The Future of Medical Science:
Ethical and Theological Implications, Part I
Jay L. Hollman, M.D.
Ochsner Clinic of Baton Rouge
16777 Medical Center Drive
Baton Rouge, LA 70816
From Perspectives on Science and Christian Faith 46 (December
© 1994 Americian Scientific Affiliation
Ethical issues in medical science in the 1990s will be numerous, occur in all disciplines of medicine, and affect all physicians. To discuss future medical ethical issues in a relatively short space, it is tempting to choose one of two extremes. One extreme is to simply catalog all ethical problems arising from new discoveries or emerging technologies, while the other extreme would be to choose one ethical issue as most important and attempt to cover it in depth. In this two-part paper, I have chosen a middle ground, providing some background on five issues in medium depth: (1) euthanasia, (2) fetal tissue transplant, (3) psychiatry and neuroscience (specifically the issues raised by homosexuality), (4) health care costs and the ethics of cost containment, and finally (5) preventive medicine, particularly as it relates to sexually transmitted diseases including AIDS. I hope to supply some background information on these selected issues and to stimulate further reading and research.
For us to meaningfully discuss euthanasia, the term must be better defined. I would choose to divide the term into four categories: (1) active involuntary, (2) active voluntary, (3) inactive voluntary, and (4) inactive involuntary. Before entering into an argument about euthanasia, it is important to define which type of euthanasia is under discussion.
Active Involuntary Euthanasia
Active involuntary euthanasia is nearly universally opposed by all philosophical viewpoints, except in cases of capital punishment. Precautions should be taken so that those who have committed crimes deserving the death penalty are killed in a humane manner with minimal suffering. The Nazi practice of killing first the infirmed and handicapped, and then the Jews, represents one of the greatest human atrocities on record. Those who hold to the sacredness of human life consider it murder to take a human life against that person's wishes simply because a family member or attending physician deems the potential victim does not possess a life that is worth living.
Active Voluntary Euthanasia
Much of the current controversy today has centered on active voluntary euthanasia and active involuntary euthanasia. Active voluntary euthanasia is also appropriately called assisted suicide. Retired Michigan pathologist, Dr. Jack Kevorkian, has attracted national media attention by helping a 54- year-old early Alzheimer patient to commit suicide.
In November 1991, Washington state narrowly defeated Initiative 119 - a referendum that would have legalized medically induced deaths for the terminally ill. Several evangelical and Roman Catholic leaders actively campaigned against this measure. This does not mean, however, that there is a Christian consensus regarding active voluntary euthanasia. A national poll released by the Boston Globe reported that 71% of Catholics and 49% of born-again Christians said they would vote for Initiative 119 (Duggins, 1992). The Netherlands is the only country where active, voluntary euthanasia is legal. Holland's guidelines are:
The patient must repeatedly and explicitly express the desire to die.
The patient's decisions must be well informed, free and enduring.
The patient must be suffering from severe physical or mental pain with no prospect for relief.
All other options for care must have been exhausted or refused by the patient.
Euthanasia must be carried out by a qualified physician.
The physician must consult at least one other physician.
The physician must inform the local coroner that euthanasia has occurred. (Horgan, 1991)
Assisted suicide raises many issues, one of which is: Is it ever right for a person to take his or her own life? Voluntary implies that the patient is in his right mind. For years the medical profession has assumed that a suicidal patient is incompetent and has always tried to save these patients from self- inflicted bodily harm. What does one do if the patient changes his mind half way through the suicide procedure? Can our current legal system protect the assisting physician from suits filed by relatives who might have wished their relative to live? What would the availability of a law similar to the Dutch law do to family relationships? Will families pressure elderly parents to accept assisted suicide rather than continue to be a drain on family resources? Once such laws are in place, the government might offer subtle financial incentives to those choosing a less expensive way to die.
Would not this also transform the doctor-patient relationship? The dual healer/killer role would be difficult to balance when a doctor tried to act compassionately in the best interest of the patient. Patients rely heavily on their physician's advice when making decisions regarding therapy. Older, paranoid patients might fail to seek an appropriate medical remedy from an unfamiliar physician because of the fear that this physician might advocate assisted suicide for their condition.
