Saturday, April 14, 2007

The Ethical Dilemma concerning Stem Cell Research

Stem cell research promises to revolutionise medical treatment and has the potential to yield cures that have long eluded scientists and doctors. Whilst researchers seek to push the frontiers of its ground-breaking potential, a debate over the ethics of experimenting with human embryos may yet threaten to stifle its future. Dr Saqib Latif discusses an Islamic approach to a debate that has deeply divided secular societies.

Introduction

Dr Clarke is a seventy three year old retired chemical engineer. For a PhD scientist with a distinguished career, he can barely recognise his wife nor remember her name and his comprehension of numbers has deteriorated such that he cannot count three consecutive figures backward. There are times when he wakes at night screaming and is unable to go back to sleep despite soothing gestures from Mrs Clarke. A week ago, she woke in the middle of the night to find him wandering in the street outside.

Alzheimer's dementia makes up almost half of all cases of dementia and is characterised by the loss of many different nerve cells in the brain. Stem cell therapy holds the key to understanding this debilitating condition and developing a possible cure. The scientific community is in broad agreement that such therapy could also provide similar advances in many other serious conditions, from Parkinson's disease to heart disease. But pivotal to the progress of stem cell research is the use embryos; specifically those surplus embryos that are generated during the IVF [in vitro fertilisation] cycle (supernumerary embryos). They are the main source for generating human embryonic cell lines (Thomson et al, 1998) and are employed in therapeutic cloning - a process with curative intent in which cells are cloned for specific human tissues using stem cells. The debate regarding the moral, legal and human status of these embryos has deeply divided liberal secular society and the discord thus created threatens to stifle scientific progress.

The various opinions regarding the use of stem cell research, or therapeutic cloning, appear incompatible and are not easily reconcilable by the application of the secular framework. On the one hand, right-to-life groups argue that an embryo becomes 'human', and should be treated as such, at the point of fertilisation, while on the other hand utilitarian views argue that the potential for public good should be weighed against the harm to infant embryos. They are views that have very little in common and have contributed to a lack of consensus on a way forward.

Scientists are not alone in attempting to grapple with these dilemmas; the liberal secular community as a whole is trying to do the same. Nancy Reagan, wife of former US President Ronald Reagan who suffered from Alzheimer's dementia, first brought the issue to the attention of the US public after making her pro stem cell research views known. Celebrities such as the late actor Christopher Reeve have campaigned for its use whilst others such as the actor Mel Gibson have spoken out against it. Both the Canadian and US governments have banned therapeutic cloning on grounds that it is immoral to conduct experiments on a human embryo. In contrast, the British Parliament has approved stem cell research and in September 2004 granted Newcastle University the first British license to conduct therapeutic cloning.

The Science of Therapeutic Cloning

Stem cells exist naturally in the body and have the remarkable potential to develop into many different cell types in the body to replace cells that are lost through natural processes. They divide just enough to maintain an organ's healthy state. In cases where there is accidental damage or a disease they may not be able to divide fast enough to replace the injured tissue, leading to an eventual loss of organ function.

It is thought that by isolating stem cells and then manipulating their development into specific tissues they can be used to replace lost cells in the human body. Examples of this include the use of insulin-secreting cells in diabetes, nerve cells in strokes or liver cells to repair cirrhosis. Studies have demonstrated that stem cells can be made to differentiate into specific cell types and that these can then be successfully transplanted. Embryonic stem cells have the greatest potential due to their intrinsic ability to develop into a wide range of cell types.

The Ethical Debate

The current debate hinges on the status of the foetus. There are two opposing views with regard to the use of embryos.

One body of opinion states that the use of any embryo for research purposes is unethical and unacceptable on the grounds that an embryo should be afforded full human status from the moment of its creation. It is not "…morally preferable to end the life of an embryo in vivo than it is to do so in vitro" (Harris, 1985, cited in Brazier, 1992). The argument is justified on theological grounds and centres on ensoulment at fertilisation.

