Bioethics for Scientists Edited by John Bryant, Linda Baggott la Velle and John Searle Copyright 2002 John

n Wiley & Sons Ltd ISBNs: 0-471-49532-8 (Hardback); 0-470-84659-3 (Electronic)

Bioethics for Scientists

Bioethics for Scientists Edited by John Bryant, Linda Baggott la Velle and John Searle Copyright 2002 John Wiley & Sons Ltd ISBNs: 0-471-49532-8 (Hardback); 0-470-84659-3 (Electronic)

Bioethics for Scientists

Edited by

Professor JOHN BRYANT

School of Biological Sciences, University of Exeter, Exeter, UK

Dr LINDA BAGGOTT LA VELLE

Graduate School of Education, University of Bristol, Bristol, UK

Revd Dr JOHN SEARLE

Exeter & District Hospice, Exeter, UK

Copyright 2002

John Wiley & Sons, Ltd., Bans Lane, Chichester, West Sussex PO19 1UD, England Phone (+44) 1243 779777

Email (for orders and customer service enquiries): [email protected] Visit our Home Page on www.wiley.co.uk or www.wiley.com All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning or otherwise, except under the terms of the Copyright, Designs and Patents Act 1988 or under the terms of a licence issued by the Copyright Licensing Agency Ltd, 90 Tottenham Court Road, London W1P 0LP, UK, without the permission in writing of the publisher. Requests to the Publisher should be addressed to the Permissions Department, John Wiley & Sons, Ltd., Bans Lane, Chichester, West Sussex PO19 1UD, England, or emailed to [email protected], or faxed to (+44) 1243 770571. Other Wiley Editorial Oces John Wiley & Sons, Inc., 605 Third Avenue, New York, NY 101580012, USA Jossey-Bass, 989 Market Street, San Francisco, CA 94103-1741, USA Wiley-VCH Verlag GmbH, Pappelallee 3, D-69469 Weinheim, Germany John Wiley & Sons Australia, Ltd., 33 Park Road, Milton, Queensland 4064, Australia John Wiley & Sons (Asia) Pte Ltd., 2 Clementi Loop 02-01, Jin Xing Distripark, Singapore 129809 John Wiley & Sons (Canada), Ltd., 22 Worcester Road, Etobicoke, Ontario, Canada M9W 1L1

British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 0 471 49532 8 Typeset in 10/12 pt Times by Vision Typesetting, Manchester Printed and bound in Great Britain by Biddles Ltd., Guildford and Kings Lynn This book is printed on acid-free paper responsibly manufactured from sustainable forestry in which at least two trees are planted for each one used for paper production.

Bioethics for Scientists Edited by John Bryant, Linda Baggott la Velle and John Searle Copyright 2002 John Wiley & Sons Ltd ISBNs: 0-471-49532-8 (Hardback); 0-470-84659-3 (Electronic)

Contents

List of Contributors vii Preface ix Part I Setting the Scene 1 1 Introduction to Ethics and Bioethics 3 Michael J. Reiss (London) 2 The Public Evaluation of Science and Technology 19 Barry Barnes (Exeter) Part II Ethics and the Natural World 37

3 Introduction to Environmental Ethics 39 Christopher Southgate (Exeter) 4 The Use of the Rainforest as a Test Case in Environmental Ethics 57 Christopher Southgate (Exeter) 5 Environmental Ethics: Further Case-Studies 73 Christopher Southgate and Alex Aylward (Exeter) 6 Human Use of Non-Human Animals: a Biologists View 85 David de Pomerai (Nottingham) 7 Human Use of Non-Human Animals: a Philosophers Perspective 101 R.G.Frey (Bowling Green) Part III Ethical Issues in Agriculture and Food Production 113

8 GM Crops and Food: a Scientic Perspective 115 Steve Hughes and John Bryant (Exeter) 9 Questioning GM Foods 141 Sue Mayer (GeneWatch, UK) 10 The Patenting of Genes for Agricultural Biotechnology 153 Steve Hughes (Exeter)

vi

CONTENTS

11 Crop Biotechnology and Developing Countries 171 Geeta Bharathan, (State University of New York, Stony Brook), Shanti Chandrashekaran (Indian Agricultural Research Institute, New Delhi), Tony May (Kingston, UK) and John Bryant (Exeter) Part IV Ethical Issues in Biomedical Science 199 12 Starting Human Life: the New Reproductive Technologies 201 Linda Baggott la Velle (Bristol) 13 Genetic Information: Use and Abuse 233 Bartha Maria Knoppers (Montreal) 14 Human Genetics and Genetic Enhancement 241 Peter Turnpenny and John Bryant (Exeter) 15 Patenting Human Genes: Ethical and Policy Issues 265 Audrey R. Chapman (Washington DC) 16 Cloning of Animals and Humans 279 Harry Grin (Roslin Institute, Edinburgh) 17 Dealing with Death: Euthanasia and Related Issues 297 John Searle (Exeter) 18 Animal Experimentation in Biomedical Research 313 Linda Baggott la Velle (Bristol) Glossary 331 Index 337

Bioethics for Scientists Edited by John Bryant, Linda Baggott la Velle and John Searle Copyright 2002 John Wiley & Sons Ltd ISBNs: 0-471-49532-8 (Hardback); 0-470-84659-3 (Electronic)

List of Contributors

Mr Alex Aylward, 64 Waterside, Haven Road, Exeter EX2 8DP, UK [email protected] Phone 01392 496392 Dr Linda Baggott la Velle, Graduate School of Education, University of Bristol, 35 Berkeley Square, Clifton, Bristol BS8 1JA, UK [email protected] Phone 0117 928 7012 Fax 0117 928 7110 Professor Barry Barnes, Department of Sociology, University of Exeter, Exeter EX4 4QJ, UK [email protected] Phone 01392 263279 Fax 01392 263285 Dr Geeta Bharathan, Department of Ecology and Evolution, State University of New York, Stony Brook, NY 11794-5245, USA [email protected] Phone 00-1-631-632-9508 Fax 00-1-631-632-7626 Professor John Bryant, School of Biological Sciences, University of Exeter, Exeter EX4 4QG, UK [email protected] Phone 01392 264608 Fax 01392 264668 Dr Shanti Chandrashekaran, Division of Genetics, Indian Agricultural Research Institute, New Delhi 110012, India [email protected] Revd Dr Audrey R. Chapman, American Association for the Advancement of Science, 1200 New York Avenue NW, Washington, DC 20005, USA [email protected] Phone 00-1-202-326-6795 Fax 00-1-202-289-4950 Professor R.G. Frey, Department of Philosophy, Bowling Green State University, Bowling Green, OH 43403, USA [email protected] Phone 00-1-419-372-2117 Fax 00-1-419-372-8191 Dr Harry Grin, Roslin Institute, Roslin BioCentre, Midlothian, EH25 9PS, UK [email protected] Phone 0131 527 4478 Fax 0131 527 4309

viii

LIST OF CONTRIBUTORS

Professor Stephen Hughes, School of Biological Sciences, University of Exeter, Exeter EX4 4QG, UK [email protected] Phone 01392 263776 Fax 01392 264668 Professor Bartha Maria Knoppers, Centre de Recherche en Droit Public, Universite de Montre al, Montre al, Que bec, H3C 3J7, Canada Phone 00-1-514-343-6714 Fax 00-1-514-343-2122 Mr Tony May, 100 Rhodrons Avenue, Chessington, Surrey KT9 1AZ, UK [email protected] Phone 0181 544 3430 Dr Sue Mayer, GeneWatch UK, The Mill House, Manchester Road, Tideswell, Derbyshire SK17 8LN, UK [email protected] Phone 01298 871898 Fax 01298 872531 Revd Dr David de Pomerai, School of Life Sciences, University of Nottingham, University Park, Nottingham NG7 7RD, UK [email protected] Revd Professor Michael J. Reiss, University of London Institute of Education, 20 Bedford Way, London WC1H 0AL, UK [email protected] Revd Dr John Searle, Exeter and District Hospice, Dryden Road, Exeter EX2 5JJ, UK [email protected] Phone 01392 432153 Dr Christopher Southgate, Department of Theology, University of Exeter, Exeter EX4 4QJ, UK [email protected] Dr Peter Turnpenny, Department of Clinical Genetics, Royal Devon and Exeter Hospital, Exeter, EX2 5DW, UK [email protected]

Bioethics for Scientists Edited by John Bryant, Linda Baggott la Velle and John Searle Copyright 2002 John Wiley & Sons Ltd ISBNs: 0-471-49532-8 (Hardback); 0-470-84659-3 (Electronic)

Preface

We can trace the origins of this book back to two sources. The rst of these is the place of science and technology within wider society. Science is not value free and we take issue with those who claim that it is so. Almost every new development in biomedical science has social and/or ethical implications. Furthermore, professionals in all elds, including science, are being reminded increasingly frequently of their responsibilities, not just within their own profession but to the wider community. Those responsibilities certainly include professional codes of practice but should also embody an appropriate concern for the way that society makes use of, for example, scientic discoveries and inventions. Scientists need to be able to enter the ethical debate: too much of the debate, especially in the media, is conducted with little scientic understanding. Scientists who recognise and understand the ethical dimension can make a major contribution. Increasing numbers of science (and especially, but not exclusively, biomedical science) students are recognising this and are thus eager to participate in courses that enable them to apply ethical principles to problems and situations arising within their academic disciplines. This introduces the second source of the book. It has grown out of our work over the last 30 years: teaching undergraduates and postgraduates, involvement in adult education at dierent levels and engaging with high school students and other young people. Further, our particular areas of activity molecular biology (JAB), human embryology and fertilisation (LBL), intensive care and palliative medicine (JFS) have led to our grappling with the implications of the rapid developments in science and medicine for individuals and for society. Complex questions have arisen about how these developments should be used; about whether or not particular courses of action are right or wrong; what is the balance between benet and harm of developments and treatments? Our thinking has often been claried as we have debated these issues with colleagues in Exeter from a wide range of disciplines, some of whom have contributed to this book. Not only have those colleagues contributed to this book but they also contribute to courses at Exeter for BSc, BSc(Ed) and MSc students. Indeed, it was the establishment of our teaching programme that actually led to the conuence of the two streams in the books history. Courses were started partly because of a growing interest amongst students and partly because of our professional concerns and interests. Our teaching activities led us to realise that there was no single text that would help, for example, an undergraduate biologist or a student

PREFACE

teacher who wished to become informed about a wide range of issues in what we call Bioethics. In the USA, the term Bioethics has, until very recently, meant Medical Ethics. In the UK the word has always had a wider meaning but the subject has been the preserve of ethicists and philosophers. Worthwhile and relevant as those disciplines are, their pre-eminence in the bioethical literature has not been helpful to science undergraduates (nor indeed to some professional scientists!). And thus a book was born. In assembling this book, as scientists we have endeavoured to engage with the modes of thinking employed by ethicists and philosophers because they play such an important part in analysing the issues and formulating ethical responses. However, we believe that ethical decision making in all the areas discussed in this book must be informed by a clear understanding of the science involved. Hence considerable space is given to presentation of the background science. Further, we have tried to discuss the thinking of ethicists and philosophers in a way that is helpful for and understandable by scientists who may not be (indeed, probably are not) familiar with the patterns of thinking in the humanities and social sciences. And then comes the hard part, the application of ethics usually evolved or derived in the context of human society, to issues in environmental science, biology, biotechnology and medicine. In order to do this we have assembled a team of authors who have responded eagerly to the challenge. We hope that the resulting text fulls our wishes to be helpful, informative and thought provoking. Mary Warnock, in the context of a discussion of public and private morality in bioethical issues, said . . . we must try to get it right, otherwise we shall be dominated for ever by the ethics of the pub bore, who will say, I think its disgusting. There ought to be a law against it. . .. For us, getting it right means providing the tools to inform our readers how to think about the issues without trying to tell them what to think. We hope, therefore that this book is a contribution to the ongoing debate in bioethics. In producing this book we have been helped and encouraged by many other people. Our co-writers, the authors who, with us, have provided the text, have shared in our vision and we thank them for their excellent contributions. We are especially grateful to Steve Hughes for his ready willingness to help and advise. Early on in our thinking about this venture we had much help and support from Suzi Leather (now Deputy Chair of the UKs Food Standards Agency), Iain Markham (now Professor of Ethics at Hope University College, Liverpool) and Christopher Southgate, who also contributed extensively to the nal product. We want to thank too, those who, although not contributing to the book itself, nevertheless helped us in discussion of particular topics, especially Donald Bruce (of the Church of Scotland Science, Religion and Technology project), Avice Hall (University of Hertfordshire) and Gordon Dunstan (formerly of Kings College, University of London). We are also grateful to several cohorts of undergraduate and postgraduate students who have participated enthusiastically in our
Warnock, M. (1998) An Intelligent Persons Guide to Ethics Duckworth, London, UK.

PREFACE

xi

courses, made helpful suggestions for improvement and constantly requested that we recommend a useful text that brings all the issues together between its two covers. Doubtless, succeeding cohorts of students will tell us whether this is the book that meets that demand! And of course, we need to say that if the book does have its shortcomings, the responsibility for those is ours and ours alone. Finally, we must thank our colleagues at John Wiley & Sons, especially Sally Betteridge, who shared our enthusiasm for this book, strongly supporting the proposal through the companys decision-making process, and Suzanne Kriston, who looked after us from the signing of the contract through to production, showing admirable qualities of tact, patience and persistence. John Bryant Linda Baggott la Velle John Searle October 2001

Bioethics for Scientists Edited by John Bryant, Linda Baggott la Velle and John Searle Copyright 2002 John Wiley & Sons Ltd ISBNs: 0-471-49532-8 (Hardback); 0-470-84659-3 (Electronic)

Index

Note: page numbers in italics refer to gures and tables; those with n sux refer to footnotes Aboriginals, respect for prey animals 867 abortion 252, 253 Abortion Act (UK, 1967) 252 action causal responsibility 106 moral responsibility 106 reasons for 105 adoption 208 availability of babies 252 babies oered for sale 208 genetic disease 250 overseas 208 Advisory Committee on Genetic Testing of the United Kingdom 234, 256 Africa GM crop technology 182 Green Revolution failure 182, 185 agency 1056 Agracetus company 156 Agricultural and Environmental Biotechnology Council 129n agricultural practice 88 agricultural products, global trade 1645 agriculture employment provision 1756 environmental impact 181 industrialisation 118 roles 1746 transformation by genetic technologies 148 Agrobacterium tumefaciens 120, 121, 160 agrochemical companies 148 business strategies 1878 economic forces 1889 markets 1867 agrochemicals use reduction 181 see also pesticides AIDS drugs 12 respiratory complications 308 alarm generation 134 allergens 331 removal from foods 123 alpha fetoprotein (AFP) 250 maternal serum screening 251 altruism 8, 51 Alzheimers disease 243 ApoE4 allele 256 experiential person 103 moral community 104 moral considerability 105 Amazon rainforest felling 65 American Society of Human Genetics Social Issues SubCommittee 237 amino acid sequences 245 amniocentesis 250, 331 anaemia 177 ANDi, transgenic rhesus monkey 243 anencephalic infants 252 moral considerability 1056 animal experimentation 85, 86, 8990 alternatives 3224 biomedical research 31829 cloning 286 diabetes mellitus 324 xed dose procedure 326, 327 guiding principles 3278 human benet 1023 indefensibility 102 legal requirements 92 legislation 88 licencing 96 medical progress 319 moral perspective 102 numbers used 95, 323

338
animal experimentation (cont.) pain 901 relevance to humans 3245 research areas 3212 thyroid disease 324 toxicity testing 3212, 3257 animal rights 912, 101, 318 Animal Rights (Salt) 317 animals abuse 87 biological diversity 87 as commodities 74, 87 communication 315 defence of 317 deprivation 89 diversity 8990 education role 3289 exploitation 86, 878, 91 genetic material rights of pedigree 159 genetic modication 935 developmental abnormalities 93 human disease models 95 human relationships 31318 killing 86 moral community 103, 104, 110 moral considerability 104 moral status 87, 88, 902, 95 nervous system 86, 89 ownership 159 pain 96 duty to protect from 98 perception 91 quality of life 104 relationships 31316 research use 320 respect for 867, 318 species 89 suering 96, 3201 capacity 89 use as food 323 utility 92 value of life 109 welfare 96, 101, 1034, 317 criteria 97 duty 912 Animals (Scientic Procedures) Act (1986) 90, 96, 286, 320 Antarctica, ozone hole 39 anthropo-apical view 51 anthropocentrism 40 animals 96 anti-environmentalist thinking 42

INDEX anti-nutritional factors 145 anti-trust legislation 154 action against agrochemical companies 148 anti-vivisection literature 89 antibiotics 93 Antinori, Severino 280, 2889 -antitrypsin (AAT) sheep 93  ApoE4 allele 256 apomixis 125, 193, 331 Arabidopsis thaliana genome sequence 11920, 165, 166 Aristotle 202, 316 articial insemination cattle 288 by husbands/partners sperm 211 Asilomar Conference (1975) 134 aspartame 119 assisted conception/reproduction 204, 207, 209 homosexuals 205 oligospermia 21011 religious views 2234 surrogacy 2289 technologies 21113 welfare of child 209 AstraZeneca 186 Australia, euthanasia in 299 autonomy 7, 304 children 250 dying 2978 erosion of expert 25 euthanasia 299300, 3012 granting 10 legitimate domain of experts 22 negating by eugenics movement 246 public policy 303 regulatory system duty 13 scientic research 10 Aventis 186 1B/1R event 116 Bacillus thuringiensis toxin 132, 138, 144, 180 bacteriophage 119 Bangladesh, climate change eects 79 barley varieties 116 BASF 186 beaurocrats, recognition of legitimate domain of experts 22 Beck, Ulrich 26, 28 Bellagio Declaration (1998) 125, 193

INDEX benecence 304 imposition 10 benet distribution 137 genetically modied crops 185 Bentham, Jeremy 6, 90, 317 bereavement, genetic death 204 Berg, Paul 134 bio-systemic view 51 biocentrism 40 radical 456 biodiversity 331 animals 87 genetically modied crop impact 144 reduction by genetically modied crops 1313 bioinformatics 331 market 266 biological imperative moral constraints 102 survival 1012 biology teaching 3289 biomedical research see animal experimentation biopiracy 1901, 270 biosafety, genetically modied crops 1845 Biosafety Protocol 135 biospherical egalitarianism 44 biotechnology drug-platform companies 266 ethical reasoning 5 justication for research projects 31 patents 2678 public views 142 responses 2830 Biotechnology and Biological Sciences Research Council (BBSRC) 320 Bland, Tony 306 blindness, vitamin A deciency 162, 177 blocked exchanges concept 276 Blood, Diane, case of 215 bookkeeping, single entry 34 bottom line, triple 12 bovine lymphocyte adhesion deciency (BLAD) syndrome 288 bovine spongiform encephalopathy (BSE) 331 ethical demands on experts 245 food safety 143 Boyes, Lilian 2989 Brady, Paul 299

339
brain function, total cessation 306 brain stem death 3056 Brazil 65 BRCA1 gene mutation 249, 256 BRCA2 gene mutation 256 breast cancer 249, 256 breast surgery, enlargement/reduction 260 breeding, selective 94 Brent-Spar oil rig 24 British Medical Association, safeguards for withholding food and hydration 307 British Societal Attitudes survey 257, 261 Brundtland Report (1987) 66 Bt toxin 132, 138, 144, 180 gene 184 Buddhism 49n business ethics 1213 Caenorhabditis elegans 856 genome sequencing 85 human disease modelling 92 life cycle 96 post-reproductive period 967 toxicological testing 92 cancer advanced 307 familial forms 256 oncomouse studies 327 smoking 324 capital replacement, plant breeding 118 carbon bound in ecosystem 57 carbon dioxide absorption capacity of trees 57 release levels 65 sink 331 cardiac arrest 305 Carson, Rachel 47, 76 Cartagena Protocol on Biosafety (1999) 149 Cartesian theory 317 dualism 88 Case for Animal Rights (Regan) 318 cassava, cyanide-generating 123 cattle articial insemination 288 breeding 287 cloning 283, 284, 2878 cultural attitudes towards 74 nuclear transfer 283 transgenic 286

340
causal responsibility 106 causeeect relationships 324 cDNA 268, 332 Celera Genomics 266 cell-culture alternatives to animal tests 93 cell dierentiation 283, 293 cell lines, patents 2678 Center for the Application of Molecular Biology in International Agriculture (CAMBIA) 192, 193 centric fusion phenomenon 116, 332 cephalopods, nervous system 89 cereals production self-suciency in UK 118 short-stalked 122, 124 CFCs 39 cheese making 119, 122 chemicals, routine animal testing 87 Chernobyl nuclear accident (1986) 39, 46, 78, 79 children autonomy 250 cloning 279, 280, 281, 28891 genetic testing 24950 moral community 105 replacement 290 see also adoption; anencephalic infants; designer babies; sex selection chorio-allantoic membrane (CAM) test 326 chorionic villus 332 biopsy 251 Christian tradition 878 belief system about nature 316 human life beginning 202 nature of humans 315 chromosomes 332 balanced translocation 249 intergeneric wheat/rye hybrid 116 pairing in grasses 116 sex 335 Church of Scotland 288 chymosin 119, 122 citizens, duty to acquaint with sciences 24 clergymen-naturalists 87 climate change 79 turbulence 53 Clonaid 280

INDEX clones 332 cloning 207n, 27995 from adult animal 283 animal experimentation 286 applications 286 cattle 283, 284, 2878 children 279, 280, 281, 28891 counselling 290 designer babies 289 developmental abnormalities 93, 2878, 289 Dolly the sheep 243, 279, 283 eciency 28991 embryo splitting 288 ethics approach 28295 debate 2812 genetic diversity protection 288 goats 284 human rights violation 290 inbreeding risk 288 media interest 280, 2812, 285 mice 283, 284 nuclear transfer 2823, 284, 285, 286 objections 288, 291 oocytes 285 psychological harm 290 public policy 289 reproductive 254 safety standards 289 sheep 283, 284 success rates 2845, 2878, 289 surrogacy 2856 temporary recipients 287 therapeutic 32, 228, 293 Clothier Report 261 Co-Ordinating Group of the International Agricultural Research Centres (CGIAR) 162 CohenBoyer patent 160 Cole-Turner, Ronald 271 collective biotechnological innovations 29 collegial arrangement 212 problem solving 30 collegial arrangement 202 internal ethical order 22 obligations 212 Collins, Francis 249 colorectal cancer, hereditary 256 commercial development 1213 genetically modied crops 186

INDEX recombinant DNA technology patents 158 commodication babies for adoption 208 embryos as sources of cloned stem cells 204n genetic enhancement 260 genetic material 160 life by gene patenting 275 pre-implantation genetic diagnosis 254 communication in animals 315 companies duties 12, 194 employee respect for condentiality 22n plant transformation technology control 161 social/ethical responsibilities 1213 see also pharmaceutical companies complement-mediated hyper-acute response 292 computer modelling 3234 conception requirements 206, 207 see also assisted conception/reproduction conduct, standards for assessment 105 condentiality genetic information 234, 235, 238 genetic records 2334 consensus 5 consent genetic information 2345, 238 resuscitation 305 consequences 58 consequentialism 42, 332 gene manipulation 259 consequentialists 6 consumer choice elimination 15 consumers eating habits 33 genetically modied crop purchase and consumption 1516 Convention on Biodiversity 135, 136 autonomy over natural resources 190 biosafety protocol 1845 national sovereignty of genetic resources 164 Convention on Biomedicare (Council of Europe, 1997) 234 Conway, Gordon 177, 185, 194

341
Cornerhouse brieng 172 corporate growth, plant breeding 118 corporate power 17980 corporations, human gene patenting 274 corridors, wildlife 132 cosmetic surgery 260 cosmetics, development 93 costbenet analysis 489 cotton Bt toxin gene 184 insect-resistance 124 patent for genetic transformation 156 Council for Responsible Genetics 272 Council of Europe 234, 2356 counselling assisted reproduction 215 cloning 290 infertility 208 prenatal testing for genetic disease 252 Cox, Nigel 2989 creatine kinase testing 246 creation doctrine 41 CreutzfeldtJakob disease 332 new variant (nvCJD) 143 criminal record 210 criminal responsibility in animals 91 crop(s) improvement 115, 116 staple 148 varieties 122 crop biotechnology in developing countries 17197 appropriate crop/trait use 1823 commercial interests 186 enabling 192 types 17880 usage 1823 crop yields developed countries 181 uctuations 14 global increase 176 selection for 115 cryopreservation 213, 214, 332 oocytes 214 cultural issues genetic modication 1267 human gene patenting 26970 plant biotechnology 1967 sex selection 2267 social norms 261 Currien, Hubert 272 customers 12

342
cuttlesh 89 cystic brosis 243 animal studies 328 carrier status 249 gene therapy 328 cystic brosis transmembrane receptor (CFTR) 248 Darwin, Charles 245, 314 Darwinism, social application 245 Dawson of Penn, Lord 301 DDT case study of malaria control 756, 77 continued use 77 death 297310 with dignity 303 premature 319 decision-making, ethical x deep ecology 434, 46, 49 extremism 52 deference reduced willingness to accord 25 withdrawal 35n Delta Pine Land Company 168n, 191 dementia end-stage 307 see also Alzheimers disease democratic accountability 34 deontology 7, 8, 42, 91, 332 conjoined twins 3089 environmental policy formulation 47n gene manipulation 259 gene transfer 126, 179 interspecic issues 9 Descartes, Rene 88, 90, 317 designer babies 260, 261 cloning 289 developed countries biopiracy 1901, 270 crop yields 181 GM seed development prioritising 1889 developing countries 74 biopiracy 1901, 270 crop biotechnology 17197 exploitation 194 farming conditions 184 food production 172, 173 free molecular tools 192 genetically modied crops 137, 1835 expertise 185 patenting 146, 149

INDEX technology 1812 inequalities 196 malnutrition 177 net food importing 174 partnership approach 1945 opportunities 190 resources protection from exploitation 272 seed saving for resowing 146, 149, 177, 191 vitamin A deciency 162 weeds 184 diabetes mellitus animal experimentation 324 insulin-dependent (type 1) 91, 291 pancreas islet cell infusion 292 Diamond v. Chakrabarty (US Supreme Court) 267, 269 Dillard, Annie 49 disability/disabled people 90, 226 acceptance in society 259 insurance 236 reduction 259 disciplines, collegially organised 212 disease agency 105 benecial interventions 249 genetic basis 2467 genetic predisposition 246 human in mammals 325 human models 92, 95 impairment of life 109, 110 inheritance pattern 246 mutations 247 resistance 123 sex-linked 226 disenhancement 252, 253 disposable soma hypothesis 97 dissection 328, 329 diversity 44 DNA analysis 249, 256 pre-implantation genetic diagnosis 253 banking 2378 bases 245 foreign 242 non-coding 266 sequence polymorphisms 166, 256 structure 244 vectors 2412, 332

INDEX DNA ligase 119 DNA mismatch repair genes 256 dogs, domestication 94 Dolly the sheep 243, 279, 283 dominion 88, 316 Donaldson, Liam 294 donor insemination 211, 212 cultural acceptance of child 213 legal standing of father 32, 213 live birth rate 221 matching criteria 212 welfare of child 215 Douglas, Mary 27 Dow Chemical 186 Down syndrome, prenatal diagnosis 250, 251, 252, 259 Draize eye irritancy test 93, 326 drought tolerance 189 drugs development 3212 rational design 92, 321 transmissible bacterial resistance 158 see also insulin; pharmaceutical proteins Duchenne muscular dystrophy 246 DuPont 186 duty of care environment 129 genetically modied crops 1516 dying prolonged 3039 requests for assistance 104, 110 see also euthanasia Earth impact of societies 46 as innite resource 42 resources use 1956 ecological foot-print 74 ecology shallow 43 see also deep ecology economic growth 66 ecosystems 332 community concept 52n devastation in Western progress 88 disruption by persistent organic pollutants 76 mature 66 stressing 39 egg donation see oocytes, donation El Nin o 53

343
electricity consumption 78 embryo, human 202, 332 chromosomal abnormality detection 289 cloning 2915 abnormality incidence 285 culture 21819 development 203 extended screening 256 genetic manipulation 25761 implantation of cloned 287 failure 21920 nuclear transfer 284 pre-implantation 203n production of surplus 228 research 28, 29, 2034, 2245, 226, 254, 2934 stem cell therapy 294 splitting 288 status perception 254 stem cells 2923 source of cloned 204n survival 203 transfer 219 see also Human Fertilisation and Embryology Act (1990) embryo, mammalian frozen cloned cattle 287 genetic testing 2434 transgenic 2423 emissions permits 65 employers discrimination 236 genetic information 2356, 238 employment in agriculture 1756 endangered breeds, cloning 2856 endo-deoxyribonucleases 119 endometriosis 219, 332 ends 314 energy demands 74 renewable sources 78 entrepreneurship, recombinant DNA technology patents 158 environment agricultural impact 181 debate 425 degradation and religious conviction 41 duty of care 129 farming practice 131

344
environment (cont.) overuse 39 political decisions 42 precautionary principle in protection 143 stress resistance 123 environmental damage genetically modied crops 129 irremediable 47 environmental dilemma 79, 80, 81 environmental economics 45, 48 environmental ethics 3954 case-studies 7581 policies guiding 745 rainforest 5767 scientic views 80 slurry store incident 734 Environmental Ethics (Rolston) 51 environmental fascism 44 environmental xes 44 environmental impact assessment 79 environmental movements anxiety creation 267 irrational attitude to science 28 nuclear power 79 risk exposure 267 utilitarianism 26 environmental policy formulation 459 economic context 478 Epicurus (Greek philosopher; 341271 BC) 6 epidemiological studies 324 epididymis 332 equity principle in patenting 157 ethical codes in protection of medical records 2334 ethical conclusion validity 4 ethical decision levels 916 ethical framework debate 4 ethical principles, conicts 81 ethical thinking 3 ethics 333 scope 3 ethnic background, donor insemination 21516 eugenics 333 genetic manipulation 259 patenting of human genes 275 prenatal screening 256 eugenics movement 2456 European Commission Group of Advisors on Ethics 237

INDEX European Community Directive on Biotechnology Patenting 271 European Directive on Legal Protection of Biotechnogical Inventions 269, 275, 277 European Ecumenical Commission for Church and Society 2712 European Patent Convention Agreement 269 European Patent Oce 156, 268 European Union, ethical issues of biotechnology 45 euthanasia 298303 autonomy 299300, 3012 case against 3013 food and hydration withdrawal 307 George V 301 involuntary 299 motivation 300 necessity 300, 3023 openness 3001 voluntary 299 exhaustion principle 155 expertise consensus 22 division 26 nance sources 256 independent 25 market mode 235 plurality 26 threats to integrity 245 experts disagreement 26 hostility towards 28 independence 235 legitimate domain of autonomy 22 exploitation, terminator technology 192 expressed sequence tags (ESTs) 165 Exxon-Valdez oil tanker incident 46, 47 eye irritation testing 93, 326 eye-spot resistance 116 EYTEX tests 326 F1 hydridisation 125, 333 barrier to ow of material 168 seed stock renewal 191 sterile seed 1689 F1 lines, true-breeding 125 fair treatment of inventors 156 fairness principle, patents 156, 157 fallopian tubes, blockage 21617 families

INDEX access to genetic information 2367 genetic information of members 2389 family history, genetic disorders 253 Fanconis anaemia 228 Farm Animal Welfare Council (FAWC) 287 farmers/farming conditions in developing countries 184 informative link with plant breeders 118 organic 1334 planting 14 practices and the environment 131 see also livestock fear generation 134 fertilisation 202, 203 fertility 2068 research 2034 fertility treatment cost 2201, 223 live birth rates 221 professional responsibility of doctors 210 religious views 2234 see also assisted conception/reproduction; Human Fertilisation and Embryology Act (1990); in vitro fertilisation fetal period 254 fetishism 32 eld margins 132 xed dose procedure 326, 327 FlavSav tomato 1223 foetal tissue, research use 214 foetus 202n, 333 aborted 214 extended screening 256 research use 214 status perception 254 food access to 176 composition modication 123 crisis 181 distribution 181 global demand 173 global production capacity 172, 173 net importer countries 174 purchasing decisions 16 withdrawal 306, 307 Food and Agriculture Organization (FAO) 177 food production

345
agriculture primary role 174 impending crisis 174 population growth 1734 sustainable 1745, 196 food safety 1278 public condence 143 scares 24 food security 1714, 195 current situation 1713 socio-economic circumstances 172 foot and mouth disease 74 forests clearance/degradation 57 see also tropical moist forests fossil fuels consumption 78 fostering 208 France, nuclear programme 78 free-market economics 45, 467 free rider problem 29, 30 freedom to operate, patenting 1612, 163 Friends of the Earth 7980 functional transgenomics 166 Gaia hypothesis 523 Galton, Francis 245 gamete donation 21416 genetic disease 250 see also sperm donation gamete intrafallopian transfer (GIFT) 211, 220 gametes 333 genetic manipulation 25761 micromanipulation 210 production problems 210 gender identity disorder 260 gene(s) 333 carriers of deleterious 30, 24950 characterisation 248 defects 205 detection 248 discovery 1656 elimination of disease genes 226 exogenous 2423, 333 ow 333 formalised information 160 fragment patents 2678 isolation 248 mutations 246 disease-causing 247 patentability 169 patenting 190, 26677

346
gene(s) (cont.) promoters 242 sequencing 248 silencing 333 switching o 122 see also human genes; mutagenesis; mutagens; plant genes gene sequence databases, private 1656 gene targeting 258 gene therapy 25760 cystic brosis 328 germline 258 somatic 258 gene transfer 119, 120, 121 deontological objection 126 inter-species 122 public concerns 142 genetic basis of disease 2467 genetic carrier status 24950 genetic code 245 genetic death 205 bereavement 204 genetic diagnosis 205, 244, 24857 children 250 pre-implantation 244, 2535 prenatal screening 2503 prenatal testing 2503 genetic disease adopted children 250 gamete donation 250 penetrance 256, 257 genetic diversity protection 288 genetic enhancement 241, 2601 genetic identity, unique 290 genetic information 2339 access prohibition 235 anonymisation 234, 2378 coding 234, 235, 2378 condentiality 234, 235, 238 consent 2345, 238 disclosure to institutional third parties 235 discrimination 238 employers 2356, 238 family members 2367, 2389 human genome project 241 insurers 2356, 238 opting-out possibility 238 privacy 238 prohibited discrimination 236 reasonableness 238 responsibility 2389

INDEX sharing 235, 238 surveillance 235 genetic linkage analysis 166 genetic manipulation cosmetic reasons 261 embryo 25761, 258 gametes 25761 technology 160 genetic material, commodication/enclosure 160 genetic modication 11920, 121, 1225, 2413 agriculture transformation 148 applications 1224 benet distribution 137 consultative process 125 crop husbandry 124 crop performance 1234 cultural issues 1267 ethical development of technology 125 food content 123 food product eects 123 gene introduction time reduction 1801 human beings 243, 247, 248 non-food use crops 124 objections 12534 position eects 120 precautionary principle 135 public spending on research 146 regulatory arrangements and human welfare 1346 research uses 11920 risk distribution 137 role of scientists 136 safety 1278, 146 surveillance 129, 138 techniques 205 time-scale to commercial production 127 un-natural technology 1267 use 17980 see also genetically modied crops; genetically modied foods genetic records, condentiality 2334 genetic resources, national sovereignty 164 genetic selection 228, 2434 genetic studies, international collaboration 235, 237 genetic testing 205 carrier 234

INDEX children 24950 predictive 234 genetic trait characterisation 245 genetic use restriction technologies (GURTs) 149, 168, 169 genetic variation, constraint to production increase 180 genetically at-risk employees 236 genetically modied crops agrochemical business strategies 1878 benet 185 biodiversity reduction 1313 biosafety 1845 biotechnology 1867 commercial agenda 186 commercial interests 137, 1467, 187 consultation 137 contamination of organic crops 1334 crop choice 182 developing countries 137, 1835 development prioritising for developed countries 1889 duty of care 1516 enabling technology 192 environmental damage 129 environmental movement impact 27 expertise requirement 185 eld trials 135 food safety testing techniques 128 gene escape 12931 genetic modication process 11920, 121, 1225 global food production 175 herbicide-tolerant 132, 1889 hybridisation with wild species 1301 incomplete knowledge 1445 insect-resistant 132 large-scale eld trials 131 markets 1867 ownership 185 partnership approach 1945 patenting 1467, 15370 power 185 public knowledge 142 regulation 1346, 1436, 150 retailers 15 revolution 185 scientic perspective 11538 seed market 187 spread of technology 175 time constraints 1801

347
trait choice 183 usage 1801 use of technology 17980 genetically modied foods 910 commercial interests 1467 environmental campaign 33 labelling 13, 14, 127, 1478 market mode deciencies 24 morality of questioning 1489 public attitudes 1413 public choice 1478 public knowledge 142 public opposition 14150 rationality of questioning 1489 regulation 1436, 150 research 11 safety 145 scientic perspective 11538 stocking by retailers 1415 genetically modied organisms 143 genetics, crop improvement 11516 GeneWatch report 189 genome, epigenetic state 289 genome sequence Arabidopsis thaliana 11920, 165, 166 rice 120, 165 see also human gene sequences genomics 1656, 333 information exploitation 266 George V, King 301 germplasm, exchange/sharing 167 global warming 39 forest degradation 57 resetting of environmental stability systems 53 goats, cloning 284 God ownership right 271 playing 259 Golden Rice 123, 138, 1623, 180, 183 intellectual property rights 163, 192 patents 163 Gompertz, Lewis 317 government duties/responsibilities 15 Graaan follicle 333 grain production, self-suciency in UK 118 grasses, chromosome pairing regulation gene 116 Green Revolution 174, 1768 failure 182, 185 genetically modied wheat 190

348
Green Revolution (cont.) health of farmers 181 successes 1812 greenhouse gas emissions 65 methane in Australia 74n Greenpeace 24 accountancy 34 genetically modied crops 27, 33 incinerators 34n gross national product, USA 49 growing season modication 123 growth hormone gene 242 haemoglobin electrophoresis 246 haemophilia inheritance 245 hamster egg penetration (HEP) assay 225 handicap acceptance in society 259 perception 236 reduction 259 severe in newborn 307 harm, prevention/redressing 13 health, fertility treatment 210 heart attacks 291 heart function cessation 305 hedonistic theory of value 6 herbicide-free cordons 132 herbicide resistance genes 184 herbicide tolerance 124 acquisition by weeds 1301 herd immunity 260 heritage, confused 290 Hettinger, Ned 272 hexosaminidase assay 246 hierarchy mode 23 experts disagreement 26 Hillsborough Football Stadium (Sheeld, UK) 306 Hindu societies 74 holism, overstress 52 Home Oce (UK) 96 Inspectors 320 homosexuals, parenthood 209 assisted reproduction 205 fertility treatment 209 honour, reduced willingness to accord 25 hospice movement 297, 298, 3023 House of Lords (UK) Bland (Tony) case 306, 307 inheritance 32

INDEX Select Committee on euthanasia 302 human beings animal relationships 31318 benets from animal research 1023 constitution 31, 2024 distinctive character 51, 315 ethical distinctiveness 512 exploitation of non-human forms of life 314 genetic modication 243, 247, 248 health 31 precautionary principle in protection 143 impairment of life 109 independent units 312 moral community 103 moral obligations to animals 318 moralising ability 315 motivation 289 nature of 334 constitution 31 quality of life 110 status 32n value of life 48, 109 wellbeing 31 human biotechnology complexity 29 embryo research 28, 29 human chorionic gonadotrophin (hCG) 251 human dignity intellectual property rights 275 respect for and patenting 2746 human disease models 92, 95 human experimentation 901 Human Fertilisation and Embryology Act (1990) 203, 209 code of practice 216 live embryo research 2245, 2934 public consultation 229 special status of embryos 2934 in vitro fertilisation 217 Human Fertilisation and Embryology Authority (HFEA) 209 code of practice 212 condentiality 213 consultation document (1994) 214, 215 new purpose for act 294 oocyte donor records 213 pre-implantation genetic diagnosis 254, 256

INDEX sperm donor records 213 human gene sequences 2445 exploitation 266 public access 154, 274 structure 324 human genes knowledge application 266 patentability technical requirements 2669 patenting/patents 26677 claims 266 ethical concerns over 26973 eugenics 275 moral objections 272 scientic research 2734 human genetics 2447 recombinant DNA technology 247 Human Genetics Advisory Commission 294 Human Genome Organisation (HUGO) 234 Ethics Committee 235, 2367 position on patenting 273 human genome project 226, 241, 245, 247 knowledge application 266 technology development 247 human life beginning 202 legally protected 225 human population, carrying capacity 44 human rights 91, 196 open future 290 public policy 303 violation by cloning 290 human society, changing 501 human species 8 humananimal relationships 31618 humanistic ethic 501 humanitys common heritage 272 humanocentrism see anthropocentrism Humboldt, Alexander von 85 Hume, David 223 hunger, chronic 172 Huntingtons disease 243, 257, 333 euthanasia 299 hydration withdrawal 306, 307 illness agency 105 impairment of life 109, 110 immune rejection 2923

349
immunosuppression 293 implantation 333 in vitro fertilisation 211, 214, 21720 failure 219, 242 female infertility 214 genetic modication 241 genetic selection 228 live birth rate 221 micromanipulation techniques 220, 221 pre-implantation genetic diagnosis 253 pregnancy establishment 242 procedure 21719 sex selection 2268 spare embryos 2245 variations 220 in vitro techniques 3223 inborn errors of metabolism 250, 253 inbreeding 333 incest condemnation 291 incinerators 34n Index of Sustainable Economic Welfare 49 India crop research 188 Green Revolution 1778 Hindu society 213 sperm donation 213 indigenous peoples, human gene patenting objections 269 individuals 34, 35 industrialisation 74 inequalities 196 infectious disease 260 infertility 2045, 2068 counselling 208 female 21416 grief 204 incidence 2078 reasons 217 treatment 205, 21416 welfare of child 215 infrastructure development 74 inheritance, diseases 246 innovations, spillover 189 insecticides 132 residues 45 insects, benecial 132 insemination donor 205 intrauterine 211

350
insemination (cont.) in vitro fertilisation 218 institutions 34, 35 private 160 instrumental approach to life 276 instrumentation, pre-implantation genetic diagnosis 254 insulin 91 chromatography purity testing 328 genetically modied 119, 127, 324 human 160 insurers, genetic information 2356, 238 intellectual property plant genes 1578 plant variety rights conicts 1679 privatisation 155n protection 1467, 273 restriction 168 intellectual property rights 154 acquisition 165 enforcement 164 GM technology 18990 Golden Rice 163, 192 human dignity 275 humanitys common heritage 272 knowledge 16970 intensive care, withholding/withdrawing treatment 307, 308 intergenerational issues 8, 9 environmental ethics 51 intergeneric wheat/rye hybrid chromosome 116 international agencies, commercial agenda 186 International Centre for Agricultural Research in the Dry Areas (ICARDA) 191 international collaboration, genetic studies 235, 237 International Human Genome Sequencing Consortium 266 International Rice Research Institute 163 International Seed Federation 187 International Service for the Acquisition of Agri-Biotech Applications (ISAAA) 163, 177n interspecic issues 89 intracytoplasmic sperm injection (ICSI) 220, 222, 248 intrauterine insemination 211 intrinsic viewpoint 259

INDEX introgression 130, 131, 334 Inuit breast milk contamination 45 inventors fair treatment 156 justice principle 156 rewards 153, 1567 iron deciency 177 Japan, tropical moist forest interests 58n Jewish faith 224 Jodi and Mary, conjoined twins 3089 Joint Appeal Against Human and Animal Patenting 271 Jonsen, Albert 282 jurisprudence 978 justice principle 304 global 17980 terminator technology 192 inventors 156 patents 156, 157 Kant, Immanuel 91, 317 Kass, Leon 291 Kevorkian, Jack 299 kin relationships 29, 30 Klinefelter syndrome 252 Kloppenburg, Jack 118 knowledge esoteric domains 21 formal 164, 165 informal 164, 165 reconstitution 28 specialised technical 289 Koko, lowland gorilla 315 Kyoto protocol 65 labelling, genetically modied foods 127, 1478 labour, division of 20, 21 land education about 50 ethic 49, 50 land community 50 language development 315 laparoscopy 334 large calf syndrome 287 lay evaluation 234 lay expertise 24n LD50 test 326 legal doctrine, patentability 267 legal recourse, harm redressing 13 legal system, adversarial 27

INDEX legislation animal experimentation 88, 90, 96 protection of medical records 2334 protection of moral seriousness of human life 201 reproductive technology 28 Leopold, Aldo 44, 49 lesbians cloning use 290 donor insemination 205, 215 fertility treatment 209 welfare of child 215 Letters Patent 154 Lewis CS 94 life beginning 202 expectancy 297 presumption in favour of 201 prolonging 298 life-forms, patenting 2701 life insurance 236 Life pro-life charity 228 limb-lengthening surgery 260 litigation property rights 274 toxicity testing 326 livestock genetic modication 286 intensive rearing 87 logging trade 57 logos 315 Lovelock, James 523 low erucate allele 131 lung function cessation 305 mad cow disease see bovine spongiform encephalopathy (BSE) maize F1 hybrid breeding technology 118 genetically modied 132 hybridisation with wild plants 130 labelling 1478 organic 133, 134 pollination 1334 malaria case study of control 758 endemic 75, 767 malnutrition 177 crop yield uctuations 14 man-in-environment image 44 Mans Responsibilities for Nature (Passmore) 501

351
marker-assisted selection 288 market mode 235 deciencies 245 shift to 258 social change 28 threats to integrity of expertise 245 market transactions, patented genes 275 markets agrochemical companies 1867 terminator technology 191 marriage, inter-racial 291 Mary and Jodi, conjoined twins 3089 Masterson family 2278, 254 masturbation 224 material transfer agreements (MTAs) 163 mating partner selection 259 means 314 media interest in cloning 280, 2812, 285 medical benet certainty 3201 medical progress animal experimentation 319 impact of patents 274 medical records protection 2334 medical research reputability 102 medical science, legal requirements for animal testing 92 medical treatment withholding/withdrawing 3034 Medicines Act (UK,1968) 322 Mendel, Gregor 245, 334 mental enfeeblement eugenics policies 245 experiential person 103 moral community 104, 105 Merck 274 messenger RNA 268 metallothionein gene promoter 242 methane production 74 mice cloning 283, 284 embryos genetic testing 2434 transgenic 2423 nuclear transfer 283 transgenic strains 95 micro-propagation 178 microepididymal sperm aspiration (MESA) 216 micromanipulation 220, 221 Midgley, Mary 66 Milgram, Stanley 11

352
milkweed 132, 144 Mill JS 6 mind 317 minorities, interests of 5 miscarriage, cadaver tissue 214 Mo Tzu (Chinese philosopher; 5th C BC) 6 molecular-marker-aided improvement 1789 molecular tools development 192 monarch buttery 132, 138, 144 monetary incentive, taboo in collegial arrangement 22, 256 Monopolies Commission 154 monopoly 154 patent assignment 1557 Monsanto 148, 168n, 186 moral code, Christian-inuenced 95 moral community 1079 animals 110 blighted life quality 110 enrichment of lives 107, 109 human members 108 humans falling outside 105 individual as part of 106 quality of life 107, 109, 110 moral considerability 1036 experiential lives 105 Moral Inquiries on the Situation of Man and Of Brutes (Gompertz) 317 moral philosophy 8 moral relations 107, 108 moral responsibility 106 moral seriousness of human life 201, 202 moral traditions 4 morals 3, 334 Morrison, Reg 39 mosquito, anopheline 75 Muir, John 44, 49 multi-criterion mapping 150 multiple-ovulation embryo transfer (MOET) 288 mutagenesis with a ag 166 targeted 93 mutagens 334 crop plant mutations 116 Mycogen 186 Naess, Arne 423, 49 Nash, Adam 228, 255, 258 National Action Plan on Breast Cancer

INDEX (USA) 234 National Institutes of Health (NIH) 270 National Research Council, risk evaluation system 150 Native Americans human gene cloning objections 270 respect for prey animals 867 nature 45 belief systems 316 integrity armation 272 manipulation 270 Nazi Germany 246 necessity, euthanasia 300, 3023 neighbours, humanistic ethic 501 nematodes 856, 334 parasitic 86 nervous system of animals 89 complexity 97, 98 net present value (NPV) equation 48 Netherlands, euthanasia 299, 300, 302, 303 neural tube defects 250, 252 neuronal stem cell injection 2912 Newbury (UK) by-pass road 42, 43, 49 Nobel Prize awards 319 non-human animals, human use biologists perspective 8598 philosophers perspective 10111 non-human world community change 50 intrinsic value 412 values 401 non-living organisms, value 52 non-malecence 304 non-obviousness, patentability criterion 267 non-sentient life 52 Novartis 186 Novel Food Regulation (EU 258/97) 147 novelty, patentability criterion 267, 269 nuclear genome, foreign DNA integration 242 nuclear power 46n case study of electricity generation 7880 decommissioning costs/risks 79 environmental eect 45 risks 80 nuclear transfer 2823 cloning 284, 286 human embryo 284

INDEX limitations 285 mammals 283 stem cell therapy 293 Nueld Council on Bioethics 129 claims within a patent 157 GM crop technology in Africa 182 in developing countries 1812 safety 184 partnership approach 1945 opportunities 190 plant transformation technology control 161, 162 trait target list 183 welfare priority 135 Working Group 135, 136 numbers, theory laden 49 nutritional supplements 184 obedience research study 11 occupations, collegial organisation 21 octopus 89 oligospermia 21011, 334 oncogenes 243, 334 oncomouse 93, 327, 334 oocytes 334 cloning 285 collection 218 donation 21416 recovery 287 in vitro maturation 287 openness, euthanasia 3001 Oregon Primate Research Center 243 organic farming 1334 organisation levels 314 ovarian cancer 256 ovarian hyperstimulation syndrome 217 ovulation stimulation 217 ownership genetically modied crops 185 patents 273 property rights 273 ozone hole, Antarctica 39 pain awareness 318 control 302, 303 perception by animals 91 quality of life 104 susceptibility 318 palliative care 302, 303

353
pancreas islet cells 291, 292 Papua New Guinea, viral DNA patenting by NIH 270 parenthood 204 Parkinsons disease 291, 292 partial agents 98 partial zona dissection 220, 222 Passmore, John 501 patent assignment 1557 Patent Cooperation Treaty 156 patentability criteria 269 legal doctrine 267 technical requirements 2679 patenting/patents agricultural products global trade 1645 applications 1567 biotechnology 2678 broad claims 156, 157 cell lines 2678 commodication of life 275 economic competition 268 enabling 1605 licences 161 entry barrier 161 equity principle 157 exhaustion principle 155 experimental exemption 157 fairness principle 156, 157 freedom to operate 1612, 163 gene fragments 2678 genes 169, 190, 26677 genetically modied crops 1467, 149 Golden Rice 163 human dignity respect 2746 human genes 26677 ethical concerns 26973 moral objections 272 scientic research 2734 impact on medical progress 274 income derived from 155 innovation enhancement 273 institutional provision 154 internal conict 156 justice principle 156, 157 legitimacy of living organisms 159 licences 160 life-forms 2701 ownership 273 plant genes 15760

354
patenting/patents (cont.) biopiracy 270 plant variety rights 1679 protection for products developed from human genome knowledge 274 public interest 2734 recombinant DNA technology 1589 reform of system 276 research exemption 157 research result sharing 274 royalties 155 set of claims 156 technical requirements for human genes 2669 transaction costs 162 Patents and Trademarks Oce (USA) 156 peer pressure 2601 peer recognition 22 penetrance 334 genetic disease 256, 257 persistent organic pollutants (POPs) 76 international ban 77 persistent vegetative state (PVS) 104, 3067 diagnostic criteria 307 moral considerability 1056 pest resistance 123, 124 pesticides hazards 177n insecticides 45, 132 use reduction 181 pharmaceutical companies 12 biotechnology 266 drug development 321 legal requirements for animal testing 92 pharmaceutical proteins 243, 286 genetically modied micro-organisms 324 pharmacogenetics 321 Phelps, Willard 191 phocomelia 322 pigs, transgenic 286 Pioneer company 148 plant biotechnology equitable access 193 partnership approach 1945 patents 1601 plant breeding 11518 benign image 117

