Update on Life Issues - June 2016

Abortion
Abortion statistics – England and Wales 2015
The annual abortion statistics, for 2015, were published by the Department of Health on 17 May.  The details can be read at https://www.gov.uk/government/statistics/report-on-abortion-statistics-in-england-and-wales-for-2015

These figures are always bad, but this year they are worse than bad – many of the key data have increased.  The total number of abortions performed in England and Wales last year was 191,014.  The number for residents was 185,824.  Both these figures show an increase over those of 2014.  This 0.7% increase may be small, but it represents some 1,000 unborn children.  Similarly, the 2015 rate of abortion has increased from 15.9 to 16.0 per 1,000 resident women aged 15 to 44.  Any such increases are wrong directional trends.

Looking at abortions for resident women, 98% were funded by the NHS and 68% took place in the independent sector clinics, like bpas and Marie Stopes, under NHS contract – these were up 1% from the previous year.  In terms of timing, 92% of abortions were carried out at under 13 weeks gestation, while 80% were at under 10 weeks, the same as in 2014.  Medical, as opposed to surgical, abortions continued to be more common and accounted for 55% of the total.  This proportion has more than doubled in the last 10 years.

Ground C, the so-called ‘social’ ground, abortions accounted for 181,231 or 98% of the total.  Ground E abortions (risk that the child would be born ‘seriously handicapped’) numbered 3,213 and represented 2% of the total.  These latter abortions showed an increase over the 2014 figure of 3,099.  This represents a 3.7% increase on 2014 and it reflects the less than compassionate view we have of the disabled.

One decrease - teenage abortion continued to fall with a total of 26,162 performed for girls aged under 15 to 19 years old.  This compares with 27,455 for 2014.  In 2015, there were 509 abortions among the under 15s and 79 for the under 14s.

Two of the notable trends in recent years have been the number of repeat abortions and the number of older women having abortions.  Both these rose again in 2015.  A total of 70,295 women had a repeat abortion and 322 had their fifth termination.  And 29,471 women aged 35 or over had abortions – up from 28,129 in 2014.

The total number of abortions performed during 2015 in Great Britain – England, Wales and Scotland (see below) – was well in excess of 200,000.  To be precise, it was 191,014 + 12,082 = 203,096.
Abortion statistics – Scotland 2015
The relevant statistics for Scotland can be found at http://www.isdscotland.org/Health-Topics/Sexual-Health/Abortions/

A total of 12,082 pregnancies were terminated in Scotland during 2015, up by 306 from the previous year.  This total represents an increase for the first time in three years.  The overall rate of abortion in Scotland was 11.6 for every 1,000 women aged 15 to 44, whereas south of the border it was 16.0 per 1,000.

 As in the English and Welsh data, this Scottish rate continued to decline in women under 20 years old, but increased among older women, particularly those aged 35 to 39 years.  The number of girls under 16 having terminations fell to its lowest figure over the past 10 years, from 364 in 2006 to just 136 in 2015.  Among women aged 35 to 39 it increased by almost 200 in just one year.

Inquiry into Freedom of Conscience in Abortion Provision

On 14 June, the All Party Pro-Life Parliamentary Group, led by Fiona Bruce MP, launched a Parliamentary Inquiry into freedom of conscience in abortion provision.

 

Section 4 of the Abortion Act 1967 specifically states that, ‘... no person shall be under any duty, whether by contract or by any statutory or other legal requirement, to participate in any treatment authorised by this Act to which he has a conscientious objection.’  The Inquiry will examine whether this so-called conscience clause continues to provide adequate protection for healthcare professionals who do not wish to be involved, directly or indirectly, in the provision of abortion.

 

The Inquiry is running only for a short period – the deadline for submissions is 11 July 2016.  Anyone can make a submission by completing an online form, by emailing, or in writing.  More information is available at www.conscienceinquiry.uk

 
Abortion (Disability Equality) Bill [HL] 2016-17
On 25 May, the Conservative peer, Lord Shinkwin, who is himself disabled, introduced the first reading of his private member’s bill – 'A Bill to make provision for disability equality in respect of abortions.'  It would outlaw abortion on the grounds of disability by repealing ground E of the 1967 Abortion Act.  The second reading has yet to be scheduled.

We Trust Women and the RCM
We Trust Women is the name of a campaign launched on 9 February by The British Pregnancy Advisory Service (bpas), the UK’s largest abortion provider.  Its aim is to scrap the ‘cruel archaic’ abortion laws that ‘prevent women from making decisions about their own bodies.’

The campaign’s primary targets are Sections 58 and 59 of the 1861 Offences against the Person Act, which still applies and still criminalises abortion – a woman can still be sentenced to life imprisonment for terminating her pregnancy.  The 1967 Abortion Act only gave doctors a legal defence for performing abortions under certain conditions.  We Trust Women wants to decriminalise all abortion – up to birth, for any reason.  It wants abortion to be treated like any other medical procedure (even though it isn’t).

The campaign is supported by a number of diverse organisations, such as Women’s Aid, Lawyers for Choice, The Fawcett Society, Birthrights, Voice for Choice, The British Humanist Association and the Southall Black Sisters.  But most disturbingly by The Royal College of Midwives (RCM), which represents almost 30,000 midwives and healthcare workers in the UK.

On 6 May, the RCM issued a position statement explicitly supporting the aims of this campaign as well as the limitation of conscience rights for midwives, and the extension of the 1967 Abortion Act to Northern Ireland.  This most extraordinary situation can partly be explained by the fact that the RCM's Chief Executive, professor Cathy Warwick, is also the head of the bpas’ Board of Trustees.

The RCM’s stance has not gone unchallenged.  An online letter, entitled Not in Our Name, is addressed to the Board of the RCM.  It states, inter alia, ‘We work to help not only women but their babies also throughout pregnancy and in childbirth.  For the organisation that represents us to support the radical position (supported by only a small minority of women) that all protections for unborn children should be removed right through to birth, and without any consultation of us members, we find utterly unacceptable.’  And, ‘We ask that the Board revoke the College’s support for this agenda, and begin to consult the membership as to the membership's views on this controversial issue.  Only when this has happened can the College develop a position that truly represents the views of its members, one which we believe can better reflect the views of British women and safeguard not only their welfare but that of their children.’  On 16 May, the RCM responded on its website, ‘Contrary to the distorted and sensationalist accounts touted by certain newspapers and lobbyists, the reality is …’  And in conclusion, ‘The RCM believes that if we are to be advocates for women then we must advocate for choice on all aspects of their care. This is not about being for or against abortion; it is about being for women and respecting their choices about their bodies.’  Meanwhile, there have been numerous calls for Cathy Warwick to do the decent thing and resign from either the RCM or bpas, or both.

The hope is that all decent midwives will sign this online letter (at the time of writing, about 800 midwives and 42,000 members of the public have) and that an honourable MP will ask the Secretary of State for Health what discussions he has had, or will have, with the RCM and bpas.  ‘Conflict of interest’ and ‘abuse of power’ are two issues that require clarification.  And perhaps all concerned should remind themselves that the RCM’s motto has been, since its founding in 1881, ‘Vita Donum Dei’ meaning ‘Life is the Gift of God’.

Teenage pregnancies – UK and US figures
The Office for National Statistics has recent reported that teenage pregnancies in the UK have fallen to their lowest level since records began.  The 2014 conception rate for 15 to 17 year-olds was 22.9 pregnancies per 1,000 girls.  At its peak in 1998, it reached 47.1 per 1,000.  And the reductions are continuing, year-on-year.  A total of 22,653 girls aged under 18 became pregnant in 2014.  This represents a decrease of 6.8 % compared with the figure of 24,306 for 2013.

Something similar is happening in the USA where the teen birth-rate is at a record all-time low.  A recent report, published by the US Centers for Disease Control and Prevention, shows that during the last 25 years, the teen birth-rate has fallen from 62 births for every 1,000 teenage women to 24 per 1,000. 

What has caused these reductions?  First, the figures are not equivalent, nor are they straightforward.  The UK data record conceptions – about half of these are ended by abortion.  By contrast, the US data record births.  Moreover, the UK data do not take account of conceptions begun, but ended early by, for example, the morning-after pill (MAP), which is being used increasingly.