The other body of opinion states that the embryo deserves no particular moral attention whatsoever. Being a person, and not merely a human, is what gives rise to moral rights. Personhood is the ability to value your own existence and this gives an individual autonomy and therefore the right to live. Embryos are not able to have insight into their own existence and so by definition are not persons. They should not therefore be afforded the rights of a person (Harris, 1977, cited in Brazier 1992).

Furthermore, in pluralistic society an approach that bases itself on one particular view cannot be justified. Scientific freedom is a legal right. Childress (2001) states: "An ethical public policy in our pluralistic society has to respect diverse fundamental beliefs. And yet it must not be held hostage to any single view of embryonic life."

The UK Human Fertilisation and Embryology Act (1990) regulated the use of embryos in medical research in the UK. It allowed for the production and use of embryos. Arguing that the embryo is special as a potential human being, the act asserts that only embryos up to the age of fourteen days can be used in medical research as their status as persons is considered to be at a minimum. The judgement to use embryos is reconciled through utilitarian principles; potential benefits from research on an embryo outweigh the need to preserve it.

Jane Maienschein, Regents Professor and Director at the Centre for Biology and Society at Arizona State University explains in her book Whose View of Life? (2004) that the conflict between science and religion, between saving the life of an individual and the right of existence of an embryo, is a false dichotomy. She states, "neither science nor religious morality alone have the answers…we need open public discussion and richer shared understanding of what is involved in defining and refining life."

The current debate is over these two opposing views. Identifying a way forward given the lack of common ground between them has proven a challenge for politicians and legal experts at both the national and international level.

Failures of Public Policy

To date the UN has been unable to pass a treaty on human cloning. In November 2004, UN diplomats shelved a planned vote on banning the cloning of human embryos. A motion put forward by Costa Rica and backed strongly by the US calling for a treaty to ban all cloning as unethical and morally reproachable was abandoned due to a deadlock over therapeutic cloning. An alternative motion drawn up by Belgium suggested that a decision to ban therapeutic cloning should be left to individual countries, but endorsed a worldwide ban on reproductive cloning (reproductive cloning is the creation of human life from stem cells).

The international community is so split that a broadly worded declaration is now being talked of instead of a treaty governing the use of stem cells. Belgian diplomat Marc Pecsteen said, "There is such division in the international community that any treaty would not make it, so the idea of the declaration is to find some general language that we could all live with."

Stem cell policy has become a sensitive and controversial topic of debate across Europe and the US. International organisations over the last three years have consistently struggled in drawing together a framework governing stem cell research. The European Union remains unable to reach a decision on funding and as a public policy debate it came to the very fore in the recent American presidential race.

In August 2001 President Bush decided that federal funds could only be used on stem cell lines already created; in effect a ban. George Bush's chief adviser on medical ethics and the chairman of the President's Council on Bioethics, Leon Kass, was quoted as saying, "A woman's body should not be a laboratory for research or a factory for spare body parts". A recent report by the President's Council on Bioethics stated that scientific freedom is not an overwhelming legal right. John Kerry in contrast backed therapeutic cloning throughout the Presidential election race and in June 2004 announced plans to allow federal funding for embryonic stem cell research.

The situation is such in the US that Congress is considering legislation that would criminalise stem cell research and punish researchers with ten year jail terms and $1 million fines. Scientists citing unparalleled government interference in "scientific and academic enquiry" argue that as in the case of dangerous chemicals and atomic energy, greater and clearer regulation is required instead of a ban (Walters, 2003).

The prospects of a ban in the US is driving stem cell research into the private sector where there is no such regulation; an environment which fuels concerns over the impact of research into reproductive cloning. Stephen Pincock writing in the Lancet (2004) quotes an American scientist as saying, "In America, with government support you can't make (human embryonic stem cell) lines, you can't do therapeutic cloning - don't even think about doing therapeutic cloning." In the private sector, however, "You can do pretty much what you want - you can buy gametes and make embryos, you can make cell lines, you can do both therapeutic and reproductive cloning."