INDEX commercialisation/commodication 118 complex traits 189 conditions for development of new varieties 11617 conventional 117, 120, 122 disease resistance 116 drought tolerance 189 genetic modication 11920, 121, 1225 mutant varieties 116 new toxins 117, 118 safety 117 selective process 117 success 118 plant genes escape from genetically modied crops 129 patents 15760, 190 enabling 1601 plant genetic transformation enabling patents 161 vector system 1601 plant resource diversion 124 plant varieties distinct, uniform and stable (DUS) 167 rights 154, 156, 1679 double protection 1679 value for cultivation and use (VCU) 167 plasmids 119, 120, 121, 158, 3345 tumour-inducing 160 vector 242 Plasmodium 75 Platonic idealism 94 playing God 259 pleasure 6 measurement 7 politicians environmental decisions 42 recognition of legitimate domain of experts 22 Polkinghorne Report (1989) 214 polluter-pays principle 45, 46, 65 polymorphisms 246, 335 poplar trees, transgenic 133 population growth, food production 1734 Porifera (sponges) 86, 89 post-harvest behaviour 123 potherbs 184

INDEX Potrykus, Ingo 123, 192 poverty 172 biotechnology benets 195 GM research application 188 malaria 767 redistribution of wealth 173 power genetically modied crops 185 plant transformation technology control 161 private institutions 160 pre-implantation genetic diagnosis 244, 2535 public consultation 256 precautionary principle 45, 47, 79, 118 environmental protection 143 genetic modication 135 human health protection 143 use of Earths resources 1956 pregnancy termination 252, 253 prenatal screening eugenics 256 genetic disease 2505 public consultation 256 prenatal testing, carrier status 250 pressure groups 24 principled pragmatism 304 privacy protection 234 private morality x pro-life groups 228, 294, 295 pro-nuclear injection techniques 286 professions 21 promoters 335 property rights 155 fragmentation 274 ownership 273 proteins, molecular modelling 92 public demand, biomedical advances 319 public discussion, scientists 2812 public good 154 public interest, patenting 2734 public interest groups, human gene patenting objections 269 public morality x public policy autonomy 303 cloning 289 human rights 303 public welfare 154 pyrogens 335 LAL test 328

355
quality of life 297 diminished 110 disenhancement 252, 253 impaired 10910 laboratory animals 327 mental illness 103 moral community 107, 109 moral considerability 105 pain 104 Que bec, genetic information access 237 Que bec Network of Applied Genetic Medicine in Canada 235 radiation, crop plant mutations 116 radical biocentrism 456 Radin, Margaret Jane 275 radish, wild 130 Raelian sect 280 railway accidents 34n rainforest see tropical moist forests rape, oil-seed canola variety 131 herbicide-tolerant 122, 188 hybridisation with wild brassicas 130, 131 low erucate allele 131 rational egoism 41, 42 rationality 316 Reagan presidency of USA (198189) 42 real wealth 49 reason 4, 315 insuciency 4 reciprocity, moral relations 108 recombinant DNA technology 158, 335 genetic modication 241 human genetics 247, 248 moratorium 134 patents 1589 reduction of animal experimentation 326 renement of animal experimentation 326 Reformation tradition 88 refuges, wildlife 132 Regan, Tom 318 regulatory approval 1314 duty to allow autonomy 13 regulatory systems, harm prevention 13 relational total-eld image 44 religious community and human gene patenting attitudes 2702, 275 objections 269

356
religious issues in plant biotechnology 1967 religious traditions 4 Renaissance tradition 88 Renwick, Timothy 291 replacement of animal experimentation 326, 328 reproduction, biological drive 2046 reproductive technologies, new 20130, 279 ethical codes 202 fertility treatment 210, 2201, 2234 genetic modication 241 legislation 28 see also assisted conception/reproduction; in vitro fertilisation reproductive tract blockage 216 research, scientic 1012 alternatives to animals 3224 arguments against 11 benets 1011 commercial tensions 2445n costbenet analysis 3201 funding 11, 320 genetically modied food crops 11 innovation 273 laboratory animal use 3212 patent exemption 157 patenting of genetically modied crops 146 quality 3201 reputability 102 sharing of results 274 resources, protection from exploitation 272 respect of persons 10 things meriting 32 responsibility 51 lay sharing 34 restriction endonucleases 158, 335 restriction fragment length polymorphism 335 resuscitation 3045 retailers, genetically modied foods 1415 reward, currency in collegial arrangement 22 rhesus iso-immunisation 250 rice cultivars 182

INDEX genome sequence 120, 165 short-stalked 122 vitamin A-enhanced 123, 124, 138, 1623, 182, 183 Rio Declaration (1992) 478, 58n, 66, 75 precautionary principle 118n Principles 6872 risk assessment 1434, 145, 150 concealment 26 distribution 137 evaluation system 150 management 143, 144, 145 nuclear power 80 protection 27 side-eects 27 technological 27 riskbenet analysis 42 Rockefeller Foundation (New York) 177, 192 Rolston III, Holmes 48, 49, 51, 52 Roman Catholic Church 224, 228 embryo research attitudes 294 Roslin Institute (Edinburgh) 279 rural life, split from urban 88 sacredness 323 safety standards in cloning 289 St Augustine 31617 St Francis of Assisi 98 Salt, Henry S 317 A Sand County Almanac (Leopold) 44, 49 Saunders, Cicely 297, 298 science application of ethics x dependence on 28 dimensions 31314 levels 314 public evaluation 1936 public opposition 35 in schools 3289 wars 35 see also research, scientic scientic information, non-patentable 268 scientists credibility 26n public discussion 2812 recognition of fallibility of knowledge 27

INDEX suppliers of instrumental knowledge 26n Scottish Episcopal Church 228 Scruton, Roger 91 seed development sector, commercialisation/commodication 118 seeds premature shedding 124 rights over 191 saving for resowing 146, 149, 177, 191 see also terminator technology self-awareness 318 self-consciousness 31516, 318 self-determination, right to 246 self-image 2601 selsh gene hypothesis 109n semen 335 analysis 217 sentience 8990, 956, 318 sex change operations 260 sex chromatin 250 sex-linked disease 226 sex ratio 2930 sex selection 2268, 254 choice 29 cultural issues 2267 sexual relationships 29, 30 shareholders 12 sheep cloning 283, 284 nuclear transfer 283 transgenic 243, 286 shelf-life 123 Shell Company 24 sickle-cell anaemia 245 side-eects, risky 27 sight loss, vitamin A deciency 162, 177 Silent Spring (Carson) 47, 76 Silver, Lee 289 Singer, Peter 89, 90, 31718 single nucleotide polymorphisms (SNPs) 256 single parenthood 252 single women donor insemination 215 fertility treatment 209 welfare of child 215 skin broblasts 293 slurry store failure case study 734 SmithKline-Beecham 274 smoking and cancer 324

357
social change, market mode 28 social justice, terminator technology 192 social life intrusions 29 reconstitution 28 social order, alteration 30 societal values 197 society duty to acquaint with sciences 24 plurality 4 socio-ethical dilemmas 249 Soil Association (UK) 133 soil erosion 58 Solomon Islands, viral DNA patenting by NIH 270 soy our labelling 147 soya beans herbicide-tolerant 127, 188 labelling 1478 speciesism 8990, 95, 318 speech 315 sperm donation 212, 214 anonymity 213, 291 cultural issues 213, 224 sperm problems, treatments for 21013 spina bida 252 spirit 317 sponges 86, 89 squid 89 stakeholders 12, 13 status, relations 25 stem cell therapy 2912 human embryo research 294 neuronal 2912 stem cells embryo 2923 research 228 sterilisation, compulsory 245, 246 stewardship 316 environmental 129 responsible 88 Stockholm Convention (2001) 77 strokes 291 severe 307 subfertility 2068, 20910 reasons 217 treatment 21021, 222, 223 substantial equivalence principle 145 subzonal insemination (SUZI) 220, 222 suering alleviation through biomedical advances 319

358
suering (cont.) animal capacity 89 capacity for 31718 not inicting 978 superovulation 217 pre-implantation genetic diagnosis 253 spare embryos 2245 superweeds 130, 131 surrogacy 205, 2289, 335 cloning 2856 surveillance genetic information 235 genetic modication 129 survival, biological imperative 1012 sustainability 66 concept 48, 53, 667 weak 66 sustainable development 66 sustainable growth 66 sustainable management, tropical moist forests 58 Swaminathan MS 1778, 185, 194 Swedish Medical Research Council 235 symbiosis 44 synteny 166 systems, value of 52 T-DNA 120, 121 Tasmanian tiger resurrection 285 TaySachs disease 246 technical expertise evaluation 234 technical skills 20 technocratic cornucopianism 42, 44 technological artefacts, ecacy 23n technologists 26n technology concepts 20 consumer 20n global eects 39 public evaluation 1936 public opposition 35 technology transfer projects 189 telos 934 alteration by genetic engineering 94 violation 93 terminal illness 297 suering 299 terminator technology 149, 168, 1912 terrorism, nuclear plants 79 thalassaemia 246 thalidomide tragedy (1960s) 92, 322

INDEX theocentrism 401 therapeutic dose testing 3212 therapeutic proteins 243, 286, 324 Thoreau, Henry 49 Three Mile Island nuclear accident (1979) 78 thyroid disease, animal experimentation 324 thyrotropin 324 Ti-plasmid 120, 121, 160 Tokai-Mura nuclear accident (1999) 78 Toke, Dave 79 tomato, genetic modication 1223 toxicity testing 3212, 3257 acute oral 326 toxicological testing 92 toxins 145 plant breeding 117 Trade Related Aspects of Intellectual Property Rights (TRIPS) 164, 190, 269, 277 traditional cultures 270 transgenes 2423 transgenic mammals 2412 progeny 243 transport demands 74 treatment, withholding and withdrawing 3078 tropical hardwood exploitation 58n tropical moist forests clearance 65 debate of interested parties 5864 case study 645 degradation 578 environmental ethics 5767 sustainable management 58 truth telling 5, 6 tryptophan, genetically engineered 128 tragedy 135 Turner syndrome 252 twins conjoined 3089 identical 290 UK Predictive Testing Consortium 257 ultrasonography 251, 253 umbilical cord, stem cells 228 Union of Concerned Scientists (USA) 128 Union pour Obtentions Ve ge ` tales (UPOV) convention 154, 167, 168 unitary essence of humans 312

INDEX United Nations Conference on Environment and Development see Rio Declaration (1992) United Nations Environmental Programme (UNEP) international treaty to ban persistent organic pollutants 77 United Nations Universal Declaration on the Human Genome and Human Rights (UNESCO, 1997) 2334, 266, 2767 universal donor cells 2923 urbanisation split from rural life 88 uncontrolled 74 US National Center for Human Genome Research 266 US National Genome Institute 2734 US Patent and Trademark Oce 2678, 271 biotechnology director 273 USA committal to unsustainable practice 66 euthanasia 299 gross national product 49 Index of Sustainable Economic Welfare 49 real wealth 49 tropical moist forest interests 58n uterus, congenital abnormalities 219 utilitarianism 67, 8, 335 contemporary 309 environmental movements 26 eugenics movement 246 frame of reference 31 human gene patenting 276 interspecic issues 9 rule-based 7 utility, patentability criterion 267, 269 value assignment application 412 instrumental 40, 42, 46 combination with intrinsic 52 intrinsic 40, 41, 42 combination with instrumental 52 systemic 52 variety use restriction technologies (VURTs) 168, 169 Varmus, Harold 294 vasectomy 335 Vavilov NI 116 viral DNA patenting 270 viruses 158 vitamin A 123, 124 deciency 162, 177 vitamin C 123

359

Walzer, Michael 276 Wambagu, Florence 177n, 182, 185 Ward, Lord Justice 308 Warnock Committee (1984) 2034, 209 Washoe, chimpanzee 315 Watson J and Crick F 244 wealth redistribution 172, 173 weeds control systems 132 developing countries 184 herbicide tolerance acquisition 1301 transgene acquisition 1301 welfare human 1078 public 154 right to 134 Wellcome Trust (UK) 266 wheat bread 11617 Japanese Norin 10 gene 190 short-stalked 122 White Jr. L 41, 49 ecological crisis 878 St Francis of Assisi 98 wilderness concept 44, 49 Winston, Robert 224 World Charter for Nature 118n World Council of Churches 2701 World Development Movement 186 World Food Summit 171 World Health Organisation (WHO) genetic information access 235, 2367 international treaty to ban persistent organic pollutants 77 World Intellectual Property Organisation 156 World Trade Organisation 164 biotechnology application 195 Trade Related Aspects of Intellectual Property Rights (TRIPS) 164, 190, 269, 277 Worm Breeders Gazette 86

360
X-linked recessive disorders 250 pre-implantation genetic diagnosis 254 sex selection 2545 xenotransplantation 286, 335

INDEX zygote 202n zygote intrafallopian transfer (ZIFT) 220

Bioethics for Scientists Edited by John Bryant, Linda Baggott la Velle and John Searle Copyright 2002 John Wiley & Sons Ltd ISBNs: 0-471-49532-8 (Hardback); 0-470-84659-3 (Electronic)

I Setting the Scene

Bioethics for Scientists Edited by John Bryant, Linda Baggott la Velle and John Searle Copyright 2002 John Wiley & Sons Ltd ISBNs: 0-471-49532-8 (Hardback); 0-470-84659-3 (Electronic)

1 Introduction to Ethics and Bioethics

Michael J. Reiss

1.1 THE SCOPE OF ETHICS

Ethics is the branch of philosophy concerned with how we should decide what is morally wrong and what is morally right. Sometimes the words ethics and morals are used interchangeably. They can, perhaps, be usefully distinguished (Reiss and Straughan, 1996), though many languages do not allow for distinctions to be made. We all have to make moral decisions daily on matters great or (more often) small about what is the right thing to do: Should I continue to talk to someone for their benet or make my excuse and leave to do something else? Should I give money to a particular charity appeal? Should I stick absolutely to the speed limit or drive 10% above it if I am sure that it is safe to do so? We may give much thought, little thought or practically no thought at all to such questions. Ethics, though, is a specic discipline which tries to probe the reasoning behind our moral life, particularly by critically examining and analysing the thinking which is or could be used to justify our moral choices and actions in particular situations.

1.2 THE WAY ETHICS IS DONE

Ethics is a branch of knowledge just as other intellectual disciplines, such as science, mathematics and history, are. Ethical thinking is not wholly distinct from thinking in other disciplines but it cannot simply be reduced to them. In particular, ethical conclusions cannot be unambiguously proved in the way that mathematical theorems can. However, this does not mean that all ethical conclusions are equally valid. After all most philosophers of science would hold that scientic conclusions cannot be unambiguously proved, indeed that they all remain as provisional truths, but this does not mean that my thoughts about the nature of gravity are as valid as Einsteins were. Some conclusions whether in ethics, science or any other discipline are more likely to be valid than others.
Bioethics for Scientists. Edited by John Bryant, Linda Baggott la Velle and John Searle. 2002 by John Wiley & Sons Ltd.

BIOETHICS FOR SCIENTISTS

One can be most condent about the validity and worth of an ethical conclusion if three criteria are met (Reiss, 1999): rst, if the arguments that lead to the particular conclusion are convincingly supported by reason; second, if the arguments are conducted within a well established ethical framework; third, if a reasonable degree of consensus exists about the validity of the conclusions, arising from a process of genuine debate. It might be supposed that reason alone is sucient for one to be condent about an ethical conclusion. However, there are problems in relying on reason alone when thinking ethically. In particular, there still does not exist a single universally accepted framework within which ethical questions can be decided by reason (ONeill, 1996). Indeed, it is unlikely that such a single universally accepted framework will exist in the foreseeable future, if ever. This is not to say that reason is unnecessary but to acknowledge that reason alone is insucient. For instance, reason cannot decide between an ethical system which looks only at the consequences of actions and one which considers whether certain actions are right or wrong in themselves (i.e. intrinsically right or wrong), whatever their consequences. Then feminists and others have cautioned against too great an emphasis upon reason. Much of ethics still boils down to views about right and wrong informed more by what seems reasonable than what follows from reasoning. The insuciency of reason is a strong argument for conducting debates within well established ethical frameworks, when this is possible. Traditionally, the ethical frameworks most widely accepted in most cultures arose within systems of religious belief. Consider, for example, the questions Is it wrong to lie? If so, why?. There was a time when the great majority of people in many countries would have accepted the answer Yes. Because scripture forbids it. Nowadays, though, not everyone accepts scripture(s) as a source of authority. Another problem, of particular relevance when considering the ethics of biotechnology, is that while the various scriptures of the worlds religions have a great deal to say about such issues as theft, killing people and sexual behaviour, they say rather less that can directly be applied to the debates that surround many of todays ethical issues, particularly those involving modern biotechnology. A further issue is that we live in an increasingly plural society. Within Europe there is no longer a single shared set of moral values. Even the various religions disagree on ethical matters and many people no longer accept any religious teaching. Nevertheless, there is still great value in taking seriously the various traditions religious and otherwise that have given rise to ethical conclusions. People do not live their lives in isolation: they grow up within particular moral traditions. Even if we end up departing somewhat from the values we received from our families and those around us as we grew up, none of us derives our moral beliefs from rst principles, ex nihilo, as it were. In the particular case of moral questions concerning biotechnology, a tradition of ethical reasoning is already beginning to accumulate. For example, most member states of the European Union and many other industrialised countries have ocial committees or other

INTRODUCTION TO ETHICS AND BIOETHICS

bodies looking into the ethical issues that surround at least some aspects of biotechnology. The tradition of ethical reasoning in this eld is nothing like as long established as, for example, the traditions surrounding such questions as abortion, euthanasia, war and trade protectionism. Nevertheless, there is the beginning of such a tradition and similar questions are being debated in many countries across the globe. Given, then, the diculties in relying solely on either reason or any one particular ethical tradition, we are forced to consider the approach of consensus (Moreno, 1995). It is true that consensus does not solve everything. After all, what does one do when consensus cannot be arrived at? Nor can one be certain that consensus always arrives at the right answer: for example, a consensus once existed that women should not have the vote. Nonetheless, there are good reasons both in principle and in practice in searching for consensus. Such a consensus should be based on reason and genuine debate and take into account long established practices of ethical reasoning. At the same time, it should be open to criticism, refutation and the possibility of change. Finally, consensus should not be equated with majority voting. Consideration needs to be given to the interests of minorities, particularly if they are especially aected by the outcomes, and to those such as young children, the mentally inrm and non-humans who are unable to participate in the decision-making process. At the same time it needs to be borne in mind that while a consensus may eventually emerge there is an interim period when what is more important is simply to engage in valid debate in which the participants respect one another and seek for truth through dialogue (cf. Habermas, 1983; Martin, 1999).

1.3 IS IT ENOUGH TO LOOK AT CONSEQUENCES?

The simplest approach to deciding whether an action would be right or wrong is to look at what its consequences would be. No-one supposes that we can ignore the consequences of an action before deciding whether or not it is right. This is obvious when we try to consider, for example, whether imprisonment is the appropriate punishment for certain oences e.g. robbery. We would need to look at the consequences of imprisonment, as opposed to alternative courses of action such as imposing a ne or requiring community service. Even when complete agreement exists about a moral question, consequences may still have been taken into account. The deeper question is not whether we need to take consequences into account when making ethical decisions but whether that is all that we need to do. Are there certain actions that are morally required such as telling the truth whatever their consequences? Are there other actions such as betraying condences that are wrong whatever their consequences? This is about the most basic question that can be asked in ethics and it might be expected by anyone

BIOETHICS FOR SCIENTISTS

who is not an ethicist that agreement as to the answer would have arisen. Unfortunately this is not the case. There still exists genuine academic disagreement amongst moral philosophers as to whether or not one needs only to know about the consequences of an action to decide whether it is morally right or wrong. Those who believe that consequences alone are sucient to let one decide the rightness or otherwise of a course of action are called consequentialists. The most widespread form of consequentialism is known as utilitarianism. Utilitarianism begins with the assumption that most actions lead to pleasure (typically understood, at least for humans, as happiness) and/or displeasure. In a situation in which there are alternative courses of action, the desirable (i.e. right) action is the one which leads to the greatest net increase in pleasure (i.e. excess of pleasure over displeasure, where displeasure means the opposite of pleasure, that is, harm). Utilitarianism as a signicant movement arose in Britain at the end of the 18th century with the work of Jeremy Bentham and J.S. Mill. However, its roots are much earlier. In the fth century BCE, Mo Tzu in China argued that all actions should be evaluated by their fruitfulness and that love should be all embracing. In Greece, Epicurus (341271 BCE) combined a consequentialist account of right action with a hedonistic (pleasure-seeking) theory of value (Scarre, 1998). Utilitarianism now exists in various forms. For example, some utilitarians preference utilitarians argue for a subjective understanding of pleasure in terms of an individuals own perception of his or her well-being. What all utilitarians hold in common is the rejection of the view that certain things are intrinsically right or wrong, irrespective of their consequences. Consider the question as to whether or not we should tell the truth. A utilitarian would hesitate to provide an unqualied yes as a universal answer. Utilitarians have no moral absolutes beyond the maximisation of pleasure principle. Instead, it might be necessary for a utilitarian to look in some detail at particular cases and see in each of them whether telling the truth would indeed lead to the greatest net increase in pleasure. There are two great strengths of utilitarianism. First, it provides a single ethical framework in which, in principle, any moral question may be answered. It does not matter whether we are talking about the legalisation of cannabis, the age of consent or the patenting of DNA; a utilitarian perspective exists. Secondly, utilitarianism takes pleasure and happiness seriously. The general public may sometimes suspect that ethics is all about telling people what not to do. Utilitarians proclaim the positive message that people should simply do what maximises the total amount of pleasure in the world. However, there are diculties with utilitarianism as the sole arbiter in ethical decision making. For one thing, an extreme form of utilitarianism in which every possible course of action would have consciously to be analysed in terms of its
CE means common era and thus BCE is a culturally wider term than BC although dates are numbered in the same way, i.e. fth century BCE = fth century BC.

INTRODUCTION TO ETHICS AND BIOETHICS

countless consequences would quickly bring practically all human activity to a stop. Then there is the question as to how pleasure can be measured. For a start, is pleasure to be equated with well-being, happiness or the fullment of choice? And, anyway, what are its units? How can we compare dierent types of pleasure, for example sexual and aesthetic? Then, is it always the case that two units of pleasure should outweigh one unit of displeasure? Suppose two people each need a single kidney. Should one person (with two kidneys) be killed so that two may live (each with one kidney)? Utilitarians claim to provide answers to all such objections (e.g. Singer, 1993). For example, rule-based utilitarianism accepts that the best course of action is often served by following certain rules such as Tell the truth, for example. Then, a deeper analysis of the kidney example suggests that if society really did allow one person to be killed so that two others could live, many of us might spend so much of our time going around fearful that the sum total of human happiness would be less than if we outlawed such practices. The major alternative to utilitarianism is a form of ethical thinking in which certain actions are considered right and others wrong in themselves, i.e. intrinsically, regardless of the consequences. Consider, for example, the question as to whether a society should introduce capital punishment. A utilitarian would decide whether or not capital punishment was morally right by attempting to quantify the eects it would have on the society. Large amounts of empirical data would probably need to be collected, comparing societies with capital punishment and those without it with regard to such things as crime rates, the level of fear experienced by people worried about crime and the use to which money saved by the introduction of capital punishment might be put. On the other hand, someone could argue that regardless of the consequences of introducing capital punishment, it is simply wrong to take a persons life, whatever the circumstances. Equally, someone could argue that certain crimes, for example rst degree murder, should result in the death penalty that this simply is the right way to punish such a crime. There are a number of possible intrinsic ethical principles and because these are normally concerned with rights and obligations of various kinds, this approach to ethics is often labelled deontological (i.e. rights discourse). Perhaps the most important such principles are thought to be those of autonomy and justice. People act autonomously if they are able to make their own informed decisions and then put them into practice. At a common sense level, the principle of autonomy is why people need to have access to relevant information, for example before consenting to a medical procedure. Autonomy is concerned with an individuals rights. Justice is construed more broadly: essentially, justice is about fair treatment and the fair distribution of resources or opportunities. Considerable disagreement exists about what precisely counts as fair treatment and a fair distribution of resources. For example, some people accept that an unequal distribution of certain resources (e.g. educational opportunities) may be fair provided certain other criteria are satised (e.g. the educational opportuni-

BIOETHICS FOR SCIENTISTS

ties are purchased with money earned or inherited). At the other extreme, it can be argued that we should all be completely altruistic. However, as Nietzsche pointed out, it is surely impossible to argue that people should (let alone believe that they will) treat absolute strangers as they treat their children or spouses. Perhaps it is rational for us all to be egoists, at least to some extent. If it is the case that arguments about ethics should be conducted solely within a consequentialist framework, then the issues are considerably simplied. Deciding whether anything is right or wrong now reduces to a series of detailed, in depth studies of particular cases. As far as modern medicine and biotechnology are concerned, ethicists still have a role to play but of perhaps greater importance are scientists and others who know about risks and safety, while sociologists, psychologists, policy makers and politicians who know about peoples reactions and public opinions also have a signicant role. Much energy can be wasted when utilitarians and deontologists argue. There is little if any common ground on which the argument can take place, though some philosophers argue that there can be no theory of rights and obligations without responsibility for consequences, and no evaluation of consequences without reference to rights and obligations. The safest conclusion is that it is best to look both at the consequences of any proposed course of action and at any relevant intrinsic considerations before reaching an ethical conclusion.

1.4 WIDENING THE MORAL COMMUNITY

Traditionally, ethics has concentrated mainly upon actions that take place between people at one point in time. In recent decades, however, moral philosophy has widened its scope in two important ways. First, intergenerational issues are recognised as being of importance (see e.g. Cooper and Palmer, 1995). Second, interspecic issues are now increasingly taken into account (see e.g. Rachels, 1991). These issues go to the heart of Who is my neighbour?. The term bioethics is often used when such questions are being considered, though in the USA and some other countries bioethics often simply means medical ethics. Interspecic issues are of obvious importance when considering biotechnology and ecological questions. Put at its starkest, is it sucient only to consider humans or do other species need also to be taken into account? Consider, for example, the use of new practices (such as the use of growth promoters or embryo transfer) to increase the productivity of farm animals. An increasing number of people feel that the eects of such new practices on the farm animals need to be considered as at least part of the ethical equation before reaching a conclusion. This is not, of course, necessarily to accept that the interests of non-humans are equal to those of humans. While some people do argue that this is the case, others accept that while non-humans have interests these are generally less morally signicant than those of humans. Accepting that interspecic issues need to be considered leads one to ask

INTRODUCTION TO ETHICS AND BIOETHICS

How?. Need we only consider animal suering? For example, would it be right to produce, whether by conventional breeding or modern biotechnology, a pig unable to detect pain and unresponsive to other pigs? Such a pig would not be able to suer and its use might well lead to signicant productivity gains: it might, for example, be possible to keep it at very high stocking densities. Someone arguing that such a course of action would be wrong would not be able to argue thus on the grounds of animal suering. Other criteria would have to be invoked. It might be argued that such a course of action would be disrespectful to pigs or that it would involve treating them only as means to human ends and not, even to a limited extent, as ends in themselves. This example again illustrates the distinction between utilitarian and deontological forms of ethical reasoning, as the issue of pain can be separated from that of rights and obligations in this case. Intergenerational as well as interspecic considerations may need to be taken into account. Nowadays we are more aware of the possibility that our actions may aect not only those a long way away from us in space (e.g. acid rain produced in one country falling in another) but also those a long way away from us in time (e.g. increasing atmospheric carbon dioxide levels may alter the climate for generations to come). Human nature being what it is, it is all too easy to forget the interests of those a long way away from ourselves. Accordingly, a conscious eort needs to be made so that we think about the consequences of our actions not only for those alive today and living near us, about whom it is easiest to be most concerned.

1.5 THE LEVEL AT WHICH ETHICAL DECISIONS ARE MADE

1.5.1 INTRODUCTION Ethical decisions are taken at a number of levels. Failure to distinguish between these can lead to sterile debates in which one side argues that X is good while the other side argues that X is bad. Consider, for example, the case of genetically modied food crops (Reiss, 2001) (see also Chapters 8 and 9, this volume). Controversies over such crops show no sign of abating; indeed, recent years have seen both an intensication of the debate about them and, if anything, a polarisation of attitudes towards them. At the one pole are those who see genetically modied crops as being dangerous or intrinsically unacceptable. Genetically modied pollen and seeds are said to be contaminating conventional crops and wild plants and to pose a threat to human health (see e.g. Friends of the Earth, 1998). At the other pole are those who see these crops as satisfying consumer choice in the West and as providing a lifeline to the prevention of famine and the alleviation of suering in many rural economies (see e.g. Dale, 1999).

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The ethical issues surrounding genetically modied crops are revealed by looking at the various stages or levels in their development, production and consumption. To a certain extent we can envisage the production and use of genetically modied crops as requiring the following steps: research by scientists commercial development regulatory approval planting by farmers the stocking of genetically modied food by retailers the purchase and consumption of genetically modied food by consumers.

While this list simplies the situation in various ways (for example, scientists are, of course, involved in both pure research and commercial development, while individuals at each of these levels also act as consumers) categorising genetically modied food production into these six levels is convenient for analysis. 1.5.2 RESEARCH BY SCIENTISTS Various ethical reasons can be advanced for allowing a particular piece of scientic research to go ahead (Reiss, 2000). One argument is the standard one that one needs strong arguments before one bans things. One of the lessons of history is that in earlier times practices were banned which now most of us consider appropriate. For example, many countries now allow women and non-property owning men to vote at elections. In those cases where countries have decided to ban practices permitted in previous time, e.g. slavery and torture, this is usually because the practices are now widely considered intrinsically unacceptable for reasons to do with respect of persons. It is noteworthy just how much we allow people to do even when we know it would, in at least some senses, be better for them if they did not. For example, it would be better for most people, from a narrow, physical health perspective, if they did not smoke cigarettes. We allow adults to smoke precisely because we think it is better to live in a society where, roughly speaking, the granting of autonomy is considered a higher good than the imposition of benecence i.e. making people do what is good for them. A particular form of the arguments against banning things reason is that scientists should have autonomy with respect to their work. This is not to assume na vely that scientists choose without any constraints their subjects for study. Indeed, it may be that one of the strongest arguments for encouraging scientists to believe that they are acting autonomously is simply the consequentialist one that many people, including, I suspect, academics such as research scientists and moral philosophers, produce their best work when they believe that they are doing what they want to do. For most people, including members of the general public, by far the most signicant reason for it being right for a scientist to carry out a piece of research

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is that there is a reasonable chance that the information gained or ideas generated will be of worth, helping to increase the sum total of human happiness or produce some other desirable benets. This is most clearly the case when we are talking about research in the applied sciences, such as medicine, electronics and the development of genetically modied crops. In addition to ethical reasons for allowing a particular piece of research to go ahead, there are arguments against doing a particular piece of research. For a start, we can imagine pieces of research where most people would consider it wrong for someone even to want to do the research. Then we can imagine cases where carrying out the research programme itself would be wrong because of the direct consequences for those involved in the research. An example is provided by Stanley Milgrams classic work on obedience in which experimental subjects thought they were administering large electric shocks to people when in fact they were not (Milgram, 1963). Despite the undoubted worth of the study, from which a considerable amount of valuable information about human psychology has been learned and which fulls all of the criteria listed above in favour of scientists undertaking research, the codes of many psychological societies would nowadays preclude such research from being undertaken on the grounds that the deception it requires is excessive. Another reason for holding that it would be wrong to carry out a particular research programme is if the programme would be expected to lead to undesired consequences. Some would hold that such an example is provided by research into genetically modied crops. However, it is dicult to defend the argument that the likely consequences of laboratory and greenhouse research into genetically modied crops are negative, in part precisely because such research ought to be able to identify certain harms (principally ecological and food safety ones) before they occur. Of course, once one considers eld trials for research into genetically modied crops, it becomes easier for it to be argued that the net consequences of these will be harmful as eld trials obviously entail a signicant degree of non-containment of genetically modied organisms. A nal and very signicant argument against a proposed piece of research is simply that, whatever its merits, given that research funds are limited, the money could be spent better elsewhere. This argument has an undoubted validity and academics in general, not just research scientists, are all too familiar with it (see also Chapter 15, in relation to the Human Genome Project). However, this argument is dicult to apply to genetically modied crops since the claims made on their behalf are considerable and dicult to reject out of hand. There would, therefore, seem to be a strong case for testing such claims. Further, if it might be the case that genetically modied crops will not alleviate world hunger but instead put small farmers out of work and lead to certain wild plant populations being damaged through genetic introgression or local extinctions, then there is a strong argument for carrying out rigorous research to establish whether these would indeed be the results of genetically modied crop technology, without having rst or simultaneously allowed commercial development to proceed to

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the point where it is much more dicult to prevent the technology from proceeding any further. 1.5.3 COMMERCIAL DEVELOPMENT There is an enormous literature on business ethics (e.g. Jackson, 1995). At one extreme it can be argued that the business of business is business. In other words, companies only have a duty to those who own them shareholders, banks, private individuals and so on. And this duty is a nancial one, i.e. maximisation of prot or some more rened version of this taking into account discounted cash ows and economic value added (Grant, 1998). At the other extreme, for example from certain utilitarian perspectives, it can be argued that companies (more formally, those who control the actions of companies) have a duty to ensure that they operate so as to maximise global happiness or some other utility (e.g. preferences). Pharmaceutical companies are particularly prone to this analysis. After all, it does seem wrong that people should be dying of AIDS simply because they and their governments cannot aord to buy drugs that would extend their lives considerably. It can be argued, though, that it is unfair of people to expect the shareholders or other owners of a particular company to forgo income for this reason. Rather, the onus is on the governments (and the electorates) in wealthy countries to provide such medication for those who cannot aord it. The most straightforward way for this would be for the governments of wealthy countries to use their powers (nancial and regulatory) to ensure that drugs are purchased from the pharmaceutical companies and sent to those parts of the world where they are most needed. Such purchases should be made at prices which still allow the companies to make a small prot. Taking into account economies of scale and the distinctions between the variable costs involved in making more of the drugs and the xed costs (principally the earlier massive investments in the development of the drugs), such prices should be markedly lower than the current market ones, reducing the cost to the donor governments very considerably. A rather dierent approach is to adopt a customer or stakeholder focus. This somewhat pragmatic approach is based on the belief that a company only remains in existence and whatever else a successful company is, it is certainly a company that survives if it satises its customers to a reasonable degree and maintains suciently good relationships with its various stakeholders (customers, employees, regulators, suppliers, etc.) for it to continue to operate reasonably smoothly. Under this reasoning, companies need to consider not just the bottom line of nancial performance. Indeed, certain companies are now talking about the triple bottom line, taking into account their social/ethical responsibilities. Companies genuinely seeking to full what they feel are their social/ethical responsibilities e.g. fair treatment of their employees, reduction of pollution still strive to be nancially successful but take on board a wider range of aims

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and objectives. In addition, their relationships with their various stakeholders are likely to be more open and more transparent and they are likely to place more weight on frequent dialogue with them. The nature of this dialogue is likely to be very dierent from a traditional company, which may simply rely on market research to identify customer needs, irregular formal negotiations with any unions and networking or the occasional piece of espionage to identify competitors intentions and capabilities. 1.5.4 REGULATORY APPROVAL Why do we need regulation rather than simply allowing those harmed by actions to take those responsible for the harm to court? One answer is that people often want regulation to prevent such harms from happening. (I may be able to sue you for harming me because you have failed to show a duty of care, for example by driving too fast, but I may prefer that the harm had never happened, for example by my government having passed laws about speed limits.) Another answer is that legal recourse is a very imperfect way of attempting to redress harms. In particular, those with little money, power or persistence stand only a small chance of successfully taking anyone, certainly a large company, to court. These considerations suggest that the particular duties of a regulatory system are (i) to prevent certain harms; (ii) to provide especial protection for those unable to take legal actions against those responsible for harms. In the case of genetically modied crops, one would therefore expect regulators to pay particular attention rstly to those especially likely to be harmed and secondly to those who lack agency. Some actors, for example non-human organisms and young children, potentially fall into both categories. Other actors, for example adults with certain food allergies, fall into just one. At the same time, it needs to be remembered that there are arguments which suggest that certain genetically modied crops may lead to a lessening of such potential harms or at least to them becoming rarer. If these crops lead to fewer pesticides being used, there may be benets both to wildlife and to human health. Regulators need to keep such possibilities in mind and be especially resistant to listening only to partial points of view whether from companies or from pressure groups. A further duty of a regulator may be to allow people to act autonomously. The persistent cry for legislation for labelling of genetically modied foods (see Chapter 9) validly has this behind it. However, a distinction can usefully be made as to whether a regulator has a duty to insist that labelling actually occurs or a duty to insist that labelling is permitted. Usually it is the former that is argued for, so in the EU there are now regulations about the labelling of genetically modied foods. I think it can be argued that it would have been better simply to have allowed labelling. (At one point companies in the USA were forbidden even from stating that their products were GM-free.) This would mean that food companies and retailers would have been free (i) to choose to label GM foods; (ii) to choose to label non-GM foods; (iii) not to bother. This

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certainly would have saved quite a bit of money and would have suited those consumers who are not too bothered (at least when it comes actually to making food purchase decisions rather than being interviewed for the Eurobarometer or other surveys) whether their food contains genetically modied ingredients or not, simply wanting it to be aordable, safe, tasty and to look good.

1.5.5 PLANTING BY FARMERS Are there particular ethical considerations that apply to farmers? A farm can be seen simply as a small company, in which case there is little to add to what I wrote earlier about commercial duties. At the same time, farms are unusual partly in that they persist much longer than many companies and partly in that they are rooted in one place. Farmers have a particular and enduring relationship with land. This line of argument might suggest that farmers have a particular duty to preserve soil and (endangered) wildlife. Preserving soil, fortunately, is also, pretty much, a duty of self-interest. No farmer seeks soil erosion. Indeed, certain of the farming practices introduced in recent years, for example, direct drilling, reduce erosion while herbicide-resistant crops whether genetically modied or not hold out the prospect of avoiding pre-emergence spraying, reducing erosion further (and, of course, also reducing the level of chemical input into the soil). Perhaps farmers also have a duty to reduce uctuations in yields on the grounds that it is uctuations e.g. two very bad harvests after 20 years of good harvests that lead to malnutrition, suering and death. It might be that uctuations would be reduced simply by maximising yields but it might be that they would better be reduced by farmers not, as it were, putting all their eggs into one basket. Such a principle might need to be backed up by some sort of state subsidy (because individual farmers would not be able to maximise their incomes) but one could imagine a situation in which farmers (collectively rather than necessarily individually) were encouraged to have a diversity of types of agricultural production (e.g. conventional, genetically modied and organic), a diversity of crop species and a diversity of varieties within each crop species (so as to reduce the chances of a pest or disease suddenly wiping out a high proportion of a nations agricultural yield).

1.5.6 THE STOCKING OF GENETICALLY MODIFIED FOOD BY RETAILERS Retailers are companies so the earlier consideration of commercial interests again applies. Is there anything distinctive about retailers and genetically modied food? One line of argument would be that perhaps retailers ought to provide choice to consumers. Certainly, major supermarket chains frequently claim that

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they provide choice to their customers, though this may be more rhetoric than the result of careful ethical reection. Indeed, the late 1990s in the UK saw a move towards the near elimination of choice for the consumer in terms of genetically modied foods. Whereas there was a time when some small supermarket chains (notably Iceland) sought to provide only GM-free foods while the major chains labelled the few genetically modied foods they knowingly sold (notably tomatoes), now all supermarket chains are doing what they can to eliminate genetically modied foods from their shelves, thereby removing choice from those who would buy these products. In fairness to retailers, they can legitimately argue that in doing this they are simply responding to the wishes of the majority of their customers. Do retailers have a duty to stock certain products for a minority of consumers even when it would be commercially better for them not to do so? It is dicult to argue that retailers do have such a duty along much the same lines as I argued earlier that pharmaceutical companies do not have a duty of charity. But just as I argued that governments in wealthy countries may have a duty to help poorer countries, perhaps governments have a duty to protect minority food interests. Perhaps governments should subsidise food products desired only by minorities e.g. organic foods, welfare-friendly meats and genetically modied foods so that they can be purchased at non-premium prices. I think this argument only has any force where there are genuinely convincing ethical arguments in favour of subsidising minority products (cf. Rippe, 2000). I doubt that I have a right to expect governments to subsidise my wish to buy wild rice as cheaply as cultivated rice. On this reasoning the arguments for subsidising genetically modied foods are weaker than those for subsidising, for example, welfare-friendly meats. 1.5.7 THE PURCHASE AND CONSUMPTION OF GENETICALLY MODIFIED FOOD BY CONSUMERS Finally we come to the duties of individual consumers. Suppose that I buy food not only for myself but also for my children or aged parents. If I believe, providing that my belief is not entirely irrational, that there is a chance, even if only a small one, that a food whether genetically modied corn, shellsh or beef is dangerous to their health, then I surely have a duty not to purchase that food unless the probability of the danger is exceptionally low and there are extremely pressing reasons why I should buy the foods (e.g. buying the food signicantly aids the farmer/sherperson of that food more than the alternative I would purchase). Given the suggestion by some scientists, albeit a very small minority of them, that genetically modied foods might be dangerous for your health, this line of argument would mean that it is the duty of parents and others with people under their care not to buy genetically modied food for their consumption. Despite my own belief that the few genetically modied foods permitted to be sold in the EU are at least as safe as conventional foods, I therefore support, for example, the decision by a number of Local Education

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Authorities in England not to purchase genetically modied foods for school meals. Suppose, though, that I buy food only for myself (or for myself and a mentally competent partner and that the two of us genuinely discuss whether we ought to buy genetically modied foods). It seems obvious that I have a right to buy either genetically modied foods or GM-free foods but is one of these courses of action better than the other? Given the present empirical uncertainty as to the environmental, health and socio-economic consequences of genetically modied crops I do not think we can say so. However, perhaps I do have a duty to keep myself informed so that if the evidence begins to weigh one side of the scale downwards I can, if needs be, amend my food purchasing decisions. The same line of reasoning makes it incumbent upon me to consider (and act upon the considerations) whether, for example, I should buy welfare-friendly food. I note in passing that as I have a large income and no children there is a greater burden of duty on me to bear such considerations in mind and act upon them than if I had a small income with several dependants.

1.6 CONCLUSIONS
There is no single way in which ethical debates about biotechnology or almost any other matter can unambiguously be resolved. However, that does not mean that all ethical arguments are equally valid. Ethical conclusions need to be based on reason, take into account well established ethical principles and be based, so far as possible, on consensus. Education and debate play an important role, helping to enable people to clarify their own thinking, express their views and participate in the democratic process. As far as biotechnology and modern medicine are concerned, both intrinsic and consequentialist arguments for and against their deployment can be advanced. Deciding whether or not particular instances of modern biotechnology and biomedical science are acceptable means looking in detail at individual cases. To a large extent, this is what the rest of this book does.

REFERENCES
Cooper, D.E. and Palmer, J.A. (eds) (1995) Just Environments: Intergenerational, International and Interspecies Issues. Routledge, London, UK. Dale, P. (1999) Public reactions and scientic responses to transgenic crops. Current Opinion in Biotechnology, 10, 203208. Friends of the Earth (1998) Genetically Modied Food: Brieng. Friends of the Earth, London, UK. Grant, R.M. (1998) Contemporary Strategy Analysis: Concepts, Techniques, Applications (3rd edn). Blackwell, Oxford, UK. Habermas, J. (1983) Moralbewusstsein und Kommunikatives Handeln, Suhrkamp, Frank-

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furt am Main, Germany. Jackson, J. (1995) Reconciling business imperatives and moral virtues. In Introducing Applied Ethics. Almond, B. (ed), Blackwell, Oxford, UK, pp. 104117. Martin, P.A. (1999) Bioethics and the whole: pluralism, consensus, and the transmutation of bioethical methods into gold. Journal of Law, Medicine & Ethics, 27, 316327. Milgram, S. (1963) Behavioural study of obedience. Journal of Abnormal Psychology, 67, 371378. Moreno, J.D. (1995) Deciding Together: Bioethics and Moral Consensus. Oxford University Press, Oxford, UK. ONeill, O. (1996) Towards Justice and Virtue: a Constructive Account of Practical Reasoning, Cambridge University Press, Cambridge, UK. Rachels, J. (1991) Created from Animals: the Moral Implications of Darwinism. Oxford University Press, Oxford, UK. Reiss, M. (1999) Bioethics. Journal of Commercial Biotechnology, 5, 287293. Reiss, M.J. (2000) The ethics of genetic research on intelligence. Bioethics, 14, 115. Reiss, M.J. (2001) Ethical considerations at the various stages in the development, production and consumption of GM crops. Journal of Agricultural and Environmental Ethics, 14, 179190. Reiss, M.J. and Straughan, R. (1996) Improving Nature? The Science and Ethics of Genetic Engineering. Cambridge University Press, Cambridge, UK. Rippe, K.P. (2000) Novel foods and consumer rights: concerning food policy in a liberal state. Journal of Agricultural and Environmental Ethics, 12, 7180. Scarre, G. (1998) Utilitarianism. In Encyclopedia of Applied Ethics volume 4. Chadwick, R. (ed), Academic, San Diego, USA, pp. 439449. Singer, P. (1993) Practical Ethics (2nd edn). Cambridge University Press, Cambridge, UK.

Bioethics for Scientists Edited by John Bryant, Linda Baggott la Velle and John Searle Copyright 2002 John Wiley & Sons Ltd ISBNs: 0-471-49532-8 (Hardback); 0-470-84659-3 (Electronic)

2 The Public Evaluation of Science and Technology

Barry Barnes

2.1 INTRODUCTION
An understanding of the formal theories of ethical and moral philosophy may be necessary for anyone who would grapple with substantive bioethical issues but it is not sucient. Also essential is an awareness of context, and a sense of how ethical debates, involving both experts and ordinary people, are structured by context and by the way that the parties to the debates perceive each other therein. In brief, a broad empirical understanding of the form and setting of ethical debate is needed, and this chapter is intended to provide the rst steps toward one.

2.2 WHAT IS BEING SPOKEN OF?

Debate in bioethics is part of the larger debate through which we seek to establish, to understand, and to set in better order, our relationship with science and technology, a relationship that is at once a source of hope and anxiety. What though are the science and technology that gure in this debate? The dictionary tells us that science is the knowledge of nature, and technology the technical skills, possessed by a specic culture. On these denitions, the science and technology of a society are a part of its cultural tradition. They are embedded in the culture that all share. And this indeed is how anthropologists encounter the technical lore and skill of simple unspecialised societies. Denitions of this kind, however, seem somehow inappropriate in the societies in which we ourselves live. We do not, in the normal way of things, reckon our cookery books and cake-baking skills to be parts of our science and technology. For us today, science and technology are other; we speak of the relationship between us and
The discussion will be biased toward Britain, and may reect some of the unfortunate idiosyncratic features of that setting over the last couple of decades. For a comprehensive survey of what the social sciences can provide by way of background empirical understanding here, see Jasano et al. (1995).
Bioethics for Scientists. Edited by John Bryant, Linda Baggott la Velle and John Searle. 2002 by John Wiley & Sons Ltd.

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them, and ask how much in the way of benet, or threat, they oer us. For the most part, this sense of otherness is the product of division of labour. As this proceeds, great amounts of knowledge and arrays of technical skills are alienated from ordinary life, and come to reside in esoteric sub-cultures, wherein experts sustain them for us, and make use of them on our behalf. The dictionary commemorates the change by oering alternative denitions, wherein science becomes the systematically acquired knowledge of a eld or discipline, and technology the practice of the applied sciences or the mechanical arts. Now science and technology may sensibly be regarded as other, and it may be meaningful to speak of their eects on our everyday culture, even if they are never totally separated from it. Above all, they now exist as a set of occupations, the specialised activities of which are recognised as beyond our ordinary understanding yet of profound signicance to us. It might be objected that whilst science has indeed become something other and alien, this is not true of technology. Is not technology all around us today? Do we not swim in it? There is indeed a sense in which we do, but in another sense we are alienated from technology more profoundly even than we are from science. If people are asked what technology is today, they tend to speak of it, not as skills, but as tools, machinery and gadgetry. Of course, skilled technical activity has always involved tools and artefacts, and any account of technology must do justice to their role. But in the context of everyday life, technology is now close to being perceived as nothing but artefacts; and the associated skills, and the people who carry them, are rarely mentioned. Technology has been reied in our imagination. Nonetheless, we do remain uneasily aware of a technology behind technology as it were, of a hidden realm of skills and processes, and hence also of people, at work somewhere or other. And if we address biotechnology with this in mind, then we may become aware of what older concepts of technology would have placed in the forefront of our attention from the start: a vast and rapidly growing body of esoteric activities devoted to the manipulation of materials. Biotechnology is a materials technology of quite formidable potency and daunting promise.

2.3 THE TRADITIONAL COLLEGIAL ARRANGEMENT

There are signicant dierences between our perceptions of science and of technology, and indeed between science and technology themselves, but they can remain in the background here. Most of what I want to say is relevant to both, and bioethical issues tend in any case to arise out of work in elds where the
This is well understood by producers of consumer technology, who try hard to overcome the problem by attering and reassuring its purchasers. Individuals are encouraged to regard themselves as empowered by technology. Our experience of this technology is often of consoles with buttons to press and switches to turn and screens to survey on sealed cases that aspire to invisibility.

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boundary between the two is blurred. The discussion here will centre on the occupational activities of possessors of empirical knowledge and expertise, and their relationship with audiences and institutions in the wider society. A traditional method of eecting a division of intellectual and technical labour in society has been to make specic domains of esoteric knowledge and skill the province of particular occupations organised along collegial lines as professions. How these professions have been organised, how they have oriented themselves to external audiences, and how they have been perceived and evaluated by those audiences are all closely intertwined questions, and so it is important to say a little about the nature of the collegial organisation involved. It is indeed one of the simplest of all forms of organisation. A clear distinction is made between those within and those without the professional group. Those within the group communicate freely with each other on professional matters; all have the same pro forma standing as competent peers and the same entitlement to exercise professional judgement. Those outside the group are denied standing on the relevant technical matters and any entitlement to evaluate them; indeed they are expected to recognise their own incompetence on such matters and acquiesce in their exclusion. Collegially organised disciplines have traditionally accepted the tasks of preserving, transmitting, enlarging, and evaluating the knowledge recognised as in their proper domain. Furthermore, external powers have permitted them to monopolise these tasks and recognised their autonomy in the execution of them. The individual members of such disciplines are not mere employees, but participants in semi-independent communities wherein specic moral and ethical obligations are recognised. Sometimes these may be codied obligations relevant to the specic powers and practices of a particular eld. Medical professionals, for example, possess extensive powers of intervention into the operation of human bodies, even against the resistance of the inhabitants of those bodies, and a strong professional ethic constrains their use. But, partly due to the increasing distrust of expert professionals to be discussed later (Sections 2.42.6), they are tending to lose powers of this kind, and to be dened simply as carriers and suppliers of advice and skill, who inform and implement the decisions of others (Barnes, 1999). And the discussion will concentrate accordingly on how a collegial framework of ethical and moral obligations characteristic of practically all elds and disciplines informs the performance of this basic role. A crucial obligation here is that which enjoins individuals to make their ndings and judgements freely available to the collective, and to cede any personal rights in them. The ndings are then evaluated by the collective in the light of its shared inheritance of esoteric knowledge and understanding, and, if accepted as valid and signicant, made available to all. Every member of the collective is thus able rapidly to acquire and utilise results which, rather than merely being idiosyncratic individual reports, have been subject to a collective quality control process and granted the imprimatur of the entire eld. But there are important prohibitions to be observed as well as positive injunctions. In

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particular, individuals may not accept direct nancial reward for their work, or for their opinions of the work of others. The recognition and regard of peers must suce as immediate reward for these, or else professional judgement would be vulnerable to external inuence and control, and liable to be less than properly disinterested. The crucial role of peer recognition as the proper currency of reward, and of the taboo on direct monetary incentives, is indeed precisely to maintain the autonomy of the specialised eld and especially the independence of the technical judgement of its members. For further discussions of this the reader is referred to the work of Barnes (1985) and Ziman (1968) and particularly to the seminal analysis of academic science by Robert Merton (1973). The existence of this internal ethical order has important implications as far as external audiences are concerned. A consensus of expertise is presented. The entire collective, and its inheritance of knowledge and competence, is seen to lie behind specic expert pronouncements. Every individual member is able to speak at least to some extent as the authoritative representative of the collective. And the unbiased and disinterested character of such pronouncements is proclaimed in the prohibition upon monetary reward. Thus, the discipline is encountered as a source of knowledge and advice deserving of credibility; and trust and deference on the part of its external audience is conrmed as the correct attitude. Expertise is properly dispensed by such a discipline, we might say, in hierarchy mode, from an authoritative transmitter to a subordinate passive receiver. And a nal ethical obligation upon the members of such a discipline is precisely to dispense knowledge honestly, disinterestedly, and only as their competence permits, to such receivers. It needs to be reiterated that expert authority in this scheme of things extends only over a delimited domain. Viewed in a larger frame, the passive receiver of advice may be one of the politicians or bureaucrats who are on top, and the expert authoritative transmitter may be just one of the many minions that they have on tap. Such politicians or bureaucrats are expected to see the advantages of following a self-denying ordinance, against transgressing upon the experts legitimate domain of autonomy or seeking to inuence her judgements therein. This ordinance, along with the reciprocal obligations of experts themselves, must be seen as a constitutive part of an overall ethical frame, within which expertise is dispensed and from which much of its credibility derives. (Whereupon it becomes unsurprising that as politicians and bureaucrats have come to scorn it, as increasingly they have in Britain in recent years, so they have corroded their own already tenuous credibility.)

