SOCIOECONOMIC IMPLICATIONS OF FETAL TRANSPLANTATION AN EXERCISE IN BIOETHICS
Gene Davis, Susan Goldie, Robert Stamper
New discoveries in biology and the technological application of these discoveries lead to many ethical problems. If our students are to be prepared for a life that will be surrounded by these dilemmas, they must be given the opportunities to think about the implications inherent in the novel situations that will arise. Actually. many ethical and moral problems appear almost daily in the current news. This module attempts to present students with a typical situation, requiring them to learn some basic information in order to understand the problem and to delve into their own personal ethics to arrive at a resolution of the problem. The exercise uses various techniques that are considered to be essential in the development of a mature social ethic.
Objectives: In this unit students will:
Format: Cooperative Learning
Students are divided into groups of five to seven. They select a leader to control the activity, a recorder to write down the group responses and a dealer to pass out information cards. As a group they answer questions and discuss the ethical problems when read by the group leader.
The teacher should roam about the room to act as a facilitator and to keep students on task.
Time: One or two 40-minute periods.
The teacher has the option to delete specific questions, ethical discussions and/or story segments.
Grade Level: This activity is intended for students in grades nine through twelve.
Subject Fields: Biology, Social Studies.
If students have never discussed ethical problems or case studies before, some basic directions would be necessary. Also, it is necessary that the students have previous knowledge of some very basic embryology and immunology. (Check the information cards for the extent of this knowledge.)
Follow-up and Evaluation (any of the following may be useful):
In 1986 the first published reports of the use of fetal tissue transplants in the treatment of Parkinson's disease focused attention on the potential social and economic impact such use of fetal tissues may have. These transplants, performed in Mexico, Sweden, and England, were intended to implant fetal dopamine secreting stem cells into the substantia nigra of patients whose own dopamine secreting cells had degenerated. Since fetal cells do not carry marker proteins they do not initiate an immune response in the host and are, therefore, capable of being incorporated into the host's body and of functioning as normal cells in the host - i.e.: as dopamine secreting cells.
The use of fetal tissue in therapeutic procedures raises many ethical issues. Indeed, the very source of fetal tissue, abortion, could become part of an enlarged discussion of fetal tissue transplantation. Obviously, such consideration would result in diverting the discussion from focusing on the basic issue. In a set of recommendations published in 1988 by a NIH panel on Human Fetal Transplantation Research, the panel wisely sidesteps the issue of abortion by adopting a position that even if abortion is immoral, its immorality can be separated from the use of fetal tissue for research by the "appropriate public policy." These recommendations were used by the U.S. House of Representatives as an ethical basis for its recently passed bill H.R. 2507
H.R. 2507 attempts to address such issues as separating the influence of fetal tissue use from the decision to have an abortion, and the possibility that a potential exists for sale of aborted fetuses by women deciding to abort. This bill would have the donor sign a statement to the effect that her decision to donate fetal tissue was made independent of her decision to undergo the abortion. This statement would then follow the tissue and be available for audit by appropriate Federal or State officials. Clearly, this raises concerns for the privacy of the donor as well as the right of government to legislate morality.
Currently, 1.3 - 1.5 million abortions are performed in the United States annually. These do not all yield tissue that can be used in tissue transplant therapy. Obviously, this means that there is a finite number of abortuses of appropriate age: before surface proteins make immune response a consideration and before cells have developed a level of structural specificity that would eliminate them for transplant use. These same considerations eliminate fetal cells from tissue culture procedures. The only source of fetal cells for some transplant procedures at this time is fresh abortuses.
It would be naive to assume that successful use of fetal tissue would be confined to one procedure only. New applications would generate an increased demand for tissues and one could foresee a time when the available tissue produced in the United States could not fill such demand. Already success has been reported in the use of fetal thymus in the reconstitution of a severe combined immunodeficient (SCID) child in Italy. The resulting chimera is now 14 years old and exhibits normal immune responses even though his T cells are of fetal donor origin. This is only one of what one must assume to be a deluge of new uses of and demand for a limited resource. Looking ahead it is possible to hypothesize further demands resulting from in-utero corrective therapies that utilize fetal cells. The list will lengthen.
