New Moral Anesthesia for Abortion

“Is it possible, once again, to hold in tension seemingly opposite ideas about abortion?” This is the main question asked by Dr. Lisa Harris in the lead editorial in the April 12, 2018 NEJM. Her concern is that in her view, since the creation in January of the new Conscience and Religious Freedom division at HHS, subsequent comments by HHS leaders “suggest that they are uninterested in discrimination against health care providers whose consciences compel them to provide care, and uninterested in injuries to patients caused by care refusals.” (emphasis hers) She wants us to return to the time of the 1973 Church Amendment when she argues that lawmakers reached common ground protecting conscious rights of healthcare workers, then holding what she describes as a tension “between abortion as a new fundamental right for U.S. women and the reality that some healthcare providers could not in good conscience participate in it.” Our inability to maintain that tension, she believes, will continue to result in our present extreme divisiveness on the abortion issue. So, specifically, per Dr. Harris: “Can we understand abortion as both something that ‘stops a beating heart’ and a fundamental right, rather than insisting it’s only one or the other?”

Trying to understand abortion as both is the problem. Cognitive dissonance is the word Dr. Harris was looking for, and she is correct that something was needed immediately after Roe v. Wade to ease that dissonance.

With Roe v. Wade in early 1973, the Supreme Court determined that the Constitution prohibits the government from stopping one individual from ending the life of a second individual who was not actively ending the life of the first individual. No one was honestly claiming that we needed Roe v. Wade to allow physicians to perform an abortion to save the life of the mother if the baby/pregnancy was immediately threatening the life of that mother. The Church Amendment, which passed shortly after Roe v. Wade became law, essentially said that no one will be forced to perform an abortion or be discriminated against if they did so – effectively permitting an individual to follow one’s own religious beliefs or moral convictions on the matter. Abortion became just a personal religious or private moral thing.

I believe that the Church Amendment was the necessary moral anesthesia that allowed the Supreme Court to surgically join the opposite ideas that an abortion is both a fundamental right and an act that “stops a beating heart”, the amendment effectively numbing our ethical faculties to what Roe v. Wade would now permit.

Had pro-choice supporters simply adhered to the Church Amendment, there would not have been growing broad demand by pro-life groups for the proposed Conscience Protection Act of 2017 (H.R. 644). I suspect most pro-life supporters hope the creation of the new HHS division will correct the concerns addressed in the failed bill.

I worry the new HHS division will be the new moral anesthesia to lull us into contentment with securing arguably necessary conscience protections at the cost of leaving Roe v. Wade intact.

In his recent blog post, The Child I Want, Neil Skjoldal nicely articulated the dehumanization that results when we create a fundamental right to “stop a beating heart.” But we have known that this would happen since that right was first established. Almost identical concepts were discussed during oral arguments of Roe v. Wade, such as the following exchange between Justice Potter Stewart and attorney Sarah Weddington, who represented Roe. (see LINK for transcript or audio of the second reargument Oct 11, 1972, approximately one-third of the way through):

Potter Stewart: Well, if it were established that an unborn fetus is a person within the protection of the Fourteenth Amendment, you would have almost an impossible case here, would you not?

Sarah R. Weddington: I would have a very difficult case. [Laughter]

Potter Stewart: You certainly would because you’d have the same kind of thing you’d have to say that this would be the equivalent to after the child was born.

Sarah R. Weddington That’s right.

Potter Stewart: If the mother thought that it bothered her health having the child around, she could have it killed. Isn’t that correct?

Sarah R. Weddington: That’s correct.

So, to answer Dr. Harris: “Can we understand abortion as both something that ‘stops a beating heart’ and a fundamental right, rather than insisting it’s only one or the other?” — I certainly hope not.

