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from Dr Donald Bruce
Director of the Society, Religion and Technology Project, Church of Scotland
to the Advisory Group on the Ethics of Xenotransplantation, Department of Health, March 1996
The following are my personal reflections on the Nuffield Council on Bioethics' report "Animal to Human Transplants - the Ethics of Xenotransplantation", and form the second part of the Society, Religion and Technology Project's submission to the Advisory Group. They are made in the light of the SRT Submission Ethics and Xenotransplantation to the Nuffield Council in June 1995, made by the working group which I chair on the Ethics of Genetic Engineering in Non-human Life Forms. They do not necessarily represent those of the group, since there was not enough time for us to discuss as a group the Nuffield report, in the short time between its publication and the Department of Health deadline.
I set down the substance of the points summarised above. In doing so, I would stress that these are criticisms of an otherwise excellent report which adds very greatly to the discussion of this issue.
The context in which the study is put plays a considerable role in shaping the arguments for and against the procedure of xenotransplantation. One can identify essentially two "cultures" in the debate, which approach this problem in very different ways, each with their own sets of assumptions. One is the medical need and human benefit culture. This expresses xenografting from the standpoint of a shortfall in physical resources (organs) which limits the availability of a medical treatment. The other is the animal welfare culture which asks whether xenografting is yet one more example of the ways we find to misuse animals for questionable human ends.
The report "sets the scene by describing the increasing success of transplantation" (1.2). At the outset then, the report presents the issue in terms of the first of these two cultures - the promise of xenografting. This is in itself a value judgement - not necessarily wrong, and perhaps unconscious - but it is rather important in the context of how we conduct debate on controversies in bioethics. A priori, one could argue there was no obvious reason to choose to look at the issue that way round, rather than the other. The result is that it inevitably places the second "culture's" views into the category of "objections" to an attractive scientific and medical endeavour. This very fact shapes the subsequent argument somewhat. This is not to say it was wrong to do so, but that the report has missed an important aspect of the debate, in not reflecting on why it chose to do it that way round. For the group to have given its reasons would have been interesting, and might also have helped the objecting parties in an often heated debate to feel a little less marginalised.
The argument for xenografting begins with the "increasing success" of transplantation (1.2). From the paragraphs which follow, however, it emerges that this is only a very qualified sense of "success". It is success, indeed, when compared with the difficulties of the early stages of transplantation, and that is encouraging. But this is not what one might expect from the common usage of the word "success" - that the most patients are cured and return to a normal and full life up to their normal life expectancy. Even if there are some who can climb hills, which is indeed a cause for rejoicing, it is not clear from paragraphs 1.4-1.5 what would be a typical quality and extension of life for each of the three organ types, nor what eventually happens in the cases where the transplant ceases to work. There is also a need to explore more critically what it means that a person has a 50-70% chance of living 5 years longer (table 1.1), relating this to different human situations.
If we are to do this form of intervention on the animal kingdom, we need to be quite clear what the actual benefits from xenografting would be, and how as a society we weight these. The report rightly draws attention to the many current uncertainties of xenotransplantation as a technique, but it needs to make more clear, if these were overcome, how good transplantation itself is. Is it good enough to justify all the various ethical "down sides", particularly regarding our use of animals? The report does not really make a good case for this. If it were the true that xenografting gave a really substantial cure, rather than just a type of remission, the case would be stronger. If, on the other hand, it is going to be a hit and miss affair, which only gives a return to a high quality of life for a relatively small percentage of the patients, it would be harder to argue it outweighed the ethical objections.
In paragraph 1.15, the important question is raised of whether animal organs would perform all the necessary functions in a human body. Without further discussion of this very serious unknown factor, the report then immediately makes what amounts to a leap of faith of sheer optimism that "many of the biological obstacles ... will eventually be overcome". What is the justification for this optimism, when we have no idea whether the organs will perform properly, let alone of any other side effects? Historical precedent points repeatedly to the fact that novel technology almost invariably turns out to have unsuspected problems. One of the key features of the trend of scepticism towards scientists which has emerged in recent years (and which is graphically illustrated acutely by the current BSE problem), is the tendency of scientists, media, industry or the Government to oversell the discoveries in the early stages, only to lose public confidence when things go wrong, or new data emerge. The greater the optimism, the greater the loss of confidence. Remember nuclear power ....
