therapeutic cloning: from consequences to contradiction

Journal of Medicine and Philosophy 0360-5310/02/2703-297$16.002002, Vol. 27, No. 3, pp. 297±317 # Swets & Zeitlinger

Therapeutic Cloning: From Consequences to Contradiction

Marilyn E. CoorsUniversity of Colorado Health Sciences Center, Denver, CO, USA

ABSTRACT

The British Parliament legalized therapeutic cloning in December 2000 despite opposition fromthe European Union. The watershed event in Parliament's move was the active and unprece-dented government support for the generation and destruction of human embryonic life merelyas a means of medical advancement. This article contends that the utilitarian analysis of thisprocedure is necessary to identify the real world risks of therapeutic cloning but insuf®cient toidentify the breach of defensible ethical limits that this procedure represents. A value-orientedapproach to Kantian ethics demonstrates that the utilitarian endorsement of therapeutic cloningentails a contradiction of the necessity of human vulnerability and a faulty valuation of thehuman embryo. The concern is that a narrow utilitarian focus ultimately commodi®es humanembryonic life and preferences outcomes as the sole determinant of moral value.

Keywords: categorical imperative, human embryo, maxim, stem cells, utilitarian

I. INTRODUCTION

Health is the goal and therapeutic cloning promises to be `̀ the key to healingwithin the human body'' says Yvette Cooper, Britain's Public Health Minister(Mayor, 2001). In an attempt to enable scientists to ®nd cures for a range oflife-threatening diseases that are presently untreatable, the British Govern-ment legalized therapeutic cloning in December 2000. The vote entailed anamendment to the 1990 Human Fertilization and Embryology Act (Fazal,2000). An expert panel informed a debate in Parliament that took intoconsideration both the medical and ethical issues surrounding the technique.The amendment passed by a two-thirds majority, with 366 members of

Address correspondence to: Marilyn Coors, Ph.D., University of Colorado Health SciencesCenter, B137, 4200 East Ninth Avenue, Denver, CO 80262, USA. E-mail: [email protected]

at UniversitaetsbibliothekD

uesseldorf on March 26, 2014

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Parliament voting in favor and 174 against (BBC News, 19 December, 2000).The hope is that embryonic stem cells derived from therapeutic cloning willprovide a source of antigen-matched tissues and organs to treat patients withserious medical problems.

The European Union (EU) took a different stance with regards to thispromising research. In September 2000, members of the European Parliament(MEPs) adopted a resolution that was highly critical of therapeutic cloning. Inan extremely close vote (237 votes to 230, with 43 abstentions) they endorseda statement that therapeutic cloning `̀ irreversibly crosses a boundary inresearch norms and is contrary to public policy'' (Watson, 2000). The MEPscalled for legislation in each member country banning cloning of humanembryos and imposing criminal penalties for any breach. They resolved thatno EU funding will be available for any research involving the cloning ofhuman embryos. Member countries remain divided on the issue (Sheldon,2000; Watson, 2000).

Therapeutic cloning is a controversial issue in the United States. At the timeof this writing, law prohibits federal funding involving the intentionalgeneration of embryos for research. However, some prominent Americanbioethicists and biotechnology companies support therapeutic cloning basedon a utilitarian analysis that cites the obligation to pursue the greater good ofpotential medical advances (Fox, 2001; Lanza et al., 2000; Mendiola et al.,1999; Pence, 1998). Others take a more cautious approach endorsing the useof adult stem cells and already existing embryonic stem cell lines as a moreacceptable means to realize the promised clinical bene®ts without the ethicalproblems of deliberately generating and destroying human embryos (Juengst& Fossel, 2000). The utilitarian argument is seductive. It emphasizes dramaticprogress toward curing devastating diseases, but the narrow focus on con-sequences excludes other ethical considerations that may warrant ®ndingalternate means to important therapies.

This article contends that the simple utilitarian analysis of therapeuticcloning is unpersuasive in three respects. First, utility is indispensable inpractical ways to assess new procedures in genetic medicine but entailsinherent dif®culties that prevent it from offering common-sense limits to usinghuman embryonic life merely as a tool. The simple utilitarian approach isunable to account for the breach of defensible ethical limits that thistechnology represents, an inadequacy that renders its endorsement suspect.Second, the obligation to pursue the best medical treatment is a prima facieobligation, not a moral absolute. The claim that medical progress must be

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pursued at all costs is misguided. Emerging scienti®c evidence and commonlyaccepted medical practices belie this assertion and suggest that other means tothe desired end may be just as ef®cacious and more acceptable (Kaufman et al.,2001). Third, the utilitarian justi®cation for legalizing therapeutic cloningultimately fails since it is grounded upon a contradiction of the necessarycondition of humanness, vulnerability (Herman, 1993). Because we as rationalhuman beings cannot escape our own vulnerability, the utilitarian argumentcontradicts self-interest and jeopardizes the protection hoped for in our ownvulnerability. Moreover, the utilitarian justi®cation mistakes the value of thehuman embryo as inadequate to provide reasons to impede its use merely asa tool of science. This article takes on the simple but signi®cant task ofdemonstrating that a value-oriented approach to Kantian ethics elucidatesthe reasons why the utilitarian analysis does not square with our deeplyentrenched moral intuitions about human therapeutic cloning.