The description does not just apply to academic contexts. Any audience seeking advice from experts requires disinterested and competently scrutinised testimony. If the products of a company are likely to kill people the company tends to prefer its in house experts to say so. The crucial dierence between academic experts and their employee equivalents is not any lack of immediate disinterest in the latter, but rather their subsequent respect for norms of condentiality.

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2.4 THE MARKET ALTERNATIVE

Technical expertise requires trust: its acceptance cannot rest upon the visible merits of its advice, nor even upon the manifest ecacy of its practices and artefacts. Even so, our relations with experts are by no means invariably conducted in hierarchy mode, and there are even those who regard it as no more than the residue of an old aristocratic order, wherein scientic professionals borrowed the organisational arrangements of priests and clerics. More common today is a market mode of orientation to expertise, wherein the validity of what we are told is something for us to decide, and expert practitioners routinely recognise our right, even as ignorant outsiders, to evaluate their expertise. In market mode, experts face fewer formal ethical demands than when they operate collegially in hierarchy mode, although it is arguable that this merely exposes them as individuals to informal ethical demands that are in practice just as great. In market conditions, experts must compete with each other, and it is this that structures and underpins their credibility. An external audience faced with conicting sources of advice or technical assistance may decide for itself which to accept, comparing one with another, and taking account, if it wishes, of their track records and reputations for veracity and/or ecacy. It is no longer necessary now for dierent elds of knowledge to be made the exclusive preserves of disciplinary monopolies, and expert judgements need no longer be uncoupled from the biases represented by direct nancial rewards. Partiality is attenuated, not by the insulation of experts, but by their exposure as a body to a range of dierent biases. Experts may seek to remain, or to appear, independent of any and all such biases if they wish, but this is no longer essential. Indeed, experts may make themselves available for hire, by interested parties free to select that one from a range of opinions that they best like the sound of; for the superior reliability and disinterest of expert judgement is no longer presumed in market mode, and lay judgement has institutional precedence over it. Consider how, in a criminal trial, the conicting expert submissions of defence and prosecution are heard by a lay jury, and the jurys judgement, not the experts judgements, of the relevant matters of fact is authoritative. So it is whenever expertise is addressed in market mode. The evaluation of technical expertise in modern societies proceeds in both hierarchy and in market mode but there are fundamental deciencies in both. Whilst an exclusively hierarchical system oers experts the opportunity to make the very most of their special knowledge and skill, the complete absence of any external accountability or lay evaluation permits abuse of privilege: a purely hierarchical approach will in theory support charlatans as readily as genuine experts. On the other hand, a pure market system expects too much of lay evaluation. If lay persons acquire the knowledge they need properly to evaluate
There is frequent controversy over how ecacious technological artefacts actually are: see Mackenzie (1990), Mackenzie and Wacjman (1985), Collins and Pinch (1998).

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technical experts, then the eciency benets of division of labour are lost and indeed there no longer is expertise; if they do not do so, then lay evaluation will necessarily be incompetent. Indeed for lay persons to presume to evaluate a consensus of technical expertise comes close to their acknowledging the special standing of experts and then promptly denying it. Given the current trend to market, it is worth citing some instances that highlight the deciencies of that mode. Currently (writing at the end of the year 2000), the British media, ever on the lookout for a food scare, are making much of policy issues raised by genetically modied foods. Debate on these issues is, of course, much to be desired. But what must it be like for a competent expert to read the relevant science, courtesy of the newspapers; or to hear the foods denounced as dangerous in passer-by interviews; or to come to realise how widespread is the belief that there are no genes in food until scientists put them there (but see also Chapter 9)? Indeed, it must be dispiriting to experts of all kinds to nd that entities they regard as intrinsic to human beings as natural organisms, genes for example, or chemicals, are widely regarded by outsiders as extrinsic intrusions, unnatural and dangerous. And it is an intriguing ethical question whether there is a duty on a society, or its citizenry, to acquaint itself with the rudimentary elements of the cosmology of the scientists on whose knowledge it chooses to rely. It is not only the misapprehensions of the public, however, that can undermine authentic expertise. The claims of formal organisations and organised pressure groups, possessed of their own in-house specialists, may also do so. Consider the campaign famously waged by Greenpeace to prevent the Shell Company from disposing of its Brent-Spar oil container in the deep ocean (Rose, 1998). As its activists were seen rushing to the rescue of the environment, it was (falsely, as came to light later) alleged that vast quantities of toxic chemicals and pollutants were present in the structure. And the mixture of televisual spectaculars and breathtaking misinformation cynically deployed was indeed strikingly successful. How must it have felt to someone with a genuine concern for the technical issues to watch this campaign deliver victory to an organisation that apparently has even less care for truthfulness than it has for legality? Not all threats to the integrity of expertise, however, are external ones. Experts may become their own worst enemies, in systems that operate in market mode. The BSE (mad cow disease) outbreak and its eruption into the public domain placed immense ethical demands on scientists and experts. Some of them will now remember episodes wherein they stood silent, as their controllers intoned expedient accounts of what the science they claimed to be guided
A fascinating complication here is the existence of lay expertise, in the possession of ordinary members, to which professional experts do well to defer; see Epstein (1996). The example of a pressure group is cited since instances of scandalous misrepresentation by companies, pharmaceuticals manufacturers for example, are all too familiar. For documentation of what is claimed, even the Greenpeace authorised version, in Rose (1998), will serve.

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by really implied. No doubt they, like those of their colleagues who risked their careers by putting their heads above the parapet, now have a special insight into the value of traditionally constituted, genuinely independent bodies of expertise. Anyone who knows him- or herself to possess genuine expertise, yet is treated nonetheless as just another interested contributor to a plethora of competing claims, is bound to be struck by the limitations of the market mode. Indeed there can be few more tragic experiences than that of such an expert watching lives being lost and resources wasted because his or her skills have been disdained and distrusted. Yet the trend is all to market. Always dominant in some contexts, it is extending ever further at the expense of hierarchy; and is now apparent in our orientation to expertise even in the most esoteric and mathematical areas of the natural sciences. It is important to consider why this is so.

2.5 THE MOVE TO MARKET

The shift to market is part of a larger development associated with systematic secular changes in the nature of our society. At the macro-level, the key changes involve dierentiation, division of labour, a shift toward democratically ordered institutions, and the spread of powers and resources to a larger and larger proportion of people. At the level of informal experience, they are manifest as a reduced willingness to accord deference and honour to others, and to acknowledge their claims to status and authority without compelling reasons. We appear to have lost the knack of deferring to those of superior standing, in whatever respect, whilst remaining fully secure in our own self-esteem. In our empowered society, the existence of independent expertise is sometimes perceived, less as an ecient institutional arrangement, and more as the cause of a democratic decit in our decision making. Deference is equated with an unreciprocated dependence, and such dependence is felt as inferiority and indignity (a feeling that some scientists are amazingly skilled at intensifying!). Use of hired expertise is a widely favoured response. We remain ready to reward experts richly for their services, but we increasingly insist on oering only direct monetary rewards, that deny, or even invert, status relations, and erode expert autonomy rather than reinforcing it as deference does. The result is a shrinking supply of genuinely independent expertise and a situation wherein most major technical decisions are fought over by the experts of conicting parties. And such experts nd themselves addressing lay audiences that, far from deferring to them, are increasingly inclined to question their advice, and even to evaluate its technical basis. Moreover, as the taboo on direct monetary reward is eroded, expertise becomes ever more closely coupled to sources of nance, and ever more liable to be
Britain has been intensely aected in recent years, not just by BSE, but also by a rabid aversion to genuinely independent expertise and indeed independent professional activity of any kind.

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perceived as in their pocket. And because those sources are plural and divided, expertise itself becomes plural and divided, often even at the collective and institutional level, since dierent elds may serve dierent client-audiences. Consequently, experts cease to speak with one voice, and come to be found on both sides of any tendentious issue, acting not just as sources of technical advice but as advocates as well. Every interest group able to purchase it secures the advice it wants to hear, from experts of some sort or other. And advisors routinely express rmly held convictions, reecting, they tell us, their own expert knowledge, in the face of the equally rm convictions of expert opponents. All this is beautifully displayed and analysed, in study after study, in the work of Dorothy Nelkin (1975; 1992). Needless to say, where experts disagree it is not possible to relate to them in hierarchy mode. Indeed, their disagreement will encourage a generalised distrust of expertise, and rightly so, since one side must be incorrect (at least within the limits of available data) in such cases, yet both represent the authority of expertise as such. Similarly, experts associated with powerful interests, even to the extent of being in their pay, cannot but engender suspicion in lay audiences and an inclination to question their authority. And distrust and suspicion of this kind is indeed ever more apparent. One highly visible way in which it expresses itself today is in a readiness to associate risks and uncertainties with scientic and technological advances, and to question the risk assessments oered by technical professionals themselves. In particular, there is an intense public interest in the risks and dangers science and technology pose to the environment. In his book, Risk Society (1988), Ulrich Beck sets out in an uncompromising fashion what is now the ubiquitous method of argument used by individuals, social movements and bureaucratic organisations alike, when they campaign as environmentalists against technological innovation. Any evident benet of a programme of innovation must be weighed, it is said, against unintended harms, whether demonstrable pollutions, or purely hypothetical future risks and dangers. Dominant powers and institutions will seek to conceal these risks and dangers, and environmentalists should help to expose them, and facilitate a more enlightened politics that takes account of them. This has indeed become a very important form of utilitarian moral argument, and many studies now exist of disputes conducted in terms of it. And on the face of it they oer support to Becks vision. Environmental movements have created extensive anxiety about a whole range of previously unacknowledged risks (or alleged risks), enough in
Scientists and technologists are monopoly suppliers of instrumental knowledge to political and state power, and this is bound to impact adversely on their credibility. And indeed how far ought outsiders to trust scientists who are content to be gagged, or to have their reports discarded, when their ndings are found politically inconvenient? What is to be made of a scientic profession that could lay bare the most recondite physical properties of the radioactive elements with magnicent objectivity, yet long had great diculty in making known even the most elementary pharmacological properties of the cannabinols? On this last topic, unfortunately, vast amounts of nonsense have been put forth, both by scientists and politicians, and a huge vested interest in untruth has been created.

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some cases to bring about substantial revisions, or even reversals, in major technological projects that initially had impressive political support. To cite a topical example in the area of biotechnology, the introduction of genetically modied crops into Britain was eectively halted in its tracks within a few months of its rst being subjected to criticism of this kind, notably by Greenpeace (see also Mayer, Chapter 9 in this volume). On closer examination, however, the lesson to be learned from these controversies is not quite what Beck suggests. For all that a powerful mobilisation of opinion is sometimes achieved, the technical knowledge actually deployed in the public sphere is typically scant and simplistic. Moreover, not only is it selectively deployed as the dierent versions of things oered by the experts of opposed sides, it is selectively believed as well, with each version securing credibility with its own distinct audience. If Mary Douglas (1992) is right, risky side-eects are imputed only to the science and technology of disliked powers and institutions, not to that of friends and allies. Consequently, maps of technological risks and dangers in a society become congruent with its members maps of the social and moral order. And controversies over science and technology become extensions of political battles ongoing elsewhere. Moralutilitarian arguments express and rationalise positions in these controversies, but institutional relationships account in a causal sense for their existence. It is worth adding that controversies over methodology and styles of inference may be structured in this way, as well as substantive expert claims. For example, the need for scientists to recognise the fallibility of their knowledge is everywhere acknowledged, but the in-house experts of environmentalist organisations often give this special emphasis. By combining it with the precautionary principle (Chapters 3 and 9) that nothing should ever be done until we are certain that it is free of risk, they can attack the plans of the high-tech organisations that are their enemies. Needless to say, the experts of these enemies are notably less inclined to dwell on the implications of fallibilism, and more likely to stress the formal inadequacy of a precautionary approach. And on this last point they are of course correct. The ethical issue of what level of protection from risks and uncertainties citizens have a right to expect is indeed increasingly addressed in terms of the precautionary principle. But this profoundly unfortunate development is a triumph of the principle only as rhetoric; for there is no way in which it can be applied authentically in what must always be an incompletely known environment replete with uncertainties. As the move to market has proceeded, so the encompassing ethical scheme in which expertise was traditionally dispensed has become harder to apply, and no alternative has emerged. This has, of course, been recognised and lamented, and various eorts have been made to ll the gap. For example, the way that the legal system orders adversarial encounters within a shared frame has inspired some largely unsuccessful experiments with science courts. But it is surely
See also Douglas and Wildavsky (1982) and Wildavsky (1995), which last serves as an admirable foil for Beck and his environmentalist approach.

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utopian to expect that opposed experts, serving diverse and conicting interests, some of which are actually furthered by the continuation of conict, are going to evolve an agreed ethical framework within which their dierences might be resolved.

2.6 RESPONSES TO BIOTECHNOLOGY

The merits of a traditional deferential orientation to expertise have been emphasised in the previous discussion, but it is now often impossible for individuals to orient to experts in this way. A political and institutional consensus in unconditional support of independent expertise is necessary to sustain the hierarchy mode, and increasingly it is lacking. Social change has produced conditions favourable to the market mode, and for better or worse that is what is likely to ourish, in conditions marked by fragmented expertise and fragmented audiences for them. Indeed, there is now so much fragmentation that it is unwise to speak of the credibility of experts among an undierentiated public. References to the public, including those to the public understanding of science, are now rarely more than the rhetorical ourishes of some specic faction or interest group. The expert must expect to attract, not just trust and support, but suspicion and hostility, from audiences moved by the principle that my enemys expert is my enemy. And experts with enemies must always expect those enemies to take any chance to undermine their credibility and faith in the extent of their powers. Ironically, it is often the awesome extent of these powers that engenders hostility to experts in the rst place. The link is certainly apparent with nuclear physics and engineering, but it seems also to be emerging in the context of biotechnology. Power arises from knowledge and competence, and wherever it emerges it engenders some hostility. Moreover, in the guise of research, scientic and technological expertise is a power that casts a shadow over not just the present but the future. Through its continuing reconstitution of knowledge and competence it forces us to accept a continuing reconstitution of our social life, whether we would or not. Many intellectuals and social scientists have drawn attention to this. Ulrich Beck (1988), for example, has spoken of societies wherein politics chases along vainly in the slipstream of an invisible science and technology, ever seeking ex post facto to regulate the powers that they constantly yet unpredictably conjure into being. A nice example here is the diculties that legislators in Britain have faced in attempting to keep pace with developments in new reproductive technologies and with the pressure for ever more extensive use of human embryos in the research involved (Warnock, 1985; Mulkay, 1997). Beck (1988) gives marvellous expression to the indignation of the political
There may be many reasons for this. Thus Beck (1988) suggests that dependence on the very science they attack is capable of greatly intensifying the bitterness and even irrationality of the attitude to science of some environmentalists.

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intellectual confronted by the untouchable power incarnate in specialised technical knowledge. How is it, he asks, specically referring to this new human biotechnology, that specialists are able cheerfully to proceed with research on techniques with truly radical implications for the institution of the family, and hence for society as a whole, without any kind of democratic control being brought to bear upon them until it is too late, and they are a fait accompli? Why should there be a constant ow of uncontrolled intrusions into the core of our social life, leaving political institutions and regulatory agencies to patch some sort of tolerable order out of their aftermath? These are important questions. And of course they bear with particular force upon the new human biotechnology, which has profound implications for familial and sexual relationships and the associated customs and practices. Nor should such questions be side-stepped by formulaic references to progress, or to the inevitability of technological advances and the need to make the best of them. The temptations of such positions to the specialist are obvious of course, and it is not to be wondered at, for example, that some biotechnologists are inclined to regard a forthcoming genetically proled and managed society, even embodying a moderate eugenics, as laudable and benign, despite the warnings of recent history (see Chapter 15). But it is important to remain aware of the complexity of the problems here, and in particular to keep in mind that the social and institutional implications of technological changes are not simply aggregates of the benets and advantages they oer to individuals. A standard feature of many individually benecial biotechnological innovations is that they create serious problems at the collective level. Consider how research has made it possible for parents to choose the sex of their childrenor their gender, as is often now erroneously said. No doubt this is a benet for the individual consumer. But if it were to lead to a 70/30 ratio of the sexes, or even of the genders, that would clearly be a collective harm. Indeed this outcome of all the individual choices involved would amount to a net harm, not just to the collective as a whole, but to each individual member of it, even though every individual choice was itself a true expression of rational self-interest. The perverse outcome here is an example of the problem of collective action, also known as the free rider problem, a problem long familiar to economists and social scientists, and scarcely less so to biologists and biotechnologists. In the instance above, the ratio of the sexes in an entire society is the product of very many decisions and actions, and no one such makes a noticeable dierence to it. It may be that a 50/50 ratio is the best for the collective, but no individual benets from acting morally to help to bring it about and individuals do better to follow self-interest, say by choosing a male child for economic reasons, and to leave others to create the desirable 50/50 ratio. But when everyone seeks to take a free ride on the moral actions of everyone else in this way, no moral action at all ensues, and the overall state of aairs that all desire
The locus classicus of discussion of this in medicine and biology is vaccination programmes.

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does not ensue. And this may happen even when the lack of this desired state is far more harmful to each individual than the loss of the individual advantage for which they acted would have been. (The relevance of the free-rider problem to bioethical issues was famously demonstrated by Hardin (1968), in an account that both clearly set out its basic form and discussed memorable exemplary instances wherein it arose. And indeed one of the best ways of overcoming any diculty in grasping the general form of the problem is still to turn to Hardins text and the examples given therein.) Biotechnological research, in impinging upon sex and kin relations and the domain of the family, intrudes into areas of life of immense signicance that are particularly vulnerable to collective action problems as new knowledge is produced. These are areas that so far have been subject to little systematic control and external regulation areas wherein conduct has only fallen into tolerably coordinated patterns because of the lack of knowledge and power of those engendering it. As knowledge and power become available, this basis of coordination may be eliminated and a profound problem of social order thereby created, precisely the kind of problem that generates anxiety and a sense of moral and ethical disorientation. There is any number of possible illustrations here, besides that given above. Carriers of deleterious genes may pose a collective action problem if they acquire knowledge of their state. For example, someone who is a knowing carrier of a deleterious recessive allele, say for one of the heritable anaemias, may consciously weigh individual good against collective good in deciding whether to procreate and with whom. And others in the know, the partner or the doctor of the carrier, for example, or even the biotechnologist who made the knowledge available, may be similarly empowered (see Chapters 13 and 14). Societies often move quickly to solve collective action problems by subjecting individuals to social inuence, regulation or control. But such moves alter the existing social order, and cumulatively have the potential radically to transform it, a point not always appreciated by technical experts themselves, who, unlike many, may expect to be as powerfully placed in any new order as in the old. Even as new human biotechnology oers individuals new powers, they are likely to encounter eorts to control their use of them, whether from peers, proximate authorities, experts, or bureaucratic creatures of the state. And particular studies have documented both benecial and tragic consequences associated with all four kinds of intervention (Wilkie, 1993). Probably the greatest cause for anxiety, however, arises at the institutional level. It could well be that the emergence of new powers and possibilities from biotechnology will for the most part be experienced as a greatly intensied medical and bureaucratic intrusion into areas of life that so far have been spared it (Nelkin and Tancredi, 1994).

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2.7 PROBLEMS OF MEANS AND ENDS

Clearly, there are impeccable utilitarian arguments with which to rationalise opposition to the benets of research and innovation, and calls for it to be externally restricted and controlled, even where both the competence of the research and its benets are recognised by its opponents. But it is not sucient to address these issues entirely in terms of utilities and the kinds of diculty represented by the collective action problem. For it may be that the entire utilitarian frame of reference becomes a bone of contention when the standing of specialised expertise is at issue. This is again a point well illustrated by reference to biotechnology (Barnes, 1999). Biotechnological research projects are commonly justied to external audiences in utilitarian terms. They will provide means to specic ends. But as a vast institutionalised system, human biotechnology must also be justied as a whole, as a means to very general human ends. Commonly, it is justied as conducive to our health and wellbeing. But human health and wellbeing can only be characterised in general terms if we have some conception of the fundamental character of human beings and hence a sense of their normal, healthy condition. Inferences about this are often made from our knowledge of human biology, which is perfectly reasonable. But to rely on such inferences is to create enormous diculties for the evaluation of a human biotechnology that aunts its capacity to change anything and everything that constitutes human biology. A technology liable to transform the basic nature of human beings cannot be justied simply by reference to the health and wellbeing of human beings as they currently are. Indeed if humans were to apply such a technology to themselves without limit or restraint, the very distinction between technological skills and artefacts and their human possessors would be eroded, and the whole basis of means/end utilitarian thinking would disappear. A utilitarian frame of justication is viable here only if a taboo is placed on any change in whatever we agree is constitutive of our basic nature (see Chapters 14 and 16 for discussion of specic examples). It would be far fetched to suggest that formal problems of this kind are sources of anxiety at the level of everyday life. Nonetheless, people are well aware intuitively that ordinary means/end thinking entails a distinction between what are means and what are ends, and that the two have to be marked as separate and made the subjects of dierent attitudes. And reection on biotechnology disturbs us at this same intuitive level because, as instrumental action, biotechnology reacts back upon us, the ends of the action, and treats us as means are normally treated. Or, at least, it disturbs because it may be that we are being treated as means, depending on what we, as ends, are taken fundamentally to consist in. This question of what we fundamentally are bothers people. Human beings have the status of independent units in their social relations each individual is treated therein as a unitary essence yet they are unsure just where to locate that

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essence, and how to think of it. It is quite common empirically for individuals to take their entire bodies as constitutive of who or what they fundamentally are. Others, having been told about them, take their genes very seriously. The members of the British House of Lords, for example, insisted on exempting themselves, as nobility, from the legislation that everywhere else gave the husband of the mother full legal standing as the father of her children by donor insemination. For their Lordships inheritance of noble nature had to be by blood, as they said (cf. Jones, 1996), and genetic connection. Nor should academics be too quick to criticise them. Moral philosophers are prone to make a similar fetish of mind or reason, and many biologists and social scientists have put forward weird and wonderful ideas of their own on these matters. There is enormous variability in the responses of individuals to this problem, but many such responses impact inconveniently upon biotechnology as an abhorrence of the use and manipulation of human cellular materials, the genome and germ cells above all, embryos and foetal tissues sometimes, even somatic cells occasionally as with those opposed to transplants or blood transfusions. Among medical researchers in Britain, this is widely referred to in private as the yuk factor, and seen as a perverse and irrational source of diculties. If we can alleviate suering, eliminate pathologies, or extend life by manipulating these materials, it is asked, then why should we be held back by taboos? But whilst the question is a good one, the presumption of irrationality underlying it is false. Those who observe taboos and avoidances cannot be dismissed out of hand as irrational. Indeed, some of their critics are more deserving of the epithet for deploying a facile utilitarianism that completely fails to reect on the utilities it invokes, or even to notice that they merit scrutiny. (The debate on therapeutic cloning in the United Kingdom in the closing weeks of 2000 oered several examples of this.) As we have seen, it is actually necessary to separate o a class of things meriting a special respect, if we are to think rigorously and consistently even in a narrowly utilitarian frame. If this class of things, the ends or goods by reference to which utilities are denable, is allowed to remain implicit, and utilities are simply taken for granted, then an impoverishment of moral and ethical discourse can result. It may, for example, become vulnerable to fetishism, that is, to the mistaken identication of means as ends; for expert practitioners are very easily (and understandably) seduced by the technical sweetness of their procedural innovations into equating what they can do with what ought to be done. The danger of fetishism is particularly acute when evaluating the utility of virtuoso interventions, such as are increasingly involved in, for example, neonatal care and radical surgery. There are cultures wherein a shared sense of sacredness is routinely sustained,
For an extended discussion of the relation of the state and the status of the individual human being with specic relevance to biological accounts of human action, see Barnes (2000). Irrational has now become a largely meaningless term in these contexts, employed in the indiscriminate abuse of those held to be opposed to scientic or medical progress.

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encompassing even a great part of the natural order. But it is a standard theme in sociology how in dierentiated societies this shared sense weakens and narrows, and continues to receive explicit linguistic recognition only in references to embodied individuals. One result is that a residual sense of the sacred may sometimes remain in cultures lacking the linguistic resources with which to legitimate and rationalise it. And it may be that intuitions of sacredness are then rationalised and reected on within the now ubiquitous utilitarian frame, using the vocabulary of motives it provides. Thus, where we nd evaluations of technological change rationalised by the standard method of weighing benets against risks, we need to remain open to the thought that the evaluations may nonetheless actually express an aversion to desecration by technology, and a concern with bodily integrity. Consider again the recent strong reaction in Britain against genetically modied foods. What it was that moved the mysterious bureaucracy of Greenpeace to attack them can only be conjectured (although it is clear that many members have a genuine concern for the environment whilst some have intrinsic moral objections to moving genes between organisms: see Chapter 9). However, the attack itself was conducted along standard environmentalist lines. There was, allegedly, the unacceptable risk of gene transfer into the environment. But the consequence of the attack was that people who had had no previous engagement with the topic became anxious about their diet. Hearing of yet more risks and dangers from the usual sources, they reacted with aversion to the indicted products, often products that they had previously been happily consuming. And as the supermarkets removed the oending boxes from their shelves, so a devastating environmentalist victory was secured and proudly trumpeted as such by Greenpeace. Whatever is made of episodes of this kind, however, and of the strange eating habits of the modern consumer, it needs to be reiterated that neither the basic tendency to separate and sacralise, nor the associated practices of taboo and avoidance, can sensibly be dismissed as irrational. On the contrary, being practices essential to the ordering of our thought and the structuring of our lives, they are indispensable even to the most uncompromising utilitarianism as we have seen, and to the most rigorous rationalism. Indeed, it is interesting to reect here on the work of rationalist popularisers of science like Richard Dawkins, wherein an uncompromising picture of human beings as natural objects is aggressively asserted. In truth, the human being is present in this work in two guises, explicitly as profane object and implicitly as sacred object, and this is actually essential to create the dualist structure required by both its moral and its epistemological arguments. Morally, a person is at once a physical system and an end of physical actions. Epistemologically, he or she is at once a physical system, and a rational soul capable of carrying the scientic knowledge that renders him or her as a physical system, and of knowing it to be correct. But how these two versions of the human being are to be related is never considered, and how that part of the physical world that is a human being maps the entire

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physical world onto itself, including that part of the world that is itself, is not addressed.

2.8 CONCLUSIONS
The task of this chapter has been to examine the institutional and cultural settings in which bioethical issues arise and the form that debates about these issues take therein. It has concentrated on relations between technical specialists and their audiences, and identied three general trends in these relations. First of all, audiences are becoming less deferential to expertise, and increasingly inclined to involve themselves, not only in judging issues, but also in evaluating the specialised knowledge relevant to them. Secondly, the audience for expertise is becoming many audiences, often with strongly opposed interests, and an analogous fragmentation is evident in expertise itself. Thirdly, whilst the utilitarian frame that currently rationalises technical decisions is widely accepted, there are grounds for believing that it fails to give proper expression to all the concerns of audiences, and notably of those audiences seeking to confront the implications of a burgeoning human biotechnology. All these trends create diculties for experts seeking to secure external credibility, and all seem set to continue. Some commentators regard a dialogue of equals between experts and a knowledgeable and empowered lay public, and an acceptance by the former of full democratic accountability, as the probable and desirable long-term outcome. But in truth there is little evidence to justify such a prediction. Whilst experts face criticism from the public, it is the comfortable criticism of a lay audience that, however active and empowered, gives no sign of being willing to share their responsibilities, or face demands for accountability of the kind that currently fall upon them. Increasingly, in representative democracies, the rule that structures debate, in what increasingly is a single-issue style of politics, is that ordinary individuals are never in the wrong. Large organisations and their specialist advisors are used as sumps for blame. The result is the prominence of pressure groups like Greenpeace, which deploy a radical innovation in accountancy: single-entry bookkeeping. And there is a corresponding failure by the media to provide anything like a comprehensive
I am writing these words in the aftermath of a rare fatal accident on the British railways. Directors of the companies involved are facing the synthetic indignation of television interviewers and being called upon to resign. The expert advice they acted on is being instantly analysed, and casually held up to ridicule. But in the same week 50 or 60 fatalities have probably occurred on the roads, where daily fatal accidents are generally passed over as the unremarkable accomplishments of ordinary individuals. Thus, incinerators arouse the ire of Greenpeace and the criticism of their in-house experts, but not questionable private means of waste disposal; and organisationally nanced genetic modication is assailed but not other kinds. It is through many such one-sided discourses, each in itself little dierent from a stream of deceit, that truth on such issues is now pursued in our highly dierentiated societies.

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picture of the consequences of technical decisions, good and ill, immediate and remote. Of course, the awkward position in which experts are currently placed is well understood by their professional bodies, which have responded by encouraging adaptation to changing circumstances. They have urged the importance of image and public relations; and of a more sympathetic engagement with outside audiences, in fora readily accessible to them, through agendas that reect practical concerns as well as narrowly technical ones. And these are perfectly understandable temporising responses to changes that may cause nuisance to individuals but do not deny the standing of expertise and the authority of science at the institutional level. Unfortunately, this crucial contrast between institutions and individuals is not everywhere so well understood. Science is now more widely respected and trusted than ever before, even if scientists are not; it has no rivals as a source of cognitive authority, even if scientists do; its institutional position remains unchallenged in a context where the scientist no longer stands as a microcosm of the institution. But these are truths that some individual scientists are badly placed to see. Indeed, some scientists have incorrectly interpreted their apparently diminished standing as a sign of a widespread irrationalism and a hostility to science as such, and have lashed out wildly against these things, for example in the highly polemical literature (e.g. Gross and Levitt, 1994; Bricmont and Sokal, 1997; Koertge, 1998) of the current science wars. These scientists should reect a little more on the fact that scientists and technologists are currently provided with greater resources than ever before, and allowed to monopolise practically all the occupational positions where empirical knowledge is the basis of power. And whilst they are entitled to believe that society would benet from being still more deferential to the authority of science, they should ask whether the increased regulation of judgement and opinion necessary to bring this about would be a price worth paying for it. This is just part of a larger ethical question raised by our proliferating science and technology. As they inexorably engender new powers, so they engender vastly increased amounts of regulation and bureaucracy. And public opposition to science and technology only serves to encourage this development; since its major eect, in practice, is to encourage pressured politicians to extend bureaucratic control ever further, even into the inner realms of science and technology themselves. There is the danger of death by administration whichever road we go down in the future, and the moral and ethical issues lying latent here need to be recognised as amongst the most profound of all those raised by
This literature represents a wholesale lapse from ethical proprieties. But withdrawal of deference can elicit intense responses, far more than withdrawal of cash and resources. And here it has led legitimately annoyed scientists into careless abuse of their relatively powerless enemies and even into treating them as legitimate targets of hatred. Indeed, the behaviour of some of the science warriors has been redolent of the custom, in earlier times, of burning alive the frail old woman living next door, on the pretext that she was powerful, dangerous, and ill disposed toward her neighbours (i.e. a witch!).

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current developments, both in biotechnology and in science and technology more generally.

REFERENCES
Barnes, B. (1985) About Science. Blackwell, Oxford, UK. Barnes, B. (1999) Biotechnology as expertise. In Nature, Risk and Responsibility. OMahoney, P. (ed), MacMillan, London, UK. Barnes, B. (2000) Understanding Agency: Social Theory and Responsible Action. Sage, London, UK. Beck, U. (1988) Risk Society: Towards a New Modernity. Sage, London, UK. Bricmont, J. and Sokal, A. (1997) Impostures Intellectuelles. Odile Jacob, Paris, France. Collins, H. and Pinch, T. (1998) The Golem at Large: What You Should Know About Technology. Cambridge University Press, Cambridge, UK. Douglas, M. (1992) Risk and Blame. Routledge, London, UK. Douglas, M. and Wildavsky, A. (1982) Risk and Culture. University of California Press, Berkeley, CA, USA. Epstein, S. (1996) Impure Science. University of California Press, Berkeley, CA, USA. Gross, P. and Levitt, N. (1994) Higher Superstition. Johns Hopkins University Press, Baltimore, MD, USA. Hardin, G. (1968) The tragedy of the commons. Science, 162, 12431248. Jasano, S., Markle, G.E., Petersen, J.C. and Pinch T. (eds) (1995) Handbook of Science and Technology Studies. Sage, Beverly Hills, CA, USA. Jones, S. (1996) In the Blood: God, Genes and Destiny. Harper Collins, London, UK. Koertge, N. (1998) A House Built on Sand. Clarendon, Oxford, UK. MacKenzie, D. (1990) Inventing Accuracy: a Historical Sociology of Nuclear Missile Guidance. MIT Press, Cambridge, MA, USA. MacKenzie, D. and Wacjman, J. (eds) (1985) The Social Shaping of Technology. Open University Press, Milton Keynes, UK. Merton, R.K. (1973) The Sociology of Science. University of Chicago Press, Chicago, IL, USA. Mulkay, M. (1997) The Embryo Research Debate: Science and the Politics of Reproduction. Cambridge University Press, Cambridge, UK. Nelkin, D. (1975) The political impact of technical expertise. Social Studies of Science, 5, 3554. Nelkin, D. (ed) (1992) Controversy: Politics of Technical Decisions. Sage, Beverly Hills, CA, USA. Nelkin, D. and Tancredi, L. (1994) Dangerous Diagnostics: the Social Power of Biological Information (2nd edn). Chicago University Press, Chicago, IL, USA. Rose, C. (1998) The Turning of the Spar. Greenpeace, London, USA. Warnock, M. (1985) A Question of Life: the Warnock Report on Human Fertilisation and Embryology. Blackwell, Oxford, UK. Wildavsky, A. (1995) But is it True? Harvard University Press, Cambridge, MA, USA. Wilkie, T. (1993) Perilous Knowledge. Faber, London, UK. Ziman, J. (1968) Public Knowledge. Cambridge University Press, Cambridge, UK.

Bioethics for Scientists Edited by John Bryant, Linda Baggott la Velle and John Searle Copyright 2002 John Wiley & Sons Ltd ISBNs: 0-471-49532-8 (Hardback); 0-470-84659-3 (Electronic)

IV Ethical Issues in Biomedical Science

Bioethics for Scientists Edited by John Bryant, Linda Baggott la Velle and John Searle Copyright 2002 John Wiley & Sons Ltd ISBNs: 0-471-49532-8 (Hardback); 0-470-84659-3 (Electronic)

12 Starting Human Life: the New Reproductive Technologies

Linda Baggott la Velle

12.1 INTRODUCTION
The bald facts of life for most people are the following: 1. we have no control over whether or not we become alive; 2. once alive we strive to stay alive; 3. we have a strong and instinctive drive to reproduce, fortied by a strong moral intuition; 4. we all eventually die. As organisms, human beings are subject to these facts of life, but over the course of human evolution and of the history of civilisation, we have developed the ability to rationalise and to moralise. The philosophical basis of this is discussed in Chapters 7 and 18. Most people believe that human life is a matter of moral seriousness: we readily understand that, as well as ourselves, the basic instinct for life is present in other people, and we appreciate that we have a moral duty to protect that instinct in them. This has been termed the presumption in favour of life (Dunstan and Sellar, 1988), and for humankind it is fundamental to our continued existence. As society has developed, the drive to protect and promote life has become increasingly formalised in peoples behaviour, to the extent that from early times it has been enshrined in legislation. However, this raises two fundamental philosophical and ethical questions: 1. When does human life begin? 2. At what point should the moral seriousness of human life require it to be protected by legislation?

Bioethics for Scientists. Edited by John Bryant, Linda Baggott la Velle and John Searle. 2002 by John Wiley & Sons Ltd.

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12.2 WHAT CONSTITUTES A HUMAN PERSON?

The new reproductive technologies involve the use of what we might coldly call human material, i.e. gametes prior to fertilisation and embryos after fertilisation, but what is the moral status of this material? Is the embryo in the dish in the laboratory a human person? Is the foetus in the womb a human person? Many attempts have been made to answer these questions. So, what does constitute a human person? Most obviously a person is a body with intelligence, rationality, self-awareness and the ability to form relationships with other persons, but to what extent do some or all of these attributes have to be present in order to constitute a human person? For example, are individuals in whom these attributes are to a greater or lesser extent impaired by permanent damage to the central nervous system less than human? This question raises so many diculties as to make us realise that to dene a human person primarily in terms of the characteristics determined by the activity of the central nervous system is inadequate (although at the end of life it is increasingly becoming an important consideration: see Chapter 17). Aristotle believed that the foetus became a human being when it was recognisably a human form, which he claimed was at 40 days for a male and 90 days for a female. Another view is that this happens when the foetus rst moves in the uterus. A traditional Christian view is that human life begins at fertilisation and that from that point on it should be fully protected as a person. This view therefore regards all the new reproductive technologies and embryo research as morally wrong because they inevitably involve the in vitro creation of embryos and the wastage of many of them. The implications of this prohibition are of course that infertile couples can never have a child and embryo research into the prevention, diagnosis and treatment of genetic disease and the causes of miscarriage cannot proceed. Many argue therefore that such an approach not only prevents benet being conferred on people but also perpetuates human suering. As the new reproductive technologies have developed so new attempts have been made over the last 30 years to nd an ethical code which on the one hand respects the moral seriousness of human life from an early stage but on the other allows the benets of these techniques to be made available to those who need them.
Note that we use terms in the following way: zygote is the immediate product of fertilisation, from the Greek word zygosis meaning coming together. A series of cell divisions, known by embryologists as cleavages, leads to the establishment of the embryo. After implantation into the wall of the uterus, the growing organism is called a foetus. Leaving aside the arbitrary nature of this judgement, we now know the default state of the human embryo is female and thus the idea that females develop in the womb more slowly than males is erroneous. This is the position adopted by the Roman Catholic Church and by certain other groups, including some of the pro-life/anti-abortion groups (not all of whom have a religious basis). It also needs to be stated clearly that many Christians do not take such a strong line on the status of the zygote or of the pre-implantation embryo.

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In the United Kingdom this approach was formalised by the Warnock Committee (1985; Warnock, 1998). Its recommendations were subsequently enshrined in the Human Embryology and Fertilisation Act, which came into UK law in 1990. The Warnock Committee examined what was known about the early development of the human embryo, namely the following. Fertilisation is a process. It takes about 30 hours from its onset to the complete genetic fusion of the sperm and the egg to form the zygote. For up to ten days thereafter, the mass of dividing cells moves down the Fallopian tube and then into the uterus. At this stage there are several possible outcomes. Many embryos do not survive; estimates vary between 50 and 80%, implying that in nature there is a signicant wastage at this stage. However, if the embryo does survive it may develop after implantation (see next bullet point) into a single foetus with its supporting placenta or it may divide into two with the subsequent development of identical twins. At the 3060 cell stage the embryo, which has now become a hollow ball of cells, begins to attach itself to the wall of the uterus. Even at this stage, the fates of the cells of the embryo are not determined. It is only as implantation is properly established that embryo and placenta start to dierentiate and then the embryo begins to exhibit polarity (i.e. to exhibit a front and a back, a left and a right and an up and a down). For the mother, this stage is very signicant because implantation leads to the missing of the menstrual period and some women claim that they feel pregnant at this point. At 14 days the process of dierentiation has led to the development of the primitive streak, from which the central nervous system will develop. In summary, between the onset of fertilisation and the next 14 days of development, the survival of the embryo is by no means certain. Survival depends on the successful embedding or implantation into the wall of the uterus and many embryos fail to do this. During these 14 days the cells are pluripotent, that is, having the potential to develop into any kind of cell, either as part of the embryo itself, or of the surrounding membranes, including the placenta, which act as a support system only, and are discarded at birth. Finally, while these dividing cells contain the potential of a nervous system there is no evidence in this early stage of nervous tissue, which is an essential part of being human. It was thus concluded that fertility and embryo research were justiable up to 14 days. However, the Warnock Committee did not say that anything could be done with these early embryos (referring specically to those created by in vitro fertilisation), but that activity should be restricted broadly to the diagnosis,
It is for these reasons that most of the people who are concerned about these issues, including many adherents of the Christian and other faiths, hold that the pre-implantation embryo is not a person although it has the potential to become a person.

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prevention and treatment of human disease (see Section 12.8). The Warnock Committee Report is thus a classical example of recognising the complexity of the issues, of bringing together ethical considerations with scientic data and formulating recommendations which are both principled and pragmatic.

12.3 THE BIOLOGICAL DRIVE TO REPRODUCE

Some non-living artefacts such as the motor car display various characteristics of life such as movement, nutrition (fuel supply), excretion (exhaust system), respiration (carburettor) and even, in the most up-to-date models, sensitivity and response (detection of light intensity, and rainfall on the windscreen), but growth and reproduction are as yet not seen in manufactured articles such as cars, so it can be argued that reproduction is the single most distinguishing characteristic of life. The genetic sorting that occurs during sexual reproduction is also a means by which natural selection, that driving force of evolution, can occur, and so is responsible for the diversity of plant and animal species on Earth. People, as organisms, are just as subject to these forces as any other with which we share the planet, and indeed the urge to reproduce is felt at the most powerful and basic biological level at various times in our lives. Since fertility is so much a part of normal life, it follows that infertility can be regarded as a pathological state. Most people have a basic instinct to have children, and when they learn that this may not be possible, they may experience a form of sorrow similar to the grief of bereavement. During the course of their lives, most people can expect that others close to them will die, but that in time the sadness that results from it will diminish. Infertility, however, can be a life-long aiction: infertile people have said that the fertile seem to take their inheritance for granted, and the loss experienced by the involuntarily childless is a form of grief which is dicult to come to terms with because there is no focus for it the grief is for the baby who never was. This bereavement may be because of what has been termed genetic death (Snowden and Snowden, 1993), which is to say the persons genetic inheritance will not be passed on to the next generation; there is little doubt that those whom it aects suer very badly. Nowadays however, issues such as involuntary childlessness are more openly and frequently discussed, and with the increasing scientic and medical understanding of the causes, considerably more can be done to help the subfertile. When a couple who decide to have a child discover that they are unable to conceive, for them it is a personal tragedy. If they are advised that assisted reproduction may oer them a chance of parenthood, they then have to decide whether it is physically, emotionally, morally and nancially acceptable to them. Infertility treatment is expen It was thus interesting that Mary Warnock, as a member of the upper house in the UK parliament, voted against the use of in vitro embryos as sources of cloned stem cells. Her reasoning was that although personhood is not ascribed to early embryos, nevertheless they should not be commodied.

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sive, both nancially and emotionally, invasive of the most intimate areas of peoples lives, and for many deeply unnatural, but such is the desperation of some childless people that they are willing to undergo many weeks, months and even years of treatment. The conditions under which they should receive help constitute one of the big ethical problems of contemporary society. Those who are opposed to infertility treatment question the right of everyone to have children. An argument often put forward is that expensive medical resources should not go into infertility treatment when there are many children already born who need parents. These resources, they contend, could be better expended in promoting improved parenting, or in other forms of medical care. Their argument is based on the view that bringing up children is more important than incubating a baby. A more reactionary opposition to infertility treatment is based on the view that infertility helps to ameliorate the problem of world over-population. However, none of these views take into account the consequences for the childless individuals whose family line will end those facing genetic death. But is it everyones birthright to reproduce? Natural selection is no respecter of peoples emotional longings, and if there is a good biological reason for being unable to have children, then it could be argued that this is natures way of strengthening the species to ensure its survival. However, as will be discussed later in this chapter, humans have overcome many problems of infertility with increasingly sophisticated and invasive techniques, and it can equally be argued that to help someone to reproduce who might otherwise be facing genetic death is not a problem, because if the rate of technological advance is plotted into the next generation any defective genes that would otherwise have died out will probably be easily dealt with by genetic testing/diagnosis or even, in the future, by genetic modication techniques (see Chapter 14). Of course, not everybody does want to have children; some have them by accident, whilst others decide consciously to avoid having a family, but for the majority of people having children is a natural and essential part of their lives. This drive appears to be independent of sexual orientation, as has been seen in the recent (2001) case of a British male homosexual couple resorting to assisted reproduction and surrogacy (in the USA) in order to have children carrying some of their own genes. Further, fertility clinics regularly have requests from lesbians for donor insemination. It is not surprising therefore, that all aspects of human reproduction have over the course of history been the subjects of intense moral and ethical debate. As medical and scientic advances have enabled more and more control over reproduction, and further means of promoting it and controlling it have been discovered, the debate has intensied. Recently, however, technical advances have moved faster than the moral discussion with the result that people have expressed their emotions, outrage and anger with increasing ardour about these issues. This chapter considers aspects of the moral and ethical issues around the new reproductive technologies the scientic and medical techniques that enable infertile or subfertile people to have children.

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Because of the technicalities involved, some detailed explanation is necessary of the biological structure and function of the reproductive process and what can go wrong with it and the medical interventions that can be made.

12.4 FERTILITY, SUBFERTILITY AND INFERTILITY

A popularly held view, encouraged by media coverage, is that global overpopulation is responsible for many problems in the world. It may therefore be surprising to learn that human fertility is relatively poor. Compared for example with rodents, reproduction in people is very inecient, and the fact that there are so many of us on this planet is due to improved survival rather than reproductive success. Even in couples who have already conceived (i.e. are of proven fertility) and are having normal unprotected sexual intercourse, the average monthly chance of getting pregnant is only 2025%, and just by chance about 10% of these fertile couples will fail to conceive during their rst year of trying. It is only after about this period of time, during which their family doctor will have carefully explained to them how to maximise their chance of conceiving, that they are referred to a specialist fertility clinic. The basic requirements for conception are shown in Figures 12.1 and 12.2. Failure of any of these will result in infertility, but some are much more likely to fail than others. The pie chart in Figure 12.3 shows the relative frequency of the various common causes of infertility. Frustratingly, the cause of a couples infertility frequently remains unexplained. Even after extensive investigation of both partners, no apparent problem may be discovered. Obviously this means that no specic treatment can be prescribed. However for couples with unexplained infertility of less than 3 years, most are within the normal range of fertility as described above, and are likely to

Figure 12.1. Conditions needed for conception female. Reproduced with permission, from Baggott, 1997

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Figure 12.2. Conditions needed for conception male. Reproduced with permission from Baggott, 1997
3% 22% 6% 8% 1 2 11% 3 4 5 19% 14% 17% 6 7 8

Figure 12.3. Frequency of common causes of infertility: 1, ovulatory failure; 2, tubal damage; 3, endometriosis; 4, cervical mucus defect/disorder; 5, sperm defect/disorder; 6, other male factor; 7, coital failure; 8, unexplained. The total comes to more than 100% because some couples have more than a single cause (Hull et al, 1985)

conceive naturally within a further 2 years. If they have been infertile for more than 3 years, it is unlikely that the woman will get pregnant by natural means, and the best hope for them to have a child that is genetically theirs is to have assisted reproduction treatment. The complete inability to conceive a child infertility is very rare. This would only be the case for example if the woman had completely blocked Fallopian tubes, or premature menopause, or if the man had a complete lack of sperm. Absolute infertility in both partners who are of reproductive age means that there are no treatment options open to them, and their only means of having a family would be to adopt or foster children. The anxiety of wondering whether
Although it has been suggested that cloning, using genetic material from one parent inserted into an

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they will be acceptable as foster parents or adopters can be as stressful as the treatment for infertility. If complete infertility is diagnosed in either partner, both, either separately or together, will be oered counselling. This is one of the most important aspects of the work of fertility centres. To help them to come to terms with their problems, people need information, and to talk to someone both informed and sympathetic about the implications of childlessness and/or fertility treatment. Most young couples trying to start a family do not expect that they may be unable to do so; infertility comes as a shock, and of course it not only aects the infertile person, but his or her partner as well. It has been seen that the worries and anger that the infertile may experience are often focused around their treatment (Jansen, 1996). This means that to be eective in the long term (whatever the outcome of the treatment) and to help prevent other problems such as their relationship breaking down, the counselling of the couple must be closely linked to the treatment. Many counsellors are now specialising in infertility counselling, which means that patients can have the benet of talking to someone who is not only independent of the medical and scientic sta who are involved in their treatment, but also has the time and expertise to listen to and help them to deal with their anxieties. They may choose to opt for adoption or fostering. There are however, relatively few healthy babies available for adoption in the UK or USA nowadays, mainly because of improved contraception, greater acceptance of single parenthood and an increased frequency of termination of pregnancy (abortion). All this has led to an increase in recent years in the number of couples adopting babies from comparatively poor and over-populated or war-torn countries elsewhere in the world. The procedures involved in adopting children from less developed countries are often far from straightforward, and many people question the morality of removing children from their ethnic and cultural roots even if it can be argued that they could have a materially and emotionally better upbringing. In the countries where there are few babies for adoption, babies have even been oered for sale, thus turning babies into a commercial commodity. For example, in a notorious case early in 2001, a British couple purchased twins from the USA after answering an advertisement placed on the Internet. An alternative to adoption is fostering. Many children who require fostering have a physical, mental and/or emotional handicap, and caring for them may require a rather dierent commitment from normal parenting. However, although fostering is often a short-term arrangement, and parting can be very painful for both the child and the foster-parents, it has enormous rewards and many people have reaped great happiness and fullment from it. Nevertheless, some infertile people may decide that neither adoption nor fostering is an option for them, and they must then get on with their lives without having children of their own.
enucleated oocyte from a donor, might in the future be a possible way for such couples to have a baby that was genetically related to one of them (but see Chapter 16).

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12.5 OPTIONS FOR THE SUBFERTILE

12.5.1 INTRODUCTION More options are open to the couple if only one partner is infertile, and even more if the specialist decides that the infertility is in fact subfertility, which is therefore treatable. Studies in many Western countries have shown that as many as one in six couples seek specialist help at some time in their reproductive lives because of diculty in getting pregnant, and that a similar number may be unable to have a baby, but do not seek help (Thompson et al, 1985). This means that infertility/subfertility is a fairly common problem. In times past, this was very much a taboo subject: childless women were said to be barren, and were often much pitied or even reviled. It is noteworthy that in those days, infertility was almost invariably assumed to be the womans problem, possibly because male infertility was often disguised by indelity. It has been claimed that up to 20% of people in Western culture are not fathered by who they think they are! (Ridley, 1995).

12.5.2 THE REGULATION OF MEDICAL TREATMENT FOR SUBFERTILITY Much medical and scientic research is focused upon causes of and treatments for subfertility, and it was partly due to public concern about these that following the report of the Warnock Committee (Warnock, 1985) the Human Fertilisation and Embryology Act was passed in the UK in 1990. A Government watchdog called the Human Fertilisation and Embryology Authority (HFEA) was established to make provision to regulate and monitor treatment centres, and to ensure that research using human embryos is carried out in a responsible way. The HFEA does this by means of a licensing system, which covers any fertilisation treatment involving the use of donated eggs or sperm or embryos created outside the body, the storage of gametes and embryos and research on human embryos. Licensed centres in the UK that oer assisted conception treatment must conform to a code of practice issued by the HFEA. An important aspect of this code of practice is that account should be taken of the welfare of the child that might result from fertility treatment. If the centre believes that for any reason the people seeking treatment are not in a position to bring up the child in reasonable circumstances, they are obliged under the Act to withhold treatment (Morgan and Lee, 1991). Of course, this is highly judgmental, and in this circumstance it is the assisted conception team, usually led by a consultant gynaecologist, which decides whether that patient may be helped to conceive in that centre. Many centres for example refuse treatment to single or lesbian women on the grounds that the child has the right to a father. The issue of homosexuality and parenthood is one that is regularly in the news, and, with the new possibilities aorded by reproductive technologies, likely to appear with

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increasing frequency. Other reasons for refusal of treatment may include health factors and criminal record. The issue of who receives treatment is highly controversial, not least because there are no clearly drawn lines. As part of their professional ethical code, doctors give precise and careful consideration to these matters, and are obliged as a profession to accept responsibility for their decisions: the buck stops with them.

