Tuesday, September 20, 2005

The Rise of “Psethics”: The “Frozen” versus “Fresh” Embryos Debate and The Bankruptcy of Contemporary Medical Ethics:

The old adage “straining at gnats and swallowing camels” is nowhere more true than in what passes for contemporary medical ethics. We really should start calling pseudo ethics something else to distinguish them from the real thing. Perhaps “psethics” (pronounced “sethics”) will serve?

The National Post of September 13, 2005 contains an article by Margaret Munro “Moratorium Urged on Use of Fresh Embryos: Women at Risk – ethicists” in which two leading Canadian physicians concerned about ethics decry the use of “fresh embryos” for establishing stem cell lines. Here are the relevant paragraphs from the Post article:

“Two leading ethicists, shocked by the use of days-old human embryos to create stem cells in a Toronto laboratory, are calling for a moratorium on "fresh" embryo donation in Canada.

Dr. Jeffrey Nisker, of the University of Western Ontario, warns in the Canadian Medical Association Journal today that women who donate their fresh (as opposed to frozen) embryos for research may decrease their chances of getting pregnant in the future.

Dr. Nisker is calling for an "immediate moratorium on fresh embryo donation until professional practice guidelines and other national regulations are developed".

Dr. Francoise Baylis, of Dalhousie University in Halifax, echoes his concerns, saying women are at risk given the "inadequate" protection now in place. She also raises questions about the "surreptitious" way a federal research agency, which has vowed to protect women and their embryos, rewrote this country's research rules in June without telling the public.

The Canadian Institutes of Health Research quietly changed the rules on June 7 to explicitly allow stem-cell researchers to use fresh human embryos. Two days later, on June 9, a Toronto research team headed by Dr. Andras Nagy announced it was not only working with fresh embryos but had used them to create Canada's first human embryonic stem cells.

Stem cells have the potential to turn into any type of cell in the body, from heart cells to new neurons. Scientists dream of using the cells to develop new treatments for everything from arthritis to Parkinson's disease.

Dr. Nisker says he was incredulous when he learned Dr. Nagy's team had used fresh embryos to produce the stem cell lines.

"These aren't leftover embryos, these are fresh embryos, which are very precious," says Dr. Nisker, who co-chaired Health Canada's advisory committee on reproductive and genetic technology which disbanded last year once the federal government passed the new law governing reproductive technology.

"Never for one moment did [the committee] imagine that a woman would ever be approached to give up a fresh embryo," Dr. Nisker said in an interview. "That was not even on our radar screen."

Infertility treatment is an invasive and potentially harmful process,and couples often end up with more embryos than they need to try for a baby. Since the late 1980s, Dr. Nisker says, it has been common practice for doctors to recommend to IVF patients that they freeze any extra embryos in case they want to try for another baby later. Physician rule books and practice guidelines make no mention of donating fresh embryos -- creating what Dr. Nisker calls as legislative and professional "grey zone" which may lead to potential harm to patients.

Dr. Nisker says the issue demands clarification and says he personally feels that physicians who ask women to donate fresh embryos may be breaking the medical code of ethics.

"There should be a national ethical debate before doctors go taking fresh embryos from women," says Dr. Nisker, who notes in his CMAJ paper that physicians who broach the subject of fresh embryo donation with patients "may unknowingly become complicit in decreasing their patients' chance of pregnancy and increasing their risk of harm."

Their concerns relate to the fact that these “fresh” embryos were somehow different than embryos that were frozen. The frozen ones it would be all right to use but “fresh ones” should not be.

Without belittling the feelings of the medical people involved (that being a very un-Canadian thing to do) - - one of whom I met at a medical conference a few years ago, their concerns and the whole debate about “frozen” or “fresh” is about a good example of what has gone off the rails in contemporary ethics as one could find.

The one I met, Dr. Jeffrey Nisker of the University of Western Ontario, quoted at length in the above article as viewing fresh embryos as “precious”, seemed a nice fellow. A few years ago he and several hundred others were wringing their hands at a conference of OB-GYNS in Alberta about a variety of issues including whether “selective reduction” of embryos left physicians exposed to litigation from “multiples” because their lives would be economically disadvantaged as against “singletons”. The claim would go like this: “I never should have been born one of a group of triplets; but for the negligence of the doctor, I’d have more money in my university fund, therefore I have been damaged and you should pay up.” I am not making this up.

