friDAY, July 25, 2003

Session 2: Stem Cell Reseach: Current Ethical Literature

Paul Lauritzen, Ph.D.,
Director, Applied Ethics Program,
John Carroll University

CHAIRMAN KASS:  This is the second session, "Stem Cell Research:  Current Ethical Literature."  As Council members surely recall, the formation of this council was connected to President Bush's decision announced in his address to the nation in August of 2001 to permit for the first time the use of federal funds to support research on human embryonic stem cells, this despite the existence of congressional statute, the Dickey-Wicker Amendment that prohibited the use of federal funds for research in which a human embryo or embryos are destroyed, discarded, or knowingly subjected to injury or death, risks of injury or death, greater than that allowed for research on fetuses in utero.

Among its other functions, this Council was charged with monitoring stem cell research; that is, following and keep abreast of all developments, scientific, medical, ethical, and legal, in this exciting area of research, embryonic and adult.  The rest of today's meeting is given over entirely to helping us fulfill that charge.

We are following and monitoring developments in the ethical argumentations on stem cell research, developments in the basic scientific research and clinical application, developments in the state laws, as these have taken place over the past two years under the current federal policy.

To aid us in these monitoring tasks, we have commissioned seven review papers:  one on recent developments of the discussions of the ethics of stem cell research, five on recent scientific and clinical developments in five separate areas of embryonic and adult stem cell research, one on recent developments in state law regarding stem cell research.

The ethics review paper was prepared by our guest for this session, Professor Paul Lauritzen, who is professor of the Department of Religious Studies and the director of the Program of Applied Ethics at John Carroll University in Cleveland.  Speaking only for myself, I would note with gratitude that Professor Lauritzen has tried in his paper to expand our horizon of the relevant ethical issues to include matters beyond the one that has so preoccupied us, namely the important issue of the moral status of the embryo.

I would like to welcome Professor Lauritzen, who will offer a beginning presentation, after which both the presentation and his paper will be open for our discussion.  Thank you very much for joining us.  We look forward to hearing from you.

DR. LAURITZEN:  Thank you.

Let me begin by saying I made the mistake of sending the slide show ahead of time and got a call from Dean Clancy last night wondering what the slide show and my presentation had to do with my report because I had decided not to simply summarize my report but to just highlight a few themes in my presentation.

And I suspect that Dean is a better and keener observer of human nature because he pointed out that perhaps not everyone would have read the report as carefully as I might have assumed.  But I wasn't going to write another presentation at nine o'clock last night.  And so I am going to give the one I wrote, which really takes some themes of my report and tries to highlight them by way of some additional data.  Mostly I am just going to read this.

Several people who have read the draft of my report have commented that for someone who argues that we should move beyond the debates about embryos and the status of the embryo, I spend a lot of time in the report talking about embryos.

At the risk of inviting that objection today, I want to begin with of slide that reproduces data reported recently from a study conducted jointly by the Society of Assisted Reproductive Technology and the RAND Corporation on the number and dispositions of frozen embryos in the country.  Forgive me if you have already considered this data, but it wasn't clear to me whether you had.

As you can see from the slide maybe and based on a survey of 340 of the 430 assisted reproductive technology practices in the United States, the documented number of embryos in frozen storage as of April 11, 2002 is approximately 400,000.

Moreover, the study was able to document the use to which these frozen embryos were designated by the IVF couples from whom they came.  Indeed, one point of the study was to determine how many frozen embryos are, in fact, available for use in the derivation of stem cell lines.

Despite the fact that many advocates of stem cell research call for deriving stem cells from embryos left over from IVF procedures, the authors of the study contend that so-called "spare embryos" are not a ready source of stem cell lines.

Of the nearly 400,000 frozen embryos in storage, apparently only 11,000 are available for possible use in deriving stem cells.  Although this seems like a large number of embryos, according to the authors, in fact, it is not.  And they break down that 11,000 along these lines.

Of those 11,000 or approximately 11,000, only 65 percent will survive the thawing process, leaving roughly 7,000 embryos.  Only 25 percent of that 7,000 will develop to the blastocyst stage, leaving roughly 2,000 blastocysts.  And only 15 percent of those blastocysts will yield viable cell lines, leaving roughly 275 cell lines.

According to this study, then, despite the large number of embryos frozen in this country, the number of potential stem cell lines available from their use is relatively small.

This is clearly an important study.  For one thing, it gives empirical grounding to the claim that we can derive stem cell lines from frozen embryos.  It is less likely to be widely cited.

My reason for beginning with it, however, is quite different.  I wish to highlight not the number of frozen embryos cited in the study but, rather, the date of the study's publication, namely May 2003.

As the study points out, the first live birth in this country from a cryo-preserved embryo was in 1986.  That means for nearly 20 years, we have had almost no idea of the scope of embryo cryo-preservation in this country.  Let me make two observations about this fact.

First, I believe it supports my claim that talk about respecting the embryo from conception is frequently more rhetorical than anything else.  If the early embryo is really to be treated as a being who deserves serious respect, you would think that we would at least know how many embryos are routinely frozen, discarded, or otherwise lost through IVF.  Not to put too sharp a point on it, but if each embryo were equivalent in value to a dollar bill, we would have lost track of nearly half a million dollars.

Second, the fact that until recently we knew almost nothing about the numbers or the dispositions of frozen embryos highlights just how unregulated the world of reproductive medicine is.

As this Council knows well and as the staff working paper to be discussed tomorrow highlights, the world of reproductive medicine is almost entirely unregulated.  Cryo-preservation of embryos is just one of the many developments in reproductive medicine that has been introduced as therapy without any sort of clinical trials and without any real oversight.  The significance of this fact in relation to stem cell research is that we have in reproductive medicine a model for what happens when commerce is wedded to desperation, when research is privatized, and when there is essentially no regulation.

More than one commentator has invoked the image of the Wild West to capture this scene.  The image strikes me as particularly apt, not least because the wild West was notoriously dangerous, at least as it has been conceived in the popular imagination.

There are clear dangers in the unregulated world of reproductive medicine.  I know there is some controversy about this point, but consider the report in the New England Journal of Medicine last year on the risks of major defects after ICSI and in vitro fertilization.

