Stem cells

Stem cells are undifferentiated cells that have the ability to form different
types of cells. For example adult stem cells from the bone marrow can form
many types of blood cells. Embryonic stem cells can differentiate into any
type of cell and are therefore called pluripotent cells. They have the
capability to form nerve cells or heart muscle cells; these cells cannot
normally regenerate. For example people who damage the nerve cells in
their spinal cord are usually paralysed below the level of their injury because
the nerve cells cannot repair and brain damage after a stroke is permanent.
Pluripotent stem cells can differentiate into any type of cells and so may be
used to repair or replace nerves or even organs. They have, until recently
have had to be taken from dead embryos and because of this many
people have ethical objections.
John Gurdon showed that adult cells can be re programmed to behave like
egg cells. That the nucleus of any cell has the information to make any other
type of cell. He transplanted the nucleus of an adult frog cell into an egg cell
of the same species which grew into a healthy adult. This led to the
possibility of cloning and paved the way for Dolly the sheep. Professor
Yamanaka from Japan built on John Gurdons work and showed in
2006 that mature cells could be unwound and regressed to form
stem cells. Not only does this evade the ethical problems of using embryos
but it can mean that it may be possible to use a persons own skin cells to
grow a replacement organ and because it is formed from his own cells there
is no possibility of organ rejection. Unfortunately the technique of
induced
pluripotent
stem
cells
uses
complex
genetic
techniques and is difficult.
A Japanese team announced last week that they had induced pluripotent
cells by simply shocking adult cells by bathing them in mild citric
acid for less than 30 min which caused them to revert into immature
embryonic stem cells. The cells were injected into a mouse embryo where
they behaved like genuine embryonic stem cells. Chris Mason ,a professor of
regenerative medicine at UCL said that the simplicity of the method was
almost too good to be true. If it works in man ,this could be the game
changer that ultimately makes a wide range of cell therapies available using
the patients own cells as starting material. The age of personalised
medicine would have finally arrived. he said.

Organs have been produced by removing dead organs such as a heart then
stripping it of heart cells using a detergent like substance leaving a collagen
frame. Stem cells were then injected into the frame and they self
differentiated into heart cells and multiplied. The hearts produced even
started
pumping,
but
were
too
weak
to
be
used.
So far stem cells have been used to form new retinas and have been
successfully used in retinal transplants. The Lancet [Nov 23 2011] reported
that a patient in Sweden had received the worlds first trachea produced from
stem cells. The patient had a cancer in his wind pipe [trachea]. An artificial
trachea was created by using a glass model to produce an artificial scaffold.
Then stem cells were inserted into the scaffold then the glass removed.
Stem cells are producing much excitement in the field of regenerative
medicine. If you have not already, have a look at the 10 min TED talk by
Professor Aubrey Grey I recommended a few months ago. He believes that
humans may possibly live for ever! He is a crazy looking guy but his ideas
have some merit and were discussed in the BMJ. Since he did the talk the
Methusela mouse prize he talks about has been won . Scientists actually
managed to make a mouse younger not just stop aging![p46 of my book] You
may also want to read P45 -50 Medicine in the future from my book Medical
School Interviews The Knowledge to help answer the common question
What do you consider to be the most exciting field in medicine.

The Times headline on Friday ran Diabetes a cure at last! However the
press often exaggerates or misunderstands. What really does this
breakthrough really mean?
A team of Harvard scientists have used pluripotent stem cells to produce
beta cells which secrete insulin. Type 1 diabetes is an autoimmune
disease [where the bodys own white cells attack its own cells] in which
beta cells which produce insulin in the pancreas are destroyed leading to a
lack of insulin which has to be given by injections. These stem cell derived
beta cells were shown in laboratory to be able to produce insulin in
response to high glucose levels like normal beta cells. They were then
transplanted into diabetic mice and were shown to be able to act like normal
pancreatic transplanted cells.
Challenges remain: This study only used a small number of mice. We do
not know as yet if the same technology will work in humans. Pancreatic

transplants from deceased donors have been used in diabetics with some
success for decades. However after a few years these usually fail because
thebodys auto immune system destroys the beta cells as it did the
patients original beta cells. One idea is to put these stem cells into a
capsulewhich would enable glucose and insulin to go freely in and out but
prevent attack from immune cells. Beta cells derived from stem cells
would only ever be a cure for type 1 diabetes not the much more
common type 2 which is mainly due to a lack of cell sensitivity to insulin.
Pluripotent stem cells are cause of much hope and excitement.
These were derived from discarded embryos and hence research using
stem cells was banned in the USA by the Bush administration but President
Obama reversed this ban. Professor Yamanaka showed in 2006 that mature
cells could be unwound and regressed to form stem cells. Not only does
this evade the ethical problems of using embryos but it can mean that it may
be possible to use a persons own skin cells to grow other cells or a
replacement organ and because it is formed from his own cells there is
usually no possibility of rejection where the bodys immune system
recognises it as foreign and attacks it [except in auto immune diseases
such as type 1 diabetes].
Pluripotent stem cells seem to have a memory. If they are given
the right environment and nutrients they recognise the type of cell
they are supposed to form. Organs have been produced by removing
dead organs such as a heart then stripping it of heart cells using a detergent
like substance leaving a collagen frame. Stem cells were then injected into
the frame and they self differentiated into heart cells and multiplied. The
hearts produced even started pumping, but were too weak to be used.
So far stem cells have been used to form new retinas and have been
successfully used in retinal transplants. The Lancet [Nov 23 2011] reported
that a patient in Sweden had received the worlds first trachea produced
from stem cells. The patient had a cancer in his wind pipe [trachea]. An
artificial trachea was created by using a glass model to produce an artificial
scaffold. Then stem cells were inserted into the scaffold then the glass
removed.
In conclusion. We are still far away from creating a cure for even type 1
diabetes. But I am excited not just about future cures for diabetes but the
use of stem cell technology for a whole range of diseases. The idea of new
healthy cells for old damaged ones -it is something we never thought
possible and could lead to an explosion of medical ability; possible cures for
dementia, Parkinsons, repairs for heart/spinal cord damage, in fact any
organ, any system. In a way it feels too much to hope for, too greedy a

dream. You the doctors of tomorrow may be practising a totally different

medicine than I am today!