The Ethics of Pet Cloning

Anyone who passes through a grocery checkout line on a weekly basis is unable to remain ignorant of the latest thoughts and insights from Hollywood. With ethical pronouncements from Hollywood, I usually find it reliable to point my moral compass in the opposite direction, at least until I have time to further evaluate the issue. Such was the case with a recent National Enquirer scoop that Barbara Streisand has cloned her now deceased Coton du Tulear dog Samantha, producing two offspring, Miss Violet and Miss Scarlett. The fact that she cloned her pet was interesting in its own right, as I did not realize this process was commercially available to the general (wealthy) public. Perhaps more interesting was the backlash Ms Streisand has experienced from Twitter (generally) and PETA (specifically) largely on ethical grounds. More on this in a moment. The Streisand scoop actually should be credited to a Variety interview and the initial ethical discussion to both the New York Times and Fox News (offering, no surprise, differing vantage points)

Sone of Streisand’s harshest criticism came from Twitter under the hashtag #adoptdontclone. One argument against the pet cloning process was that it was unjust; given the fact that only rich people could afford the price tag, which according the NYT link above ranged around $50,000. Another argument against the process was to remind Ms. Streisand that Miss Violet and Miss Scarlett were not the same as the original Samantha, even though they might look or even act in a manner that might remind Streisand of her dear departed. These arguments touched on the very themes of genetic determinism vs. environmental nurture, admittedly in a rudimentary way. The PETA arguments described the pain and suffering they claimed that the female dogs experienced during the required egg harvesting needed for the cloning process to be successful, arguments eerily similar to risks women experience related to egg harvesting for some IVF procedures.

The strongest or, at least, most popular argument leveled at Ms. Streisand was that cloning her pet eliminated the possibility that she might adopt an already existing puppy, who very much needed a loving pet owner to provide that puppy a better future. While no one presently is making a similar argument against human cloning in favor of human adoption (since human cloning is presently illegal), similar arguments have been made with IVF vs. adoption.

The point of all this was to appreciate some of the ethical arguments by the lay press presently used against pet cloning by Hollywood’s elite and wonder whether, if and when human cloning is accessible to the general (wealthy) public in the future, similar arguments will resurface to protect the humans involved then with the same loud voice used to protect the animals now.

The Bioethics of a Modern Death Mask

By the time you read this, a company called Nectome will have pitched its business plan to investors at Y Combinator as a company who has designed a technology called Aldehyde-Stabilized Cryopreservation to preserve all of your connectome, which is all of your brain’s interconnected synapses. Doing this, they argue, can preserve your memories, allowing the company to effectively “upload your mind”. One problem with the technology is that the process is 100% fatal as you have to die during the cryopreservation process to make an accurate connectome.

Oddly, the fact that you have to die for the process to be successful is not considered a deal breaker. Twenty-five individuals have already plunked down the $10,000 deposit to be first on the list to eventually have their brains perfectly preserved in this manner. The process also depends upon future scientists being able to figure out a way to use these perfectly embalmed brains to “reboot” their consciousness. Never mind that no one presently knows how that rebooting process might work or whether the present process captures everything that will be necessary some 100 years in the future when the complete technology will hopefully actually exist. Presumably, smarter people will have all of that detail eventually worked out. What is important at present, particularly if you have a terminal disease, is to preserve your brain so you can be rebooted in the future. A new state law in California called the “End of Life Option Act” makes the application of this novel technology legal for terminal patients (at least as best as can be determined as the legal details have yet to be tested in court). A very nice overview of this new technology and the new company itself may be found in the latest Technology Review article by Antonio Regalado.

There are scientists, such as neuroscientist Ken Hayworth, president of the Brain Preservation Foundation, who believe that a connectome map could provide the basis for reconstituting a person’s consciousness. At its base, this theory assumes that the physical brain is not only the necessary but presumably the sufficient source of consciousness. Capturing the synapse pattern would certainly be essential for recreating the hardware (and perhaps the software) of the brain to restart one’s electrical pattern leading presumably to rebooting one’s consciousness.

