The Stem Cell Debate: Ethical Questions

The story for the year 1997 was the sacred. We fear a Promethean blunder. We fear that our own human hubris will violate something sacred in our nature; and we fear that nature will retaliate with disaster. To protect ourselves from a possible Promethean blunder by science, we are tempted to stop further research with the commandment: "thou shalt not play God!"

Then, during 1999, we opened the first few pages on chapter two of the cloning controversy story. I will refer to this chapter as "the stem cell debate." The debate has only begun. What is not yet clear is just what needs to be debated. Perhaps nothing. Perhaps everything. What is clear is that the fallout from the cloning explosion is still lighting fires here and there. Whether or not the public will add stem cells to the fuel to make those fires burn hotter remains to be seen.

Stem cells have become front page news in Australia, as well as in the United States and other countries. On February 4, 1999, the Australian National Academy of Science issued a position statement. Note the structure of Recommendation 1.

Council considers that reproductive cloning to produce human fetuses is unethical and unsafe and should be prohibited....However, human cells derived from cloning techniques, from germ cells should not be precluded from use in approved research activities in cellular and developmental biology

Here two things are put together. First, disapproval of reproductive cloning for the purposes of making children. Second, approval of research on human embryonic stem cells, approval even in the face of ethical squeamishness regarding embryo research. If this Australian statement is a barometer, we need to ask: what is the cultural weather forecast? What might be coming?

In what follows it will be my task to report on the fast-moving frontier of stem cell research within the field of anthropology, agenda questions raised by science that need to be addressed by systematic theologians and public policy makers. I will ask more questions than I am ready to answer. Yet, I believe that such work invested in trying to formulate the relevant question (die Fragestellung) takes us more than just halfway toward a helpful answer.

The Human Embryonic Stem Cell Debate
Science, Ethics, and Public Policy
Edited by Laurie Zoloth

Human embryonic stem cells can divide indefinitely and have the potential to develop into many types of tissue. Research on these cells is essential to one of the most intriguing medical frontiers, regenerative medicine. It also raises a host of difficult ethical issues and has sparked great public interest and controversy.

This book offers a foundation for thinking about the many issues involved in human embryonic stem cell research. It considers questions about the nature of human life, the limits of intervention into human cells and tissues, and the meaning of our corporeal existence. The fact that stem cells may be derived from living embryos that are destroyed in the process or from aborted fetuses ties the discussion of stem cell research to the ongoing debates on abortion. In addition to these issues, the essays in the book touch on broader questions such as who should approve controversial research and what constitutes human dignity, respect, and justice. The book contains contributions from the Ethics Advisory Board of the Geron Coroporation; excerpts from expert testimony given before the National Bioethics Advisory Commission, which helped shape recent National Institutes of Health policy; and original analytical essays on the implications of this research.

Pros and Cons

Debates over the ethics of embryonic blastocysts.

Latest Developments

The most recent research has shown that there are many options available other than working with embryonic stem cells. Stem cells can be obtained from cord blood or derived by manipulating differentiated cells (i.e. skin cells) to revert them to a pluripotent state. These are alternatives that may help broaden the acceptance of stem cell research.

Background

In November 1998 the first published research paper reported that stem cells could be taken from human embryos. Subsequent research led to the ability to maintain undifferentiated stem cell lines (pluripotent cells) and techniques for differentiating them into cells specific to various tissues and organs.

The debates over the ethics of stem cell research began almost immediately in 1999, despite reports that stem cells cannot grow into complete organisms.

In 2000 – 2001, governments worldwide were beginning to draft proposals and guidelines in an effort to control stem cell research and the handling of embryonic tissues, and reach universal policies to prevent “brain-drains” (emigration of top scientists) between countries. The CIHR (Canadian Institute of Health Sciences) drafted a list of recommendations for stem cell research in 2001. The Clinton administration drafted guidelines for stem cell research in 2000, but Clinton left office prior to them being released. The Bush government has had to deal with the issue throughout his administration. Australia, Germany, UK and other countries have also formulated policies.

(Continued from Page 1)

Pros

The therapeutic cloning. Stem cells provide huge potential for finding treatments and cures to a vast array of diseases including different cancers, diabetes, spinal cord injuries, Alzheimers, MS, Huntingtons, Parkinsons and more.

There is endless potential for scientists to learn about human growth and cell development from studying stem cells.

Use of adult-derived stem cells, from blood, cord blood, skin and other tissues, known as IPSCs, has been demonstrated to be effective for treating different diseases in animal models. Umbilical-cord-derived stem cells (obtained from the cord blood) have also been isolated and utilized for various experimental treatments. Another option is use of uniparental stem cells. Although these cells lines have some disadvantages or shortcomings compared to embryonic cell lines (they are shorter-lived), there is vast potential if enough money is invested in researching them further, and they are not technically considered individual living beings by pro-life advocates.

Cons

Use of embryonic stem cells for reasearch involves the destruction of blastocysts formed from laboratory-fertilized human eggs. For those who believe that life begins at conception, the blastocyst is a human life and to destroy it is unacceptable and immoral. This seems to be the only controversial issue standing in the way of stem cell research in North America.

Where It Stands

In the summer of 2006 President Bush stood his ground on the issue of stem cell research and vetoed a bill passed by the Senate that would have expanded federal funding of embryonic stem cell research. Currently, American federal funding can only go to research on stem cells from existing (already destroyed) embryos. Similarly, in Canada, as of 2002, scientists cannot create or clone embryos for research but must used existing embryos discarded by couples. The UK allows embryonic stem cell cloning.

