MEDICAL ETHICS: IT IS NOT JUST FOR ETHICISTS ANYMORE--THE CASE STUDY OF STEM CELL RESEARCH
Patrick Norris, O.P.
Notre Dame professor R. Scott Appleby, in delineating the qualities of the next pontiff, singled out the fact that the pope of the future must be able to proclaim the gospel to secularized and religiously agnostic political leaders, economists, World Bank officials, genetic engineers, and esteemed panels of ethicists who recommend decisions on questions of life and death.[i] In some ways, Appleby is perhaps understating the qualifications needed in the next pope. In the world of bioethics, we are inevitably and sometimes quickly moving away from the days of simple, compartmentalized decisions between physicians and patients. If the Catholic Church is to be serious in its response to Pope John Paul II’s call to a new evangelization, it must grapple with a vast array of fields and interested parties.[ii] In examining the perennial challenge to go out to the whole world and proclaim the Gospel, the Church must deal not with the evangelization of culture, but multiple cultures. If the Church fails either to see this or respond to it accordingly, it will be relegated to an inconsequential role in the formation of individual consciences and the establishment of public policy in the field of health care ethics. In order to understand this evolution and challenge to the Church in the 21st century, I will examine the issue of stem cell research as a paradigm for understanding the growing complexity of the field of bioethics and the Church’s role in it.
THE CHURCH AND BIOETHICS
The discipline of what is commonly known societally as bioethics is relatively new, developing in tandem in the mid 1900s with technological advances in the field of medicine. The Catholic Church had already been weighing in on what we call bioethical issues in its long tradition of moral theology, be it a condemnation of abortion in the Didache in the first century, di Vittoria’s analysis of the use of life support during the 1500s, or Pope Pius XII’s extended discourses on bioethical topics in the 1940s-1950s. As a result, grounded in a natural law tradition, the Catholic Church had a “running start” on the rest of society as the ethical questions surrounding organ transplant, dialysis, abortion, etc. emerged in the latter half of the 20th century.
However, with the passage of time, the growing secularization of society, and the advances in technology, the discipline of bioethics has matured. An ethical analysis of an issue such as HIV/AIDS involves not just moral and theological principles but must integrate a whole host of fields: medicine, nursing, social services, religion, pharmaceutical industry, law, politics, advocacy groups, insurance, etc. Today, even a seemingly simple issue such as the prescription of antibiotics for a child with an ear infection must resolve questions of the individual versus the common good, the real effect of the over-prescription of antibiotics on the development of antibiotic resistant bacteria, the economics of the meat industry and its use of antibiotics to produce healthier and cheaper food products, and the cost-effectiveness concerns of the pharmaceutical industry in developing new types of antibiotics to combat resistant strains. Perhaps the issue that best exemplifies this merging of various cultures in ethical decision making and its concomitant challenge to the Church is that of embryonic stem cell research. A proper understanding of the topic and the Church’s response requires a review of the science of stem cell research, the magisterial input of the Church, a theological and philosophical analysis, political and legal dimensions, public advocacy interventions, and economic concerns.
