Human Nature: Science, Technology, and Life.

Drill Babies, Drill

Two arguments have persuaded the United States to fund stem-cell research using destroyed embryos. One is that the research will save lives. The other is that the embryos, left over from fertility treatments, will otherwise be wasted.

Both arguments are now being applied to fetuses.

More here.

Obama and Stem Cells, Continued

I say it's moral. So do two thinkers from opposite ends of the political spectrum. At the Hastings Center's Bioethics Forum, Daniel Callahan, a cofounder of the center, points out that supporters of stem-cell research have been wrong

to conflate opposition to stem cell research and a variety of other actions by the Bush administration. That administration was guilty of manipulating, or suppressing, scientific information on a wide range of issues, including global warming and sex education. I call that behavior patently anti-science as well as a misuse of government power. But its stem cell opposition did not encompass any distortion of the science of such research. That is not how it argued its case.

Meanwhile, in the Washington Post, Yuval Levin, a former executive director of Bush's bioethics council, argues that

science policy is not just a matter of science. Like all policy, it calls for a balancing of priorities and concerns, and it requires a judgment of needs and values that in a democracy we trust to our elected officials. ... To distort or hide unwelcome facts is surely illegitimate. But to weigh facts against societal priorities—economic, political and ethical—in making decisions is the very definition of policymakers' duty.

One reason I like these two guys is that they're clear-eyed critics of spin and self-delusion, even when the spin and delusion are coming from their own allies. On the relationship between science and politics, I particularly recommend Levin's new book, Imagining the Future: Science and American Democracy. He's right that Obama's decision doesn't moot or end the debate about using embryos. So let's honor that debate by continuing it.

Levin quotes President Kennedy, who said that many modern problems require

very sophisticated judgments which do not lend themselves to the great sort of 'passionate movements' which have stirred this country so often in the past. Now they deal with questions which are beyond the comprehension of most men.

Against this "technocratic temptation," Levin argues for democratic oversight. In principle, I agree. But the comments I've received from readers about Obama's stem-cell decision worry me. Many people on both sides seem ill-informed or self-deluded about basic scientific questions. Liberals are denying the simple fact that human embryos are the beginnings of people. Conservatives are pretending that adult stem cells are more powerful than embryonic ones. If ordinary people want to govern science policy, they need to educate themselves so they can govern well.

(By the way: To all of you who protested that torture is different from stem-cell harvesting: Of course it is. That's the nature of comparisons: The things being compared differ in many respects. The similarity in this case is that on both issues, moral objections are being dismissed as interference in a purely technical question of saving lives. That, not the merits of stem-cell research, was the point of the article.)

Second, Levin writes that in announcing his decision on Monday, Obama "argued that to deny free rein to stem cell science is to ignore and reject the promise of science as such." The president "pledged that his administration would ‘make scientific decisions based on facts, not ideology,'" and his executive order "omits any mention of ethical debate."

I think what happened Monday is more complicated than that. Based on the spin that came out of the administration over the weekend, I expected Obama to make exactly the argument Levin describes. But he didn't. Among other things, Obama said:

Many thoughtful and decent people are conflicted about, or strongly oppose, this research. I understand their concerns, and we must respect their point of view. But after much discussion, debate and reflection, the proper course has become clear. The majority of Americans ... have come to a consensus that we should pursue this research. That the potential it offers is great, and with proper guidelines and strict oversight, the perils can be avoided.

And:

I can also promise that we will never undertake this research lightly. We will support it only when it is both scientifically worthy and responsibly conducted. We will develop strict guidelines, which we will rigorously enforce, because we cannot ever tolerate misuse or abuse. And we will ensure that our government never opens the door to the use of cloning for human reproduction. It is dangerous, profoundly wrong, and has no place in our society, or any society.

Levin is right about Obama invoking facts over ideology. But that was in the context of Obama's memorandum on scientific issues generally.

