Dear Editor,

Unfortunately, scientists have used fetal tissue in research since at least the 1930s, now the secrets of the Dead-Baby Industry reveal that aborted fetuses being dissected alive, harvested and sold in pieces to fuel a vast research enterprise. There are social implications of its existence. We all need moral intensity these days. We all need to take it very seriously. Patel¡¦s paper is written to obviate the need for a discussion of the "unfettered fetus industry"; the central thesis is that we can harvest totipotent stem cells from something other than an embryo. The argument is that there is no need to develop an embryo, much less a whole fetus, before we can harvest these important stem cells -- they may be derived from enucleated eggs, which are never fertilized, as well as parthogenically activated eggs that again, are never fertilized by a sperm. Hence, there need never be "embryo harvesting" or "fetus harvesting" because stem cells can be derived from non-embryonic tissue.

The next step should certainly be cultivation of discarded tissue, i.e., utilization of "damaged ova" to create useful stem cells from growingly incapable destroyed cells. Now what matters is to found how to sift through an abortus to discover the destroyed ovum; and how to use this damaged ovum once we found.

Note that there is 'The problem is destruction of a human organism' by Beverly B. Nuckols. (4 April 2006)

Nevertheless, in Patel¡¦s article, there is an effort trying to express some of the ideas behind what we should and should not value, irrespective of whether or not we call it an embryo. The argument that a blastocyst is untouchable with regard to full moral contemplation is disproved by the appearance of "blighted ova" in Patel¡¦s article. More over, the deliberation of "in some remote sense" the somatically transferred nucleus constitutes an embryo is still not a good argument, since under that circumstance every single cell of the human body could have been called an embryo.

In my opinion, I do agree with Nuckols¡¦ viewpoint that it is important to define an embryo. Even though this critique may eventually have its merit, her argument seems without exploring the reasons why we call "a blastocyst with an inner cell mass" an "embryo." Hence, her critique appears to miss the key point of Patel¡¦s paper, which is that we ought to establish technologies that meet the middle ground, such as parthonogenetically created stem cells -- so that there will be no need for us to debate on where the stem cell comes from.

In my view, unfortunately, fetal tissue applied to both clinical aspect and its experimentation thus far is only the first step. Once it is stood it will be accepted. Once accepted, what will be followed? How long before we have an unfettered fetus industry in which the organs of unborn babies are bought and then put up for sale as commonly as pints of blood. At least in my opinion, we certainly need very badly to take some middle ground, such as parthonogenetically created stem cells for research and therapy.

Bing Tang, MD
Research Ethics
Danville
California

Dear Editor,

We agree with Schildman and colleagues1 that there is a need for better information about doctors’ and patients' thoughts on resuscitation decision making and that good teaching of medical ethics to undergraduates is likely to be a key step in ensuring sound decision-making by doctors.

Among their important findings are those showing that most doctors who have been formally trained in clinical ethics at one medical school believe that any competent patient should be engaged in discussion before a “do not attempt resuscitation” (DNAR) decision is made, implicitly including those for there is no prospect of benefit. Interestingly, a significant minority of their sample do not believe this. The authors’ discussion considers only one of the reasons offered by Manisty & Waxman2 for not discussing DNAR, that it may destroy hope. We think that it is not always right to discuss resuscitation decisions with patients explicitly but argue that there are other, better reasons.

Why discuss treatment options with patients? We should do so because that discussion will inform treatment decisions, which is good for the patient, fair, and respects their autonomy. It ticks all the right ethical boxes. But when a treatment will not be offered because it is somehow inappropriate, we do not normally discuss it unless a patient specifically asks about it. We do not list treatments not on offer; we discuss those which a patient might be in a position to accept or to refuse. Discussion of non-available treatment options ticks no boxes at all because it cannot inform a decision.

There are two reasonable objections to this claim. One is that an attempt at resuscitation is never inappropriate for a patient who would want it. This claim is implicit in much of the guidance on DNAR decisions but is hard to defend. Why should resuscitation be unique in being offered regardless of the lack of prospect of benefit? There are differences of degree between it and other treatments – in urgency and in necessity – but no other difference in fact. There is no good moral reason to think that we need consent to withhold resuscitation. No good argument is offered for the unique status sometimes accorded to it. Indeed perhaps there is a prima facie case that one should have appropriate consent before attempting, rather than withholding, resuscitation. It may be objected that contemporaneous consent is unobtainable, and this is true; but the consent proposed to withhold resuscitation is necessarily obtained in advance and we regard spontaneous competent advance refusal of resuscitation as valid, so there is no reason to think that advance consent cannot be sought. “When your heart stops because you are dying, a point at which you have arrived in spite of our best efforts,” the consent form might read, “it is proposed that we begin mechanical and pharmacological methods that have ……..% [for advanced cancer patients insert ~0% here] of success, or that may work but cannot serve you any useful purpose.” We all have patients whose chief complaint is that they remain alive, and those who have been subjected to a non- consensual resuscitation complain bitterly. Presumably those who die during an unwanted and non-consensual resuscitation attempt would complain more bitterly still. This prima facie case may of course fall to all sorts of objections, but it highlights the difficulty in the unique claim for resuscitation that consent should be required for withholding and not for treatment. There are, in summary, patients for whom resuscitation stands no chance of meaningful benefit, notably those who are inexorably dying of a known progressive disease3.

