Ethical Issues in Stem Cell Therapy From the Micro to the Macro

Thomas A. Shannon Department of Humanities and Arts
Worcester Polytechnic Institute

I. Introduction

As with many developments in bioethics in the last decade, stem cell research and the promises implicit in it hit both the scientific community and the media with a cosmic explosion, leaving in its dust many people--scientists and ethicists, among others--who were both astonished and confused about this latest development. What I want to highlight in this presentation is that this therapy has both micro and macro issues and while many have focused on the micro issues--the status of the organism from which the stem cells are obtained, the macro issues--commitment to high tech medicine and therapies that are directed to the privileged--are often neglected. I will argue that while there are ethical justifications possible for obtaining stem cells from human embryonic tissue, nonetheless the larger social issues argue for at least caution in pursuing stem cell research.

II. Stem Cell Research: The Micro Ethical Issue

The most critical micro ethical issue in stem cell research is the source of the stem cells themselves: the human embryo. These have been obtained in two different ways: one is from germ cells from aborted fetuses and the other is from cells from embryos not used in IVF.

In the former case, the particular ethical issue is that of cooperation in the evil of abortion--assuming of course that abortion is a moral wrong. If abortion is not a moral wrong, the particular micro ethical problem is ensuring the separation of the consent to use the tissue for this purpose from the consent to the abortion to ensure that the abortion is not coerced. If one thinks that abortion is wrong, one could still argue that researchers using the tissue are at a sufficient moral distance from the abortion to be able to use the tissue.

The latter case--using embryos from IVF clinics or, as some would want, generating embryos to obtain their stem cells--presents the more difficult--for many--ethical problems. If one's position is that personhood begins with the process of fertilization, then one would argue that no human embryo could be used in this way. I wish to develop the other possibility: namely, that while bearing a unique--at least thus far--genetic code and while assuredly human, the embryo at this stage is not a person and thus some interventions can be done.

For me this argument has three levels. First, though genetically unique, the cells in the very early embryo--at the zygote and blastomere stages--are totipotent. That is, they are not yet differentiated or committed to the particular cells they will become in the body--heart cells, liver cells, etc. These totipotent cells have the capacity to become any body part--hence their obvious desirability for stem cell research. However, the very totipotency of the cells, while conferring some biological unity on the developing organism, also strongly suggest the absence of a more critical ontological level of organization.

Second, again--though genetically unique at this stage and because the cells are yet totipotent--the developing organism is not individualized. That is, while this organism has a biological unity and organization, its cells can still be separated through twining or divided through embryo division and thus different whole organisms obtained. The blastomere is an organism that can be divided into parts each of which can become another organism. Such an organism is divisible such that its parts can become wholes. And such an organism is by definition not an individual. For an individual is literally indivisible--or if divided, is divided in such a way that what remains are parts only. The individual is no longer there.

Third, though the NBAC describes this as a human life form, I think a more suitable, though perhaps more complicated, way of thinking of the early embryo till the time of differentiation is that of a biological expression of human nature. I base this on the philosophy of individuation of the medieval philosopher Duns Scotus who I assure you had never hear of stem cells, much less anything else in modern genetics. But I think elements in his theory of individuation lend themselves in a particularly helpful way to evaluate morally the status of the blastomere. The term Scotus uses is "common nature" and is a part of his larger theory of individualization. This common nature is essentially the basis for the definition of an entity--what all members of a particular class share in common. But what is important for Scotus is that this common nature is indifferent to being either a particular individual or referring to all members of that particular class. Thus, for Scotus, the common nature needs something else--an individualizing principle--to make it a particular being of this class. Additionally this common nature has a unity to it, but a unity less than a numerical unity. That is, the common nature is not an individual being---which would by definition give it a numerical unity--but rather has a unity characteristic of or common to members of the entities it defines. Scotus' principle of individuation constricts, as he says, the form of this common nature into an individual, rendering this being individual, unique, and distinct from all others of the same species. This process of individuation also renders it indivisible, thus giving it a numerical unity and, therefore, incapable of being divided into two wholes.