12.6 TREATMENT OF HUMAN SUBFERTILITY

12.6.1 INTRODUCTION Problems of subfertility aect both sexes approximately equally. Little help was available until the pioneering work of Margaret Jackson, a family doctor in Exeter, UK, who used articial insemination by donor to help some childless couples. This remained the only real technique involving the use of gametes outside the body until in the UK gynaecologist Patrick Steptoe and embryologist Robert Edwards brought about the fertilisation of human eggs by human sperm in the laboratory (Edwards et al, 1980). Subsequently they successfully transferred the resulting embryos back into the uterus of the woman, resulting in the birth of the rst test tube baby, Louise Brown, in 1978. Since then this treatment for subfertility has become available to more and more couples. Many of the procedures of reproductive technology are surrounded with considerable moral and ethical controversy, and the nal part of this chapter is devoted to a discussion of the main issues. 12.6.2 TREATMENTS FOR SPERM PROBLEMS Relatively speaking, less is known about the causes and fewer remedies are available for problems of male subfertility. However the study of male reproduction (andrology) is now the focus of an increasing amount of research. Problems of gamete production account for much male subfertility, and various options for the treatment of poor sperm quality are available. Although a few cases of azoospermia (total lack of sperm in the semen) have been successfully treated with administration of hormones, very little could be done until recently about either azoospermia or asthenospermia (poor sperm quality). These couples were usually advised to consider donor insemination. Now, however, various techniques of micromanipulation of gametes have been developed (see Figure 12.5). Although technically dicult and very costly, using these techniques, babies have been born to couples in which the mans sperm is either of very poor quality or absent from the ejaculate. These procedures and their attendant ethical problems will be discussed more fully below. Oligospermia (low sperm count) can often be helped by taking general measures to improve health, such as losing weight, stopping smoking, reducing alcohol intake and avoiding stress. Assisted

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reproduction remains the best hope for a man with such a diagnosis, and the various techniques, described in the following sections of this chapter, are aimed at overcoming the natural barriers presented to the sperm in its journey to fertilise an oocyte, thus bringing the egg and sperm closer together. Assisted reproduction technologies Assisted reproduction technologies is a general term covering those procedures that help a couple to conceive by manipulating their own, or donor, gametes outside the body. The two main methods are articial insemination, and in vitro fertilisation (IVF) and its variations. Articial insemination Articial insemination is the term used for the technique of introducing sperm to a womans body by a syringe and catheter. AIH (articial insemination by husbands or partners sperm) involves a sample of carefully prepared sperm cells being deposited at and around the top of the womans vagina or cervix. Intrauterine insemination (IUI) is a variation on this, and is a procedure in which the prepared sperm cells are put directly into the womans uterus, via the vagina and cervix. The chance of successful conception is maximised by careful monitoring of the time of ovulation (egg release from the ovary). The men for whom articial insemination is a suitable treatment for subfertility include those who have a problem with normal sexual intercourse, perhaps caused by impotence, failure to ejaculate properly, or spinal injury. Articial insemination is less successful in men with oligospermia. IUI can also help couples in which the woman has identied subfertility, such as producing cervical mucus that is hostile to the sperm. These methods are also employed in cases of unexplained infertility, in which they are occasionally successful, but most couples are carefully counselled, and their hopes should not be raised too high. Articial insemination techniques can, of course, be used with donor sperm. The term used for this is donor insemination (DI). The method of depositing the sperm in the womans reproductive tract is exactly the same as for AIH, but the sample used originates from an especially recruited, fertile donor. Donor sperm may also be used in other fertility treatments, such as IVF (in vitro fertilisation) or GIFT (gamete intrafallopian transfer). The couples for whom it oers hope of having a baby, which is genetically the womans, include those where the the the the the man has oligospermia or azoospermia, or asthenospermia man has had a vasectomy, which is unreversed man has had surgery, radiotherapy or injury to his reproductive tract couple have incompatible blood groups man is a carrier of a serious genetic disease.

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Some clinics will also treat women who have no male partner, but wish to have a baby without having had a heterosexual relationship. Decisions on these ethically sensitive cases are always made after very careful consideration of the welfare of the child, as is required by the HFEAs code of practice. Treatment of the couple by DI is the culmination of much commitment by many people. There are three main steps: recruitment and screening of donors; testing, freezing and preparing the sperm and nally insemination. Relatively few DI centres have their own donor clinic. This is because there must be a large population of potential donors to make it worthwhile. Towns and cities with a large student population often have donor clinics, but recruitment can also be from other sectors of the population, such as police, re and ambulance services and also from men of proven fertility who have decided to undergo vasectomy. Those centres that do not recruit their own donors buy in frozen samples from larger centres. Potential donors are rst interviewed to nd their family and sexual history, so that possible chromosomal and serious sexually transmitted diseases may be identied. For example someone who had had a close relative die of Huntingtons disease, or who admitted to a promiscuous lifestyle, would probably be dissuaded from sperm donation at an early stage. Travelling expenses only are paid to donors, so they must be very committed, because they may have to donate as often as twice per week for many months. They must be aged between 18 and 55, and be t and healthy. Each donors semen sample is then analysed in the laboratory, to assess its volume, density (sperm count), motility, morphology and presence of antibodies, and also to screen for infections such as hepatitis, syphilis and HIV. To be acceptable for storage, three samples, three months apart must have at least sperm count greater than 60 million cm (40 million cm is required for fertilisation) ejaculate volume greater than 2 cm 50% progressive motility of sperm (swimming forwards) freezethaw survival greater than 40% 50% normal sperm morphology no antisperm antibodies (which would aect the sperm function in the womans body) negative for viral or bacterial infections. Not surprisingly, up to 95% of potential donors, for one reason or another, fall away from the programme. There is something of a shortage of good quality sperm samples, particularly among some ethnic groups. Careful record is made of the donors physical characteristics, and when selection of a donor is made prior to insemination, choice will be made on the basis of a match with the social father-to-be, normally the womans husband or partner. The criteria for matching donors and recipients are usually ethnicity, body build, hair and eye colour, height, blood group and religion. If a donors sperm meets all the criteria listed above, subsequent samples from him are prepared in the laboratory for freezing

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in liquid nitrogen at 196 C, where they can be stored indenitely in special tubes called straws. This process is known as cryopreservation. After six months of donation and storage, the man is screened again for infections such as HIV. If this proves negative, his samples can be released for use in treatment. A specialist fertility nurse, who will have monitored the patients menstrual cycle until ovulation, most often performs the DI. At this time, the nurse selects a donor straw, and allows it to thaw at room temperature. Having updated the storage records, and checked the thawed sperm cells are alive, the nurse performs the insemination procedure as described above. Success rates for DI average at around 10% for intracervical, and up to 20% for IUI per cycle of treatment. Couples are usually advised that they should think of their treatment as a six- or eight-month course, rather than a series of individual treatments. It has been estimated that 5060% of women undergoing a series of six treatment cycles become pregnant. The donor, although the genetic father of any child born as a result of DI treatment, has no legal obligation to the child, and has the right to remain anonymous. This is an important function in the UK of the Human Fertilisation and Embryology Authority, which keeps a record of all sperm (and oocyte donors), but maintains condentiality of identication. If someone over 16 who knows or suspects that they were conceived as a result of DI (or oocyte donation) inquires of the HFEA about their genetic parentage, the Authority can tell them whether they were born as a result of a donated gamete, and also whether they are related to anyone they may wish to marry. The actual identity of the donor is never disclosed. It is interesting to note, however, that at present the legal limit for pregnancies from any one donor is ten, and as soon as that donor reaches this gure, his sperm cannot be used in further DI treatment, and must be discarded. Obviously the chance of one person born as a result of DI treatment nding out from the HFEA that the person whom they wish to marry was also born as a result of gametes from the same donor is extremely remote. A recent initiative in the USA involves a very dierent, open approach to the identity of sperm donors. This is emerging in response to the need of children born as a result of DI to know the identity of their biological father. It poses an interesting ethical dilemma, and one that is set to be debated for some time to come. Among some people there remains a real fear about cultural acceptance of a child conceived by DI. There is also the matter of the harmfulness of keeping secrets that will not go away, perhaps leading to the possibility of the child rejecting the social parents when it nds out the truth of its biological parents. Often it is the infertile husband or partner for whom maintaining secrecy is the most important (Jansen, 1996). There seems to be a cultural pattern here. In the West, many countries have legislation similar to the HFE Act (1990) in the UK, requiring anonymity of donors. However, in Indian Hindu society, where extended families are the norm, a brothers sperm donation is the favoured option.

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12.6.3 FEMALE INFERTILITY AND OOCYTE (EGG) DONATION For a woman who is unable to produce oocytes at all, but who has a functional uterus, donated oocytes oer the only hope of becoming pregnant with a child that is genetically that of her partner. The donated oocytes are placed in a specially prepared dish containing culture medium with the partners sperm, and replaced in the usual way for a routine IVF treatment cycle (see below). For two important reasons, oocyte donation cannot be regarded as directly comparable to sperm donation. Firstly, oocytes are in much shorter supply, as a donor must go through the procedure of ovarian stimulation and oocyte retrieval (described below), and may yield at best only a few oocytes. Understandably, very few women are able to make this commitment, which, compared with the method used by men to produce sperm samples for donation, is inconvenient to say the very least! Secondly, cryopreservation of oocytes is less certain than freezing of sperm because the delicate meiotic spindle apparatus can easily be irreversibly damaged by the freezing procedure and the oocyte is unable to divide after it is thawed. This means that complicated management of recipients and donors is necessary if suitable oocytes are to become available to women requiring this type of fertility treatment. Consequently, donated oocytes are in extremely short supply. They are needed not only for treatment of infertile women, but also for research on such projects as development of improved protocols for oocyte cryopreservation, development of a contraceptive vaccine and development of micromanipulation techniques, as well as for basic developmental biology research. Potential donors must be between 18 and 35 years old if the oocytes are to be used in the treatment of others. They must also be oered counselling, and given full information about the implications of their donation. In common with sperm donors, an oocyte donor is required to give full details of her medical history, and of any inherited diseases in her family. She will also be tested for such infections as hepatitis B and HIV. Any child born as the result of treatment with her donated oocytes, although genetically her ospring, will not be legally hers, and as with sperm donors, the HFEA maintains a register of oocyte donors, but does not disclose identifying information. Scientists and doctors have responded to the problem of oocyte shortage by seeking new sources of eggs. Research suggested that ovarian grafts from live donors or from cadavers and ovarian tissue from aborted female foetuses could be used to treat some infertile women. In 1994 the UKs Human Fertilisation and Embryology Authority issued a consultation document on this issue, and wide-ranging public debate followed. The main issues were the following. Should ways of increasing the number of eggs available for treatment be sought? Should tissues and eggs from cadavers and aborted foetuses be used in treatment
For example, the three editors of this book, together with others making up the Exeter Ethics Group, participated in the consultation: Human Fertilisation and Embryology Authority: Public Consultation document: Donated ovarian tissue in embryo research and assisted conception. A response (May, 1994).

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or research? Who should give consent to use the tissue or eggs, when should consent be given, and in what form? The Polkinghorne Report (1989) gave guidance on the research use of foetuses and foetal tissue. It was stated that tissue from a therapeutically (legally) aborted foetus could be used provided any decision concerning its use is separated from the decision to induce abortion. It is the principle of separation that is important in this context, because it means that the abortion cannot be performed in order to provide tissues for other use, and the mother should not be inuenced in her decision to have an abortion for this reason. The report also suggested that a mother who had a miscarriage or a termination of pregnancy because the foetus had died should not be approached to give her consent for the use of the foetal tissues. During the debate on the HFEAs consultation paper (1994), it became clear that for many people in the UK there was an intuitive revulsion (which may have reected some strongly held ethical views) towards the use of foetal tissue in this way. How the child might feel if it were to learn that its biological mother had been an aborted foetus can only be speculated upon. Many people believed that the law, based on moral principles, should ensure that no one should ever have to face this particular knowledge about their genetic heritage. As a result of consultation it was decided that the use of oocytes from cadavers or aborted foetuses should not be permitted in fertility treatment (HFEA, 1994). One of the most important issues surrounding assisted reproduction that involves the use of donated gametes sperm or eggs is that of consideration for the welfare of the child born as a result of treatment of this kind. The HFEA will only grant a treatment licence to a centre that satisfactorily counsels its patients. Among the questions explored with the patients is whether, when and how to tell the child of the circumstances of his or her conception. Before DI became a relatively common procedure, it was very rare for parents to tell a child that he or she was conceived as a result of DI. However, since the HFE Act came into force in 1990 the legal status of the child is protected, and patients are often advised that it is in the childs best interest to know about this aspect of his or her origin. When single women or lesbian couples request DI treatment, the centre is obliged to consider the matter of the childs need for a father before oering treatment. Many centres refuse to treat such women on these grounds. This, together with the matter of consent, was the central issue in the case of Diane Blood, a British woman who wanted to use her deceased husbands sperm to have a baby by assisted reproduction. The husband, Stephen, had died suddenly of meningitis before he could give his consent for the use in this way of his sperm (or indeed for its collection), and the HFEA, acting strictly within the law, refused to grant Mrs Bloods request. However, the decision was overturned in the High Court, and, following treatment in Belgium, Mrs Blood eventually gave birth to her son in 1999. In some rare cases gametes of a matching ethnic group are unavailable to a couple seeking treatment. This situation parallels the dicult social and/or moral problems that may occur when children of a dierent ethnic background

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are fostered or adopted by a family. Again, before oering treatment, the centre must give careful consideration to the circumstances surrounding any particular case of this kind. The HFEAs Code of Practice requires centres to take into account each couples preference in relation to the general physical characteristics of the donor that can be matched according to good clinical practice. It would however not be regarded as good clinical practice if a couple were allowed to be treated with gametes of a dierent ethnic origin than the man or woman. It has recently become possible, using donated eggs, to treat postmenopausal women to enable them to have children. It has been argued that men can father children at a very advanced age, and so medical science should enable women to become mothers later in life as well. Some people see this as a great advantage for women who want to build their careers before having children. Most women go through the menopause in their early 50s, but the range is 4555. At around 3840 a womans fertility declines rapidly, and the chance of miscarriage rises, whether she has conceived naturally or by assisted reproduction technology. It is widely held that it is not fair on a child to have a much older mother, who may die while the child is still young or indeed who may nd it dicult because of age to be an active parent right through the childs pre-adult life. However, the HFEA takes the view that each case should be considered individually, and that it is not necessary or advisable to x an upper age limit for the treatment of infertility. The next set of causes of subfertility involves problems of gamete interaction. Any blockage of the male reproductive tract that prevents the maturation and subsequent passage of sperm through the excurrent ducts, epididymis, vas deferens or sperm ducts will compromise fertility. This may be caused by disease, or may have been carried out surgically, as for example in vasectomy; more rarely, congenital abnormalities may result in blockage. These ducts are extremely narrow, but developing techniques of microsurgery can sometimes re-establish patency of these tubes with the result that sperm can again be present in the ejaculate. If this procedure fails, the only recourse is to a relatively new method called microepididymal sperm aspiration (MESA), in which a very few immature sperm are withdrawn, under anaesthetic, directly from the epididymal duct using a very ne needle. They are then used in assisted reproduction procedures. MESA is not generally available, as there are only a few practitioners able to do it. The failure rate is very high. If the entire epididymis is blocked, it is possible to remove sperm still undergoing spermatogenesis from the testis and inject them directly into oocytes. Developmental work on this procedure is still on-going, but the number of live births resulting from it is increasing. Tubal obstruction in the female tract is a common cause of infertility, and can also be remedied by microsurgery. Providing the blockage is not too complicated, this technique is relatively successful. In an alternative to tubal surgery the Fallopian tubes are by-passed completely using assisted reproduction methods.

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12.6.4 IN VITRO FERTILISATION (IVF) In vitro means in glass and it is either in a test tube, or, more usually, in a type of petri dish that the gametes of the man and the woman are actually mixed in the laboratory in such conditions that fertilisation in vitro may occur. Following fertilisation and early development, up to three embryos may, under the Human Fertilisation and Embryology Act (1990), be replaced in the womans uterus. The success rate as measured by the number of live births per treatment cycle is increasing, but must still be regarded as poor: the UK national average ran at 11.1% per cycle of treatment in 1990, improving to 18.2% in 2000 (HFEA, 2000) (see Figure 12.4). Many fertility centres have their own websites on which they publish their success rates. Some clinics in the USA claim nearly 40% live births per treatment cycle. It should be borne in mind that this high rate is probably due in part to careful selection of patients for example younger women, those who have had previous children and those with simple reasons for subfertility have a far greater chance of success with IVF. Couples with a range of reasons for subfertility can be helped with IVF. Among these are women with blocked Fallopian tubes, men with oligospermia that is not so severe that there is no realistic chance of fertilisation, couples in whom the sperm and cervical mucus are incompatible, women with endometriosis, but whose ovaries are still functional, couples who have more than one cause of subfertility, couples who have unexplained infertility, women who have complete ovarian failure, and who are receiving donated eggs fertilised by their partners sperm. IVF is a complex and very demanding treatment for all who are involved in it, and ethical issues arise at each stage. The main steps are the following. 1. Stimulation of ovulation during the treatment cycle (sometimes called superovulation). The best chance of getting pregnant from IVF occurs when more than one embryo is replaced in the uterus. A regime of hormone administration is needed to mature more than one Graaan follicle in each cycle. Commonly, the natural functioning of the womans pituitary gland is downregulated by using drugs that block the release of the hormones that control the egg maturation function of the ovaries. Further drugs are given to stimulate the production of many eggs. Ultrasound scanning is used to monitor the development of the eggs. When they are mature, further drugs control their release from the ovary. There is some risk that this regime may induce a potentially fatal condition known as ovarian hyperstimulation syndrome. Because of this, and also because it may be the couples preference, some treatment centres use natural cycle IVF, in which no superovulatory drugs are employed. As the

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woman almost always produces a single egg, her chance of success is signicantly reduced. 2. Semen analysis and preparation. On the morning of the womans egg collection, the man produces a semen sample, having already had a full semen analysis, to ensure that there are no indications that his sperm would not be able to fertilise an egg. The sperm to be used for the IVF are carefully prepared, and approximately 100 000 motile sperm are selected for the in vitro insemination. Sometimes, perhaps due to stress and anxiety, the man is unable to produce a useable sample, and in spite of the preparation of his partner, the treatment cycle may have to be abandoned if the sample cannot be produced in time. 3. Oocyte collection. There are two main methods for this: ultrasound guidance and laparoscopy. The former is more usual, and can be done with the woman sedated, in which case she comes in for the oocyte collection as an out-patient. Light intensity in the theatre and embryology laboratory is kept to a minimum to protect the oocytes from ultraviolet light, which is thought to be harmful to them. A ne needle is passed through her bladder or vagina and guided by ultrasound to the ovary. Each follicle is visualised, and in turn is punctured, the oocyte and its surrounding uid being gently sucked (aspirated) into a tube containing culture medium. This tube is immediately handed to the embryologist who examines the contents under a microscope, recording any oocytes collected. The surgeon then proceeds to the next follicle, and the process is repeated until all the follicles on both ovaries are aspirated. After the oocyte collection is complete, the woman is allowed to rest until she has suciently recovered to go home. Use of a laparoscope (an instrument allowing the surgeon to look directly into the abdomen) for oocyte collection gives a very clear view of the follicles. A general anaesthetic is needed for this method, so recovery is not so rapid. The collecting needle is inserted through the womans abdominal wall separately, and the procedure for follicle aspiration is the same as before. The oocytes are placed in separate labelled tubes, then taken in a heated test tube block back to the laboratory. 4. Insemination. The oocytes are graded according to their maturity, and each is put into a separate droplet of fresh culture medium, which is held in steady conditions in an incubator. The 100 000 sperm are added to each droplet and returned to the incubator until the following day. 5. Fertilisation and embryo culture. The oocytes are inspected 1218 hours after insemination to see whether they have been fertilised. Re-insemination of apparently unfertilised oocytes sometimes brings about fertilisation, but any abnormal looking oocytes are discarded. Some treatment centres transfer the fertilised oocytes at this stage to the woman, but others return them to the incubator for a further 24 hours, during which time the rst embryonic cleavage divisions occur. Following this, the embryos are graded according to quality. The best three are selected to be transferred back to the woman, and any others that are suitable may be frozen for possible use in subsequent cycles. These extra embryos can also be donated to another couple who are unable to create

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their own, or, alternatively, given to research. This raises again the issue of the ethical status of the early embryo that was discussed earlier in the chapter. For those who believe that personhood is established by fertilisation and syngamy the concept of spare embryos and their use in destructive procedures is abhorrent. However, for most people the creation of spare embryos is regarded as a necessary part of the in vitro procedure. 6. Embryo transfer. The woman lies comfortably on the bed, often with her partner nearby. As soon as the woman is ready, the embryos are drawn up into a ne exible catheter with a small amount of medium. The embryos are gently ushed into the uterus via the cervix. The woman lies quietly for an hour or so, and then goes home. Embryo transfer is quite painless, and she is able to go about her usual life straight away. Some treatment centres give additional hormones at this time in order to maximise the chance of implantation. Sensitive pregnancy tests can be given 14 days after embryo transfer. The chance of multiple pregnancy is quite high, for example 27% of all pregnancies achieved by IVF in 1989 were multiple pregnancies. As IVF is such a complicated procedure, reasons for failure can occur at any stage: the ovaries may fail to produce follicles (15%) oocyte collection may be impossible because of the inaccessibility of the follicles (5%) the oocytes may not be fertilised (2025%) the embryos may fail to develop normally (20%) the embryos may fail to implant, and a menstrual period follows. This is by far the greatest cause of failure of IVF, and the one that is least well explained. There is evidence that this happens relatively frequently in normal fertile women after fertilisation has occurred following sexual intercourse (as was discussed in Section 12.2). As mentioned immediately above, the most common cause of IVF failure is failure of the embryo to implant in the lining of the uterus. Implantation requires normal function of the endometrium, or lining of the womb. Endometriosis is one of the common causes of this type of subfertility. This condition can be treated either medically, in which case drugs are administered to suppress menstruation, or surgically when the aected areas of tissues are removed. The former treatment protocol usually takes at least 69 months, in which conception cannot occur, and there is no guarantee that the endometriosis will not return as soon as normal hormonal function is restored. The outlook with the surgical approach is comparable. Mild cases of endometriosis can be treated such that pregnancy is possible, but the chance of this is far less with increasing severity of the disease. Some women with congenital abnormalities of the uterus can have corrective surgery. Often however, there is no apparent explanation for failure of an embryo to implant, but medical research, probing at the micro-

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scopic and even molecular level of structure of the reproductive tract, indicates that abnormalities of the membranes of the endometrial cells may be responsible. There are a number of variations on the basic IVF procedure described above. One commonly used technique is GIFT (gamete intrafallopian transfer), which involves oocyte collection and immediate replacement into the Fallopian tube together with 2300 000 sperm prepared in the same way as for IVF. It is less successful than IVF, but is a simpler and cheaper procedure, requiring less complex laboratory facilities. ZIFT (zygote intrafallopian transfer) involves transferring oocytes to the Fallopian tube following a period of incubation with sperm. The transfer is done before any cell division is seen, but it does require laboratory incubation in order to achieve syngamy. However, because the fertility team cannot be sure that the oocyte is in fact a zygote (fertilised oocyte), this method is not often used. Following pioneering work done in Belgium (Silber et al, 1995), and subsequently in the UK by Simon Fishels team in Nottingham (Fitzpatrick, 1999), micromanipulation techniques in which the natural barriers to the incorporation of the genetic material of sperm into the oocyte itself are overcome, have become available for treatment of subfertility (see Figure 12.5). The outer coats of the oocyte present considerable obstacles to sperm that have poor motility or morphology. The cumulus cells surrounding the oocyte when it leaves the ovary can easily be dissected away by hand and the protein coat, called the zona pellucida, can be breached to allow more easily the entry of sperm. This can be done by forcing a very ne glass needle through it (partial zona dissection), or directing a jet of acidic medium at it (zona drilling: Figure 12.5a). Two additional procedures go a stage further. They are both extremely dicult technically, but have the potential to overcome virtually any fertility problem involving the gametes. Subzonal insemination (SUZI: Figure 12.5b), a technique pioneered in the UK (Fishel et al, 1990), involves introduction of a single sperm cell between the zona pellucida and the oocyte surface membrane. The sperm still has to bind with the oocyte membrane to gain entry to the interior of the oocyte, but the barriers presented by the outer coats are overcome. As a method of assisted reproduction it is likely to be superseded by intracytoplasmic sperm injection (ICSI: Figure 12.5c), in which mature, immotile or very immature sperm cells alike can be induced to fertilise an oocyte by being injected via a micropipette directly into the cytoplasm of the oocyte. The success rate of these methods is relatively low, although they are improving, and many researchers and clinicians working in the treatment of subfertility believe that these are important developments for the future. 12.6.5 THE COST OF FERTILITY TREATMENT There are very few clinics in the UK at which patients can have IVF paid for by the National Health Service. This means that unless they live in certain health

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24 22 20 18 16 (%) 14 12 10 8 6 4 2 0 91/92 92/93 93/94 94/95 95/96 96/97 97/98 IVF DI Micromanipulation

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98/99

Reporting period

Figure 12.4. Live birth rates per treatment cycle for licensed treatments 19911999 (HFEA Annual Report, 2000)

authority areas and can wait for a considerable period for an appointment, if they want or need IVF treatment, they must go to a private clinic. This can be very expensive. There is no certainty of, or even strong likelihood of, a positive outcome from IVF treatment. The success rates of even the best centres rarely exceed an average of 15% live births per cycle of treatment. Most centres charge a fee per cycle, and a course of treatment can easily run into thousands of pounds. It could be argued that if people who are healthy apart from being unable to conceive want this labour intensive, hi-tech treatment, then they should be prepared to pay for it. On the other hand it could be said that everyone who wants a baby but is unfortunate enough to be unable to have one ought to be treated free. In fact, it is a measure of the desperation of the involuntarily childless that they are prepared to incur large debts in order to pay for the treatment. It is also a very sad fact that the rate of marital breakdown of couples who have undergone failed IVF treatment is said to be greater than the national average. Those couples who experience repeated failures of IVF treatment may also experience an additional burden of grief over and above that caused by their childlessness. In countries such as the UK that have state-funded healthcare the issue of whom should pay for the cost of infertility treatment is based, at least in part, on the type of pathological condition it is considered to be. It might be likened to (a) an ordinary disorder such as appendicitis, which is deserving of NHS treatment, (b) a dysfunction of a particularly tragic and compelling kind, such as spina

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(a) Partial zona drilling (PZD)

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Acid saline solution

Holding pipette Glass needle Perivitelline space

(b) Subzonal insemination (SUZI) Perivitelline space

Holding pipette

Zona pellucida

Oocyte surface membrane Sperm

Injection pipette

(c) Intracytoplasmic sperm injection (ICSI) Oocyte cytoplasm

Holding pipette

Sperm

Injection pipette

Figure 12.5. Diagram of oocyte showing a) partial zona drilling (PZD), b) Subzonal insemination (SUZI) and c) intracytoplasmic sperm injection (ICSI). Reproduced with permission, from Baggott, 1997

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bida, or (c) a complaint of questionable status, such as baldness, which a person might want treated for relatively trivial reasons. The question of what constitutes human nature, already discussed in this chapter, lends evidence to the argument for infertility falling into the (b) category. Most people seem to have a natural desire to have children, and intrinsic to this desire seems to be having children in the ordinary way, i.e. sexual intercourse, followed by pregnancy and labour of the genetic mother, then birth and nurturing of the children within the family. Infertile couples are unable to have children in this way, and are therefore unable to experience full satisfaction of this natural desire. By denition, no form of infertility treatment can satisfy a couple in all aspects of this desire: it is a damage-limiting approach. This has led to some people forming the opinion that infertility treatment comes into the (c) category listed above. However, most couples who have received infertility treatment would say that it is better, sometimes very much better, than nothing.

12.7 RELIGIOUS VIEWS ABOUT FERTILITY TREATMENT

Some of the existing views about assisted reproduction based on religious beliefs centre around what is deemed to be natural or unnatural and whether that which is considered to be unnatural is therefore immoral. This is by no means the straightforward question it might appear to be. It could be argued that medical treatment for example is unnatural, but few would argue that it is immoral. The philosopher David Hume (17111776) said I am surely morally permitted to get out of the way of a falling rock which might otherwise kill me, despite the fact that the motion of the rock is the outcome of natural law. Such arguments have been developed by many ethicists and it is generally accepted today that naturalness versus unnaturalness is very far from being a reliable criterion in reaching ethical decisions as shown, for example, by Reiss and Straughan (1996) and in a specically Christian context by Bruce et al (2001). However, the statement that some procedure is not natural, and by implication therefore is not acceptable, is still made often enough to be considered here. What is natural or unnatural with respect to human nature is very dicult to disentangle. It is part of human physical, psychological and emotional behaviour to form pairs, reproduce by sexual intercourse and raise their own children: this is human nature. To try to outwit this nature by intervening in reproductive processes with for example abortion, contraception, assisted conception and masturbation could be said, on the basis of an ethical framework based on natural law, to be at best futile, and at worst dangerous and potentially destructive. However, natural facts about species are actually facts only about most of their members. Common and familiar exceptions to this view of normal human nature exist: humans are sighted, but some people are born blind, humans are mammals, but not all women are able to breast feed, humans have a drive to

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reproduce, but some people are voluntarily childless, and others kill their own children. Furthermore, in the case of assisted reproduction the argument that it is unnatural bites both ways. If most humans have a natural desire to form reproductive pairs and raise their own young, then the attempt to thwart this desire is as potentially calamitous or futile as the attempt to do anything else unnatural. Hence it can be argued that fertility treatment is acting in accordance with nature, rather than against it. However, one of the most inuential organisations that oppose the technologies of assisted reproduction, namely the Roman Catholic Church, does so in eect on the basis of natural (i.e. Gods) law. It is embedded in Roman Catholic doctrine that the natural purpose of sperm is to fertilise, within the female body. It should be remembered that this doctrine was developed before any understanding of the existence of male and female gametes. The man was said to provide the seed and the woman was simply the garden in which the seed was incubated. Spilling the seed, whether by masturbation or by coitus interruptus, was and is, despite a proper understanding of the role of both male and female in reproduction, still regarded as sinful, as is the frustration of the sperms natural function by contraception. This has clear implications for the production of sperm by masturbation and its subsequent manipulation, whether for donor insemination or for in vitro fertilisation. It needs also to be mentioned here that in some African cultures masturbation is believed to compromise potency, and thus men refrain from it. This has implications for donor insemination programmes, because men of this ethnic origin rarely volunteer to be sperm donors. Finally it must be stressed that, in contrast to the Roman Catholic Church, other Christian denominations do not object to either contraception or to assisted reproductive technology. Neither does the Jewish faith oppose these interventions; indeed in the UK at the time of writing, one of the leading medical practitioners in the eld of human fertility, Lord Robert Winston, is a practising Jew.

12.8 SPARE EMBRYOS AND EMBRYO RESEARCH

The processes of superovulation and IVF often produce more embryos than are required for a treatment cycle, or even a series of treatment cycles. As has been mentioned earlier, for those who believe that these early embryos are people, this is a very contentious issue. The couple undergoing treatment sometimes gives their consent to these spare embryos being used in research. In the UK the Human Fertilisation and Embryology Act (1990) states that any research pro The main basis for this is to be found in the story of Onan, Genesis chapter 38, verses 110 in the Old Testament of the Bible. Ironically (remembering that the Old Testament is actually a Jewish book), current Jewish doctrine does not forbid either the manipulation of gametes in vitro or contraception.

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ject involving the use of live human embryos must be licensed by the HFEA. The licences are only issued after thorough and careful scrutiny of the research proposal. The type of research that can be undertaken is strictly limited and very closely monitored by the HFEA as it proceeds. Licences are only given to projects if they are considered to promote advances in the treatment of infertility, increase knowledge about the causes of congenital disease and to develop methods for detecting genetically abnormal embryos before implantation, increase knowledge about the cause of miscarriage, develop more eective methods of contraception. Experimental procedures on human embryos are only permitted under the law for the rst 14 days after the mixing of the gametes in other words before the appearance of the primitive streak. This has led to the coining (not by clinicians, but by biologists) of the term pre-embryo, perhaps in an eort to defuse any possible ethical objections of the type hinted at above (pre-embryo may sound rather less human than embryo). Under the UKs Human Fertilisation and Embryology Act (1990), certain types of research on human embryos are prohibited. These include replacing a human embryo in an animal, nucleus substitution this procedure comprises removal of the nucleus of an embryonic cell (blastomere) and replacing it with the nucleus taken from the cell of another person or embryo, altering the genetic structure of any cell while it forms part of an embryo, cloning of human embryos for the purposes of infertility treatment. Other than in these circumstances, it is only after this period of 14 days from fertilisation that legally protected human life begins. The embryo that has been experimented upon must not be maintained either in vitro, frozen, or replaced into a woman after that time; it must be destroyed. The mixing of human gametes with those of another species is also prohibited unless a licence is granted. A diagnostic test known as the hamster egg penetration (HEP) assay is sometimes used to see how well sperm can penetrate an egg. The hamster egg is unique in that when its outer coat is removed chemically it will permit binding and penetration of a wide variety of sperm from other mammalian and even non-mammalian species. In the HEP assay, about 40 hamster eggs are harvested from a freshly killed, superovulated hamster. The eggs are incubated with the test sperm, and after 34 hours the eggs are xed and stained, and the percentage of eggs with sperm heads inside them is calculated. Although this procedure gives some measure of the fertilising ability of the sperm, it is by no means routinely performed in centres oering assisted conception treatment. However, it is a useful research tool under certain circumstances, but requires a licence under the Act. For some people, the use of animals in this way is in itself a serious ethical issue (see Chapter 19).

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12.9 CURRENT AND FUTURE DEVELOPMENTS

12.9.1 ETHICAL CONSIDERATIONS Such is the sensitivity of feeling about human embryo research that the development of any new technique for the treatment of infertility must be strictly regulated. Research licences are only granted when it can be demonstrated that the researchers will add to the body of knowledge, and in doing so gain technical competence. Only then can they be allowed to use a new technique in the treatment of patients. It is with this careful and painstaking approach coupled with on-going public debate that big issues, such as what has been termed by the media designer babies, can be approached responsibly. There is no doubt that research will continue to strive to improve on nature: indeed, the elimination of undesirable genes may be one of the consequences of the Human Genome Project, but this should always be tempered with the question what is undesirable? For further discussion of these major issues, see Chapters 13 and 14. Although there is little doubt that elimination of certain genes, such as those for Duchenne muscular dystrophy, cystic brosis or haemophilia, from the human population is desirable, anxieties surrounding these ideas do raise the spectre of genetic and ethnic cleansing. Lessons learned from past and recent history must inform each step on the middle ground in the implementation of advances in reproductive technology.

12.9.2 SEX SELECTION Techniques are being developed that may be able to separate sperm bearing an X chromosome from those bearing a Y chromosome. This means that, using assisted conception procedures such as IVF, it may become possible much more reliably to choose the sex of the baby. This has become known as sex selection. As yet this has not reproducibly been achieved with human sperm, in spite of the claims of some practitioners. Success has, however, been claimed with bull sperm, which have dierently shaped heads compared with human sperm. This enables the bull sperm, when placed in an electromagnetic eld, to be separated fairly reliably according to electrical charge, which appears to correspond to the chromosomal content of the nucleus. There are two main ethical problems surrounding sex selection. The rst concerns the medical reasons for doing it, and the second concerns the social reasons. In cases where a woman risks having a child with a life-threatening, sex-linked disease, choosing the sex of the child may ensure that it is born healthy. Most people, given a choice, would rather have a healthy child than one with a severe disability, and most people, given the same choice for themselves, would rather be healthy than disabled. However, this is not to diminish the value or contribution to society made by these disadvantaged people. On the other hand, in a family for example with one or two children of one sex, the couple

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may want to have another child of the opposite sex. Alternatively, some cultures may attach higher status to one sex, and wish to ensure that this is the gender of the child they have. Such social reasons for inuencing the proportion of girls and boys born are not considered by the HFEA to be desirable. The arguments put forward in favour of sex selection were that there is no evidence that it may have an adverse eect on society, that couples wanting a child of a dierent sex may carry on having more children than they really want, or can support, that sex selection is an important medical advance, which it would be wrong to deny people who wanted it. In formulating the policy on this issue, these arguments in favour of sex selection were felt to be outweighed by those against it. Sex selection for social reasons is rarely in favour of girls. For example, inheritance of titles or wealth are often only legally possible in the UK through the male line, and in some ethnic populations there may be a considerable nancial implication of having girls when it is time for them to marry. Some people think that it is important for the rst born child in a family to be a boy. Position in the family is known to have an eect on a childs psychological development, and the eect of having a majority of rst-borns as boys may reinforce adverse sexual stereotypes, perceptions of gender status and patterns of sex discrimination already present in society. It will be readily seen that these are culturally based arguments against sex selection for social reasons. In the absence of this cultural backdrop, for example if society were matriarchal instead of patriarchal, or if social order were neither matriarchal nor patriarchal, but equal, these arguments would not exist, and there would be no need to deny sex selection. The arguments against sex selection for social reasons are therefore based on the admission that gender has value, and it was seen that this is not an appropriate attitude to encourage, and the practice on these grounds is not permitted under the HFE Act (1990). Now, sex selection is permitted for sound medical reasons, but only where postfertilisation techniques are used. In a specic case, the Masterton family, from Scotland, had four boys and then a girl, after the birth of whom Mrs Masterton was sterilised. The daughter was killed in a tragic accident, and the Mastertons applied to one of ve clinics licensed by the HFEA to undergo IVF treatment with sex selection to try to have another daughter. They were advised by the HFEA that permission could only be given on medical grounds, usually only given for families with a history of inherited, gender-specic diseases. The Mastertons case, it decided, was made on social grounds and so turned down their application for treatment in the UK. The couple contested this decision in court under the European Convention on Human Rights, and nally went to Italy for the treatment. However, the only successfully fertilised egg resulted in a male embryo, and the Mastertons decided

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not to proceed with embryo transfer. Although they rejected the embryo, they gave permission for it to be stored for donation to a childless couple. They told their sons that they might have a brother born in another family. The moral objections to the use of embryo sex selection in this case were based on the precedent it set for design of babies. The pro-life charity Life held that this was an example of simple eugenics, and expressed its opposition to manipulation of gender numbers in society. A spokesman for the Roman Catholic Church also condemned it not only because of the sex selection, but also on the basis that male embryos would be destroyed in the process (in addition to that churchs objection to IVF in general), although the Roman Catholic authorities and Life sympathised with the tragic case. However, a Scottish Episcopal bishop thought that this was an exceptional case, and that the HFEA should consider relaxing its policy in such circumstances. 12.9.3 GENETIC SELECTION In the recent case in the USA, baby Adam Nash was especially conceived in vitro after precise genetic selection to be a bone marrow donor for his sister, who suered from the rare and fatal blood disorder Fanconis anaemia, inherited from the Nash parents (see also Chapter 15, where Peter Turnpenny and John Bryant discuss this case in the context of genetic enhancement and designer babies). The case involved a high level of clinical and scientic expertise, and not a little good fortune, as, of 12 embryos produced from the IVF procedure, only one was found to match the criteria (i.e. absence of Fanconis anaemia coupled with an immunological match to the unwell sibling). After the embryo transfer, in spite of the high probability of failure with the implantation of only one embryo, baby Adam was delivered in good health. Stem cells were removed from his umbilical cord, and transplanted into his sister in the hope that they will reconstruct healthy bone marrow in her. It can be argued that this practice has some ethical currency in that the sisters life might be saved at no cost to the brother. However, that the baby was designed for the purpose, and did not give his informed consent to donating his stem cells, may to some be unacceptable.

12.10 SURROGACY
Some women who have functional ovaries but are unable to become pregnant have undergone oocyte retrieval and IVF with their husbands sperm, but make an arrangement with another woman to have the embryo(s) transferred to her uterus, with the hope of pregnancy and a live birth. This is surrogacy, and a special provision has to be made in court to allow the genetic parents to become the legal parents, because in law the woman who bears and gives birth to a child
Daily Telegraph, London, UK, 5 March 2001.

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is the legal mother, regardless of the childs genetic origin. In the UK the court will only grant the parental order if it is satised that no money has been involved in the surrogacy. In other words, the surrogate mother cannot be paid for carrying the other couples child. This issue again brings into question the concept of having children. It is the perception of some, probably most, people that pregnancy, labour and birth are essential features of this process, but clearly, as in the case of surrogacy, it is possible using assisted conception techniques that a couple can achieve the birth of their genetic ospring without the genetic mother going through pregnancy and birth. It is interesting to speculate from the ethical point of view exactly who has had the baby after the full procedure: drawing up the legal contract between the commissioning couple and the surrogate mother, the gamete collection from the commissioning couple, the IVF by the embryologists and andrologists, the embryo transfer by the medical team and the surrogate mothers pregnancy and birth.

12.11 CONCLUSION
The increase in pace of the revolution in reproductive technology and medicine has outstripped the moral debate, with the result that almost weekly there is a new sensation in the media. However, this is not to say that people are slow to come to terms with the importance or even the complexity of new techniques or possibilities for treatment. The ethics surrounding the issues of human reproduction are at the same time fundamental and extremely complex: this makes it dicult, if not impossible, to be completely right or wrong about them. The controversies give rise to real dilemmas because of technical diculties, uncertain outcomes and variance of principles. Critical reading and frequent discussion help to inform a persons views, and this is very important because although laws exist on such matters as fertility treatment this legislation should always at least take account of the views of society as a whole, although it can also be argued that public opinion can be a very dangerous arbiter of the law. This is not to say that the relationship between social morality and the legislature is static: indeed, one informs the other. Engaging in debate and voicing opinion is particularly important when new guidelines are being drawn up. The HFEA regularly puts out public consultation documents on such issues as sex selection and the use of donated ovarian tissue in embryo research and assisted conception, and the questions raised by these matters are discussed by treatment centres, church groups, political gatherings, academic departments and so on. Above all it is most important for everyone to keep trying to come to terms with these dicult moral problems, by thinking carefully about their signicance not just for oneself, but also with empathy for those more directly aected.

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12.12 SUMMARY OF THE KEY ETHICAL ISSUES

1. Articial reproductive technologies separate sexual intercourse from procreation. 2. Donor insemination breaks the link between the genetic parent and the nurturing parent. 3. In any treatment involving the donation of gametes, there are issues about the condentiality of the genetic parent(s). 4. The issue of the moral status of the human embryo and the question of when life begins are at the heart of any procedure involving the creation of embryos outside the body, and their subsequent destination. 5. In the last few decades, the attitude of many people to what they are owed by the world has changed. Some now feel that they have the right to have what they want, including children. This may be in spite of the fact that they suer the pathology of infertility. 6. The adequacy of funding for medical treatment and the fairness of its distribution raises the issue of priorities. 7. There may be circumstances in which the harm caused by articial reproductive technologies outweighs the benets.

REFERENCES
Baggott, L.M. (1997) Human Reproduction. Cambridge University Press, Cambridge, UK. Bruce, D., Horrocks, D., Bryant, J.A., Burnside, J., Carling, R., Carruthers, P. Hall, A.M. and May, A. (2001) Modifying Creation? GM Crops and Foods: A Christian Perspective. Paternoster, Carlisle, UK. Dunstan, G.R. and Sellar, M.J. (eds) (1988) The Status of the Human Embryo: Perspectives from Moral Tradition. Exeter University Press, Exeter, UK. Edwards, R.G., Steptoe, P.C. and Purdy, J.M. (1980) Establishing full term human pregnancies using cleaving embryos grown in vitro. British Journal of Obstetrics and Gynaecology, 87, 737756. Fishel, S., Antinori, S., Jackson, P., Johnson, J., Lisi, F., Chiariello, F. and Versaci, C. (1990). Twin birth after subzonal insemination. Lancet, 335, 722723. Fitzpatrick, M. (1999) New technique treats male infertility. Journal of the American Medical Association, 282(15), http://jama.ama-assn.org/issues/v282n15/ull/ jmn1020-4.html Human Fertilisation and Embryology Authority (HFEA) (1994) Report on Donated Ovarian Tissue in Embryo Research and Assisted Conception. Human Fertilisation and Embryology Authority (HFEA) (2000) Ninth Annual Report and Accounts of the HFEA. Hull, M.G.R., Glazener, C.M.A., Kelly, N.J., Conway, D.I., Foster, P.A., Hinton, R.A., Coulson, C., Lambert, P.A., Watt, E.M. and Desai, K.M. (1985) Population study of causes, treatment and outcome of infertility. British Medical Journal, 291, 16931697.
For example, there has been a case in which a woman sued a clinic following the birth after IVF of triplets rather than the twins she specied.

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Jansen, R. (1996) Overcoming Infertility: a Compassionate Resource for Getting Pregnant. Freeman, New York, USA. Morgan, D. and Lee, R.G. (1991) Blackstones Guide to the Human Fertilisation and Embryology Act 1990. Blackstone, London, UK. Reiss, M.J. and Straughan, R. (1996) Improving Nature? The Science and Ethics of Genetic Engineering. Cambridge University Press, Cambridge, UK. Ridley, M. (1995) The Red Queen: Sex and the Evolution of Human Nature. Penguin, London, UK. Silber, S.J., Nagy, Z., Lui, J., Tournaye, H., Lissens, W., Ferec, C., Liebaers, I., Devroey, P. and van Steirteghem, A.C. (1995) The use of epididymal and testicular spermatozoa for intracytoplasmic sperm injection: the genetic implications for male infertility. Human Reproduction, 10, 20312043. Snowden, R. and Snowden, E. (1993) The Gift of a Child. Exeter University Press, Exeter, UK. Thompson, W, Joyce, D.N. and Newton, J.R (eds) (1985) In Vitro Fertilisation and Donor Insemination, Proceedings of the 12th Study Group of the Royal College of Obstetricians and Gynaecologists. Warnock, M. (1985) A Question of Life: The Warnock Report of the Committee of Enquiry into Human Fertilisation and Embryology. Blackwell, Oxford, UK. Warnock, M. (1998) An Intelligent Persons Guide to Ethics. Duckworth. London, UK.

Bioethics for Scientists Edited by John Bryant, Linda Baggott la Velle and John Searle Copyright 2002 John Wiley & Sons Ltd ISBNs: 0-471-49532-8 (Hardback); 0-470-84659-3 (Electronic)

13 Genetic Information: Use and Abuse

Bartha Maria Knoppers

13.1 INTRODUCTION
Privacy as a human right and condentiality within the physicianpatient relationship are well accepted principles. Recent developments in, human genetic research have, however, brought some unique issues to the fore. The rst is that of maintaining the condentiality of medical records (to say nothing of the research records themselves) while accepting access by researchers; the second is that of access by third parties such as insurers and employers; the third is that of familial disclosure, and nally, the fourth is the emerging trend towards the anonymising of DNA samples and information so as to avoid any possible abuse. Taking these issues in turn, we shall argue that the rst should be claried through legislation, the second through a moratorium for insurers and an amendment to discrimination laws for employment, the third through ethical codes of conduct and that the last approach, while ethically and legally expedient, needs to be rethought. Indeed, automatic anonymisation to ensure condentiality is both ethically and scientically short-sighted. We would contend that only the normalisation and integration of genetic information as protected medical information can avoid abuses worse than the ones currently imagined.

13.2 CONFIDENTIALITY OF RECORDS

Most legislative or ethical codes protecting medical records foresee specic exceptions for research purposes, although genetic research is not mentioned. At the international level, only the Universal Declaration on the Human Genome and Human Rights (UNESCO, 1997) and the World Health Organisations Proposed International Guidelines on Ethical Issues in Medical Genetics and Genetic Services of that same year specically address the issue of access to genetic information in medical records for research purposes. UNESCOs position is that
Bioethics for Scientists. Edited by John Bryant, Linda Baggott la Velle and John Searle. 2002 by John Wiley & Sons Ltd.

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. . . genetic data associated with an identiable person and stored or processed for the purposes of research or any other purpose must be held condential in the conditions foreseen by law (art. 7). One international directive that specically addresses the issue is the Human Genome Organisations (HUGO) Ethics Committee Statement on the Principled Conduct of Genetic Research (1996), which states That recognition of privacy and protection against unauthorized access be ensured by the condentiality of genetic information. Coding such information, procedures for controlled access, and policies for the transfer and conservation of samples and information should be developed and put into place before sampling. This was followed by the 1998 Statement on DNA Sampling: Control and Access, which went even further in allowing researchers access both to genetic information and to leftover tissues removed during medical care provided that patients were notied and did not object. At the regional level, the 1997 Convention on Biomedicine of the Council of Europe limits predictive or carrier testing to scientic research linked to health purposes (art. 12) and mandates condentiality generally: 1. Everyone has the right to respect for private life in relation to information about his or her health; 2. Everyone is entitled to know any information collected about his or her health. However, the wishes of individuals not to be so informed shall be observed; 3. In exceptional cases, restrictions may be placed by law on the exercise of the rights contained in paragraph 2 in the interests of the patient (art. 10). Dierent countries however have taken explicit positions on access to genetic information for research. The Advisory Committee on Genetic Testing of the United Kingdom in its Advice to Research Ethics Committees (1998) permitted access but distinguished between anonymised and coded information, the latter requiring an explicit consent from the patient before access for research would be provided (see Section 13.5). This position typies that of most countries. One interesting further addition to this common national approach is that of the USAs National Action Plan on Breast Cancer (1999). This group maintained that the privacy protections for experimental research data in which health care is not delivered should exceed the protections established for medical records. Rules for third-party access to medical records should not be uniformly applied to experimental research data (rec.1). Neither should. . . researchers. . . place individually identiable experimental research data not utilized for health care in the medical record (rec. 2). This position is notable in that it addresses research records per se and mandates increased protection. While it is common practice for researchers to keep such data separate, few countries have specic statutory rules on genetic research records and on the need for dierent approaches. Even if the information in the medical record is medically relevant, the patient

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must explicitly consent to such inclusion. Indeed, according to the United Kingdom Advisory Committee, . . . concern over disclosure is particularly acute where the research involves late onset disorders, but remains a signicant issue in all genetic testing (art. 2.1). The Que bec Network of Applied Genetic Medicine in Canada also introduced a new element in its May 2000 Statement of Principles: Human Genomic Research, by extending the obligation of professional condentiality to all members of the research team (prin. III, 1). Finally, no discussion of the condentiality of and access to genetic research results would be complete without mention of increasing surveillance of how this information is shared among researchers. In particular, international collaboration has come under scrutiny. For example, the Swedish Medical Research Council in its Research Ethics Guidelines for Using Biobanks (1999) maintains that only coded material can be sent abroad. Publication of the results of genetic research should also avoid any possible identication of individuals. It is evident from the above that two approaches are possible here. The rst is to tighten the legislation and deontological rules governing the protection of medical information and explicitly include all research records within such increased protection; the second would be to adopt legislation specic to research records. This issue is all the more important when we consider possible access by employers and insurers.

