Science Created Dilemmas

This is a summary, compiled as at June 2005, of individual talks given to the U3A Science Group during the 1990s and early 2000s.

Over the past few years I have given a series of talks to the Harrow U3A Science Group. They all had one basic theme – the problems and dilemmas that our generation have created, but which we will probably have to leave to the next generation to resolve. These problems have arisen as a result of the enormous advances in science, chiefly in medicine, since WW2.

For the most part these scientific and medical advances are for the benefit of mankind but many of them create moral, ethical and legal dilemmas that never existed before. The dilemmas I deal with are the advances since WW2 – i.e., for the most part in our lifetimes and which, one can perhaps say, have been created on our behalf.

I do not deal with pre-WW2 problems – problems that have always existed e.g. if there is a shortage of medication, or hospital beds or facilities for an operation - how do you decide which patient should be treated and who, perhaps, be allowed to die? That problem has always existed, and probably always will. But where medical advances have created opportunities for treatment that did not exist before, and where it is those advances that have created fresh dilemmas, they come within our scope. Basically I am dealing only with new problems – ones that never existed before the past 50 years or so.

In these talks I ask questions – There are perhaps no true answers – there will just have to be a consensus of what we do about it.In all these cases it is not a question of one party being right and the other wrong. That’s easy to decide.You probably know the story about the two people who had a dispute and went to the priest, or rabbi or mullah or whatever. The first man told his side of the dispute, and the rabbi said, “H’m, yes, you are right”. The second man told his side, and the rabbi said to him as well, “H’m, yes, you are right”. A bystander who heard all this said, “But how can they both be right”. The rabbi turned to him and said, “H’m, yes, you are right”.What do we do when they are both in the right?

The wide range of subjects I have discussed over the years include:

In Vitro Fertilisation, DNA, Making use of embryos, Cloning, Transplanting of body parts, Experiments on animals and humans,Surrogate pregnancy. Genes and Genetic engineering, Internet, Resuscitation of very sick babies and terminally ill adults, Stem cell research, Storage of gametes and ovarian tissue Nuclear Power, Genetically modified crops, Nanotechnology, Intellectual Property Rights (Patents) and so on.


And day by day dilemmas that previously one would have never dreamed of arise, and it shows how these dilemmas have grown over the past 50 or 60 years or so.

I talk each time, of course, about only some of this large number of dilemma areas.There are two types of objection to modern scientific work. One is on ethical or moral grounds i.e. that it is simply wrong and we should not do it.The other is that it is dangerous. The dangerous developments are the types which some people fear may bring about the destruction of life as we know it and examples are the first three listed above. The ethical problems mostly involve individual human beings.

Every scientific discovery creates some problem. The discovery may be greatly for the benefit of everyone, or most people, but there is bound to be aspects which are considered wrong from some point of view, and every discovery is bound to bring about some unhappiness.

Adam & Eve disobeyed and ate of the Tree of Knowledge and started to make discoveries, and you know what happened to them. And for 5000 years we have been trying to get back to Eden. Prometheus was punished for stealing knowledge of Fire from the Gods even though it was of great value to people on earth.

Every scientific advance today will have some people saying they have gone, or are about to go, a step too far. But people’s attitudes change. When in vitro fertilisation started a few decades ago, many people considered it an abomination and contrary to nature. Over the years IVF has performed wonders and brought much happiness, and today very few voices are raised against it.

But IVF has permitted further developments such as the production of embryos for experimentation purposes, or for storage for use many years later, or for extracting Stem Cells to assist others, and even for selection to produce what are called “designer babies”. Many people would say these advances are many steps too far.It is up to us, or our children, to consider the ethical issues and make up our minds about what is right or wrong, or what our consensus of opinion should be.

Well, let’s dive in with examples of the type of dilemma I’m talking about – dilemmas that would not have been thought of in one’s wildest dreams (or nightmares) only a few decades ago:


Implantation of embryos.

Now, for quite a while it has been possible to create an embryo “in vitro”, i.e. in a test tube, by extracting eggs from a woman and fertilising them in vitro with the husband’s, or today one should say, partner’s sperm. Previously the embryo would be implanted right away in the biological mother and, if it took, the embryo would develop, after about eight weeks or so, into a foetus and a child would then be born in the normal way. Thousands of infertile parents have benefited.

Generally a few embryos would be implanted to increase the chances of one taking – and often this would produce twins, or triplets or even more, which itself created an ethical dilemma about whether the NHS should bear the cost of the inevitable extra post-natal care needed, when the procedure had been done privately at the wish of the parents.

However, more recently it has became possible to go further and freeze the embryo and preserve it, (although this is still a controversial subject) and implant the embryo, or embryos, some time later. This became a godsend to childless women who had developed various forms of cancer, where the therapy, chemo or radio, would destroy all the eggs in her body.

The new procedure has been to extract some of her eggs before the cancer treatment, fertilise them with the partner’s sperm in vitro and then freeze and store the resulting embryos. When the woman had recovered from her cancer treatment the embryo (s) would be implanted into her uterus to produce a child. Incidentally the freezing caused problems but recently we read about a new process of quick thawing which may solve some of those problems. Such is the speed of modern medical advance.