A commonly cited study of euthanasia performed in the Netherlands in 1990 demonstrated that 1.8% of all Dutch deaths in the second half of 1990 were due to euthanasia (Van der Maas, et al. 1991). In 0.3% of deaths, the physician assisted the patient in suicide by prescribing drugs. In 0.8% of deaths, the physician performed life-terminating acts without explicit and persistent request. Thus, 2.9% of all Dutch deaths were premature due to a decision by the physician. Patients gave several reasons for requesting physician-assisted death. In only 10% of the cases was pain the sole reason noted. The most frequent reason given was loss of dignity (57%).
In a larger theological and philosophical sense, many patients find the months or years after the diagnosis of a terminal illness to be some of their richest and best. Suffering is not all pointless. Facing terminal illness often allows a person to make peace with God and resolve bitter disputes with family members. It is alarming that in the Dutch experience so many requested suicide because of the loss of dignity. A Christian society should make even the dying feel dignified and wanted. Theologically, the sovereignty of God is to be respected. Active, voluntary euthanasia tries to usurp God's sovereignty. From a pragmatic perspective, the negative societal consequences of legalization outweigh any individual benefit. The Christian Medical and Dental Society and the American Medical Association have adopted resolutions opposing physician assisted suicide. I believe that those who think through this issue will oppose active voluntary euthanasia.
Inactive Voluntary Euthanasia
In inactive voluntary euthanasia, the physician allows the patient to live out the natural history of a terminal disease. This is the purpose of living wills and advance directives. When a patient with heart failure refuses a cardiac transplant, or an elderly patient refuses aortic valve replacement for aortic stenosis, or a patient refuses to be intubated and defibrillated when he or she experiences cardiac arrest, they are not committing suicide or devaluing their lives, but rather are living out the natural history of their disease. The role of the physician is first to know the particulars of the patient well and second to understand thoroughly the natural history of the patient's disease. Once this information is available, the physician should discuss frankly with the patient and family the treatments available and how therapy might impact on the natural history of the patient's illness. Once the patient is fully informed, a course of action should be outlined allowing the patient's wishes to be implemented. Allowing the patient to choose a less aggressive treatment program does not mean that the individual has committed passive suicide or denied the sacredness of human life. We need to allow people freedom to limit medical interventions. If we will be honest in discussing our mortality, we can defuse much of the pressure for active, voluntary euthanasia.
Despite advances in medical technology and the humanist's optimism that individual immortality is on the horizon, careful study of the aging process by geriatric physicians reveals that aging is a complex multisystem failure. Cardiac reserve is decreased by a stiffness of the ventricle that slows the filling of the heart; pulmonary gas exchange and minute ventilation decrease; the skeletal system loses calcium and strength, predisposing it to fractures; and the immune system declines in its ability to resist infection and destroy cancer. Perhaps of greatest concern is the decline in brain function: the ability to learn, and the ability to perform complex functions. A study of a representative sample of 85-year-olds in Gothenburg, Sweden demonstrated that nearly one-third were demented (Skoog, 1993). If we live long enough, each of us will experience a decline in cognitive function.
This response is evident in our reflexes and variability in heart rate response to various stimuli. This variability is directly related to the number of brain cell connections in the brain. The size of brain cells and the number of synaptic connections decline with age (Lipsitz, 1992). This loss of brain connection eventually affects cognition, but before this becomes evident, there is a decline in response to new stimuli, slowing of reflexes, and an inability to form new creative associations. While mental decline can be slowed by active use of the mind, the brain, and the mind with it, are programmed for senescence.