13.3 INSURERS AND EMPLOYERS

Again, it bears mentioning that the absence of an explicit text on access by insurers and employers to genetic data does not mean that such access is either possible or denied. Indeed, the prohibition against discrimination based on genetic characteristics or the protection of personal data generally, or of medical information specically, can determine access by such third parties. At the international level, the 1997 World Health Organisations Proposed International Guidelines go further in not only specically prohibiting access to genetic information (Table 4 in the document) but in the case of banked samples state . . . insurance companies, employers, schools, government agencies and other institutional third parties that may be able to coerce consent should not be allowed access, even with the individuals consent (Table 10 in the document). This recognises the vulnerability of applicants for insurance and employment, who will almost always automatically consent. The HUGO Ethics Committee attacks the problem another way by stating in its 1998 Statement on DNA Sampling Unless authorized by law, there should be no disclosure to institutional third parties. . .. At the regional level, as early as 1992 the Council of Europes Recommendation on Genetic Testing and Screening for Health Care Purposes maintained that Insurers should not have the right to require genetic testing or to enquire about the results of previously performed tests, as a pre-condition for the conclusion or

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modication of an insurance contract (prin. 7). It should be noted however that such limitations do not prevent employers from requesting medical information when relevant to particular aptitudes required for a job or from screening employees for the purposes of job safety or environment. Insurers too have always used family history or health questionnaires to determine premiums. At the level of individual countries, four positions have been taken with regard to life and disability insurance in countries that already have universal health insurance coverage: (i) legislative prohibition (e.g. Belgium, 1992), (ii) voluntary moratorium by the industry (e.g. France, 1999), (iii) a proportional approach (e.g. The Netherlands, 1999) and a hybrid between (ii) and (iii) (as in the UK, 200001). The proportional approach means that access to genetic information or tests will only be required when the amount of insurance sought exceeds income or a certain specied amount. No such clear position has emerged concerning employment. The situation is quite dierent in the United States, where lack of universal health insurance and the fact that most employers are also insurers means that at present (early 2001) state laws address only the issue of health insurance by prohibiting access to genetic information or tests for the purpose of obtaining such insurance. Obviously, neither life insurers nor employers have the states role to provide social security. Nevertheless, much can be said for advocating a moratorium on requesting access to genetic test results to ensure that patients continue to see their physicians and participate in research. Such a moratorium would also provide the industry with the necessary time to ensure that their actuarial tables are accurate, considering the complexity of genetic information. Another possible reform in the area of employment is to extend the denition of prohibited discrimination to include perception of handicap, since most cases of employment discrimination occur when the genetically at-risk are perceived and treated as already ill.

13.4 FAMILY MEMBERS

Genetic information is not only personal or social, as we have just seen in discussing its economic impact on access to insurance and employment, but it is also necessarily familial. This raises unique issues since medical secrecy has always been considered a legal and professional obligation between a physician and an individual. It is interesting to note the relative degree of uniformity at the international level for access by family members when serious burden can be avoided (Table 7 in the World Health Organisations Proposed International Guidelines, 1997). The HUGO Ethics Committee in its 1998 Statement on DNA Sampling is more explicit as to the precise conditions when such exception could be made: Special considerations should be made for access by immediate relatives. Where there is a high risk of having or transmitting a serious disorder and prevention or

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treatment is available, immediate relatives should have access to stored DNA for the purpose of learning their own status. These exceptional circumstances should be made generally known at both the institutional level and in the research relationship. Surprisingly, regional statements are relatively absent on this issue though, in 1997, the Group of Advisors on Ethics of the European Commission in an Opinion on the Ethical Aspects of Prenatal Diagnosis suggested that . . . the woman or couple should be strongly recommended to allow the release. . . of genetic data relevant to other family members (art. 2.8). In 1998, the American Society of Human Genetics Social Issues SubCommittee issued a Statement on the Professional Disclosure of Familial Genetic Information. The Society was careful to not advocate a legal duty but rather considered such disclosure to be ethically permissible. It did so after an extensive review of international and national positions. It also maintained that At a minimum, health care professionals should be obliged to inform patients about the implications of their genetic test results and about the potential risks to their family members. Moreover, after the death of a person, the province of Que bec has gone so far as to legislate a right of access by blood relatives in the case of medical need for familial or genetic conditions. We recommend that the exceptional circumstances described above should be adopted in ethical codes of conduct so that the considerations underlying this exception to medical secrecy are clear for health professionals.

13.5 CODING AND ANONYMISATION

The advent of genetic testing and research has, as we have seen, created new issues and challenges. Concerns about the possible uses and abuses led to the proposition in the early 1990s to protect genetic information through coding. The advent of DNA banking however, together with the international collaboration common to genetic research, led to the elaboration of dierent, more stringent standards. Indeed, ethics review committees and researchers themselves began to anonymise samples. Anonymisation involves not only irrevocably removing all identiers but also ensuring that the samples are not identiable in any way. Some clinical and demographic data however can still accompany the sample. However, the ethical and legal safety oered by anonymisation carries scientic risks. Once anonymised, the clinical data accompanying the sample cannot be updated since the source, i.e. the person, cannot be found. This makes their scientic usefulness short-lived unless used as controls. The HUGO Ethics Committee was the rst to warn against this trend in its Statement on DNA Sampling (1998). It is also evident that research with anonymised samples means that relevant ndings can never be given back to the participant. These limitations have led Estonia (in contrast to Iceland) to

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advocate using coded samples in their national DNA bank so as to be able one day to give medical information back to its citizens. This issue remains to be addressed by most countries. Further distinctions also need to be made concerning the use of archived samples remaining after medical care. Here too, increasing restrictions are denying access in the absence of an explicit consent to research. While, obviously, patients requiring care are not signing up for research and while the old practice of using such abandoned material without consent no longer corresponds to modern values and concerns, perhaps a system of notication upon admission to hospital together with the possibility of objection (opting-out), and the anonymisation of these leftover samples would be a better approach. We recommend therefore that serious consideration be given before automatically requiring that research samples be anonymised before secondary use and that the use for research of leftover samples from medical cases be subject to notication.

13.6 CONCLUSION
There is no doubt that, like information about mental illness 50 years ago, genetic information is still considered stigmatising. The rapid increase of knowledge of genetic risk factors in all common disease may serve to temper this fact. Such cultural normalisation may also serve to encourage family members to share information with other at-risk relatives. The condence to share information, to be tested or to participate in research or to reveal ones status to employers or insurers, however, will be largely dependent on the protection aorded such medical information or research records. Furthermore, the current trend towards genetic exceptionalism rather than integration is skewing the control of and access to DNA samples, whether obtained specically for research or left over after medical care. While we should proceed with caution, it is not certain that anonymisation in DNA banking necessarily corresponds to the will of participants. If asked, such participants may well agree to coding both for their own health needs and for those of future generations. Imagined abuses should not overshadow the reality of present and future therapeutic uses. Finally, we may dene a number of general over-arching principles that should be considered in the use of genetic information. These are condentiality and the right to privacy (but see below: responsibility) no discrimination, for example by employers, on the basis of genetic information reasonableness; for example, insurers have a legitimate interest in medical history in order to assess risk the question is are they being reasonable or so unreasonable that they are being entirely motivated by prot rather than by the legitimate interests of the client? responsibility for example to disclose to family members a genetic diagnosis

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of which ignorance would cause harm or prevention from gaining access to benet or therapy. Reference to these principles will contribute signicantly to the prevention of the abuse and the promotion of the appropriate use of genetic information.

REFERENCES
Advisory Committee on Genetic Testing (ACGT) (1998) Advice to Research Ethics Committees, UK Department of Health, London, UK. http://www.doh.gov.uk/pub/docs/doh/recrev3.pdf American Society of Human Genetics (ASHG) (1998) Professional disclosure of familial genetic information. American Journal of Human Genetics, 62, 474483. Belgian Parliament (June 1992) Loi sur le contrat dassurance terrestre. Moniteur Belge, 20 August, 18 283. Council of Europe (1992) Recommendation No. R (92)3 of the Committee of Ministers to Member States on Genetic Testing and Screening for Health Care Purposes. International Digest of Health Legislation, 43, 284289. Council of Europe (1997) Convention for the Protection of Human Rights and Dignity of the Human Being With Regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine. International Digest of Health Legislation, 48, 99105. Fe de ration Franc aise des Socie te s dAssurance (FFSA) (1999) Les Assureurs Franc ais Renouvellent leur Engagement de ne pas Utiliser les Tests Ge ne tiques, press release. Group of Advisers to the European Commission on the Ethical Implications of Biotechnology (GAEIB) (1997) Ethical Aspects of the 5th Research Framework Programme. http://europa.eu.int/comm/sg/biotech/en/ biotec13.htm Human Genome Organisation (HUGO) (1996) Statement on the principled conduct of genetic research. Genome Digest, 3, 23. Human Genome Organisation (HUGO) (1998) Statement on DNA sampling: control and access. Genome Digest, 6, 89. National Action Plan on Breast Cancer (1999) Recommendation to protect privacy in genetics research. Science, 285, 13591361. Netherlands Parliament (1999) Medical checks law. International Digest of Health Legislation, 50, 6870. Network of Applied Genetic Medicine (2000) Statement of principles: human genomic thique. Network of Applied research. In La Recherche en Ge ne tique Humaine: Cadre E Genetic Medicine, pp. 217. http://www.rmga.qc.ca/doc/principesen2000.html Swedish Medical Research Council (1999) Research Ethics Guidelines for Using Biobanks, Especially Projects Involving Genome Research. http://194.52.62.221/SinglePage/SinglePage.asp?ItemID=670 UNESCO (1997) Universal Declaration on the Human Genome and Human Rights. (http://www.unesco.org/ibc/uk/genome/project/index.html United Kingdom Parliament (200001) Genetics and Insurance (House of Commons Select Committee on Science and Technology). HMSO, London, UK. World Health Organisation (WHO) (1997) Proposed International Guidelines on Ethical Issues in Medical Genetics and Genetic Services. WHO/HGN/GL/ETH/98.1. http://www.who.int/ncd/hgn/hgnethic.htm

Bioethics for Scientists Edited by John Bryant, Linda Baggott la Velle and John Searle Copyright 2002 John Wiley & Sons Ltd ISBNs: 0-471-49532-8 (Hardback); 0-470-84659-3 (Electronic)

14 Human Genetics and Genetic Enhancement

Peter Turnpenny and John Bryant

14.1 INTRODUCTION
In this chapter we discuss the possibilities for, and the ethical and social implications of, genetic modication and enhancement of humans. The discussion needs to be set in the contexts of rstly the development of techniques for in vitro handling of gametes and embryos, and for genetic manipulation of non-human mammals, and secondly, increases in knowledge of human genetics, including the information provided by the human genome project (HGP). It is also very relevant to consider the impact of past and current developments in human genetics on medical practice and patients needs. The early sections of this chapter introduce this technical background.

14.2 GENETIC MODIFICATION

The advent of recombinant DNA techniques and of new reproductive technologies, especially those associated with in vitro fertilisation (Chapter 12), provided a powerful combination of tools that raised the possibility of genetic modication of mammals. The ethical issues raised by the genetic modication of mammals (and other animals) are discussed extensively in Chapter 6. In this section we conne ourselves to the technical aspects (but return to ethical issues when discussing humans: Sections 14.4.1 and 14.7). The theoretical basis is straightforward. Foreign DNA is introduced into oocytes (unfertilised ova) prior to in vitro fertilisation or into newly fertilised ova. The genetically modied embryo is then introduced into the uterus in the normal fashion and, provided a pregnancy is established successfully, a transgenic (genetically modied) mammal will eventually be born. The progress from this theoretical framework to practical reality requires answers to several technical questions. Firstly, can DNA vectors be developed that will deliver foreign genes to the target cell without the possibility of the vector itself having deleteriBioethics for Scientists. Edited by John Bryant, Linda Baggott la Velle and John Searle. 2002 by John Wiley & Sons Ltd.

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ous eects? Secondly, will the incorporation of exogenous DNA into the host cell genome aect either the fertilised ovums ability to establish a pregnancy or the development of the foetus? Thirdly, will the foreign gene be appropriately expressed in the mammal that is born? Fourthly, will the foreign gene be transmitted to the progeny? Using mice as the initial experimental animals, these questions were at least partially answered in the early 1980s (see, e.g., Brinster and Palmiter, 1984; Jaenisch, 1988). Injection of a plasmid, i.e. a small circular piece of DNA, containing the gene of interest into the nucleus (germinal vesicle) of an unfertilised oocyte (followed by fertilisation), or into the pronucleus of a fertilised ovum, leads to the integration of the foreign DNA into the nuclear genome of the recipient cell. Use of a plasmid as vector avoids the possibility of side eects (such as tumour formation) that had been observed when vectors based on certain viruses were used. The establishment of pregnancy with embryos from in vitro fertilised ova had been achieved in the 1970s indeed, the rst human test-tube baby was born in 1978. (This is discussed further in Chapter 12). The success rate for transgenic mouse embryos is lower, however, than with unmodied embryos. Presumably the trauma of injecting the DNA into the egg is sucient to induce abnormal early development in a signicant proportion of the embryos, leading in turn to failure at the stage of implantation. Thus, in early experiments, the success rate for birth of mice (and indeed other mammals) from embryos that had been genetically manipulated was only about 25% of that achieved with non-manipulated embryos (Church, 1987). Although this gure has been improved on since then it is still clear that the success rate is lower with transgenic embryos. So it is possible to obtain the birth of mammals, mice in this discussion, from transgenic embryos. The remaining technical questions relate to the function of those genes. The exogenous genes are indeed expressed and the pattern of expression is appropriate for the promoter (the tract of DNA adjacent to a gene that contains the genes ono switch) that is spliced to the gene. Thus, in pioneering experiments (reviewed by Jaenisch, 1988) on the expression of the rat growth hormone gene in mice, the gene encoding growth hormone was spliced to the promoter for the metallothionein gene (metallothioneins are small proteins produced in response to heavy metals). Exposure of the transgenic mice to the heavy metal inducer of the metallothionein gene led to the rat growth hormone gene being switched on, with dramatic eects. Experiments in which the transgene was placed under the control of developmentally regulated promoters (i.e. promoters that switch genes on at particular times during development of the animal) also gave expression at the appropriate developmental stage in the appropriate cells. Indeed, this has been the basis of many of the applications of transgenic mammals (see below). However, the level of expression of the exogenous gene varied considerably from animal to animal. As with plants (Chapter 8), this is generally ascribed to position eects, i.e. the variation in the level of expression is associated with variation in the position at which the

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transgene integrates into the host genome. Finally, the exogenous genes were indeed shown to be transmitted to the germline and thus subsequently to progeny, although, again, the extent to which the gene was expressed in progeny was variable (possibly because of the phenomenon of gene silencing). These variations in expression, both in the original transgenic mice (the T0 generation) and in the progeny (T1), have implications in relation to the possible application of these techniques to humans (Section 14.7). However, these problems have not prevented the use of transgenic animals in research and in biotechnology. For example, mice can be modied with mutant genes that cause monogenic diseases such as cystic brosis or Alzheimers or Huntingtons diseases, or with oncogenes that can be activated to induce tumour formation. Indeed, in the UK alone, tens of thousands of transgenic mice have been used in biomedical research. Larger mammals have also been targets for genetic modication. For example, there are transgenic sheep that produce pharmaceutical proteins such as blood-clotting factor 9 in their milk. Indeed, it was from a transgenic sheep that Dolly was cloned (Chapter 16). With Dolly, the motivation for such cloning was to reproduce the genetic makeup of the nuclear donor sheep without the risk of the variation in expression in the progeny (and incidentally, avoiding the need to sex-select the progeny), thus replicating a commercially valuable animal. Further discussion of this lies outside the scope of this chapter but these examples serve to illustrate that genetic modication techniques rst developed for mice have now been successfully applied to other mammals, including, most recently a primate, namely the rhesus monkey (see commentary by Vogel, 2001). The birth at the Oregon Primate Research Center of ANDi, the rhesus monkey carrying a foreign gene, has, it is claimed (see e.g. Higheld, 2001) brought the genetic modication of humans closer. However, in a technical sense this is not true because rstly, the in vitro fertilisation and embryo implantation techniques used have been much more fully optimised for humans than for monkeys and secondly, the genetic modication procedure was one that could have already been applied to humans. Nevertheless, those who subscribe to the slippery slope argument believe that in genetically modifying a primate, the psychological barrier to genetically modifying a human has been breached or at least dented (see also Sections 14.5 and 14.7).

14.3 GENETIC SELECTION

In mammalian embryos, the denition of cell lineages occurs relatively late. This means that the cells generated during the early cell divisions (termed cleavages by embryologists) are non-determinate. Further, experimental manipulations have demonstrated that it is possible to remove one cell from an eight-cell embryo without disturbing subsequent development (Figure 14.1) Thus, if there is a need to ascertain whether or not an embryo possesses a particular gene, one

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Figure 14.1. Removal of one cell from an eight-cell embryo in order to carry out pre-implantation genetic diagnosis. Photograph reproduced by permission of Dr A.G. Schmutzler.

cell may be removed for testing before placing the embryo in the uterus (or replacing it into the uterus if it has been obtained by embryo rescue after a normal in vivo fertilisation). Such testing may be used to detect the presence of the foreign gene after injection of DNA into a fertilised ovum, or to conduct genetic testing on the embryo which is appropriate for the situation. This is discussed more fully in Section 14.6.3.

14.4 HUMAN GENETICS AND THE HUMAN GENOME PROJECT

14.4.1 SOME HISTORY One of the frustrating aspects of reporting science to a wider public is the frequency with which one achievement or advance is confused with another. Thus, we often hear it stated that Watson and Crick discovered DNA. In fact, DNA was discovered in the 19th century and its key role as the genetic material was established in the 1940s. It was precisely because of this role that Watson and Crick were attracted to work on it and their major achievement was to develop a model a model that has stood the test of time for its structure (Watson and Crick, 1953). We see a similar confusion when it comes to human genetics. A slightly premature announcement in the year 2000 that the rst draft of the human genome sequence was complete (Butler and Smaglik, 2000; Macilwain, 2000; Marshall, 2000a) led many commentators to suggest that
The announcement was made somewhat prematurely because a commercial company, Celera

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there had not been any work on human genes before the establishment of the Human Genome Project. The truth is rather dierent and is set out here because of its relevance to the wider applications of science and to the ethical implications of those applications. Long before the establishment of genetics as a science in the early years of the 20th century there was awareness (as documented by Steve Jones, 1996) that certain traits seemed to be transmitted from generation to generation or to be associated with particular families. Indeed, it was a mistaken extrapolation from this awareness that led to the establishment in the 1880s of the eugenics movement in the UK and then in other countries. However, the re-discovery in 1900 of the work of Mendel resulted in a clearer understanding of the nature of inheritance and indeed, led to the Eugenics Society of the UK making a study of the inheritance of haemophilia in the royal families of Europe. This work, published in 1911, provided clear evidence that the gene is sex linked (although, as noted by Jones, there was some inkling as long ago as AD 200 that uncontrolled bleeding may be a familial condition: a Jewish rabbi exempted from circumcision the cousins of a boy who had bled to death after being circumcised). The rst genetic trait to be characterised at the molecular level was sickle-cell anaemia, in which the mutation aects the amino acid sequence of the blood protein haemoglobin. In these days of rapid DNA sequencing it is interesting to note that the amino acid dierence between normal and sickle cell haemoglobin (a single amino acid change from glutamic acid to valine) was identied as long ago as 1957 by laboriously sequencing the puried proteins. Further, the genetic code, i.e. the relationship between the sequence of bases in DNA and the sequence of amino acids in protein, was unravelled in some very elegant biochemical experiments in the 1960s. Thus it was possible to predict the base change in DNA that led to the amino acid change in the protein. However, direct conrmation of that prediction had to wait until DNA sequencing methods became available after the advent of recombinant DNA techniques. As already mentioned, an early impetus for study of human genetics was eugenics, the theory that human society could be improved by encouraging the reproduction of the stronger elements in society and discouraging the reproduction of the weaker elements. From the end of the 19th century through to the Second World War, eugenics movements and societies were well established in several countries, including the UK and the USA. In several countries, eugenics policies were adopted by governments, leading to programmes of compulsory sterilisation of those perceived to be feeble-minded or degenerate (see Dyck, 1997; Wikler, 1999). The supposed scientic basis of this was a social application of Darwinism, aimed at ensuring that the ttest survived. Indeed, the founder of the eugenics movement, Francis Galton, was a cousin of Charles
Genomics, which had invested in 300 DNA sequencing machines, threatened to scoop the publicly and charity funded Human Genome Project (Macilwain, 2000; Marshall, 2000a). This tension between the commercial and non-commercial research programmes is still not fully resolved (Marshall, 2000b; Smaglik, 2000). See also Chapters 13 and 15.

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Darwin. Ethically, the policies were based on a type of utilitarianism in which the outcome was seen as improving the health (in its widest sense) of society at large. However, as is pointed out by Reiss in Chapter 1 of this book, a utilitarianism which simply aims at increasing the overall level of happiness, pleasure or well-being in society can lead to the legitimate rights of individuals being ignored or over-ridden. This was certainly true in the eugenics movements in which programmes such as compulsory sterilisation (see above) negated the autonomy and right to self-determination of individual humans. Further, those making the decisions as to who should be sterilised had obviously already classied themselves as being amongst the stronger and more desirable elements in society, a view which was doubtless reinforced by the power that was exercised over those who were the subjects of their decisions. Eugenics fell out of favour, largely as a result of the extreme eugenic practices in Nazi Germany, and indeed the word eugenics, which was originally coined to mean good inheritance, is now a pejorative term. However, it has been suggested by some authors (see below) that certain applications of our new knowledge of human genetics may in fact be eugenic in that they seek to eliminate (as far as is possible) certain genetically based disease states from human society. We discuss this further in Sections 14.6 and 14.7 but readers who wish for more in-depth treatments of the topic are referred to Dyck (1997), Kuhse (1999) and Wikler (1999). Since the middle of the 20th century one of the main motivations in the study of human genetics has been to understand the genetic basis of disease. About 4500 diseases, some relatively common but most of them unusual if not extremely rare, are known to be caused by mutations in single genes, whilst approximately 20 000 chromosomal aberrations have been reported to date (C. Scott, personal communication, 2001), a gure which is likely to rise as more microabnormalities will be discovered with emerging technology. Further, as we now know, mutations and polymorphisms within certain genes are involved in determining predisposition to certain diseases (see Section 14.6). Study of genetic diseases in humans is of course limited by our inability to undertake mating experiments between people possessing particular alleles (although apparently some such experiments were enforced in Nazi Germany). Thus, for example, prior to the advent of DNA analysis, the assessment of genetic risk for a couple wishing to have children depended on the pattern of inheritance of the condition in their family and knowledge of the population frequency of particular gene mutations, which could be calculated by epidemiological studies and statistical methods. There were just a few conditions where the estimation of genetic risk could be modied (not necessarily accurately) by other means, e.g. creatine kinase testing in X-linked Duchenne muscular dystrophy, hexosaminidase assay in autosomal recessive Tay-Sachs disease, and haemoglobin electrophoresis in the (autosomal recessive) thalassaemias. The development of recombinant DNA
The Oxford Chromosome Abnormality Database, funded by the South East National Health Service Executive.

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technology in the 1970s was highly signicant and began to impact clinical medicine by the mid-1980s. The ability to use microbial cells to grow genes, combined with techniques to dissect DNA and detect particular sequences, meant that for the rst time it was possible to directly investigate at least some of the genetic changes that lead to the development of a disease. Thus, the genes involved in several heritable diseases, including cystic brosis, had been identied, cloned and characterised by the end of the 1980s (see also Section 14.6) prior to the establishment of the HGP. This in turn meant that diagnostic and detection techniques based on actual gene sequences were becoming available.

14.4.2 THE HUMAN GENOME PROJECT In 1988 a consortium of scientists in the USA persuaded Congress that the time was right for the establishment of a coordinated programme to sequence the entire human genome (for a fascinating account of the history of the project, the reader is referred to Shapiro, 1991). The programme was set to run from 1990 to 2005 and, in the USA, $3 000 000 000 was initially allocated to the project. This sum included 5% allocated to study the ethical and social implications of the project. The decision to set up the HGP was not without it critics. In the USA some members of the public (and presumably some members of Congress: the decision was not unanimous) believed that the money could have been spent in other ways, raising questions about allocation of limited resources (in fact, an almost constant theme in the realm of publicly funded activities). Even amongst the science community there were some who, at least at that time, believed the establishment of the project to be a major mistake (e.g. Rechsteiner, 1991). However, the project went ahead and, in many ways, the criticisms have been answered. The spin-os for other areas of science have been dramatic. The extent of assured funding for the research led to signicant investment in the development of technology to facilitate the research and much of this has been equally applicable in, for example, plant molecular biology. Focusing on the HGP itself, about two-thirds of the work has been undertaken in the USA with most of the rest being split between the UK, Germany, France, Japan and Canada. The results have been spectacular. By the middle of the year 2000, some four and a half years before the formal closure of the project, the sequences of the majority of the genes of an average human were known (Butler and Smaglik, 2000; Macilwain, 2000; Marshall, 2000a), as was the identity of many disease-causing mutations. This acceleration in acquisition of knowledge about human genetics has almost immediate applications in medicine, as we describe in Sections 14.6 and 14.7. However, before moving on to those applications it is necessary to consider, in the light of increased knowledge of human genes, the possible use of genetic modication techniques with humans since this has some bearing on possible future choices in human genetics.

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14.5 GENETIC MODIFICATION: APPLICATION TO HUMANS

In Section 14.2 we showed that various forms of genetic manipulation of mammals are not only feasible but are actually in use. At this point it is appropriate to remind ourselves that many of the techniques developed for mice will be equally applicable to humans. Indeed, as is shown in Chapter 12, the human was the second species for which in vitro fertilisation was successfully achieved. Further, the development of a variety of techniques for delivery of sperm to the unfertilised ovum, e.g. ICSI intracytoplasmic sperm injection, in order to optimise fertilisation (Chapter 12), means that there is extensive experience in the manipulation of ova. Section 14.4 illustrates that our knowledge of human genetics has increased signicantly as a result of the application of molecular techniques to the study of human genes (including the work of the HGP). In particular, this research has facilitated the identication of individual genes. For many of these the function is not at present clear, although knowledge of gene function is growing apace. Nevertheless, for a signicant proportion of genes their function has been clearly dened. The research has also led to extensive experience of the manipulation of human genes. The combination of knowledge and experience in human embryology and in human genetics thus sets the scene for the possible genetic manipulation of humans. There are three general approaches to this: gene detection/genetic diagnosis (with the concomitant possibility of rejection of particular genotypes), removal or replacement of genes, addition of genes (either to confer a specic genetic trait or to over-ride the eects of a mutant gene, as in gene therapy). We now turn to discuss these aspects in relation to their applications, both actual and possible.

14.6 GENETIC DIAGNOSIS IN CLINICAL PRACTICE

14.6.1 INTRODUCTION As described above, the advent of recombinant DNA techniques led to a previously undreamed of capability to identify, isolate and characterise genes, including human genes. This gave a new impetus to human genetic research and even before the formal establishment of the HGP many human genes had been analysed. For many geneticists, a particular milestone was the isolation in 1989 of the large and complex gene that encodes the cystic brosis transmembrane regulator (CTFR). Since then, the isolation, sequencing and further characterisation of human genes has accelerated dramatically. Indeed, as already men-

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tioned, the rst draft of the human genome was published in 2000. Progress is set to continue well into the 21st century as the fruits of the HGP are realised together with technological advances, such as DNA micro-arrays, that will permit ever more rapid analysis. In an astonishingly short period of time human DNA analysis will have progressed from crude and laborious fragment sizing using a limited range of restriction endonucleases to rapid, far ranging, and relatively inexpensive methods of direct sequencing with the potential to identify a myriad of polymorphisms and mutations. Two main diculties will accompany this huge surge in descriptive knowledge of our molecular genetic anatomy. Firstly, the interpretation and health implications of many sequence variations may not be clear for a long time and, secondly, the applications of the technology will generate socio-ethical dilemmas due, at least in part, to the current paucity of benecial interventions. The unfortunate reality is that treatment in genetic medicine lags far behind our ability to diagnose uncommon inherited disorders and to identify susceptibility risk factors for common conditions. Despite this, it should not be assumed that making genetic diagnoses has no value. Francis Collins, the second director of the HGP (the rst was James Watson) describes the relief of a woman shown not be carrying the BRCA1 (breast cancer pre-disposition) mutation present in other members of her family (Collins, 1999). However, positive diagnoses may also be benecial. Although little may change for the aected individual, particularly in cases of moderate or severe mental retardation, there are often positive results for the patient and/or family through empowerment conferred by the knowledge and sense of control that is brought to the situation. The resolution of diagnostic uncertainty, and the fact that subsequent investigations are focused on a known rather than unknown problem, means that patients and parents are usually very relieved. Many parents attest to the importance of being able to explain their childs condition when others ask what is wrong (Skirton, 2000), and in very practical terms having a diagnosis often expedites support through the education and social benet systems. New insights into the complications and possible prognostic scenarios may accompany a diagnosis, there may be genuinely useful medical interventions that can be tried, and comfort and solidarity may be available through the excellent work of the relevant patient support group. These aspects of genetic science in the clinical setting may seem very subliminal compared with the headline issues and major breakthroughs that take the world by storm. However, they are signicant in our understanding of enhancement and tell us a lot about what is, or may be, important for many people, namely a sense of control (Berkenstadt et al, 1999), a degree of certainty (Skirton, 1999), and the need for cognitive closure (Webster and Kruglanski, 1994). Parents may also push for closure in relation to resolving the genetic carrier status of their child(ren) with respect to cystic brosis, balanced chromosomal translocation, or any condition/gene that is present in the family but unlikely to have implications for the child until adult life or leading up to reproductive

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decisions. The genetic testing of children has been dealt with thoroughly elsewhere (Report of a Working Party of the Clinical Genetics Society (UK) 1994; Clarke, 1997) but is an important issue in the enhancement debate. Few would have any objections to testing children if their adverse genetic status could be managed, and therefore enhanced, by practical and benecial medical interventions or surveillance. If this does not apply, however, whose quality of life is enhanced by the testing? The child has been denied the opportunity to make a fully informed decision about testing as an adolescent or adult and may feel their right to autonomy has been abrogated. The evidence that testing in childhood for carrier status is harmful is not, however, strong or convincing (Fryer, 2000) and the whole debate is likely to move on as families become better informed and seek more control over their information. At present, most parents understand the issues about respecting the childs autonomy when this is fully explained, though a substantial amount of childhood genetic testing is being undertaken, mainly due to parental pressure (Proctor et al, 1999). Furthermore, it would appear from an international survey that geneticists in Asia, Latin America, and southern/eastern Europe are more likely to accede to parents wishes for their children to be tested compared with geneticists in northern/western Europe and the USA (Wertz, 1998). Prenatal testing, of course, may diagnose carrier status, in which case the situation is known throughout childhood, but this represents a special circumstance. The special situation for adopted children (Turnpenny, 1995), and those conceived by gamete donation, is often dicult and complex. 14.6.2 PRENATAL SCREENING AND TESTING Inevitably, a recurring issue in the moral and ethical debate is termination of pregnancy, and in this context the use of screening programmes as well as specic prenatal and pre-implantation genetic testing and diagnosis. As with molecular genetics, what is possible today could only have been dreamed of a generation ago. The discovery that alphafetoprotein (AFP) was greatly raised in the amniotic uid of neural tube defect (NTD) pregnancies (Brock and Sutclie, 1972) led the way for the widespread introduction of antenatal screening programmes in the 1980s. The technique of amniocentesis was rst introduced for prenatal diagnosis in the 1950s for rhesus iso-immunisation (Bevis, 1953), and subsequently it became a route for treating this condition in the foetus by intra-peritoneal blood transfusion (Liley, 1961, 1963). In the 1960s amniocentesis was used to analyse sex chromatin (Riis and Fuchs, 1960; Serr and Margolis, 1964) for severe X-linked recessive disorders, as well as some inborn errors of metabolism (Jecoate et al, 1965; Nadler, 1968), and the rst prenatal diagnosis of Down syndrome was made (Valenti et al, 1968). The procedure extracts a small quantity of amniotic uid from around the foetus, usually at 16 weeks gestation, and can be used for biochemical analysis of the uid itself (e.g., AFP), foetal karyotyping (chromosomal analysis) or quantitative enzyme testing (for inborn errors of metabolism) on cultured amniocytes. Most of the analyses

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performed on amniocytes can be undertaken on chorionic villus (CV) tissue obtained by biopsy of the edge of the developing placenta from 11 weeks gestation, a technique pioneered during the 1970s (Hahnemann, 1974) and developed during the 1980s (Ward et al, 1983). If the sample is adequate analysis can usually be direct without the need for culturing cells, and so a result is achieved perhaps eight weeks earlier than would have been the case by amniocentesis. For this reason CV biopsy is often preferred when there are indications for planned prenatal testing. Occasionally it is desired to look directly at foetal blood and this requires the skilled procedure of sampling from the umbilical cord from about 18 weeks gestation; even less often biopsy of foetal tissue such as skin, liver or muscle might be undertaken for very specic tests. Each of these invasive procedures carries a small risk of provoking miscarriage. None of these procedures would be performed today without the aid of ultrasonography, the most widely used of all antenatal screening modalities. Indeed, ultrasound examination has all but taken over from AFP in screening for NTD. Whilst very sensitive in being able to detect structural abnormalities in the foetus, it is not necessarily very specic in matching anomalies with a precise diagnosis. This may pose serious dilemmas for clinicians and extreme anxiety for parents, some of whom would prefer, with hindsight, not to have known. Accurate measurement of foetal dimensions, for instance, can identify short limbs and predict that the child will have a form of dwarsm but not necessarily distinguish which of the many dierent types aects the unborn baby. As dierent forms of dwarsm are accompanied by dierent medical complications and prognosis, which is exactly the sort of information parents seek, counselling is often, at best, somewhat vague. Since the midlate 1980s maternal serum screening of AFP and human chorionic gonadotrophin (hCG) in early pregnancy, combined with maternal age, and sometimes other serum markers and foetal measurements on ultrasound (Wald et al, 1997, 1999), has given rise to an entire industry aimed at prenatal detection of Down syndrome. Many original research articles on every conceivable aspect of this subject have been published, which, ipso facto, could be interpreted as a statement from a section of the medical research community that Down syndrome individuals are of less worth and value than normal people. The alternative position is one where the status of all foetuses is something very much less than fully human, combined with the right of the pregnant woman/couple to make an autonomous decision about the fate of her foetus. Most health authorities in the UK fund Down syndrome screening programmes, which are therefore available to any pregnant woman. Antenatal screening programmes are also available in most countries of western Europe (Ireland, Norway and Sweden are exceptions), North America and Australia and expanding in Asia and South America (W.J. Huttly, personal communication, 2001). Prenatal screening, testing and diagnosis in all its forms has greatly extended
The Wolfson Institute, London, UK.

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the element of choice about whether or not to continue an established pregnancy, the principle having been given basic legality in the UK by the Abortion Act of 1967. Previously, choice was available only at the stage of whether or not to risk conception, or whether to seek an illegal termination of pregnancy, although as we have seen, medical termination of pregnancy was becoming an option for X-linked recessive disorders. In some countries and societies the limits of choice remain as they were in the UK prior to 1967. One result of choice has been a dramatic decline in the population of newborn babies available for adoption in the last 20 years as abortion numbers have increased, combined with general acceptance of the status of single parenthood. The conditions currently targeted by publicly funded antenatal screening programmes are primarily NTDs (spina bida and anencephaly) and Down syndrome. These qualify for expensive screening by virtue of their frequency and severity. Acceptance of these programmes is not, however, universal. Objections are frequently based on the status of the foetus (see Chapter 12) but may also centre on what constitutes a severe condition. Furthermore, not everyone is convinced by arguments based on the cost-eectiveness of screening and there is unease in many quarters about public health search and destroy policies whose concerns are primarily nancial. In addition, there may be only limited explanation and counselling given in relation to the screening tests for Down syndrome, so that women are not, paradoxically, provided with full, informed choice (Al-Jader et al, 2000). Indeed, the information about testing may be presented in such a way that it is perceived as routine rather than voluntary (Al-Jader et al, 2000), thus being more dicult to opt out rather than opt in. Nevertheless, a majority of unsuspecting parents who nd themselves faced with a choice of whether or not to terminate a Down syndrome foetus will do so (Wald et al, 1997; Al-Jader et al, 2000). Not to do so is perceived as what could be termed disenhancement to their future quality of life. This presupposes that their plans and aspirations for themselves (and their perfect child) will be life enhancing to an extent that cannot be matched by caring for, and developing a relationship with, a Down syndrome child. But very few of these (potential) parents have ever had any real contact or experience of children with Down syndrome, so the decision to terminate is often based on a very limited appreciation of the condition. Some parents testify to the positive enhancement that a Down syndrome child has brought to family life, so much so that they choose not to have screening for Down syndrome in subsequent pregnancies. It is not unusual, of course, that foetal karyotyping for Down syndrome, apart from revealing the sex of the infant (parents can choose whether or not to have this disclosed), identies some other chromosomal abnormality such as Turner syndrome (females with only one X karyotype 45, X) or Klinefelter syndrome (males with an extra X 47, XXY). Parents are often unprepared for ndings of this kind and are presented with a choice that was not part of their planned approach to prenatal testing. This requires urgent counselling in order for parents to make an informed decision about the pregnancy but the quality of the information may vary substantially (Abramsky et al, 2001).

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The vast majority of rare inherited and congenital disorders are not catered for in routine prenatal screening, though those including structural defects might be detected by ultrasound. Many (but not all) conditions can be tested for when the foetus is known to be at risk because of a positive family history where a precise diagnosis has been made, often when a couple have already had an aected child. In these cases planned prenatal diagnosis is a choice based on very intimate knowledge of the condition in question, balanced with the eect that a second aected child would have on the entire family dynamics. For many couples the decision is far from easy. They may already have had to come to terms with a sense of guilt at being parents of one aected child, perhaps now loved and absorbed into family life, but face the prospect of condemning a subsequent aected child in utero, and by inference casting a judgement on their rst. In their case the decision about prenatal testing is more complex and calculated, though again primarily concerns the avoidance of future disenhancement. Experience in clinical practice suggests that the decision to undergo prenatal testing and termination of pregnancy, as a generalisation, becomes easier as the severity of the medical condition worsens. Inborn errors of metabolism leading to neuro-degeneration and early demise are frequently viewed as being devoid of any real hope because they usually breed true and the outcome is inevitable and predictable. These decisions may be more dicult in the future if realistic treatment options become available. 14.6.3 PRE-IMPLANTATION GENETIC DIAGNOSIS There are many couples, and not just those with objections on grounds of religious faith, for whom termination of pregnancy is not acceptable as a way of exercising choice in the face of genetic risk. This may be due to their views on the status of the foetus, the physical and emotional trauma of undergoing termination, or a combination of these. Some take steps not to have further children but others are attracted to pre-implantation genetic diagnosis (PGD). In this technique eggs cells from the mother are harvested for fertilisation by her partners sperm but the procedure requires hormonal super-ovulation and surgical recovery. In vitro fertilisation (IVF) techniques (Chapter 12) then produce embryos which are subjected to biopsy of a single cell at the eight-cell stage, about 48 hours after fertilisation (see Figure 14.1). To succeed, DNA analysis must be possible on the genetic material from this single cell. Even then, if pregnancy is successfully established after implantation of embryos (usually two) selected for low risk, centres providing this service oer the patient-clients conventional prenatal testing in order to be sure that no mistake has occurred. The hurdles to be overcome are considerable because of limited availability of the expertise, a success rate in the region of only 20% per cycle of treatment, and lack of public health service funding, which means that couples often have to raise much of their own nance. This raises ethical issues regarding equality of access to these services, which is part of a wider debate about the rationing of resources and the

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ethical principle of justice in the delivery of health care. In the UK treatment of this kind is tightly regulated through the Human Fertilisation and Embryology Authority (HFEA), which is dealt with elsewhere (Chapter 12). For individuals and couples who hold the view that full human status begins when a sperm fertilises an egg, PGD is not acceptable. However, PGD is acceptable to many couples who cannot put themselves through the emotional trauma of conventional prenatal testing and possible termination of an established pregnancy. This raises very interesting issues regarding the way these couples perceive the status of the embryo as compared with the foetus. Technically, embryonic life is that period of early development during which the vast majority of body structures are formed, which for humans is the rst eight post-ovulatory weeks (approximately 10 weeks gestation); the foetal period extends from eight weeks to birth (ORahilly and Mu ller, 1992). To many couples the acceptability of testing the very early embryo reects, in a very experiential way, the reasoning behind the Human Fertilisation and Embryology Act (1990) in the UK, which allows the use of (and research on) human embryos up to 14 days (see Chapter 12). However, it seems unlikely that the views of couples requesting PGD have been directly inuenced by these regulations. Currently, PGD in the UK is only granted a licence when it is undertaken for clear medical reasons, i.e. in situations of known genetic risk. This includes X-linked disease where it is not possible to undertake specic genetic analysis to determine which of the male embryos are at high or low risk. In these cases only female embryos are implanted. It is not currently permissible to use PGD for sex selection for purely social or family reasons. This was challenged in the autumn of 2000 by a Scottish couple with four sons who lost their only daughter in an accident (Cramb, 2000). The mother was sterilised after their daughters birth and sought PGD to implant only female embryos but this is not allowed within the UK regulations. They were treated in Italy but gave up the only embryo arising from the treatment because it was male (Wormersley, 2001). The motivation to use the technology in this way could be regarded as a form of commodication, or instrumentation reproductive treatment undertaken to meet very specic aspirations and needs of the parents. The same would be true of reproductive cloning if, for example, a sample of tissue from the deceased child had been available in culture. The concept of the newly created child as a commodity or instrument is an extension of the normal desire of couples to become parents to a level where having the child is conditional on certain characteristics or qualities which the parents require; in the case cited the condition is female sex. The situation where X-linked genetic risk is less easily dened is not clear. An example would be a couple who had two sons with some form of communication or autistic disorder, though without a specic genetic diagnosis. Epidemiological evidence suggests boys are more commonly aected than girls, prompting the couple to request sex selection on these grounds. The diculty here is knowing whether the population ratio can be meaningfully applied to an individual

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family because there are many dierent underlying causes of communication/autistic disorder, most of them not yet elucidated, and there can be no certainty that X-linked inheritance is operating. In the USA, where reproductive technologies are unregulated, the case of Adam Nash (Hall and Davis, 2000), who was born in August 2000, has brought a new dimension to embryo selection for health reasons. His sister Molly, six years old when Adam was born, has the condition Fanconis anaemia, and her bone marrow is failing. Inherited as an autosomal recessive condition, both parents are healthy carriers of the faulty gene, with a one in four risk of having an aected child in each pregnancy. With the support of their reproductive physicians the parents opted for PGD, not just to avoid Fanconis anaemia but also to positively select for a tissue match for Molly by HLA testing. From 12 fertilised eggs only one proved to full the dual requirements of not having Fanconis and being a perfect tissue match. Implantation of this embryo was successful and stem cells harvested from the umbilical cord at birth were subsequently infused into Molly in the hope that her bone marrow will be repopulated by normal tissue. It is the rst time that PGD has been specically carried out for the purpose of providing medical help for another person, in this case a sibling, and can also be considered as a form of commodication in the embryo selection and genetic enhancement debate. Objections can be raised on the grounds that the child has no choice about being a tissue-matched donor, or instrument, for the sick sibling, and therefore the childs feelings were not seriously taken into account. We do not know whether the child will, in the future, be proud to have helped the sibling in this way or perhaps experience some sort of identity crisis at having been an instrument for the purpose of the siblings health. Will they be closer siblings because of this treatment, or will they have a very unnatural relationship? If the sick sibling were not to respond to treatment and die anyway, how would such an outcome aect the donor siblings psyche and self-identity? On the other hand, some might argue, none of us actually chooses to be brought into the world, many of us are unplanned accidents, and this undermines arguments about utilitarianism and identity. In the UK, the HFEA relaxed its guidelines in late 2001 to grant a licence for a case similar to that of the Nash family. An important issue in the Nash family case, but common to all IVF, whether for PGD or infertility treatment, is the creation of many surplus embryos that will never be used. Whether this is acceptable clearly depends on ones views on the status of the early embryo but the ethical debate must also now address the potential creation of human embryos purely for stem cell research so-called therapeutic cloning. This has recently been approved in principle by a large majority vote in both houses of the UK Parliament (December 2000 and January 2001), in stark contrast to a European Parliament resolution in September 2000. These important issues are covered more fully elsewhere (Chapters 12 and 16).

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The likely development of relatively rapid and less expensive techniques for analysing hundreds of thousands of DNA sequences inevitably raises the question of how this might eventually be applied to prenatal screening and testing, as well as medical examination for employment and insurance. Concern over the prenatal issues prompted two public consultation exercises held in the UK during 2000, one from the HFEA dealing with PGD, and the other from the Advisory Committee on Genetic Testing (now absorbed into the Human Genetics Commission) dealing with more conventional prenatal screening and testing. Key questions will be the extent to which extended screening will be regarded as cost-eective by public health and the demand shown by the general public. However, there is also the issue of whether extended prenatal screening will be perceived as a form of eugenics and the way forward is likely to be very cautious. Signicantly, the HFEA public consultation on the use of PGD showed support in cases of serious genetic disorders but concern over wider implications of the technique. Any additions to the range of conditions screened will need to be deemed serious in the perception of both the public and relevant medical specialists. If such screening depends on invasive prenatal procedures to make a denitive diagnosis, thus carrying a risk to the pregnancy, it is unlikely to be attractive to pregnant women/couples. For these reasons it seems likely for the foreseeable future that screening and diagnosis for rare conditions will be restricted to those families directly aected, unless non-invasive tests are developed which can modify the risk (as in maternal serum screening for Down syndrome). There is, in fact, great interest in a technique that may have the potential to dramatically alter the way screening is oered, namely the ability to harvest foetal cells from the maternal circulation. Foetal cells dier from maternal cells in size and other characteristics but of course there are relatively few of them. If techniques to separate them eciently are perfected screening may be possible without the risks associated with invasive procedures. If extended screening at the embryo stage in PGD, and the foetus in established pregnancy, becomes feasible for a range of severe mendelian disorders it will also be technically possible for mutations and polymorphisms that confer risk, or predisposition, for important medical conditions. Well known examples are mutations in BRCA1 and BRCA2 for breast and breastovarian cancer, and the equivalent mutations in DNA mismatch repair genes for hereditary colorectal cancer. In both these familial forms of common cancers the mutations confer a high risk of developing the disease, though it is not inevitable. The penetrance is therefore not 100% but somewhat lower, perhaps 6085%. Then there are risk factors with far less predictive value, such as the ApoE4 allele in Alzheimers disease. Many such risk factors are likely to be identied in the next wave of human genome research with so much emphasis on single nucleotide polymorphisms (SNPs), various of which might be found to have predictive value in, for example, schizophrenia, manic depression, autism, diabetes, and various cancers.

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Will there be requests for tests of this kind if they are technically possible? At present this is dicult to say. Even with a serious, late onset degenerative condition demonstrating full penetrance, such as Huntingtons disease, experience gathered through the UK Predictive Testing Consortium indicates that prenatal tests are relatively uncommon, with 162 having been performed over the complete six year period 199499 (S.A. Simpson, personal communication, 2001). A small number of resolute couples are taking the PGD route. Some choose gamete donation but most couples elect for the time-honoured options of having children regardless of the risk, or not having any (or more) children once they know the risk. For some of those who start a family regardless of the risk, one factor which often inuences their decision, particularly in the late onset disorders, is the hope that treatment for the disease will be found in time to benet the next generation, and therefore enhance life for their children. This experience in clinical practice is supported by evidence from research. Data from the British Social Attitudes survey of 1998 (Stratford et al, 1999), including a wide range of questions on genetic research, suggest that people understand and draw a distinction between conditions which are seriously handicapping, whether mentally or physically, and those that might lead to premature death in adult life or give rise to dierences of appearance, such as extreme short stature. This is reected in responses to questions focused on medical conditions that might justify abortion. In clinical practice, of course, experience relates overwhelmingly to individuals, couples and families personally aected by specic problems, whereas a public survey asks questions of people who, for the most part, respond in accordance with their innate feelings and/or belief systems. This is important in trying to evaluate the potential uptake of prenatal genetic testing, for perception of risk is not merely a function of the arithmetical chance but more so of the severity or burden of disease, which itself includes crucial elements of chronicity in the prognosis, and therefore the time available for reasonable quality of life. Future choice in genetic testing at all stages of life may therefore, in theory at least, be confusingly extensive, but the use of such tests to enhance individual or family life seems likely to be conducted within the framework of cautious restraint that characterises current practice, applicable mainly to those personally aected. The British Social Attitudes project plans to repeat its survey at intervals in order to provide a measure of changing attitudes with time.