The US figures have been explained by increases in teen pregnancy prevention efforts that are operating at the community level, such as schools' sex education programmes.  In addition, there are reports of declines in sexual activity among teens, as well as increases in the use of the most effective contraceptive methods available.

Similar reasons probably play out in the UK too.  But there are other, more surprising, possible causes.  Nowadays, UK teenagers are spending more time in their bedrooms on social networking sites, like Facebook, Instagram and Snapchat.  Therefore, apparently, they spend less time meeting up, getting drunk, doing drugs and having sex.  Last year, Ofcom reported that 16 to 24-year-olds in the UK spent more than 27 hours a week on the internet.  In the US, a report published in 2015 by Common Sense Media found that teenagers spent 9 hours a day on media technologies – that is more than they typically sleep.  Also perhaps teenage attitudes are changing away from young motherhood, recognising the dignity of human intimacy, delaying sexual intercourse, even the value of early human life.  Is that too optimistic?

But I still think that the MAP is playing a major and unrecorded part here.  Every year 600,000 MAPs are supplied to UK women.  It is estimated that 1 in every 9 women under the age of 30 has used the MAP at some time.  That figure increases to 1 in 5 among sexually-active teenage girls. 

Abortion worldwide
A recent study in The Lancet, published online on 11 May and entitled, ‘Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends’, estimates that there are now 56 million abortions performed every year worldwide.  That figure suggests that one in every four pregnancies is ended by abortion.

The study comes from the World Health Organisation and the famously pro-abortion Guttmacher Institute, based in New York, which was once the research arm of Planned Parenthood.  Those researchers make several observations.  For instance, they say that the global abortion rate is actually declining.  Worldwide, the abortion rate is now 35 per 1,000 women aged from 15 to 44 years.  This is down from 40 per 1,000 during the 1990s.  Moreover, the authors claim that pro-life laws do not reduce abortion numbers because the decline is not even – it is more pronounced in the developed world where abortion is legal, in contrast to the developing world where abortion is often illegal.  The authors conclude, not surprisingly, that, ‘Ensuring access to sexual and reproductive health care could help millions of women avoid unintended pregnancies and ensure access to safe abortion.’

Pro-life experts dispute some of these findings.  For instance, the availability of abortifacients, like the morning-after pill (MAP), which can cause early abortions, are not included in any official figures.  Moreover, merely improving access to contraceptives in a one-size-fits-all approach is not the answer.  And because women commonly have health concerns and a dislike of the side-effects of many contraceptives, there is a need for more ethical methods of birth control and a more woman-centred approach to these issues.

Abortion in China
According to a new US study the number of abortions performed in China each year is far higher than its government has reported.  In addition, forced abortions and sterilisations continue to rise.

China’s National Health Population and Family Planning Commission claims that the country aborts 13 million unborn children annually.  However, according to the 2015 edition of the US State Department’s Country Reports on Human Rights Practices, released in April, that figure is a gross underestimate.  It stated that, ‘an official news media outlet also reported at least an additional 10 million chemically-induced abortions were performed in non-government facilities.’  The Chinese annual total is therefore more like 23 million.  Part of the discrepancy is the Chinese government’s failure to count medical abortions as well as those performed in facilities not registered with the government.

If 23 million is the true figure, then that is abortion on an industrial scale.  Do the maths – it is 43 unborn lives terminated every minute of every day.  China has deep, deep problems.  But she is not alone.

Abortion thinking in the USA
Every year the Gallup pollsters publish results on so-called American ‘values and beliefs’.  Abortion is one of the issues included.  Last month it was announced that 47% of respondents rated abortion as ‘morally wrong’, while 43% said it was ‘morally acceptable’.  A further 9% thought it depended on the situation and 2% had no opinion.  This anti-abortion vote is up from 45% in 2015.  It is not the first time that self-styled opponents of abortion have outnumbered its advocates, but it is satisfying to see that the US population is still basically pro-life.


Gene editing
Editing the human embryo
The world’s first gene-editing experiment using human embryos was carried out by a team led by Junjiu Huang at Sun Yat-sen University in Guangzhou, China.  The group used CRISPR-Cas9 to modify the gene responsible for β-thalassaemia, a potentially fatal blood disorder.  Their results were published in April 2015 edition of the online journal Protein & Cell under the title, ‘CRISPR/Cas9-mediated gene editing in human tripronuclear zygotes.’

The second attempt, published in April 2016, also came from China.  It appeared in the Journal of Assisted Reproduction and Genetics by the stem-cell scientist Yong Fan and colleagues at the Guangzhou Medical University.  The paper was entitled, ‘Introducing precise genetic modifications into human 3PN embryos by CRISPR/Cas-mediated genome editing.’  They collected a total of 213 human embryos, donated by 87 IVF patients.  These embryos were reported to be unsuitable for implantation because they contained an extra set of chromosomes – they were destroyed three days after the experiment.  Fan’s team used CRISPR–Cas9 editing to introduce into some of the embryos a mutated gene known as CCR5Δ32.  Some humans naturally carry this mutation and they are resistant to HIV, because the mutation prevents the rogue virus from entering the human T-cells of the immune system.

Both of these Chinese gene-editing trials used embryos that had been rejected by IVF clinics because they contained an extra set of chromosomes.  It is therefore far from clear if the results from either of these studies are relevant to healthy human embryos.  Moreover, Fan et al., reported that, ‘In the embryos containing the engineered CCR5Δ32 allele, however, the other alleles at the same locus could not be fully controlled because they either remained wild type or contained indel mutations.’  In other words, technical difficulties abounded.  Genetic analysis showed that only 4 of 26 human embryos targeted were successfully modified.  And not all the embryos’ chromosomes contained the CCR5Δ32 mutation – some contained unmodified CCR5 and others had acquired different mutations.

Fan et al., defended the necessity of their so-called proof-of-principle experiments.  Others criticised them for ‘just playing with human embryos’.  Yet the Chinese group recognised the serious implications and limitations of their sort of work because their paper concluded, ‘We advocate preventing any application of genome editing on the human germline until after a rigorous and thorough evaluation and discussion are undertaken by the global research and ethics communities.’

Nevertheless, subsequent experiments are already being devised, if not already completed, in China and elsewhere.  For example, at the Karolinska Institute in Stockholm, Fredrik Lanner is preparing to edit genes in human embryos.  Lanner thinks that the passage of time and a lengthy ethical discussion – neither of which has conspicuously occurred – have blunted the controversial nature of such research.  He may be right or it may be his wishful thinking – the line between hype and hope can be so very narrow.

Meanwhile in Britain, during February 2016, Dr Kathy Niakan of the Francis Crick Institute in London was given the green light by the HFEA to modify human embryos by CRISPR-Cas9 gene-editing technology – the first in the UK.  At the beginning of May, her team began preparatory work on the programme following its approval by the Cambridge Central Research Ethics Committee.  However, the start of the trial may be delayed for several months because of difficulties in obtaining a sufficient number of human embryos to be donated by consenting patients undergoing IVF.

Every new and ground-breaking biological technique gives rise to early bioethical anxieties.  Yet, as time passes, acceptance and then permissiveness typically win the day.  As Schaeffer and Koop wrote in 1979 within the context of abortion, infanticide and euthanasia, ‘Practices once labelled unthinkable are now considered acceptable.’  Nothing in the realm of human genetic engineering has the huge potential to change the human race, and thus holds the power for good or for evil, as CRISPR.  How will we use and abuse it?

Using and abusing CRISPR
There is as yet no global consensus on the potential uses and abuses of CRISPR technologies.  On 28 and 29 April, two conferences were held in Paris, one organised by European and the other by US scientists.  They were attended by the world’s leading figures in stem-cell research and ethics to discuss human gene-editing research.  Some of their key conclusions were as follows.  While most countries prohibit germline gene editing, it is certainly not ready for clinical application in humans.  Basic research should therefore continue.  The UK is still the only country to permit mitochondrial replacement techniques (MRT) and Niakan’s human embryo work (see above), which will result in germline alterations.  Neither the US nor China consider it prudent to approve MRT technology at this time.  There is no consensus on the status of the human embryo.  There is a consensus that public discussion of gene-editing technologies are urgently needed with the hope that ‘broad, informed consent’ can be obtained before any clinical application of gene editing in humans begins.

