If no travel restrictions, then….quarantine?

As the Ebola epidemic rages on, the debate about travel limitations has moved inevitably to the next stage: whether there ought to be a quarantine imposed on healthcare providers and others returning from service in endemic areas. We have been reading two opposing views, one emphasizing, as did Governor Christie of New Jersey, that “the obligation of elected officials is to protect the public health of all the people,” and the other warning of the “disincentive” and “stigma” that would affect those healthcare professionals who might volunteer in West Africa.

The fear of stigma remains a curious phenomenon. It is plainly obvious by now that healthcare workers caring for Ebola patients are the most likely Americans to catch the disease. I propose that their free and unquarantined movement through society would not make them suddenly immune to stigma. If science and its facts are to guide our decisions, we must not shirk from finding all facts that are relevant to the decision at hand. For example, key to such a decision would be to find out how likely it would be that healthcare workers would change their mind about serving in the Ebola epidemic if they knew that they’d face a 21-day quarantine afterwards. I won’t claim to know the answer, but nobody else knows it either. If “science” is to be our guide, then we ought to do the research and not speculate. One could easily posit that healthcare workers would be encouraged by having the confidence that they would return to accommodations that would ensure that the risk that they would transmit a deadly disease to loved ones was zero. As one Army physician told me, if he were exposed to a patient with suspected Ebola, he would not go home to his wife and children until the risk was nullified.

The Army’s self-imposed quarantine is enlightening. The Army knows full well how disruptive such a risk could be to a community, undermining its ability to function, both in how it supports itself and how it moves toward its goals (for the Army, of course, its mission). It knows the importance of establishing confidence and trust within its community, and with its neighbors. The Army also has vast experience in safety and risk assessments, and as anyone who has gone through the Army’s mandatory safety training knows, risk is determined by both the likelihood of occurrence and the severity of consequences. Admonitions from the director of the CDC that Ebola is not contagious like cold or flu viruses are willingly silent on the obvious fact that if a person catches Ebola, he or she is likely to die. My opinion is that Major General Darryl Williams is more circumspect about the totality of consequences than is Dr. Frieden.

Similarly, if our society is going to move forward on the admirable mission of assisting nations in West Africa, we need to have the confidence and trust in each other, and throughout our entire complex and interactive society, that can only be achieved by the discipline and assurances exemplified by the Army’s latest actions. I am sure there is a science for that.

Exaggerated response to a limited clinical study

A preliminary report was published online on 1/23/12 in Lancet about the first two patients in safety studies of injecting retinal pigment epithelium cells derived from human embryonic stem cells into the eyes of patients with different kinds of retinal blindness. What can be concluded from the studies is that no tumor formation or rejection was noted in these two patients four months after the injections. That is not enough information to make any conclusions about the safety of this treatment and safety is the only thing these studies are designed to assess. There are some who have questioned why such limited data would even be published, but the headlines in the press were amazing. They ranged from “Early Success in a Human Embryonic Stem Cell Trial to Treat Blindness” (Time) and “Blindness eased by historic stem cell treatment” (New Scientist) to “Embryonic stem cells: can we make the blind see?” (Forbes).

Why would very limited initial results from preliminary safety studies have such an exaggerated response? Part of it undoubtedly has to do with our culture’s desire to find miraculous cures in science. In fact the Forbes article says “Restoring sight to the blind is, literally, a miracle…when the cells inside the eye are damaged, there is nothing we can do. Until now.” Another part may be due to economics. These studies are being funded by a private company, Advanced Cell Technologies, which stands to benefit from any positive publicity. The company’s Chief Scientific Officer, Robert Lanza, was quoted in the New Scientist article emphasizing the improvement in the vision of one of the patients. The studies are not designed to assess the effectiveness of the treatments to improve vision and vision was only measured to look for deterioration as a possible side effect. One of the other researchers involved noted that the other patient was found to have some slight improvement in vision in both of her eyes, even though only one was treated, suggesting any improvement was due to the immunosuppressant drugs used or a placebo effect.

Scientific discoveries can at times be very beneficial, but we need to take very preliminary studies such as this one as what it is – preliminary. We should not induce false hopes in people with retinal blindness that they are going to be cured. We should not forget that there may be some studies and treatments that should not be done, such as those which require the destruction of human embryos when other methods for deriving retinal pigment epithelial cells could have been used.

