Ethical questions of Ethical questions of stem cell researchstem cell research

Jozsef Kovacs MD. PhDJozsef Kovacs MD. PhDSemmelweis University-BudapestSemmelweis University-BudapestInstitute of Behavioral SciencesInstitute of Behavioral Sciences

Department of BioethicsDepartment of Bioethics

Historical remarksHistorical remarks

1978—The first infant (Louise Brown) was 1978—The first infant (Louise Brown) was born following in vitro fertilization (IVF)born following in vitro fertilization (IVF)

1997—First successful Somatic Cell Nuclear 1997—First successful Somatic Cell Nuclear TransferTransfer (SCNT) (SCNT) (cloning) in a mammal (cloning) in a mammal

1998—Isolation and culturing of the first 1998—Isolation and culturing of the first human pluripotent embryonic stem cell lineshuman pluripotent embryonic stem cell lines

To drive stem cells to differentiate into a To drive stem cells to differentiate into a desired cell type is still not a solved problemdesired cell type is still not a solved problem

The types of stem cellsThe types of stem cells

Human Embryonic Stem Cells (hESC) Human Embryonic Stem Cells (hESC) (pluripotent) (pluripotent) Pluripotent stem cells: they cannot form a Pluripotent stem cells: they cannot form a

whole organism, but they can specialize into whole organism, but they can specialize into almost all forms of adult cell typesalmost all forms of adult cell types

Umbilical cord stem cells (multipotent)Umbilical cord stem cells (multipotent) Adult-derived stem cells Adult-derived stem cells

(multipotent)(multipotent)– Multipotent stem cells: can give rise only Multipotent stem cells: can give rise only

to some specialized cellsto some specialized cells

The source of human The source of human embryonic stem cells (hESC-s)embryonic stem cells (hESC-s)

1. They can be isolated from the inner cell 1. They can be isolated from the inner cell mass of human embryos (blastocyst)—these mass of human embryos (blastocyst)—these embryos can be found in IVF (in vitro embryos can be found in IVF (in vitro fertilization) clinicsfertilization) clinics

2.Primordial germ cells retrieved from first-2.Primordial germ cells retrieved from first-trimester aborted fetusestrimester aborted fetuses

3. To use somatic cell nuclear transfer 3. To use somatic cell nuclear transfer (SCNT)=cloning to produce embryos, and (SCNT)=cloning to produce embryos, and then the same as 1. (therapeutic cloning)then the same as 1. (therapeutic cloning)

4. To transform multipotent adult stem cells?4. To transform multipotent adult stem cells?

The promise of stem cellsThe promise of stem cells To cure diseases likeTo cure diseases like

– DiabetesDiabetes– Heart diseaseHeart disease– Parkinson diseaseParkinson disease– Alzheimer diseaseAlzheimer disease– Neurodegenerative disordersNeurodegenerative disorders– Spinal cord injurySpinal cord injury– Replace cells injured by traumaReplace cells injured by trauma

The advent of regenerative The advent of regenerative medicinemedicine

Therapeutic cloningTherapeutic cloning Regenerative medicine will transform Regenerative medicine will transform

our conception ofour conception of– AgingAging– Personal identityPersonal identity

The ethical dilemma of hESC-The ethical dilemma of hESC-therapytherapy

Extracting the stem cells kills the Extracting the stem cells kills the embryo (which is in the blastocyst embryo (which is in the blastocyst stage of development)stage of development)

Is destroying the embryo killing a Is destroying the embryo killing a human person?human person?

If a 4-5 days old embryo is a person, If a 4-5 days old embryo is a person, then healing a person with stem cells then healing a person with stem cells is performed by killing an other oneis performed by killing an other one

The moral status of the The moral status of the blastocystblastocyst

The basic questionThe basic question– At what stage of embryonic development At what stage of embryonic development

does the life of the embryo deserve the does the life of the embryo deserve the same respect and protection due a same respect and protection due a newborn infant?newborn infant?