How Islam Negotiates the Ethical Quagmire

The current debate on stem cell research demonstrates the shortcomings in a liberal secular framework negotiating a way forward. Whilst President Bush explained his decision to withdraw federal funding for therapeutic cloning by saying, "I have made this decision with great care, and I pray it is the right one", Professor Maienschein (2004) aptly expresses the unease of the opposition; "In a country founded on separation of church and state, it is not clear why it is prayer that should guide an American president to policy decisions about bioscience."

The extent to which views on ethics and morality should influence public policy is contested heavily. But such disputes say nothing of the challenge that confronts scientists, politicians and thinkers in agreeing on a set of ethics in the first instance or to identify a source for them; reaching a consensus appears an insurmountable task. A secular framework may regard beliefs on the humanity of the embryo or foetus as matters of personal faith which are respected as personal choices in a pluralistic society and given no precedent over any other. But relegating them from decisions of political or public policy leaves a void in answering questions on ethics, morality and indeed life. Because, of its own, a secular framework has no inherent standard that can provide guidance in a debate that is in need of an understanding of human life. As a result, the myriad of personal beliefs on human life and ethics have themselves come to occupy a pivotal role in the debate.

But due to the lack of an inherent standard, a secular framework also lacks the ability to arbitrate between these opinions in order to decide which to utilise and which to ignore, other than to hope for an elusive consensus. Margaret Brazier, Professor of Law at Manchester University, in her book 'Medicine, Patients and the Law' (1992) describes the difficulty for the law to respond to such a "divergence of moral opinion" and states that a "consensus is impossible to attain". She states, "When does it (the embryo) acquire the same right to protection as you and I enjoy? Is it at fertilisation…? Or is it at some later stage in embryonic development? This might be at fourteen days, when the primitive streak forms, or when brain activity…is discernible at eight to ten weeks. Or is it much, much later, indeed after birth?" She continues, "A liberal democracy should respect divergent moral views. But that is anathema to 'pro-life' groups…The embryos true nature is unproveable. I happen to believe that the embryo is very probably of the same moral value as myself. I cannot prove that belief. But then nor can those who maintain that humanity is just another animal species prove their contention."

It is not the divergence of views, nor the plethora of opinions, that represent the problem alone, but rather the inability to reconcile them. Reconciling between the opinions can be a near impossible task, and dishonest to each opinion, when they are essentially incommensurable. Reconciling them against some common standard is a false option as a moral and ethical standard is conspicuously absent in a utilitarian paradigm and continuously evolving liberal secular society. Indeed, after the birth of secularism, through liberty, the use of utility has become increasingly dominant within public life. This is the heart of the dilemma that confronts liberal secular societies and which has led to the current impasse.

The Islamic approach to areas of contentious medical research, such as stem cell research, which involve experimenting on, or with, life - human or animal - is altogether different. The contrast of its approach is due to the contrasting ideas and principles that form its framework and its outlook on the relationship between beliefs on personal and temporal matters.

The Islamic framework seeks to expand continually the frontiers of scientific and medical research in order to reap its potential for improving the quality of human life. Indeed, the Islamic world's rich contribution to the field of medicine is widely acknowledged within the western medical profession, particularly the Moorish heritage in Andalusia. The Islamic framework does not lack an inherent standard on experimenting with human life through attempting to ensure that broader beliefs on life - which form the principal basis of many ethical paradigms - remain matters of personal faith. It is based upon one belief that consistently forms the basis of its views on ethics, morality, its political and economic philosophy, as it does on the use of medical research. As a result, it produces a system that is characterised by a degree of coherency. It is not in need of continually trading-off economic, political or technological needs with social or ethical concerns, or with the well-being of the community; a common reference point and texts define the scope of each and the inter-relationships between them. It also provides a coherent and secure framework for governing medical research, as it will not propel scientific research regardless of its consequences.