Science, politics, ethics, and emergency contraception

Last December 7th, Health and Human Services Secretary Kathleen Sebelius instructed the FDA not to give over-the-counter (OTC) status to the emergency contraceptive drug Plan B One-Step for girls under age 17 (It is currently OTC for all women 17 years of age and older). Sebelius gave as her reason her “conclusion that the data … are not sufficient to support making Plan B One-Step available to all girls 16 and younger, without talking to a health care professional.”

Commentators immediately went ballistic, bemoaning the “fact” that the science shows that this product should be approved OTC for all ages, but that politics overruled the science. Last week a Perspective piece in the New England Journal of Medicine (NEJM) made the same assertion, as did an earlier Viewpoint in JAMA.

However, there is more to these claims of scientific-objectivity-being-overruled-by-politics than meets the eye. Science can only tell us what is or what can be, never what should be. You cannot from the premise, “We can do such-and-such,” derive the conclusion, “Therefore, we should do such-and-such,” without the intervening value statement that “Such-and-such is good, or desirable, or right.”

In his inaugural address, President Obama promised to “restore science to its rightful place” in government, to “base our public policies on the soundest science.” But public policy decisions are inevitably decisions about what should be done; every regulation in the law is an acknowledgement that those governing believe that one particular way of doing or taxing or regulating something is better than the alternatives. In other words, every policy decision is based in some part on ethics and morals — things which objective science cannot reveal to us. To “restore science to its rightful place” means “let’s get our facts straight.” This is important: good ethics (and good policy) must start with good facts. But science’s rightful place is not, and cannot be, to make the ethical decision for us.

Science can tell us the chances of Plan B One-Step preventing pregnancy after unprotected intercourse. It can give us statistics about how women use it and what the potential side effects are. It can not tell us whether or not it is a good thing that a 12-year-old who just had unprotected intercourse should be able to get the medicine without talking to an adult such as a medical provider.

Sebelius appealed to a lack of scientific data in making her decision; I do not know if she also had an unspoken political agenda. It seems at least mildly improbable that someone so staunchly pro-choice, who is part of the administration of a President and a political party that do not oppose Plan B on political or ideological grounds, would herself do so to gain political points or power. But I do know that, contrary to all the pundits, this decision, like all policy decisions, cannot be made by empirical science alone. The accusation of “Politics trumps science” is just a front for those whose own politics, morals, and ethics lead them to a different conclusion.

A small plea for more humanities in medical education

In 1910 a professional educator named Abraham Flexner published Carnegie Foundation Bulletin Number Four, also called the Flexner Report. Flexner visited all 155 medical schools in the United States and wrote a scathing report on the general condition of medical education in this country. Based on his findings, he made several recommendations for medical education reform, which for the most part were adopted by the medical schools (at least the ones that were not closed as a result of the report!). Part of the effect of the report was to ground and immerse medical training in basic sciences and scientific research.

A perhaps unintended consequence of the reforms the report sparked is that some medical personnel and researchers are well-versed in science, with data and empirical observation and precise methods, but lack acquaintance with the humanities. This has great implications for ethics. Data is important; all good ethics begins with good data. But scientific inquiry can only tell us what is, what can be done. It can say nothing directly about what ought to be done; that is, at least partly, the job of ethics. To get any deeper than very superficial ethical skimming requires engagement with the humanities, with the best thought and writing and wisdom and beauty of centuries of philosophy, theology, literature, social studies, and the arts.

The overweening optimism, bordering on hubris, exemplified in some research agendas such as genetic manipulation, cloning, or transhumanism might be tempered by conversation with the great thoughts and acts and perspectives of the past. The infatuation, bordering on worship, of the new and technological that imbues medicine and medical research today might be softened by realizing that it is not only the new and shiny that has value, but the old and well-worn also.

Would embedding scientific medical education in the humanities make the difference I hope it would? It is hard to say, but as long ago as 1926 Hugh Cabot, dean of the University of Michigan Medical School, wrote that “I am not prepared to admit at the present time that in the equipment of the practitioner a knowledge of science is of more real value than a knowledge of the way in which mankind has behaved in the past and how he is on the whole behaving at the present time. The problems of medicine, on the whole, are quite as likely to require sound judgment based upon a knowledge of history, sociology, philosophy and psychology as on the facts of science.”

