2017 abortion statistics revised

Something strange happened to the latest official abortion statistics for England and Wales, published in June 2018 – they were incorrect.  And so, in December 2018, the Department of Health and Social Care issued a revised set of figures.  Apparently the abortions notification system (ANS) had malfunctioned.  This caused a shortfall of 3,041 cases (1.5% of the total) missing from the 2017 figures as well as the removal of 176 duplicate records from the data for non-residents.

These numerical corrections may seem small, but they translate into disturbing trends.  For example, the revised total number of abortions in England and Wales reached a 10-year high.  There were in fact 197,533 abortions performed in 2017, a rise of 4% on 2016 and the highest figure since 2008, when there were more than 200,000.  The revised total for women not normally resident in England or Wales was 4,633.  Of these non-residents, 65% travelled from the Republic of Ireland and 19% from Northern Ireland.  In addition, the overall rate of abortion for residents increased from 16.0 per thousand women aged 15 to 44 in 2016 to 16.7 in 2017.  There was no consolation in the original statistics, there is even less in the revised figures.

Decriminalisation on the Isle of Man
The Isle of Man – that pretty, self-governing region of the British Isles – has become the first, and so far the only, place in the British Isles to decriminalise abortion, that is, take it out of the criminal law and make it a mere health issue.  The new law will allow abortion ‘on request’ for any reason up to 14 weeks and in certain circumstances, such as ‘serious social grounds’, between 15 and 23 weeks.  From 24 weeks until birth, abortion will be permitted when pregnancy could cause risk to the mother's life or if the baby when born would suffer serious impairment or die shortly after birth.  Those seeking abortions up to 14 weeks will not need the approval of two doctors.  In addition, there will be an opt-out clause for conscientious objectors and a provision for ‘buffer zones’ around abortion clinics.

The Isle of Man has never been subject to the 1967 Abortion Act.  Instead, abortion was governed by its restrictive Termination of Pregnancy (Medical Defences) Act 1995.  Although fewer than 10 abortions were carried out on the Island annually, around 100 women are thought to have travelled to the UK every year for private abortions.  In January 2017, Dr Alex Allinson MHK, a retired GP, was granted permission to bring forward his private members draft Abortion Reform Bill.  This went out to public consultation, which resulted in 3,644 responses.  The vast majority of feedback, of the order of 80%, was in favour of the various proposals of the Bill.  A revised Bill was given a first reading in the House of Keys on 23 January 2018 and a Second Reading a week later on 30 January.  It then went to a Committee of five and returned to the House for its Report Stage.  On 1 May, members of the House of Keys, the equivalent of Westminster's House of Commons, passed the Bill by a margin of 22 votes to 2.  On 6 November 2018, additional amendments to the Bill were approved unanimously by both branches of the Tynwald, namely, the Legislative Council and the House of Keys.  At the 15 January 2019 sitting of the Tynwald it was announced that the Abortion Reform Bill 2018 had received Royal Assent – the Bill was now an Act.  However, it is not yet in force because the Department of Health and Social Care (DHSC) must first ensure all its provisions are in place, including a full pre- and post-abortion counselling service.  This is not expected to occur until mid-2019.  Thus ends the Isle’s long-running abortion debate – alas, the action is soon to begin.

Abortion in the Republic of Ireland
Sadly, on New Year’s Day 2019, abortion services became legal in the Republic of Ireland.  In May last year, 66.4% of voters backed the repeal of the Eight Amendment to the Irish Constitution in a referendum.  This Amendment protected unborn children and permitted abortion only when the life of the mother was at stake.  The new law makes abortion legal up to 12 weeks gestation.  There is also a mandatory three-day ‘cooling off’ period for women requesting abortions.

By December 2018, the Bill to legalise abortion services in the Republic had passed all its stages after members of the Dáil had voted in favour of the legislation by 90 votes to 15, with 12 abstentions.  It followed hours of debate and more than 60 amendments.  The Health Minister, Simon Harris, promised an abortion service would be available from 1 January 2019, but Irish GPs and obstetricians doubted that the country’s first abortions would go ahead as planned by that date.  At that time, only 4.13% of GPs – 165 out of 4,000 – had signed up to provide abortion services.  In addition, numerous pharmacists, nurses and midwives had all expressed opposition to the new law.  In anticipation of the forthcoming changes, on 30 November, misoprostol, the first ever abortion pill for use in Ireland, had been officially approved.

Far from everyone is happy.  The former Sinn Fein politician, Pedar Tobin, lamented the change in the law.  He said, ‘Leo Varadkar [the Irish Taoiseach], stated this week [in his New Year's Day statement] that the introduction of one of the most extreme abortion regimes in Europe was a sign of social progress.  It shows how upside down our world has become that when the State seeks to end the lives of thousands of individual human beings it is considered progress.’

Abortion pill in England
On 27 December, the Department of Health and Social Care made the requisite authorisations to allow the home-use of the abortion pill, misoprostol, in England.  This is the second pill used in medical abortion procedures.  The first pill is mifepristone, which must still be obtained by attendance at a clinic.  This means that from 27 December it has been legal for women in England to self-administer the second abortion pill at home.  Such arrangements have already been made in Wales (from June 2018) and Scotland (from October 2017).  There are continuing concerns about its use without medical supervision as well as its safety and associated emotional aspects. 

Abortion in Northern Ireland
A cross-party group of MPs at Westminster, seeking to liberalise the abortion laws in Northern Ireland, has accused the government of attempting to scupper its plans in order to protect its survival deal with the Ulster Democratic Unionist Party (DUP).  In the latest attempt in January, the Labour backbencher, Stella Creasy, had intended to put down an amendment to the current draft Domestic Abuse Bill, but she claims her plans had been thwarted.  Most of that Bill had nothing to do with Northern Ireland.  The Westminster government has long insisted that abortion is a devolved matter and therefore an issue for the Northern Ireland government at Stormont – this is presently dissolved because of power-sharing disagreements between its two major parties, the DUP and Sinn Fein.  Stella Creasy and others, driven by the vogue for decriminalisation of abortion and their rancour that Northern Ireland is not subject to the 1967 Abortion Act, are trying to force some political leverage so that Northern Irish women can procure abortions in their homeland.  This is despite the results of a ComRes poll, published in October 2018, that showed that 66% of these women want decisions about abortion taken by locally-elected politicians, not those at Westminster.  The fight goes on.

Abortion in Wales for NI women
The introduction of legal abortion in Ireland has increased the pressure on Northern Ireland to legalise it there.  In 2017, free terminations were made available for women from Northern Ireland in both England and Scotland.  In what seemed like an act of UK solidarity, the Welsh Assembly government announced on 6 November 2018 that women from Northern Ireland could have free abortions on the Welsh NHS.  What the Assembly failed to announce in its press release was the result of the public consultation on this scheme.  It showed that 98.26% were against the proposal.  Only 1.74% of respondents were in favour.  And not one person from Northern Ireland who responded was in accord with it.  So why was it introduced?  Darren Millar, a member of the Welsh Assembly, commented, ‘This is one of the most ridiculous consultation exercises I have ever witnessed.  What is the point of holding a public consultation if you simply end up doing what you want to do anyway?  This consultation is a complete sham.  Clearly it was nothing more than a tick-box exercise for the Welsh Government.’  Too true.  But abortion advocates take no prisoners.