We can think of the blastomere as the biological equivalent of Scotus' concept of common nature because while this entity is genetically distinct from its parents, it is not yet individualized. This does not occur until after the process of restriction is completed, some two weeks after fertilization is completed. To my mind this process is an interesting biological compliment to Scotus' concept of common nature's being constricted into an individual. After this process is completed, the cells become committed to being specific cells in specific body parts. This is the biological beginning of true individuality and marks a critical ethical line.

Until the line of individuation is crossed biologically, these cells are indifferent to becoming specific cells in this particular body by virtue of their totipotency; they are not morally privileged by virtue of individuality or, a fortiori, by personhood. They are morally privileged by being human cells, cells which manifest the human genome, and an entity which represents the essence of human nature. Essentially such research would be utilizing cells that in fact are the reality of human nature in its most basic form and meaning. Such a presentation of human nature in the blastomere is preindividual and prepersonal. And because this is human nature and not individualized human nature (the minimal definition of personhood), I argue that cells from this entity could be used in research to obtain stem cells. Clearly consent from those from whom such entities come must be obtained for this research and the blastomeres must be handled with respect. But ultimately, such research is not research on a human person; it is research on human nature and in principle is morally permissible.

Yet a word of caution needs to be added here. To use such cells in research is to objectify human nature, to make it a means to an end. While it is clear that--all things being equal--it is ethical to do research on humans and while it is clear that humans can donate body parts for research, it is another thing to generate human embryos exclusively for research. While I would not argue that ending the life of such an organism at the totipotent stage is murder--for there is no subject of such an act--such a means of obtaining stem cells does reduce the embryo to an object. Therefore, we need to be exceptionally cautious about such use and perhaps make the use of such cells the last resort.

III. Stem Cell Research: The Macro Ethical Issues

The promise of stem cell research is significant and important. There is the likelihood of using such cells for drug development, toxicity testing, study of developmental processes, learning about gene control, and developing specific cells for use with bone marrow, nerve cells, heart muscle cells, and pancreatic islet cells. The further promise of such research is captured the common description of such cells as "immortal". The hope is that such cells can be directed to develop in specific ways so they can be directly injected into the problem area and these cells can replace or compensate for the diseased cells there.

Several comments are in order. First, the promise. One of the characteristics of research into genetics is exaggeration and inflation of claims or, as it is called by some, gene hype. One of the most extreme examples was the claim by a senior scientist at the beginning of the genome project that the success of the project would lead to solving the problems of poverty and homelessness. While everyone can appreciate the ridiculousness of this claim, others claims are not seen as exaggerations or as significant promissory notes. What we have yet to recognize is the immense and substantive gap between discovery and cure. This is not an argument against stem cell research per se. It is a call to recognize inflated claims that are used to justify commitment of money to a process that is highly experimental and untested. The claim is not the reality, but one would not always know that from listening to discussions of various discoveries.

Second, commitment to stem cell research is a commitment to business as usual in the medical community. That is, a commitment to stem cell research is a commitment to high tech, very expensive rescue medicine. Now clearly that is the dominant mode of medicine practiced across much of the United States, particularly in the wealthier areas. And clearly high tech medicine is where the money is to be made. Pursuing stem cell research continues this practice and continues to draw large sums of money from other possible uses. As with all other research efforts, particularly in the area of genetics, stem cell research offers great promise for the cure of diseases. But the success of such research will be extremely costly and the product of such research will also be costly because investors will be seeking an adequate return on their investment.

Additionally, as E. Richard Gould points out, a commitment to secure property values in human body parts such as embryonic tissue commits us implicitly to specific health policies. First, we will seek out cures for diseases and turn "away from discovering the underlying social and environmental causes of diseases." Second, we would commit ourselves to a health policy "that holds that health status is improved by access to newer and better treatments." Finally, this policy would suggest that "disease ought to be viewed as an individual problem specifically as a problem of the individual's genetic code, in stead of as a social problem."

The very difficult social question is: is this the way to continue to go with research and medicine? Should we continue down the track of high tech, rescue medicine with its emphasis on intervention and cure or is it time to have a substantive conversation on other models of medical practice and medical intervention? I do not want to pick on stem cell research, but it is clear example of another promissory note in modern medicine with the payment to be picked up at the cost of other interventions and research into human well being, as well as the delivery of health care itself.