According to this study, infants conceived of reproductive technology were more than twice as likely as naturally conceived infants to have major birth defects diagnosed during the first year of life and were also more likely to have multiple major defects.  These were the odds ratios after the numbers were adjusted for maternal age, multiple births, and other factors that might have skewed the data upward.

Moreover, the increased risks were not confined to just one organ system.  They were found in cardiovascular, urogenital, musculoskeletal, and gastrointestinal systems.

Again, my point is not to focus on specific problems with reproductive medicine, as it is currently practiced, but to highlight a pattern.  Just as opposition to embryo research has led to the privatization of work on in vitro fertilization, with virtually no oversight or regulation of IVF, so, too, has it led to the privatization of stem cell research with similar results.

This is one reason I have noted the relation of IVF and stem cell research in my report.  The other is that I do not think we have fully appreciated the deep tensions between the widespread acceptance of IVF and a widespread profession of respect for the early embryos.

A foolish consistency may be the hobgoblin of little minds.  And Emerson may be right that such a consistency is adored by statesmen, philosophers, and divines.  But consistency in ethics is rarely foolish.

I have no quarrel with Emerson's advice to speak your mind forcefully today, even if it flatly contradicts what you thought and said yesterday.  My concern is that we speak out of both sides of our mouths simultaneously when we say that destroying an embryo is killing a person or that, indeed, the early embryo deserves profound respect and also say or act as if discarding embryos in IVF is non-problematic.

I tried to illustrate this point in my report by drawing attention to the cartoon comparing reactions to a stem cell clinic and an abortion clinic and then asking the reader to imagine that an IVF clinic is substituted for the stem cell clinic.  Here is the cartoon.

As you can see, the cartoon depicts protesters in front of a stem cell research lab, condemning those who worked there as being anti-life.  Down the street at the abortion clinic, the workers are noting how quiet things have gotten at the facility since the stem cell lab opened.

The point of the cartoon, of course, is that opposition to stem cell research appears to be almost as passionate as opposition to abortion and that there is perhaps an irony in the fact that pro-life advocates, thus, appear to be committed to demonstrating against research being done to find treatments for Alzheimer's, Parkinson's, and other devastating illnesses.

Now, try to imagine protesters standing outside an IVF clinic or, even better, outside maternity wings, condemning couples who use IVF as murderers or at least complicit with murder.  It is almost impossible to imagine this scene.  And it is worth asking why.

If the early embryo is fully a person, shouldn't we condemn IVF and work to prohibit it?  Is condemning stem cell research but accepting IVF not inconsistent?

Of course, one response to this alleged inconsistency would be to say that we should, in fact, be consistent in trying to prohibit both IVF and embryonic stem cell research.  I do not subscribe to that position myself, nor do I think it is a politically viable option.  But it would at least be consistent.

Notice, however, that a ban on embryonic stem cell research will not eliminate the many issues raised by the prospect of regenerative medicine.  And that is another theme from my report that I wish to highlight.

Although the ethics debate has mostly focused on the status of the early embryo and has, therefore, tended almost exclusively to issues raised by embryonic stem cell research, we need to take a closer look at issues raised by the prospect of adult stem cell research as well.

I have discussed some of these issues in my report.  And I merely list some of them here.  They include issues of social justice; of commodification or of commerce; issues about the conception of nature and what nature might mean; issues about human embodiment; issues raised by the erosion of species boundaries, so-called hybridization; and issues for implications of personal identity and moral responsibility.

Worries about eroding the boundaries among species, about destabilizing the concept of nature, and about treating human bodies merely instrumentally are related.

I believe that this cluster of issues deserves special attention going forward.  And, again, my point is that it's a cluster that is raised for adult stem cell research as well as for embryonic.  So that while we ought to continue debating the status of the embryo, we also ought to move beyond that debate to focus on these other issues as well.

I also think that we might do well, at least initially, to think about these issues outside of the contested question of human nature.  For example, I wonder whether there is some merit in considering the pervasive human manipulation of nonhuman animals.

For example, it may be useful to take as more than a curiosity the so-called transgenic art of Eduardo Kac.  Several years ago Kac made headlines around the world with his public art intervention that included Alba, the green fluorescent protein bunny.

As you may recall, Alba was an albino rabbit that glowed green under certain light because it had been genetically altered and carried a gene from a jellyfish.

Kac defined transgenic art as "a new art form based on the use of genetic engineering to transfer natural or synthetic genes to an organism to create new living beings."  And here is a slide of Kac with Alba.

Many people were outraged at Kac's creation.  And many dismissed his work as a publicity stunt.  But, in fact, part of the point of the Alba project was to generate a public conversation on the cultural and ethical implications of genetic engineering.

According to Kac, "The creation of a chimeric animal forces us to examine notions of normalcy, heterogeneity, purity, hybridity, and otherness."  Here is Alba glowing green.

The claim that I just read is a bit too jargon-filled for my taste.  That he did not use "alterity," instead of "otherness," is astonishing.  But Kac's work invites us to reflect on the implications of turning nonhuman animals into artifacts.  Of course, we have been doing that for a very long time.  Still, it's worth thinking carefully about our reaction to the creation of Alba.

It is worth asking whether our reaction to Alba is different from our reaction to, say, the creation of the Harvard oncomouse and if so, why.

I began my written report with a passage from C. S. Lewis.  And so it's perhaps fitting to draw my presentation to a close with another passage from the "Abolition of Man."  Lewis writes, "Now, I take it when we understand a thing analytically and then dominate it and use it for our own convenience, we reduce it to the level of 'nature' in the sense that we suspend our judgments of value about it; ignore its final cause, if any; and treat it in terms of quantity.  The repression of elements in what would otherwise be our total reaction to it is sometimes very noticeable and even painful.  Something has to be overcome before we can cut up a dead man or a live animal in a dissecting room."

Although it is perhaps justifiable to reduce the world of nature to mere nature, as Lewis puts it, I am inclined to agree with him that something is lost when we do so.

When I reread the "Abolition of Man" in working on this presentation, I was struck by the fact that the sort of dynamic Lewis describes here is very close to that recorded in Jonathan Glover's impressive work "Humanity, A Moral History of the 20th Century."

