Volume VII Issue i

Volume VII Issue i

Reconstructing Reproduction and other Components of Female Health

Also inside:

The Ethics of

Lethal Injection Executions Neuroscience

in Security and Defense

Penn Bioethics Journal and Society The Penn Bioethics Journal (PBJ) is the nation’s premier peer-reviewed, undergraduate bioethics journal. Established in 2004, the Journal features and provides a venue for the contributions of undergraduates to bioethics. The PBJ, embracing the interdisciplinary focus of bioethics, reviews and publishes reports of empirical research and analysis of previous work -- addressing debates in medicine, technology, philosophy, public policy, law, theology and ethics among other disciplines.

The biannual Journal also features news briefs and editorials reviewing current bioethical issues, as summarized by our undergraduate editorial staff. Undergraduate editors and authors have a unique opportunity to get involved with the peerreview process through the collaborative and rigorous review and preparation of the PBJ. With an audience ranging from scholars in the field to a broader public seeking unbiased information, the Penn Bioethics Journal scholastically involves all undergraduates interested in the extensive field of bioethics.

Email bioethicsjournal@gmail.com to get more information about bioethics at Penn.

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Archived editions of the Journal and information about the submission process can be found on our website: http://bioethicsjournal.com The editorial staff also focuses on expanding boundaries of Penn undergraduates by hosting campus-wide events through the Penn Bioethics Society. These include formal lectures, case study presentations, public debates, debriefing of current bioethical issues and student-led conversations.

To receive our weekly newsletter, apply to join our editorial staff, or make any inquiries, please email penn.bioethics.society@gmail.com The Penn Bioethics Journal is published twice a year by the University of Pennsylvania, Philadelphia, PA. All business correspondence, including subscriptions, renewals, and address changes, should be addressed to the Penn Bioethics Journal, 3401 Market Street, Suite 320, Philadelphia, PA 19104. www.bioethicsjournal.com Manuscripts for publication should be submitted according to the submission rules on the website: www.bioethicsjournal.com/submit.html Subscription rates are by request. Permission must be requested for any kind of copying, such as copying for general distribution, advertising or promotional purposes, creating new collective works, or for resale. Requests for these permissions or further information should be addressed to bioethicsjournal@gmail.com Copyright Š 2011 Penn Bioethics Journal, Philadelphia, PA. ISSN: 2150-5462

PBJ

Pe n n B i o e t h i c s J o u r n a l

EDITOR IN CHIEF Andrew Jakubowski PUBLISHER Yunica Jiang MANAGING EDITORS Genevieve Barnard Megan Dwyer Vinayak Kumar Sofia Liou Anand Muthusamy Tali Warburg ASSOCIATE EDITORS Jonathan Bekisz Pratima Bhattacharyya Sonya Davey Elana Furman Matthew Gazzara Angela Halstead Nastasia James Hanna Kamaric Hagop Kaprielian Rachel Lee Amy Li Emer Lucey Brittany Mayweather Katie McCarthy Loren Miller Zaina Naeem Chelsea Ott Sonya Parashar Fahim Pyarali Sasha Riser-Kositsky Shelby Rosario Joshua Seaver Michael Shmulevich Andrew Wadley ASSOCIATE PUBLISHERS James Feuereisen Eileen Mayro Abby Worthen BUSINESS MANAGER Dara Bakar COVER DESIGN Yunica Jiang FACULTY ADVISOR Jonathan Moreno, Ph.D.

Questions or Comments?

Please direct all inquiries to the Editor in Chief at bioethicsjournal@gmail.com

Contents 4

Letter from the Editor

5

Bioethics in Brief

Andrew Jakubowski

Articles 8 12

An Ethical Analysis of Uterine Transplantation Allison Gulluck, University of Minnesota

In Vitro Fertilization: A History and Discussion Vinayak Kumar, University of Pennsylvania

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Lip Service(s): Discourses on Designer Vaginas

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Neuroscientific Technologies in Security and Defense Strategies

Jessica Y. Neasbitt, University of California, Berkeley

Sonya Parashar, University of Pennsylvania

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Medical Ethics During the War on Terror: Detainee Treatment and Experimentation by Health Professionals Thomas A. Quinn, University of Pennsylvania

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The Ethics of Medical Involvement in Lethal Injection Executions: Discussing the Role of the Anesthesia Provider Giby George, Drexel University

AWARD FOR EXCELLENCE IN UNDERGRADUATE BIOETHICS For each issue, the PBJ grants the Award for Excellence in Undergraduate Bioethics along with a cash prize. Nominations are given by the PBJ editorial board, and the winner is selected by an outside editorial committee from the Penn Center for Bioethics. For this issue, the selection committee consisted of Arthur Caplan, PhD and Jonathan Moreno, PhD.

Letter from the Editor

Andrew Jakubowski Editor in Chief

Dear Readers, It is with both excitement and pleasure that I present our twelfth issue—Volume VII, Issue i—of the Penn Bioethics Journal. This issue features scholarly articles and informational briefs covering topics ranging from reproductive technologies to lethal injection, experimentation ethics to the obesity epidemic. This diversity of topics highlights why I am so passionate about bioethics: the field is all-encompassing and ever-evolving.

Volume VII, Issue i is the first publication of the current Editorial Board and the culmination of over a year’s worth of hard work. I am very proud of the accomplishments that the staff has made and the growth we have experienced as a team. I feel that it is necessary to formally thank the Associate Editors, Associate Publishers, Business Manager, Managing Editors, and Publisher for all of their hard work. I would also like to thank—and congratulate—the authors featured in this issue for their fine articles and support of the Penn Bioethics Journal.

Lastly, I must extend my appreciation to those graduate programs and professional organizations that chose to financially support the Penn Bioethics Journal by placing ads in our publication. I sincerely hope to collaborate with and work beside many of these aforementioned individuals and groups in the future.

Looking ahead, I encourage all of you to help our journal continue to expand and improve: submit an article, an editorial, or a commentary for our next issue, or become involved in the reviewing and editing processes.

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As Editor in Chief, my ultimate goal is to develop a product that readers can both enjoy and respect. That being said, I hope that you savor your next bite of the PBJ.

4

Andrew Jakubowski

Editor in Chief University of Pennsylvania C’13

Bioethics in Brief

Bioethics in Brief Strengthening Protections for Scientific Research Subjects: Accountability and Compensation In 2010, the U.S. Government admitted to promoting research that intentionally infected already marginalized Guatemalans with sexually transmitted diseases. Moreover, because nonclinical research, some clinical research trials, and research not linked to U.S. federal institutions are not required to be recorded in a public database, many instances

“The panel felt strongly that it was wrong and a mistake that the United States was an outlier in not specifying any system for compensation for research subjects.”

The review panel made five recommendations for regulating scientific research. First, research and recruitment of participants must be sensitive to local cultural practices.

Knowledge of the local milieu can help minimize risks and discern genuine consent to participate in research. Second, researchers and regulators of research should complete ethics training. Third, all research that constitutes “greater than minimal risk” should be registered and the resulting findings should be reported. These three stipulations would create a framework of accountability that would minimize harms and identify those deserving compensation. Fourth, a compensation system should be established and could be modeled after The U.S. National Vaccine Injury Compensation Program. The vaccine program, an alternative to the tort system, simply provides compensation for those who file a legitimate claim. Fifth, existing laws should be used more effectively instead of drafting and passing new regulations. The Presidential Commission plans to reconvene in November to draft recommendations for stronger regulations. Before the end of the year, the commission hopes to submit a report detailing finalized proposals.

-Anand Muthusamy, University of Pennsylvania

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Selyukh, Alina. “Compensation System Needed for Injured Research Subjects: Panel.” Reuters. 31 Aug. 2011. Web. <http:// www.reuters.com/article/2011/08/31/us-injured-researchidUSTRE77U4ZI20110831>.

Stein, Rob. “Compensation System Urged for Research Victims.” Washington Post. 30 Aug. 2011. Web. <http://www.washingtonpost.com/ national/health-science/compensation-system-urged-for-researchvictims/2011/08/28/gIQALqFcpJ_story.html>.

IRP - United States. Presidential Commission for the Study of Bioethical Issues. Research Across Borders: Proceedings of the International Research Panel (IRP) of the Presidential Commission for the Study of Bioethical Issues. <http://bioethics.gov/cms/sites/default/files/IRPProceedings%20and%20Recommendations_0.pdf>

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of harm may go unreported. In light of these findings, the Presidential Commission for the Study of Bioethical Issues formed an international review panel to assess standards of care of participants in scientific research. The panel included ethicists and clinical researchers from the United States, Brazil, Russia, India, China, Uganda, Belgium, Argentina, Egypt, and Guatemala (IRP 2011). Amy Gutmann, the chairwoman of the commission, stated, “The panel felt strongly that it was wrong and a mistake that the United States was an outlier in not specifying any system for compensation for research subjects other than, ‘You get a lawyer and sue’” (Stein, 2011). Prior to the government’s disclosure of the Guatemalan study, the Department of Health and Human Services already had begun revising regulations on

treatment of research participants. The Guatemalan study and the growth of clinical trials abroad, however, have sparked greater international pressure on the U.S. to provide compensation for victims (Selyukh 2011).

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Bioethics in Brief

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Creating Life: The Science of Playing God

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Since the discovery of the structure of DNA in the early 1950’s, a surge of interest in the scientific community has driven tremendous progress in the field of molecular biology. Through genetic recombination techniques, organisms can be modified to carry out our basic commands. But one question remains: have we gone too far?

Craig Venter, one of the pioneers in the Human Genome Project, was recently attributed with the creation of artificial life. He had assembled a bacterial genome of Mycoplasma mycoides from “small preassembled units” and inserted it into a genome-free host bacterium of a closely related species (Macrae, 2010). The new organism began functioning just as M. mycoides had, demonstrating the success of this technique.

The possibilities that this raises are astounding, as one can create new life by artificially generating genetic material and inserting it into the cell type of choice. Unlike commonly used DNA recombination techniques, this is not modification of life by insertion of a small fragment of DNA but true creation of life. More importantly, it is customizable. With the success of this trial run, it is clear that if the components essential to cell function are included along with the genes of interest, one can make an organism that can express any number of desirable characteristics.

This recent innovation can allow for the creation of microorganisms that can aid in environmental cleanup efforts.

Another application could be in terraforming, the artificial modification of a planet or moon to make it more similar to Earth and compatible to life. Currently, the most promising candidate is Mars, where such organisms can be utilized to reduce atmospheric CO2 levels to Earth-like levels (Wall , 2011).

However, as was the case with the advent of controlled nuclear reactions, these microorganisms may also serve military purposes in the near future (Macrae, 2010). This technology has greatly expanded the risk of bioterrorism and

Image: dream designs / FreeDigitalPhotos.net

biological warfare, as new infectious agents can be made to overcome traditionally used vaccines and bypass the immune system to create extremely effective killing agents.

Suddenly, the vision of a post-apocalyptic world is now entirely within reach.

Naturally, this innovation raises some controversies.

Should we as humans play God and create life forms? Is it ethical for us to create life for the sole purpose of harnessing it for our own needs as biological engines and biochemical factories? Should this technique be banned and regulated to prevent abuse or celebrated and encouraged as a means to a better future?

-Vinayak Kumar, University of Pennsylvania Macrae, F. “Scientist accused of playing god after creating artificial life by making designer microbe from scratch - but could it wipe out humanity?” Daily Mail. 3 June 2010. Web. <http://www.dailymail.co.uk/ sciencetech/article-1279988/Artificial-life-created-Craig-Venter-wipe-humanity.html> Wall, M. “Synthetic life could help humans colonize mars.” MSNBC. 22 August 2011. Web. <http://www.msnbc.msn.com/id/44229804/ns/ technology_and_science-space/#.TmXLYxzKuhQ>

Obesity Rates Projected to Soar In the United States today, about a third of the population is obese. Current predictions predict that approximately one half of Americans will be obese by 2030. As the number of obese individuals rises, so does the number of cases involving obesity related diseases, such as type 2 diabetes, heart disease, stroke, and some cancers. Medical costs related to obesity-related matters are expected to total nearly $66 billion a year by 2030 (Moisse, 2011).

Dr. Ken Fujioka, director of the Center for Weight Management at the San Diego Scripps Clinic, believes that our nation should focus on prevention, which requires various shifts in policy. Most health officials stress that the rising rate of obesity must be tackled at the level of the individual.

Educating Americans on how to make healthier choices on a day-to-day basis, such as choosing to take a walk rather than playing a video game, is the first step towards improving the

health status of our country (Moisse, 2011).

Of particular concern is the increasing incidence of obesity in children. The number of obese teens has tripled since 1980, and nearly 17 percent of U.S. teens are obese today.

Type 2 diabetes, a disease that obese children are more susceptible to, is a major concern of health officials. What will happen in the future is hard to predict since the effects of overweight youth have yet to be adequately studied (U.S. Department of Health & Human Services).

-Tali Warburg, University of Pennsylvania Moisse, Katie. “Obesity Rates Projected to Soar.” ABC News. 25 Aug. 2011. Web. <http://abcnews.go.com/Health/Wellness/obesity-ratesprojected-soar-report/story?id=14381466> Assistant Secretary for Planning and Evaluation. “Childhood Obesity.”

U.S. Department of Health & Human Services. Web. <http://aspe.hhs. gov/health/reports/child_obesity/>

Bioethics in Brief

Doctors See Business Strategies as a Way to Better Meet Patients’ Needs As the United States healthcare system sees major changes in structure, some doctors are beginning to think more like business people. While doctors in private practice have always had to treat their operations like the businesses they are, more doctors are taking an entrepreneurial approach to their careers serving patients (Freudenheim, 2011).

Recent M.D. graduates frequently eschew the traditional career paths of doctors a generation before and take their healthcare ideas to startup businesses. While industry is often seen as the more efficient way to address consumer needs, such transitions raise bioethical questions (Stone, 1997). Should doctors and patients operate under a capitalistic economic model? And do monetary incentives alter physicians’ opinions about what is best for their patients?

Some argue that doctors will be more conscious of the cost of health services, and that the sector will benefit from business-savvy physicians (Freudenheim, 2011). Others contend that care givers will prioritize their personal in-

Do monetary incentives alter physicians’ opinions about what is best for their patients? come’s stake in higher esteem than the best interest of their patients when making recommendations to patients.

But the rise in medical professionals seeking business training is certain. In the last two decades, the number of American universities offering joint degree programs in medicine and business jumped from fewer than ten to more than 65 (Freudenheim, 2011).

-Megan Dwyer, University of Pennsylvania Freudenheim, M. (2011), Adjusting, more M.D.’s add M.B.A. The New York Times, 5 Sept 2011, B1.

Stone, D. A. (1997). The doctor as businessman: The changing politics of a cultural icon. Journal of Health Politics, Policy and Law, 22(2), 533-556.

One Sperm Donor, 150 Offspring

-Sofia Liou, University of Pennsylvania Mroz, Jacqueline. “One Sperm Donor, 150 Offspring.” The New York Times. 5 September 2011. Web. <http://www.nytimes. com/2011/09/06/health/06donor.html?_r=1&pagewanted=all>

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and ethical front. Among other potential negative consequences of having so many children fathered by the same donor, is accidental incest. Partnership between half siblings could produce unnaturally high numbers of recessive gene disorders, and this concern is amplified by the fact that half siblings often interact with and live in the vicinity of one another.

The actions of sperm banks clearly have wide-reaching societal effects – ones that reach donor children, donor families, as well as donors themselves, who are often unaware of just how many children they will father through a single donation. In terms of ethics, society must ask what is in the best interests of the child-to-be. Is it fair for children to never know about the other half of their genetics? Do these children have a fundamental right to know who their half siblings are? While sperm banks are making a fortune by distributing donor sperm at an unforeseen magnitude, these are important questions to ask.

The fact of the matter is that the fertility industry is a novelty in the United States. There is a loose set of guidelines, and the long-term implications have yet to be fully understood. In light of these societal and ethical issues, there has recently been a stronger push for legislation surrounding sperm and egg donations.

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In Britain, a sperm donor is legally limited to fathering ten children. In the United States, there is no limit as of yet. The result? One sperm donor and 150 offspring. As the number of children born through artificial insemination has risen in the U.S., so has the demand for donor sperm. This demand, in turn, has generated large pools of donor siblings.

Although mothers of donor children are encouraged to report births to the sperm bank, only about a third actually do, which prompted the creation of the Donor Sibling Registry back in 2000 by Wendy and Ryan Kramer (Mroz, 2011).

On this website, parents can use unique identifying numbers specific to sperm donors to find other children from that donor. Mothers of donor children are often shocked to learn of how many half siblings her child has – frequently 50 or more. This has raised multiple concerns on the genetic

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Article

An Ethical Analysis of Uterine Transplantation Allison Gulluck‡ In the United States, over 7.3 million women suffer from infertility. Twenty percent of infertilityare due to uterine anomalies. Without the presence of a functioning uterus, pregnancy is extremely difficult or impossible. Advancements in fertility options as well as organ transplantation technologies have made uterine transplantations a possibility. The procedure allows women previously unable to conceive to become pregnant. It is important to examine the potential implications of utilizing this method as means of reproductive therapy. Because the risks of uterine transplantation are not completely understood. In order to protect the health of potential mothers and fetuses, uterine transplantation should not be used as a means of reproductive therapy.

