Update on Life Issues – June 2010
This total for England and Wales represents a fall of 3.2% over the previous year. The abortion rate also fell to 17.5 per 1,000 resident women aged 15-44 compared with 18.2 in 2008, and the under-16 abortion rate was 4.0 and the under-18 rate was 17.6 per 1,000 women – both lower than the previous year.Any decline in the abortion statistics is always welcome and the retreat from that awful 200,000 barrier of the previous three years is something of a relief. But, but, but, the figures are still horrid – still over 3,500 abortions every week in the towns and cities where we all live and 63,309 (34% of the total) were for women who had previously had at least one other abortion and 17,916 were carried out on girls aged under 18, including 1,047 on girls aged 14 or under.
Additional headline data for 2009 were that 94% of these abortions were funded by the NHS and well over half (60%) took place in the independent sector under NHS contract – in other words, UK taxpayers funded them. Most (91%) abortions were carried out at less than 13 weeks of gestation, while 75% were at under 10 weeks. Only 2,085 abortions (<1% of the total) were under ground E, namely, the risk that the child might be born handicapped. And medical abortions, as opposed to surgical abortions, accounted for 40% of the total.
Abortion and Pills
This latter figure is a reminder of the increasing popularity of the RU-486 abortion regime (one mifepristone tablet followed, three or fours days later, by one of misoprostol) used during the first nine weeks of pregnancy. Of course, early abortions caused by the morning-after pill (Levonelle One Step or Levonelle 1500 containing levonorgestrel and effective up to three days after unprotected sexual intercourse) and its more recently-introduced cousin, EllaOne (ulipristal acetate, effective for up to five days), are not counted in the official UK figures. Nobody knows how many abortions they trigger.
It has often been recommended, by among others, the National Institute for Health and Clinical Excellence (NICE) just a couple of months ago, that women keep a stash of morning-after pills (MAP), just in case. The Cochrane Database of Systematic Reviews examined data from the USA, China, India and Sweden and recently issued a report entitled, Advance Provision of Emergency Contraception for Pregnancy Prevention. It concluded that such a strategy has no effect on pregnancy rates. The researchers found that advance supplies of the MAP fail if – wait for it – women choose not to take them! And that is apparently what many women decide to do.
Abortion and Fetal Pain
In late June, the Royal College of Obstetricians and Gynaecologists (RCOG) issued two important Working Party reports – one entitled, Fetal Awareness and the other, Termination of Pregnancy for Fetal Abnormality.
The first report stated that, ‘The fetus cannot feel pain before 24 weeks because the connections in the fetal brain are not fully formed’ and thus, ‘because the 24 week-old fetus has no awareness nor can it feel pain, the use of analgesia is of no benefit.’ This conclusion flies in the face of common sense and scientific evidence, much of which has been consistently ignored by the RCOG.
The RCOG therefore concluded that it is neither necessary nor desirable to use drugs to protect the unborn child against pain when carrying out an abortion. That notwithstanding, whether an unborn child feels pain when being aborted is a side-issue. The fundamental issue remains the injustice and cruelty of the practice – administering analgesics would not alter this. However, on the basis of the precautionary principle, the RCOG might have been expected to suggest painkiller injections into the fetus. But who cares? – for many doctors, the fetus is just a disposable thing.
And what about the second report on eugenic abortion for fetal abnormality, which can be carried out up to birth, at 40 weeks. Even the RCOG would admit that pain can be felt some time post-24 weeks. So surely the RCOG would recommend analgesia for such late abortions? No, according to the RGOC, not even then. The RCOG is adamant, its report, ‘does not purport to give ethical guidance.’ Yet one of the primary functions of the medical Colleges is to establish principles and uphold professional standards among its fellows and members. Professor Allan Templeton, chairman of one of the Working Parties stated in the RCOG’s press release, ‘I believe we now have robust and updated guidance for healthcare professionals.’ Once the culture of death has entered into the hearts and minds of individuals and organizations, sub-standard ethics and practice, including grave dereliction of duty, inevitably follow.
These issues are not of concern just within the UK. This April, Nebraska became the first state in the USA to make abortion illegal after 20 weeks, precisely to spare the fetus pain and physical distress. This is alandmark challenge to one of the key tenets of Roe v. Wade, namely, the viability standard, which also holds so much sway among UK lawmakers. The current UK coalition government has no plans to change the upper limit of 24 weeks, but if there were a private members’ bill, it is understood that the Prime Minister, David Cameron, would support a modest reduction in the limit. The Deputy Prime Minister, Nick Clegg, has previously voted against any such decrease.