NHS
It is the party conference season, when the main political parties meet
with their members, talk about the issues of the day and what is likely to
be in their manifestos for the election next year.
As usual the NHS has been a major issue in the party conferences and is
therefore likely to be in the forthcoming election with both parties promising
that the NHS will be better of under their care. Why? The NHS frequently
comes top in lists of the things that the British people are most proud of.
Nigel Lawson a former health minister once said that the NHS is the
nearest thing that the British have to a national religion David
Cameron said before the last election that Tony Blair summed up
his priorities in three words Education, education, education; I can sum up
mine in three letters -NHS.
Labour has proposed a mansion tax for properties over 2 million, the
proceeds of which will be used to fund more services for the NHS.This is
estimated to raise a maximum of 2.5 billion -not so generous when you
consider this represents less than an extra 2.5% of the present NHS budget
of 110 billion. Davis Cameron moved his wife to tears by speaking about
the death of his disabled son and the NHS during his conference speech and
promised to ring fence the NHS budget and have GPs working 7 days
a week. Both parties also promised reforms to the NHS. Having just
weathered a period of major reform with increasing privatisation and more
administration and paperwork my heart sinks. Politicians rarely acknowledge
that the World Health Organisation and the Commonwealth Institute [a
widely regarded American think tank] have recently declared the NHS to
be the most effective, efficient health system in the developed
world.
We have an ageing population, one where obesity related diseases
such as type 2 diabetes are consuming an ever increasing
proportion of
the
budget
and new
drugs
and
medical
advancements are going to cost more. As a result all developed
countries have a problem with rising health care expenditure. In my
opinion reorganisation does not overcome these factors.Staff costs are
said to be responsible for 75% of the NHS budget. Cuts in staff and a

culture of target chasing were said to be some main reasons for the Mid
Staffordshire scandal.

A lot of papers talked about the NHSs worsening finances and how it was
failing to keep up with increasing demand for services. Some discussed a
proposal for perhaps charging 10 for appointments and how if they did it
might be the beginnings of a slippery slope.
It is worth remembering , before we panic, that 500 million, although it
sounds a lot, is only 0.5 % of the NHS budget which is over 100
billion.Many companies would be pleased to miss their target budget by
such a narrow margin and that last year the NHS delivered a 330 million
surplus. No need to panic and start charging yet I would suggest.
The papers and politicians often talk about the NHS as if it is failing but
thefacts show the opposite. Yes there are challenges. We have an ageing
population, probably the most unhealthy population in Europe [highest
obesity, high alcohol intake and high smoking rates]. Despite this in June
2014 the NHS was declared the best healthcare system in the
world by an international panel of experts who rated its care superior to
countries which spend far more on health.
The report, produced by the Commonwealth Fund, a Washington-based
foundation respected around the world, examined an array of evidence
about performance in the 11 most developed countries, including detailed
data from patients, doctors and the World Health Organisation.
The same study declared healthcare provision in the US as the worst of the
11 countries it looked at. America denies care to many patients in need
because they do not have health insurance and is also the poorest at saving
the lives of people who fall ill, it found.
The United Kingdom ranks first overall, scoring highest on quality,
access and efficiency, Their findings amount to a huge endorsement of
the health service, especially as it spends the second-lowest amount on
healthcare among the 11 just 2,008 per head, less than half the 5,017
in the US. Only New Zealand, with 1,876, spent less.

Some people argue that those who take risks with their health by over eating
and poor life style choices should not expect the tax payer to pay for the
consequences of their choices.
Others argue that a persons autonomy has to be respected. They have a
right to decide how to live their life if they wish. It is important to be non
judgemental and act in the best interests of that patient which means
treating the consequences of their habits. If those who are obese are denied
treatment for their condition a slippery slope may be created in which
those suffering from illnesses which may be in part also self inflicted such
as smoking related diseases or injuries from extreme sports may in future
also
find
themselves
excluded
from
state
funded
treatment.
It is more cost effective for the NHS to pay for gastric by-pass operations
than pay for the consequences of obesity [eg diabetes drugs and joint
replacements
for
arthritis]
At present ethical principles held by most, including the medical profession
would value the principles of autonomy and beneficence [doing what most
benefits the patient] over the idea that in doing so we would not be fair to
others in this rights versus responsibility debate.

Figures published by the NHSs Health and Social Care Information Centre
suggested that two thirds of men and half of all women are now overweight
or obese in the UK. Only a third of adults manage 30 minutes of exercise
once a week. It seems that the British are now the fattest in Europe!
What can we do about it? The BMA demanded a tax on sugary drinks and
aban on unhealthy food adverts targeted at children. This of course
raises questions about the infringement of personal liberties. But in this
country and others such as the USA and Denmark, which have introduced
similar legislation, there is the growing realisation that unless we do some
thing and try and tackle our unfit, overweight population our health systems
might
not
be
able
to
afford
the
consequences.
As a GP I promote exercise for it seems most disorders from diabetes,
menopausal hot flushes [helps temperature regulation and maintains bone
density], to insomnia [promotes natural relaxation and sleep]. I often write a
very simple exercise plan on a prescription to emphasise its value as a
treatment. I refer the overweight to Slimmimg World and Weight
Watchers and gyms [they can attend for free courtesy of the
NHS] but doctors get notoriously bad results hence the rise in gastric
bypass operations. Many have argued that we should pay people to lose

weight and exercise, give them a monetary incentive and this would be far
cheaper in the long run for the NHS. Some health bodies have already tried
this and it works [see link below]! What do you think?