Third, who will be the beneficiaries of stem cell research? The rhetoric is that all will benefit. But in the meantime, the benefit will be reaped by two groups. One: those who are insured and whose insurance will cover the treatment. Two: those who can afford to buy it. Because of the millions of Americans who are uninsured, underinsured or whose insurance will not cover such experimental protocols, the vast majority of citizens will not have access to whatever benefits come from this therapy. Additionally, depending on how the science goes, researchers may focus on single cell genetic diseases because these are easier to identify and target. But again this narrows the field of application considerably. While it may be the case that research on single cell genetic diseases using material derived from stem cells provides the possibility of cure for many who might otherwise be without a remedy for their disease, nonetheless this is still a significant directing of scarce resource of research money to a small population. Thus, even should the therapy prove successful, the number of people who stand to benefit from it are a small subset of the whole population and perhaps even a small subset of all those with genetic diseases.

Fourth, and already alluded to, is the cost of such treatment in both experimental and therapeutic stages. This kind of research is time consuming and labor intensive. While computers and other automated systems aid tremendously, the main part of the work is both theoretical--understanding genetic structures and planning the research--and practical--carrying out the experiments and studying their results. Well-equipped labs with sophisticated equipment in addition to a highly trained staff are the basic entry requirements for this kind of work. And if much of the research will be funded by private capital because of current federal difficulties over the use of human embryos, one can be sure investors will want a return. And as mentioned, that return will take the form of expensive therapy. Patients whose incomes are not in the upper 5% would not be able to pay for such therapy--as they are not able to pay for many other therapies in our current medical system. Even those who have good insurance plans will have difficulties because of the continued restriction on what will be covered by such plans and a growing reluctance to fund experimental therapies. Again the number of possible beneficiaries narrows.

In an early paper on justice and the HGP, Karen Lebacqz suggested that one way to achieve justice would be through some form of price controls in any medications or interventions resulting from HGP research since this research is supported in part by public funding. Thus while private capital investments are an important source of funding for the HGP, significant monies are derived from, for example, the NIH. My point is not that such funding is wrong or improper; rather, it is to suggest that there is an obligation in justice to acknowledge these public sources of funding and a relatively easy way would be to follow Lebacqz's suggestion of some form of price controls.

IV. Conclusions

In conclusion, I would argue that the micro ethical debate over the use of early human embryos is not the key factor in resolving the larger stem cell debate. While I think it is the case that an argument can be made for the use of such cells, another more critical variable is the consequences of such an objectification of human nature in this way. Thus while I would argue that in principle there is an argument for the use of such cells, the consequences of such use might be more problematic than we currently realize.

However, I think the more important argument is what I have identified as the macro argument, the social context in which such cells will be used. Here I would argue that minimally we should be very cautious about going down the path of stem cell research. First, what we have with stem cell research is yet another promissory note from scientists. Let us at least develop some more specific understanding of the therapeutic implications through animal research on stem cells. And if one opposes such research on animals, I would note that a fortiori that one should also oppose it on humans for exactly the same reasons. Second, developing research on stem cells commits us to the same medical model that is already causing such a complex of problems in health care. Business as usual is not going to resolve our health care crisis. Perhaps, it is time to apply the brakes in some areas to try to solve some problems in other areas, i.e., public health. Finally, those who are most ill and most vulnerable will most like not have access to the benefits of therapies derived from stem cell research, should they in fact materialize. Insurance plans will probably not cover such experimental treatments and those without insurance or underinsured will not have the funds available to purchase such services. Is focusing on developing expensive cures for a narrow range of diseases the most effective use of public money and social resources?

I am not opposed to the HGP or research deriving from it. I am not in principle opposed to stem cell research. What I am suggesting is a moratorium first to develop some experimental results to see what we are getting into and second to force us to think through what kinds of health care reforms we need and how stem cell research might fit into that, if at all.

transformations@wpi.edu
Maintained by: webmaster@wpi.edu
Last modified: Aug 31, 2004, 17:07 EDT