Healthcare for all called an ethical issue

A professional association of U.S. bioethcists has come out in favour of President Barack Obama's plans to make public health insurance available to the 50 million Americans currently uninsured.

Collegiate bioethicists waded into the health-care reform debate Tuesday, declaring that "the current state of health care is unethical" and branding as false criticisms that congressional proposals would threaten patient choice or deny older Americans medical treatment.

"We felt we needed to speak up. The tenor of the debate has become quite strained and full of misinformation," said Jeffrey Kahn, president of the new, 60-member Association of Bioethics Program Directors. Kahn also heads the Center for Bioethics at the University of Minnesota.

"There is no morally defensible reason why some Americans get excellent medical care at costs they can afford and other Americans lose their homes or go into bankruptcy attempting to secure treatment for a seriously ill loved one," a statement from the group said.

"The current proposals being debated in Congress all go a long way toward making health care in America more just," it said. The group disputed what it called "the top three myths" about the proposals: that they would prevent individual control over health decisions, that costs would be cut by prohibiting costly treatments and that older people would be denied end-of-life care.

"This [end-of-life argument] may be the most pernicious myth of all," the statement said. Instead, a provision would pay doctors to spend time with dying patients and their families as they describe the care they want. The statement is on the group's website, www.bioethics directors.org.

The bioethcists have posted a fact sheet disputing the claims made by critics of the healthcare plan.

The ethics of birth and death

A couple of interesting stories in the Toronto Star this morning, looking at two medical ethics issues. I was out of town, so didn't write either.

The first looked at when a woman is too old to have a baby, sparked by the death of Maria del Carmen Bousada, who gave birth to twins in December 2006 at age 66.

When it comes to motherhood, how old is too old?

Fertility experts and ethicists re-examined that question yesterday after hearing that a 69-year-old Spanish mother died Saturday, leaving behind 2-year-old twins conceived with a younger woman's eggs and donated sperm.

Maria del Carmen Bousada is believed to have been the world's oldest new mother. She gave birth in December 2006, shortly before her 67th birthday, after telling a clinic in Los Angeles she was 55, the facility's maximum age for single women receiving in-vitro fertilization.

The story goes on to outline the medical reasons for most in-vitro clinics to refuse the treatment to older patients -- the children have more health problrms -- and concluded with Margaret Somerville of McGill questioning whether medical science should be used to do things that are impossible in nature, rather than just stepping in when nature fails.

The other story looked at the other end of the spectrum. Pegged to the assisted suicide death of British conductor Edward Downes and his wife, Joan, at a Swiss clinic it asked whether more countries, including Canada, should allow assisted suicide.

"Whenever it's in the news, we know this comes up again and again," said Olga Krassioukova-Enns, executive director of the Winnipeg-based Canadian Centre for Disability Issues. "This issue, this question, affects people with disabilities and seniors and anyone part of a family."

In May, Bloc Québécois MP Francine Lalonde of Montreal reintroduced a private members' bill to amend the Criminal Code to allow assisted suicide. A similar one she introduced in 2005 failed.

A number of high-profile cases in Quebec recently drove her to try to get the bill passed again.

"We need to have this in order to allow people to make their own choice under certain conditions when the time is right for them to die," said Lalonde yesterday.

Last year, a Quebec man was acquitted after he was charged with helping his disabled uncle commit suicide. A Vancouver man was charged in May with giving his friend a loaded shotgun and a demonstration on how to use the weapon to commit suicide.

Alex Schadenberg, founder of Euthanasia Prevention Coalition, said Canadians want better end-of-life care. The mindset that older people and those with disabilities don't want to live as long as possible is a misconception, he said.

Making academic fraud a crime, have your say

A story in the online version of The Scientist is sparking calls from readers that academic fraud be criminalized, with the journal now polling readers.

The original story documentedsome $23 million (US) in grants handed out to researchers at the University of Alabama at Birmingham who lied about their methodology and falsified data in at least 16 journal articles. The story is based on records from the US Department of Health's Office of Research Integrity.

The scientists, Judith Thomas and Juan Contreras, formerly at the University of Alabama at Birmingham (UAB), falsely reported that they performed double kidney removals on several rhesus macaques in experiments designed to test the effectiveness of two immune suppressing drugs -- Immunotoxin FN18-CRM9 and 15-deoxyspergualin (15-DSG) -- in preventing rejection of the a single transplanted kidney.