Given the potential for growth in demand for fetal tissues and the fixed amount of such tissue generated by legal means in this country the possibility for a black market looms. Trade in fetal tissue could impact third world nations resulting in trafficking by persons whose motives are purely profit. The whole issue of quality is a further adjunct to an increase in the demand for fetal tissue. How are recipients to be assured of getting viable tissue that will suit the therapy ? With an increase in demand for fetal tissue, who will receive transplant therapy when both a SCID patient and a Parkinson's patient need the only available cells? What criteria will be used to decide?
We have tried to raise your consciousness with regard to the social and economic ramifications of a developing field. What follows is a case study based on recent research in fetal transplantation. The accompanying questions serve as models upon which dialogue may be developed in cooperative learning groups. It is hoped that this dialogue will both help students develop an appreciation for the complexity of the ethical issues raised as well as provide a review of the anatomy and physiology of the immune system.
Note: This exercise uses information cards to help the students along and thus save time. It requires the students to recognize information that will be important to the solution of the problem and also involves all of the students in the process. For advanced students this procedure may not be necessary since they may either already know the information or may be assigned to look up the information as an extra assignment.
FETAL TISSUE TRANSPLANT
Sit in a circle so that each member of the group can easily converse with any other member. Select one member of your group for each of the following activities:
Leader - reads the story and controls the discussion.
Recorder - writes down the answers as determined by the group.
Dealer - passes out the Information Cards, continuing around the circle until no cards remain.
There are three sections to each part of this study: the Story which is a narrative that presents a situation involving the necessity to make ethical decisions, a Question section to aid you with the understanding of background material and an Ethical Discussion.
The leader first reads the Story and then continues with asking the questions. When a Question is asked by the Leader, group members should examine their Information Cards to see if they have information that will help with the answer. Those that have usable information read the information to the group. More than one card may be necessary to answer a question. Group members are not permitted to exchange Information Cards or read what other members have on their cards.
Once group members understand the background information the Ethical Discussion can attempted.
There are always many solutions to an ethical problem. There is NO right solution. Do NOT write down what you FEEL, but what you conclude after considering who will be affected by the decision, the values involved and the relative importance of each value.
Dr. Burns is a medical doctor who is working in a research hospital. She has hypothesized that fetal tissue injected into a baby with severe combined immunodeficiency disease (SCID) would develop in such a way as to cure this disease.
Questions: (Use the information cards to help you answer these questions. More than one card may be necessary to completely answer a question.)
1. What is meant by fetal tissue?
2. What is an immunodeficiency disease?
3. What happens to cells as they develop?
4. What problem would be expected to occur when the cells from one person are placed within the body of another person?
5. What characteristics of fetal tissue might make it suitable for such an operation?
Ethical Discussion A:
a. What dilemma does Dr. Burns face? List all of the ethical problems that may arise as a result of this dilemma.
b. What is the range of values to be considered?
c. Examine these values in light of the situation presented and decide which should take precedence. Give reasons to support your ranking.
d. Explain why you think Dr. Burns should or should not be able to do such an experiment.
e. List additional information that you think would be necessary to know about before you choose what would be the most appropriate solution.
Dr. Burns has had twelve years of experience in this field of research. Recently, she tested a transplant technique on 48 nude mice and found that the procedure worked in 87% of the mice. Later, the technique was successful in 72% of the operations performed on Rhesus monkeys. The Rhesus monkeys had been treated with drugs that destroyed the ability of their immune systems to operate. The fetal tissue for these experiments had been obtained from women who had abortions in the hospital where Dr. Burns works.
6. What characteristics must the fetal tissue have for a successful operation?
7. Why did Dr. Burns test the hypothesis on animals before testing on humans?
8. Why did Dr. Burns experiment with mice before monkeys were used?
9. Why would the information gained from monkeys be more valuable than that obtained from mice? Should Dr. Burns have treated the monkeys with drugs first?
