Opinions vary on the bioethics of bioengineered skin
A seeming medical miracle is not without detractors
Reports of seemingly miraculous results from applications of bioengineered skin accrue almost daily since its approval by the Food and Drug Administration last May. Recently, an 8-week-old baby born with Dowling-Meara, a potentially fatal skin disease, became the first newborn to be treated with applications of Apligraf.
Because the infant might have died without the treatment, opposition to use of the material may be difficult for proponents to understand. However, some groups oppose bioengineered skin because the product is made from cells derived from neonatal foreskins, and they view circumcision as child abuse.
Jonathan Moreno, PhD, Kornfeld professor of biomedical ethics and director of the Center for Biomedical Ethics at the University of Virginia in Charlottesville, addresses the issue this way:
Incipient life’ issue not implicated
"One question is similar to the linkage issue between stem cell tissue and abortion. Does an innovative research field with potentially major implications for clinical care get morally underlined in connection with another practice with which many people have serious moral difficulties? [Stem cell research is] a much tougher case because in the case of abortion, the central issue is the status of incipient life. In the case of procedures that might use materials derived from circumcision, there is no issue of another incipient life. So at least one problem, the so-called innocent third party,’ is out of the picture.
"With the linkage problem, you need evidence. Is there evidence this would cause more circumcisions? I don’t see any reason to think that this is going to cause more people to have their male children circumcised. Secondly, we might be in a position in which an immortal cell line could be created at some point so that it wouldn’t be necessary to use new material. I would hope that the people who are working on this would try to move us in that direction as quickly as possible in order to eliminate this issue."
Moreno adds that even if bioengineered skin production "didn’t discourage circumcision, and even if we couldn’t create cell lines within a short period of time, then we move to the other question, which is, Is this practice so heinous that we shouldn’t do anything at all that could even symbolically be seen to sanction it?’ The anti-circumcision people argue that there is no evidence there are any health benefits to circumcision. It may not be possible to argue that cancer rates are reduced by the absence of the foreskin, but it is very much harder to argue that infections are not reduced."
Some anti-circumcision groups have tried to move bioengineered skin production into the genital mutilation arena. "I don’t think you can make a case that male circumcision is analogous to female genital mutilation," says Moreno. "The only reasonable argument the anti-circumcision people have is that this is a procedure that causes pain to the child. Given that the pain, so far as we know, doesn’t cause any permanent damage to the child, and that there are ways to ameliorate the pain, and considering the deep feeling that some social groups have [about the cultural need for circumcision], I don’t think that the argument against circumcision quite gets over the threshold that they need to get over. Of course, some religious groups may object to the use of their children’s tissues for research purposes because they regard this tissue as something that has to be dealt with in a ritual fashion. You can’t assume the parents are going to have no moral interest in the tissue, so there’s going to have to be some kind of consent procedure."
Practical uses outweigh metaphorical ones
Rabbi Elliot Dorff, rector and professor of philosophy at the University of Judaism in Los Angeles, vice chairman of the Committee on Jewish Law and Standards of the Conservative Movement, and author of Matters of Life and Death: A Jewish Approach to Modern Medical Ethics, says, "Before we had the ability to use the foreskin medically, traditionally it was planted in the garden along with a seed. The idea was, May he grow and be fruitful.’ The skin itself has no status in Jewish law. It’s not a living organ or organism. If you can use it for saving someone’s life, that’s a very good use for it. If foreskins can be used in this way, then I would say even that it would be a positive obligation on our part to donate foreskins from circumcisions for this purpose rather than to use them in the rather metaphoric way of burying them."
M. Gregg Bloche, MD, JD, of the Georgetown/Johns Hopkins University Program in Law and Public Health in Washington, DC, touched on the consent issue in a recent article in the Journal of the American Medical Association: "Mainstream bioethics theory, that invoked by courts and government commissions, has yet to make a place for these underlying moral judgements. Instead, leading bioethics authorities tend to present the question of whether a person has consented autonomously to something as an empirical inquiry. . . . The law of informed consent, for example, has empowered patients in therapeutic settings."1
Valid consent’ vs. informed consent’
Kenneth W. Goodman, PhD, director of the University of Miami’s Bioethics Program, says he feels strongly that to be valid, such consent needs to encompass much more than the phrase "informed consent" conveys. "You could inform someone of what you were going to do, and if you did it in a threatening way, their consent’ would be invalid." Goodman prefers the term "valid consent," meaning that consent must, in addition to being informed, also be voluntary and given by people who have the mental capacity to give it.
"It’s customary to allow parents to make all sorts of decisions for their children, and certainly for their infant children," Goodman points out. "Nevertheless, it’s the sort of thing you want to make sure they give their permission to if it involves research or clinical use. Perhaps 20 or 30 years from now, we will no longer need that source of tissue. One of the things we do with any kind of research on tissue or cells is make clear to people that they’re not going to share in any profits that the university or the corporation makes."
Harold Y. Vanderpool, MD, professor in the history and philosophy of medicine, Institute for the Medical Humanities, University of Texas Medical Branch at Galveston, had an eye-opening experience on the strong emotions surrounding circumcision. "At one point here at the University of Texas Medical Branch, I thought that we should have a rounds on that in family medicine. I thought it would be a slam-dunk in terms of everyone being able to talk about it in a rational fashion, to get the latest medical information and to talk about patient management and so on. Well, I had not seen a cat fight in medical ethics that matched that discussion!
"I assume if one could be able to bioengineer skin in some other way, that would be preferable, but at the same time, I think that the opposition position that assumes that circumcision is child abuse is certainly a minority one and would not be accepted by perhaps the majority of American citizens," Vanderpool adds.
Reference
1. Bloche MG. Clinical loyalties and the social purposes of medicine. JAMA 1999; 281-283.
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