To appreciate adequately the ethical signi®cance of therapeutic cloning, itis important to address the scienti®c methods involved. Science providesimportant information about the molecular processes that control the devel-opment and maintenance of life. A bioethical analysis that ignores or distortspertinent science is either uninformed or disingenuous. It is critical to under-stand the science correctly in order to assess the ethical issues accurately anddraw good conclusions. However, science alone cannot dictate right or wrongin a moral sense or comment on the good for humankind. Science determineswhat can be done, not what should be done.

II. THE SCIENCE OF THERAPEUTIC CLONING

The aim of therapeutic cloning is to provide compatible tissues and organs forreplacement therapy. Scienti®cally, the procedure is surprisingly simple. Eachcell of the body carries within its nucleus a copy of an individual's completegenetic makeup, the genome. In cloning or somatic cell nuclear transfer(SCNT), the nucleus from a single adult cell, a skin cell for example, can befused with an enucleated egg to provide a rejuvenating environment for theadult nucleus. The egg initiates a dedifferentiation process whereby thegenome reverts back to the embryonic state and then triggers early embryonicdevelopmental cues that stimulate the embryo's genome to follow the naturalcourse of development. A blastocyst that has characteristic morphology forms,including a trophoblast that gives rise to the placenta and the embryoblast that

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harbors the embryonic stem cells. The next step in human cloning forreproductive purposes is to implant the resulting embryo into a woman'suterus with the purpose of gestating an infant. In contrast, cloning fortherapeutic purposes destroys the embryo in order to extract stem cells fromthe inner cell mass. Embryonic stem cells are promising since they can besteered with various hormones and growth factors to develop into almost anytissue or organ in the body. The hope is that embryonic stem cells willsomeday provide treatment for patients suffering devastating disorders such ascardiomyopathy, Alzheimer's disease, Parkinson's disease, type 2 diabetes,osteoporosis, and a host of others. Stem cells produced by therapeutic cloninghave the advantage over those harvested from embryos resulting from IVF oraborted fetuses in that the cells generated through therapeutic cloning areimmunologically matched to the patient and thus avoid problems of rejection(Richards, 2000).

Before this technique can provide real clinical bene®ts for patients, manyhurdles related to ef®cacy and safety must be overcome. First, because of theexpense and medical risk involved in procuring the large numbers of humaneggs that are necessary, therapeutic cloning may prove unrealistic as a clinicalalternative (Cibelli et al., 2001). Second, there is much to learn about stem cellbiology and the mechanisms that regulate their self-renewal. It is unknown ifstem cells will differentiate properly after transplantation, form tumors, orotherwise develop inappropriately in vivo (Reya et al., 2001). Third, in orderto maintain embryonic stem cells in culture in an undifferentiated state, theymust be combined with mouse ®broblast cells (Donovan & Gearhart, 2001).Until science develops another culture medium, the transfer of embryonicstem cells into humans for therapeutic purposes is a xenograft. At present,embryonic stem cells are very important for understanding human develop-ment and studying the mutations that lead to many cancers. However, giventhe medical risks of inter-species transplantation and the scarcity of humaneggs, clinical bene®ts are far-off and speculative.

The Human EmbryoThe science of therapeutic cloning inherently involves the widely debatedissue of the value of the human embryo. Deliberation about the human embryobegan, in some form, with the writings of Aristotle and continued on throughtwo and one-half millennia until the present time. Thoughtful people holddiffering views on the status of the human embryo that bridge almost as large aspan as the historical debate. Positions range from those who regard the early





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embryo as a person with rights and interests (Ashley & Moraczewski, 2001;Doer¯inger, 1999; Iglesias, 1990; John Paul II, 1995) to those who believe thatthe embryo is too rudimentary in development to have any moral status at all(Mori, 1993; Seller, 1993; Singer, 1994). The most widely agreed uponviewpoint holds that the human embryo is a potent symbol of human life thatdeserves profound respect (Meyer & Nelson, 2001; Robertson, 1995, 1999),but individual interpretations of respect vary extensively.

The intent is not to resolve the question of the moral status of the humanembryo here, but to establish two characteristics upon which there is generalagreement: the human embryo is alive and human. `̀ The genetic material inthe embryo, the DNA, contains the information in chemical code for thedevelopment of the embryo into a being which comes to be regarded as ahuman person'' (Seller, 1993, p. 138). The embryo is radically different froma sperm or egg or any other cell in the human body, none of which possessesany internal code of self-actualization. Biologically, the human embryo is anorganism with an independent inherent teleology to develop into a humanperson. As such, it is both physiologically alive and genetically human(Juengst & Fossel, 2000).

Among those who agree on the biological distinctions above, some contendthat embryos cloned from an adult somatic cell are not human embryos in the`̀ conventional sense'' since they are `̀ not the result of fertilization'' (Lanzaet al., 2001). On the basis of this distinction, they argue that it is acceptable togenerate and destroy embryos based on potential therapeutic bene®t. This is acurious argument that seems to rest upon procedure and location, rather thanscience. If the product of therapeutic cloning is not a human embryo in the`̀ traditional'' sense, what is it? Is it a nonentity, a simple mass of cells, aprecursor of an organ or a tissue? Scienti®cally, it is none of the above. Theembryo produced through therapeutic cloning is an organism that containshuman DNA with an independent genetic program that directs the type ofbeing the embryo will become. It has the same chance of developing into ahuman being as a conventional embryo if transferred to a womb to implant andgestate. As such, the only scienti®c difference between a cloned embryo and aconventional embryo is that a cloned embryo contains DNA that is the asexualreplication of a single genome rather than the combination of two parentalgenomes.

