Mitochondrial replacement boosterism

A new Viewpoint article (available for free, without a prescription) from the Journal of the American Medical Association (JAMA) asserts that the United States is acting too slowly to advance mitochondrial replacement techniques (MRTs), the so-called “3-parent baby” approach that would seek to prevent mitochondrial DNA disease, which is transmitted maternally.  The authors approve of the recent recommendations by the afore-named Institute of Medicine (IOM), but are dismayed that, for now, recent federal legislation blocks FDA from further consideration of MRT applications.  This runs counter to the principle of beneficence, they argue, by foreclosing the possibility of reproductive relief for the estimated 800 US women affected each year.  This is their number, not mine, and presumably refers to 800 attempted births per year by women affected with these mitochondrial diseases, which are inherited and so present in an affected individual for life.  Again, the goal would be to allow these women to conceive and, one hopes, give birth to an unaffected offspring. 

In any event, the authors of the article in question find the IOM’s recommendations thoughtful, but the aforementioned legislation thoroughly unreasonable.  Besides blocking the advance of science in the U.S., we are ceding ground to the U.K., where it’s full speed ahead for clinical applications of MRTs.

Now, the IOM recommendations were anything but slapdash, reflecting careful thought leading to conclusions with which one may yet disagree.  What troubles me about the JAMA piece is how cavalier the authors are in embracing MRTs as the camel under the tent for doing anything and everything to the human genome.  They write (emphases are mine, not theirs):

“[The recent] developments [regarding MRTs] are nothing short of historic and their significance multifaceted. First, mitochondrial replacement therapy represents the sole example of state-approved germline gene therapy in the human. Second, it comprises the only known intervention with the potential to reduce the burden of mitochondrial DNA diseases. Third, it constitutes the first case in which organelle and, indeed, whole cytoplasmic cellular replacement are being contemplated. Fourth, it irrevocably alters assisted reproduction by placing it at the center of future genome editing efforts. Fifth, it acts as a test case for the regulatory adjudication of other emerging reproductive innovations. Examples include but are not limited to editing the genome of the human embryo and the prospect of using somatic (eg, skin) cells to generate eggs and sperm in a laboratory dish.”

I encourage readers to let this paragraph sink in.  The thinly-veiled argument is that putting breaks on these technologies is illegitimate not only because it violates the principle of beneficence, but more importantly because it could delay the day when humans are fully engineered.  The authors and their apologists will object that I am putting words into their mouths, but I think their enthusiasms are showing.

Read the whole thing.

Medical errors and more medical errors

Last week the BMJ reported that annually, there are 251,000 hospital deaths due to preventable medical errors in the US. There’s some debate about the calculations that they used to arrive at that number, and about what exactly constitutes a medical error. However, rather than quibble over the fine points, let’s acknowledge that medical errors are an ethical problem that must be addressed. In this post I would like to widen the conversation beyond the hospital walls. Below is a sample of some deaths due to preventable medical errors that weren’t included in the BMJ calculations (most of these ones happen outside of hospitals); nevertheless, they too affect thousands of people annually. I will also attempt to provide a taxonomy of the relevant errors.

Deaths due to the inability of the patient to obtain medical care because they couldn’t afford the care or the insurance — unknown number. The medical error here is a systemic one, the rationing of health care on the basis of who can pay for it.

Deaths of patients due to their being the subjects of human research — unknown number. This is peculiarly prevalent among embryonic patients (as Jon Holmlund wrote about last week). The medical errors include the failure to extend to embryonic research subjects the protections enumerated in the Declaration of Helsinki. There is also a category error: classifying embryonic patients as something other than human beings.

Deaths of embryonic or fetal patients through elective induced abortion — 977,000 (2014 data). The same category error as previous comes into play here: the failure to recognize the humanity of the unborn human.

Deaths of patients from drugs prescribed by their physician for the purpose of suicide — the numbers data is incomplete. The number is relatively low but projected to grow as more jurisdictions legalize physician-assisted suicide. The errors here include a professionalism lapse (forgetting that the professional status of medicine was established, among other things, on the dictum that doctors do not give deadly drugs, even if asked to do so). There is also the error of hubris: the belief that doctors can decide that someone should be allowed to kill themselves.

Preventable medical errors, all.