It looks to me as though the administration hasn't resolved how it's going to treat these issues. The mentality Levin describes—burying moral objections and portraying embryo research as just another case of Bush's "war on science"—pervades most of the spin coming out of the White House and its feeder institution, the Center for American Progress. That's why the White House paired the stem-cell order with the announcement on restoring scientific integrity. But for some reason, Obama himself isn't entirely playing along. His remarks on Monday sounded a lot like what he has said about abortion and other social issues: acknowledging moral disagreement while striving for consensus or at least compromise. I think the administration is unresolved, and we should encourage it to acknowledge and grapple with the moral questions.

Third, Levin describes the moral question this way:

If (as modern biology informs us) conception initiates a human life, and if (as the Declaration of Independence asserts) every human life is equally deserving of some minimal protections, government support for the destruction of human embryos for research raises profound moral problems.

I cringe at this interpretation of the Declaration. Levin believes that equality means a 5-day-old embryo has the same right to life as a 5-year-old girl. I just can't buy that. I'm a gradualist. I value the 5-day-old embryo because it's on its way to becoming the 5-year-old girl. But it's not there yet. It hasn't acquired the sentience and cognition that characterize a full-fledged human being.

The Declaration says we're created with an unalienable right to liberty as well as life. But that hasn't stopped us from regulating liberties in proportion to maturity, as we do, for example, with curfews and driving. Why can't we exercise the same discretion with respect to life? Yes, life is a more basic right. But maybe that just means that instead of drawing lines after birth, as we do with liberty, we should confine our line-drawing about life to the period before birth.

Slippery slopes run both ways. Let's call that Human Nature's second law. If we don't draw moral lines against the exploitation of embryos, we may end up obliterating respect for human life generally. But if we're so afraid of that prospect that we refuse to draw lines permitting the use of any embryos under any conditions, we may end up obliterating the moral difference between embryos and full-grown people. Liberals should think seriously about the first scenario. Conservatives should think just as seriously about the second.

Torture, Stem Cells, and Scruples

The same Bush-Rove tactics are being used today in the stem-cell fight. But they're not coming from the right. They're coming from the left. Proponents of embryo research are insisting that because we're in a life-and-death struggle—in this case, a scientific struggle—anyone who impedes that struggle by renouncing effective tools is irrational and irresponsible. The war on disease is like the war on terror: Either you're with science, or you're against it.

More here.

A Kidney Stimulus Package

The other day, I was reading about a new procedure in which a kidney was extracted for transplant through the donor's vagina. And it got me thinking: If kidney donors deserve special surgical benefits—which is what doctors argued in this case—then what other benefits should they be offered? How about free medical care? How about cash?

The Johns Hopkins doctors who performed last week's vaginal kidney delivery describe several special benefits. "An organ donor, in particular, is most deserving of a scar-free, minimally invasive and pain-free procedure," says one Hopkins surgeon. The natural-orifice procedure supplies these benefits. According to Dr. Robert Montgomery, head of the Hopkins transplant division, "Removing the kidney through a natural opening should hasten the patient's recovery and provide a better cosmetic result."

The doctors see these benefits not just as a special reward but as an inducement. "This approach could have a tremendous impact on people's willingness to donate," argues Montgomery. The shorter recovery time "greatly reduces the inconvenience of donating and we're hoping that will encourage more people to donate."

I've written before about the horrors of the international black market in organs from living donors. Federal law goes further, banning the provision of any "valuable consideration" in exchange for an organ. But the law adds that this term doesn't apply to "the expenses of travel, housing, and lost wages incurred by the donor."

So it's OK to compensate donors for lost income opportunities. And it's OK to make sure that they, of all people, get the most pain-free procedure with the best "cosmetic result." What else?

Sally Satel, a friend of mine and a frequent Slate contributor, points out that other countries have taken further steps. In When Altruism Isn't Enough: The Case for Compensating Kidney Donors, she reports that last year, "the Dutch health minister directed health insurers to reduce annual fees by 10 percent for registered organ donors."

