Xenotransplantation

An aid to ethical discernment

prepared by a working group on behalf of the Church Office of the Evangelical Church in Germany and the Secretariat of the German Bishops' Conference

Joint Texts No.13, 1998

Xenotransplantation

An aid to ethical discernment

6. Ethical aspects

6.1   Opportunities and risks

In 1996 the Swiss Science and Technology Council  sent out invitations to tender for a project on xenotransplantation with the focus on technology assessment. The tender documents were accompanied by a compendium of arguments that lists the pros and cons of animal-to-human transplants. According to that listing, xenotransplantation and preliminary research offer the following opportunities:

  • to overcome the shortage in donor organs, thus preventing the untimely death of human beings and improving the quality of life of the people affected;

  • to abolish the encumbering question of organ donation, for instance after a family member has suffered a fatal accident and the relatives must take a decision on whether to donate organs for transplantation purposes;

  • to do away with the burdensome practice of having to operate on the organ recipient within hours after a human donor organ has become available;

  • to overcome ethically reprehensible trafficking in donor organs and "transplantation tourism";

  • to improve the quality of life and to save costs through kidney transplants as compared to hemodialysis practised over a period of years;

  • to gain new insights into immune defence which could also be of use for human-to-human allotransplantation;

  • to develop the economic potential of companies that are involved in medicinal control or suppression of immune defence;

  • last but not least to develop the economic potential of companies that produce or breed transgenic animals for xenotransplantation.

These arguments are contrasted by the following risks:

  • the risk of transmitting animal pathogens to humans;

  • uncertainty whether the animal organ will adapt to the life expectancy of the human recipient or whether the graft organ will retain the life expectancy that is specific to the donor species;

  • uncertainty whether an animal organ is in the long run compatible with the biochemical processes within the human body;

  • ethically based reservations as to what degree we may use animals and manipulate their genes, and, in particular - if this option should ever be brought to bear - in how far primates may be used as an organ resource;

  • the selection of the first patients, because the first clinical experiments carried out on human beings will entail a great degree of uncertainty regarding their survival;

  • a possible redistribution of resources in the field of research and health care, due to the efforts undertaken in xenotransplantation, which might be to the detriment of other sectors such as prevention research; 

  • the acceptance of xenotransplantation by the people directly concerned (the development of a "chimera identity") and their families as well as by the general public; 

  • last but not least the question of what will become of people's motivation to donate organs if there appears to be an unlimited number of animal organs available for xenotransplantation.

 This list seems to be rather comprehensive in contrasting the pros and cons. In the following, we will not elaborate these, but they are to serve as a background for finding a position regarding the ethical conflicts in the context of xenotransplantation.
 
 
 6.2    Ethical conflicts

 The way xenotransplantation is assessed from an ethical point of view does not differ much in principle from the approaches taken in similar fields of medical ethics. However, according to current knowledge, xenotransplantation seems to entail considerable risks. That is why xenotransplantation in humans will not appear ethically defensible until independent bodies (ethics committees) have qualified the risk as ranging within acceptable limits. Even though the Churches' involvement in such ethics committees cannot comprise a professional examination of the medical risks, it can, however, concentrate on reviewing the procedures for risk assessment and compliance monitoring. In particular during the introductory phase it is advisable to have such an authority to monitor and accompany the process continuously, so as to avoid haziness when drawing the dividing line between therapeutic attempts and human experiments. Apart from that, all rules that are always listed in such cases apply here, too, especially requiring the patient's informed consent.

 Against the backdrop of the expected opportunities and feared risks of xenotransplantation some specific problems emerge that might lead to ethical conflicts. This text is not about solving these conflicts. Rather, it aims at providing a helpful instrument to gain orientation in such a situation of conflict and to take a decision that one can square with one's conscience.

 These are potential fields of conflict:

  • The conflict between the human's right to live versus the animal's right to live, or between interhuman solidarity and solidarity with the fellow creature.

    Genetic manipulation of animals, which is necessary for xenotransplantation, marks a further step in the process of turning animals into a technologically exploitable resource, and this clearly touches upon the concept of animals as fellow creatures. In this context one must not ignore the problematic fact that animal experiments have to be undertaken to advance xenotransplantation. Even though these experiments in principle do not differ from other animal experiments for medical purposes, and the benefits derived from using animals in xenotransplants are incomparably greater - for they might save a human life - as compared to eating animal meat, which is a generally accepted practice, one must not forget that xenotransplantation will always have to maintain the provisional character of a makeshift solution in view of the shortage in human donor organs. This attitude, which is an expression of solidarity extended to fellow creatures, should be held in high esteem - in spite of all advantages of xenotransplantation listed above.

