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BIOMEDICAL ETHICS What ends will or should the new technology serve? What values should guide society’s adjustments? By what standards should the assessment agencies assess? What do we mean by the betterment of humanity? What is a good person? What is a good life? What is a good community? “THE NEW BIOLOGY” 1. Control of Death 2. Control of Life 3. Control of Human (genetic) Potential 4. Control of Human Achievement Kass, Leon. (1971). The New Biology: What Price Relieving Man’s Estate? Science, 174(4011):779-788 “THE NEW BIOLOGY” “…we may be rapidly acquiring the power to modify and control the capacities and activities of men by direct intervention and manipulation of their bodies and minds.” [p. 779] Kass, Leon. (1971). The New Biology: What Price Relieving Man’s Estate? Science,174(4011):779-88 “THE NEW BIOLOGY” “Biomedical technology may make it possible to change the inherent capacity for choice itself…humans can for the first time recreate themselves.”” [p. 780] Kass, Leon. (1971). The New Biology: What Price Relieving Man’s Estate? Science,174(4011):779-88 CONTROL OF DEATH Heroic Medicine / Euthanasia Infant Mortality Organ Transplants / Stem Cells Infectious Disease Degeneration / Aging CONTROL OF DEATH What is Death ? “The absence of life” “The permanent end of all life functions in an organism or part of an organism” “Cessation of all vital functions without the capability of resuscitation” “The irreversible loss of all brain function” HEROIC MEDICINE Karen Ann Quinlan 1975; mixed alcohol & tranquilizers; passed out; aspirated vomit “persistent vegetative state” Parents fought to remove life support After removing support, she lived another 10 years HEROIC MEDICINE Terry Schindler-Schiavo 1990; K deficiency; coma Woke a few weeks late in a “locked state” Receives food and water via gastic feeding tube In 1998 Terri’s husband asked to have the food tube removed; parents fought; still pending EUTHANASIA Percent Affirmative Responses (%) [NORC, 1977-94; General Social Surveys Combined] 90 80 70 60 50 40 30 20 10 0 Fundamentalists Catholics Strong Moderate Protestants Moderate Liberal Protestants Minimal EUTHANASIA Percent Affirmative Responses (%) [NORC, 1977-94; General Social Surveys Combined] 90 Strong 80 Moderate Minimal 70 None 60 50 40 0-11 yrs HS graduate Some College 4+ years College INFANT MORTALITY US Infant Mortality by ‘Race’ YEAR WHITE BLACK Male Female Male Female 2001 1995 1990 6.2 7.0 5.1 5.6 15.5 16.3 12.5 13.9 8.5 6.6 19.6 16.2 1985 10.4 7.9 20.8 17.2 1980 12.1 9.5 24.2 20.2 [National Center for Health Statistics, 2001] ORGAN TRANSPLANTS Which organs? • • • • • • • • • • Kidney Heart Liver Lung Pancreas Intestine Cornea Skin Bone Bone Marrow ORGAN TRANSPLANTS Survival Rates -98% 95% 85% 79% 70% 70% 65% 65% kidney liver heart pancreas small intestine multi-organ lungs heart/lungs ORGAN TRANSPLANTS [OPTN, December 31, 2002] 90,000 # of patients 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 ‘91 ‘92 ‘93 ‘94 ‘95 Patients on wait list at end of year ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 Number of transplants ORGAN TRANSPLANTS UK Organ Donors [as of Dec 31, 2002] Registrants (millions) < 0.30 0.30 - <0.60 0.60 - <0.70 0.70 - <0.80 0.80 - <0.90 0.90 - <1.0 ≥ 1.0 [NHS, December 31, 2002] ORGAN TRANSPLANTS ORGAN TRANSPLANTS Who Gets the Transplants ?? • Young, white, boys • Wealthy individuals • Shortage of available organs = lucrative black market trade • Cycle of transplant access = rich to poor; black to brown to white; female to male ORGAN TRANSPLANTS Suggested Solutions • Education programs to elicit more donors • Futures market -- financial incentive donor’s kin • Use organs from executed prisoners • Regulated transplant centers • Non-human sources • Mandatory donation FETAL TISSUES • Undifferentiated cells that can be easily manipulated • Cannot become a fetus In Vitro Fertilized Egg Blastocyst Stage Inner Stem Cell Mass Undifferentiated Cells Specialized Cells blood cells neural cells muscle cells FETAL TISSUES Limb Amputations Spinal Cord Injuries Neurological Disorders Heart Disease Burns Diabetes Treatable Disorders • Understand human growth and development • Pharmacology • Restore any cell type FETAL TISSUES Spinal cord injuries Parkinson’s Alzheimer’s INFECTIOUS DISEASE Infectious Disease Rates, US * Cases per 100,000 1950 1960 1970 1980 1990 2000 Diphtheria Mumps Measles TB 3.83 0.51 0.21 - - 55.55 3.86 2.17 0.13 23.23 5.96 11.17 0.03 211.01 245.42 >0.005 >0.005 >0.005 - 30.83 18.28 12.25 10.33 6.01 Syphilis 