Use of stem cell lines from alternative non-embryonic sources has received more attention in recent years and has already been demonstrated as a successful option for treatment of certain diseases. For example, adult stem cells can be used to replace blood-cell-forming cells killed during chemotherapy in bone marrow transplant patients. Biotech companies such as ACT are researching techniques for cellular reprogramming of adult cells, use of amnionic fluid, or stem cell extraction techniques that do not damage the embryo, that also provide alternatives for obtaining viable stem cell lines.

Out of necessity, the research on these alternatives is catching up with embryonic stem cell research and, with sufficient funding, other solutions might be found that are acceptable to everyone.

On March 9, 2009, President Obama overturned Bush's ruling, allowing US Federal funding to go to embryonic stem cell research. However, the stipulation applies that normal NIH policies on data sharing must be followed. Despite the progress being made in other areas of stem cell research, using pluripotent cells from other sources, many American scientists were putting pressure on the government to allow their participation and compete with the Europeans. However, many people are still strongly opposed

Research Ethics and Stem Cells

Stem cells show potential for many different areas of health and medical research, and studying them can help us understand how they transform into the dazzling array of specialized cells that make us what we are. Some of the most serious medical conditions, such as cancer and birth defects, are caused by problems that occur somewhere in this process. A better understanding of normal cell development will allow us to understand and perhaps correct the errors that cause these medical conditions.

Research on one kind of stem cell—human embryonic stem cells—has generated much interest and public debate. Pluripotent stem cells (cells that can develop into many different cell types of the body) are isolated from human embryos that are a few days old. Pluripotent stem cell lines have also been developed from fetal tissue (older than 8 weeks of development).

As science and technology continue to advance, so do ethical viewpoints surrounding these developments. It is important to educate and explore the issues, scientifically and ethically.

The discovery, isolation, and culturing of human embryonic stem cells has been described as one of the most significant breakthroughs in biomedicine of the century.1 This description would be warranted by virtue of the biological uniqueness of these cells alone—their ability to self-renew infinitely while retaining a remarkable capacity to differentiate into any form of cell tissue. But as well as this, the culturing of embryonic stem cells holds tremendous potential for the development of new forms of regenerative medicine to treat debilitating or fatal conditions that would not otherwise be curable.2

It is somewhat of an irony that the discovery of cells with such a tremendous potential for improving and prolonging our own lives, should bring with it some of the most trenchant and intractable questions about the value of life itself. The harvesting of embryonic stem cells results in the destruction of the embryos from which they are harvested. It results, in other words, in the expiration of the very beginnings of a possible human life. Issues about the value of life emerge here in perhaps their most stark and poignant form in the question of whether life for those already existing should be improved at the seeming expense of a possible human life that has just come into being.

Needless to say, what the most ethically justified response is to this sort of question is far from obvious. It is not immediately apparent, either, just what should count as the appropriate criteria for assessing possible responses to it. Indeed, it is even contentious as to what the right concepts and terminology are for framing the central questions. What is clear, though, is that it would be remiss to fail to engage with these questions in a manner that is commensurate with their depth, complexity and importance.

With due regard to that, the following discussion provides a brief overview of some of the core ethical issues arising from the Research Involving Embryos Bill 2002 and to some extent the Prohibition of Human Cloning Bill 2002.3 The public debate has focused mostly on ethical problems associated with the destruction of embryos (in the case of the first Bill), and with the creation of cloned human embryos (in the case of the second Bill). The current paper will confine its primary focus to the first set of problems, since many of the salient ethical issues about cloning will arise, as it turns out, in connection with embryonic stem cell research.4

1 Key Ethical Issues in Embryonic Stem Cell Research

The paper takes most of the major ethical concerns in the debate to be encompassed by the following core questions:

• What, in principle, is ethically at issue with destructive embryo research?

• What is important when it comes to judging the value of the potential consequences of destructive embryo research?

• In what does the value of the human embryo consist?

• Does the means by which an embryo expires—whether it is destroyed or merely succumbs—make a moral difference?

• Is there anything morally worse about using embryos created for research purposes compared to using existing excess or surplus ART (assisted reproductive treatment) embryos?

The purpose of the following discussion is to clarify some relevant moral and conceptual distinctions connected with these core questions, and to clarify the basic structure of the major views and argument themes that have been developed by philosophers, bioethicists and theologians in response to these questions. Of course, in their more fully expanded form these distinctions and arguments will involve subtleties and complexities that are beyond the limited scope of this paper to address. Nonetheless, the discussion here will hopefully give an impression of where some of those further complexities and subtleties might lie.

The Basic Ethical Problem

The possibility of destructive embryo research, particularly embryonic stem cell research, presents us with a moral problem because it appears to bring into tension two fundamental moral principles that we esteem very highly: one principle enjoins the prevention or alleviation of suffering, and the other enjoins us to respect the value of human life. As noted, the harvesting and culturing of embryonic stem cells has considerable potential to bring about remarkable potential benefits in the way of alleviating debilitating medical conditions. So, it satisfies the first principle to a very great degree.

On the other hand, there is a case to be made that the harvesting of human embryonic stem cells violates the second principle in that it results in the destruction of human life with value (i.e. human embryos). Accordingly, both principles apparently cannot simultaneously be respected in the case of embryonic stem cell research. The question then is which principle ought to be given precedence in this conflict situation. Should we give more weight to the first, and permit destructive embryonic stem cell research because of its remarkable potential benefits? Or should we give more weight to the second, and prohibit destructive embryonic research because it violates respect for the value of the

2 Key Ethical Issues in Embryonic Stem Cell Research

embryo as the very beginnings of a possible human life? This, at bottom, is the ethical problem generated by destructive embryo research.

Crude as it may sound, responding to this problem calls for a moral calculation—a decision about how the positive value of destructive embryo research is to be weighted, from a moral point of view, in comparison to the negative value (or disvalue) of destroying embryos. Whatever way that calculation is done, it is important to get a clear idea of what moral weight each side of the equation has. This will involve:

(i) developing a sound and accurate picture of what the real value is of the benefits of embryonic research, and

(ii) clarifying what the value of embryos might consist in, and what, if anything, may be wrong with destroying them.