THE SCIENCE OF STEM CELL RESEARCH
Technically, stem cells are cells that have the ability to divide indefinitely in culture and have the capability of giving rise to specialized cells.[iii] Stem cells can be isolated from such sources as adults, umbilical cord blood, and fetal and embryonic tissues. Embryonic cells harvested from the inner cell mass of an embryo are considered pluripotent, meaning that they can give rise to the over two hundred different cell types in the human body but not another organism. Adult and cord blood stem cells are thought to be multipotent, meaning that they can give rise to a more limited set of specialized cells. Scientists offer three predominant areas of health care in which embryonic stem cell research will be extremely beneficial. First, the study of pluripotent cells will allow us to know better the process of human development and why genes turn on and off during our lifetime. Second, the development of drugs would be enhanced through testing on cell lines instead of people thereby improving the speed and safety of pharmaceutical research. Third, the most well known and potentially far-reaching application is the cure of disease. Stem cells can be manipulated into developing into specific cells, organs, or tissues to replace damaged tissue or to restore function in human beings. Diseases such as Parkinson’s, Alzheimer’s, coronary, diabetes, spinal cord damage, etc. could be cured or their effects ameliorated.[iv]
Although adult and cord blood stem cells had been previously isolated and used therapeutically, in 1998, two different sets of United States researchers developed human pluripotent stem cell lines: bone from the inner cell mass of excess frozen human embryos donated from in-vitro fertilization clinics (University of Wisconsin), the other from fetal tissue from elective abortions (John Hopkins University). These discoveries were newsworthy for several reasons in the field of stem cell research. Adult stem cells have less plasticity than embryonic stem cells (the ability to be transformed into multiple cell types different from the cell’s original makeup) and have not been isolated from all different types of bodily tissues. Therefore, the isolation of embryonic stem cells and the creation of cell lines was seen as a great advance in 1998. Scientists theorized that embryonic stem cell lines that would be pluripotent could treat a greater variety of diseases. Because of the immaturity of the cells, they would be less likely to cause an immune system rejection. Moreover, they would be more plentiful and easier to obtain than adult stem cells. Then, in February of 2004, Korean researchers announced a further advance in the field. They cloned adult human cells, extracted embryonic stem cells and developed a cell line.[v] This cloning for research purposes (often referred to as therapeutic cloning) offered the advantage that in future clinical uses, there would be less likelihood (although not a zero percent chance) of immune system rejection because the embryonic stem cells would have been derived from the patient’s own adult cells. To date, embryonic stem cell research has offered no actual cures but extensive potential.
However, there are several scientific questions left unresolved since the 1998 discoveries. First, many researchers believe that adult and cord blood stem cells may be more malleable than originally thought.[vi] Thus, cell lines could be developed that would side-step the controversy over the source, and if derived from the patient, would eliminate the rejection concerns. Second, because of the immaturity of embryonic cells, there is a concern that they might be more likely than adult stem cells to grow in an uncontrolled fashion once inserted into the person. Third, in practice, embryonic stem cell lines are much more fragile and harder to grow than originally presumed. Consequently, scientists have already indicated that hundreds of cell lines derived from the destruction of thousands of embryos would be needed to create cell lines of sufficient diversity and stability to be used in clinical application. Fourth, the use of cloning for research purposes advanced by the Korean scientists contains a host of issues about the safety of cloning including the possibility of greater irregular cell divisions and the age of cloned cells (e.g., was Dolly the sheep her age or her age plus the age of the cells from which she was cloned?). Finally, researchers are not absolutely sure that their theory will work. That is, there is a great difference between potential cures and actual ones as researchers strive to determine how to coax the undifferentiated stem cell lines into differentiated cells (e.g., liver, bone, heart, etc.). Although the media has given the impression that clinical applications are imminent, they in fact may be a decade or more down the road.
This brief review of the science indicates the complexity and rapidly changing nature of medicine and genetic medicine specifically. It suggests that if the Church is to contribute intelligently to the field of bioethics, it must more than ever be informed scientifically and work to promote ethical formation for scientists both within Catholic institutions and in the pew.
The Church’s magisterial teaching on the issue of the destruction of human embryos has been unambiguous. Since the Congregation for the Doctrine of the Faith released Donum vitae in 1987, the Church has constantly affirmed that the embryo is to be considered as a human person with associated rights.[vii] Pope John Paul II has consistently indicated that embryonic stem cell research is unethical.[viii] The advance of medicine cannot be bought at the price of sacrificing human life. On the other hand, using adult or cord blood stem cells does not create any inherent difficulty and would be consistent with the Church’s teaching on healing illness and extending life.
