Community Health Needs Assessment (CHNA) Essay Example for Free

Community Health Needs Assessment (CHNA) Essay In the recent Community Health Needs Assessment (CHNA), orthopedic cases are projected to increase in the Trinity Hospital over the next five years. The assessment displayed that orthopedic cases are likely to flow from 11,800 to 17,338 (+46%); joint and spine procedures by 30%; and outpatient joint and spine procedures are expected to rise by 350%. The assessment highlighted the orthopedic services and the needs of the Trinity community. Some of the needs were shortage on physicians and specialist, gear, physical therapy services, and surgical suites. When looking at the business side of things you must understand supply demand. When demand rises and supply goes unchanged, a shortage will follow leading to greater costs equilibrium and if demand does not change and supply drops a short happens. This means there will be an increase in the overall revenue because of the rise in the demand for the orthopedic services. The community has a high demand for orthopedic services so it is and the population size for the aging community is growing so it is likely these services will be at an all-time high in five years. A recent needs assessment displayed that the current orthopedic cases are expected to rise 46%, with a 30% growth in inpatient joint and spine procedures. As expected outpatient joint and spine procedures are projected to grow by 350%. The orthopedic center is in a high demand area and the numbers show a defined market area within. There are also two private local hospitals in competition with very good orthopedics programs, which makes the need for Trinity’s to have a strong orthopedic program. Research shows that the main location is within the community with a projected population growth of 4%, this sets the demand for a quality orthopedic program to cover the growing community. The needs assessment shows that with an established orthopedic center, it is possible that we are able to provide everyone in the Trinity community with quality service for. It would be very feasible to develop the new center right away in order to meet the demands of the community and provide adequ ate treatment and services with adequate equipment. The orthopedic center development should allow us to incorporate an international trend of providing quality healthcare for all citizens in the community and spending less money. Regardless of the ability to pay we must also look into ways to reduce spending and still providing quality healthcare. The development of a plan that will allow patients to be treated despite financial ability  and health insurance could also help us meet the demand in the community. While our country does not offer a national healthcare system, our facility can incorporate the international trend. In addition to developing an integrated health system developing a selective groups of physicians and healthcare workers to provide adequate services. Currently there are two groups that are moving in the area. Fortunately one group has recently secured office space to open a branch of orthopedic practice on campus with the Trinity community, which helps us move to the integrated healthcare system. This benefit s the Trinity community by providing more services and quality programs to assist more patients. The ultimate goa at Trinity is to provide quality healthcare to all citizens of the Trinity community Robotic surgery and current digital equipment would be complementary to the new orthopedic center in surgical units. In addition to this we are able to accommodate the demands of orthopedic cases we deal with in the facility within our surgical units adequately. The development of the surgery facilities provide the advantage to recruit orthopedic groups that desire to be closer to Trinity and apply for privileges for the facility. There are currently twenty operating rooms that are equipped with the basic setup necessary to accommodate the orthopedic program. The rooms are equipped with two CT scanners, MRI scanner, X-ray, nuclear medicine, mobile PET scanner, and ultrasound services. The nursing staffs at Trinity are devoted and skilled which helps increase orthopedic nursing certification rate to 75% showing that this is a strong area in the facility. Although we may not be highly recommended the drive towards patient quality care it is a major part of the increase in demand of services. Even though all our service lines compliment the orthopedic program, it is clear that we can work hand- in- hand to develop a valued healthcare system and meet the demands, not only for patients but all hospital staff as well. The recent research shows that we could cut cost by building a new 5000 square foot physical therapy/rehab center adjacent to the Trinity campus. The new building costs estimates to about 600,000 verses 700,000 to purchase the space adjacent to the Trinity campus. In order to expand the services by adding a radiology department and have two MRI machines could cost approximately $3,000,000. Currently in the capital reserves we have 25,000,000 so this would be feasible for this service line expansion. Adding an orthopedic center could potential gain approximately 2100 new surgical cases and also gaining about 6500 visits in physical therapy. This can bring the profit margin to about $2,171,500. According to the five year projection plan, it is projected that there will be about $25,000 in gross charges per orthopedic surgical case. It is also clear that there is a $275 in gross charges per physical therapy treatment. 31% is the ratio of cost in charges when calculated. The Medicaid, Medicare and self- pay patients are at an all-time high right now so it is projected that the orthopedic program will increase in revenue and gain more pay-in patients. Developing a bundle payment program can allow the patient insured and uninsured an opportunity to get quality care and treatment in an affordable manor. A community hospital with the orthopedic center in it will be great in the future to help increase utilization, and also make-up for the decreased volume seen with the damage of the OB program and decay of general surgery volumes. An increase in the utilization could help our key financial indicators and also develop an effective profit plan for years to come. In order to increase the amount of specialists that are in the center we will need to target the patients who need total joint care. Developing a patient navigation system for these pacific patients can be a huge way to market the new service line to the community also coordinating care and appointments for the patients. This will also be a chance to provide physicians with the ability to sustain private practices and still work in the facility and have hospital privileges. It is