Stem Cell Rx No Longer For Sale on Google

Perhaps once a week, I will be asked by a patient about the potential benefits of stem cells for reversing the normal affects of age, particularly with respect to arthritis of the knee joints, hip joints or the degenerative discs in the lumbar spine. I believe one of the reasons for this interest has come from increasing advertisements by various clinics in my region of East Tennessee claiming stem cells are the answer for these problems. My region is not unique. A simple Google search on “stem cells for knee pain” yields ads for clinics offering such treatment.

Stem cells are cells that have potential to become any type of cell in the human body such as a new blood cell, nerve cell or bone/cartilage cell. Scientists are rapidly learning how to find or create stem cells, as well as how to safely use them to replace old or missing cells, thus restoring function in worn out, damaged or diseased areas of the body. In fact, stem cells are presently used to replace the bone marrow for some individuals with certain cancers and disorders of the blood and immune system, and in many of these cases, the results are lifesaving.

The problem is that stem cell treatment remains yet unproven in all other medical conditions, including the age-related arthritis conditions which I treat. This lack of efficacy has not stopped clinics from offering and patients from receiving stem cell injections with the hope of achieving improved function or cure. I am willing to grant that many offer these treatments with the sincere hope and belief that they are acting in their patient’s best interest, though I suspect not all have the patient’s best interest in mind. Unfortunately, there have been severe adverse events. Examples include blindness following an injection of stem cells into the eye, and loss of function with development of a spinal cord tumor following stem cell injection into the spine.

The FDA is trying to educate the public and prevent stem cells from being offered for unproven treatments. The FDA has the authority in the US to stop these unproven treatments and take punitive action if needed. This is not to suggest that the FDA is in the business of preventing legitimate investigation into the potential benefits of stem cells, such as this Mayo Clinic Phase 1 study looking at the risks of injecting stem cells in to the cerebrospinal fluid of patients following a spinal cord injury to see if this particular stem cell technique causes harm (with future studies needed to determine benefit).

The FDA is recently getting some help from Google. On September 6th, Google announced it would stop accepting ads for unproven medical treatments, including stem cell therapies. It is early in the effort and the initial link above still has four ads for non-bone marrow stem cell treatments returned with the Google search. Maybe by the time you read this blog entry, the stem cell ads for unproven treatments will be gone.

I am hopeful that stem cells will eventually provide patients with safe therapies that repair injury and return patients to normal health. Offering that promise without the studies that prove such benefit is unethical and potentially harmful. It is good to see Google favoring human welfare over financial profit.

Bioethics as Comedy

Sometimes comedy takes a cultural activity to its logical conclusion to reveal an absurdity that is so humorous everyone will talk about it. Sometimes a bioethical argument takes a cultural activity to its logical conclusion to reveal an absurdity that is ethically so troublesome hopefully everyone will talk about it. Recently, popular comedian Dave Chappelle combined the two.

Sponsored by Netflix and speaking at The Tabernacle in downtown Atlanta, Mr. Chappelle offered the following bioethical observation during his comedy monologue. I have removed all descriptive adjectives non-essential to his main argument. Speaking about abortion as a woman’s right to choose, he observed:

“I don’t care what your religious beliefs are or anything. If you …[are a man,]…you need to…[keep quiet]…on this one, seriously. This is theirs, the right to choose is their unequivocal right. Not only do I believe they have the right to choose, I believe that they shouldn’t have to consult anybody, except for a physician, about how they exercise that right.

Gentlemen, that is fair. And ladies, to be fair to us, I also believe that if you decide to have the baby, a man should not have to pay. That’s fair. If you can kill this…[baby,]… I can at least abandon them. It’s my money, my choice. And if I’m wrong, then perhaps we’re wrong.”

Mr. Chappelle comedically paired “My body, my choice” with “My money, my choice” and something well short of bioethical hilarity ensued. Regardless of what you think about his proposed moral equivalency, a simple Google search on the above quoted portion of his comedy monologue suggests this particular “bioethics as comedy” approach certainly has everyone talking.