This is all very laudable.  But not every country was present at these conferences, and consensus is not necessarily unanimity, and there are always rogue scientists who will ignore or stretch agreed boundaries.  I wish I were more optimistic, but I have lived through the debates which set legal limits on abortion, human embryo experimentation, and so on.  They all became plastic and elastic.

The view from the USA
A recent article entitled ‘The Public and the Gene-Editing Revolution’ by Robert J Blendon et al., was published in The New England Journal of Medicine (2016, 374: 1406-1411).  It analysed 17 opinion polls to gauge the US public’s attitude to gene therapy and gene editing.  To cut a long story short, it stated that, ‘Most of the public favors [sic] gene therapy for clinical use in patients with serious diseases.  The majority do not support gene editing in human embryos or germline cells, but the level of opposition varies depending on its goals.’  And with respect to the latter, ‘A majority of Americans approve of gene editing aimed at preventing one’s children from inheriting certain diseases.’  On the contrary, ‘… they do not approve of using gene editing to improve the intelligence or the physical traits or appearance that one’s child would inherit.’  But as the authors noted, ‘Of course, public opinion could change over time as discussions of these issues continue to evolve and as more is learned about the implications and safety of gene-editing technologies.’

CRISPR obviously makes ‘designer babies’ thinkable, if not yet possible.  For the moment, a bioethical restraint exists.  If, and when, such experimentation proceeds and goes wrong, scientists will be highly vulnerable, though not, of course, as vulnerable as the unborn child.  Such a fear of public scorn may, at least for the time being, act as an effective deterrent against rash and illicit science.
Assisted Reproductive Technologies
The 14-day rule challenged
It was always bound to happen – everyone knows that laws and boundaries are there to be broken and breached.  I wrote in my 2014 book, Bioethical Issues (p. 114), ‘And will there be calls for the fourteen-day rule to be extended?’  And so it has come to pass, the 14-day rule, recommended in the UK by the Warnock Committee in 1984 and enshrined in law by the 1990 Human Fertilisation and Embryology Act, is now under threat.

The Warnock Committee, having decided that human embryos could be the subject of research, were faced with defining how long they could be experimented upon.  It plumped for 14 days.  It was always a daft and arbitrary limit, but it satisfied the general public that something was being monitored and forbidden.  Indeed, the Warnock Report stated (section 11.19), ‘… some precise decision must be taken in order to allay public anxiety.’

And so the 14-day rule, signalled by the appearance of the inconsequential ‘primitive streak’, was hailed as a brilliant and progressive regulatory decree – in truth, it was an intellectually indefensible tenet.  In at least 12 countries, this limit has been enshrined in law, and in 5 other jurisdictions it occurs in guidelines that govern embryo research.  And for years it has remained unthreatened.  Human embryos have previously been grown in vitro for typically 7 days, 9 at the most.  Until that is, the recent simultaneous publication of work by UK and US scientists in Nature and Nature New Biology.  They managed to grow human embryos in vitro for up to 13 days after fertilisation, which is well beyond the time of about 7 days for implantation to begin in the womb, in vivo.

The two innocuously-titled publications from the Cambridge and Rockefeller Universities are Deglincerti, A., et al., (2016), 'Self-organization of the in vitro attached human embryo.'  Nature 533: 251–254.  And, Shahbazi, M.N., et al., (2016), 'Self-organization of the human embryo in the absence of maternal tissues.'  Nature Cell Biology, doi:10.1038/ncb3347.

The work is the result of developing growth conditions that mimic the womb in which surplus embryos, donated by couples undergoing IVF, could be successfully cultured for an extended period.  The scientists reckon it will improve our understanding of implantation biology and thus improve the success of IVF techniques.

Professor Magdalena Zernicka-Goetz, a senior author on both papers and head of the Mammalian Embryo and Stem Cell Group, University of Cambridge, stated that, ‘Implantation is a milestone in human development as it is from this stage onwards that the embryo really begins to take shape and the overall body plans are decided.  It is also the stage of pregnancy at which many developmental defects can become acquired.  But until now, it has been impossible to study this in human embryos.  This new technique provides us with a unique opportunity to get a deeper understanding of our own development during these crucial stages and help us understand what happens, for example, during miscarriage.’

This is interesting.  Now, implantation, rather than the primitive streak, has become the touchstone, the centre of interest, of early human development.  And of course, to attract public approval, any such basic research must have an associated human interest story – in this case, it is determining the causes of infertility and miscarriage, plus improving embryonic stem-cell technologies.  This is what is called consequentialism.

So, because what was previously technologically impossible has now become feasible, the call has gone out – we need augmentation, we need more than 14 days.  John Harris, the doyen of utilitarian bioethics from the University of Manchester, jumped in early with this, ‘The overwhelming consensus of scientific opinion, as of this week, is that much of considerable scientific and therapeutic importance can be learned by extending the 14-day limit for a further week, to 21 days…’  A group of US bioethicists more circumspectly stated, ‘Now that the culturing of human embryos beyond 14 days seems feasible, more clarity as to how the rule applies to different types of embryo research in different jurisdictions is crucial.  Moreover, in light of the evolving science and its potential benefits, it is important that regulators and concerned citizens reflect on the nature of the restriction and re-evaluate its pros and cons.’  The Nuffield Council on Bioethics announced that it will hold a colloquium later this year to consider a change in the law.  The US National Catholic Bioethics Center offered a different possibility by suggesting that because the 14-day rule was flawed to begin with and that it paid only ‘lip service to the moral status of the human embryo’, the cut-off point should be fertilisation.

The suggested range of options is broad – from fertilisation to when the embryo develops into a foetus and can experience pain, exhibit brain activity or survive outside the womb.  In effect, they call for a ban through to a bonanza.  According to many legislators, neither of these extremes will make for good public policy in our pluralistic societies.  Even so, deep and worrying shifts in what is permissible research have occurred recently with, for example, the UK government’s 2008 approval of the production of human-admixed embryos.  Or, in 2015, its permission for the clinical use of mitochondrial-replacement therapies and their germline changes to future generations.  Or again, in February 2016, its authorisation to edit the genome of human embryos using CRISPR technology.

The case for extending the 14-day rule was deftly explained in a recent editorial by three US bioethicists in Nature (533: 169–171).  They wrote, ‘… when they [regulations, like the 14-day rule] are understood to be tools designed to strike a balance between enabling research and maintaining public trust, it becomes clear that, as circumstances and attitudes evolve, limits can be legitimately recalibrated.’  Though, of course, ‘Any formal changes to this rule should occur through similar processes of consensus-building involving experts, policymakers, patients and concerned citizens.’

Oh dear, we are in for protracted debates, consultations, lobbying and balloting.  But, as I started this piece with the truism that, ‘everyone knows that laws and boundaries are there to be broken and breached.’  So, will there now be a new 21-day rule by 2020?  And a 45-day rule by 2030?

Embryo heal thyself
Now here is a curious tale.  It was published in the March 2016 edition of Nature Communications (doi:10.1038/ncomms11165) under the title, ‘Mouse model of chromosome mosaicism reveals lineage-specific depletion of aneuploid cells and normal developmental potential.’  It comes from the group at Cambridge led by Magdalena Zernicka-Goetz (see above).

The article reported that, ‘Live-embryo imaging and single-cell tracking in chimeric embryos, containing aneuploid and euploid cells, reveal that the fate of aneuploid cells depends on lineage: aneuploid cells in the fetal lineage are eliminated by apoptosis, whereas those in the placental lineage show severe proliferative defects.  Overall, the proportion of aneuploid cells is progressively depleted from the blastocyst stage onwards.  Finally, we show that mosaic embryos have full developmental potential, provided they contain sufficient euploid cells, a finding of significance for the assessment of embryo vitality in the clinic.’

Now for the translation from the Scientese.  The researchers used the drug reversine, which disrupts normal cell division and induces the condition known as aneuploidy, so that cells contain an abnormal number of chromosomes.  They then created mosaic embryos at the eight-cell stage.  These contained two populations of cells - half had the normal number of chromosomes, while the other half had an abnormal number.  The cells were tagged with fluorescent dye and time-lapse imaging was used to track the fate of each cell for 48 hours.  The scientists found a reduction in the number of daughter cells derived from the abnormal cells.