What a difference a year makes. Last year we celebrated the NHS as one of
the great accomplishments of Britain. Danny Boyle paid tribute to the NHS
during the Olympics opening ceremony because universal healthcare is
one of the core values of British society.The health service was featured
as one of Britains proudest achievements during the 27 million
spectacular. Boyle said the NHS was an amazing thing to
celebrate and dedicated a whole section of his show to the health service.
Few disagreed with him. However 2013, this year has been the year of
the Mid Staffordshire scandal and the Francis enquiry into it. The NHS has
been lambasted and the general publics perception has plummeted
According to this weeks BMJ there never has been such a bad year for the
NHS in its entire 65 yr history.
About 500 people are estimated to have died of negligence and appalling
standards of care seem to have been unearthed in Mid Staffordshire. It is
thought that there probably has never been a scandal on the scale of Mid
Staffordshire NHS Trust. The Francis report was published in February and
talked of the Wilful neglect prompting the health secretary Jeremy Hunt
to claim the need to put compassion back into the NHS. The Francis report
also prescribed a fundamental culture change for the entire NHS to
put patients first. The Francis Report mentioned that a culture of target
chasing and management agendas of cost cutting took precedence
over patient care in an effort to reach the financial targets required to
gain NHS Trust status. Many Nursing staff lost jobs and staff to patient ratios
were badly hit. Targets distort priorities. As soon as you have a target the
thing being measured becomes more important, attributes such as
compassion and empathy that are hard to count start not to
count. Caring andconsideration are hard to measure and even harder
to legislate for.

April 1st [April fools day] marked the day of the takeover of the NHS by
the National Commissioning Board. The new changes are designed
to open up the NHS in England to competition by for profit
companies. PCT [Primary Care Trusts] have been abolished and their work
allocated
to GP
led
commissioning
groups who
will
now

have responsibility to ensure their patients health needs are met. They
will decide how 80% of the NHS budget is spent. GPs have been given this
responsibility as they have daily contact with patients and local
services and know their patients needs. GPs will have to put services
out to tender [consider any willing provider] and any organisation can
bid to provide services not just NHS hospitals. Critics warn that big, often
multi national companies who have been active in lobbying the government
will cherry pick the most profitable services and destabilise the rest
of the NHS.
GPs do not relish becoming the masters of the new NHS universe. Clare
Gerada, their representative, said that the new changes allow for;
the wholesale dismantling of the NHS and privatisation of the
supply, organisation, planning, finance, and distribution of
healthcare. She goes on to say that the regulations will leave general
practitioners
bearing the brunt of the publics wrath, while much of the health
budget is handed over to the for-profit commercial sector, services are
closed, and entitlements to universal healthcare are eroded.
Is this the beginning of the end of the NHS as the BMJ cover that week
suggested [see above picture] and after the Francis report will any one
carethat much?
Howard Lyons was given the job of making money by selling the NHS brand
and expertise abroad by this Government. Today Health UK will be officially
launched at a health trade fair in Dubai. According to Mr Lyons he already
has had dozens of enquiries from governments around the world and
hundreds from embassies.
Danny Boyle said in the summer that he included dancing doctors and
nurses and the NHS because the NHS was very dear to peoples hearts. He
added one of the core values of our society is that it does not matter who
you are, you will get treated the same in terms of healthcare..And that felt
like something that we thought was a great thing to celebrate. Other
countries are apparently interested in the NHS because as Howard Lyons
says overseas the NHS is a very, very strong brand. It means safety,
security, health care for all and there are others who want to emulate that.
Many hundreds if not thousands of doctors volunteer for spells in third world
countries and many well known UK hospitals already provide training and

send consultants to teach abroad; having a central organisation promoting

them as a part of the NHS would perhaps ensure it is done in a less ad hoc
fashion.
Our medical schools and Royal Colleges and training are highly rated. Those
of you who will become doctors in this country have the satisfaction of
knowing that your medical degree is accepted and welcomed worldwide. The
UK invented among other things MRI scans, CT scans, and IVF and we have
won 34 Nobel prizes for medicine more than any other country apart from
the USA. The NHS model of primary care is highly regarded. The skills and
the gate keeper role of GPs are important in keeping costs down [see p 56
of my book Medical School Interviews All You Need To Know The Knowledge].
The National Institute of Clinical Excellence [NICE] is well regarded as a
leader in evidence based medicine [p 69-72]
All countries face enormous challenges with regard to health care. All
developed countries have rapidly rising health care costs because of an
ageing population and increasing technology. Enoch Powell, a former Health
Secretary declared spending on health a bottomless pit and indeed it can
be. Britain however spends less of its GDP on health than any other
developed country yet it does well in its performance with good survival and
treatment rates for chronic conditions and mid ranking rates for cancer
survival compared with other developed countries. The USA which has
almost non existent primary care, spends twice as much of its GDP as Britain
on health care yet has the worst health care statistics of all the developed
nations. In August 2011 The WHO [World Health Organisation] showed that
the UK saved more lives for each pound spent than any other developed
country [apart from Ireland] over 25 years.
The NHS is an important subject for medical school applicants, as Danny
Boyle said, it is dear to most people and you will be expected to know about
it. Surveys consistently rank the NHS number one when British people are
asked to decide what things about Britain they are most proud of. You as a
potential medical student should know about how it was founded, its core
principles and how it runs. The NHS will pay for some of your clinical years at
medical school and your training as a junior doctor. Its principles and ethics
should become part of you. It does have problems and faces major
challenges and we should all strive to improve it. However like virtually all
doctors, I am profoundly grateful and proud to work for the NHS and truly
appreciate the fact that I never have to add to a patients distress by
demanding payment!