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Introduction

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Each year, more than 6 million women in the United States become pregnant, and the same number of women experience infertility. For women without functional reproductive organs due to genetic conditions such as MayerRokitansky-Küster-Hauser or an unplanned hysterectomy, fertility options do not allow them to sustain their own pregnancies. This is devastating for many hopeful parents whose only other options for parenthood are surrogacy and adoption.

For women suffering from infertility, the possibility of transplanting reproductive organs has been on the table for decades. Some physicians previously explored the possibility of transplanting human uteruses. But the idea has largely been ignored because of the discovery of other less invasive fertility options like in-vitro fertilization and the failures of experiments conducted in various animal models during the early 20th century (Confino, Vermesha, Jrb, & Gleichera, 1986). Modern medicine has revolutionized lives by providing patients with the opportunity to replace organs that no longer can sustain proper function. With medicine constantly advancing, physicians and doctors are seeking to do more than replace a non-functioning kidneys and livers. As a result, they have again started exploring the possibility of uterine transplantation as a common procedure.

In 2000, physicians in Saudi Arabia performed the first human uterine transplant on a 26 year old woman that desired more children but had undergone a hysterectomy six years earlier. The uterus was obtained from a 46-yearold live donor undergoing a voluntary hysterectomy. Postoperatively, the woman appeared to be healing as expected (Fageeh et al., 2002). Nine days after the transplant, the patient started to experience symptoms consistent with organ rejection which ultimately led to a complete hysterectomy of the necrotized organ 90 days later. Physcians concluded ‡ University of Minnesota, allisongullick@gmail.com

that a lack of vascular blood flow and subsequent clotting contributed to the organ rejection (Fageeh et al., 2002).

Although this procedure failed to sustain the transplanted organ and allow for pregnancy, it was hailed as a medical breakthrough that spawned public interest, especially from those suffering from uterine infertility factors.

At first glance, this potentially beneficial procedure appears to be a revolutionary breakthrough for women suffering from uterine factor infertility. Women desperately wishing to become mothers and experience pregnancy may have the opportunity that they previously did not have. Potential uterine transplantation requires both the evaluation of the ethics of organ transplantation and the feasibility of its use as a potential reproductive therapy.

In 2008, the International Federation of Gynecology and Obstetrics released an ethical guideline in response to the increasing interest in uterine transplantations. Under careful consideration, the committee deemed uterine transplants as “ethically inappropriate” because of the lack of safety data and known risks to live donors (Milliez 2009).

Defining “Womanhood”

Unfortunately, in American culture, womanhood is often defined by possession of sexual organs and fertility (Mcquillan, Greil, Shreffler, & Tichenor, 2008). Society sometimes places unneeded stress on women who have a compromised womanhood by not having the ability to conceive. Having or not having a particular functional organ should not define a person. It seems unjustified to say that a person born without arms cannot be classified as a human, but this is purely the same logic. In a society where modern medicine is aimed at fixing individuals, it comes as no surprise that women are willing to undergo invasive procedures to restore fertility and restore their womanhood.

Would uterine transplantations then be a justified method in gender reassignment surgeries? Surely one defining

An Ethical Analysis of Uterine Transplantation biological process of womanhood is menses and transsexuals would argue that it would be a beneficial procedure in order to feel more like a woman. A transwoman from Texas publically announced that she wants a uterine transplant in order to become the first pregnant transsexual female.

Currently, physicians have agreed that this procedure will only be performed in women with uterine infertility factors (University of Gothenburg; Sahllgrenska University Hospital, 2011; Nair, Stega, Smith, & Priore, 2008). But this position raises a new set of questions about how culture defines gender as well as the role equality would have in this sort of procedure.

Currently vital organ transplants are performed to sustain and extend life. Uterine transplantation, however, is not categorized as “vital” because the uterus is not required to live a disease-free life (George J. Agich, 2003). Supporters of uterine transplantation as a means of reproductive therapy argue that providing women with the opportunity to experience pregnancy and produce children increases their quality of life and therefore ought to be considered as a potentially beneficial procedure.

Risks to the Fetus

Risks to the Mother

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The World Health Organization firmly believes that all women should have the right to reproduce. Women who are competent, have the right autonomously choose which treatments they wish to have performed on them, even if these procedures are against the will of a physician.

Becoming pregnant through the use of assistive reproductive therapy treatments is an acceptable procedure if it does not pose significant risk Procedures such as in-vitro fertilization carry few risks, so the acceptability is rarely questioned. However, uterine transplantation is an invasive and complicated transplant surgery that exposes a woman to a variety of risks. The complexities of the arterial and vein structure of the uterus and surrounding organs as well as the proximity to the bladder and kidneys contribute to the risk of damage (Del Priore MD, MPH , Sieunarine, MD, Ungar, MD, & Smith, MD, 2007). In addition, adverse trauma experienced during transplantation and subsequent healing of the uterus may impair the function of the uterus all together (Brännström, Wranning, & Altchek, 2009). For example, in experiments conducted in ewes, complications arising from post-operative inflammation interfered with normal uterine function and potentially compromised the structural support of the uterus . Without the ability to have strong structural support, pregnancies within a transplanted uterus would be riskier. Furthermore, the uterus requires a large and constant blood supply, that when not grafted correctly, would most likely result in organ death or rejection. (Greiss Jr, MD, 2008). Although many transplanted organ procedures are complicated, the vast volume of blood needed to ensure a healthy organ is complicated. In the human model, this appears to be the reason why organ death occurred (Fageeh et al., 2002). Finally, the transplantation of other organs and pregnancy also puts the expectant mother at a higher risk of developing complications such as pre-clampsia and hypertension (McKay et al., 2006).

Under current proposed recommendations, women would only be able to have one pregnancy after uterine transplantation. This riases another question relating to the costs and benefits of the procedure. Is the danger the procedure worth the opportunity to potentially foster one pregnancy? For many women unable to carry a pregnancy, the answer is yes.

However, the potential of not becoming pregnant through uterine transplantation may occur because women would

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Rarely are the associated risks of an action on an individual-to-be evaluated, but this is important for a pregnancy that could potentially result from a transplanted uterus.

The primary focus of the procedure ought to be the wellbeing of an infant gestating in a transplanted uterus because preterm decisions can permanently affect the rest of a child’s life. Individuals conceived through uterine transplantation do not have any choice in their creation and gestational circumstances, so they do not have the ability to weigh the procedure’s harms and benefits. Being provided with life is the biggest benefit of all, but what if the quality of life is jeopardized because of a created circumstance? Because no pregnancies after a uterine transplantation have occurred in humans, there is no way to accurately categorize the risks to a developing individual. However, pregnancies in mothers who have received other sorts of organ transplants can be used as a data to determine the potentiality of risk associated with uterine transplantation.

To sustain a transplanted uterus, the recipient must take a regiment of immuno-suppressants to dampen her immune system’s response to prevent organ rejection . The FDA has publicly acknowledged that two commonly prescribed immunosuppressants cause birth defects; studies on the risks of other available medications are inconclusive (U.S. Food and Drug Administration, 2008, Louden, 2009). The National Transplantation Pregnancy Registry conducted studies on pregnancy and immunosuppressive therapy, finding that there are increased health risks and complications for gestating fetuses of mothers undergoing immunotherapy (Coscia et al., 2009).

For example, 47% of infants born to kidney transplant recipients taking immunosuppressants were underweight (weighing less than 2,500g) whereas only 8.2% of all USborn infants are underweight. Factors other than immu-

nosuppressant medications impact children of transplant mothers, too. For instance, 29.9% of delivered babies born to mothers prescribed cyclosporine experienced intrauterine growth reduction (IUGR), which is defined as a fetus falling at or below the 10th percentile of weight for gestational age.

Few studies have been conducted to observe the long-term impacts of these drugs. However, any time an infant is born underweight or suffers growth retardation, it has increased risk for a variety of short-term and long-term health problems. It remains unknown what role these drugs would have on human infants gestating inside the transplanted organ.

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Article also need to undergo in-vitro fertilization, a treatment with relatively high failure rate.

Like with other reproductive therapies, the physician must carefully determine if a woman’s genes predispose her to developing a child with the same limitations. A physician treating a woman at risk for a uterine disorder must assess whether using her eggs is feasible and responsible. The most common disorder for the absence or failure of uterine development is Mayer-Rokitansky-Küster-Hauser syndrome which, in some cases, also results in the absence of a vagina (Guerrier et al., 2006). It is often associated with other genetic abnormalities such as unilateral renal agenesis. In Mayer-Rokitansky-Küster-Hauser syndrome, women are still capable of producing viable eggs within their ovaries.

However, they lack the mechanical functions of fertilization and carrying of a developing fetus. This disorder occurs in one out of every 4,500 female births and has no definite inheritance pattern. Because little is actually known about this disorder and its inheritance pattern, using ovum produced by a woman with known possible inheritable abnormalities should be carefully thought. Producing a child that has a chance of having the same medical anomaly may place them in the exact same position of their mother.

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Monetary Costs

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The proposed cost of uterine transplantations is unknown, but physicians predict that the total cost of the transplantation alone may cost upwards of half a million dollars. Under current recommendations, women who were able to carry a baby to term would undergo a hysterectomy afterwards. Plus, there are the costs associated with in-vitro fertilization, a procedure that has a relatively low success rate in itself. Younger women (<35 years old) have the highest chance of pregnancy with approximately 30% of all in-vitro fertilization procedures resulting in a live birth (Centers for Disease Control and Prevention 2010). But as a woman ages, her chances of in-vitro fertilization success rapidly declines, resulting in subsequent cycles need to be performed.

The extensive cost and risks that allows for only one pregnancy may fail to justify the use of the procedure. Human life does not have a price tag assigned to it, so many individuals unable to become pregnant naturally feel that any amount of money spent does not compare to the benefits of parenthood. However, like most other infertility options that are funded in some states by insurance, it brings into question whether this should also then be compared to other transplants that are not usually covered by insurance such as skin or limb transplants.

For families seeking to become parents but unable to successfully do so, adoption exists as an alternative option.

Within the United States, 111,000 children were waiting to be adopted in 2009 . Adoptions of a non-biological child vary in price, depending on a variety of factors. A domestic public adoption, for example, can have no cost, whereas a private independent adoption can exceed $40,000 USD (Child Welfare Information Gateway, 2011).This high-

lights the feasibility of adoption as a method of achieving parenthood that would not place as much of a financial burden on families, health insurance providers, and hospitals.

Conclusion

Currently, uterine transplantation is, at best, in its infancy.

Because this procedure is elective and unnecessary for human survival, undergoing this sort of procedure provides more harm to the overall health of the transplant recipient than good. A series of ethically appropriate questions still remains. What happens if the transplant rejects during a pregnancy? Will this expensive procedure be covered by health insurance? What are the rights of a deceased organ donor? Do we have to designate that we want our reproductive organs donated? The future of this transplant practice is unknown, but as long as women continue to express a desire for it, researchers and physicians will continue to develop it.

Because only one human model has been publicized for study, it’s difficult to determine the feasibility of this procedure. More careful studies must be conducted to determine whether the health and safety of both mother and fetus are preserved. If the desire to produce a healthy child is the expected and desired outcome, then uterine transplantation should not be a method of reproductive therapy because the risks about the potentially harmful effects this may have on a developing fetus are currently unknown. Placing restrictions on this procedure does not restrict infertile women’s rights to parenthood but rather protects the health and safety of the mother and the unborn child.

About the Author

Allison Gullick is a recent graduate from the University of Minnesota, where she majored in Biology, Society, and Environment.

Dr. Mary Faith Marshall is the faculty sponsor for this submission. She is the Associate Dean for Social Medicine and Medical Humanities, Professor of Family Medicine and Community Health, Professor in the Center for Bioethics, and Co-Chairman of the University of Minnesota Medical Center Ethics Committee.

An Ethical Analysis of Uterine Transplantation References Brännström, M., Wranning, C. A., & Altchek, A. (2009, November).

Experimental uterus transplantation. Human Reproduction Update, 16(3), 329-345.

Centers for Disease Control and Prevention, American Society for Reproductive Medicine, Society for Assisted Reproductive Technology.

(2010). Assisted Reproductive Technology Success Rates: National Summary and Fertility Clinic Reports. Atlanta: U.S. Department of Health and Human Services.

Child Welfare Information Gateway. (2011). Costs of adopting. Washington D.C.: U.S. Department of Health and Human Services, Children’s Bureau.

Confino, E., Vermesha, W., Jrb, T., & Gleichera, N. (1986, August). Nonvascular transplantation of the rabbit uterus. International Journal of Gynecology & Obstetrics, 24(4), 321-325.

Coscia, L., Constantinescu, S., Moritz, M., Frank, A., Ramirez, C., Maley, W., et al. (2009). Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation. Clin Transpl., 103-22.

Del Priore MD, MPH , G., Sieunarine, MD, K., Ungar, MD, L., & Smith, MD, J. R. ( January 2007). Human Uterus Retrieval From a Multi-Organ. The American College of Obstetricians and Gynecologists., 109(1), 101-104.

Fageeh, W., Raffa, H., Jabbad, H., & Marzouki, A. (2002, March). Transplantation of the human uterus. International Journal of Gynecology & Obstetrics, 76(3), 245-251.

George J. Agich, P. (2003, May). Extension of Organ Transplantation: Some Ethical Considerations. The Mount Sinai Journal of Medicine, 7(3), 141-147.

Greiss Jr, MD, F. C. (2008). Uterine and Placental Blood Flow. The

Global Library of Women’s Medicine.

Guerrier, D., Mouche, T., Pasquier, L., & Pellerin, I. (2006). The MayerRokitansky-Küster-Hauser syndrome (congenital absence of uterus and vagina) – phenotypic manifestations and genetic approaches.

Journal of Negative Results in BioMedicine.

Louden, K. (2009, February). Pregnancy After Transplantation: Improving Outcomes Through Counseling, Close Management, and Research.

Nephrology Times, 2(2), 11-13.

McKay, M.D., D. B., & Josephson, M.D., M. A. (2006, March 23). Pregnancy in Recipients of Solid Organs — Effects on Mother and Child.

The New England Journal of Medicine(352), 1281-93.

Mcquillan, J., Greil, A. L., Shreffler, K. M., & Tichenor, V. (2008, August).

The Importance of Motherhood Among Women in the Contemporary United States. Gender & Society, 22(4), 477-496.

Milliez, J. (2009, September). Uterine transplantation: FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics., 106(3), 270.

Nair, A., Stega, J., Smith, J. R., & Priore, G. D. (2008). Uterus Transplant.

Annals of the New York Academy of Sciences, 1127, 83-91.

U.S. Food and Drug Administration. (2008). Information for Healthcare Professionals: Mycophenolate Mofetil (marketed as CellCept) and Mycophenolic Acid (marketed as Myfortic). U.S. Department of Health and Human Services, Medwatch.

University of Gothenburg; Sahllgrenska University Hospital. (2011).

Investigation of patient and donor. Retrieved from Uterus Transplantation Project: http://www.uterustransplantation.se/patient/investigation-patient-and-donor

Penn Bioethics Journal Volume VII Issue i 11

Article

In Vitro Fertilization: A History and Discussion Vinayak Kumar‡

Penn Bioethics Journal

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Robert Edwards was recently awarded the Nobel Prize in Medicine or Physiology for developing in vitro fertilization (IVF). Since its invention, IVF has raised several ethical questions, some of which this paper attempts to address. While some people consider IVF to be highly unethical in its development, current use, and derivatives (mainly embryonic stem cell research), this paper attempts to prove that mankind is better off with the procedure than without it. Adoption is not always an option for families. While the abuse of IVF is possible, it is rare and regulations can reduce such risks. Freeze storage of embryos is not unethical because it seems to increase vitality, indirectly reduce the risk of autism, and not put the embryo in discomfort. Similarly, embryos are indifferent to experimentation because they are unaware of their surroundings. Selective fetal reduction is not unethical due to the reduction of suffering and risk. Overall, the ultimate happiness of families and the development of innovative treatments far outweigh the loss of embryonic cells, making IVF an excellent modern treatment for infertility.

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On October 4, 2010, Robert G. Edwards was announced as the Nobel Prize winner in Medicine in Physiology or Medicine. Edwards, an 85-year-old British biologist and “Father of the Test Tube Baby,” won this prestigious award for the development of the now common procedure called in vitro fertilization (IVF). His research opened the opportunity for infertile couples to have biological children and also contributed to the establishment of embryonic stem cell research. His findings stirred up some of the greatest controversies of the age, such as the ethics of embryonic research and treatment. While there are controversies surrounding the topic, IVF is generally accepted as an ethical, beneficial practice and is commonly considered a solution to infertility.

The initial development of IVF is attributed to Robert Edwards and Patrick Steptoe. Edwards initially became involved in reproductive manipulation when he studied mouse fertilization and experimented with hormones to alter the ovulation times of mice (Timmer, 2010). Later on, he turned his focus to rabbits and showed that “rabbit egg cells could be fertilized in the lab and give rise to offspring” (Vogel, 2010). He then moved to human experimentation and studied the human ovaries in great detail to determine how to utilize hormone treatment to induce ovulation. Through trial and error, he was able to isolate an oocyte outside of the body and fertilize it with sperm in 1969 (Vogel, 2010). This experiment comprised the first case of in vitro fertilization, though the fertilized oocyte was not implanted in utero. Edwards then began his famous collaboration with Steptoe, a pioneering obstetrician ‡ University of Pennsylvania, vikumar@sas.upenn.edu

and gynecologist who developed a noninvasive method for obtaining the necessary oocytes called laparoscopy (Wade, 2010). Undoubtedly, had Steptoe lived, he would have shared the Nobel Prize with Edwards because of his ingenious method of retrieving eggs and his legal authority to perform medical procedures though the Nobel Prize is not award posthumously, Steptoe’s contribution to science will always be remembered.