For the record, I agree that he is right that both are wrong.

A meaningful life

The MIT Technology Review recently published an interview with Ezekiel Emanuel, chair of the University of Pennsylvania’s department of medical ethics and health policy, entitled “A doctor and medical ethicist argues life after 75 is not worth living.”  It appears to be a follow-up to a provocative article that Emanuel wrote in The Atlantic five years ago, “Why I Hope to Die at 75” (Emanuel makes clear in the interview that he did not choose that title.)

After stating that he is not advocating euthanasia, Emanuel makes some thought-provoking points in the interview.  For example, he observes that we don’t spend enough money on children: “one of the statistics I like to point out is if you look at the federal budget, $7 goes to people over 65 for every dollar for people under 18.”  To truly affect impactful change, it seems wise to focus on the health of children.

Emanuel also challenges the idea that a longer life span means a healthier life: “We’re having more disabilities.  We have people with more problems.  And even more important, for most people, is the biological decline in cognitive function.” For Emanuel, cognitive decline calls into question any advances made in average life span.  Apparently, 70 is not the new 50.

When asked about the ‘iconic innovators in Silicon Valley—people like Peter Thiel and Larry Ellison,’ Emanuel does not pull his punches: “. . . [T]hey’re fascinated with life extension [in general]? Naw, they’re fascinated by their life extension. They find it hard to even contemplate the idea that they are going to die and the world is going to be fine without them.”  Though somewhat pointed, Emanuel’s comments underscore some of the issues with individuals pursuing ‘immortality.’  Is it really for the betterment of society or an unhealthy preoccupation with self? 

To me, Emanuel’s most troubling remarks come when he addresses the issue of people who are active well into their 80s: “…when I look at what those people ‘do’, almost all of it is what I classify as play.  It’s not meaningful work.  They’re riding motorcycles; they’re hiking.  Which can all have value—don’t get me wrong.  But if it’s the main thing in your life?  Ummm, that’s probably not a meaningful life.”

Emanuel’s wish to die in his mid-70s reflects his interpretation of what a meaningful life is.  For him, meaning consists in doing research, publishing findings, and contributing to the academic community and by extension, the public life.  Even the thought of mentoring young people, though important, doesn’t appear to hold Emanuel’s interest for long.  

What constitutes a meaningful life?  While meaning is a very personal question, I would like to affirm the important role that the elderly play in our community.  Perhaps their ‘productivity’ is not the same as it used to be, and their health is in decline, but those are not adequate measures of meaning.  It seems to me that those who are well along life’s journey have much to share with their children and friends about living. There is meaning beyond this, of course, but at the very least it is a move away from the “be productive or die” perspective.

My hope is that society’s definition of meaning will eventually expand and more fully include people of all ages.

Much going on about heritable genome editing

The first meeting of the International Commission on the Clinical Use of Human Germline Genome Editing was held in Washington, DC on August 13.  This is a US/UK commission convened by the UK Royal Society, the US National Academy of Medicine, and the US National Academy of the Sciences.  Space for in-person attendance at these meetings appears limited, but information is freely accessible on the internet.  For example, the meeting materials and videos from the August 13 can be accessed here, and one can register to be on the Commission’s mailing list at this link. 

It is challenging for anyone with a “day job” whose work is not dedicated to the field of gene editing to try to keep up with developments, so the open access to information is welcome.  The August 13 meeting included numerous basic science discussions as well as some from biotechnology companies seeking to develop gene editing approaches.  As discussed often on this blog and elsewhere, so-called “somatic” gene editing—that is, gene therapy of fully-formed individuals by editing an undesirable gene such as one known to cause disease–appears generally to fall within the existing regime of human research ethics and regulation and pose relatively few unique ethical issues.   The day included industry presentations regarding somatic gene editing, either “in vivo”—involving injecting the gene editor into a person—or “ex vivo”—involving removing cells from a person, editing the cells in the medical lab, then re-injecting the gene-edited cells into the person’s body as a form of treatment.  In neither case is the editing inherited across generations, avoiding the larger issues of manipulating human beings more fundamentally, and, as your present correspondent has consistently argued, unacceptably.