The experimental protocol was to remove one intrinsic kidney, replacing it with a transplant and starting the monkeys on immunosuppresants, and then remove the other intrinsic kidney a month later, according to Richard Marchase, UAB's vice president of research. "What occurred in a good number of these animals was that [Contreras and Thomas] never performed the second surgery," Marchase told The Scientist. In a statement emailed to The Scientist Marchase called the misconduct "a very serious offense."

Thomas's and Contreras's research was funded with more than $23 million in grants from the National Institutes of Health. UAB officials learned that Contreras and Thomas had left one native kidney intact in at least 32 animals -- which allowed those animals to live and inflated the apparent effectiveness of the drugs -- on January 27, 2006, when Thomas reported that she found an experimental monkey with one of its native kidneys intact and blamed Contreras for the mistake.

The scale of the fraud and the implications of the falsified results -- patients could have ended up getting dangerously wrong treatment -- led to readers of the original story going onto the Scientist web site to call for criminal fraud charges to be laid, prompting the journal to poll readers for their thoughts.

Feel free to join in.

 

Bad news for men -- artificial sperm

A team of British researchers claimed this morning to have developed a method to create sperm from embryonic stem cells.

Researchers at Newcastle University and the NorthEast England Stem Cell Institute say they used a new technique to derive what they described as sperm cells from embryonic stem cells. Stem cells have the potential to become any cell in the body.

Newcastle research leader Karim Nayernia said in a statement Wednesday that the technique would allow researchers to study how sperm develops and possibly help develop treatments for infertile men.

The research was published Wednesday in the journal Stem Cells and Development.

The Independent newspaper immediately wondered if this meant "a world without men." Ethicist John Harris, professor of bioethics at The University of Manchester and editor-in-chief of the Journal of Medical Ethics, said no man would need to be considered infertile again.

Now, if this research is confirmed, all they will need is a very large supply of male stem cells. Might we see the George Clooney stem cell line (assuming he were to consent to it)? I can see no objection. It is no more wrong to choose the genes of your child than your reproductive partner. Indeed, we have always sought to do both, choosing our partners on the basis of our -- sometimes erroneous -- belief about the sort of children likely to result. I see nothing wrong with people exercising that choice using the technology as it becomes available.

If it is not wrong to wish for a bouncing brown-eyed baby girl, why would it become wrong once we had the technology to play Fairy Godmother to ourselves and grant our own wish?

Not all ethicists see it so simply.

"This area has potential powerful clinical applications mixed with people's concerns over embryo research," says Insoo Hyun, a bioethicist at Case Western Reserve University who specializes in stem-cell-related ethical issues. "All the ingredients are there for a really, really lively ethical debate."

Others simply doubt the research.

"I am unconvinced from the data presented in this paper that the cells produced by Professor Nayernia's group from embryonic stem cells can be accurately called 'spermatazoa," said Allan Pacey, a senior lecturer in andrology at the University of Sheffield.

Pacey said in a statement that the sperm created by Nayernia did not have the specific shape, movement and function of real sperm.

Azim Surani, a professor of physiology and reproduction at the University of Cambridge said the sperm produced by the Newcastle team were "a long way from being authentic sperm cells."

Too much Tamiflu

The case of a Danish woman developing a drug-resistant strain of swine flu after being given low doses of the Tamiflu vaccine is raising questions about how and when to hand out the vaccine.

On 29 June, Denmark's National Board of Health announced the first known case of H1N1 swine flu resistant to the most popular antiviral drug. The woman was in contact with an infected person and was put on low-dose Tamiflu as a precaution, but she developed flu anyway.

She has now recovered after taking the antiviral Relenza, and the drug-resistant strain appears not to have spread. The State Serum Institute in Copenhagen assumes resistance emerged during treatment with Tamiflu, as low doses can favour the emergence of resistant strains.

It appears to be an isolated case, so on one is ringing alarm bells at the moment, but the case is is causing some questioning of the standard policy to treat those close to swine flu patients as a preventive measure. Doing so, after all, could lead to the development of a more dangerous strain of the flu than the current one -- which could be disastrous. 

British Medical Journal blogger Iain Brassington, a bioethics lecturer at the Centre for Social Ethics and Policy at the Law school at Manchester, points out that this puts governments and medical officials in a bind. Do they risk making things worse down the road by treating people now, or not?

