Category: Bioethics

“Don’t Resist Until It’s Too Late”

frogboil.jpgThe debate on cognitive enhancement has reached BoingBoing and the NYT. I’ve been skeptical of the topic before, and this snippet from Benedict Carey’s article gave me little reason to change my mind:

Dr. Anjan Chatterjee, an associate professor of neurology at the University of Pennsylvania who foresaw this debate in a 2004 paper, argues that the history of cosmetic surgery — scorned initially as vain and unnatural but now mainstream as a form of self-improvement — is a guide to predicting the trajectory of cosmetic neurology, as he calls it. . . .

The public backlash against brain-enhancement, if it comes, may hit home only after the practice becomes mainstream, Dr. Chatterjee suggested. “You can imagine a scenario in the future, when you’re applying for a job, and the employer says, ‘Sure, you’ve got the talent for this, but we require you to take Adderall.’ Now, maybe you do start to care about the ethical implications.”

On this line of thought, in the early stages of the development of enhancement technology, it’s untoward to object to its deployment because it’s rare. One person’s use of the drug doesn’t appear to harm anyone directly. But by the time the “Adderall requirement” arises, the drug is so common that it’s likely futile to resist the requirement to take it. It’s the old “boiled frog” syndrome.

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The Culture of Cosmetic Surgery Reaches Iran

Mehrdad Oskouei’s documentary “Nose Iranian Style” offers a fascinating (if depressing) look at the rhinoplasty capital of the world: Iran. Here’s the summary:

A large and growing percentage of . . . people in Iran [about 60-70,000 per year] . . . have their noses made smaller through rhinoplasty, even young Moslem women who hide most of their faces with traditional scarves. Filmmaker Mehrdad Oskouei explores this phenomenon [by interviewing] a number of teens who have either had the operation or are considering it, the parents to give their blessings to this practice (and their money to the plastic surgeon), and trends in Middle Eastern culture which may be contributing to this wave of new noses.

The film starts with a group of girls cheering upon hearing that Iran is “nose job” capital of the world, and a series of uncomfortable (if illuminating) encounters and montages follow. News reports have tracked the trend for a while, but the film does an extraordinary job juxtaposing the pre- and post-modern aspects of contemporary Iranian life that contribute to the pressure to abrade, upturn, and minimize noses. Though some religious authorities oppose the trend, they appear feckless throughout the film. (One plastic surgeon states that “Plastic surgery is better appearance for people, and I think God [would] like this.”) A few more thoughts on the comparative role of law and norms in addressing the rise of the rhinoplasties below.

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“The Notion that We Should All Look the Same is Hatred”

So argued Marilynn Wann (author of Fat?So!) in response to a recent bill introduced in the Mississippi legislature to ban the obese from being served in “any food establishment that is required to obtain a permit from the State Department of Health . . . that 12 operates primarily in an enclosed facility and that has five (5) or more seats for customers.” Wann believed that Miss. House Bill 282 would amount to size discrimination.

I find the bill bizarre–less a constructive solution than an effort to stigmatize. Kelly Hills offers some measured commentary on the anti-obesity push generally:

[Some of the obese] are comfortable with their weight, and don’t appreciate being “bullied” by society to adhere to an ideal they don’t believe is accurate. These folks often espouse the motto “healthy regardless of weight”, placing an emphasis on health outside of weight. After all, the reasoning goes, if someone is 65 lbs overweight, but perfectly healthy otherwise, what business is it of anyone just what that weight is? People come in all sizes, and as long as the individual is healthy, what that size is shouldn’t matter to anyone.

The anti-obesity movement has to be predicated on a “duty to be healthy“–and some would say that focus on the individual itself is a controversial priority of health reform, given that there is so much that can be done to change social structures that would lead to better health outcomes. As Michael Pollan has noted, changes to the farm bill could probably do more to improve America’s eating habits than individual stigmatization. The context of food choices–not cultivation of willpower–is key.

Hat Tip: Medical Humanities Blog.

Police on Steroids, Profs on Ritalin

cyborgflower.jpgThere has been some excellent blawgospheric comment on the Mitchell Report, a Black Sox scandal for our age (see, e.g., Jeff Lipshaw, Howard Wasserman, Michael Dimino and Alfred Yen). My question is: what will be the cultural impact? I think two recent stories on performance enhancement in other fields provide some clues, and suggest the wisdom of the PCBE’s worries.

First, the Village Voice has a long story on some possibly inappropriate steroid/HGH use in the NYPD. I say “possibly” for two reasons: 1) the slippery “therapy/enhancement” distinction here and 2) the threat posed by bulked up criminals. The Voice reports that “the Brooklyn District Attorney’s Office knows of 29 cops and at least 10 NYPD civilian employees—all well under the age of 60—who have received prescriptions for [steroids for] hypogonadism.” Doctors quoted in the story find it implausible that so many officers would have this disorder–but there are probably other physicians who have a much broader concept of disease. And if suspects are bulking up on illegal substances, who can blame the cops for trying to catch up?