Sounds good, right? If you do a good deed for your fellows, don't you deserve a reward? You're supplying a medical benefit to the community. Doesn't the community owe you, at a minimum, a discount on your health insurance?

And why stop at 10 percent? Satel notes that Saudi Arabia's Cabinet recently "passed a law to compensate unrelated living donors with lifelong medical care."

Still onboard? Let's keep going. Satel proposes to amend the definition of "valuable consideration" in U.S. law so that states can offer "incentives" for organs. The incentives, she explains,

could take many forms, perhaps as simple as an offer of lifelong Medicare coverage or a credit on the federal income tax. States could, perhaps, implement their own creative incentive ideas, such as the utilization of tuition vouchers, state income tax credit, loan forgiveness, or contributions to retirement accounts.

After all, lifelong medical care, which we've already agreed is appropriate, is a quantifiable benefit. What if the reward you really need isn't medical? What if you need a college education or a professional degree? What if you're struggling with your student loans or your mortgage? Can't we do something for you?

Don't worry. We're not talking about cash. Under most of the proposals outlined by various authors in Satel's book, benefits would be "in-kind," with "a months-long cooling-off period prior to surgery" so that nobody rushes to donate out of financial desperation. The value of the incentives might range from $15,000 to $40,000. And according to surgeon David Cronin and economist Julio Elias, there would be one further payoff:

A smoothly functioning pilot period of in-kind rewards might, however, allow the public to adjust to the very idea of compensation so that actual payment became more socially acceptable over time ...

That's a good bet. Satel opposes cash payments, and a bill awaiting introduction in Congress, the Organ Donor Clarification and Anti-Trafficking Law of 2009, would reassert the ban on cash transactions (in fact, it would increase penalties for them) even as it legalized state-provided in-kind incentives. The question is whether such legal distinctions would hold firm in the face of the increasing social acceptability of compensation.

So here's the dilemma: If we maintain the ban on "valuable consideration," Americans with sufficient wealth will keep going abroad to buy organs from living donors on the black market. Those without sufficient wealth will wait for freely donated organs, and some will die waiting. On the other hand, if we relax the ban, we might get used to the idea of compensation and end up buying and selling organs legally.

Which is worse?

Adjustable Glasses

Last month, we talked about the transition from George W. Bush to Barack Obama and what it might signify for biotech policy: a shift from a conservative interest in technological frontiers to a progressive interest in distributive justice. Less debate, for instance, about things like future artificial wombs, and more attention to things like incubators made from car parts. The point of car-parts incubators was that nobody cares about the latest million-dollar American baby born at 21 weeks when you live in a country where preemies die at 35 weeks. What most of the world needs is an affordable incubator that works for most preemies and can be reliably maintained.

Here's another target for the progressive ethic: eyeglasses. The man leading the charge is Joshua Silver, a physicist at Oxford. In Saturday's Washington Post, Mary Jordan explains the situation:

In the United States, Britain and other wealthy nations, 60 to 70 percent of people wear corrective glasses, Silver said. But in many developing countries, only about 5 percent have glasses because so many people, especially those in rural areas, have little or no access to eye-care professionals. Even if they could visit an eye doctor, the cost of glasses can be more than a month's wages. This means that many schoolchildren cannot see the blackboard, bus drivers can't see clearly and others can no longer fish, teach or do other jobs because of failing vision.

Silver's answer: Adjustable glasses.

[T]he more liquid pumped into a thin sac in the plastic lenses, the stronger the correction. Silver has attached plastic syringes filled with silicone oil on each bow of the glasses; the wearer adds or subtracts the clear liquid with a little dial on the pump until the focus is right. After that adjustment, the syringes are removed and the "adaptive glasses" are ready to go. Currently, Silver said, a pair costs about $19, but his hope is to cut that to a few dollars.