Science and a Christian worldview

Christian bioethics continuously lives at the interface of biotechnology and Christian moral values. Recently some students asked me to talk with them about whether I saw any conflicts between science and a Christian worldview. Their question took me back to the first CBHD bioethics conference that I attended in 2007 and Alvin Plantinga’s talk about that issue. He expressed things that I had understood, but had never heard expressed as well as he expressed them.
Plantinga made it clear that the conflict was not a conflict between Christian thought and science, but a conflict between the philosophy of naturalism and Christianity. He pointed out that many people assume that science, which is a method of acquiring knowledge about the physical world, was identical with philosophical naturalism which says that all that exists and all that we can know is what we can know through the empirical methods of science. However, understanding that science is a proper way to learn about the physical universe does not imply that naturalism is true, and science does not depend on supposing naturalism. In fact Plantinga showed that naturalism forms a very poor foundation for science, because the unguided evolution that must be assumed by the naturalist as the process by which human cognitive processes were formed does not give us reason to believe that those cognitive processes would be reliable sources for truth. (I always knew there was some reason why I liked epistemology.)
It is actually a Christian worldview that provides the foundation that science needs to function. We believe that God has created the universe so that it is rationally understandable and has given human beings the ability to accurately perceive the universe and cognitive faculties that are designed to comprehend truth. Those are the presuppositions needed to expect science to be a valid method for discovering the nature of our universe.
The problem is not that there is a conflict between science and a Christian world view. The problem is why someone without a Christian worldview would think that science is a reliable source of truth.

Doing Drugs for Science

 

There is a place in Chicago where you can be paid to take mind-altering drugs.

In the Human Behavioral Pharmacology Laboratory at the University of Chicago, psychiatry professor Harriet de Wit studies various licit and illicit mind-altering drugs, from caffeine to Ecstasy, by testing their effects on human volunteers. The purpose of the research is to find out how different people react to different drugs, in order to answer the central question of drug abuse research: Why do some people become addicted to drugs when most people who try them do not?

Study subjects must be between the ages of 18 and 35 and have no history of drug abuse, except those volunteers participating in the studies of Ecstasy, who must already have tried the drug.  After the studies are completed, there is no long-term follow-up of volunteers.

The story in which I first read of these studies was on the front page of the August 7th Sunday Chicago Tribune. The studies are approved by two review boards and the national advisory council of the National Institute on Drug Abuse; yet, reading about the research, I felt a bit uneasy. I believe that research done on human subjects is supposed to have at least a potential benefit to the subjects under study. Will the knowledge gained in these studies really have enough of a potential benefit to the subjects to outweigh the risk? According to the story, “studies have shown that experiments like these do not make subjects more likely to use illicit drugs.” But that does not rule out the possibility that someone who takes part in these studies could thus become exposed and addicted to an illegal drug they might otherwise never have encountered. I vividly recall patients describing to me the stories of how they became addicts the first time they took a drug (cocaine and meth are the two I remember in particular), and I can easily imagine that happening in a study such as those described; in fact the story tells of one subject who was given methamphetamine and liked the feeling of the drug: “I felt extra happy . . . I was cheerful and peppy.”

Am I overly cautious?  Am I too obstructionist?  Is the knowledge gained from these studies worth the chance that even one person might, through participation in the study, become addicted to an illegal drug?  In other words, is this ethical human-subject research?

 

Contemplating “The Scandal”

CBHD Scandal of Bioethics Conference Graphic

CBHD Scandal of Bioethics Conference Graphic

This coming July, the Center for Bioethics & Human Dignity will host its 18th annual conference. This year’s theme is “The Scandal of Bioethics: Reclaiming Christian Influence in Technology, Science & Medicine.” The conference theme poses a number of interesting questions that, I believe, would be worth considering in advance of the meeting.

First, do you believe Christian moral reflection has been marginalized in bioethical discourse and public policy decision-making, and if so, in what ways?

Second, what may we cite as the evidence of a contemporary bioethics bereft of Christian influence? How might the bioethical terrain differ from its present state if the Christian voice had enjoyed a more sustained presence in public policy discourse?

Third, to what may one attribute this marginalization of Christian moral reflection in bioethics? Is the problem external to the Christian community, or do we share in the blame? If the latter, in what way?

We’ll save the question of a way forward for another post, but perhaps you have other questions pertaining to the diagnosis of a diminished Christian influence in contemporary bioethics and its underlying cause(s).

Your comments?