There seems to be an interesting dilemma generated: while governments presumably ought to take steps to ensure the availability of prophylaxis, this also generates a risk that they’re creating a much bigger problem further down the line. I don’t think that this is an argument against prophylaxis per se - of course governments should deal with the threat as it stands at the moment (and anything else would be a counsel of despair), and the threat of resistant H1N1may never be realised - but the point would stand that, in doing what they ought to do now, they may be making things worse in the long run. And that means that meeting the present danger isn’t nearly as morally straightforward as it would seem at first.

I'll be keeping an eye out for more drug-resistant strains.

 

 

The ultimate silk purse

Researchers in China claim to have figured out a way to coax cells from any part of a pig's body -- they used cells from a pig's ear and bone marrow -- into any type of cell in the body, just like embryonic stem cells.

The breakthough could set the stage for pigs being raised to grow organs for humans for transplantation, the researchers say.

Lead researcher Dr Lei Xiao, of the Shanghai Institute of Biochemistry and Cell Biology, said many other attempts had been made to transform adult cells from animals such as pigs into "pluripotent" stem cells, but they had failed.

He said: "Therefore, it is entirely new, very important and has a number of applications for both human and animal health."

Dr Xiao's team reprogrammed cells taken from a pig's ear and bone marrow, using a cocktail of chemicals introduced into the cells via a virus.

Tests showed that the reprogrammed cells were capable of becoming any of the cell types that make up the three layers in a developing embryo.

Dr Xiao said pigs were a potentially ideal source of organs for transplant, as their organs were similar in function and size to those found in humans.

In its blog,the American Journal of Bioethcis quipped that the breakthrough could help save the pig's reputation after the swine flu scare.

Medical researchers have long looked to pigs as a potential source of human organs in a field known as xenotransplantation, saying it could help with chronic shortages of organs from transplant.

Professor Chris Mason, an expert in regenerative medicine at University College London, said: "This breakthrough to produce pig stem cells potentially reinvigorates the quest to grow humanised pig organs such as pancreases for diabetics and kidneys for chronic renal failure.

"The clinical use of humanised porcine tissues and organs (xenografts) has moved a long way forward in recent months with successful small-scale clinical trials.

There's a certain "yuck" factor for many people, however, and animal rights activists and religious groups have objected to the idea.

Dr Sebastien Farnaud, science director of the Dr Hadwen Trust for Humane Research, said: "Persisting with highly speculative research that would see us use sentient animals as little more that living organ grow-bags, is not only ethically unsupportable but also scientifically dubious.

"Creating pig stem cells does not necessarily remove the risk of organ rejection but even more worrying is the risk of infecting patients and the wider public with pig viruses."

Altruistic vaccines

I wrote an article in today's Toronto Star about a novel way to fight Dengue Fever -- or potentially any other disease passed on by mosquitoes.

The idea is an "altruistic vaccine" that does nothing to help the person actually getting the shot. Instead, the person's blood is rendered poisonous to any mosquitoes who bite the vaccinated person -- making the little critters unable to spread the disease.

The vaccine is being developed at Queensland University, in a part of Australia with a fast-growing Dengue problem. Global warming is being blamed for its rapid spread. The Bill and Melinda Gate Foundation is funding the work.

All vaccines have some altruist qualities to them, ethicist Angus Dawson told me, in that governments fund vaccination programs to prevent the spread of disease. Altruistic drugs take that one step further by giving no direct benefit to the person getting the shot.

That much is in the story.

What I couldn't fit in was Dawson's observation that the research is an example of society continuing to look for technological solutions to problems with wider causes.

It would perhaps be more ethical, says Dawson, founding director of the Centre for Professional Ethics at Keele University in Britain and now a visiting ethicist at the University of Toronto's Joint Centre for Bioethics, to address the long-term, underlying causes of disease spreading in general -- such as poverty, lack of access to proper care and global warming.

 He's right, of course, but I won't hold my breath.

Swine flu on Facebook

The American Journal of Bioethics has set up a Facebook group to provide up-to-the-minute information on the current swine flu outbreak.

Launched today, pandemic.bioethics.net is your leading source for bioethics news, commentary and scholarship related to swine flu (H1N1), vaccine research, public health policy and more.

Whether you want up-to-the minute news updates, to comment on what we are writing here at bioethics.net, or to post your own news stories and to write your own comments via Twitter or Facebook, pandemic.bioethics.net is the primary source on the Internet for ethics and pandemics.

Available starting today also via our website, AJOB and Taylor and Francis have made available all pandemic-related publications for a six-month period. Links to those publications are available at blog.bioethics.net and pandemic.bioethics.net.