How to explain this phenomenon?  Further experiments showed that the abnormal cells had a significantly higher rate of apoptosis, or programmed cell death, a process that occurs naturally to eliminate harmful or damaged cells.  These mosaic mouse embryos were then transferred to surrogate mothers and allowed to develop to full term.  Thirteen of the twenty-six embryos transferred resulted in live pups, which remained healthy four months after birth.

In other words, the very early embryo has the ability to repair itself by getting rid of abnormal cells.  At least, in mice.  Does the same restorative process occur in human embryos?  As Zernicka-Goetz stated, ‘We found that even when half of the cells in the early stage embryo are abnormal, the embryo can fully repair itself.  It will mean that even when early indications suggest a child might have a birth defect because there are some, but importantly not all abnormal cells in its embryonic body, this isn’t necessarily the case.’

Does this have implications for IVF and pre-implantation diagnosis (PGD) of human embryos?  Yes, it does.  These results do not contest amniocentesis, which can detect genetic abnormalities at between 14 and 20 weeks of a pregnancy.  But they may have important implications for testing done much earlier.   PGD is performed on embryos that are only a few days old.  In the test, a single cell is removed – without damaging the embryo – and that cell is tested for chromosomal defects.  Based on this present study, a positive PGD test may be misleading if that abnormal cell was destined to be eliminated from the embryo.

Professor Magdalena Zernicka-Goetz, the study’s senior author, was inspired to carry out this research following her own experience when pregnant with her second child at the age of 44.  A chorion villus sampling (CVS) test, undertaken at about 12 weeks of her pregnancy, found that as many as a quarter of the cells in her placenta were abnormal.  Could her developing baby also have abnormal cells?  She spoke to geneticists about the potential implications and found that very little was known about the fate of embryos containing abnormal cells.  Hence her work, at least initially, with mouse embryos.  Her son, Simon, was born healthy.

The latest figures from the HFEA
In March 2016, the HFEA published its latest Report, Fertility Treatment in 2014 - Trends and Figures.  The data may seem to be out-dated because they refer to 2014 and 2013 – but think about it, IVF conducted in 2013 produced babies mostly born in 2014, and then allow for some late returns from clinics, plus some sluggish bureaucracy and publishing capabilities by the HFEA, and there you have it – the 2013-14 data are hot.

The raw numbers are these.  During 2014, a total of 52,288 women had 67,708 cycles of IVF in 82 clinics – the cycles represent a near 5% increase from 2013.  In addition, 2,511 women had a total of 4,675 cycles of donor insemination (DI) in 85 clinics – a 1% cycle increase over the previous year.  The success rates of IVF rose slightly to 26.5% in 2013 from 25.9% the year before.  The multiple birth rate – that most medically-dangerous aspect of IVF for both mothers and babies – dropped from one in four IVF births in 2008 to one in six in 2013.  And IVF has become a huge medical business – if the cost of an average treatment cycle is reckoned to be £4,000 then in 2014, the industry was worth at least £270 million.

For the first time this Report included information on ova freezing.  Although the number of women freezing their ova has risen from just 59 in 2005 to 816 in 2014, the number of ova being thawed and then used in IVF treatments is still very low.  In 2013, only 102 of the total 65,000 IVF cycles performed used previously frozen ova and the approximate success rate was only 14%.  These figures run counter to the commonly-held idea that career-minded women can, even should, postpone child-bearing by freezing their ova.  The strategy appears to be numerically small and also numerically unsuccessful.  The message is clear – women should not regard ova freezing as a guarantee of a future pregnancy.

The HFEA’s silver anniversary
Anyone who has dipped into this website or my books over the last 15 or so years will be well aware how I have repeatedly railed against the HFEA.  This is principally for two reasons – first, for its lack of bioethical backbone and second, for its bureaucratic incompetence.

Nevertheless, it is true that the HFEA has now lasted for 25 years – it was set up in 1991 as a result of the 1990 Human Fertilisation and Embryology Act.  Yet, even a cursory reading of previous articles on this website will expose the numerous corporate failings and abject incompetence of the HFEA to fulfil its remit, manage its staff, control the clinics, publish transparent data, protect IVF patients, refuse any research licences, and much more besides.  Indeed, the HFEA has long been a somewhat toothless regulator, a paper tiger.

Nevertheless, Sally Cheshire, chairwoman of the HFEA, welcomed the recent Report (Fertility Treatment in 2014 - Trends and Figures, see above) as a sign that the UK’s fertility sector is in very good shape.  Looking back over 25 years of regulation of the sector, she wrote, ‘When the HFEA first started, 25 years ago, the success rate from IVF was around 15% and the multiple birth rates were very high, at 28%.  As treatments and practices have improved, the birth rate has almost doubled and multiple births are down by a half.  This shows that clinical progress and the dedication of professional staff, in a well-regulated sector, significantly improves patient care and outcomes.’  She also stated, ‘As the UK’s dedicated fertility regulator for 25 years, our goal is to ensure every patient gets the best possible care, and the positive story this Report tells is that fertility patients have never had a better chance of having a family in a safe setting.  This is testament to the professionalism and expertise of the staff in fertility clinics.’

Not all of us agree with her breezy assessment.  For example, last year, the most senior family judge in England and Wales, Justice James Munby, castigated the HFEA and several IVF clinics for their ‘widespread incompetence across the sector’ and the ‘alarming and shocking’ failures that left dozens of couples who had a child through artificial insemination by donor (AID) in doubt about whether the child legally belonged to both of them.

Another fierce critic has been Lord Robert Winston – a man with whom I rarely agree bioethically.  He argues that the HFEA has not always had a ‘positive story’ to tell.  He has frequently castigated it.  For example, in his 2006 book, A Child Against All Odds, Winston has a few pages (pp. 197-202) of diatribe which begins, ‘…while the establishment of the HFEA produced minor benefits, there is little evidence that British citizens are better off as a result of its existence.  The only exception to this is the practice of multiple embryo transfer has been largely curtailed in Britain.’  And he continues, ‘But the clinical results of IVF in Britain are certainly no better than in most other western countries and there is little evidence that IVF patients here are less exploited than elsewhere.’  Moreover, Winston maintains that, ‘Although members of the HFEA sometimes boast that our legislation – and our regulatory body – is the envy of the world, it is clear that the deficiencies in the British system are so great that very few advanced countries (with the exception of Canada) have copied it.’  And he continues in a similarly disparaging vein for several more paragraphs.

Whatever the HFEA’s failings, big and small, there is one colossus that cannot be ignored.  The HFEA has not, and never has had, a consistent and robust bioethical foundation.  It rarely, if ever, says, ‘No’.  It has permitted and presided over the deliberate destruction of hundreds of thousands of human embryos in the name of infertility treatment and research.  It may see itself as a shining example of an innovative, progressive organisation, but it was born morally broken and has never recovered.  I cannot wish it a happy 25th birthday.

Another new IVF technique
It is called next-generation sequencing (NGS).  And it is hailed as a cheap technology that will improve the success rate for thousands of women on conventional IVF.  There is talk that pregnancy rates among women in their mid-thirties could be boosted from about 25% to almost 80%.  Yes, we know hype when we hear it.

NGS allows embryologists to select the embryos that have the greatest likelihood of growing into healthy babies.  About half of all IVF embryos contain the wrong number of chromosomes – so even if they result in pregnancies, there will often be severe complications.  Chromosomal counting, a form of pre-implantation genetic diagnosis (PGD), already exists, but it is expensive, making the cost of an enhanced IVF cycle as much as £9,000.  Hence only about 1 in 2,500 women undergoing IVF currently use it.  NGS would be considerably cheaper, perhaps adding between £2,000 and £3,500 to standard IVF fees, roughly halving the cost of PGD.

The world’s first NGS baby was born in the USA in 2013.  The method has been introduced and pioneered in the UK at the Oxford Fertility clinic.  The first UK child, named Biagio, as a result of NSG treatment was born in January 2016 to Ewa Wybacz and her husband Sergio Russu.  She had been told, because of earlier illnesses, that she would never conceive.  Doctors fertilised about 15 of her ova, 10 survived, 7 were discarded, 3 were selected, 2 were frozen and 1 transferred.  Nine months later Biagio Russu was born.