The rest of this paper outlines some of the ethical arguments and philosophical considerations that have been considered relevant to these two matters.

Evaluating the Benefits of Embryonic Stem Cell Research

Evaluating the beneficial consequences of embryonic stem cell research is not straightforward. There are complexities associated with assessing how realistic the potential of the benefits is, how alternatives with different combinations of benefits and drawbacks are to be compared, and factoring in all of the sometimes overlooked possible consequences of embryonic research.

Judging the Benefits

Most attention has centred on the medical potential of embryonic stem cell research and cultivation, particularly somatic gene therapy for genetic disorders5, and the generation of replacement tissues and organs for transplant.6 There is no doubt that these outcomes, once realised, would be highly valuable. It is important to keep in mind, however, that currently these benefits are potential ones. A sound evaluation of stem cell research needs to take account of the likelihood of achieving its beneficial outcomes. In matters of science, and particularly, in areas that are newly developing and comparatively uncharted (such as embryonic stem cell research), it is sometimes difficult to settle on those probabilities with complete confidence. It is the nature of scientific discoveries and progress, that they are not easily predicted. Both advances and impediments to advancement can arise unexpectedly. This uncertainty about how real the potential benefits are, needs to be kept in mind when weighing and evaluating the consequences of embryonic stem cell research.

3 Key Ethical Issues in Embryonic Stem Cell Research

Comparing the Benefits and Harms of Alternatives to Embryonic Stem Cell Research

Adult Stem Cell Research

Whether destructive embryonic stem cell research is the right thing to do or not, will partly depend on what the alternatives are, and how their particular benefits and drawbacks balance out. There is another research program involving adult stem cells that are present in and drawn from bone marrow, brain and gut, and other tissues. Some of these stem cells have a capacity to differentiate into a limited number of different cell types, such as blood cells, muscles and neurones (i.e., they are multipotent), but they have not been shown to be pluripotent (able to differentiate into any cell-type) in the way that embryonic stem cells are.7 This limitation means that adult stem cells offer more limited potential benefits in regenerative medicine and gene therapy, at least from the standpoint of our current understanding and available biotechnology. (But with that said, it is worth keeping in mind the points made above about the limited predictability of scientific advances, including the possibility of inducing adult stem cells to differentiate into a greater range of tissue types.)

The harvesting and use of adult stem cells for biomedical purposes, however, avoids some of the ethically and biomedically problematic features of using embryonic stem cells. For a start, harvesting adult stem cells does not involve the destruction of embryos. The extent to which that is an advantage will depend on the extent to which that destruction turns out to be a bad thing, (and this will be taken up shortly). Tissues grown from adult stem cells will be immunologically compatible with the person from whom the stem cells are harvested. This means that those tissues can be transplanted into that person without fear of the body rejecting them. Tissues produced from embryonic stem cells for the purpose of regenerative therapy, however, are unlikely to be immunocompatible with the person for whom they are intended. The immunological properties of the tissue are set by the characteristics of whatever embryo the stem cells are derived from.

Apart from the ongoing use of immunosuppressant drugs (with its possible serious side effects), two other potential solutions to this immunological limitation have been suggested. The first proposes a 'tissue bank' with a sufficiently large number of different embryonic stem cell types to generate tissue that can be immunologically matched with different recipients. Hall points out, however, that 'this would require a huge number of human embryonic stem cell lines (the number being a matter of debate). Such an embryonic stem cell bank would be technically difficult and expensive to generate. The number of embryos that would be required to produce the cell bank would probably test public support … '8. The second possible way of overcoming the problem of immunological incompatibility is through what has been called 'therapeutic cloning'. In this process, the nucleus of a human oocyte or egg is removed and replaced with the nucleus of a cell taken from the body of the intended tissue recipient. The new egg is induced to develop into an embryo, from which immunocompatible stem cells are harvested. The embryo will be a human embryonic clone of the recipient, with all his/her

4 Key Ethical Issues in Embryonic Stem Cell Research

exact genetic characteristics. To date, there have only been one or two reported attempts at human cloning that have met with some success.

A number of ethical objections have been expressed to therapeutic cloning, all revolving around the creating of an embryo, and moreover, the creating of an embryo for a use that will destroy it. These objections and arguments usually rely centrally on certain views about the value or moral status of the embryo, and these views will be outlined later in the paper.

Whatever benefit the pluripotency of embryonic stem cells has in generating immunocompatible tissue, this benefit is likely to be possible only at the cost of having to engage in either the morally contentious practice of human (therapeutic) cloning, or the morally contentious practice of using (and destroying) a large number of embryos to create a sufficient range of embryonic stem cell lines for organ banks. It is especially important to note also, that if the Prohibition of Human Cloning Bill 2002 is passed in its current form, and any kind of human cloning, including therapeutic cloning, is prohibited, there will be less opportunity to maximise the potential benefits of embryonic stem cell research, and embryonic stem cells will effectively have less of the advantage they would otherwise have over adult stem cells.

The Inevitable Succumbing of Surplus IVF Embryos

The Research Involving Embryos Bill 2002 only permits excess ART embryos existing before 5 April 2002 to be used for research purposes in accordance with a licensing regime. It is a fact about those embryos that they would likely expire or succumb anyway. They would still be destroyed, in other words, but through exposure to natural processes. On the face of it, this looks as if the harm or negative value involved in embryos expiring (whatever it might be) will be the same whether embryo research is allowed or not. In each case the embryo will expire.