14.7 MANIPULATION OF GAMETES AND EMBRYOS FOR HEALTH AND ENHANCEMENT

14.7.1 GENE THERAPY The term gene therapy refers to any procedure or technique used to treat a medical condition by genetic modication of cells or tissues in the patient. The concept encompasses many possible strategies but current approaches generally

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involve the transfer of genetic material, i.e. genes, into the patients cells. Gene therapy, or genetic manipulation in any form, is currently only permissible on somatic tissues and not germline tissues. Manipulation of the early embryo should be included with the latter since this can reasonably be expected to aect the germline tissues in later development. The reasons for this legal position are easily appreciated when there is so much uncertainty about the safety and side eects of manipulating human genomic DNA at such a fundamental stage. For example, the position eects to which we referred in Section 14.2 mean that at present it is not possible to predict the level at which the inserted gene will be expressed in an individual. This problem will not be overcome until it is routinely possible to insert genes into specied locations within the genome. Limited success for targeting specic genomic locations has been achieved for mice (Thompson et al, 1989) and more recently for sheep (McCreath et al, 2000) but to date for no other mammal. However, even if gene targeting is achieved there may still be variation between individual transgenic animals. Safety issues and concerns about the long term consequences and hazards, possibly persisting over many generations, are additional major concerns about germline, as opposed to somatic, gene therapy. We simply do not know enough about the potentially damaging and irreversible perpetuation of genomic changes in succeeding lineages. At present, therefore, there is substantial consensus that humankind is not yet ready for this. Some take the view that human genetic engineering at the level of the gamete or early embryo will never be acceptable. This is largely because of fears that it represents a new techno-eugenics that will lead ever increasingly to attitudes of genetic determinism in relation to disability and behaviour, and discrimination at all levels in a society increasingly commercially driven. In addition, it may be seen as a step too far in tampering with our own biological nature. In this whole debate about the future applications of genetic science to humans there are many What if. . . ? scenarios. One of these, undoubtedly, is What if gene therapy and genetic manipulation of the germline can be shown to be safe, practical and eective? Should this transpire there are likely to be signicant voices advocating use of the techniques to treat, or more accurately, prevent, disease, especially where a family has already been aected. In the absence of regulation, if it can happen, it almost certainly will happen, as the case of Adam Nash demonstrates. Once a precedent is set, other cases generally follow. On one level it can be argued that germline gene therapy represents a higher ethical standard than embryo selection or termination of pregnancy, especially if it reduces suering and the side eects of conventional therapies. However, it seems unlikely that an excess production of embryos with some form of selection can be avoided. This objection would be circumvented if genetic manipulation of gametes could be successfully achieved because most people do not ascribe to sperm and ova the status of life that they ascribe the zygote (i.e. the newly fertilised ovum). There are counter ethical arguments to genetic manipulation of either em-

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bryos or gametes. Firstly, there is still concern about the irreversible eects of manipulation for the succeeding lineage, and many take the view that this is always going to be unacceptable for humankind. This is very much seen as unnatural and playing God, building on the notion that it is inappropriate for humans to be tampering with natural forces, controlling their own destiny, and putting faith in genetic determinism. Others see this as an over-sentimental attitude, arguing that humankind has been modifying (and indeed polluting) the environment and the biosphere over aeons in far more signicant ways. We have also clearly exercised a great deal of choice in the selection of mating partners, often operating within societies which are heavily stratied from the social and economic viewpoints. Is this, in itself, not a form of biological selection, and if so, is it natural or unnatural? There is a school of thought which very much sees the natural versus unnatural debate primarily as a function of how we view the world now, i.e. the unnaturalness of much that developed societies take for granted is not recognised. Further, the division between natural and unnatural does not provide us with clear-cut ethical guidelines (Reiss and Straughan, 1996). Rather, our ethical assessment of a particular intervention may depend on whether actions or judgements are viewed intrinsically/deontologically (see Chapter 1) or consequentially. The intrinsic viewpoint regards an action or judgement as either right or wrong in itself, and by implication cannot identify any circumstances where it is justied to change position. The consequential viewpoint allows for exibility because rightness or wrongness is judged by the eects or consequences that an action has. Even recent history tells us that much that was considered wrong in the past is now at least tolerated, if not fully accepted. However, the intrinsic (deontological) and consequential approaches need not necessarily be seen as opposite ways of making ethical judgements. Rather, they may each be seen as the context within which the other operates. Thus there may be intrinsic ethical arguments about not pursuing genetic technologies, but not to do so may be to neglect an opportunity, and therefore fail, to prevent and relieve human suering. However, to pursue them for reasons other than the prevention or relief of human suering would be wrong. Thus the two approaches may act as constraints, one upon the other. A second major argument against the genetic manipulation of embryos centres around the acceptance of handicap and disability in society and therefore parallels the concerns relating to prenatal Down syndrome screening, as discussed already. If we strive for a society in which genetically determined handicaps and disabilities are reduced, are we making a statement that the handicapped and disabled have no value, or, if they have value, that it is very much inferior to those who are able in mind and body (Shakespeare, 1998; Kuhse, 1999)? In relation to termination of pregnancy for handicap and disability, some would see this as an echo of the eugenics movement of the 19th and early 20th centuries, as discussed in Section 14.4.1. Failure to take account of the views of the handicapped and disabled exposes serious insensitivity and failure to be inclusive, at best, and deciencies in our understanding of what it means to be

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human, at worst. The worth of human civilisation may justiably be measured by its level of care for the sick and underprivileged, who will always be there. However, an underlying tenet in the art and science of medicine is to treat and prevent disease, and relieve suering. On this basis it may be fully justied to include genetic manipulation as a form of therapy to prevent handicap and disability. In relation to the worlds major health problems of infectious epidemics and famines, humankind has not, hitherto, exercised any restraint in trying to abolish these on the basis that they are somehow good for us. In fact, as we now appreciate, a certain level of infectious disease probably is good for us as a species the herd immunity eect but no individual or family would choose to be suerers. Extending this reasoning to genetic disease, humanity benets from the unique contribution of the handicapped and disabled because they are individuals with equal value to the able-bodied and society learns that caring for this group is part of what it means for all human beings to coexist with mutual respect and inter-dependency. However, for a family already severely aected by a serious genetic condition, one understands, and has sympathy with, the choice they may make to prevent the condition appearing again. These arguments are likely to continue to be held in balance in the whole debate. If genetic manipulation of embryos and/or gametes becomes feasible, safe and eective, however, it is likely that it will be applied, and probably limited to, those couples and families who have already been aected by a serious genetic disease, which is very close to current medical genetic practice as it relates to prenatal diagnosis. 14.7.2 GENETIC ENHANCEMENT Genetic manipulation of embryos and gametes as it relates to enhancement takes the whole debate to another level, and conjures up images of a brave new world of designer babies. If it becomes possible to modify stature, hair or skin colour, athletic or musical ability, for example, by genetic engineering, will there be a demand for it? The answer may well be yes, but this does not make it generally acceptable. There is a powerful argument that it represents a form of eugenics, or at the very least, once again, commodication parents making their children into instruments of their own pleasure, meeting their own aspirations rather than fully acknowledging them as individuals in their own right. One diculty, however, is how we perceive the distinction between treatment and enhancement. This is well seen in relation to short stature and the publicity surrounding a young adolescent girl undergoing limb lengthening surgery in the UK, at the expense of the National Health Service, in order to give her enough height to full her ambition of becoming an air hostess (Alderson, 2000). There are similar controversies in relation to breast enlargement or reduction surgery, sex change operations for gender identity disorder, and pure cosmetic surgery. One persons enhancement is another persons treatment and there are grey areas for which there is unlikely ever to be a consensus. Self-image, peer

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pressure, and the cultural norms of a society are all important factors in determining individual perception of enhancement versus treatment. However, in the UK the Clothier Report (Report of the Committee on the Ethics of Gene Therapy, 1992), has rejected genetic manipulation for cosmetic reasons. It can be argued, of course, that many, if not most, parents already practice a form of commodication by bringing up their children a certain way, with their own values or within their own belief system, or giving them privileged opportunities through private education or expensive extra-curricular activities. Whilst this touches on many social issues which are not within the scope of this chapter, most people draw a distinction between this type of enhancement and premeditated, biologically engineered enhancement which leaves much less to the imagination and is clearly aimed at some ulterior motive of self-gratication and/or competitive advantage. Genetic enhancement through manipulation of embryos or gametes strikes at the very heart of what it means to have ones own identity through natural laws of chance, the acceptance of what nature (or for many people, God) allocates to an individual, as if in a personalised ticket. This, it seems, is a powerful undercurrent in the understanding of who we are as individuals and as a species. It is supported by evidence from the British Social Attitudes survey (Stratford et al, 1999). This highlighted support for genetic research and gene manipulation for the detection, prevention, and treatment of disease but there were deep reservations for the application of this technology for enhancement. The responses in relation to modifying antisocial behaviours such as violence and aggression were less clear, thus highlighting a grey area of the kind that will always court controversy. It remains to be seen how public opinion will evolve as the technology moves on. We should not assume that human genome research is leading steadily and inexorably towards designer babies and there is no suggestion at present that this is acceptable either to scientists or the public. As one writer put it in relation to publication of the rst draft of the human genome, This is the key to life but not the secret of a perfect one (Daniels, 2000). One could also paraphrase a well known biblical quotation: Man shall not live by DNA alone. There is increasing promise of successful forms of treatment for disease that do not require genetic manipulation of embryos and gametes, and so the framework of ethical issues may develop a dierent focus. It is important that the ethical debate remains vigorous, keeping pace with scientic progress and seeking broad views through public consultation.

14.8 CONCLUDING REMARKS

Human genetic research has already brought enormous change to clinical medicine, and on a daily basis individuals, couples and families are beneting from existing applications in genetic testing and experiencing enhancement in dier-

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ent ways. Genetic manipulation poses new and exciting possibilities as well as huge challenges and ethical dilemmas. However, it is likely that the focus for the foreseeable future will continue to be on patient-clients for whom it will be directly applicable. It is also increasingly probable that human genome research will inuence public health policies as more is learned about disease susceptibility in dierent groups and populations. The challenges will be to translate and communicate anticipated benets and health enhancements to the public, as well as protecting them from abuse and misuse of the technology (see also Chapter 13).

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Diagnosis of adrenogenital syndrome before birth. Lancet, ii, 553555. Jones, S. (1996) In the Blood: God, Genes and Destiny. Harper Collins, London, UK. Kuhse, H. (1999) Preventing genetic impairments: does it discriminate against people with disabilities? In Genetic Information: Acquisition, Access and Control, Thompson, A.K. and Chadwick, R.F. (eds), KluwerPlenum, New York, USA, pp. 1730. Liley, A.W. (1961) Liquor amnii analysis in management of pregnancy complicated by rhesus sensitization. American Journal of Obstetrics and Gynecology, 82, 13591370. Liley, A.W. (1963) Intrauterine transfusion of foetus in haemolytic disease. British Medical Journal, 2, 11071109. Macilwain, C. (2000) World leaders heap praise on human genome landmark. Nature, 405, 983984. Marshall, E. (2000a) Human genome: rival sequencers celebrate a milestone together. Science, 288, 22942295. Marshall, E. (2000b) Human genome: storm erupts over terms for publishing Celeras sequence. Science, 290, 20422043. McCreath, K.J., Howcroft, J., Campbell, K.H.S., Colman, A., Schnieke, A.E. and King, A.J. (2000) Production of gene-targeted sheep by nuclear transfer from cultured somatic cells. Nature, 405, 10661069. Nadler, H. (1968) Antenatal detection of hereditary disorders. Pediatrics, 42, 912918. ORahilly, R. and Mu ller, F. (1992) Human Embryology and Teratology. Wiley-Liss, New York, USA. Proctor, A.M., Clarke, A. and Harper, P.S. (1999) Survey of genetic testing in childhood. Journal of Medical Genetics, 36 (Suppl. 1), S73. Rechsteiner, M.C. (1991) The human genome project: misguided science policy. Trends in Biochemical Sciences, 16, 455. Reiss, M.J. and Straughan, R. (1996) Improving Nature? The Science and Ethics of Genetic Engineering. Cambridge University Press, Cambridge, UK. Report of the Committee on the Ethics of Gene Therapy. (1992) HMSO, London, UK. Report of a Working Party of the Clinical Genetics Society (UK) (1994) The genetic testing of children. Journal of Medical Genetics, 31, 785787. Riis, P. and Fuchs, F. (1960) Antenatal detection of foetal sex in prevention of hereditary disease. Lancet, ii, 180182. Serr, D.M. and Margolis, E. (1964) Diagnosis of fetal sex in a sex linked hereditary disorder. American Journal of Obstetrics and Gynecology, 88, 230232. Shakespeare, T. (1998) Choices and rights: eugenics, genetics and disability equality. Disability and Society, 13, 665682. Shapiro, R. (1991) The Human Blueprint: the Race to Unlock the Secrets of our Genetic Script. St Martins, New York, USA. Skirton, H. (1999) Genetic nurses and counsellors preparation for practice with families at risk of cancer. Disease Markers, 15, 145147. Skirton, H. (2000) A longitudinal study of genetic counselling for families needs, expectations and outcomes. PhD Thesis. University of Exeter, UK. Smaglik, P. (2000) Forces for collaboration falter with human genome in sight. Nature, 408, 758. Stratford, N., Marteau, T. and Bobrow, M. (1999) Tailoring genes. In British Social Attitudes 16th Report. Jowell, R., Curtice, J., Park, A. and Thomson, K. (eds), Ashgate, Aldershot, UK, pp. 157178. Thompson, S., Clarke, A.R., Pow, A.M., Hooper, M.L. and Melton, D.W. (1989) Germline transmission and expression of a corrected HRPT gene produced by gene targeting in embryonic stem cells. Cell, 56, 313321. Turnpenny, P.D. (ed). (1995) Secrets in the Genes: Adoption, Inheritance, and Genetic Disease. British Agencies for Adoption and Fostering, London, UK.

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Valenti, C., Schutta, E.J. and Kehaty, T. (1968) Prenatal diagnosis of Down syndrome. Lancet, ii, 220. Vogel, G. (2001) Infant monkey carries jellysh gene. Science, 291, 226. Wald, N.J., Huttly, W.J. and Hennessy, C.F. (1999) Downs syndrome screening in the UK in 1998. Lancet, 352, 336337. Wald, N.J., Kennard, A., Hackshaw, A. and McGuire, A. (1997) Antenatal screening for Downs syndrome. Journal of Medical Screening, 4, 181246. Ward, R.H.T., Modell, B., Petrou, M., Karagozlu F. and Douratsos, E. (1983) Method of sampling chorionic villi in rst trimester of pregnancy under guidance of real time ultrasound. British Medical Journal, 286, 15421544. Watson, J.D. and Crick, F.H.C. (1953) Molecular structure of nucleic acids: a structure for deoxynucleic acids. Nature, 171, 737738. Webster, D.M. and Kruglanski, A.W. (1994) Individual dierences in need for cognitive closure. Journal of Personality and Social Psychology, 67, 10491062. Wertz, D.C. (1998). International perspectives. In The Genetic Testing of Children. Clarke, A. (ed), Bios, Oxford, UK, pp. 271287. Wikler, D. (1999) Can we learn from eugenics. In Genetic Information: Acquisition, Access and Control, Thompson, A.K. and Chadwick, R.F.(eds), KluwerPlenum, New York, USA, pp. 116. Wormersley, T. (2001) The Daily Telegraph, 5 March, 7.

FURTHER READING
In addition to the above references we suggest for further reading Marteau, T. and Richards, M. (eds) (1996) The Troubled Helix. Cambridge University Press, Cambridge, UK.

Bioethics for Scientists Edited by John Bryant, Linda Baggott la Velle and John Searle Copyright 2002 John Wiley & Sons Ltd ISBNs: 0-471-49532-8 (Hardback); 0-470-84659-3 (Electronic)

15 Patenting Human Genes: Ethical and Policy Issues

Audrey R. Chapman

In February 2001 two rival teams utilizing dierent methodologies published working drafts of the human genomic sequence. The Human Genome Project has been a massive project, on a scale unparalleled in the history of biology, with very signicant scientic and human health implications. It will help us to understand the biological substructure of human nature. The sequencing of the human genome will also provide scientists with tools to identify the genes whose defects or mutations are assumed to be the cause of genetically based diseases and to develop new therapies and approaches for a wide range of diseases and problems (see Chapter 14). However, we have a long way to go to be able to apply this knowledge. Although scientists have a very clear idea of the biochemical mechanisms involved in the function of genes (i.e. in providing the instructions for synthesis of proteins) they are still very far from understanding the complex interplay of genes and the regulatory cascades and networks that must operate in the development and indeed in the daily life of multi-cellular organisms. One of the startling discoveries of the Human Genome Project is that we apparently have only 26 00030 000 genes, many fewer than the 100 000 that were anticipated. This means that human genes (and, likely, mammalian genes in general) and gene control mechanisms are probably far more complex than those of other organisms; indeed it is likely that as yet unknown regulatory sequences exist, perhaps amongst the non-coding DNA, sometimes referred to in the past as junk DNA. The unexpectedly low number of human genes compared with the actual genetic complexity of humans suggests that specic human genes carry out a far greater range of functions than those in other organisms; the model of one gene codes for one protein may have to be discarded. Thus the sequencing of the human genome represents, not an ending, but the beginning of a new approach to biology. Clearly the new genetic knowledge we are gaining will be signicant to the human future. How genetic data will be used and whom they will benet are critical issues. This chapter argues that the resolution of these issues will depend
Bioethics for Scientists. Edited by John Bryant, Linda Baggott la Velle and John Searle. 2002 by John Wiley & Sons Ltd.

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at least in part on seemingly arcane decisions about the patenting of genetic information. It thus asks whether it is ethically or scientically appropriate to grant patents or other forms of intellectual property rights for genetic information.

15.1 CURRENT SITUATION

Two consortia with major dierences in approach to patenting have now sequenced the human genome. One of the teams, the International Human Genome Sequencing Consortium, is a predominantly public eort headed by the US National Center for Human Genome Research, which has also received signicant support from the Wellcome Trust in the UK, one of the largest private medical foundations in the world. This team is committed to free and unlimited access to its data in order to promote the greatest public benet. By doing so, it is giving expression to a central principle of the United Nations Universal Declaration on the Human Genome and Human Rights: The human genome underlies the fundamental unity of all members of the human family, as well as the recognition of their inherent dignity and diversity. In a symbolic sense, it is the heritage of humanity. The rival team is a private initiative by Celera Genomics, a US based corporation in the vanguard of eorts to use the human genome sequence to make money for private investors. Celera had a major advantage over the public team because it was able to make use of its data without having to reciprocate. Currently, Celera is restricting access to its database and charging fees for most uses of this information. It is also staking out patent claims on those genetic sequences that have the most promise for developing diagnostics and treatments. Moreover, Celera is not alone. Stock market analysts estimate that there are more than 100 drug-platform biotechnology companies attempting to exploit genomic information by developing drugs. The bioinformatics market will soon exceed $1 billion per year. The highly competitive eort to patent genes has been variously compared with the 19th century partition of Africa by the colonial powers and the California gold rush (Marshall, 1997). Given the issues at stake, there are four signicant questions that should be considered. The rst is whether human genetic information can fulll the technical requirements for patentability. The second is whether it is ethically appropriate to patent human genes. Third, does patenting of genetic information promote scientic research and contribute to human welfare? And fourth, does patenting human DNA and tissue demean human life and human dignity?
Universal Declaration on the Human Genome and Human Rights, UNESCO 1997, UN General Assembly 1999. (http://www.unesco.org/humanrights/hrbc.htm). See commentary in Nature, 409, 745 (2001).

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15.2 FULFILLING TECHNICAL REQUIREMENTS FOR PATENTABILITY

Historically, governments have sought to promote creativity, the dissemination of ideas, development of inventions, and scientic progress by providing time limited protection to creators and inventors in the form of intellectual property rights, such as patents and copyrights. There have been three primary criteria to qualify for patentability: novelty, utility, and non-obviousness (see also Chapter 10). To be novel an invention must not have been known and available to the public at the time of the application. Utility refers to usefulness. To qualify, a proposed patent must specify concrete function, service, or purpose. Nonobviousness has a technical denition: an invention cannot obtain a patent if the dierences between its subject matter and the prior art are such that The subject matter as a whole would have been obvious at the time the invention was made to a person having ordinary skill in the art to which said subject matter pertains. Legal doctrine also traditionally distinguished between objects someone designs from simpler materials by reason of a plan or principle and objects that an individual simply discovers or produces by applying a process or instrument to natural materials. The former was considered to be an invention and therefore patentable, but the latter was not. Prior to 1980, some 200 years of legal doctrine conceptualized life forms as products of nature and therefore unable to meet the criteria for patentability. However, in a landmark case in that year, Diamond v. Chakrabarty, the US Supreme Court ruled, in a narrow 54 decision, that genetically modied living organisms were not natures handiwork but the result of human ingenuity and research and therefore patentable subject matter. In making this decision, the justices apparently assumed that the refusal to accord patent rights in genetically engineered organisms would slow down the pace of research in this eld and make US companies less competitive. In rendering its decision, the court explicitly refused to consider non-economic issues, holding that non-economic values, such as respect for life, were outside its purview in deciding cases related to patent law. The decision stated that only Congress could address matters of high policy (Gold, 1996). However, the US Congress has preferred not to consider the appropriateness of granting life patents, and the US Patent and Trademark Oce has been free to set policy without any meaningful ethical or political oversight by the courts or political representatives. The lack of legislative guidelines in the US has meant that the US Patent and Trademark Oce (PTO) has been free to determine policy on narrow technical grounds. After 1980, the PTO began to grant new kinds of biotechnology patent,
35 United States Code, Sec. 103. Diamond v Chakrabarty, 477 U.S. 303 (1980).

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rst on newly developed plant varieties and seeds (1985; see Chapter 10), then on non-naturally-occurring non-human multicellular living organisms, including animals (1987), and more recently to cover genes, gene fragments, and cell lines that are functionally equivalent to those occurring in nature. Accelerated international economic competition for markets has encouraged other patent oces in Europe and Japan to follow suit. In Europe, the European Patent Oce granted the rst patent for a microorganism in 1981, the rst patent for a plant in 1989, even though the relevant legal provisions were not clear, and a patent for a genetically modied animal in 1992 (Salazar, 1999). In 2000, patents covering the methods of producing cloned non-human animals, human cell lines, and early human embryos, and also covering such animals, cell lines, and embryos as the products of cloning, were awarded in Britain despite their apparent violation of the European Directive on the Legal Protection of Biological Inventions. Patents on the same are pending in the US at the time of writing, early in 2001 (Poland, 2000). Currently, the major patent oces issue thousands of life patents every year. To rationalize the granting of genetic patents, the PTO claims that a gene patent applies not to the DNA itself but to the process of altering it in some way using human knowledge to create something else (Stone, 1995). In seeking to clarify eligibility for patenting, PTO ocials distinguish between naturally occurring DNA sequences and sequences that are isolated and puried and claim that the latter meets the requirement of being distinguished from the natural state and are thereby patentable subject matter. However, all that occurs in the process of identifying and cloning the coding region of a gene is the removal of the introns (the non-coding DNA sequences that interrupt the sequences that code for proteins) via the synthesis of complementary or cDNA (using messenger RNA as a template for this). Therefore this distinction can quite rightly be considered to be intellectually trivial. Messenger RNA exists in nature and cDNA is just a copy of this sequence. One recent analysis likens claims that synthesizing cDNA is an alteration of nature, and as such a human invention, to saying that the same invention could be re-patented if translated into a dierent language (Bobrow and Thomas, 2001). Nevertheless the situation is that the PTO now issues patents on genes, gene fragments, proteins, and cell-lines that are functionally equivalent to their naturally occurring counterparts. Moreover, the patents issued cover the gene, gene sequence, or protein itself, not simply the process of reproducing, isolating, or purifying it. Advocates of patenting also argue that it takes considerable ingenuity and investment to obtain genetic sequences and copy them and claim that this provides a sucient warrant to support patenting. In the past, the process of isolating genes and determining sequences was cumbersome and time consuming, but new technologies have changed how discoveries are made. Currently, however, this work is done primarily by automatic gene sequencing machines that churn out sequences quite mechanically, incredibly quickly, and at a relatively low cost. DNA sequences identied through such high throughput

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sequencing can perhaps best be characterized as new scientic information (Eisenberg, 2000) and scientic principles and knowledge are not patentable subject matter. Criteria for patentability were developed to apply to mechanical inventions and from the above analysis it is questionable as to whether life forms, particularly genetic sequences, fulll these conditions. Genetic patents would not seem to fulll the rst or third criteria, novelty and non-obviousness. Given the present state of genetic knowledge, few patent applications for genes or genetic fragments can specify the function of the genetic information in question or the likely applications. This obviously limits the utility of this information. The only clear value of much of this information is its potential utility through licensing access to the data and that benet would accrue only to the patent holder, not to the general public (see also Chapter 10).

15.3 ETHICAL CONCERNS

That there are ethical implications of treating life forms as just another useful product was pointed out by critics at the time of the landmark Chakrabarty case and has been a source of ongoing contention. Ethical implications constitute grounds for excluding subject matter from patentability under some intellectual property regimes. The European Patent Convention Agreement and the European Directive on the Legal Protection of Biotechnological Inventions allow members to exclude subject matter from patenting to protect ordre public or morality, including to protect human, animal or plant life or health or to avoid serious prejudice to the environment. This provision also appears in the World Trade Organizations Trade Related Aspects of Intellectual Property Agreement, generally known as TRIPS. US patent law, however, does not condition patent recognition on ethical criteria. And even in Europe patent examiners have construed moral criteria so narrowly that few, if any, ethical considerations are likely to exclude patent applications. The European Patent Oce, for example, only excludes patents whose exploitation would be abhorrent to the overwhelming majority of the public or a contravention of the totality of accepted norms (Drahos, 1999). Three sets of communities have raised ethical issues about genetic patenting on an ongoing basis indigenous peoples, the religious community, and public interest groups. A small but growing number of secular ethicists have also been critical of the ethical implications of patenting. The opposition of indigenous groups to genetic patenting reects a belief that nature and all biological materials within nature are held as sacred trusts and therefore cannot constitute human property. According to one recent statement, nobody can own what
Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS Agreement) (1994), Section 5: Patents, Article 27 (2), published in a collection of documents compiled by the World Intellectual Property Organization, WIPO Publication No. 223 (E), Geneva, 1997.

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exists in nature except nature herself. . . . Humankind is part of Mother Nature, we have created nothing and so we can in no way claim to be owners of what does not belong to us. The very concept of manipulating nature is also oensive to many traditional cultures. The perspective of one Native American is that DNA is not ours to manipulate, alter, own, or sell . . . It was passed on from our ancestors and should be passed on to our children and future generations with its full integrity. Because indigenous knowledge, culture, and resources are understood to belong in common to the community, members of these communities frequently object to the fundamental principle of patent law, vesting property rights in individuals, especially over living things. That there have been widely publicized examples of biopiracy involving foreigners patenting plants cultivated by indigenous groups without consent or compensation, further alienates many groups. There is particular suspicion about human genetic patenting resulting from several high prole cases. In 19931994, for example, more than 30 organizations representing indigenous peoples objected to eorts by the (US) National Institutes of Health (NIH) to patent viral DNA taken from human subjects in Papua New Guinea and the Solomon Islands (Resnik, 1999). The outcry eventually prompted NIH to vacate the patent it received. Although the religious community has generally been supportive of genetic research and applications, many churches and religious thinkers have been uncomfortable with genetic patenting, especially when the patents are composition of matter (or structure) rather than process patents. Shortly after the landmark 1980 Supreme Court decision allowing the patenting of life forms, the General Secretaries of the National Council of Churches, the United States Catholic Conference, and the Synagogue Council of America sent a letter to President Jimmy Carter warning that control of life forms by any individual or group poses a threat to all humanity:
We know from experience that it would be na ve and unfair to ask private corporations to suddenly abandon the prot motive when it comes to genetic engineering. Private corporations develop and sell new products to make money, whether these products are automobiles or new forms of life. Yet when the products are new life forms, with all the risks entailed, shouldnt there be broader criteria than prot for determining their use and distribution?

Echoing these concerns, a 1989 World Council of Churches publication, Biotechnology: Its Challenges to the Churches and the World, opposed the patenting of life-forms: The patenting of life encodes into law a reductionist conception of
Indigenous Peoples Statement on the Trade-Related Aspects of Intellectual Property Rights (TRIPS) of the WTO Agreement, signed by indigenous peoples organizations and networks at the United Nations, Geneva, Switzerland, on 25 July 1999 and reprinted in GeneWatch, 12 (October 1999): 1011. Debra Harry, the director of the Indigenous Peoples Council on Biocolonialism, was so quoted in Steve Olson (2001). A letter to the President of the United States, reprinted in Panel on Bioethical Concerns of the National Council of the Churches of Christ/USA (1984) Genetic Engineering: Social and Ethical Consequences. Pilgrim, New York, USA, Appendix A.

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life which seeks to remove any distinction between living and non-living things . . . This mechanistic view directly contradicts the sacramental, interrelated view of life intrinsic to a theology of the integrity of creation (World Council of Churches, 1989). The best known US initiative by the religious community on patenting was the 1995 Joint Appeal Against Human and Animal Patenting signed by the titular leaders of some 80 religious faiths and denominations, including prominent clergy from Protestant denominations and Catholic and Orthodox churches as well as Jewish, Muslim, Buddhist, and Hindu leaders. The brief text calls for a moratorium on the patenting of life:
We, the undersigned religious leaders, oppose the patenting of human and animal life forms. We are disturbed by the U.S. Patent Oces recent decision to patent body parts and several genetically engineered animals. We believe that humans and animals are creations of God, not humans, and as such should not be patented as human inventions.

According to this statement, patents on genes or organisms represent the usurping of the ownership rights of the sovereign Creator. However, not all religious thinkers or communities would agree with the claim that patents amount to a symbolic demeaning or infringement of Gods role as Creator. Theologian Ronald Cole-Turners view, for example, is that Gods ownership right does not entail exclusion or domination, but instead the right to dene the purpose and value of each creature, as well as to dene the moral relationship among creatures. Stressing that Gods ownership is fundamentally dierent from ours, Cole-Turner explains that God owns all things, not in an exclusive sense, but precisely in the opposite way, that is, to give all the goodness of creation as gifts to be shared by all creatures. . . . Gods ownership does not exclude but relativizes and qualies human ownership (Cole-Turner, 1999). He goes on to conclude that there should be no theological objection to biological patents as long as individuals and corporations exercise their intellectual property rights in a way that is consistent with the purposes that God denes. Churches in Europe, as well as in the US, have taken strong positions against patenting biological material. The European Ecumenical Commission for Church and Society, a multi-disciplinary group of experts from a number of Protestant, Anglican, and Orthodox national churches and councils of churches, made several critical submissions to the European Commission and the Parliament at various stages of the drafting of a European Community Directive on Biotechnology Patenting. Their concerns related both to the process, particularly the lack of adequate consultation with the public, and to substance. Their critique included the failure to provide a proper basis for the key ethical judgements implicit in the directive, beyond merely commercial arguments, which were not deemed adequate. The Commission for Church and Society also
Joint Appeal Against Human and Animal Patenting, text of the press conference announcement made available by the Board of Church and Society of the United Methodist Church, Washington, DC, 17 May 1995.

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pointed out that the draft did not mandate the establishment of a body able to assess the ethical aspects of patents. Another source of opposition to gene patenting on moral grounds is the intuition that it is not appropriate to grant intellectual property rights over humanitys common heritage. In a 1991 letter to the journal Science, Hubert Currien, then the French Minister for Research and Technology, argued that It would be prejudicial for scientists to adopt a generalized system of patenting knowledge about the human genome. A patent should not be granted for something that is part of our universal heritage (Currien, 1991). Philosopher Ned Hettinger uses a similar line of reasoning to oppose gene patents. Hettinger (1995) claims that proper appreciation for the three and a half billion year story of the development of life on this planet and respect for the processes of evolution and speciation preclude gene patenting. He goes on to observe that
Just as it is presumptuous to patent laws of nature, so too it is presumptuous to patent genes, which are equally fundamental to nature. Ideally, gene-types should be treated as a common heritage to be used by all beings who may benet from them. As previously existing, nonexclusive objects that may be used benecially by everyone at once, no one should possess the right to monopolize gene-types with patents or to lock up genes through any other property arrangements.

The Council for Responsible Genetics, a US based non-governmental organization, has actively campaigned against genetic patenting since 1995. Its statement No patents on life argues that no individual, institution, or corporation should be able to claim ownership over species or varieties of living organisms or hold patents on organs, cells, genes, or proteins, whether naturally occurring, genetically altered, or otherwise modied (Wilson, 1999). Similarly, its Genetic Bill of Rights, intended to protect human rights, privacy, and dignity, states that all people have the right to a world in which living organisms cannot be patented, including human beings, animals, plants, and all of their parts (Council for Responsible Genetics, 2000). Like the Council for Responsible Genetics, many Third World activists have participated in campaigns against patenting designed to arm the integrity of nature and to protect their resources from exploitation by foreign corporations. It should be noted that proponents of life patenting rarely contest the substance of the ethical and religious concerns noted here. Their approach generally has been to argue that patents are ethical because the patent system motivates corporations to make investments in expensive medical research that bring wide benets. Another line of reasoning popular among patent supporters is that patenting should not be equated with ownership but instead merely constitutes the grant of an exclusive right to prevent others from making, using, or selling the protected invention without express permission for a period of 20 years (see
A Submission to the European Parliament on the Common Position of the draft Directive on the Patenting of Biotechnological Inventions from the European Ecumenical Commission for Church and Society, Strasbourg, 28 March 1998, posted on the website of the Society, Religion and Technology Project, Church of Scotland, http://www.srtp.org.uk/eecept45.shtml

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also Chapter 10). But whether patents are a form of ownership depends on ones understanding of property. Here it is important to note that property is not an all or nothing concept; property rights can admit of degrees, and by this line of reasoning patents are a form of ownership (again, see also Chapter 10).

15.4 GENETIC PATENTS AND SCIENTIFIC RESEARCH

Traditionally, the central rationale for intellectual property protection is that incentives and rewards to inventors and creators stimulate economic and social development and thereby benet human welfare, but an approach that works for artistic works and technology does not necessarily have the same benets when applied to genetic knowledge. At the least, patenting complicates access and increases the cost to the consumer. The current patent system is also likely to inhibit new product applications of genetic knowledge. The business community, as well as the patent oces, maintain that innovation in genetic and biomedical research and technology requires or is enhanced by patent protection. Industry representatives typically argue that strong patent protection is the only safeguard that can provide incentives to investors to take the long-term risks required for the development of new biotechnology products. They typically claim that it costs from $300 to $500 million in the US for a single product to move from inception through testing and FDA approval. Writing in Science (Doll, 1998), the director of the US Patent Oces biotechnology division oered the following justication:
Without the incentive of patents, there would be less investment in DNA research and scientists might not disclose their new DNA products to the public. Issuance of patents to such products not only results in the dissemination of technological information to the scientic community for use as a basis for further research but also stimulates investment in the research, development, and commercialization of new biologics. It is only with the patenting of DNA technology that some companies, particularly small ones, can raise sucient venture capital to bring benecial products to the market place or fund further research. A strong U.S. patent system is critical for the continued development and dissemination to the public of information on DNA sequence elements.

Many scientists though have questioned the appropriateness and scientic benets of granting genetic patents, particularly on raw genomic data. The international Human Genome Organisation, often known as HUGO, has taken a very strong position against the patenting of partial and uncharacterized genetic sequences and argued that doing so would impede the development of diagnostics and therapeutics, which is clearly not in the public interest (The Human Genome Organisation, 1995). Both HUGO and the US National Genome Institute have been dedicated to the early release and public availability
See, for example, the several articles by corporate representatives in Chapman (1999). This gure has been contested by patent critics, some of whom believe it is closer to $30 million. The issue is dicult to resolve because it depends on what items are included in the calculations.

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of human genetic sequences. Many individual scientists and organizations view patenting as contrary to the tradition of shared knowledge in scientic discovery. A number of studies have shown that life sciences faculties, particularly those with industry support, are far less likely to share research results with colleagues. Often this information is kept condential to protect its proprietary value beyond the time required to le a patent (see, e.g., Blumenthal et al, 1996). This has become increasingly problematic as more and more academic scientists and institutions develop relationships with corporations. Others fear that patenting will impede research and therapeutic applications of the knowledge generated by the Human Genome Project. During the Human Genome Project several major corporations, including Merck, supported eorts to keep genetic sequences in the public domain on a public database that would not be subject to patenting. But again, there are dierences of perspective in the scientic community and corporate world. Some genetic scientists have established or joined biotechnology companies and become part of the rush to patent. Craig Venter, a former sta scientist of the National Institutes of Health, who is now the chief of Celera Genomics, is a prime example. Corporations, such as SmithKline-Beecham and Celera Genomics, have sought patent protection for their sequences, and even corporations that oppose the patenting of genetic sequences, such as Merck, fully endorse patent protection for products developed from that knowledge. Recently, there have been articles published in both Science and Nature that argue that current patent policy is likely to jeopardize rather than to facilitate medical progress. The authors share the concern that the proliferation of gene patents is resulting in a welter of claims and counter-claims to the same sequences. According to these analysts, the resulting fragmentation of property rights among too many owners will result in a situation where development of new products will require a complex and dicult bundling of agreements, something researchers may nd dicult to achieve. Because each patent holder can potentially block the others and thereby deter applications of the knowledge, conicting claims will undoubtedly produce legal challenges. Litigation is generally slow and expensive to wage, and the legal process therefore is likely to drain resources and block applications of genetic knowledge. As a consequence, intellectual property rights may lead to fewer useful products for improving human health (Heller and Eisenberg, 1998; Bobrow and Thomas, 2001).

15.5 PATENTING AND RESPECT FOR HUMAN DIGNITY

The concept of the inherent dignity of the human person is the grounding for internationally recognized human rights. It is also a central concept in most Western legal systems. A number of critics have raised concerns about whether the patenting of human genes infringes respect for human dignity. Clearly some

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potential applications of genetic patenting would be problematic. The 13th Amendment to the US Constitution prohibits the owning and selling of human beings. For this reason an application to patent an entire set of genes of a specic person would violate US law. Some of those who object to patents on the grounds that intellectual property rights impair human dignity do so because of a commitment to preserve human genetic integrity. They anticipate that DNA sequences, once patented, might be altered either to eliminate aws or to enhance human potential (see Chapter 14). Here the opposition to eugenics intersects with the patent debate. To protect the dignity and integrity of the person, the European Directive on the Legal Protection of Biotechnological Inventions, excludes the following from patentability: (i) processes for cloning human beings; (ii) processes for modifying the germ line genetic identity of human beings (i.e. processes for producing inheritable genetic modications); and (iii) uses of human embryos for industrial or commercial purposes. The most immediate issue is whether patenting knowledge of a portion of DNA constitutes a direct threat to human dignity. Some opponents of patenting argue that it does and therefore advocate that protections should extend to human tissue, body parts, and genetic information (see, e.g., Mitchell, 1999). Most philosophers and theologians (e.g., Peters, 1999) disagree because they believe that the concept of human dignity applies to the whole person and not to component parts. Another distinction that some analysts propose is the dierence between the status of human material in the body and outside of it. Thus, even if they recognize a moral basis for excluding patenting of human material, they argue that these protections do not extend to patenting ex vivo DNA sequences. A related issue raised by religious thinkers and also by some secular ethicists is the concern that patenting demeans and commodies life. Commodication is the process by which something previously valued in a non-economic manner comes to be understood as a commodity, that is, the appropriate subject of free market transactions. The legal theorist Margaret Jane Radin (1996) distinguishes between literal or narrow and broad or metaphorical senses of commodication. It is the latter, a worldview that conceives of human attributes as owned objects even where no money literally changes hands, that some critics fear will undermine the Kantian conception of the person as an end rather than as a means. As one religious critic pointed out, The patenting of genes, the building blocks of life, tends to reduce it to its economic worth. For some the conict is between reverence for life and exploitation of life, life valued for its marketability and life valued as an intrinsic gift. I concur with the view that there are categories of things, life forms in
Directive 98/44/EC of the European Parliament, paras. 40, 41. Quoted by Ted Peters (1996). The statement by Bishop Kenneth Carder was made available to this author by the United Methodist Board of Church and Society.

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particular, that by their very nature should not be treated as economic commodities. To do so is to adopt an instrumental or utilitarian perspective, which is to treat life as a means rather than as an end. Here I think it is useful to refer to Michael Walzers concept of blocked exchanges (Walzer, 1983). He notes that there are entities about which society has determined distribution should not be on an economic basis. His list of blocked exchanges, or things that cannot be bought and sold, includes human beings, criminal justice, freedom of speech, press, religion, and assembly, exemptions from military service or jury duty, political oces, and love and friendship. He does not, however, specically mention genes, human tissue, or body parts, possibly because his book Spheres of Justice was published in 1983. Taking Walzers insight, I believe that patenting is incompatible with reverence for life and human dignity.

15.6 CONCLUSION
Human genetic patenting as currently applied is counterproductive and raises serious ethical issues. To date patent regulations in the US and Europe have evolved through dialogue within a limited circle in which commercial interests have been favored and those representing the broader public interest virtually excluded. The result has been a tendency for the patent system to increasingly extend its sway to encompass life forms by lowering the requirements for novelty, inventiveness, and utility (Bobrow and Thomas, 2001). What is needed now is nothing short of a major reform of the patent system, preferably through an international policy forum with broad representation of views. The nature of the patent system is too important to leave to the patent examiners to determine on narrow technical and economic grounds. Far from being an obscure technical issue, these standards will have major impacts on the lives and well-being of current and future generations. In undertaking such a review, there needs to be a reexamination of the costs and benets, both economic and ethical, of intellectual property regimes, particularly how the current system applies to raw genomic information. The international character of genetic research underscores the need to develop common intellectual property standards. Otherwise individuals and corporations may seek patents in the venue with the lowest standards with other patent oces then pressured to follow suit. It would be important for the reform of the patent system to reect the principles in The Universal Declaration on the Human Genome and Human Rights, particularly the following two articles:
Article 14: States should take appropriate measures to foster the intellectual and material conditions favourable to freedom in the conduct of research on the human genome and to consider the ethical, legal, social and economic implications of such research. . . .
Universal Declaration on the Human Genome and Human Rights, 1997, 1999.

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Article 18: States should make every eort, with due and appropriate regard for the principles set out in this Declaration, to continue fostering the international dissemination of scientic knowledge concerning the human genome, human diversity and genetic research and, in that regard, to foster scientic and cultural co-operation, particularly between industrialized and developing countries.

Certainly there are many measures that could be undertaken even within the current systems that would impose more stringent criteria based on ethical considerations. The principle of broad public access to and benet from genetic information must be protected. As the UNESCO drafted Universal Declaration on the Human Genome and Human Rights recognizes, the human genome underlies the fundamental unity of all members of the human family, as well as the recognition of their inherent dignity and diversity. In a symbolic sense, it is the heritage of humanity. Implementing the ethical principles in the European directive and in TRIPS in a meaningful way could be a starting point. Doubtless that would require the establishment of mechanisms that would be competent to make ethical evaluations as part of the patent process. None of this will happen, however, without awareness of the problems in the current system and considerable public pressure.

REFERENCES
Blumenthal, D., Campbell, E.G., Causino, N. and Louis, K.S. (1996) Participation of life science faculty in research relationships with industry. New England Journal of Medicine, 335, 17341739. Bobrow, M. and Thomas, S. (2001) Patents in a genetic age: the present patent system risks becoming a barrier to medical progress. Nature, 409, 763764. Chapman, A.R. (ed.) (1999) Perspectives on Genetic Patenting: Religion, Science and Industry in Dialogue. American Association for the Advancement of Science, Washington, DC, USA. Cole-Turner, R. (1999) Theological perspectives on the status of DNA: a contribution to the debate on genetic patenting. In Perspectives on Genetic Patenting: Religion, Science and Industry in Dialogue, Chapman, A.R. (ed), American Association for the Advancement of Science, Washington, DC, USA, pp. 149166 (see especially p. 152). Council for Responsible Genetics (2000) The Genetic Bill of Rights. GeneWatch, 13, 23. Currien, H. (1991) The human genome project and patents. Science, 254, 710. Doll, J.J. (1998) The patenting of DNA. Science, 280, 689690. Drahos, P. (1999) Biotechnology patents, markets and morality. European Intellectual Property Review, 21, 441449 (see especially p. 444). Eisenberg, R.S. (2000) Re-examining the role of patents in appropriating the value of DNA sequences. Emory Law Journal, 49, 783800 (see especially p. 785). Gold, E.R. (1996) Body Parts: Property Rights and the Ownership of Human Biological Materials. Georgetown University Press, Washington, DC, USA (see pp. 8183). Heller, M.A. and Eisenberg, R.S. (1998) Can patents deter innovation? The anticommons in biomedical research. Science, 280, 698700. Hettinger, N. (1995) Patenting life: biotechnology, intellectual property, and environmental ethics. Environmental Aairs, 22, 267305.
Universal Declaration on the Human Genome and Human Rights. 1997, 1999.

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The Human Genome Organisation (1995) HUGO Statement on Patenting of Genomic Sequences. HUGO, Bethesda, MD, USA. Marshall, E. (1997) Companies rush to patent DNA. Science, 275, 780781. Mitchell, C.B. (1999) A Southern Baptist looks at patenting life. In Perspectives on Genetic Patenting: Religion, Science and Industry in Dialogue, Chapman, A.R. (ed), American Association for the Advancement of Science, Washington, DC, USA, pp. 167188. Olson, S. (2001) The genetic archaeology of race. The Atlantic Monthly, 287, 6979. Peters, T. (1996) Should we patent Gods creation? Dialogue, 35, 117132. Peters, T. (1999) DNA and dignity: a response to Baruch Brody. In Perspectives on Genetic Patenting: Religion, Science and Industry in Dialogue, Chapman, A.R. (ed), American Association for the Advancement of Science, Washington, DC, USA, pp. 127136. Poland, S.C. (2000) Genes, patents and bioethics: will history repeat itself? Kennedy Institute of Ethics Journal, 10, 265281. Radin, M.J. (1996) Contested Commodities: the Trouble with Trade in Sex, Children, Body Parts and Other Things. Harvard University Press, Cambridge, MA, USA (see pp. 1213). Resnik, D. (1999) The human genome project: ethical problems and solutions. Politics and the Life Sciences, 18, 1523. Salazar, S. (1999) Intellectual property and the right to health. In Intellectual Property and Human Rights. World Intellectual Property Rights Organisation and Oce of the United Nations High Commissioner for Human Rights, Geneva, Switzerland, pp. 6592 (the relevant passage is on p. 76). Stone, R. (1995) Genetic engineering: religious leaders oppose patenting of genes and animals. Science, 268, 1126. Walzer, M. (1983) Spheres of Justice: a Defence of Pluralism and Equality. Basic Books, New York, USA (see pp. 100103). Wilson, K. (1999) CRG says: no patents on life! GeneWatch, 12, 11. World Council of Churches (1989) Biotechnology: its Challenges to the Churches and to the World. World Council of Churches Sub-Unit on Church and Society, Geneva, Switzerland.

Bioethics for Scientists Edited by John Bryant, Linda Baggott la Velle and John Searle Copyright 2002 John Wiley & Sons Ltd ISBNs: 0-471-49532-8 (Hardback); 0-470-84659-3 (Electronic)

16 Cloning of Animals and Humans

Harry Grin

16.1 INTRODUCTION: A STAR IS BORN . . .

New reproductive technologies have attracted great interest ever since the birth of the rst test tube baby in 1978. The current intense media and public fascination with cloning stems, however, from the birth not of a child, but of a sheep. Dolly was the rst mammal cloned from an adult cell and she was born at the Roslin Institute near Edinburgh, Scotland on 5 July 1996 (Figure 16.1). Dolly was derived from cells that had been taken from the mammary gland of a six year old Finn Dorset ewe and cultured in the laboratory. Individual cells were then fused with unfertilised eggs from which the maternal nucleus had been removed. Two hundred and seventy-seven of the reconstructed embryos each now with a diploid nucleus from the adult animal were cultured for 6 or 7 days within the uterus of temporary recipient ewes and then recovered by surgery. Twenty-nine of the embryos that appeared to have developed normally were implanted into 13 surrogate Scottish Blackface ewes. One became pregnant and gave birth to a live lamb, Dolly, some 142 days later (Wilmut et al, 1997). When Dolly was announced to the world in February 1997, Roslin was besieged by the media (Wilmut and Grin, 1997). Journalists and TV crews ew in from around the world and Dolly quickly became the most photographed sheep of all time. The Pope condemned cloning outright and President Clinton called on his recently established National Bioethics Advisory Committee to report on the ethical and legislative implications within 90 days. Dolly Parton, the actress and Country and Western singer, said that she was honoured to have a sheep named after her and that there was no such thing as baaaed publicity. The immediate assumption was that a cloned human child could not be far behind and this triggered an explosion (at least in the media) of fears about the future. Clones would be created, it was said, for example as sources of spare parts, by dictators seeking immortality or to re-create dead children. However, the small size of the Roslin Institutes post bag suggested that the general public understood that most of the scenarios that the press were imagining (Figure

Bioethics for Scientists. Edited by John Bryant, Linda Baggott la Velle and John Searle. 2002 by John Wiley & Sons Ltd.

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Figure 16.1. Dolly as a lamb, with her Scottish Blackface mother

16.2) were unlikely to be realised and could, as a consequence, be enjoyed in safety just like the X Files. A large part of the attraction for the media was that the story could be written from so many angles: articles appeared on the news, science, environment, health and business pages. Even the racing correspondents had their chance when cloning was proposed as a solution to the infertility of US champion racehorse Cigar. The medias fascination with cloning has continued ever since, encouraged by a steady diet of newsworthy stories. With Dolly being a clone alone, some scientists speculated that she was not repeatable or that she was a mistake or even a fake. Publication of additional DNA evidence and news of the cloning of the rst adult mice killed that particular angle. Stories followed about attempts to clone mammoths or to resurrect extinct species of birds and, slightly more credibly, to rescue endangered species. In October 1998, the publication of a paper describing the isolation of the rst human embryonic stem cells (Thomson et al,1998) initiated a vigorous new debate about the possibility of cloning human embryos for stem cell therapy. Several groups claimed to be preparing for cloning a child, including elderly Chicago physicist Dr Richard Seed (see Cohen, 1998), a company, Clonaid, with ties to the previously unknown Raelian sect (www.clonaid.com) and, more recently, Italian IVF expert Professor Severino Antinori (see Abbott, 2001).

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Figure 16.2. A few of the thousands of headlines on cloning

16.2 ETHICAL DEBATE IN THE MEDIA SPOTLIGHT

The origin of news stories in the media makes fascinating study. Investigative journalism is rare and almost all coverage originates from the hundred or so press releases sent to each journalist each week. The steady succession of cloning stories over the past four years represents the interplay of a wide range of vested interests: journalists wanting to make an impact with their editors, science journals competing with each other for subscriptions, new biotechology companies wanting to attract investors, pro-life and patients groups seeking to inuence public opinion, authors promoting their latest books, embryologists seeking immortality and scientists and ethicists seeing a new opportunity to advance their careers. Although much of the early coverage was more to do with providing entertainment than information, it is clear that cloning raised genuine disquiet among the vast majority of the population. The possibility of creating a child that was the genetic copy of an existing individual was seen as very dierent from assisted reproduction that, for all its sophistication, still represents the union of an egg and a sperm. Creation of a sense of urgency is almost obligatory for news reporters, but there is little doubt that many also saw cloning as yet another example of science progressing too far, too fast. As current attitudes in Europe to genetically modied (GM) crops demonstrate (see Chapters 1, 2, 8 and 9) it is very much in the interest of scientists to engage in public discussion about the impact of new technologies earlier rather than later. Discussion directly with the public can engage only a tiny fraction of the population: if scientists are to improve the quality of debate about new technologies, then we have little alternative but to learn how to make our views heard through the media. This in turn means accepting its limitations: a focus on news, 30 second soundbites and an adversarial approach to debate. We also

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need to be prepared to comment on a much broader range of issues than our own narrow speciality and to address the social impact of our work in terms the public understands. Like most scientists, I have had no formal training in ethics but over the past four years I have participated in a fair number of ethical debates around the world. One observation perhaps now obvious to readers of this book is that professional ethicists are most eective when they provide the rest of us with insight into how we might come to our own conclusions. The individual that had the most lasting impact on my own views was Professor Albert Jonsen of the University of Washington and formerly chair of the National Advisory Board on Ethics and Reproduction in the US. In a talk at the Institute of Bioethics in Madrid in 1988, he proposed three steps to ensure a disciplined approach to exploring the ethical implications of cloning. His advice seems equally applicable to any new technological advance. Firstly, to determine exactly what the scientists involved in the research are doing and what they believe they can do: in essence to separate sensible speculation from fantasy and develop an honest appreciation of the range and limits of the science. Secondly, to consider a limited number of applications in depth. The applications chosen should be realistic scenarios that have a signicant impact on society rather than simply curiosities. Thirdly, to examine the ethical implications of each application by imaginative use of analogies from our own experience. In the case of the question of confused genetic identity of clones, for example, to refer to our experience of identical twins or to foster children. The structure of the rest of this chapter attempts to follow these themes. It rst describes the current state of the art of cloning and what might be possible with the technology in the foreseeable future. It then moves on to consider three possible applications the cloning of farm animals, the cloning of children for infertile couples and the cloning of embryos in stem cell research.

16.3 THE CURRENT STATE OF THE ART

16.3.1 A BRIEF HISTORY OF NUCLEAR TRANSFER Cloning simply provides genetic copies. Gardeners clone when they take cuttings, Nature provides clones in the form of identical twins, molecular biologists clone genes and cattle breeders have been producing cloned calves by embryo splitting for over 20 years. Cloning by nuclear transfer is not novel. The technique was rst reported in frogs in 1952 and has been used widely since in amphibians to study early development (see McKinnell, 1985, for a very readable review). These early

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studies showed that the rst few cell divisions after fertilisation produce cells that are totipotent (i.e. they can develop into all of the cell types that make up the whole animal). As the embryo develops, the cells lose this property and the success of nuclear transfer rapidly declines. Some nuclear transfer experiments using cells from adult frogs produced viable embryos, but these never developed beyond the tadpole stage. Nuclear transfer in mammals proved to be more dicult, in part because mammalian oocytes (eggs) are so much smaller than those of amphibians. The cloning of mice using nuclei from very early embryos was claimed in 1977, but this work was not repeatable and interest among developmental biologists waned. Research on nuclear transfer in cattle continued, stimulated by the prospect of large commercial benets of copying the very best performing animals. By the middle of the 1980s several research groups from around the world had produced cloned sheep and cattle by transferring nuclei directly from cells taken from very early embryos. Steen Willesden, working for Granada Genetics in the US, had produced live calves by nuclear transfer from embryos that had progressed to the 64- and 128-cell stage and this was the rst suggestion that nuclear transfer in mammals was possible from at least partially dierentiated cells. Many of the calves were larger than normal and had to be delivered by Caesarian section (see Kolata, 1997, Wilmut et al, 2000, for a full history of nuclear transfer up to the birth of Dolly). In 1995, Keith Campbell, Ian Wilmut and colleagues produced live lambs Megan and Morag by nuclear transfer from cells from early embryos that had been cultured for several months in the laboratory. In 1996, they produced four lambs from embryo cells, three from foetal cells and, in collaboration with PPL Therapeutics, one, subsequently named Dolly, from an adult cell (see Figure 16.3). 16.3.2 THE SIGNIFICANCE OF CLONING FROM AN ADULT ANIMAL For developmental biologists, the ability to clone from adult animals overturned one of the fundamental tenets of developmental biology. Most scientists had believed that in most, if not all vertebrates, dierentiation the gradual process of specialisation that allows the fertilised egg to develop into the 200 or so cell types that make up the whole animal was irreversible. After all, even over a 90 year lifespan a liver remains a liver, a nerve cell a nerve cell. The production of a live lamb from a cell taken from the udder of a 6 year old ewe demonstrated that dierentiated animal cells are not after all immutable. 16.3.3 SUBSEQUENT PROGRESS At rst Dolly was a clone alone but in August 1998, a group in Hawaii published a report of the cloning of over 50 mice by nuclear transfer (Wakayama et al, 1998). Since then, research groups around the world have reported the

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Figure 16.3. Cloning by nuclear transfer. The six images were taken through the lens of a microscope connected to a micromanipulator rig and show the key steps in nuclear transfer: Top left: an unfertilised sheep oocyte is held by gentle suction on the end of a broad-tipped pipette. Middle left: a ne pipette is inserted into the egg and the maternal nuclear DNA removed by suction with some of the cytoplasm. Bottom left: under UV light, the maternal DNA is shown in the pipette rather than in the oocyte. Top right: diploid mammary gland cells in culture. Middle right: one diploid cell has been picked up in the pipette and inserted into the enucleated oocyte. Bottom right: enucleated oocyte containing intact diploid cell. A short electric pulse is then used to fuse the membranes of the two cells together and to stimulate the single-celled reconstructed embryo to begin to divide and multiply. Simple? The creation of Dolly required the collection of 430 oocytes from over 40 super-ovulated ewes and these were used to create 277 reconstructed embryos. These were then surgically transferred to the uteri of temporary recipients and recovered six to seven days later, again by surgery. Only 29 embryos appeared to have developed normally to the blastocyst stage, and when these were implanted in 13 surrogate mothers only one became pregnant

successful cloning of adult cattle, sheep, mice and goats. Equally competent groups have had no success in cloning rabbits, rats or monkeys. There are dierences in early development between species that might inuence success rate. In sheep and humans, the embryo divides to between the eightand 16-cell stage before nuclear genes take control of development, but in mice this transition occurs at the two-cell stage. In 1998, a Korean group claimed that they had cloned a human embryo by nuclear transfer but their experiment was terminated at the four-cell stage (as seen in a British TV documentary in the BBCs Panorama series broadcast in February 1999) and more recently there has been a report of the cloning of several early-stage human embryos in a commercially-funded lab in the USA (Cibelli et al, 2001).

