Unconditional access to non-invasive prenatal testing (NIPT) for adult-onset conditions: a defence

Over the past decade, non-invasive prenatal testing (NIPT) has been adopted into routine obstetric care to screen for fetal sex, trisomies 21, 18 and 13, sex chromosome aneuploidies and fetal sex determination. It is predicted that the scope of NIPT will be expanded in the future, including screening for adult-onset conditions (AOCs). Some ethicists have proposed that using NIPT to detect severe autosomal AOCs that cannot be prevented or treated, such as Huntington's disease, should only be offered to prospective parents who intend to terminate a pregnancy in the case of a positive result. We refer to this as the 'conditional access model' (CAM) for NIPT. We argue against CAM for NIPT to screen for Huntington's disease or any other AOC. Next, we present results from a study we conducted in Australia that explored NIPT users' attitudes regarding CAM in the context of NIPT for AOCs. We found that, despite overall support for NIPT for AOCs, most participants were not in favour of CAM for both preventable and non-preventable AOCs. Our findings are discussed in relation to our initial theoretical ethical theory and with other comparable empirical studies. We conclude that an 'unconditional access model' (UAM), which provides unrestricted access to NIPT for AOCs, is a morally preferable alternative that avoids both CAM's fundamental practical limitations and the limitations it places on parents' reproductive autonomy.

Palliative Farming

Billions of animals live and die under deplorable conditions in factory farms. Despite significant efforts to reduce human consumption of animal products and to encourage more humane farming practices, the number of factory-farmed animals is nevertheless on an upward trajectory. In this paper, we suggest that the high levels of suffering combined with short life-expectancies make the situation of many factory-farmed animals relevantly similar to that of palliative patients. Building on this, we discuss the radical option of seeking to reduce the suffering of factory-farmed animals through the use of drugs that alleviate pain and distress, administered under a regimen where experiential wellbeing is prioritized over the aim of avoiding drug-dependence.

Gene Editing, Identity and Benefit

Some suggest that gene editing human embryos to prevent genetic disorders will be in one respect morally preferable to using genetic selection for the same purpose: gene editing will benefit particular future persons, while genetic selection would merely replace them. We first construct the most plausible defence of this suggestion-the benefit argument-and defend it against a possible objection. We then advance another objection: the benefit argument succeeds only when restricted to cases in which the gene-edited child would have been brought into existence even if gene editing had not been employed. Our argument relies on a standard account of comparative benefit which has recently been criticised on the grounds that it succumbs to the so-called 'pre-emption problem'. We end by considering how our argument would be affected were the standard account revised in an attempt to evade this problem. We consider three revised accounts and argue that, on all three, our critique of the benefit argument stands.

Genome Editing in Livestock, Complicity, and the Technological Fix Objection

Genome editing in livestock could potentially be used in ways that help resolve some of the most urgent and serious global problems pertaining to livestock, including animal suffering, pollution, antimicrobial resistance, and the spread of infectious disease. But despite this potential, some may object to pursuing it, not because genome editing is wrong in and of itself, but because it is the wrong kind of solution to the problems it addresses: it is merely a 'technological fix' to a complex societal problem. Yet though this objection might have wide intuitive appeal, it is often not clear what, exactly, the moral problem is supposed to be. The aim of this paper is to formulate and shed some light on the 'technological fix objection' to genome editing in livestock. I suggest that three concerns may underlie it, make implicit assumptions underlying the concerns explicit, and cast some doubt on several of these assumptions, at least as they apply to the use of genome editing to produce pigs resistant to the Porcine Reproductive and Respiratory Syndrome and hornless dairy cattle. I then suggest that the third, and most important, concern could be framed as a concern about complicity in factory farming. I suggest ways to evaluate this concern, and to reduce or offset any complicity in factory farming. Thinking of genome editing's contribution to factory farming in terms of complicity, may, I suggest, tie it more explicitly and strongly to the wider obligations that come with pursuing it, including the cessation of factory farming, thereby addressing the concern that technological fixes focus only on a narrow problem.