But this impression can be a little oversimplified. Some philosophers argue that there is a moral difference between acts and omissions, between actively killing something, and passively failing to intervene to stop its death from other causes (when one could have). Even though the outcome is the same in each case, it can be argued that there is something worse, or more morally culpable, about actively bringing about the death oneself. There are different views on what the moral difference between killing and letting die amounts to, and there are those who argue that there is no significant difference. Whichever way one comes out on this, it is not clear that the act-omission distinction maps neatly onto the particular embryo research scenario under discussion. Destroying surplus embryos through research is certainly an act. But so too, some would argue, is removing surplus embryos from the cold storage that keeps them from expiring. They would hold that this looks less like failing to intervene in independently occurring causal processes (that will lead to expiry), than an act that sets those processes in motion. If this is true, then the first impression above will stand. The harm or negative value involved in embryos expiring (whatever it might be) will be the same whether embryo research is allowed or not.

5 Key Ethical Issues in Embryonic Stem Cell Research

Some would argue that there is an important logical upshot from this. If the only two alternatives in the circumstances (destroying embryos in research vs making them succumb) involve the same level of harm or disvalue or moral wrongness, but embryo research involves much greater benefits than the other alternative, then it could be argued, it makes sense to opt for the more beneficial embryo research. And indeed, some might construe that as a sufficient case for the moral preferability of that option. (This would change, of course, if the relevant alternatives change—if say, embryos were purpose created for research, which were not pre-existing and destined to be expired).9

Taking into Account all of the Relevant Benefits and Harms

The embryonic stem cell debate has been pre-occupied with the biological and medical benefits or drawbacks of that research. Central as these certainly are, there are nonetheless other, often-overlooked non-medical impacts that may be important to factor in. Some of the major among these are possible social impacts including:

De-sensitisation to the Destruction of Human Life

It is argued by some10 that allowing the destruction of embryos to become an entrenched practice would serve to desensitise the scientific establishment, regulating bodies, and society in general, to the destruction of life in general. An increased social toleration of loss of life, it would be argued, may make it easier for society to accede to (currently) more controversial practices involving the ending of life such as, late term elective abortion, or withdrawal of treatment for severely disabled infants, for example. This 'slippery slope' argument about potential consequences is based on empirical assumptions about the causes and effects of certain social attitudes, and needs to be assessed in the light of their plausibility.

Contributions to Social Oppression

One strong but minority strand of argument emphasises the impact that biotechnology has on broader social relationships. It has been argued that 'research should be evaluated not only in terms of its effects on the subjects of the experiment but also in terms of its connection with existing patterns of oppression and domination in society'.11 There is a considerable body of writing that explores the impacts of new reproductive technologies (such as IVF) on the interests of women, particularly how those technologies might contribute to oppression.12 In the case of embryonic research, it is sometimes argued that women who donate ova or embryos are at risk of exploitation to the extent that male-dominated medical practice appropriates their reproductive labour for research and commercial benefits. Women are at risk, therefore, of being alienated from their reproductive labour. Moreover, it is argued that women's body parts are at risk of being commodified, and their acts of altruistic donation demeaned, if downstream users can develop commercial applications for stem cells developed from their ova and embryos.13

6 Key Ethical Issues in Embryonic Stem Cell Research

The Value of the Embryo

What weight does the other side of the moral equation have? What is wrong, if anything, with destroying embryos? If there is something wrong with that, is it sufficiently wrong to outweigh or override the benefits of embryo research, and therefore, render that research morally impermissible? Most of the leading arguments about the rightness or wrongness of destroying embryos are based on some view or other about the moral status of the embryo—how the embryo ought to be regarded or treated from the moral point of view, in virtue of it arguably possessing certain morally important intrinsic characteristics.

It is relatively uncontroversial to describe embryos as human life (at its very beginnings). It is another thing, however, to describe embryos as persons, or human beings, or potential persons, etc. These descriptions are morally laden in that they carry with them potential implications about what can and cannot be done to embryos from a moral point of view. What those potential implications are, and indeed, whether they are sound ones, will depend on the nature and plausibility of the particular arguments that accompany each view on the moral status of the embryo. There are different views about this moral status. The leading views speculate that embryos have the status of:

• persons, or

• potential persons, or

• divine creations, or

• subjects of moral 'harm', or

• the beginnings of human life, with intrinsic value, or

• organic material with no more moral standing than other body parts.

Each of these will be outlined in turn, with particular attention to (i) what the intrinsic moral characteristics are the each particular view attributes to embryos, and (ii) what these alleged characteristics or moral status are held to imply for our moral treatment of embryos—particularly whether they can ever or never be destroyed.

Embryos have Status as Human Beings or Persons

Some argue that, despite obvious physical differences between developed humans and embryos, the latter ought still be regarded as human beings or persons. One of the more plausible arguments to this effect relies on pointing out that there is no non-arbitrary point in the physical growth continuum between embryo and developed human that counts as a morally significant dividing line.14 Consequently, if individuals at their fully developed stage are human beings or persons, there is no non-arbitrary ground to think that they should not count as the same at their embryonic stage. Those who hold otherwise,

7 Key Ethical Issues in Embryonic Stem Cell Research

according to this argument, need to indicate the developmental point at which personhood, or status as a human being, is acquired.

The argument continues that it is a very deeply and commonly held view in modern liberal democracies that individual persons are deserving of especially strong moral respect in certain ways. All individuals, by virtue of being persons, have fundamental rights not to have their basic human interests interfered with in certain ways, and most importantly, their interest in the maintenance of their life and bodily integrity. If embryos have the status of persons, then they too will have rights not to be harmed or killed. Or, put in another way, we will be under a very strong moral obligation not to harm or kill embryos.