During June, Marie Stopes International (MSI), one of the largest providers of abortion worldwide, broadcast, for the first time in British television history, an advertisement for its abortion services, without ever mentioning the ‘A’ word. The 30-second commercial for MSI’s so-called ‘post-conception advice services’ was repeatedly broadcast on Channel 4 and it drew hundreds of complaints from outraged viewers. The deception of the advertisement, the intrusion into the nation’s living rooms, the ability of MSI as a charity to afford the commercial, the trivialisation of abortion to the level of soap and beer advertising and the targeting of the vulnerable are among the concerns that provoked the protests. Now that this TV precedent has been set – what next?
Assisted Reproductive Technologies
IVF is seemingly never out of the news. And so often the news is not good. Here are 10 such examples.
IVF in Ireland
There has been a long-running legal case in Ireland, as reported in the Update - February 2010. Mr and Mrs Roche underwent IVF treatment in 2002. One child, their second, was born as a result of this treatment, but three of their remaining embryos were frozen and stored in a Dublin fertility clinic. Not long after, the Roches separated. Against the wishes of her estranged husband, Mrs Roche wanted the embryos thawed and transferred to her womb. The legal challenges started. These covered profound questions of the extent of protection the embryos should be afforded under Article 40.3.3 of the Irish Constitution, as well as issues of the right to life, and reproductive rights stemming from IVF. The outcome has been that Mrs Roche’s request was denied. The embryos no longer have to be stored. And now the Irish Supreme Court has ordered the Attorney General to pay most of the Roches’ legal costs, estimated at more than €2.5 million. IVF is never cheap.
IVF Drugs and Supermarkets
IVF and Bodyweight
Being overweight is never good for anyone’s health. But overweight women undergoing fertility treatment double the risk of miscarriage compared with normal weight women, according to a recent study of 300 women conducted at Guy's and St Thomas' Hospital in London. Women with a body mass index (BMI) of over 25 suffered a 35% miscarriage rate.
IVF and Three-Parent Embryos
Spares can be so useful – spare tyres, spare cash, spare embryos. What? At Newcastle University
IVF and Financial Returns
It was only a matter of time before someone calculated the monetary value of IVF. The task fell to the European Society of Human Reproduction and Embryology (ESHRE) Infertility and Society Task Force. Its recent report showed that, given that it costs about €15,000 to conceive an IVF child, governments receive an eight-fold return on this investment 30 years after that child enters the workforce. The report concluded that IVF therefore makes, ‘good clinical and economic sense.’ Ah yes, the very same unethical arguments used in favour of abortion, infanticide and euthanasia.
IVF and Blunders
Nobody likes to make mistakes, but when blunders occur in IVF, the outcomes are never trivial. Yet figures from the HFEA show that the number of such mistakes in England and Wales went up from 182 in 2007-8 to 334 in 2008-9, an increase of 85%. These incidents varied from ova
IVF and Children’s Health
IVF and Ovum Raffling
IVF has always had the ability to demean and trivialise human life. In March it reached a new low with the Bridge Centre, a fertility clinic in London, raffling a human ovum. It was little more than a publicity stunt with the winner being able to pick the donor by racial background, upbringing, health, education and appearance. And the prize included £13,000 of free IVF treatment to be provided by the Bridge Centre’s new US partner, the Genetics and IVF Institute (GIVF) in Fairfax, Virginia. The Bridge Centre has since distanced itself from the idea of such a raffle or a lottery. It merely wanted to highlight, ‘the chronic shortage of donor eggs in the UK.’ Of course. And what was the runner-up’s prize?
IVF and Abortion
If either IVF or abortion can trivialise human life, then when combined the effect is overwhelming. And it happens.
IVF and Age Limits
And finally, to counter those who maintain there should be no age limit
Euthanasia and Assisted
Assisted Suicide in Switzerland
Switzerland's law on assisted suicide is certainly concise. Since 1940, it has been permitted as long as those involved are neither selfishly nor financially motivated. The Swiss believe that personal autonomy trumps any interference by the State. However, this ultra-liberal thinking may be about to change. The presence of the assisted suicide organization, Dignitas, and the unsavoury publicity created by its trade, are creating calls for greater legal controls. During the past 12 years, Dignitas has assisted more than 1,000 people to die. The fact that many of them have been foreigners, plus the fact that some have not been terminally ill, have begun to embarrass and worry the Swiss authorities.
These concerns peaked recently when dozens of urns containing human ashes were discovered in the bottom of Lake Zurich. Though it has yet to be established who dumped these urns, the finger has been pointed at Dignitas because they all bore the label of the crematorium used by that organization.
Meanwhile, the Swiss government has produced two draft papers on assisted suicide. One would ban the practice altogether. The other would limit the practice to those who are terminally ill, with a few months to live, as evidenced by two independent doctors – it is the more likely option to be adopted. In addition, patients would need to demonstrate that theirs were sustained and informed decisions. Such requirements would effectively close down the Dignitas business, because the majority of its foreign patients arrive in Switzerland, see a Dignitas doctor, and die within 24 hours. Yet herein lies the problem – once any bioethical door has been opened, shutting it, even partially, is very, very difficult.