Now, two childless women were due to have cancer treatment. To be able to have children later they and their partners went through this procedure and when the cancer treatment had been done and the women had recovered, they wanted the embryos implanted so that babies would result in the normal way.But, in their case, it was not that easy. In the meanwhile both partners and the women had separated , and both men refused to allow the implantation to take place. One woman accepted the situation and took it no further. The other woman went to court.

She argued that the biological mother should have the right to bear the child that she and the biological father had willingly conceived.The biological father argued that he should not be forced to become the legal father against his will with all the financial consequences. Once the embryos were destroyed the biological mother would never, ever, have a child of her own, while the biological father could go off and have as many as he wanted. Is that fair? Well, what does the law say?

The Human Fertilisation and Embryology Act 1990, which controls these matters, said that at the time of re-implantation both the biological father and biological mother must agree to the implantation, otherwise the embryos must be destroyed.In court after court right up to the House of Lords, it was decided that the biological father could not be forced to become the legal father (with all the responsibilities that meant) without his consent. The woman took the case to the European Court of Justice claiming that under the Human Rights Act she was entitled to have a child. The court agreed that she had the right to have a child, but not the right to be given a child. It was all very sad, and all very difficult. However, discussion is continued about whether the Act should be altered.

(As at 13 Apr 2007 her appeal to the European Court of Human rights had been rejected in a 5 – 2 decision. She then appealed to the Grand Chamber which is the highest tribunal in the European Court of Human Rights. 17judges considered her appeal and in April 2007 her appeal was again rejected. There is no appeal above the Grand Chamber, and the embryos would be destroyed.

In their judgment the Grand Chamber said that they considered that her right to become a parent in the genetic sense should not be accorded greater weight than his decision not to have a genetically related child with her. Accordingly the UK rule under the Human Fertilisation and Embryology Act could not be over-ruled. That Act stated that in such cases both genetic parents must consent and approve at every stage, otherwise the procedure cannot continue).

There have been much discussion and disputing about the many pros and cons, and a clamour for a change in the law will continue. One strong point in her favour is that unless the embryo or embryos are implanted in her, she can never become a genetic mother but he can have as many children as he wishes.On the other hand however, if the situation were reversed and the original partner were to become infertile, one would not expect Natalie Evans to agree to the embryos being implanted into his new partner.
(the discussion continues...)

Such a dilemma would never have even been thought of a few decades ago, and it is an example of the dilemmas that scientific advances over the past few decades have produced. The development of IVF and the later storing ( and selecting) of embryos produced a host of moral dilemmas that were previously unheard of.


Let us take another example of this type of new dilemma. A child in a family called Hashmi suffered from a serious, and ultimately fatal, blood disease called Beta Thalassaemia. The usual treatment is by transplanting marrow that contains stem cells, taken from the bone of a matching donor – usually a sibling. The parents attempted to produce suitable children by normal methods but failed. It was suggested that the parents should produce a number of embryos, made by fertilising in vitro the eggs of the mother by the sperm of the father.

Scientists would be able, by examining the embryos while they were a few days old, to determine which would produce foetuses, and then babies, that would not themselves suffer from the disease, but would have the matching stem cells which might cure the sick brother. Those embryos would be implanted into the mother’s uterus, but the other embryos would be destroyed. The appropriate stem cells would, in fact, be taken ultimately from the umbilical cord at the time of birth.

Apart from the ethical question of whether one should actively destroy unused embryos that some people would consider already human, the ethical question that arose is: is it morally right to bring a child into the world for the purpose of it being of benefit to someone else? It could be a slippery slope. Would it lead to producing human embryos for general use by other people, leading on, perhaps, to allowing those embryos to grow into foetuses, or babies or even grown people, purely to be used for spare part surgery? Is that far-fetched? Many people don’t think so.They think it is quite on the cards.

The parents applied for permission to the Human Fertilisation and Embryology Authority (HFEA), created under the 1990 Act. That authority had been given power to authorise the selection of “suitable” embryos, i.e. embryos free of certain hereditable diseases for implantation to produce a healthy child. This was intended to be for the benefit of the child itself. There were many arguments for and against but, after much discussion, the Authority gave permission for the parents to go ahead, even though the selection of embryo would not be for the benefit of the child itself but for another’s benefit. The House of Lords upheld that decision by broadening the meaning of “suitable” to include being suitable from the mother’s point of view. I think it was a surprising decision.

In this particular case it could produce a desirable result, but it does create serious dilemmas that the new Parliament will have to resolve. Does it mean, as some complain, that it is now up to the mother to select the babies that she considers more “suitable”. Does that include “designer babies”, such as male or female, blue eyed , tall or short etc because she considers those characteristics more “suitable”? We shall have to wait and see what Parliament decides.

One’s gut feeling is that that in that particular case the decision is reasonable, but it can lead to problems. Apart from the “slippery slope” question, psychologists wonder what effect it will have on the selected child when it learns that it was brought into the world, not just for itself, but mainly (or exclusively) for the benefit of another... It’s a dilemma and the answer is not yet known.