Surrogacy for singles
ARTs are beginning to run way ahead of the Zeitgeist.  We could (just about) understand, but not approve, the legalisation of surrogacy for infertile married couples, then for unmarried couples, then for same sex couples.  Now it is for singles.  That is a bridge too far.

Under UK law, the woman who gives birth to the child is automatically considered to be the child's legal parent.  A parental order is the means by which legal parenthood is transferred from the surrogate to the intended parents.  This was never enough for ART advocates.  On 3 January 2019, a remedial order came into force which gives single people in the UK the same rights as couples to become the legal parent of his or her surrogate-born child.

Of course, we all understand why legal parenthood is so important.  It defines the very identity of the child as a human being, who he is, and who his parents are.  As Sir James Munby, past president of the Family Division of the High Court, has stated, ‘It has the most profound personal, emotional, psychological, social and, it may be in some cases, cultural and religious, consequences.’  Nevertheless, surrogacy, and all it entails, still provokes weighty questions – is it right and proper to breed regardless of whose gametes are used?  What about the marriage covenant?  What about being conceived, born and nurtured within the traditional family unit of two opposite-sex parents?  Deliberately creating ‘patchwork families’ is never a good idea.

Even so, the new law is not all-inclusive.  It does not cover couples or single people whose surrogate children were created using both donor ova and donor sperm, known as double donation.  The new law is applicable only when there is a genetic link between the child and at least one of the parents.

Surrogacy gone mad, again
No-one could predict this mess.  A 35-year-old woman, known as Ms XX, received a late cancer diagnosis from the NHS.  Her botched surgical treatment meant that she was left with severe damage to her bladder and bowel and irreparable damage to her uterus and ovaries.  However, she had 12 of her own ova harvested before her cancer treatment.  She is now infertile but wants to have four surrogate babies in the USA at UK taxpayers’ expense.  The High Court and the Court of Appeal have already awarded her compensation of more than £1.1m, including up to £558,945 for commercial surrogacy in America.  On 15 January 2019, the NHS submitted a 28-page application to the Supreme Court seeking permission to appeal against the pay-outs.  A decision is awaited.

Womb transplants
Here are two more novel chapters in the Reproductive Revolution.  First, from the Lancet (2018, 392: 2697-2704).  A 32-year-old woman in Brazil has become the first in the world to give birth after a transplantation of a uterus from a deceased donor.  The woman suffered from congenital uterine absence and the 45-year-old donor, and mother of three, died of subarachnoid haemorrhage.  Because her ovaries were functional, the recipient underwent one IVF cycle 4 months before the transplant – this procedure, using her husband’s sperm, resulted in eight cryopreserved blastocysts.  Pregnancy occurred after the first single embryo transfer 7 months post-transplantation.  The baby girl was delivered by Caesarean section on 15 December 2017, near gestational week 36.  The uterus was removed in the same surgical procedure as the delivery and immunosuppressive therapy was also suspended at the same time.

Second, the Daily Mail (15 November 2018) reported that an Indian woman has given birth to a child gestated in her mother’s transplanted uterus.  Meenakshi Walan needed a uterus transplant, because hers had been damaged after a miscarriage and three abortions.  She gave birth to a daughter conceived by IVF nearly a year and a half after the transplant.  The baby girl was born in Pune, in the western Indian State of Maharashtra, via via Caesarean section on 18 October 2018, after 32 weeks gestation.  Her uterus was concurrently removed.  Such births from ‘borrowed wombs’ are not common.  The first birth after uterine transplantation from a living donor occurred in Sweden in 2013.  Since then there have been 39 similar procedures, resulting in 11 live births.

Mitochondrial donation for infertility
Mitochondrial donation (MD) was developed to prevent passing on potentially deadly mitochondrial diseases.  If a woman's ova contain mitochondria with a deleterious gene mutation she would previously have been unable to give birth to healthy, genetically-related children.  Now, for the first time, MD has been used to treat infertility.  Greek and Spanish researchers have announced, though details have yet to be published, that a clinical trial using MD has resulted in a pregnancy.  Once born, the baby will be the first as a result of treatment for infertility by maternal spindle transfer (MST).  MST is not permitted in Spain, so the Barcelona-based Embryotools partnered with the Institute of Life in Athens, Greece, to carry out the clinical trial.  The pregnant woman is a 32-year-old Greek, and has previously had four failed IVF cycles and two surgeries for endometriosis.  She is one of 25 women taking part in the study, but the researchers are waiting to see the outcome of this first pregnancy before performing more embryo transfers.

The first MD-child resulting from MST was born in Mexico in 2017 to an Israeli couple who had lost previous children to Leigh syndrome.  A clinic in Ukraine previously claimed to have established MD pregnancies using the related technique, pronuclear transfer (PNT).  The difference is that MST takes place before the ovum is fertilised, and PNT just after.  Both MST and PNT are legal in the UK following a decision by Parliament in 2015, but only when used to prevent passing on serious mitochondrial diseases.  The first patients were approved for the treatment in February 2018, but so far, no children have been born as a result.

Polycystic ovary syndrome (POS)
POS is the most common cause of female infertility, affecting up to 1 in 5 women worldwide, many of whom struggle to become pregnant.  The condition is typically characterised by high levels of testosterone, ovarian cysts, irregular menstrual cycles, and problems regulating blood sugar, but the causes have long been a mystery.  Recent research suggests that it may be caused by a hormonal imbalance before birth.  The findings have already led to a cure in mice, and a drug trial is set to begin with women.

Paolo Giacobinin and colleagues at the French National Institute of Health and Medical Research have found that the syndrome may be triggered before birth by excess exposure in the womb to a hormone called anti-Müllerian hormone.  The research was published as Tata et al., ‘Elevated prenatal anti-Müllerian hormone reprograms the fetus and induces polycystic ovary syndrome in adulthood’, Nature Medicine ( 2018, 24: 834–846).  The researchers injected mice with excess anti-Müllerian hormone which in turn raised the concentrations of testosterone and resulted in the females displaying many of the hallmark symptoms of POS.  These effects were reversed by administering cetrorelix, a drug used to control hormones during IVF treatments.

If POS is indeed passed from mothers to daughters via hormones in the womb, that could explain why it has been so hard to pinpoint any genetic cause of the disorder.  The findings may also explain why women with POS seem to become pregnant more easily in their late 30s and early 40s because anti-Müllerian hormone concentrations are known to decline with age.  These findings also open up a range of possibilities for further investigations and possible POS treatments.

IVF add-ons
In mid-January 2019, the Human Fertilisation and Embryology Authority (HFEA) issued a statement that add-ons were being offered to IVF patients ‘without conclusive evidence that any of them increase the chance of a pregnancy.’  The statement was also signed by ten other groups including the British Fertility Society, the Royal College of Nursing and the Royal College of Obstetricians and Gynaecologists.  Such add-ons include endometrial scratching, in which doctors scratch the womb lining in an attempt to release chemicals and hormones that make it more receptive to an embryo implanting, and treatments designed to prevent the mother’s immune system rejecting the embryo.

Couples obviously want to increase the chances of successful IVF so they are vulnerable to buy add-ons which can add thousands of pounds to the cost of IVF.  Nowadays 60% of IVF patients pay privately for their treatment and 74% of women who had such treatment in the past two years purchased at least one add-on.  The HFEA is calling for ‘a culture change among fertility professionals’ saying that they have a duty of care ‘which should separate pressure from patients and commercial interests from their best practice advice.’  At last, after years of being made aware by others, the HFEA is attempting to regulate the rip-off IVF cowboys – after all, that is the HFEA’s very job.  And the HFEA should be kept busy because a recent report by Allied Market Research reckons the IVF services market in the UK will be worth $685.4 million, or about £522.2 million, by 2022.  Whether that figure is with, or without, add-ons was not specified.