The Ethics of Creating and Using Human-Animal Chimeras

Rapid advances in gene-editing and stem-cell technology have expanded the range of possible future applications in human-animal chimera research. Most notably, recent developments may allow researchers to generate whole personalized human organs in pigs for the purpose of transplantation into human patients. Though human-animal chimera research in small animals, such as mice, is routine, human-animal chimeric techniques are now increasingly being applied to larger animals. Moreover, these chimeras include increasing amounts of human material, which is potentially present in more morally significant locations, such as the brain and the reproductive system. These developments raise important ethical questions about whether we should create such chimeras, and if so, how we should treat them. Answers to these ethical questions are needed to inform the development of policies regulating human-animal chimera research and its applications. Here, we provide a review of some of the most important or widespread ethical concerns.

No Pain, No Gain? In Defence of Genetically Disenhancing (Most) Research Animals

Every year, around 12 million animals are used for the purpose of scientific research in the European Union alone. The procedures performed on them often cause significant pain and suffering. Despite regulations aimed at reducing this suffering, we can expect millions of research animals to continue to suffer in the near to mid-term future. Given this reality, we propose the use of gene editing to create research animals with a reduced capacity for suffering, in particular, from pain. We argue that our proposal would be in line with moral principles embedded in European regulations regarding animal research, and that it would facilitate compliance with these regulations. We also respond to the strongest argument against our proposal-the 'no pain no gain' argument.

A conception of genetic parenthood

We seek to develop a plausible conception of genetic parenthood, taking a recent discussion by Heidi Mertes as our point of departure. Mertes considers two conceptions of genetic parenthood-one invoking genetic resemblance and the other genetic inheritance-and presents counter-examples to both conceptions. We revise Mertes' second conception so as to avoid these and related counter-examples.

The epistemic costs of compromise in bioethics

Bioethicists sometimes defend compromise positions, particularly when they enter debates on applied topics that have traditionally been highly polarised, such as those regarding abortion, euthanasia and embryonic stem cell research. However, defending compromise positions is often regarded with a degree of disdain. Many are intuitively attracted to the view that it is almost always problematic to defend compromise positions, in the sense that we have a significant moral reason not to do so. In this paper, we consider whether this common sense view can be given a principled basis. We first show how existing explanations for the problematic nature of compromise fall short of vindicating the common sense view, before offering our own explanation, which, we claim, comes closer to vindicating that view. We argue that defending a compromise will typically have two epistemic costs: it will corrupt attempts to use the claims of ethicists as testimonial evidence, and it will undermine standards that are important to making epistemic progress in ethics. We end by suggesting that the epistemic costs of compromise could be reduced by introducing a stronger separation between ethical debate aimed at fulfilling the epistemic role of ethics, and ethical debate that aims to directly produce good policy or practice.

Intra-Family Gamete Donation: A Solution to Concerns Regarding Gamete Donation in China?

Gamete donation from third parties is controversial in China as it severs blood ties, which are considered of utmost importance in Confucian tradition. In recent years, infertile couples are increasingly demonstrating a preference for the use of gametes donated by family members to conceive children-known as "intra-family gamete donation." The main advantage of intra-family gamete donation is that it maintains blood ties between children and both parents. To date there is no practice of intra-family gamete donation in China. In this paper, we investigate intra-family adoption in China in order to illustrate that intra-family gamete donation is consistent with Confucian tradition regarding the importance of maintaining blood ties within the family. There are several specific ethical issues raised by intra-family gamete donation. It may, for example, result in consanguinity and the semblance of incest, lead to confused family relationships, and raise concerns about possible coercion of familial donors. Confucian tradition provides a new approach to understand and deal with these ethical issues in a way that Western tradition does not. As a result, we suggest intra-family gamete donation could be an acceptable solution to the problem of infertility in China. However, further discussion and open debates on the ethical issues raised by intra-family gamete donation are needed in China.