(A few years later Parliament had to decide on this dilemma during debates on whether the whole Human Fertilisation & Embryology Act should be brought up to date. This question of ''Saviour Siblings'' produced long and, heated discussions, but it was decided that it was wrong to produce a child that was being produced for another's benefit. The selection should only be to decide whether, in view of that child's own health condition, they should continue with the implantation).

Incidentally, the very word ‘selection’ is unfortunate, It was the word used in the German concentration camps to decide who would die or be allowed to live. some people would say that selecting which embryos should be allowed to live and which to be destroyed is, in principle, the same thing. Incidentally, research into genetic engineering and embryology in Germany and Austria is far less advanced than in other countries because of the particular German history in the misuse of that science to produce a superior race of people.

Critics say that selecting embryos is “playing God”. All human embryos are, they say, actual or potential human beings, and selecting which are to live and which to die should not be allowed. As an editorial in the Times newspaper some time ago said, “What was previously in the gift of Nature, or God, is now a matter of consumer choice”. Previously, one would not know until the child was born (and perhaps not even then for many years) what the child’s condition, or state of health was going to be. Is it a good thing that now we can know in advance, and is it a good thing that we can do something about it in advance?


World Wide Dangers.

The ethical problems we have just discussed involved only a few people. Some problems are of much wider, even world-wide, concern. Some such are Nuclear Power, Nanotechnology and GM Crops.

Nuclear Power is going to be more and more a problem and a dilemma, but soon we will have to decide. Nuclear power can solve many environment and fossil problems and, whether we like it or not, I think we will almost certainly have to take that route. Nuclear Stations are a danger (remember Chernobyl?) and disposing of nuclear waste will be a problem for a long time. It is intensely difficult weighing up the risks against the benefits but we will have to decide. The present Nuclear Fission system will in due course be overtaken by the safer Nuclear Fusion, but it looks as if that will remain a dream for at least another half century the demand won’t wait.

Nuclear power in the wrong hands can lead on to Nuclear Weapons - and nuclear weapons are a terrifying problem. It may be that while USA and Russia were, in practice, the only two powers to have them in large numbers and with the ability to deliver them, that balance of power of mutual destruction might well have prevented a conflict between them. But with more recent proliferation of these weapons, or the ability to produce and deliver them, a new dimension of fear of world conflict is emerging. What do we do to control it?

Another, more recent development is Nanotechnology, which operates on particles that are about a billionth of a metre in size. (That is a thousand millionth of a metre and a thousand times thinner than a human hair). It is impossible to imagine small sizes like that. Scientists are researching the use of molecular sized “nano-robots” that would be able to travel harmlessly through the bodies and even the tissues of people suffering, for example, from cancer, carrying chemicals that would search out individual cancerous cells and destroy them, leaving the other cells healthy. Today attempts to cure people of cancer cause great damage to otherwise healthy cells.

Some groups, including the Prince of Wales, fear that these nano-robots could be able to replicate themselves, could develop their own intelligence and then “take over” the world. Well, maybe, but considered too fanciful to be taken seriously.

Genetic Modification of crops.

It is claimed that this might poison our countryside and also poison all of us. But, on the other hand, it could lead to the ability to feed the starving millions around the world. When genetically modified crops (GM) first came in, many people argued that it was “mucking about with nature” to produce crops that way; that GM food was “un-natural”. Well, I can tell you that not a single item of food on your breakfast table this morning was “natural”. If it were left to nature every item of food that we eat, every flower that we grow would be very, very different from what it is now.

There is the story of a gardener who was showing the vicar around his beautiful garden. The vicar commented on God’s wonderful works. The gardener said he wasn’t so sure about that. . He said that when he returned after leaving the garden in God’s hands for a few weeks he found the garden in a terrible mess!

For hundreds, thousands, of years farmers have been altering their crops, and domesticating wild animals, taking action that might never have occurred by “natural” means. Domesticated animals are domesticated and not wild because we acted “unnaturally” in domesticating them. What scientists, including GM scientists, do, is provide the conditions where nature, acting in accordance with its own rules, produce what we want.

There is an anti-GM argument that what the scientists are doing never occurs in nature and that they are introducing a new mixture of genes that could have horrifying results. Well, obviously every “new” food has to be tested vigorously, and I can tell you that millions upon millions of people in many countries have eaten GM food for years and there have been no examples where the GM aspect has been responsible for illnesses, and none of the horrifying consequences have occurred.

One can argue that the testing has not gone on long enough – remember the thalidomide problem – but how long is long enough? Every advance carries some risk – and that applies when a cereal manufacturer adds something to the cereal to improve marketing, or when a nuclear power station is built.

There is an ethical question that must be resolved.It is claimed that GM food can be the answer to the third world’s food problems. That may be, but you know that farmers normally keep a proportion of this year’s crop for use as seed next year. Now it is claimed that GM manufacturers are able to produce seed that will grow wonderful crops this year, but the seed the crop produces are deliberately made sterile. So the farmer would have to go back to the supplier and buy a fresh lot of seed every year.Can that be ethically right?

Every manufacturer of cars or tractors etc, tries his best to make you go back to him to get “genuine” spare parts, when exactly the same spare part can be supplied by some one else more cheaply.The manufacturer of the GM seed, like Monsanto, are protected by patents that prevent other manufacturers producing the same thing more cheaply. Should they be protected that way? It is a question.