Several of us Day-Two speakers in the audience (Day One was the practical side of things and Day Two the theoretical) sat there with our eyes standing out like organ stops listening to their discussions. Things were much, much worse than I had imagined. The original issues of respect for dignity of developing humans (leaving aside the neat philosophical dispute about “personhood” or the frank obfuscation of “potential human life”) had moved on with the widespread practice of abortion and now “selective reduction” was a commonly accepted thing as well.

I spent a considerable time that evening rewriting what I was going to say and the next morning pointed out, in no uncertain terms, what seemed to be the corruption of medical ethics in what were being raised as “ethical concerns” and what was being ignored.

I told the conference attendees that the term “selective reduction” which was used by everyone the day before without complaint was, in fact, a euphemism for “selective termination” and “termination” a nicer way of saying “killing” and that supposed “ethical concerns” about whether “multiples” (those fortunate enough to have been selected then inserted into the womb in batches, like at a fish hatchery, to heighten the chance of survival) would be disadvantaged in life when compared with the “singletons” (who got there because his or her siblings had all been massacred by the caring professionals) rather missed the point.

The point was, and they did not disagree with this - - at least to my face, that their techniques and what medicine had already taken on board, had blinded them to the realities of what they were doing. They had lost sight of the reality of their medical practices, turned unique human entities into disposable (or, worse, “useful”) things and were now just protecting their often well padded posteriors against the ever rapacious litigation strategies of lawyers who would get hefty payouts should their newly thought out claim of action succeed. Claims for damages, like human lives, appeared to be (or not to be) in the eye of the beholders.

In such a world as this, Hamlet’s question “to be or not to be” has been dramatically changed. In Shakespeare’s play it was an ontological question framed within a world in which there were certain moral verities related to human being and suicide. In this current climate of psethics human being itself is now up for grabs. In medicine the decision about “to be or not to be” is increasingly circumscribed by second order practical questions. Being has, in fact, become contingent upon the human will and that only loosely contained by ever-shifting guidelines. Ethics had to become psethics in order to cope. Ethics must not necessarily be done but they must be seen to be done - - that is the essence of the new psethics.

Without going too far with my analogy, the way litigation was being discussed at the conference in relation to the termination (sorry, “selective reduction”) of humans (sorry “embryos”) was rather like asking if the guy who adjusts the gas nozzles on the gas chambers is going to be exposed to litigation for not doing it correctly. Who cares? The far bigger issue and the one that moralists should be interested in is the morality of the gas chambers themselves!

Simply put, no longer are “medical ethics issues” governed by any coherent moral approach based on the application of moral reasoning to facts. Now they are increasingly a set of ever changing practical “guidelines” of acceptable medical practice based on what we “feel” we can live with that is always just one step more “developed” (some would say barbarous) than the last step we took away from genuine respect for human entities. Calls for moratoria are a regular feature in the endless “progress” of medicine from area to area. What starts out as “grey” soon becomes, for some, the way to make a lot of gold.

With each step we all get just further and further away from any kind of moral basis at all - - except one: thou shalt maximize thy income. Yea, unto the third and fourth generations shalt thou maximize it. Thus speak the Law and the Profits.

Having moved, rather reluctantly, from the “pro-choice” to the “pro-life” (or if you are a modernist not too keen on logic “the anti-choice”) position while studying the ethics of abortion at Cambridge University and then seeing the paper published here and there in a variety of journals and books, I have little time for those like most modern physicians who refuse to examine where the logic of their position on abortion and human experimentation is taking our cultures.

The line between the instrumental reduction of unique developing human entities from lives we should regard as having inherent dignity (even if we choke at applying the term “sanctity of life” to them) to being “fresh” or “frozen” subjects for destruction at the hands of geneticists is a line that leads, sooner or later, to the instrumental evaluation of all human beings. Just wait and see and, oh yes, watch the signs of the times - - such as this supposed “fresh/frozen” debate.