Of course, this is no more than new generation eugenics – picking the most genetically good-looking, the one most likely to succeed.  But this is not really new.  Embryologists, given a choice will always select subjectively, by eye, which embryos look the most attractive.  NGS makes this process less subjective, more scientific.  But if you use science to control and ensure that the best of genes are handed down to the next generation, that’s eugenics.

How old is too old?
What is the best age for a woman to have a baby?  Conventional wisdom reckons it to be about 26 years old.  When is it too old?  Most would say mid-40s – after all, women become menopausal for a reason.  It is therefore no surprise that a worldwide gasp was caused by an Indian couple, well into their 70s, who recently had a baby boy by IVF.  To say it’s unnatural is an understatement.

In April, Daljinder Kaur, thought to be 72-years-old, gave birth to a 2 kg, apparently healthy, baby boy, named Arman Singh, following two years of treatment at the rogue National Fertility and Test Tube Baby Centre at Hishar in the Indian north-western state of Haryana.  Donor ova had been used.  She and her 79-year-old husband, Mohinder Singh Gill, said they had almost given up attempting to raise a family.

Most fertility specialists believe it was unethical and reckless to provide such an elderly woman with IVF treatment.  Typical of the protesting outcry was that of Hrishikesh D Pai, the former president of the Indian Society of Assisted Reproduction.  He said, ‘It is outrageous.  It is inappropriate to do it and it is not in the best interests of the parents or the unborn child to do it.’

There is a well-known lack of regulation of assisted reproductive technologies throughout India.  Some seven years ago guidelines were drawn up, but the government has consistently failed to implement them.

IVF guidelines vary from country to country.  In the UK, NICE (the National Institute for Health and Care Excellence) recommends that NHS clinics should not provide IVF to women over the age of 43.  Similar age limits exist in other European countries.  However, treatment in private UK clinics is not bound by such a limit.  For instance, in March 2016, 55-year-old Sharon Cutts gave birth to triplets at the Jessop Hospital in Nottingham after fertility treatment had failed in London but was successful at a clinic in Cyprus.  At the other extreme, IVF in the USA is virtually unregulated.  There, it is largely governed by doctors’ ethical stance and what is medically feasible.

Yet post-menopausal IVF creates all sorts of additional bioethical dilemmas.  It renders IVF even more unnatural.  Whatever the stresses and strains, both biological and psychological, for this particular elderly Indian couple, the fact is that their child will probably soon be an orphan.  When asked if it would be difficult to bring up a child at her ripe old age, Daljinder Kaur reportedly said, ‘That thought never crossed my mind.  God will take care of everything.’  That is not a Christian sentiment, it is wishful thinking.

IVF for the elderly in China
As a result of the Chinese government’s recent abandonment of its one-child policy, scores of older couples are turning to IVF in a desperate bid to have a second child.

Demand for IVF at major clinics in Beijing and Shanghai has increased dramatically.  According to Dr Liu Jiaen, who runs a private hospital in Beijing, ‘More and more women are coming to ask to have their second child.’  He estimated that the numbers of women contacting him for IVF had risen by 20% since the relaxation of the policy, at the start of the year.  Before, the average age of his patients was about 35.  Now most of them are older than 40 and some of the women are fast approaching 50.

There are also reports that increasing numbers of Chinese couples are heading overseas for IVF treatment.  In certain other countries it is typically cheaper and can also give parents the option of choosing the gender of their child, whereas sex-selective IVF is prohibited in China.  Apparently, the number of IVF tourism agencies in China has increased from 5 in 2013 to over 50 in 2016.

Another knotty case of IVF
A 60-year-old UK woman wants to use her late daughter's frozen ova to give birth to her own grandchild.  She wants to take the ova to a New York clinic to be fertilised with donor sperm and any subsequent embryos to be transferred to her.

In 2014, the HFEA refused to release the ova from storage (OK, so the HFEA sometimes says, ‘No’).  Last year the mother contested this decision in the High Court, lost, but was granted leave to appeal.  Now the case is being heard at the Court of Appeal in London, before a panel of three judges.

The sticking point is simple.  The HFEA says that full written consent is required before the ova can be released.  The woman says that her daughter, who died five years ago from bowel cancer at the age of 28, had verbally endorsed the plan.  If the HFEA eventually gives permission, it is thought that the mother could become the first person in the world to become pregnant using a dead daughter's ova.  Knotty or what?

‘Three-person’ IVF - not so simple or safe?
In February 2015, the UK government lifted a ban on the controversial technique known as mitochondrial replacement therapy (MRT), or ‘three-parent’ IVF.  It aims to prevent mothers from passing on harmful genes to children through their mitochondria.  The HFEA has yet to green-light the procedure for clinical use – it wants further evidence of MRT’s safety.

Meanwhile, Dieter Egli, a stem-cell scientist at the New York Stem Cell Foundation Research Institute has raised serious reservations about the technique.  His group’s experiments have been published in Cell Stem Cell (2016, 18: 749–754) under the title of ‘Genetic drift can compromise mitochondrial replacement by nuclear transfer in human oocytes.’  They have shown that if a small number of mutant mitochondria are carried over and retained after the transfer of the maternal nucleus into the donor ovum, which is apparently a common occurrence, they can sometimes outcompete healthy mitochondria in the ‘new’ embryo.  In other words, the carried over mitochondria could potentially cause the disease the therapy was designed to avoid.

However, in early June, a paper by Louise Hyslop and colleagues from the Wellcome Trust Centre for Mitochondrial Research, Newcastle and entitled, ‘Towards clinical application of pronuclear transfer to prevent mitochondrial DNA disease’ was published in Nature (2016, doi:10.1038/nature18303).  The team reported the first preclinical studies on pronuclear transplantation (PNT).  Problems with normally-fertilised ova led them to develop an alternative approach based on transplanting pronuclei, shortly after completion of meiosis, that is, on the same day as fertilisation, rather than shortly before the first mitotic division.  They created these IVF embryos using some 500 ova from 64 donors – a huge number of gametes from a large cohort of women.  This new procedure, called ‘early pronuclear transfer’, promoted, ‘… efficient development to the blastocyst stage with no detectable effect on aneuploidy or gene expression’ – that is, embryos from the new technique appeared to be no different from those generated by conventional IVF.  After optimisation of the procedure, mitochondrial DNA (mtDNA) carryover was reduced to <2% in the majority (79%) of PNT blastocysts.  In other words, embryo development was not adversely affected and the amount of faulty mitochondria being passed was significantly reduced.

The research team concluded that, ‘… PNT has the potential to reduce the risk of mtDNA disease, but it may not guarantee prevention.’  The team leader, Doug Turnbull stated, ‘… we have found no evidence the technique is unsafe.’  But is ‘not unsafe’ the same a ‘safe’?  Whether these results will satisfy the demands of the HFEA that ‘three-parent’ IVF is sufficiently safe before any clinical trials can commence, we shall wait to see.  If approved, then the Newcastle team will be able to apply for a licence to offer the procedure to women, with the expectation that babies could be born in 2017.

On the other hand, is pursuing PNT really sensible?  What about using the more specific gene editing techniques?  In April 2015, researchers at the Salk Institute for Biological Studies in La Jolla, California reported (Cell, 2015, 161: 459–469) success using gene-editing technology in preventing mitochondrial diseases being passed from female mice to their offspring.  Could this be the answer for humans too?  Bioethically, the whole area is a mess.  Alternatively, adoption is a wonderful way to start a family if a couple considers themselves to be genetically at risk.

Arise Sir Douglass Turnbull
In the recent Queen’s Birthday Honours List among the Knights Bachelors was, ‘Professor Douglass Matthew Turnbull, Professor of Neurology, Newcastle University, services to Health Care Research and Treatment particularly Mitochondrial Disease.’  Need I say more?
Stem-Cell Technologies
Regulating stem-cell technologies
Should stem-cell research and its application be a global free-for-all?  On 12 May, the International Society for Stem Cell Research (ISSCR) issued updated and extended guidelines for such work – Guidelines for Stem Cell Research and Clinical Translation.  These new guidelines provide a model of self-regulation, which many consider to be a better form of regulation than a collection of diverse national laws.

The new ISSCR guidelines assert that any attempt to modify the nuclear genome of human embryos for the purpose of human reproduction should be prohibited at this time.  They do, however, endorse continued laboratory-based research on human embryos and the derivation of stem-cell lines from them.  That is disappointing.