HFEA reports
In mid-December, the HFEA published its second annual state of the fertility sector report plus the first-ever national fertility patient survey.  According to the ever-optimistic HFEA, the report apparently showed that the UK fertility sector performed well in 2017-18 with HFEA licensed clinics meeting the standards required.  Inspections of 101 licensed clinics took place in 2017-18 with most awarded renewed four-year licences, the maximum length possible.  Very few adverse incidents took place compared with the number of treatment cycles, which continue to rise year on year.

The number of adverse incidents reported in 2017 remained low at 570 (0.7% of all treatment cycles) although this showed an increase of 4.6% from the previous year.  There were no grade A incidents – the most severe, but the proportion of grade B incidents increased to 41% in 2017-18, compared with 32% in 2016-17.  The number of grade C incidents decreased from 328 to 302 in 2017-18.  The increase in grade B incidents resulted largely from a greater awareness of the need for clinics to report these and issues associated with third parties who provide services to clinics.  Clinical incidents included laboratory events, equipment failure and cases of severe or critical ovarian hyperstimulation syndrome (OHSS) which clinics must report to the HFEA immediately. The risk of OHSS from fertility treatment remains low, but there were 52 patients reported as having severe or critical OHSS in 2017-18.

The independent national survey of patients who recently had fertility treatment revealed that 75% of patients were satisfied with their treatment experience at clinics – meaning, presumably, that 25% felt they had had an unsatisfactory treatment experience.  There were no significant differences in satisfaction levels among patients whether they paid privately or were treated by the NHS, but 62% of private patients paid 'more than they expected' for treatment.  Women patients were more likely than their partners to say that they felt involved and treated with respect and dignity in certain aspects of their treatment, while those who had received treatment more recently reported higher levels of the use of treatment add-ons than those who were treated two to five years ago.

Sally Cheshire, chairwoman of the HFEA said, ‘I am pleased that this report indicates there is continued good performance across the UK fertility sector, but we know there is more work to be done to make sure that all patients receive the best quality of care.’  In 2017-18, more patients approached the HFEA with complaints about their clinics.  There were 86 complaints from patients who had been unable to resolve their grievances with their clinics, a 21% increase on the number received in 2016-17.  Yes, indeed.  Come on HFEA, make your watchdog teeth bite!

Embryo testing for IQ
An American genomics company is negotiating with IVF clinics to provide genetic ‘risk scores’ for embryos with intellectual disability.  Genomic Predictions, based in North Brunswick, New Jersey, claims that it can offer prospective parents a risk profile for a range of conditions, like breast cancer, diabetes and, most controversially, low intelligence or low IQ.  Nathan Treff, a co-founder of the company, told The Times (16 November 2018) that this is an extension of screening that currently exists for other conditions, such as Down’s syndrome.  ‘Chromosomal abnormalities are already evaluated,’ he said.  ‘For complex disorders, though, we have to evaluate the entire genome in order to get the risk.  The very extreme end of risk, the opposite of intellectual ability, is intellectual disability.  There is a potential to avoid that condition by selecting an embryo that does not have it.’  He however failed to mention the corollary, namely that human embryos ‘with that condition’ would be readily destroyed.

The company’s system does not identity the disabilities in a particular embryo.  Instead it gives the risk of predisposition to diseases.  It claims to be the first to identify polygenic risk scores for embryos rather than adults.  In theory, the same technology could be used to select for high intelligence.  But Genomic Predictions claims that it will only offer it for ‘mental disability’, although another co-founder of the enterprise, Stephen Hsu, told New Scientist, ‘If we don’t do it, some other company will.’

The idea might become popular with IVF clinics, because it means that parents could soon choose to have children through IVF partly on the basis of their intelligence.  Currently, the system is available only in the US.  In order to be approved in the UK the test would need to be licensed by the Human Fertilisation and Embryology Authority.  Simon Fishel, president of Care Fertility, believes it should do so.  Fishel told The Times, ‘It’s always about balancing the good versus the potential for bad.’  He does not believe that the possibility of selecting against embryos with intellectual disabilities is part of a slippery slope.  ‘Cognitive disability is a health issue.  We’re not talking about whether we need to make more intelligent people in society,’ he said.  But not everyone has been in favour.  Ewan Birney, director of the European Bioinformatics Institute, said he was worried about using this to select for intellect.  He believes that, scientifically there could be unintended consequences, with not enough yet known about the mechanism through which these genetic variants affect intelligence.  Lynn Murray, spokesperson for Don't Screen Us Out, a group that campaigns against prenatal testing for Down’s syndrome, told the New Scientist, ‘If we consider inclusion and diversity to be a measure of societal progress, then IQ screening proposals are unethical.  There must be wide consultation.’  All screening procedures have a downside – they can so easily become ‘search and destroy’ missions, especially where human embryos are concerned.  And is screening sensible if no treatment is available?



What has He done?
There is but one story in this section.  He is Dr He (pronounced ‘hay’) Jiankui, a researcher from the Southern University of Science and Technology in Shenzhen, China.  He claims to have created the world’s first genetically-engineered human babies.  It was always bound to happen, some time, somewhere, but when the news broke on 26 November 2018 it was no less stunning.  They happen to be non-identical twins, who have been given the likely aliases of Lula and Nana to protect their privacy.  The girls were born prematurely to their mother Grace a few weeks before, though they were apparently healthy.

He Jiankui maintains he used the gene-editing technique, CRISPR-Cas9, to alter the girls’ DNA to give them immunity from HIV.  He’s team first recruited seven couples from an Aids advocacy organisation, based in Beijing, called Baihualin – the husbands were HIV-positive whereas the wives were not.  Sperm samples from the men were washed to ensure that no HIV was present.  The researchers then used ICSI (intracytoplasmic sperm injection) to inject a single sperm from each of the men into an ovum obtained from each of the men’s partners.  Then the CRISPR–Cas9 toolkits were added.  When the embryos were three to five days old, a few cells were removed and checked to assess if editing had been accomplished.  A total of 22 embryos were created, 16 of these were successfully gene edited and 11 of these embryos were transferred in six IVF cycles.  Only one pregnancy resulted and went to term, though there is reportedly an additional ‘early-stage’ pregnancy from the trial.  The fate of the remaining embryos is uncertain.  The procedure, now commonly referred to as ‘gene surgery’, disabled the CCR5 gene which codes for a protein that allows some common strains of HIV, the virus that causes Aids, to enter a cell – in other words, the aim was to protect the girls from future HIV infection.  However, while one of the twins, Nana, has both copies of the CCR5 gene edited, the other twin, Lulu, has inadvertently received only one edited copy.  This means that the latter twin will probably not be protected from HIV infection, but might instead have a slower disease progression if she ever did contract the virus.  In addition, CRISPR-Cas9 can cause mosaicism, whereby not all copies of the target gene are edited, which could, later in life, prove to be catastrophic.  Why then transfer that embryo?  Evidently the parents wanted to, but were they ever properly informed of the risks, or were they simply enticed by free IVF treatment?  There is evidence that they thought they were merely part of an Aids vaccine development project.

