Cost or Benefit? The Ethical Dilemma of CRISPR for Sickle Cell

For Victoria Gray, a common cold used to send her into a panic of whether she’d end up in a hospital because of her sickle cell anemia she was diagnosed with as a baby. According to the Mayo Clinic, sickle cell anemia is an inherited disorder that impacts the shape of red blood cells that are responsible for the transport of oxygen throughout the body [1]. Gray has been given a life changing CRISPR gene editing treatment that alleviates the effects of the disease. Now, Gray is able to live her life without pain medication and late-night hospital visits—all because of this new technological development and study [2]. However, CRISPR may present unknown challenges, such as ethical concerns surrounding bodily autonomy, an emphasis on Western perspective, and the possibility of detrimental side effects such as other congenital illnesses if used in utero.    

There is currently no cure for the condition, instead just ways to manage symptoms. Those with sickle cell anemia experience severe episodes of pain called ‘pain crises,’ anemia, swelling of hands and feet, frequent infection, delayed growth, and problems with vision [1]. The severity of these symptoms creates a high demand for researching a cure—with 100,000 Americans’ health being compromised by the disease [3]. 

On a genetic level, sickle cell anemia results from a single point substitution, which CRISPR corrects with extreme precision depending on this specific mutation. [4]. CRISPR gene editing is now being explored as a solution to alleviate the symptoms of sickle cell anemia with the Nobel prize-winning ability to change, disrupt, delete, or correct regions of DNA [4]. 

Multiple studies performed by Vertex Pharmaceuticals Inc, in collaboration with CRISPR Therapeutics and Stanford Medicine, have made CRISPR able to be administered in a single injection. Stem cells, which are unique in their ability to differentiate into a variety of specialized cells, are taken up from the patient, edited with CRISPR technology, and then injected back into the patient to produce normal, functional cells. The mutation in sickle cell affects the shape of hemoglobin, which shuttles oxygen from the lungs to tissues, and can be restored to its functional state and wild type shape. The editing targets defective cells with the DNA sickle cell anemia mutation by cutting the defective DNA and delivering the correct amino acid to the sequence [5]. Vertex Pharmaceuticals Inc hopes to get this treatment approved by the FDA in late 2023 or 2024 [2]. 

This single-injection approach to CRISPR can provide a more cost-effective and accessible form of treatment for populations living in poverty as an alternative to expenses of pain management, blood transfusions and frequent hospitalizations. CRISPR can also replace the monthly infusions of donor red blood cells that, according to the Red Cross, utilize 16 million units of blood every year [6]. Infusions are not only painful, but reducing their frequency can alleviate the strain of recent blood shortages as a result of the coronavirus pandemic, with fewer blood donors now more than ever. Therefore, CRISPR technology can eventually lower costs for the healthcare expenditures that can be allocated to other research initiatives. 

CRISPR also provides hope for treatment both during and after pregnancy for sickle cell anemia. According to a paper published in the National Library of Medicine, other gene therapies like germline therapies prevent disease through CRISPR injection into eggs and sperm. However, germline therapies are unknown in how they impact fetal development. [7].    

When used in utero, one study published in the peer-reviewed medical journal Cell found that Cas9—the enzyme used to cut the DNA—can cause major chromosome loss [8]. This potential outcome could lead to symptoms and diseases worse than what the patient originally had –  which poses notable risk to those accepting treatment. If done in utero, this could lead to other congenital disorders [9] leading to the question of if the benefits of experimental treatment, like living pain free, is worth the potential risk of irreversible disability.   

In addition, researchers have a very poor understanding of how cells are affected by CRISPR technology. With CRISPR, although created with the intention to be precise, it is often unknown if the target mutation was effectively removed or edited. The types of repair mechanisms that are initiated with CRISPR are not always accurate to create other point mutations. Alternatively, CRISPR uses generic sequences to identify the target mutation. If these nucleotides are very common and can be found in other places of the genome, CRISPR may edit the wrong gene. 

With these potential dangers, the patient is not the only one to be considered when providing treatment. We must instead weigh the potential dangers of chromosome damage or loss on the quality of life of the multiple generations impacted by the treatment. Ultimately, CRISPR gives the fetus no choice in whether to accept the treatment, whereas CRISPR modifications made in adults allow the individual to express their bodily and medical autonomy. This brings into question the role of medicine and how it designates sovereignty. 

CRISPR also poses ethical concerns due to its ability to preferably pick one gene over another. The new term ‘CRISPR babies’ has developed from concerns for human gene-editing allowing for customized children. Instead of just addressing genetic diseases, many criticize the potential for genetically modifying children to skew the natural variation that comes with sexual reproduction for the ‘ideal,’ ‘healthy’ child. Definitions of health and ‘model children’ may create artificial selection driven by prejudice that unequally values different racial identities. When heterozygous, sickle cell anemia creates a natural resistance to malaria which is prevalent in warm climates, like Africa [10]. Just the treatment of sickle cell anemia based on Western ideas of ‘health’ may create an even larger health crisis and mismanagement of health resources for malaria in Africa. So, although CRISPR can improve well-being and reverse the effects of sickle cell anemia, if done in gestation, it could produce even more vulnerability in African populations. Curing sickle cell anemia may reduce this heterozygosity that presents advantages for survival which would make them more at risk for the deadly effects of malaria. Hence, will CRISPR be used to relieve the symptoms of individuals suffering from sickle-cell, or creating another cover for mismanaged and racialized healthcare? 

There are not only unknown risks on the biological level, but also the socal level for future disease applications. However, for the immediate future, this technology could present an exciting step forward for those who suffer and live in fear of viruses and simple discomforts the general population face. This technology—despite its many unknowns and risks—could act as a step in alleviating suffering of many health-compromised populations by providing an efficient, cost-effective treatment alternative.  

However, the remaining concerns of CRISPR technologies highlight the question: ‘to what extent should a technology be used to eliminate undesirable traits?’ Who will be deciding the ethical use and removal of these traits? Although CRISPR technologies hold the potential to address global diseases that wreak havoc on the economies and welfare of populations, they also prompt concern for their future abuse and potential side effects. Overall, CRISPR presents a massive leap in the world of gene editing that has the potential to provide relief by addressing the symptoms of sickle-cell. Humanity is now entering into a new frontier of technology where survival is not just of the fittest, but left up to the powerful effects of technology. 

References

1. Mayo Foundation for Medical Education and Research. (2022, March 9). Sickle cell anemia. 

Mayo Clinic. Retrieved March 28, 2022, from

https://www.mayoclinic.org/diseases-conditions/sickle-cell-anemia/symptoms-causes/syc-20355876

2. Stein, R. (2021, December 31). First sickle cell patient treated with CRISPR gene-editing still 

thriving. NPR. Retrieved March 28, 2022, from https://www.npr.org/sections/health-shots/2021/12/31/1067400512/first-sickle-cell-patient-treated-with-crispr-gene-editing-still-thriving

3. Centers for Disease Control and Prevention. (2020, December 16). Data & statistics on Sickle 

Cell Disease. Centers for Disease Control and Prevention. Retrieved March 28, 2022, from
https://www.cdc.gov/ncbddd/sicklecell/data.html

4. CRISPR/Cas9. CRISPR. (n.d.). CRISPR Therapeutics. Retrieved March 28, 2022, from
http://www.crisprtx.com/gene-editing/crispr-cas9

5. Stanford Medicine. (n.d.). CRISPR is a gene-editing tool that's revolutionary, though not 

without risk. Stanford Medicine. Retrieved March 28, 2022, from

https://stanmed.stanford.edu/2018winter/CRISPR-for-gene-editing-is-revolutionary-but-it-comes-with-risks.html

6. US Blood Supply Facts. Facts About Blood Supply In The U.S. | Red Cross Blood Services. 

(n.d.). Retrieved March 28, 2022, from https://www.redcrossblood.org/donate-blood/how-to-donate/how-blood-donations-help/blood-needs-blood-supply.html   

7. U.S. National Library of Medicine. (2022, March 1). What are the ethical issues surrounding 

gene therapy?: Medlineplus Genetics. MedlinePlus. Retrieved March 28, 2022, from
https://medlineplus.gov/genetics/understanding/therapy/ethics/ 

8. Allele-Specific Chromosome Removal after Cas9 Cleavage in Human Embryos. Cell .
(2020,October29). Retrieved March 28, 2022, from
https://www.cell.com/cell/fulltext/S0092-8674(20)31389-1  

9. Wu, K. J. (2020, October 31). CRISPR gene editing can cause unwanted changes in human 

embryos, study finds. The New York Times. Retrieved March 28, 2022, from
https://www.nytimes.com/2020/10/31/health/crispr-genetics-embryos.html

10. Parichy, D. (2022, November). Reverse genetics. [Presentation]. University of Virginia, Charlottesville, VA, United States.   