As with any human society, disagreement and difference may also exist in an Islamic society, and a complete consensus on all state medical policy may be an impossible ideal. The process of extracting Islamic legislation to tackle new problems (ijtihad), such as the use of stem cell research, may well result in differing opinions amongst jurists. But it will not oscillate between fundamentally different ethical standpoints nor stifle scientific progress through attempting to reach consensus between irreconcilable opinions on human life itself. There is agreement on the principles, ideas and sources that govern medical research, 'ethical', legal or otherwise, and the differences relate to applying them in particular circumstances. It is not halted by an impasse regarding the fundamental nature, sources and core principles that should define a framework to determine the status or legal rights of the foetus; a deadlock that still lies at the heart of the debate in the West.

The word for Islamic law - Sharia - linguistically means the path water takes; clear, unambiguous and defined. It is through the process of ijtihad that new problems are evaluated and Islamic legislative rules and principles are derived, whether in the field of medical research or otherwise. Jurists tasked with the job of extracting these rules are required to engage in an objective study of stem cell research and must analyse the nature and form of the embryo, stem cells and the biological processes concerned by drawing upon all the relevant scientific information available. Jurists then undertake a similar exercise in understanding the Islamic texts that discuss a relevant or similar subject matter, and through them a verdict is extracted. The process is defined and the extracted legislation can be evaluated by comparing it against objective measures, such as the accuracy with which it has understood the reality of the technology or of the relevant Islamic texts.

Therefore, the Islamic verdict on stem cell research is derived through this process of ijtihad.

A summary of the Islamic verdict on stem cell research

Stem cells can be derived from a number of sources:

1. From some adult tissues (such as bone marrow)
2. Early embryos made through IVF that are not needed for infertility treatment
3. From the blood cells of the umbilical cord at the time of birth

Problems arise when the properties and potential of these different cell sources develop into particular tissues. Stem cells derived from early embryos have the potential to develop into a greater variety of different tissues. The potential of tissues from the umbilicus, foeti (mature embryos) and adult tissues are more limited.

1. Use of adult tissues to produce stem cells

If the adult tissue originated from a living human being, its use would be allowed with the person's consent. This is because according to Islam, a person has a legal (Shari) authority over his organs. For example, if a person's hand or eye is removed by another person, the wounded can demand blood-money (diya) as compensation. The victim can also choose to forgive the one guilty of causing the loss of the organs. In either case, the fact that the victim is granted the final say over the organs, through the choice of how they should be compensated, indicates that he has the right to make decisions regarding them. He can thus choose to donate his organ to another person in need of it, provided the organ is not vital for his own survival. Stem cells fulfil this requirement.

2. Use of IVF to produce stem cell

This is where stem cells are derived from early embryos which are no longer needed for infertility treatment (supernumerary embryos). IVF as a means to aid fertilisation between a husband and wife is allowed according to Islamic jurisprudence. The nature of the IVF process is that embryos will be formed that will not be needed for placement in the woman's womb. These can be utilised for the purpose of producing stem cells. Supernumerary embryos such as those produced through IVF would not be considered as dead since they never had life. The Islamic texts define the point at which an embryo can be considered alive at 42 days.

3. Use of blood cells of the umbilical cord to produce stem cells

The umbilical cord can be used to extract stem cells if it is required for medical treatment or research.

Stem cells can be used from live adults, umbilical cords, IVF embryos and aborted foeti under 42 days gestation. They cannot however be extracted from dead human tissue and foeti above 42 days gestation.

Not only does Islam allow stem cell research, but it could potentially throw the field wide open. The present model of using supernumerary embryos has met with limited success in producing embryonic stem cell lines. Present research, though not conclusive, is suggesting that higher quality embryos such as blastocysts lead to a higher efficiency of embryonic stem cell production (Cowan et al, 2004). Blastocysts are the collection of cells that are in the next developmental stage from the embryo. From an Islamic jurisprudential perspective it is acceptable to use foeti up to the age of 42 days for stem cell extraction and hence the potential exists for the highly refined production of stem cells.

Stem Cell Research - An Opportunity

The Prophet Muhammad gave Muslims reason to be encouraged about medical research when he said "There is no disease that Allah has created, except that He has created its cure".