By all measures, He has crossed that widest of bioethical red lines – human reproductive germline editing.  Others have tinkered with human embryos but they have never transferred them to women for reproductive purposes, thus making a permanent change to the germline that can be passed onto future generations.  Not unnaturally, controversy and widespread condemnation surrounded the announcement of this event.  There are at least eight unsettling aspects to consider.  First, the news was broadcast by Dr He himself via an initial YouTube video, followed by others, and then two days later, on 28 November, at the Second International Summit on Human Genome Editing in Hong Kong, rather than by the customary route of a detailed paper in a peer-reviewed scientific journal, or even as a preprint.  He appeared contrite, ‘I must apologise this result was leaked unexpectedly.’  Really?  Who made the videos?  Second, it was premature.  The science is novel and insufficiently tested for efficacy and safety.  Moreover, it is banned in most countries.  The work has therefore been condemned as dangerous and unethical.  Lord Winston spoke for the majority of the research community when he said, ‘If this is a false report, it is scientific misconduct and deeply irresponsible.  If true, it is still scientific misconduct.’  Similarly, Robin Lovell-Badge, from the Francis Crick Institute in London, who attended the Hong Kong Summit, was also critical of He’s work, ‘It’s a very foolish thing to embark on what’s clearly a very novel, provocative technique when you clearly don’t fully understand the gene you’re working with.’  The Summit’s organising committee declared in a closing statement, ‘We heard an unexpected and deeply disturbing claim that human embryos had been edited and implanted, resulting in a pregnancy and the birth of twins.  Even if the modifications are verified, the procedure was irresponsible and failed to conform with international norms.’

Third, why use this complex protocol to knock out CCR5 and protect against HIV?  There are other, simpler methods readily available, such as standard antiretroviral therapy for HIV or Caesarean sections to deliver the babies of mothers with the virus.  Moreover, loss of CCR5 function increases the risk of severe or fatal reactions to some other infectious diseases.  In other words, the trial was not one of unmet medical need, but one that was life-risking rather than life-saving.  Fourth, who is this Dr He?  He is a 34-year-old who first worked with the CRISPR gene-editing technology while obtaining a doctorate in biophysics from Rice University in Houston.  He then undertook postdoctoral research at Stanford and returned to his native China in 2012.  There he founded two genetic-testing companies and became affiliated to the University in Shenzhen.  Though he presented some preliminary CRISPR-Cas9 research at scientific conferences in the United States, he disclosed to only a very few people that he was planning to transfer gene-edited human embryos to women in order to create pregnancies.  Moreover, He had no experience of running human clinical trials.  When asked at the Summit why he went ahead with the experiment despite the global opposition to such research, he simply did not answer the question.  But evidently He had long wanted to get into gene editing.  He had visited Feng Zhang, a CRISPR pioneer, at his laboratory at MIT, who warned him against editing human embryos for reproduction.  Mark DeWitt, a geneticist at the University of California, Berkeley, says that he advised the same.  Jennifer Doudna at Berkeley, another CRISPR pioneer, refused He’s request for a visit because she thought he was not doing anything related to this technology.  Now, she wonders whether He was ‘trying to leave a trail’ of reputable contacts so he could say that he had broad support for his work.  So, was he grossly incompetent, utterly naïve, or out-and-out grandstanding?

Fifth, the hospital linked to the alleged births has denied authorising the procedure and has accused He of forgery.  This HarMoniCare Women & Children’s Hospital in Shenzhen has said that the signature approving the experiment may have been falsified – it has asked the police to investigate.  A precautionary statement on a social media site, issued by 100 Chinese scientists, called for better State legislation, ‘It is a great blow to the global reputation and development of biomedical research in China.’  A Chinese government minister said, ‘China has banned reproductive use of gene editing in human embryos.  The experiment has violated laws and regulations in China.’  Dr He may be in serious trouble.  A week after his appearance at the Hong Kong conference, He was reported to be under house arrest at his university and then on 21 January it fired him.  There are rumours He may face charges of bribery and corruption – crimes which are severely punishable, even by the death penalty, in China.

Sixth, safety remains the fundamental concern.  Would unintended and unexpected changes occur in the girls’ genomes?  Apparently, multiple whole genome and targeted deep sequencing techniques were undertaken before embryo transfer, during the pregnancy, and then after birth.  The results, according to He, indicate that the girls' genomes were changed as intended and that no off-target editing or large deletions had occurred.  Only time will tell.  As yet the work has received no independent confirmation.  Seventh, He has, somewhat belatedly, stated that his intention is to publish full details of the methods used and the results obtained in the near future, ‘My raw data will be made available for third-party review.’

And eighth and lastly, there is the hefty matter of ethics.  Many say they are troubled about the ethical implications of He’s work.  Herein is a strange bioethical paradox.  Most of these upset scientiss have no ethical qualms about germline engineering in principle, only it seems, in practice.  Take for example, Dr Kathy Niakan of the Francis Crick Institute in London, who holds the first UK licence to use CRISP-Cas9 in human embryos.  She has said, 'If true, the report is very concerning.  This would be a highly irresponsible, unethical and dangerous use of genome editing technology.’  ‘Unethical’ eh?  This is the woman who considers it entirely ethical to experiment on and subsequently destroy human embryos.  And it is a fair bet that the vast majority of the others, who have been ‘ethically’ offended by He’s work, care little about issues like human embryo destruction, PGD, IVF and abortion.  Oh, you can almost feel the professional jealousy – beaten by a maverick Chinaman!  And if you like your ethics to be mawkish, here is an extract from one of He’s YouTube videos, ‘Family is society’s bedrock.  Our children are the centre of family life.  If we can protect a little girl or boy from certain diseases, if we can help more loving couples start families, gene surgery is a wholesome development for medicine.’  Oh dear, isn’t that touching, how could you dare to gainsay it?

So what’s to be done now the big red line has been crossed?  There is no going back.  It is no longer whether reproductive genome editing should be permitted, but rather what kind of genes, and how many, can be altered.  We are caught in the classic ethical dilemma between ‘can’ and ‘ought’.  The once bold statement of the Council of Europe’s 1997 Convention on Human Rights and Biomedicine, which prohibited germline interventions, ‘The ultimate fear is of intentional modification of the human genome so as to produce individuals or entire groups endowed with particular characteristics and required qualities’, now looks seriously out-of-date.  As Francis Collins, the US National Institutes of Health (NIH) director, said in a statement on 28 November, ‘The need for development of binding international consensus on setting limits for this kind of research now being debated in Hong Kong, has never been more apparent.’  OK, so there could be a global moratorium, but that is not the same as a permanent ban.  And there could be a global registry set up by governments to record this sort of research, but cooperation could never be mandatory.  And anyway, other rebel scientists may now feel emboldened to 'have a go' surreptitiously.  And never forget that vain glory, hubris and kudos can also be powerful drivers, even among seemingly-dull, white-coated boffins.  Ultimately these are questions for society, not just scientists.  Yet bioethics has a nasty habit of travelling rapidly down slippery slopes propelled by the imperative for research, the cause of celebrity and ineffective bioethical guidelines.  The future of gene-editing human embryos does not look bright.  Whatever the outcome – and could it, just could it all be fake news? – Dr He has unquestionably left a scientific legacy, alas, it is an appalling one.