The Reopening of Schools in a Global Pandemic: An Ethical Exploration

On March 11, 2020, the World Health Organization (WHO) declared the coronavirus to be a public health emergency of international concern (PHEIC). Following the declaration, suspension of in-person classes occurred along with the implementation of various other social distancing measures. As coronavirus numbers have come down, a shift from virtual back to in-person education has been pushed. Different states and districts have approached the issue of reopening schools in a variety of ways, trying to balance both health and educational concerns. 

For students in K-12, each grade's material builds on each other, raising concerns about the effectiveness of virtual learning in preparing students for the future. According to the Nation’s Report Card, a congressionally mandated test overseen by the Department of Education, scores in reading, writing, and mathematics declined during the pandemic. Since 2019, the average math score for fourth graders dropped 5 points and the average score for eighth graders dropped 8 points. Both grades experienced a drop of 3 points in reading tests [1].

Peggy Carr, the commissioner for the National Center for Education Statistics, said that “[These scores] are the largest declines in mathematics that we have observed in the entire history of this assessment,” [1]. However, while scores dropped drastically in math, scores in reading and writing may have been less impacted since the student’s home environment often plays a larger role in developing these skills.

These trends are concerning; however, data is otherwise too limited to make the claim that virtual learning is solely responsible for declining test performances. Remote learning looks different from state to state, district to district, and family to family. Carr emphasizes that other factors often play a role in the quality of online learning students receive, such as an unstable home environment or limited access to the internet [1].

Virtual learning does impact, though, the student’s ability to connect with others, from friends to mentors, placing additional mental and emotional strain on the child and family. Over the last few years, a trend of worsening emotional health, increased stress, and a lack of peer connection has occurred along with increasing rates of drug overdose deaths, self-harm, and eating disorders [5]. These trends raise concerns about how social isolation during virtual learning may negatively impact students, especially for those who rely on schools for support and community they can’t find at home.

For example, for students with special needs, the abrupt transition to online learning meant many students lost essential instructional time [5]. For some LGBTQ students, the closing of schools cut them off from community and essential safe spaces. In a survey conducted by EdWeek Research Center asking students if they were experiencing more problems in school after the pandemic, 83 percent of LGBTQ teenagers said they were while only 69 percent of heterosexual high schoolers also said they were [4].  

With decreased social distancing, though, comes the concern of further COVID spreading and mutation, like we saw with Omicron last year. While not as lethal as other variants, Omicron’s high transmissibility made it possible for the virus to quickly infect entire units of people, like nursing staff, flight attendants, and teachers [3]. Data through July 28, 2022 shows there have been 14 million child COVID-19 cases, 19% of all cases, with pediatric hospitalizations peaking in January 2022 during the Omicron surge [5]. 

Another concern is the possibility for school openings to cause spreading among family units and older populations. One study attempted to analyze this potential phenomenon, but could not collect enough data to suggest whether or not school openings are associated with transmissions across different age groups [2]. The study did find, though, that teachers and their significant others in open schools had higher rates of COVID-19 infections than teachers and their partners in closed schools [2]. 

Despite the concerns surrounding academic test score declines, a variety of factors also influence the necessity of opening schools or continuing virtual education. Virtual learning varies from district to district and from home to home making the process of identifying flaws within the virtual model difficult. Virtual education does, though, place additional strain on already vulnerable students cutting them off from community and vital support services. While the concern about COVID is still very real, a holistic look at students and the role schools play in their lives is essential to understanding the unique demands the pandemic has placed on students and what they need next from their school administrators. 

References:

1. Camera, Lauren. (2022, Oct. 24). Pandemic Prompts Historic Decline in Student Achievement on Nation’s Report Card. U.S. News. https://www.usnews.com/news/education-news/articles/2022-10-24/pandemic-prompts-historic-decline-in-student-achievement-on-nations-report-card#:~:text=An%20overwhelming%20majority%20of%20states,of%20the%20impact%20of%20the

2. Chernozhukov, V., Kasahara, H., & Schrimpf, P. (2021). The Association of Opening K–12 schools with the spread of covid-19 in the United States: County-level panel data analysis. Proceedings of the National Academy of Sciences, 118(42). https://doi.org/10.1073/pnas.2103420118 

3. Powell, Alvin. (2022, Oct. 11). Is the pandemic finally over? We asked the experts. Harvard Gazette. https://news.harvard.edu/gazette/story/2022/10/is-pandemic-finally-over-we-asked-the-experts/

4. Will, M. (2022, January 31). When school goes remote, many LGBTQ students lose a safe space. Education Week. https://www.edweek.org/leadership/when-school-go-remote-many-lgbtq-students-lose-a-safe-space/2021/03#:~:text=With%20remote%20learning%2C%20he%20added,build%20to%20survive%2C%20frankly.%E2%80%9D 

5. Williams, Elizabeth, & Drake, Patrick. (2022, Aug. 05). Headed Back to School: A Look at the Ongoing Effects of COVID-19 on CHildren’s Health and Well Being. Kaiser Family Foundation. https://www.kff.org/coronavirus-covid-19/issue-brief/headed-back-to-school-a-look-at-the-ongoing-effects-of-covid-19-on-childrens-health-and-well-being/

CRISPR is Revolutionary – but at What Cost?

CRISPR, the groundbreaking gene-editing tool of the last decade, has permanently altered the field of genetics for the science world. The tool efficiently targets specific sequences of genetic code and has revolutionized studies on genomes of a plethora of organisms. CRISPR has played an especially vital role in tackling diseases as the technology enables replacing harmful DNA sequences with healthy ones. 

The first cell therapy study with CRISPR was conducted just in 2019 to treat Victoria Gray’s sickle cell disease symptoms.1 Sickle cell anemia is an inherited disease that results in the formation of crescent shaped blood cells.2 For the disease’s thousands of victims, these crescent shaped blood cells can inflict episodes of pain by blocking blood flow in the body. This can make normalcy for sickle cell patients extremely challenging and prompt those like Victoria Gray to turn to new methods such as CRISPR gene editing. 

Prior to the clinical trial with Gray, the only known cure for sickle cell was a bone marrow transplant, which is where the stem cells responsible for the faulty hemoglobin in sickle cell are found. This process involves killing the stem cells through chemotherapy and replacing them with healthy cells from a donor.3 The main issue with this solution is finding a donor, and the reason why researchers began to experiment with CRISPR as an alternate treatment. 

Scientists focused on using CRISPR to edit a fetal hemoglobin gene that would produce enough healthy cells to counter the defective sickle cells. After extracting and editing Gray’s cells with this process, scientists infused billions of modified stem cells back into her body. For patients such as Gray, CRISPR is life changing – she was able to resume her daily activities without the burden that sickle cell brought upon. However, for others, the outcome can be disheartening and even deadly. 

In October of 2022, 27-year old Terry Horgan passed away during a study testing similar gene editing techniques to Victoria Gray in hopes of curing his fatal condition of Duchenne muscular dystrophy. The muscle degeneration disease is caused by a gene mutation that prevents dystrophin, a protein important for holding muscles intact, from being produced properly. Researchers at the University of Massachusetts are unsure of the exact details of what caused the death, but considering methodology, speculation points toward CRISPR possibly playing a crucial role.4

Based on what examination finds in the next few months, Terry Horgan’s death may be a large setback in research and investments towards CRISPR gene editing. The situation bears resemblance to the death of Jesse Gelsinger in 1999, which heavily set back the field of gene therapy at the time. Similar to Horgan, Gelsinger volunteered to be a part of a clinical trial that involved new gene therapy methods. Gelsinger had ornithine transcarbamylase deficiency syndrome (OTCD) where ammonia builds up to lethal levels in the blood due to a damaged or missing transcarbamylase enzyme.5 To treat OTCD, researchers developed a harmless cold virus to contain working copies of the OTC gene, which would be injected into the patient and integrate the added gene through infection of cells. While the method caused mild side effects in other patients, the viral vector caused a fatal inflammatory response for Jesse Gelsinger and dismantled the field of gene therapy for its deadly risks.6 

After nearly two decades of research, gene therapy slowly overcame its controversy with new policies requiring researchers to be cautious with human subjects.7 However, gene therapy clinical deaths still occur from time to time.8For Horgan’s case, it has called attention to how CRISPR gene therapy methods are still extremely new – and both its other abilities and long term effects are unknown.9 As CRISPR evolves and develops to have new uses, an ignorance towards its capacity to affect the human genome can lead to only more tragic deaths. 

CRISPR’s unique ability to edit almost any part of the genome holds great power, and this is what can give rise to several ethical issues. In the same year of Gray’s successful CRISPR cell therapy treatment, Chinese scientist He Jiankui was sentenced to 3 years in prison for inserting genetically modified embryos unknowingly into two women seeking in-vito fertilization.10While he had positive intentions of absolving them of HIV, an immune disease with great danger towards its victims, it is a reminder that CRISPR puts researchers in potentially-concerning positions of control. 