With Steptoe’s help, Edwards began to produce embryos ready for implantation. Over the course of several years, he further developed this procedure and finally succeeded: an embryo was successfully implanted in utero, leading to the birth of Louise Brown (Vogel, 2010).

Several ethical questions were raised following this success. Should IVF be employed when there are alternatives such as adoption? Will IVF be abused, as in the infamous Octomom case? Was it unethical for so many embryos to have perished during the initial experimentation? Is it wrong to cryogenically store the unused embryos? Should selective fetal reduction be allowed? These questions, posed largely by the Roman Catholic Church, the main opponent of in vitro fertilization, are pressing and difficult and without simple answers.

To address the nature of these questions, it is necessary to understand clients of IVF treatment and their motives.

In general, this procedure is used by men and women with severe fertility issues. Male fertility issues involving inactive sperm can be overcome with IVF to artificially fuse the sperm and egg. However, women derive the main benefits from IVF. Women may be faced with infertility situations

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patient’s will. While this case highlights the possibility of IVF abuse, it is important to remember that physicians are in control of the procedure. Kamrava is currently facing “a hearing that could lead to the loss of his medical license,” which sounds a warning to the rest of the medical community of the consequences of IVF abuse (Duke, 2010). This steep price for negligence may be enough to deter further abuse in this field.

Opponents of IVF, many of whom are affiliated with the Roman Catholic Church, do not directly challenge IVF as a method, but rather the ethics of storage, experimentation, and selective reduction of these embryos. The main points of the opposition are that “the number of embryos sacrificed is extremely high” and that those that have “defects are directly discarded, [which] implies a purely utilitarian treatment of embryos” (Vatican, 2008). These opponents declare that Edwards was responsible for the deaths of these human beings and for the creation of a method that undermines the sanctity of life. Essentially, these religious groups claim that IVF is unethical because of the unforgiveable loss of life involved.

However, supporters of IVF claim that the procedure has opened new doors for human life. People are no longer limited by their reproductive defects; they are capable of creating the child they so desperately want. After all, during unsuccessful intercourse in which the egg is not fertilized, numerous gametes that had the potential to form a human are lost. When summed over the total number of failed intercourses, which is quite common outside the narrow six-day period ending on the day of ovulation, a tremendous amount of energy and potential lives have been lost (Wilcox, 1995). Yet, opponents to IVF and its derivatives do not compare the loss of these embryonic components to the loss of an early-stage embryo.

Before contesting these arguments further, an important fact of IVF must be brought to light: during IVF, embryos are implanted at Day 2-3 of development (Laverge, 2001) during which the embryo is still an undifferentiated cluster of 4-8 cells (Overview, 1997). Because no differentiated tissues have developed (including the nervous system), it cannot even be argued that the embryos are in discomfort or pain. These embryos are completely unaware of their surroundings. They are in fact, incapable of feeling awareness.

These cells have the potential to develop into a human only if they are placed in a very specific environment, namely the uterus.

Michael Gazzaniga, President of the Cognitive Neuroscience Institute, defines the stage when true life begins by analyzing the neural development of the brain in great detail to understand when an embryo becomes a sentient human. In his description of the development of the embryo, the early signs of a brain form around Week 4, and random electrical activity is observed in the brain at Week 5 (analogous to the electrical activity in clinically dead patients).

Reflexes appear during Weeks 8-10, though at this point, “it is more like a sea slug, a writhing, reflex-bound hunk of sensory-motor processes that does not respond to anything

Penn Bioethics Journal

such as defective fallopian tubes and scar tissue from ectopic pregnancy that prevent them from successfully conceiving. Women may also be naturally barred from conceiving by menopause. With in vitro fertilization, these barriers to pregnancy may be overcome, as the mature egg is extracted with the help of modern hormonal treatments, fertilized, and then implanted in the uterus (either that of the biological mother or the surrogate mother).

As previously discussed, the main benefit of in vitro fertilization is that it provides families with a method of overcoming their infertility. After all, 7.3 million women in the United States alone aged 15-44 have “impaired fecundity” (CDC, 2009). This condition prevents women from successfully conceiving without assistance.

At this point, before deciding on the expensive IVF procedure, which costs $10,000-$25,000 in the United States, families are encouraged to explore all their options (Institute for Reproductive Health, 2010). Despite the exorbitant price, over four million babies worldwide have been born through IVF to date (Vogel, 2010). This impressive statistic reveals that families willing to pay for this service greatly prefer their own genetic offspring. If this is what the parents truly desire, then banning IVF and forcing them to make an “adoption or nothing” choice may place undue strain on the affected families. Case studies prove that children raised in households where they are not wanted are at an increased risk for psychological, emotional, and physical trauma (Glaser, 2000). It is necessary that children are raised in a loving, nurturing environment to maximize the probability that they grow up to become productive members of society. Though couples are regularly asked to explore alternative options to save time, money, and energy, the demand for IVF is still high according to the number of reported procedures. This is why such “alternative method” arguments against in vitro fertilization are not adequate enough to ban this globally-recognized procedure.

This raises the question of whether there can be restrictions to prevent abuse. Nadya Suleman – otherwise known as Octomom – is an American woman who used IVF to have octuplets despite already having six children, lacking the financial means to support them properly, and undergoing a dangerous pregnancy (“Octuplet’s Mom,” 2009). It is undeniable that she abused the IVF procedure by endangering her own life, jeopardizing the lives of her children, and draining federal financial aid, but a great deal of blame also lies on the physician attending her, Michael Kamrava.

It was irresponsible and dangerous for him to ignore reason and comply with her request to implant twelve embryos into her uterus. While the exact number of embryos to transfer is at the discretion of the fertility clinic, generally 2-3 embryos are implanted at a time, depending on the age of the mother and the particular infertility circumstances of the couple (Institute for Reproductive Health, 2005).

Kamrava could have properly delineated all the risks involved to dissuade her, or he could have even declined her as a patient had she proven to be unreasonable. He had the ability to refuse treatment, yet he irresponsibly followed his

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in a directed, purposeful way” (Gazzaniga, 2005). Though the fetus can survive outside of the uterus in neonatal care at Week 23, the cutoff age beyond which the fetus is protected from abortion, its consciousness develops with the complex synaptic networks formed during Week 28. Gazzaniga said it best when he stated, “Laying down the infrastructure for a mature brain and possessing a mature brain are two very different states of being” (Gazzaniga, 2005). When put into this perspective, the pre-blastocyst cluster of cells used in IVF should not be considered a sentient human.

There are those who argue that since the cell cluster has the potential of growing into a human, it should not be subjected to inhumane treatments such as freeze storage.

To address this, it is important to remember that embryos are stored and frozen because it would be inhumane to continuously extract eggs from the mother for IVF. Failure to implant or develop is a common event in IVF, occurring in about 52.7-83.3% of procedures, depending on the age of the patient (“Clinic Summary Report,” 2008). In the event that a pregnancy is successful, the remaining embryos are placed into storage rather than disposed of immediately, since most families tend to have multiple children. The average number of children per woman in the U.S.A. is 2.06 (Central Intelligence Agency, 2010). One may wonder why doctors do not fertilize embryos each time the couple decides to have another child, thereby reducing the number of frozen embryos in storage. The answer is that the risk of bearing a child with autism and other defects increases with the age of the parents, with “fathers over 40 [being] six times as likely as fathers under 30 to have a child with autism” (Brown 2008) and mothers over 35 being 1.3 times as likely as mothers aged 25–29 years to have an autistic child (Durkin 2008). Therefore, it is in the best interest of the family to use eggs harvested when the parents are young.

By reducing the risk of creating a child that will suffer from a lifelong debilitating disease, storage of embryos is an ethical procedure.

To further address the ethics of freezing embryos, some studies have shown that the number of low birth weight babies is 3.6% higher for singletons and 7.9% higher for freshly fertilized embryos than cryogenically stored embryos (Wennerholm, 2009). Furthermore, there are multiple studies that state that there is no harmful effect of cryogenically storing an embryo (Hirst, 2011). These studies indicate that freezing embryos is equivalent or better than fertilizing them afresh for IVF because it leads to similar or healthier offspring. Can freezing be an inhumane treatment if it does not adversely affect and may in fact increase an embryo’s viability?

Despite these arguments, opponents still find the idea of long-term storage and selective fetal reduction of these embryos repugnant. They believe long-term storage is imprisonment without rights and selective elimination of the embryos is murder. Once again, it is important to recall that an implanted embryo is a cluster of a few identical cells loosely held together by a membrane. The embryo is incapable of awareness to the surroundings and therefore

does not recognize when it is frozen. When this cell mass is cryogenically stored, all cellular processes are carefully halted such that they can restart after careful thawing. To label this method of storage as imprisonment is also to label a comatose person in a hospital as a prisoner. Clearly this is not the case, because the comatose man is indifferent to his surroundings. Just as in the case of an embryo, his lack of consciousness and the constraints on his mind and body are greater limitations for him than his environment.

Similarly, the idea of selective fetal reduction is particularly distasteful to opponents. In this process, less viable fetuses are eliminated from the uterus after implantation.

While this issue ties into the larger concept of abortion, this argument will address only IVF-related selective termination. Research indicates that the choice of fetal reduction is most often performed in the interest of the health of the mother and of the remaining fetus(es). Because IVF involves the insertion of multiple embryos in hopes of a successful implantation, multiple pregnancies occur in 20% of successful IVF procedures (Australian Bureau, 2001).

This can lead to several maternal problems such as “almost certain preterm delivery, prefaced by early and lengthy hospitalization, higher risks of pregnancy-induced hypertension, polyhydramnios, severe anemia, preeclampsia, and postpartum blood transfusions” (Overall, 1990). Similarly, the infants themselves are at risk of “premature delivery, low infant birth weight, birth defects, and problems of infant immaturity, including physical and mental retardation…. [and] may…suffer a lengthy costly process of dying in a neonatal intensive care unit” (Overall, 1990). In the interest of the health and well-being of the mother and the remaining fetuses, sometimes it is necessary to eliminate one of the fetuses to save the majority. This procedure usually occurs between Weeks 9-12 (Davis, 2008). Once again, the argument that the fetus, defined in humans as an embryo about eight weeks after fertilization, has no sensory capabilities must be utilized. When the fetus is eliminated, it feels nothing and is aware of nothing, being the “sea slug” that cannot exist out of the womb as Gazzaniga described.

Beyond the biological and health perspective, selective abortion may be a procedure that improves the livelihood of a family. Children are an enormous financial and temporal investment. And, after paying for the costly IVF procedure, a family may not have the funds or capability to support multiple children at once. Nadya Suleman’s current condition serves as an extreme example of this, as she is financially overstretched with such a large family. However, less extreme examples also illustrate this fact. Mae Collier’s quintuplets require a tremendous amount of resources. She “changes diapers fifty times a day, and goes through twelve liters of milk a day and 150 jars of baby food a week, [while] her husband spends much of his time working and building the family’s new house” (Overall, 1990). While it is not all that uncommon for families to have five children, it is very uncommon to have quintuplets, or even triplets for that matter. This puts a tremendous financial and emotional drain on families that are not ready for such large families.

In Vitro Fertilization IVF include the high cost of the procedure, the questionable ethics of storage and experimentation on the embryos, and the potential propagation of unfavorable genes in the gene pool, such as those that result in infertility. Because we cannot restrict people on their right to procreate if IVF is fully accepted, we can eliminate the two arguments regarding the propagation of favorable and unfavorable genes.

This argument boils down to the question of whether the tremendous advances in science, medicine, family development, and human happiness are worth the high costs of the procedure and the “inhumanity” of storing, experimenting on, and selectively aborting undifferentiated embryos. To most, the answer is clear: because the embryos are not suffering and all of humanity has gained and will continue to gain from the development of IVF, the losses are acceptable so long as parents consent to the procedure.

The debate over IVF stormed throughout Robert Edwards’s career in the early days and continues to haunt him today. However, now that the majority of people view his innovative procedure as a tool to decrease suffering in their lives, IVF has become too popular a movement to subdue. It is unfortunate that his career was initially adversely affected by the controversy. Britain’s government-run Medical Research Council denied him funding, and, at one point, he “was continually involved in lawsuits” (Wade, 2010). It is fitting that he received the Nobel Prize for his achievement despite the controversies surrounding his work. Edwards truly revolutionized the field of reproductive health, and in vitro fertilization led to subsequent developments that will aid society in the years to come.

Penn Bioethics Journal

All taken together, losing the health or lives of the mother and fetuses or forcing a couple with limited finances to support a large family creates added struggle.

Selective reduction of fetuses is a method to reduce this suffering. There are some who support IVF for its role in helping couples start families but choose to oppose IVF because it involves selective reduction, which they decry as an unethical breach of the sanctity of life that promotes eugenics, given that it is the weakest embryos that are often eliminated. These arguments are ill-founded because this procedure reduces suffering, trauma, and the life-threatening risk of multiple pregnancies for the mother and the fetuses, at the cost of an indifferent cell mass. Because the embryos are only a small cluster of undifferentiated cells that are incapable of thought and awareness, the benefits derived from storage and experimentation far outweigh the loss of cells.

Yet, regardless of how indifferent the subject of the experiment is, opponents point their fingers at scientists for being willing to experiment on their fellow human beings.

This brings up the question of whether it is ethical for scientists to experiment on these cells despite the obvious fact that the cells have no sense of awareness. The debate has transformed from an argument of logic into a clash of principles. This makes the question less simple to answer, and the pros and cons of IVF must be reevaluated. The positives of IVF are numerous. In vitro fertilization can provide infertile couples with a family; it has successfully aided in the birth of four million babies globally. It can allow certain favorable genes to be propagated in the gene pool, expanding the talents and abilities of the next generation and improving progress. IVF has paved the way for a better understanding of the origin of life. It has led to the development and expansion of scientific research of new treatments for various disorders. The negatives associated with

About the Author Vinayak Kumar is a junior at the University of Pennsylvania, where he is majoring in Biochemistry.

Dr. Ponzy Lu is the faculty sponsor for this submission.

He is a professor of Chemistry at the University of Pennsylvania.

Australian Bureau of Statistics, Australian Demographic Statistics. (2001).

Confinements Resulting in Multiple Births (3101.0). Canberra: Retrieved from http://www.abs.gov.au/ausstats/abs@.nsf/featurearticlesb ytitle/729445EA93DFE747CA256B20007EB589?OpenDocument Brown, Phyllis. (2008). Link confirmed between advanced mother’s age, autism. Informally published manuscript, University of California, Sacramento, California. Retrieved from http://www.universityofcalifornia.edu/news/article/22790 Centers for Disease Control and Prevention, CDC/National Center for

Health Statistics. (2009). Infertility Retrieved from http://www.cdc. gov/nchs/fastats/fertile.htm Central Intelligence Agency, (2010). The World Factbook. Retrieved from https://www.cia.gov/library/publications/the-world-factbook/geos/ us.html Clinic summary report. (2008). Society for Assisted Reproductive Technology. Retrieved from https://www.sartcorsonline.com/rptCSR_PublicMultYear.aspx?ClinicPKID=0 Davis, Bets. (2008, March 21). Should I Consider a Multifetal Pregnancy

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References

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Reduction?. Retrieved from http://www.revolutionhealth.com/conditions/reproductive-health/infertility/decision/mfpr Duke, Alan. (2010, October 18). Octuplet mom’s doctor faces license revocation hearing. CNN, Retrieved from http://articles.cnn. com/2010-10-18/entertainment/octuplets.doctor.hearing_1_kamrava-fertility-doctor-embryos?_s=PM:SHOWBIZ Durkin, Maureen. (2008). Advanced parental age and the risk of autism spectrum disorder. American Journal of Epidemiology, 168(11), 1268-1276.

Gazzaniga, Michael S. (2005). The ethical brain: the science of our moral dilemmas. Dana Press.

Glaser, D. (2000). Child abuse and neglect and the brain--a review. J Child Psychol Psychiatry, 41(1), 97-116.

Hirst, Mark. (2011). Prognostic factors influencing fresh and frozen IVF outcomes: an analysis of the UK national database. Reproductive BioMedicine Online, Retrieved from http://www. sciencedirect.com/science?_ob=ArticleURL&_udi=B986R521NWPG-1&_user=489256&_coverDate=01%2F26%2F2011&_ rdoc=1&_fmt=high&_orig=gateway&_origin=gateway&_sort=d&_ docanchor=&view=c&_acct=C000022721&_version=1&_urlVersion=0&_userid=489256&md5=bbcfbfa3de2e17829b2bd371b0722d 93&searchtype=a#FCANote Institute for Reproductive Health (2005). In vitro fertilization. Cincinnati, OH. Retrieved from http://www.cincinnatifertility.com/infertility-treatment/in-vitro-fertilization Institute for Reproductive Health (2010). Money Back IVF Guarantee.

Cincinnati, OH. Retrieved from http://www.cincinnatifertility.com/ infertility-treatment/in-vitro-fertilization/money-back-ivf-guarantee.

Laverge, Heleen. (2001). A prospective, randomized study comparing day2 and day 3 embryo transfer in human IVF. Human Reproduction, 16(3), 476-480.