Yet the moral analysis is not so simple. As is often the case in health care today, one must address the topic of material cooperation with evil. For instance, Catholic hospitals frequently struggle with the question as to whether they may form partnerships with other institutions which engage in unethical behavior unrelated to the desire to form mergers. With regards to the questions of embryonic stem cell research, the question of cooperation with evil arose in 2001 after President Bush announced his Administration’s position that there would be federal funding for research on already existing stem cell lines derived from human embryos. There would be no federal funding for research on embryonic stem cell lines created after the announcement.[ix] This left open the possibility of private funding of embryonic stem cell research with its associated difficulties of duplication of efforts and a lack of governmental oversight to insure reproducibility of results. In drawing this line, President Bush appealed to a “cooperation with evil” argument, reasoning that the evil had already occurred and that we should derive good from the evil as long as we would not be complicit with future evil. Many bishops in the United States, although appreciating the restrictions imposed by the President, opposed his overall proposal, essentially citing the potential scandal from being involved in such research along with the consideration that other reasonable and ethically licit means existed to accomplish the medical goals of research. Given the unknown yet potential promise of cord blood or adult stem cell research, one could not use illicitly-obtained stem cell lines. The bishops did not address the issue from the broader perspective of the principal of cooperation with evil.[x]
Nevertheless, the issue of cooperation may eventually confront the Catholic magisterium if adult stem cell trials turn out to be ineffective and embryonic stem cell research shows great promise. Although one could never justify the destruction of human embryos, could the Church sanction research on already existing cell lines?[xi] This too will be a challenge for the Church’s teaching authority as issues become more complex in health care. Decrying practices that are intrinsically evil remains a clear and rather straightforward role of the magisterium. However, making determinations about the application of the principal of material cooperation with evil will require a greater sophistication and a usage of the gift of prudence.
THEOLOGICAL AND PHILOSOPHICAL THOUGHT
The challenge for the Church in evangelization is most ably demonstrated in this controversy. Inconsistent thinking, varying moral methodologies, and multiple interpretations of scientific data inhibit a Catholic response to the issue. What are the types of murky thinking that dot the landscape of the debate? Some people oppose any interventions on a genetic level (including adult stem cell research) indicating that we should not play God. In doing so they forget that the Catholic tradition acknowledges that God works through creation and the gifts of science and technology to improve the human condition as long as individual well-being is respected and that decisions do not worsen overall social living conditions. In Congress, representatives have focused debate on the Book of Genesis and the incident of God breathing life into Adam in order to determine the moral status of the embryo. Certainly the Scriptures provide a context for interpreting current problems, but the Church must guard against the practice of reading modern issues back into the text. Still other people indicate that they are pro-life and opposed to abortion and the destruction of embryos in utero but not those that exist outside of the womb. From a logical point of view, an extrinsic factor of the physical status of the embryos (cryogenically preserved) cannot alter the moral status of the entity because personhood is an intrinsic quality. Finally, most people who have supported research cloning have indicated a desire to prevent cloning designed to bear a child. However, logically, if cloning to bear a child were proven safe, opponents would have a difficult time presenting a coherent rationale for their opposition. Thus, moral repugnance (which also occurred after the birth of the first test-tube baby in 1978 ) is inadequate to block the slippery slope which begins with research cloning. In all of the above examples, the Church is eminently qualified to bring its keen sense of moral analysis to dispel inconsistent thinking.
A more problematic challenge to the Church is the differing moral methodologies prevalent in society. The pragmatic consequentialist ethical methodology common in the United States becomes more deeply rooted in people’s minds because of the huge purported benefit of embryonic stem cell research. Thus, although society generally agrees that we should not use individuals as means to an end, exceptions should be made when the stakes are so high (e.g., curing Alzheimer’s disease). As a result, bioethical task forces commissioned by the government could say unabashedly and pragmatically that the embryos being used in research should be respected because of their moral worth.[xii] This prompted some to wonder how doing research on and destroying such embryos showed respect.
In addition, society has invoked a lesser of two evils argument (different from the cooperation with evil argument) indicating that if these embryos were going to be discarded anyway, why not do research on them to achieve a good so that they would not die in vain. The challenge for the Church continues to be to help people distinguish between physical evil and moral evil. As such, the inevitability of death does not provide the ethical warrant to cause the death.
Another challenge for the Church is to further the debate about the moral status of the embryo.[xiii] This challenge does not differ from that of the overall abortion debate. The task of evangelization lies in shifting the discussions from the rights of the woman to that of the embryo using the advancements of science. Defining clearly what constitutes personhood and then examining the narrative of the person from a scientific standpoint will support the Church’s presumption that personhood begins at fertilization.[xiv] That is, the complexity of cellular interactions even in the first stages of embryonic development are raising questions about traditional concerns about the individuality of the embryo prevalent even in theological circles.[xv] In confronting this issue, the Church must address the philological component that subtly transforms the debate. Consider the terminology people employ such as therapeutic cloning and reproductive cloning to justify the former. From the Church’s perspective, all cloning is reproductive.