Silver has already distributed some 30,000 pairs, chiefly through the U.S. Department of Defense, which is giving away 20,000 (with U.S. public-relations inscriptions attached) in Africa and Eastern Europe. His next goal is to disseminate another million pairs in India. The ultimate target is 1 billion people who need glasses but don't have them.

Silver's glasses are ugly. They don't correct astigmatism or catch glaucoma. They're inferior to what the eye-care industry can sell you. But they're superior to what most people in need of vision correction can buy, which is nothing. I'm a congenital critic of utilitarianism (the idea of promoting the greatest welfare of the greatest number of people) when it threatens humanity. But when it serves us -- all of us -- I'm a big fan.

If you like Silver's vision, here's his Web site. Take a good look.

Organs, Haste, and Culpability

We have a verdict in the premature-organ-harvesting case.

Let's go to the Los Angeles Times for a summary of the case. Two years ago, the patient, Ruben Navarro, lay close to death after a heart attack.

His mother had given permission for organ donation, and a team that included [Dr. Hootan] Roozrokh flew in from San Francisco on behalf of a regional transplant network.  Roozrokh ... was to supervise a donation after cardiac death ... In most transplants, the removal of organs occurs only after a patient is declared brain-dead. In donations after cardiac death, a patient's brain is irreversibly damaged but still functioning minimally. With a family's consent, the patient is removed from life support and, once the heart has stopped, the patient is declared dead, and organs may be removed minutes later. Many experts say, however, that organs are usable only if they can be retrieved within 30 minutes after the machines are turned off.
According to prosecutors, Roozrokh ordered up excessive doses of the painkiller morphine and Ativan, an anti-anxiety drug, so that Navarro would die within that crucial half-hour. As it turned out, he died eight hours later and Roozrokh did not remove any organs.

So the basic problem was that Navarro's medical care was being directed by a guy sent to the hospital to get his organs—and that the doctor's actions may have helped the organs but not the patient. The doctor was looking at a felony charge, dependent adult abuse, with a possible sentence of four years.

Verdict: Not guilty. But the jury also issued this statement (handwritten PDF here):

Ruben's case has identified that Donation by Cardiac Death (DCD) is in desperate need for further identification of prescribed policy in order to continue successfully as a viable option for organ donation in this country. Refining the nationwide protocol of DCD organ procurements will be an important part of Ruben's legacy...

In other words, Roozrokh may have crossed the line, but the jury blames the system, or lack thereof, for failing to draw the line clearly in the first place. I think the jury did the right thing. Most of us are selectively pious. We like to single out villains when bad things are done. It's harder to admit that the bad things are extensions of good ideas and that the people behind those ideas include us. What happened to Navarro wasn't a bad doctor. It was a system that has increasingly pushed boundaries to get organs that save lives. As Art Caplan puts it in the Times story:

There's a growing waiting list; there are more centers competing for donors; and it's a very lucrative procedure for hospitals. It's against that backdrop that the story of a doctor being sent out to come back with organs unfolds.

The pressure has reached the point where doctors at one hospital, as noted here,

removed hearts from infants 75 seconds after their hearts stopped. The infants were declared dead of heart failure even as their hearts, in new bodies, resume ticking.

It's a discomfiting new trend of treating people as bags of organs. But the driving force behind this trend isn't Hootan Roozrokh. It's all of us.

Meat Wagons

If you're old enough to imagine your dead body being carted away, you're probably old enough to remember "Meat Wagon Action Set," the sidesplitting (oops—wrong metaphor!) parody ad that first aired on Saturday Night Live in 1977. It looked like an ordinary commercial for a kids' race-car set until one car crashed and burst into flames. That's when the flagship vehicle arrived: an ambulance that picked up the bodies and hauled them away. In the background, you could hear the manly jingle, "Meat Wagon ..."