- For further information about the NHS, how it works and comparisons with
other health systems read my book Medical School Interviews All You Need
To Know The Knowledge pages 51-73

ethics
A couple have a child with Fanconis Anaemia. This is a severe genetic
disorder which leads to early death. It can be cured by a bone marrow
transplant from a suitable match. Siblings commonly can provide that
match.
The couple want to have a child and are undergoing IVF in order to make
sure that an embryo will not have Fanconis Anaemia. As well as screening
embryos to ensure they do not have the disease they can also choose an
embryo that will be a suitable match for the existing embryo. Stem cells can
be taken from the umbilical cord [which is usually discarded] of the new
baby and used to cure the existing child.
Should they be able to select an embryo for this reason? What issues arise?
Answer
It is important to look at the issue from all points of view with the concepts of
the 4 pillars in mind: harm [maleficence] and benefit [beneficence],
autonomy and Justice [is it fair].
The Existing Childs
The child has the possibility of cure from a serious condition. However how
will he view his new sibling; will he feel that there is a debt of gratitude
owing? Will he feel that he must be for ever grateful?
The Parents
IVF involves injections, egg stimulation and operations and is not without
risk. However in this case the parents are going through IVF
anyway because they wish to select an embryo unaffected by the disease.
The parents want another child anyway and are not just having a child to
cure another. As parents they love the existing child and would want to avoid
the pain and suffering of seeing their existing child suffer and die.

Parents should have autonomy they should therefore perhaps have

theright to consider the benefits and harms and make a decision for
themselves.
The Unborn Childs
It is important that the child is loved for itself. The child may grow up
thinking that they were only created to cure their sibling. If for some reason
their sibling dies would they feel as if they had failed and feel responsible?
Societys Point of View
It is important to look at how such decisions may affect society. Are such
procedures viewed as fair [ethical pillar of Justice]. Does using science to
ensure perfect children raise the spectre of eugenics; does it decrease
tolerance of the disabled? We have recently enjoyed the Para Olympic
Games but it worth remembering that many such athletes such as Ellie
Simmonds and Oscar Pistorius may be nowadays aborted. Is it right to have a
society that says such lives are worth less than others is that fair?
Embryo selection may continue down a slippery slope which may lead
todesigner babies where parents choose embryos according to features
such as hair colour, height and sex
Many, particularly some religious groups would oppose embryo selection
because it is unnatural and humans are in a way playing God.
My point of view
[you will probably be pushed to say what you think but remember that you
should give your point of view after you discuss all the arguments]
Personally I feel that the benefits out weighs the harms. There is an
enormous benefit to the existing child and parents who want another child
and are under going embryo selection anyway. There is very little possible
harm to the unborn child.
There is no evidence that decreasing disability leads to greater intolerance of
those already disabled. I reject the argument that it is unnatural and
therefore society should not allow it. The practise of medicine involves
interfering with the natural course of illnesses and conditions to alleviate
pain and suffering and prevent death. When ever a major advance is made in
medicine [such as blood transfusions or IVF] there are always some that say

that it is unnatural and wrong but these innovations tend to be eventually

accepted by the majority of the population as being beneficial.
Emmanuelle Kant, the German philosopher stated that an action was moral if
the intention was good and it did not cause harm and a further test would be
if all others in society carried out that action it would not cause harm. For
example if a couple were to choose the sex of their embryo it does not harm
society but if everyone did so it may, so it should not be allowed. In this
case, the choosing of a saviour sibling there would be no obvious harm. The
slippery slope scenario can be avoided by ensuring embryo selection was
performed for severe, inherited diseases only.
Stem Cells are crucial to develop organisms. They are nonspecialized cells
which have the potential to create other types of specific cells, such as
blood-, brain-, tissue- or muscle-cells.
Stem cells are in all of our body and lives, but are far more potent in a fetus
(also spelled foetus, ftus, faetus, or ftus) than in an adult body.
Some types of stem cells may be able to create all other cells in the body.
Others have the potential to repair or replace damaged tissue or cells.
Embryonic Stem Cells are developed from a female egg after it is fertilized
by sperm. The process takes 4-5 days.
What is Stem Cell Research?
Stem cell research is used for investigation of basic cells which develop
organisms. The cells are grown in laboratories where tests are carried out to
investigate fundamental properties of the cells.
Aborted fetuses are not the only source of stem cells
There are stem cells in the both placenta and blood contained in the
placenta. Also the primary source of stem cells is from blastocysts. These are
fertilized human eggs that were not implanted into a woman.
The controversy surrounding stem cell research led to an intense debate
about ethics. Up until the recent years, the research method mainly focused
on Embryonic Stem Cells, which involves taking tissue from an aborted
embryo to get proper material to study. This is typically done just days after
conception or between the 5th and 9th week.

Since then, researchers have moved on to more ethical study methods, such
as Induced Pluripotent Stem Cells (iPS). iPS are artificially derived from a
non-pluripotent cell, such as adult somatic cells.
This is probably an important advancement in stem cell research, since it
allows researchers to obtain pluripotent stem cells, which are important in
research, without the controversial use of embryos.
There were two main issues concerning stem cell research with both pros
and cons:
1.

How the knowledge will be used

2.

