How private enhancement decisions led to a public health crisis

 

The proponents of using medical techniques not just for treating disease and dysfunction, but also for enhancing normal form or function, often appeal to privacy. Since most public and private insurance schemes do not pay for enhancement technologies, people who desire such “treatments” pay out of their own pockets; so, the argument goes, if they’re not hurting anybody, and they’re paying for it themselves, what’s the problem?

One of the more popular enhancement technologies worldwide is the cosmetic surgical procedure of breast augmentation. In the last few weeks a crisis of sorts has erupted around a particular brand of silicone breast implant, manufactured by the now-defunct French company Poly Implant Prothese (PIP) and exported all over Europe and South America. It turns out that the silicone used in PIP’s implants was not medical-grade, but industrial-grade, made to be used in mattresses; this may make the implants more prone to rupture. Rupture can lead to increases in inflammation and scar tissue formation.

About 300,000 of PIP breast implants are thought to have been used worldwide. This week, France and Venezuela took the step of offering to pay for the removal (but not the replacement) of all PIP implants. “We have to remove all these implants,” said Dr Laurent Lantieri, a French plastic surgeon “We’re facing a health crisis …” France will pay for ultrasounds every six months for those women who opt not to have the surgery.

Two things to note: first, removal of an implant is not like taking out a splinter. It is a major surgery, under general anesthesia, with all of the attendant risks — and expenses — of surgery. Second, other than those women who had implants inserted after breast cancer surgery, all of the women involved paid for their augmentation themselves. But now the state — that is, the citizens of France and Venezuela — will be paying for the corrective surgeries.

All techniques and technologies carry unintended and unforeseeable consequences. Even with the best planning and forecasting, all techniques will surprise us in some way. Medical techniques, because they work directly on the human body, have the potential and power to do very great unintended harm. The silicone breast implant crisis is an example of how choices made in private can have significant unforeseen consequences and costs for the public. The argument that using medicine for enhancement is merely an individual and private decision is simply not valid. How many more individuals will be hurt, and how much more will society pay, as enhancement techniques — and their unforeseen consequences — proliferate?

Why Bioethics Needs the Church (and vice versa)

Back in June I wrote a post to let people know about the newly published book Why the Church Needs Bioethics edited by John Kilner with contributions from many people connected to Trinity and the Center for Bioethics and Human Dignity. At the time my appreciation for what the book represented was based on the people involved and what they had set out to do. I just finished reading the book and they have accomplished their goal well.
They titled the book Why the Church Needs Bioethics, but it could easily have been titled Why Bioethics Needs the Church, because what comes through is how bioethics and the church need each other. I found the insights of biblical scholars and theologians such as Richard Averbeck, Kevin Vanhoozer and D.A. Carson particularly helpful in dealing with the issues of infertility treatment, enhancement, and the end of life that are the focus of the book. But many others from areas as diverse as business ethics, counseling, law, intercultural ministry, medicine and nursing, pastoral care, preaching and Christian education brought insights from all parts of the church to enlighten how we see the bioethical issues that people deal with in real life and how the church can play a role in helping them through difficult times. John Kilner, William Cheshire and John Dunlop brought each section of the book together to help the reader see how it all fit.
The church needs an understanding of bioethics to be able to help people as they face bioethical issues in their lives. Bioethics needs the church to enrich its understanding of how biblical truth impacts bioethical issues and how the body of Christ can prepare people for and help people through the bioethical challenges they face in their lives. Those of us involved in both bioethics and the church are challenged to bring those two together for the good of all.

The Pill Mill

My classmate Avi Viswanath posted a great article on Bioethically Speaking on the “pill mill” industry in Florida.  Pain-killer drug addiction is a big problem in the U.S., and Florida has become the hub for easily-obtained drugs.  In my own training, I encountered “Pez dispenser” physicians who gained the reputation as the “go-to” guys for medications like diet pills.  In one instance, a diabetic woman came to the office asking for diet pills that her primary care physician of many years would not prescribe her.  My attending, without preforming a physical exam, prescribed the pills.  Twice while I was training there, pharmaceutical reps came by for 20+ minute visits.  They seemed to be very friendly with the physician.

Read more about the physician-led “pill mill” drug industry at tamhscbioethics.wordpress.com.

 

Cognitively Enhanced College Students

It’s likely that only a very small number of people are surprised to learn that Adderall, a methamphetamine-based prescription drug used to treat symptoms associated with ADHD, is often used by college students who do not have ADHD to help them study.

Perhaps even fewer people are surprised that most athletes take some form of methamphetamine before a game to help them stay focused.

So it should come as no surprise that often professors and researchers use Adderall to help them push through a deadline. American pilots often will use some form of methamphetamines to help them focus. Some lawyers use it to help prep for a big case.