Some of the disparities witnessed in the ethical viewpoints regarding thehuman embryo stem from widely differing interpretations of `̀ respect''. Evenmore fundamentally, the hidden discrepancies in the way persons evaluate the





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ethical issues result from a focus on different aspects of the ethical landscape.Different foci, concentrated either on the means or the consequences of theethical event, can in¯uence the assessment of the morality or immorality of anaction. In the extreme, a single focus can be so prevailing as to exclude ornegate additional data from another perspective. The inadequacies of a narrowapproach become especially problematic when applied to complex judgments,such as the ethics of human therapeutic cloning, which entail both medical andethical complexities.

III. THE CONSEQUENCES: NECESSARY BUT INSUFFICIENT

The consideration of consequences in terms of a bene®t versus harm analysisis necessary in the assessment of human therapeutic cloning. In order to beethically justi®able, an action or procedure must result in overall bene®t orproduce the least amount of harm if good results cannot be achieved. It isindisputable that good should be maximized and harm minimized in the healthcare arena. An assessment of the harm versus bene®t of therapeutic cloningcauses the professional to re¯ect on the real world risks of stem cell therapyand its potential to produce overall bene®t. Utilitarian reasoning discernsthat which science can know or predict in situations where individuals canencounter either bene®t or harm. Moreover, utility deals with ethicalquandaries in terms of empirical facts without referring to metaphysicaldistinctions and, as such, is compatible with the medical model. In the absenceof an acceptable anchor for moral deliberation in contemporary society, utilityrenders bioethical questions empirically analyzable, often avoiding a possiblestalemate caused by differing worldviews. For these reasons, utility isindispensable in practical ways to evaluate human therapeutic cloning.

Utilitarian consequentialism is insuf®cient, in itself, as a means of assessinghuman therapeutic cloning because, according to the imperative to maximizepleasure and minimize pain, a suf®ciently propitious outcome can justify anunethical means. If the only way of maximizing utility is acting in a way that isethically unacceptable by common standards of morality, the simple utilitarianapproach could endorse that action. For example, utility entails ethical in-adequacies when dealing with questions concerning the generation of humanembryos for research. Since the early embryo has no capacity for pain, there isno utilitarian reason to prevent procedures that treat the human embryo only asa tool of research. If the goal is healing or improving the human species, the





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utilitarian can argue the appropriateness of human therapeutic cloning on twocounts. First, pain is absent or minimal. Second, any impropriety of the meansis superseded by the bene®ts garnered from embryonic research. Thesearguments render justi®able most research procedures attempting to alleviatepain or increase overall pleasure. Utility emphasizes the avoidance of aggre-gate harm, but it lacks the capacity to determine what constitutes a bene®t orharm. For this reason, utilitarian reasoning could potentially sanction ethicallyindefensible technological control over human life. When the impropriety ofmeans is superceded by bene®ts gained from a procedure, the narrow focus onthe minimization of pain can overlook other important values and actuallythwart the ability to make ethical distinctions.

The issues articulated by the debate over therapeutic cloning illustrate boththe strengths and weaknesses of simple utilitarian reasoning. The utilitarianargument `̀ weighs the fate of the embryo, from which these cells are derived,against the therapeutic value to patients with real medical needs'' (Juengst &Fossel, 2000, p. 3180). Juengst and Fossel ground their outcomes-basedargument by considering the cost of not pursuing the potential bene®ts oftherapeutic cloning. The obligation to do good, bene®cence, is a foundationalprinciple of bioethics. The potential for good via therapeutic cloning issigni®cant. Juengst and Fossel caution that `̀ if ethicists or the public wouldrestrict the uses of embryonic stem cells, then they must bear responsibility forthose patients they have chosen not to try to save by this means'' (Juengst &Fossel, 2000, p. 3183). For example, the numbers of persons waiting for tissueand organ transplants are mounting and the quantity of donated tissues andorgans have not increased correspondingly. Therapeutic cloning provides apotential source of immunologically matched transplants, eliminating theneed for life-long immunosuppressive therapy. The promise is alluring, but thescienti®c possibility of realizing the bene®ts is still elusive. For example,scientists can steer stem cells to look like liver cells, buy they still do notunderstand how to make them function appropriately. `̀ This requires not onlyproducing the multiple cell types that it contains, but also precisely organizingthese cells into a three-dimension tissue structure'' (Baltimore, 2001).Scientists are the ®rst to acknowledge the enormity of the challenge involvedin realizing the promised bene®ts.