I have a couple of ethical problems with this technology, though I am sure there are more. The most obvious is that the process hastens the death of the individual, regardless of their terminal illness. The person will not be dying from their illness but from the cryopreservation process. This technology would not be legally possible without the new California law that will ascribe the death to the terminal illness rather than Nectome’s cryopreservation process, presumably shielding Nectome from product liability suits. Only in California could a terminal patient’s family sue the manufacturer of their vehicle for a malfunction in the brakes that resulted in their loved one’s premature death as they were in the process of driving their loved one to a Nectome facility to die by brain cryopreservation with the hope that the loved one could live again.

Another ethical problem is the transhumanist lure of a brain being rebooted, effectively allowing immortality of one’s consciousness. Aside from the presently unproven science of the rebooting process, who would be the recipient of the successful rebooted consciousness? By that I mean “who” (or what) is regaining consciousness? If the physical brain is the basis for consciousness, and recreating a new but exactly reproduced connectome is the thing that becomes conscious, would it really be you becoming conscious, or someone or something else entirely? Who really enjoys the rebooted memories? What if it is not really you that is being rebooted but someone or something else with your life’s memories? This would be the worst “bait and switch” advertising scam ever devised! What till the FTC begins filling suit. But seriously, are we just our consciousness or a necessary combination of physical mind and body, or a necessary combination of spiritual soul and physical mind/body? What exactly are we? Why do we think we can achieve immortality in the first place? If we can, is the Nectome method the right way of going about this process?

The Christian faith argues for a different process, but uses language such as “dying to self” and being “born again”, which sound similar to Nectome but are indeed very different. Per Nectome, if you die, using our cryopreservation technology, you can live again by regaining your consciousness in the future. The biblical concepts of being born again and dying to self reflects a believer having faith in the salvation offered by Christ’s death on the cross and subsequently humbly subjecting oneself to God’s will rather than one’s own will for the future, both temporally on earth and eternally in heaven.

I recommend the Christian process of being born again rather than the modern death mask soon to be offered by Nectome.

Belgian Euthanasia: Volunteers No Longer Necessary?

A recent resignation letter by one member of Belgium’s Euthanasia Commission suggests the slippery slope of who meets the criteria for legal euthanasia is becoming even more slippery. Dr. Ledo Vanopdenbosch sent his resignation letter to members of the Belgian Parliament who oversee the commission. His concern was with one of the main requirements of the law, which demands that the individual patient formally request euthanasia. Vanopdenbosch claims euthanasia occurred on a psychiatric patient without his or her request. His resignation has generated substantial concern not only because Vanopdenbosch is a committee member but also because he is considered a strong advocate of euthanasia. Here is the AP article in Voice of America with the details.

One of the main tasks of the Belgium Euthanasia Commission is to review every euthanasia case to make sure each case meets the legal criteria necessary for euthanasia. Any case in doubt is referred to the public prosecutor’s office. It is perhaps telling that in the last 15 years since legalization of euthanasia in Belgium, over 10,000 individuals have been euthanized but only one case has been referred to prosecutors by the commission with the concern that it may have been performed illegally. Vanopdenbosch argues that the commission is acting in place of the courts, a potential conflict of interest given that those on the commission are generally considered strong supporters of euthanasia. In addition to the slippery slope metaphor used earlier, one might also add that the foxes are guarding the henhouse.

An internal review of this particular case resulted in the committee claiming that what really happened was an accidental death related to palliative care rather than actual involuntary or non-voluntary euthanasia, as is claimed by Vanopdenbosch. The general population will never know, as commission protocol and privacy concerns prevent the details of the case from ever reaching the light of day. In absence of further details, one wonders whether the alleged palliative care for the unknown psychiatric condition was formally requested by an otherwise competent patient or just provided absent his or her formal consent but “in his or her best interest” by the patient’s physician or caregivers.