Most prominent ethicists, philosophers and commentators would agree that persons have a status deserving of strong and special moral respect, protection and dignity. Many, however, would dispute that embryos should be considered persons or human beings in any serious sense. Even if one cannot point to an exact black and white dividing line in human development, it is still reasonable (they hold) to point to the fact that wherever the transition occurs, embryos do not have the psychological, physiological, emotional, intellectual properties that we tend to centrally associate with personhood. Embryos, particularly the very early pre-implantation blastocysts involved in stem cell research,15 do not, for instance, have consciousness, individuality, the ability to reason, or the ability to form courses of action in life and to choose between them.16

Embryos have Status as Potential Persons

Some ethicists have a response to the foregoing objection to viewing embryos as persons. It is to concede that embryos do not currently exhibit these properties of personhood, but they will, if allowed to develop and fulfil their potential. To the extent that embryos are potential persons, it is argued, they ought to still be accorded the moral respect and dignity that personhood warrants.

This potential person argument gains some of its impetus from the observation that we still treat humans as persons (with the attendant moral respect) when they are temporarily unconscious or asleep. While in these incapacitated conditions, individuals are not conscious, can not reason, and can not form and choose courses of action—the characteristics we associate with personhood. But we still see it as morally wrong to harm them or violate their basic rights. It is argued that we see it this way because we know that even though they are not able to exercise the properties of personhood in their present state, these people will be able to when they become conscious again. This same reasoning it is argued, and the fact they will exercise these capacities when they eventually become fully developed humans, should inform our attitude to embryos.

8 Key Ethical Issues in Embryonic Stem Cell Research

Three types of concern have been expressed about this argument:

• the probability of IVF embryos developing into full-term successful births is low. There is a high rate of foetal loss in early embryos—up to 73 per cent in pre-implantation embryos.17 If probability is a reflection of potential, then there is relatively little potential for any one pre-embryo to become a person.

• Potential is very context-dependent, and it may not make sense to talk simply about the potential of something. The probability of an IVF embryo becoming a successful birth depends heavily on human action and intervention (e.g., transferral to the uterus), as well as other biological conditions (e.g., whether the embryo implants, grows to term, is born properly, etc., etc.). A great deal has to come from the outside for a successful birth, in the case of both natural and assisted pregnancy. So much so, it might be argued that it is not entirely clear what could be meant when speaking of the inherent potential of an embryo to become a person.18 From what contextual base line could that inherent potential be measured? (Some might also wish to point out that, in the case where surplus IVF embryos are used for stem cell harvest, these would naturally succumb anyway, and consequently would not have the potential to become persons.)

• Some would argue, that it is not clear why something that could become a person should be morally regarded as if it actually were a person. They would hold that the observation made above about people who are temporarily unconscious does not necessarily make the required case. Arguably, we treat the temporarily unconscious with the full moral respect of personhood because we knew that before lapsing into unconsciousness they had all the properties of personhood, and we know they will have them again after they come out of it. This scepticism is not presented as suggesting that the potential personhood of embryos counts for nothing in the way they are regarded morally. Only that it might not count for the full complement of rights and respect that actual persons warrant.

Before leaving these views about the moral status of embryos as persons or potential persons, there is an important qualification to be noted. Even if embryos were shown to have this status, and the accompanying moral respect, dignity and protections due to persons, it can be argued that this still might not necessarily mean that embryos should never be intentionally destroyed. A lot depends on one's philosophical understanding of the moral rights and obligations associated with personhood. Some would argue that the human right not to be killed, and the moral obligation not to kill persons, are absolute and inviolable, and must be observed with no exception, regardless of what the consequences are. Others might argue that the obligation not to kill persons, although a very very strong obligation, is not an absolute and indefeasible one that can never be overridden. There may be some circumstances where very great harms can be averted by actively ending someone's life. For example, assassinating Hitler and saving 6 million Jews, or even pulling the plug on life-support in order to spare someone's intense suffering. Someone very attuned to the importance of consequences, therefore, might want to hold that even if embryos do have the full complement of human rights, it is still not an absolute and indefeasible obligation not to destroy embryos regardless of the consequences. The fact

9 Key Ethical Issues in Embryonic Stem Cell Research

that many people would accept abortion in cases where the pregnant woman is at significant physical risk, is testimony to the prevalence of this consequentialist turn in people's ordinary moral thinking.

Embryos have Status as Divine Creations

It is sometimes implicit in some points of view, particularly theistic ones, that embryos warrant special moral importance because they are divine creations in being the beginnings of human life. In other words, embryos are not ours to destroy (nor create).

A number of concerns might be expressed about this view. For those who do not subscribe to a theistic worldview, the most obvious would relate to questions about the reality of a divine creator or creative agency. It is not clear what publicly available procedure could resolve that question. Some might also observe that this argument, at least in its simple form, could be too strong, since it argues against the destructive use of e.g., plants. On top of this, some might add, our limited knowledge of the nature of the divine tends to also limit our understanding of what divine status exactly implies re our moral obligations.

Embryos are Harmed by their Destruction (Whatever their Moral Status)

It is generally held that one of the traditional reasons for protecting life, is that loss of life causes various sorts of harm—to the killer, those close to the deceased, society in general, and most importantly the deceased. Some have argued that loss of embryonic life is a harm, inflicted on the embryo, by destroying it. Philip Devine, for instance, argues that:

… loss of life ... is a harm that can be inflicted on any organism; plants and non-human animals. Human organisms of every stage of development including the embryonic can all suffer loss of life.19

Others, however, have argued that embryos cannot be harmed in the sense we usually understand that idea. The eminent American social and legal philosopher, Joel Feinberg, for instance, analyses the concept of harm in terms of the 'thwarting, setting back, or defeating of an interest'.20 For a being to have an 'interest', for Feinberg, is a matter of it having beliefs, desires, expectations, aims and purposes. These, he holds, are what are thwarted, in the thwarting of an interest. According to his views trees or the environment are not themselves morally harmed by their destruction. Feinberg allows that future or potential interests might be attributed to a developing embryo, but that these only take effect if and when the potential interest becomes actual. Another theorist makes this same point by example:

Imagine that, just as Dr Frankenstein reached for the lever that would bring life to the assemblage of body parts on his laboratory table, someone appalled at the experiment smashed the apparatus. That act, whatever we think of it, would not have been harmful or unfair to the assemblage, or against its interests.21

10 Key Ethical Issues in Embryonic Stem Cell Research

The nub of this view is that because embryos are not the 'subject' of interests, they cannot be the subject of basic rights that protect interests.