A recent CNN report discusses the advantages and drawbacks to college students taking ADHD drugs to boost their grades.  Here are some of the key points from the article:

  • Adderall is abused more than marijuana on college campuses and is easier to get
  • 30% of students on college campuses have illegally used Adderall or Ritalin and the percentage increases with upper classmen.
  • 80% of upperclassmen in fraternities and sororities have taken Adderall or Ritalin
  • A Nature article that advocates regulated use of these drugs for improving performance suggests that these drugs would be better for the individual and society:  “In the journal Nature in 2008, a commentary by five researchers said, “We should welcome new methods of improving our brain function.” They added, “Safe and effective cognitive enhancers will benefit both the individual and society.””
  • The student in the interview saw marked improvement in his grades.
  • Students consider Adderall slightly more dangerous than Mountain Dew, and not nearly as dangerous as drinking beer or smoking.
  • The article points out several of Adderall’s side effects.

While the article touches on this, I am not writing to discuss the health hazards or side effects associated with stimulants such as Adderall or Ritalin or methamphetamines in general. I am also not writing about ADHD. I do think ADHD is an important topic, but that is not the point. My point is to ask should “study drugs” be legal for people to use?

The Nature article mentioned above seems to think so. However, after having recently read through another book on the eugenics movement, the language in the quote above sounds strangely familiar. More productive people could certainly benefit society, but how this benefits the individual is a stretch. For example, if everyone were to take cognitive enhancers, then those that were at an advantage have now gone back to being “average” or “sub-average.” The competition remains the same, only the standards are higher. The only time the individual obtains some benefit from methamphetamines is when he is one of the few using them while the standards are still based on prior capabilities. Having the advantage is relative.

Implied in the language of “benefitting society” is the idea of the perfectly productive person, or what a person should be. The message that “you are a better person when you are on drugs” should not be taken lightly. This idea assumes that a very narrow range of particular personality types are better than others. Then this personality is valued (perhaps implicitly) as the norm. As Carl Elliot astutely observes in his book Better than Well,

Perhaps some people are simply temperamentally unsuited to life at this fever pitch – drinking espresso in front of a computer screen, fax humming, speakerphone on, e-mail zipping in and out, lunch at the desk, people popping in and out of the office. Not everyone wants to live their life as if they were on the trading floor of the New York Stock Exchange, even if they could handle the pace. Maybe those who worry about Ritalin are really worrying that we have sped up the rhythm of American life to such a frenzied drum roll that those who march to the beat of a different drummer – or rather, who idle slowly rather than march – will simply be left behind (Elliot, Carl Better than Well 260, 261).

Replace that list with the college years: staying up all night with friends, going to parties every weekend, dealing with relationships, work, going to classes following by forty hours per week reading and studying for the 3 big tests that always seem to have the importance of determining your future all while averaging four to five hours of sleep on a diet with all of the nutrients that Raman noodles and pizza has to offer. And then the student in the interview complains about not being able to concentrate. Very few people can handle this pace, but beginning in college and carried on through adulthood, it is expected. No one wants to admit that he or she can’t handle it.

Secondly, in the article, the senior college student interviewed is quoted as saying that when he takes study drugs, “I’m more driven. I don’t focus on anything else…No distractions, no socializing, just on with it.” The ability to concentrate on one thing (something Lord Chesterfield considered a mark of genius), the ability to focus and commit to one project, the ability to manage your time, the ability to make a conscious decision for delayed gratification – These skills are some of the most important lessons learned in undergraduate and graduate school. With the aid of study drugs, students don’t learn these skills. What they do learn are the facts to pass the test. However, with the advent of Google, anyone can look up facts. Google has changed the way we do academics. No longer is the guy with the biggest database of facts the most valuable player in your company (or medical team, or research team), it’s the guy who knows how to find, filter, and assess the facts in such a way that he arrives at creative solutions. Most people decide to go to college in hopes of landing a good job after graduation. Thus far, there is no pill for ingenuity and resourcefulness. Facts are cheap, and the last thing an employer needs is a $50,000 database.

Cybrid-gate in the UK

In last week’s blog (July 26), I highlighted an article from Wired magazine (August 2011) titled “Extreme Science”  in which Wired explores seven “shocking experiments” that scientists could learn from if they were willing to set aside their ethical concerns.  One experiment involves cross-breeding humans with chimpanzees in order to better understand human development.

What I find fascinating about all of this is that the Wired article was written as if unethical experiments don’t occur; as if, in reality, scientists are guided by a moral compass.  But are they?  Just 2 days before I wrote my blog, The Daily Mail (a British publication) reported that over a 3-year span scientists “have created more than 150 human-animal hybrid embryos in British laboratories.”  So, what Wired posed as a hypothetical thought experiment was already happening (albeit secretly) in the UK.