Glover writes, "Human responses are the core of the humanity which contracts within humanity.  They are widely distributed.  But to identify them with humanity is only partly an empirical claim.  It remains also partly an aspiration."

As Glover powerfully argues, morality must be rooted in human needs and values.  And these needs and values are both rooted in human nature and grounded in human aspiration.

As we move forward to wrestle with issues of stem cell research, we ought to be conscious of what is at stake in the possibility of redefining either our natures or our aspirations, for, as Glover makes clear, the inhumanity of humans is a frightening and all too familiar thing.

Thank you.

CHAIRMAN KASS:  Thank you very much.  I assume, Professor Lauritzen, that both the presentation and the paper are fair game in the discussion.

DR. LAURITZEN:  Sure, absolutely.

CHAIRMAN KASS:  Does someone want to start?  Jim Wilson, please?

PROF. WILSON:  I wanted to be clear, Professor Lauritzen, in your views.  You displayed the differences in the cumulative prevalence of diagnosed major birth defects singled in infants resulting either from natural conception or IVF and pointed out that the data suggest that that incidence is roughly twice as high with IVF as it is with natural conception.

Do you conclude from that that we should be opposed to IVF?

DR. LAURITZEN:  No.  I mean, first let me say that data is somewhat controversial, I gather, in that there are other studies that don't show that kind of risk.  Rather, my point is that we don't have the data.  I mean, that is part of the issue here.

I have to go back and look, but I think that data actually came from western Australia.  So it doesn't even reflect data in this country.  I think that is right.  I would have to go back and look.

The point is we are not tracking the potential health consequences of in vitro fertilization in anything like the way we should.  And it seems to me part of the reason is that this is an area, reproductive medicine is, which has almost no oversight.  And it obviously also has almost no federal funding.

Had there been federal funding, there might have been more oversight.  But even apart from the issue of federal funding, it is an issue of one area of medicine where the move from a novel idea, like intracytoplasmic sperm injection, moves very quickly into clinical practice when it is really a therapeutic modality that has been largely untested.

And then it is offered as a therapy when it is really, in fact, experimental and not tracked in any significant way.  So we don't know, long term, what the genuine health risks have been.

So that one of the issues here I think a staff working paper - the Council may have flagged that.  The little regulation there is tends to be sort of consumer protection regulation so that prospective couples using IVF should be protected in some way, get adequate information about success rates of clinics and things of that sort when, in fact, there may be larger public health issues about the long-term implications for women and children, for the women undergoing high-dose hormones to induce hyperovulation and for the children to see if there are long-term health consequences or, for that matter, short-term ones.

PROF. WILSON:  Could I make one follow-up?

DR. LAURITZEN:  Please?

PROF. WILSON:  I certainly agree with you about the unfortunate lack of longitudinal research that will track babies from these processes.  My view is that we should encourage this.

But let's suppose there is this longitudinal research to the extent that we can.  And let's suppose, in effect, it replicates the data you have presented for the United States over the long term.  Would such data lead you to question the value of IVF?

DR. LAURITZEN:  Well, I think it raises certainly issues about which there is a significant literature in the philosophical side of things about so-called harm to future children.

And there are folks like John Robertson who have argued a variation of the point that essentially you can't harm by bringing that into existence because without the technology, this child would not exist or the adults that might come from the child.

So that even if it turned out that there were significant health risks, much higher rates of cancer in children, in vitro fertilization procedures, that you haven't, in fact, harmed those children because they wouldn't have existed otherwise.

My own view is that that is not the right approach to frame it entirely in terms of harm to the specific child and compare that to nonexistence, which obviously is a difficult comparison.

So I'm dodging your specific question, I think, a bit except to say we ought to sort through it.  I mean, obviously there is no regulation preventing couples to reproduce who are carriers of known genetic effects with a certain percentage likelihood of problems for their children.

So I am not saying necessarily that that would mean we should shut down IVF programs, but it's information we need.  It's, frankly, information that ought to be a kind of obviously a fairly detailed part of the informed consent process for couples considering using IVF.  And I don't think that any of those things are true now.

PROF.WILSON:  Thank you.

CHAIRMAN KASS:  Janet Rowley?

DR. ROWLEY:  I would like to follow up on both your comment and then Jim's question because I think that it is extraordinarily important that we emphasize, as we have in previous Council meetings and in the document we have under consideration, the lack of reliable long-term data on the outcome of IVF and ICSI and other procedures.

I think we have to emphasize that that is because there has been no money available to gather such data.  And such data is going to be very, very costly to obtain.

I know just in terms of our own research projects of tracking down cancer patients and what's the long-term outcome of their treatment, that to try to find these individuals is extremely difficult.

The laws have just been changed, the Privacy Act.  So I would think that before you can contact any individual, you have to go to the clinic.  The clinic has to go to that patient and say that they're trying to collect information and would the patient be willing to provide that information before you can even begin the collection process.

So this is no small task that we have set and that apparently CDC is embarking on because it is a two or a three-stage process before you get it.

And you say research is privatized.  This is the only area of medicine in which research is privatized.  And, again, that leads to the problems that we are currently facing.

CHAIRMAN KASS:  Thank you.

DR. LAURITZEN:  Can I just make one observation on that?

CHAIRMAN KASS:  Please?

DR. LAURITZEN:  I think there is going to be that difficulty of getting consent.  There is also I think in the case of reproductive medicine the additional difficulty that the prospective parents in giving that consent would have to be acknowledging in a way that is different from cancer, where the expectation is that there is going to be certain morbidity and mortality.

Well, the assumption that most infertile couples have is that if we go forward with this, we are going to have a healthy child and there aren't going to be long-term problems.  So I think to some degree, reproductive docs are going to be a bit reluctant to raise the specter of potential long-term harms going in.

DR. ROWLEY:  Can I make two comments?  One, my impression is that most infertile couples who live in states where there is no insurance and, therefore, they are paying 30 to 50 thousand dollars for this procedure are pretty sophisticated and, as a consequence, know the risks that they face.

What we are trying to get is data on children 5 or 10 years old or older now and what is their status so that the individuals involved in IVF 5, 10, or 15 years ago gave no such consent for this follow-up information.  And that is the first step of running a survey, to get their permission to even contact them to get the information.

