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Posts Tagged ‘ethics’

Forgive the crude title, but this is the question I was discussing with a group of healthcare professionals recently. The specific topic was ‘brain death’, which is a phrase so widely used today that it hardly ever gets questioned. If someone’s brain is ‘dead’ then surely the person is dead as well? If the human brain has ceased to function then surely the human being has ceased to be alive? Not necessarily.

Much of the controversy is about organ transplantation. If you are going to take someone’s heart and give it to another person, you have to be sure that they are dead before you remove the heart, otherwise the act of removing the heart will be the very cause of their death. At least, that’s what most ethicists would say. The surgeon wants to know that he or she is taking a heart from a corpse and not killing a person. For many years, it has been assumed that if someone is certified ‘brain dead’ then they are definitely dead, and the transplant can go ahead. But this is being questioned more and more.

E. Christian Brugger, Senior Fellow of Ethics at the Culture of Life Foundation, gives some background:

For purposes of organ removal, there are two commonly accepted sets of criteria for determining that death has occurred: the “cardio-respiratory” standard and the “neurological” standard (sometime referred to as the “whole brain death” criterion). The Uniform Determination of Death Act formulated in 1981 by the President’s Commission and widely adopted throughout the U.S. defines the first as the “irreversible cessation of circulatory and respiratory functions”, and the second as “the irreversible cessation of all functions of the entire brain, including the brain stem.” Although each criterion focuses upon a limited set of critical functions, the state of death of the entire human organism is thought to be able to be inferred by focusing on any one of them.

In his 2000 address, John Paul II says that when “rigorously applied” the neurological criterion “does not seem to conflict with the essential elements of a sound anthropology.” He goes on to say “therefore a health-worker professionally responsible for ascertaining death can use these criteria [i.e., cardio-respiratory and neurological] in each individual case as the basis for arriving at that degree of assurance in ethical judgment which moral teaching describes as ‘moral certainty'” (No. 5).

In other words, the pope states that the neurological criterion seems to be a reliable basis for arriving at moral certitude that a person has died, which is required before harvesting vital organs can be legitimate.

But new questions have come up in the last few years.

Research has emerged in the past decade, especially by D. Alan Shewmon, professor of pediatric neurology at UCLA Medical Center and Consultant for the Pontifical Academy of Sciences, challenging the reliability of the widely accepted neurological standard.

Recall the pope says that death consists in the “disintegration of that unity and integrated whole that is the personal self” (no. 4), and that we can identify biological signs that follow upon the disintegration. It seems to follow that an apparent absence of certain biological signs of somatic (bodily) disintegration can raise reasonable doubts as to whether death has occurred.

Shewmon’s research demonstrates conclusively that the bodies of some who are rightly diagnosed as suffering whole brain death express integrative bodily unity to a fairly high degree.

Brain dead bodies cannot breathe on their own since the involuntary breathing response is mediated by the brain stem, which has suffered complete destruction. So the bodies need to be sustained on a mechanical ventilator, which supports the body’s inspiration and expiration functions (breathing in and out). But with ventilator support, the bodies of brain dead patients have been shown to undergo respiration at the cellular level (involving the exchange of O2 and C02); assimilate nutrients (involving the coordinated activity of the digestive and circulatory systems); fight infection and foreign bodies (involving the coordinated interaction of the immune system, lymphatic system, bone marrow and microvasculature); maintain homeostasis (involving a countless number of chemicals, enzymes and macromolecules); eliminate, detoxify and recycle cell waste throughout the body; maintain body temperature; grow proportionately; heal wounds (i.e., the immunological defense of self against non-self); exhibit cardiovascular and hormonal stress responses to noxious stimuli such as incisions; gestate a fetus (including the gaining of weight, redistribution of blood flow favoring the uterus, and immunologic tolerance toward the fetus); and even undergo puberty.

The data is indisputable. Yet there is considerable disagreement on how to interpret the data with respect to the question of human death. Some scholars such as James M. DuBois, writing in the 2009 “Catholic Health Care Ethics” manual published by the National Catholic Bioethics Center, refer to this long list of functions of brain dead bodies as “residual biological activities” no more expressive of life than the twitching of a lizard’s amputated tail. Others, including scientists and several philosophers and theologians who, with me, accept magisterial teaching, are less comfortable setting them aside as possible signs of true somatic integration.

Although Shewmon’s evidence certainly does not establish that brain dead bodies are the bodies of living (albeit highly disabled) persons, in my judgment, and in that of other competent scholars and scientists, it raises a reasonable doubt that excludes “moral certitude” that ventilator-sustained brain dead bodies are corpses.