The other story is on concentration-enhancing drugs increasingly used not only by students (an old problem), but now by professors. Andrew Sullivan asks, “So if a prof wants to do a little Provigil, it’s no worry for me. Why should it be a worry for anyone but the prof himself?” I think there are several reasons, not least the potential for medicalized competition to invade spheres of life we now deem constitutive of our identity. But for now let me just focus on how the police and profs examples intersect.

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The Worst Self-Justifying Column You’ll Ever Read

800px-Man_and_woman_undergoing_public_exposure_for_adultery_in_Japan-J__M__W__Silver.jpgIs here. Romana: immediately contact your divorce lawyers! (I hope she retained the copyright on her illustrations.) Seriously, though, is anyone meant to be convinced by silly arguments like these?

“From a Darwinian perspective, sexual jealousy is easily understood. Natural selection of our wild ancestors plausibly favored males who guarded their mates for fear of squandering economic resources on other men’s children. On the female side, it is harder to make a Darwinian case for the sort of vindictive jealousy . . . No doubt hindsight could do it, but I want to make a different point. Sexual jealousy may in some Darwinian sense accord with nature, but “Nature, Mr. Allnutt, is what we are put in this world to rise above.” Just as we rise above nature when we spend time writing a book or a symphony rather than devoting our time to sowing our selfish genes and fighting our rivals, so mightn’t we rise above nature when tempted by the vice of sexual jealousy? I, for one, feel drawn to the idea that there is something noble and virtuous in rising above naturein this way. I admit that I have, at times in my life, been jealous, but it is one of the things I now regret. Assuming that such practical matters as sexually transmitted diseases and the paternity of children can be sorted out (and nowadays DNA testing will clinch that for you if you are sufficiently suspicious, which I am not), what, actually, is wrong with loving more than one person? Why should you deny your loved one the pleasure of sexual encounters with others, if he or she is that way inclined? The British writer Julie Burchill is not somebody I usually quote . . . but I was struck by one of her remarks. I can’t find the exact quote, but it was to the effect that, however much you love your mate (of either sex in the case of the bisexual Burchill) sex with a stranger is almost always more exciting, purely because it is a stranger. An exaggeration, no doubt, but the same grain of truth lurks in Woody Allen’s “Sex without love is an empty experience, but as empty experiences go it’s one of the best.””

Ladies and Gentlemen, meet biology’s version of Richard Posner, minus any sense of how people actually think or act. What’s the argument here? That jealousy is a legitimate emotion because it is genetically based (for men, but not for women) or that regardless of the Darwinian pull, it is something that women should must now rise above, because Dawkins wants to step out?

(Image Source: A japanese couple being shamed for adultery, wikicommons).


Stem Cell Research and the Presidential Race

Thanks to Dan and Frank for inviting to blog about my new book, Stem Cell Century: Law and Politics for a Breakthrough Technology. The book analyzes a broad range of issues related to stem cell research and regenerative medicine. Only one chapter out of 10 (“The Embryo Wars”) considers the debate over the ethics of conducting research that requires the destruction of human embryos and the Bush policy of severely limiting federal funding of research on stem cell lines derived from embryos. But the announcement, two weeks ago, that two teams of scientists have succeeded in reprogramming adult cells to behave like embryonic stem cells has the potential to open a new chapter of the embryo wars that will play out in the presidential campaign.

Two weeks ago, it seemed pretty clear that embryonic stem cell research was a wedge issue that the Democrats would exploit in the 2008 election. All of the Democratic candidates not only favor federal funding of research on stem cell lines derived from embryos, they are quick to point out their position and criticize Presiden’t Bush’s funding restrictions. Most Americans, including most Democrats, most independents, and perhaps half of Republicans, support the research. The Republican candidates, on the other hand, tend to downplay the issue, whether they appear to support the research (McCain, Giuliani) or oppose it (Thompson, Romney–although the latter has changed his position, as he has on many issues, since he was the governor of Massachusetts), because the issue tends to split religious conservatives and economic conservatives.

The cell reprogramming success has not weakened the commitment to embryonic stem cell research of most members of the scientific community, because it is too early to tell whether the new cells – called induced pluripotent stem cells – will actually be as useful as embryonic stem cells, and because the new cells are made by inserting genes (which can cause cancer) with retroviruses (which can cause cancer). Not only does this mean that the IPS cells could not be used to create treatments that would be injected into humans (a long-term goal of stem cell research), it also suggests that they might not serve as good models of diseases for the more immediate goals of stem cell research: studying how degenerative conditions develop and creating large quantities of diseased cells in order to more efficiently screen chemical compounds that might be effective as treatments. Some prominent scientists believe the drawbacks of IPS cells at the current time are likely to be overcome; others think they are not.