The potential is clearly huge in therapeutic cloning. At a genetic level, a multitude of cell lines can be generated to examine genetic and chromosomal abnormalities. Cell lines from patients could revolutionise gene therapy by allowing in-vitro study of gene mutations at early developmental stages and exploration of what goes wrong in the differentiation process. These lines prove invaluable in the study of conditions with a genetic aetiology such as Parkinson's disease, Alzheimer's dementia and schizophrenia.

Research at a basic level has already produced promising results. There are a number of papers in the July 2004 edition of The Lancet which illustrate this. Wollert et al (2004) injected bone marrow stem cells into the affected artery of patients who had just suffered a heart attack. The team from Hannover managed to demonstrate a moderate increase in heart function compared to control. Joannides et al (Lancet, July 2004) were able to generate primitive nerve cells from adult human skin providing a basis for further experiments and uncovering a potential treatment in neurological disorders.

Humanity should have available the expertise and technology to utilise stem cells. These primitive cells which can be encouraged to grow and develop into more specific tissues such as skin, neurons and pancreatic tissue could be used to treat burns, Parkinson's disease, motor neuron disease, diabetes, multiple sclerosis or even head injury. The future could hold the potential to regenerate ischaemic neural and cardiac tissue simply by infusing stem cells into a vascular territory. Could the day arrive when there would be no need for classes of drugs such as ACE inhibitors or beta-blockers which work to improve heart function, while simultaneously making huge profits for the pharmaceutical industry?

The Prophet Muhammad said that whoever saved a life it is as if he saved all of humanity. Islam views medical research as a must and states as an underlying premise that there is a cure for every illness. Spurred by this philosophy, the Islamic world made significant contributions under the Caliphate to the fields of medicine, surgery, chemistry, toxicology and many other scientific disciplines that relate to human health care. Many of these historic endeavours have subsequently influenced much of the modern practice of these disciplines. During the Abbasid era, whilst Europe witnessed a 'dark age', Baghdad flourished as a centre of medical discovery and innovation, training physicians from across the Islamic world and beyond, including Europe. The translation of Arabic medical works to Latin provided a gateway through which Europe accessed some of the Islamic world's discoveries. The seizure of Spanish territories by the forces of Ferdinand and Isabelle brought knowledge of the medical endeavours of Spaniards such as Abu al-Qasim ('Abulcasis') (936-1013), ibn Zuhr of Seville (1094-1162), ibn al-Khattib (1313-1374) and ibn Khatima of Granada (d 1369) and many others, to Europe. In the words of Carly Fiorina, CEO of Hewlett Packard, "…this civilisation was driven more than anything, by invention. Its architects designed buildings that defied gravity. Its mathematicians created algebra and algorithms that would enable us to build computers, and the creation of encryption. Its doctors examined the human body, and found new cures for disease."

Islam seeks to push the frontiers of scientific possibility and to develop technologies and methodologies that allow for the greatest advances in the shortest possible time. It instructs that a cure be sought for every illness within a clear and well defined legal framework. This is for the purpose of curing the sick and is not driven by the need to make vast profit from their suffering. So Islam would value combating malaria and cholera worldwide just as much as the treatment of ischaemic heart disease in the West. It would also aim to make therapeutic cloning available to all those in need of it, regardless of their socioeconomic status.

As politicians continue to struggle to define a legislative framework to govern therapeutic cloning, Mrs Clarke will watch the rapid deterioration of her husband. He is in great physical health but does not resemble the man she married 50 years ago. The money they had saved for the holidays they had put off for so long and for a comfortable retirement will now go towards nursing care for her husband.

Bibliography

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Wollert, KC, Meyer, GP, Lotz, J, Ringes-Lichtenberg, S, Lippolt, P, Breidenbach, C, Fichtner, S, Korte, T, Hornig, B, Messinger, D, Arseniev, L, Hertenstein, B, Ganser, A, Drexler, H (2004) Intracoronary autologous bone-marrow cell transfer after myocardial infarction: the BOOST randomised controlled clinical trial. Lancet 364: 141-8

By Dr Saqib Latif

Source: New Civilisation Magazine, Spring 2005

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