It’s not an argument to say that a brain dead person is necessarily still alive – it simply suggests that there are serious doubts and questions about the meaning of brain death. And as long as such questions remain, we shouldn’t pretend that we have absolute confidence that a brain dead person is definitely dead. And if that’s the case, then there are implications for how we continue to care for such persons, and whether or not we transplant their organs.

If you want to follow this up, see this article on the Signs of Life conference on brain death in 2009; Pope Benedict’s 2008 address to a conference about organ transplantation; a Linacre Centre paper that touches on brain death, and another about the definition of death; and the NHS page about brain death, which includes the following uncritical remarks:

Brain death occurs when a person in an intensive care unit no longer has any activity in their brain stem, even though a ventilator is keeping their heart beating and oxygen circulating through their blood.

Once a brain stem death has occurred, the person is confirmed dead.

Unfortunately, there is no chance of a person recovering once their brain stem has died. This is because all of the core functions of the body have stopped working and can never be restarted. Although a ventilator can keep the heart beating, the person is effectively dead.

If permission has been given, organs can be removed for transplant and ventilation is withdrawn. Once ventilation is withdrawn, the heart stops beating within a few minutes.

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If you are looking for online resources in bioethics, here are a couple of useful sites (following on from my recent post about the distortion of language in bioethical reporting).

Dolly the Cloned Sheep

The United States Conference of Catholic Bishops has a bioethics page with links to various articles and downloadable pamphlets. The topics include: stem cell research, cloning, genetic enhancement, IVF, eugenics, human dignity, reproductive technology, etc.

The Anscombe Bioethics Centre is the main Christian bioethics institute in Britain. The resources are here (articles, publications, newsletters, etc); and there is a big list of articles and links here at their old Linacre Centre site (I’m not sure if all these articles have been moved over yet).

I also happened to come across this very informative blog last week called Mary Meets Dolly, “A Catholic’s Guide to Genetics, Genetic Engineering and Biotechnology”. The author, Rebecca Taylor, has her own page of links (I can’t recommend them all as I haven’t looked at them all yet…). And this is from her ‘About’ page:

My name is Rebecca Taylor.  I am a clinical laboratory specialist in molecular biology, and more importantly, a practicing Catholic. I have been writing and speaking about Catholicism and biotechnology for five years. I have been interviewed on EWTN radio on topics from stem cell research and cloning to voting pro-life.

All of this began several years ago when I was discussing stem cells and cloning with an older gentleman at a family party.  He was very knowledgeable about biotechnology, but was surprised about many little-known and quite misleading facts.  He asked where I had gathered those facts, and I told him I was reading every pertinent scientific reference I could get my hands on. He looked me in the eye and said, “Young lady, it is not good enough to read, you must do something!”  I found out later he was a former U.S. congressman from California.

Indeed, I began to notice a general lack of understanding about contemporary issues in genetics, genetic engineering, and reproductive technology, issues that have shaped, and will continue to shape, the future of humanity, for good or ill.  I work with professionals whose business is medical genetics, and even they are confused about the pragmatics, not to mention the ethics, surrounding cloning, stem cells, and recent advances in genetic engineering.  If professionals could be confused, I feared that the average Catholic would feel lost amidst the scientific jargon and, unfortunately, the hype.

I decided to start marymeetsdolly.com to try and provide Catholics with solid, pertinent resources and clear, plain commentary so they could be more conversant with the issues proffered by the newest of the “brave new world” movements.

With this website, I hope to take what I have learned (through months of studying the technologies and ethical stances involved) and explain the advances and the issues in terms the person-on-the-street can understand.  With the help of my father, a theologian, I hope to juxtapose and illuminate today’s genetic research and engineering with the Church’s teachings on the sanctity of human life.

At this site, Catholics can find information to better understand stem cell research, therapeutic and reproductive cloning, genetic testing, and much more.  The Topics section has articles covering various technologies; what is moral, what is immoral.  It also has articles on pertinent topics by other authors.  The Books section has a reading list for those who want to do their own research.  The Links page has a list of websites through which one can keep up to date in this rapidly changing field.  The Glossary page lists important terms and their definitions.  The Church Teaching page has official Catholic Church teaching on reproductive issues and the sanctity of human life.  The Blog has my daily thoughts on new developments and a chance for you to respond.  And my favorite, the Quotes section, has all the verbal gems I have found that say it all.  

On the question of language, see her post about whether our understanding of when human life begins is a matter of belief or of knowledge.

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An article about bioethics in the Times gives a frightening example of the way language can be distorted to misrepresent the truth and skew an ethical argument (last Friday, 11 March, page 3). It makes you wonder whether it’s just lazy journalism, or whether the Times has some particular interest in slanting the ethical debate in these areas.