The man at the centre of this recent disagreement (to call it a “debate” would be to give it the illusion of being a formal thing leading to a decision and it is not that), one Doctor Andras Nagy, who works at the Samuel Lunenfeld Research Institute affiliated with the University of Toronto is quoted in the Post article as follows:

"We never ever use any embryos -- fresh or frozen -- that are not otherwise destined to destruction," says Dr. Nagy. He says some embryos do not meet "quality criteria" for freezing, or sometimes there is only one spare embryo,which most clinics would consider "not practical" for freezing. In other cases, couples simply do not feel comfortable with freezing their embryos for later use.

"In all these cases, the embryos would get destroyed if not donated to research, and the risks to the woman that Dr. Nisker refers to is non-existent," says Dr. Nagy.

Note here that the embryos would simply be “wasted” if they were not going to be “used” - - and we are conservation based society are we not? How obvious the ethics in these situations then!

But there is more. Just so we are all assured that things are on track in terms of process and review and institutional solidity we are assured as follows:

“[Dr. Nagy] also notes that his team "strictly follows" guidelines set down by the stem cell oversight committee which reviews and approves research for the Canadian Institutes of Health Research.”

Oh, but wait, things might not be as simple as that. There appears to be some flux or uncertainty in the guidelines themselves. The article quotes a learned Professor as saying:

“The change in the CIHR guidelines and its timing raise many unanswered questions, says Dr. Baylis, who holds a Canada research chair in Bioethics and Philosophy at Dalhousie. Until December she sat on the governing council of the CIHR, which is Canada's lead health research agency.

The way CIHR has been making and changing rules regarding embryo use in stem cell research is "a serious threat" to both the interests of the Canadians donating embryos and the integrity of the CIHR policy-making process, says Dr. Baylis. She has just completed a 26-page paper that she hopes will help "incite" some corrective action.

Dr. Alan Bernstein, CIHR president and spokesman for the stem cell oversight committee, refused to comment on Dr. Nagy's work saying it would be inappropriate to publicly discuss a specific project. But he said he is aware of Dr. Baylis's concerns and says he has staff looking into them. Dr. Bernstein said the change to the stem cell guidelines was posted on the CIHR Web site in June and it is "a big extrapolation" to imply that the policy change was timed to coincide with Dr. Nagy's announcement.

As for Dr. Nisker's concerns about donation of fresh embryos, Dr. Bernstein says "there are some issues of substance here," and suggested the issue would be best and most appropriately addressed by Health Canada.”

Ah yes, someone is in charge, some ethics are in place. The only question is “who is in charge?” and “what are the ethics that are supposedly in place?”

It was fair to say that after the Alberta paper the responses were mixed. In fact for much of the rest of the conference I felt like someone who had passed a considerable amount of noisy gastric wind in a crowded elevator just after the power went out in the building. I had said the things many of them had thought were out of the way. Well, surprise! They aren’t and never will be. Ignored, undoubtedly, irrelevant, never.

This brings me back to the latest “hand-wringing” supposed “ethical” issue: is using a “fresh” embryo (note the use of “fresh” versus “frozen” to discuss unique human entities by the way…when will we start using “organically grown” or give them “Grade A” stamps of approval like we do with other agricultural products?) worse than using a “frozen” one? Hmmm. Let’s see. Is killing a cold person less bad than killing a warm one?

Welcome to the modern world of pseudo medicine raising pseudo ethical problems and the media discussing it all as if it is real and relatively harmless. I suppose this gives us all the comfort that something “ethical” is going on and the “experts” will ensure that nothing too bad comes to pass. Thus spoke the frogs to one another as the water temperature went up and up and up…

I suppose even when we see the first human head actually grafted onto (or emerging naturally from) the body of some kind of newly genetically developed and extremely useful reptile (possibly for Armed Forces use) we will be confident that it was all done ethically and with proper attention to the Guidelines after a suitable number of “moratoria” along the way just to keep us all comfortable that things were progressing as they can, should and must.

CENTREBLOG: Volume 101
Iain T. Benson©