It is presently unknown whether or not Dr. Vanopdenbosch’s resignation will result in any changes in the structure, function or transparancy of Belgium’s Euthanasia Committee. At the very least, one would expect to see an increase in referrals to the public prosecutor’s office for legal oversight. It is simply unbelievable that the committee has only encountered one case out of 10,000 cases that they found sufficiently suspect to refer to prosecutors for legal review. Perhaps more importantly, I want to believe that even those supporting euthanasia would be against all forms of non-voluntary euthanasia, particularly involuntary euthanasia. Sadly, I am naive. In our post-modern world, how can any death be a “good death” unless, at the very least, the competent patient in question so stipulates?

(For an excellent recent YouTube interview containing a brief history of euthanasia, please see this link of an interview with Dr. Richard Weikart, Professor of History at California State University, Stanislaus. Some highlights: at 10:40 where he touches on Belgium and psychiatric euthanasia, at 19:00 where he discusses the slippery slope argument, and at 21:30 regarding non-voluntary euthanasia)

DIY CRISPR Kits – Gene Editing for the Rest of Us

One might think with the amazing advance of technology and easy access to nearly infinite data via the Internet that we, as a society, would see a reduction in false claims of benefit for novel medical procedures and untested medications. Sadly, it seems to be just the opposite. I seem to be spending gradually more time with my patients reviewing the results of their internet research for new solutions for their chronic back pain. Their efforts are laudable even though the “hoped for” benefits claimed in their researched solutions are woefully lacking. Unfortunately, often this exercise in reviewing the outside data takes valuable time away from the remainder of the office visit.

Reviewing false or confusing information is one thing but preventing patients from self-experimentation with untested medications or unproven treatments is another. Enter the biohacker and companies offering do-it-yourself (DIY) kits claiming to allow anyone to experiment with CRISPR (a method of genetic editing) for self-administration. Emily Mullin covers biohacking and DIY CRISPR very nicely in her recent article in the December Technology Review. To me, this has the feel of the 1980s when a curious kid with some basic programming knowledge, an inexpensive computer and a modem can access previously forbidden government systems, potentially unleashing havoc on the rest of us (WarGames, anyone?) After all, now that we know the human genetic code, all we need is for someone to just provide the instructions and tools for editing that code, then anyone could tweak their own DNA. Easy peasy lemon squeezy, right?

Recently, the FDA has been busy trying to prevent medical clinics from administering untested stem cell treatments (see Neil Skjoldal’s recent November blog entry on (Stem Cell Clinics & the FDA). Imagine the significant increase in the scope of the regulatory problem if individuals can order a DIY CRISPR kit off the Internet!

While we might chagrin at the naiveté required to believe the street-side pitch of the Old West Carter’s Little Liver Pill salesman, that same pitch via a modern tech savvy YouTube video (complete with separate internet links) somehow offers a new level of legitimacy. The Technology Review article speculated that one of the featured companies was preparing not a vaccine but a treatment for herpes. In less than 8 weeks from the article’s publication, Aaron Traywick, CEO of Ascendance Biomedical, publically self-injected himself with his firm’s untested and non-FDA approved “treatment” for herpes. The linked article by Reegan Von Wildenradt in the popular magazine Men’sHealth offered an excellent counter as to why this type of “science” might be suspect, including quotes from ethicist Arthur L. Caplan at NYU in support of the standard FDA process for screening medical treatments.

We often lament in this blog that technology is advancing so rapidly that we fail to have a fair public hearing and discussion of the ethics involved in a particular biomedical advance. Now it seems our time may be better spent speaking out first about the basic risks of the new technology and doing our best to support the FDA in their massive task of policing the Internet to prevent a DIY CRISPR kit from falling into the wrong hands – ours.