Embryos have Status as Human Life with Intrinsic Value

Even if the foregoing views of Feinberg were accepted, some have argued that there is still something bad about the loss of life that is involved in the destruction of an embryo. In an attempt to get at the heart of this persistent residual conviction, the prominent Anglo-American legal and political philosopher Ronald Dworkin has proposed that we need to look at the value of a life in a particular way. Dworkin observes that we can conceive of the value of a life from two (compatible) points of view or directions. We very often think of the value of lives from the inside, as it were, in terms of the value they have to the livers of those lives. Through rights and liberties, we protect a person's life and interests, not because these are valuable from the point of view of the universe, but because they are important to the person concerned. But as well as recognising that a life has value to the liver, we also recognise that a life can have value from a more objective and impersonal point of view. In much the same way that a unique and magnificent work of art has intrinsic value, a value which makes it deserving of respect and protection, Dworkin observes that a single human life commands respect. Dworkin eloquently encapsulates the intrinsic value of human life in the following.

(a single human life has value) … no matter in what form or shape, because of the complex creative investment it represents and because of our wonder at the divine or evolutionary processes that produce new lives from old ones, at the processes of nation and community and language through which a human being will come to absorb and continue hundreds of generations of cultures and forms of life and value, and, finally, when mental life has begun and flourishes, at the process of internal personal creation and judgement by which a person will make and remake himself, a mysterious, inescapable process in which we each participate, and which is therefore the most powerful and inevitable source of empathy and communion we have with every other creature who faces the same frightening challenge.22

Thinking of the value of a life in this more external or impersonal way, argues Dworkin, provides another way of understanding what of moral importance is lost in the loss of a human life. Because this understanding is not based on any supposed moral harms to the liver of the life, as the subject of human interests, it is an understanding that can be applied in the case of human life at its very beginnings, i.e., embryos.

There is however one crucial qualification in Dworkin's view. There are degrees of intrinsic value of a life depending on the stage at which the life is being lived, and correspondingly, there are degrees of respect that ought to be shown it at those stages. Dworkin observes that we tend to make different judgements of how great a loss the ending of a life is at different stages in that life. For example, many would argue that a life ended at the peak of its achievements and promise is a greater loss than a life lost at its sunset, after its achievements and promise have been realised. Some also would argue that

11 Key Ethical Issues in Embryonic Stem Cell Research

a human life that ends at its very beginnings is a less serious loss than a life that ends some time after it has begun to actively engage in the process of human and social involvement that Dworkin speaks of in the passage above. We do, for instance, see sudden infant death as a more serious loss than early miscarriage, or failure of an embryo to implant. These different judgements of the degree of loss involved in the ending of a life, reflect the degree of intrinsic value we attach to human life at those stages. Or so Dworkin argues.

The important implication of Dworkin's arguments, is that even though embryos, as human life, deserve respect and protection, the degree of respect and protection they warrant may not be as great as that accorded to later stage human life. Consequently, some would argue that there may be circumstances where the limited loss of value involved in an embryo being destroyed is outweighed from a moral point of view, by the possible benefits in allowing that to happen.

Embryos have the Status of Mere Body Parts

Some might hold that embryos are merely parts of other people's bodies until they reach a certain autonomous or independent developmental stage (and there will be differing views on when that might be). Accordingly, embryos have no independent moral status at all, and are merely the property of the people from whose body they came. The only respect due to embryos is the respect that should be accorded other people's property. This no-status view is argued for on grounds that none of the other arguments in favour of an independent moral status are compelling.

Embryos Created for Research Purposes?

Is it somehow worse to use embryos created specifically for research, than it is to use embryos that are surplus to the reproductive treatments for which they were created? In other words, is there anything independently wrong with creating embryos for research purposes above and beyond whatever (if anything) might be wrong with destroying them as part of the research process?

Some argue that creating embryos for research is to create them merely as a means to others' ends (no matter how laudable those ends might be).23 If embryos do have a significant person-like moral status (as, e.g., persons, potential persons, divine creations), then this amounts to treating them with deep moral disrespect. They are being commodified. However, when embryos are created for reproductive purposes, each has the same initial chance of being transferred to the uterus, even if it will probably turn out that not all of them are needed in the end. They are still being created 'respectfully'—for a use that fits with their intrinsic or natural ends or purpose, not others'.

Some would reply, however, that this argument is based on a view about the moral status of embryos that needs to be fully established. Moreover, if using embryos for others' ends is wrong, then that may well count against the donating of embryos for research purposes.

12 Key Ethical Issues in Embryonic Stem Cell Research 13

Another argument has been expressed which does not rely on attributing person-like moral status to embryos, but something more like the status outlined in Dworkin's views noted above. Embryos, even if they are not the holders of rights, nonetheless have considerable value to the extent that they are the beginnings of a possible human life. Embryos can, therefore, function as powerful symbols and provide the opportunity for a community to demonstrate or express commitment to human life generally by, for example, condemning creation of embryos for research purposes. As the philosopher John A. Robertson says, 'In taking such a stance, persons define or constitute themselves as highly protective of human life.'24 Robertson notes, however, that this same symbolic respect for life can be expressed through allowing embryos to be created so that others' lives can be prolonged, or deaths averted.