Our theological perspective as a Church on mortality and suffering also plays into our ability to speak to the broader bioethical issues in society. In a consequentialist worldview, the fear of diminishment of function and the dread of death contributes to people’s willingness to cross ethical bridges that they might not ordinarily traverse. To what extent as a Church are we raising questions about death and dying apart from the usual ones about the use or non-use of life support? To what extent should we extend life?[xvi] How do we understand this life as a penultimate good in light of everlasting life? Are we realizing that essential theological components such as suffering and resurrection must be part of evangelization of culture?
Finally, as the following sections will indicate, a crucial question for the Church is how do we speak with an ethical voice that is faithful to our tradition and yet palatable to secular society?[xvii] That is, as the fields of concern grow, how does one keep a theological component in the debate so that it does not merely become an issue decided by finances, political whims, and a consequential analysis of the safety and efficacy of a particular therapy?
The shift from the Clinton Administration to the Bush Administration and the concomitant changes of policy on stem cell research suggest how much moral practice is influenced by partisan politics rather than objective moral theory. This can be seen in a couple of ways. First, a comparison of the respective bioethics commissions and their conclusions under the different administrations reveals a partisan approach to the issue.[xviii] Second, with political appointment also goes the power often to legislate either for or against research. In acknowledging this power, it should be mentioned that such power is exercised pragmatically rather than coherently. Thus, President Bush’s funding decision mentioned above pleased neither side completely nor did it alienate everyone completely. Consequently, the Church in its attempt to evangelize is confronted not only with a powerful source of influence in moral formation of the country but an inconsistent one.
In attempting to deal with this issue, the Catholic tradition does not understand itself as separated from political interaction as some Christian communities do.[xix] The Church’s appeal to a natural law tradition in theory facilitates its ability to interact in the arena of law and politics. But the interactions of the last several years in this field suggest that much of what happens in the moral life of our country is highly dependent on the political and legislative arenas. The evangelization of culture necessarily seems to require the evangelization of politics. To what extent will the Catholic Church be able to do this given its past history of the Peace and Economic pastoral interventions?
A growing trend in the field of bioethics in terms of funding and legalization of research involves the use of public icons to advocate for a cause. Thus, Mary Tyler Moore who suffers from diabetes, Michael J. Fox with Parkinson’s disease, and Christopher Reeve with paralysis testified before Congress and have made their position known to the American public. In the effort to evangelize culture, the messenger can take precedence over the message itself, especially when the messenger is an icon with whom many of the television generations identify and sympathize. Such figures do not come with any specific ethical expertise or nuanced argumentation.[xx] They simply attempt to change the culture because they are the culture. The challenge to the Church, then, is to use a similar tactic. Of note, perhaps the Church possesses one of the greatest icons of all in Pope John Paul II, who despite suffering from the ravages of a Parkinson’s like disease, refuses to adopt an ends justifies the means methodology for the sake of physical health. But to what extent has the Church used this image in its pulpit preaching as it tries to capture the moral imagination of people? If the Church is serious about impacting bioethical issues in the future, it must attend to the questions of public advocacy especially in a time when the Church lacks popular icons such as Fulton Sheen or even Joseph Bernardin as it struggles to have a public voice in the wake of the sexual abuse scandal. Moreover, it must attend more closely as to how the media reports on the issue of health care and bioethics in order to shape the debate.[xxi]
In his campaign for election, Bill Clinton reminded the public that “It’s the economy.” The Church’s ability to be a leaven for the world in the field of health care now and into the future will be dependent upon how well it addresses the issue of economics in health care. Regarding the issue of stem cell research, billions of dollars are at stake for biotech companies: some companies have come into existence and already dissolved in the last few years. Clearly, any research that could provide a cure for Alzheimer’s disease would be a financial bonanza. Hence various bio-tech and pharmaceutical companies have spent millions of dollars in lobbying efforts to convince legislators and patient advocacy groups to approve embryonic stem cell research.[xxii] In the midst of these economic maneuverings, attempts to give credibility to bio-tech companies through ethical advisory boards have met with only limited success because of conflicts of interest and a lack of true regulatory power.[xxiii] As a result, the interaction between greed and power continues to shift the issue away from any profound ethical moorings.