Understanding aging is relevant to euthanasia in that it is important to understand the declining cost-benefit of performing expensive procedures in the elderly. For example, bypass surgery in a patient over seventy is performed with an increased risk of death, an increased risk of complications during hospitalization, and an expected longer recovery period following hospital discharge. If an elderly patient refuses extraordinary measures or declines extensive surgical procedures, this is not equivalent to denying a teenager potentially curative treatment of lymphoma because his parents are Christian Scientists. A mature understanding of the complex process of aging will help save us from simplistic answers to end-of-life decisions. Furthermore, rational understanding of the complex, multifaceted process of aging helps to keep humanistic hopefulness in check.
In science and medicine, we frequently encounter those who believe that a solution to man's mortality is just a few experiments or vitamins away. In actual fact, elimination of cancer and coronary artery disease would only prolong life by a few years. Other diseases of senescence such as dementia, accident, stroke, and pneumonia would quickly kill those spared cancer and atherosclerotic coronary artery disease. Doing what is reasonable to prevent premature aging is laudable, but to accept aging as inevitable is to view man in a proper perspective before God.
A special case of inactive voluntary euthanasia relates to people with "locked in state." In this condition, the brain and brainstem are intact but because of degenerative neuromuscular disease, severe cerebral palsy, or a severe high spinal cord injury, the patient's movement is confined to facial movements with or without minimal arm movement. The recent court case of Bouvia v. Riverside General Hospital concerns a woman with cerebral palsy and quadriplegia who desired to have her feeding tube removed so that she could be allowed to die (Pellegrino, 1989). Although she has won her case in court, she has not chosen to exercise this right.
This small group of patients deserves real compassion and understanding. Many of their desires for death are related to individual depression and discouragement just as they are in the general population. Creating meaningful life for these people through the support of family, church, and the development of biomechanical equipment should give most of these patients the desire to live. Fortunately, this class of patients is relatively small.
Inactive Involuntary Euthanasia
When the patient is comatose or brain impaired and unable to make decisions regarding his therapy, the physician and family must make decisions for the patient. If they elect to withhold treatment and allow the patient's disease to follow its natural course then they are participating in inactive involuntary euthanasia. To understand this area better, several definitions are necessary.
Brain death. There is no evidence for cortical or brainstem function. Life cannot be sustained without a ventilator and major life support systems. Brain death is determined by a bedside examination by a competent neurologist or other physician.
Persistent vegetative state. The patient exhibits these symptoms (1) eyes are open, but the patient is unconscious, (2) spontaneous eye movements but no sustained tracking, (3) inability to follow commands, (4) no "cognitive" response, (5) no "voluntary" language, (6) intact brainstem reflexes and sleep-wake cycles, (7) spontaneous breathing but impaired chewing and swallowing, and (8) bowel and bladder incontinence (Child Neurology Society Ethics Comm., 1991).
Persistent vegetative state can be simply summarized as brainstem function without cortical function. The cortex or cerebrum is responsible for association, processing of visual and auditory stimuli and volitional movement. The brainstem controls autonomic functions such as breathing and reflex blinking of the eyes. A person can live with brainstem function alone for years, provided this person is supplied with food (usually through a feeding tube) and basic supportive nursing care to prevent bedsores and infections. As best we can scientifically determine, these people do not have conscious thought.
The subject of euthanasia for each of these two groups of patients is quite different. First, brain death is legal death. It is from these patients that organs are often harvested for transplant. There is no ethical dilemma in discontinuing treatment in this subset of patients.
Persistent vegetative state creates the most difficulty for physicians. This has been the subject of numerous court cases, highlighted by the Quinlan case, which was the first case to reach the Supreme Court. In this case, a 21-year-old was resuscitated after the accidental ingestion of sedatives and alcohol. She remained in a persistent vegetative state until her death ten years later from infection.
Unlike "locked in" state, persistent vegetative state is relatively common, being seen in perhaps 1% of the nursing home patients in this country or 40,000 patients (Spudis, 1991). It is this group of patients that cause the greatest ethical dilemma in the euthanasia controversy. The Christian Medical Society published two articles with contrary opinions on dealing with persistent vegetative state (Schiedermayer, 1992; Pankratz, 1992).