U.S. Complicity and Japan's Wartime Medical Atrocities: Time for a Response

Shortly before and during the Second World War, Japanese doctors and medical researchers conducted large-scale human experiments in occupied China that were at least as gruesome as those conducted by Nazi doctors. Japan never officially acknowledged the occurrence of the experiments, never tried any of the perpetrators, and never provided compensation to the victims or issued an apology. Building on work by Jing-Bao Nie, this article argues that the U.S. government is heavily complicit in this grave injustice, and should respond in an appropriate way in order to reduce this complicity, as well as to avoid complicity in future unethical medical experiments. It also calls on other U.S. institutions, in particular the Presidential Commission for the Study of Bioethical Issues, to urge the government to respond, or to at least inform the public and initiate a debate about this dark page of American and Japanese history.

Procreative altruism: beyond individualism in reproductive selection

Existing debate on procreative selection focuses on the well-being of the future child. However, selection decisions can also have significant effects on the well-being of others. Moreover, these effects may run in opposing directions; some traits conducive to the well-being of the selected child may be harmful to others, whereas other traits that limit the child's well-being may preserve or increase that of others. Prominent selection principles defended to date instruct parents to select a child, of the possible children they could have, likely to have a good (or nonbad) life, but they do not instruct parents to independently take the well-being of others into account. We refer to these principles as individualistic selection principles. We propose a new selection principle-Procreative Altruism-according to which parents have significant moral reason to select a child whose existence can be expected to contribute more to (or detract less from) the well-being of others than any alternative child they could have. We present the case for adopting Procreative Altruism alongside any of the major individualistic selection principles proposed to date and defend this two-principle model against a range of objections.

Coercion, incarceration, and chemical castration: an argument from autonomy

In several jurisdictions, sex offenders may be offered chemical castration as an alternative to further incarceration. In some, agreement to chemical castration may be made a formal condition of parole or release. In others, refusal to undergo chemical castration can increase the likelihood of further incarceration though no formal link is made between the two. Offering chemical castration as an alternative to further incarceration is often said to be partially coercive, thus rendering the offender's consent invalid. The dominant response to this objection has been to argue that any coercion present in such cases is compatible with valid consent. In this article, we take a different tack, arguing that, even if consent would not be valid, offering chemical castration will often be supported by the very considerations that underpin concerns about consent: considerations of autonomy. This is because offering chemical castration will often increase the offender's autonomy, both at the time the offer is made and in the future.

Embryo deaths in reproduction and embryo research: a reply to Murphy's double effect argument

The majority of embryos created in natural reproduction die spontaneously within a few weeks of conception. Some have argued that, therefore, if one believes the embryo is a person (in the normative sense) one should find 'natural' reproduction morally problematic. An extension of this argument holds that, if one accepts embryo deaths in natural reproduction, consistency requires that one also accepts embryo deaths that occur in (i) assisted reproduction via in vitro fertilisation (IVF) and (ii) embryo research. In a recent paper in this journal, Timothy Murphy criticises both the initial argument and its extension. Murphy argues that double-effect reasoning can justify embryo deaths both in natural reproduction and IVF, but not in embryo research. Thus, according to Murphy, one can, without being inconsistent, (1) believe the embryo is a person and accept natural reproduction and IVF, and (2) accept natural reproduction and IVF, while rejecting embryo research on the ground that it involves embryo deaths. I show that Murphy's argument is problematic because double effect cannot justify embryo deaths in standard IVF practices. The problem is that the proportionality criterion of double effect is not met by such practices. Thus, Murphy's argument fails to support (1) and (2). An implication of his argument failing to support (2) is that it does not defeat the position I have defended in the past-that if one accepts standard IVF practices one should also accept embryo research, including research with embryos created solely for that purpose.