Even for somatic gene editing, however, “getting it right” in the form of editing the genes intended, and only those, and developing approaches to assess and control for longer-term or unintended risks is still a substantial set of tasks, as was described in a presentation by an official from the FDA.

The day also included a presentation from the separate World Health Organization multidisciplinary advisory panel, which held its first meeting in March 2019 with another one having been due this week in Geneva, Switzerland.  At the March meeting, the WHO panel adopted three main recommendations for developing oversight of human genome editing:

  • Establish a structured mechanism for collecting and curating details about proposed and ongoing research;
  • “it would be irresponsible at this time for anyone to proceed with clinical applications [they mean trying to establish a pregnancy or birth] of human germline genome editing”
  • Establish approaches to obtain input from the “broadest possible range of stakeholders” and “explore opportunities for an open, online mechanism for seeking input.”

All that said, the Salk Institute in San Diego is working on a new technique of editing, called SATI (short for intercellular linearized Single homology Arm donor mediated intron-Targeting Integration [say THAT three times fast!], which is expected to be more versatile than the current “preferred” technique called CRISPR-Cas9.  Biologic details between the two differ, but the ethical issues mainly apply to applications, and are therefore the same for both.  But don’t be surprised if you hear about “SATI” for 5-10 minutes in the news sometime.

And scientists at Cornell Medical Center in New York City are trying to gene-edit human sperm to alter the characteristics of children conceived using them.  Pressing ahead with getting ready for the WHO panel’s “clinical applications.”

Mildred Solomon of the Hastings Center has recently added her voice to those pointing out that whether heritable human genome editing should ever be done is not just a matter of weighing benefits vs risks, but involves much more momentous possibilities that should give us pause.  The key graphs:

“Even as [the WHO and US/UK commissions] regroup to produce clearer guidance, however, I sense a shift in the debate. For a very long time, the scientific and bioethical consensus was that we must not do human germ-line modifications—that we should not change gametes and embryos in ways that would be permanent, affecting all future generations. In contrast, somatic modifications, which affect only the person in whom the edits are made, have been mainly uncontroversial.

But that border between germ-line and somatic genome modification is blurring; the zeitgeist feels different. There is a growing sense of inevitability that we will eventually do human germ-line modification and that our only obligation is to wait until it is safe. When that day comes, we may want to make permanent heritable changes to the human species to eradicate otherwise intractable diseases. We should, however, enter this discussion with eyes wide open, considering each application on its own merits and anticipating a wide range of issues that go well beyond safety. Many of these issues are explored in Human Flourishing in an Age of Gene Editing, which will be published by Oxford University Press on August 28, 2019.”

I’m willing to forgive the plug for a book from people at Dr. Solomon’s institution, which is where the editors of the book in question work.  It looks worth checking out.  In the meantime, the US/UK commission has called for “expert evidence” to assist them in the task “to develop a framework for considering technical, scientific, medical, regulatory, and ethical requirements for human germline genome editing, should society conclude such applications are acceptable.”  Follow this link to have a look at their questions.

Veil of Ignorance and Unrestricted Abortion

As a Christian, it seems to me that the most logically consistent application of justice is based upon the belief that all human beings bear the image of God, the imago Dei, and as bearers of the image, have equal human dignity, deserving of equal and just treatment by others, both morally and legally, regardless of our varying human attributes (as expounded here at page 163). I realize that not all human beings believe in this God so their systems of justice naturally differ from mine. Resolving conflicting understandings of justice is what makes the intersection of law and bioethics challenging. Currently, nowhere is this conflict so challenging as in the issue of unrestricted, elective abortion.