According to The Daily Mail, “155 ‘admixed’ embryos, containing both human and animal genetic material, have been created since the introduction of the 2008 Human Fertilization Embryology Act.  This legalized the creation of a variety of hybrids, including an animal egg fertilized by a human sperm; ‘cybrids’, in which a human nucleus is implanted into an animal cell; and ‘chimeras’, in which human cells are mixed with animal embryos.”  http://www.dailymail.co.uk/sciencetech/article-2017818/Embryos-involving-genes-animals-mixed-humans-produced-secretively-past-years.html

The Human Fertilization and Embryology Act of 2008, Section 4A, contains some of the following prohibitions:

“(1) No person shall place in a woman –

(a) a human admixed embryo,

(b) any other embryo that is not a human embryo, or

(c) any gametes other than human gametes.

(2) No person shall –

(a) mix human gametes with animal gametes,

(b) bring about the creation of a human admixed embryo, or

(c) keep or use a human admixed embryo…”

So far, so good.  Or so I thought.  The Act continues:  It is illegal to do #2 above (i.e., mix human gametes) “except in pursuance of a license.

In other words, it is still possible, with government authorization, to mix human gametes with animal gametes to create an admixed embryo.  The only restriction, according to the Act, is that the admixed embryo cannot be kept or used after the first 14 days of its existence.  Indeed, it is also possible, according to the wording of the Act, to create an admixed embryo, store it (i.e., freeze it) over a period of time, and then at some future point do research on it, as long as it is not allowed to live beyond 14 days.

(To view The Human Fertilization and Embryology Act of 2008, go to:  http://www.legislation.gov.uk/ukpga/2008/22/contents)

But the story’s intrigue deepens.  The creation of the cybrids” in the UK was apparently done in secret.  As noted in a recent Christian Medical Fellowship blog (July 26): “there seems to be a murky mix of confusion and secrecy from which the true facts and figures are difficult to extract.”  But why the secrecy if research was being done within the guidelines of The Human Fertilization and Embryology Act?

Furthermore, the research was not carefully documented.  It is less than clear the exact numbers of cybrids that were created.  The Christian Medical Fellowship reports that, “According to The Independent “many more cybrid embryos were created – 278.  That large number is naturally of concern, but also of concern is that the numbers don’t match the figure of 155 released last week.  The Government has avoided answering that question.  Moreover, if all funding (apparently) stopped in 2010 and the licence was revoked from the only researcher, when were these 155 (or 278) embryos created?  Were they all created before 2010?  Or are they still being created?  If so, by whom?” http://www.cmfblog.org.uk/2011/07/26/155-animal-human-embryos-created-in-the-uk-%E2%80%93-we-think/?doing_wp_cron

In other words, in spite of government oversight, an assortment of so-called “ethical guidelines,” and the best intentions of scientists, it’s less than obvious that research is done within any firm restrictions.  The CMF concludes that “the glaring discrepancies in the figures issued by The Human Fertilization and Embryology Authority shows it is not fit for purpose when it comes to regulating the scientists.  It is incapable of keeping accurate records and is unable to keep on top of what is going on in research, either with embryos or eggs.”

I ended last week’s blog with the following observation:  “Humans have also demonstrated a natural tendency to push the moral envelope, to give priority to what can be done over what should be done.  Time will tell whether experiments that are now considered unethical will one day be the norm.”  Apparently we no longer need to wait for “time” to make this announcement.

Parental Guidance Before and After Birth

 

As I sat sipping coffee and reading articles on the moral implications of genetic interventions in the germ-line (don’t yawn), a perfect picture was painted at the table across from me.  A young and boisterous child spoke of his aspirations for the future, vehemently proclaiming to a doubting adult audience, “I want to be a teacher, a singer, a dancer, a hospital man, I want to be everything.”

 

His ambitions were a bit outlandish.

 

His father, or who I believed to be his father, responded: “Do you know how you can be all of those things? You can be an actor.  This way you can be a teacher one day, and a singer another, and…”

 

“No, I want to be them all!”– Clearly the aspirations of the father were distinct from that of the son.

 

Imagine, if you will, that your direct (active) influence on your child could begin before conception. What if you could unify your aspirations before birth? No longer would you have to squelch his dreams as he bellows across Starbucks…

 

Although this is not yet in our grasp, Gender selection and disease screening are already a possibility. What if more options become available?

 

John Harris, recognizing this future possibility in his book Enhancing Evolution, avows an ethical parity in genetic interventions before conception and parental influences after birth. Could this be true?  Are encouraging your child to play an instrument and (in some future world) fashioning an embryo to be a world-class musician morally equivalent?

 

I would say there is a distinct difference between choosing for our children potential traits in embryo and guiding our children along in life. No doubt both influences are according to parental values. However, by choosing traits we are no longer discussing influence in terms of persuasion and direction, we are discussing a new kind of coercion.

 

What do you think?