Back then, "meat wagon" was just slang for ambulance. No more. It's about to become quite real. Here's the skinny (oops—bad metaphor again!) from Rob Stein of the Washington Post. Backed by a three-year federal grant,

New York City is working on a plan to deploy a special ambulance to collect the bodies of people who have died suddenly from heart attacks, accidents and other emergencies and try to preserve their organs. If the "rapid-organ-recovery ambulance" succeeds, officials would like to expand the unique pilot program citywide with a fleet of ambulances and eventually duplicate it in other cities.

Stein explains how the plan would work:

Once all hope for resuscitation was gone, and as long as no family members objected, the victims' bodies would be transferred to the organ ambulance team, even if the victims' willingness to be organ donors was unclear. The crew could then perform measures on the body to prevent the organs from deteriorating, including chest compressions with an automated device and pumping oxygen into the lungs through a tracheal tube to keep blood and oxygen flowing. The crew might also administer the blood-thinning drug heparin to prevent clots while speeding to Bellevue. At the hospital, doctors could take additional steps, such as inserting a plastic tube known as a cannula into an artery, usually in the groin, to infuse the body with fluids to cool and preserve the organs. Organ bank workers would then assess whether the person was a suitable donor, determine whether they had an organ donor card or were listed on an organ donor registry, and try to locate a family member to give consent.

As you can imagine, the plan is freaking some people out. One bioethicist calls it "disgusting." But let's step back and understand what's going on here: Medicine is becoming ever more efficient and rational. Thanks to improving technology, organs that were previously useful only to their owners are now useful to other people, too. This has created pressure on doctors to think about dying people as resources, not just as patients. This pressure, in turn, has driven a movement to loosen organ-collection rules so that people who aren't yet brain-dead can be prepped for harvesting.

Meat wagons are the next step. They advance the rationalization of organ harvesting from the hospital to the street. Instead of letting perfectly good innards go to waste, they go out and get them.

If this creeps you out, you're not alone. But remember Human Nature's first law: In technology, bad things don't happen because they're bad. They happen because they're good. Nearly 100,000 Americans are officially waiting for organ transplants. Just yesterday, a friend of mine disclosed that her kidneys are failing, and she needs a donor. When you think about all these people, it seems crazy that healthy organs are being routinely thrown away with their owners. Stein reports:

Currently, New York City paramedics try for about 30 minutes to revive patients whose hearts have stopped before declaring them dead, while a doctor monitors their efforts remotely. The bodies are then taken to a funeral home, morgue or medical examiner's office.

The meat-wagon plan would end this presumption of nondonation. But the shift of presumption wouldn't start at death. It would start beforehand. Things you would never do to a hopelessly dying loved one—automated chest compressions, oxygen pumping, and injections of blood thinners of preservatives—make perfect sense when you start to think of that person as a failing organ bank. Nature doesn't give you the luxury of waiting for total, irreversible death. She starts ruining organs well before that. If you want them, you have to move fast.

Meat wagons won't be the last step in the movement toward efficient organ harvesting. The next steps are already underway. As Stein points out, the compressions and injections would begin on board the meat wagon "even if the victims' willingness to be organ donors was unclear," in order to keep open the harvesting option while organ collectors hustle to locate family members and lobby them for consent.

The next barrier to go will be the five-minute rule. Under the current plan, Stein reports, "The organ team would wait five minutes after EMTs give up on resuscitation, to create a clear demarcation between efforts to save lives and those to preserve organs." But in those five minutes, lots of organs will spoil. Once we've accepted the idea that dying people are also organ banks, it's hard to see why we'll tolerate this delay. We'll probably shorten it a minute at a time.

We'll also dispense with the distinction between ambulances and meat wagons. For now, officials are determined to keep these functions in separate vehicles, so families and neighbors don't freak out when the ambulance shows up. But in the long run, it makes no sense to have a vehicle on the scene that can do only half the job. I can't imagine cities assembling, staffing, and dispatching fleets of meat wagons when they already have fleets of ambulances ready to be dually equipped.