One such differing theory of justice is by the late John Rawls, in his 1971 Theory of Justice. Briefly, Rawls conceived arriving rationally at a theory of justice by conducting a thought experiment whereby rational persons would determine justice by conceiving it from an “Original Position” behind what he termed a “Veil of Ignorance”. At this Original Position, no one knows what eventual position they would subsequently hold in society, including wealth, health, class, education, minority status, religion and sex/gender. Since justice would be determined prior to one’s random subsequent placement in society, no decision from behind the Veil of Ignorance within the Original Position ought to favor one classification over another because no one would know in advance into what classification one might fall. No one religion would be favored since one might not believe in that religion or any religion at all. No one racial group or sex/gender would be favored since one might not be included in that group or sex/gender.

So what does the Theory of Justice have to say about elective abortion? Interestingly, Rawls himself only wrote once parenthetically on the subject of abortion as it pertained to his theory. It was a very brief footnote in support of abortion, unfortunately not a rigorous defense. As one might expect, different people have used Rawls’s theory to support or refute abortion. I have included links to two such example position papers (RawlsAbortionPro and RawlsAbortionCon). Both of these papers (and others like them) hinge on whether or not one believes the embryo or fetus has sufficient “personhood” or “moral potential”, qualifications that are indeterminate from within the Theory of Justice. Facts are preferred to beliefs when rationalizing from the Original Position behind the Veil of Ignorance, since one does not know in advance what one might believe once subsequently existing in society. Are there any facts that one might use from the Original Position to consider the Rawlsian justice of abortion regardless of one’s beliefs about personhood or moral status of the unborn?

Consider the following: EVERY actual human being invited by Rawls to step with him behind the Veil of Ignorance into the Original Position to determine justice MUST have already passed from conception through the stages of embryo, fetus, newborn infant and immature youth before reaching that nebulous stage of human development called personhood in order to receive the coveted invitation. For the sake of argument, let’s grant that Rawls only wanted the philosopher-kings, IQs above 180, possessors of the apex of personhood, Harvard, not Yale, to join him behind the Veil. Would any of these persons reasoning from the Original Position permit unrestricted, elective abortion of an otherwise healthy unborn human, given that the unborn human aborted might be one of them? The beliefs about the personhood or moral status of any of the earlier stages of development prior to personhood of these great thinkers are irrelevant. What is factually relevant is that all of these great thinkers must each pass through all these stages of development before achieving personhood. None would, from that Original Position, choose unrestricted, elective abortion of themselves to be a just outcome, simply because death has to be the worst of all social categories in which to land after leaving the Original Position. Or is that just my belief?

Treating all humans as equal image bearers of God regardless of any other human characteristics we might possess seems to me a better basis for a theory of justice than one rationally designed by our best and brightest fellow humans. Living that out is the real challenge.

Baseball Statistics, Racism and 23andMe

I enjoy watching baseball on TV or even listening to a game on the radio. I am amused by the discussions of the announcers, usually around the 8th or 9th inning, particularly when the result of the game is already decided due to a lopsided score. The announcers begin doling out complex baseball statistics. As a former math and engineering student in college, I find this part of the game fascinating.

“Well John, I think this may be the first time Cincinnati Reds player Yasiel Puig has ever been involved in a late-game brawl with the entire Pittsburgh Pirates bench so soon after being traded to the Cleveland Indians earlier during tonight’s game and just 14 days after a Full Moon to boot.”

In baseball, as in life, if you specify an event in sufficient detail with enough variables, you are accurately characterizing that unique event. Some diehard baseball fans argue that with enough baseball statistics, the predictability of the outcome of any future game will become trivial.

In blog-related news, the New England Journal of Medicine recently had two thought-provoking “Perspective” opinion pieces dealing with racism in medicine. The first by medical student D.W. Paul, Jr. is entitled Ghosts of Our Collective Subconscious – What Blackface in a Yearbook Photo Means for Medical Education and the second by Dr. Tara Vijayan entitled ”Browner” – Creating Narratives of Race. Both are unfortunately available by subscription only. Among other things, both articles point out the obvious problems that occur when we reflexively categorize individuals by a single variable – such as one’s skin color – and attempt to predict current or future reality by that single variable. Habitually trivializing people in this manner results in prejudice, bias and bigotry.