The impact of money is not limited to companies. Individual researchers must struggle to obtain limited financial resources from the government. Thus, a research avenue that can promise significant and more immediate clinical results will garner more support. This is why in 1998, the general public was given the impression that if there were funding for embryonic research, a cure would be right around the corner. The economic impact can also be seen in the desire for patents of procedures. Some people have speculated that under President Bush’s plan, many dollars allocated for research will have to be used to pay royalty fees to those who have developed the stem cell lines. These economic concerns provide a substantial barrier to the Church’s effort to evangelize. Yet, there are even darker forces at work which shadow the ability to shape public policy.
Specifically, the Church must address the insidious practice of the overall commercialization of the body wherein the body is turned into a product thereby losing its theological importance and neglecting its proper context of God’s sovereignty and our stewardship.[xxiv] As Robert Bellah notes, our primary relationships in life have lost all meaning except as a type of market exchange.[xxv] Greed thus has led to a deeper anthropological concern of commercialization and its subsequent negative impact on human dignity.
Finally, there is the concern that has become part of the Churchs overall analysis of health care: how does the advent of a new technology impact our ability to care for the poor and provide for basic health care?[xxvi] Will stem-cell technology (if it becomes a reality) be available on a generalized basis or only to the well-off? How does this pursuit of technology square with the Church’s preferential option for the poor? What other health care goods are sacrificed for the sake of this particular type of technology.[xxvii] What health care goods are lost because of inordinate spending on morally suspect enterprises in society?
A cursory examination of the bioethical issue of stem cell research provides a paradigmatic example of the challenges facing the Church as it moves into the 21st century. In some ways, it seems as though the Church has failed to evangelize culture. Although the Church remains highly competent in the arena of theological, ethical, and scientific discourse, it appears that economic, media, and political forces threaten to marginalize the Church and its teaching. Yet, in St. Paul’s second letter to Timothy, he admonishes Timothy to preach the word of God and to stay with the task whether convenient or inconvenient, warning him that people will not tolerate sound doctrine but instead surround themselves with teachers who will tickle their ears (2 Tim. 4: 2-3). Today and as we look to the future of health care ethics, there are many voices which draw people from the truth. The task of evangelizing culture is now inconvenient, complex; and at times discouraging.
Nevertheless, if the Church is to plant the seeds of good news and be relevant in the discipline of bioethics, it must be able to converse with a variety of different sub-cultures within our society. It must be at times peaceful as a dove but other times as cunning as a serpent using the tactics of opponents in the struggle to win hearts and minds. The particular example of stem cell research provides the perfect illustration of the complexity of the task. Yet the task, although daunting in the face of constant developments in science, should not be a source of discouragement because, aided by the Spirit, the Catholic Church in its historical and theological background possesses the requisite abilities to address the issues particularly with its affection for the truth, whether it is arrived at through religion or science. Perhaps in some ways in the end, the issue is not so complex, it is merely a matter of helping people hear the simplicity of the truth of the Gospel. In conclusion, the words of Dr. Seuss from his text Horton Hears a Who are most instructive: “I suspect that there must be something alive on that small speck of dust, some sort of person, of very small size, too small to be seen by my elephant’s eyes. If so I should save him because, after all, a person’s a person no matter how small.”
[i]. R. Scott Appleby, Job Description for the Next Pope, Foreign Policy (Jan.-Feb., 2004), 63.
[ii]. John Paul II, Ecclesia in America, no. 6.
[iii]. For a good summary of the basic science surrounding stem cell research, see National Institutes of Health, Stem Cells, Scientific Progress and Future Research Directions, (Washington, DC: NIH, 2001).
[iv]. National Institutes of Health, Stem Cells: A Primer, (Washington, DC: NIH, 2000).
[v]. Nell Boyce, The Clone is Out of the Bottle, U.S. News & World Report (Feb.23-Mar. 1, 2004), 40-44.
[vi]. For a representative sample see National Catholic Bioethics Center, Destroying Human Embryos for Research, Ethics & Medics 25 (March, 2003), 3. Also see http//:www.stemcellresearch.org.