Until then, fear not the meat-wagon siren. As long as you can hear it, it wails not for thee. At least, not yet.

Marrow With Children

If you're tired of reading about how dead Hillary Clinton is or how long it'll take her to admit it, fly with me across the Atlantic for a couple of minutes. A monumental debate is going on in the British House of Commons over the Human Fertilisation and Embryology Bill, which will influence how governments around the world regulate family and reproductive issues in the next century.

Everything's on the table in this free-for-all: late-term abortions, human-animal hybrids, and IVF for lesbians and unmarried women.

The liberals are steamrolling the conservatives. None of the proposed restrictions has passed. But what's really intriguing is the difference in vote counts among the various issues. It tells us something about which values people care about most. Is it life? Sex? Human dignity?

Here's how many members of Parliament voted for each proposed restriction:

A. Ban abortions after 22 weeks instead of the current 24 weeks: 233.

B. Require clinics to consider the "need for a father" in approving women for IVF: 217.

C. Ban abortions after 20 weeks: 190.

D. Ban the use of gutted animal eggs to make human embryos for research: 176.

E. Ban genetic testing of embryos to choose (for implantation and birth) those that could grow tissue for transplant to an already-born sibling: 163.

F. Ban abortions after 16 weeks: 84.

So the most popular restriction was on late-term abortions. Chalk one up for life.

But wait: The number of votes to prevent lesbian parenthood beat out the number of votes to prevent abortions after 20 weeks. From this, you could make a pretty good argument that feminists are right: Some supporters of abortion restrictions care more about regulating sex and family structure than about protecting life.

Personally, I'm sure of this. The proof is that most people who support abortion bans also support exceptions for rape and incest, where the life considerations are the same, but the sex and family-structure considerations are different.

Now look at the vote count on banning human-animal hybrids. The hybrids in question aren't equal mixtures of human and animal. They're fully human cell nuclei cloned inside eviscerated animal eggs, for lack of available human eggs. In other words, the animal contribution is minimal, almost inconsequential. Furthermore, the embryos are just for research and cell derivation, not for procreation. I'm not saying this is unobjectionable. I'm just pointing out that the degree of mixture is trivial.

Nevertheless, the number of votes to ban it is more than double the number of votes to ban abortions after 16 weeks. To that extent, "human dignity" beats out life. It seems that keeping our DNA separate from that of animals is more important than saving those second-trimester babies.

But that's still not the headline, in my book. The headline is that restrictions on lesbian IVF and trivial species mixture outpolled restriction of genetic testing to choose embryos for tissue harvesting. The common term for this practice is "savior siblings." Here's the prototypical situation: Your daughter has a serious disease. She needs compatible bone marrow. The best way to get it is for you and your spouse to make another baby and transplant its bone marrow to her. But not all your offspring will have tissue that matches hers. To guarantee a match, you need to make a batch of embryos, implant one that matches, and forget about the rest.

The happy ending is that your daughter is saved, and you've made another child to love. But you've also crossed a line. You've made a bunch of human embryos and then flushed them not because of anything wrong with them, but because they weren't useful. And if there's no tissue match, you've crossed that line for nothing.

In my view, the rise of this mentality -- the reconceptualization of human beings as medical tools and resources -- is way more dangerous than gender upheaval, species-mixing, or even abortion. Abortions, no matter what you think of them, are defensive. Tissue harvesting, on the other hand, carries an affirmative mandate. It entitles you, and arguably obliges you, to deliberately create new human life, which will then live or die based on its utility to others.

Contrary to pro-life rhetoric, there's no broad incentive to increase the number of abortions. But there's plenty of incentive to increase the number of sibling saviors. That's why sibling saviors scored so well in the House of Commons. This is one thing I've learned from covering biotechnology: Bad things don't happen because they're bad. They happen because they're good.

Keep an eye on this utilitarian mindset as we continue to take ourselves apart. As the British debate illustrates, it'll be hard to stop.