This would never happen in baseball. For instance, I have yet to hear the following from an announcer:

“Well John, looking at the stat sheet on this next relief pitcher for the Pirates, it just says he’s white. For our radio listeners, from where I’m sitting, I must say our statisticians have nailed it as he is one of the whitest relief pitchers I’ve ever seen”.

I can promise you that when Yasiel Puig steps up to the plate, he doesn’t care about that relief pitcher’s skin color. He is far more concerned about the speed of his fast ball or the spin rate of his curve ball.

Enter 23andMe (or similar service). For the first time, the average person can send in a sample of saliva and get back a detailed DNA graph and report revealing the multiple countries of origin of their great grandparents and beyond. Having readily available DNA information may not be completely without its problems, and this blog has touched on some of these in past postings. However, one benefit of this technology may well be to convince people that we are a kaleidoscope of genetic material, much more complex, and far more interrelated, than our skin color alone would suggest.

If we are not going to treat our neighbors with the respect and dignity due unique image bearers of God, let us at least stop treating them as if they have only one variable worth considering – the color of their skin – and begin treating them like they have complex baseball statistics. Maybe then we will more accurately describe them, and, in doing so, perhaps better understand and appreciate them.

We should start now and not wait until the 9th inning.

Should Abortion be a Trivial Event?

A recent NEJM Perspective by Drs. Jane Henney and Helene Gayle is calling for reduction in the current restrictions on Mifepristone, previously better known as RU-486. Mifepristone, a progesterone blocker, which effectively opens the cervix of the uterus, when combined with misoprostol, which promotes contractions of the uterus, forms the two-pill combination marketed as Plan C – an effective, safe, self-administered home medical abortion. Arguing that the drug has been shown to be far safer than originally thought, and because many US women are accessing foreign internet sources of potentially suspect quality Mifepristone, Drs. Henney and Gayle are encouraging the FDA to make the drug available from regular US pharmacies rather than at special medical/surgical clinics from a restricted set of doctors as it is presently distributed.

At the time of its initial FDA approval in 2000, it was unknown whether mifepristone would have a high risk of excessive bleeding or incomplete abortions so it was approved under FDA Subsection H, which required that the drug be dispensed directly from a physician (rather than a pharmacy) who can provide blood transfusion or surgical abortion. Drs. Henney and Gayle argue that numerous studies since 2000 support that this level of restriction is unnecessary. This is not to say that the risks of Mifepristone are zero but rather, as one of their arguments goes, there are many other medications available from a pharmacy via prescription that have higher risks so why single out Mifepristone? They are not specifically calling for the medication to become “over-the-counter” (meaning available without prescription) but they list other countries where this is the case.

Their concern about the ease of obtaining Mifepristone (or Plan C) over the Internet is not exaggerated. A quick search of the Internet shows one advocate website called plancpills.org providing a report card where their own secret shoppers grade various Internet sites offering Mifepristone for sale. Another popular site called AidAccess.org offers an informative video, telemedicine consultation as well as foreign sourced Mifepristone and this site is presently one of the least expensive sources of the drug.

One of the statistics offered in support of abortion, especially medication-based abortion such as Plan C, is that these processes are safer for women from a morbidity and mortality standpoint than actually being pregnant, particularly the labor and delivery of birthing a baby. Of course, it (always) goes without saying that the same processes are nearly universally fatal for the baby. But, for arguments where the morbidity and mortality of the child are excluded, abortion, particularly medication-based abortion, has become a relatively safe process.

I have no doubt that the present restrictions by the FDA on access to Mifepristone will be reduced for the reasons Drs. Henney and Gayle have provided, perhaps eventually to point of making Plan C available over the counter.

Abortion is becoming a trivial event.

Abortion kills a human being.

Killing a human being should not become a trivial event.

Good from Evil

I was given an article by a student of mine following his one month elective rotation with me in which we spent some clinical time discussing bioethical issues. The May 2019 web article by Sharon Begley from Statnews.com had to do with an interesting medical dilemma first presented in 2016 by Dr. Susan Mackinnon from Washington University in St. Louis. I have briefly summarized Begley’s article in the first part of today’s blog and extended her point at the end.