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Success rates remain low in all species, with between 1 and 4% of reconstructed embryos leading to live births as reported in the published data (see Pennisi and Vogel, 2000, for a detailed review). With unsuccessful attempts at cloning unlikely to be published, the actual success rate is certainly substantially lower. Many cloned ospring die late in pregnancy or soon after birth, often through respiratory or cardiovascular dysfunction. Abnormal development of the placenta is common and this is probably the major cause of foetal loss earlier in pregnancy. Many of the cloned cattle and sheep that are born are much larger than normal and apparently normal clones may have some unrecognised abnormalities. The high incidence of abnormalities is not surprising. Normal development of an embryo is dependent on the methylation state of the DNA (i.e. the pattern of active and potentially active genes) contributed by the sperm and egg and on the appropriate reconguration of the chromatin structure after fertilisation. Somatic cells have very dierent chromatin structure to sperm and reprogramming of the transferred nuclei must occur within a few hours of activation of reconstructed embryos. Incomplete or inappropriate reprogramming will lead to dysfunctional regulation of gene expression and failure of the embryo or foetus to develop normally or to non-fatal developmental abnormalities in those that survive. Improving success rates is not going to be easy. At present, the only way to assess the quality of embryos is to look at them under the microscope and it is clear that the large majority of embryos that are classied as normal do not develop properly after they have been implanted. A substantial eort is now being made to identify systematic ways of improving reprogramming. One focus is on known mechanisms involved in early development, and in particular on the imprinting of genes. Another is to use technological advances in genomics to screen the expression patterns of tens of thousands of genes to identify dierences between the development of reconstructed embryos and those produced by in vivo or in vitro fertilisation. It is important to recognise the limitations of nuclear transfer. Plans to clone extinct species have attracted a lot of publicity: an Australian project aims to resurrect the Tasmanian tiger by cloning from a specimen that has been preserved in a bottle of alcohol for 153 years and another research group announced plans to clone a mammoth from 20 000 year old tissue found in the Siberian permafrost. However, the DNA in such samples is hopelessly fragmented and there is no chance of reconstructing a complete genome. In any case, nuclear transfer requires an intact nucleus, with functioning chromosomes. DNA on its own is not enough: many forget that the Michael Crichton novel Jurassic Park was a work of ction. Other obvious requirements for cloning are an appropriate supply of oocytes and surrogate mothers to carry the cloned embryos to term. Cloning of endangered breeds will be possible by using eggs and surrogates from more common breeds of the same species. It may be possible to clone using a closely related

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species but the chance of successfully carrying a pregnancy to term would be increasingly unlikely if eggs and surrogate mothers are from more distantly related species. Proposals to save the Panda by cloning, for example, would seem to have little or no chance of success because it has no close relatives to supply eggs or to carry the cloned embryos.

16.4 APPLICATIONS OF CLONING

Cloning by nuclear transfer has a wide range of possible applications. It is already being used as a research tool to understand the mechanisms involved in dierentiation and de-dierentiation of cells. It could, in principle, be used to produce unlimited numbers of genetically identical animals to improve, for example, the sensitivity of testing regimes for new pharmaceuticals or vaccination regimes (see Chapter 18). Our own motivation for cloning was to develop better ways of genetically modifying farm animals. Until recently the only way to produce transgenic cattle, sheep or pigs was by injecting a suitable DNA construct directly into one of the pro-nuclei in a recently fertilised egg (see also Chapter 14). The injection tends to damage the genomic DNA and during the repair processes one or more copies of the injected construct can be incorporated into the animals genome. When the injected embryos are implanted perhaps 24% of them give rise to transgenic ospring. Pro-nuclear injection provides no control of the number of copies of the construct or where they are incorporated and as a consequence many of the transgenic animals fail to express the gene at high enough levels. Importantly, pro-nuclear injection only allows genes to be added. Nevertheless, pro-nuclear injection has been used to create transgenic sheep and cattle that produce human proteins in their milk and transgenic pigs for possible use in xenotransplantation (i.e. as a possible source of organs for transplantation into humans). More sophisticated genetic modications are possible in mice using embryonic stem (ES) cells but, despite much eort, no ES cells have yet been isolated from farm animal species. Nuclear transfer allows cultured cells to be converted into live animals: if the cells are genetically modied rst, then the cloned animals produced will also be genetically modied. The rst transgenic sheep produced by nuclear transfer were born in 1997 and carried a gene coding for human blood clotting factor IX. Nuclear transfer has since been used to insert genes at a dened locus in the genome and such targeted insertion is seen as a more reliable way of ensuring high levels of transgene expression (see Chapter 14). All of these applications represent yet another use of animals in research and in the UK would be regulated under the Animals (Scientic Procedures) Act 1986. The ethical issues surrounding animal experimentation are covered in Chapters 6, 7 and 18; here we concentrate on the ethical implications raised

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specically by cloning in cattle breeding, in human reproduction and in stem cell research.

16.5 CLONING IN CATTLE PRODUCTION

16.5.1 RATIONALE Beef and dairy cattle account for 40% of farm income in the UK and cattle are the most important farm animal species worldwide. Much of the genetic progress in the breeding of cattle is made in relatively small elite herds, with the genetic merit of individuals being assessed on a combination of the animals own performance and on the performance of its near relatives. Progress that is made within elite herds is then passed on to commercial farmers by use of the elite semen in articial insemination. Semen provides only half the genes to the next generation and, as a consequence, the performance of the average dairy cow in the UK is estimated to be some 10 years behind the very best. With cloning, it would be possible to remove this dierence within one generation. Farmers who could aord it would buy embryos that would be clones of the cows with greatest genetic merit. Frozen cloned embryos would be delivered to the farm much in the same way as semen is today, perhaps from breeders overseas. In 1997, the UKs Ministry of Agriculture, Fisheries and Food commissioned the Farm Animal Welfare Council (FAWC) to report on the ethical implications of cloning in farm animal production. At the time, this request seemed premature. However, a large number of calves have since been cloned by research groups in Japan, New Zealand, France, Germany and the US and two cloned cattle were recently sold at auction in Wisconsin for over $40 000 each. Such prices represent the animals novelty rather than their true economic value and costs would need to be brought down to about $100 for each elite embryo before cloning would be economically attractive for the average farmer. 16.5.2 ETHICAL CONCERNS The FAWCs report (FAWC, 1998) listed a number of requirements that it considered would need to be fullled before cloning should be used routinely in livestock production. These included the elimination of the large calf syndrome, the avoidance of temporary recipients, as in the protocol that produced Dolly, and the use of non-surgical techniques for recovering oocytes and implanting the cloned embryos. The report also raised concerns about the dangers of inbreeding. The conditions that FAWC sought to impose to protect the welfare of animals are exactly the same as those that would need to be met for cloning to be economically viable and are already part way to being met. In vitro maturation of oocytes is a well developed art in cattle (though not in sheep) and ovaries from

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the slaughterhouse provide an unlimited supply of eggs for nuclear transfer. Protocols for in vitro culture of embryos to the blastocyst stage are similarly well established in cattle and non-surgical implantation of embryos is already used routinely. The relatively low success rate and high incidence of developmental abnormalities remains a major challenge and can probably only be consistently addressed when much more is known about the mechanisms involved in reprogramming and the adverse eects of in vitro embryo culture. If this research is successful, in 20 years time a majority of cattle in developed countries might be clones. The risks of inbreeding are well known to livestock breeders and there would need to be clones of many dierent elite animals to ensure that whole herds are not going to be vulnerable to diseases or nutritional inadequacies. Mistakes can occur. The widespread use of semen from a single Holstein Friesian bull from the US led to up to 25% of some herds suering from bovine lymphocyte adhesion deciency (BLAD) syndrome and the allele responsible had to be eliminated from aected herds by marker-assisted selection (Shuster et al,1992). Cloning could increase the risk of such undetected defects and the proposal by FAWC that specic rules should be introduced to protect genetic diversity is a sensible precaution. A more fundamental objection to cloning in livestock production was voiced by some who saw it as yet another step towards treating animals merely as machines, with the Church of Scotland viewing widespread cloning of livestock as a step too far (Bruce and Bruce, 1998). Another concern was that cloning would provide yet another way for farmers to push animals even closer to physiological limits in their drive for productivity. This later criticism is of breeding goals rather than of the methods used to achieve them: cloning could be used, for example, to more rapidly disseminate genetic improvement in disease resistance, to the benet of the animals as well as to farmers. If cloning is to become practical in the future, then the techniques used in cloning would be little dierent in terms of their impact on animal welfare from methods already in widespread use in livestock production such as articial insemination, multiple-ovulation embryo transfer (MOET) and cloning by embryo splitting (see MAFF, 1995). However, attitudes to farming practices are changing in the auent part of the world and practices that were acceptable in the past may not necessarily be so in the future.

16.6 CLONING A CHILD

When Dolly was announced to the world in February 1997, the prospect of using the same technology to clone a child was met with almost universal condemnation. UNESCO declared that the cloning of a child would be contrary to human dignity and the prospect was variously described as grotesque, revolting, appalling and a nightmare scenario. Opinion polls indicated the large majority of the public agreed.

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The overwhelming evidence from the cloning of animals is that any attempt now at reproductive cloning in humans would be unlikely to succeed, and if a pregnancy were established that there would be a high risk of death of the child late in pregnancy or soon after birth. Dr Zavos, one of the consortium led by Professor Antinori, has implied that IVF clinics are able to screen human embryos for abnormalities (Stern, 2001). Methods are available for detecting major chromosomal abnormalities in early embryos but there are none that could detect the overall epigenetic state of the genome that appears to be critical for normal development of reconstructed embryos. In such circumstances, any group that intends to attempt to clone a child is being reckless. Some have correctly pointed out that fears on safety were used in the 1970s to try to prevent IVF. However, few experiments were carried out in animals before IVF was tried in humans and, while there was little evidence that IVF was safe, there was no evidence that it was unsafe either. Research on cloning of animals is expected to improve success rates and reduce the incidence of developmental abnormalities and an inevitable question that will arise in the perhaps not too distant future is: is this technology now safe for use in humans? Those opposing new technologies often develop Olympian standards of safety to prevent developments (see, for example, the discussion about GM crops in Chapters 8 and 9), but an obvious threshold would be when abnormalities in cloned animals are reduced to the level of those in animals produced by natural mating. Even this may be too high a standard: no-one suggests, for example, that older women should be prevented from having children even though it is well known that the risk of Downs syndrome increases markedly with age. With improvements in success rate likely, societies need to have developed clear and defendable public policies to address the inevitable pressure from prospective parents or IVF clinics to allow cloning. In Europe it seems safe to predict that public sentiment will remain opposed to cloning and that few (if any) parliamentarians will be prepared to campaign for a change in the law on behalf of the handful of parents that might benet. By contrast, the emphasis in the USA on the right of the individual and the general antipathy to regulation by the state is likely to put the burden of proof on those wanting to restrict cloning. One of the diculties in translating the immediate visceral reaction (gut reaction or yuk factor) against reproductive cloning into a more logical view of the rights and wrongs is the wide variety of scenarios envisaged for its use. In his book Remaking Eden (1997) for example, Professor Lee Silver saw cloning being used in the future to create designer babies with improved intelligence and physique and the gradual emergence of two types of human: the privileged genrich and the unimproved rest. Such speculation almost certainly misrepresents what science will be able to do. While we know that intelligence is an inherited trait, it is controlled by several if not many genes and proving that any one specic gene has a signicant eect would depend on our willingness to carry out long term, controlled experiments on hundreds if not thousands of children.

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While this might make a good story line in an episode of X Files, it is unlikely ever to be acceptable in real life. The sort of future imagined in Professor Silvers book also misrepresents human motivation. Cloning by nuclear transfer is not going to be any more ecient than IVF: the idea that many (or any) women would be prepared to go through several rounds of an IVF-like protocol on the o-chance that her child would have two to three more IQ points seems a very male fantasy. More importantly, such speculation into the distant future distracts from real ethical issues that we should be facing up to now. Some have suggested that cloning would allow couples to replace a child that had tragically died or to allow lesbian couples to have children without involving a man. Interestingly, a study by the Wellcome Trust (Wellcome Trust, 1998) found no evidence that either lesbians or women who had lost children through miscarriage showed any more enthusiasm for cloning than the rest of the population. In considering such cases, it may well be dicult to separate our views on cloning from our attitudes to the decline in family values or the misguided logic of the parents who believe they could recreate their dead child. A simpler and therefore perhaps more useful case would be the married couple in their early 30s. The woman is fertile but the mans testes failed to develop properly in childhood so that he cannot produce sperm. They both desperately want a child but have rejected anonymous sperm donation. They view the cloning of a son using a donor cell from the father as an acceptable option, since it would provide them with a child that both partners had contributed to creating. For the purpose of this study let us look forward to the year 2020 by which time the success rate of cloning in animals has improved dramatically. The IVF clinic involved is well respected and is deliberately avoiding publicity. Arguments used against cloning in such circumstances tend to focus on the interests of the child. UNESCO, for example, has proposed that cloning violates a basic human right to a unique genetic identity and to an open future. Critics of this line of argument rightly point out that this right is not one that Nature accords to identical twins, who in any case can and do grow up with personalities and behaviours all of their own (Harris, 1998; Pence, 2000). The concept of an open future is also going to be increasingly called into question as we understand more about the genes that inuence our health and well being. Nevertheless, the factors that inuence our sense of identity are complex and it may well be that cloned children will believe that their uniqueness has been compromised. Some have argued that a cloned child would suer psychological harm because of confused and ambiguous relationships with other members of the family. Parents might have unlled expectations of the child based on their experience of the partner from which he or she was cloned. The mother of a cloned son might have diculties in reconciling her relationship between the clone she married and the clone she carried. Counselling of prospective parents might reduce the risk but others have suggested that the confused heritage of clones would be little dierent from children who have been fostered or adopted (Green, 1999). However, fostering and adoption are devices to accommodate

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unforeseen and unplanned circumstances they are attempts to make the best of an otherwise intolerable situation (ONeill, 2000; see also Chapter 12). By contrast, the confused heritage created for the clone child is the result of a deliberate act and one that the child might resent. Some have asserted that the most important thing for a child is the unconditional love of its parents, rather than the manner or circumstances of its birth. Experience with anonymous sperm donation suggests that those of us who have never had the need to question our genetic inheritance can underestimate its importance. Two thousand children have been conceived in this way in the UK but only a very small minority of their parents have found it possible to tell their child of his or her origins and children who do nd out inadvertently or later in life nd the knowledge deeply disturbing. This experience suggests that cloned children will have, on average, rather more to cope with in their adolescence than the normally conceived child and, although some parents might be well equipped to handle the additional challenges involved, most will nd it very dicult. Although considerations of safety and the interests of the child are important, they in no way account for the strength of feeling expressed by so many against reproductive cloning. Leon Kass attempted to address this discrepancy by asserting that repugnance is the emotional expression of deep wisdom, beyond reasons power to articulate (Kass, 1997) and Timothy Renwick invited comparison of cloning with other human activities that provoke or have provoked bitter condemnation, including incest, bestiality and inter-racial marriage (Renwick, 1998). Societys condemnation of incest has some similarities to cloning in that it results from knowledge of its genetic consequences and the disruption of family relationships and is supported by a combination of social mores, religious taboos and legislation in all societies. By contrast, inter-racial marriages, which have provoked extreme reactions in the past, for example, in the Southern USA, are now rightly accepted as a part of the richness of modern life. Is our opposition to cloning one that will stand the test of time or will it be like our attitudes to homosexuality or IVF, where the majority do not wish to become involved themselves but will accept perhaps reluctantly the rights of others to do so?

16.7 CLONING OF HUMAN EMBRYOS

16.7.1 STEM CELL THERAPY Many common degenerative diseases are a consequence of the failure of just one of the 200 or so types of cell that make up our bodies. Type 1 diabetes, for example, is caused by the failure of the islet cells in the pancreas to produce enough insulin. Parkinsons disease is largely a consequence of the inability of certain neurones in the brain to produce enough neurotransmitter. The longer term eects of strokes and heart attacks are the result of the death of a relatively

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small number of brain or heart cells downstream of the blocked blood vessels. Attempts to treat such diseases using drugs have had limited success and research groups around the world have begun to develop novel treatments based on transplants of healthy cells. Injection of neuronal stem cells into the brains of rats with experimentally induced stroke has been shown to cause signicant improvement in performance. The transplanted cells seem to be recruited into the existing repair mechanisms, migrating small distances within the damaged tissue and converting to the most appropriate cell type through the action of locally produced growth factors. In studies in mice, cardiomyocytes injected into the damaged areas of the heart after experimentally induced ischaemia have been shown to integrate with neighbouring healthy tissue and function normally. Results such as these are encouraging the search for cell therapies for a much wider range of degenerative diseases including spinal cord injury, congestive heart failure, osteoarthritis and osteoporosis, hepatitis and muscular dystrophy. The cells being used in these early experiments come from a variety of sources. Parkinsons disease patients, for example, have been treated with cells from human or pig foetuses. The so-called Edmonton protocol involves infusion of diabetic patients with a suspension of pancreatic islet cells obtained from cadavers. These sources are clearly not practical for routine treatment of the hundreds or thousands of patients that could ultimately benet from cell therapy and the search is now on for alternatives which will be both safe and cost eective. Much current attention is focused on stem cells, and in particular on human embryonic stem (or ES) cells. 16.7.2 EMBRYO STEM CELLS All mammals start life as a fertilised egg or zygote. After ve to six days and seven or eight cell divisions, the developing embryo consists of a small ball of cells about a tenth of a millimetre in diameter (i.e. smaller than the full stop at the end of this sentence). The outer cells of this blastocyst are destined to become part of the placenta, whereas the embryo stem cells (ES) of the inner cell mass will go on to form the foetus proper. The ES cells are therefore the progenitors of all of the 200 or so terminally dierentiated cell types in the complete animal. Embryo stem cells were rst isolated from mice in the early 1980s. They can divide and multiply indenitely in the laboratory and, when grown in appropriate cocktails of growth factors, can be directed to dierentiate into a wide variety of dierent cell types. Putative ES cells were isolated from human embryos in 1998 and have similar characteristics. Human ES cells are of particular interest for cell therapy because they can be obtained free of contamination from other cell types, will multiply indenitely in culture and can potentially be converted to any cell type needed by patients (Pederson, 1999). A major problem to be addressed is that of immune rejection. Cells injected into the brain are partially protected from immune rejection by the bloodbrain

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barrier. By contrast, cells transplanted to other tissues would be recognised as foreign and immediately destroyed by the complement-mediated hyper-acute response. In theory, human stem cells could be genetically engineered to reduce their immunogenicity and provide universal donor cells that could be used in any patient. A more practical approach would be to create a bank of human ES cell lines representative of the major tissue types in the population as a whole and then withdraw cells of the most appropriate cell line as and when required. Both strategies would require patients to remain on immuno-suppressive drugs for the rest of their lives, adding to both the cost of treatment and the risk of infection or carcinoma. 16.7.3 THE ROLE OF NUCLEAR TRANSFER IN STEM CELL THERAPY The ability to clone animals from adult cells suggests a radical new approach to the problem of tissue incompatibility. Perhaps 1015 years into the future when cells are needed for transplant, skin cells could be obtained from patients simply by scraping the inside of the mouth. These skin broblasts would then be multiplied many times in the laboratory before being converted to the specic cell type needed for the disease being treated. When these cells were returned to the patient, they would not be rejected: they are the patients own cells. At present the only way to achieve such a transformation would be to use part of the process used to clone whole animals. The skin cell from the patient would be introduced into a human egg from which the nucleus had been removed and the resulting human embryo incubated for six to seven days before recovery of ES cells. Incubation of these cells with appropriate growth factors would then be used to obtain the desired cell type. Such therapeutic cloning is an aid to research rather than a routine way of creating stem cells for every patient. Very few human eggs are surplus to requirements from IVF clinics in the UK whereas the numbers of potential patients for cell therapy runs into hundreds of thousands. On practical grounds alone it will therefore be essential to nd ways of avoiding the use of human eggs if stem cell therapy is to achieve its true potential. It may be possible to use other types of cell perhaps embryo stem cells to reprogramme the donor nucleus. More radically, if we understood the mechanisms by which the cytoplasm of the oocyte is able to facilitate the reprogramming of dierentiated cells, we may be able to recreate appropriate conditions for reprogramming in the test tube. Such an ability would escape the chronic limitations on supply of human eggs and avoid the routine creation and destruction of human embryos that many people would nd ethically unacceptable. 16.7.4 AN ETHICAL DEBATE BROUGHT TO A CONCLUSION Research on human embryos is already allowed in the UK under the Human

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Fertilisation and Embryology Act 1990. Under the 1990 Act human embryos are given special status but not that of a human being. This designation was consistent with UK attitudes to abortion and the morning-after contraceptive pill. Research on human embryos was allowed only up to 14 days of development and only under licence from the Human Fertilisation and Embryology Authority. Research was also only allowed for only ve specic purposes connected with fertility, contraception and genetic disorders. In December 1998, the Human Fertilisation and Embryology Authority and the Human Genetics Advisory Commission published a joint report recommending that two new purposes should be added to the 1990 Act: to progress new therapies for diseased or damaged tissues or organs and mitochondrial diseases (HGAC, 1998). The government responded by asking Professor Liam Donaldson, the UKs Chief Medical Ocer, to convene an expert panel to review the case in detail. The Donaldson Report (CEGC, 2000) was published on 16 August 2000 and fully endorsed the proposed changes in the HFE Act. The government immediately accepted all the recommendations of the report and, as with the original 1990 Act, the government oered a free vote in both Houses of Parliament. The Catholic Church and pro-life groups were most active in opposing the proposed amendment to the 1990 Act, arguing that human life began at conception and therefore that any research on human embryos was wrong. Others were content that embryos that were surplus to requirements from IVF clinics could be used for research (with appropriate consent) rather than simply discarded, but some who accepted this position were uneasy about the deliberate creation of human embryos for research purposes. The creation of human embryos for research purposes is allowed under the original 1990 Act but only 108 embryos have been created in this way since the HFEA started to grant licences. Some argued that the cloning of embryos would be the start of a slippery slope to reproductive cloning and others actively promoted an overly optimistic view that stem cells for therapy might be obtained from adult tissue or umbilical cord blood rather than from embryos. The end result of four parliamentary debates at the end of 2000 and beginning of 2001 was a decisive vote in favour of the amendment in both the House of Commons and House of Lords. Researchers in the UK can now apply to the HFEA for a licence to carry out research on human embryos to progress stem cell therapy. Applications have rst to be passed by an ethics committee created by the research organisations involved before being submitted to the HFEA. It then sends the application to external referees and only when their opinion is available is the application considered by the licensing sub-committee of the HFEA. Other countries including Sweden, Denmark, the Netherlands and France already allow research on human embryos (EC, 2000) and some are considering similar amendments to their national legislation as introduced in the UK. In marked contrast, the legal position in the USA is very confused, with research on

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human embryos being allowed in the private sector but not with federal funds. In 2000, the Head of the National Institutes of Health, Dr Harold Varmus, fearing researchers in the USA might be left behind, proposed a compromise that would allow federal-funded researchers to carry out research on human embryo stem cells that had been isolated in the private sector. At the time of writing (early 2001), it seems highly unlikely that this device will survive the new Bush administrations sympathy for the pro-life lobby.

16.8 COMMENT
The existence of bodies such as the Human Fertilisation and Embryology Authority and the Farm Animal Welfare Council has greatly helped to provide a focus in the UK for ethical debate on cloning. Such government-sponsored vehicles, however, have their limitations. The almost universal negative reaction to human reproductive cloning when Dolly was announced to the world meant that there was little or no incentive for anyone within the political or scientic establishment to formally question whether this response was justied. As a consequence, the reaction to more recent announcements of proposals to clone children has simply been to repeat expressions of outrage and the opportunity to deploy more thoughtful and arguably more persuasive arguments for not proceeding along this particular path is being missed through lack of appropriate preparation.

REFERENCES
Abbott, A. (2001) Trepidation greets plans for cloning humans. Nature, 410, 293. Bruce, D. and Bruce, A. (1998) Animal ethics and human benet. In Engineering Genesis: the Ethics of Genetic Engineering in Non-Human Species. Bruce, D. and Bruce, A. (eds), Earthscan, London, and Church of Scotland, Edinburgh, pp. 12715. CEGC (2000). Stem cells: medical progress with responsibility. Report of the Chief Medical Ocers Expert Group on Therapeutic Cloning on www.dti.gov.uk/cegc. Cibelli, J.B., Kiessling, A.A., Cuni, K., Richards, C., Lanza, R.P. and West, M.D. (2001) Somatic cell nuclear transfer in humans: pronuclear and early embryonic development. The Journal of Regenerative Medicine, 2, 2531. Cohen, P. (1998) Crossing the line. New Scientist, 17 January, 45. EC (2000) Ethical aspects of human stem cell research. Opinion of the European Group on Ethics and Science and New Technologies to the European Commission, No. 15. FAWC (1998) Report on the implications of cloning for the welfare of farmed livestock, Farm Animal Welfare Council, Surbiton, Surrey, UK. Green, R. (1999) I, clone. Scientic American Presents, 10, 8082. Harris, J. (1998) Rights and reproductive choice. In The Future of Human Reproduction: Ethics, Choice and Regulation. Harris, J. and Holm, S. (eds), Clarendon, Oxford, UK, pp. 537. HGAC (1998) Cloning Issues in Reproduction, Science and Medicine. Joint report by the Human Genetics Advisory Committee and the Human Fertilisation and Embryology

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Authority on www.dti.gov.uk/hgac Kass, L. (1997) The wisdom of repugnance. New Republic, 2, 512. Kolata, G. (1997) Clone. The Road to Dolly and the Path Ahead. Penguin, London. MAFF (1995) Report of the Committee to Consider the Ethical Implications of Emerging Technologies in the Breeding of Farm Animals (Banner Committee Report). HMSO, London, UK. McKinnell, R.G., (1985) Cloning: of frogs, mice and other animals. University of Minnestoa Press, Minneapolis, MN, USA. ONeill, O. (2000) The good enough parent in the age of new reproductive technologies. In Ethics of Genetics of Human Procreation, Haker, H. and Beyleveld, D. (eds), Ashgate, London, pp 3348. Pederson, R. (1999) Embryonic stem cells for medicine. Scientic American, April, 4549. Pence, G.E. (2000) Re-Creating Medicine: Ethical Issues at the Frontiers of Medicine, Rowman and Littleeld, Lanham, MD, USA (see especially Recreating our genes: cloning humans, pp.119135). Pennisi, L. and Vogel, G. (2000) Clones: a hard act to follow. Science, 288, 17221727. Renwick, T.M. (1998) A cabbit (cat/rabbit) in sheeps clothing: exploring the sources of our moral disquiet about cloning. Annual of the Society of Christian Ethics, 18, 259274. Shuster, D.E., Kehrli, M.E., Ackermann, M.R. and Gilbert, R.O. (1992) Identication and prevalence of a genetic-defect that causes leukocyte adhesion deciency in Holstein cattle. Proceedings of the National Academy of Sciences, 89, 92259229. Silver, L. (1997). Remaking Eden: Cloning and Beyond in a Brave New World. Avon, New York, USA. Stern, A. (2001) The Boston Globe, 26 January. Thomson, J.A., Itskovitz-Eldor, J., Shapiro, S.S., Waknitz, M.A., Swiergiel, J.J., Marshall, V.S. and Jones, J.M. (1998) Embryonic stem cell lines derived from human blastocysts. Science, 282, 11451147. Wakayama, T., Perry, A.C.F., Zuccoti, M., Johnson, K.L., and Yanagimachi, R. (1998) Full term development of mice from enucleated oocytes injected with cumulus cell nuclei. Nature, 394, 369374. Wellcome Trust (1998). Public Perspectives on Human Cloning. A Social Research Study. Wellcome Trust, London, UK. Wilmut, I., Campbell, K. and Tudge, C. (2000) The Second Creation: Dolly and the Age of Biological Control. Headline, London, UK. Wilmut, I. and Grin, H. (1997) Seven days that shook the world. New Scientist, 22 March, 22. Wilmut, I., Schnieke, A.E., McWhir, J., Kind, A.J. and Campbell, K.H.S. (1997) Viable ospring derived from fetal and adult mammalian cells. Nature, 385, 810813.

Bioethics for Scientists Edited by John Bryant, Linda Baggott la Velle and John Searle Copyright 2002 John Wiley & Sons Ltd ISBNs: 0-471-49532-8 (Hardback); 0-470-84659-3 (Electronic)

17 Dealing with Death: Euthanasia and Related Issues

John Searle

17.1 INTRODUCTION
There are only two absolute certainties about life; it begins and it ends. We are born and we die. Until the early part of the 20th century, death was an accepted part of life. Many diseases were incurable. People died at home rather than in institutions. War took its toll of young men most notably the First World War of 191418. Life expectancy was much shorter compared with today. Infant death rates were high. By the end of the 20th century, advances in therapeutics, surgery and medical technology had conquered many diseases and enabled those with chronic disease to live for a long time, often with a good quality of life. With these advances came the popular view that death could be postponed almost indenitely. The current search is for an understanding of the genetic, nurturing and environmental components of the ageing process with a view to slowing it down and prolonging life even further. As a result of these changes there have been two parallel but dierent developments. First, the terminally ill have often been neglected. In the 1960s and 70s hospital sta commonly hurried past the beds of the dying because they represented a failure of modern medicine which was dicult to face. The distressing symptoms, emotional turmoil and social disturbance of dying were frequently left unattended. Two responses followed this neglect. First, the Hospice Movement, pioneered by a doctor, Cicely Saunders, took the care of the dying seriously. Distressing and painful symptoms were relieved; the emotional and social upheaval alleviated and spiritual comfort provided. Those close to the dying person were well supported. The hospice emphasis is that although the person is dying, they can live fully to the end of their lives within the limitations of their illness. Others however, have taken the view that the only certain way to control the pain and distress of dying is to end the persons life. This argument has been bolstered by the prevailing ethical principle of Western society which is that of individual autonomy. This principle says that my life is my own to do with it
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whatever seems best for me. Despite the remarkable eectiveness of hospices this view is increasingly promoted. Secondly, one outcome of advances in medicine is that life can be prolonged, but in some cases with a very poor quality of life. In intensive care units, people who would have died within a few days can be kept alive by drugs and machines, only to die a few weeks later. Victims of dementia and severe strokes may survive long beyond the time when they have lost the ability to know about or respond to the world around them. People with advanced cancer may be subjected to surgery, radiotherapy and chemotherapy with little prospect of a reasonable quality of life being secured. Again, two views have emerged in response to these developments. There are those who say that life must be preserved at all costs. Others believe that nature should be allowed to take its course. There then follows a further question in the debate: if in some people, treatment is either not to be instituted or withdrawn and the result of that is that they die, what is the dierence between this and euthanasia that is actually killing them? After all the outcome is the same. They die. The dilemma that confronts society at the beginning of the 21st century is how to nd a way through this complex web of ethics and medicine. This chapter will explore ways of doing so by looking rst at the euthanasia debate and then discussing the grey area of when continuing medical treatment is prolonging dying rather than promoting life. It will conclude with some case studies to illustrate these dilemmas.

17.2 THE EUTHANASIA DEBATE

17.2.1 WHAT IS EUTHANASIA? The English word euthanasia is derived from two Greek words that mean a quiet and easy death. That is something for which most people hope as they do not want their dying to be prolonged, painful or violent. However, in the present debate, euthanasia means something dierent. Voluntary euthanasia is dened as the deliberate ending of a persons life, at their request, because they nd their illness and/or disability intolerable. The assumption is that as doctors have both the knowledge and the means for doing this, they will normally administer it. Such an act by a doctor is, in English law, unlawful. However, the British Courts have increasingly taken a lenient view when euthanasia has been administered and the doctor prosecuted. Two cases illustrate this point. In 1991, Dr Nigel Cox, a consultant physician in Winchester, gave Mrs Lilian Boyes a lethal injection of potassium chloride. She was in severe pain from rheumatoid arthritis. The pain made her howl and scream like a dog. Dr Cox believed that the only way to end this appalling suering was to terminate her life. He was convicted of murder but given a suspended prison sentence. How-

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ever, the regulatory body of the medical profession, The General Medical Council, found him guilty of serious professional misconduct and required him to undergo training in the control of severe pain and palliative care before allowing him to return to work. On Boxing Day (26 December) in the same year, Paul Brady killed his brother James, by giving him ve times the normal dose of the sleeping drug, temazepam, washed down with alcohol. He nally smothered James with a pillow. James was suering from Huntingtons disease and had begged his family to help him to die. At the High Court, in Glasgow, Paul Brady was initially charged with murder. This was reduced to culpable homicide, thereby allowing the court to admonish him and not to impose a custodial sentence on him. The judge accepted that there were powerful mitigating factors. He said you brought your brothers life to an end at his own earnest and plainly heartfelt request (Christie, 1996). However, the debate is in fact wider than a handful of specic cases. Indeed, the issue has been brought the attention of wide television audiences. In the UK for example, the television soap operas Brookside and EastEnders have, during the period 19952000, both dealt with the issue of helping somebody to die because their suering in a terminal illness was severe. The momentum in support of voluntary euthanasia in the developed world has increased considerably. In 1996, euthanasia became lawful in the Northern Territories of Australia. Seven people took advantage of this change before it was overturned by the Federal Australian Parliament (Kissare et al, 1998). In the United States of America the debate was brought powerfully into the public arena in April 1999. Dr Jack Kevorkian, a pathologist, is a passionate advocate of the right to die. He had assisted over 100 patients in bringing about their own death. In Michigan, he was found guilty of second-degree murder and sentenced to 10 to 25 years in prison. In the State of Oregon, on the other hand, physicianassisted suicide is lawful for patients judged to have less than six months to live. In The Netherlands, voluntary euthanasia has been practised by doctors for two decades and therefore provides the largest single source of data about the practice. Until the end of 2000 euthanasia was actually unlawful although the Dutch Courts recognised it as acceptable medical practice. However, the practice has now been formally legalised. So far, there has been no serious call for involuntary euthanasia. This is dened as the deliberate ending of a persons life, without their request, because some other party considers their life intolerable or its quality not worth having. One of the key issues in the debate is whether the legalisation of voluntary euthanasia would lead to the practice of involuntary euthanasia. 17.2.2 THE CASE FOR VOLUNTARY EUTHANASIA There are three main arguments for making voluntary euthanasia lawful: autonomy

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Autonomy is the key ethical argument in the debate. The basic question is whether or not human beings have the right to decide themselves how they will end their lives. This has been vividly expressed by Brian Clarke in his play Whose Life is it Anyway?, which played in the West End of London in the 1970s. The central character, Ken Harrison, is paralysed from the neck downwards and has no use in either his arms or his legs. He wants to die and says, I have coolly and calmly thought it out and I have decided that I would rather not go on. Each must make his own decision (Clarke, 1978). The argument is that what is intolerable for me is for me to decide and if I wish to be delivered from that by dying, that is my decision. There is growing support for this view. As long ago as 1985, 85% of people questioned in a survey in the United States of America believed that they had the right to decide for themselves how they died (The New York State Task Force on Life and the Law, 1987). This is frequently cited in feature articles and correspondence columns of newspapers and magazines. Necessity If autonomy is the key philosophical argument in favour of voluntary euthanasia, necessity is the most emotionally powerful. Case histories are cited of people dying in great pain and distress. In 1995, the BBC television series Panorama screened a programme about euthanasia in The Netherlands. A man had motor neurone disease, which causes progressive muscular paralysis but leaves sensation and mental function intact. His general practitioner told him that not only would he become increasingly disabled, but also his breathing would become more dicult as his lungs became waterlogged and that he would eventually choke to death. Faced with this the patient asked to have his life ended, which the doctor did, injecting him with a lethal combination of anaesthetic drugs. The protagonists of voluntary euthanasia almost always quote cases where the suering has been terrible and pain poorly controlled. The motivation is compassion and a desire to see people die without pain and with dignity. Openness There is some evidence that doctors in the UK do practice euthanasia. It is clearly dicult to obtain evidence about an unlawful practice but in one study (not peer reviewed) carried out through anonymised questionnaires, of 273 doctors questioned, 163 had at times been asked by patients to end their lives. Of

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these, 124 had taken steps to hasten death and 38 had actually complied with the request (Coulson, 1995). In another study, 50% of doctors questioned wanted the law changed. The argument is that if some doctors are covertly practising euthanasia, the law should be brought into line with such compassionate medical practice, thereby removing the threat of prosecution from doctors. These arguments were dramatically illustrated by the death of King George V in 1936. On the night of 20 January 1936, the royal physician, Lord Dawson of Penn, was summoned to Sandringham by Queen Mary. King George V was dying from heart failure. The following morning, The Times carried the rst news that the King was dead. The assumption was that he had died naturally in his sleep. What actually happened was only made public 48 years later with the publication of Dawsons diaries. Of the evening of 20 January 1936 he had written
at about eleven oclock it was evident that the last stage might endure for many hours, unknown to the patient, but little comporting with the dignity and the serenity which he (the King) so richly merited and which demanded a brief nal scene. Hours of waiting just for the mechanical end when all that is really life has departed only exhausts the onlookers and keeps them so strained that they cannot avail themselves of the solace of thought, communion and prayer. I therefore decided to determine the end.

Dawson then gave the King intravenously a lethal dose of morphine and cocaine and he died. A timely public announcement in the appropriate newspaper was assured and Dawson was able to return to London by the morning to his private practice (Ramsay, 1994). Dawsons brief entry encapsulates all the main arguments in favour of euthanasia: the patient was terminally ill his dignity was assured his suering was relieved the relatives were spared a long bedside vigil.

17.2.3 THE CASE AGAINST EUTHANASIA The triad of autonomy, necessity and openness is a formidable one. But those who oppose the legalisation of voluntary euthanasia raise two important questions. Is there a downside to the exercise of autonomy? Are there eective ways of controlling the pain and distress of terminal illness apart from killing the person? Is voluntary euthanasia necessary? The downside to autonomy That each person should be able to make their own decisions about their own lives is an important general principle in the conduct of civilised human aairs.

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However, men and women are not only individuals; they are part of society. Human responsibilities therefore extend beyond self to others, to the community. Thus a second important principle in the conduct of civilised human aairs is that individuals may only exercise their rights in so far as they do not infringe the rights of others. So does the right to die by voluntary euthanasia infringe the rights of others to live? In 1989 the Dutch Government appointed a commission under the chair of the Attorney General to report on the extent and nature of medical euthanasia practice. The report was published in English in 1992 and its ndings were as follows: Total number of deaths in The Netherlands in 1990 12 900 Deaths not terminated or assisted by the doctor 9200 Termination of life at patient request 2300 Assisted suicide 400 Termination of life without patient request 1000 28% of all deaths in The Netherlands in 1990 involved the active participation of a doctor, but 7.7% of all deaths were actually procured by a doctor without the request of the patient (Van Der Maas et al, 1996). In four out of ve cases the doctor said that there was no alternative way of relieving symptoms. This practice continues in The Netherlands and has been extended to other conditions (Hendin et al, 1997). In 1994 a Select Committee of the British House of Lords, while recognising the right of every competent person to refuse medical treatment, rejected any proposal to make voluntary euthanasia lawful because such a law would threaten the weak, the vulnerable and the mentally incompetent. What is voluntary for some would be assumed to be in the best interest of others. Is voluntary euthanasia necessary? If the pain and other distressing symptoms of terminal illness and chronic disease cannot be eectively controlled, the case for voluntary euthanasia on compassionate grounds is strong. The House of Lords Select Committee took a great deal of evidence on this point. It concluded that through the outstanding achievements of those who work in the eld of palliative care, the pain and distress of terminal illness can be adequately controlled in the vast majority of cases (House of Lords, 1994). However, there remain about 4% of people in whom pain control is very dicult. This has always been acknowledged by palliative sta (Gilbert, 1996), but they are equally clear that therapeutic strategies can be used to give these people a reasonable quality of life and that certainly nobody need die in pain (Saunders, 1999). The Exeter Hospice (which is typical of hospices in the UK) contributes to the care of 700 people with
The correct term is lacking capacity.

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terminal illness every year, 300 of whom require in-patient care at some time. The sta do not encounter any persistent rational demand for euthanasia (Gilbert, 1996). In the 1995 Panorama programme about euthanasia in The Netherlands the patient with motor neurone disease was told that he would become increasingly breathless as his lungs became waterlogged and that eventually he would choke to death (as mentioned earlier), but the fact is that in the worlds largest series of deaths from this disease these end-stage complications were never encountered (OBrien et al, 1992). It is dicult not to conclude that either the doctor was ignorant or he misled the patient. A frequent criticism of those who work in palliative care is that, in order to relieve pain, they progressively increase the dose of powerful pain-relieving drugs and thereby shorten the persons life. They are charged with hypocrisy as it is claimed that they are administering euthanasia covertly. Two objections are put forward to counter this charge (Gilbert, 1996). Firstly, there is a wide individual variation in response to these drugs. Huge doses can be given to some individuals with seemingly little eect while others respond to much smaller doses. Part of the skill in palliative care is to titrate the dose of drug against the persons response. Secondly, pain acts as a physiological antagonist to the depressing eects of these drugs on respiration. These arguments against voluntary euthanasia being necessary to ensure death with dignity also cut across the argument about openness. Once the eectiveness of good palliative care is recognised, this argument evaporates and becomes one not about changing the law but about ensuring that doctors and other healthcare workers are properly trained in the care of the terminally ill, and that such care is regularly reviewed and audited. Pressure continues to be put on many governments in the developed world to legalise voluntary euthanasia. Those who see such a move as a threat to the weak, the vulnerable and the terminally ill oppose it with equal vigour. The debate is set to go on for some time. However, the history of the last 50 years is that public policy is eventually determined by the ethos of perceived human rights and personal autonomy (but see the discussion on utilitarianism in Chapter 1).

17.3 PROLONGING DYING

17.3.1 INTRODUCTION The arguments for and against voluntary euthanasia are fairly sharply dened. However, the area of withholding or withdrawing medical treatment from a person whose illness or disability has a very poor outlook and renders miserable their quality of life is much more complicated, although the arguments are no less vigorously pursued. The pro-life groups have taken a passionate stand

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against any act of omission that seems to them to result in the shortening of human life, however tenuous the hold on life may be. Healthcare workers and the English courts have taken the view of principled pragmatism, trying to balance a number of ethical principles, which are sometimes in conict. These principles, which underlie contemporary medical and healthcare practice, were set out by Beauchamp and Childress in 1979 and are widely accepted. There are four main principles. Benecence: a doctor must always act in a persons best interest, that is in a way which confers benet upon that person. Non-malecence: a doctor must not harm a person. That can never be in a persons best interest. Autonomy: a doctor may not do anything to a person without their consent. Any person has an absolute right to refuse medical treatment. Justice: a doctor must act in such a way that resources are apportioned equitably within a society. The application of these is not always straightforward. Medical and surgical treatment always involves risk. No drug is devoid of side eects and no operation can be undertaken with an absolute guarantee that there will not be any complications. Consent to treatment can only be given to persons who are competent; that is to say they understand what is being oered to them and they understand and can articulate the consequences of refusing it. Where a person lacks the capacity to do this because of age, mental dysfunction or unconsciousness, doctors have to consult with those who have an interest in that persons welfare; however, ultimately the law accords to the doctor the privilege of deciding what is benecial to that person and what the balance is between benet and harm. All healthworkers recognise that resources are limited and that healthcare provision cannot do all that it is possible to do. Nonetheless, when facing an individual person they want to do what they consider to be in that persons best interests, irrespective of cost, notwithstanding that doing one thing for this person may prevent something else being done for another person. It is within this context that decisions have to be made about withholding or withdrawing treatment in some cases. There are ve areas to consider: resuscitation brain stem death permanent vegetative state intensive care, cancer treatment and heroic surgery conjoined twins.

17.3.2 RESUSCITATION Since 1960 the technique of external cardiac massage and expired air ventilation and electrical debrillation has saved the lives of many people who would

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otherwise have died suddenly because their heart stopped beating from some reversible cause. Since the introduction of this technique the question who should be resuscitated? has been asked. A consensus emerged that it should not be embarked on if the patient did not wish it it would be futile the costs were too great the subsequent quality of life would be unacceptable.

Despite this consensus there has been recent public concern about resuscitation. On the one hand people continue to be resuscitated in hospital when there is little or no hope of securing a reasonable outcome because the person has in fact reached the end stage of their disease. Their cardiac arrest is in fact death. Clearly to embark on resuscitation under these circumstances does not benet the person and may cause them harm. On the other hand in the late 1990s it became clear that doctors were making decisions not to resuscitate patients should they have a cardiac arrest, without any discussion with them beforehand. This clearly infringes the principle of consent and betrays the partnership of trust between doctor and patient. 17.3.3 BRAIN STEM DEATH Death occurs when one of three organs cease to function the brain stem, the heart and the lungs. If one of these stops working the other two cease to function rapidly thereafter and death occurs. By the early 1970s it became possible to interrupt this process where the organ initially failing was the brain either because of accident (a severe head injury) or disease (a severe stroke). By passing a tube into the persons trachea and attaching it to a ventilator (life-support machine), it is possible to inate the lungs with oxygen and thereby maintain the function of the heart, in the hope that recovery of the brain would occur and all three organs be able to function near normally again. A key question then arose: was it possible to distinguish between those people in whom such recovery would occur and those in whom it would not? That is to say, is it possible to identify those in whom the brain damage is fatal and the inevitable process of death has simply been interrupted? When this happens the higher centres of the brain, which are the neurological basis of personhood, can neither receive nor transmit information. In 1976 (Conference of Medical Royal Colleges and their Faculties, 1976) a series of reliable tests was developed, which enabled this distinction to be made by demonstrating whether or not the brain stem, which connects the higher centres of the brain to the rest of the body, had been destroyed. When brain-stem death is shown to occur, the ventilator is turned o and the heart and lungs rapidly cease to function. Such an act is not causing death but recognising that death has already taken place.

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However, not everybody has accepted this concept, maintaining that death can only be said to have occurred when there is total cessation of brain function. When the stem of the brain has been destroyed, electrical activity of the higher levels of the brain may persist for some time. Their view is that death can only properly be said to have occurred when there is no electrical activity in the brain and thus to turn o a ventilator before this happens is tantamount to euthanasia. The criteria for establishing death of the brain stem and the actions which follow have never been enshrined in statute. The legal position seems to be that a person is dead when a doctor says they are dead. 17.3.4 PERMANENT VEGETATIVE STATE (PVS) In PVS the brain stem is intact so that the heart and lungs continue to function normally without articial support. It is the higher centres of the brain that have been destroyed. People with PVS display sleepwake patterns and respond reexly to stimulation but show no evidence of cognitive function. They are unable to swallow and have to be fed through a tube placed in the stomach via the nose and the oesophagus. With expert nursing care they can be kept in this condition for years and indeed many have been in the past. However, by the early 1990s two key questions were being asked by those looking after them and their families. Is such a person alive? Is feeding through a tube when the person is unable to take food and hydration normally through the mouth an articial means of support? These questions were highlighted by the case of Tony Bland in 1993. He had been a victim of the Hillsborough Football Stadium (Sheeld, UK) disaster in 1989. He had been severely injured but resuscitated and treated. However, he never regained consciousness and had been in a PVS for three years. The doctors looking after him and the hospital in which he was resident took the case to the courts. The two key questions were addressed, rstly in the Family Division of the High Court, then in the Court of Appeal and nally in the House of Lords which conrmed the judgement of the lower court. The Law Lords took the view that Tony Bland was not alive in any normal meaning of the word. They also accepted that feeding him via a tube was a form of medical treatment that was not only futile since Bland could never recover but was also being administered without his consent. They made it clear that in a person without capacity, doctors have a clear duty to do that which is benecial to a person. However, feeding in this way could not benet Bland. Indeed there was no benet that could be conferred upon him. They therefore ruled that it was lawful to withdraw food and hydration (Airedale NHS Trust, 1993). This was done and Bland died some days later. While many regarded this ruling as both wise and compassionate, others were profoundly disturbed by it (Fergusson, 1993; Hume, 1997) for three reasons.

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They argued that this was in fact euthanasia, if not openly at least by the back door, because of the following factors. Hitherto death had been dened as irreversible cessation of the activity of the heart or the lungs or the brain. In this sense Bland was not dead. Food and hydration are basic human needs and while someone is alive there is a moral duty to provide them. The intention of stopping food and hydration was that Bland would die. However, the counter-argument to this is that the Law Lords based their decision on the answers to two vital questions. First, was there any possibility of Bland recovering? Second, could he swallow food and uid when it was oered to him on a spoon or in a cup? The answer to both questions was no. If the answer to either question had been yes then there was a duty to continue feeding him. But as the answer to both questions was no withdrawing food and hydration was reasonable. It is principled pragmatism. However, the decision is absolutely dependent on the accuracy and reliability of the diagnosis. The Royal College of Physicians issued strict diagnostic criteria for PVS (Recommendations and Standards, 1996). The British Medical Association recommended two safeguards in making decisions to withhold food and hydration. These cases should be subject to formal clinical review in each case by a senior doctor with experience of the condition from which the person is suering. This doctor must not be part of the team treating the person. All cases should be reviewed regularly to ensure that appropriate procedures and guidelines are followed. In England it remains a requirement that the permission of the courts is necessary before food and hydration can be withheld in cases of PVS. It is no longer necessary to do so in Scotland. The situation is anomalous, as in other conditions, such as end stage dementia and severe stroke, where the answers to the two key questions are no, uid and hydration can lawfully be withdrawn without recourse to the courts. 17.3.5 WITHHOLDING AND WITHDRAWING TREATMENT Finding the balance of what constitutes a persons best interests extends to other areas of medical practice. Examples include intensive care, the treatment of advanced cancer and the care of the new-born with severe handicap. One way of approaching this has been to quantify the risk of death and placing patients thereby into categories of the likelihood of death occurring irrespective of the treatment being proposed or given. This does not give an absolutely certain prediction about what is going to happen to each individual person but together with the progress of the condition over a longer or shorter period of time enable the best judgement to be made. This judgement will never be perfect but the

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nature of medicine is such that the most that can be achieved is a good enough judgement. Of course at some date in the future that judgement may be dierent and a dierent decision made. A good example of this is the respiratory complications of AIDS. In the mid1980s the onset of respiratory failure in patients with AIDS was inevitably fatal and therefore to embark on intensive care treatment only prolonged the time of death by a short time, while also imposing on the person a considerable burden of suering. By the late 1990s the prognosis for patients with AIDS related respiratory disease had improved considerably and therefore such treatment became justiable. 17.3.6 CONJOINED TWINS A recent British example of the dilemmas at the end of life that modern medicine has generated is well illustrated by the case of the conjoined twins, Mary and Jodi. The issue at stake was should the twins be separated by a surgical operation? The expert medical opinion in this case was that Jodi did have a chance of a reasonable quality of life if she were separated from her twin, even though that separation would cause the certain death of the other twin, Mary. Both twins would inevitably die without such separation since Mary was only oxygenated through the heart and lungs of Jodi and Jodis heart would eventually fail irreversibly if such a burden were imposed on it indenitely. In his summary (as given to The Times newspaper, 2000), Lord Justice Ward said, In my judgement it is overwhelmingly in Jodis interest that she be given the chance to live a normal life with a normal expectation of life. It is certainly not in her best interest to be left to die. He went on, In my judgement it cannot be in Marys best interest to undergo surgery which will terminate her life. He described the dilemma thereby facing the court as follows: It is in the best interests of Jodi that separation takes place. It is in the best interests of Mary that it does not. . . . The only solution is to balance the welfare of each child against the other to nd the least detrimental alternative. . . . One cannot escape from the fact that Mary has always been fated for early death: her capacity to live has been fatally compromised. . . . Nobody but the doctors can help Jodi. Mary sadly is beyond help. The best interests of the twins is to give the chance of life to the child whose actual bodily condition is capable of accepting the chance to her advantage, even if that has to be at the cost of the sacrice of a life which is so unnaturally supported. . . . The least detrimental course is to permit separation to take place. While many people welcomed this judgement, others were deeply disturbed by it. The courts view was determined by trying to solve the dilemma of benet versus harm. If the operation did not take place Jodi and Mary would be harmed. Jodi would be harmed by the inevitable harm which was going to befall Mary. However, if the operation took place, Jodi would benet but Mary would be irreparably harmed. The argument is a utilitarian one, what benet is obtained by each course of action? This approach lacks deontological principles and raises many questions. Was

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Mary of less value than Jodi? How can an operation be ethical if it results in the death of one of the twins? Mary was being used instrumentally in order that Jodi might benet, thereby turning on its head the traditional view that the end can never justify the means. On what grounds did the court rule against the parents, who did not wish the operation to take place? Is death the worst fate that could happen to Jodi? Questions also arose about the possibility of harming Jodi. Were the doctors being overly optimistic about her future quality of life? May she not suer psychological harm in later life knowing that she lived only because her twin sister was killed? The case illustrates the increasing gap in society between traditional deontological ethics and contemporary utilitarian ethics.

