Stem Cells: A Bioethical Balancing Act

Some day medical science may be able to heal or alleviate ailments like Alzheimer’s disease, Parkinson’s disease, diabetes, spinal cord injuries, heart disease and cancer by giving patients new cells that have been guided to act as replacements for their own damaged tissue. Sometimes the starting stem cells could be culled from organs and tissue in the recipient’s own body, like the bone marrow, ensuring a perfect match. But many scientists argue that more promising research is being conducted on even less specialized and hence more versatile stem cells taken not from adults but from very early embryos, about a week after fertilization. At that point the embryo is a sphere whose inner cell mass contains many cells that are as yet undifferentiated. They can still form any tissue of the body, and perhaps even a new embryo. About two years ago, scientists began culturing these cells to develop new therapies for disease. But harvesting stem cells means destruction of the embryo.

Research on embryonic stem cells thus presents bioethics with a classic moral dilemma: is it ever right to cause some evil to achieve a greater good? Does the end justify the means? Those who put a priority on advancing medical relief for physical suffering focus attention on the good to be gained and minimize or negate the value of the embryo lost. Others, who see the embryo as having value in its own right and who put a priority on protecting the unborn, believe saving lives through medical advances cannot justify the direct taking of other lives. To the means/end conflict must be added still another complication. Neither means nor end can be looked at in isolation from their context and all the ramifications any attempt to balance the two would have for the welfare and moral fabric of society. Does sacrificing embryos lead to a general disrespect for life and even its commercialization? Would prohibition of such research dangerously restrict scientific inquiry and signify callousness toward those who suffer serious illness? And how about the value our society puts on technology, especially in medicine? Are we too trusting that new biotech discoveries will solve age-old human problems like aging, suffering and death? What do we have to say to the justice question about who will get to use these new therapies if they are produced?

New N.I.H. Rules

Judging from recent policy developments, it seems that many believe biomedical science to be leading the way to a more healthy human future in which stem cell research will play an important part. From 1996 until last summer, the United States banned the use of federal money for embryo experimentation, including stem cell research. This restriction did not apply to privately funded research. The National Institutes of Health (N.I.H.) interpreted the law to mean that federally funded researchers could use stem cells if they were derived from embryos by private companies. Many critics called this policy hypocritical. So last August, N.I.H. issued revised guidelines, permitting scientists using public grants to use stem cells derived by others, but also prescribing rules to be followed by those extracting the stem cells from donated embryos. Thus, although stem cells cannot be derived with public money, this activity is still brought under the purview of federal regulation and monitoring.

Publicly funded scientists may now use frozen human embryos that were originally created in the course of infertility treatment for couples who no longer need them. Under the new guidelines, the couples must consent to donate their embryos and would neither receive payment nor be permitted to designate a recipient of the resulting tissue. Moreover, the stem cell research would have to be reviewed scientifically and ethically four timesonce in the researchers’ home university and three times at N.I.H.

Shortly before the N.I.H. change, Britain too established new guidelines, which permit therapeutic cloning. This involves creating an embryo by implanting the nucleus of an adult cell in an egg, stimulating it to grow as an embryo and then harvesting stem cells rather than implanting the embryo into a woman’s uterus with the aim of reproduction. Therapeutic cloning is intended to facilitate the use of a medical patient’s own cell to produce a stem cell-providing embryo, a technique that has already proved successful in repairing heart damage in mice. The British guidelines go further than the U.S. rules, since U.S. researchers supported by public funds may not take stem cells themselves, and may use cells only from embryos that already exist and that will otherwise be discarded.

Britain’s chief medical officer, Liam Donaldson, advocates research using embryos in light of the great potential to relieve suffering and treat disease. President Bill Clinton referred to the potentially staggering benefits of stem cell research and tacitly found destroying embryos to weigh lighter in the balance. While still acknowledging the need for ethical standards, he opined that we cannot walk away from the potential to save lives and improve lives, to help people literally get up and walk. A New York Times editorial heralded the U.S. policy change on embryo research as the path to breathtaking medical breakthroughs and referred to the cost as involving just a clump of microscopic cells and clumps of embryonic cells.