suggested that we continue to work closely with those practices that are moving in the same direction as Trinity help outline the exact plan that has been developed for the marketing. A key marketing strategy that can be used in the marketing area is advertising. Highlighting the high quality services and giving the physicians satisfaction rate which is 90% could convince new patients to come to Trinity. Adding the orthopedic group adjacent to the Trinity campus, a referral service could be developed. The system should be set up as Trinity refers the orthopedic cases to the physicians group who will then in return refer all of their patients to the new orthopedic center for surgery, physical therapy, etc. Working directly with the physicians can give a more unified unit where everyone is able to benefit and also help increase their revenue equally among the practices and the hospital. Marketing can weigh in  on the expanding growth of the orthopedic specialists that are on staff and the new orthopedic center. Patients will be provided with referral information if the patient is in need for physician’s services on Trinity campus. We can also give referral for physicians who are not directly connected to the Trinity facility but have privileges at the facility. These physicians are able to use the referral services and in return refer patients to our facility and the new orthopedic center. Resources Kohn, L. T., Corrigan, J., Richardson, W. C., Donaldson, M. S. (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press. McLaughlin, C. P., Kaluzny, A. D. (1999). Continuous quality improvement in health care: Theory, implementation, and applications. Gaithersburg, MD: Aspen Publishers

Germany’s Inclusion as a Permanent Member of the UN Security Council: Breaking Free from its Historic Subservience :: Essays Papers

Germany’s Inclusion as a Permanent Member of the UN Security Council: Breaking Free from its Historic Subservience The Federal Republic of Germany, once a menacing dictatorship on a path of world domination, is currently the leading nation in the European Union and the third-leading contributor to the United Nations. Germany has come a long way since its reunification in 1990. It is now fully committed to a foreign policy based around peace, stability, and development, Germany is entirely committed to protecting the future of the global community. Germany maintains that the accomplishment of these goals resides in the strengthening of international organizations, specifically the United Nations, and for a more active participation by the German Republic. Germany’s active role in the United Nations can be reflected in its participation amongst the UN’s various arms, specifically the Security Council. Currently on its fourth term as a non-permanent member of the Council, Germany, with a majority of support from the General Assembly of the UN, has declared its willingness for a seat as a permanent member of the Security Council. In an effort to change its bloodied past, Germany hopes its inclusion as a permanent member would allow them to facilitate further peacekeeping missions with greater ease. Additionally, Germany hopes to increase the scope of international developmental projects undertaken by the UN. The idea of a unified federation of the world’s nations was first spawned by German philosopher Immanuel Kant in the late 18th century. Kant believed that this federation of nations would be founded on a platform of â€Å"Universal Hospitality,† in which no person â€Å"had more right than another to a particular part of the earth† (Kant). He also expressed that no country should interfere with the government of another. In addition, larger, more powerful countries shall not use smaller countries for their own gain. Such a federation would perform as a collective security against aggressors. With the conception of the League of Nations, Kant’s doctrine became a reality in the early 20th century after World War I. The League of Nations lasted from 1920 to 1946 with 63 different countries represented (Encarta). Though it lacked the backing of superpowers, such as the United States, and did not sustain its goal of preventing another world war, the League of Nations provided a model for the United Nations in 1941. Germany’s Inclusion as a Permanent Member of the UN Security Council: Breaking Free from its Historic Subservience :: Essays Papers Germany’s Inclusion as a Permanent Member of the UN Security Council: Breaking Free from its Historic Subservience The Federal Republic of Germany, once a menacing dictatorship on a path of world domination, is currently the leading nation in the European Union and the third-leading contributor to the United Nations. Germany has come a long way since its reunification in 1990. It is now fully committed to a foreign policy based around peace, stability, and development, Germany is entirely committed to protecting the future of the global community. Germany maintains that the accomplishment of these goals resides in the strengthening of international organizations, specifically the United Nations, and for a more active participation by the German Republic. Germany’s active role in the United Nations can be reflected in its participation amongst the UN’s various arms, specifically the Security Council. Currently on its fourth term as a non-permanent member of the Council, Germany, with a majority of support from the General Assembly of the UN, has declared its willingness for a seat as a permanent member of the Security Council. In an effort to change its bloodied past, Germany hopes its inclusion as a permanent member would allow them to facilitate further peacekeeping missions with greater ease. Additionally, Germany hopes to increase the scope of international developmental projects undertaken by the UN. The idea of a unified federation of the world’s nations was first spawned by German philosopher Immanuel Kant in the late 18th century. Kant believed that this federation of nations would be founded on a platform of â€Å"Universal Hospitality,† in which no person â€Å"had more right than another to a particular part of the earth† (Kant). He also expressed that no country should interfere with the government of another. In addition, larger, more powerful countries shall not use smaller countries for their own gain. Such a federation would perform as a collective security against aggressors. With the conception of the League of Nations, Kant’s doctrine became a reality in the early 20th century after World War I. The League of Nations lasted from 1920 to 1946 with 63 different countries represented (Encarta). Though it lacked the backing of superpowers, such as the United States, and did not sustain its goal of preventing another world war, the League of Nations provided a model for the United Nations in 1941.

