the Electric Monk

The trappings of human experience come in many guises: music, literature, fashion, and for some of us, drugs. A recent New Yorker article by Margaret Talbot argues that while LSD was the prototypical drug of the consciousness-expanding ’60s, the 2000’s are characterized by a very different type of drug: neuro-enhancers. Medications such as Adderall, Provigil, and Ritalin, intended to treat ADHD and other behavioral disorders, have found a very different use in enabling stressed college students and task-laden employees to handle their workload. A study from the University of Michigan’s Substance Abuse Research Center found that in 2004, 4.1 percent of American undergraduates had taken neuro-enhancers for non-clinical use. At some schools, the percentage was far higher–up to 25 percent.

Three major questions arise from Talbot’s piece.

From a scientific point of view, do these neuro-enhancers really “enhance” our abilities? Talbot writes that they can make you more efficient, but can’t help you become more creative.

Talbot’s observation, taken to its logical conclusion, suggests that the values of completion and competence, rather than excellence and creativity, have come to dominate our civilized lives. Does this presage a highly efficient, strung out, focus-less, pill-popping society that we don’t want to be a part of anyways? Or are we already living in it?

Perhaps most importantly, is there something ethically wrong with altering our brains by giving them the mental equivalent of steroids? If neuro-enhancers really do confer a significant edge, then do they unfairly benefit those who can afford to use them or are willing to use them without a prescription? What is the difference, if any, between the enhancing effects of these drugs and those of caffeine?

–Elsa Kim

Yesterday was the kick-off of yet another bioethics conference. From the perspective of an outsider like me–and a journalist to boot–”Ethical Issues in the Prioritization of Health Resources” seems like a hard sell. I struggle to imagine a less sexy title. (Perhaps “Academics Arguing about the Rights/Wrongs of Divvying Up Drugs and Doctors”?) But my prejudice was toppled by the following bizarre scene.

About 200 academics sat silently like parishioners in pews. Floating over their heads was a disembodied voice with a lilting Hispanic accent. It was Mexico’s Vice-Minister of Health, Mauricio Hernández, calling from his office to describe the difficult decision of how to stretch his limited budget to administer pneumococcal vaccines to his country’s children. The vaccine manufacturer recommends 3 doses, but it seemed to be more cost-effective to cut a corner from the standard of care and give only 2 doses. This is certainly the first time I’ve witnessed a politician on the phone with a packed room of academics, seeking their advice on a real-world, life and death dilemma.

Of course, deciding who should be given access to limited health resources is by definition a matter of life and death. But traditionally, philosophers who deal with the underlying ethics have not gotten their hands dirty with the real-world details. “Philosophers like us often say that we should learn about the issues from the experts who actually deal with them,” said Oxford bioethicist Roger Crisp. And rather than stopping there, “we should go on to try to make a positive difference.” This conference is supposed to be an opportunity for exactly this.

Crisp was the first speaker in a 3-man panel of academics who took the floor after the Vice-Minister. (Besides the Mexican vaccine dilemma, the conference learned about a dialysis machine shortage in Thailand and a new cancer drug that can extend life by a few months for an exorbitant cost. But more on those in a later post.) In contrast to the nitty-gritty of these real-world cases, the panelists battled it out on a very different plane–the abstract and esoteric world of moral theory. To give a sense of the flavor: Crisp added a new term to the menagerie of philosophical ‘isms (“sufficientarianism”); Alex Voorhoeve pondered whether it would be right or wrong to use a “philosophical laser” to prevent harm to one person from a plummeting meteor if not doing so would result in a greater benefit to another person; and JP Sevilla argued that redistributing people’s health (rather than money) was tricky because health is so “chunky”.

These are just caricatures of their arguments, of course. Abstraction is a necessary tool for teasing ethical issues apart. But the contrast between academic argument and real-world dilemma was dramatic. So I posed a real-world meta-question to the panel: Why does your work matter?

Voorhoeve considered his work in terms of national healthcare policies. “NICE is making some wrong decisions,” he said, referring to the ironically acronymed National Institute for Health and Clinical Excellence, the body that decides which drugs and treatments are not worth paying for in the UK. According to Voorhoeve, those decisions seem to derive ultimately from arguments made by another philosopher, All Souls don Derek Parfitt. So aside from the benefits to “mental hygiene,” he said, there are very practical reasons to get these philosophical arguments right.

With exquisite British self-deprecation, Crisp considered himself in the context of “all the philosophers over the centuries whose work is read and taken seriously.” Considering how vanishingly small that number is, he concluded, “I don’t think I matter.” But he went on to mount a poetic defense for the role of bioethics. “It’s like astronomy,” he said. The sky is filled with stars too dim to make out. “We’re trying to look deeper, helping each other to see a little farther.”

I was most touched by Sevilla’s reply. “What should I do to make the biggest difference for the benefit of all?” he wondered out loud. Public policy? Business? Even activism can have a more direct impact than academic bioethics. “The reason I do it is probably just that this is what I am best at,” he said. “Do I make a difference with these ideas?” He hopes so.

–John Bohannon

These days, nothing can stop you from becoming a parent, not even death. A woman recently celebrated in a New York courtroom after winning permission to harvest sperm from her dead fiance, just hours before the sperm’s 36-hour shelf-life had expired. “This was his wish,” she claimed. A woman in Texas was allowed to harvest sperm from her dead son in order to raise a “replacement child.” The sperm of a dead soldier was given to his Israeli parents so they could continue the family line, even though he left no will nor explicit consent. Being a dead parent has never been so easy.

Do dead men have rights when it comes to fatherhood? More generally, do people have a fundamental right to not be a parent, even after death? When it comes to dead men, after all, the responsibilities of parenthood are not a concern: They’re deadbeat dads by definition. So what exactly is at stake?