CHAIRMAN KASS:  Thank you.

Just as one fact, I understand that the NIH is gearing up for a massive study on children, a prospective study.  And it might be of interest to us to explore the ways in which some of the things that we would be interested in might be incorporated in the planning of this study as it goes forward.  But that's for a later discussion.

I had myself in the queue.  Let me deal with things in the paper, rather than in the presentation.  A couple of comments and then a question.  First, I guess it's fair to say you criticize what you take to be the excessively individualistic treatment of the ethical questions, especially as they are concerned with the matters of the embryo or even the language of rights in this area.

I would simply observe that in questions of life and death, which, after all, are things that befall individuals, a certain individualistic focus ought not to be pejorative but is somehow necessary, that there might be other kinds of goods that are here that don't concern individuals, but the people who care about whether or not embryonic life is destroyed will, in fact, care about the death of individuals.  And that can't be avoided.  Whenever you are dealing with a question of death, you can't sort of avoid that.  That would be an observation.  I don't imagine you would dissent from it.  I would take that as a friendly amendment.

Second, on the questions of economics and commerce, it seems to me there are three things potentially that are bothering you here.  One is the notion of commerce in the body altogether.  Second are questions having to do with distributive justice and unequal access to the benefits that are available.  And third is a kind of faint whiff of a dislike of profit, although it doesn't come out very strongly.

These are questions that have come up around the table before.  And I am sometimes sympathetic to these arguments, but reading your paper made me less so for these reasons.

It seemed to me that the mere assertion of inequality is not ipso facto a demonstration of injustice, though the question of equal access is important.  The remarks about the truck company said, after all, why should they be able to profit from the embryos when the people whose embryos they were don't?  The answer to that is they have mixed their labor with it extracting the stem cells.  The embryos as such are not by themselves valuable until somebody has done something to them.  So at least there is a prima facie case for saying that there is some claim for profit.

And then on the question of commerce in the body, I am not so sure whether it is the money changing hands that bothers us as much as it is sort of the free alienation of body parts.  We don't object to people selling their labor, although people have done so.  And, therefore, I wonder whether what might bother us is even - if there was something that was somehow disquieting simply about the giving of an embryo for research, we would be bothered by the fact that someone might be paid for it.  I think the commercial aspect of this is a sign that there is something beneath the commerce that is troubling to us.

I have got more, but that is too much.  Let me stop.  I would be interested in your comment, really, on this nest of the economic questions.  It's not the first time that we have taken them up, but we haven't taken up in the stem cell context.  And I think it would be useful to spend a few minutes on that.

DR. LAURITZEN:  Sure.  Well, my first reaction is to say that I'm not sure your nose for the smell of the concern about profit is on target.  I would be happy to accept a larger stipend for my work here.  So we can talk about that afterwards.

CHAIRMAN KASS:  People make exceptions to their own case.

DR. LAURITZEN:  I mean, I do think it's a fair observation.  And it depends, I suppose.  One point about the embryo, the difference between the researcher who mixes his or her labor to produce the product and the embryo is going to depend, of course, what stage we're talking about with embryo research.

And, arguably, women have mixed the labor of their body in producing either the eggs and going through the hormone regimens to generate the embryos or if we're talking about an embryo then subsequently brought to term, obviously there is the work of gestation, though I don't like that kind of language particularly.  And that may just be my anti-profit convictions of some sort.

As you were talking, I was trying to think of some comparisons.  Here I am just trying to mine an intuition in a way that as I thought about surrogacy, for example, in the past, I have always found the prospect of surrogacy more troubling in a case where there is a paid surrogate than in a case where there might be a family member who has stepped forward to carry a child.

So I am not sure quite how you put the point, but there is something about the commercial aspect of paying the surrogate that seems problematic in a way that a sister or a cousin or something who might offer to gestate a child doesn't invoke.  So I am not sure -

CHAIRMAN KASS:  Why is that?

DR. LAURITZEN:  Yes.  I think it is a good question.  In part - well, I'm not sure.  Let me say that my inclination at this point is to draw on the story of the minister who had gone to seminary and had training in doing sermons, which I haven't had the benefit of.  This guy was giving a talk at the university.  And he had a written text.  I went up afterwards.  In the margin throughout, there were a couple of marginal notes that were "PP."

So I was puzzled by this.  And I asked him what they referred to.  And he said, "Pound the pulpit."  So he always pounded the pulpit at the weakest point in his argument.  And I'm inclined to pound the pulpit here.

I'm not sure that's the best response, but it may be all I can come up with right now.

CHAIRMAN KASS:  Gil Meilaender and Alfonso.

PROF. MEILAENDER:  At the risk of dismaying our chairman, although perhaps not to your surprise, I want to come to a question about the structure of your paper, the way you work it out, where you suggest that there has been too much attention paid to the embryo status question and not enough to this other range of things.  Leon congratulated you on that, and I want to worry about that a little bit.  Well, okay, Leon, I am just having a little fun with you.

I haven't at the moment come up with a great analogy, but if in the instance of warfare, for instance, we were using all sorts of very large, powerful weapons with very little concern about the collateral damage that came to people apart from the military targets themselves and I was worried about that and you said, "Well, yeah, but let's don't focus too much on that.  Let's worry about the fact that we are probably stereotyping our enemies when we think we can do this to them," that we may coarsen our sensibilities in pursuing warfare in this way, that acquiescing too quickly in this may keep us from developing other better kinds of weapons and those are the things that we really ought to worry about while proceeding to bombing the living daylights out of them in this way, it would strike me that - and you will recognize that this is a version of a different formulation - that would be an argument for sort of unlimited casualties always with tears.

We should always feel bad about these casualties because of all of these other reasons involved while we continue to inflict them.  It seems to me that that is sort of the structure of your argument.  And while I don't wish to deny that one or another of the issues that you raise might be important to think about, indeed, that they are all important and that taken as a package, they bear considerable weight, I can't imagine that we would worry so much about them if we had entirely set aside the issue that you say we have worried too much about, namely what we ought to think about the embryo.

And so I guess what I want to know is, will you accept my description of the structure of your argument as sort of unlimited stem cell research always with tears?  And if you will, are you really prepared to defend that kind of moral argument?