The controversy surrounding the case arose from how the volunteers in the study were not fully informed of the genetic modification happening to the embryos, and while it made large strides forward in gene editing, this behavior should not be tolerated due to its unpredictable risk for future generations.11 Additionally, gene editing embryos can easily be exploited for nontherapeutic methods, posing questions of autonomy in light of CRISPR. The case raises questions of who should decide what genes must or should be edited. With the wrong mindset, the abilities of CRISPR can be warped into a modern form of eugenics, embodying the same intentions to remove “undesirable” qualities but with gene editing. 

Because of the intense disciplinary action taken in Jiankui’s instance, there has not been another gene editing scandal of that caliber, but this doesn’t mean it cannot happen again. The ethical issues of editing human embryos range from its future unknown effects for the subjects to unnatural creations of mankind. While CRISPR gene editing may seem like it can improve quality of life for an individual, it is nearly impossible to evaluate whether CRISPR could make a substantial impact. In the cases of Gray and Horgan, the risk of CRISPR is understandable as the gene editing methods were utilized to help eradicate diseases they sought treatment for. 

This differs from completely eliminating genes and other genetic material that are considered “undesirable,” which would fall under the HIV case with Jiankui. The eugenic mindset may sound harmless, but it is the same that led to forced sterilization and euthanization in WWII to artificially create the Aryan race Nazis desired.12 This method of complete eradication brings forth an ableist mindset that those with disabilities have nothing to contribute to society. However, those with disabilities are human and have equal rights to life and autonomy just as those without them. Additionally, they have redeemable lessons to share and add another level of diversity to civilization. Disabilities give us the ability to explore different perspectives that pave the way towards kindness, empathy, and generosity. These qualities are essential in ensuring our relationships as human beings to one another are respectable. Beyond modern eugenics, CRISPR can pose another problem, which are lines of social inequality. 

As research with genetic diseases and CRISPR progresses, a division between those who can afford the treatment and those who must suffer will begin to emerge. For example, to treat a child with spinal muscular atrophy, the cost of a single gene therapy treatment Novartis is upwards to 2 million without insurance.13 With insurance, the price of one treatment is reduced to $10,000, but the number is still extremely unaffordable for most families. Here, the responsibilities fall on companies to make these treatments more affordable or pose a risk of alienating those with disabilities further out from society. 

This is not to say that we should do without CRISPR gene therapy, but to recognize the broader health and social effects that exist as much is unknown about the tool. While CRISPR has been able to significantly alter the lives of those who suffer from genetic diseases, it has also been responsible for deaths and exploitation. 

We must continue to acknowledge that CRISPR is a privilege full of medical uncertainties. If examined thoughtfully and integrated into the medical field carefully, CRISPR possesses the capacity to cause incredible healing. If not, it may become another point of division – decisions made today that will influence all of our shared tomorrows. 

References: 

1. Stein, Rob. “First Sickle Cell Patient Treated with CRISPR Gene-Editing Still Thriving.” NPR, NPR, 31 Dec. 2021,  https://www.npr.org/sections/health-shots/2021/12/31/1067400512/first-sickle-cell-patient-treated-w ith-crispr-gene-editing-still-thriving. 

2. “What Is Sickle Cell Disease?” National Heart Lung and Blood Institute, U.S. Department of Health and Human Services, https://www.nhlbi.nih.gov/health/sickle-cell-disease. 

3. BeTheMatch.org. “Sickle Cell Disease (SCD) .” Be The Match, https://bethematch.org/patients-and-families/about-transplant/blood-cancers-and-diseases-treated-by-t ransplant/sickle-cell-disease--scd-/. 

4. Ungar, Laura. “Death in US Gene Therapy Study Sparks Search for Answers.” AP NEWS, Associated Press, 4 Nov. 2022, https://apnews.com/article/science-technology-health-business-genetics-79f4a9b76426ec40c367957e3 bb9cf4a. 

5. “Ornithine Transcarbamylase Deficiency.” MedlinePlus Genetics , U.S. National Library of Medicine, https://medlineplus.gov/genetics/condition/ornithine-transcarbamylase-deficiency/#causes.

6. Rinder, Meir. “The Death of Jesse Gelsinger, 20 Years Later.” Science History Institute, 16 July 2019, https://www.sciencehistory.org/distillations/the-death-of-jesse-gelsinger-20-years-later. 7. Savulescu, Julian. “Harm, Ethics Committees and the Gene Therapy Death.” Journal of Medical Ethics, Institute of Medical Ethics, 1 June 2001, https://jme.bmj.com/content/27/3/148. 

8. Liu, Angus. “2 Deaths after Novartis' Zolgensma Put Gene Therapy's Liver Safety in the Spotlight Once Again.” Fierce Pharma, 12 Aug. 2022, https://www.fiercepharma.com/pharma/two-deaths-after-novartis-zolgensma-bring-gene-therapys-liver -safety-spotlight-again. 

9. “The Gene Editor Crispr Won't Fully Fix Sick People Anytime Soon. Here's Why.” Science, https://www.science.org/content/article/gene-editor-crispr-won-t-fully-fix-sick-people-anytime-soon-h ere-s-why. 

10. “Chinese Scientist Who Produced Genetically Altered Babies Sentenced to 3 Years in Jail.” Science, https://www.science.org/content/article/chinese-scientist-who-produced-genetically-altered-babies-sent enced-3-years-jail. 

11. Lanphier, Edward, et al. “Don’t Edit the Human Germ Line.” Nature, vol. 519, no. 7544, 2015, pp. 410–411., https://doi.org/10.1038/519410a. 

12. “Eugenics .” United States Holocaust Memorial Museum, United States Holocaust Memorial Museum, https://encyclopedia.ushmm.org/content/en/article/eugenics. 

13. “Paying for CRISPR Cures: The Economics of Genetic Therapies.” Innovative Genomics Institute (IGI), 18 May 2022, https://innovativegenomics.org/news/paying-for-crispr-cures/.

China's Zero-Covid Policy in Shanghai: The Pandemic's Legacy

On one side of the world, citizens peer outside strictly quarantined homes to find closed shops, empty streets, and healthcare workers armed to the teeth in personal protective equipment. On the other hand, it is almost business as usual. The way the United States has experienced and managed the COVID-19 pandemic vastly differs from China. In the U.S. today, vaccination clinics, hybrid classes, and non-mandatory masking have permanently altered the country’s landscape; many people are ready to move onto a new normal [1]. Yet, three years into the COVID pandemic, China’s dynamic zero-COVID policy still remains, defining the daily lives of an estimated 1.5 billion people. Mass public health responses should give more weight to bioethical, human impacts, and it is time to take a critical look at China’s policy from a non-western perspective to do just that. 

First, the motivations and implications of China’s dynamic zero-COVID policy must be established to understand its human impact. The policy was first created by the Chinese government to contain the initial outbreak of COVID in Wuhan during March of 2020. The policy decrees that the Chinese government will take “dynamic” action to eliminate cases that arise as necessary [2]. The implication of this statement has been two-pronged: prevention through frequent PCR testing, especially in cities, and lockdowns. Particularly in the latter, tactics can include neighborhoods to whole cities quarantining in their homes or government-controlled facilities, for weeks or even months. Now, Xi Jinping, the president of the People’s Republic of China and the general secretary of the Chinese Communist Party, stakes much of his political reputation on the policy in hopes that its success will carry him through his unprecedented third-term tenure for CCP’s general secretary position [2]. 

All this begs the question: has the policy truly been successful? From a purely statistical perspective, there is no denying that it has. According to Johns Hopkins University’s COVID mortality analyses, China has 1.12 deaths per 100,000 people [3]. On the other hand, the U.S. has the highest mortality rate in the world, with 326.74 deaths per 100,000 people [3]. Indeed, as The Atlantic science journalist Ed Yong states in his article The Pandemic’s Legacy Is Already Clear, negative responses to U.S. government-issued vaccine and mask mandates have led to less efficacy in containing it, making the country more vulnerable to new variants [4]. In comparison, China reflects its highly collectivist values in going to extreme measures to put the interest of the whole country or the “group” above the individual. 

However, from a bioethical perspective, the zero-COVID policy tells a different story. Shanghai’s lockdown this past spring demonstrates the need for public health responses to look beyond cultural values and prioritize bioethical concerns. In early April 2022, a large spike of COVID cases in Shanghai led to the entire city being shut down for two months, making this lockdown one of the most severe across the globe. Hundreds of thousands of Shanghai residents were forced to quarantine in their homes or designated facilities, relying on government-issued delivery services for medical supplies and food. People posted calls for medical help online when they could not get to the hospital they needed. In fact, facilities exacerbated the vulnerability of the elderly in this otherwise highly effective method [5]. In April, COVID spread widely among elderly Shanghai residents at the Donghai Hospital, many of whom were not vaccinated, and yet no extra protections were made for this already at-risk population. To make matters worse, families were not allowed to visit their elderly relatives in the hospital for a long time. Mr. Shen, a 45-year-old businessman, is just one example of the human cost of this policy. His father, who was already immunocompromised, died alone after running out of medication while waiting in a 400-person line [5]. 