The Obligation to Minimize SufferingThe obligation-based argument used in support of pursuing human therapeuticcloning is reminiscent of the utilitarian reasoning of Dr. Rieux in Albert





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Camus's The Plague (Camus, 1970). The novel raises the broad themes oflove, freedom, suffering, death, and the more speci®c issues of the duty of thephysician and the interrelationship between the biological and psychosocialaspects of life. During the spring of 1940 until February 1941, the city of Oran,Algeria, was thrust into a battle against the deadly bubonic plague. In thenovel, Rieux describes the reactions of society and individual characters to theall-consuming challenges of communal sickness and death. The fundamentalsimilarity between Rieux and the utilitarian mandate for therapeutic cloning isthat the moral reasoning involved in both is consequence-based and focusedon the obligation to minimize suffering. Rieux's ethics from the beginninguntil the end of the siege were clear. As a doctor, his duty was to ®ght theepidemic. This is the obligation that the utilitarian argument emphasizes sowell. Rieux realized that if he ¯ed, the suffering would be far worse for hisfellow citizens without the services of a doctor. He was well aware thathe could not stave off the ravages of the plague, but possibly he could providetemporary alleviation from pain for those who were quarantined and con-demned to death.

The difference between Rieux's utilitarian calculus and that used in thedefense of therapeutic cloning is that the good doctor did not use life merely asa means to an end, but preferenced life as an end in itself.1 Dr. Rieux did notpropose that his life, or any other life, was expendable as a means of achievinga supposedly higher goal. He had devoted his entire life to ®ghting illness anddeath and was not about to give up the struggle. The argument in favor oftherapeutic cloning corresponds to that of Dr. Rieux in that the intent of bothis to maximize therapeutic bene®t; it differs in the rectitude of the meansdesignated to achieve that objective.

It is wrong to use human life merely as a means to the well-being of anotheror many others (Kant, 1956). Kant determined that rational nature has asingular worth, a dignity, `̀ insofar as it is capable of morality'' (Kant, 1956).Barbara Herman, a contemporary philosopher, extends upon this groundingprinciple of Kantian ethics. Herman asserts that `̀ beings with dignity do nothave a relative value, either in the sense of one having more dignity thananother or in the sense of many having more dignity than a few . . .'' (Herman,1993, p. 238). Dignity is not `̀ additive''; each human being possesses an entirecomplement. Because rational agents all have the capacity to conform theirwills to the principle of good willing, `̀ each has all the dignity there is tohave.'' Herman bases this assertion on the absolute value of rational nature.She claims that it is `̀ absolute in that there is no other kind of value or





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goodness for whose sake rational nature can count as a means'' (Herman,1993, p. 238). For this reason, the notion of sacri®cing one human being forthe bene®t of many is mistaken in that it does not recognize that what iscounted are not objects but ends of rational willing.2

IV. THE MANDATE: OBLIGATORY NOT ABSOLUTE

Biotechnology is a much-needed tool to serious ®ght disease. Patients(a category that includes everyone at some time) want the best treatment andultimately a cure for a host of life-threatening disorders. It is the obligation ofscience and medicine to pursue this end, as Dr. Rieux modeled. The primaryobligation is bene®cence. This principle ¯ows from the special character ofthe healing relationship established between health care professionals andpatients (Pellegrino, 2001). Bene®cence mandates more than preventing harm(nonmale®cence); it requires doing good (Hippocrates, 1972). As such,bene®cence is a principle and a guide to action. `̀ Bene®cence in trust ± that is,bene®cence that encompasses the patient's complete well-being, and notsimply his medical well-being ± becomes the ordering principle'' of the practiceof medicine (Pellegrino, 2001, p. 53).

However, the practice of bene®cence in health care is a prima facie duty,not an ethical absolute. Beauchamp and Childress de®ne prima facie prin-ciples as `̀ an obligation that must be ful®lled unless it con¯icts on a particularoccasion with an equal or stronger obligation'' (Beauchamp & Childress,1994, p. 33). In the absence of extenuating circumstances we have theobligation to honor the principle of bene®cence. Prima facie duties, such asbene®cence, may be abandoned with suf®cient evidence that a more com-pelling duty exists. Gilbert Meilaender uses a just war analogy to demonstratethat utilitarians have a case for `̀ moral necessity'' in therapeutic cloning, butnot at all costs. There is suf®cient proof that there are alternatives to theintentional generation and destruction of human embryos to negate the claimof a moral absolute. `̀ They have not yet ventured to make a case for strategic

necessity ± to show that progress cannot be made, even if more slowly, bymeans that do not involve destruction of embryos'' (Meilaender, 2001, p. 12).Utilitarian arguments pass brie¯y over mounting evidence of the ef®cacy ofexisting stem cells lines and adult stem cells to cite the uncertainty of thesecells to produce the promised bene®ts in a `̀ timely fashion'' (Lanza et al.,2000). They speculate that therapeutic cloning is likely the `̀ end run'' around





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the hurdles that will enable science to achieve the sought-after goal. Yet, theemerging scienti®c data do not support the cloning of human embryos as theonly and/or best means to produce rejection proof tissues and organs(Almeida-Porada et al., 2001).

While embryonic stem cells are key to understanding the biology ofdifferentiation and disease, therapeutic applications are likely to come fromadult stem cells. There is mounting evidence that adipose, hematopoietic,mesenchymal, and neuronal cells are an alternate source of stem cells withpreviously unexpected plasticity (Beauchamp et al., 1999; Bjornson et al.,1999; Fox, 2001; Johansson et al., 1999; Kaji & Leiden, 2001; Pittenger et al.,1999). The range of plasticity demonstrated by adult stem cells was un-expected until evidence reported early in 2001 demonstrated that stem cellsfrom diverse sources give rise to different cell types to repair the body: bloodinto muscle, nerves into blood, fat into muscle, bone, and cartilage. As citedpreviously with regard to embryonic stem cells, the challenge lies in makingcells derived from adult stem cells function effectively. If this hurdle can beovercome, adult stem cells promise to be a practical, ef®cient, and therapeuticoption that avoids the ethical problems associated with the therapeutic cloning(Almeida-Porada, 2001).