A confusing aspect of the right to not procreate is that it’s actually “a bundle of rights,” says I. Glenn Cohen, an assistant professor at Harvard Law School. In a recent paper, he argues that parenthood comes in three flavors: genetic, legal, and gestational. The man whose sperm was harvested becomes a genetic parent; the surrogate mother is a gestational parent; and the law might allocate legal parenthood to one, both, or even to third parties who become the child’s legal guardians. Do you have an equally protected right to not become each of these different types of parents?

According to Cohen, as a matter of constitutional rights, you don’t. The US constitution clearly protects a woman from becoming impregnated without her consent. And in certain circumstances involving reproductive technologies, it protects people from unwanted legal parenthood. But we are on much weaker constitutional grounds in the case of post-mortem fatherhood because this genetic parenthood does not carry with it legal or gestational parenthood.

But there are arguments to be made against harvesting sperm from dead men. In a second paper, Cohen explores some of the moral consequences. Arguing that harm is being done to the dead man “requires treading into contested philosophical waters,” he says, such as “whether death puts us beyond both benefit and harm.” But it certainly kicks up some financial dilemmas. For example, do posthumously conceived children get shares in any inheritance from the dead father? (If so, then sperm-harvesting could be as lucrative as gold-mining in some cases.) Also, harm could be done to society, for example by undermining norms for violating bodily integrity. (If harvesting dead men’s sperm becomes routine, what next?)

But do these concerns outweigh the interests of the women described in the first paragraph? Would you deny the recently bereaved girlfriend, wife, or mother?

–John Bohannon

In the fiery debate over taming the cost of US healthcare, there is a dirty word that no one wants to use: Rationing. When he was interviewed last week on the Daily Show, the president’s chief budget nerd Peter Orszag said that spiraling healthcare costs dwarf the banking crisis as a long-term financial threat. He carefully avoided suggesting that medical treatments or supplies might need to be rationed. But in a world with limited resources, rationing of some kind is inevitable. Consider one of the hardest cases of all: What should we do with limited Tamiflu stocks during an epidemic of bird flu?

The avian influenza virus has not mutated into a form that can spread epidemically, but public health experts warn that this could happen at any time. The only drug available to treat people with bird flu is Tamiflu (oseltamivir phosphate), but supplies are limited. At some point, hospitals could be forced to decide how to allocate what they have left. But who should be saved? And who gets to call the shots?

Harvard bioethicist Jim Sabin wrestled with this question last month during a seminar at the National Undergraduate Bioethics Conference. He painted a chaotic picture of hospitals using different allocation strategies at the same time. Hospital A keeps a stock of Tamiflu for staff who become exposed, to ensure that they will continue to be able to respond to the outbreak. Hospital B uses its remaining resources to try to save its sickest patients. In order to maximize the number of survivors, Hospital C reserves its drugs to treat patients who present within 48 hours of disease onset and are thus most likely to respond to treatment. Hospital D assumes that Tamiflu supplies will soon be depleted regardless of strategy, so it treats all probable and confirmed cases, regardless of severity. Finally, Hospital E is giving priority to younger patients.

Which hospital’s method should be adopted for the entire community? Or should hospitals be forced to unify their actions at all? If we can decide on the right strategy now, perhaps we can gain greater confidence that when the shots do need to be called, they’ll be called right. (Note: One strategy that Sabin left out is giving treatment only to those who can pay for it, which is the essence of US healthcare today.)
—Jennifer Marett

Would you abort an unborn child? What if it wasn’t yours?

Believe it or not, this is the question faced by a group of surrogate mothers in California this past week, and by a woman in Japan the week before that.

If you read Slate, you may have been following William Saletan’s commentary on these stories, which all have to do with the mixing of modern technology and age-old questions of body and ownership (personal organ sales anyone?).

In one case, couples in California working through a broker company hired surrogate mothers to have their children. The company lost all the money to bad investments, and found themselves unable to pay the already-pregnant surrogates.

By previous court ruling, the surrogate women, if they wanted to, could simply abort the fetuses. This would void their contract, but they weren’t being paid either way, and as emotionally gratifying as it may be, carrying their child to term could come with all sorts of expenses and dangers that they were no longer being compensated for.

What should the surrogate mothers have done? Do they have a moral obligation to continue bearing someone else’s child?

Would your answer change if the “surrogacy” was unintended? What if a woman undergoes in vitro fertilization (a way to get around infertility, among other uses) and the doctor implants the wrong embryo inside her? Is this woman obligated to keep her child? If this question seems easier than the one above, why?

In case you’re worried, all of the surrogates did decide to keep the children, although the woman with the mistaken embryo did not. The question stands, however — even if the women decided to terminate their surrogate pregnancies, would that have been wrong? Is this example a reason to disallow surrogate pregnancies altogether?

–Jue Wang

A question posed by Myles Axton, editor of Nature Genetics, emailed to the Monk from China:

Three days of gin snowed in in Tahoe. You play more boldly if you do not understand your position well. After teaching me how to play battleships on a chess board, the late great Bob Vaile asked me to consider the following question: Should technological safety precautions be interpreted in a static conservative framework or in a dynamic Darwinian one?

For example, is human evolution being retarded by the slowness with which we can acquire mutations? Maybe if background radiation were higher, our descendants would be fitter and able to achieve more.

Quite apart from noting that Bob was responsible for the analysis and design of failsafes for both nuclear weapons and of a nuclear reactor perched on the San Andreas fault, I doubted whether human evolution is either driven or enabled by mutation rate. And in any case, increased variation will lead to significant wastage and suffering that will need to be offset by the increased fitness of a few mutant offspring for what will be an altered and more challenging environment filled with some very quick and scary cockroaches.

–Myles Axton