One of the ISSCR’s key proposals is that all proposed manipulations of human embryos, including gene-editing and mitochondrial replacement therapy (MRT or ‘three-parent’ IVF), should now undergo similar reviews to those that use embryos to create stem-cell lines.  All such research should be added to the remit of existing embryonic stem-cell research oversight (ESCRO) committees.  The ISSCR also took the opportunity to insist that researchers should not overstate the clinical implications of their stem-cell experiments – I’ll vote for such anti-hyperbole.

Tight regulation of such controversial areas of biological advancement is always welcome.  But these ISSCR guidelines appear to be pretty liberal, and they are guidelines, not rules with any legal sanctions.  How do you restrain the maverick?  If I knew that, the courts would be virtually empty.

Treating MS with stem cells
Multiple sclerosis (MS) is an autoimmune disease that affects the central nervous system.  Around 2.5 million people worldwide and 100,000 in the UK suffer from MS.  It is apparently close to being cured – what a remarkable claim.  It comes after results from a pioneering treatment at the University of Ottawa were published.  Patients were first subjected to aggressive chemotherapy, which destroyed, rather than just suppressed, their immune systems.  Second, the latter were ‘reset’ using stem cells previously harvested from the patient’s own bone marrow.  Some have defined this novel practice as, ‘We kill you and then we rescue you.’

Of the 24 patients treated, aged between 18 and 50, one died because of a shutdown immune system, 70% experienced an end to relapses and the disease’s progression, and 40% had their condition effectively suppressed.  The follow-up period averaged 6.5 years.

Now the downside – this study involved small numbers, its aggressive chemotherapy is hazardous, and it is not a cure for MS.  But the results, for a disease with very limited treatment options, are impressive.  Moreover, it is relatively simple – chemotherapy plus autologous haematopoietic stem-cell transplantation (aHSCT) are both tried and tested techniques.

One of the patients was Jennifer Molson.  She was diagnosed with aggressive MS in 1996 at the age of 21.  Her treatment began in 2002.  She has said, ‘Before my transplant I was unable to walk or work and was living in assisted care at the Ottawa hospital rehabilitation centre.  Now I am able to walk independently, live in my own home and work full time.  I was also able to get married, walk down the aisle with my dad and dance with my husband.  I’ve even gone downhill skiing.  Thanks to this research I have been given a second chance at life.’

This promising research was published online (9 June 2016) in The Lancet by Harold Atkins et al., and under the title, ‘Immunoablation and autologous haemopoietic stem-cell transplantation for aggressive multiple sclerosis: a multicentre single-group phase 2 trial.’

Treating cataracts with stem cells
Currently, the only treatment for cataracts, the leading cause of blindness worldwide, is to extract the affected lens and implant an artificial intraocular lens.  Lin and colleagues from China and the USA have reported a novel method (Nature, 2016, 17: 323-328).  They isolated lens epithelial stem/progenitor cells (LECs) from rabbits, monkeys and human infants and discovered two genes, Pax6 and Bmi1, which are essential for LEC renewal.

They designed a surgical technique, which preserved the epithelial stem cells, which in turn allowed the regeneration of the lens, which restored visual function.  When the team used their new minimally-invasive technique on 12 infants (aged 0–24 months; 24 eyes) they reported lens regeneration within three months of surgery and by eight months, the regrown lens was described as being ‘comparable to a native lens.’

One of the lead researchers, Kang Zhang, professor of ophthalmology and chief of Ophthalmic Genetics at University of California, San Diego, stated, ‘We believe that our new approach will result in a paradigm shift in cataract surgery and may offer patients a safer and better treatment option in the future.’  Another triumph for adult stem-cell technology?

Corneal tissue from iPS cells
Kohji Nishida of Osaka University in Japan and colleagues reported (Nature, 2016, 531: 376–380) the growth of eye-like structures in laboratory dishes using induced pluripotent stem cells (iPS cells) derived from human cells.  The researchers called these self-formed ectodermal autonomous multi-zone (SEAM) of ocular cells.  These proto-eyes grew in a target-like pattern with each ring of the target containing cells that correspond to a different layer of the eye – the ocular surface ectoderm, lens, neuro-retina and retinal pigment epithelium.  Then the scientists isolated cells that could grow into corneal epithelial cells, the outer layer of the eye.  When transplanted to the eyes of rabbits with experimentally-induced corneal damage, the human cells repaired the wounds and recovered visual function in these corneally-blinded animals.

Is there no end to the potential and effectiveness of non-embryonic stem-cell treatments?  Will the success of iPS-cell treatments create a new and burgeoning speciality within regenerative medicine?
Euthanasia and Assisted Suicide
Assisted suicide in Oregon
In 1997, the people of Oregon voted to introduce the world’s first assisted suicide legislation, the Death with Dignity Act (DWDA).  In February 2016, the Oregon Health Authority published its annual Report, referring to 2015 data.

According to the Report, ‘During 2015, 218 people received prescriptions for lethal medications under the provisions of the Oregon DWDA, compared to 155 during 2014.  As of January 27, 2016, the Oregon Public Health Division had received reports of 132 people who had died during 2015 from ingesting the medications prescribed under DWDA.  Since the law was passed in 1997, a total of 1,545 people have had prescriptions written under the DWDA, and 991 patients have died from ingesting the medications.’

Commenting on the Oregon Report, the UK’s Dignity in Dying organisation stated, ‘… there have been no cases of abuse and no widening of the law’s eligibility criteria.  The fears expressed by opponents to a change in the law in this country are the same ones expressed in Oregon in 1997.  Data published last week confirms what we already knew – that none of these fears have been realised.’

Others disagree that all is so tickety-boo.  For example, Oregon relies almost exclusively on doctors self-reporting such assisted deaths.  Moreover, Oregon bureaucrats have no budget or legal authority to conduct independent investigations if they obtain information of ‘abuses’.  The Report implies that these deaths were voluntary, but it does not address this subject.  And for those who think that because these deaths account for only 0.39% of the total deaths in Oregon, they should consider, for example, California – the Golden State recently legalised assisted suicide and it has a population ten times greater than Oregon.  Simple maths would suggest that California could therefore experience 1,300 extra suicides per year.

And why do mainly white, single, well-educated, elderly Oregonians wish for assisted suicide?  Uncontrolled pain is often thought to be the principal reason, but few mentioned it.  The three main reasons given were ‘less able to engage in activities making life enjoyable’ (96%); ‘losing autonomy’ (92%); and ‘loss of dignity’ (75%).  ‘Inadequate pain control or concern about it’ was mentioned by just 29%.

Whatever the bioethical arguments surrounding assisted suicide, the Oregon statistics are increasing year-on-year.  Legalise anything, whether abortion or a speed limit, and a growing proportion of the population will push the boundaries, extend them and eventually break them – it is called human nature.  We hate laws because deep-down we are natural rebels.

Assisted suicide in Canada
In February 2015, the Canadian Supreme Court declared that denying patients access to assisted suicide and voluntary euthanasia is a violation of their human rights.  The various jurisdictions within Canada were given a year – until 6 February 2016 – to pass legislation consistent with this decision.  The federal government requested a six-month extension but the Supreme Court gave it just four months, until 6 June.

On 14 April 2016, the Canadian government tabled a new draft law, Bill C-14, to decriminalise euthanasia and doctor-assisted suicide.  It will amend the nation’s criminal code to exempt ‘medical assistance in dying’ from prosecution.  The proposed new law will apply only to mentally-competent adults with a ‘grievous and irremediable’ medical condition, and only where a natural death has become ‘reasonably foreseeable’.

On 4 May, Bill C-14 resoundingly passed its second reading by 235 to 75 votes in the House of Commons after the government passed a ‘guillotine’ motion to close debate on the draft legislation after only two-and-a-half days.  The debate was rushed and many members were exasperated.  And on 17 June, Senators voted 44 to 28 to accept the final version of Bill C-14.  During that afternoon, the Bill received the formality of royal assent from the governor-general - it thus became Canadian law.  The new legislation revises the Criminal Code to exempt healthcare practitioners who provide, or help to provide, medical assistance in dying from otherwise applicable criminal offences.