Researchers claim to have found what they hail as the `̀ true'' stem cell withunexpected regenerative powers in adult bone marrow. These stem cells candevelop into epithelial cells of the liver, lung, GI tract, and skin contributing tothe clinical treatment of genetic disease and tissue repair (Krause et al., 2001;Orlic et al., 2001; Zuk et al., 2001). Orlic et al. also reported that transplantedbone marrow cells could be reprogrammed to repopulate dead myocardium ininfarcted mice. The Orlic study veri®ed that `̀ locally delivered bone marrowcells can generate de novo myocardium, ameliorating the outcome of coronaryartery disease'' (Orlic et al., 2001). Research on adult stem cells in adiposetissue reports similar ®ndings. Unwanted human fat contains stem cells thatcan develop into bone and cartilage in the laboratory (Zuk et al., 2001). Plus,fat cells have the added bonus of being plentiful, dispensable, and easilyaccessible. Most importantly, autologous adult stem cells garnered from apatient's bone marrow or adipose tissue avoid the problems of rejection oftransplanted tissue from allogeneic sources. Adult stem cells can be isolatedfrom most human tissues and organs, grown in culture, and directed to pro-duce many diverse tissues.

These ®ndings challenge the utilitarian argument that medical progressnecessitates moral blinders to the ancillary issues generated by human





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therapeutic cloning. Moreover, there are examples in contemporary medicineillustrating that society relinquishes otherwise bene®cial ends to prevent theuse of human life on the fringes of existence merely as a means. Threeexamples illustrate established practices in medicine that prohibit the use ofhumans devoid of rationality as a tool of medicine, despite the potential oftherapeutic bene®t. In each case, respect for the dignity of vulnerable humanssupersedes the mandate of bene®cence in health care. Casuistic reasoning is apractical way to compare the dilemma engendered by therapeutic cloning tosome common procedures in medicine. Casuistry is the deliberative processthat utilizes familiar and accepted procedures to analyze new and ambiguousones (Jonsen & Toulmin, 1988). It focuses on pertinent experiences withprevious cases to assist in practical decision making in current cases.

The dead donor rule proscribes organ donation with parental consent fromanencephalic newborns who expire after treatment is withdrawn (Silberner,1999). Anencephalics lack an upper brain, but they have brain stem function.Such infants are legally alive since existing criteria require whole-brain deathfor a declaration of death. Legally, the removal of their organs prior to wholebrain death constitutes homicide. The application of the dead donor rule toanencephalic newborns is a topic of debate since viable organs cannot beobtained from these infants after death. The ethical argument adverse toapplying the dead donor rule to anencephalic infants cites bene®cence to therecipient and the consenting families who wish to wrest bene®t from theirtragedy. It also contends that the newborns lack consciousness and will diesoon and, thus, are not harmed (Medical Task Force on Encephaly, 1990).Arguments in favor of applying the dead donor rule in this instance cite theimportance of not killing individuals who are alive (Pellegrino & Thomasma,2001). Also, this argument holds that the numbers of anencephalics born arelow and the small number of recipient children bene®ted does not warrantthe potential harms. The concern is that the authorization to harvest organsfrom live anencephalics would extend to other vulnerable life or reinforcepublic fears that potential organ donors would be allowed to die prematurelyto harvest their organs. Therefore, application of the dead donor rule toanencephalic infants prevails.

Another example will reinforce the point that accepted medical practiceforsakes bene®t to patients in deference to respect for human remains.Hospital policy on teaching and practicing procedures on newly deceasedpatients is such a practice. The human embryo and the newly dead differ inthat the ®rst is alive but in an arrested state of development and the second was





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alive but is no longer living. However, policy on the newly dead is germane tothis discussion because both embryos and the recently deceased are on thefringes of life and lack rationality at the time of the proposed research. Arepresentative policy on the treatment of the newly dead from a universityhospital requires written or oral permission from an appropriate representativeor an available written advance directive before non-mutilating proceduresmay be taught and/or practiced. Health care providers must master andmaintain skills in certain life-saving treatment such as cricothyrotomy, venouscannulation for central line placement, endotracheal intubation, tubethoracostomy, or pericardiocentesis. The newly dead provide good opportu-nities for teaching and review because there are tremendous bene®ts to begained for both future patients and professionals from practicing procedureson a human subject. Since a corpse is legally no longer a person, lacksinterests, and cannot be harmed, it is considered an excellent subject.However, hospital policy requires permission from the family or a writtenadvance directive before such procedures may be practiced. It is very dif®cultto ask grieving relatives to give consent for procedures on their deceasedloved-ones and, as a result, a timely opportunity frequently eludes the housestaff. A representative hospital policy justi®es relinquishing the real bene®t ofpracticing on the newly dead if consent is not obtained because `̀ while it isnecessary to train health care providers, it is important to respect the dignity ofthe deceased . . . .'' (University of Colorado Hospital, 2001).