P.S. – I’m accepting names for the title of the future Hollywood blockbuster where the son of Matthew Broderick and Ally Sheedy injects himself with his own DIY CRISPR-modified DNA and …

Citizenship, Surrogacy and the Power of ART

A recent LA Times article by Alene Tchekmedyian explores a complicated case involving birthright citizenship, surrogacy and same-sex marriage. Briefly, a California man, Andrew Banks, married an Israeli man, Elad Dvash, in 2010. At the time, same-sex marriage was not legal in the US leaving Elad unable to acquire a green card for residency (via the marriage) so the couple moved to Canada where Andrew has dual citizenship. While in Canada, the couple conceived twin boys, Aiden and Ethan, using assisted reproduction technology (ART) whereby eggs from an anonymous donor were fertilized by sperm from Elad and Andrew and then implanted within the womb of a female surrogate and carried to term. When the US Supreme Court struck down the federal law that denied benefits to legally married gay couples in 2013, Elad applied for and was granted his greed card. The present controversy occurred when Andrew and Elad applied for US passports for the twins. US State Department officials required detailed explanation of the boys’ conception, eventually requiring DNA tests which confirmed Aiden to be the biological son of Andrew and Ethan to be the biological son of Elad. Aiden was granted a US passport while Ethan was denied. The family has since traveled to the US (Elad with his green card and Ethan with his Canadian passport and temporary 6 month visa) where they are now suing the State Department for Ethan’s US birthright citizenship. They are arguing that the current applicable statute places them wrongly in the category of children born out of wedlock rather than recognizing their marriage, thus discriminating against them as a binational LGBTQ couple.

Birthright citizenship is a complicated legal arena and I am no lawyer. The US is even more complicated because we allow birthright citizenship to be conferred jus soli (right of the soil) in addition to jus sanguinis (right of blood). The twins were not born in the US so establishing “bloodline” is needed. The law specifies conditions where one parent is a US citizen and one is not a US citizen, and there is further differentiation depending on whether the children of the US citizen were born in or out of wedlock. They also vary depending on whether the US citizen is male or female, with the law more lenient (easier to acquire citizenship) for the child of a woman than of a man.

While the legal challenge here will almost certainly involve potential issues of discrimination of LGBTQ binational couples, the problem is really with the current legal definitions of parent as it relates to surrogacy in general. The State Department actually has a website dedicated answering questions related to foreign surrogacy and citizenship. The real issue is that the State Department relies upon genetic proof of parentage for foreign surrogacy births. In the present case, the surrogacy occurred outside the US, Elad is the genetic father of Ethan and Elad is not a US citizen; therefore Ethan is not a US citizen. While I’m deep in the weeds here, technically, Aiden and Ethan are not fraternal twins in the usual sense but rather half siblings (and this assumes that the donor eggs are from the same woman; otherwise the boys would be unrelated despite sharing the same pregnant womb through the magic of ART). Had Ethan been physically born via surrogacy in the US, he would have acquired his citizenship via jus soli (see US map for surrogacy friendly states near you).

This problem is just as confounding for heterosexual couples using foreign surrogates, and the problem is global. A more detailed technical legal discussion may be found here. A heterosexual couple using donor eggs and donor sperm and using a foreign third party surrogate would have exactly the same problem establishing US citizenship for “their” child. A similar problem would exist for an adopted embryo gestated in a foreign country by a foreign surrogate. If either the egg or the sperm of the US citizen is used for the surrogate birth, the child would be granted birthright citizenship.

The main difference for homosexual couples is that only one spouse can presently be the biological parent. I say “presently” because with ART it is theoretically possible (and may become actually possible in the future) to convert a human somatic cell into either a male sperm or a female egg. At that point, both spouses within a same-sex marriage could be the biological parents of their child. The present legal issue is not the result of a cultural prejudice against anyone’s sexuality but with the biological prejudice of sex itself. ART has the potential ability to blur the categories of sex as culture is now blurring the categories of gender. Should we consider this a good thing?

Given the present technological limits of ART, the simple issue of US citizenship could be resolved in all these cases if the US citizen parent simply adopted the child. Elad correctly points out that while adoption of Ethan by Andrew would grant Ethan US citizenship, it would not grant Ethan birthright citizenship, a necessary requirement for Ethan to someday run for US president. ART may be forcing us to look at changing our definition of parent but should it change our definition of biology? Ethan is the biological son of Elad. He is able to be the legally adopted son of Andrew and enjoy the benefits of US citizenship as currently does his half brother Aiden. He is not able to become the biological son of Andrew and enjoy the additional benefit of birthright citizenship via jus sanguinis.