Euthanasia and Organ Donation
Here is a pair of bioethical issues that you may not have previously conjoined – euthanasia and organ donation. Yet the two have been approvingly coupled by a couple of bioethicists from Oxford University, Julian Savulescu and Dominic Wilkinson. Their article, Should We Allow Organ Donation Euthanasia? Alternatives for Maximizing the Number and Quality of Organs for Transplantation was published in the May edition of the journal, Bioethics.
Savulescu and Wilkinson make their utterly utilitarian case thus: ‘It is permissible to withdraw life support from a patient with extremely poor prognosis, in the knowledge that this will certainly lead to their death, even if it would be possible to keep them alive for some time. It is permissible to remove their organs after they have died. But why should surgeons have to wait until the patient has died as a result of withdrawal of advanced life support or even simple life prolonging medical treatment? An alternative would be to anaesthetize the patient and remove organs, including the heart and lungs. Brain death would follow removal of the heart (call this Organ Donation Euthanasia (ODE)). The process of death would be less likely to be associated with suffering for the patient than death following withdrawal of LST [life-sustaining treatment] (which is not usually accompanied by full anaesthetic doses of drugs). If there were a careful and appropriate process for selection, no patient would die who would not otherwise have died. Organs would be more likely to be viable, since they would not have sustained a period of reduced circulation prior to retrieval. More organs would be available (for example the heart and lungs, which are currently rarely available in the setting of DCD [donation after cardiac death]). Patients and families could be reassured that their organs would be able to help other individuals as long as there were recipients available, and there were no contraindications to transplantation. This is not the case at present with DCD, since many patients do not die sufficiently quickly following withdrawal of LST for organ retrieval.’
‘If we believe that we should not remove organs from patients who are still alive, even where they have consented to this and would otherwise die anyway, then one alternative would be to euthanize the donor and retrieve organs after cardiac death had been declared. This would already be a theoretical option in countries where euthanasia is permitted. Organ donation after cardiac euthanasia has been described in a patient in Belgium. Organ donors could be given large doses of sedative, and cardioplegic agents (to stop the heart). Again, this would reduce the risk of patients suffering after withdrawal of LST and make organ donation possible for some patients who would otherwise not be able to donate. In an extreme case, they might choose to undergo euthanasia at least partly to ensure that their organs could be donated.’
So there we have it – two birds with one stone, double usefulness, euthanasia with a dual purpose, good arising from tragedy, wish fulfilment for two people. How could anyone object? Here is the test – can you argue the opposing case? One day you may have to!
Doctors and Assisted Suicide
In the wake of the publication, in February 2010, of the Director of Public Prosecutions (DPP) definitive guidelines concerning the prosecution of those involved in assisting suicide, the British Medical Association (BMA) has issued a two-page guidance for doctors facing such requests from patients.
Thankfully, it is firm and clear, as the following quotation
demonstrates: ‘The BMA advises doctors to avoid all actions that might be
interpreted as assisting, facilitating or encouraging a suicide attempt.
This means that doctors should not:
• advise patients on what constitutes a fatal dose;
• advise patients on anti-emetics in relation to a planned overdose;
• suggest the option of suicide abroad;
• write medical reports specifically to facilitate assisted suicide abroad; nor
• facilitate any other aspects of planning a suicide.’
That other doctors’ body, the General Medical Council, has also recently issued guidance urging doctors to begin discussing end-of-life care with their terminally-ill patients well in advance of their final days. With some caveats, that advice makes good sense and should enable more patients to die well.
Euthanasia and the Near Future
Despite what seems to be sustained opposition to legalising euthanasia, there is no room for complacency. We must not be lulled into believing that all is quiet on the euthanasia front. Its advocates are busy, everywhere. For example, in Germany, a landmark ruling by its Federal Court of Justice has given approval for what some call ‘passive’ euthanasia of terminally-ill patients. The Court overturned a conviction of attempted manslaughter by a lawyer, Wolfgang Putz, who advised a woman to cut the intravenous feeding tube keeping her comatose mother alive. In Belgium, a recent study has shown that during 2007, five years after the practices were legalised, euthanasia (voluntary and non-voluntary) and assisted suicide accounted for 2.0% of all deaths in Flanders, the Dutch-speaking part of that country. And the latest figures from Holland should further alarm us. During 2009, the number of reported Dutch deaths by euthanasia rose by 13% to 2,636, following an increase of 10% in 2008. These rises have led a concerned Dutch health ministry to launch an official inquiry into their euthanasia laws. Meanwhile, in the UK, pro-euthanasia groups, such as Dignity in Dying with its now claimed 25,000 supporters, are actively recruiting and planning. A apparent lull in the battle is never the time to relax.