A third example illustrates that the obligation of bene®cence is prima facie

and can be overridden by a greater, con¯icting duty. Currently, a woman whochooses to abort a fetus cannot donate the resulting tissue to a speci®crecipient (Bell, 1994). This ruling precludes the initiation or termination of apregnancy with the intent to donate fetal tissue to a speci®c bene®ciary fortherapeutic bene®t. The purpose is to prevent the use of vulnerable human lifeas a commodity. The utilitarian arguments opposed to this ruling cite the useof fetal tissue for transplantation to save another's life as justi®cation to allowdonor-designated recipients (Kinney, 1995±1996). The implicit assumption isthat the duty to alleviate suffering overrides the obligation not to use the fetusas merely a means of therapy.3 In contrast, the reasons supporting the rulingstress the duty not to instrumentalize human life by intentionally becomingpregnant and aborting for therapeutic purposes (Kinney, 1995±1996).Moreover, the separation of the decision to conceive or abort and the decisionto donate negates any allegation of complicity on the part of the medicalprofession in the fetal demise. The reasoning is that the intentional initiation





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of a pregnancy or the abortion of an existing pregnancy to produce tissue fortherapeutic purposes is a breach of ethical limits. For this reason, societyrelinquishes the therapeutic bene®t gained from such procedures.

The obligation to pursue the best care and treatment for patients isindisputable unless a special situation demands a con¯icting action. Inextreme situations, a prima facie duty is overridden for good reason, but it isnot annulled. `̀ The fact that a requirement ± and on occasion this might be animportant ethical obligation or a central professional commitment ± hasproved contingently unmeetable does not exempt an agent from its claims''(O'Neill, 2001). The principle remains in place to inform subsequent action.For example, bene®cence continues to inform the obligation to treat humanlife as an end in itself and, as such, de®nes the practice of good medical care.Bene®cence expresses the nature of medical activity as the service of thepatient's good: `̀ the restoration or improvement of health and, moreproximately, to heal, that is, to cure illness and disease or, when that is notpossible, to care for and help the patient to live with residual pain, discomfort,or disability'' (Pellegrino, 2001, pp. 52-53).

V. THE CONTRADICTION: HUMAN VULNERABILITY

We turn to the work of Immanuel Kant to offer an alternative ethicalperspective from which to analyze legislation regarding therapeutic cloning.In the Groundwork of the Metaphysics of Morals, Kant proposes thecategorical imperative as a means of assessing maxims (Kant, 1956). Thecategorical imperative requires a moral agent theoretically to will an action asa universal practice and then examine it to assess its function as a law ofhuman nature. An action is ethically acceptable if its maxim can be conceivedas a law of nature without a conceptual contradiction or without contradictingthe conditions of human willing. Kant offers examples to illustrate differentdegrees of gravity with the problem of legislating contradictions. His ®rstexample is a suicidal person whose maxim is `̀ from self love to shorten life ifits continuance threatens more evil than it promises pleasure'' (Kant, 1956,G422). Kant argues that such a maxim contradicts itself in that it isincompatible with the notion of humanity as an end in itself. Anything thatcon¯icts with the conditions of continued human existence contradicts thewill. For Kant, because the maxim entails a contradiction, it cannot hold asuniversal law.





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His second example cites a man who borrows money with good reason, anddecides that he will promise to pay it back even though he knows that hecannot. He formulates his maxim based on the consequence that if he tells thelender the truths, he will not receive the much-needed loan. Kant argues thatthis maxim necessarily contradicts itself since it belies the very nature of apromise. His ®nal example describes a rich and talented man who determinesthat he will give himself over to the pursuit of pleasure and not contributeanything to the well-being of others. This maxim contradicts the will since itdenies the claim of mutual need. These maxims are principles of action thatentail inherent contradictions because their content con¯icts with self-interestand counters valued conditions of life: preservation, promise keeping, andmutual assistance. A similar inherent contradiction in the justi®cation oftherapeutic cloning is the basis of the ethical uneasiness that its legalizationengenders.

Herman suggests that the analysis of maxims intended by the formalcategorical imperative procedure consists of two components of the notion ofcontradiction (Herman, 1993). In other words, in order to be noncontradictory,and therefore ethically permissible, a maxim must pass two tests: ®rst, it mustbe conceptually possible (contradiction in conception) and, second, it must notcon¯ict with the will itself (contradiction in will). The ®rst test assesses themost general form of a maxim to express a `̀ deliberative presumption''against certain maxim types (Herman, 1993, p. 117). The second focuses uponthe speci®c content of the maxim, in that it questions whether the maximcontravenes something that we must will as rational agents in a reason-givingsense. The expectation is that the categorical imperative is a form of moraldeliberation that will challenge our moral intuitions and provide reasons toexplain their rightness or wrongness.4

In ethical terms, the legalization of therapeutic cloning is a universalizedmaxim. The general form of the universalized maxim is: scientists and/orphysicians generate human embryonic life when needed as a tool of medicine.The ®rst test is to determine whether or not one can conceive, withoutcontradiction, of a world based upon this maxim. Given suf®cient ®nancialresources and availability of human eggs, it is certainly possible to conceive ofa world where scientists and/or physicians generate cloned embryos as ameans of therapy. It would be possible to sustain a system of nature with thisas a universal maxim. It would be a chilling world, but it is a sustainableworld. The second test of the maxim is whether or not one can theoreticallywill universal therapeutic cloning without one's will contradicting itself. The





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question is asked by the second test: is it cogent to will a world where humanembryonic life has no value and thus provides no reason to impede itsdestruction? Does this contradict the will of rational agents? The contradictionof will test `̀ does not ask whether it would be rational to will the world ofindifference to life in the sense of assessing the risk. The test should ratherbe seen as de®ning a conception of rational willing through its proceduralrequirement'' (Herman, 1993, p. 121).