The average American swing voter might not see things quite this way, however. Many people who favor embryonic stem cell research find the destruction of early-stage embryos troubling but justified by the potential medical benefits. Voters in this group might think that the creation of IPS cells has changed the cost-benefit analysis. A number of conservative commentators have already argued aggressively that the IPS discovery vindicates the Bush funding policy and shows that neither medical research nor ethics need to be compromised, and the Romney campaign issued a press release saying essentially the same thing. Meanwhile, all the pro-research candidates – Democrats and Republicans – have been noticeably silent the issue since the IPS announcement. I haven’t seen a statement or comment by any of them (if any readers have, please let me know). My guess is they are waiting to see polls that show whether the majority of Americans still favor embryo research. For the first time since 2001, the pro-research side is now on the defensive.

Are Survivors’ Costs a Pro-Life Issue?

The conservative Manhattan Institute recently commissioned a study of a gap in life-expectancy gains over the past 20 years. The data that inspired the study are startling:

While U.S. life expectancy increased by 2.33 years from 1991 to 2004, some jurisdictions — the District of Columbia (5.7 years), New York (4.3 years), California (3.4 years) and New Jersey (3.3 years) — led the way, while others, such as Oklahoma (0.3 years), Tennessee (0.8 years) and Utah (0.9 years), trailed the national average by significant margins.

To make a long story short, the researcher found that found that “longevity increased the most in those states where access to newer drugs . . . in Medicaid and Medicare programs has increased the most.”

Unfortunately, budgetary rules often make the federal government concentrate more on the costs of such interventions than their benefits. For example, the CBO counts “increased costs to the Medicare program for extending the life of its beneficiaries” as “survivors’ costs.” Tim Westmoreland’s fascinating article on the topic (95 Georgetown L.J. 1555, June 2007) calls this “euthanasia by budget:”

In describing why its model included costs but no savings from new access to pharmaceuticals, the Congressional Budget Office said, inter alia, “ [T]o the extent that a drug benefit helps people live longer, they may consume more health care over their remaining lifetime than they would have without the benefit.” In other words, it is still cheaper for Medicare beneficiaries to die.

One wonders if the same reasoning was behind a Texas law that permitted hospital authorities to cut off life support to a conscious woman.

I admit that Daniel Callahan has eloquently questioned the “research imperative,” and perhaps his reasoning could be extended to health care more generally. But it strikes me that in our accounting the costs and benefits of health care in this country, budgetary savings arising out of early death ought to be suspect.

Vanity Taxes vs. Worthless Competitions

vanity.jpgNew Jersey adopted a “vanity tax” in 2004, levied on “any medical procedure performed on [an] individual which is directed at improving [his/her] appearance and which does not meaningfully promote the proper function of the body or prevent or treat illness or disease.” In a critique of the tax, Michael Duel argues that it is sexist and such surgery is frequently nondiscretionary:

Women can either feel inferior, enjoy a lower quality of life, and be rejected by mainstream society, or else suffer the pain and toil of cosmetic surgery to achieve the exact same ideals society uses to reject them.

Cosmetic surgeons have also railed against the tax, unctuously declaiming that it “discriminates against women” because they buy about 86% of the procedures.

NOW President Kim Gandy has a nice response to that canard:

In general, I’m opposed to most things that impact women disproportionately, but disproportionate use isn’t a good measure if a tax is unfair or not. I can’t imagine someone arguing against having a luxury tax on yachts because more of them are bought by men.

State Senator Karen Keiser is uppping the redistributive ante in Washington state, with a plan to earmark vanity tax revenue for health insurance for poor children. As one tax policy analyst claims, “In this anti-tax climate, these user-based, selective tax proposals are more palatable than broader ones.”

Duel also attacks the vanity tax as a matter of tax policy, but I have a feeling he misses its point. . .

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Limits of Performance Enhancement

antlers.jpgImagine it’s 2020, you’ve begun working at a firm, and you’re having trouble keeping up. All the other employees are working 75 hours a week, take no vacations, and seem both alert and happy all the time. You ask some confidantes there “how do you do it?” All mention some variety of cognitive enhancement: one takes modafinil to concentrate, another uses chemicals that were originally designed for fighter pilots. Do you take the pills to keep up?

That was one of a few hypos posed yesterday during a presentation I made to the Yale Information Society Project. Though I thought the problematic nature of that situation pretty intuitive, I got pushed to specify exactly what was wrong. So here are some ideas, from different perspectives:

1) Safety: What if the drug shortens lifespan? Surely that’s a problem that would make this scenario pretty analogous to steroids in sports. I hope no one seriously thinks that we want to allow athletes to risk terrible consequences in the future to compete better today. I also think that even a small increase in risk to health ought to render the “super worker” pills problematic. . . . though I admit it’s hard to specify how much. Shortening life expectancy by a month? a year? 10 years? I’ll admit that the choice between those options is an inevitably ideological one.

But let’s assume for now these pills are as safe as caffeine. What’s the harm then? Four takes below the fold…

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