Shanghai is not the only major Chinese city that has been in sudden mass lockdown like this. Beijing, Chengdu, and Shenzhen are just a few examples. Each lockdown equates to millions of changed lives. Even after lockdown, the daily impact of the zero-COVID policy is apparent; there is still mandatory PCR testing to get on public metro transport, and quarantines are still common even in neighborhoods that just have one or two cases. Public resistance towards the policy has been strong — with their lives clearly on the line, citizens posted their outrage, fear, and despair on social media platforms that contrasted with the cheery lockdown response that the government has tried to project in the media [6]. The usual government censorship struggled to contain public opinion that called for policymakers to rethink China’s COVID controls. 

In fact, just this past month on November 26th, 2022, protests in Shanghai in the wake of a deadly fire in a Urumqi quarantine facility added extra pressure to the Chinese government. In response, China has rapidly lifted the strictest parts of their zero-COVID policy, allowing citizens with symptoms to isolate at home instead of state-sponsored facilities and opening up free travel within the country without need for proof of negative tests [7] The immense rise in infections and sudden shift in the government’s language around COVID-19 has caused concern that the country’s healthcare system could be overwhelmed. However, from the relieved public’s response, one thing is certain: public health responses are malleable and should adjust based on the needs of a country. 

Shanghai’s reality is one that I, living on the other side of the world, could not ever imagine. I remember watching a Chinese New Years skit performed not too long before the lockdown started. In the skit, citizens young and old smiled wistfully and conversed, wearing KN95 masks, over food delivery and across apartment porches. No matter how these stringent policies have been quelling COVID mortalities, no one should have to live like this for months and years. Yet, the U.S. is a painful reminder that individualist policies downplay the truth that pandemics affect the collective, and individuals must do their part to keep everyone safe. No matter how different cultural values may be, the bottom line is that we all are humans, stumbling our way through a changed world with hope. While people across the world from each other may not live these stories, they must listen and learn from them. Inevitably, this will not be the world’s last pandemic; let these stories be what informs and strengthens public health responses to the next one.

References: 

1. John Gramlich, “Two Years Into the Pandemic, Americans Inch Closer to a New Normal,” Pew Research Center, March 3, 2022. 

2. Reuters, “Factbox: What is China's zero-COVID policy and how does it work?,” Reuters, November 3, 2022. 

3. Johns Hopkins University, “Mortality Analyses,” Johns Hopkins Coronavirus Resource Center. 

4. Ed Yong, “The Pandemic’s Legacy Is Already Clear.” The Atlantic, September 30, 2022. 

5. John Liu, Amy Chang Chien, & Paul Mozur, “Outbreak at Shanghai Hospital Exposes Covid’s Risks to China’s Seniors.” The New York Times, April 1, 2022.

6. Vivian Wang, Paul Mozur, & Isabelle Qian, “China’s Covid Lockdown Outrage Tests Limits of Triumphant Propaganda,” The New York Times, April 27, 2022.

7. Frances Mao, “China abandons key parts of zero-Covid strategy after protests,” British Broadcasting Corporation, December 7, 2022.

Ethics of Various Methods of Organ Donation for Transplantation

Ethics of Various Methods of Organ Donation for Transplantation 

In the United States and around the world we are failing to meet the demand for organ transplants. In the U.S. there are well over 100,000 patients waiting for organs in order to save their lives but fewer than 15,000 donors become available per year [1]. This shortage has caused heated debates over the best system for organ donation for the purpose of transplantation. The primarily proposed solutions include expressed consent, presumed consent, and mandated choice. This shortage has also led to the development of a highly lucrative black market for organs which is plagued with unethical and dangerous practices [1]. This is not an issue that only touches certain groups or classes of people, it is an issue that can affect almost anyone, and as a result, it should be an issue that we all commit to addressing. After a practical and ethical review of each of the proposed systems, I will show why I have come to the conclusion that with certain supports in place the most ethical and practical solution is implementing a system of mandated choice. 

In order to properly evaluate the best system for organ transplantation, it is important to understand the history of the procedure and what organ donation and transplantation actually look like. In 1954, doctors performed the first successful organ transplant of any organ using a kidney. In the 1960s organ transplant surgeries became consistently viable and since then there have been many technological advancements that have made it a truly life-saving procedure with the need for regulation [1]. Organs that have the potential to be harvested after death if viable include both kidneys, the liver, both lungs, the heart, the pancreas, the intestines, the hands and face, various tissues, the corneas of the eyes, and even in certain situations the limbs. Organs that can be donated while an individual is alive include one kidney, one lung, part of the liver, the pancreas, and the intestines. These can be donated because it is possible to survive without them, however, it is important to note that sometimes lifestyle changes are required after the removal [2]. Furthermore, there is a 5-10% risk of a surgical complication occurring and a 0.5-1% risk of death for a living donor depending on the specific procedure [3]. Even though organ donation, especially while one is still alive, is an extremely honorable action, it is important that individuals are properly educated on the risks they are taking on when they make that decision. The huge demand for this lifesaving procedure and the shortage of viable organs have created the perfect conditions for the extremely lucrative enterprise of organ trafficking to occur. There are two types of organ trafficking which are important to distinguish: the first one is human trafficking for the purpose of organ removal, and the second is organ, tissue, and cell (OTC) trafficking. Human trafficking for the purpose of organ removal is when an individual is transported and then their organs are removed. While OTC trafficking is the removal of someone's organs which are then transported and sold for transplant. In yearly revenue, the underground organ trade makes between $600 million and $1.2 billion. The organs used are generally sourced from donors in developing countries that are then bought by patients in wealthy nations like the United States. Frequently, donors in developing nations make the decision to sell their organs because they need to pay for necessities like food or shelter which makes them especially vulnerable. On the other hand, for many recipients of these illicit organs, the unsafe nature of receiving illicit medical care in a developing nation can end up making the benefits of the transplant obsolete with high rates of contraction of infectious diseases and rejection of the organs. Both patients and donors are coming from a place of extreme desperation to survive in one way or another. This need has created a prime situation for organ traffickers to take advantage of both parties and create an extremely profitable system [1]. In order to address this and end the abuse present it is necessary to pursue a more effective system of organ transplantation. 

Since organ donation is a system that has so much potential for abuse of those in need it is important to centralize bioethical principles in the conversation. In order to do this it is imperative to understand the necessary terminology. The primary pillar that organ donation is founded on is altruism [3]. This is when an individual's actions are motivated by making a positive impact on others without regard for their own benefit [3]. Along with altruism, it is extremely important to discuss the bioethical principles of autonomy, beneficence, and nonmaleficence. Nonmaleficence means to do no harm and is especially important when it comes to living donor transplants because there is a substantial risk that the donor is undertaking [3]. Beneficence as it applies to bioethics is the obligation for healthcare professionals to do good. This includes the sharing of knowledge and resources in order to ensure that a patient is able to make a decision with proper knowledge of their options, also known as informed consent [3]. Autonomy has to do with the right to freely make decisions concerning oneself. When it comes to organ donation this is extremely important, especially in regard to individuals donating organs. Nobody or no situation should put anybody in a position where they feel like they have no other choice than to donate an organ. When dealing with vulnerable populations like in systems of organ transplant it requires the utmost prioritization of ethicality. 

Now that there is a firm understanding of the problem, the procedure, and the ethical concerns that must be taken into account, an examination of each proposed system can be done. One of the proposed and most commonly practiced systems around the world, including the U.S., is expressed consent. An expressed consent system, also known as an opt-in system, relies entirely on altruistic donations from individuals who have indicated on an official form or in the presence of two adults their intention to donate after their death [1]. The primary benefit to an expressed consent model from an ethical standpoint is that it maintains the autonomy of potential donors by ensuring that every individual who donates actually wanted to donate because they took some form of official action to indicate this choice. However, in a more practical sense, a major drawback of this model is that it has proven to be extremely ineffective at meeting the demand for organs [4], which, as shown, can increase the demand for organs in the black market. This can actually create a potential counterargument to the ethicality of this system by raising the question that if a system is increasing the number of people turning to the unethical black market can it be an ethical system itself? While surveys show that a majority of citizens support organ donation, many often do not take the necessary action to become a donor and document their intention [4]. In fact, one poll found that 70% of the respondents indicated a desire to donate their organs but only 42% of Americans are registered donors and similarly in the UK only 39% of citizens are donors [5]. This causes the system to lose out on many potential organs continuing to contribute to the shortage. Some have even gone as far as to argue that US law about organ donation relies too heavily on altruism and will, therefore, worsens the shortage of organs [1]. 