Lifespan extension and the doctrine of double effect

Recent developments in biogerontology--the study of the biology of ageing--suggest that it may eventually be possible to intervene in the human ageing process. This, in turn, offers the prospect of significantly postponing the onset of age-related diseases. The biogerontological project, however, has met with strong resistance, especially by deontologists. They consider the act of intervening in the ageing process impermissible on the grounds that it would (most probably) bring about an extended maximum lifespan--a state of affairs that they deem intrinsically bad. In a bid to convince their deontological opponents of the permissibility of this act, proponents of biogerontology invoke an argument which is grounded in the doctrine of double effect. Surprisingly, their argument, which we refer to as the 'double effect argument', has gone unnoticed. This article exposes and critically evaluates this 'double effect argument'. To this end, we first review a series of excerpts from the ethical debate on biogerontology in order to substantiate the presence of double effect reasoning. Next, we attempt to determine the role that the 'double effect argument' is meant to fulfil within this debate. Finally, we assess whether the act of intervening in ageing actually can be justified using double effect reasoning.

Hydrops fetalis and pulmonary lymphangiectasia due to FOXC2 mutation: an autosomal dominant hereditary lymphedema syndrome with variable expression

Non-immune hydrops fetalis may find its origin within genetically determined lymphedema syndromes, caused by mutations in FOXC2 and SOX-18. We describe a newborn girl, diagnosed with non-immune hydrops fetalis at a gestational age of 30 weeks. Family history revealed the presence of an autosomal dominant late-onset form of lymphedema of the lower limbs in her father, associated with an aberrant implantation of the eyelashes in some individuals. The newborn, hydropic girl suffered from severe pulmonary lymphangiectasia, resulting in terminal respiratory failure at the age of 3 months. Genetic analysis in both the father and the newborn girl demonstrated a heterozygous FOXC2 mutation, i.e., c.939C>A, p.Tyr313X. Her two older sisters are currently asymptomatic and the parents decided not to test them for the FOXC2 mutation.

CONCLUSION

Patients with a mutation in the FOXC2 transcription factor usually show lower limb lymphedema with onset at or after puberty, together with distichiasis. However, the eye manifestations can be very mild and easily overlooked. The association between FOXC2 mutation and neonatal hydrops resulting in terminal respiratory failure is not reported so far. Therefore, in sporadic patients diagnosed with non-immune hydrops fetalis, lymphangiogenic genes should be systematically screened for mutations. In addition, all cases of fetal edema must prompt a thorough analysis of the familial pedigree, in order to detect familial patterns and to facilitate adequate antenatal counseling.

Complicity in stem cell research: the case of induced pluripotent stem cells

Many who object to human embryonic stem cell (hESC) research because they believe it involves complicity in embryo destruction have welcomed induced pluripotent stem cell (iPSC) research as an ethical alternative. This opinion article aims to show that complicity arguments against hESC research are prima facie inconsistent with accepting iPSC research as it is currently done. Those who oppose hESC research on grounds of complicity should either (i) oppose iPSC research as well, (ii) advocate a radical change in the way iPSC research is done, (iii) demonstrate that complicity arguments against iPSC research are weaker than those against hESC research or (iv) reject complicity arguments against both hESC and iPSC research, either by adopting a more limited conception of complicity that allows acceptance of some hESC research, or by accepting that destroying embryos for important scientific research is not wrong.

Role of diaphragmatic surgery in 69 patients with ovarian carcinoma

Diaphragmatic stripping or coagulation is a technique aiming to optimally cytoreduce ovarian cancer. We investigated the complications, the overall survival, and the relapse rate following this procedure. Records of 69 patients with diaphragmatic involvement who underwent debulking surgery between September 1993 and December 2001 were reviewed. A total of 69 patients underwent diaphragmatic surgery as part of cytoreductive surgery for epithelial ovarian cancer. In 17 cases, the diaphragmatic tumors were stripped from the muscle, in 22 cases coagulated, and in 30 cases stripped and coagulated. Postoperative complications were pleural effusion (41 cases, 3 needed a chest drain, 7 needed a pleural puncture, 1 needed both) and pneumothorax (4 cases, 1 needed a chest drain). In one case of bilateral pleural effusion, the patient developed pneumonia. In one case of pleural effusion on the right side, the patient needed a pleural puncture and developed a partial atelectasis of the middle lobe of the right lung. The median overall survival was 66 months in the stripping group compared with 49 months in the coagulation group. In 56 cases (81%), the patient developed a relapse, and the first site of relapse was the diaphragm in 11 cases (20%). We conclude that diaphragmatic resection is an important part of optimal debulking surgery with an acceptable morbidity.