How Is Globalization Affecting the Spread Of Diseases? Essay

Although there are several articles discussing globalization and health, it is important to understand the processes of globalization affecting health outcomes and the local and global health responses. One of the major focal point of this article has been the association of globalization and infectious disease. Although globalization is already at widespread interest on its emergence and impact, there’s still a limited agreement on what is it precisely. Globalization is a term that is behind misunderstood by many of us. Its definition is dependent upon ones arguments. The term is being contested by many people who are in big dispute regarding the issue. Some of us may define it as a process of increasing global temperature due to undisciplined chores of people. However, this meaning is just a part of its definition as understood by many of contemporary people even scientists. Globalization is manifested in the increase of international transportation, communication and other people chores. It is a complicated and multi-faceted set of processes having widespread impacts on humans. According to Saker et. al. (2004), globalization is defined as â€Å"changing the nature of human interaction across a wide range of spheres including the economic, political, social, technological and environment†¦.. the process of change can be described as globalizing in the sense that boundaries of various kinds are becoming eroded. This erosion can be seen to be occurring along three dimensions: spatial, temporal and cognitive. † It is being motivated and constrained by a couple of forces: economic processes, technological developments, political influences, cultural and value systems, and social and natural environmental forces. These forces have direct or indirect effects to the health aspects among humans at a number of different levels. As globalization experienced by the different parts of the world, some wide-range changes impacting on the health aspects remains unclear. This paper will tackle about the interrelation between globalization and spreading of infectious diseases. In addition, it will also discuss, in some cases, the management of diseases. It also aims to improve the understanding regarding the phenomenon as it influences infectious diseases. Thesis Statement Because of the alarming incidence of the spread of many diseases among different countries, many believe that one of the major causes of this spread is globalization itself by physical, natural, social, cultural, economical, political, and technological interaction between countries. Globalization: An Interdisciplinary Approach The phenomenon affects many of social aspects including health. The redistribution and movement of bacteria or viruses is one of the detrimental effects of globalization. We know that globalization is a big opportunity for the economy to boost. However, it is also the factor that promotes unfriendly social force that affects those in the periphery of societies. The two sides endorse a negative aspects but it also support for a positive effects. Then, what really is globalization, for bad or for good? If we try to scrutinize the aspect and all of its processes of globalization, we could find out that health sciences could benefit from the explicit thoughtful understanding of the phenomenon. Globalization really changed the health aspects of the whole planet. Many infected persons of a certain disease don’t know its causes or even the disease itself. Diseases are coming closer to us because of international travels become easy, simple and common place. Globalization, together with climate change, bridges the easy advancement and transfer of pathogens. Common dieses could become a plague and virulent diseases. For instance, due to the ever-changing ecosystems, vector-borne diseases such as the Bluetongue virus and West Nile Fever have spread extremely. Besides, the circulation and propagation of Food and Mouth Disease is caused by the intensification of commercial movement. Northoff (2007) said that â€Å"most of the emerging infectious diseases are not new: they began by affecting animals, but as time has passed, the diseases breached the species barrier. † Globalization as Disciplines The processes of globalization have a potential force in the influence in health, economy and politics. Globalization brings couple of positive effects in terms as developed in international relations, political economy, and health society. As being stated regarding the inference of globalization: â€Å"an understanding of global health issues at the turn of the twenty-first century could benefit substantially from the voluminous literature on globalization from international relations, including the subfields of social and political theory and international political economy. This is a rich and voluminous literature. It documents what structural changes are occurring toward a global political economy, how power relationships are embedded within this process of change, what varying impacts this may have on individuals and groups†¦Ã¢â‚¬  (Mayer, 2008). It just implies that globalization is more than a mere increase in â€Å"international independence and international connectivity† (Mayer, 2008). Another negative factor it brings is the deviated patterns in diseases due to regular change social and natural patterns. Many decades and, perhaps, centuries old had established historical transformation. According to Mayer (2008), â€Å"globalization certainly contains elements of increasing global interdependency, the decline of international boundaries as deterministic social constructs, and the erosion of distance as an inhibitor of human interaction for some but not all segments of societies—though the effects of distance are highly variable, and some societies remain locally constrained. † Furthermore, the term is not only referring to the regular advances of increasing goods and people, but also to the movement of capital. According to Dr. Jeffrey Koplan, director of the Centers for Disease Control and