Bioethics for the New Millennium
December 27, 1999
Web posted at: 4:28 p.m. EST (2128 GMT)
by Jeffrey P. Kahn, Ph.D., M.P.H.
Director, Center
for
Bioethics
University of Minnesota
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(CNN) -- Like the continuing surge of the stock markets, bioethics issues show no sign of abating as we face the dawn of a new millennium. But the issues that confronted us at the end of the 20th century will be quite different than those we can expect to face in the first part of the 21st.
Medical technology has changed our perspectives about life, death, and even how we understand illness, through modern-day miracles such as respirators, in vitro fertilization, organ transplantation, and genetic testing. These therapies have been focused on treatment of illness and disease, and if nothing else -- the passing century should be known for medicine's incredible advances and contributions to overall health and life span.
Medicine in the next century will continue to develop new approaches to treat and cure illness, but a new emphasis will emerge towards enhancement. This will include treatment of diseases before their symptoms appear while patients are seemingly healthy; and treatments that don't target illness at all but will allow us to control our bodies and make us stronger, smarter, and live longer. But with these technologies that can be used to enhance our lives will come new issues about who will have access to them and how they will be paid for, questions about when their risks are outweighed by their benefits, and even the most fundamental questions about whether and when such changes actually change who we are. Some examples:
"Made to order" organs. The next century will see the end to the need for cadaver or living donor organ transplants. The technology will be developed to grow organs that are perfectly matched to their recipients. This will mean the end to organ shortages, and no need for drugs to suppress the immune system over a lifetime. And instead of reserving transplantation for those who are desperately ill, anyone whose organs are damaged -- whether by disease, genetics or self-abuse -- could order a replacement kidney, heart or liver. But the new issue will be cost. Will responsibility for illness play a role in whether insurance companies will pay for these transplants, and if so, will only the rich be able to live as dangerously as they please and then buy made to order organs?
Cures for chronic diseases and illnesses. Instead of waiting for chronic diseases to eventually take their toll, treatments will be used to proved potential cures while people are still relatively healthy and symptom-free. This might include bone marrow transplant for diseases like rheumatoid arthritis, limb and joint transplants when originals start to wear out, and gene therapy to prevent genetically linked heart disease, cancer, and other diseases. But these treatments will have risks, so the possibility of permanent cures will have to be weighed against the risks of the therapies themselves. Also, to realize these benefits will require early (pre-symptomatic) testing -- again raising questions of cost and access. This will create a serious problem for "optional" enhancement technologies such as intelligence-enhancing or memory-extending gene therapy or drugs, or limb transplants, since it is unlikely that insurers will pay for such treatments. So the rich can get richer in new ways.
Widely available gene therapy. Gene therapy is on the cusp of becoming effective. This bodes huge medical impact, since they are therapies that provide permanent cures at the molecular level -- no more drugs, no more treatments after a single "magic bullet" has its effects. The questions will arise around how serious a disease or illness must be to warrant the use of gene therapy, and whether to use the technology not to cure, but to enhance performance. Since such therapies will work at the genetic level, we'll need to decide whether they should be used on fetuses, children, or wait until adulthood. This will be easier for decisions about treating diseases that have effects in childhood but much more difficult for decisions about other uses, such as enhancing height or athletic ability, changing sexual orientation, or treating late onset diseases.
In addition to new enhancement therapies, research will continue on what now seem like science fiction technologies such as bionic body parts and many more artificial technologies -- blood, skin, nerves, and even the artificial womb. This will raise the 21st century version of questions about parentage, "your mother was a flask!," and about how much and what kind of parts can be changed before we're not "us" anymore.
All this means that the next century promises remarkable possibilities for our lives. We just need to be sure we look ahead and try to understand their costs and ask whether we can afford to pay them -- or we'll enter the next century older but no wiser than we were in the last one.
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Medicine in the next century will continue to develop new approaches to treat and cure illness, but a new emphasis will emerge towards enhancement. This will include treatment of diseases before their symptoms appear while patients are seemingly healthy; and treatments that don't target illness at all but will allow us to control our bodies and make us stronger, smarter, and live longer. Organs will soon be grown in labs, gene therapy will be available to make us smarter, and artificial technologies will give us everything from bionic body parts to an artificial womb. Should we use these technologies, and if so, who should have access to them? Who should pay for them?
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on a wide range of bioethics topics.
"Ethics Matters" is a biweekly feature from the
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