Concerns about the methods

The first issue is really not just about stem cell research, as it may be applied
to most research about human health.
Since 2007, the second point, concerns about the methods involved, has
been less debated, because of scientific developments such as iPS.
1) Stem Cell Research - Arguments Regarding the Usage of the
Knowledge
As you will most probably notice, the following arguments are not exclusively
in use when talking about stem cell research.
Pros
Stem cell research can potentially help treat a range of medical problems. It
could lead humanity closer to better treatment and possibly cure a number
of diseases:

Parkinsons Disease

Alzheimers Disease

Heart Diseases, Stroke and Diabetes (Type 1)

Birth Defects

Spinal Cord Injuries

Replace or Repair Damaged Organs

Reduced Risk of Transplantation (You could possibly get a copy of your

own heart in a heart-transplantation in the future
Stem cells may play a major role in cancer

Better treatment of these diseases could also give significant social benefits
for individuals and economic gains for society
Cons

"We should not mess with human life."

"Humans should not be trying to play God"

Some argue that stem cell research in the far future can lead to
knowledge on how to clone humans. It is hard to say whether this is true,
but we have seen devastating consequences of other research-programs,
even with good intentions, such as nuclear research.
2) Stem Cell Research - Pros and Cons About the Methods
Involved
The controversy regarding the method involved was much tenser when
researchers used Embryonic Stem Cells as their main method for stem cell
research.
DISCLAIMER:
These points are based on the old debate about the methods of stem cells
research, from before 2007. Since then, scientists have moved on to use
more ethical methods for stem cell research, such as iPS. This section serves
as an illustration of the difficult evaluations researchers may have to
analyze.
Pros Before 2007

"The benefits of stem cell research have such a great outcome that
they outweigh the ethical issues." (Cost-benefit-analysis)

"If someone is going to have an abortion, isnt it better that we use it

for something useful?"

Adult stem cells would not be that interesting because they do not
have the same properties as stem cells from a fetus.

The research would give great insights about the basics of the body.
Cons Before 2007

Critics against stem cell research argued that the ethical issues of
scientific work on aborted fetuses did not justify the possible benefits.

"A life is a life and that should never be compromised. A fertilized egg
should be valued as a human life even if it is in its very first weeks.
Destroying human life in the hopes of saving human life is not ethical."

We should (and will) develop more ethical methods (such as using

adult stem cells) which will enable us to research ethically. We should wait
until those methods are available.

The scientific value has been overstated or has flaws. E.g. we do not
know for sure that we can use stem cells to clone transplantable organs.
Conclusion
The stem cell-research is an example of the, sometimes difficult, cost-benefit
analysis in ethics which scientists need to do. Even though many issues
regarding the ethics of stem cell research have now been solved, it serves as
a valuable example of ethical cost-benefit analysis.
The previously heated debate seems to have lead to new solutions which
makes both sides happier.
Stem Cell pros and cons had to be valued carefully, for a number of reasons.
When you are planning a research project, ethics must always be considered.
If you cannot defend a study ethically, you should not and will not be allowed
to conduct it. You cannot defend a study ethically unless the presumed cost
is lower than expected benefits. The analysis needs to include human/animal
discomfort/risks, environmental issues, material costs/benefits, economy etc.
Why was the debate regarding the stem cell research so intense?
First, it was a matter of life - something impossible to measure. And in this
case, researchers had to do exactly that: measure life against life.
Both an abortion and someone dying, suffering from a possible curable
disease, is a tragedy. Which have the highest value? Does a big breakthrough
in the research justify the use of the method in the present?
Would the benefits of studying abortions outweigh the costs? The choice was
subjective: Nobody knows all the risks or all the possible outcomes, so we
had to value it with our perception of the outcome. Perception is influenced
by our individual feelings, morals and knowledge about the issue.
Second, at the time we did not know whether the research was necessary
and sufficient to give us the mentioned health benefits.
Third, other consequences of the research are uncertain. Could the research
be misused in the future or not? We simply do not know. All knowledge

acquired, within research or other arenas, may be used for evil causes in the
future - it is impossible to know.
The Stem cell research-debate is an example on how people value various
aspects differently. It is also an example of how critics and debate can lead to
significant improvements for both sides.

YES Tom Lynas

To me it seems fair that those who take risks should accept their consequences. If an owner leaves the front door to
their home open, they must remember no insurer will help if it is burgled. If a gambler stakes his last 10 on a horse,
he should be prepared to go hungry that night. And when a daredevil puts on his wingsuit before leaping over a
precipice, he must realize that action might be his last.
A similar argument can be made for the subsidising of National Health Service treatment with money from risktaking individuals. Of course, every man and woman should be free to live as dangerous an existence as they choose,
but I feel that people who deliberately ignore medical warnings are not the most deserving of free medical care.

Recent cuts to health spending give this debate a renewed significance

Recent cuts to health spending give this debate a renewed significance. Since its establishment in 1948, the NHS has
always struggled to reconcile the increasing costs of advances in medical knowledge and technology with the financial
restrictions of state funding. The present situation is particularly grave despite its promises, the Coalition
Government has made significant cuts to the healthcare budget (around 800 million between 2010 and 2012) and a
recent poll found that only 40 per cent of hospital bosses believe their organisation will balance the books in 2014-15.
With this in mind, the idea that the NHS should begin to charge some patients for self inflicted visits seems worth
exploring. Northern Ireland Health Minister Edwin Poots suggested earlier this year that the UKs overburdened
accident and emergency departments should issue drunks with a bill for the cost of their care. While Poots proposal
was met with criticism, it has a certain appeal. I enjoy drinking as much the next person, but I know that illness and
injury are likely results if I overdo it. I think the assumption that I can consume enough to need hospitalising without
any penalty is a childish one.

