell tumor problem
The Yamanaka team announced in a Science paper today that it was able to induce pluripotency in cells taken from the liver and intestinal lining of mice -- and in the process they found that the retroviruses used to turn the cells pluripotent don't have to insert themselves at specific sites in the cells' DNA. That opens the window for possibly getting the retrovirus to insert the necessary genes (or "factors" as scientists call them) at places in the cells' DNA that aren't associated with tumor growth.*
The risk of iPS cells turning cancerous is one of the big obstacles to the cells being used therapeutically. And if scientists can't figure out how to solve that problem, it becomes much less likely the cells will eventually be used that way.
Speaking of Yamanaka, the LA Times reports that he's become a huge celebrity in Japan, somewhat to his annoyance.
-Greg Dahlmann
*Quick review: there's concern iPS cells could turn cancerous because the retroviruses used to insert the genes necessary for inducing pluripotency can also cause errors in the cells' DNA, which in turn can cause tumors.
State biotech funding and patience
Via Art Caplan comes a piece from the Boston Globe that's essentially a reality check for states looking to cash in on biotech funding initiatives:
The same day that President Bush won a second term, California voters approved a bold plan to pour $3 billion of taxpayers' money into stem cell research over the next decade. Supporters argued the investment would save millions of lives through new medical therapies, generate millions of dollars in added tax revenue, cut healthcare costs by billions, and create thousands of high-paying jobs.
Three years later, Californians are still waiting for some results. Until recently, most of the money was tied up in lawsuits. And even now that the tap is flowing, proponents acknowledge it could take years, if not decades, for the grants to pay off.
"It's too early," said Alan Trounson, president of the California Institute for Regenerative Medicine, the agency charged with administering the stem cell funds. "There are very few substantial developments [in medical science] that have happened in less than 25 years. There have been some, but they tend to be rare."
In other words, the scientific process takes time -- and it doesn't include any guarantees. Something to keep in mind as the next political cycle gets into full swing.
-Greg Dahlmann
The five most popular Bioethics News stories from the week of Feb 4
Here are the most popular Bioethics News items from last week based on average clicks per day:
1. Doctor accused of masterminding Indian kidney thefts arrested
(AFP) Police apprehended Amit Kumar and his brother in Nepal. Kumar reportedly fled India after details of his massive illegal organ transplant operation surfaced last month.
2. Hospitals trying to improve informed consent forms
(Wall Street Journal) Approaches include the "teach back" method, writing the forms at a lowering reading level and the use of interactive digital diagrams.
3. Do you tell your child about using an egg donor?
(Boston Globe) Most psychologists recommend that parents be open with a child about his or her genetic origins. But surveys indicate that a large portion of parents who have used donated eggs keep that fact a secret.
4. Questions about Jarvik's qualifications, rowing ability
(New York Times) Members of Congress are continuing to look into the Lipitor ads in which heart device inventor Robert Jarvik appears rowing. It recently came out that Jarvik wasn't actually rowing (they used a double), which some say makes the ads dishonest.
5. British researchers create embryo with DNA from one man and two women
(The Telegraph (UK)) Researchers hope the technique could be used to prevent genetic diseases caused by flaws in the mitochondria.
NYT Mag on fetal pain
Yesterday's NYT Mag included a very interesting piece surveying research into if, when and how fetuses and babies experience pain:
But [Kanwaljeet] Anand was not through with making observations. As NICU technology improved, the preterm infants he cared for grew younger and younger — with gestational ages of 24 weeks, 23, 22 — and he noticed that even the most premature babies grimaced when pricked by a needle. “So I said to myself, Could it be that this pain system is developed and functional before the baby is born?” he told me in the fall. It was not an abstract question: fetuses as well as newborns may now go under the knife. Once highly experimental, fetal surgery — to remove lung tumors, clear blocked urinary tracts, repair malformed diaphragms — is a frequent occurrence at a half-dozen fetal treatment centers around the country, and could soon become standard care for some conditions diagnosed prenatally like spina bifida. Whether the fetus feels pain is a question that matters to the doctor wielding the scalpel.
And it matters, of course, for the practice of abortion. Over the past four years, anti-abortion groups have turned fetal pain into a new front in their battle to restrict or ban abortion. Anti-abortion politicians have drafted laws requiring doctors to tell patients seeking abortions that a fetus can feel pain and to offer the fetus anesthesia; such legislation has already passed in five states. Anand says he does not oppose abortion in all circumstances but says decisions should be made on a case-by-case basis. Nonetheless, much of the activists’ and lawmakers’ most powerful rhetoric on fetal pain is borrowed from Anand himself.
Human ES Cells for Huntington Disease – the Australian Way
By Ricki Lewis
Palm Springs – I’ve been hearing about stem cells at scientific meetings for nearly a decade – from the yearly International Society for Stem Cell Research meetings, to stem cell symposia at various large conferences, to focused events such as the New York Stem Cell Foundation meetings. But it is a poster at a meeting here in Palm Springs that really has excited me.
Men and HPV
A study published late last week in the Journal of Clinical Oncology reported that the human papillomavirus (HPV) -- which causes cervical cancer in women -- is becoming a leading cause of oral cancer in men. According to one of the study's authors, during the next 10 years HPV will probably pass tobacco and alcohol to become the number one cause of these cancers.