More stem-cell mavericks
More bad news for the stem-cell industry.  StemGenex Inc. is a San Diego-based clinic that has used fat-derived adult stem cells to treat a wide variety of diseases from multiple sclerosis to Parkinson’s to Alzheimer’s.  The company is already being sued by a number of former patients about false claims it has made for the efficacy and patient satisfaction rates of its treatments.  StemGenex removes adipose cells from a patient, cleans them, recovers fat stem cells and then injects them claiming that these can treat a range of health problems by performing different biological functions, replacing damaged bodily cells and improving immune function.  Many stem-cell scientists say it is impossible that adipose stem cells could do all that.

In late October 2018, the US Food and Drug Administration (FDA) sent a formal warning letter to the company alleging that it is marketing products without appropriate FDA oversight and ‘multiple complaints involving possible adverse events’.  It also cited several quality control problems with the company’s manufacturing processes.  But StemGenex is not alone.  FDA Commissioner, Scott Gottlieb, confirmed that though stem-cell medicine remains a source of great potential for health benefits, ‘We continue to see bad actors exploit the scientific promise of this field to mislead vulnerable patients into believing they’re being given safe, effective treatments.  These stem-cell producers are leveraging the field’s hype to push unapproved, unproven, illegal, and potentially unsafe products.  This is putting patients’ health at risk.’

Nor is the US alone – stem-cell mavericks around the world are hawking snake oil treatments.  Nevertheless, across the US hundreds for stem-cell clinics have appeared over the past five or so years.  Almost all of them sell therapies, typically costing between $5,000 and $20,000 per treatment.  These treatments are unproven, possibly unsafe and ineffective and untested in either animal or human studies.  They are not approved by the FDA and many are specifically forbidden by federal regulations.  The FDA appears, at last, to be conducting a crackdown on these charlatans.  Earlier in 2018, the FDA requested permanent injunctions to stop two major players – Cell Surgical Network in Beverly Hills (but with a network of more than 100 clinics throughout the USA) and US Stem Cell Clinic in Florida – from marketing their stem-cell therapies.  Both companies are currently challenging these sanctions.

Model embryos
As if there were not enough bioethical issues to contend with, here is another.  Adult stem cells, good – embryonic stem cells, bad.  That simple bioethical binary mantra is beginning to crumble.  Over the last few years, given the right conditions, mouse and human induced pluripotent stem cells (iPSCs) have been shown to spontaneously organise themselves into 3-D structures that are increasingly similar, in form and function, to mouse or human embryos.  These new entities are known as model embryos.  Moreover, more recently with mouse models, it has been possible to incorporate additional tissues that resemble yolk sacs and placentas.  In mammals, these ‘extra-embryonic organs’ grow in tandem with the embryo, mediate its implantation and create an interface with the mother.  Such models can also be transferred into the wombs of mice where they begin to implant.  In other words, stem cells can now become ‘model’ embryos that are almost indistinguishable from ‘real’ embryos in the laboratory.

In utilitarian terms, these model embryos may well be useful for research into contraceptives, infertility treatments, developmental disorders and transplant organs.  But how are these model embryos to be regarded?  What should their legal and bioethical status be both now, and in the future, as they become more sophisticated and more like their natural ‘real’ counterparts?  Unlike the latter, formed through the fusion of sperm and ova, model embryos can be generated in large numbers and therefore lend themselves to high-throughput genetic testing and drug screening on the road to possible therapeutic discoveries.

So far work with human stem cells lags behind that accomplished with mice.  Nevertheless, human stem cells have already been manipulated to demonstrate aspects of gastrulation and the formation of the beginnings of the amniotic cavity.  And, because so little is currently known about the early days of human embryogenesis, these model embryos are, for many researchers, fascinating and attractive biological entities.

What is needed now, as a first step, is some sort of international discussion to produce policies and regulations as well as a free flow of information about research projects and achievements.  But before these aims can be achieved, the nature and status of model embryos must be decided.  Herein lies a fundamental problem – the nature and status of ‘real’ human embryos has yet to be decided satisfactorily for they are currently offered precious little protection and are unthinkingly destroyed on an industrial scale.  The supposedly pioneering Warnock Report of 1984 ducked this defining issue entirely and so has virtually every such bioethical committee ever since.  The only substantial outcome from most of these think-tanks has been the arbitrary 14-day rule, and even that is now up for challenge and extension.

Despite the current appallingly inadequate answers with regard to real embryos, one of the first fundamental questions to ask is this, should model embryos be treated legally and bioethically as human embryos, now, or in the future?  If the answer is ‘no’, then researchers could use these model embryos both in scientific and in preclinical applications, unfettered by current legislation or guidelines on human embryo research.  If the answer is ‘yes’, then work with these models would be permitted only in countries that currently allow the creation of human embryos for research, such as the United Kingdom.  A supplementary question is, at what point does a partial model embryo contain sufficient biological material and characteristics to be regarded as a whole embryo?  In other words, what stage of biological correspondence must be reached before the 14-day rule might apply to model embryos?

A second fundamental question should be, are these model entities capable of developing to term?  However, any research protocol needed to answer this question would itself encounter severe bioethical hurdles.  The worldwide ban on human reproductive cloning should prevent such experiments from being conducted on model embryos.  Or at least that was true until late last year.  Now we live in the post-He period – and who knows how many other rebels – and his genome-edited twins.

When considering the appropriateness of most novel human bioethical issues it is hard to be other than pessimistic.  What protections do the various stages of human life enjoy?  Not many is the drab answer.  What can start out as a seemingly tightly and well-regulated activity invariably becomes less so.  This is that bioethical slippery slope – ridiculed by moral philosophers and feared by the morally sensitive.  Yet slippery slopes are an inevitable part of the entire human condition of declension – derided by the wicked and dreaded by the righteous.  Consider this biblical pathway of decline, ‘… but each one is tempted when, by his own evil desire, he is dragged away and enticed.  Then, after desire has conceived, it gives birth to sin; and sin, when it is full-grown, gives birth to death’ (James 1:14-15).  Is there not a universal slippery slope contained therein?



RCP poll of members
During February, the Royal College of Physicians (RCP) is to poll its 35,000 members and fellows on whether or not they want a change in the law to permit assisted suicide and euthanasia.  Specifically, the poll will ask respondents whether they think the College should remain opposed to ‘assisted dying’, or whether it should adopt a new position of neutrality.  In a sinister move, the RCP said, ‘following this new poll, the RCP will adopt a neutral position until 60% of respondents say that it should be in favour of or opposed to a change in the law.’  In other words, unless 60% of respondents say they oppose euthanasia, the College will change its current position of opposition to one of neutrality.  Why should a supra-majority be required to maintain the status quo?  This is a menacing first step towards adopting a position of support for euthanasia.  Neutrality implies ‘we are no longer against’.  It amounts to tacit support for assisted suicide.  John Saunders, a former chairman of the RCP’s ethics committee, has called the move a ‘sham poll with a rigged outcome’ and ‘manifestly unreasonable’.  Indeed, is this RCP ploy bizarre, or undemocratic, or madness, or what?

In 2014, five-years ago, a similar RCP survey was conducted.  It found that 44.4% of respondents thought the College should be formally opposed to assisted suicide.  A further 31.0% said it should be neutral and only 24.6% wanted it to support assisted dying.  Asked whether, regardless of their support or opposition to change, they would personally be prepared to ‘participate actively’ in assisted dying were it to be legalised, 58.4% said no.  These results were similar to those from a 2006 RCP poll.  This current 2019 poll and its threatened move to neutrality suggests that the RCP has been shanghaied by a minority on its Council and captured by lobbyists for assisted suicide.  Most medical organisations oppose changing the law.  And do not forget that in 2015, in a free vote in the House of Commons on the Assisted Dying (no. 2) Bill 2015-16, MPs overwhelmingly rejected it by 330 votes to 118.  The results of the RCP poll are expected in March.