From a scientific perspective, persistent vegetative state results from brain injury, usually due to head trauma or temporary loss of oxygen supply to the brain, also called anoxic brain injury. Although late recovery from anoxia is possible, there is a diminishing probability of recovery with time. If no recovery is observed by four months, essentially no patient will recover. Following head trauma, late recovery beyond one year is extremely unlikely even in a young person. Clinical testing is of limited value prognostically, but positron emission tomography might yield valuable prognostic data with time (Spudis, 1991). A recent review of persistent vegetative state has summarized the science, highlighting the importance which mechanism of injury, age, and duration of persistent vegetative state have in determining prognosis (Multi-Society Task Force on PVS, 1994).
The ethical dilemma in these patients begins once the probability of recovery is minimal. When recovery is 1/1000 or less, is it ethical to discontinue treatment? Often at this stage the patient is not on a ventilator but dependent on tube feedings to maintain life. Court cases such as the Quinlan, Brophy and Johas cases have centered on discontinuing nutritional support. Given nutritional support and proper nursing care, these patients may live for years in nursing homes.
Religious opinions regarding discontinuing medical treatment vary greatly even in our culture. Orthodox Jewish opinion is most firmly against any discontinuation of supportive treatment. Catholics generally would "see withholding nutrition or hydration as passive euthanasia and morally offensive if the intention was to directly kill the patient by this means." However, if the intention was to remove the patient from an unusual, gravely burdensome, extraordinary or futile medical intervention, with the foreseen but unintended consequence that death would come more quickly, this would be understood as a legitimate allowing-to-die, and would not be considered euthanasia (Bone, 1990). The problem with this Catholic view is that this can be two different ways of describing the same act.
The mainline Protestant view emphasizes patient autonomy. The pivotal question is, "What would the patient desire to be done if he could participate in the decision?" This follows from the golden rule of treating another as you yourself would like to be treated. In actual practice, it usually allows for the withdrawal of medical intervention since almost all who give advance directives do not wish to continue in persistent vegetative state when the probability of recovery is less than 1%. This approach is pragmatic, but does not deal with the absolute rightness or wrongness of discontinuing nutritional support in a patient with persistent vegetative state.
The second major class of passive involuntary euthanasia relates to infants. The case of "Baby Doe," involving an infant with Down's syndrome and esophageal atresia, is an example of this class. The parents refused to permit corrective surgery, which in this case would connect the esophagus with the stomach, preferring instead to allow the handicapped infant to starve to death. There are now laws to protect such handicapped infants. But is it always wise to do everything possible for every handicapped infant?
I personally am afraid of any stronger laws in this area. The medical circumstances are complex and are not easily covered by law. Hypoplastic left heart disease is a congenital anomaly in which the main pumping chamber of the heart is severely undersized. However, the scientific value of corrective operations on children with this anomaly are regarded as experimental and controversial. They are, without question, expensive. Without an operation or cardiac transplant, infants with this abnormality will die within a few weeks of birth. I believe that it would be wrong to compel parents by law or litigation to have a child with hypoplastic left heart undergo a corrective operation.
To resolve passive, involuntary euthanasia is beyond the scope of this paper. It is better for us to work on the science and the ethics in this area than to have the cases decided in the court. Advanced directives, by which we discuss and give our desires to our relatives and our physicians, are of value. The more concrete we can be in these matters, the more helpful they are. The issue raised by patients in a persistent vegetative state with virtually no hope for recovery should be addressed.
Euthanasia is a very broad term with many different meanings. We can be both for it and against it depending upon which definition is used. Active, involuntary euthanasia as practiced in Auschwitz is clearly murder and is condemned. Active voluntary euthanasia (assisted suicide) creates a great potential for abuse. Christians who think through this issue will very strongly oppose it. There is nothing wrong, however, with living out the natural history of a disease once the patient is informed of the alternatives. There is still no clear consensus on withdrawal of supportive care in persistent vegetative state; sharpening the science may help us define this issue better.