146.02 68.78 45.26 30.51 54.52 11.23 Gonorrhea 192.50 145.40 297.22 445.10 277.45 129.04 [CDC Control & Prevention, (2001). Summary of notable diseases, Morbidity and Mortality Weekly, 50(53)] INFECTIOUS DISEASE Infectious Disease Rates • same trends to not appear in all segments of US society • same trends to not appear worldwide • increased virulence of once ‘conquered’ diseases • emerging pathogens DEGENERATION Worldwide Life Expectancy Rates (in yrs) Andorra Macau 83.49 81.87 Mozambique Botswana 31.30 32.36 San Marino 81.43 Zambia 35.25 Japan 80.93 Lesotho 36.94 Singapore 80.42 Angola 36.96 [CDC, December 31, 2003] * US life expectancy = 78.16 years ** UK life expectancy = 77.14 years CONTROL OF DEATH Right to Die Schiavo Kevorkian UK Standards Stem Cell Research Ronald Regan Christopher Reeves Michael J. Fox Health Care Benefits Socio-economic divide Changing demographic National Health Care ? Cost of Medical Care 2/3 $$ last month Rationed care Utah plan Eldercare Changing demographic From kids to parents Isolation CONTROL OF LIFE “Test-Tube Babies” • In vitro fertilization • 1978; Edwards & Steptoe • Baby Louise Brown • Common practice today especially for older women • Not sanctioned by the Catholic church CONTROL OF LIFE Sperm sample Hormone injected Fertilization of egg Pregnant mother Insertion of embryo into uterus Suction device Nutrient solution Recovered eggs Blastocyst CONTROL OF LIFE • What to do with cast off cells? • What are the legal rights of embryos? • When used, what are the rights of the surrogate mother? Who are the surrogates? • Who’s responsible for a defective baby? HUMAN POTENTIAL • 6% of consultations with doctors are related to genetic disorders • 26% of all institutional beds are occupied by patients with genetic disorders • 8.5% of all infant deaths are the result of a single gene defect • Over 600 single gene defects are known, another 800 suspected • On average, we all carry 6-8 defective genes HUMAN POTENTIAL Negative Eugenics -- identify & eliminate unwanted genetic traits • Ultrasound • Chorionic villi testing • Amniocentesis • Genetic counseling • Sterilization HUMAN POTENTIAL Ultrasound • uses sound waves • detects visible defects handheld transducer HUMAN POTENTIAL Amniocentesis • Combined w/ultrasound • fetal waste products HUMAN POTENTIAL Chorionic Villi Testing • Microscopic projections lining the outermost layer of the embryonic sac • same genetic material as fetus • sampled at 10-12 weeks gestation • fast turnaround time HUMAN POTENTIAL Genetic Counseling HUMAN POTENTIAL Sterilization Carrie Buck case HUMAN POTENTIAL Positive Eugenics HUMAN POTENTIAL Cryobanks HUMAN ACHIEVEMENT Neurological, psychological and physiological manipulation • Mood altering & enhancing medications • Cosmetic endrochronology HUMAN ACHIEVEMENT Valium • diazepam • addictive potential high - 2 wks • birth defects -’floppy child’ syndrome • ‘for relief of psychic tension and its somatic symptoms’ • females outnumber users 2.5 to 1 HUMAN ACHIEVEMENT Valium • most widely prescribed drug worldwide in the 60s & 70s • marketed to our desire for a ‘good life’ • prescribed for anxiety, depression, insomnia, and anxiety • caused depression, anxiety, and insomnia HUMAN ACHIEVEMENT Growth Hormone Growth Hormone • given to normal but small kids • add 6” height, 50% muscle mass • recombinant DNA technology HUMAN ACHIEVEMENT Hypothalamus Adrenal Cortex Kidney Tubules Pituitary Thyroid Mammary Glands Testis Uterine Muscles Ovary Bone BIOMEDICAL ETHICS Rational or Rationed Medicine ? Derek Roberts • Control of infertility, increase in life expectancy, reduction in infant mortality , reduced infectious disease = diminished limits on population growth Peter Singer • Should everyone have access to care, regardless of ailment ? BIOMEDICAL ETHICS Rational or Rationed Medicine ? Derek Roberts • $4,700 per person per year paid for health care • increases at 6X the rate of inflation per year Peter Singer • High deductibles for families - $2,000 • Racial divide in access, regardless of income BIOMEDICAL ETHICS Rational or Rationed Medicine ? Derek Roberts 0 = costs nothing, gives back alot 3 = costs a little, gives back some Peter Singer 7 = society sustains them beyond what they pay back 10 = costs from the start, not possible to pay back BIOMEDICAL ETHICS What ends will or should the new technology serve? What values should guide society’s adjustments? By what standards should the assessment agencies assess? What do we mean by the betterment of humanity? What is a good person? What is a good life? What is a good community?