These dilemmas caused by Nanotechnology, Nuclear Power and GM crops may include ethical elements but the basic question is whether it is wise to develop them further We have to assess the risk, weigh it against the benefits, take precautions, and then make a decision.

With all the dilemmas I am talking about, there are always two sides to the question. The balancing of rights and assessing benefit and risk, is very difficult and it is usually impossible to come down 100% on one side or the other. Which brings me to the story of the man who was accused of a crime and insisted on being defended by a one-armed lawyer. He said he was fed up with these lawyers who kept saying: “On the one hand - but on the o-t-h-e-r.....”.

We have just referred to Patents. Let us have a look at that problem area. The cost to a pharmaceutical company of producing a completely new medicine or, for example a particular DNA test, runs into many perhaps hundreds, of millions of pounds. Throughout the world the research is all
done by private companies. They risk vast sums of money on research, finding out how to produce the pure product, and then they have the laborious task of getting it authorised by the medical authorities in the various countries. And sometimes it all fails in the end. So when it succeeds they need to recoup what they have spent and also be left with a profit, otherwise they will go out of business.

All countries realise this. So, when a manufacturer markets a new medicine or test they are permitted to patent the product, so that for a period time no one else is allowed to make it, or use it, without buying a licence, And the original manufacturer is also able to charge a higher price for the product without, in theory, fear of competitors copying the product and selling it more cheaply.

Copying a medicine that has been developed and approved, is comparatively simple and cheap. Some companies copy it slightly differently in the hope they can “get round” the patent. Some unscrupulous companies even manufacture exactly the same medication, wrap it in the same packaging as the original, and supply it as the original. This, of course, is illegal, but it happens and leads to many legal battles. Big money is involved.

There are ethical dilemmas about the extent to which the original discoverer of the product or test should be protected. This became a prominent problem regarding the expensive retro-viral drug to control AIDS that is rampant in Africa. And it is a particular problem for the 1% of Jewish Ashkenasi women who carry the genetic mutation of Tay Sachs, and accordingly have a greater pre-disposition to Breast Cancer. It is feared that the DNA test devised and patented by the company Myriad Genetics will become too expensive for the NHS. Their patent was to be challenged in the European Patent Office in June 2005.

Now, let’s look at some more discoveries since WW2:

DNA

Fifty two years ago, in 1953, two young scientists, Watson and Crick, discovered the structure of DNA.DNA is deoxyribonucleic acid. No doubt you know about the double helix shape of the molecule. Roughly it is like a ladder that has been twisted round into a spiral shape. The “rungs” of this “ladder” are made up of only four different chemicals which are the basic bricks of DNA. The sequence in which these four chemicals lie along the whole length of DNA is called the genome.

The sequence contains many, many thousands of steps and the actual sequence in which those four chemicals lie along the DNA determine how every form of life on earth will develop. Be it plant or animal, fish or fowl or human, however big or small, the sequence of those four chemicals on the DNA of the parents, determine that their offspring will have the sequence that will produce a worm from a worm, a rose from a rose and a human from human parents. Only four chemicals are involved: Adenine, Cytosine, Guanine, Thiamine - A C G T.

After many years of intense labour the actual sequence in which these four chemicals follow each other in humans, the human genome is known. The genome consists of separate sections, called “genes”, each of which serves a separate purpose.Scientists have been able to discover what many of the genes do – and also which cause, when not “normal”, a tendency to particular illnesses or disabilities.

It was also originally thought that a person’s DNA determines not only future health characteristics, but also social characteristics like personality and criminal tendency. But those features in a person are much more complex and depend on far more than just the DNA. What happens after the DNA stage is perhaps even more important than the DNA itself. Incidentally what should be done when health tendencies are known from the DNA raises many ethical questions, such as whether they should be disclosed to an insurance company or to a prospective employer.

The different sequences in the DNA (the order in which those four molecules of chemicals lie next to each other) run into millions. The sequences are so complex that it means that almost every person’s DNA is special to that person. It is said that the chances of two people’s DNA being the same can be measured as 1: several million or even more.

A National Database of DNA would mean that the identity of a missing person can be established almost immediately; a speck of the attacker’s DNA on a rape victim will give a very good clue to the identity of the attacker almost at once. Medical records can be made immediately available after an accident and so on. But many people say it is unethical to force people on to such a register.

DNA can assist in so many ways, and in ways that we can’t yet imagine. DNA plays an enormous part in forensic medicine – where medicine and law coincide. In crime it has an obvious and well known value, but it creates a problem in another aspect of law. We have all heard of cases where people have been found guilty of a crime and imprisoned and then, perhaps many years later, DNA proves they were innocent all the time. They are obviously released and compensated.

BUT (these BUTS keep cropping up) what about a person who was judged Not Guilty – and then later DNA proves he was guilty? What then? There is a rule called Double Jeopardy in English law, which says that once a person has been tried for an offence, he cannot again be tried for the same offence, whatever fresh evidence arises. There must be many people who know they were wrongly acquitted. DNA is such powerful evidence that it could prove that an accused person who was found Not Guilty was in fact guilty. Should new DNA evidencebe used to try such a person again.?
It is likely that in the future cases of murder and rape the Double Jeopardy rule would no longer apply.