Octuplets’ mom: ‘All I ever wanted’. (2009, February 6). Cable News Network. Retrieved from http://www.cnn.com/2009/US/02/06/octuplets.mom/index.html?iref=allsearch Overall, Christine. (1990). Selective Termination of Pregnancy and Women’s Reproductive Autonomy. The Hastings Center Report, 20(3), 6-11.

Overview. (1997).Web Page, School of Medicine, University of Pennsylvania, Philadelphia, USA. Retrieved from http://www.med.upenn. edu/meded/public/berp/overview/BV_1.html Timmer, John. (2010, October 04). In vitro fertilization delivers medicine Nobel Prize. Ars Technica, Retrieved from http://arstechnica.com/ science/news/2010/10/in-vitro-fertilization-delivers-medicine-nobelprize.ars Vatican. Congregation for the Doctrine of Faith, (2008). Dignitas personae Vatican: Retrieved from http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_20081212_ sintesi-dignitas-personae_en.html Vogel, Gretchen. (2010). IVF Pioneer Wins Medicine Nobel. Science, Retrieved from http://news.sciencemag.org/sciencenow/2010/10/ivfpioneer-wins-medicine-nobel.html Wade, Nicholas. (2010, October 04). Pioneer of in vitro fertilization wins Nobel Prize. The New York Times, Retrieved from http://www.nytimes.com/2010/10/05/health/research/05nobel.html?pagewanted=2 Wennerholm, et al. (2009). Children Born After Cryopreservation of Embryos or Oocytes: A Systematic Review of Outcome Data. Human Reproduction, 24(9), 2158-2172.

Wilcox, Allen. (1995). Timing of sexual intercourse in relation to ovulation - effects on the probability of conception, survival of the pregnancy, and sex of the baby. The New England Journal of Medicine,333, 1517-1521.

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Lip Service(s): Discourses on Designer Vaginas Jessica Y. Neasbitt‡ “2010 Might Just Be the Year for You to Make-Over Your Labia” -Slogan on presenter’s slide at the Second Global Symposium of the International Society of Cosmetogynecology (Braun, 2010)

“A vagina is for life, not for Christmas.”

-Clare Edmondson in LOTL magazine (2009)

Introduction

‡ University of California, Berkeley, jyneasbitt@berkeley.edu

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a host of discursive elements employed by members on all sides of the debate (Foucault, 1978).

As such, it is of paramount interest and importance that such discourse comes under close scrutiny. Any discourse must be recognized not only as an “instrument and effect of power” but also as an interruption of the same, providing opportunities for resistance and points of departure for tactical and/or strategic development (Foucault, 1978).

Within the discourse lie the cracks and ruptures, as well as the overlaps, where these groups both meet and disrupt each others’ views and work. This paper will utilize discussions of the role of neoliberalism in the medical marketing model to explore questions of the “natural” and some of the meanings imparted upon bodily diversity. Such an analysis will enable a critique of both sides of the FGCS debate.

With such goals in mind, this paper narrows its field of examination to the recent interactions of two very specific groups: doctors who perform FGCS and the New View Group (NVG). The NVG is one of the most vocal and academic groups to challenge the practice of FGCS. In late September of 2010, representatives from both groups were in Las Vegas to attend their respective conferences and symposia, which brought both groups and their myriad discourses into close circulation. By examining the discourses of FGCS in which these two groups engage, it is possible to observe the locations of said discourses, which, far from inhabiting the binary they are often framed in, actually touch upon and play off of one another. Of these locations, two stand out as the most common confluences of the discourses of FGCS: neoliberal market practices and the two-sex model of gender.

Penn Bioethics Journal

The above statements, as disparate as they appear at first glance, reference the same phenomenon: a group of procedures known collectively as Female Genital Cosmetic Surgery (FGCS). Enjoying a rise in popularity and media attention over the past decade, FGCS has become a symbol to some groups of the medical field’s growing power over and financial investment in women’s bodies. Comprised of academics, feminists, activists, journalists, and medical professionals, these groups are producing a variety of responses and challenges to FGCS as well as to the growing medicalization of sex in general, which they feel is a direct result of these procedures. As voices and tensions rise on both sides of the debate, the public is inundated with conflicting claims.

This paper charts and explores the two most prominent discussions regarding FGCS. Most of the activity and discourse surrounding FGCS can be classified as either in favor of or in opposition to the procedures. This is not to say that the categories never overlap or always exist in a state of direct opposition. While individuals may consider themselves firmly entrenched in one of two distinct camps, the reality of the situation is much less clear. Each group consists of a myriad of actors, both individuals and institutions, and produces various discursive elements. These include but are not limited to legal treatises, media of all types, financial codification, personal testimonies, advertisements, and scholarly texts. Taken in the Foucauldian sense, such discourse cannot, in and of itself, be seen in such a concrete, oppositional mode as these groups seem to posit themselves. These groups cannot be simply viewed as groups among which there exists a dominant and dominated discourse. Each discussion should be considered as

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Neoliberal Markets and Designer Vaginas

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One major convergence of the various discourses of FGCS is within the growing rhetoric related to neoliberal markets and the transactions, discussions, and practices thereof. The approach of these discourses and the assemblages from which they originate are often presented as that of direct opposition between two groups. Supporters of FGCS, mainly the surgeons who perform the procedures and their (prospective) patients, and those critical of the practice, most often feminists, academics, and activists, often disagree. Surgeons in favor of the practice claim to be providing a service that meets female demand for genitals that either conform to a certain aesthetic, increase sexual pleasure, or do both. To this end, female demand is situated as implied agency, with surgeons enabling women to exercise their individualism (Braun , 2010; “Laser Vaginal”, 2010). Groups opposed to the practices, on the other hand, often address the supply of FGCS as the result of a complex web of market and legal shifts. When analyzing these discourses in relation to neoliberal and free market rhetoric, the reality is more convoluted and opinions occasionally overlap.

A key element of various FGCS-focused discourses, as well as their function within neoliberal ideologies, is dependent on how basic terms of the debate are defined. A full understanding of these terms and their usage is imperative in formulating a responsible critique. Consider the numerous and contested meanings of the word nature – and the several permutations thereof – that are commonly deployed in various discourses of FGCS. These multiple meanings of nature can rarely be separated from each other, and form messy, indiscrete categories (Williams, 1985). Nature serves distinct and, at times, contradictory purposes for various speakers on all sides of the issue. In the case of the surgeons, pharmaceutical companies, and the marketing teams representing both of these groups, nature is commonly inferred when the term “normative” is invoked. To be “natural” or “normative” in this sense refers to the generalization of a common quality (Williams, 1985) – or a “norm.” Due to the presumed neutrality of scientific discourse, which adds weight to proclamations of the medical world, these common qualities are frequently able to transition into “medical norms” (Foucault, 1978, Terry & Urla, 1995).

An oft-cited example of this process is the adoption of the Masters and Johnson “Human Sexual Response Cycle” as the basis for classification and nomenclature of sexual dysfunction by the American Psychiatric Association (Tiefer, 2006). In some literature, Masters and Johnson’s theory is even referred to as the “‘natural’ sexual response cycle” (Marshall, 2002). As a result of its acceptance as the measure of a normative, natural response, this tool became the one against which the medical establishment measures all sexual responses, physiologies, behaviors, etc. Those individuals who fall outside of the cycle risk being labeled non-normative and/or unnatural.

When reviewing the medical literature regarding sexual dysfunction, there is a sense of a studious avoidance of most

derivations of the term “natural,” which would theoretically allow for more diversity than a normative model. While many scientists and physicians throughout the centuries have been aware of such diversity and difference, they have rarely viewed such variations as benign. In fact, it is within these variations where we find “…recurring slippages between concepts of ‘difference’, ‘deviance’, and ‘pathology’.”

(Terry & Urla, 1995). In this context, FGCS becomes an answer to these “deviances” and “pathologies,” which thrive under the twin protections of a relaxed, neoliberal market and the medicalization of sexuality (Tiefer, 2010). One result of this process is an increase of pathologies mapped onto the female body as a result of the creation of certain cosmetic procedures and the normalization of these cosmetic surgeries as a tool to excise said pathologies (PaulyMorgan, 1991).

Many of the feminist scholars and activists who engage with the industries providing FGCS reference nature and/ or the natural in their rhetoric. It is not surprising, however, that they do so with a different meaning in mind. Often, the term is used to describe the physical bodies of humans, coming from the Latin nasci (to be born) (Williams, 1985).

This usage refers to characteristics present at birth. These terms are, again, couched in the utilization of norm and normative as synonyms. While this usage acknowledges the diversity of the natural human body, including genitals (Tiefer 2010, Karras, et. al, 2010), it also flirts with contradictions as many academics posit the body in the realm of social and/or cultural construction (Tiefer 2010). Judith Butler’s work on the “naturalness artificially induced” addresses nature in the way most utilized by the discourses of feminist scholarship and activism (Butler, 2004). One of the most common threads is that of the “naturalness” of the diversity of genitalia as non-pathological and, thus, not in need of the non-natural or technological surgical interventions (Braun & Tiefer, 2009).

In relation to the above discussion, it is important to understand that under current neoliberal practices and conditions, the market has moved beyond the basic supply and demand model. Demand is created by the market, which supplies for said demand (Brugett & Handler, 2007, Ashcroft, et al., 2007). For example, some critics of FGCS cite the creation of a genital pathology as the direct result of an industry created remedy. A key element of such a critique is the notion that, once a particular behavior or variation has been pathologized, it enters the realm of the medical, a discipline that generally seeks to cure pathologies. Designating the naturally occurring variations of genitalia as pathology, then, is an example of a larger overall move toward what the NVG refers to as the “growing medicalization of sex” (New View Group, 2000). This “medicalization of sex” shares similarities with other pathologies of excess such as the Victorian-era pathologization of female sexuality and the contemporary pathologization of obesity. For the purposes of this research, however, the “growing medicalization of sex” can be most directly traced to a pair of legal decisions whose major effect has been the entry of health

Discourses on Designer Vaginas genitalia are those that do not exist without the imposition of surgery or other corrective measures. As such, women’s bodies become the “docile bodies” of Foucault, able to be “…subjected, used, transformed and improved” (Foucault, 1977).

The 1973 ruling discussed above also ensured the legality of the copious pages of “before and after” photographs of genitalia featured on surgeons’ websites and in their advertising and promotional materials (Tiefer, 2010). Practitioners of FGCS have pages of these photographs available at the click of a mouse, as well as links to YouTube videos featuring themselves performing FGCS (“Laser Vaginal”, 2010). By positing the “after” photographs of highly sculpted, nearly identical genitalia as the aesthetic and healthful ideal, these surgeons tacitly pathologize the genitalia featured in the “before” photographs as unnatural or abnormal, as bodies that require their “expert interpretation” (Terry & Urla, 1995).

In her highly critical coverage of The International Society of Cosmetogynecological Surgeons’ (hereafter ISCGS) 1st Annual Symposium, Cosmopolitan reporter Molly Tiffin quoted a surgeon referring to the highly desirable “Barbie-doll look” for women’s genitals (Tiffin, 2010). Thus, the discourse has circled back upon itself at a place where a woman’s genitals seem to only attain the highly homogenized yet aesthetically acceptable ideal with outside aid.

Gender, Genital, and the Two-Sex Model

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This idealization of highly homogenous genitalia, as well as the pathologization of diversity that accompanies it, are indicative of the important role of the well-established “two gender/sex” model in Western societies. This model is another nexus upon which discourses of FGCS rely, with all sides heavily invested in utilizing said model to convince prospective consumers of FGCS that theirs is the idea that most aligns with the correct concept of acceptable genital aesthetics. While gender’s relation to anatomy is complex, it is also tenuous. Many feminist scholars connect the heavy involvement of society and myriad discourses in the construction of bodies. Within many societies there is a large amount of importance attached to the differences between male and female bodies, and gender and sex are both highly influenced by these distinctions. Anne Fausto-Sterling’s work Sexing the Body is an excellent example of a rich field of feminist scholarship that questions the use of these differences in determining the sex and/or gender of all people, including persons born with ambiguous genitalia in particular (Valentine & Wilchins, 1997).

Western society’s needs to equate sex, gender, and genitals allows for effective usage of the two-sex model within the discourses of FGCS. Braun and Tiefer (2009) contend that social categorizations have resulted in a gendered dimorphism so ingrained within our society that any lack of distinct genital differences between male and female humans is seen as pathological. Under such a system, there is an increased importance to have definitive,

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and medical sciences into the realms of the media, the market, and the marketing industry (Tiefer, 2008).

These decisions were the 1982 Supreme Court case that ruled that doctors could advertise their services and the 1997 removal of FDA prohibitions against the direct advertisement of pharmaceutical companies’ products (ibid).

Both decisions were endemic of the “market-friendly” government of the time and illustrative of the “hands-off ” approach of neoliberal markets (Ashcroft, et. al, 2007). While some consumer groups favored the new laws due to what initially appeared to be an added incentive for companies to be competitive, many medical professionals felt that the new legislation created a definitive conflict of interest (Tiefer, 2008). Cosmetic surgeons and drug companies inundated the public with advertisements for their products and services while utilizing the same advertisements to create a perceived medical need and a very real demand for those same products and services (Tiefer 2010, Marshall, 2002,).

The media and advertising campaigns that create the worry (of an abnormal genital appearance) and produces the demand for FGCS are the same campaigns that offer medical assistance through FGCS. In this instance, FGCS proposes to help women by fashioning the consumer’s body into a more normal, natural, and non-pathological feminine state.

The manipulative abilities of the media are illustrated by the growing visibility of highly altered, ‘cookie cutter’ genitals (Braun, 2005). Such genitals are evident within pornography (print, film, and web based) as well as on the web in the form of plastic surgeons’ advertisements, websites, and YouTube videos (“Laser Vaginal”, 2010). Society’s increasing level of exposure to these kinds of images is the result of another market-friendly court decision. The 1973 decision that relaxed obscenity laws opened the door to images that were deemed “acceptable within community standards,” directly leading to a dramatic increase in the production of pornography. When combined with the advent of the Internet, these factors increased how often women are exposed to vaginas (Green, 2005). Exposure often leads to comparison. But, in the vast majority of cases, what woman are viewing as ideal genitalia are bodies already altered via surgery, Photoshop, or both (Green, 2005, Weil-Davis, 2002). These alterations are not made known to people viewing them, which is made clear when examining statements by a number of surgeons who perform FGCS. One such individual, Dr. Alter, suggests that the genital model/ideal that his clients are informed by comes from heterosexual pornography, a phenomenon he has termed the “Penthouse effect” (Green, 2005). Dr. David Matlock, who is considered a pioneer in the field of FGCS, has suggested pornography to his prospective patients as a sort of catalogue in which to seek possibilities for an ideal post-operative goal. Doctor Matlock, based in Beverly Hills, suggested to his patients that they consult Playboy magazine in order to view examples of “the aesthetically pleasing vulva” (“Laser Vaginal”, 2009). This gives further cause for a troubling of this apparent paradox in which the most attractive and aesthetically acceptable (re: normal)

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visible differences between the two sexes or genders, and these differences are what cosmetic surgical procedures seek to emphasize. The growing debate surrounding such gendered dimorphism can be seen in the fight currently being waged by intersexual adults and their allies against surgical sex assignments performed on infants born with “ambiguous genitalia” (Valentine & Wilchins, 1997). The societal premium placed on distinct and visible differences between male and female genitalia contributes to the creation of both the supply of and the demand for FGCS. As a result, some feminists argue that FGCS be viewed on a continuum that includes other varieties of genital modification, from pubic hair removal (Braun & Tiefer, 2009) to Female Genital Mutilation (FGM) (Green, 2010). While these are extremely disparate actions, the argument for a continuum when addressing questions of genital diversity is one backed as a useful tool in scientific and medical communities (Fausto-Sterling, 2000).

Feminists and members of the medical community not involved with cosmetic surgery have been addressing practices of FGCS with growing criticism. Advertisements which stress alterations that heighten gendered differences based on the appearance of genitalia raise ethical questions and are seen as accentuating form over function. They also imply that enhanced function will follow a modified form, especially when it comes to women’s genitals. This is worrisome because there is a lack of empirical evidence supporting claims like, “FGCS leads to better and more sex for women.” Some FGCS surgeons have refused to discuss any scientific aspects of their work, citing “scientific information as proprietary” and trade-marking their procedures (Tiefer, 2010; “Laser Vaginal”, 2010) in order to protect both their profits and their work against potential challenges from within the fields of medicine and science.

The ISGCS discussed ways to avoid requirements to provide empirical evidence regarding their procedures, such as declaring them purely cosmetic, during meetings at their 2010 annual symposium in Las Vegas (Braun, 2010). It is notable that such a move would result in the negation of any medical claims regarding the necessity of these surgeries, which would in turn result in the eradication of insurance coverage of FGCS in most, if not all, instances.

The Medical Marketing Model- Purchasing Power as Agency for Sale?

With talk of the patenting of surgical procedures and discussions of making FGCS a purely “out-of-pocket,” elective procedure, discussions return to the medical marketing model of the neoliberal markets of Western societies. Tiefer recognizes the 1998 release of Viagra and the advertising deluge that accompanied it as the watershed moment in the creation of this “medical marketing model” (Tiefer, 2010).