Treating alcohol-related injuries costs the NHS 3 billion annually

Treating alcohol-related injuries costs the NHS 3 billion annually and any charges would help cover this cost, while
deterring excessive consumption and ultimately easing pressure on the service. The UK had 2.8 hospital beds per
1,000 people in 2012, compared to 8.3 in Germany and 6.3 in France removing thousands of binge drinkers from
the wards would be a good way to start tackling this deficit.
Smoking is another example of a risky habit that people continue to practice against doctors advice. 463,000 adults
were admitted to hospital last year as a result of smoking-related illnesses. Estimates as to the cost of these patients
vary (somewhere between 2-6bn) but what cannot be disputed is that they divert precious resources away from
those who have contracted illness through no fault of their own. It is terrible to hear of anyone being diagnosed with a
respiratory disease or heart condition, but is it so wrong to ask those who have put themselves at an increased risk to
take responsibility for their actions? Why not ask them to make a small contribution?

Critics will doubtless look for flaws in this scheme. They may point out that one of founder Aneurin Bevans core
principles was that the NHS should be free at the point of delivery. They may fail to mention section 2 of the
National Health Act, which states that an exception to this rule is where the injury or illness is self-inflicted.

It is unfair that their medical treatment should be of a diminished quality because

of the minority who willingly endanger themselves

Others may claim that those who smoke and drink to excess fund their care through taxes. And yet so do many
millions of adults who have healthier lifestyles. It is unfair that their medical treatment should be of a diminished
quality because of the minority who willingly endanger themselves.
Finally, there is the question of judging whether a visit is self-inflicted or not. I accept that there could be ambiguity as
to how far an individuals actions are the reason for their visit. But every vetting process has to begin somewhere. It
may, for example, be difficult to judge how much disability benefit a person is entitled to, or how much compensation
someone requires after an accident. The sooner we introduce this fairer system, the sooner we can fine-tune the way
we assess incoming patients.
We all learn at some stage in life that our actions have consequences. If this principle applies to the legal, political and
financial worlds, why should healthcare be exempt? The NHS is a national treasure that sets a benchmark for the way
a state looks after its citizens. This said, the ever mounting costs of running such an operation have put its standards
under threat.
While this small act of privatisation may be controversial, it will guarantee continued support to those who need it
most.
We must remember that the potential financial burden will cause misery also image credit: Flickr/PhilandPam

NO Nick Herbert
How do you determine a self-inflicted injury? It seems as if people arguing that the NHS should charge those with
self-inflicted injuries in A&E see it as a black and white issue. Whereas to many, the issue seems confusingly grey. The
potential problems with ascribing the title of Self-Inflicted to an injury seem too many to make this system plausible.
The idea of paying for emergency treatment, regardless of whether you caused it yourself, jars with the fundamental
principles of the NHS. I cant help but think of a two-tiered system in which those with less suffer more than they
need to. I do not mean that poorer people will not receive treatment, but we must remember that the potential
financial burden will cause misery also.

I cant help but think of a two-tiered system in which those with less suffer more
than they need to
The NHS was created to help people regardless of economic background and by charging people we make that point
redundant. Going to A&E will become something that gets calculated against cost rather than something we
instinctively turn to. Someone with a worrying stomach-ache might regret opting against the costly trip to the hospital
when their appendix ruptures.

Another problem is that of mitigating circumstances. What makes an accident that persons own fault? If a person
uses tools which he knows are faulty, provided by an employer, and has an accident, is this the fault of the employer
or the employee? Surely the employer should never have given the faulty tools out in the first place, but likewise, the
employee shouldnt have used the tools if they were known to be faulty. It can be argued that either party is liable.
There will always be factors that mitigate the full extent of culpability and an investigation will mean more effort
spent on an enquiry which would take up both money and time better spent elsewhere. This shows the idea of
payment within the NHS would hinder not help.
If we charge for self-inflicted injuries, why not go further and charge for the treatment of self-afflicted diseases? If we
are going to go against the fundamental principles of the NHS, lets go all-out. Why should we pay for the treatment of
diabetes or heart conditions caused by what people will argue are poor lifestyle choices?
According to Diabetes UK, diabetes treatment reportedly costs the NHS 10 billion, whereas the estimates of the cost
of alcohol-related problems range from 3.5 bn 6 bn. Granted, not all of the 10 bn is being spent on self-afflicted
cases, but a good portion of it is. And you know what they say, a billion here and a billion there and soon youre
talking about real money.
This argument is ludicrous; we pay for the NHS with the knowledge that our taxes may not be paying for our own
treatment now but one day someone elses money could be paying for your healthcare.

Not everyone can afford to simply accept their charge. Surely this would
necessitate an appeals process?
Another question is who adjudicates? The doctor? That would add another problem. It seems that, in these
circumstances, the doctor in question could not win. It is perfectly plausible that a person could lie about their
symptoms to avoid higher costs, this way the doctor cannot treat the patient. The doctor-patient relationship could be
damaged, not just in the individual case, but also in a wider context. The idea of Money-Grabbing Doctors, whilst
most likely false, is one that could get public support. Not everyone can afford to simply accept their charge. Surely
this would necessitate an appeals process?
An appeals process would be necessary and beneficial to nobody. There would be the administrative costs of
launching and holding an appeals tribunal. Medical staff involved in the treatment and subsequent appeal in question
would have to give up time and effort that could be better served elsewhere.
So we have financial costs for the tribunal itself and costs in terms of time.And if the patient loses, are they now
lumbered with the cost of the appeal and the treatment, which they might not have been able to afford anyway? And if
the NHS Trust in question loses, the taxpayer now funds the treatment they would have paid for anyway and also the
cost of an appeal.
The idea of this unnecessary added cost, which will be given to either party based on a subjective decision, helps
nobody and can be avoided by disregarding the idea of people paying for self-inflicted injuries.

Want to make more money for the NHS? Then close tax loopholes, increase
education on healthy lifestyles, and the dangers of smoking and alcoholism
The NHS is not a charity; it is paid for by taxes. Want to make more money for the NHS? Then close tax loopholes,
increase education on healthy lifestyles, and the dangers of smoking and alcoholism.