BUT (again a but) mistakes can be made and we must not be too complacent about DNA testing. DNA can easily become contaminated and give false results, but the technology and its reliability is improving day by day.

Incidentally, DNA testing is obviously useful in “paternity” cases where women need to prove that a man with whom she had sexual intercourse, or if she claims raped her, is actually the genetic father of her child. It can also be used to prove he is not the genetic father – and there lies a problem.

Some fathers have doubts whether his wife’s child is also his (the number of jokes there are on this topic shows that it is a real fear). The test is quite simple – all that is needed is a small amount of tissue, like blood, hair or skin from the child and from the man, and it can all be done in confidence over the internet and by post! The way these tests, ordered on the internet is done is quite suspect and one can imagine the trouble it can cause. It is actually illegal, but that does not mean it isn’t done. But should it be carried out officially under control and available to anyone who happens to want it, without having to get a court order? Is it wise? Is it ethically right?

In France recently a man claimed from his wife and her lover repayment of the cost of bringing up a child that a DNA test showed was not his. He succeeded! Last year a man was charged with selling on the internet DNA tests at £600 a time. In fact he did not do any real testing and as often as not just guessed at the result. He must have caused an enormous amount of grief to parents. He was sentenced to three years imprisonment.

Because of the structure of the double helix, when an egg is fertilised by a sperm, half the DNA (i.e. one of the strands) from each parent is taken and the two halves combine to create the new being. The new being has certain characteristics taken from the DNA of each parent, but is not exactly like either of them....

...and that brings us to the ethical problem of...

Cloning.

Scientists can now perform a type of miracle that most people, and most governments, consider is certainly a step too far. Nature has always now and then produced twins that are identical to each other, (but different from each of their parents). Somewhere, shortly after fertilisation, the new DNA splits into two identical lengths of DNA and produces twins that have DNA different from their parents, but identical to each other.
Scientific technology can now produce CLONES that until recently could only be produced by nature. Artificial cloning can be for two purposes. There is Therapeutic Cloning and there is Reproductive Cloning. Reproductive cloning is in theory forbidden everywhere, but Therapeutic cloning may be more acceptable . More about that later.

At the start of the process the artificial cloning technique is the same for both. It is quite complicated but I’ll try to explain it briefly. Normal cells (called “somatic” cells) in the human body contains 46 “chromosomes” which contain the DNA. The reproductive cells, i.e. the egg and sperm, contain only 23 chromosomes each. During sexual reproduction these two reproductive cells combine at the fertilisation stage and become the normal 46 chromosome. In time, it will produce the child that will have the same 46 chromosomes in every cell of its body, except in its reproductive cells of eggs or sperm,which will have only 23 chromosomes. That child will not be a clone.

Cloning is the process by which an embryo, identical with one biological donor, can be produced. The first stage, as I have said, is the same for both therapeutic cloning and for reproductive cloning. A normal egg is taken from a woman, her half DNA (that is the 23 chromosomes) is extracted from it and replaced with all the 46 chromosomes of DNA taken from a somatic cell of the donor. The egg now has a full complement of 46 chromosomes. A small electric shock is applied and it starts the normal process of producing the embryo.

It is at this stage that reproductive and therapeutic cloning diverge. If reproductive cloning is being attempted the embryo would be implanted in an intended “surrogate” mother to produce, in due course, an offspring identical with the donor (i.e., a “clone” of that donor). What I have said is an over- simplification; it is an extremely difficult process and would only occasionally succeed. Producing such an identical human child is universally condemned (but how can it be universally controlled?) InEngland, it produced Dolly the sheep, but poor Dolly did not live a normal life. Claims of success have been made in various parts of the world but it does seem that England and Korea may have succeeded with a human clone, and no doubt every advanced, or semi-advanced country, can do it if it wants to.

The more acceptable, but still very controversial, type of cloning is cloning for therapeutic purposes. The same procedure is followed to produce a cloned embryo, except that the 46 chromosomes are taken from a somatic cell of the sick patient, so that the embryo will be a clone of that patient. By about the eight-cell stage of the embryo the stem cells are extracted from the embryo, for injection into the patient. Hopefully, these stem cells will develop in a way that will produce a cure.

Stem cells are basic cells that have the ability to grow into any and every part that make up the human body. As these cells have exactly the same DNA as the patient, the patient’s body should not reject them but allow them to grow to produce a healthy substitute for the unhealthy part of the patient’s body. Rejection by a body’s immune system of unwanted invasions is vital for the body’s survival, but it can be over zealous and, as in transplants of living bodily parts, it will usually reject them unless the DNA is exactly the same as its own. Therapeutic cloning is still in its very early stages and much further research is vital. However, if it is successful it is thought it could alleviate, or even cure, many serious and life threatening illnesses.