Today, a man lies dying of liver failure in a hospital. There is little expectation that he will be one of the lucky few to receive a transplant before he becomes too ill to save. Even if he did receive a transplant, he will be burdened with taking multiple anti-rejection drugs for the rest of his life, which in and of themselves would significantly compromise his health.

Tomorrow, scientists develop a method to build this man a new liver, one that would be a perfect match for him, requiring no anti-rejection drugs whatsoever. There is a catch. To perfect such a solution would require the destruction of other lives. Would Judaism sanction such a solution?

Jewish law clearly forbids the taking of one life to save another. The Talmud forbids saving one's life at the expense of another by asking how one knows that his life is more valuable than his neighbor's. Perhaps your neighbor's life is more valuable.

WHEN THE FETUS IS A THREAT TO LIFE

One may kill someone who is unjustly pursuing a third party to kill him.

But, what if the life that would need to be sacrificed was that of a fetus? May we permit abortion to save the life of an already born person? The Mishna clearly states that if the life of a woman in labor is threatened by her fetus, the fetus should be aborted. But once a portion of the baby has emerged, we may not abort the fetus, because "one may not set aside one person's life for the sake of another." The principle behind this ruling is that one may kill someone who is unjustly pursuing a third party to kill him. Since the fetus, who is not yet considered a "complete" person, is "pursuing" the mother in a way that will inevitably result in her death, we may kill it first. But, once it has even partially emerged, it is considered a full-fledged person. Now we are faced with a dilemma, states Rabbi Moshe Feinstein, one of the most respected rabbis of the 20th century: who is pursuing whom?

WHEN PURSUING EACH OTHER

Imagine that you are transported back in time to Weehawken, New Jersey, on July 11, 1804. As you step out of the time machine you see Aaron Burr, pulling out a revolver to shoot Alexander Hamilton, Former United States Secretary Of The Treasury. Simultaneously, you see Hamilton also drawing his revolver to kill Burr! What should you do? Kill Burr? Kill Hamilton? Jewish law would rule that you may kill neither, because they are pursuing each other and you do not know which one, if either, is an innocent party.

In our case of the baby struggling to be born at the expense of the mother and the mother struggling to survive at the expense of the fetus, are not the baby and the mother each "pursuing" the other? In such a case, the general rule is that we may not choose either, since each is a complete and autonomous person, and each is both the pursuer and the pursued. Luckily for us, these scenarios are very rare occurrences in our day thanks to Caesarian sections.

A life-threatening situation for another adult would not justify our killing a fetus.

But, since the rationale for abortion in Jewish law is based on the fetus being a pursuer of the mother, a life-threatening situation for another adult would not justify our killing a fetus, since the fetus does not threaten the life of anyone except the mother. Therefore, we cannot allow abortion, even to save the life of our patient with liver failure.

DESTROYING "PRE-EMBRYOS"

But there is hope. What if the scientists "merely" needed to destroy excess fertilized eggs from in vitro fertilization (IVF) procedures that are only a few days old and have not yet been implanted in a woman's uterus? Is the destruction of these "pre-embryos" ethically acceptable to us? That is exactly the debate that currently rages regarding stem cell research.

While stem cells can be derived from aborted fetuses and even adults, the best source for stem cells is the small clump of cells that compose the early zygote only a few days following conception. Therefore, to best investigate the latent possibilities inherent in stem cells, scientists wish to use the approximately 100,000 "excess" frozen pre-embryos that are "left over" from earlier IVF attempts. Is it ethical to allow the destruction of pre-embryos to obtain stem cells for research that may some day save thousands of lives?

Early stem cells have the ability to differentiate into every cell of the human body, potentially forming an entire fetus. If we were able to manipulate the conditions controlling cellular differentiation, we might create replacement cells and organs, potentially curing illnesses such as diabetes, Alzheimer's disease, and Parkinson's disease.

But, the ultimate promise of stem cell technology would be to combine it with cloning. Imagine our man dying of liver failure. If we could clone one of his cells, but instead of allowing the cloned cell to develop into a fetus, we might place it into the appropriate environment that would cause it to differentiate into a liver that would be virtually genetically identical to that of the sick man. If we could "grow" this liver to maturity, we could offer the sick man a liver transplant without the risk of rejection and without the need for anti-rejection drugs.

Unfortunately, we still do not know if we can successfully clone a human, nor are we sure what practical value can be derived from stem cells. It will require years of very expensive, labor-intensive research to determine the potential that stem cells hold for the treatment, palliation, and cure of human illness.

ARE "PRE-EMBRYOS" INCLUDED IN THE PROHIBITION OF ABORTION?

Is it ethical to sacrifice pre-embryos to experiment with their stem cells in the hope of some day saving many lives? While many ethical issues arise, the key one is whether pre-embryos are included in the prohibition of abortion. The consensus thus far is that it an embryo is not protected by the limitations on abortion until it is implanted in a woman. Most rationales given for why the Torah forbids abortion, except to save the mother's life, revolve around the fetus being within the woman.

The consensus is that an embryo is not protected by the limitations on abortion until it is implanted in a woman.

The logic of only ascribing humanity to an embryo once it is implanted in the womb is simple. Left undisturbed, an embryo in its mother's womb will most likely continue to grow and reach parturition. But the pre-embryo created by IVF, if left untouched in its "test tube," will die. The pre-embryo requires active intervention to even reach a situation which we consider to be true potential life. The alternative to this reasoning would be to argue that the killing of adult skin cells is forbidden, since a person could potentially be cloned from any cell in an adult's body.