The optimistic claims of paragraph 1.16 also seem to call for a more searching critique. It is not clear that how need for careful matching would literally be "eliminated". Surely, there would still be questions of matching size? And at this point in time one could not know, for example, whether certain "lines" of animal organs would work better for some groups of people than others. If all went well, availability would certainly be improved beyond all recognition, but to suggest that "xenografts could be offered as and when they were needed" also seems an exaggerated claim. Delivery could be constrained by a number of factors which are not mentioned here - such as
The reason for making these points above is that a treatment - transplantation - has been developed whose potential may never be matched by the resources for doing it, either in terms of organs, or of health care facilities. An ethical dilemma arises out of the pressure this fact puts on other criteria. The medical imperative of the doctor who says "what we could do if only we had ...." can easily become a driving force which is apt to sideline all other criteria. We are familiar with absolute objection of some people to animal usage of this sort. We are less aware of the opposite effect of regarding the main ethical imperative in favour of xenografting - that it is a "good thing" to prolong life and ease suffering - with a status close to that of a moral absolute, which overrides all other ethical considerations. With this we would not agree.
It is a matter of concern that the DoH Advisory Group is not a joint venture with MAFF, since the ethical issues interface the two departments' responsibilities. The DoH group needs especially, therefore, to take note of the concern expressed above in point 3, as well as the other animal use concerns raised in this submission, since the animal welfare considerations might not feature as strongly as an ethical imperative as the healthcare concerns of the sponsoring department. This, yet again, points to the need for a standing Royal Commission on Bioethics which would be more readily able to address properly the inter-departmental as well as inter-disciplinary aspects.
The consideration of the more fundamental ethical issues was most welcome. Paragraphs 1.25 - 1.30 made some important points, albeit that it was not clear how the weighing in 1.30 had actually been done. There were disappointing features, however, when it came to the animal issues.
The main fundamental case considered was that of total objection on principle to animal experimentation of any kind. While undoubtedly very important for some people, and also useful to set the scene, it is much the most extreme position amongst many. It is apt to become something of an "Aunt Sally" to be knocked down, while rather missing the point that is most at issue. The more common fundamental objection would be the view that would not object in principle to all experimentation with animals, but would fundamentally object to this particular use. It raises some questions germane to the case of xenografting, which are missed by simply lumping fundamental objections into the one basket represented by their most extreme form. This is a point our SRT working group looked at in some detail, but does not seem to be seriously discussed in the Nuffield report. For example, the "yuk factor", not only for the patient but for society at large, and the question of unfamiliarity with novel technology, are both points which merited a proper discussion.
The second disappointment was that this discussion was presented (in 4.7 - 4.8) mainly in terms of "animal rights". As far as could be judged from the text of the report, none of those quoted were actually basing their concerns on this concept. Why then should the working group discuss the issue in terms no one else was using? This is especially the case when animal rights has proved such a problemmatical ethical concept. Several theologians and moral philosophers have declared the inappropriateness of the idea, pointing out that rights are ascribed only to moral agents who are capable, on their part, of exercising responsibilities. Since it is nonsense to talk of animals having responsibilities towards us, it is argued, so it is nonsense to talk of their "rights". In Christian ethics, moreover, the very notion of "rights", as it has come to be used in society, is seen by many as an aberration of the nature of human personhood, based around the self-centred individual. It turns on its head the nature of the Christian gospel of self-giving love and service to one another. For my part, I would rather talk of my responsibilities or duties towards others, than their rights, and this can quite naturally include animals as well as humans, without anomaly.