DR. LAURITZEN:  What you need to know is that Gil has accused me of this once before.  I think I denied it in that context and will probably deny it again here.

It seems to me that in urging in some way the expansion of the moral discussion, I don't want to suggest that we not attend to the status of the embryo.  There may be a way in which I put my point too rhetorically sharply to try to suggest that.

So I don't want to suggest that we stop talking about the embryos, the status of the embryo.  We are going to have sharp disagreements around the room.  And there is a sense in which what I said in the report was suggestive of the fact that, look, it's hopeless.  We're never going to make any progress on this.  So let's just stop talking about it.

And I may have come close to saying something like that.  I didn't mean to.  After all, we have made progress on moral status questions in the past.  I mean, we certainly in this country have made progress with regard to African American status and the status of women historically.

I think there is some reason to suggest that we have made at least some progress with regard to thinking about the status of nonhuman animals.  So I think their status questions are important and we should continue to talk about them.

But my point, instead - and I suppose this is something of a structural issue.  My point is to say, why don't we bracket for a moment that which divides us and focus on that about which we are united?  There may not be universal agreement about those thing we're united about, but I think we would find more commonality around the table if we started focusing on some of the issues that I identified that apply to both embryonic stem cell research and adult stem cell research, which might, in fact, lead us to hesitate to do embryonic stem cell research, not because we share the conviction that their early embryo is a person with a full moral status but because we agree on a cluster of other values.

So that I don't think I am necessarily suggesting that we continue doing, necessarily doing, embryonic stem cell research and just wringing our hands about it, though I do say in the end, just to try to weigh my own position out, in fairness, that I think it is justified to go forward with both embryonic stem cell research and adult stem cell research in a carefully regulated way.

PROF. MEILAENDER:  As long as we're haunted by it.  Is that the language?

DR. LAURITZEN:  Yes, that we will be haunted by it, we will be wringing our hands about it and I will be crying and tearful.  But I could easily be persuaded that part of the regulation would be, for example, moratorium on embryonic stem cell research until we do more adult stem cell work but, even there, be awfully careful about how we are doing it.

So I don't entirely accept your characterization, but it's not entirely unfair either.

CHAIRMAN KASS:  I have Alfonso.  Bill, do you want on this point or -

DR. MAY:  Not directly.

CHAIRMAN KASS:  Okay.  Then I'll put you on the queue.  Alfonso?

DR.GÓMEZ-LOBO:  I'm going to refer to the paper as well, but I'll preface that by saying that, unfortunately, it seems to me on certain moral issues, we just have to have sharp disagreements, the idea focusing on what we have in common.  That papers over the deeper question, will it not serve the American public?

I read your paper over a couple of times because I don't see in the paper the presentation of the arguments.  I see descriptions.  I see appeals.  But, for instance, to put embryonic stem cell research and adult stem cell research as closely connected it seems to be obscures an argument that some of us have against one and in favor of the other.  That's why, for instance, I would say I am all for stem cell research.

My only concern, my single concern is that we not use, destroy, or instrumentalize human beings to do that.  That is why, for instance, one of the great challenges I see for the scientist is just try to figure out how to get those stem cells without destroying the organisms.

It's a challenge from someone who is viewing this from the point of view of moral philosophy.  And that's why I am very interested in your arguments for your final statement that you think that an embryo is not a person.

And just to go out on a limb, let me give you an argument.  And you please try to refute it.  I would say the following.  I have a twin brother.  I was conceived 64 years ago.  I got my genetic inheritance from my father presumably at the time.

Genetically I am the same individual I was back then.  And spatio-temporally also, I have the relationship of saying this with that early embryo.  If you pursue me in time and space, it turns out that I am the same individual.

And then my second premise, well, I am a person now.  I am a human being now, and I should be respected now.  Why should I not have been respected then?

DR. LAURITZEN:  Well, a couple of things, first about your earlier point.  I guess what I want to press you on is why your only concern about stem cell research, adult or embryonic, is that it may destroy human beings.

I think there is certainly a range of issues that I think have come up in other Council deliberations that I would urge you to take up going forward about the social implications of profoundly enhancing human characteristics in various ways, perhaps radically increasing the human life span.  Whether that is realistic or not is another matter.  But if, in fact, it is, it seems to me to raise important moral issues.

Already this morning we have had some discussion.  Dan talked about Harold Varmus' concern about access to therapies.  All of those issues are I think terribly pressing moral ones.  And they don't have anything at all to do with destroying embryos or necessarily destroying human persons.

So in a way, that's what I mean to say.  I think we would have a very interesting conversation about that when we didn't talk about embryos at all.

The second part has to do with embryos.  There is some material in the report that I think is at least intriguing to talk about the developmental potential of that early embryo as if it was, in effect, a kind of little homunculus that just is going to develop in a set way is just biologically inaccurate, that it's the interaction of a complex set of systems that in your case, in fact, led to an arc that 64 years later is you.  And you can trace back that arc.  But that doesn't mean that there was the potential in that early embryo or only one natural kind of teleology that leads to you.

In a different environment, it would have led to some other.  Well, if we derive stem cells and then grow an organ from them, say, well, we say that heart, we can trace back to that embryo that was then disaggregated to produce the stem cells.

I didn't jot down everything you said but genetic relation, spatio-temporal relations, you could trace the same arc backwards if the environment were such that it produced something else.

This is a fairly common argument, but I don't find it compelling.

CHAIRMAN KASS:  I'll give you one more round briefly.  You see the incorrigibility of this.  One more shot.

DR.GÓMEZ-LOBO:  I'll follow the rules.  A heart is a part of an organism.  It's not a complete organism.  And what matters, really, is the entity through time of the complete organism, it seems to me.

CHAIRMAN KASS:  Michael Sandel, Bill May, and then Rebecca is what I have.

PROF.SANDEL:  I liked your paper very much.  I was just going to offer a brief reply that you might offer to Leon, but while I'm at it, I could also offer you a brief reply to Alfonso.

DR. LAURITZEN:  That would be great.

PROF.SANDEL:  That would be that it's also true that every oak tree was once an acorn, but it doesn't follow that acorns are oak trees or that we should regard the loss of an oak tree as the same as the loss of an acorn.