Experimentation on nonviable human embryos

Nature News recently reported that a second Chinese research team has done research on non-viable triploid human embryos in which they used CRISPR-Cas9 genome editing to introduce a mutation that cripples the immune cell gene CCR5 and would make individuals with the mutation resistant to HIV. This research raises a multitude of ethical concerns. Should we be pursuing such research when we have not decided whether using these techniques to create individuals who would be brought to birth would be permissible? Does the fact that only 4 of 26 human embryos targeted were modified and that those were not modified on all of their chromosomes and there were a large number of unintended mutations indicate we are nowhere near ready to try this technique on human embryos? If this could be done effectively would we want to make children with an impaired immune system, but who are resistant to HIV?

I would like to focus on a more basic ethical concern. The researchers in this and the prior Chines study reported in April 2105 justified experimenting on human embryos by using embryos that were non-viable. They obtained from a fertility clinic early human embryos that were triploid, meaning they came from eggs that were fertilized by two sperm and contain 69 chromosomes rather than the normal 46. This is a fatal condition. Most naturally occurring triploid fetuses miscarry in the first trimester and the very few who survive until birth seldom live more than a few days after birth. Embryos created during IVF that are identified as being triploid are not implanted since those doing IVF desire a healthy child, not a disabled one. The researchers contend that the fact that these embryos will not survive makes it permissible to use them for genetic research because it removes the concern that a genetically modified human being could be born.

However, does the fact that a human embryo is destined (almost always) to die prior to birth mean that it is permissible to use that embryo as a research subject? If a human embryo is a human being who has been made in the image of God, then the life that the embryo is living has value and should be respected even if that individual will never be born. When we do research on children who are not able to voluntarily consent to being research subjects we restrict that to research that either has minimal risk to the subject or is being done to try to benefit a child for whom no other treatment is available. Embryos are not able to consent to be research subjects, yet this research is being done on them with great risk to the life that they do have and with no intent to benefit them. If these two sets of researchers do not believe that human embryos deserve this type of respect, then why not use normal embryos instead of triploid ones? In both cases they would be experimenting on living human beings who are incapable of consent and are being killed and the end of the research. Why would it be more acceptable to do that with human beings who are more disabled and have a shorter life expectancy?

We have made significant ethical advances over the past century in our understanding of how we should conduct human subject research. We need to remember that human embryos are human subjects when they are used in research.

“Imago Dei” by any other name…

William Shakespeare reminded us that an object’s essence is not determined by the label we assign to it. No one has since proven Shakespeare wrong. Despite this fact, nowhere have labels been more strongly asserted than in the bioethical debate of abortion. Exactly what or who exists in the uterus of a pregnant human female? The list of labels is long and includes: “baby”, “the pregnancy”, “embryo”, “fetus”, “the products of conception”, “the unborn” and “potential future person”. These labels may honestly reflect an individual’s sincere belief or understanding of the essence of the object in question. But the labels can impede an honest discussion of and agreement upon the essence of that very object. Termination of a baby carries more moral alarm than termination of a pregnancy even though both refer to the same event. We even have different labels to identify the opposing groups on the abortion issue that avoid naming the procedure; Pro-Life and Pro-Choice.

With abortion being the third rail of social politics, it should surprise no one when we see our politicians on both sides of the aisle politically injured when mishandling the subject. When asked if a pregnant woman should be held liable for seeking an abortion in some hypothetical future where abortion is illegal, Mr. Trump eventually suggested she might be subject to “some form of punishment”(1), though later walked back the statement after realizing his assertion upset both Pro-Choice and Pro-Life groups. Since this was a legal rather than ethical question, a non-lawyer could similarly struggle to rationalize how one presently can be held criminally liable for the unintentional death of the fetus of a pregnant woman via a motor vehicle collision(2) but not held criminally liable for the intentional death of the same fetus under current (read: legal) abortion laws(3). No discussion was undertaken from an ethical standpoint to explain why punishment might be deserved in the first place.

Within a week of Mr. Trump, Ms. Clinton caused a different abortion controversy by “referring to the unborn as a person”, drawing the ire of her Pro-Choice supporters(4). The label “person” usually carries moral protection prohibiting, for instance, potentially fatal surgical procedures without informed consent, and abortion is certainly fatal, at least from the standpoint of the unborn, particularly when promoted to a person. Similar to a previous statement above, aborting a person carries more moral alarm than aborting the unborn.

For the Christian, the essence of the pregnancy, products of conception, embryo, fetus, unborn or potential future person must include the Image of God, the Imago Dei. It is this essence that provides moral boundary and ethical guidance regardless of other human attributes, whether potential or realized. See this recent blog entry for further detail.