Should we change the definition of birthright citizenship because ART is changing our definition of parent?

Will Medical Compliance Ever Become Non-Voluntary?

A recent article by Dr. Lisa Rosenbaum in the New England Journal of Medicine explored both the benefits and drawbacks of Digital Adherence Monitoring. The focus was on the FDA’s recent approval of Abilify MyCite, a medicine technology that combines the medication aripiprazole, used to treat various psychiatric diseases such as schizophrenia, certain features of bipolar disorder and depression, with a digital ingestion tracking system. This voluntary digital health feedback system (DHFS) works by having the patient wear a skin patch that is triggered when the pill contacts the acid in the stomach. This event is then recorded and tracked on the patient’s smartphone. The patient can then permit their caregivers and/or physicians to access the data via a web portal. The company responsible for the DHFS, Proteus, has shown improvement in patient’s systolic blood pressure using DHFS compared with standard care. The article primarily focuses on using the technology to help doctors work with their patients to determine the reasons for non-compliance.

While this presently voluntary technology obviously can track pill ingestion and this data can certainly help doctors and patients improve medication treatment adherence, I wondered about non-voluntary uses of the technology. This particular DHFS confirms that the prescribed pill was actually ingested regardless of what the patient or their caregiver may claim. Would an insurance company be permitted to have access to this data in exchange for payment for a particularly expensive medication? Could a government agency require such a system in exchange for providing coverage for a patient for a procedure whose subsequent outcome is improved with the use a given medication?

Dr. Rosenbaum offered in her article that she thought it unethical to withhold coronary artery bypass from one of her patients with whom she was fairly certain would not subsequently take the dual antiplatelet therapy post revascularization. Using a DHFS eliminates mere suspicion. Prematurely discontinuing of thienopyridine therapy (antiplatelet drugs such as Effient, Ticlid, or Plavix) after a similar cardiac stent placement has been shown to increase the risk of both re-hospitalization and death within the subsequent 12-month period. Given the success of the Proteus DHFS in reducing systemic high blood pressure, mandating this DHFS to monitor antiplatelet therapy immediately post cardiac stent placement should reduce both patient morbidity and mortality during the following 12-month period.

A consequentialist in charge of public health care expenditures might disagree with Dr. Rosenbaum regarding the ethics of providing a revascularization procedure in an individual who is poorly compliant with beneficial post-procedure medication compliance. Bluntly, why spend the money if the patient (for whatever reason) is going to act in a manner to reduce the benefit of her procedure? Thankfully, money is not the only healthcare utility worth measuring and economists are not yet fully in charge of healthcare delivery, though they appear to have an ever increasingly important seat at the table.

So, I think DHFS technologies such as Abilify MyCite will slowly become non-voluntary.

The Brain and The Internet

The current Technology Review contains an article by Adam Piore featuring Dr. Eric Leuthardt, who, as the title claims, is “The [Neuro]Surgeon Who Wants to Connect You to the Internet with a Brain Implant”. After spending Christmas with my married millennial children, I am convinced there are no further connections required. But Dr. Leuthardt isn’t satisfied with clumsy thumbs and smartphones – he wants a hard-wired, direct brain-to-Internet solution. The article nicely covers both the history and current “state-of-the-art” technology of brain-machine interfaces, as well as the barriers we have yet to solve before Dr. Leuthardt’s dream of a brain-internet connection is a reality. I encourage a full read of the entire article as backdrop to the questions I will focus upon for the remainder of this blog entry. Dr. Leuthardt’s research partner, Gerwin Schalk, a computer scientist focused on decrypting the vast volume of brain electrical signals from the current implants used, sets the stage with the following quote:

“What you really want is to be able to listen to the brain and talk to the brain in a way that the brain cannot distinguish from the way it communicates internally, and we can’t do that right now,” Schalk says. “We really don’t know how to do it at this point. But it’s also obvious to me that it is going to happen. And if and when that happens, our lives are going to change, and our lives are going to change in a way that is completely unprecedented.”