Prevention, infectious and chronic diseases is not locally widespread but also permeate globally (â€Å"CDC Says Globalization Will Affect Disease Spreading†, 2002). Koplan stated that illnesses and globalization are being related to one another. He said that â€Å" because globalization sets a common agenda for the public health workers of the world, more opportunities are available to developing countries that previously trailed behind most other nations† (â€Å"CDC Says Globalization Will Affect Disease Spreading†, 2002). In addition, he stated that physical borders are practically worthless. He said the biggest risk is the speed at which diseases can be multiply and extended. According to him, due to population amplification, diseases are also gained its spreading due to constant mixture of people and infectious diseases. He also added that as country reach the level of Industrialization, people also become wealthier. Affluence brings new health fear such as obesity. Most of developed countries have a high incidence of a bad health lifestyle and they have high rates of cardiovascular diseases. According to Northoff (2007), the bluetongue virus is widely spreading as it is infected the United States. The virus is an animal virus that recently arrived in the US. It just implies that no country could claim that they are free from any diseases. This non-contagious virus affects all the ruminants such as goats, deer, cattle and sheep. However, this virus is not transmitted directly between animals and no effects in humans. The bluetongue virus was first revealed in South Africa but it has already reached many countries. In fact, it already traversed the Mediterranean by the end of 1990s. The virus had been found in Belgium, Luxembourg, Netherlands, and North France and United Kingdom since the summer of 2006. The reason upon the continuous and increased pace of spread of the virus remains unclear. The virus was already acclimatized to new local insect carrier of the Culicoides genus which endures cold temperature. Indeed, some people couldn’t believe that the virus already affects European countries considering their high latitudes. According to Northoff (2007), the virus is already prevalent in Corsica and Sardinia but could even endure in northern European countries. In addition, he said that â€Å"Transboundary animal diseases† are originally restricted to tropical countries but they are already swelling due to globalization such as West Nile Virus, transmitted through mosquitoes or carried by birds, Leishmaniasis, a parasitic ailment that proliferates through the bite of infected sand flies and tick-borne Crimean Congo Haemorrhagic Fever. African horse sickness, a disease passed on by the same midges that also carry bluetongue and African swine fever. Mosquitoes that also bring diseases such as dengue also reached European countries. Influenza, or better known as Flu, is the most common disease in animals today. In 1918 in Spain, the first great flu plague had happened. It was recorded that 40 million people died from the H1N1 strain of the virus. Also, in 1957, the H3N2 and latter the H4N2 was seen damaging many lives. Globalization brings also the resistance of bird flu, a highly pathogenic strain of avail influenza called the H5N1 virus type. In fact, in the past four years, there were 251 recorded cases of H5N1, among them are fatal. This case merely suggests that we are in the predecessor level of a Bubonic plague. Since the globalization refers to the movement of people, goods, tourism and other aspects, it also favors the widespread of animal viruses and other diseases around the planet. The exposure and immunity of viruses and bacteria causing diseases increase their mobility and resistance that international community should take it seriously. With regard, early detection of these viruses is needed as an effective defense mechanism. In order for these measures to be taken up successfully, strong political support and funding of a government is required considering most of the countries are not prepared with this new threat. The challenges that we are facing today and being aggravated by globalization, suggest that we must be aware and vigilant to find partnerships for the deterrence and control of epidemics and pandemics. These cases and the treatment of diseases and the development of preventive measures should be delve into and advanced. Collaboration may be the best strategy to be able to research, develop and provide medications to prevent and treat neglected diseases before it become a pestilence. Since diseases have no physical countries when it comes to their spreading out, international support among countries involved. Without the collaboration and cooperation of those infected countries will lead to the widespread of the diseases among other parts of the world. From time to time, it may be also necessary to convince the authorities of the countries involved that cooperation is very important. In addition, for our health security to be secured, it is essential to promote partnerships between private and public sectors. In this way, research and development of neglected diseases are increased and advanced and the spread of viruses at their source could be attacked. There are treatments of some diseases but they are very toxic, often causing death, and ordinary people couldn’t buy it for it is so expensive. Even worse, there are diseases that have no treatments which results to sudden death. Spreading of infectious Disease Some pathogens live in the environment and affect human directly. However, some pathogens, can only survive as a host. If the transmission occurs between humans, the infection is transmittable. The processes and mode of transmission is influenced by different factors. For example, according to Saker et. al (2004), â€Å"transmission of vector-borne diseases is influenced by factors which affect vector numbers (e. g. warmer temperature increases mosquito reproduction rates), contact between humans and vectors (e. g. tourism brings people to areas where malaria-carrying-immune people to