An almost starkly opposing system is presumed consent. In this system, also known as an opt-out system, every individual is presumed to be an organ donor unless registered with a government database to express their opposition. A number of European countries have opt-out systems including Spain, France, Austria, Italy, and Norway. These countries that use this model have drastically higher percentages of citizens who are donors [1]. In all countries that practice this model, consent can only be presumed when it is determined that the donor was aware of the fact that not opting out meant they were deciding to donate their organs. As a result, a physician is only able to proceed with organ harvest after verifying that there is no documentation of a refusal either through the government or corroborating stories from multiple family members [7]. The primary objection to a presumed-consent policy is that some view it as a loss of autonomy because there is no affirmative choice by an individual to donate their organs. Many physicians and bioethicists view it as unethical to invade an individual's body without their expressed consent. In this model, it is incredibly possible for consent to be presumed of someone who was unaware of the need to opt out or was uneducated about the decision they were making, removing autonomous choice. Objectors to this model go on to argue that it is inherently worse to mistakenly remove someone's organs when that is against their wishes than not donate the organs of someone who wanted to because it is a blatant violation of primary ethical principles. However, those who support presumed consent respond to the argument of a loss of autonomy by countering that the model actually increases autonomy because it allows the donor instead of the family to make the final decision. Another argument in favor of presumed consent is that it is ethical because it provides the greatest good for the greatest number of people. Furthermore, some say that the burden of educating about presumed consent falls to those who object to donation rather than those who support it because the goal of donation and transplantation is overall morally good [4]. 

One extremely well-known model of the successful practice of presumed consent is in Spain. Out of any country in the world, Spain has the highest rate of organ donation with 33.5 per 1 million residents donating after death. Spain has developed an intense societal respect for organ donors which contributes to the success of the program. This policy is also extremely cost-effective because in the long run paying for a kidney transplant is cheaper than long-term dialysis. However, it is important to note that most countries that utilize a presumed consent model have universal healthcare or a combination of it with private care. This is significant because it means that all citizens are eligible to receive transplants while in a system; with entirely private health care only citizens who have insurance or money for the procedure would be eligible for transplants. While there are some countries that this model has worked well for, it is important to note that not all countries have experienced this same success. In the late 90s, Brazil adopted a policy of presumed consent but quickly repealed it because most doctors refused to harvest organs without expressed consent [4]. While the model of presumed consent is extremely effective at increasing the rate of organ donation it has many problems when it comes to respecting the autonomy of donors making it difficult to deem it a reliably ethical system. 

Another system that is less common but addresses many of the flaws with the previous two models is mandated consent. In this system, it is required that all citizens, specifically adults, indicate their preferences for donation as a part of a required activity like filing taxes. One example of the use of a mandated choice model is in the state of Illinois where residents are required to designate their desire to donate or not in order to renew their driver's license. As of 2009, there was a signup rate of 60% compared to the national rate at that time of 38%. The primary ethical benefit of this system is that since it requires a clear choice to be made it enhances individual autonomy [1]. It ensures that a person's wishes would be honored whether they would like their organs donated or not. This is in line with the generally accepted view that individuals are more suited to make decisions about organ donation than their families [6]. Other advantages of this system include eliminating the barrier of family consent, increasing public awareness about organ donation as everyone would be forced to consider it, and would eliminate current delays resulting from getting family consent which would increase the viability of donated organs [6]. One ethical challenge that has been brought up about mandated choice is how it would be possible to ethically compel someone to make this choice. For example, if someone were to refuse to make this choice how could they be forced to do so in an ethical way? The answer seems fairly simple: if a decision about whether or not to be an organ donor becomes a required part of taxes or getting a driver’s license then not making a decision would mean you did not complete the required material. As a result, the individual would experience the consequences of that. This respects all central parts of bioethics including autonomy because respecting someone’s autonomy does not mean they do not have to comply with certain regulations, it means that they are able to make a choice. There are many other required decisions on tax forms like whether or not to donate to the Presidential Election Campaign Fund. Ultimately, a system of mandated choice would be the most ethical and effective at increasing the supply of organs for transplantation. 

Systems of organ donation for the purpose of transplantation are highly dependent on the morality and central values of a society. As shown, there are countries that have been able to make each system work well enough and have it widely accepted by the general public. However, a system can be accepted by society and still be unethical or ineffective at achieving its goal. While an expressed consent model meets ethical standards it is grossly unable to meet the demand for organs. On the other hand, while a presumed consent model is extremely successful at meeting this demand, it brings up serious ethical questions about whether there is true respect for autonomy, especially in a country with an insufficient education system. The system of mandated choice is able to require an autonomous choice to be made in an ethical way while simultaneously increasing the number of donors and, therefore, the number of available organs for transplantation. While it may seem as if this is an issue that is out of the control of individuals, it is those individuals that the chosen system will most profoundly affect whether it is as a potential recipient, donor, or nondonor. As a result, it is imperative that citizens of the world evaluate both the effectiveness and ethicality of potential systems and advocate for the one that meets these standards best, which in my opinion is a model of mandated choice. This system could provide greater access to organs which can prolong the lives of so many people and allow them to live full lives and allow vulnerable populations of donors to be protected from abuse and effectively the robbery of their organs. The situation has reached a point of dire need. It requires that everyone take action through education and advocacy to ensure that as a world and individual nation there is protection for the most vulnerable and achievement of the highest standard of medical care possible.

References 

1.  Kelly, E. (2013, May 1). International organ Trafficking Crisis: Solutions Addressing the Heart of the Matter. Boston College Law Review, 1317-1349. 

2. What Can Be Donated. (2021, September). Health Resources & Service Administration. Retrieved November 25, 2022, from https://www.organdonor.gov/learn/what-can-be-donated.

3. Dalal, A. R. (2017, June 24). Philosophy of organ donation: Review of ethical facets. National Library of Medicine. Retrieved November 15, 2022, from 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4478599/

4. Zink, S., Zeehandelaar, R., & Wertlieb, S. (2005, September). Presumed vs Expressed Consent in the US and Internationally. AMA Journal of Ethics. Retrieved November 15, 2022, from 

https://journalofethics.ama-assn.org/article/presumed-vs-expressed-consent-us-and-intern ationally/2005-09#:~:text=Countries%20with%20presumed%20consent%20have%20gen erally%20seen%20higher,1986%2C%20donation%20rates%20fell%20by%2050%20perc ent%20%5B3%5D.

5. Goldman, R. (2012, May 1). States See Instant Spike in Organ Donors Following Facebook Push. ABC News. Retrieved November 25, 2022, from 

https://abcnews.go.com/Health/states-instant-spike-organ-donors-facebook-push/story?id =16255979#:~:text=More%20than%20112%2C000%20Americans%20are%20awaiting %20organs%2C%20and,support%20donation%2C%20only%2042%20percent%20are%2 0registered%20donors. 

 6. Spital, A. (1997, March 27). Mandated Choice For Organ Donation. Official Journal of Transplantation. Retrieved November 15, 2022, from 

https://journals.lww.com/transplantjournal/Fulltext/1997/03270/MANDATED_CHOICE_ FOR_ORGAN_DONATION.23.aspx. 

7. Presumed Consent & Mandated Choice for Organs from Deceased Donors. (n.d.). AMA Code of Medical Ethics. Retrieved November 15, 2022, from 

https://code-medical-ethics.ama-assn.org/ethics-opinions/presumed-consent-mandated-ch oice-organs-deceased-donors. 

Physicians Have a Duty to Treat Patients in Times of Personal Risk

Covid-19 has led to renewed interest and discussion regarding the duties of physicians in a high risk environment. The pandemic resulted in large shortages in emergency and critical care providers, and those that remained were overworked and dealing with shortages of key equipment such as personal protection devices. In one study during the pandemic, about 25% of physicians and nurses thought it was ethical for health care providers to abstain from treating patients given the personal risk to themselves and their families [1]. Those who choose healthcare as a career certainly assume certain risks relating to psychological stress, long hours, and personal risk such as exposure to harmful and potentially deadly infections. When these challenges increase dramatically, which moral and ethical duties are inherent in the jobs of physicians? I argue that there is an ethical duty for physicians to treat patients despite the personal risk involved during events such as pandemics.

An important consideration in discussing physicians’ duties and responsibilities is that of implied consent. Since it is commonly accepted that some patients are infected and contagious, it is reasonable to assume that risk is inherent in the field of medicine, and by entering the field certain risks are implied and accepted. Although this does not imply that a duty to treat exists, it establishes an accepted reality regarding physician practice.