Noel Douglas Conway – the latest
Noel Conway is the 68-year-old man from Shrewsbury who suffers from terminal motor neurone disease.  He would like the option of a legal assisted suicide when he has reached the final six months of his life.  Previously, on 27 June 2018, the Court of Appeal rejected Mr Conway’s request on the grounds that it is for Parliament to decide the issue.  On Thursday 22 November, his legal team appeared in an hour-long emergency appeal before three Supreme Court judges, Lady Hale, Lord Reed and Lord Kerr.  Their task was to consider whether or not to allow a full hearing of this right-to-die case.  On 27 November 2018, their judgement was delivered – permission to appeal was refused.  The Supreme Court judges gave eight reasons for their refusal.  They are most instructive and may be read here.  Noel Conway’s case will therefore proceed no further.

Mr Conway responded, ‘Today’s decision is extremely disappointing.  It means that I will not be able to have my arguments heard by the highest court in the land.  Dying people like me cannot wait years for another case to be heard.  I am particularly disappointed that the Courts have instead listened to the arguments of doctors who have never met me but think they know best about the end of my life.  I have no choice over whether I die; my illness means I will die anyway.  The only option I currently have is to remove my ventilator and effectively suffocate to death under sedation.  To me this is not acceptable, and for many other dying people this choice is not available at all.  All I want is the option to die peacefully, with dignity, on my own terms, and I know that the majority of the public are behind me.  It is downright cruel to continue to deny me and other terminally ill people this right.  This is the end of the road for my case, so we must now turn our attention back to Parliament.  I hope that MPs will listen to the vast majority of their constituents and give people like me a say over our deaths.’

Paragraph 3 of the Supreme Court’s judgement is especially relevant.  It states, ‘Mr Conway could bring about his own death in another way, by refusing consent to the continuation of his NIV [non-invasive ventilation].  That is his absolute right at common law.  Currently, he is not dependent on continuous NIV, so could survive for around at least one hour without it.  But once he becomes dependent on continuous NIV, the evidence is that withdrawal would usually lead to his death within a few minutes, although it can take a few hours or in rare cases days.  The evidence from the specialist in palliative care who is looking after him is that medication can be used to ensure that he is not aware of the NIV being withdrawn and does not become uncomfortable and distressed.’

Nobody would demur at Mr Conway’s sentiments.  However, greater issues are at stake – including the meaning of life, the protection of the vulnerable, the intention of the law, the trust in medical professionals and the preservation of society.  While our hearts are with Mr Conway, our heads must be elsewhere, beyond the personal and the particular.

Mr Conway has been supported by the Dignity in Dying organisation.  Its chief executive, Sarah Wootton commented, ‘We will now turn our attention back to Parliament and demonstrate to our MPs the strength of feeling on assisted dying.  Last time around, MPs failed in their duty to represent the views of their constituents.  Next time, we hope they will stand up for a safer, more compassionate law that benefits dying people.’  Yet, as already mentioned above, Parliament has no apparent appetite to legalise assisted suicide.  In September 2015, at the first House of Commons vote on the issue for 20 years, MPs overwhelmingly rejected the Assisted Dying (no. 2) Bill 2015-16 by 330 votes to 118.

This welcome and sensible conclusion to this latest right-to-die case recognises that the 1961 Suicide Act is good law.  While it decriminalised suicide, it retains punishment for those who assist and it protects the vulnerable.  In other words, ‘it has a stern face and a kind heart’.  Its present blanket ban on assisted suicide and euthanasia keeps us all safe.  We must have the utmost empathy and sympathy for all those who live and suffer on a daily basis.  However, the gravity and consequences of changing the law on assisted suicide, whether these men and women are terminally ill or not, whether their diseases are debilitating or not, are too great.  The outcome would be too far-reaching, too devastating for the disadvantaged, the disabled and the dying.  The floodgates would be opened – medical practice, legal protection and our regard for human life would never be the same again, and never so safe.

Simon Binner – a postscript
On Wednesday 10 February 2016, BBC2 TV broadcast the 90-minute documentary, How to Die: Simon’s Choice.  It was the story of Simon Binner and his decision to commit assisted suicide at the so-called Eternal SPIRIT Foundation ‘clinic’ in Basel, Switzerland.  Simon, by his own admission, was an alpha male.  He was a Cambridge graduate, affluent, sporty, fun-loving, articulate, quick-witted and a strong-minded business man.  He was married to Deborah and had three step-daughters, Zoe, Hannah and Chloe.  Outwardly, it was a happy, well-off family – inwardly, it was already acquainted with tragedy – Chloe had died from bone cancer in 2013, a month before her 18th birthday.  That heartbreak was ratcheted up in early 2015, when Simon was diagnosed with an aggressive form of motor neurone disease (MND) and a prognosis of between 6 and 24 months.

He had decided in the car on his way back home from the hospital diagnosis on 7 January 2015 that he would either kill himself or be euthanized.  The issue of palliative care was raised, ‘I’m not doing that.  I’ll chose a date.’  And he did – his 58th birthday on Monday 2 November.  And so he began to make the arrangements.  He even announced his pending death plans on LinkedIn.  On the other hand, his wife Deborah had ‘… always been quite anti-assisted dying.’  In fact, she was ‘utterly terrified of it.’  From the beginning, she stated that she, ‘feels so strongly that this isn’t the right thing to do.’  But she confessed that she and Simon, ‘Don’t, can’t talk about it.’

A week before the appointed day, Debbie conceded, ‘I feel furious, tender, loving, protective, so pleased I married him and I will miss him terribly.’  The fateful Monday arrived.  Simon played a recorded final message to Debbie, his wife of 14 years, ending with, ‘Anyway, time and tide wait for no man, I love you very much Debbie.  Goodbye.'  At 9.38 am, he then, with a smile on his face, moved the drip valve to ‘open’.  Debbie and four friends, but not Hannah or Zoe, witnessed it all.  Two weeks later Debbie was interviewed.  She had forgotten huge chunks of what happened in Switzerland.  But she recalled some tender little episodes – how she loved putting his cufflinks on and making sure his shoes were done up properly.  But she acknowledged that she was still in shock and trauma.  She was angry, missing him and guilty.  ‘Did I do enough?’, she repeatedly asked herself.

Now, Deborah Binner, the 55-year-old grieving widow and a former Sky News presenter, has written a book about her experiences.  In Yet Here I Am: One Woman’s Story of Life After Loss (2018, Splendid Publications Ltd., 304 pages, £9.99, ISBN-13: 978-1909109773) she reveals how she felt ‘abandoned’ by her husband after he chose assisted suicide in Switzerland.  She felt she had no choice but to support her husband’s wishes and so she reluctantly agreed to go with him to Switzerland after he twice attempted suicide at their home.

Her chronicled reactions to her husband’s one-way trip and its aftermath are as instructive as they are raw.  ‘Simon’s death feels unresolved.  To me it felt angry, rejecting and abrupt.  It felt a lot like a suicide.  I think he genuinely thought that taking his life was courageous and that it would save us a lot of heartache seeing him spiral into full disability.  I know that his intentions were entirely pure.  But surely it is equally brave to live with an illness, a disability, to embrace vulnerability and to accept that none of us really has that much control.’