Dr. Mackinnon had a patient who was having severe leg pain following multiple knee surgeries. Dr Mackinnon was providing the final surgical attempt to isolate the nerve presumably being compressed by scar tissue in hopes of surgically decompressing that nerve to permanently relieve the patient’s severe pain. If the surgery was not successful, the only other option at that point was to amputate the leg. During the surgery, she used an old anatomy book called The Pernkopf Topographic Anatomy of Man, which unambiguously has the best illustrations of nerves around the knee, and successfully located and decompressed the nerve in question and successfully avoided an amputation.

So, what was the dilemma?

As Begley points out in her article, it came to light in the mid-1980s that the illustrations used in the Pernkopf atlas were based in part on the bodies of people executed by the Nazis in the late 1930s. The moral dilemma for Dr. Mackinnon was therefore:

“…even now, the Pernkopf illustrations are unsurpassed in their accuracy and detail, especially their depiction of peripheral nerves…and although a few journal papers may have an equally good, single illustrations, finding the right paper takes time that Mackinnon did not have as she stood over her patient.”

Dr. Mackinnon had been given the Pernkopf atlas as a graduation gift in 1982 but the Nazi history behind the atlas was not known until the mid-to-late 1980s, the full history of which only became known to her after the surgery. Should she continue to use an atlas that contains illustrations of the bodies of people executed by the Nazis? If used, is there a duty to inform a current patient about the nature of the atlas? Can sufficient good be derived from the atlas given the unspeakable evil required to create it to permit its ongoing use?

She posed her dilemma to Rabbi Joseph Polak, the Chief Justice of the Rabbinical Court of Massachusetts, who consulted Prof. Michael Grodin of the Elie Wiesel Center for Jewish Studies at Boston University. Their opinion became known as the Vienna Protocol, due to the origins of the Pernkopf atlas. Their response may be found in this link, which I believe is better read in the full context of the Vienna Protocol than summarized by your humble blogger. For those of you who must read the opinion before reading the entire protocol, please follow the link and scroll to the 4th to last page at number 12 in section C entitled “The Protocol and Recommendations”.

The evil that created the Pernkopf atlas was the Nazi occupation of and executions that occurred in Austria during World War II. It is no longer occurring. No one in the present is suggesting that we resume executing people to gain more anatomic drawings to complete additional volumes of the atlas. Any good resulting from the current use of the atlas isn’t being offset by any ongoing evil of creating more atlas. The evil of the Pernkopf atlas is contained in the past and, in that sense, finite. Containing the evil seems to be a necessary step in obtaining good from that evil.

I mention this in closing as I believe there are current analogies of activities performed in the name of scientific good where we condone ongoing evil. Studying fertilized ova until sacrificing them on Day 14 (an evil) in the name of learning about human reproduction (a good) is one modern day example. In Vitro Fertilization done to obtain a healthy baby with genetic traits we want (a good) that results in the death(s) of other fertilized eggs we don’t want (an evil) is another. There are other examples we have discussed within this blog. I believe we need to contain and hopefully discontinue these and other practices if we want to claim the information we gain can honestly be called good.

Ending well

By Steve Phillips

This past week I attended the CBHD summer conference. This year’s theme was “Taking Care: Perspectives for the End of Life.” As usual, the conference was filled with thought-provoking sessions and many good personal interactions. While I have much to think about from many of the sessions the one that impacted me the most was the concluding plenary session by John Kilner titled “Dignity and Life on the Line: Ending Well.” This session impacted me in a number of ways. Not the least was remembering how much Dr. Kilner has impacted my life as I listened to him talk about the end of life from the perspective of one going through his own end-of-life journey. It also came at a significant time for me as my wife and I have been grieving the recent death of her father.