We have been here before, many times.  In January 2015, the UK House of Commons debated that most controversial issue of ‘three-parent’ IVF, which would permit germline genetic modification.  The debate was given just 90 minutes!  It was an hour and a half that changed the world.  ‘Act in haste, repent at leisure’ has seemingly little traction among politicians.

Moreover, Canada, like every other country that passes such ground-breaking legislation, will soon be faced with a dilemma.  Drafting a law that is both watertight and benign – writing down on a piece of paper the strict conditions of eligibility, while also protecting the vulnerable – is an impossible task.  Every authority knows that.  Furthermore, Canada also faces a bioethical paradox.  As the US lawyer and bioethicist, Wesley J Smith, has commented, ‘Canada is implacably against the death penalty.  Yet it will soon embrace a regime of wild, wide-open euthanasia imposed on the nation by its Supreme Court.  Killing murderers bad, killing the sick, disabled, mentally ill, and depressed, who have not been given suicide prevention, good.’

Euthanasia and assisted suicide in the Netherlands
Euthanasia statistics for 2015 have recently been released in the Netherlands.  The total was 5,561.  This represents an increase of 4% compared with 2014 and a 50% increase over the last 5 years.  The rise is mainly due to euthanasia being implemented for demented elderly people, as well as psychiatric patients.  The inclusion of these two new categories raises even more bioethical questions than ‘ordinary’ euthanasia for those with ‘unbearable suffering with no prospect of improvement.’

In 2015, 109 demented persons (81 in 2014) were killed even though they were sufficiently ‘mentally competent’ to express their own will.  Another 56 patients with psychiatric disorders (41 in 2014) were put to death at their own request.

Euthanasia and assisted suicide in Belgium
Like the Netherlands, Belgium is incessantly pressing to expand the criteria and scope of euthanasia.  Laurette Onkelinx, the leader of the Belgian Socialists and a former Deputy Prime Minister, has recently proposed three such innovative bills.

The first bill would remove a five-year sunset clause for advance declaration of a patient’s willingness to undergo euthanasia.  Thus a document written 20 or 30 years before would still be considered valid, no matter if patients had subsequently changed their minds.  The second bill would force doctors to give a rapid turnaround to requests for euthanasia.  They would have to answer within seven days.  If they refused, they would have to transfer the patient’s file to a doctor who would be willing to give a lethal injection.  If enacted, the physician’s right to conscientious objection to euthanasia would be removed.  The third bill would remove the right of institutions, like hospitals or nursing homes, to refuse to allow euthanasia on their premises.

In March, a spanner was thrown into this Belgian drive for euthanasia.  Dr Catherine Fonck, a Member of Parliament and a renal physician, asked a pertinent question of the Belgian Health Minister, Maggie De Block.  Why, she enquired, has the full text of the country’s euthanasia law never been published?

The answer given displays a mixture of indifference and incompetence.  It turns out that the original text of 2002 was amended in 2005 with the intention of improving the control of the lethal drugs used in euthanasia.  Both chambers of Parliament agreed that extensive information about the drugs and the pharmacist should be included in the official report submitted by the attending physician.  The amendment received royal assent.  It was therefore the law of the Kingdom of Belgium.

But it was never published in the Moniteur Belge (the Belgian official gazette) of 13 December 2005, so no one knew about it.  Corrections were published in the gazette of 25 September 2006, but the amendment did not appear there, either.  Why not?  Is Belgian euthanasia legislation regarded as trivial?  Because the practice is so successfully steaming ahead, does it really matter that such legislative loose ends are not tied up?  The irritated Health Minister agreed to correct the Moniteur Belge.

Assisted suicide in Switzerland
Meanwhile assisted suicide in Switzerland is also surging ahead.  In 2015, at the Exit ‘clinic’ alone, in the Germanic part of Switzerland, there were 782 assisted suicide deaths, up from 583 in 2014.  Of the deceased, 55% were women and 45% men.  Besides EXIT, the other main assisted suicide ‘clinics’ in Switzerland are those of Dignitas and the Eternal Spirit.  In 2014, the total number of such deaths from all these Swiss facilities was reported to be around 836.  These data indicate that there was a 34% increase for 2015 compared with 2014.

The BMA and assisted suicide
On 21 June, at the Annual Representatives' Meeting of the British Medical Association (BMA) held in Belfast, delegates voted against changing its opposition to assisted suicide.  Motion 80 stated, ‘That this meeting believes that the BMA should adopt a neutral stance on assisted dying.’  It was rejected by 198 votes to 115.

Dr Mark Porter, the chairman of BMA Council, noted that the debate marked the eighth time in 13 years that the BMA had considered the matter, and stated that, ‘Nobody can credibly say this issue has been suppressed or obfuscated.’  This significant vote by doctors, and that of the Marris Bill in the House of Commons last year, when the proposal to legalise assisted suicide was heavily defeated by 330 votes to 118, should settle the issue in the UK for the foreseeable future.

Assisted Dying Bill [HL] 2016-17
In view of the previous item, it is surprising that Lord Hayward has introduced this new Bill in the House of Lords.  In summary it is, ‘A Bill to enable competent adults who are terminally ill to be provided at their request with specified assistance to end their own life; and for connected purposes.’  It had its first reading on 9 June.  It is similar to the Marris Bill.  It deserves to be similarly defeated.
USA and Elsewhere
Will it be Trump or Clinton?
One Republican governor called Donald Trump, ‘an egomaniac who has no principles.’  Hillary Clinton is regarded by many as, ‘out-of-touch, greedy and even corrupt.’  What a choice the American people face as they vote on Tuesday 8 November for their new President.  Does it matter?  Yes.  Does it matter bioethically?  Yes.  For a start, few conservative bioethicists will mourn the departure of Barack Obama from the White House.  He has turned out to be the most anti-life, pro-abortion President ever.

But what about the incomers?  Clinton is easy to read.  She is undeniably a progressive liberal.  A vocal supporter of a woman’s right to choose and a staunch backer of Planned Parenthood, the leading abortion organisation in the US.  Trump is harder to read.  As a business man he has no particular political record by which to judge him.  He is also something of a slyboots.  One day he is pro-life, the next day he is a fan of Planned Parenthood.  Let the people decide!

Antonin Scalia (1936 – 2016)
One of the first duties of the incoming President will be the appointment of a new judge to the Supreme Court.  This is occasioned by the death on 13 February of Antonin Gregory Scalia, at the age of 79, while on vacation in Texas.  He had nine children.

Scalia was renowned for his legal mind and for his adherence to the US Constitution.  His rulings were consistently in opposition to recognising a Constitutional right to the abortion of the unborn child.  His death leaves the Supreme Court with eight members and more significantly in a 4 – 4 balance on the abortion and other key bioethical issues.  President Obama has vowed to appoint a judge of his choice before he leaves office.  Such an appointee would almost certainly tilt the Court’s balance in favour of abortion for several years to come.

The Planned Parenthood saga
Like all sagas, it plods on and on.  It started in July 2015, when the Center for Medical Progress released undercover videos of Planned Parenthood officials evidently offering to sell tissue samples from aborted foetuses.  A Congressional panel was set up to investigate the foetal tissue research company StemExpress, which was implicated in the illegal trafficking.  In June 2016, the panel found that StemExpress and its transacting abortion clinics had violated federal patient privacy and informed consent regulations. 

The chairwoman of that panel, Marsha Blackburn, said, ‘The contract [between StemExpress and the clinics] changes the way both entities view the young woman: her baby is now a profit-center.  This betrayal of a young woman’s trust should disgust us all.  It takes financial advantage, obtains consent through coercion, and deceives the woman, all in violation of federal privacy laws.’

In the meantime, Planned Parenthood is also under fire from different quarters.  For example, Kansas has voted to defund Planned Parenthood permanently.  In May, a bill to prevent the abortion provider from accessing the state revenue stream was passed by both houses, 87 to 34 in the House of Representatives and 32 to 8 in the Senate.  The Kansas state Governor, Sam Brownback, a pro-life Republican, is expected to sign the measure soon.  See, the saga rolls on.