 

Painting by David S. Goodsell - mitochondria at top right

The article is about a new ‘therapy’ designed to cure mitochondrial failure, which can cause fatal conditions that affect about 100 children in Britain each year. These are the facts, reported in a ‘How it works’ box at the side, and sifted from the body of the article: two embryos are created, both from the father’s sperm, but one from the mother’s egg, and one from a donor’s egg. Two pronuclei are taken from the ‘mother/father’ embryo, which is then discarded. These are then placed in the ‘donor/father’ embryo (from which the pronuclei have been removed), which has healthy mitochondria. This newly ‘created’ embryo is implanted in the mother’s womb and allowed to gestate.

So let’s be clear: an embryo is harvested (I can’t find a better work) of its pronuclei, then discarded, and another embryo is given new pronuclei and allowed to grow. It’s embryos we are talking about. Leave aside for the moment what you think about the personhood of embryos, or their dignity or worth, or whether they have a soul, etc. The scientific point that no biologist would deny is that an embryo is a human life in its very earliest states; a new creature, at the beginning of its life, biologically/genetically distinct from the life of its parents.

Mark Henderson, Science Editor in the Times, does explain all this. But he peppers the article with ambiguous phrases about what is actually happening. First, in the main article, he writes that ‘the treatment involves merging DNA from two fertilised eggs, one from the mother, the other from a donor’ [my italics here and below]. This is strictly true, but it’s a strange way of referring to embryos. It would be much more natural to talk about two embryos rather than two fertilised eggs, and the suspicion is that this is a way of drawing attention away from the reality that embryos are being harvested and discarded.

Second, in a Commentary box also written by Henderson, he writes, ‘The notion of creating a baby with a small genetic contribution from a third parent is bound to strike some people as controversial’. This is a misleading. The mitochondrial DNA in the new embryo will have been indirectly inherited from the donor – in this limited sense the donor makes a ‘contribution’; but it is actually taken from the embryo that has been created from the donor’s egg and father’s sperm. The ‘small genetic contribution’ is not taken from a third parent (which sounds like a benign piece of information), it is taken from a newly created human embryo.

Notice how Henderson is comfortable calling the finally created healthy embryo a ‘baby’, but never refers to the discarded embryo that has had its two nuclei removed as a baby.

Henderson goes on to say in his Commentary that the new procedure adds a fresh dimension to issues of surrogacy and egg donation ‘because a third person will also contribute a small amount of DNA to the baby’. I presume he is trying to say that the third person contributing the DNA is the donor. Once again, it’s true that the mitochondrial DNA is indirectly inherited from the donor, but the ‘contribution’ is made directly by the embryo not the donor.

Then, in the caption underneath the photograph of a baby’s foot held in an adult’s hand, we read that ‘The technique replaces faulty mitochondria from the mother with a healthy form from a second egg‘. This is completely untrue. The healthy mitochondria do not come from an egg, they come from a newly created embryo, which has its pronuclei replaced with the pronuclei from another embryo.

The ‘How it works’ box is both honest and dishonest at the same time: the text says ‘These [pronuclei] are injected into a healthy embryo‘; yet the caption right beside it, under the illustration, says ‘Egg with healthy mitochondria‘. Perhaps Henderson was not responsible for these captions and boxes.

You may think I’m being obsessive about language. It just frightens me how language can be manipulated in a reputable newspaper to distort the truth and mask both the scientific and ethical reality of one of the most serious issues facing our culture. It makes you wonder whether the Times is seeking to promote a controversial scientific procedure rather than just report it and let the facts speak for themselves.

Here is the full Commentary [subscription required]:

The notion of creating a baby with a small genetic contribution from a third parent is bound to strike some people as controversial.

Yet Professor Turnbull’s team, which has developed the new IVF technique, is driven by the noblest of ethical motives: the desire to help families affected by a devastating burden of disease.

If the procedure is approved by Andrew Lansley, it stands to help women like Sharon Bernardi, from Sunderland, who has seen six children die in infancy because they inherited mitochondrial disorder.

When Professor Turnbull published promising results a year ago, she posed for photographs with her son Edward, then 20, who had a mitochondrial condition called Leigh’s disease.

Mr Bernardi died last week. As scientists began to consider whether the therapy should be used on patients, his death serves to illustrate the terrible impact these disorders can have — and the need for prevention.

When weighing the advice they will give to Mr Lansley, the expert panel he has convened will consider the safety and effectiveness of Professor Turnbull’s procedure.

They will want to see evidence that human embryos created this way appear to be normal, as well as the results of animal studies.

The medical benefits will need to outweigh the risks that are always involved when techniques like this move from laboratory and animal experiments into human reproduction. There are also ethical issues to be considered.

The principle that more than two parents can contribute biologically to the birth of a child is already recognised in Britain, as egg donation and surrogacy are legal. The new procedure adds a fresh dimension, however, because a third person will also contribute a small amount of DNA to the baby.