This model leans heavily on both neoliberal market conditions and the rhetoric of neoliberalism, which emphasizes personal responsibility and self-improvement and results in the emerging role of self-surveillance to ensure adherence

to the tenets of said rhetoric. Such self-policing behaviors include taking personal responsibility over and engaging in self-improvement of genitals that do not conform to the aesthetic invented by the industry itself. Thus, the market need not police its citizens, since citizens are already policing themselves.

The medical marketing model and neoliberal markets also both engage in a system of rewarding certain consumer behaviours with open approval, which, when backed by the power of media and the capitalist imperative of consumption, often become behaviours rewarded – and thus striven for – by society itself. One example of this is the industry’s celebration of “early adopters” to risk: In the instance of FGCS, these were the women who were willing to take a chance and have the procedures before FGCS was more publicized and accepted. In discourses of neoliberalism, “early adopters” are lauded as cutting edge, brave, and “empowered consumers” (Tiefer, 2010). Consequently, these women were held up as exemplars of agency and power, savvy consumers who utilized new technologies to assert control over their unruly bodies. The highly advertised result of their actions was praise, an ideal aesthetic, and – as a direct result – better and more sex.

The self-regulation that results in the appearance of the discussed “empowered consumer” plays a crucial role within the framework of expanding neoliberal markets. In these markets, the creation of new pathologies produces a category of consumer subjects created via the marketing of new technologies and the pathologies they purport to address.

The result is new and increasing demands for these technologies from a growing consumer base. Since consumer is a word with a complicated history and has been used by various parties in different ways, it is important to understand what meanings of “consumer” are used within these discourses and this area of study.

As a general rule, when the medical and/or pharmaceutical establishments refer to patients as consumers, they are referring to the 20th century, popular use of the word as a synonym for any purchaser of goods (Williams, 1985).

Using this word in such a way gives the appearance of autonomy. As such, it can give an unquestioning subject a feeling of control over a market situation that is actually designed to control or influence his or her actions. This can be especially true in the case of FGCS in the current culture of the “sexual imperative” (Tiefer, 2010), imposed by the aforementioned self-policing that is often a demand of the neoliberal market (Brugett & Handler, 2007). This imperative is similar to the Catch-22 introduced by other technologies, often masked as responsibilities we assume for having them available to us. To have said technologies available, not using them indicates pathology while using them indicates need based on pathology. While it would appear to be a conundrum, the allusion to autonomy in the marketing of these technologies often sweetens the deal, leading the unquestioning public to admit pathology but then gain strength and autonomy through the consumption of a “cure” like FGCS (Braun, 2010).

Discourses on Designer Vaginas The shifting role of consumers and evolving neoliberal market practices are also both of significant import in the evolution of the discourses of FGCS. The place of commerce has dramatically changed in recent history, and society is no longer dependent on a market with an actual, physical location (Brugett & Handler, 2007). With the advent of telephone and Internet shopping and facilitation by television advertisements and infomercials, neoliberal practices have turned the “air” itself into a marketplace. With this transformation, a comparable shift in the supplied goods is also occurring as we move closer to Adam Smith’s initial ideals of [neo]liberalism: The possession of “…a bunch of ‘objects’ as litmus test…” for civilization (Ashcroft, et. al, 2007). The current demand for luxury goods and services in many Western societies bears this out, it is arguable that FGCS, with its lack of sanction within most of the medical academy due to its cosmetic nature, and its out of pocket costs due to a similar lack of sanction within the insurance community, is a luxury good and/or service (Tiefer, 2008; Green, 2010). In a capitalist, consumer culture such as that of America, the ability and decision to purchase FGCS services is then seen as a liberated exercise of personal freedom and betterment, and the highly homogenous “designer vagina” becomes a mark of independence whose irony is made invisible.

Conclusion

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Questions of visibility can be seen as a place where the discourses of FGCS once again converge. While both sides seek publicity, what kind of publicity and how that publicity is utilized are where we see a bifurcation in this seemingly common quest. As surgeons and other proponents of FGCS continue to inundate the market with advertisements for FGCS, activists like the NVG respond in kind, utilizing such diverse tools as sidewalk protests, counter-symposia, journal articles, and congressional testimony. Both sides struggle to stay in the limelight of the ever-expanding media juggernaut, hoping that exposure will inform the public of the “correct” course of action to take within this minefield in order to not only survive, but thrive. In this case, as we watch the intricate discursive choreography of both groups, we must ask ourselves the obvious question: Why should we care at all? If the discourse is never-ending and the logic is circular, what do we hope to accomplish with the knowledge attained at either side’s table?

The most general goal and straightforward answer rests in the humanistic ideal. If we understand the neoliberal forces at work within the markets discussed in this paper as akin to Aihwa Ong’s (2006) “…technology of government…” as a “…profoundly active way of rationalizing governing and self-governing in order to ‘optimize’” (p. 3), then we can begin to comprehend what is at stake. Put simply, the “optimization” and self-governing discussed by Ong are requirements in the attainment of Foucault’s (1977) normalization and/or homogenization. As such, they become stepping stones to a more highly regarded state of

citizenship and belonging in a society that prizes neoliberalism and the ability of its attendant technologies to define those who do not belong within said privileged sphere of appropriate citizenship. In such circumstances, the luxury and autonomy represented by undergoing FGCS is equated with just such responsibility and self-policing, via the “mandate of good health” that is one of the main components of “good” citizenship in neoliberal markets (Tiefer, 2010). On the other hand, women who resist these procedures risk this choice defining them as less than ideal members of society, a dangerous place to reside as the “domain of the non-conforming is punishable…” (Foucault, 1977).

Posited thus, we see that the neoliberal influences that reside within the discourses of FGCS are still, at their most basic, about control. It is only who exerts this control that is being questioned and contested within all sites of FGCS discourse. That this control is so closely linked to ideas of normative sex, gender, and appropriate citizenship is the result of ruptures and fissures. It overlaps within the discourses of FGCS, which can be visualized as tangling and spilling together, leaving us with a discursive Venn diagram of sorts. As such, the discourses of FGCS cannot be viewed in their entirety without pieces from all involved parties being included. As with most concepts in this world, it is more messy and complicated than either side would care to admit.

In addition to discussions of control, perhaps as a result of them, future critiques of FGCS should address the growing questions regarding the possible regulation of these procedures. My discomfort with any regulation of women’s control of their own bodies aside, there is a very real need for a comprehensive exploration of what autonomous agency might look like in cases of FGCS. How can we recognize the difference between women who seek out these procedures due to extreme physical and/or psychological necessity and those who feel the surgeries are necessary due to societal pressure to conform to industry created aesthetics?

What would constitute acceptable, necessary prerequisite conditions for FGCS? Perhaps, as some members of the ISGCS discussed at their 2010 symposium (Braun, 2010), declaring the procedures to be purely cosmetic would be a start. While this would not ensure that surgeons are trained in a particular discipline (such as urology or gynecology) or regulated beyond the statutes that currently govern the cosmetic surgery industry, it would end the problematic tendency toward dubious medical claims now employed by many practitioners.

A further possibility lies within an inquiry into the medical field itself, which had no standard for healthful/“normal” labial length as of the time of this writing. In fact, Braun and Tiefer (2009) discuss the wide diversity in all aspects of women’s genitals, referencing a study whose results also found that visible labia minora are “statistically ‘normal’ and probably more common than invisible ones.” Despite this fact, their research goes on to state that the same (“statistically ‘normal’”) visible labia minora are pathologized as hypertrophic if they extend past the labia majora to a “cer-

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Article tain degree.” The definition of what this “certain degree,” however, has no apparent evidence base and is debated to be anywhere from 2cm to 5cm (ibid). If there is no evidence to support pathologizing this diversity of female genitalia and no real agreement within the medical field regarding the exact definition of what constitutes said pathology, then we would be wise to question its necessity. Why utilize such inexact and unsubstantiated terminology at all? Perhaps it is time to rethink the tools of FGCS discourse, starting with one of the most powerful: language. If there is no evidence and no industry standard, why does the term “hypertrophic labia minora” exist within these or any discourses? Contemplating how such terms originate, how language circulates, and what factions benefit from these processes would serve as an excellent starting point in analyzing the power structures at work within the discourses of FGCS for potential ethical conflicts and possible solutions.

About the Author

Jessica Neasbitt is a recent graduate from the University of California, Berkeley, where she majored in Gender and Women’s studies.

Dr. Juana Maria Rodriguez is the faculty sponsor for this submission. She is an Associate Professor of Gender and Women’s Studies and the Vice Chair for Pedagogy at UC Berkeley.

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Braun, V. (2005). “In search of (better) sexual pleasure: Female genital ‘cosmetic’ surgery”. Sexualities, 8(4), 407-424.

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Article

Neuroscientific Technologies in Security and Defense Strategies Sonya Parashar‡

Introduction

“Mind Control” and the History of Human Research Ethics

‡ University of Pennsylvania, parashar.sonya@gmail.com

The Trust Drug?

This history has long cast a cloud over legitimate brain research, especially in the national security environment.

In recent years, there has been growing academic interest in understanding the role of naturally occurring substances in mental activity. Contemporary work that exemplifies the renewed interest includes the examination of oxytocin, a hormone that mainly acts as a neurotransmitter, and its role in helping to establish trust.. Deciding with whom to share one’s thoughts, and under what conditions, is a fundamental question of disclosure and personal privacy.

One 2005 paper described trust experiments with 156 college students (Zak, Kurzban, & Matzner). In exchange

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No discussion of the ethics of neuroscience and national security research is complete without reference to the controversial history of research relating to the brain and behavior following World War II, specifically the 1947 trial of 23 Nazi doctors and bureaucrats for concentration camp experiments. As part of the judges’ decision, the Nuremberg Code became an internationally accepted code of research ethics for human experiments, though its precise meaning and limitations were unclear (Moreno 2006).

Nonetheless, over the next decades, a few countries and international medical organizations began, somewhat fitfully, to develop standards for medical research. The U.S. Department of Defense adopted a policy modeled after the Code in 1953, becoming the first U.S. government agency to do

Penn Bioethics Journal

Many people believe that modern neuroscience will present vastly expanded opportunities for national security operations, including public safety arrangements and military and intelligence applications. This paper will provide a survey of some of the technical possibilities that are now in use, under investigation, and being speculated about.

This paper will also refer to some of the legal and ethical questions raised in each case and historic precedents. The combination of potentially invasive neurotechnology and questions of public policy is sure to ignite controversy in the years ahead.

In the 21st century, potentially intrusive technologies like wiretaps and thermal imaging seem to be giving way to new and more advanced devices, including those that may be brought under the heading of neurotechnology. Novel imaging, stimulation, and pharmacological interventions may provide access and control over mental activity. Neurotechnologies currently under development might provide the means of altering mental states, such as trust, and assessing psychological states. To the degree that these technologies can be validated and depending on a substantial public interest in the information or modification they may provide, at what point does a reasonable expectation of privacy give way? This question raises a flurry of other questions regarding the accuracy and precision of these technologies in detecting psychological states and the possibility of obtaining unexpressed information from individuals.

so (Moreno 2001). But these efforts did not stop government agencies from conducting human experiments that pushed the bounds of these guidelines. One type of experimentation of particular interest was mind-altering drugs.

Among the first known and documented experiments during the Cold War were those involving a recently synthesized hallucinogen, Lysergic acid diethylamide (LSD).

LSD was accidentally discovered in 1943 by Dr. Albert Hoffman in Basel, Switzerland, not far from the SS doctors at the Dachau concentration camp (Moreno 2006). The Nazis were already experimenting with mescaline as a form of “truth serum.” Concerned about the potential for “brain washing” high-level nuclear scientists, the CIA became interested in defending against mind-controlling substances after World War II. In the CIA, Sidney Gottlieb led a project entitled MKULTRA, which had the aim to understand how to control the human mind using LSD (Moreno, 2001). In one experiment, several scientists’ drinks were spiked with LSD. For one of the unwitting participants, Frank Olson’s experiment went awry. Although the exact circumstances are still contested, the participant’s ingestion of LSD caused a psychiatric crisis that resulted in a fatal fall from the tenth floor of the Statler Hilton Hotel in New York City. Despite this outcome, Gottlieb continued his research in mind manipulation. Agency interest in the application of psychoactive drugs was only intensified as reports were coming out of the Korean War of “glassyeyed” American prisoners. These prisoners seemed to have been manipulated in some way that made them more cooperative, including the signing of false confessions of war crimes (Moreno, 2006).

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for $10, subjects were randomly paired and instructed to make monetary transactions through a computer. The first partner was informed that whatever money she gave to her partner was then tripled and transferred into her partner’s account. The second partner was then informed how much money the first partner gave to her and the total in the account. The second partner was then asked how much money (if any) she would give back to her partner. After this anonymous exchange, twenty-eight milliliters of blood were drawn from each subject and then analyzed for various hormones. The authors hypothesized that, “when people receive a money transfer that is voluntary and intentional, connoting trust, peripheral oxytocin will be higher than when people receive a monetary transfer absent in intention of trust. Behaviorally, this will be associated with trustworthy behavior.” The findings did not fully support the hypothesis; the researchers found that oxytocin responds to signals of trust but is not associated with producing trust itself. However, there may be a causal relationship between perceived trust and oxytocin.

A 2009 experiment described a study testing whether oxytocin is present when one experiences empathy (Barraza & Zak 2009). Using emotional and unemotional videos, the investigators hypothesized that oxytocin levels would increase after viewing the emotional video, and, if there was an increase, it would correlate with a propensity to be more generous to a stranger. Again, the population of subjects was derived from a college campus with 145 undergraduate participants (Barraza & Zak 2009). Two blood samples were taken from each participant. These students were divided into three groups: those who viewed the emotional video and played the Ultimatum Game (UG), those who viewed the control video and played the UG, and those who viewed only the emotional video. The videos were used to test the relationship between oxytocin and empathy. In order to test for generosity, the UG was used to assess this quality. In the UG, the subjects were paired randomly and anonymously. The first partner was given $40 (compensation for two blood draws), and then asked to split the money between him and his partner. His partner had no money prior this encounter. If the second partner accepted the split, both partners were paid the money. However, if the second partner rejected the split, neither partner received any money. Then, subjects were informed of their earnings and given the opportunity to donate the money to charity.

After the analysis, the authors of the paper came to several realizations: empathy correlates to a 47% increase in oxytocin from the baseline and response rates higher in women than in men. These same higher levels were associated with more generosity during the UG. The paper concluded that this is “the first evidence that oxytocin is a physiological signature for empathy and that empathy mediates generosity.” Interestingly enough, in 2005, Swiss researchers conducted a similar experiment in which the subjects were given a spray of oxytocin or the placebo through the nose (Moreno, 2006). In this case, subjects were asked to invest assets through a “banker” so that scientists could as-

sess people’s decision-making processes. From this study, it was concluded that the oxytocin subjects were more likely to trust the banker. However, other scientists have stated that this is a coincidence because it would have taken hours for the oxytocin to pass through the blood-brain barrier (Moreno, 2006).

With the increasing knowledge of mind-altering substances, the logical question to ask is, “Under what circumstances would these drugs be used?” For example, agencies could possibly eliminate the argument for “enhanced (physical) interrogation” and replace it with drug-induced interrogation. Critics will note that mind-altering substances disrupt personhood and autonomy, thereby invading one’s privacy. Forcefully changing brain chemistry, even temporarily, cripples the ability to make an informed decision and to control the information given out. It may allow access to information that might not have been otherwise available prior to the substance. In situations of interrogations, the subject already has comprised rights. Chemical alteration appears to raise the stakes. However, traditional interrogation techniques like sleep deprivation are also brain chemical disruptors. It may be hard to argue that the new psychopharmacologies change the ethical balance.

Enhancement One set of questions about neurotechnologies such as fMRIs, privacy, and national security is raised by the investigation and interrogation of those who are suspected of being threats to public safety, including potential terrorists.

Another set of questions is raised by the possible use of neurotechnologies in improving the capacities of soldiers.

Individuals who are members of armed forces cede nearly all of the rights of other citizens, including their personal privacy (Gross, 2006). Their autonomy is diminished, and therefore, so are other rights that are logically dependent on personal autonomy. Members of armed forces are also expected to undergo a high level of risk in fulfilling their responsibilities, such as keeping fit for duty or returning to their stations, and they may be required to accept medical interventions. In general, soldiers are not obligated to participate in unnecessary medical experiments. But they may be ordered to use unapproved drugs or devices if hostilities have broken out or are imminent and the risk-benefit balance is thought to be acceptable by government authorities.

In such cases, the normal informed consent requirements are waived or modified. Soldiers may also be required to participate in field testing of new materials that have not been validated in controlled studies and to accept training as preparation for novel conditions. Commanders may conclude that an innovative but non-validated intervention provides an increased likelihood of a successful combat mission with reduced loss of life and is therefore necessary.

This being the case, military necessity trumps other considerations. Clearly, once all these other rights are diminished, the right to privacy that is normally accorded to citizens follows naturally.

Article

Training and Learning

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A 2009 National Research Council report undertaken at the request of the U.S. Army focused on potential areas of research in neuroscience that might have Army applications. Among the objectives the Army outlines for the report were to: Identify and recommend novel technologies, methodologies and approaches for assessing and guiding the training of Army personnel to enhance soldier learning… examine pre-existing methodologies and technologies in the government, private and academic sectors to improve cognitive and behavioral performance, under high stress conditions…

The report is then divided into seven chapters that address each of these objectives. Those of particular interest are the establishment of neuropsychological baselines and techniques to “enhance” operatives through neurotechnologies.

One chapter discusses soldier training and learning.