Personhood voting in the US
In April, the Alabama House of Representatives’ Health Committee approved a proposed constitutional amendment declaring that ‘life begins at conception’.  The personhood bill’s sponsor, Ed Henry, said that the measure is not a direct attack on abortion, but it would establish that abortion conflicts with the state’s values, and its purpose was to give voters the ability to establish the position that life begins at conception.  If approved by three-fifths of the members of both the state’s House and Senate, this personhood amendment would then go before Alabaman voters in November.  Of course, implementation of such a piece of legislation would have widespread consequences for abortion, some contraceptives, IVF, and so on.

Also in April, a committee in the Missouri House of Representatives approved its own personhood constitutional amendment.  That amendment would establish the right to life for ‘unborn human children at every stage of biological development.’  Such personhood legislation has previously been introduced in other states, such as Colorado, North Dakota and Mississippi, but has fallen at voter referendums.

In early June, the governor of Oklahoma, Mary Fallin, signed a pro-life bill that will teach the general public and students that ‘abortion kills a living human being’.  It is called the Humanity of the Unborn Child Act and it requires the state health department to develop a new public information campaign about the developmental stages of the foetus and alternatives to abortion.

Abortion in Poland
While most of the Western world has been legalising abortion for the last several decades, two exceptions stand out.  They are Ireland and Poland.  Abortion in Poland was widespread for four decades during the Communist era.  Since 1993, it has been more restrictive.  It is available only in cases of grave foetal defect, rape or incest, or serious threat to the life of the mother.

Now Poland’s the new majority party, Prawo i Sprawiedliwość (Law and Justice), has responded to a grass-roots campaign and is moving to make abortion even more restrictive.  Doctors who perform an abortion could be punished with up to five years imprisonment.  The only exception would be the ‘unintended’ death of a foetus while saving a woman’s life.  The response of Polish abortion activists has been apoplectic.  Poland’s politicians are under immense pressure from all sides.

As one of the new provision’s most prominent supporters and a well-known lawyer, Jerzy Kwaśniewski, has declared, ‘The state has the duty to protect the life of all.  It also has the duty to help families with sick and handicapped children.  It also has the duty to give real help to raped women, not to give them all a ‘quick fix’ in the form of 1,300 zł (£230) for an abortion in a public hospital.’

Morning-after pills, far and wide
A new phone app, which delivers the morning-after pill (MAP) within 24 hours to anywhere in the world, including the gates of the Glastonbury Festival, has been launched.  It is called Doctor Care Anywhere.  This subscription-based delivery service costs £20 every month and gives users access to a UK-trained doctor 365 days a year between the hours of 08.00 and 22.00.  Predictably, a spokeswoman for bpas said, ‘Any service where women can get emergency contraception in a timely manner has to be a positive thing.’

Sexual health experts in the UK have warned of the dangers of obtaining the MAP from foreign sources on the internet.  Apparently it is being sold illegally on eBay for just £5.  The MAP is available in the UK only from GPs, sexual health clinics, pharmacists or a few internet chemists.  But all these sources involve some form of medical consultation – eBay purchases would obviate this hurdle.  I searched on eBay for the MAP, but to no avail.  However, second on the list was my booklet, The Morning-After Pill, published by the Christian Institute!

In late May, the French Health Minister, Marisol Touraine, announced that from now on it will be easier for students to get access to the MAP in schools.  France has scrapped the previous criterion of demonstrable ‘emergency and distress’ before girls could be issued with the MAP.  This, according to M. Touraine, will make it quicker and easier for pupils to get their hands on the MAP from the school nurse.  She said, ‘All students should know that the door to the school nurse is open at all times, and that they don't need to have any kind of justification for entering.’

Meanwhile in Poland, there is currently just one form of MAP available without a prescription for women 15 and over.  It became available over the counter early last year, following a decision by the European Commission to authorise its prescription-free sale.  However, the Polish health ministry now wants to reinstate the prescription requirement in the coming months.  Opponents have labelled this move, ‘politically and ideologically motivated.’  Yes, of course, it is.  Do they consider we live in a morally-neutral universe?  Do they consider that dishing out MAPs to schoolgirls is not ‘politically and ideologically motivated’?

In mid-May, New Jersey Senator, Cory Booker, introduced The Access to Birth Control Act into the Senate.  This bill would impose huge fines on pharmacists who refuse to dispense the MAP, known in the US as Plan B and Ella.  It would therefore remove conscience protections for pharmacists.  The text specifically states that the Religious Freedom Restoration Act would no longer apply.  A pharmacist may only refuse to fill a prescription based on his ‘professional clinical judgment’, not on any personal or religious conviction.  According to the bill, violators will be fined up to $1,000 a day, or up to $100,000 ‘for all violations adjudicated in a single proceeding’.
Miscellaneous

We all know it is a mad, mad world out there.  Yet the world of bioethics can sometimes outplay almost every other avenue of human endeavour.  Here are just three examples of such bioethical craziness.  And remember most of these researchers get paid for being daft.

Reversing brain death
Despite all the doubters, an Indian company, working with a US biotech enterprise, has obtained a green light from the US clinical trials authority to test a protocol for reversing brain death.  Dr Ira Pastor, the CEO of the American biologics company, Bioquark Inc, believes that this could be a breakthrough technology.  He regards it as ‘another step towards the eventual reversal of death in our lifetime.’  The Reanima Project has received approval to experiment on 20 subjects diagnosed with brain death at the Anupam Hospital in Rudrapur, a small city about 250 km east of New Delhi.

Yes, it is true.  The US National Institutes of Health website states, ‘This is the proof of concept study with multi-modality approach (using intra-thecal bioactive peptides, stem cells, laser and transcranial IV laser and Median Nerve stimulation as adjuvants) in cases of brain death due to traumatic brain injury having diffuse axonal injury to document possibility of reversal of brain death (BD).’

I am not sure when, or how, participants will be recruited for this study.  I will not be applying and I suggest you do not either.

Rights for bees and ants
Peter Singer is at it again.  He is the Australian bioethicist, domiciled in the US as the Ira W. DeCamp Professor of Bioethics at Princeton University.  His 1975 book Animal Liberation: A New Ethics for Our Treatment of Animals, helped inspire the animal liberation movement.  He is also famous for supporting infanticide in his notoriously shocking 1985 book, co-authored with Helga Kuhse, Should the Baby Live? in which he recommended that after birth a disabled baby should be subjected to a 28-day period of treatment non-intervention before a verdict of life or death is pronounced.

Anyway, Singer now has found a new field to plough.  He is considering a charter for insect rights that might include a ban on killing honeybees and a call for the use of repellents, rather than insecticides, on ants.  He defends this folly by saying, ‘Scientists and philosophers have argued that insect consciousness needs to be taken seriously.  Although their brains are different from ours, there are parallel aspects and they may be conscious, sentient creatures … which could affect our actions with regard to them.’  You should now feel mildly flabbergasted.

Loss of virginity is genetic
Many people who lose their virginity in their early teens blame it on social and environmental factors – stupidity, drunkenness, bad company, fecklessness, partying, peer pressure, and so on.  According to some researchers, based mainly in Cambridge, Boston and Reykjavik, they should not be so hard on themselves.  Why?  Because biological factors, particularly genes, are also to blame for early virginity loss.  The relevant article by Felix Day and colleagues is entitled, ‘Physical and neurobehavioral determinants of reproductive onset and success’ (Nature Genetics, 2016, 48: 617-623).

These researchers analysed data from three different databases – the British Biobank with more than 120,000 male and female participants, Iceland's population-wide genetic database of 241,000 people and the US Women's Genome Health Study in which 21,000 women participated.  They reported that the age of first sexual intercourse was related to 38 different genes.  These genes included not only puberty-associated genes, but also genes that contribute to the natural differences of each person's personality traits.  In particular, they considered that genes responsible for risk-taking tendencies play a significant part in having sexual intercourse at a young age.

This is hokum.  It is also called determinism, the root of that lamest of excuses, ‘My genes made me do it.’  This cannot be correct.  Indeed, if it were true, it would run counter to the rugged insistence of the Bible’s teaching that each human being is a free moral agent, responsible before God for his or her own actions, thoughts, affections and intentions (Romans 3:19; 8:5–8; Ephesians 2:3; 4:17–19).  If you lose your virginity prematurely, you, yourself – head, heart, body, mind and soul – allowed it.  With notable exceptions, such as rape and incest, everybody chooses when.  Yes, they really do.  And yes, you did too!
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