areas where malaria is prevalent), intermediate host numbers (e. g. dams provide breeding grounds for snails carrying schistosomiasis), or human or animal behaviors (e. g. warmer temperatures encourage people to bathe in pools, which may be contaminated by schictosome larvae. † Pathogens are highly receptive to the surroundings. The reasons are: their ability to live and multiply depends on the existing right climatic and nutritional conditions and local conditions. Saker et. al (2004, page 10) stated: â€Å"Diverse environmental factors, such as ambient climate and the presence or absence of overcrowding, clean water or particular types of flora and fauna, influence a pathogen’s chances of flourishing and causing disease. Some pathogens thrive in warm and wet climates while others only survive in colder, drier conditions. Still others can survive almost anywhere. Thus some pathogens cause disease worldwide while others are only found in well-defined areas where the local environment is favorable to their propagation. The latter is particularly true for vector-borne diseases since here the local environment needs to support the survival and multiplication of not only the offending pathogen but also the relevant vector and often a third host as well. † Since, in general, the rate at which a single case of human illness generates new infections depends on the combination of biological and social factors. Thus, transmission is affected not only in the number of infectious agents but also by the living states of the human population. References: (2002). CDC Says Globalization Will Affect Disease Spreading. Retrieved April 26, 2008, from Boston University Website: http://media. www. dailyfreepress. com/media/storage/paper87/news/2002/02/14/News/Cd c-Says.Globalization. Will. Affect. Disease. Spreading-184907-page2. shtml Northoff, E. (2007). Spread of bluetongue confirms animal diseases on the rise. Retrieved April 26, 2008, from Food and Agriculture Organization of the United Nations Website: http://www. fao. org/newsroom/en/news/2007/1000675/index. html Mayer, J. (2008) The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Workshop Summary – Forum on Microbial Threats. Retrieved April 26, 2008 from Washington: Website: http://books. nap. edu/openbook. php? record_id=11588&page=197 UNESCAP. Globalization and Health. Retrieved April 26, 2008, from Bangkok: Website: http://209. 85. 175. 104/search? q=cache:K0_IsfsCTaQJ:lib_user5. unescap. org/esid/hds/issu es/GlobalizationHealth. pdf+HOW+GLOBALIZATION+AFFECTING+SPREAD+DISE ASES&hl=tl&ct=clnk&cd=6&gl=ph Kerpelman, T. (2008). Aid & Trade: Containing Pandemics. Retrieved April 26, 2008, from ICVolunteers Website: : http://www. icvolunteers. org/index. php? what=news&id=302 Saker, et. Al. (2004). Globalization and Infectious Disease: A review of the Linkages. World Health Organization

The stem cell debate - Free Essay Example

Sample details Pages: 33 Words: 9996 Downloads: 9 Date added: 2017/06/26 Category Statistics Essay Did you like this example? 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. Don’t waste time! Our writers will create an original "The stem cell debate" essay for you Create order 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 Bushs 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 cellhuman embryonic stem cellshas 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 alonetheir 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 expireswhether it is destroyed or merely succumbsmake 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 calculationa 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 wh en 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 changeif 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 womens body parts are at risk of being commodified, and their acts of altruistic dona tion 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 embryohow 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 embryosparticularly 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 actionthe 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 embryosup 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 ones 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 someones life. For example, assa ssinating Hitler and saving 6 million Jews, or even pulling the plug on life-support in order to spare someones 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 peoples 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 harmto 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 persons 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 po int 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 Dworkins 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 Dworkins 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 peoples 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 peoples 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 respectfullyfor 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 Dworkins 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 ones life at the expense of another by asking how one knows that his life is more valuable than his neighbors. Perhaps your neighbors 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 persons 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 womans 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, Alzheimers disease, and Parkinsons 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 mothers 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 mothers 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 adults 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: https://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 bodys 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 cells 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 cant scientists find a way to unmask all of a cells 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 dont 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 dont 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 Childrens 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.