  • The conflict that emerges from the differences in perception by those directly affected by xenotransplantation and other people.

    Particularly because these perceptions are diverging by nature, it would be important to question the scope of one's own discernment and to promote a better understanding for the situation of people holding opposite views. To persons directly affected, the hope attached to xenotransplantation could easily lead to both their ignoring the larger context of the issue and underestimating the risk. By contrast, people not directly affected by the issue, when they analyze the broader scope of the topic, are in danger of not sufficiently acknowledging the existential significance of xenotransplantation for patients and their families. A balancing of the diverging perceptions can only be achieved by means of dialog.

  • The conflict that is caused by the idea of carrying an animal organ within a human body.

    The individual and social identity of a human being is not exclusively determined by the physical existence, but also by the concept individuals have of themselves, including their physical features, as well as the concept others have of that person and, in the end, the perception God has of that individual. When an animal organ is implanted into a human being, the graft can therefore not take away this person's human identity, but essentially it can be integrated in this individual's identity. However, one should not try to explain away the fact that problems of individual and social acceptance might result out of this. The people concerned should be offered psychological counseling, and doctors and medical staff should have a choice on whether they would like to volunteer to participate in xenotransplantations.

  • The conflict between accepting one's own finiteness as predetermined by the physical existence and the redefining of limits at any cost.

    Even if xenotransplantation should not be generally charged with the allegation that people do not come to grips with their personal finiteness, it continuously raises the question of the limits humans have to accept. In Christian belief, death does not simply mean to fall out of life, but to participate in life in a hidden way, that is in the life of the crucified and risen Lord Jesus Christ. Renouncing the prolongation of one's life by means of xenotransplantation can be a decision based on faith which can testify to a different and more comprehensive precept of life that goes beyond mere medical or biological aspects. On the other hand, the decision in favor of prolonging one's life through xenotransplantation can be taken in awareness of the responsibility one has for other people, as for instance the closer family circle.

 6.3   The researchers' ethos

 Since research acquires the greatest significance at the present stage of development of xenotransplantation, the researchers' ethos has to receive particular attention. In xenotransplantation, no different rules are applied as compared to research in other fields. As the quest for knowledge is rooted in human nature and forms part of human culture, it would be neither realistic nor responsible to renounce research in general. A responsible ethical approach begins with the individual and regards responsibility as the individual's obligation to render account to rightful claimant authorities (e. g. one's conscience, fellow humans, the state) for any aspirations and actions attributable to that individual. The degree of responsibility is determined by the degree of personal freedom and the resulting possibilities to become actively involved. The following aspects of researchers' responsibility have to be distinguished:

  • The responsibility of researchers consists first and foremost in gaining new insights, on the basis of qualified research, which society depends on. Humanity needs the ingenuity of researchers not least to cope with future problems.

  • Researchers are fully responsible for the ethical acceptability of the methods they use to gain knowledge. If the process of gaining insights and knowledge, i. e. the research method, is not neutral from an ethical stance, a decision has to be taken on the admissibility of this method. As appropriate, the decision can be mandated to the authority of a professional organization or become subject to legal stipulations. 

  • The researchers' responsibility furthermore consists in giving consideration to the impact of their actions. Whatever they do has to be geared to the objective of maintaining human life and human dignity.

    - It is an inherent feature of new insights that they do not always entail the possibility to give a complete impact assessment. It would not be right to limit research just because the impacts cannot be foreseen or because abuse cannot be ruled out.

    - Researchers are obliged to examine critically whether their new insights and the modes of application that they can foresee could have harmful consequences. They are obliged to draw attention to any dangers known to them, but also to the consequences of failing to engage in research and development. With respect to the general public and the scientific community they have to fulfill their duty to inform, which consists in the dissemination of scientific findings and scientific reason.

    - The distinction between basic research and applied research does not provide an adequate approach to assigning different types of responsibility. There is a difference in as far as harmful impacts are more readily foreseeable in applied research than in basic research. That is why ethical conflicts tend to emerge here more frequently.

  • As the results of research can have far-reaching consequences and the knowledge about these impacts is chiefly accessible to the researchers involved, they shoulder a specific primary responsibility.

  • The special responsibility of researchers for their work continues to accompany them as they engage in a working group or join an institution. Researchers share a personal responsibility in the framework of their scope of action and effectiveness.

  • Those who act within the given framework of their responsibility will not be held responsible for the abuse of scientific findings by others, as long as they have no knowledge of it.

  • The responsibility of researchers also extends to truthfulness in research, that is to the correct presentation and analysis of research results as well as to informing experimentees and patients involved in the studies.

  • With respect to the general public and the state, the responsibility of researchers furthermore includes advocating the freedom of science in teaching and research.



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