Pro-Life Protest

Unsurprisingly, loud cries of protest went up from many pro-life and Catholic leaders. According to the Catholic News Service, the Virginia-based American Life League objected that the new guidelines sanctioned murder by sacrificing the most innocent of all human beings in a legacy of death. Former Republican presidential candidate Gary Bauer similarly described the new policy’s result as infanticide, just another example of snuffing out innocent life. A statement from the Vatican’s Pontifical Academy for Life acknowledged the validity of aiming to relieve human suffering, but insisted that the embryo is a human life too, and hence a subject with rights. Taking aim at the broader social context in which stem cell research is encouraged, Bishop Elio Sgreccia, vice president of the academy, characterized the U.S. government as yielding to the pressures of the industries that want to commercialize human health. The pope himself weighed in on Aug. 29 in a speech to transplant surgeons in Rome, in which he applauded attempts to remedy organ failure but excluded the growing of new tissue that had its origin in embryonic stem cells. Improved health is not the only criterion of medical morality, he argued, since all human endeavors must meet the broader and higher standard of the integral good of the human person. Including the embryo in the category person, John Paul II excluded human cloning, the destruction of embryos and the use of embryonic cells as means to better medical treatment.

Such vigorous denunciations may seem hyperbolic, an overreaction to the innovations and uncertainties of scientific progress, threats to the freedom of inquiry required for cutting-edge science and a senseless barrier to humanitarian goals to those who are not persuaded by other teachings in the areas of sexual and medical ethics. They may ask why the church furthers a seemingly unreasonable obsession with embryos at the expense of the victims of disease, the elderly in general and their families. On a deeper consideration of the issues at stake, however, perhaps many on different sides of questions like contraception, abortion and infertility therapies could come to agree that the pope and Vatican have highlighted important values that are too often submerged in the general acclaim for new biogenetic advances.

When Is an Embryo a Person?

First is the embryo itself. What does appropriate respect for an early embryo really demand? Precise answers here are not easy to attain. The Roman Catholic Church takes a strongly protective stance toward embryos, asserting in the 1987 Vatican instruction on reproductive technologies, Donum Vitae, that the embryo must be treated with the respect due a person. Many hesitate to treat the embryo with unqualified personal respect; even in Roman Catholicism, liturgical and pastoral care for those experiencing a miscarriage and those experiencing the death of a child are quite different. Many bioethicists, including Catholics, have made the argument that the embryo cannot be considered a person until after about two weeks of development, at which point it implants in the uterine lining and can no longer split into identical twins. Their rationale is that it is implausible to attach personhood to a being whose individuality is still unsettled and for whom there is naturally about a 40 percent chance of not making the transition to implantation and survival.

The counterargument is that as long as an embryo is a developing life with a human genetic code, it is a person despite its uncertain identity and prospects. This ongoing debate is partly a response to new birth control methods that prevent the early embryo from implanting in the uterine lining, as well as to in vitro fertilization and preimplantation genetic diagnosis, both of which also involve manipulation and sometimes destruction of early embryos.

I personally am not convinced that we will find some all ornothing developmental line of demarcation, after which an embryo must be treated with all the dignity of a person and before which its value is negligible. Even Donum Vitae grants that there is no scientific proof of the personal status of the fertilized egg and acknowledges that the magisterium has not taken a definitive philosophical position on this matter (I.2). Practically, the search for such a line seems to result more in denial of status before the magic moment than in enhanced protection after, and this is no doubt a major motivation of the church’s repeated insistence that the early embryo be given the benefit of the doubt.

Surely it is no more adequate to dismiss the embryo as simply a clump than it is to regard it as the moral equivalent of an infant. Even those who are not willing to view it as a person or individual with a full set of rights, as does official Catholic teaching, should be able to agree that an embryo is a form of human life in its beginning stages. My concern is that the new regulations are one more instance of scientific and legal erosion of the respect due early human life and the procreative process itself. Both are increasingly being commercialized and subjected to technological incursions. Research on and use of embryos is intended to help couples and relieve suffering, but it is also driven by gains for researchers, clinics and pharmaceutical companies. Hence policies that encourage research on embryos deserve intense scrutiny.

Commercialization

Commercial interest in the embryo and its cells tends to vitiate the integrity of the arguments of those who want to use itthat respect for the embryo can and will set significant limits on exploitation of its utility and that legal restraints are unnecessary. Private companies supplying stem cells must be remunerated for their services. There are also tremendous financial incentives for researchers to investigate medical uses of stem cells so as to sell their knowledge to for-profit pharmaceutical companies or to work directly for those companies. Under U.S. law, the only protection the embryo is afforded in recognition of that status is its immunity to being bought or sold. Is that enough? And is this limit even observed in practice if products derived from embryos, like stem cells, can be sold? Bishop Sgreccia’s concerns about commercialization must be addressed.