People who propose a charge to NHS services need to consider that one day it may well be you being asked to pay for
treatment you desperately need but desperately cant afford.
**People

should take some responsibility for their own health: the treatment of self-inflicted
diseases should not be the responsibility of doctors in the NHS.

People taking some responsibility implies that people should not only be looking after their
health by avoiding activities that have heavy consequences, but also paying for their treatment as
it is there fault. For example, people shouldnt smoke as they know that they are likely to get
lung cancer or emphysema and if they do smoke, they should immediately make efforts to quit
smoking rather than continue with treatment to solve all problems.
Responsibility of doctors in the NHS suggests that tax money should not pay for peoples
problems which they created and that doctors should instead take time to diagnose those who are
ill by external factors such as pathogens.
Overall, this statement indicates that doctors in the NHS should only treat those who have no
inflicted illness upon themselves- only innocent people should be helped in the crime of illness
while the guilty should pay for their disease.
Implications of self-inflicted diseases include:

Diseases that have come about by a person doing an activity that

has consequences that very likely to occur in a persons lifetime.
Smoking can cause lung cancer but people still smoke.

An accident from doing an activity such as breaking your foot when

jumping down from a tree or a car crash. People have many safe car
journeys but one stupid thing can cause a crash and serious injury.
One limitations of self-inflicting could be whether perfect health means that
you will never get ill again. If you get ill from a mild virus, for example,
perfect health would mean that the immune system would be strong and
attack it without you getting too ill. So if another person got dangerously ill
from the same virus, its a self-inflicted disease as they havent got perfect
health. It would be more of an individual analysis of what self-inflicted
diseases were in treatment rather than a general perspective
Doctors should treat all patients because:

The NHS is funded by us, tax payers. If the NHS decided to cap who got
treated and who didnt, there would be uproar. People would claim it to be
unfair. Doctors are being paid to treat in the best interests of the patient

and not to dictate whether a disease shouldnt be treated because it is selfinflicted.

Reasons for self-inflicted diseases are not necessarily the patients
fault; external causes such as stress from work or socio-economic
backgrounds can be a problem. For example, obesity is more common in
poorer areas due to lack of education and money meaning junk food is a
lot more cheaper to pay for.

1. The embryo has full moral status from fertilization onwards

Either the embryo is viewed as a person whilst it is still an embryo, or it is
seen as a potential person. The criteria for personhood are notoriously
unclear; different people define what makes a person in different ways.

Arguments for this view

Arguments against this

view

Development
from
a
fertilized egg into to baby is
a continuous process and
any attempt to pinpoint
when personhood begins is
arbitrary. A human embryo
is a human being in the
embryonic stage, just as an
infant is a human being in
the infant stage. Although
an
embryo
does
not currently have
the
characteristics of a person,
it will become a person and
should be given the respect
and dignity of a person.

An early embryo that has

not yet implanted into the
uterus does not have the
psychological, emotional or
physical properties that we
associate with being a
person. It therefore does not
have any interests to be
protected and we can use it
for the benefit of patients
(who ARE persons).
The embryo cannot develop
into a child without being
transferred to a womans
uterus. It needs external
help to develop. Even then,
the probability that embryos
used for in vitrofertilization
will develop into full-term
successful births is low.
Something
thatcould potentially
become a person should not
be
treated
as
if
it
actually were a person

2. There is a cut-off point at 14 days after fertilization

Some people argue that a human embryo deserves special protection from
around day 14 after fertilization because:

After 14 days the embryo can no longer split to form twins. Before this
point, the embryo could still be split to become two or more babies, or it
might fail to develop at all.
Before day 14, the embryo has no central nervous system and
therefore no senses. If we can take organs from patients who have been
declared brain dead and use them for transplants, then we can also use
hundred-cell embryos that have no nervous system.
Fertilization is itself a process, not a moment. An embryo in the
earliest stages is not clearly defined as an individual.
3.
The
embryo
has
increasing
status
as
it
develops
An embryo deserves some protection from the moment the sperm fertilizes
the egg, and its moral status increases as it becomes more human-like.

Arguments for this view

Arguments against this

view

There are several stages of

development that could be
given
increasing
moral
status:

We protect a persons life

and interests not because
they are valuable from the
point of view of the
universe, but because they
are important to the person
concerned. Whatever moral
status the human embryo
has for us, the life that it
lives has a value to the
embryo itself.

1. Implantation of the
embryo into the uterus wall
around
six
days
after
fertilization.
2.
Appearance
of
the
primitive
streak

the
beginnings of the nervous
system at around 14 days.
3. The phase when the baby
could
survive
if
born
prematurely.
4. Birth.
If a life is lost, we tend to
feel differently about it
depending on the stage of
the lost life. A fertilized egg

If we judge the moral status

of the embryo from its age,
then
we
are
making
arbitrary decisions about
who is human. For example,
even if we say formation of
the nervous system marks
the start of personhood, we
still would not say a patient
who has lost nerve cells in a

before implantation in the

uterus could be granted a
lesser degree of respect
than a human fetus or a
born baby.
More than half of all
fertilized eggs are lost due
to natural causes. If the
natural process involves
such loss, then using some
embryos
in
stem
cell
research should not worry
us either.

stroke has
human.

become

less

If we are not sure whether a

fertilized egg should be
considered a human being,
then we should not destroy
it. A hunter does not shoot if
he is not sure whether his
target is a deer or a man.

4.
The
embryo
has
no
moral
status
at
all
An embryo is organic material with a status no different from other body
parts.

Arguments for this view

Arguments against this

view

Fertilized human eggs are

just parts of other peoples
bodies until they have
developed
enough
to
survive independently. The
only
respect
due
to
blastocysts is the respect
that should be shown to
other peoples property. If
we destroy a blastocyst
before implantation into the
uterus we do not harm it
because it has no beliefs,
desires, expectations, aims
or purposes to be harmed.