The reply to Leon, do you want to hear that now?

DR. LAURITZEN:  Absolutely, and anybody else.

PROF.SANDEL:  The reply to Leon might be that the reason that commerce in the body is objectionable in a way that is independent from the giving, as in your surrogacy case, the reason there may be a difference is that to support your intuition that there is something objectionable to commercial surrogacy that might not be the case with gifted surrogacy, say, of a sister, for example, that the ground for that intuition might be that the body isn't private property, open to any use that we may desire or devise, but, instead, is a gift with a certain telos.  This should appeal to Leon, in fact, a natural telos, which means that it's not open to use for other lesser purposes, like making money.

So that in the case of commercial surrogacy, this would be a case of using the body or selling oocytes, for example.  This would be a case of using the body for a purpose at odds with its telos, namely making money.

But to donate or to gift without any commercial transaction for one's sister, say, to carry her child wouldn't be objectionable in the same way.  It would still be in accord with the natural telos of the body.

CHAIRMAN KASS:  I won't say more than it's an odd natural telos to say that one woman's uterus is to carry the child of someone else, even out of love.  I mean, that's a new kind of natural teleology.  We would have to argue about it.

PROF.SANDEL:  But you would agree, wouldn't you, that it's in line with the natural purpose in a way that selling it to make money clearly isn't?

CHAIRMAN KASS:  No.  It's a nice try.  But I think that if there weren't something disquieting about the thing itself, the fact that money changed hands wouldn't even occur.  The same thing is true about prostitution.  The same thing is true about a whole range of things.

I am not saying it is wrong, but we are not, most of us are not, upset with the fact that people sell their labor.  And the money changes hands.  And it may distort human relations profoundly, but we don't regard that somehow as a deep violation in the same way as a lot of people seem to regard the selling of body parts as a violation.  And that must mean it has something to do with the alienation of one's body from one's self to begin with.

PROF.SANDEL:  It's use, rather than alienation.  The intuition at odds with this is kidney fails, a lot of people that object to a market in kidneys who wouldn't necessarily consider that our position requires you to say that there is something objectionable to a kidney transplant as such.

CHAIRMAN KASS:  I said, "disquieting."  I didn't say, "objectionable."

PROF.SANDEL:  Well, even disquieting.

CHAIRMAN KASS:  There is.  There is something to begin with disquieting about taking an organ from one body and putting it in another.  I think it's terrific that we do it.  It's not a question of an objection.  But it's odd.

I'm sorry.  I'm not on trial here.  It is Bill May.

DR. MAY:  I hadn't planned to say anything on surrogacy, but it seems to me not simply the question of the telos of the body, but it's different.  Gestating is different from manufacturing, where you can distinguish the process from the product.  But in gestation, there is a kind of bonding to what is within you.  And the releasing of that child to another because it's a bond ought not simply to be based on commerce.

The early court case on this said they tried to distinguish process from product, you know.  And merely buying the process misses what is going on for the woman and bonding and why it should not be an enforceable contract.  It can only be a gift because a kind of bonding has gone on.

I was interested in another issue, and I will take advantage of my opportunity here to say you and Dan Callahan have brought up front the issue of access to benefits in a way that it seems to me we have not as frontally discussed that topic.  It has come up from time to time, but it really hasn't been as openly discussed across a couple of sessions.  And I wanted to deal with that issue.

There might be a way of talking about the status of the embryo but relate that issue to the import for access to product.  Some of us in this group did not agree with the idea of a total ban on cloning for research purposes.  We talked about the intermediate status of the embryo, that it is not fully there with the claim of the human.  And, therefore, we were not ready to talk about a ban.

On the other hand, it is not nothing.  It is not yard-lot materials.  It has a kind of intermediate status.  And that has implications.  Most of our time was spent on the issue of how you do the research and respect for this pre-implanted embryo.  Most of the discussion was in that area.

But it seems to me if you use the pre-implanted embryo in research, one has to talk about regulations that not only constrain how you conduct that research, let's say the 14 days before the neural streak an all of that, but if you are using this human source and you are removing it from life, you are not removing it from the circle of human indebtedness.

And that is a consideration that is not simply individualism.  It's that you are conducting research on something that doesn't have the full claim of urgent human needs of extant human beings.

But, on the other hand - and I would not want to use the word "resource."  I would call it "source," a human source.  And if you are conducting this research and removing it from life, you are not removing it from the circle of human indebtedness.  And that has consequences not only in how you conduct the research, but you structure the results in such a way that all of those who are in need have access to the benefits of that research.

Otherwise one creates I think a lack of respect for what one has used.  And that doesn't mean you don't pay researchers and so forth, but you think through the problem of the health care system.

I think Dan this morning talked about and you yourself talked about expanding the issues.  We're concerned to talk about are we going to produce a lot of products that would be available only to the few and not to all of those in need.

And it may be the status of the embryo, this intermediate status, is not simply individualistic reflection but forces us to think about the communal significance of what we have done and the necessity of honoring it in such a way to make sure that it reaches not just the few privileged but the many.

CHAIRMAN KASS:  Gil, do you want -

PROF. MEILAENDER:  Yes, just really quickly.  Bill, this is a question for you.  We're letting Paul off the hook.  I know you have made this argument before.  And I am sort of afraid I may be asking the kind of question where I am just asking you to repeat yourself, but I really don't understand that argument; that is to say, the "circle of indebtedness" language.

So that if we use some embryos and distribute the knowledge gained unequally, we have somehow not honored those embryos that we used; whereas, if we distribute the knowledge equally, we have honored them.

Now, I just don't understand.  I am prepared to grant that it would be better to distribute the knowledge equally than unequally.  I just don't see what in the world this has got to do with whether we have honored the embryo as a human source.  Can you help me?

DR. MAY:  I'm not sure that I can do it in a form that doesn't realize your fears.  It just seems to me that in making use of this to produce this benefit, one has to insist that it reach the many.  And that is not simply some principle out there separate from, indeed, what has been done.

PROF. MEILAENDER:  May I try once more?

CHAIRMAN KASS:  Briefly, yes.

PROF. MEILAENDER:  So we honor the slave better if we distribute the cotton garments equally than if we distribute them unequally.