‘While Simon’s turmoil had ended, in some ways mine was just beginning.  I didn’t want Simon to suffer, but I didn’t want him to die, either.  Watching him plan his own death, while I still wanted more time, was overwhelmingly traumatic.  My head understands the intellectual arguments and I find it hard to disagree with them.  But my heart still says no.  Should we not be kinder, more patient, more respectful of human life?  Isn’t how we support the dying so central to who we are as human beings?  And there’s a part of me that believes it’s better, if a person has the best possible care, to let nature take its course.  Personally, I am absolutely fuming that my husband left me to fend in this world alone.  That was not the deal.’

And now?  She is certainly not an advocate for the legalisation of assisted dying.  ‘I worry deeply about how people who are ill can lose the sense of mattering to other people.  If there were the option of ending it all relatively simply, would they feel pressure to opt for that rather than become a “nuisance”?’  She refuses to be a poster-girl for assisted suicide because of the traumatic ‘after-effects on the family and friends left behind.’  Instead, motivated by Chloe’s premature but happier death, she chooses to spend her free time fund-raising for childhood cancer and highlighting the need to improve cancer treatment for all.  Assisted suicide is ghastly.  Herein ends today’s bioethical lesson.

Geoff Whaley
On Thursday 7 February, this 80-year-old retired accountant died in the arms of his wife of 52 years, Ann, at the Dignitas 'clinic' in Switzerland.  Ann will then return, as a widow, to their Buckinghamshire home and finally face the finality of it all.  She has already admitted, 'I’ve put my emotions in a box.  That box will open when it’s all over.  I know it’s going to be awful, just so empty.'  Some days before they travelled, Thames Valley police had received a tip-off that Mrs Whaley had booked flights and hotel reservations and might therefore be considered to be 'assisting' in her husband's suicide.  The police subsequently dropped their investigation.

Two years ago, Mr Whaley was told he had motor neurone disease (MND) and in December 2018 that he had between 6 and 9 months to live.  Almost immediately after his initial diagnosis he knew he wanted an 'assisted death' – it has cost him about £11,000.  The family has been supported by Dignity in Dying.  Mr Whaley has said, 'I want the law rewritten to allow people in certain circumstances to take their own life [while ensuring] that any weak or vulnerable people are protected against abuse.  The two things are not mutually exclusive.'  Mr Whaley had left letters to his four grandchildren, aged 4 to 17, and to numerous friends – 'I didn't want to go through 50 goodbyes so I've written them all a short note to be sent in due course.' 

He also wrote an open letter to all MPs.  It began, 'By the time you read this, I will be dead.'  It continued, 'The law in this country robbed me of control over my death.  It forced me to seek solace in Switzerland.  Then it sought to punish those attempting to help me get there.  The hypocrisy and cruelty of this is astounding.  Though it is perfectly legal for me make arrangements and travel to Dignitas by myself, the minute anyone else ‘assists’ me in any way – which is essential, due to my condition – they are liable for prosecution.'  It ended, 'No family should ever have to endure the torment we have undergone in recent weeks, but it will be easier to bear knowing that by sharing it we can contribute to future change.  I sincerely hope that you will truly listen to our story and see the suffering you are inflicting by upholding the status quo.'

It is reckoned that there are between 50 to 60 Britons who go to Swiss 'clinics' each year to die.  Mr Whaley may be the latest, but he will certainly not be the last.

Canada extensions
Legal euthanasia is not entirely settled in Canada.  It was in June 2016 that the Canada government approved Bill C-14 amending its Criminal Code to legalise euthanasia and physician-assisted suicide, or as it is known there, ‘medical assistance in dying’ (MAID).  Now, just two and a half years later, the government is considering whether to extend the criteria of eligibility.  This comes as no surprise – we call it ‘the slippery slope’.  It happens wherever assisted dying has been legalised.  We’ve seen it all before in the Netherlands, Belgium and elsewhere.

The Canadian government is currently mulling over a discussion paper published by the Council of Canadian Academies.  The three controversial areas are first, requests for euthanasia by mature minors – do the under 18s have the maturity to deal with life-and-death issues?  Second, advance requests – should euthanasia be requested before the patient loses decision-making capacity which would make them ineligible for MAID?  Third, requests where mental illness is the sole underlying medical condition – what is ‘intolerable suffering’ and might the condition improve?  How long before any, or all, of these criteria are embraced?  Probably, not long.

Belgian doctors on trial
At last, an alleged case of criminal euthanasia is being investigated since the practice was legalised in Belgium in 2002.  In November 2018, a Belgian court ruled that two doctors and a psychiatrist from East Flanders had illegally assisted in the unlawful killing of a woman suffering from autism.  The 38-year-old Tine Nys was euthanized on 27 April 2010.  Her sisters, Lotte and Sophie, claimed that the doctors acted incompetently and failed to follow the relevant legal guidelines.  A court in Ghent found that there was sufficient evidence that the conditions and procedures of the Euthanasia Act had not been observed.  The case is ongoing – the three medical professionals will be charged with illegal poisoning.  They can appeal the judgement.

Dutch doctor on trial
It was announced in November 2018 that a geriatric doctor, who helped a nursing-home patient with severe dementia to die in April 2016, will be prosecuted for breaking Dutch euthanasia guidelines.  The case will be the first under the law since it was established in 2002.  The Public Prosecution Department has said, ‘This case addresses important legal issues regarding the termination of life of dementia patients.’  The case centres on a 74-year-old woman who had drawn up a living will some years before her admission to the nursing home.  ‘But it was unclear and contradictory.  Although the woman had regularly stated that she wanted to die, on other occasions she had said that she did not want to die.  This case has been referred to court to get these questions answered,' said a Department spokesman.

It is alleged that the doctor had ‘overstepped a line’ when ending the life of the patient.  A report from the Regional Euthanasia Committees stated that the doctor, who cannot be named, had administered a sedative without the patient’s consent.  The woman also woke up during an injection of the thiopental and began to physically resist.  The doctor directed family members to restrain the patient while the rest of the euthanasia agents were quickly administered.


Preventative health
We are, or should be, all interested in human health, especially our own.  In November 2018, the UK government promised an extra £20.5 billion for the NHS to be spent specifically on preventive health projects.  Currently, the NHS spends a massive £97 billion on health treatment versus a modest £8 billion on prevention.  According to the health secretary, Matt Hancock, that spending pattern must change.  Yes, we know what they say, ‘Prevention is better ….’

Almost 1 in 3 of the population in England, that is 15 million people, suffer from a chronic illness, some with co-morbidities.  Most long-term conditions and many non-communicable diseases, such as heart disease, stroke, cancer, chronic lung disease, diabetes and dementia, have no cure so must be managed.  The NHS currently spends 70% of its budget on the treatment and care of those with these long-term conditions.  Many of these could have been prevented by changes in lifestyle.  The new money will focus on preventative measures targeted at helping people change their unhealthy lifestyles, putting people back in charge of their own health.

So what can be done?  The benefits of preventive health care are obvious – quitting smoking, exercising more, eating additional fruit and vegetables, consuming less salt and more fibre, guzzling fewer sugary and alcoholic drinks, and so on – such measures invariably bring about better well-being.  Some protest this is not a matter for the 'nanny state', but rather the sole responsibility of the individual.  But many people need help.  Lifestyle changes, such as giving up the fags or cutting down on the booze, can be effectively supported.  So can breastfeeding, which protects babies from gut and respiratory diseases as well as women from breast cancer, yet England has one of the lowest breastfeeding rates among the developed world.  The reason is simple – new mothers find it very hard to continue breastfeeding when they do not receive support.  The evidence is clear – if people receive the right support, they can often make healthy lifestyle choices or changes.  So by providing that support, the NHS can incentivise people to take preventative health measures.