By taking embryonic stem

cells out of an early embryo,
we prevent the embryo from
developing in its normal
way. This means it is
prevented from becoming
what it was programmed to
become a human being.

IVF
Children on hold: The case of frozen supernumerary embryos

One of the by-products of the typical IVF treatment is the creation

of supernumerary embryos. More embryos are brought into existence than
can be safely replaced in the first cycle. The remaining embryos are frozen to
be used later if the first trial proves unsuccessful or when the couple wants
another child. However, not all embryos are replaced and not all parents
indicate what should be done with them. The accumulation of frozen
embryos has resulted in impressive numbers of embryos stocked in the
freezers of the large fertility clinics. The exponential growth of their number
urges on the ethical reflection on the fate of these embryos. In 1996, a
British organization known as the Human Fertilization and Embryology
Authority (HFEA) estimated that a total of 52,000 frozen embryos existed in
the United Kingdom. In 2000 there were a total of 71,176 frozen embryos in
Australia and New Zealand .Any legislation on limit of duration of
preservation prior to the destruction of these supernumerary embryos
underscores the potential pitfalls inherent in allowing political expediency to
supersede basic humanness' and commonsense.
There are several ethical and moral issues surrounding the embryo freezing
process. These include the following:
Fate of the stored embryos on the death of couple 'orphaned' embryos.
Ownership of the embryos if the couple divorce.
Safety of embryo freezing.
Concern that the length of time embryos have been kept in storage
might have a detrimental effect on the outcome of frozen embryo transfer
and possible increase in fetal abnormalities. However, no long-term studies
have been carried out since the age of the oldest child born as a result of
frozen embryo transfer is only 14 years. In addition, there is no evidence that
extended storage is detrimental to the outcome of treatment.
1. Defining initiation of life ethically?
Amid all the talk about the ever-increasing availability of in vitro
fertilization techniques, one issue is almost never mentioned; namely,
what happens to all those extra embryos?
Often surplus embryos are involved in process of IVF to substantially
enhance the chance of pregnancy .Whether they are laboratory
artifacts or not and when life begins are obvious questions. This puts a
question mark on the sanctity-of-life. So, theologists argue that we
should give the embryo the benefit of the doubt and consider life at
the very beginning [10]. and humans should be spatio-temporally
continuous with the embryos and fetuses they once were. if human life
initiates at fertilization then ivf is experimentation upon a human being
and should follow the norms of that type of research. moreover,
discarded zygotes or embryos lost in unsuccessful implantations, at
present a foreseen possibility of ivf, would be human.
Report suggests that out of 150 attempts to implant human embryos
only 4 actually were successful and only 1 was carried to term.
Knowingly and willingly wasting human beings is unethical. On the

other hand, if there is evidence that human life does not begin until
after implantation, then IVF would not be unethical from the point of
view of the zygote because only animal life would be present. The
following query sums up this aspect of the issue: Is the zygote human
life with potential or potential human life?
Human life must be respected and protected absolutely from the
moment of conception. From the first moment of his existence, a
human being must be recognized as having the rights of a person.
When this fundamental moral line is violated or obscured, categories of
people become devalued and they become easily used for utilitarian
purposes. Human life is precious from the moment of conception; but,
unfortunately this respect for human life is being eroded in our
contemporary society
Chromosomal and Other Congenital Defects
Pregnancy is something of a lottery for all couples. However, compared
with couples who conceive spontaneously, for those who require IVF,
the lottery is weighted more heavily against a successful outcome at
every stage of the process, not just conception. Stepping away from
God's law always introduces chaos into our lives. Nowhere is this truer
than in the case of in vitro fertilization. This is the reality alongside the
hope that must be conveyed at counseling to all couples contemplating
treatment. Throughout the short history of assisted reproduction there
has been concern to monitor the safety of this important technology It
is well established that infants conceived following in vitro fertilization
(IVF)are more likely to be born preterm, of low birth weight and to be a
twin or higher order multiple than spontaneously conceived infants
[20,21,22]. the evidence relating to the risk of birth defects is less clear.
An increase in chromosomal abnormality in IVF babies due to technical
inadequacy has been observed [15]. numerical abnormalities alone
were found in 71.7% of morphologically normal embryos [ 4]. and in
those morphologically abnormal, only 3 out of 14 had a normal
chromosomal complement [5]. congenital malformations include
increased neural tube and cardiac defects [6].
In such unfortunate cases, should the parents be able to sue? In fact it
is not easy to prove whether the fault lies in negligence during
laparoscopic, IVF or implantation procedures [ 15]. the congenital
disability act, 1976 helped little to solve the problem [15]. the warnock
committee suggested a licensing system be used to control [2,3].
moreover, preimplantation diagnosis of genetic diseases may help to
lower down the risk [8].
Legal Stand
Our judicial system has trailed woefully behind the complex bioethical
dilemmas that accompany the rapid advances in biotechnology, biomedicine,
and assisted reproductive technologies. Artificial conception raises the

possibilities of myriad problems - legal or otherwise, which may need

resolution by legislation or national guidelines. These relate to:
The question of embryo research and the time limits to be placed on it
Basic questions such as - when does life begin? What are the rights of
an embryo? , remain unanswered.
Guidelines on semen banking
The child's right to access to information about his/her genetic
background and mode of conception
The legality of surrogacy
The registration and monitoring of IVF clinics to ensure that infertile
couples are not exploited.
This field requires legislative measures after considering these ethical
concerns to prevent it from going down slippery slope of exploitation and
abuse. Regulations preventing commoditization of embryos could save us
from slouching toward a brave new world as we seek to redeem the great
biomedical promise of our time.