What's in a name? Embryos, entities, and ANTities in the stem cell debate

This paper discusses two proposals to the US President's Council on Bioethics that try to overcome the issue of killing embryos in embryonic stem (ES) cell research and argues that neither of them can hold good as a compromise solution. The author argues that (1) the groups of people for which the compromises are intended neither need nor want the two compromises, (2) the US government and other governments of countries with restrictive regulation on ES cell research have not provided a clear and sound justification to take into account minority views on the protection of human life to such a considerable extent as to constrain the freedom of research in the area of stem cell research, and (3) the best way to deal with these issues is to accept that many people and most governments adopt a gradualist and variable viewpoint on the human embryo which implies that embryos can be sacrificed for good reasons and to try to find other, less constraining, ways to take into account minority views on the embryo. Finally, another more efficient and time and money sparing compromise will be proposed for those who accept IVF, a majority in most societies.

Preimplantation HLA typing: having children to save our loved ones

Preimplantation tissue typing has been proposed as a method for creating a tissue matched child that can serve as a haematopoietic stem cell donor to save its sick sibling in need of a stem cell transplant. Despite recent promising results, many people have expressed their disapproval of this method. This paper addresses the main concerns of these critics: the risk of preimplantation genetic diagnosis (PGD) for the child to be born; the intention to have a donor child; the limits that should be placed on what may be done to the donor child, and whether the intended recipient can be someone other than a sibling. The author will show that these concerns do not constitute a sufficient ground to forbid people to use this technique to save not only a sibling, but also any other loved one's life. Finally, the author briefly deals with two alternative scenarios: the creation of a human leukocyte antigen (HLA) matched child as an insurance policy, and the banking of HLA matched embryos.

Creating and sacrificing embryos for stem cells

The compromise position that accepts the use and derivation of stem cells from spare in vitro fertilisation embryos but opposes the creation of embryos for these purposes is a very weak ethical position. This paper argues that whatever the basis is on which defenders of this viewpoint accord intrinsic value to the embryo, once they accept the creation and sacrifice of embryos to benefit infertile people with a child-wish, they do not have a sound moral argument to condemn the creation and sacrifice of embryos to benefit ill and injured people.

Human embryonic stem cell research: why the discarded-created-distinction cannot be based on the potentiality argument

Discussions about the use and derivation of pluripotent human embryonic stem cells are a stumbling block in developing public policy on stem cell research. On the one hand there is a broad consensus on the benefits of these cells for science and biomedicine; on the other hand there is the controversial issue of killing human embryos. I will focus on the compromise position that accepts research on spare embryos, but not on research embryos ('discarded-created-distinction', from now on d-c-d). I will point out that this viewpoint is hard to maintain. The main focus is that the 'revealed beliefs' of its defenders are inconsistent with their 'professed beliefs', more specifically with their main argument, i.e. the potentiality argument. I will point out that (1) the defenders of d-c-d actually grant a relative moral status to the human embryo, (2) this moral status is dependent on internal and external criteria of potentiality, (3) potentiality seen as a variable value that also depends on external criteria cannot justify d-c-d, and (4) an approach to human embryonic stem cell-research that would also allow the use of research embryos is more compatible with the feelings, attitudes and values of those who currently defend d-c-d and, therefore, could lead to a broader consensus and to actions that alleviate individual human suffering.