As per Shakespeare, we cannot ignore the smell of the rose, regardless of how we choose to label it. Would that we could not ignore the essence of the Imago Dei, regardless of our ethical, social or political beliefs.

 

The pertinent portion of note 3: “If the mother can intentionally terminate the pregnancy at three months, without regard to the rights of the fetus, it becomes increasingly difficult to justify holding a third person liable to the fetus for unknowingly and unintentionally, but negligently, causing the pregnancy to end at that same stage. There would be an inherent conflict in giving the mother the right to terminate the pregnancy yet holding that an action may be brought on behalf of the same fetus under the wrongful death act.”

Translational Science as an Ethical Imperative

An acquaintance recently sent me a copy of an article from the December 7, 2015 edition of The New Yorker magazine, describing efforts of a neurosurgeon to use an unconventional approach to treating terminal brain cancer.  Follow the link and read the article for the whole story, but the physician in question was acting on anecdotes of people whose brain tumors had improved dramatically after serious post-operative wound infections. (Surgery is the front-line, but generally inadequate, treatment for these tumors.)  The physician purposely infected the wound of one of his patients with Enterobacter aeroenes, a bacterium normally found in the bowel and in human feces.

The first patient had a dramatic improvement and lived for a few years after—a highly unusual, positive result.  The second one did not do so well.  There was a small number of people treated in this way, and results were mixed at best.

From the article, it seems clear that this was a good doctor trying to help his patients—one who had done a practice-changing clinical trial and who understood that some treatments may “work”—that is, have a biologic effect as expected—but not help the patient—that is, the effect does not translate into any actual clinical benefit against the disease.  This is a common problem in the development of new treatments, especially for cancer, where clinical trials often do no better than showing “a correlation with a correlation with something you care about,” as a former senior official of the National Cancer Institute put it to me (not about this neurosurgeon’s approach, but about something else) some years ago.

“Innovative therapy” is not the same as “clinical research” or “human subjects research.”  The former is performed by a licensed physician using his clinical judgment to try to apply available means for the best care of his patient.  The latter tries to collect generalizable knowledge and, one hopes, help the study subjects in the process.  Often in clinical trials, especially the earliest trials of the newest approaches to therapy, the latter (“direct benefit” to subjects) is not attainable, but the former (the “indirect benefit” that may translate into future direct benefit for other people, or for society at large) is.  In early cancer trials, overoptimism, implicit or explicit, is often a concern, leading to something called a “therapeutic misconception.”

In this case, the doctor took pains NOT to create a therapeutic misconception.  He didn’t oversell the idea to his patients.  With the first case, the local IRB—the ethics board—did not think its oversight was needed, calling the approach “innovative therapy.”  As the number of patients receiving the attempted treatment increased, the IRB started to think it should get more involved.

To make the story short, enough was done without formal IRB review or FDA regulatory review that it was decided, in retrospect, that several people should be disciplined for, in essence, getting out over the end of their skis with the idea.  The author of the article contrasts this case with the Duke University studies into using a modified poliovirus to treat brain cancers, something that was the subject of a widely-noted report on 60 Minutes last spring (subscription required to view online).  That approach was studied in the laboratory for years before being tested in patients.

A big challenge with “alternative” or unorthodox treatment approaches for desperate diseases is that they are typically blind shots.  Now, if you know you don’t have long to live, you might be willing to let a blindfolded marksman shoot a wild animal off your head, knowing he might hit your head instead.  And, frankly, many new treatments are still “semi-blind” at least.  But (and leaving aside for now the whole question of how much of what kind of regulation is best) there is something of an ethical imperative for doctors exploring new treatments to perform the most disciplined scientific research they reasonably can to try to understand what is going on with their new idea, how to improve their chances of success, and how to limit undue risk to their patients.  It’s part of integrating medical research into good patient care, and it’s called “translational,” trying to translate a set of observations or laboratory results into a defined treatment with some reasonable estimates of the risks and benefits.

“Shrinking” IRBs and Cutting-Edge Bioethics

A recent conversation from my IRB work—for several reasons, I must limit the details of the case:

An IRB had received, for review and approval, a research protocol for gene editing of human embryos obtained from an IVF clinic.  The embryos would be at about the 150-cell stage—an early stage at which some (incorrectly, as I understand the science) believe a fertilized, dividing-and-differentiating zygote has not yet attained sufficient maturity to be called an embryo.  These embryos would have been “donated,” in compliance with current law and regulation, including informed consent from the relevant party or parties.  Further, the embryos would have been found to have a “life-threatening” mutation by preimplantation genetic diagnosis (PGD).