17.4 CONCLUSION
Modern medicine has brought huge benets to human beings, especially in the developed world. For many people life expectancy has been extended with a good quality of life. But with this has come the ability to sustain life when there is little or no prospect of recovery or of anything approaching a reasonable quality of life. Dying is being prolonged. Ancient philosophers understood this well; For in much wisdom is much vexation and those who increase knowledge increase sorrow (Ecclesiastes, Chapter 1, verse 18). Doctors and their healthworker colleagues have three duties in the face of this dilemma: rst to maintain a persons right to life, second to preserve their right to die and third to distinguish between the two (Dunstan, 1985).

APPENDIX: SOME CASE HISTORIES

CASE 1 You are parents. Two days ago your 18 year old son had a motor cycle accident. He has severe head injuries and has been in an intensive care unit on a life support machine for the last 48 hours. The doctors tell you that his brain is dead and can never recover. Will you agree to the life support machine being turned o? CASE 2 You are a general practitioner. You have a patient who is a man of 40 with a wife and two children aged 13 and 11. He has battled with cancer for three years and he is now dying. He has, you think, four to six weeks to live. One day when you are visiting him at home he says to you Doctor, my wife and I have talked about

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this and we realise that there is nothing more that can be done for me. Please would you give me an injection so that I can die peacefully in my sleep? We have a written request here which we have both signed and our next door neighbours have witnessed it. Would you give the injection? CASE 3 You are 50. Your widowed mother is 85 and you are her only child. She is blind. She had a stroke two years ago and is conned to a wheelchair. She is mentally alert and cheerful and well looked after in a local nursing home. She has no nancial diculties. You will inherit a substantial capital sum after her death. Three days ago she had a major bowel operation for cancer which the doctors say was curative. She has developed complications and is confused. The doctors want to do another operation to repair a leak in her bowel but they are not sure whether or not she will survive the operation. She will certainly die if she does not have the operation. Should she have the operation?

REFERENCES
Airedale NHS Trust v. Bland (1993) Appeal Cases 835. Beauchamp, T. and Childress, J. (1979) Principles of Biomedical Ethics. Oxford University Press, Oxford, UK. Christie, B. (1996) Man walks free after Scottish euthanasia case. British Medical Journal, 313, 961. Clarke, B. (1978) Whose Life is it Anyway? Amber Lane, Ashover, UK. Conference of Medical Royal Colleges and their Faculties (1976) Diagnosis of brain death. Lancet, ii, 10691070. Coulson, J. (1995) Doctors oppose legal mercy killing for dying. British Medical Association News Review, March, 15. Dunstan, G.R. (1985) Hard questions in intensive care. Anaesthesia, 40, 479482. Fergusson, A. (1993) Should tube-feeding be withdrawn in PVS? Journal of the Christian Medical Fellowship, April, 48. Gilbert, J. (1996) Palliative medicine: a new speciality changes an old debate. In Euthanasia: Death, Dying and the Medical Duty. Dunstan, G.R. and Lachmann, P.J. (eds), British Medical Bulletin, 52, 296307. Hendin, H., Rutenfrans, C. and Zylicz, Z. (1997) Physician assisted suicide and euthanasia in the Netherlands. Journal of the American Medical Association, 277, 17201722. House of Lords (1994) Report of the Select Committee on Medical Ethics. HMSO, London, UK, para 241. Hume, B. (1997) The death of trust. The Times, London, 27 November. Kissare, D., Street, A. and Nitschke, P. (1998) Seven deaths in Darwin: case studies in the Rights of the Terminally Ill Act, Northern Territory, Australia. Lancet, 353, 10971102. The New York State Task Force on Life and the Law (1987) Life-sustaining treatment: making decisions and appointing a health care agent. OBrien, T., Kelly. M. and Saunders, C. (1992) Motor neurone disease: a hospice perspective. British Medical Journal, 304, 471473.

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Ramsay, R. (1994) A king, a doctor, and a convenient death. British Medical Journal, 308, 1445. Recommendations and Standards (1996) The permanent vegetative state. Journal of the Royal College of Physicians of London, 30, 119121. Saunders, C. (1999) Euthanasia: the Heart of the Matter. Hodder and Stoughton, London, UK. The Times, London (2000) Siamese twins: the judgement. 23 November, 7. Van der Maas, P.J., Van der Wal, G., Haverkate, I., de Gra, C.L.M., Kester, J.G.C., Bregje, D., Onwuteaka-Philpsen, D., Van der Heide, A., Bosma, J.M. and Willems, D.L. (1996) Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in The Netherlands. New England Journal of Medicine, 335, 16991705.

Bioethics for Scientists Edited by John Bryant, Linda Baggott la Velle and John Searle Copyright 2002 John Wiley & Sons Ltd ISBNs: 0-471-49532-8 (Hardback); 0-470-84659-3 (Electronic)

18 Animal Experimentation in Biomedical Research

Linda Baggott la Velle

18.1 ANIMAL RELATIONSHIPS: HUMAN AND NON-HUMAN

Bioethical issues arise when there are questions about what is right and wrong for people to do with other organisms. This chapter will discuss human relationships with other species of the vertebrate class to which we ourselves belong the mammals. Few bioethical issues arouse the passion of some people so strongly as does the use that others make of mammalian species in sport, fashion, agriculture and scientic research. We need look no further than the current UK parliamentary debates about foxhunting, the use of animals in testing cosmetics, the mass culls of livestock in the attempt to eradicate foot-and-mouth disease and the vociferous demonstrations against the work of the pharmaceutical company, Huntingdon Life Sciences. These issues are presented to us daily in the media. To do justice to each of these would need more than just one chapter of this book. After an overview of the historical and philosophical thinking that has informed our present relationship with other mammals, this chapter will look in more detail at human use of animals in biomedical research, and will touch briey on the role of animals in education. All ethical decisions are formed from a range of choices. These choices can best be made from within an informed ethical framework. But how is this framework constructed? An important part of the history of the developed world has been the transition of human activity from a series of strategies for survival towards a civilisation with human welfare at its centre (see Table 18.1). But this benet has a cost. Scientic (biomedical) advances aimed at alleviating human suering and premature death are brought about as a result of the public demand for them. Implicit in this is the acceptance of the processes of science by which these advances are brought about. (See, for example, Chapter 2.) There are three important elements in the practice of science. These are the following.

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BIOETHICS FOR SCIENTISTS Table 18.1 Levels of organisation and science Level of organisation International organisations Nations Societies Individuals Organs Tissues Cells Subcellular fractions Molecules Atoms Subatomic particles Studied by

Politics Social sciences

Biomedical sciences

Chemistry Atomic physics

1. The acquisition of new knowledge and understanding. 2. The application of that knowledge and understanding (note that some would call this technology). 3. The ethical aspect. In the context of the use of animals in the rst and second elements of science, this chapter will examine the third by discussing the values that inform opinion about what is right or wrong. In order to begin a discussion about whether other (non-human) forms of life should be exploited by humans we might begin by considering some aspects of the characteristics of life. What distinguishes the living from the non-living? Pupils in school biology classes will readily answer, Mrs Gren! (movement, respiration, sensitivity, growth, reproduction, excretion and nutrition), and of course these are the basic qualities that humans share with most other organisms. However, the quality of our relationship with those other organisms is not based on these common features. As David de Pomerai has argued in Chapter 6, we feel closer to other mammals than we do, say, to molluscs or plants. Although in the 19th century Darwin said the dierence in mind between man and the higher animals, great as it is, certainly is one of degree and not kind, surely the complexity of this relationship has its foundations in more than phylogenetic taxonomy?

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So what, precisely, distinguishes humans from other members of the animal kingdom? The main characteristics are probably those of rationality and its vehicle, language. Many philosophers have claimed that humans alone have reason this is all-or-nothing. That we are endowed with the ability to reason enables us consciously not merely to make decisions pertinent to our survival, because other animals are manifestly able to do this. We are also able to decide what is right or wrong. This heightened ability to moralise has, probably from the beginning of the history of Homo sapiens, shaped the development of human community and ultimately civilisation. It is clear even to the casual observer that animals can communicate with one another, but it also seems obvious that their level of communication has a limited vocabulary. There is evidence that our closest relatives among the primates can understand human language. For example, Washoe the chimpanzee can understand 150 meaningful signs and words, and Koko the lowland gorilla around 500 signs using language (Dolins, 1999). There are many other reported instances of communication in other animals. So while we may not be alone in being able to generate, learn and use language, there seems little doubt that the level of sophistication reached by even the simplest of human languages far exceeds any communication system developed in any other species. The development of language has facilitated, enhanced and augmented the ability to moralise, an idea that resonated with early religious thinking. Speech and reason are linked in the notion of logos an ancient Greek word simultaneously meaning reason, word, discourse, and saying. For example, the rst version of the New Testament contained the word logos in the opening words of the gospel according to St John:
In the beginning was the word, and the word was with God and the word was God (Holy Bible, Revised Standard Version).

Philosophical and religious thinkers, from the earliest days of recorded language, have wrestled with the question of what it means to be human. Christians, for example, believe that alone in the animal kingdom humans are spiritual beings. The question of the nature of the spirit and its relationship to mind and consciousness are well beyond the scope of this chapter, but remain among the most profound questions facing philosophers, scientists and theologians today. It is interesting to note that the rise of neuroscience has given recent impetus to the debate. Whether self-consciousness is a uniquely human characteristic is an almost unanswerable question because of the layers of complexity associated with the concept. One might consider the extent to which some form of consciousness might be applied to any organism that responds to stimuli, and even extend this question to a consideration of the status of robots and computers in this context. It is dicult then, to escape from the conclusion that the ability to moralise mediated by self-consciousness and language is a uniquely human characteristic. As moral agents, therefore, having a perception (knowledge) of good and evil,

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justice and injustice and so on, how has our relationship with other animals developed through the course of history?

18.2 HUMANANIMAL RELATIONSHIPS: HISTORICAL PERSPECTIVES

There has been a long tradition in Western thought that emphasises the dierences between humans and animals. These dierences, it is said, are signicant enough to justify our using them for food, experiments, fun and fashion (but see Chapter 7). Across the world, within all cultures people use animals as pets, subjects in experiments, objects of study, objects of reverence, the basis for subsistence and objects of nancial gain. This implies that humans have taken on the role of creator, protector, and/or steward over the animal world. Some may even add the word exploiter. How has this perceived right to exercise control over animals lives and even over the existence or disappearance of an entire species arisen? In order to start to answer this it is necessary to look at Judaeo-Christian tradition that has inuenced much thinking in this area. The author of the book of Genesis, the rst book in the Jewish and Christian scriptures, says in Chapter 1 verse 28
Be fruitful and multiply, and ll the Earth and subdue it; and have dominion over the sh of the sea and over the birds of the air and over every living thing that moves upon the Earth. (Holy Bible, Revised Standard Version).

The important word here is dominion, and the idea that as humans it is right that we should dominate all other species probably springs from this. Indeed, as discussed by Christopher Southgate in Chapter 3, some environmental ethicists blame this Judaeo-Christian concept of dominion for the present ecological crisis. However, for those who attempt to base their bioethical and environmental ethical thinking on biblical principles, it is worth noting that another theme of the creation narratives, and indeed throughout the biblical text, is that humans are to exercise stewardship rather than dominion over the creation. Many belief systems about nature, Christianity included, are based at least loosely on, or have some similarity to the thinking of the ancient Greek philosopher Aristotle (384322 BCE). He rst proposed the idea that humans alone are rational, suggesting the natural hierarchy illustrated in Table 18.2. Aristotle saw rationality as a divine virtue, so humans alone among organisms have a divine element within them. This divine element is seen in Christian thinking as the uniquely human spiritual dimension. This idea was reinforced in early Christian thinking by the inuential St Augustine (CE 354430), who taught that the commandment You shall not kill (Exodus 20 v13, RSV) does not apply to animals, because animals are irrational, and therefore dissociated from us by lack of rationality (reason). Augustine thus believed that God

ANIMAL EXPERIMENTATION IN BIOMEDICAL RESEARCH Table 18.2 Aristotles natural hierarchy Mind/God Humans Animals Plants Stone

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Perfect reason Rational Sentient Alive Inanimate

subjected animals to humans for their use and that it was also right for people to keep them alive for their own uses. The next major interpretation of the relationship between humans and other animals was by the French philosopher, Rene Descartes (15961650). The Cartesian theory was based on the ideas that there is no distinction between mind and spirit and that possession of a mind or spirit is an all-or-nothing matter, uniquely human. He thought that animals were akin to machines operating without consciousness, and that it was not morally wrong to exploit them. Descartes was, however, isolated in his view. Most philosophers of the time agreed that animals could suer and that inicting suering on them was wrong. Emmanuel Kant (17241804) believed that humans had no direct duties to animals because they are not self-conscious, so they cannot judge. He further believed that animals are a means to an end and that end is man, so animals are mans instruments. However, he qualied this by stating that it is sometimes wrong to hurt animals. Kant believed that how we treat an animal aects or determines how we treat other humans. This has become known as the indirect duty view. Implicit in this is the idea that wanton inicting of suering harms the perpetrator. In other words, we should be kind to them not because of our duty to them directly, but because it is good practice for being kind to humans, those who can judge us. We have no duties directly towards animals, not even those of compassion or sympathy, but we do have a direct moral obligation to other humans for compassion, because this will improve our society. By the end of the 19th century people were thinking more in terms of animal welfare. Early works, such as Lewis Gompertzs Moral Inquiries on the Situation of Man and Of Brutes (1824) and Henry S. Salts Animals Rights (1892), defended the rights of animals. However, it was not until the late 20th century that a more forceful defence of animals gained signicant ground and the notion of animal welfare became an increasingly important issue in the public debate. In 1975 the contemporary Australian ethicist and philosopher Peter Singer put forward the view that animal and human interests are comparable in moral terms (Singer, 1975). He believes that the principle of equal consideration in interest cannot be limited to humans. Whether or not an animal is self-conscious enables the distinction of personhood to be drawn but in Singers view this is irrelevant to animal welfare. Echoing the words of the English utilitarian philosopher Jeremy Bentham (17481832), The question is not, can they reason? Nor, can they talk? but, can they suer? Singer argues that the capacity for suering

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is the vital characteristic that entitles a being to equal consideration (Singer, 1991). This, he contends, is because sentience is the only defensible boundary. If we dene suering as the susceptibility to pain, awareness of being in pain, or of about to be in pain, there is little doubt that most vertebrates can suer. However, the extent to which they are aware is questionable, but there is good evidence to suggest that the great apes have a high degree of self-awareness. This raises the question of the extent to which sentience contributes to self-consciousness, and thus the extent to which self-consciousness is a purely human characteristic. Controversially, Singer goes on to argue that logically, the intellectually impaired, the disabled, infants, and embryos are akin to non-human animals as far as justifying experiments are concerned. A central tenet of his opinions is that if we say it is acceptable to use animals for our own ends in ways which cause them to suer just because they belong to another species because they are only animals then we are showing a form of prejudice akin to racism or sexism (see also Chapter 7). Thus the word speciesism was coined, and to its adherents underlies all our uses of animals that cause them harm. However, we should note that Singers position embodies an element of utilitarianism and does not in fact prohibit the use of animals by humans. In his book The Case for Animal Rights (1985), the American philosopher Tom Regan oers a detailed analysis and critique of Peter Singers philosophy, and then proposes an alternate route towards an understanding of humanitys moral obligations to animals. He develops the idea of animal rights, arguing that animals possess morally important characteristics, and those that we use for food, experiments, sport and fashion all have inherent value, equal to our own. Animals have an equal right to be treated with respect, not to be used as mere resources. Regan argues that this right is violated by our current practices and goes on to call for a total abolition of the use of animals in science, agriculture, and sport. Regan rejects the indirect duty view of Kant and Singers utilitarianism because he believes that a good end does not justify evil means. So far in this chapter, I have given an overview of the issues in our relationship with other animals, and the historical development of the range of attitudes held by people today. Many fundamental problems, such as what is it to be human, as well as bioethical questions, such as whether animals have equal rights, have been raised. Clearly there is not sucient space here (but see Chapters 6 and 7) to explore all these avenues, so because of its far-reaching relevance to humankind I shall go on to discuss the issue of the role of animals in the advancement of biomedical science.

18.3 THE USE OF ANIMALS IN BIOMEDICAL SCIENCE

18.3.1 INTRODUCTION

As this brief overview of the development of humananimal relationships over

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the course of history has shown, the acceptance that human life is more intrinsically valuable than that of other animals is deeply rooted. An important part of the history of the developed world has been the transition of human activity from a series of strategies for survival towards a civilisation with human welfare at its centre. In this context, the purpose of biomedical research and testing is to increase our knowledge and understanding of the normal structure and functioning of the body and how this changes as a result of disease or injury, and to develop safe and eective treatments for the various malfunctions. Table 18.3 lists some of the major medical advances that would have been impossible without experiments performed on living animals. Since the beginning of the 20th century, two-thirds of the Nobel Prizes awarded for medicine have been for discoveries and advances in which laboratory animals played a crucial role. So perhaps it is not surprising that those with knowledge of medical history and medical research agree that animal research is central to medical progress.

Table 18.3 Examples of medical milestones reached as a result of animal research 1500s 1600s 1700s 1800s 1906 1907 1912 1914 1922 1929 1937 1937 1940 1941 1948 1950 1956 1967 1973 1979 1992 1995 1998 2000 First use of tourniquets to staunch bleeding from wounds Circulation of blood described First vaccination First use of anaesthetics First use of aseptic technique Corneal transplants Blood transfusion Kidney transplants Kidney dialysis Insulin isolated to treat diabetes Penicillin to treat infections Heart lung machine, open heart surgery, valve replacements, pacemakers Anticoagulants Whooping cough vaccine Diphtheria vaccine Drugs for high blood pressure Drugs to control transplant rejection Polio vaccine Heart transplants Treatments for leukaemia Drugs for asthma Hib meningitis vaccine Understanding of programmed cell death, with implications for treatment of e.g. Alzheimers disease, rheumatoid arthritis, stroke First cloned mammal Dolly the sheep After natural mating and gestation, Dolly gives birth to lamb Polly

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18.3.2 WHAT ANIMALS ARE USED IN RESEARCH? In Chapter 6, David de Pomerai discusses some of the invertebrate animals that have been so valuable in the elucidation of basic biological processes. In the UK the law aords protection only to vertebrates and a very limited number of invertebrates in the context of scientic research. Parliament rst passed an act in 1876 to control the use of animals in medical research. This was strengthened in 1986 when the Animals (Scientic Procedures) Act passed into law. This requires that the Home Oce must license all scientic procedures carried out on any vertebrate (and certain invertebrates such as the octopus). A procedure is dened as any intervention that causes pain or suering, and is somewhat broader than an experiment, including, for example, the use of animals to produce natural products for research or treatment (about 10% of all procedures). A research project, the premises in which the animals are kept, and the principal researcher all have to be licensed for the procedure, and all are regularly inspected by Home Oce Inspectors, who have medical or veterinary as well as scientic qualications. Table 18.4 shows the proportion of vertebrate types involved in regulated procedures in Great Britain in 1999. Scientic research, particularly that involving the use of animals, is very expensive, and the funding available is limited. This means that research must be worthwhile, and before granting funds for a project, the trustees of grant-giving bodies, such as the Biotechnology and Biological Sciences Research Council (BBSRC) in the UK, must satisfy themselves of the potential value of the research. To do this, they undertake a costbenet analysis in which they consider whether the benets (positive consequences) outweigh the costs (negative consequences). This approach was rst outlined by Bateson (1986), and involves ranking the proposed research on three axes: quality of research, certainty of medical benet and animal suering. In this model, a high quality project with high possibility of medical benet, might be permitted even if the animal suering score was high. However, if a project was only of average
Table 18.4 Animals used in scientic procedures Vertebrate group Primates (e.g. marmosets and macaques) Dogs and cats Rodents (vast majority are rats and mice) Small mammals other than rodents, (mostly rabbits and ferrets) Large domestic mammals (vast majority sheep, cows, pigs) All other vertebrates: sh, amphibians, reptiles and birds % total regulated procedures 0.2 0.4 86 1.7 2.4 9.0

Figures from the Research Defence Society (2001). The great apes, chimpanzees, orang-utans and gorillas have not been used for research in this country for over 20 years and their use is now banned. All specially bred laboratory species. Includes many fertilised hens eggs after the half-way stage of incubation.

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quality, with a medium expectation of useful outcome, it might not be permitted even if animal suering was also rated low. The main problem with this algorithmic approach is that of deciding on the score values for each axis how is the balance of animal suering evaluated against the benets? This is the crux of the problem: the issue around which the controversies of animal research centre. 18.3.3 AREAS OF RESEARCH AND TESTING IN WHICH LABORATORY ANIMALS ARE USED In the Western world, by law, any chemical or medicine destined for human use must be rigorously tested before it can be made available to the market (see Figure 18.1). Developing countries, which do not have the resources to undertake this work, rely on a safety guarantee for drugs, toiletries, household cleaning materials, and cosmetics and so on from such countries as the UK, USA, France, and Germany. Animals are used by the scientic community in basic biomedical research aimed at nding out about the mechanism of disease, and also in product safety testing. Using the statistics for 1995, it is possible to break down types of animal procedure as shown in Figure 18.2. When a pharmaceutical company decides to fund the development of a new drug targeted at a specic disease, traditionally the rst, or biochemical stage is to synthesise about a thousand dierent compounds. However, the information arising from the various genome projects is leading to a dierent approach known as rational drug design. This developing science, also called pharmacogenetics, will inevitably raise its own bioethical issues. In whatever way the candidate compounds are produced, they are tested on animals in which the disease condition is reproduced in a series of experiments designed to nd out whether the compound under test has any benecial eect on the condition. This brings the number of test compounds down to about a hundred. The next set of animal experiments elicits the maximum therapeutic dose for the minimum toxic
7% 21% 49% 1 2 3 4 23%

Figure 18.1. Sectors using scientic procedures involving animals in the UK (data from RDS, 2001) 1. Pharmaceutical industry 2. Fundamental scientic/medical research (non-university) 3. Fundamental scientic/medical research (university) 4. Safety testing centres

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1 2 3 4 5 6

Figure 18.2. Areas of research and testing in which animals are used (data from RDS, 2001) 1. Developing new treatments for diseases, or ways of preventing diseases 2. Fundamental biological and medical research 3. Preparing natural products used in medical research and treatment 4. Safety testing (less than 0.2% on cosmetics and toiletries) 5. Animals with an inherited genetic defect bred for medical research 6. Developing new methods of diagnosis

eect. Before the potential drugs can go on to clinical trials, the company must be sure that through animal testing it has answered the basic questions: does it treat the disease? What is the optimum dose? What are the long-term eects? How does the body break down the compound? Failure to do this can have disastrous consequences as was seen in the early 1960s when about 10 000 children were born in the UK with phocomelia (deformed, ipper-like limbs) as a result of their mothers taking the drug thalidomide to ease the morning sickness of early pregnancy. In the UK rigorous testing of all medicines is now required under the Medicines Act of 1968. It has been estimated that it takes an average of 710 years to develop a new drug from the time of rst identifying a novel compound through to its successful use in patients at a nancial cost of up to US$250 million. 18.3.4 ARE THERE ALTERNATIVES TO RESEARCH INVOLVING ANIMALS? Those opposed to the use of animals in this way sometimes claim that there are alternatives, frequently citing in vitro techniques, computer modelling and epidemiological methods. The scientic community remains unconvinced, for two major reasons. Firstly, the complexity of the body, in both health and disease, cannot be reproduced by any of these means; to see the eect in the living body, animals are used because to use people would be unethical (but see Chapter 7). The second main argument for using animals in scientic research is that these other techniques are extensively used as well, and are complementary with animal work, contributing vital evidence to the overall conclusions. The phrase in vitro literally means in glass, and it has come to be used for many test-tube, or laboratory bench procedures. These techniques involve the study of isolated molecules, cells and tissues, obtained from human, animal,

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micro-organism or plant sources. Such research gives base line information about the interactions between molecules, within or between cells, or about organ function. Evidence from Home Oce and Medical Research Council reports as well as from published biomedical literature all suggests that in vitro methods are extensively used (Paton, 1993). Over the last 20 years the annual number of animal experiments has almost halved, mainly because of the resources needed for the higher standards of animal welfare, scientic advances and stricter controls. It is interesting to speculate on the extent to which the decline in the actual number of procedures carried out on live animals may be related to the decreasing rate of drug innovation. In evaluating these numbers it should be noted that the total number of animals used in scientic procedures is very much less than that involved in human food supply: recall, for example, that in the UK 800 million chickens are raised (mostly under conditions much less humane than are required for animals used in research or testing), slaughtered and eaten every year, let alone the millions of pigs, sheep and cattle. As is evident from Figure 18.3, about 2.3 million animal procedures are carried out each year, of which 86% involve rodents and a further 9% involve non-mammalian vertebrates (as in Table 18.4). Even given that each procedure may require several animals (in order to provide replicates and controls in properly conducted experiments) these numbers are but a very small fraction of those relating to use of animals as food. Computer modelling is also a widely used approach. It is possible to build up an extensive bank of information from previous studies, and then interrogate this database, for example to discover the fate of drugs in the body such as the accumulation in dierent tissues and the rate of breakdown and excretion. Analysis of experimental data is made easier by computers, and is often used in this way to predict whether an experiment involving animals is necessary.
6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0 Animal experiments Procedures

1960

1965

1970

1975

1980

1985

1990

1995

Figure 18.3. Numbers of animal experiments and procedures over the past 40 years (RDS, 2001)

1999

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Computers can also increase the eciency of some research techniques, for example by high-speed computation, and for control of complex experiments. Software can mimic physiological processes such as respiration, and can be used to test theories about the action of new drugs. In none of these uses can the computer be said to be replacing a whole animal in an experiment, and in many of the uses described above computer methods serve merely as a prelude to an investigation using animals. Epidemiological studies give information about the body in health and disease, and about the distribution of diseases in society in time and space (Smyth, 1978). It enabled for example the link between smoking and lung cancer to be made (Royal College of Physicians, 1962), and over the last decades has established causal relationships between many other diseases and environmental factors. Epidemiological methods are also able to provide evidence in the search for adverse reactions to new drugs, but only at the stage of clinical trials, i.e. when the animal work is already done. Although epidemiology can show useful information on cause, it is relatively powerless to provide any evidence for the mechanisms of these causeeect relationships, or how this may be important in developing treatments for diseases. The way that smoking causes cancer was, controversially, determined by a series of experiments on tissues and animals to isolate the carcinogenic substances in tobacco. 18.3.5 ARE FINDINGS FROM RESEARCH ON ANIMALS RELEVANT TO HUMANS? An argument often put forward by those opposed to animal experiments is that they produce little eect on human life expectancy or disease rate, because animals are dierent from people (Ryder, 1975). Most biologists now believe that the variety of mammals in the world today, humans included, have evolved over the last 120 or so million years from tree-shrew-like common ancestors. Apart from the obvious dierences of body size, shape, and covering, we are anatomically and physiologically very similar to other mammals. Advances in molecular genetics show that the structure of the human genome is more like that of other animals than was previously thought possible. Whilst the similarities are of obvious use to the researcher wishing to mimic a human condition in say a rat, the dierences can also give useful information about human diseases and how they might be treated. For example, important clues from a mouse with muscular dystrophy suering less muscle wastage than a human patient with the same disease might contribute to a treatment for this devastating disorder. Animal experiments have revealed a similarity in the functioning of certain vitamins and hormones in people. This had led to the successful treatment of several human conditions, such as diabetes (with insulin from the porcine or bovine pancreas), and thyroid disease (with thyrotropin from the bovine pituitary). We should note however that many human therapeutic proteins are now produced in genetically modied micro-organisms. These similarities mean that

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veterinary drugs, for example antibiotics and analgesics, are often identical to those used in human medicine. Disease is a universal mammalian problem, and maladies such as cancer, heart failure, asthma, rabies and malaria are suered by many species. Most human diseases exist in at least one other mammalian species (Cornelius, 1969). 18.3.6 SOME ISSUES OF TOXICITY TESTING Multinational agencies such as the European Commission and the OECD have produced a formidable battery of regulations and guidelines on the toxicity testing that must be carried out not only on new drugs, but also on agrochemicals, industrial chemicals, substances for household use, foodstus, and food additives. Similar codes of practice exist for the testing of pollutants. Toxicity testing on animals gives information on toxic action and its cause, and can be used to make predictions about the risks to other biological systems including those in other species in dierent circumstances. Tests are carried out at all levels of biological organisation, from the organelle to the ecosystem (see Table 18.5). The test substance can be administered by the oral route directly into the stomach, or in the diet/drinking water; by inhalation; ectopically by administration directly to the skin or body surface or parenterally e.g. by injecting intraperitoneally or intravenously. Clearly, to be sure of the safety for human use of any substance the range of possible tests is very extensive. This is where ethical problems become apparent.
Table 18.5 Types of toxicity testing Type of eect Acute toxicity Subacute/chronic toxicity Carcinogenicity Reproductive toxicity Topical toxicity Immunotoxicity Genetic toxicity Neurotoxicity Ecotoxicity Toxicokinetics Test on animals The eects of limited dosage Exposure from a few days most of life span Specic tests of the potential to produce tumours lasting for not less than 2 years in rodents Action on gametogenesis, mating, foetal development, development to sexual maturity Local eects at the site of application, e.g. skin, eye, lungs Eects on immuno-depression, autoimmunity, hypersensitivity Study of damage to DNA, inherited abnormalities, onset of cancer Study of the eects on the nervous system Study of eects on population, health of ecosystem Detailed analysis of uptake, distribution, metabolism, and excretion of the test substance by a cell, tissue, organism, or ecosystem

After Dayan (1993).

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The main reason for using animals in these tests is the same as that for using animals in research: that the body is a complex system, which cannot accurately be reproduced. The other main argument in favour of animals in research, namely that information is directly transferable from animal to human, does not hold so good in this type of testing. This is because the dierences in physiological pace and anatomical structure between individuals and species have a marked eect on the toxicity eect. Consider these results of LD50* tests of dioxin on various animals: Guinea pig 1 g kg\ Hamster 5000 g kg\ Female rat 45 g kg\ Male rat 22 g kg\. This vast dierence in toxicity among such closely related animals clearly shows the problems in extrapolating this sort of data to human beings. However, this test, once notorious amongst animal rights campaigners, is now all but abandoned in the UK. In 1999 the UK Home Oce announced that licences for the LD50 acute oral toxicity test . . . will no longer be granted if a suitable alternative is available. There are however some tests, e.g. for botulinum, where the LD50 cannot be replaced, and licences can still be granted whilst many other countries still continue to use the LD50 routinely. The British Toxicological Society has developed the xed dose procedure, a milder and more humane test, which uses fewer animals and is designed such that none receives a fatal dose of the test substance. Another infamous procedure is the Draize eye irritancy test, often used to test cosmetics and household products. The test substance is placed in one eye of a rabbit and the other is left untreated for comparison. This has attracted high levels of public concern, and has been strongly criticised on the grounds of cruelty, and claims have also been made that it produces unreliable results that might bear little relation to human responses. Animal campaigners have focused public attention on such toxicity and irritancy tests with the result that several major cosmetic and household product companies began a serious search for non-animal methods to full their scientic and corporate objectives. Alternatives to the Draize test, such as the chorio-allantoic membrane (CAM) test that uses 10 day old hens eggs, and EYTEX, which uses a clear gel from jack bean protein to mimic the cornea of the eye, have been developed. Although this has meant that the Draize test is now less widely used, no alternative gives the quality of results obtainable from the Draize, so work continues to nd a good replacement. The Draize test still continues to be used by companies because of the necessity to cover themselves against possible litigation, particularly in view of the increasingly litigious public in the USA and now in the UK. The ethical issue here is that if we accept that we have the right to know
* The LD50 test (dened by OECD Guideline 401) determines the substance dose required to kill 50% of the test animals.

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whether a substance will harm us, then we have little alternative in the present scientic climate to accept the results of toxicity testing. This raises the issue of what should or should not be tested. Where is the line to be drawn across a list that includes, inter alia, medicines (human and veterinary), pollutants, agrochemicals, household products, toiletries, building and household materials, cosmetics, and childrens toys? If testing on non-essential substances those below where we choose to draw our line were banned, then we would have to continue to use those products already available, and could not enjoy the development of improved products, for example less allergenic cosmetics, more ecient kitchen oor cleaners, improved sun blocks, and so on. Alternatively, it could be argued that we do not need these new items, because the cost, i.e. the need to use animals in testing, is too high.

18.4 THE GUIDING PRINCIPLES IN ANIMAL RESEARCH

The vast majority of responsible scientists do not want to use animals unnecessarily or to cause them unnecessary suering. Russell and Burch (1992) drew up the three guiding principles of renement, reduction and replacement in animal research, which are used today. Renement aims to reduce animal suering to a minimum. In order for a UK Home Oce licence to be granted any research involving animals must be designed to minimise distress or suering. For example, anaesthetic or analgesic is normally given if any painful procedure is to be carried out. When levels of substances, such as hormones in the blood, need to be regularly measured, the animal can be tted under anaesthetic with an in-dwelling catheter, so that it does not have to undergo the repeated stress of being caught, held and having blood drawn. Animals such as the oncomouse, specially bred to inherit fatal diseases such as some forms of cancer, can be humanely killed earlier rather than later in an experiment. The xed dose procedure, described above, is another example of renement. This notion extends to the husbandry of the animals in research holdings. The vast majority of laboratory animals spend most of their lives simply living in their cages and not being used in an experiment, and eorts to enhance their environment are often made in an attempt to improve their quality of life. Reduction is the principle in which the number of animals used is minimised. As already discussed, in vitro and computer-based investigations often precede animal work, and the information gained from these sources informs the design of the proposed experiment, so the optimum number of animals for statistical validity is found. Variation of individuals within a species is a basic problem in biological investigation, but this can be overcome by using genetically identical animals, and laboratory bred animals that are free from infections or illnesses that might skew the experimental results. This can considerably reduce the numbers of animals needed for meaningful results.

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Replacement is the principle of replacing animal procedures with non-animal techniques wherever possible. As discussed, the complexity of the whole organism is such that eorts to nd eective non-animal techniques have been disappointing. Notable successes include the LAL test for pyrogens, which can be performed in vitro, and testing the purity of insulin by chromatography. Both these tests were previously carried out on animals. As science progresses, new non-animal techniques will continue to develop, but in some cases the new knowledge of gene manipulation may lead to the production of genetically tailored animals for specic research. This may lead to an increase in the number of some animal procedures, almost exclusively involving rodents, particularly mice. For instance it is now possible to breed mice with cystic brosis, having the same symptoms as children with cystic brosis. Gene therapy, rst applied to the mice, may oer a medical breakthrough for this disease (Boyce, 1999). The principle of the 3Rs, renement, reduction and replacement, is the basis of the ethical consideration given to the use of animals in biomedical research and testing. Research into renement and reduction of procedures continues, but so does the development of new products, which may involve more new tests. It seems unlikely that replacement will ever be total. Scientists have a strong ethical responsibility to predict and warn of the harmful eect of toxins, but must balance this with the need to minimise the scale of their experiments, and any suering to animals. Nevertheless, for those ideologically opposed to the use of animals in this way, any such use is simply too much.

18.5 EDUCATION
Although this chapter focuses mainly on the relationship of humans and animals in scientic research and testing, the role of animals in education is pertinent. One powerful argument in favour of the use of animals in education is that new medical practitioners and scientists cannot be trained without practising on animals. In higher education, a considerable number of practical sessions involving freshly killed whole animals and tissues are routine. Students may opt out of these classes in certain programmes, but this is not possible in some biomedical courses. In school science in the UK, live vertebrates are never used in any practical work. No school can be licensed to undertake a regulated procedure under the 1986 Act, but traditionally biology lessons have often included dissection the cutting up of a dead animal or animal organ. There has been a reduction in the use of animals in school science in many countries, because of a shift in the perspectives of both pupils and teachers. Fewer live animals are kept in schools and colleges, because of ever more prescriptive health and safety regulations, and ever tightening curricular constraints (Lock and Millet, 1992). In the UK, examination boards at school level do not now require dissection. Some teachers rue this move away from direct contact with biological materials, arguing that it sanitises the study of biology. Traditionally, the argu-

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ments in favour of using dissection as a teaching and learning strategy are that it uniquely provides knowledge and understanding of internal structures and of the quality of tissues and an appreciation of the whole organism. Because of its hands-on approach, the learning is through active involvement in investigation. Some teachers argue that dissection provides an opportunity to overcome revulsion, and by so doing engenders a greater understanding and respect for life. Those opposed to dissection claim that it involves the taking of life, because animals supplied to educational institutions are specially reared and killed for the purpose, and this is morally wrong. They claim that the students can become desensitised, because animal life is devalued and treated as expendable, so less respect for life is created as a result of dissection classes. They believe that dissection might oend the sensitivities and conscience of some students, thus alienating them from the study of life sciences, as a result of which some able students may choose careers in other elds. Arguing that dissection rarely involves more than observation and memorisation, they suggest that students are not challenged with higher-order intellectual activity, such as forming hypotheses or analysing and interpreting data.

18.6 CONCLUSIONS
This chapter has explored some of the ethical dilemmas that arise in the quest for scientic understanding through research upon mammals. In recent years the ethical debate has gathered momentum, sometimes becoming acrimonious and even giving rise to acts of terrorism as evidenced by recent (early 2001) events at a UK testing laboratory. It is virtually impossible to set out a completely neutral position, but as well as supplying some basic information about animal-based science, I have attempted to put forward the main ethical arguments. However, in the end, the moral position one chooses to adopt is a personal decision. It behoves everyone who is willing to accept the safety of virtually every consumable product to engage with these dicult matters. The debate is certain to become increasingly important as we learn more about the lives of all animals.

REFERENCES
Bateson, P. (1986) When to experiment on animals. New Scientist, 20 February, 3032. Boyce, N. (1999) The gene healer. New Scientist, 163, 4345. Cornelius, C.E. (1969) Animal models a neglected medical resource. New England Journal of Medicine, 281, 934945. Dayan, A.D. (1993) Safety testing: problems of perceptions, denitions and understanding. In Ethical Issues in Biomedical Sciences: Animals in Research and Education. Anderson, D., Reiss, M. and Campbell, P. (eds), Institute of Biology, London, UK. Dolins, F.L. (1999) Attitudes to Animals: Views in Animal Welfare. Cambridge University Press, Cambridge, UK.

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Lock, R. and Millett, K. (1992) Using animals in education and research; student experience knowledge and implications for teaching the National Science Curriculum. School Science Review, 74, 115123 Paton, P. (1993) Man and Mouse: Animals in Medical Research. Oxford University Press, Oxford, UK. Regan, T. (1985) The Case for Animal Rights. University of California Press, Berkeley, CA, USA. Research Defence Society (2001) http://www.rds-online.org.uk/home.html Royal College of Physicians (1962) Smoking and Health: a Report of the Royal College of Physicians of London on Smoking in Relation to Cancer of the Lung and Other Diseases. Pitman, London, UK. Russell, W.M.S. and Burch, R.L. (1992) The Principles of Humane Experimental Technique. Universities Federation for Animal Welfare, Wheathampstead, Hertford, UK. Ryder, R.D. (1975) Victims of Science. Davis-Poynter, London, UK. Singer, P. (1975). Animal Liberation: a New Ethics for Our Treatment of Animals. Avon, New York (see especially pp. 2791). Singer, P. (1991) Animal Liberation. AvonHearst, New York, USA. Smyth, D.H. (1978) Alternatives to Animal Experiments. Scholar, London, UK, in association with the Research Defence Society, London, UK.

FURTHER READING
In addition to the above references the following are recommended for further reading. Anderson, D., Reiss, M. and Campbell, P. (eds) (1993) Ethical Issues in Biomedical Sciences: Animals in Research and Education. Institute of Biology, London, UK. Carruthers, P. (1992) The Animals Issue: Moral Theory in Practice. Cambridge University Press, Cambridge, UK.

Bioethics for Scientists Edited by John Bryant, Linda Baggott la Velle and John Searle Copyright 2002 John Wiley & Sons Ltd ISBNs: 0-471-49532-8 (Hardback); 0-470-84659-3 (Electronic)

Glossary

Allele: one of any pair of alternative hereditary characters; many genes can exist in two (or sometimes more) forms at a locus (i.e. position on a chromosome), each of which is an allele. See also polymorphism. Allergen: a substance that induces allergy. Amniocentesis: procedure in which a sample of amniotic uid is withdrawn from a pregnant womans womb. Cells in the uid are then tested for chromosomal or genetic abnormalities. Amniocytes: cells in the amniotic uid. Androgynous: having sex organs of both female and male. Andrology: the study of male reproduction. Annelids: invertebrate phylum of segmented worms. Antihelminthic (drugs): drugs toxic to parasitic at worms. Apomixis: the formation, without fertilisation, of seeds that contain viable embryos. Arthropods: phylum of jointed legged invertebrates. Asthenospermia: abnormally formed spermatozoa. Autosome: typical, i.e. non-sex, chromosome. Azoospermia: total lack of spermatozoa in the seminal uid. Back-cross: to mate a hybrid to one of the parental stocks; a hybrid resulting from such a mating. Biodiversity: the range of living organisms in a particular habitat, community or biosphere. Bioethics: the ethics related to biology and medicine and to medical and biological research, or the informing of ethics by biological knowledge. Bioinformatics: study of biological systems using the tools of information technology. Blastocyst: a mammalian embryo at around the time of implantation when it forms a hollow ball of cells. Blastomere: undierentiated cell of an embryo during the early cleavage stage. Bovine spongiform encephalopathy (BSE, mad cow disease): a degenerative disease of the central nervous system of cattle, which is thought to be transmissible to humans; related to CreutzfeldtJakob Disease. Carbon dioxide sink: an organism, community or ecosystem that takes up carbon dioxide from the atmosphere. Carcinogen: substance that induces the formation of malignant tumours. Cardiomyocytes: heart muscle cells.

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cDNA: complementary DNA, a DNA copy (made in the laboratory) of the natural sequence of messenger RNA. Centric fusion: fusion of the centromeres of chromosomes. Centromeres: the constricted regions of chromosomes at which pairs of new (daughter) chromosomes are held together in the early stages of cell division. Chorionic gonadotrophin: hormone of pregnancy. Chorionic villus: fold of the chorion, a membrane external to and enclosing the amnion. Chromosome: one of a number of structures in the nucleus of a cell containing genetic material, the number of which is characteristic for the species. Each chromosome is, in eect, a subset of the total number of genes possessed by the organism. Clone: organisms identical in genetic make-up, produced asexually from one stock or ancestor. May also be used as the verb, to clone. Both noun and verb are also used in the context of DNA, as in molecular cloning, the multiplication of particular DNA sequences by growing them in genetically modied bacterial cells. Coelenterates: phylum of hollow bodied invertebrates having body walls of two cell layers, for example jelly sh. Consequentialist: line of argument that follows directly as a result of foregoing events or factors. Ethical system based on evaluation of the consequences of an action. CreutzfeldtJakob Disease: a degenerative, incurable disease of the human central nervous system, related to BSE (see above). Cryopreservation: preservation of cells or tissues at very low temperatures, e.g. in liquid nitrogen. Cultivar: a plant variety used in agriculture or horticulture. Deontology: the study of duty and/or obligation as an ethical concept. DNA vectors: carriers of DNA sequences into the genomes of other organisms, e.g. bacterial plasmids. Ecosystem: a biological community of interacting organisms and their physical environment. Embryo: the stage of life between the rst cell division after fertilisation until the completion of organogenesis. In the human this is during the rst eight weeks of pregnancy. Embryologist: scientist who studies early development; scientist who manipulates human gametes and embryos under license in fertility treatment. Enabling technology/technologies: the basic scientic techniques that can be applied for use e.g. in medicine or agriculture. Endometriosis: a condition in which tissue identical to the endometrium is found outside the uterus, e.g. in the ovaries or Fallopian tubes. Endometrium: the lining tissue of the uterus. Epididymis: part of the male mammalian reproductive tract between the testis

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and sperm tube in which the spermatozoa mature and acquire the ability to fertilise an egg. Epistemology: the theory of knowledge, especially with regard to its methods and validation. Ethics: study of sets of moral principles; systematisation of the principles involved in moral decision making. Eugenics: the process of improving the human population by genetic selection for desirable inherited characteristics. Excurrent duct: tubes of the reproductive tract in which there is an out-going ow. Exogenous genes: literally, genes from outside; in general this refers to genes that are transferred from one species to another. F1: the rst lial generation; hybrids arising from a rst cross. Successive generations are denoted F2, F3 etc. P1 denotes the parents of the F1 generation, P2 the grandparents etc. Fetus/foetus: the stage of development between organogenesis and birth. Gamete: a reproductive cell (spermatozoon or ovum) containing half the number of chromosomes of a somatic cell and able to unite with one from the opposite sex to form a new individual. Ganglion: a mass of nerve cell bodies giving origin to nerve bres. Gene: an individual hereditary unit in a chromosome consisting of a characteristic sequence of DNA. Gene ow: the spreading of genes resulting from out-crossing and from subsequent crossing within a population. Gene silencing: the switching o of genes (not usually used in the context of the normal ono control mechanisms). Genome: the total genetic content of an organism. Genomics: the study of the genomes of organisms, particularly in relation to information content and sequence organisation. Germ cell: a cell belonging to the specialised cell lineage that gives rise to gametes (sperm and eggs) in a multicellular animal or plant. Germinal vesicle: structure within an ovum, containing the genetic material, before the extrusion of the polar bodies (see below). Graaan follicle: ovarian structure in which an ovum is brought to maturity. Heterozygous: having dissimilar, alternative forms of a gene for a given characteristic. Homozygous: having identical genes for a given characteristic. Huntingtons disease: hereditary, incurable and degenerative disease of the human central nervous system. Hybridisation: process of interbreeding organisms to produce heterozygotes. Implantation: process by which an embryo becomes embedded in the lining of the womb. Inbreeding: breeding through a succession of parents belonging to the same stock/lineage, or within very closely related lineages.

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Intra-cytoplasmic: within the cytoplasm of a cell; inside the cell surface membrane. Introgression: the introduction, by plant breeding, into elite crop lines/varieties of genes/traits from related varieties (or even from closely related wild species). Has also been used recently to describe (the possibility of ) transfer of transgenes (see below) from GM crops into wild populations. Intron: region of a gene containing a sequence of DNA which does not code for a protein but is transcribed as part of a pre-mRNA molecule and then excised by RNA splicing to produce mRNA; introns are so called because they intervene between exons, or sequences of DNA that do code for proteins. Karyotype: group of individuals with the same chromosome number and similar linear arrangement of genes in homologous chromosomes; the chromosome complement of such a group. Laparoscopy: examination of the interior organs by a bre optic instrument (laparoscope) inserted into the abdominal cavity. Mendelian: the normal pattern of inheritance of single genes, as originally described by Gregor Mendel. Monogenic diseases: diseases resulting from the action of a single (defective) gene, e.g. sickle-cell anaemia. Morals: the study of goodness or badness of human character or behaviour, or of the distinction between right and wrong; the outworkings in action of systems of ethics. Mutagen: a substance capable of inducing a heritable change in the nucleotide sequence of DNA. Mutant: an organism that has undergone a permanent, heritable change in structure and/or function based on a change mutation in DNA. Nematodes: invertebrate phylum of round worms. Neoplasm: a mass of cells, the growth of which is abnormal, excessive, persistent and un-coordinated. Benign neoplasms grow only at the site of origin; malignant neoplasms spread to other sites in the body. Neurone: a nerve cell. Oligospermia: low sperm count. Oncogene: gene that makes a cell cancerous; typically a mutant form of a normal gene (proto-oncogene) involved in the control of cell growth or division. Oncomouse: a genetically modied strain of mouse programmed to form malignant tumours. Oocyte: female gamete; egg, ovum. Organelle: an organised structure with a specic function or functions within a cell, e.g., a mitochondrion. Out-crossing: breeding with new stock. Penetrance: the frequency, measured as a percentage, with which a gene shows any eect. Phylogenetic: concerned with the history of development of a species or race. Plasmid: small circular DNA molecule that replicates independently of the

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genome. Used extensively as a vector for transfer and cloning of DNA. Pluripotent: capable of forming many dierent types of cell (see also totipotent). Polymorphism: occurrence within a population of an organism of dierent varieties based on dierent alleles of a given gene. Promoter: the tract of DNA adjacent to a gene that contains the genes ono switch. Pronucleus: egg or sperm nucleus in the zygote prior to nuclear fusion. Pyrogen: substance capable of producing heat in the body. Recombinant DNA: novel combination of DNA sequences made by recombining dierent DNA sequences in the laboratory, e.g. insertion of a mammalian gene into a bacterial plasmid. Restriction endonuclease: enzyme that recognises a specic short sequence of nucleotides in DNA and cleaves the DNA wherever this sequence occurs; extensively used in recombinant DNA technology. Restriction fragment length polymorphism: a change in the nucleotide sequence of DNA such that a recognition site for a particular restriction endonuclease (see above) is either lost or gained. This will cause the generation of dierent fragment lengths around that site when the DNA is cleaved with the endonuclease. Semen: seminal uid containing spermatozoa. Somatic: concerned with the body cells (as opposed to the germinal cells). Spermatogenesis: sperm formation in the testes, from spermatogonia, through primary and secondary spermatocytes and spermatids to spermatozoa. Surrogacy: process by which a woman bears a child on behalf of another woman, from an egg fertilised by the other womans partner. Syngamy: fusion of gametes during sexual reproduction; point at which the male and female genetic contributions fuse to become the zygotic genome. Teratogenic: term applied to a substance that induces gross abnormalities during development. Totipotent: genetically capable of forming a whole organism. Transgenes: genes that have been transferred via a vector from one organism to another. Utilitarianism: the doctrine that actions are right if they are useful or for the benet of the majority; guiding principle of the greatest happiness for the greatest number. Vasectomy: surgical procedure in which the vas deferens is severed and tied to stop sperm cells entering the seminal uid. Carried out for contraceptive purposes. X chromosome: one of the two sex chromosomes, singly represented in the heterogametic sex (male in humans) and paired in the homogametic sex (female in humans). Xenotransplantation: transplantation of cells, tissues or organs from one species into another. Y chromosome: one of the two sex chromosomes, in mammals exclusive to

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males. Zona pellucida: protein coat surrounding an oocyte and early embryo, shed immediately prior to implantation. Zygote: cell formed by the union of spermatozoon and oocyte; a fertilised egg.