The main answersThe main answers– Conservative: at conceptionConservative: at conception– Liberal: at birthLiberal: at birth– Moderate: at some stage during embryonic Moderate: at some stage during embryonic

developmentdevelopment

The conservative positionThe conservative position

All human beings have the same valueAll human beings have the same value Human life begins at conceptionHuman life begins at conception Killing an embryo is just as bad as killing adultsKilling an embryo is just as bad as killing adults Problems:Problems:

– Theoretical: Theoretical: It uses the term „human life” in two different meanings: It uses the term „human life” in two different meanings:

(human life at a cellular level and human life as the life of (human life at a cellular level and human life as the life of an organism)an organism)

„„But the zygote is a potential human being”—then it only But the zygote is a potential human being”—then it only potentially has a right to life potentially has a right to life

The potentiality argument leads too far—it would prohibit The potentiality argument leads too far—it would prohibit contraception as well contraception as well

The liberal positionThe liberal position

It takes into account women’s right It takes into account women’s right to self-determination over their to self-determination over their bodies, which is relevant in case of bodies, which is relevant in case of abortionabortion

It is, however, irrelevant, when the It is, however, irrelevant, when the status of the embryo, outside the status of the embryo, outside the woman’s body is consideredwoman’s body is considered

The moderate positionsThe moderate positions

Common in them: development is Common in them: development is relevant to attain full moral statusrelevant to attain full moral status

The gradualist position: human life is The gradualist position: human life is valuable at all stages of its valuable at all stages of its development, but it becomes more and development, but it becomes more and more valuable during development until more valuable during development until it reaches full moral statusit reaches full moral status

At what point is personhood reached?At what point is personhood reached?

The symmetry between The symmetry between brain death and brain birth brain death and brain birth

I. I. Human life (morally and legally) Human life (morally and legally)

comes to an end by brain death comes to an end by brain death The brain dead is biological still alive The brain dead is biological still alive

(its organs can be used for (its organs can be used for transplantation purposes)transplantation purposes)

The end of biological life and the end The end of biological life and the end of personal life do not coincide—of personal life do not coincide—personal human life ends earlier, than personal human life ends earlier, than biological lifebiological life

The symmetry between The symmetry between brain death and brain birth brain death and brain birth

II. II. Similarly: human life (morally and legally) Similarly: human life (morally and legally)

begins by brain birth (at 10th week of begins by brain birth (at 10th week of gestation, at the end of embryonic gestation, at the end of embryonic development)development) (Goldenring, 1982) (Goldenring, 1982)

Embryos (before the 10th week of Embryos (before the 10th week of gestation) are biologically humans, but gestation) are biologically humans, but are still not personsare still not persons

Fetuses (after 10th week of gestation) Fetuses (after 10th week of gestation) have functioning brainshave functioning brains

The symmetry between The symmetry between brain death and brain birth brain death and brain birth

III. III. Human biological life is longer, than Human biological life is longer, than

the life of the human personthe life of the human person– It begins earlier (at conception) than It begins earlier (at conception) than

personal life, and ends later (at biological personal life, and ends later (at biological death, the death of the last living cell of death, the death of the last living cell of the organism)the organism)

The life of the human person begins The life of the human person begins later, than biological life (at brain later, than biological life (at brain birth), and ends earlier (at brain death)birth), and ends earlier (at brain death)

ConclusionConclusion

Embryos do not have a right to life, Embryos do not have a right to life, fetuses do havefetuses do have

This moderate position is reflected in This moderate position is reflected in some widespread practicessome widespread practices

Some basis for convergenceSome basis for convergence

Few accept the full implications of Few accept the full implications of the view, that the embryo is a person the view, that the embryo is a person with full moral status (Ronald with full moral status (Ronald Dworkin)Dworkin)

These implications would beThese implications would be– Abortion would not be permittedAbortion would not be permitted

to save the mother’s lifeto save the mother’s life even in case of rape or incesteven in case of rape or incest

Conclusion: this in practice favors Conclusion: this in practice favors some form of the moderate positionssome form of the moderate positions

If the blastocyst is a person, is If the blastocyst is a person, is stem cell research necessarily stem cell research necessarily

unethical?unethical? We could use organs for We could use organs for

transplantation purposes, even if transplantation purposes, even if they resulted from a homicidethey resulted from a homicide

Similarly, if IVF technology involves Similarly, if IVF technology involves discarding the surplus (spare) discarding the surplus (spare) embryos, using their cells before embryos, using their cells before discarding them could be acceptable, discarding them could be acceptable, if the user did not contribute to the if the user did not contribute to the creation of the embryo?creation of the embryo?

Is discarding the embryo better Is discarding the embryo better than deriving ES cells from it?than deriving ES cells from it?