What would it mean for us to develop and implement a brain interface separate from our current physical senses of seeing, hearing, smelling, tasting and touching? What Schalk and Leuthardt want is to develop a brain interface that is as good at receiving sensory input as our current five senses and equally as good at affecting our physical environment as our current voice, arms and legs. But it doesn’t have to stop there (and in fact, I do not believe it would). If the brain cannot distinguish data input via these new artificial links from data input via “normal” physiology, why not insert novel visual, auditory, olfactory, tactile or motor information as well as linkages amongst these – the experiences of which become actual memories. How could one tell memories in which you had actually participated from ones that were virtual? Would it matter? Anyone had any trouble with unwanted Internet ads or computer viruses lately?

For the record, I am generally all-in for most replacement artificial body parts, such as heart, lung, skin, kidney, liver and limbs (allowing for the bioethical concerns generally voiced on this blog). I am admittedly concerned as we develop technologies that start accessing (and potentially augment or replace) portions of the human brain, as I think that this starts to tinker with an individual’s very sense of self – one’s identity. Does altering the brain’s manner of sensory processing potentially also alter the brain’s experience of sense of self? Until we answer that question, we should tinker extremely cautiously or perhaps not at all (I am presently favoring the latter).

Of course, all of this skirts around the larger issue of exactly where my sense of self lies. Does my brain completely contain and therefore solely determine my identity or is my identity part of a more complex interface between the physical brain and a non-physical soul? That is a big question for a six-paragraph blog to answer but one that deserves consideration as we seek to develop artificial interfaces within the brain that not only change the way I experience my environment but potentially how I experience my self.

With regard to hooking my brain directly to the Internet, given what I’ve seen of the Internet to date, I will leave my thumbs and smartphone as my interface of choice, at least for the near future.

The Hubris of Head Transplantation

As a rehabilitation physician with an interest in acute spinal cord injury, I try to keep abreast of neuroscience research both in animals and humans that might suggest a breakthrough in spinal cord injury recovery. Sadly, despite increased awareness by the general public from high-profile individuals who suffered this devastating injury (notably Christopher Reeve and his foundation), ongoing research in chemical, cellular transplant (including some stem-cell) and electrical stimulation, and advances in emergency medical and surgical management of the acute spinal injury, medical science has not seen dramatic improvement in spinal cord injury functional recovery since I began my practice almost 30 years ago. I spend some time reviewing the results of my patient’s Internet research into “claims of cures” as they desperately look for any solution to their disability. I thought I had seen everything until I was given a 2015 link to a TEDx talk by Italian neurosurgeon Dr. Sergio Canavero and saw a subsequent recent USA Today article regarding his plans for an imminent head transplant scheduled to occur in China sometime later this month or early next year. In fairness, 99.999% of the scientific news coverage condemns the planned surgery (including the TED community) and the popular news coverage consistently leads with a picture of Gene Wilder in his role in the Mel Brooks movie Young Frankenstein (as in this link)

In short, Dr. Canavero is planning to remove the head of a patient who has a severe progressive musculoskeletal disease and transplant it onto an otherwise healthy brain-dead individual who will act as the donor body. Canavero claims that unlike random high-energy trauma that destroys a significant section of the spinal cord as a result of an accident, his technique uses a precision cutting instrument that minimizes cord trauma, combines this with cryopreservation techniques that cool the head down to 12 degrees Celsius during the transplant, and uses a substance commonly used as a laxative called polyethylene glycol (PEG) to reconnect the spinal cord on the donor body followed by proprietary electrical stimulation of the donor body spinal cord to maximize recovery. Sounds pretty easy, right?