10. Why did Dr. Burns use nude mice for her experiments?
Ethical Discussion B:
f. Should Dr. Burns be allowed to experiment on animals? Give your reasons.
g. Do you think the results of the experiments with animals were good enough for human experimentation to begin? Would you require 100% success with animals first? Would you want more animals tested? What problems might prevent the testing of more animals?
h. Make two lists: one with reasons supporting the use of fetal tissue and one supporting the prohibition of the use of fetal tissue. Rate the reasons in each column from the most important to the least important. From your ratings determine what course of action seems to be the best.
i. If your mother had a SCID child, would your assessment of the situation change? What if your best friend had a SCID child?
j. Should the mother's permission be obtained for the experimental use of her fetus? Should the mother be paid for giving her fetus to the hospital for experimental use?
k. Should the mother's permission be obtained for medical use of the fetus (the curing of a disease)? Should the mother be paid for giving her fetus to the hospital for medical use?
l. Should the mother be able to name the recipient of the fetal tissue?
Caroline is not married and is on welfare. Two days ago she had a baby, Jeff, who was identified as having SCID. That same day Marilyn Stone had an abortion because she and her husband felt that their family was big enough. Dr. Burns obtained the fetus. During many hours of delicate work she removed the essential tissue from the fetus and transfused it into the blood of SCID baby Jeff.
11. What special care must a SCID baby have in order to remain alive?
12. What specific immunological problem do SCID people have?
13. What kind of fetal cells did the researcher use in order to make this transplant? Why are these cells necessary for an immune system to function properly?
14. Why didn't baby Jeff's body reject the injected cells?
Ethical Discussion C:
m. Explain why Dr. Burns should or should not have performed this operation.
n. Should Dr. Burns' plans for the operation have been approved by some kind of a medical review board before she tried the operation?
o. Before the operation the mother, Caroline, could not have afforded to pay for the medical costs needed to keep her baby Jeff alive. Who, then, would have had the responsibility to pay for his care?
p. List the problems that might occur if the demand for fetal tissue for operations such as SCID is greater than the amount of fetal tissue available.
q. If Dr. Burns cannot find fetal tissue when she needs it, should she search for sources outside of this country?
r. If fetal tissue is scarce, what means should be used to determine who will receive the tissue for an operation?
The U.S. House of Representatives passed H.R. 2507 in an attempt to restore federal funding to research into transplanting human fetal tissue. President Bush appointed a panel to investigate fetal research and its ethical implications. Even though the panel recommended the continuation of fetal research with certain restrictions, President Bush continued the moratorium on such research.
Fetal research is being done in other countries and in a few private institutions in the U.S. Success has been found in the treatment of Parkinson's Disease and Alzheimer's Disease.
The hospital's Board of Review tells Dr. Burns that since the hospital is partially funded by federal money she must cease her fetal transplant studies.
15. Why are fetal transplants useful in the treatment of Parkinson's Disease?
16. How do fetal transplants help cure Alzheimer's Disease?
17. What is meant by tissue culture?
Ethical Discussion D:
s. What options are open to Dr. Burns now?
t. List at least three reasons why President Bush would continue the moratorium on fetal transplants when the techniques could be helpful to many people.
u. Will the moratorium on the availability of fetal tissue provide opportunities for the development of a tissue black market?
v. If tissue culture of fetal tissues becomes commercialized, to whom should the tissue belong? Should the donor of the fetus receive residuals in the same way that people in the music industry do when their records and tapes are played commercially?
w. In the U.S. it is illegal to sell human organs: they are always donated to an organ pool. If fetal tissue can be maintained in a relatively undifferentiated state, and biotechnology can determine the future of these cells, does this mean that selling fetal tissue is selling human organs?
(Information to the teacher)
Each group will require a complete set of Information Cards.
Before the activity cut out each Information Card with scissors. They will last longer if they are glued to 3 X 5 cards and laminated.