Embryo-rights groups will oppose the technique, because it involves merging two embryos, one of which is destroyed. It will also concern some people who object to manipulating DNA in irreversible ways, even if there is a medical benefit, or who feel it is wrong to subject a potential child to a procedure to which it cannot consent.

Mr Lansley could approve the work himself, but given its controversial nature he is more likely to give MPs a free vote. This would provide the first test of this Parliament’s attitude towards bio-ethics. David Cameron, whose disabled son Ivan died in 2009, is understood to be privately supportive.

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I was teaching philosophical ethics yesterday and came across these quotations I’d saved up about the possibility of human freedom.

Isaiah Berlin

The first, from Thomas Nagel, simply describes what a hard-core version of determinism looks like:

Some people have thought that it is never possible for us to do anything different from what we actually do, in the absolute sense. They acknowledge that what we do depends on our choices, decisions, and wants, and that we make different choices in different circumstances: we’re not like the earth rotating on its axis with monotonous regularity. But the claim is that, in each case, the circumstances that exist before we act determine our actions and make them inevitable. The sum total of a person’s experiences, desires and knowledge, his or her hereditary constitution, the social circumstances and the nature of the choice facing them, together with other factors that we may not know about, all combine to make a particular acting in the circumstances inevitable. This view is called determinism… [quoted in Alban McCoy, An Intelligent Person’s Guide to Christian Ethics, 34-35]

The second quotation, from Isaiah Berlin, is about how freedom is in fact a presupposition of ordinary personal and social life, whether we like to admit it philosophically or not:

The whole of our common morality, in which we speak of obligation and duty, right and wrong, moral praise and blame – the way in which people are praised or condemned, rewarded or punished, for behaving in a way in which they were not forced to behave, when they could have behaved otherwise – this network of beliefs and practices, on which all current morality seems to me to depend, presupposes the notion of responsibility, and responsibility entails the ability to choose between black and white, right and wrong, pleasure and duty; as well as, in a wider sense, between forms of life, forms of government, and the whole constellations of moral values in terms of which most people, however much they may or may not be aware of it, do in fact live. [Liberty, 324]

If you want to follow all this up, you can read Alban McCoy’s very helpful chapter about determinism here on Google Books.

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It’s obvious that the language we use affects the force of our arguments. And there are many examples of how an uncomfortable truth can be disguised by changing the language used to describe it.

There is a beautiful and unsettling example of this in one of the Times leaders this morning. The topic is the decision to award the Nobel Prize for Medicine to Professor Robert Edwards for his pioneering work in IVF. (The photo is of Alfred Nobel not Edwards!)

Professor Edwards’s work has its critics. The Roman Catholic Church opposes some IVF, on the ground that it can involve the destruction of embryos. And it is beyond argument that this is what happens: fertility clinics generally fertilise many eggs, and often implant two, to maximise the chance that one will survive. The remaining tiny embryos are then frozen or discarded.

But there is nothing anti-life in IVF: the embryos are created to produce babies and allow the chance of parenthood to couples who want a child of their own. Nature itself creates and fertilises many more eggs than become babies.

The embryonic cell can also be taken apart, at an early stage, to yield stem cells. Research using stem cells offers the promise of finding a cure for debilitating conditions such as Parkinson’s disease.

Do you notice how the language of ’embryo’ in the first and second paragraphs is changed, without any fuss, to ’embryonic cell’ in the third paragraph? As if the leader writers are happy to talk about embryos being ‘frozen and discarded’, but uncomfortable with the idea that ‘the embryo can also be taken apart, at an early stage, to yield stem cells’. So the sentence that would have seemed most natural is changed to ‘the embryonic cell can be taken apart…’

I don’t know if this is the art of persuasion, or a subconscious unease with the moral position being taken and the starkness of the language required to describe it (‘taking apart embryos’). Either way, it shows how important it is to monitor the language being used to make ethical arguments, and to question why someone chooses to adapt their language in unexpected ways.

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On 18 April 2005 the then Cardinal Ratzinger preached to the cardinals who were assembled in Rome to elect the new Pope. He provoked a huge amount of discussion by saying that Western culture is creating ‘a dictatorship of relativism’.

Here is the homily in full; and here is the relevant paragraph:

Today, having a clear faith based on the Creed of the Church is often labeled as fundamentalism. Whereas relativism, that is, letting oneself be “tossed here and there, carried about by every wind of doctrine”, seems the only attitude that can cope with modern times. We are building a dictatorship of relativism that does not recognize anything as definitive and whose ultimate goal consists solely of one’s own ego and desires.

I was involved this week in a programme by Edward Stourton about the significance of this provocative term, and the place of religion more generally in contemporary culture and politics. The Analysis programme was broadcast on Radio 4 on Monday evening; you can listen to it hear on BBC iPlayer.

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