To learn more and to join in on the dialogue, visit us on Facebook, bookmark our URL, or select any of the links above.

Summer Johnson, PhD

The group already has links to several articles related to pandemic planning, including one on mandating vaccinations, another on ensuring people live up to their responsibilities during a pandemic and one on rationing vaccine.

It's an open group, so anyone can join and invite others to join.

Preparing for a swine flu pandemic

Margaret R. McLean, director of bioethics at the Markkula Center for Applied Ethics at Santa Clara University, says preparing for a swine flu pandemic must be about far more than stockpiling vaccines or freeing up hospital beds.

It must also go hand-in-hand with ethics, she says.

In a video  posted to YouTube, McLean discusses the issue, drawing on research she did two years ago looking into response to a possible bird flu pandemic.

In pandemic planning, as in medicine in general, the allocation of these scarce medical resources is the most difficult ethical issue confronting the current health care system. No one wants to speak of rationing, but it occurs daily and necessarily escalates during a disaster. In a time of pandemic, rationing is inevitable and must be done in a manner that is transparent, respectful of persons, inclusive, accountable, proportional, fair, and minimizes harm.

Drawing on the Canadian experience with the 2003 SARS outbreak, the authors of “SARS and Hospital Priority Setting” (Jennifer AH Bell, et al) argue that a public health crisis demands heightened attention to fairness: “In the midst of a crisis such as SARS where guidance is incomplete, consequences uncertain, and information constantly changing, where hour-by-hour decisions involve life and death, fairness is more important rather than less.”

The World Health Organization, meanwhile, has a 33-page document outlining the ethics of pandemic planning, looking at such issues as access to treatment, quarantine, the role of health care workers, the importance of international co-operation, etc.

Swine flu ethics

Hong Kong says it will detain in hospital anyone arriving there who has a fever, at least until it can be proven that they don't have swine flu.

Hardly a surprising reaction by a place that was the epicentre of the SARS outbreak six years ago, but it raises interesting ethical questions about the needs of the many versus the rights of individuals.

Is it ethical to effectively jail someone merely on the suspicion of illness? On the other hand, with thousands, perhaps millions, of lives at stake if this thing becomes a pandemic, would it unethical not to detain people?

Tough questions, to be sure, but ones that I suspect we'll be hearing more about in the coming days as swine flu continues scaring people around the world.

Detention sounds like an easy answer, but it raises some practical problems. For one, will people avoid getting treatment for fear that doing so will get them detained? If even a handful of people react that way, the results could be catastrophic. On the other hand, can we count on people to do the right thing and get tested -- and stay indoors if diagnosed -- without strict controls?

Local health authorities are meeting around the world to discuss theses issues.

Another practical concern is deciding who will get vaccinated against this new flu. Health care workers will almost certainly be top of the list, but even the details of that could be up for debate. I wrote in the Toronto Star last fall about a study that argued that not all medical staff should get the flu shot during a pandemic. Why would a foot doctor be needed. it asked.

Better, it said to direct some of the vaccine to truckers and public works staff to ensure that food, water and electricity remain available through any health crisis.

"It takes a lot of people to keep society going," says Nancy Kass, a professor at the Johns Hopkins Berman Institute of Bioethics and lead author of the study in the most recent edition of the journal Biosecurity and Bioterrorism.

Traditional pandemic planning calls for giving first priority for medical treatment to hospital staff and "first responders" to a crisis, such as firefighters and ambulance workers, so that the immediate health crisis can be dealt with effectively.

But as Hurricane Katrina showed three years ago, the study argues, "the after-effects of a disaster can be as damaging as the precipitating event," as electricity and heat are cut off, clean water becomes scarce and sewage starts to back up.

"There could be widespread social chaos, significant outbreaks of other infectious diseases, and severe anxiety, with the possibility of social degeneration, looting, or even violence as people try to secure needed supplies," the study says.

Even people whose homes were not damaged by the hurricane had trouble getting food, electricity and gasoline, Kass says in an interview.

Up to 40 per cent of the workers whose job it is to keep the lights on and the water flowing could be absent from work after a pandemic, the study says. That's enough to cause a breakdown of such services.

I will be watching to see how the many ethical issues play themselves out with the swine flu story.

Meanwhile, blogger Janet D. Stemwedel (aka Dr. Free-Ride) has been keeping track of how various airlines and others are responding. From a Canadian perspective, both Air Canada and WestJet are waiving fees for changing Mexican travel plans.