The first impression of the IRB’s primary reviewer (a scientific member for you readers familiar with regulations about the makeup of an IRB) was that the study was approvable on an expedited basis—that is, without a discussion at a full IRB meeting.  Current regulations identify nine categories of research eligible for expedited review.  The study in question arguably fits criterion #3:  “Prospective collection of biological specimens for research purposes by noninvasive means.”

Under current law and regulation, this is a reasonable view.  The Code of Federal Regulations (45 CFR 46.204) includes requirements for the protection of live human fetuses who are subjects of research.  The regulations define “fetus” as “the product of conception from implantation until delivery.”  Research involving dead fetuses, in whole or in part, including those obtained as a result of elective abortion, is to “be conducted only in accord with any applicable federal, state, or local laws and regulations regarding such activities.”  As the Congressional Research Service points out in a general reader-friendly FAQ document (go to https://www.fas.org/sgp/crs/misc/R44129.pdf), any research involving human subjects must be approved by an IRB in advance, but the dead fetus is not considered to be a human subject.

It’s logical to apply the same considerations to embryos used in research, and PGD, and, to be sure, IVF itself.  Of course, these embryos are usually destroyed in the process, and all the related issues of embryo or fetal tissue donation are raised in the process.  In the present case, were the research to be done on embryos intended for implantation and bearing in pregnancy, the embryos would be human subjects as well, and all the related issues—consent and others—that I and others have discussed on this blog in the past would apply as well.  It’s arguable that, to be sure all regulations are met, an IRB should send research like the proposal in this case to full review. (One question I would have is how strict is the definition of “life threatening” mutation.)

For those who, like me, argue that human life begins at conception and might like to see the current regulations changed, that probably would require a new statute—a law passed by Congress and signed by the president.

But none of those thoughts is my main concern here.  Rather, I think of the recent discussions of whether it is wise to edit the genes of human embryos or germline cells (eggs or sperm).  Scientists meeting in Washington DC recently issued a statement that it would be “irresponsible” to proceed with such editing in embryos intended for pregnancy.  There appeared to be at least a cautious embrace of basic research on editing genes in these cases, however, implying support for proposals like the one crudely outlined here.  But some leading scientists in the gene editing field disagree, arguing for a broader societal discussion first.

And, in that light, consider the shrinking role of the IRB.  I think the standard understanding of the IRB’s jurisdiction, in the early 21st century, is narrow—it is empowered only to address whether current regulations are being met.  Whatever the individual members of an IRB may think about the broader questions of the wisdom of forging ahead with human embryo or germline gene editing, I bet most IRBs would not think that it is not their business to weigh in on whether studies like the one described here should be done at all.  In other words, whatever societal discussion of these ethical issues is needed, the IRB is walled off from it.  Am I the only one who finds it ironic that IRBs, which had their genesis in the effort to prevent mistreatment of human research subjects, and whose members are required to have varying backgrounds, are considered unqualified to weigh in on matters like this?

Undiscussed issues in the debate over human germline genetic modification

Jon Holmlund’s 12/10 post on the use of somatic cell gene modification to treat sickle cell disease and two recent articles in The Telegraph have me thinking about human germline genetic modification again. One of the points in Jon’s post was that somatic cell genetic modification does not have the ethical problems of germ line genetic modification. The Telegraph articles discuss a group that has proposed a global ban on the genetic modification of human embryos and the views of the British government’s Chief Scientific Adviser, Sir Mark Walport, who advocates for Britain being at the forefront of this research.

While there are safety concerns with somatic cell genetic modification as with all new medical technology most agree that there are unique concerns with germline genetic modification. The group supporting the “Open Letter on Reproductive Human Germline Modification” focuses on the concern that this technique “could irrevocably alter the nature of the human species and society” in addition to safety concerns. Much of their focus is on the likelihood that the use of germline genetic modification would lead to a biological divide between the rich who could afford genetic modification and the poor who could not.