But the ethics of therapeutic cloning is being discussed right now all over the world.Those in favour of therapeutic cloning claim there is a fundamental difference between reproductive and therapeutic cloning. With reproductive cloning the aim is to reproduce a human being. With therapeutic cloning the intention is to use the stem cells from the embryo when it is only a few days old, and when it can be considered just a “bundle of cells” The embryo is then destroyed. The aim of therapeutic cloning is to save life, not create it.

But, again, is it right to produce a human embryo just for the purpose of providing stem cells for the benefit of someone else?Incidentally, there is a basic difference in attitude to stem-cell research in different countries. In USA it became a big issue in the Presidential election. President Bush said he is not actually banning stem-cell research, as many Christian fundamentalists in his party would like, but he would not grant any public funds to research it. Kelly said this amounts to a ban. The British government wants Britain to be in the forefront of stem-cell research, and American research scientists are in fact coming to UK to carry on the research.

The main ethical argument against Therapeutic Cloning is that at the moment of fertilisation a human being is formed. It may be only a tiny being and perhaps just a few bundles of cells, but it is human and should be treated with all the respect due to a grown human being. . It should not be used for our own purposes, and then destroyed. They say that any claims that at the early stages it has only human potential are made for our own selfish purposes.

It is indeed very difficult to know up to what stage it should be ethical, if indeed it is ethical at all, that the fertilised egg should be used for our own purposes. Is it when the primitive streak or first signs of a nervous system appears which seems to be within 14 days or so? If it cannot be used after fertilisation would it mean the end of stem-cell research?

It is a real ethical, religious and even legal dilemma. Even if a consensus can be achieved, stem cell research would have to be strictly controlled to try to prevent misuse.I think that in UK experiments can be carried up to the 14 day stage.

Well, it is something to think about. What do you think? The ethical dilemma of therapeutic cloning will be a problem that won’t be solved overnight.


Resuscitation

There are cases currently in the courts about the right of doctors to cease treating patients where the doctors decide it is not in the best interests of the patient to be resuscitated..You probably know the saying:

“Thou shalt not kill but needst not strive, officiously to keep alive”.

In English law you may not kill, but if you do nothing to prevent another person being injured or dying you are not guilty of an offence. Thus if you see that a person is drowning you are not guilty if you do nothing to try and save him or bring help. Doctors, however, do have duties towards their patients, and the main one is to strive to keep them alive. But what is meant by “keeping alive”?

Modern medicine can keep patients nominally alive, where previously there was no choice. They are permitted in certain circumstances, where it is not in the patient’s interests, to refrain from taking steps to revive the patient, even if resuscitation would keep him nominally alive.They are not permitted actively to cause death to occur (that would be murder) but, in theory, may for example refrain from giving any food or water.

You will remember the case of the American paralysed lady who had been fed through a tube in her neck for many years. The whole country was involved in the dispute and the courts finally ruled that the tube had to be removed and the lady allowed to die. Is removing the tube the equivalent of killing her – or is there a difference? It’s a dilemma.

There are strict rules and regulations that govern the matter, and it must be discussed with the patient if possible, otherwise with the relations. Where the patient is a sick child or baby the parents are obviously involved. It is always an agonising decision to make and one has sympathy with all involved, in particular the parents. If the doctors and the parents cannot agree the court is asked to decide.

That has happened in a case in UK where the baby was born three months early weighing only 450gr (16 ounces). She has damaged heart and lungs, has nearly died (and been resuscitated) on three occasions. The hospital says that if it happens again the Intensive Care Unit would not want to accept her. The doctors say she will never be able to leave hospital. The child is now ten months old and the parents say she recognises them. The parents refuse to accept that the doctors can do nothing more for the child. They insist the hospital must do all it can to keep her “alive” in the hope that one day medical advances will permit their child to live a normal life. The effort and facilities the hospital would have to provide would inevitably be a strain on its resources.

How does one balance up the pros and cons in a case like this? I think that on other occasions when this problem came before the court, the courts agreed that the doctors’ decision was the right one. What about this case? The parents wanted the child to be kept alive as long as possible in the hope that a “miracle” might happen.

In this particular case the High Court earlier decided that it was not in the 11 month old baby’s best interests that she should be artificially resuscitated when her condition next deteriorates. The parents appealed. The court upheld the previous decision but wants to be kept informed about the child’s condition.

I am glad I do not have make a decision like that, but some doctors have to make decisions like that all the time. It is a great pity that in sad cases like these the English adversarial system of trial has to be used. It is so much better to get a consensus. But what is the alternative if one party refuses, for whatever reason, to give way?

Secular and Religious Attitudes.

I should like at this stage to say something about my understanding of the difference in secular and religious attitudes to these types of dilemmas. It is not easy to summarise as, with dilemmas like these, there are inevitably differences and contradictions within all aspects of society. Basically, I would say, the secular attitude is based on RIGHTS and the religious attitudes on OBLIGATIONS.

Thus when a dilemma arises, the secular attitude is to look at it from the point of view of the rights of the parties involved, and in particular the right of the patient to decide what should happen. The religious attitude is what are the obligations of the patient and his family and medical advisors.

All orthodox religions have the attitude that human life has infinite value, that ageing, illness and death are part of life, and one is obliged to maintain and improve one’s quality of life. Thus the patient must not withhold treatment or commit suicide, or approve of euthanasia. This suggests a diminished role for the patient to make decisions, but the secular attitude is that the patient has complete autonomy (assuming he is capable of making decisions).