Herman's construal is a departure from the traditional interpretation ofcontradiction in Kant. It requires that rational willing have content withnormative signi®cance, more content than is traditionally included under theKantian notions of consistency and contradiction. Her value-orientedunderstanding of Kant argues that there are certain things that cannot berationally willed, given the kind of rational beings we are (Herman, 1993).The contradiction of will in the legalization of therapeutic cloning con¯ictswith one of those special conditions of human agency that Herman identi®esas inescapable, vulnerability. Vulnerability is often a function of age, gender,race, religion, class and morbidity. Vulnerable human beings can be defense-less, voiceless, exposed, susceptible to harm, and less able to participate ininformed decision-making. Since we cannot exempt ourselves from thecondition of vulnerability, we cannot ignore the claims of other vulnerablehuman life. For this reason, it is contradictory to will a world in whichvulnerable human life can be deliberately generated and/or destroyed. Manysituations arise when a vulnerable person needs protection. Such a maximcontradicts self-interest in that it jeopardizes the protection that an agent needsin his or her own vulnerability. `̀ It is because we cannot escape the conditionsof our mortality and vulnerability that we may not take the lives of others atwill'' (Herman, 1993, p. 123).

Up to this point, Herman's interpretation applied to the human embryoidenti®es the contradiction of will in generating and destroying humanembryos as the denial of human vulnerability. The contradiction in will is notassessed in terms of harm to the embryo or the loss of embryonic life, butrather in terms of the erroneous valuation of the human embryo as insuf®cientto provide a reason not to generate and destroy it. Having identi®ed a reason,mutual vulnerability, the brunt of the contradiction of will argument `̀ showsthat it is impermissible to discount the value of human life to the currencyof our purposes'' (Herman, 1993, p. 123). Based upon a faulty valuation ofthe human embryonic life, one cannot accurately assess the rightness orwrongness of therapeutic cloning.5





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In a passage in the Groundwork following the formula of the kingdom ofends, Kant makes a distinction that is particularly helpful in further clarifyingthe value of the human embryo. While it is dif®cult or impossible to applyeighteenth century thought directly to a twenty-®rst century concept of thehuman embryo, the exercise is somewhat informative. Kant's ethics assert thatthe rationality of humankind is very different from that of other animals, inthat the human being can set his or her own ends. But, for Kant, rationalitydenotes only an extrinsic value. It is human freedom and autonomy that is theintrinsic basis of worth. `̀ Autonomy is therefore the ground of the dignity ofhuman nature and of every rational nature'' (Kant, 1956, G436). Humanembryos, whether conventional or cloned, have no autonomy or freedom and,as such, are dubious contenders for Kant's moral domain. The capacity formorality is the only condition by which a rational being is an end in itself or alaw-making member in the kingdom of ends (Kant, 1956, G433). To claimotherwise is not the purpose of this discussion.

While a human embryo does not meet the Kantian requirements ofrationality, neither is it a thing that `̀ contains merely the ground of thepossibility of an action'' (Kant, 1956, G427) for reasons developed sub-sequently. Kant sets up a clear distinction between the category of rationalhuman life that has an intrinsic value as an end in itself and things that havepractical or instrumental value as a means to another's end (Kant, 1956,G427). Following the formulation of the kingdom of ends, Kant makes afurther distinction that helps elucidate why it is unethical to generate a humanembryo merely as a tool of research. He divides entities in the kingdom ofends into those things that have a price and those that have a dignity. Thingsthat have a price have an equivalent, something else can be substituted in theirplace; things that have no equivalent have neither substitute nor price (Kant,1956, G434). Kant included morality and `̀ humanity so far as it is capable ofmorality'' among those entities that have no equivalent (1956, G435). I am notarguing that human embryos are capable of morality in the Kantian sense.Rather, I propose that an examination of the categories of things that have aprice will demonstrate that the human embryo is not among them.

In his discussion of things that have a monetary worth, Kant describes twocategories of price, market price and affective price (affektionspreis). Amongthose objects or attributes that have a market price, Kant includes thingsrelated to general human inclinations and needs, for example, skill anddiligence in work. Entities in this category command a price because they area means to another's end or an instrument to achieve a sought-after state of





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affairs. The human embryo exceeds this category because it possesses a fullset of human chromosomes that independently directs its future growth anddevelopment. In the absence of technological manipulation, the embryoautonomously sets its own end; another does not dictate what end it will serve.Kant proceeds to identify a second category of entities that have a price. Itscomponents do not ful®ll a need but merely satisfy a certain taste or preferenceand thus have an affective price. Wit, lively imagination, and humor arequalities that he cites as having an affective price. Entities in this categoryhave a value only if they elicit the favor and approval of the customer. Thehuman embryo supercedes this category because its value is not dependentupon human whim. Rather, the embryo is beyond all price in that it constitutesa necessary condition of human origination.6 At the present time, there is noalternative means of continuing the human race. This is a moral point, as wellas a scienti®c fact, because the continuation of human life is a necessarycondition of morality.