Fetal Tissue Transplant
Use of fetal tissue involves several issues: (1) Is there a high scientific probability that fetal tissue transplant will help patients? (2) If it is proven that fetal tissue is of value, and abortion on demand is considered an unacceptable source, are there sufficient alternative sources of fetal tissue (i.e. tissue from ectopic pregnancies and spontaneous abortions)? (3) Does it make sense to use tissue from abortion on demand? (4) Are there alternative methods that could accomplish the same objective?
The scientific answer to the first question raised by fetal tissue transplant is still open. Fetal tissue has been used for pancreatic transplant to insulin dependent diabetics, and fetal brain tissue has been transplanted to the substantia nigra of patients suffering from Parkinson's disease. Fetal bone marrow cells have been transplanted to patients with aplastic anemia. Potential applications are nearly limitless: fetal brain tissue injected into the affected area shortly after a stroke might improve neurologic recovery; injecting fetal cardiac cells into a recent myocardial infarction might allow for the regrowth of functional myocardial cells instead of the formation of scar tissue.
The transplantation of fetal brain tissue has been investigated for over 20 years in rats and non-human primates (Quinn, 1990). Transplantation in humans is still too early to judge scientifically (Sladek, 1988). Adrenal allografts were tried prior to fetal transplant. In this technique, the patient's own adrenal tissue was taken from his or her adrenal gland and placed in the brain. This technique has now by and large been abandoned because of questionable efficacy and autopsy findings uniformly demonstrating non-survival of the adrenal tissue. It is, however, theoretically feasible that fetal tissue will work where adrenal tissue failed, because of the ability of the fetal brain tissue to divide and send out dendrites, and because of the low antigenic expression on the cell membrane.
The results to date with using fetal brain tissue transplant to treat Parkinson's disease are mixed. A few dramatic improvements have been reported, but uniform improvement has not been demonstrated. The dramatic cases have occurred in younger patients with Parkinson's disease and in patients with MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine) induced Parkinsonism. These patients have acquired Parkinsonism from the use of MPTP as a recreational drug. Recent publications suggest that patients who receive the most fetal tissue appear to benefit the most (Spencer, 1992; Freed, 1992; Widner, 1992). The most successful transplants have been in young patients with MPTP induced Parkinsonism who have received neuronal tissue from four fetuses.
There are other mechanisms to explain the improvement. Postsurgical breakdown of the blood brain barrier may allow more effective transport of anti-Parkinsonian drugs or regeneration of host brain tissue, as has been demonstrated in animals (Sladek, 1988). The longer term effects of fetal brain transplant have not been studied in humans. There is concern about the effects of fetal tissue if it does continue to grow. Fetal tissue is programmed to grow for two decades, which might result in a graft fetal brain tumor, which could cause obstruction of the ventricles of the brain and cause hydrocephalus, an obstruction to the drainage of cerebral spinal fluid. Hydrocephelus, if unrecognized, can lead to dementia. The immunology of maturing fetal cells is largely unstudied: rejection of fetal tissue might be associated with significant host brain injury (Sladek, 1988). In summary, apart from the ethical issues surrounding the use of fetal tissues, there are unresolved scientific issues regarding the value of fetal tissue transplant.
Source of Fetal Tissue
What about the source of fetal tissue? Can spontaneous abortions and/or ectopic pregnancies supply the fetal tissue necessary for scientific investigation? Spontaneous abortion or miscarriage is recognized in 10-15% of pregnancies. The actual incidence is about 40%; however, very early miscarriages are unrecognized and probably would not be useful for fetal transplant. Of the fetuses analyzed, about 50% of fetuses miscarried in the first three months of pregnancy have chromosomal abnormalities, while only 20% of fetuses miscarried during the second trimester have chromosomal abnormalities. Three viruses (cytomegalovirus, herpes simplex, and rubella), a protozoa (Toxoplasma gondii), and a bacteria (Ureaplasma urealyticum) have been isolated from spontaneous abortions (Annas, 1989). Screening fetal tissue for chromosomal abnormalities and possible infection would add days and expense to fetal tissue harvest.