Ignoring the ethical issues for a moment, the main overarching technical problem is that the head transplant technique has yet to work when tried on any animals. Subsections of the technique have shown limited benefit such as using PEG to encourage spliced segments of spinal cord to heal. But a success (partial at best) in one small area never guarantees success on a broader application. Condemning this whole endeavor from an ethical standpoint is therefore a moot exercise. Recommending such a surgical procedure that has never been successful should be ethically abhorrent regardless of anyone’s worldview.

One final comment may be worth considering. If you watch the TEDx YouTube link of Dr. Canavero to the bitter end, he gives you a hint at what motivates his work. He makes the case for eventually perfecting his technique such that the human brain can become immortal. Transplanting a head onto a younger body (and repeating the process) effectively allows a head to live forever. He suggests connecting a head to a machine to achieve the same result. He is really talking about immortality of the human consciousness and actually refers to the brain as a filter for consciousness. It seems the pinnacle of human hubris to believe that we can achieve for ourselves immortality unless it were already available to us.

I suggest that John 6:47-51 offers a better way.

Uterine Transplantation – for Men?

Susan Haack began exploring the topic of uterine transplantation in women on this blog back in February 2014. In just under 4 short years, the technology has not only successfully resulted in live births in several women who received the uterine transplants, but outgoing president of the American Society of Reproductive Medicine, Dr. Richard Paulson, is suggesting we consider exploring the technique in men. While there are certainly hurdles to overcome (need for cesarean section for the actual birth, hormone supplementation, complicated nature of the transplant even for cisgender women), Dr. Paulson does not consider these barriers insurmountable for transgender women.

Dr. Julian Savulescu, professor of practical ethics at Oxford, has cautioned that initiating a pregnancy in a transgender woman may be unethical if it poses significant risk to the fetus. The above-linked article misquotes his concern as a concern over “any psychological harm to the child born in this atypical way”. The following is his actual quote from his own blog:

Therefore, although technically possible to perform the procedure, you would need to be very confident the uterus would function normally during pregnancy. The first US transplant had to be removed because of infection. There are concerns about insufficient blood flow in pregnancy and pre-eclampsia. A lot of research would need to be done not just on the transplant procedure but on the effect in pregnancy in non-human animals before it was trialled in humans. Immunosuppressives would be necessary which are risky. A surrogate uterus would be preferable from the future child’s perspective to a transplanted uterus. Uterine transplantation represents a real risk to the fetus, and therefore the future child. We ought to (other things being equal) avoid exposing future children to unnecessary significant risks of harm.

One putative benefit might be the psychological benefit to the future mother of carrying her own pregnancy. This would have to be weighed against any harm to the child of being born in this atypical way.

His concerns are the baseline medical risks involved in using a transplanted uterus to conceive a child regardless of the sex of the recipient. None of his concerns relate to the psychological harm to the child potentially caused by a uterine transplantation in a transgender woman as opposed to a cisgender woman. Savulescu is explicit in the beginning of his blog that “[t]he ethical issues of performing a womb transplant for a [sic] transgender women are substantially the same as the issues facing ciswomen.” Is the only risk to the child “born this atypical way” just the additional need for hormone supplementation in the transgender woman compared to the cisgender woman? Can we really know, a priori, what all of the attendant risks to the child really are with uterine transplantation in a transgender woman?

Regardless, let’s assume Savulescu is correct, that there is indeed no ethical difference between carrying a child to term via uterine transplantation between a cisgender woman and a transgender woman. There certainly can be no ethical difference between carrying a child to term via uterine transplantation between a transgender woman and a cisgender man. If the foregoing is true, can there be any ethical barrier preventing a man via uterine transplantation to use his sperm to fertilize a donor egg and carry his baby to term? After all, per Savulescu, all we need be concerned about from a bioethical standpoint are the technical issues/risks of uterine transplantation regardless of the recipient’s biological sex or self-identified gender.

In Genesis, God created two complimentary sexes and stated this difference was good. We are moving toward eliminating differences between the sexes and arguing that this is good. Both of us cannot be correct.

I wonder if Dr Haack thought that we would get this far down this particular bioethical slippery slope in four short years?