The chapter notes that civilian experiments use a university population, namely undergraduate students, as subjects

in their experiments and use these results to predict what happen in a military setting. Using the right population is crucial because it will help create the appropriate baseline when assessing results. The report suggests that, for military purposes, a more suitable experimental population such as high-performance athletes could be used. Highperformance athletes mirror the cardiovascular fitness, psychological motivation to perform, training/learning in immersion, and the demanding environment present in military life. There is already extensive literature assessing and evaluating athletes in training, including stress, social interactions, and mild and repetitive concussions that mirror traumatic brain injury in soldiers.

One of the other potential advantages of neuroscientific technologies is monitoring and predicting changes in individuals’ performance efficiency; the neuroscience advantage over self-reporting could allow for self-assessment and even prediction of how an individual’s baseline performance is affected before, during, and after exposure to a particular environmental stressor (physiological, affective, cognitive, and social). Nevertheless, neuroimaging faces a huge order since it must have the sensitivity and specificity needed for monitoring performance in extreme environments, while quantifying and predicting behavior and performance. Experimenters must “distinguish altered activity from normal activity in specific brain structures of those individuals who subjectively report performing at normal levels in order to identify individuals whose performance” in future missions is at high risk of declining.

The 2009 report also discusses the use of neurotechnologies to assess the psychological condition of those who have just entered the armed forces. Currently, “the only Army testing instrument that includes significant elements of neuropsychology and cognitive neuroscience is the Automated Neuropsychological Assessment Metrics (ANAM)”, which evolved during the Vietnam War. At the time, it tested the cognitive ability of soldiers after exposure to chemical agents. The exam “ranges from a simple test of reaction time to dual-task interference tests, which are useful for assessing executive function.” Another use for this test might be to obtain a baseline neuropsychological functions; a number of commanders have instituted predeployment baseline testing for all their troops so that if that if these troops return with a traumatic brain injury (TBI), there will be a gauge as to “how far off ” they are from their normal baseline.

These same technologies can also help in evaluating intra- and interpersonal behavior. Some factors, such as coping with the “unpredictability of danger, concern about resiliency and sustained performance in combat, inability to control situations, separations from family, recovery from injury and death or injury of comrades, and anticipation of returning to civilian life” can weigh heavily on soldiers before, during, and after deployment. Knowing these factors, officials can develop a scenario, add conditions such as “time constraints on decisions, sleep deprivation, environmental stressors,” and then review group unity and look at

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A basic part of preparation for armed conflict is seeking to enhance the abilities of fighters so that they gain an advantage over a potential adversary. Over the past 2,000 years of combat, those enhancements have proceeded to the extent that, where once a single soldier armed with a long sword could control a few square feet (basically the length of the sword), now a single fighter pilot can control hundreds of miles of territory. Despite the priority given to military necessity over soldiers’ bodily autonomy, improvements in warfighter cognition have been much harder to achieve. The U.S. Army has shown interest in neuroscience technologies in both guiding their selection of soldiers and then further enhancing their abilities.

Nevertheless, the U.S. Army’s interest in the neurotechnologies of enhancement is not novel. In 1988 and 1994, the U.S. National Research Council’s Committee on Techniques for Enhancement of Human Performance reported on topics such as “enhanced training, deceiving and deception, managing stress… subliminal self-help, neurolinguistic programming, hemispheric synchronization, hypnosis, and meditation.” The committee also reported, though it did not endorse, Army interest in extra-sensory perception (ESP) and psychokinesis (PK). One of the reports described “warrior monks who would leave their bodies at will, levitate, psychic healing, and walk through walls,” and could potentially guide an incoming missile into another dimension where it would harmlessly detonate (Druckman and Swets 1988). More recently, two other National Research Council reports on army applications of neuroscience were produced in order to further guide the national security agencies’ interest in neuroscience. These two were entitled “Emerging Cognitive Neuroscience and Related Technologies” (2008) and “Opportunities in Neuroscience for Future Army Applications (2009).”

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Neuroscience Technologies “the neuropsychological characteristics that correlate with the observed behaviors can be examined for insights into whether and why cooperation is sustained or fails.” One way these programs are being developed is through game theoretic scenarios in which groups have the ability to cooperate, compete, or punish. One limitation to examining teamwork through these technologies is that fMRI, PET, and magnetoencephalography are techniques used in isolation. So, the ability to assess behavior changes is limited to those situations since the techniques were not designed to take interpersonal influence into consideration.

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Improving Decision-Making

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The 2009 Army’s neuroscience report also discusses ways in which the Army might allocate funding so that it can optimize soldiers’ decision-making abilities and sustain soldier performance for up to 96 continuous hours. One of the main problems with decision-making, especially decision-making under stress, is that humans tend to make “suboptimal” decisions. However, individuals can be taught how to be efficient decision makers.

The report describes how neuroimaging may optimize the decision making of “its soldiers and officers in both—(1) identifying and providing countermeasures to suboptimal decision making and (2) identifying and making optimal use of individual variability in decision-making traits.” The advantage that neuroscience has brought to understanding belief-based decision-making is said to be the “ability to assign component processes to specific brain regions and to potentially target these regions for monitoring and modulation purposes.” Suggestions were also made to account for individual traits during the process. Exams, such as the Neuroticism-Extroversion-Openness (NEO) personality inventory and Minnesota Multiphase Personality Inventory (MMPI), attempt to account for these traits. Emotional reactivity can also be quantified in decision-making using galvanic kin response (GSR), which essentially measures the changes in skin conductivity or rate of sweating. This particular exam may also be useful in diagnosing soldiers with post traumatic stress disorder (PTSD).

Extended Performance

Neuroimaging technologies are closely related to research and development in other areas of interest that they might help measure, such as improved soldier performance for extended periods. DARPA’s “peak soldier performance” program aimed to improve metabolism on demand so that an individual could operate at a high level for three to five days without sleep and calories, using only nutrition pills (Moreno, 2006). Recent experiments have addressed the stresses that seem to accompany prolonged performance, including: …stresses on the soldier affect both mind and body—the brain and the traditional somatic systems and organs. Due to complex interactions between neurophysiological and conventional physiological responses, a stressor contributes to the degradations of

performance that occur during sustained and intense operations and growing importance of individual variability in all of the areas where neuroscience can contribute to Army applications (“Committee on Opportunities in Neuroscience for Future Army Applications,” 2009).

One of the major conclusions of the Army neuroscience report is that performance during prolonged periods of physiological and mental stress “depends not only on the ability to maintain the physical effort required but also to maintain good mental functioning.” Stress can partly be managed by alleviating Central Nervous System (CNS) fatigue. According to the report, “CNS fatigue may be caused in part by reduced glucose availability, imbalances between serotonin, dopamine, adenosine, along with an increase in circulating ammonia, inflammatory cytokines, and sometimes elevated brain temperature.” In order to prevent CNS fatigue, a hearty dosing of carbohydrates and caffeine (which increase glucose and dopamine), while decreasing serotonin and adenosine, is prescribed. Another possible treatment is with quercetin and curcumin, which “may work through their antioxidant and anti-inflammatory activity along with an increase in mitochondrial biogenesis.”

Essentially, quercetin has a similar binding affinity to that of caffeine; in addition, its antioxidant properties may allow soldiers to operate at full capacity for 72 hours.

Prolonged wakefulness is included in the umbrella of sustained soldier performance. Essentially, how does one beat the need to sleep without foregoing sleep and facing the consequences of sleep deprivation? There have been some studies that show that napping in one hemisphere at a time while still being awake in the other hemisphere allows for the memory consolidation that seems to be an important function of sleep. Furthemore, the drug N-methyl-Daspartic acid, NMDA, a receptor-positive modulator, also enhances memory consolidation. Currently, some other medications are being prescribed for sleep-depriving environments. Modafinil (brand name Provigil), is prescribed for pilots in the Air Force who are tasked to fly prolonged missions (Moreno, 2006). Historically, amphetamines and caffeine were the warfighters’ drugs of choice, but they may give way to new anti-sleep agents. Setraline hydrochloride (Zoloft, Lustral) is often prescribed to troops who have sustained repeated combat exposure to reduce the consequences of persistent stress and risk of depression. However, there are important issues of abuse and long-term effects like unacceptable risky behavior and other poor decisions, not to mention significant variations in drug response.

Brain imaging will have an important role in assessing the risks and benefits of these drugs.

Conclusion National security agencies’ interest in neuroscience remains modest. The future depends on success in the laboratory and its potential for field application. However, scientific and engineering standards will not by themselves establish the acceptability of neuroscience-based technolo-

gies. The public may be more willing to tolerate questionable or non-validated technologies if they appear to provide any advantage over an adversary, especially if those involved are military personnel or suspected terrorists whose privacy rights are compromised. The uses of neuroimaging in various contexts that bear on public safety but raise questions of personal privacy and autonomy will require strict watching.

About the Author

Sonya Parashar is a recent graduate from the University of Pennsylvania, where she majored in Ancient History and Biology.

Dr. Jonathan D. Moreno is the faculty sponsor for this submission. He is the David and Lyn Silfen University Professor of Medical Ethics, Professor of History and Sociology of Science, and Professor of Philosophy at the University of Pennsylvania.

References “Committee on Military and Intelligence Methodology for Emergent Neurophysiological and Cognitive/Neural Science Research in the Next Two Decades.” National Research Council of the National Academies (2008). Emerging Cognitive Neuroscience and Related Technologies.

(Washington, D.C.: The National Academies Press) “Committee on Opportunities in Neuroscience for Future Army Applications.” National Research Council of the National Academies (2009).

Opportunities in Neuroscience for Future Army Applications. (Washington, D.C.: The National Academies Press) Druckman, D. and Swets, J. A. (eds.) (1988). Enhancing Human Performance: Issues, Theories, and Techniques. (Washington, D.C.: The National Academies Press) Gross, Michael L. (2006) Bioethics and Armed Conflict: Moral Dilemmas of Medicine and War. Cambridge, MA: MIT. Marks, John D. (1988) The Search for the “Manchurian Candidate”: the CIA and Mind Control. New York: Dell.

Moreno, Jonathan D. (2001) Undue Risk: Secret State Experiments on

Humans. New York: Routledge.

Moreno, J.D. (2006) Mind Wars: Brain Research and National Defense.

(Washington, D.C.: Dana Press) “Planning Committee on Field Evaluation of Behavioral and Cognitive Sciences-Based Methods and Tools for Intelligence and Counterintelligence.” National Research Council. (2010). Field Evaluation in the Intelligence and Counterintelligence Context: Workshop Summary.

Washington, DC: The National Academies Press.

United States v. Scheffer, 523 U.S. 303 (1998) Barraza, Jorge, and Paul Zak. (2009)”Empathy toward Strangers Triggers Oxytocin Release and Subsequent Generosity.” Values, Empathy, and Fairness across Social Barriers 1167: 182-89. Print.

Zak, Paul, Robert Kurzban, and William Matzner. (2005) “Oxytocin Is Associated with Human Trustiworthiness.” Hormones and Behavior 48: 522-27. Print.

For information and application materials, contact: Director of Admissions, Center for Bioethics and Health Law, Suite 300, Medical Arts Building, 3708 Fifth Avenue, Pittsburgh, PA 15213; bioethic pitt.edu; 412-647-5700; see also www.bioethics.pitt.edu.

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Designed for clinicians, lawyers, and students of the humanities and social sciences, this interdisciplinary program emphasizes the philosophical foundation of bioethics and offers opportunities for clinical experience and in-depth research. This program of the Center for Bioethics and Health Law and the School of Arts and Sciences allows students to combine study in ethical theory, philosophy and history of medicine, cultural and gender studies, health law, public health, and social sciences. Students may complete coursework, including clinical practica, in one calendar year. A thesis is required. Joint JD/MA and MD/MA programs are available. Applications are considered on a rolling basis, beginning February 1 until August 15 or until the class is filled. Financial assistance may be available to highly qualified applicants who apply early.

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MASTER OF ARTS IN BIOETHICS University of Pittsburgh

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Article

Medical Ethics During the War on Terror: Detainee Treatment and Experimentation by Health Professionals Thomas A. Quinn‡

The United States’ War on Terror has resulted in considerable change in national policy and practice regarding the treatment of detainees. Since the beginning of the war, health professionals practicing within the government and military have had conflicting duties that have resulted in the mistreatment of detainees. The force-feeding of detainees in the Guantanamo Bay detention center and the CIA’s research on “enhanced interrogation techniques” represent unethical medical treatment and experimentation, respectively. To prevent further abuse, the bioethical community must address both the United States’ current oppressive policies regarding the treatment of detainees and the challenges inherent in practicing medicine, when in a military and/or government capacity.

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Introduction Health professionals who serve in the military or the government have responsiblities that inherently conflict with each other. As practitioners of medicine, they must balance the principles of beneficence, non-maleficence and autonomy. To complicate matters, by serving in the military or for the government, they must abide to the orders of their superiors. This inherent conflict of duty has resulted in medical mistreatment in the realms of both clinical practice and research, especially during times of war.

The Nazi hypothermia experiments serve as a prime historical example of cruel medical experimentation conducted by physicians in the name of military necessity. The German Luftwaffe and U-boat service lost many pilots and sailors due to hypothermia in the North Sea. As a result, the Nazis invested time and funds in research that could both ascertain the survival time of humans in the cold waters as well as determine the most effective way to warm individuals should they be rescued (Pozos, 2003). The Nazis established a set of experiments, most of which were conducted by Dr. Rascher in the Dachau concentration camp during 1942. One set of experiments determined the human response to freezing water in a tank that was kept between 2.3-12oC (35.6-50oF). Prisoners were either naked or dressed in the equipment of a Luftwaffe pilot, including a life jacket. Collected measurements included rectal, skin, and sometimes intragastric temperatures (Pozos, 2003). By studying those not participating in the re-warming experiments, Dr. Rascher determined that death occurs between fifty-three to one hundred minutes of immersion in ice water. Neverthless, Dr. Rascher’s experimental notes showed that while it took an undressed person between eighty minutes to six hours, a man in full aviator’s dress took six or seven hours to kill (Alexander, 1949). The post-war 1946 Alexander Report says that 107 subjects were tested with at least 13 deaths recorded. However, a technician working

for Dr. Rascher claimed that 280-300 subjects were tested and that 80-90 of those subjects died (Pozos, 2003).

Despite the fact that the hypothermia studies were extremely cruel and inhumane, Dr. Rascher obtained results that aligned with his goals for the study. He found that rapid rewarming of subjects in a hot bath was the best method for raising the core body temperature of hypothermic subjects (Pozos, 2003). This would prove relevant in that Nazi pilots shot down over the North Sea would be rescued but still die due to a their decreased body temperature (Pozos, 2003). In addition, he found that ethanol consumption did not help the rewarming of subjects. This was a common myth at the time, and alcohol was often given in an effort to better rewarm rescued hypothermic soldiers (Pozos, 2003).

A final significant find was that the subjects’ core body temperatures dropped faster and lead to quicker fatalities if their back of the neck and head were submerged (TWC, 1949-1953). This finding would lead to improvements in life vest design that are still applicabletoday.

Nevertheless, these supposed benefits came at the inexcusable cost of human life and suffering. Following the atrocities of these experiments and others headed by members of the Third Reich, many of the physicians involved were indicted during the subsequent Nuremburg Trials.

Some received jail time and others were given death sentences. Afterwards, the Nuremburg Code was adopted in an effort to protect against further abuse in human subject research.

While this code protects human subjects from being deliberately killed, the United States has recently been heading in a direction where some dubious actions by physicians are not only being permitted but also encouraged by the military and the government. Like the previously mentioned experiments, more contemporary experiments have been carried out under the guise of national interest.

Actions have been in what the physician deems the pa-

28 ‡ University of Pennsylvania - College of Liberal and Professional Studies, ThomasQuinn87@gmail.com

Medical Ethics During the War on Terror tient’s best medical interest but have been at the expense of patient autonomy and decency. Discussion and awareness of the difficult decisions physicians face during war are imperative to prevent further deterioration of medical practice and research.

After the September 11, 2001 terrorist attacks on the World Trade Center and the Pentagon, the United States declared a war against terrorism. Some unfortunate byproducts of the war have been the changing of US policies regarding the Geneva Convention’s applicability to Taliban and Al Qaeda detainees and the dilution of the requirements for what is considered human experimentation by the 2006 Military Commissions Act. The combination of unethical government policies and the inherent conflict of duty put military or government health professionals in a precarious situation.

Modified U.S. policies regarding force-feeding, waterboarding, human experimentation, and other inhumane treatment have blurred the line between legally and ethically acceptable and unacceptable practices. Governmental pressures lead U.S. health professionals to relax their ethical standards. The has resulted in an increase in significant wrongdoings in clinical practice and human research. Two case studies, namely the Guantánamo Bay force-feeding and the CIA torture experiments, illustrate this problem and point to an urgent need for action by the bioethics community.

Medical Treatment: Guantánamo Bay Force-Feedings

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Since the opening of the Guantánamo Bay detention camp in 2002, a number of detainees have gone on hunger strike with at least 210 striking at the peak of its severity in August 2005. Prison hunger strikes have historically occurred in countries where individual rights have been violated. Prisoners in these situations often hunger strike as their only available means to protest, since they are deprived of normal channels for issuing grievances such as petitions, open letters, and freedom of expression (Reyes 1998).