Partly because of market incentives to pursue certain kinds of profitable new techniques in genetic science, temporary or provisional bans on various types of research are frequently overridden once the public becomes accustomed to a new technology and starts to trust that assurances of enormous benefit may be less fantastical than they initially seemed. A temporary moratorium on human cloning was removed in 1997, after the National Bioethics Advisory Commission recommended not only that cloning to produce children be banned, but also that nonreproductive cloning be permitted to advance research. In nonreproductive cloning, an embryo is created by transplanting an adult cell’s nucleus into an ovum, but it is not placed in a uterus or gestated. Since creating embryos for research remains banned in general in this country, federal funding for nonreproductive cloning was never approved. The British guidelines of August 2000 now explicitly permit nonreproductive cloning of embryos to supply stem cells for new therapies. This sets a precedent for creating embryos for research alone in the United States as well.

In the United States, the ban on using stem cells had already been reinterpreted to permit publicly funded scientists to use stem cells derived by others; the new N.I.H. guidelines extend regulation and hence tacit approbation to researchers taking stem cells as long as they adhere to the guidelines. It does not take a huge stretch of the imagination to anticipate that scavenging stem cells from leftover frozen embryos will eventually be federally funded and may convert into permission to expand the embryo supply by cloning embryos from such spares (which would amount to creating, not just using, embryos). If this is followed sooner or later by permission to create research embryos outright from sperm and ova, then the present ban on creating embryos for research will have been gradually but completely overturned. Conception will be a laboratory means to advance a new technology expected to result in the cutting-edge medical treatments that people in the wealthier social sectors have come to take for granted.

Laws should not be inflexible. Scientists have a right not only to acquire knowledge and expertise, but to earn a living commensurate with their skills. And it is undeniable that there are important competing values in the stem cell debate, as in many other debates that arise with the emerging astounding power and promise of biotechnology. Even those who see the embryo as worthy of much more significant legal protection than it now enjoys should be able to appreciate that the good of the embryo can conflict with other equally important goods, especially the needs of those who are indisputably human persons. But that is exactly the point. In the stem cell debate we are dealing with a conflicteven a clashof important values that should not be ignored or sidestepped just to make our moral and policy choices seem more simple and easy, as when infanticide is set off against the destruction of a mere clump of cells. Instead, we need to take a long critical look at what we do, can and should expect from technology, medicine and big business. It is disconcerting to witness the frequency with which public standards in biomedical research change to follow the money.

Issues of Social Justice

The moral issues involved in stem cell research are not limited to the safety of embryos, nor even to the development of medical science. They include a commitment to all those who are marginalized in the present health care access system, as well as a commitment to improve the moral quality of relationships in the social body. Neither of these commitments is fully comprehended when the focus is on protecting the freedom and success of research, or on enabling the well-insured to command the benefits stem cell research promises. Although reasonable arguments exist both for and against stem cell research, we need to supply a corrective to the idea that new biomedical techniques are an unbounded and unassailable force for good. On this score, the incremental public financing of stem cell research is a step in the wrong direction.

President George W. Bush has opposed stem cell research in the past, but Health and Human Services Secretary Tommy G. Thompson has supported such research. This month Thompson appointed a panel of experts to advise him on the issue. For that very reason, it is important that the U.S. public take a more active and informed interest in the standards now being set by our government under the strong influence of high-level scientists and biotechnology investors, with the help of political pressure from some advocacy groups representing various disease constituencies. The decades before us will repeatedly bring home how hard it is to acknowledge the inherent dignity and limits of human life; to balance scientific research, the right of individuals to seek and receive top quality care and equitable access to care for all; and to limit the role of economics in social relations. Moreover, the difficulty in assessing and respecting the rights of individuals at the beginning and the end of life will certainly not disappear.

Changing our social ethos from one of individualism and trust in technology (one in which money above all brings power and respect) to one imbued with a spirit of solidarity, a holistic vision of health and commitment to all who suffer social, physical or spiritual ills is a tall order. I am not ultimately sure exactly what intrinsic moral status an embryo has or how to weigh new medical discoveries against other individual and social goods in the big picture. I do know that broader and more careful public participation in decision-making about the social role of biotechnology is absolutely necessary to preserve medicine’s traditional goals of healing and humanizing life in an age when medical and economic institutions are increasingly intertwined.