In 1847, the American Medical Association published its first Code of Ethics stating, “When pestilence prevails, it is their [physicians’] duty to face the danger, and continue their labors for the alleviation of suffering even at the jeopardy of their own lives” [2, p. 3]. While this wording no longer exists in the AMA code, it points to the long tradition of self-sacrifice in the field of medicine, a concept which draws many to pursue the profession. In addition, pledges made by physicians such as the Hippocratic Oath reference the special nature of physicians’ duties. The World Medical Association has a similar pledge, although like the Hippocratic Oath, does not address risk to physicians [2].

When discussing the difficult concept of physician duty to treat, it is also useful to consider the ethical concept of beneficence. In their work entitled, Bioethics: The Islamic Perspective, Al-Bar and Chamsi-Pasha argue that the principle of beneficence has special meaning for health care workers, and implies unique moral obligations. They state, “beneficence is a continuum…professionally things which are considered as supererogatory for the public become obligatory for the professional, e.g., a physician or nurse in a hospital where he is tending patients with highly infectious diseases” [3, p. 132]. This perspective goes a step further in applying unique moral duties to physicians.

Making broad arguments about moral and ethical duties is particularly challenging, because physicians may face health risks that extend to others–family members at home may be especially vulnerable to an infectious disease. Although contentious, the concept of beneficence still applies: physicians have a unique commitment to provide. In the case of a future epidemic, perhaps one that is more lethal than Covid-19, a physician who pauses their labors to protect members at home may indirectly result in deaths of others. Risks that extend into a physician’s personal life should not interfere with priorities when health care is valuable and dire. These duties should be clearly outlined for prospective health care providers, as ambiguities in a code of ethics will not guarantee care from physicians.

References

1. McConnell D. (2020), “Balancing the duty to treat with the duty to family in the context of the COVID-19 pandemic”, Journal of medical ethics, April 24, 2020

1. Kirsch T. D. (2022), “Heroism Is Not a Plan-From "Duty to Treat" to "Risk and Rewards”,” The American journal of bioethics, March 4, 2022

1. Al-Bar MA, Chamsi-Pasha H. “Contemporary Bioethics: Islamic Perspective”, Cham (CH): Springer, May 28, 2015

Towards a Brave New World: The Huxleyan Reality of Using Pharmacological Neuroenhancement

Among all possible contingencies, there has been an evident progression toward the dystopian future foretold by visionary writers such as Aldous Huxley in particular. Huxley’s 1932 novel Brave New World alluded to the pre-existing epidemic that concerned the use of pharmacological neuroenhancement for improved cognitive and affective functioning (i.e., attention, memory, mood, etc.) via legal or illicit drug use [1]. But at what costs? As portrayed in the novel, the drug “soma” induces feelings of happiness while nullifying any kind of discomfort and pain [2]. Such quixotic concepts have been exploited to serve as a form of enhancement to construct the best version of our brains, especially in the postmodern era [3]. The use of pharmacological neuroenhancement, synonymously known as brain doping, by healthy subjects for non-medical purposes to enhance performance and work has been a common practice that can be traced back to the ancient Greeks who used pharmacological neuroenhancement when competing in the Olympic Games [4]. Although intense polarization has been ceaselessly ongoing between transhumanists and bioconservatives in the neuroenhancement debate.

While transhumanists argue in favor of utilizing pharmacological neuroenhancement as a form of genetic engineering to increase human cognitive abilities and thereby radically change the ways through which our species develop, bioconservatives are skeptical of such propositions and dismiss any morally permissible ideas related to modifying our natural intelligence. In their views, bioconservatives criticize the transhumanist ideal of perfection and their hubristic ambition to override the inherent principles of nature, which echoes the warning conveyed by Huxley that the perturbing influence of eugenics-inspired biotechnologies must be resisted. It is therefore imperative to critically examine and analyze the philosophical basis for both stances in relation to the ethics of using pharmacological neuroenhancement and to ultimately unveil the truth of the Huxleyan reality—a nightmarish, oppressive vision that Huxley once envisaged and feared.

In utilitarian terms, an alluring aspect as promised by the effective use of pharmacological neuroenhancement is increased cognitive functioning, which transiently improves performance in any given activity such as learning and memorization [7]. One familiar example is the use of psychostimulants like methylphenidate (brand name: Ritalin) among college and university students. Taking such neuroenhancement drugs lead to improved working memory and increased attention, which reportedly helps students study for longer hours and study more productively with reduced anxiety. Of note, however, is that the original purpose of the stimulant is meant to be prescribed to treat individuals with ADHD, [7] and not for augmenting one’s cognition for the benefit of improving the human cognitive condition [9]. All progress throughout the course of human civilization is rooted in the fundamental belief of climbing to the next step in the evolutionary hierarchy, which motivated the need to intervene and manipulate the systematic complexities of the human mind for the sake of continuing progress. In the instance of using pharmacological neuroenhancement to increase one’s cognitive abilities, an intelligence-based hierarchy as modeled after the social infrastructures that exist in the Huxleyan reality would thus be born [2]. Living under this type of hierarchy implies that even though an individual would rather prefer not to take neuroenhancement drugs, he or she would nevertheless be pressured to take the drug in an increasingly competitive environment to be on par with someone who is already conditioned to take the drug on a regular basis [5]. The aftermath would then result in the problem of, does the individual still retain his or her autonomy?

Calling transhumanism “the world’s most dangerous idea,” the political scientist Francis Fukuyama suggests that when giving in to the temptations of transhumanist thought such as in the goal of enhanced cognition, the impulse to buy into such ideas oftentimes would cause the individual to be blinded to the actual price [10]. Notwithstanding the utopian ideal, it is noteworthy to mention the health risks along with the addictive effects associated with taking neuroenhancement drugs that may pose harm to the individual, to which many of the users are oblivious [11]. By taking the use of neuroenhancement drugs out of its medical context for unintended purposes such as serving as a studying aid, the thin line that distinguishes enhancement from treatment is blurred as a result. In doing so, the individual becomes vulnerable to, among other things, increased blood pressure, nausea, and irregular palpitations from the effect of altered brain chemistry as a result of taking psychostimulants [12]. Ironically, the case of memory enhancement may also cause impairment to memory retrieval by interfering with the balance between remembering and forgetting due to information overload in the higher-order capacities of the brain [3]. Hence, while it is reasonably acceptable for individuals with mental illnesses or cognitive deficiencies to take neuroenhancement medications to reinstate normal brain functioning, the inverse is true in the case of enhancement where safety is a primary ethical concern. 

A supporting argument used to oppose bioconservatism is that pharmacological neuroenhancement promotes fairness and equity, notably for individuals who may be disadvantaged in some ways when compared to others in the context of applying to schools or finding employment [13]. Interventions by unnatural, pharmacological means thus allow underperformed individuals to have improved capabilities by elevating their lower cognitive functioning to match the normal baseline functioning [5]. However, this argument fails to take into account the socio-economic barriers that influence how justly neuroenhancement drugs will be distributed among a given population [13]. Problems would arise when disparities become apparent by considering the fact that neuroenhancement drugs may not be affordable for everyone, especially for the lower classes and those without health insurance coverages. Hypothetically, even if neuroenhancement drugs were made universally accessible through public policy solutions or government mandates, ethical concerns may be raised with regard to losing one’s liberty as a direct result of being coerced into taking neuroenhancement drugs. The likely outcomes of this hypothetical scenario have already been reflected in vaccine mandates throughout the course of the COVID-19 pandemic, where some individuals expressed antagonism in response to such mandates to protect their liberty and personal choice [5]. However, in the Huxleyan reality, liberty simply does not prevail. While coercion may be justified in the context of vaccine mandates for disease prevention, this hypothetical scenario as it applies to enhancement supports the bioconservative argument by resembling the events that were detailed in Brave New World, in which the citizens of Huxley’s dystopia all became mentally compromised by virtue of taking soma as administered by the World State [2]. Hence, when the cause for coercion is unjustifiable, it becomes worthy to ponder upon the question, is there any degree of freedom to our actions when under the influence of neuroenhancement drugs?  

Bioconservatives, moreover, continue to reinforce their objections to the use of pharmacological neuroenhancement with rationales that are beyond the preceding arguments related to safety and fairness, one that reveals the psychological horror of using pharmacological neuroenhancement. Imagine a baseball player taking neuroenhancement drugs such as steroids to increase their competitiveness on the playing field; as a result, ten home runs were hit in a single game. Contrast this with a baseball player who accomplished the same feat but without the use of neuroenhancement drugs; instead, it was the result of rigorous training and real effort [13]. The questions now present themselves as, which of the two players is more undeserving of his achievement and unworthy of praise? Does integrity not matter? The answers, of course, are obvious. Our intuition is capable of telling us what is morally responsible and what is not. In the case of the baseball player who used neuroenhancement drugs, the erosion of human agency rendered his achievement to become “hollowed” and his character to become morally “defective”, supplemented by the loss of personal dignity and overall humanity according to the foundational ethical framework that governs our morals and values [14]. Because at the end of the day, the credit does not go to the baseball player, but rather to the pharmacist who prescribed the drug or to the dealer who sold the drug.