One Jewish halachic view, however, is that when the patient is terminally ill and in pain, treatment can be stopped. Christian orthodox view is that the embryo is a human being from the moment of conception and must be treated as such. Jewish Talmudic Law assumes that full title to life arises only at birth, but there are restrictions on when abortion is permitted. In Islamic law the soul is linked to personhood, and the stage at which the soul enters the embryo varies from 40 days to 4 months after conception - but abortion is subject to controls.

The strict religious view is that everything must be done to prolong life but once the “death process” has begun it should not be hindered. It must, of course, often be a question when the death process has begun, after which treatment should be halted. It must be hoped that when a rabbi, or priest or mullah, is presented with these dilemmas he will attempt to ease as much as possible the pain suffered by both the patient and the family, irrespective of his own orthodox views.

Abortion

Abortion has always been an ethical as well as a medical problem. Recently however, medical advances permit keeping a premature baby alive in circumstances where previously it would have died. The current limit in UK for abortion is 24 weeks of pregnancy, except for particular medical reasons. Many babies born between 20 and 24 weeks are able to survive – although many with sad disabilities. There has been discussion about reducing the limit to 20 weeks but in June 2005 GPs voted against reducing the limit. Many people condemn abortion at any stage. What should the limit be?

Transplant of body parts.

Shortly after WW2 the first heart transplant took place in S.Africa. The recipient did not survive long. Since then more and more heart transplants have taken place and the recipients have been living longer and longer. Also transplants of kidneys, liver, lungs etc have become more common. Research continues with practically every organ of the body.

But there are two main problems. First, the medical problem of “rejection”. Over the millions of years of evolution our bodies have produced wonderful methods of protecting us from “foreign” invasions of all sorts of microbes etc. When this invasion occurs the body’s “immune” system attempts (usually with remarkable success) to reject the invaders. The immune system can be so powerful that it sometimes reacts to its own body as if it were foreign, with serious results. This is auto- immune disease. Thus any attempt to transplant a foreign body, like someone else’s heart or kidney etc, is faced with overcoming the intense inclination of the recipient’s body to reject it.

There are drugs that aim to reduce this rejection (but these drugs can also produce undesirable and dangerous side effects). The best way is to get a “match”. The best matches, as we have said, are likely to be between siblings, but a heart can only in practice be taken from a donor who has just died, and it is unlikely that a sibling will conveniently die at the right time There is actually a book based on a murder for that reason.

Doctors have to rely generally on donors who, in their lifetimes, donated their organs to be removed on death. And we have all heard of a mad rush to get a matching heart to a seriously ill person before the heart deteriorates.

The situation is not quite so dire regarding transplants of, for example, kidneys. We each have two kidneys and can easily carry on living with one only. Parts of a liver can be taken for transplant as what is left of the liver can repair itself to its normal size (provided it is not the liver of an alcoholic!) . So siblings, or parents, can come to the rescue with little or no harm to themselves.

In USA they have, or plan to have, a National Register to match in advance between recipient and donors who donate on their death. In UK the Department of Health say it is only ethical to take a kidney from a close relative or friend, but it is expected that sooner or later there will have to be a register here of donors and recipients who are strangers to each other.

There is an extreme shortage of kidney donors, and there are a large number of people in dire need of them. So what happens? The market intervenes. A large market – a black market in effect – where people are paid to give one of their kidneys while they are still alive. I understand there is a flourishing market in India where for a small payment by our standards, but an enormous amount by their standards, many poor Indians are selling one of their kidneys to be despatched to Britain. The intermediaries claim they extract the kidneys under ideal hospital conditions (but one can be a bit cynical about that). In U.K. presumably the kidneys are checked carefully, not only for matching, before being implanted in the patient Incidentally, quite recently a man advertised in USA for a kidney donor, As a result he obtained a kidney and paid, he says, only the donor’s expenses.

Is such a trade ethically right? We may discuss that question academically, but it is obvious what the answer would be from a patient here who is, perhaps literally, dying for a transplant. A while ago a British doctor, originally from India, arranged for his patient to get such a kidney from India. The patient had to pay for it, but the British doctor received nothing. He apparently did it just to help his patient. Unfortunately for this doctor the General Medical Council was told about it and he was struck off for a period. Was that right? The GMC were right in following the rules, but equally was the doctor not right in wanting to assist his patient?

If the “trade” were legalised it could be easier for it to be monitored officially all the way from the donor to the recipient. It would then, perhaps, all be done on a healthier and fairer basis. BUT, and there is always the “but”, people selling their kidneys, in England as well as abroad, would obviously be from the poorer classes who are desperate to assist themselves or their families. Does this mean we would create an “underclass” of people whose bodies can be “plundered” for our benefit? And if these body parts can be bought and sold would it mean that people who would normally donate their organs on death would cease to do so?

There is a similar problem with blood. In USA, I think, people are paid to donate their blood. That is forbidden in Britain. These are problems, with practical, as well as ethical, elements.Incidentally, should the donor be permitted to specify the type of person who should, or who should not, be the recipient of his body part?In England that is not permitted.