Through hunger protests, the detainees at Guantánamo challenged the lawfulness of their indefinite detention and the harsh conditions of their confinement. Problems faced by the prisoners include religious discrimination, denial of family contact, and lack of basic resources such as proper food, water, sunlight, and medical treatment. Notably, the right to have a legal advisor is denied, and a neutral body to observe the situation and maintain basic standards in the detention center is absent. Many of the detainees intended to strike until either they starved or their demands were met (Gutierrez 2005). These hunger strikes have led to the force-feeding of detainees by military medical personnel, presumably “to save lives.” Pentagon spokesman Navy Lt. Cmdr. J.D. Gordon, for example, cited Defense Department officials saying “preservation of life through lawful, clinically appropriate means is a responsible and prudent

measure for the safety and well-being of detainees (White 2006)”.

Force-feeding hunger strikers violates the 1975 World Medical Association’s Declaration of Tokyo which states, “Where a prisoner refuses nourishment and is considered by the doctor as capable of forming an unimpaired and rational judgment concerning the consequences of such voluntary refusal of nourishment, he or she shall not be fed artificially” (World Medical Association 1975). It is important to note that the declaration has also been endorsed by the American Medical Association, which represents U.S. physicians.

Although the Declaration of Tokyo is not a legally binding international law, it is an internationally accepted set of guidelines that explicitly condemns physician participation in torture and cruel, inhumane, or degrading treatment, as well as any act that diminishes the ability of the victim to resist such treatment. The enforcement of the Declaration is entirely up to national and state regulatory bodies.

Unfortunately, the human rights abuses stemming from the force-feedings of mentally competent detainees go beyond the violation of consent and enter the realm of abuse and disregard for basic human decency. One detainee described the process during an interview with lawyers in January 2006: “The head is immobilized by a strap so it can’t be moved, their hands are cuffed to the chair and the legs are shackled... they ask, ‘Are you going to eat or not?’ and if not, they insert the tube. People have been urinating and defecating on themselves in these feedings and vomiting and bleeding. They ask to be allowed to go to the bathroom, but they will not let them go. They have sometimes put diapers on them (Golden et al., 2006).”

Other accounts describe this treatment and placement in solitary cells with no food or water for five days before the authorities resumed the force-feedings with larger tubes.

They estimated these Nasal Gastric (NG) tubes to be the thickness of a finger. According to the accounts, the riot guards would remove these “NG tubes by placing a foot on one end of the tube and yanking the detainee’s head back by his hair, causing the tube to be painfully ejected from the detainee’s nose. Then, in front of the Guantánamo physicians ... the guards took the tubes from one detainee, and with no sanitization whatsoever, reinserted it into the nose of a different detainee. When these tubes were reinserted the detainees could see the blood and stomach bile from the other detainees remaining on the tubes.” The head of the detainee hospital watched and made no attempt to intervene (Thomas, 2005).

It is understandable for health professionals to desire the preservation of life, but their desire does not give them free reign to disregard detainee autonomy. It especially does not warrant the degradation and abuse that the hunger-striking detainees endure. The problem has worsened since the Department of Defense adopted the policy of force-feeding despite its contradiction to the Declaration of Tokyo. The pressure of governmental orders coupled with a desire to “save lives” puts health professionals in a difficult position that has ultimately resulted in a serious human rights violation.

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Article

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Human Experimentation: CIA Torture Experiments

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Physicians for Human Rights (PHR) is an international nongovernmental organization that seeks to promote health by protecting human rights. Its role is to expose human rights violations and to hold those accountable, including physicians. Several reports presented by PHR indicate that health professionals working for the CIA monitored the tortuous interrogations of detainees, collected and analyzed the results, and sought to derive generalizable inferences to be applied to subsequent interrogations. Essentially, these health professionals were involved in illegal human experimentation. The interrogations utilized so called “enhanced interrogation techniques (EIT’s),” including waterboarding, forced nudity, sleep deprivation, temperature extremes, stress positions and prolonged isolation.

According the PHR reports, medical professionals monitored all waterboarding practices and collected information that was used to design, develop and deploy subsequent waterboarding procedures. The August 2009 PHR report detailing physicians aiding in the torture of detainees states: “Medical doctors and psychologists colluded with the CIA to keep observational records about waterboarding, which approaches unethical and unlawful human experimentation. Interrogators would place a cloth over a detainee’s face to block breathing and induce feelings of fear, helplessness, and a loss of control as they poured water over the face to simulate the sensation of drowning. A doctor would stand by to monitor and calibrate this physically and psychologically harmful act, which amounts to torture.” According to the report, the required presence of health professionals did not make these methods safer, and only served to sanitize their use and enable the abuse to escalate, thereby placing them in the position of calibrating harm rather than serving as protectors and healers as required by their ethical oath (Allen et al., 2009).

Evidence later appeared in a June 2010 PHR report detailing explicit examples of physicians engaging in unethical human subject research and experimentation. One result of their research was that a physician recommended the addition of salt to the water used for waterboarding detainees in order to prevent hyponatremia, a potentially life threatening condition caused by low sodium levels in the blood and excess water ingestion. This change in protocol was deemed necessary due to the potentially large volume of water detainees could ingest from multiple bouts of waterboarding.

The technique, named “waterboarding 2.0,” was used on one CIA detainee, Khalid Sheik Mohammed, at least 183 times (Raymond et al., 2010).

Other examples of health professional involvement in illegal human experimentation exist, including the monitoring and assessing of varying levels of sleep deprivation in order to support legal definitions of torture and to plan future sleep deprivation techniques. Interrogators subjected detainees to varying levels of sleep deprivation including 48,

96, and 180 hour increments. In addition, health professionals subjected detainees to combined applications of EIT’s to determine if one type of application over another would increase the detainee’s susceptibility to severe pain. The goal of that research appears to have been only to assess the legality of the EIT’s and to guide their future application (Raymond et al., 2010).

EIT’s, which had previously been recognized as illegal, were redefined by the Bush administration to be “safe, legal, and effective” as long as they did not pass the “legal threshold” for severe physical and mental pain established by the Department of Justice Office of Legal Counsel (OLC). The OLC defined torture as an act causing “long-term” mental harm or physical “pain and suffering” equal to the pain and suffering inflicted by either organ failure or death (Ozer 2003).

Physicians for Human Rights states that this process of human experimentation appears to have been motivated by the need to justify and shape future interrogation policy and procedure, as well as the legal environment in which the interrogation program operated. By calibrating the EIT’s so they do not cross the threshold for torture as established by the OLC, they could mitigate the legal liability of interrogators against torture charges by providing a “good faith” defense. It would also legitimize the use of these EIT’s against detainees.

While the OLC may have legalized the use of EIT’s and there may have been motivations to participate, such as employment by the CIA or feelings of nationalistic duty in a post-9/11 USA, health professional involvement in torture opposes their duty to “do no harm.” In addition to the aforementioned motivations for conducting these experiments, any potential additional motivations by medical professionals to strive for some kind of “safe, legal and effective” torture, as misguided as that already is, is overshadowed by the fact that they participated in illegal human experimentation on a vulnerable prisoner population. This nonconsensual experimentation is contrary to the Nuremberg Code and the Belmont Report, and should therefore be deemed a crime against humanity. Overall, this case study illustrates how widely acknowledged standards can be disregarded by health professionals during times of war. It also highlights the necessity for the bioethics community to address this problem.

Conclusion The case studies discussed serve as examples of how the United States health professionals have allowed the pressures of war to affect their ethical judgment. The inconsistency among current governmental policies with conventional international standards for ethical conduct has created an environment that facilitates deviation from proper medical conduct in both clinical practice and research. Although these policies have created an undesirable environment, health professionals have a professional responsibility to practice ethical medicine regardless of the pressures of politics and war. Despite whatever governmental or military roles they

Medical Ethics During the War on Terror been involved in the force-feedings in Guantanamo and the CIA EIT experiments should be released to the public. They should be referred to state licensing boards for breaches in professional codes of conduct to be potentially delicensed and put under criminal investigation for abuse and torture.

The third strategy – to drive change in U.S. policy back to international standards – may prove to be the most difficult.

This third goal seeks to outlaw the unethical medical practices that have pervaded the U.S. since the start of the War on Terror and would effectively reduce the potential for health professionals to be put in precarious situations in the first place. As of now, the Guantanamo Bay detention camp remains open. Fortunately, the provisions of the 2006 Military Commissions Act suspending habeas corpus are no longer in effect. However, the Military Commissions Act also lowered the bar for what is considered biological research and gives a supposed legality to physician involvement in the tortuous CIA EIT experiments. The Military Commissions Act’s vague wording regarding biological experimentation disregards informed consent and fails to consider that research is being conducted on an inherently vulnerable prisoner population. Clearly, the Act is a diversion away from highly moral international law, and should therefore be revised or nullified. The tighter language found in the Geneva Convention that defines illegal human experimentation needs to be recognized as the standard and must be upheld by the U.S. government. Bioethicists must discuss viable methods of pressuring policy makers to revert the US’s position back towards that of complying with international ethical standards.

Dr. Weltz, a Nazi physician that was also involved in the hypothermia studies, used war as a justification for the experiments. He said, “The Hippocratic Oath ... is an honorable historical document, which, however, does not altogether fit present times... Medicine based upon the principle of nil nocere (“do no harm”) is a very impoverished medicine, and we are unfortunately not in a position to carry on medicine on that simple principle today (TWC 1946-1954).” As shown, this line of thinking can easily arise during the pressures of war. If the issues described in the paper are not addressed during the coming years, the opportunity remains open for further human rights abuses and atrocities to be committed in the name of nationalism.

Thomas A. Quinn is a recent graduate from the University of Pennsylvania, where he majored in Bioengineering with minors in Biology and Chemistry.

Dr. Evelyne Shuster is the faculty sponsor for this submission. She is a Lecturer of Medical and Research Ethics at the University of Pennsylvania.

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About the Author

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may concurrently have, they are health professionals first and foremost.

Unless the bioethics community exercises pressure on the U.S. government to change its “War on Terror” policy and to respect human rights when dealing with detainees, abuse will continue under the pretext of national security.

The bioethics community could concentrate on a three-fold strategy: 1) educate health professionals about the conflicts of duty inherent in concurrently working for a governmental agency or the military, especially during times of war; 2) enforce greater accountability for health professionals and punishing those involved in unethical medical clinical practice or research, especially those accused of crimes against humanity, and; 3) apply increased pressure on the U.S. government to respect international human rights laws, the Geneva Conventions, and the International Covenant on Civil and Political Rights. The first strategy – educating health professionals about issues that can arise as a result of conflicts of duty – can be accomplished by greater instruction on this issue for both medical students and practicing physicians. A 2007 study questioning students from eight medical schools found that 94% had received less than one hour of instruction about military medical ethics. Considering the lack of instruction, it’s not surprising that 33.8% did not know the Geneva Convention states that physicians should “treat the sickest first, regardless of nationality” or that 33.9% did not know when it is permissible to disobey unethical military orders (Boyd, 2007). Therefore, it is imperative that medical students receive greater instruction on conflicts of duty with topics that include working within the confines of both the military or government. This can be accomplished by reviewing case studies and fostering discussion amongst the students. The same recommendation applies for practicing physicians, especially those already working in the military or government. A starting place for accomplishing this may be to require that medical schools cover these topics.

The second strategy – to enforce greater accountability and punish those breaching established international ethical standards – is necessary in order to provide justice for those that have been wronged, to prevent future wrongdoings by the perpetrators, and to provide a deterrent to others. Information on the physicians that are known to have

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References

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Alexander, L. (1949). Medical Science Under Dictatorship. The New England Journal of Medicine, 241(2), 39-47.

Allen, S., et al. (2009, August). Aiding Torture: Health Professionals’ Ethics and Human Rights Violations Revealed in the May 2004 CIA Inspector General’s Report. Physicians for Human Rights. Cambridge, MA. Boyd, J., et al. (2007). U.S. medical students’ knowledge about the military draft, the Geneva Conventions, and military medical ethics. Int J Health Serv, 37(4), 643-50.

Golden, T., & Schmitt, E. (2006, February 22). Force-Feeding ������������������������ at Guantánamo Is Now Acknowledged. New York Times. Retrieved from http:// www.nytimes.com/2006/02/22/international/middleeast/22gitmo. html Guantanamo Force-Feeding Tactics are Called Torture. Washington Post.

Retrieved from http://www.washingtonpost.com/wpdyn/content/ article/2006/02/28/AR2006022801344.html Gutierrez, G., et al. (2005). The Guantánamo Prisoner Hunger Strikes & Protests: February 2002 – August 2005. Center for Constitutional Rights. Retrieved from http://ccrjustice.org/files/Final%20Hunger%20 Strike%20Report%20Sept%202005.pdf Ozer, E. J., et al. (2003). Predictors of Posttraumatic Stress Disorder and Symptoms in Adults: a Meta-Analysis. Psychol Bull, 129, 1243.

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Pozos, R. (2003). Chapter 15 - Nazi hypothermia research: should the data be used?. In T. Beam (Ed.), Military medical ethics. volume II (pp.

437-461). Washington, DC: Office of the Surgeon General at TMM Publications.

Raymond, N., et al. (2010, July). Experiments in Torture: Evidence of Human Subject Research and Experimentation in the “Enhanced” Interrogation Program. Physicians for Human Rights. Cambridge, MA. Reyes, H., (1998, January). Medical and Ethical Aspects of Hunger Strikers in the Custody and the Issue of Torture. Geneva: International Committee of the Red Cross.

Thomas, M. (2005, November 7). Mark Thomas is Sickened by Guantanamo. New Statesman. Retrieved from http://www.newstatesman. com/200511070015.

TWC. Trials of War Criminals Before the Nuremberg Military Tribunals - Washington D.C., U.S Govt. Print. Off.,1946-1954, Vol. IV:10811084.

TWC. Trials of War Criminals Before the Nuremberg Military Tribunals - Washington D.C., U.S Govt. Print. Off., 1949-1953, Vol. I:220.

White, J (2006, March 1).

World Medical Association. (1975) Declaration of Tokyo. Toyko, Japan.

Article

The Ethics of Medical Involvement in Lethal Injection Executions: Discussing the Role of the Anesthesia Provider Giby George‡

During executions by lethal injection, inexperienced and uneducated non-medical personnel called “lethal injection technicians” are often required to perform the execution, allowing for the possibility of physical pain and suffering by the condemned. The involvement of physicians and nurses in lethal injection executions is said to violate the belief that members of the medical community are to “preserve life when there is hope of doing so.” Thus, involvement in lethal injection executions goes against the policies of the American Medical Association (AMA), American Nurses Association (ANA) and, most recently, the American Board of Anesthesiology (ABA) (AMA, 2010). In cases of execution by lethal injection, however, courts determine the fate of condemned individuals. Therefore, members of the medical community cannot legally preserve the lives of sentenced individuals. In these cases, physicians and nurses, specifically anesthesiologists and nurse anesthetists, must strive to alleviate the physical pain and suffering of the condemned during the remaining moments prior to their execution. In executions, the anesthesiologist and/or nurse anesthetist should not intend to or aim to carry out capital punishment as a tool of the government but rather to ensure the respectful, humane treatment of the condemned.Should the U.S. government and the medical community be unable to mutually conciliate in order to ensure the physical welfare of the condemned in lethal injection executions, then an alternative, suitable mode of execution must be established by policymakers that would both adhere to the Constitutional mandate against “cruel and unjust punishment” and not be said to conflict with medical ethics, as expressed in the AMA’s Opinion 2.06.

Introduction

Volume VII Issue i

‡ Drexel University, gibyvgeorge@gmail.com

drug(s) via IV infusion, maintaining IV access, monitoring cardiac rhythm and/or electroencephalography (EEG) activity, and pronouncing death (Gawande, 2006). The involvement of non-medical personnel, who are less educated, less experienced, and/or uncertified in medical practices relating to injection procedures, poses a risk to the physical welfare of the condemned, and may consequentially violate the Constitutional prohibition against “cruel and unusual punishment” ( Johnson, 2008). Therefore, a balance must be struck between honoring medical ethics and abiding to the U.S. Constitution (Lanier and Berge, 2007).

It is important to note that the issue here is not whether capital punishment itself constitutes “cruel and unusual punishment” and is permissible under the U.S. Constitution, but rather whether or not allowing medical personnel to participate in lethal injection executions would conflict with modern medical ethics.

The AMA’s Code of Medical Ethics, incorporated by a number of other medical organizations, dictates the practices of medical personnel, specifically those of physicians and nurses. To continue prohibiting the medical community from assisting during lethal injection executions would, in addition to possibly violating the U.S. Constitution, be contradictory to the public role of the physician, which remains “to [heal] the sick and [alleviate] suffering,” as pre-

Penn Bioethics Journal

Given that capital punishment is legal in more than half of the states in the U.S. and that the most frequently employed mode of execution in each of these states is lethal injection, the medical community, specifically physicians and nurses, should be permitted to participate in lethal injection executions to moderate the physical pain of the condemned.

Currently, in most cases, physicians and IV –certified and –experienced medical professionals are either prohibited from or strongly advised against partaking in lethal injection executions by the major medical associations (Waisel, 2007). Medical societies, board associations, and overseeing healthcare professionals and authorities regard the involvement of medical personnel in lethal injection executions as a direct violation of the Hippocratic Oath and of the American Medical Association’s (AMA) Code of Medical Ethics (Waisel, 2007; Lanier and Berge, 2007).