IVF programs necessarily entail discarding IVF programs necessarily entail discarding spare embryosspare embryos

Deriving ES cells from spare embryos before Deriving ES cells from spare embryos before discarding them will lend permanence to the discarding them will lend permanence to the embryoembryo (McGee—Caplan, 1999) (McGee—Caplan, 1999)

Conclusion: destructive embryo research Conclusion: destructive embryo research destroys the embryo less, than discarding it destroys the embryo less, than discarding it

If IVF programs are permitted, it is If IVF programs are permitted, it is inconsistent to prohibit derivation of ES cells inconsistent to prohibit derivation of ES cells from spare embryosfrom spare embryos

The relevant questionsThe relevant questions

Is destructive embryo research on Is destructive embryo research on donated spare embryos of IVF donated spare embryos of IVF programs ethically acceptable?programs ethically acceptable?

Is the creation of embryos for Is the creation of embryos for research purposes ethically research purposes ethically acceptable? acceptable?

The major policy positions The major policy positions regarding human embryo and regarding human embryo and

hESC research I.hESC research I. (Walters, (Walters, 2004)2004) Total prohibition:Total prohibition:

– embryo research and research on embryo research and research on existing hESC lines is forbiddenexisting hESC lines is forbidden

Almost total prohibition:Almost total prohibition:– Embryo research is forbidden but Embryo research is forbidden but

research on existing hESC lines is research on existing hESC lines is permittedpermitted

Moderate view:Moderate view:– Research is permitted only on surplus Research is permitted only on surplus

(spare) embryos of IVF programs(spare) embryos of IVF programs

The major policy positions The major policy positions regarding human embryo and regarding human embryo and

hESC research II.hESC research II. The liberal view:The liberal view:

– The creation of embryos specifically for The creation of embryos specifically for research purposes is permitted research purposes is permitted

The radical viewThe radical view– Cloning of human embryos for research Cloning of human embryos for research

purposes is permitted purposes is permitted The ultra radical viewThe ultra radical view

– The transfer of human somatic cell The transfer of human somatic cell nuclei into animal eggs is permitted nuclei into animal eggs is permitted

„„Radical” and „ultra radical” Radical” and „ultra radical” countries from the point of countries from the point of

view of hESC researchview of hESC research UK; Belgium; SwedenUK; Belgium; Sweden India; ChinaIndia; China Israel; South Korea; SingaporeIsrael; South Korea; Singapore USA (2 states: California and New Jersey)USA (2 states: California and New Jersey)

Controversial research that can be carried out there:Controversial research that can be carried out there:

The creation of embryos specifically for research purposesThe creation of embryos specifically for research purposes Cloning of human embryos for researchCloning of human embryos for research The transfer of human somatic cell nuclei into animal eggsThe transfer of human somatic cell nuclei into animal eggs

Evaluation of consistency in Evaluation of consistency in various positionsvarious positions

Total prohibition--consistentTotal prohibition--consistent Almost total prohibition (USA, Almost total prohibition (USA,

Germany)Germany)– Reason: the prevention of future embryo Reason: the prevention of future embryo

destructiondestruction– But: IVF program (accepted in these But: IVF program (accepted in these

countries) involve embryo destructioncountries) involve embryo destruction– Conclusion: this position is inconsistentConclusion: this position is inconsistent

The moderate position—consistent The moderate position—consistent

The superiority of the liberal The superiority of the liberal position to the moderate oneposition to the moderate one

Moderate position—allows only the use of Moderate position—allows only the use of spare embryos from IVF programs spare embryos from IVF programs – Implicit presumption—treating infertility is a goal Implicit presumption—treating infertility is a goal

that justifies the destruction of some embryosthat justifies the destruction of some embryos Liberal position—allows to create embryos Liberal position—allows to create embryos

for research purposesfor research purposes If a non-life saving treatment (treating If a non-life saving treatment (treating

infertility) justifies the destruction of infertility) justifies the destruction of embryos, why the promise of a life-saving embryos, why the promise of a life-saving treatment does not? treatment does not? (Clarke, 2006)(Clarke, 2006)

The answer depends on the acceptability of The answer depends on the acceptability of the principle of double effectthe principle of double effect

The separation of state and The separation of state and churchchurch

The difference between opponents and The difference between opponents and proponents of destructive embryo research proponents of destructive embryo research proved to be intractableproved to be intractable

Imputing full moral status to the embryo is Imputing full moral status to the embryo is mostly based on religious premisesmostly based on religious premises

Can the health needs of persons submitted Can the health needs of persons submitted to the religious views of others?to the religious views of others?

The constitutional principle of separation The constitutional principle of separation of church and state should be followed of church and state should be followed