Paragraph 4.10 is a surprising and misleading expression of Christian ethics in this area, in that it rightly speaks of God giving human beings the freedom to use animals, but it omits to mention his parallel command of a duty of care for them and for all the creation, which the same part book of Genesis clearly lays down. Even if the Christian Medical Fellowship had not made this clear (which would surprise me), our SRT group made a point of saying this in its own submission, and I believe the Church of England did also. It is a crucial point because, in a nutshell, here is perhaps the central issue of whether it is right in principle to do xenografting - we may use animals, but not for just any reason; is this one step too far?
It seems highly dubious to claim (4.26) that the Banner committee "reached similar conclusions" to the statement of the Institute of Medical Ethics Working Party. The wording of paragraph 4.26 may simply be ambiguous, but it fails to convey the distinctiveness of the Banner Committee's approach in having a non-consequentialist first principle. The IME has no counterpart to Banner's 1st. principle, and indeed the gist of the IME's first point is almost its opposite. Banner's first premise is that there are some harms we should never do to animals for any reason. The IME's first premise is, in effect, that there are some harms we justifiably should do to animals in the interests of biomedical research.
The report concludes that "the use of pigs for the routine supply of organs for xenotransplantation is ethically acceptable." (10.14). This seems to be too sweeping and open-ended an assessment, and this perhaps my most serious concern with the report. It makes no judgement of the different ethical situations which might arise in any applications of xenotransplantation that might be considered in future. The SRT Project submission considered that the case for hearts was probably acceptable, but warned that this should not be taken as carte blanche for all types of xenotransplantation. We should not simply assume the right to take organs from animals in all other cases, given that we had once decided it was acceptable to do it in one case. The case for other organs would need to be weighed against any fundamental objections regarding the organ, and against the benefits being claimed. If the supply of organs became to all intents and purposes limitless, there is the danger that animals would be seen as "fair game" for transplanting any organ for any reason. The SRT submission drew attention to the danger of the commodification of animals in this way. Our concerns in this area have not been sufficiently addressed by the Nuffield report. We would expect a case-by-case assessment for each new application, weighing harms and benefits (as in, for example, the Animal Procedures Act).
In this context, an apt observation was made in paragraph 4.22 concerning our attitudes and relationship to nature, suggesting that we should not do things that will make a wrong relationship worse. But this seems to have been a purely theoretical point, because there is no serious attempt to apply this possibility to the case in point of xenotransplantation. This question should have been put and answered. This is a disappointment in a report of this magnitude, because the question of the abuse of nature is one of the fundamental underlying concerns of our times.
It is also puzzling that the point in 4.22 is presented as conditional - if there is a wrong relationship and exploitation of other species. The group should be in no doubt that our relationship with nature in general and animals in particular was not right. If it were right, we should not have ozone holes, acid rain, global warming, widespread loss of soil and habitat, not to mention the legacy of ill-treatment of animals. In the view of the MAFF Banner Committee, "highly objectionable side-effects as regards animal welfare" are occurring simply from traditional selective breeding - see paragraphs 4.16 - 4.17 of its report. Having appreciated the possibility of an ethical objection here, the Nuffield report should have evaluated it, not left it as a rhetorical question. If it was "cause for thought", then the group should have done the thinking!
The Nuffield report goes in some depth into the primates issue, which is not much of an issue for the UK since we do not have large numbers of indigenous primates anyway. The discussion of the unacceptability of using primates as sources of animal organs seems to be based on the close kinship argument. There is force in the argument with regard to transmission of disease, but the intrinsic argument is less clear. Given the legth of discussion on primates, it is a surprise how brief is the discussion which concludes that xenografting is acceptable for pigs. It turns on the fact that while pigs are seen as intelligent and sociable animals, they are seen to share capacities with human beings to a lesser degree than primates. The adverse effects of xenografting on pigs are seen as not outweighing human benefits. This is a major ethical judgement, which begs many questions. What justifies this demarcation? Is it because any non-primate is useable simply because they are not primates, or is it because a certain degree of similarity is not found, regardless of species? The report does not give an adequate reason why it draws the boundary here, rather than, say mammals vs non-mammals, or animals vs plants. Further thought needs to be given on the implications of drawing an intrinsic distinction between primates and other mammals. For Christians, this is significant, as it introduces a gradation in animals - and thus in what we may do to them - that would go beyond what would have a biblical warrant. God creates animals "after their kinds" but there is no sense that those that we would now call genetically closer to humans are any more valued than, say, sparrows.