Walport takes the view that decisions about whether it is right to use human germline genetic modification are risk/benefit decisions and downplays ethical concerns other than safety. He is quoted as saying it was important to think about genetic engineering in a “sensible way” which involved “careful discussion and debate”’ of both scientific and ethical issues. “We shouldn’t think about technologies in a generic way. Is it a good or a bad thing,” he said. “There are potentially good uses and there are potentially abuses.” His consequential thinking excludes the possibility that there is anything inherently wrong with human germline genetic modification or the experimentation on human embryos required to develop this technique that he is supporting. It also assumes that modifying embryos so that parents who carry a genetic disorder can have biologically related children who do not have the disease they carry outweighs the potential harms.

While concerns about safety and concerns about social impact and inequality are valid, there some things that are being missed in the public debate. One is the issue of experimentation on human embryos. The request for permission by the Francis Crick Institute in London to do genetic modification experiments on human embryos in spite of the previous British ban on such research includes the stipulation that the embryos will be killed by 14 days after conception. These human embryos are being experimented on and destroyed with no benefit to themselves. This makes the research itself wrong no matter what benefit could possibly result from the research.

Another is the nature of the potential benefit of this technique. Sometimes it is expressed as having the potential to rid the human race of serious genetic diseases. That really is not true. Even if it would be amazingly successful it would only be able to allow parents who are carriers of a genetic disease and have the resources to know that they are carriers and the resources to undergo expensive reproductive technology to have a child who does not have that specific disease and who would not pass on that disease to his or her offspring. The disease would still be passed on by parents who did not know they were carriers or who did not have the resources to do this type of technology. That would not eliminate the disease from the human race. It is all about the reproductive “rights” of affluent parents and the profit that can be made by the reproductive technology industry in catering to their desires.

Babies and unnecessary pain in research

A Reuters news service article this week reported that many babies are subjected to excessive or unnecessary pain in the course of medical research.  The article provided a link to an online report from the journal Acta Paediatrica.

The authors of the article in question (freely available through the link above) summarized their review of 46 recent (previous 2 ½ years) clinical trials testing analgesic treatments for pain caused by medical procedures performed on neonates—babies in the first month of life.  As anyone who has visited the doctor knows, medical procedures can cause pain, sometimes more, sometimes less.

The article’s authors found that a majority of the studies used a concurrent control group that did not receive any analgesia, or placebo, to compare with an experimental analgesic drug or method.  The problem with that is that there are numerous standard pharmacologic and non-pharmacologic analgesic methods that may be used for neonates and older infants.  By denying those to some subjects, the investigators did a disservice to these neonates, the authors argue.  Their argument is entirely reasonable.  They further find fault with ethics committees that approve such research, journals that publish the results, and parents of the infants, who provided consent either out of ignorance or for some other unknown reason.  All of this should stop, they argue, in favor or research designs in which all subjects receive at least standard-of-care analgesia.

This looks like an easy one: a fundamental criterion for ethical research on human subjects is that risks be minimized to the extent possible and reasonable, and consistent with good scientific and medical practice.  Further, risks of research must be reasonable and proportionate to the likely benefits, direct (to the subjects) or indirect (to society at large, in the form of useful knowledge gained).  On one level, what we have here is unethical use of placebos.

As straightforward as this may be, I bet it is something that can easily get by IRBs/ethics committees.  I don’t follow pediatric research, for example, and had not known about some of the standard analgesic methods.  Several are quite simple—swaddling or stroking the baby, warming a heel before a pinprick, or giving the baby some sugar solution, for example.  I had no idea these had analgesic effect.  (I’m a father of two, but my sons are grown, and it’s been a while…)

To dig this information out may take rather more scholarship than most IRB members—scientific or non-scientific—are inclined or able to do.  But it’s essential.  Even more essential is proper scholarship by the researchers, who should know better, to design studies that are as ethical as possible.

A further point:  procedures that adults may not think so bad, like a vein stick or heel stick to draw blood, may hurt a baby like the devil.  The Reuters article cited separate research showing that needle pricks cause babies severe pain, and an expert in the study of pain was quoted as saying that a heel prick could hurt a baby all the way up to the knee.

Again, I had no idea.  Certainly medical practice should take this into account, and I imagine it does or it will.  But a simple blood draw on an adult is typically considered “minimal risk,” which is defined as causing no more pain or discomfort than is ordinarily encountered in normal daily activities of life or routine medical examinations or tests.  The implication is that even routine blood testing in infants should be considered more than minimal risk.  And ethical guidelines for research on children demand that more-than-minimal-risk studies in children clear a higher benefits hurdle than similar research in adults.