Further complicating the use of spontaneous abortion tissue is the tissue's passage through the vagina, which contaminates the fetal tissue with bacteria. Tissue viability is also at issue, since during the spontaneous delivery process the fetus suffers anoxic injury. The very controlled method of harvesting tissue from induced, elective abortion which can sterilely obtain tissue from largely healthy fetuses, has every potential advantage over fetal tissue that was harvested from randomly occurring spontaneous abortions (Brundin, 1990).
Moreover, induced abortions are relatively concentrated at abortion clinics, allowing for the harvest of many fetuses in a single day. Spontaneous abortions occur at home and in a random distribution of hospitals and clinics at all hours of day and night.
It is felt that to obtain enough tissue for transplant, multiple fetal donors are necessary; the most successful fetal neural transplantations for Parkinson's disease require four fetuses (Widner, et al.). These can be easily obtained from an abortion clinic. The logistics of obtaining four fetuses of similar age from spontaneous abortions within 1-2 days are awesomely complicated. Thus, for all the above reasons spontaneous abortion does not appear to be a reasonable method for obtaining fetal tissue for transplant.
Ectopic pregnancies hold some theoretical advantages over spontaneous abortions as a method for fetal tissue harvest. Ectopic pregnancy usually occurs in the fallopian tube. Although the fertilized egg can implant and develop normally, its growth cannot be sustained because of the small diameter of the tube. Typically, by 8-12 weeks of development, distension of the fallopian tube results in abdominal pain. Surgical removal of the fetus is then indicated to preserve the life of the mother. Use of this tissue for possible fetal transplant poses no ethical problem since the fetus cannot be carried to maturation. This tissue, unlike spontaneous abortion, is not likely to be infected or have chromosomal abnormalities. Surgical harvest affords a sterile method perhaps even superior to that of elective induced abortions. Ectopic pregnancies are increasingly frequent, with 78,400 occurring in 1985. Kathleen Nolan, a pediatrician-ethicist from the Hastings Center in Washngton, D.C., has argued that there is sufficient fetal tissue available from this source to supply fetal transplant research needs (Post, 1991). There are, however, technical problems with the use of fetal tissue from ectopic pregnancy.
First, women whose ectopic pregnancies are diagnosed late may have suffered a tube rupture, damaging the fetus in the process. Second, even if the tube remains intact, there can be significant injury to the fetus from anoxia. Third, many women are diagnosed shortly after they have missed their period. If a woman's pregnancy test is positive and an ultrasound shows no fetus in the uterus, an early ectopic pregnancy is diagnosed. The patient (and fetus) are given a large dose of an antimetabolite, methotrexate, and fetal death occurs. This necrotic fetus will be absorbed or passed down the fallopian tube, eliminating the need for a surgical procedure and, therefore, the possibility of fetal harvest.
Anoxic injury and early treatment of ectopic pregnancy using antimetabolites will considerably reduce the number of fetuses available for harvest. However, there would still be a significant number of suitable ectopic fetuses available.
The problems of multiple sites and random presentation are similar to those of solid organ transplant, and might be solved if there were a commitment to obtain fetal tissue in this manner. Preservation of fetal tissue is also an issue. For the brain transplant in the rat model, the tissue must be used in 5 days to optimize growth in the recipient. It is naturally more expensive and more difficult to obtain tissue in this manner, but it is ethically acceptable. This method could supply enough tissue for pilot trials in major medical centers. If fetal transplant were demonstrated to be useful for a variety of conditions, demand for fetal tissue could easily exceed the supply, creating a problem similar to that experienced with solid organ transplants. Ethical issues would be more sharply defined and the pressure to use tissue from induced abortions greater if it could be positively demonstrated that fetal tissue transplant had definite benefits.
The National Institutes of Health (NIH), under the Bush administration, issued a request for proposals for the establishment of a national fetal tissue transplant bank utilizing fetal tissues from ectopic pregnancies, spontaneous abortions, and stillbirths. Critics have claimed this program is not worthwhile (Garry, 1992). As of early 1993, however $6 million had been awarded to five centers to establish these tissue banks. The future and relevance of these tissue banks is in question following the Clinton administration's decision to lift the ban on fetal tissue transplant.