Experiments on Animals and Humans for Medical Research.


Animals can neither consent or object to experiments on them. There are very few medications in use today that were not at some time tested on animals. Are we entitled to use animals in this way for our benefit? If so, which animals? How high up the animal ladder? For some diseases animals like gorillas that are closely related to us have to be used. Animal Rights Activists have no doubts about it and spread information (and mis-information) about what happens.

In England there are now very strict rules and regulations about the use of animals. But if it is wrong to experiment on animals should it be banned even if it means the research will be exported to countries that care less for the welfare of the animal? A little while ago a senior person in the Animal Rights organisation was receiving treatment for a serious illness. The medication she was given would not have been available if it had not first been tested on animals. Her excuse for agreeing the treatment was that alive she could help animals more than if she were dead!

And what of experiments on humans? In theory humans can make an informed decision about whether they agree to be experimented on. Terminally ill patients? Convicted criminals in return for a lighter sentence? Researchers often experiment on themselves – sometimes with fatal results. The history of research in the 19th century shows how often research was carried out on soldiers or civilians who happened to be in hospital, without them knowing. And we recently heard about the experiments on children in an orphanage in Ireland – and that was in our lifetime.

And what of the terrible experiments carried out by the Nazis on prisoners in concentration camps? No doubt medical research may have benefited to some extent. Should such wrongfully obtained knowledge be used? The ethical view is that it should not be used, even if could help sick patients, but is that the wise thing to do? Should it be used to assist further “clean” research? To draw an analogy from law - In English law any evidence or confession that has been obtained by illegal means, may not be used in court – even if it is conclusive evidence of guilt. An extension of that ethical problem is: what if the illegally obtained information permits the police to follow a different lead which itself leads to legally acquired evidence –is it ethical that that evidence should be used?

Storage of gametes (i.e. sperm and eggs.)

Sperm has been able to be stored for some time, and has been used when there was a danger that the male partner may die or be unable to produce sperm. It has been used by soldiers or men on dangerous jobs or missions. You probably remember the case of Diane Blood. Sperm taken from her partner while he was comatose and dying, was used by her after his death to produce an embryo in vitro and subsequently to produce his child. As the donor of the sperm could not have given his consent (he was comatose at the time) it was not permissible in England. However it was carried out abroad and in fact she was subsequently permitted to register her dead partner as the legal father.

Whether it was ethically right or wrong I think we would probably feel it was the proper thing to do!

And now, briefly :

Confidentiality

HIV & AIDS has spread widely since WW2. If a person has been diagnosed with HIV AIDS, should his or her partner, or others with whom he or she is sexually active, be warned.? Normally all medical information is confidential. Should that apply to HIV AIDS?

A TB sufferer who had infected 12 people refused to be treated. He could be detained in hospital but he could still refuse treatment. He was violent and a danger to the nurses. He has a right to privacy so his name could not be published and people be warned to keep away. Should the state keep him safely locked up and his medicine forced into him? Whatever his behaviour, is it ethically right for the state to do that?

Autonomy.
In medicine this means that the patient (provided he is mentally competent) is entitled to decide what medical intervention he is to have. A seriously ill Jehovah’s Witness had cancer and was ready to accept (and indeed demanded) part of the treatment but refused the part that involved his being given blood.The doctors considered that the patient had the right to decide. They administered only the first part of the treatment and did not administer the blood. They and the nurses then suffered torment watching him die. He said he had refused to do anything that he thought would prejudice his chances of being accepted into Heaven. Were the doctors right?

Internet

Internet is only about 15 years old, but it has entered into almost every aspect of communication – often with results not only unexpected but also disastrous to many children – and also many adults. It is a powerful instrument for good, but its very instant, international aspect creates problems and dilemmas about how to control it. The Western technology of internet is of great value to terrorists when organising their activities and propaganda. And it enables large numbers of people to “swarm” to one spot at incredibly short notice to behave as a “mob”.How do we control Internet? We do not yet know the answer.

Some further questions.

• Should a family, entirely of deaf people, be entitled to choose an embryo that would produce a deaf child? They claim that it would enable the child to fit in better with the family.
• Should "Siamese twins" be separated for the purpose of giving the one a better chance of survival, if it means definitely killing the other? The Law says killing is illegal even to save one’s own life – (except in self defence).Marooned Sailors marooned on a raft selected one who would be killed to provide food to keep the others alive . It was treated as murder.
• Should life support continue to keep a terminally ill pregnant women alive (perhaps weeks... or months) to enable the foetus to grow and be born?
• Should a 7 year old child be forced to give bone marrow to save its sibling even if the child refuses to give it. Can a 7 year old give "informed" consent or refusal?

Conclusion:

So, in conclusion, our grandparents would be amazed at the type of ethical problems we are faced with today. We know that as science advances, and it is advancing more and more rapidly, our children and grandchildren are going to be faced with dilemmas that we, in our wildest imagination, cannot envisage.

In the scientific world generally, and in the field of medicine particularly, there will be no advance that does not bring with it a dilemma. To quote a phrase from medicine - there is no gain without pain.

Thank you.

-oOo-