As you probably know, there's a vaccine against a group of the most common strains of HPV. The FDA approved its use for girls and young women in 2006. And this new information about men and oral cancer prompts the question: should we be thinking about giving the vaccine to boys, as well?
The are two parts to that question, one scientific and the other cultural.
First, the science: researchers don't actually know if the HPV vaccine can protect men against oral and genital cancers. Apparently there is some research into this angle and presumably an answer should (maybe, probably, eventually) surface.
That brings us to the cultural part of all this. After the HPV vaccine gained approval, Merck -- the company behind the vaccine -- started pushing for states to mandate that girls get the shot. The push has garnered a lot of resistance, in part because of concern among cultural conservatives that giving girls a vaccine against a sexually transmitted infection might somehow encourage them to have sex. That concern seemed to contain a certain amount of general uneasiness about daughters and sex -- almost a "You want to vaccinate my daughter against an infection she can get by doing what? I'M NOT LISTENING I'M NOT LISTENING I'M NOT LISTENING" response.
Now that the focus is shifting towards sons, it will be interesting to see how people react. Will the concerns about promoting promiscuity still hold if boys are in line to get the jab? And if not, will that make people re-think their earlier objection?
-Greg Dahlmann
Earlier on blog.bioethics.net:
+ Glenn McGee in The Scientist: How Much Should Gardasil Cost?
Cribsheets from Seed
Seed Magazine has been posting a collection of one page info sheets for a bunch of different scientific subjects. The first topic in the series: stem cells (that's a thumbnail to the right). Even though the crib sheets skim the surface of the topics (that is the point, after all) and can be a little out of date (the stem cell sheet doesn't include any mention of iPS cells or other recent developments), they still look pretty useful. There's so much talk in the popular media about things like avian flu, genetics and nuclear power, but sometimes I wonder how many of the people doing the talking actually have some understanding of the subject at hand. A little bit of info -- in an easy to digest form -- could go a long way.
-Greg Dahlmann
Following up: academic fraud, sitting on research, wrecked football players
Here are a few updates and extensions to earlier posts on blog.bioethics.net:
Academic journal deja vu
A few weeks back two researchers at the University of Texas Southwestern Medical Center reported in Nature that they had found evidence of thousands of duplicated and plagiarized articles in biomedical journals. The researchers used a text analyzer called eTBLAST to turn up suspicious articles. And now results from the program have led a journal to make a retraction. The Harvard Crimson reports that Best Practices & Research: Clinical Rheumatology pulled a 2004 review article last week after it was found to contain many sections copied from a 2003 article in the journal Expert Opinion on Drug Safety. And get this: the two authors -- the copier and the copied -- knew each other.
The five most popular Bioethics News stories from last week
Here are the most popular Bioethics News items based on average clicks per day:
1. Pope defends church's role in bioethics discussions
(Reuters) During a speech the Pope said technologies such as embryonic stem cell research, embryo freezing and IVF have "shattered the barriers meant to protect human dignity."
2. Female sperm? Male eggs?
(Daily Mail (UK)) A handful of researchers are working on the creation of eggs and sperm from stem cells, which would theoretically allow for same-sex reproduction.
3. Stem cell research mentioned in State of the Union
(Reuters) President Bush called iPS cell research a "landmark." He touted the approach as way to "move us beyond the divisive debates of the past" and vowed to increase funding for it.
4. Archbishop forbids Catholic school field trips to bodies exhibit
(Cincinnati Enquirer) The leader of the Archdiocese of Cincinnati says the use of plastinated bodies "fails to respect the persons involved."
5. Commercial stem cell banks criticized
(New York Times) Experts say there are many doubts about the usefulness of banked cells. And they say that many of the companies behind these banks are making claims the science probably can't back up.
Do nerds have a different sense of empathy?
The WHO reported today that anti-malaria efforts in Rwanda and Ethiopia have cut the number of deaths from the disease in half. It attributes the success to the use of insecticide-treated bed nets and better drugs. This is great news because malaria is a huge public health problem -- probably more than most of us in the developed world realize: a million deaths and maybe 300 million more clinical cases each year. In Africa, malaria accounts for nine percent of all deaths. And this from a disease that we're learning we really can do something about.
But the numbers are so daunting. According to the WHO, roughly two billion people live in areas affected by malaria. The scale is almost too much to really get your head around.
A while back Clive Thompson wrote in Wired about research into the psychology of numeracy and how that affects our feelings of empathy:
I've been reading the fascinating work of Paul Slovic, a psychologist who runs the social-science think tank Decision Research. He studies a troubling paradox in human empathy: We'll usually race to help a single stranger in dire straits, while ignoring huge numbers of people in precisely the same plight. We'll donate thousands of dollars to bring a single African war orphan to the US for lifesaving surgery, but we don't offer much money or political pressure to stop widespread genocides in Rwanda or Darfur.
You could argue that we're simply callous, or hypocrites. But Slovic doesn't think so. The problem isn't a moral failing: It's a cognitive one. We're very good at processing the plight of tiny groups of people but horrible at conceptualizing the suffering of large ones.