The hubris objection as illustrated by the aforementioned example denounces the transhumanist methodology of undermining intrinsic values such as grit and tenacity and underappreciating our “gifted” character and powers with which we derived from nature, and further ridiculing the Promethean desire to be dominant over the natural order [15]. This objection was originally configured by political philosopher Michael Sandel and supported by physician-scientist Leon Kass. Kass added to Sandel’s argument of “giftedness” by emphasizing the dire consequences of substituting our moral virtues with pharmacological neuroenhancement-induced effects. Consider this thought experiment: If drugs that were originally meant to treat patients with PTSD become easily accessible to anyone, how many people without mental illnesses would be willing to take such drugs for the purpose of preventing bad memories from consolidating in their minds? While the feelings of trauma or sorrow from an unfortunate experience is undesirable, taking neuroenhancement drugs to block out those feelings and the associated painful memories of that experience would hinder our ability to develop the necessary mechanisms to cope with the myriad of negative feelings that are essential to our psychology [16]. In consequence, we would miss the opportunity for personal growth upon losing our self-control and fail to integrate the adversities of our lives to our character development. We no longer feel the sharpness of that feeling of pain, but do we still retain the courage to stand up and walk forward? This question often appears in the Huxleyan reality in which the character John “the Savage” is refused the right to be unhappy because unhappiness is not a realized concept [2]. When an individual wishes to take soma to relish in pleasure and escape from disillusionment, but in exchange, the individual would forever be trapped in a peaceful fantasy that juxtaposes the cruel reality, where does real happiness lie? To John, real happiness lies in enduring excruciating pain but knowing that it will all be worthwhile—like acing a test after hours spent studying or winning a game after the amount of effort that was spent during practice. Thus, it is within reason that taking shortcuts via artificial means offers no meaning in our pursuit of accomplishments—irrespective of the scale—and such conducts only pathologize our imperfections. 

To live with dissonance and the unanticipated are preconditions to appreciating what life has already given us and its beauty, thus enabling us to live a flourishing life that is fulfilling without external interventions that could potentially disfigure the relationship that we have with ourselves and restrict our exercise of freedom. In reference to the words of John who chose to be unhappy, we can cherish the notion that unhappiness is bliss, for it ensures that we still preserve our individual identities and the autonomy to taste the flavors of life: “I don't want comfort. I want God, I want poetry, I want real danger, I want freedom, I want goodness. I want sin” [2]. While the endeavor to advance the evolution of human cognition is appealing, one must be cautious of the dubious means represented by the unnaturalness of pharmacological neuroenhancement, as it is irresponsible to toy with our very own subjective experiences and personality traits in the midst of ambiguities [3]. Let it be known that the aspiration to enhance our cognition may lead to the inability to achieve a complete understanding of ourselves and ultimately to the downfall of our own humanity; even more so, it is at odds with our inalienable human rights in which the happiness that we would find from pharmacological neuroenhancement is only illusionary under this fallacy. The Huxleyan reality of using pharmacological neuroenhancement is not an inevitable future, and can be averted if we first consider the question: What am I willing to lose? 

References

1. Heller, S., Tibubos, A. N., Hoff, T. A., Werner, A. M., Reichel, J. L., Mülder, L. M., ... & Dietz, P. (2022). Potential risk groups and psychological, psychosocial, and health behavioral predictors of pharmacological neuroenhancement among university students in Germany. Scientific reports, 12(1), 1-10.

2. Huxley, A. (1998). Brave new world. HarperPerennial. 

3. Fuchs, T. (2006). Ethical issues in neuroscience. Current opinion in psychiatry, 19(6), 600-607.

4. Bowers, L. D. (1998). Athletic drug testing. Clinics in sports medicine, 17(2), 299-318.

5. Roskies, A. (2021, March 3). Neuroethics. Stanford Encyclopedia of Philosophy. Retrieved October 21, 2022, from https://plato.stanford.edu/entries/neuroethics/ 

6. Sandel, M. J. (2009). The case against perfection: Ethics in the age of genetic engineering. The Belknap Press of Harvard University Press. 

7. Schleim, S., & Quednow, B. B. (2018). How realistic are the scientific assumptions of the neuroenhancement debate? Assessing the pharmacological optimism and neuroenhancement prevalence hypotheses. Frontiers in Pharmacology, 9, 3.

8. Marazziti, D., Avella, M. T., Ivaldi, T., Palermo, S., Massa, L., Della Vecchia, A., ... & Mucci, F. (2021). Neuroenhancement: state of the art and future perspectives. Clinical Neuropsychiatry, 18(3), 137.

9. Liszka, J. (2021). Pragmatism and the Ethic of Meliorism. European Journal of Pragmatism and American Philosophy, 13(XIII-2).

10. McNamee, M. J., & Edwards, S. D. (2006). Transhumanism, medical technology and slippery slopes. Journal of Medical Ethics, 32(9), 513-518.

11. Shipman, M. (2019, May 8). The ethics and challenges surrounding neuroenhancement. NC State News. Retrieved October 22, 2022, from https://news.ncsu.edu/2019/05/neuroenhancement-ethics-challenges/ 

12. Nootropics. Cognitive enhancers - Alcohol and Drug Foundation. (n.d.). Retrieved October 22, 2022, from https://adf.org.au/drug-facts/cognitive-enhancers/ 

13. Forlini, C., & Hall, W. (2016). The is and ought of the ethics of neuroenhancement: mind the gap. Frontiers in Psychology, 6, 1998.

14. Faber, N. S., Savulescu, J., & Douglas, T. (2016). Why is cognitive enhancement deemed unacceptable? The role of fairness, deservingness, and hollow achievements. Frontiers in Psychology, 7, 232.

15. The president's Council on Bioethics: What's wrong with enhancement? (n.d.). Retrieved October 22, 2022, from https://bioethicsarchive.georgetown.edu/pcbe/background/sandelpaper.html 

16. Kass, L. R. (2003). Ageless bodies, happy souls: biotechnology and the pursuit of perfection. The New Atlantis, (1), 9-28.

Cryonics: The Cure for Death?

Zombies have been a popular science-fiction creation for decades, and the idea of resurrection goes back even further. How can a person be revived from death? Is it morally correct for such a thing to happen? These questions are relevant yet again due to recent interest in cryonics.

Cryonics is the technique of deep-freezing a dead body with the hopes that future scientists will be able to revive and restore it to full health. The process starts while the patient is still alive. They can sign up for the procedure through a cryonics facility, paying anywhere from tens to hundreds of thousands of dollars for a second shot at life. With this contract in place, a standby team will spring into action once a patient is pronounced legally dead, usually waiting in the hospital with the patient until it’s time. The team keeps the body stable while it is transported to the facility: supplying enough oxygen and blood to maintain minimal brain function, circulating the anticoagulant heparin to prevent blood clotting, and packing the body in ice while it is en route. A medical team awaits upon arrival [1]. 

The long-term preservation takes place on-site. Blood is drained from the patient and replaced with a mix of medical-grade antifreeze and organ-preserving chemicals, known as cryoprotective agents. If the body were to be placed directly in vats of liquid nitrogen the water in cells would expand to form ice crystals and the cells would be destroyed. With the added chemicals, organs and tissues are protected because the chemicals clump together in cryogenic temperatures. They form a solid that is molecularly similar to glass, and this new “glass” prevents the cells from bursting. Next, the body is cooled on a bed of dry ice until it reaches -130ºC (-202ºF). This completes the vitrification process, or the process of deep cooling without freezing, and allows cells to enter a state of suspended animation [2]. The body is finally inserted into an individual container and then placed into a large metal tank filled with liquid nitrogen at around -196ºC (-320ºF). It is stored head-down in these vats so that the brain will be most protected if there is ever a leak [3]. 

Currently, there are around 500 human bodies stored in vats around the world because of cryonics, with the majority being in the U.S. Major companies include the Cryonics Institute, KrioRus, Shandong Yinfeng Life Science Research Institute, and Alcor Life Extension Foundation. Alcor is the most expensive and best-known cryonics company in the U.S., charging $200,000 to handle a full human body and $80,000 to just preserve a brain (called “neuro” preservation) [3]. 

During the COVID-19 pandemic, these companies were forced to adopt new operating room rules. At Alcor, this looked like restricting the application of its medical-grade antifreeze solution to only the brain and leaving everything below the neck unprotected. It was also harder to reach clients quickly because of travel restrictions and limitations on hospital access [3]. 