Stem Cell Technologies
The wonders of stem cell technology, in particular those of the non-embryonic variety, continue to astound. Let the following examples amaze you.
Remember Claudia Castillo, the Spanish mother of two, who in 2008 had the remarkable world’s first operation to insert a ‘new’ trachea section built from her own stem cells? Now a 10-year-old British boy has become the first child to undergo a whole windpipe transplant constructed from his own stem cells. He was born with a condition known as Long Segment Congenital Tracheal Stenosis, resulting in a very narrow trachea. Doctors at Great Ormond Street Hospital used a donor trachea, stripped it to its collagen scaffolding, and then injected it with stem cells taken from the boy’s bone marrow – so the organ is being regenerated inside the boy’s body over the coming months. And it seems to be working.
IPS cells from Blood
In the 2 July edition of the journal Cell Stem Cell, three research groups – led by George Daley at the Harvard Medical School, Boston, Massachusetts, Rudolf Jaenisch at the Whitehead Institute for Biomedical Research, Cambridge, Massachusetts, and Keiichi Fukuda at Keio University, Tokyo, Japan – reported the production of induced pluripotent stem (IPS) cells from human blood.
Stems Cells from Amniotic Fluid
Yet another source of stem cells has been reported. Scientists at the Wake Forest Institute for Regenerative Medicine, North Carolina have discovered them in human amniotic fluid. While team leader, Anthony Atala, would not yet claim these cells were truly pluripotent, he said they were versatile and non-tumour forming when tested in animals. This latter characteristic may prove advantageous in their usefulness in clinical trials, compared with tumour-causing embryonic stem cells.
Stem Cells and the Heart
Jean-Paul Tremblay, a 59-year-old construction worker from Montreal, recently had a routine coronary artery bypass operation. But before the surgical team closed him up they added a little extra – stem cells purified from his bone marrow that they had removed from his pelvic bone earlier that day. Mr Tremblay’s condition had caused him to become weak and fatigued, but post-operatively his heart was almost normal and his health had dramatically improved. It is thought that the stem cells will work by regenerating the patient’s blood vessels and heart muscles. The task now is to assess how much of the patient’s improvement was caused by the bypass operation and how much by the added stem cells. Fascinating!
Stem Cells and the Vatican
Even the Vatican is getting involved in adult stem cell research as an alternative to the use of embryonic stem cells. In April, the Roman Catholic Church announced its backing, both ethical and financial, for the study of intestinal adult stem cells by a group of experts led by the University of Maryland School of Medicine. The aim is to examine the potential use of these cells in the treatment of intestinal diseases. A pump-priming fund of $2.7m is required – how much the Church is prepared to contribute has not yet been disclosed. Such 'money-where-your-mouth-is' support is commendable.
Synthetic Life – Hubris or Nemesis?
On 20 May, the maverick biologist and flamboyant entrepreneur J Craig Venter and his research team announced in the journal Science that they had created a world first – a synthetic life form, predictably nicknamed, Synthia. It has taken them 15 years of trying at a cost of $40m. This triumph of synthetic biology was hailed by some commentators as an achievement as profound as the production of the first atomic bomb, and as 'a defining moment in biology'. Others hailed it as the progenitor of better drugs, less thirsty crops, greener fuels, and so on. But, despite all of this media hype, all is not quite as it seemed. Sure, it was an important technological achievement, but scientists already possess the know-how to, for example, alter bacterial genes to order.
What Venter and his colleagues had actually done in this proof-of-principle study was to synthesize chemically an artificial genome, which had been computer designed, and put it in the ‘shell’ of Mycoplasma mycoides, a well-known, simple bacterium. The result was a functioning, replicating new bacterial species with no ancestors. But Venter’s ‘new species’ is not an entire, new creation, rather it merely carries a new set of artificial genes – all its other cellular components are from another bacterial strain. Artificially creating all of these other components is currently beyond the means of scientists. And anyway, DNA, genes, a genome, whether produced artificially or naturally, are not life – the latter is almost unimaginably more complex.
So what is the true significance of this work?It will undoubtedly open up new areas of discovery. Artificial genome production could lead to the generation of specific artificial cells with specific biological properties for specific biological functions. Yet some are fearful. They warn of the harmful possibilities that such new laboratory-created species could exert on currently existing forms of life. They are already calling for comprehensive regulation and vigilant monitoring to ensure the safe application of this emerging technology. Even Venter and his co-workers recognise the potential problems arising from their work – they concluded their Science report, ‘As synthetic genomic applications expand, we anticipate that this work will continue to raise philosophical issues that have broad societal and ethical implications. We encourage the continued discourse.’ So, whatever the future, be it hubris or nemesis, synthetic biology has arrived and we must face the novel bioethical issues it raises.