The statement is then made, without any further discussion, "It is difficult to see how, in a society in which the breeding of pigs for food and clothing is accepted, their use for life-saving medical procedures such as xenotransplantation could be unacceptable." This is one of the report's most important and fundamental conclusions, yet it seems to come out of the air, as if self-evident. It seems to fly in the face of the apparent support given in paragraph 4.21 to the SRT Project's comment about eating animals not necessarily justifying xenografting. It fails to consider its novel & "artifical" nature or the change it represents in our relations with animals. It begs the question expressed earlier about whether xenografting is really "life saving", or merely granting a period of remission. It also takes for granted a set of value judgements of the weighing of societal "goods", which it does not explore and examine. This is disappointing. In a report of this importance one would have expected some idea of how the working group went about weighing the possible adverse (animal) effects and the likely (human) benefits (c.f. paragraph 5.3).
The justification in paragraph 4.38 of harm to a small number of primates if xenotransplantation became a successful procedure is invalid, because it already presumes the success of the xenografting experiments which the primates would be used for. By definition, we cannot know in advance if it will be successful, becaue that is the whole point of the experiment. Presumably the harm would have been unjustified if it does not succeed. It would have been fair to say "if a reasonable case can be made that there are realistic prospects of success...", but as it is the group has already prejudged the experiments as if they were a success, which they have not justified.
Some more minor points not in the summary
There seem to be some inconsistencies over animal welfare issues. Paragraph 4.49 seems to be making a blanket claim for no adverse effects in the welfare of pigs developed for xenotransplantation, where paragraph 5.13 limits the claim only to the effects of genetic modification procedure. Which is correct? Bearing in mind the important reservation expressed in 5.22, the claim in 4.49 especially seems somewhat questionable, yet this is the crucial one of the argument. Moreover, the conclusion of paragraph 5.23 that the quality of life problems are not insurmountable sounds very sweeping. On what basis can this be said to be more than wishful thinking? Some of the problems may be soluble, but it is difficult to see how, with the imperative of disease-free facilities, the pigs could have anything other than rather artifical surroundings for their lives.
Most of our group would agree that the transfer of genes does not confer a fundamental change of identity on the organism concerned, but not for the reason given in paragraph 4.47. On the contrary, the argument there appears to perpetuate the fallacy which appeared in the Polkinghorne report on genetically modified foods regarding the identity of a gene of human origin. We regard it as disingenuous to argue that genes taken and copied are no longer to be associated with the type of organism from which they came. The very point of using them is for the information which they represent. It is irrelevant that a gene is chemically a millionth copy or has been isolated from the organism, because the information is the same and the function of that information in the originating organism is what the experimenter desires in the new organism. Moreover, many people still perceive the connection, irrespective of how many times it has been copied. From a Christian perspective this is a reductionism which has lost sight of the holistic identity of the original organism. By the same token, the identity of the new organism is also holistic and not violated just the change of one or two genes, so we end with the same practical conclusion, but for a very different, and more valid, reason.
Since the report raises the question of benefits to ethnic minorities, in paragraph 1.16, did the group seek to find out from such groups what would be their priorities if medical science was to provide for the particular needs of their people. Would they have chosen xenotransplantation or something else? This also relates to the Methodist church's point concerning the "opportunity cost" of the research, quoted in paragraph 8.13.
Postscript
There are many aspects of the Nuffield report which went beyond areas of our working group's remit or competence - notably disease transference, early patients and the health care system. In the time available I have only been able to comment on the more obvious criticisms of the report. The detailed criticisms I have set down should not, moreover, be seen as expressing a poor view of the report as a whole. On the contrary, I applaud its working group on a pioneering work of high quality on a very difficult subject. It is a very valuable contribution to the continuing debate on xenotransplantation.
Dr Donald Bruce
Director of the Society, Religion and Technology Project, Church of Scotland
29 March 1996
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