[vii]. Congregation for the Doctrine of the Faith, Instruction on Respect for Human Life in its Origin and on the Dignity of Procreation, Origins 40 (1987), 697-711. See also John Paul II, Evangelium vitae, no. 60.
[viii]. John Paul II, Evangelium vitae, no. 63.
[ix]. George Bush, Address on Federal Funding of Embryonic Stem-Cell Research, Origins 31 (2001): 213-15.
[x]. Reaction to President Bushs Decision on Embryonic Stem-Cell Research, Origins 31 (2001): 205-13. The position of the bishops is consistent with their stance (NCCB) on using fetal tissue from elective abortions in Ethical and Religious Directives for Catholic Health Care Services (Washington, DC: 1995), no. 66.
[xi]. For a discussion of the issue of complicity and cooperation, see Vincent Branick and Therese Lysaught, Stem Cell Research: Licit or Complicit? Health Progress 80 (Sept.-Oct. 1999): 37-42. The Pontifical Academy for Life understands such cooperation as proximate mediate material cooperation which would be illicit given the gravity and the closeness of researchers to the evil. See Pontifical Academy for Life, Declaration on the Production and the Scientific and Therapeutic Use of Human Embryonic Stem Cells, (August 25, 2000), 3rd response.
[xii]. National Bioethics Advisory Committee, Ethical Issues in Stem Cell Research, (September 1999), 2, 53.
[xiii]. C.f., John Kavanaugh, Who Counts as Persons (Washington, DC: Georgetown University Press, 2001).
[xiv]. Benedict Ashley and Albert Moraczewski, Cloning, Aquinas and the Embryonic Person, The National Catholic Bioethics Quarterly 1 (Summer, 2001), 189-202.
[xv]. It should be noted that there is still debate amongst theologians about the status of the early embryo. See Kevin Wildes, The Stem Cell Report, America 181 (October 16, 1999),14.
[xvi]. David Gems, Is More Life Always Better? The New Biology of Aging and the Meaning of Life? Hastings Center Report 33 (July-Aug., 2003): 31-39.
[xvii]. Is the recent success of The Passion of the Christ an indication that society indeed wants to engage the religious dimensions of life in a public manner?
[xviii]. C.f., the moratorium proposed by Bushs Council on Bioethics: The Presidents Council on Bioethics, Human Cloning and Human Dignity: An Ethical Inquiry (Executive Summary), Origins 32 (2002): 165-72.
[xix]. For a representative example of the Churchs efforts to influence the political arena, see Richard Doerflingers testimony on behalf of the USCCB before the Subcommittee on Labor, Health and Human Services, and Education Senate Appropriations Committee, Hearing on Stem Cell Research, http://www.nccbuscc.org/prolife/issues/bioethic/stemcelltest71801.htm, (July 18, 2001).
[xx]. In her testimony, Mary Tyler Moore opined that: The embryos that are being discussed . . . bear as much resemblance to a human being as a goldfish. As quoted by Jesse Holland, Celebrities, Scientists Make Their Cases on Stem Cell Research, Chicago Tribune (Sept. 15, 2000), section 1, p. 6.
[xxi]. Peter Simonson, Bioethics and the Rituals of Media, Hastings Center Report 32 (Jan.-Feb., 2002): 32-39.
[xxii]. Shaun Taylor-Corbett, Life for Sale?: Embryo Research: Profit vs. Ethics, The Public I (October 4, 2001), 1-2.
[xxiii]. Gladys White, Foresight, Insight, Oversight, Hastings Center Report 29 (Mar.-Apr., 1999): 41-42.
[xxiv]. Dorothy Nelkin and Lori Andrews, Homo Economicus: Commercialization of Body Tissue in the Age of Biotechnology, Hastings Center Report 28 (Sept.-Oct., 1998): 30-39.
[xxv]. Robert Bellah, Class Wars and Culture Wars in the University Today, Academe (July, 1997): 24.
[xxvi]. For a discussion of the problem of our love affair with technology, see Daniel Callahan, Too Much of a Good Thing: How Splendid Technologies Can Go Wrong, Hastings Center Report 33 (Mar.-Apr., 2003): 19-22.
[xxvii]. Rebecca Dresser, Setting Priorities for Science Support, Hastings Center Report 28 (May-June, 1998): 21-23.
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