So, something else to watch out for.

Restoring Study 309: Figures don’t lie, but . . .

This week the BMJ published an article written under the “Restoring invisible and abandoned trials initiative.” This 2013 initiative was undertaken to bring unpublished trials to light and to correct misreported trials, “. . .to see whether access to and reanalysis of a full dataset from a randomized controlled trial would have clinically relevant implications for evidence based medicine.”  The BMJ article details the reanalysis of  Study 329, a 2001 study funded by GlaxoSmithKline (GSK) (then SmithKline Beecham), published in The Journal of the Academy of Child and Adolescent Psychiatry (no hack journal), and written, not by any of the 22 named authors, but by a GSK-hired ghostwriter. Study 309 purported to show that GSK’s antidepressant drug paroxetine was both effective and safe for the treatment of adolescents with depression. GSK’s marketing campaign based on the study touted its “REMARKABLE Efficacy and Safety,” and in the next year alone over two million prescriptions were written for children and adolescents in the United States.

The researchers for the BMJ article went back and laboriously dredged up original, previously-unavailable patient-level data from the trial and re-analyzed it using the original study protocol; essentially, they re-performed the original study, with two crucial differences: they weren’t being paid by the drug’s manufacturer, and they did not repeat the subterfuge employed in reporting the original study to mask the outcomes. Based on their independent analysis of the more-complete data set, their conclusions are that paroxetine is no more effective than placebo, and that it results in significant harms, including suicidal ideation. Along the way, they uncover the sleight-of-hand the original study used to come up with its conclusion, including practices like describing suicidal ideation as “emotional lability” (thus making it look like the drug in question didn’t cause suicidal ideation, just the far more benign-sounding emotional lability).

An accompanying article in BMJ details Study 309’s checkered history: it has come under repeated fire since 2002, and its falsehoods were a factor in the Department of Justice’s criminal charges against GSK. Amazingly (or not?), “None of the paper’s 22 mostly academic university authors, nor the journal’s editors, nor the academic and professional institutions they belong to, have intervened to correct the record. The paper remains without so much as an erratum. . .”

Meanwhile, many people, medical and non-medical alike, still believe, based on this study, that antidepressants like paroxetine are safe and effective for adolescents.  How many people have been harmed by these massive lies, perpetrated in the interest of making an illegitimate profit off of other people’s afflictions? This one seems to qualify for all three categories of deceitfulness: Lies, d__ned lies, and statistics.

The Personhood Problem

This week, a New York judge dismissed a case seeking to free and grant personhood to two chimpanzees being used in studies by Stoney Brook University. Manhattan Supreme Court Justice Barbara Jaffe issued a thirty-three page document outlining the reasoning behind her decision. A higher court had ruled on a similar case last year, so she was bound to follow suite.

The Nonhuman Rights Project, who sought to free these chimps, made arguments for personhood based on their powers of cognition and “their similarity to humans in DNA composition, communication, and self-awareness.”

There is more at stake with these kinds of decision than the rights of nonhuman animals, however. The kinds of arguments used to grant personhood to nonhuman animals also run the risk of questioning and potentially even removing the status of personhood from some humans. If we are to follow these kinds of criterion for personhood, we risk alienating young children, the elderly, and the disabled from having personhood.

Animal rights and pro-choice activists often have a similar list of qualifications for personhood that, either intentionally or unintentionally, exclude some people from personhood. In her famous argument against granting personhood to fetuses, Marry Anne Warren cites five necessary conditions for personhood:

1. Consciousness

2. Reasoning

3. Self-Motivated Activity

4. The Capacity to Communicate

5. Self-Awareness

If a being fails to meet any of one these criteria, Warren argues, that being is not a person. While her argument was designed to prove that a fetus is not a person, it is also strikingly similar to the arguments used by the Nonhuman Rights Project. Additionally, if this logic is followed, not only are some animals persons, but some humans are not persons, and these groups are already the most vulnerable in our society, especially the elderly and the disabled.

As much as I sympathize for animals used in research and kept in poor conditions, I have a responsibility as a Christian to “Learn to do right; seek justice. Defend the oppressed. Take up the cause of the fatherless; plead the case of the widow,” (Isaiah 1:17 ESV).

How can I address injustices toward animals without promoting logic that excludes some people from personhood? Is it possible to balance these two causes, or must one fall in favour of the other?