ANOTHER RATIONALE

Additionally, there is another sound reason to allow destruction of pre-embryos to save a life. When necessary to save a life, Judaism requires us to transgress all of the laws in the Torah, with the exception of murder, adultery, and idol worship. For example, if someone is gravely ill on Yom Kippur, we would drive in a car to get them non-kosher food even if necessary to save their life. If a pre-embryo is not covered by the Biblical commandment of "thou shall not murder," then we might allow destroying a pre-embryo for its stem cells if it would save the life of an already born person. We are left with the question of whether research is considered the saving of a life. This argument becomes even more appealing if concrete life-saving medical treatments can be demonstrated.

For these as well as many other reasons, many contemporary halachic decisors have ruled that the destruction of preexisting pre-embryos for stem cell research is permitted (see my more extensive article on stem cell research and Jewish Law at: http://www.jlaw.com/Articles/stemcellres.html)

CHEAPENING THE VALUE OF HUMAN LIFE

Nevertheless, many Rabbis oppose the deliberate creation of pre-embryos for the purpose of their destruction, as this would cheapen the value of human life.

The halachic process offers fascinating insight into all areas of ethics, including biomedical ethics. It gives us the opportunity to evaluate the explosion of technology that surrounds us through the lens of the Torah, insuring that we remain the masters of our science and not vice versa. Judaism has no issue with technology. It only requires the ethical and responsible use of science to better our lives. Let us pray that tomorrow, our patient with liver failure will be cured.

Stem Cell Biology and Its Complications

The renewed debate over embryonic stem cells highlights the advances and complications that have arisen in the field since its controversial beginnings.

Multimedia

Graphic

Type of Stem Cells

Related

* Stem Cell Ruling Will Be Appealed (August 25, 2010)

The cells are a sort of blank slate, plucked from human embryos just a few days after fertilization. They tantalize scientists because they could in theory turn into any of the body’s 200 mature cell types, from blood to brain to liver to heart. They could be used to study and treat diseases and to study the basic biology of what determines a cell’s destiny — why a heart cell becomes a heart cell, for example, instead of a brain cell.

The problem is their origin — human embryos. In order to get stem cells, embryos must be destroyed. It is this fact that led to the court ruling on Monday blocking most federal financing for embryonic stem cell research.

The scientist who isolated human embryonic stem cells in 1998 struggled with this dilemma, consulting ethicists before proceeding. But in the end, the scientist, Dr. James Thomson of the University of Wisconsin, decided to go ahead because the embryos were from fertility clinics and were going to be destroyed anyway. And, he reasoned, the work could greatly benefit humanity.

Yet despite the high hopes for embryonic stem cells, progress has been slow — so far there are no treatments with the cells. The Food and Drug Administration just approved the first clinical study, a dose and safety test, of human embryonic stem cells to treat spinal cord injuries.

All along, though, scientists wondered if they could sidestep the ethical debate by creating embryonic stem cells without the embryos. Every cell has the same DNA. A heart cell is different from a liver cell because it uses different genes. But all the genes to make a liver cell, or any other cell, are there in the cell. The liver genes are masked in a heart cell and vice versa. Why can’t scientists find a way to unmask all of a cell’s genes and turn it directly into a stem cell without using an embryo?

A few years ago, two groups of researchers — one led by Dr. Thomson — did just that. They discovered that all they had to do was add four genes and a cell would reprogram itself back to its original state when it was a stem cell in an embryo. Like an embryonic stem cell, that reprogrammed cell seemed to be able to then turn into the many kinds of specialized cells in the body, an ability called pluripotent.

What has happened since that discovery, scientists say, is that stem cell biology turned out to be more complicated than they anticipated. Besides the stem cells from embryos, there are so-called adult stem cells found in all tissues but with limited potential because they can only turn into cells from their tissue of origin. And there are these newer cells made by reprogramming mature cells.

Now researchers are trying to figure out whether stem cells made by this reprogramming process really are the same as ones taken from embryos. Some say they found subtle differences between these cells, known as induced pluripotent stem cells, or I.P.S.C.’s, and embryonic stem cells. Others are not so sure.

They say they need embryonic stem cells as a basis of comparison, a gold standard to see if the newer reprogrammed cells are as good.

“We are not at the stage where you will find many investigators saying, ‘We don’t need embryonic stem cells because I.P. cells are the same,” said Dr. Timothy Kamp, a stem cell researcher and professor of medicine at the University of Wisconsin School of Medicine and Public Health. “We don’t know that yet.”

One complication is that different labs use different methods to obtain the reprogrammed cells and to study them, Dr. Kamp said. As a result, he said, “not all I.P. cells are the same.”

John Gearhart, director of the University of Pennsylvania, and one of the first to isolate human embryonic stem cells, said some investigators ended up with reprogrammed cells “that will have little utility.” They are only partly reprogrammed, he explains.

“One worries about how safe and effective they are going to be” if they are ever used in therapies, Dr. Gearhart said.

Dr. George Q. Daley, a stem cell researcher at Children’s Hospital in Boston, saw subtle differences in a recent study. When he just compared the two types of cells side by side with molecular tests, they looked identical. Then he tried turning them into various types of mature cells and comparing the results.

Dr. Daley published a paper in March, in Nature Biotechnology, reporting that mouse I.P.S.C.’s from different tissues remembered, in a sense, where they came from. He has a similar paper under review showing the same effect with human induced pluripotent stem cells.

In the mouse study, it was harder to get pluripotent mouse cells derived from a skin cell, for example, to turn into blood cells than it was to get pluripotent stem cells made from blood cells to turn into blood cells.

“They tended to remember their tissue of origin,” Dr. Daley said.

Researchers need to find ways to make the cells forget where they came from, he said.

M.I.T., said he was not certain there were meaningful differences between human embryonic stem cells and human induced pluripotent cells.

But to answer that question will require the use of embryonic stem cells for comparisons, Dr. Jaenisch said.

“Things are very much in flux,” he said. “We will probably need human embryonic stem cells for a while. And then we probably will not need them anymore.”