DR. MAY:  Well, you have assumed that I have equated the pre-implanted embryo with an extant human being.

PROF. MEILAENDER:  Well, it was a human source.  That's all.

DR. MAY:  That sets me up for an equation that I am not prepared to assert.  I already began with the notion of the intermediate status.  And the slave does not have an intermediate status.

CHAIRMAN KASS:  Mr. Lauritzen, do you want to respond to the original comment?

DR. LAURITZEN:  I was hoping Michael would do that for me, but let me say just a couple of things.  In the past, I have tried to weigh out a position that tries to avoid understanding the early embryo as a person with a full set of rights and to use language that is common and controversial about respecting this as a source or whatever precise language we use and that one way to do that would be, in fact, to do the research on adult stem cell first, see what we can learn there as a last resort and perhaps invoking fairly explicitly just war theory to do this deterrence of using embryonic research if we hit dead ends.

There are some issues about scientifically whether that is a viable strategy, I understand.  But over time, I have come to be a little concerned that - and this is I think reflected to some degree in the report.  I have become somewhat suspicious of the language of respecting the early embryo.  And this I think partly goes to Gil's point, while, nevertheless, destroying itregularly, et cetera.

Perhaps the better way to proceed here would be to talk about a slightly different frame for thinking about this, the way in which we have increasingly kind of instrumentalized everything about our world.  I mentioned before the instrumentalization of non-human animals so that they're simply now artifacts that we create with different traits without any concern for their value as independent organisms.

And I think we see the same dynamic with in vitro fertilization, frankly, with regard to embryos.  Whatever we happen to think about their status, I think there is little question that in vitro fertilization has led to the kind of instrumentalization of embryos that ought to give us real pause so that we get some new idea about how to create an embryo.  Somebody dreams up ICSI.  Oh, I know.  We can do that this week.  And we don't hesitate.

So I think the danger here is a danger that is difficult to appreciate when you throw it into a certain context where the frame of the debate is largely about protecting individual rights and individual autonomy.

So a John Robertson is going to say, "Who is harmed?"  Well, unless you give some account of the early embryo as capable of experiencing harm, there doesn't seem to be a good answer, at least in terms of the objects or subjects direction.

But it may be that we are harmed when we so approach the world around us as something that we ought to be utterly controlling in every aspect so that everything turns into a human artifact, including humans.

So that's a very different tact on the issue that to some degree could remain agnostic about embryo status, I think.

CHAIRMAN KASS:  Let's see.  Rebecca?

PROF. DRESSER:  I liked the way that you are trying to bring in other issues because I do think this is a complicated area.  And I think, especially when we are talking about a topic that has public policy implications in a pluralistic country like ours, we should think more broadly.

So I wanted to mention a couple of other points that maybe you might want to think about that I have talked about and that bother me about the stem cell debate.

One is the area of what I would call truth-telling and the way that both adult and embryonic stem and all other kinds of stem cell research is being discussed in terms of the exaggeration I think of promise.  I don't know about exaggeration of promise but exaggeration of speed with which this is likely to develop into therapies, the likely success of any therapies, degree and percentage of people it is likely to help, all of those kinds of things.

I think in bioethics, we started with informed consent and we went along with a focus on truth-telling to patients about a serious prognosis and terminal prognosis.  And now in the United States, at least, there is a strong belief that physicians should be honest with patients about a prognosis that may not be very optimistic.  So I think that we need to talk about research of all sorts in those terms.  And I really see a violation of that in this area.  So that is something that I think might be worth mentioning.

The other is, is it worthwhile to think about an ethical value of deliberation, accommodation, and compromise when we are talking about issues like this that, as I said, have public policy implications.

And knowing that we live in this nation where people have very strong beliefs on different sides, how should we think about the problem and the activity of coming together to try to work out policies, of course, in different areas?  But should we give ethical weight to the idea that perhaps I will give a little on my favorite outcome in order to reach an accommodation that might be acceptable to more people?

And, again, that's something I have personally felt in working with this issue and something that might be worth separating out and talking about on its own terms.

Thanks.

CHAIRMAN KASS:  Thank you.

Shall we collect a few or do you want to respond?

DR. LAURITZEN:  That's fine.

CHAIRMAN KASS:  Let me collect a couple of others and see.  I have Bill Hurlbut and then Mary Ann.

DR. HURLBUT:  I want to return to the idea of commodification.  I think it's very helpful to what you said earlier about reflecting back on the embryo in light of these other categories of consideration.

When I think about the issue of commodification, I am naturally drawn to thinking about, well, what is it that you are commodifying or selling, commercializing even.

And when I think about the body parts or associated body realities that could be commercialized, I think of people selling their hair for people to make wigs.  That doesn't bother me very much at all, maybe none.

Blood, that's a little more something there, but that seems okay to me.  Sperm or ova, that troubles me a little.  There's more going on there, and maybe troubles me a lot.  Selling a kidney definitely bothers me.

And then selling your whole life really bothers me if you know what I mean; in other words, "I'll give up my life.  I'll sell you my life."  Okay?  Somebody might sell their life so that their children got money, for example, to survive.  That bothers me a lot.

So there is a spectrum going on there.  On the one hand, something seems simple, trivial, and okay.  On the other, it requires highly significant justification to even give up your life or to give up a significant part of it.

What is it that bothers me at the far end of that spectrum?  What is the key here?  I think it has to do with something that you would call integrated organismal integrity, identity, or continuity that we can give up something that doesn't challenge those three, but if we give up something that does, we have to have a really good moral reason for doing it.  So commodification of an expendable part is completely different than commodification of a whole human life.

And then when I reflect on it, what bothers me about sperm, for example, is not just that it's giving up a part of the being.  In this case when you give it up, it doesn't hurt the static reality of the organism.  It's that you're giving up a part of what you might say is the dynamic of an integrated identity and continuity.  You're giving up a relational dimension of being.

There is no significant disruption of a relationship to sell hair, but selling a sperm or a womb, use of a womb, is not just part of the static being but parts of dynamic relational being.

So it seems to me that the key here is that the moral meaning is in identity with the integrated organismal integrity and the integrated of dynamic process or continuity or overall purposefulness.

