We desperately need a public debate about xenotransplantation
By George Monbiot. Published in the Guardian 22nd August 1996.
Tonight Channel 4 tells the disturbing story of a 13-year-old girl who, because she has Down’s Syndrome, has been denied the heart and lung transplant which is her only hope of survival. Hospitals argue that a severe shortage of suitable organs means they must make hard choices about who gets transplants. They give priority to “normal” people, rather than to people whose lives after the transplant would still not be considered “whole”.
Their valuation of human life seems crushingly unfair, but there’s no question about the shortage of organs. Almost 5000 people in Britain are waiting for new kidneys, and hundreds have almost lost hope of receiving new hearts, lungs or livers. People with Down’s Syndrome – though many are afflicted with failing hearts – are not even included on the waiting lists. Every year the dearth of suitable organs condemns scores of people to a slow and horrible death. It’s hardly surprising that there’s a rush to get round the problem. But the ethics of the proposed solutions may be just as unwholesome as the ethics of leaving Joanna to die.
In the United States, which has a problem very much like ours, there is now an increasingly vociferous lobby in favour of reversing the 1984 National Organ Transplant Act, and enabling the sale of human organs. The Act, the lobbyists argue, denies the poor an opportunity to use their assets to improve their prospects.
In India, for example, desperate people will ward off starvation by selling bodily parts. Corneas go for £2500 (leaving the vendor blind in one eye), kidneys for £900 and patches of skin for £30. The trade is largely voluntary, if the only means of warding off destitution is truly voluntary. But wherever there is a market there is, of course, the possibility of coercion – ruthless people deceiving or bullying the poor and weak into surrendering their resources. The press in many Third World countries abounds with tales of such practice – of drugged people waking up to find their eyes have gone, of children being kidnapped and killed for their organs, of anaesthetized patients losing their kidneys. Some are exaggerated, some are wholly fictitious, yet some, like the case of the mental hospital in Argentina which sold at least 2000 patients, are well-documented. When human organs bear a price, life itself becomes a tradable commodity.
It is, quite rightly, illegal to buy organs in Britain, but not, according to the Department of Health, to travel abroad to get them. But the chief hopes of people like Joanna and her parents lie not with humans but with pigs. Some researchers believe that, within a few years, transplants of whole organs from animals to humans will be routine. “Xenotransplantation”, its exponents say, averts the moral dangers of a trade in human organs, while ensuring a supply of bodily parts to hospitals as regular as the supply of meat to supermarkets.
The xenotransplantation debate has so far concentrated almost exclusively on the risks of generating new human diseases. These are, researchers acknowledge, unquantifiable. Pathogens which may have lain harmless and undetected in a pig could, in the new environment of a human body, burst into malign fecundity. Earlier this year, the Nuffield Council on Bioethics recommended that anyone receiving a xenotransplant should be closely monitored for unusual diseases for the rest of his life. For the same reason, apes and monkeys should not be used as organ sources.
These seem to be sensible precautions, and may well be included in the Kennedy Commission’s report on the ethics of xenotransplantation, which is due to be published by the Department of Health within the next few months. But in the United States, researchers are working to a different set of standards, following an Institute of Medicine report proposing that transplants from primates are acceptable. As new human diseases are international problems, proceeding without an international protocol looks hazardous.
But even if we overcame the risks of disease, there’s a real danger that the principal ethical questions are being fudged. Protagonists of xenotransplantation tell us that there are no new ethical issues at stake. Humans, they say, have practised biotechnology for millennia. This is simply another step along that road, qualitatively no different from breeding dachshunds or preparing vaccinations.
But ordinary pigs are no good for transplantation. Human DNA must be added to their genome in order to prevent patients from rejecting their organs. Both the “transgenic” donor pigs and the experimental processes involved have been patented. To get a patent, your process must be both novel and inventive – in other words, a clear conceptual step beyond what has gone before. The researchers can’t have it both ways. Either xenotransplantation is merely the continuation of a tradition, and therefore ineligible for patents, or it is novel and patentable, and begs a whole new set of ethical questions.
For example, some xenotransplantation operations – such as bone marrow grafts – will only work if the animal cells migrate throughout the human body, so that the patient becomes a cellular mixture of human and animal. What does this mingling do to our identity? What does the receipt of the heart and lungs of a pig do to a patient’s sense of self? Are, in turn, the transgenic pigs in any sense human? Do they have a different set of rights?
But technology is racing ahead of ethics. The Papworth Hospital in Cambridgeshire may be the first place in the world to make a realistic attempt at the transplantation of a whole animal organ into a human body. The director of transplant services says he “will probably wait” until the Kennedy Commission report, but hopes to begin human trials within a year or two.
One of the most extraordinary adventures humankind has ever undertaken – the breaking down of barriers between ourselves and other species – is about to begin, attended, remarkably, by the virtual absence of public debate on any but technical matters. To Joanna and her parents, advocating a moratorium on xenotransplantation trials until we’ve thought much harder about what we’re doing must seem like yet another cruel blow. But this issue is simply too big to botch. Technology is no substitute for ethics.