In instances when physicians are either prohibited from participating or reluctant to become involved in executions, non-medical personnel, commonly referred to as “lethal injection technicians,” may be requested to provide medical assistance ( Johnson, 2008). Such medical assistance may entail establishing intravenous (IV) access for the subsequent administration of the drug(s), administering the

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Ethics of Medical Involvement in Lethal Injection Executions mised on the AMA’s Opinion 2.06 (Black and Slade, 2007).

Prior to elaborating on this argument and addressing the counter-arguments that may be posed, a brief history of execution by lethal injection, namely its development and the current drug regimen(s), may aid in understanding the reason for lethal injection execution.

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History of Execution by Lethal Injection an Current Drug Regimen(s)

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Originally, lethal injection was proposed as a humane alternative to existing methods of execution such as electrocution, hanging, the gas chamber, and the firing squad (Kellaway, 2003). Following a Supreme Court ruling in 1971 in Furman v Georgia, the aforementioned modes of execution were established to be unconstitutional, as they constituted “cruel and unusual punishment” (Lanier and Berge, 2007). These modes of execution were found to be either too time-consuming or dangerous ( Johnson, 2008).

The death penalty was therefore revoked for a period of approximately five years, during which suitable, alternative modes of execution were being investigated.

Following this brief hiatus, the death penalty was reinstated by the Supreme Court in 1976 in Gregg v Georgia, prior to the development of the lethal injection (History of the Death Penalty, 2010). Subsequently, execution by a three-drug regimen lethal injection was first developed by Jay Chapman, MD, later approved by Stanley Deutch, MD in 1977, and then first performed in Texas, 1982 (Denno, 2007; Kellaway, 2003).

Oklahoma became the first state to adopt lethal injection as its primary means of execution (Methods of Execution, 2010). Since the first lethal injection execution in 1982, presently, all 35 states that permit capital punishment list lethal injection as their primary mode of execution (Methods of Execution, 2010). Seventeen of these states require direct or indirect physician participation (Zimmers and Lubarsky, 2007). Few states provide the condemned with the previously mentioned alternative modes of execution (Methods of Execution, 2010).

According to the three-drug lethal injection regimen, three drugs are delivered sequentially via IV infusion. First, sodium thiopental, a short-acting barbiturate, is administered and is intended to sedate the sentenced individual (Koniaris et al., 2005). The administration of sodium thiopental is absolutely crucial as it prevents the sensation of pain associated with potassium chloride administration (Heath, 2008). Therefore, in this three-drug protocol, sodium thiopental serves the role of the anesthetic (Heath, 2008). Administered next is a dose of pancuronium bromide, a neuromuscular blocker, intended to induce paralysis of the individual’s bodily muscles, including those that are responsible for respiration (Koniaris et al., 2005). And, finally, a dose of potassium chloride is given, which is aimed to cease the cardiac function of the condemned (Koniaris et al., 2005).

In this regimen, the final dose of potassium acts as the

“executioner,” while the other two drugs are intended to lead to insensitivity to pain and paralysis of the muscles, respectively (Heath, 2008). If only potassium were administered via IV, this dose alone would be excruciatingly painful, leading to uncontrollable chest pain and severe vascular irritation (Heath, 2008). As such, this single dose would, in addition to violating the U.S. Constitution, fail to adhere to the goals of the Department of Corrections. Briefly, these goals include “death,” “noncruelty,” “avoiding unpleasant visual experiences for observers and staff,” “rapidity,” “preservation of staff anonymity,” and “minimized psychological stress on staff ” (Heath, 2008).

Due to the reported complications associated with this three-drug regimen, a newer single-drug protocol was introduced, in which solely sodium thiopental is administered in excess (Methods of Execution, 2010). In this method, sodium thiopental no longer serves the role as the anesthetic agent, as it produces death as a result of apnea (Heath, 2008).

In 2009, Ohio was the first state to legally adopt this singledrug lethal injection protocol in place of its original threedrug regimen (Methods of Execution, 2010). The state of Washington, as of March 2010, also approved this singledrug regimen; however, the condemned are still offered the option of the original three-drug protocol (Methods of Execution, 2010).

In considering the discussed drug regimen(s), it is important to indentify whether the administration of a dug is considered a medical or non-medical procedure. As Dr. Heath states regarding the initial dose of sodium thiopental, “Administration of general anesthesia, including the induction, maintenance, and continued assessment of anesthetic depth, is done to prevent severe pain; it is a therapeutic procedure and a medical procedure” (2008). The latter two drugs, however, intended to induce paralysis and cease cardiac function, respectively, are not administered “with therapeutic intent” and therefore are not technically medical procedures (Heath, 2008). Execution by lethal injection is thus essentially an amalgamation of both medical and non-medical procedures. However, as a result of the current prohibition against physician involvement in lethal injection executions, lethal injections have been, in many instances, performed by inexperienced, untrained, and uneducated lethal injection technicians, often leading to a number of unnecessary complications.

Complications Reported with Lethal Injection Executions Performed

by Non-Medical Personnel

A number of lethal injection executions have been reported over the years, in which the execution was performed incorrectly and/or the condemned was inadequately anesthetized, presumably leading to the sensation of pain in both cases ( Johnson, 2008). In fact, it has been reported that of the 1,054 lethal injection executions performed to date in the U.S., at least 40 of the executions entailed unexpected complications ( Johnson, 2008).

Article thal injection requires the use of three—or, in some cases only one—anesthetic agent(s), lethal injection execution indirectly falls under the jurisdiction of anesthesiology ( Johnson, 2008).

Anesthesiologists, however, are specifically forbidden by The American Board of Anesthesiology (ABA), a division of The American Board of Medical Specialties, from partaking in any form of capital punishment. The consequence of participation is loss of board certification by the ABA (The American Board of Anesthesiology (ABA), Inc., 2010).

Both nurses (including CRNAs) and remaining physicians are only strongly advised against participating in lethal injection executions by the American Nurses Association (ANA) and the AMA, respectively (Gawande, 2006). If deemed necessary, however, either the ANA or the AMA may involve state licensing boards, in which case either the nurse’s or physician’s license, respectively, to practice in a given state may be revoked.

In the case of many physicians and nurses, however, most are not IV-experienced despite being IV-certified. Anesthesiologists and CRNAs are the exceptions, both groups being IV certified and experienced in the practice ( Johnson, 2008).

In addition to this, anesthesia providers are well-aware of both the pharmacodynamic and pharmacokinetic properties of the various drugs. For instance, non-anesthesia providers may or may not be aware that, due to a precipitation reaction, sodium thiopental and pancuronium cannot be administered either simultaneously in a single syringe or directly sequentially through the IV without having flushed the IV ( Johnson, 2008).

The participation of IV–certified and IV–experienced medical professionals may moderate, if not altogether eliminate, the occasional pain of lethal injection execution, thereby alleviating the suffering of the sentenced individual.

Additionally, participation by anesthesia providers may rectify any reported unconstitutionality claims associated with lethal injection executions.

Medical Involvement in Lethal Injection Executions

Volume VII Issue i

With lethal injection execution being classified as both a medical and non-medical procedure, the paradox thus remains as to why the medical community refuses to participate. Proponents of the ancient Hippocratic Oath and leaders of medical associations such as the AMA and the ANA, among others, and select Board associations (namely, the ABA) believe that the participation of physicians and medical personnel in lethal injection execution violates medical ethics. In reciting the ancient Hippocratic Oath, the physician vows “not to give a lethal drug to anyone if [he] [is] asked, nor will [he] advise such a plan” (Greek medicine: the Hippocratic Oath, 2002). Accordingly, the AMA incorporates this philosophy into its Code of Medical Ethics, specifically into Opinion 2.06 regarding capital punishment.

It establishes the role of the physician by stating: “A physician, as a member of a profession dedicated to preserving life when there is hope of doing so, should not be a participant in

Penn Bioethics Journal

Dr. Mark Heath, an anesthesiologist, cites a lethal injection execution case in which the condemned individual, Mr. Diaz, was subjected to unnecessary physical pain as a result of an incorrectly performed execution (Heath, 2008). Dr. Heath states, During Mr. Diaz’s execution, both catheters were improperly positioned in extravascular locations in the soft tissues of his arms, and none of the administered drugs were delivered into the circulation. After failing to deliver thiopental in Diaz’s first arm, the executioners administered a massive overdose of pancuronium into his other arm. If the second intravenous catheter had been functioning properly, Diaz’s execution would have appeared serene and humane…However, Diaz slowly died of the gradual absorption of infiltrated thiopental, pancuronium, and potassium.

During a 34-minute interval, he gasped “like a fish out of water” and gradually became still.

Dr. Heath concludes by noting that the pain and suffering endured by Mr. Diaz were, in fact, a direct result of the lack of experience and knowledge of the non-medical personnel that had performed the execution.

Similarly, Kevin Johnson, a Certified Registered Nurse Anesthetist (CRNA), describes an instance in which the condemned had experienced a number of unanticipated, adverse effects as a result of participation by inexperienced and untrained technicians ( Johnson, 2008). Johnson recounts the execution of Mr. Clark, who was punctured repeatedly with a needle—reportedly, 22 attempts—in order to establish IV access. Following the administration of the three drugs, it was observed that Mr. Clark’s arm was swelling noticeably. Mr. Clark, meanwhile, was fully conscious, stating repeatedly that the drugs were not working.

Technicians then decided to re-establish IV access, requiring another 30 or so minutes. Mr. Clark was subsequently pronounced dead, following the total duration of 90 minutes, as opposed to the expected 10-15 minute time period (Kellaway, 2003).

As suggested by each of the discussed examples, professional medical participation in the lethal injections executions could have moderated or altogether eliminated the physical pain of the condemned.

Inadequate administration of one of the drugs in the three-drug regimen may also be classified as a lethal injection complication in which the condemned is inadequately anesthetized. For instance, in considering the effects of the neuromuscular blocking agent, the second of the three sequentially delivered drugs, which is meant to induce paralysis of the muscles, the resulting paralysis of the sentenced individual’s limbs may mask inadequate initial anesthesia (Curfman, Morrissey, and Drazen, 2008). Essentially, the condemned individual, ultimately in pain by the last step of the three-drug regimen, will be unable to convey his or her internal pain to the external world.

For this reason, priority must be given to anesthesiologists and CRNAs, the majority of whom possess both the knowledge and experience “to ensure [that] lethal injection is humane” ( Johnson, 2008). As execution by means of le-

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Ethics of Medical Involvement in Lethal Injection Executions

36

a legally authorized execution” (American Medication Association (AMA), 2010). The AMA further defines physician participation, specifically in the case of lethal injection execution, by stating that any sort of physician involvement in lethal injection execution may be regarded as physician participation, excluding the ultimate certification of death (AMA, 2010). To date, this statement has only been incorporated by one Board association thus far: the ABA, which has announced that anesthesiologist participation in capital punishment may be punished with board certification suspension (ABA, Inc., 2010).

With regard to the original Hippocratic Oath, it is important to note that the Oath has since been repeatedly rewritten and rephrased to accommodate changes in recent legislature. For instance, the modern Oath states that while the overall goal of the physician may be to save a life, the physician may also be required to take a life (Lasagna, 1964). Presumably, it may be this version of the Oath that is applied to explain the controversy of abortion. As such, the AMA does note in its Code of Ethics that physicians are permitted to perform abortions. Again, however, a paradox emerges as both lethal injection and abortion constitute the taking of a life. With regard to the anesthetic component of both procedures, in both instances, the anesthesia provider’s ultimate goal would be to alleviate, or altogether eliminate, the physical pain of the individual.

Medical authorities continue to assert, however, that the role of the physician is to heal and not to harm. In speaking of lethal injection execution, however, the physician’s role would be neither to heal nor to harm. In this context, the physician’s role or is to alleviate the suffering of the individual. More specifically, participation by an anesthesiologist or CRNA would be ensure that unnecessary physical harm is prevented. When countered with the aforementioned point, opponents tend to argue that medical participation in capital punishment would equate medicine with death and execution, thereby tarnishing its reputation. However, if the ancient Hippocratic Oath could be amended and the Code of Ethics can be revised to accommodate legislature such as Roe v Wade, then it should likewise be applicable in the case of execution by lethal injection.

Similar to abortions, lethal injection executions are capable of being performed without direct physician or nurse involvement. However, the results, as discussed prior, would undoubtedly be calamitous, with the individual’s health and safety at dire risk. True, in the instance of lethal injection executions, the condemned have been sentenced to death and therefore will undoubtedly die with or without medical assistance. However, as Black and Sade (2007) argue, “healing the sick and alleviating suffering is the primary role of physicians in U.S. society.” Thus, it is not up to the physician to judge and discriminate which individuals deserve medical assistance and which do not. Furthermore, there are undoubtedly those that will argue that, in the instance of lethal injection executions, the condemned deserves to suffer because he or she has committed some sort of heinous crime. Again, physicians and healthcare professionals cannot discriminate in this way without violating medical

ethics.

In Opinion 2.06 in the Code of Medical Ethics,, the AMA establishes that the role of the physician is to preserve life “when there is hope of doing so” (AMA, 2010). In cases of the death penalty, however, a separate governing body has already decided the fate of the condemned. Therefore, the preservation of life by the medical community is not exactly feasible. At this point, the role of the anesthesia provider should be to alleviate the suffering of the condemned during the final moments of their lives. In this interpretation of the Code, physician and nurse participation would not be in violation of modern medical ethics.

Conclusion Medical involvement in lethal injection executions, specifically by anesthesiologists and CRNAs, should be permitted by governing medical authorities, including the ABA and the AMA, as to moderate, if not altogether eliminate any physical pain that the condemned may otherwise suffer. Such participation by medical personnel would not be in direct conflict with the ABA’s policy, as there is no hope of preserving life in this instance, in which the fate of the condemned has already been predetermined by the government.

In response to this assertion, the argument might then revolve around whether the medical community should “concede” to government mandates such that the physician will essentially be acting as a “tool of the government” (Waisel, 2007). However, as differentiated by Dr. Waisel, “In this case, a physician is not acting as a tool of the government; he is acting as a physician whose goals temporarily align with the goals of the government” (2007). Even further, he delineates, “Although the outcome may be death, the act of the physician may be solely to provide comfort” (2007).

The current impasse between the U.S. Government and the medical community may thus be resolved by allowing physicians and nurses, specifically anesthesiologists and CRNAs, to participate in lethal injection executions, as to ensure the respectful and physically humane treatment of the condemned. Should such an agreement be unattainable, then it may perhaps be required that policymakers, and not physicians, devise a suitable alternative to the current mode of lethal injection execution that would not be said to conflict with the ethos of the medical profession.

About the Author

Giby George is a recent graduate from Drexel University, where she majored in Biology.

Dr. Jennifer Stanford is the faculty sponsor for this submission. She is an Assistant Teaching Professor of Biology at Drexel University

References American Medical Association. (2010). Code of Medical Ethics: Current Opinions with Annotations, 2010-2011. Chicago: AMA. Black, L. & Sade, R. M. (2007). Lethal injection and physicians: state law vs. medical ethics. JAMA, 298(23), 2779-2781.

Curfman, G. D., Morrissey, S., & Drazen, J. M. (2008). Physicians and execution. NEJM, 358(4), 403-4.

Denno, D. W. (2007). The lethal injection quandary: how medicine has dismantled the death penalty. Fordham Law Review, 76(1), 49-128.

Gawande, A. (2006). Perspective. When law and ethics collide – why physicians participate in executions. NEJM, 342(12), 1221-29.

Greek medicine: the Hippocratic Oath. (2002). U.S. National Library of Medicine. National Institutes of Health. Retrieved 8 October, 2010, from http://www.nlm.nih.gov/hmd/greek/greek_oath.html.

Heath, M. J. (2008). Commentary. Revisiting physician involvement in capital punishment: medical and nonmedical aspects of lethal injection.

Mayo Clinical Proceedings, 83(1), 113-23.

History of the death penalty. (2010). Death Penalty Info. Death Penalty Information Center. Retrieved 8 October, 2010 from http://www. deathpenaltyinfo.org/part-i-history-death-penalty#const.

Johnson, K. W. (2008). The medical-legal quandary of healthcare in capital punishment: an ethical dilemma for the anesthesia provider. AANA, 76(6), 417–19.

Kellaway, J. (2003). The History of Torture and Execution. Guilford, CT: Lyons Press.

Koniaris, L. G., Zimmers, T. A., Lubarksy, D. A., & Sheldon, J. P. (2005).

Inadequate anesthesia in lethal injection for execution. The Lancet, 365, 1412-14.

Lanier, W. L., & Berge, K. H. (2007). Physician involvement in capital punishment: simplifying a complex calculus. Mayo Clinical Proceedings, 82(9), 1043-46.

Lasagna, L. (1964). The Hippocratic Oath: modern version. NOVA. Retrieved 8 October, 2010 from http://www.pbs.org/wgbh/nova/doctors/ oath_modern.html.

Methods of execution. (2010). Death Penalty Info. Death Penalty Information Center. Retrieved 8 October, 2010 from http://www.deathpenaltyinfo.org/methods-execution.

The American Board of Anesthesiology, Inc. (2010). Anesthesiology and Capital Punishment: Commentary. Raleigh, NC: ABA. Waisel, D. (2007). Commentary. Physician participation in capital punishment. Mayo Clinical Proceedings, 82(9), 1073-80.

Zimmers, T. A. & Lubarsky, D. A. (2007). Physician participation in lethal injection executions. Current Opinion in Anesthesiology, 20(2), 147–51.

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