Kant's categorization of things that have a price and those that admit of noequivalent clari®es the anxiety caused by the legalization of therapeuticcloning. It is implausible that human embryonic life could be both withoutequivalent and concurrently a tool of research. If the human embryo exceedsthe categories of entities that have a price and is without equivalent as thesource and symbol of human life, then those who espouse the generation ofembryos merely as a tool of research are mistaken in their valuation and lackthe support they need for their claims.

VI. CONCLUSION

The watershed event in the legalization of therapeutic cloning is the active andunprecedented government support for the generation and destruction ofhuman embryonic life merely as a means of medical advancement. `̀ While thenatural loss of human embryos is not a moral tragedy, their intentionalconception and diversion to meet another's needs may well be'' (Juengst &Fossel, 2000, p. 3183). This technique raises fundamental concerns about howwe value human embryonic life and rank it alongside the research agenda. Inthis situation, utility accepts a dangerous affront to the worth of humanembryonic life in the name of more immediate goals. The concern is that anarrow utilitarian focus ultimately commodities human embryonic life andpreferences outcomes as the sole determinant of moral value and the strategy





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of justi®cation. Instead, the moral event takes place in a dynamic inter-relationship of context, character, motive, and results that cover the fullquality of human action. A moral justi®cation should be as multi-faceted asthe human persons who mount it and the real world situation to which it isapplied. A value-centered approach to ethical analysis arouses an opennessand honest humility about our shared humanity and the reality we live asembodied beings in the world.

NOTES

1. Means and ends are used here in the Kantian sense. Kant's conception of a means is a thing, aperson, or a state of affairs that is a condition for bringing about some other state of affairs. Athing, person, or a state of affairs is a means in so far as it becomes a tool. Tools function in acertain way to bring about a state of affairs that someone desires. In contrast, entitiesconstitute an end when they are valued in themselves without becoming merely a means tosome further end. Kant contends that persons are `̀ ends in themselves'' because in somesense they are outside of causal hierarchies that have a number of causal antecedents andconsequences. Therefore, to treat a person as a means only is to ignore the part of humannature, rationality, that quali®es the person as an ends in itself (Kant, 1956, pp. 429, 431,433).

2. `Intent of the agent' is an important descriptor in the assessment of an act with ethicalimplications. The act represents that which the agent wills (state of affairs), and the intentindicates why the agents acts (motive). These distinctions are critical in ethical assessments,but frequently obscure. Occasionally the desired end of an action is thwarted due tounanticipated accidents or interventions, clouding the moral appraisal of intent. Also, thesame purposeful action can be the result of different motivating concerns, adding anotherfactor to obfuscate the assessment of moral worth. More signi®cantly, the determination ofintent is elusive for only the agent herself can accurately assess her intent.

3. An example from an ethics case assignment done by a ®rst year interdisciplinary group ofhealth care students illustrates this situation. Suppose that Mr. Jones is an aging man withprogressively degenerating Parkinson's disease. His youngest daughter and her husband areexpecting their ®rst child. They realize that genetically compatible stem cells harvested fromtheir fetus' brain could signi®cantly improve Mr. Jones' quality of life. They discuss thepotential donation of their fetus to treat Mr. Jones with their physician. He is unable to helpthem carry out their desire due to the ruling that prohibits a woman from donating fetal tissueto a designated recipient.

4. The categorical imperative (CI) is subject to numerous well-known objections. It is outsideof the scope of this article to respond to critiques of Kant, but it may be helpful toacknowledge them. Some of the common objections include: assessment of very generalmaxims with the CI results in overly rigorous duties and prohibitions, maxims of everydayethical agents are not usually general but contain morally relevant particulars, and anysigni®cant increase in detail of maxims renders clear moral judgments with the CI unlikely(Herman, 1993). Herman offers the two-component test of contradiction as a means of





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taking advantage of the CI procedure's success with very general maxims and provide ameans of assessing speci®c content.

5. Herman claims that she has identi®ed a conception of value at the center of Kant's ethics.That said, she does not suggest that moral judgments are made according to some scale ofvalues but, instead, explicates the conception of value in Kantian moral theory. She extendsthe role of the CI, through the two-test evaluation of contradiction, to determine if the valueof rational agents is acknowledged in a given maxim. As such, it is not the concept of dutybut the judgment of value in rational agents that comprises the heart of Kant's ethics andmakes it `̀ non-teleological'' (Herman, 1993, p. 125).

6. While I have demonstrated the human embryo is not something that commands a price, itdoes not follow that it has a dignity in the Kantian sense. They are incapable of morality and,as such, do not qualify as ends in themselves in Kantian moral theory. Kant is clear about thestatus of those beings that possess rationality and those that are a means to another's end. Heis unclear about those beings that have the potential for rationality. He may not regard beingsthat are incapable of reciprocal moral action as moral beings. My intent here is not toexamine the concepts of potentiality or reciprocity and their application to the humanembryo; that is well beyond the scope of this discussion. My task was to show that the humanembryo is without equivalent in both a Kantian and a scienti®c sense and therefore ismisclassi®ed as a tool of research.

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therapeutic cloning: from consequences to contradiction

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