The Use of Tissue from Elective Abortions
Does it make sense to use tissue from induced abortion? If there were no question about the morality of induced abortions, the transplant researcher would be likely to choose tissue from induced abortions. The abundance of tissue available and the convenience of daily elective procedures make this method optimal in many ways. Proposals for improving tissue harvest at no increased risk to the mother are also under consideration.
The 21-member NIH Human Fetal Tissue Transplantation Research Panel (established in 1988) chose to separate the issue of the morality of induced abortions from the use of fetal transplant. They did provide ethical guidelines for obtaining tissue from induced abortions that, if enforced, would eliminate several areas of potential abuse:
(a) The decision to terminate a pregnancy and the procedures of abortion should be kept independent from the retrieval and use of fetal tissue.
(b) Payments and other forms of remuneration and compensation associated with the procurement of fetal tissue should be prohibited, except payment for reasonable expenses occasioned by the actual retrieval, storage, preparation, and transportation of the tissues.
(c) The decision and consent to abort must precede discussion of the possible use of the fetal tissue and any request for such consent as might be required for that use.
(d) The pregnant woman should be prohibited from designating the transplant-recipient of the fetal tissue.
(e) Anonymity between donor and recipient should be maintained, so that the donor does not know who will receive the tissue, and the identity of the donor is concealed from the recipient and transplant team.
(f) The timing and method of abortion should not be influenced by the potential uses of fetal tissue for transplantation or medical research (Consultant to the Advisory Committee to the Director of the National Institutes of Health, 1988).
These guidelines attempt to morally isolate the issue of fetal transplantation from the morality of elective induced abortion. That is to say, even if abortion on demand is wrong, using these guidelines should prevent a second wrong from occurring. This issue sidesteps a major unresolved moral question of the late 20th century - is abortion on demand wrong? Can the use of fetal tissue, in fact, be isolated from the morality of abortion on demand?
To bolster the argument that the issues are separate, defenders of the panel's view have argued that a cardiac transplant surgeon who transplants a heart from a brain dead murder victim is not an accomplice to the murder, nor does transplant of this heart increase the probability of murder in society. He is only making the best of a tragedy. This analogy has limitations. It is more accurate to consider the following one.
Suppose a famous cardiac transplant surgeon is summoned to South America to aid in the care of a dictator who is dying of heart failure. Upon arrival, the surgeon learns that there is no method established for organ procurement but histocompatibility testing is done well. After consulting with members of the local surgical team, the surgeon learns that a harvest is planned from a member of the country's Olympic team. Prior to its arrival, the Olympic team was screened. A young sprinter was shown to be a four antigen match with the dictator. The sprinter has now been summoned to the hospital and is being put to sleep on the pretext that an abnormality on his blood screening requires a surgical exploration. The transplant team awaits the approval of the guest surgeon to begin the harvest.
Alternatively, the transplant surgeon comes to South America to aid the dictator dying of heart failure. Again there is no organized method of donor procurement but this dictator was deeply loved throughout his country. When the men on death row at the National Penitentiary learned of their leader's plight, they asked if one of them could donate their heart on the day of their scheduled execution. A young healthy prisoner is a four antigen match to the dictator. He is about to be put to sleep. Again the transplant team awaits the approval of the guest surgeon to begin.
Because the transplant surgeon knows the source of the donor heart, he is morally accountable. Fetal tissue transplant surgeons similarly have a linkage with abortion on demand. While they may argue that these abortions are occurring anyway and they are only trying to bring some good from an evil or morally neutral act, the reality is that abortion on demand need not occur. Trying to bring good from abortion on demand ennobles it. If fetal tissue grafts are successful, it would create a new constituency of patients, families, and a medical industry complex anxious to see abortion on demand perpetuated.