This brings me back to the point that Michael Sandel and I think it was William May and Leon were in a few minutes ago.  What is the difference between selling and giving?  Well, it seems to me that giving can sometimes be justified, even at the loss of something, integrity, identity, and continuity, because it is an adult form of voluntariness.

You are doing something that is a very high order act of hopefully consciousness, which preserves the fullness of being of the individual as a moral entity.  This, in turn, brings me back downstream to your comments that these larger issues of commodification and so forth can inform our understanding, not just of the absolute total landscape but can actually focus back down on the status of the embryo.

For me, as I read your paper, I thought yes, yes as I went all along.  And I got to the end.  And I thought, every one of these categories makes me more concerned about the moral status of the embryo.

Obviously commodification of the embryo violates the things I have been talking about; whereas, selling or giving a body part, let's say giving, is a high order of self-donation.  Relegating an embryo to research is exactly at the opposite end.  It really is commodification.  It doesn't have the voluntariness of giving in it at all.  It's a violation of something that is fundamentally human in the process.

So what seems to me is going on here, at least from my perspective as I looked at all of this, is all of your categories, commodification or, worse, at the level of the embryo, justice, giving something its due, is worse at the level of the embryo because it's not taking something from anything that has a choice.  The idea of natural embodiment, the embryo, everything we are is deeply, inextricably in continuity with that embryo.

The erosion of species boundaries raises a specialized dilemma here, violation of integrity, which is at the concern of that ethical consideration.  And, finally, the implications for personal identity and a deeply rooted thing that it is.

So I don't know if this at all makes the point, but what I would like to say is that I think these issues are of one piece and that organismal integrity and identity and continuity seem to focus all of your higher concerns right back down again, I mean, both directions, of course, but there is a whole package here that is inextricably related.

CHAIRMAN KASS:  Do you want to take both of these together?  I mean Rebecca Dresser's earlier comment.  Please respond if you wish.

DR. LAURITZEN:  Well, let me just respond to the last part.

CHAIRMAN KASS:  Okay.

DR. LAURITZEN:  Then I can go back to Rebecca's.  It just suggested some friendly directions in which it might be pursued.  I actually think that is a very interesting observation.  And I want to think fairly carefully about that because I think that you may be right about this.

It may provide some language for actually teasing out some of the concerns I want to articulate about adult stem cell research and then rethink their implications for embryonic stem cell research.

I forget the exact language you used.  What did you say, the organismal integrity?  I wonder if that isn't threatened in some significant ways, not by selling parts of our bodies but purchasing new possibilities for our bodies in a way that might fundamentally change who we are.

I have thought about this a little bit.  I got married when I was 24 and have been faithfully married to my wife now for quite a few years.  And at 24, I promised to be faithful until death do us part, but that was a commitment of about 50 years.  And if we doubled the life span, I am making that commitment for 100 years or something.  What would that commitment look like and whether it would fundamentally change how we thought about an institution like marriage and things of that sort?

I think it would have implications for personal identity and responsibility over a very extended period of time.  So there would be questions about purchasing as well as selling.

My initial reaction, going back to the embryo, is mixed.  On the one hand, I want to think more carefully about this notion of eroding the sense of a kind of natural trajectory because if there isn't that kind of natural trajectory, then I don't think what is threatened with the embryo early on is that unity that you describe because it has got multiple possible trajectories depending on the environment, the interaction, et cetera.  But I want to think about that more because I think it is a very interesting observation.

DR. HURLBUT:  One little brief follow-up on that.  I think that, actually, what you said has a power to it, but I see it at the other end of life.  I think the embryo is not as contingent as the full human being who has a sense of real opened determinacy and contingency.

I mean, sure, environment is going to affect things a lot for sure, the final trajectory.  I think it is more determined early and less determined later.  And so if the criterion of expendability is in determinacy, it wouldn't be the embryo.  It would be the up and breathing, bubbling human beings.

CHAIRMAN KASS:  Mary Ann?  We will break in about three minutes.

PROF.GLENDON:  I'm going to follow Dan Foster's illustrious example except just to say that Dr. Lauritzen I think has responded in his last remarks to the concern I was going to raise that what I think we're getting at when we use terms like "instrumentalization," "commodification" is really a deep concern about what kind of people we are becoming when we make certain decisions.  And so I think this has been a really fruitful discussion.

CHAIRMAN KASS:  Yes.  I would like to take at least one minute to add one thing to underline something that I thought was fairly good in the paper.  It ties in with things that we didn't talk very much about in Dan Callahan's presentation.  I found the two papers very nicely complementary.

That really has to do with the questions of the goal of stem cell research, combining both the embryonic and the adult and thinking through the purposes for which these are used, purposes which I think all of us at first glance will simply endorse what we endorse for generative medicine.

But the question about the limits of that and whether or not that really isn't also using things at the beginning of life to transform not just the trajectory but also the question of whether there really ought to be an end or a completion I think is a very important issue here.

I've got sort of half-baked notes for an essay called "The Old Man and the Embryo," in which it's at least paradoxical that one comes to look upon these cells, which are in some ways part of the seed of the next generation, to come to see them as the salvation for those of us who are getting close to the end.

And if you want to present yourself with a kind of parable in stock terms, imagine Abraham, the biblical Abraham, and Sarah in a desolate world except for an IVF clinic.  And they manage themselves.  I guess I've got to make two embryos.  They manage a couple of embryos.  And the question is whether the embryo ought to be Isaac or ought to be the cure for Abraham's Parkinson's disease.  Then you take that and universalize the matter, and I think you see something of the difficulty here.

This is not an objection to stem cell research.  I want to underscore that.  But there is something going on here about the way in which we think about the things at the beginning of life in relation to things at the end of life.  And they're becoming somewhat unmoored.

I think your paper I think highlights the importance of thinking about those things and the powers, what we're going to use these powers for, as well as the questions of the ethics and the means upon which we for the most part so exercised ourselves.  So I'm in your debt for that and for much else as well.

CHAIRMAN KASS:  Council members, show up at five of. Thank you very much.

(Whereupon, at 12:25 p.m., the foregoing matter was recessed for lunch, to reconvene at 2:00 p.m. the same day.)