Further, we know that there are harms in attempting resuscitation. The harms are negligible when balanced with the enormous benefit of a life saved, but they are significant when there is no benefit to outweigh them. A person who has already died may not be harmed by the trauma to her body, but one who is about to die and who is subjected to this attempt will certainly be harmed at a crucial moment, the ending of her life. Others are harmed too by resuscitation attempts, including relatives, staff and other patients. Finally the care of patients in general at the end of life would be harmed if dying patients were subjected to this attempt regardless of whether it could work. Considerable advances in end of life care centre around recognising the process and the moment of dying and responding to it appropriately, and are severely compromised when at the very last moment we dive in with measures that can no longer succeed in maintaining life. To put this another way, there is no consistency in caring for a patient as someone who is dying if he is someone in whom resuscitation would be appropriately attempted. If the attempt would be appropriate then the focus of care should be different.

So for some patients resuscitation is inappropriate in that there is no prospect of benefit and significant potential harms to the patient and others. The other plausible objection to withholding discussion of it arises from the claim that discussing a treatment that will not be offered does some other kind of good by including a person in decisions about their care. It is true that patient involvement in decision-making may be beneficial, which is why it is best practice in dealing with patients at the end of life. In our experience the claim that doing so destroys hope is not universally true; in fact it can foster hope and it is in any case right for other reasons concerned with personal autonomy. But the benefit in discussing a non-available treatment is small for most patients and must be balanced against the harm from the discussion. Most patients are distressed by explicit discussion of end of life matters. This distress can be justified when it achieves something but is unjustifiable when it achieves nothing.

Therefore, we argue, there is a group of patients in whom resuscitation should not be attempted and with whom it should not be discussed. There are better ways to achieve the goods that we seek for them.

References:

1 Schildann J, Doyal L, Cushing A & Vollmann J. “Decisions at the end of life: an empirical study on the involvement, legal understanding and ethical views of preregistration house officers.” Journal of Medical Ethics 2006; 32: 567-570.

2 Manisty C & Waxman J (2003) “Doctors should not discuss resuscitation with terminally ill patients:FOR” British Medical Journal 2003;327:614-615 (13 September),

3 Ewer MS, Kish SK, Martin CG, Price KJ & Feeley TW (2001) “Characteristics of cardiac arrest in cancer patients as a predictor of survival after cardiopulmonary resuscitation” Cancer 2001; 92: 1905-12.

Dear Editor,

Angell et al found that in 'only' 11/18 research applications did three research ethics committees agree entirely. I note that in 4/7 cases of disagreement, this was due to a mix of provisional and unfavourable opinions which I suggest reflects the willingness of many committees to offer a (very) provisional opinion to inadequately prepared researchers to help them to salvage their proposal and avoid the need for re-application. More importantly, the authors have entirely overlooked the most telling finding of their study: not a single application was unanimously considered entirely ethically sound without further revision. Indeed, a favourable opinion was given by only one committee on a single occasion. This in my view justifies entirely the continuing need for ethical review, however flawed.

Dear ditor,

It has recently been brought to my attention that the physicians of the Groningen Hospital who originally proposed the Groningen Protocol have proposed to violate the first two conditions of the original Groningen Protocol:

(1) The suffering must be so severe that the infant has no prospects for a future. (2) There is no possibility that the infant can be cured or alleviated of her affliction with medication or surgery.

For example, Dr. Verhagen has maintained that the Protocol could apply to infants that are not necessarily terminally ill, but nevertheless may face a compromising future. In essence, the Groningen Protocol has begun to make quality of life judgments.

This does not, however, render my paper moot, rather I think it makes the thesis that much more important. The purpose of my article was to defend the ethics of the Groningen Protocol in its original form and intent. I still stand by this argument. However, if the Groningen physicians have commenced making quality of life judgments, they have strayed away from the original purpose of the Protocol, and this, I believe, may have concerning ethical implications. As I write in my paper:

“…the Groningen Protocol does not make quality of life judgments, and it is because of this very important requirement that the Protocol strikes me as humane and morally permissible, for it seems utterly vicious to extend the life of a suffering infant with no prospects for a future. If the infant did have a possible future ahead of her, I would be more hesitant to condone a legal practice that begins to make quality of life judgments, for such judgments can be, and have been, subject to error.”

Therefore, my article should be read as an attempt to defend the Groningen Protocol as it was originally intended, and as a warning against eroding the two above-mentioned conditions, which I argue is key for maintaining the moral permissibility of this kind of nonvoluntary euthanasia.