However, even without those very personal things, what Dr. Kilner had to say about the end of life was significant. He reminded us that the dignity of human life that exists because every human being has been created in the image of God applies as much or more at the end of life as any other time. Since God has intended in our creation for us to be an internal reflection of him, death is truly an enemy. However, death is an enemy that has been defeated by Jesus in his resurrection. Our approach to death can be wrong if we fail to recognize either of these things. If we do not recognize death as an enemy, we may not pursue appropriate treatment, or we may pursue intentional killing as a means of avoiding suffering. Either of those is wrong. We should intend life and not death. If we fail to recognize that the enemy death has been defeated, we may try to avoid death at all costs and pursue over treatment that increases suffering because we have made life on this earth into an idol.

He also reminded us that the process of dying can include things that are positive. All human life is worth living. The life that we are living as we are in the process of dying can be of benefit to God, others, and ourselves. As we in our weakness put our lives in God’s hands and allow his body, the church, to care for us, we bring glory to God. We allow others to be blessed by serving as they care for us. In the weakness of dying we can find the hope and joy that come from God whose strength is manifested in us in our weakness. I pray that when the time comes God will help me to end my life well in this way. I also pray that I will be able to help others end their lives well.

Thank you Dr. Kilner for all that I have learned from you by your teaching, your encouragement, and the example of your life.

Defense of Abortion as Killing

It is rare to hear a defender of abortion plainly admit that the act of abortion is killing. So, I was curious as to how such an individual would defend that killing. Dr. Sophie Lewis has recently done so in her new book, Full Surrogacy Now: Feminism Against Family. The publisher, Versa Books, has put out a short YouTube video interview, where she outlines her “abortion as killing” defense. The video is just over 2 minutes and she articulates her point clearly. While I have not read her new book, summaries from the publisher suggest the overarching theme is that pregnancy is “gestational work” done by women without appropriate compensation (permission, time, money, recognition…), resulting in their exploitation. Pregnancy (and procreation in general) ought best be done by willing “gestational workers” with clearly defined contractual obligations and recompense. Surrogacy is the answer. There is much to unpack here so I want to focus the remaining blog entry on her defense of abortion as killing as stated in her linked video above.

Her central defense of abortion as killing is as follows:

…looking at the biology of the hemochorial placentation helps me think about the violence that, innocently, a fetus meets out vis-a-vis a gestator. That violence is an unacceptable violence for someone who doesn’t want to do gestational work. The violence that the gestator meets out to essentially go on strike or exit that workplace is an acceptable violence.

The gestator going on strike or exiting the gestational workplace is the act of abortion. In her view, pregnancy is gestational work that can result in workplace violence or, at least, unacceptable work conditions that exceed those previously agreed upon. At that point, Dr. Lewis believes it should be permissible for any woman to leave the workplace, even though that exit causes an ultimate violence to the fetus – the killing of that fetus. She holds the placental attachment to the uterus as a sufficiently biologically violent condition that should permit a biologically violent defensive reponse with the abortion.

It is hard to make these acts either biologically or morally equivalent. Biologically, there is nothing violent about a placenta developing an attachment to a uterus. In fact, using Dr. Lewis’s workplace metaphor, it is the job of the placenta to attach to the lining of the uterus and it is the job of the uterus to receive such an attachment – it is what both were designed or evolved to do. Even if we accept her workplace violence metaphor, it is rare for the violence of the placental attachment to the uterus to result in the death of the mother just as it is equally rare for the violence of the abortion NOT to result in the death of the fetus. These are hardly biologically equivalent events.

Morally, it is hard to argue, even in her terms, that the mother’s choice to terminate gestational work is equivalent to the baby’s placental attachment, even if we grant her claim that both are equally violent. The mother always has the choice in deciding to terminate the pregnancy – the fetus never has a choice or intentional control of the placental attachment process at any point during the pregnancy. After all, intentional choices are made by persons not fetuses. I doubt that Dr. Lewis wishes to cede further moral ground by granting personhood to a fetus.

Maybe that is why Dr. Lewis stipulates that the baby’s violence is innocent. Frankly, the obvious innocence of the baby makes it even harder, if not impossible, to morally justify the violence she desires us to find acceptable.