As in most areas of modern life, economists like to poke their collective nose into health spending.  And the monetary paybacks from preventative health measures look promising.  For example, every £1 spent on preventing teenage pregnancy saves £11 in abortion, antenatal and maternity costs.  A similar return comes from every £1 invested in cycling infrastructure.  Overall, every £1 spent on preventative health generates a return of £14 plus the original investment.  And all those costs exclude the upside of the paybacks in personal well-being.  According to the King’s Fund, the health think-tank, cuts in public health spending is ‘the falsest of false economies’.

What is the Christian response?  How should we regard bodily health in general and preventative health in particular?  We should always act to guard (I Corinthians 16:13), refresh (Romans 12:2) and develop (2 Peter 3:18) our trio of mind, spirit and body, despite the inevitable declines that occur with ageing.  But look around your congregation and see the evidence of, for example, overeating.  Two-thirds of adults and a quarter of children in the UK are either overweight or obese – apparently it makes no difference either if people are within or without the church.  And the vast majority of the problem is self-inflicted.  We are not Greeks - the body is important for Christians.  There is a decisive verse to help us all, ‘Do you not know that your bodies are temples of the Holy Spirit, who is in you, whom you have received from God?  You are not your own’ (I Corinthians 6:19).  We have a duty to look after this body of ours, to keep it healthy, certainly not to abuse it. 

The healthiest old people are those who are relatively rich, well-educated, non-smokers, and mentally and physically active - we may not be able to modify the first item on this list, but we can certainly have a serious bash at the latter four.  Indeed, evangelical Christians might be expected to be among the healthiest people alive since most of us keep mentally alert, we read, listen to sermons, visit and talk to others, we do not abuse drugs, we know the value of bodily exercise, we lead a simple lifestyle, know contentment, and so on.  How is your home of the Holy Spirit?  Do you preventively care for it?  Don't you think you should?

Adoption numbers falling
There were only 3,820 children adopted in England during 2017 after being in care.  This is down from 4,370 a year earlier and from 5,360 in 2015.  In 1968, there were some 27,000 adoptions in England and Wales.  What is happening?  David Cameron, while prime minister, famously promised that the adoption process would become easier since much of the red tape would be abolished.  The number has slumped in part because in 2013 Sir James Munby, then president of the family division of the High Court, declared that social workers must increasingly seek to place vulnerable children with other family members, in what is known as kinship care, before non-relatives can begin proceedings to adopt a child from care.  In addition, some, perhaps all, local authority children’s services budgets are under huge pressure.  The upshot has been that the system has begun to stagnate.

It is not that there are no children waiting.  The number of children in local authority care is at a ten-year high.  In 2017, it reached 75,420 – up by 4% on the previous year and up from 59,370 in 2008.  These children may increasingly be regarded as of ‘the wrong type’.  More often they come from higher risk environments, that is, homes with addiction or mental illness affecting a parent or their partner, or places of domestic abuse.  And the children themselves can have their own ‘additional needs’ such as physical, behavioural or psychological problems.

Adoption, with its biblical precedents – such as 2 Samuel 9, Galatians 4:4-7 and Ephesians 1:5 – used to be the route by which many infertile couples raised a family.  It is still an honourable practice among many Christian couples, those with and without their own genetic children.  Sad to record that several well-intentioned Christian couples have been blackballed by overzealous, politically-correct social workers because their lifestyle is considered too extreme, like praying, reading the Bible and keeping Sunday special.  Couples needing advice on these issues might like to contact Cornerstone, the UK’s only Christian adoption and fostering agency.

The shrinking UK family
UK families are getting smaller.  The grand Victorian households with their six or eight children have long been consigned to history.  The 21st-century family is markedly different with ever-declining numbers of offspring.  The latest figures for 2017 from the Office for National Statistics (ONS) and published on 22 November 2018, show that women, within that reproductive cohort of 18 to 44 years old, have on average just 1.89 children.  This is a record low.

The ONS compared two groups of women – those born in 1972, who are now in their mid-40s and unlikely to have any more children, and those born in 1945, who are now typically grandmothers.  The former had 1.89 and the latter had 2.19 children.  And there are other comparative trends – the numbers of families in England and Wales with just one child grew from 14% to 18% and childlessness also increased in women from 10% to 18% in just that one generation.  It is easy to think of reasons for the shrinking family – careers, infertility, economics, abortion, and so on.  But there is a more fundamental demographic issue here.  For any society to maintain a robust and balanced population, that is neither growing nor declining, the so-called replacement rate is reckoned to be 2.1 children per woman.  The UK, like most other countries in the developed world, is below that vital datum.  Family life is undeniably shrinking.

God and bioethics
It is beyond cavil that for 2,000 years and more, Christianity has undergirded the growth of good medicine, including both ethics and practice.  With its Judaeo-Christian doctrines and its Golden Rule of Matthew 22:39 it has been the driving force (alongside the Hippocratic Oath) that has created that wholesome and welcome culture of life.  More recently Christianity has similarly informed and influenced the development of that pioneering field of study called bioethics.  Many early bioethicists were theologically trained and Christians have, and still do, play key roles in the scholarship and application of ethics in medicine and biology, aka bioethics.  But the more recent rise of atheism and agnosticism and anti-Christian rhetoric have changed the moral compass of Western societies.  So, now that, according to Nietzsche, ‘God is dead’, how has this ethical shift affected the tone and content of bioethical debate?

Answers to that question are tendered in a valuable edition of the Journal of Medicine and Philosophy (November 2018, 43: 615–745) entitled ‘Bioethics After the Death of God’ and edited by Mark J Cherry of St. Edward’s University, Austin, Texas.  The publication is a tribute to the work of the American philosopher H. Tristram Englehardt, Jr, who ‘fell asleep in the Lord’ on 21 June 2018, aged 77.  He was professor at Rice University, in Houston, Texas.  He was raised a Roman Catholic and died a member of the Orthodox Church.  The volume, which contains six articles by different authors, focuses on Englehardt’s assessment of the rise of pluralism in Western societies and the consequent decline of an objective understanding of practical morality.  His thesis was simple – without a ‘canonical’ source of truth in religious belief, moral debate has become ‘interminable’.  In other words, the Bible and its robust propositional truths are essential and necessary to grasp, debate and act.  Otherwise bioethics is flailing in a slough of post-modern gobbledegook, situation ethics and worse.

This is how Cherry, in his Introduction, describes that slough, ‘Without the ability to appeal to unconditioned moral meaning or to an unconditioned absolute perspective on reality to secure a canonical moral perspective, there can be no moral truth per se.  There are only the particular moral intuitions that different persons affirm.  This is why, for example, central concerns, such as in vitro fertilization with embryo wastage, the use of donor gametes in third-party-assisted reproduction, physician-assisted suicide, and other forms of medically assisted dying, are no longer appreciated as serious matters of morality and bioethics.  Each has been deflated and demoralized into mere personal lifestyle and death-style choices.  Without access to a fully objective account of being, humans create their own criteria for veracity and, as a result, morality and truth become plural.’  That is a resolute and perceptive critique of modern bioethics.  It is also why biblical bioethics make sense.  Long live truth!