Despite these more challenging circumstances, business was thriving. KrioRus and Alcor reported receiving a record number of inquiries during Covid, likely because the pandemic brought death to the forefront of people’s minds. Valeriya Udalova, chief executive of KrioRus, noted that “perhaps the coronavirus made them realize their life is the most important thing they have and made them want to invest in their own future” [3]. Jim Yount, a member of the American Cryonics Society, also commented that “something like covid brings home the fact that they are not immortal.” [3]

But how likely is it that people who “invest in their own future” by signing up for cryonics will see their money well spent? Can this process really add decades, or even centuries, to a person’s life? The quick answer is probably not. It hasn’t been proven that complex human systems can be “stored” with the help of these facilities. All we know for sure is the technology available to us right now, none of which can revive these dead bodies. In this way, the cryonics industry is built entirely on optimism since companies place the tall order of revival in the hands of future scientists.

Supporters believe death is not just the moment when the heart stops; it is a process of deterioration that humans are capable of intervening in. They generally concede there isn’t any guarantee that future science will be able to reanimate these people. Nonetheless, the odds of revival with cryonics are still better than without it. This much is certainly true: scientists can’t resuscitate a pile of ashes or bones, but at least cryonics provides a body to work with. Plus, “if you’re starting out dead, they say, you have nothing to lose.” [3]

At the same time, cryonics company websites hardly drive home the uncertainty involved in these procedures. The Alcor website advertises cryonics as “an ambulance into the future” and states that “cryonics is currently the best-known method for pausing the dying process in a way that allows for potentially restoring good health with medical technology in the future.” It also says that “cryonics sounds like science fiction, but it’s based on modern science.” [4] While the website is transparent about the procedure’s reliance on technology that doesn’t yet exist, it also advertises the success of cryonics as being only a matter of time. There are no disclaimers about the uncertainty involved or the industry’s foundations of sheer optimism. Is it misleading for websites to lack precautionary messaging? Perhaps it is within their right as private companies to advertise themselves as they wish, but it could also be considered immoral to require prospective clients to read between the lines on such important subject matter.

There are also a plethora of questions that arise when thinking about the fact that at the end of the day, these are private companies working for profit. Cryonics companies are quite literally in the business of death. Who can determine if they are acting in their client's best interest, and do they even have the incentive to do so given that the bulk of their work happens once their clients are dead? The image of these companies has already begun to tarnish, since in 2009 there were allegations that Alcor was mishandling bodies and even hastening clients’ deaths [5]. Who will hold these companies accountable in such a delicate industry?

A unique set of questions arises from assuming cryonics will be successful. Given the prohibitive pricing of these procedures, society could reach a place where wealthy people are immortal. Would this be a fair change? Wealthy people already have better access to medical care and longer life expectancies. Perhaps immortality as a result of wealth is a natural progression for society, or perhaps there is some line to be drawn as to just how much money should be able to buy.

There’s also the question of sustainability. We already struggle with overpopulation. Is it ethical to exacerbate this for our descendants by sending people from our century into the future? 

On a different note, we must examine how society as a whole would be affected by mass cryopreservation. New and old generations would eventually be living together- would society be able to progress or would it be held stagnant by the continued presence of old ideas? As USC student Anu Rajendran put it, the “advancement of culture could slow down,”making cryonics detrimental to the larger society [6].

Although it is impossible to answer these ethical questions without lived experience, they are still important to consider as the cryonics industry grows. The procedure’s allure is undisputed. If successful, patients could be treated with new cures to mend an untimely death or have decades more with loved ones (if they also partake). Most ethical dilemmas wouldn’t be realized unless millions of people were choosing to be cryopreserved, but if the process were successful and affordable that could very well be the case. Thus, it is critical to consider all possible effects of the procedure as it gains popularity.

References

1. How Cryonics Works. (2005, January 5). HowStuffWorks. https://science.howstuffworks.com/life/genetic/cryonics.htm 

2. Cryosleep - An Overview of Cryonics, Cryosleep and Cryotherapy. (2018, October 17). The Medical Futurist. https://medicalfuturist.com/are-you-going-to-wake-up-from-cryosleep/ 

3. Wilson, P. (2021, June 26). The Cryonics Industry Would Like to Give You the Past Year, and Many More, Back. The New York Times. https://www.nytimes.com/2021/06/26/style/cryonics-freezing-bodies.html 

4.  What is Cryonics? (n.d.). Alcor. Retrieved November 24, 2022, from https://www.alcor.org/what-is-cryonics/ 

5. News, A. B. C. (n.d.). Former Alcor Employee Makes Harsh Allegations Against Cryonics Foundation. ABC News. Retrieved November 24, 2022, from https://abcnews.go.com/Nightline/alcor-employee-makes-harsh-allegations-cryonics-foundation/story?id=8764331 

6. Rajendran, A. (2017, December 13). The Frozen-Undead: Ethical Implications of Suspended Animation and Cryonics. Viterbi Conversations in Ethics. https://vce.usc.edu/volume-1-issue-1/the-frozen-undead-ethical-implications-of-suspended-animation-and-cryonics/ 

Painful Justice: Botched Executions and Capital Punishment

The death penalty has been practiced as a fundamental tool in criminal and judicial systems for thousands of years and has played an integral role, both socially and punitively, in many ancient and modern societies. The practice of capital punishment in the United States began in the colony of Jamestown with the first reported execution occurring in 1608 [1]. This practice has withstood the test of time, remaining a possible sentence in twenty four states [2]. Many states, most recently, Virginia, which outlawed the practice of the death penalty in 2021, have stopped carrying out executions altogether as a form of criminal punishment. Currently in the states where the death penalty is still practiced, the most common and widely used method of execution is lethal injection, in which various medications are administered through intravenous injections resulting in the death of the prisoner. This method of execution is regarded, generally, as the most humane and is not meant to cause any pain to the person being executed [3]. 

In striving for this aversion to pain in the practice of lethal injection, legislators and advocates aim to parallel the philosophies of the medical field. In medicine, practitioners attempt to reduce the pain of patients undergoing procedures through anesthesia and control for pain in post-op recovery with pain medications as strong as morphine or fentanyl. When all goes well, lethal injection is similar to any other medical procedure where pain is managed or even completely absent for the patient. However, this is not always reality. Lethal injection has the highest rate of failure among other contemporary methods of execution sitting at 7.12%, while other methods such as electric chair or firing squad have failure rates of 1.92% and 0% respectively [4]. 

These so-called botched executions subject the person being executed to visible extreme pain, discomfort, and distress. One such execution made national news when an Oklahoma man was seen convulsing and throwing up during his execution [5]. In multiple cases, executions have failed due to prisoners who have compromised veins as a result of drug use that make it harder to insert an IV through which to inject the drugs. In these circumstances, a decision must be made to continue with the execution by finding other ways to insert IVs, such as in hands, necks, and other places on the body, causing extreme discomfort for the prisoner involved [4]. In these cases, physicians often aid technicians in establishing an IV through which to administer the drugs. And in this way, physicians play a central role in the medical killing of another human being. If the consistency of lethal injection as a mode of capital punishment requires physicians to play a role in carrying out this work, physicians must face various ethical dilemmas in weighing the benefits of both “justice” and medical ethics, similar to the ethical dilemmas of euthanasia or assisted suicide. 

 Lethal injection, the most “humane” method of execution, comes with complications not seen with other methods of executions that put into question the efficacy of lethal injection. The use of firing squads has dwindled over the years due to the sheer carnage it endows the body of the prisoner with, and execution by electric chair has similarly dwindled due to concerns over  pain and suffering during the procedure [6]. So now, we have been left with lethal injection. If the most “humane” method of execution is still having unforeseen consequences for the prisoners who are being executed, perhaps capital punishment as a whole needs to be reevaluated as a practice. 

References 

1.  “History of the Death Penalty.” Death Penalty Information Center. https://deathpenaltyinfo.org/facts-and-research/history-of-the-death-penalty/early-history-of-the-death-penalty. 

2.  “State by State,” Death Penalty Information Center. https://deathpenaltyinfo.org/state-and-federal-info/state-by-state. 

3.  “So Long as They Die: Lethal Injection in the United States,” Human Rights Watch. https://www.hrw.org/report/2006/04/23/so-long-they-die/lethal-injections-united-states#:~:text=Compared%20to%20electrocution%2C%20lethal%20gas,it%20mimics%20a%20medical%20procedure. 

4.  “Botched Executions,” Death Penalty Information Center. https://deathpenaltyinfo.org/executions/botched-executions. 

5.  “Oklahoma executes inmate who dies vomiting and convulsing,” AP, October 28, 2021. https://apnews.com/article/us-supreme-court-prisons-executions-oklahoma-oklahoma-attorney-generals-office-6e5eedd1956a38f83db96187651f145c. 

6. “South Carolina judge halts the use of firing squad, electric chair,” Washington Post, September 7, 2022. https://www.washingtonpost.com/nation/2022/09/07/south-carolina-firing-squad-electric-chair/.