Although the law may prevent counseling physicians from advising a pregnant teenager who is considering abortion about the potential good from fetal tissue transplant, it cannot stop family members and boyfriends from using this argument. In this regard, we must agree with bioethicist Carson Strong when he says that the morality of abortion and the use of fetal tissue for transplant are linked (Strong, 1991)
Even if the majority of the twenty-one members of the NIH panel believe that the two issues are not linked, the vast majority of members of the pro-life movement in America believes that they are. When Halifax Hospital in Nova Scotia performed the first fetal brain transplant for Parkinson's disease, there were strident objections from pro-life groups, on the grounds of the familiar slippery slope argument (Jones, 1992).
The political reality is that the morality of abortion on demand and the use of fetal tissue is linked in the minds of a significant portion of Americans. This is the reason that the ban on federal funds for fetal tissue transplant remained in effect during the Bush administration.
Until the personhood issue of the early fetus can be resolved, i.e., until a definite answer to when life begins is resolved, the use of fetal tissue for transplantation will remain controversial. It is ethically indefensible for four young lives to be taken so that one Parkinson's disease patient might receive some temporary relief of his symptoms. The only rational defense is to declare the young fetuses non-persons.
Alternatives to Fetal Tissue Transplant
Are there alternatives to fetal transplants? It is beyond the scope of this paper to explore all alternatives to every proposed form of fetal transplant. However, for Parkinson's disease, as for other proposed forms of fetal tissue transplant, several alternative therapies exist. First, there are other forms of autologous transplants. Although adrenal tissue transplant in its current form has not been shown to be successful, it might be possible for specially modified adrenal or carotid body cells multiplied through a cell culture with certain trophic factors to be suitable for transplant.
Pharmacologic research has shown that deprenyl (selegiline) can slow the progression of Parkinson's disease (Parkinson study group, 1989), and can decrease cell loss in the substantia nigra (an area of the brain affected by cell loss in Parkinson's disease). Vitamin E may also act synergistically with deprenyl to slow neural loss in Parkinson's disease (Gilman, 1992). When directly infused on neuronal tissue, brain-derived neurotrophic factors can prevent neuronal degeneration. Studies of local trophic factors and mechanisms to induce them locally or implant them in a sustained release form in local areas of the brain might suggest ways to alleviate symptoms (Hyman, 1991; Otto, 1990).
Most analogous to fetal transplant is the use of fetal neurons derived from cell cultures. Assuming the initial fetal cells were obtained in an ethically acceptable means (such as from an ectopic pregnancy), the use of cultured fetal cells might yield a more predictable source of transplant for Parkinsonian patients. Interestingly, it is the legal and financial issues of ownership of the fetal culture that have inhibited growth in this area.
There are a number of possibilities dealing with the issues raised by fetal tissue transplant, and several possible areas for further research. The scientific issue of the efficacy of fetal tissue transplant needs to be carefully studied and patients must be monitored for long-term problems related to this method of treatment. The availability and feasibility of using fetal tissue from ectopic pregnancies need to be investigated. It is possible that there might be enough tissue for research centers to begin pilot work. Presently, there is no scientific basis for widespread application of fetal tissue transplant. Alternative research needs to be explored and encouraged through laws defining ownership of fetal cultures.
Conclusion and Perspective
Beyond the scientific issue, there are important political perspectives. Is it right to spend tax dollars for research that a significant percentage of Americans consider immoral? If this research is so valuable, why can't the worth be shown from privately funded investigations? If our society is careful not to fund studies that might have racial overtones, why do they feel so free to use public funds for studies that might be repulsive to many committed Christians?
We do not allow the transplantation of organs from executed criminals, in part because this would offend those opposed to capital punishment and in part because of concerns that this might sway a judge or jury to recommend the death penalty over imprisonment. If we are as a society to be sensitive to the concerns of those opposed to capital punishment, should not similar concerns be afforded to those who oppose abortion on demand? Justice would dictate waiting on fetal transplant until the issue of abortion on demand is resolved. Federal funding for such experimentation should be deferred. There are other morally acceptable ways to help persons suffering with Parkinson's disease.
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