Harold Shapiro, Ph.D.
Princeton University and Chair, National Bioethics Advisory Committee
"Public Bioethics: The Case of Stem-Cell Research"
October 24, 2001

Harold Shapiro: I am great fan of the public part of public bioethics and I want to indicate why in just a moment and then I'll look at the issue of embryonic stem-cell research in the context of public bioethics. Let me just say a few words about terminology at the beginning. Everyone talks about stem-cell research. I'm not a scientist but I do know there is a difference between 'embryonic stem-cells' and 'other stem-cells'. I am going to use 'stem-cells' just like that. When I say that, I mean 'embryonic stem-cells' and it just saves me an extra word as I go through and I'll talk a bit about other kinds of stem-cells later on.

I going to talk about this in two sections, that is, "Why is this an ethical issue?" and even if we can decide very quickly why it is an ethical issue, "Why is it a public policy issue?" There are many ethical issues that have nothing at all to do with public policy and which public policy ought to have little or no interest. And I think this is a case where we have to understand: 1) why this is an ethic issue, why you might consider it an ethical issue and in particular why it's an ethical controversy. And then alright you have an ethical issue over which there is some conflict. Should public policy take an interest or why should public policy take an interest in this particular problem? I'll then conclude by outlining what the National Bioethics Advisory Commission had to say about this and what President Clinton had to say about this and what President Bush had to say about this. And I'll conclude with some words on moral pluralism and indeed I hope to leave you with a moral to this story when I'm finished.

Now, as you've heard just a few moments ago, there are three key words in dealing with public bioethics. One, the three words I pick up is a 'group', that is it's an ethical discussion taking place in a group context. It is 'public', that is it's deliberations take place in public and moreover, it's an issue on which there might be some reason for 'public policy' to act. That's what I mean by public bioethics. It could be a public bioethics unrelated to public policy but I'm going to be considering it and looking at it only with respect to open group discussions, on public deliberations on issues of some interest to public policy.

Now there are many people who are against, even aghast at the idea of public deliberations of this kind. After all, few people would suggest that it would be useful to negotiate the A.B.M. or the provision of the A.B.M. treaty in public. It would seem to many people to undermine the formation of sensitive public policy. I would suggest, however, that whenever it is possible, it is healthy to carry out public policy deliberations in public. Especially in the 'bluebird of democracy' and especially on a controversial issue. As I'll say a little later on, if we accept the fact that this is a country where we accept moral pluralism, then there is no alternative to public deliberations and careful thinking on important controversial issues. On not only controversial but when public policy, which governs us all, is at stake. I also have an observation on the public nature of discourse, because I think actually, that these deliberations, taking place in public, rather than hindering the debate actually improve the debate. Now, I know that all you members of the National Bioethics Advisory Commission do not agree with that but I think it is true and I'll tell you why.

First of all, it disciplines the discussion of the committee itself. Many of you have belonged to committees and unless they are very different from the committees I belong to, the discussion if often not very disciplined. When you are talking in public, however, the public nature of that, the fact that there's other people listening, puts a certain discipline in the discussion which I think makes people think carefully and more particularly, think before they talk. And I think that is a very healthy thing for group discussions.

Secondly, you receive more relevant input from the public. If the public knows what you are discussing, knows what you are thinking about, the chance if greater of you receiving relevant input. Input that, in fact, might change your mind on something is much, much higher. It's almost impossible if the sessions are closed.

You also, in public, have an opportunity to demonstrate respect for other points of view. Points of view which might be at variance with the committee's own deliberations and the stream of thinking and recommendations towards what it is headed. Talking about these in public, explaining your position in public gives you and opportunity to show respect and empathy to views other than your own. Again, my own view on the controversial issue of public policy issue is involved, that is a critically important part because if you are making public policy decisions and recommendations on controversial issues there are going to be some losers. You have to come down on one side or the other on the particular situation. And it has always seemed to me that in a democracy such as ours it's easier to live with opinions different than yours if you feel you are respected and if you feel you are whole. And open meetings give you a very good chance to do that. I am, therefore, a great fan of public bioethics. I hope to see more rather than less of it as we go ahead.

Now let me turn to the issue that we are here to discuss, namely, stem-cell research. Now the first question is: "Is it an ethical issue?" Because for lots of research that goes on, we don't normally think of this research as having ethical content. Of course, all research has ethical content but we don't think of them as controversial ethical issues as we move forward on the biological frontier or the frontier of biology. But the use of embryos in research is different because it reveals in a rather pure form, the issue of respect for "life", if you want to put life in quotation marks, from the moment it begins and raises at least the following three questions:

Does the embryo enjoy the moral status of a born person at any stage of its development? An obvious question. If it does have the moral status of a born person that sort of ends the discussion. Public policy is pretty clear what to do in that respect. But if it does not have the moral status of a born person, what State protection should we provide it, if any, at different stages of its development? That's really the heart of the question that we have to answer if you believe that it does not have the status of a born person.

And then you have to ask yourself a logical question, namely, is it logically possible to say that life only needs some sort of State protection or the embryo only needs some form of State protection at different stages of its development? And if so, what kind of logic would you use to defend that perspective if that's the perspective that you take?

So, when you start using embryos in research, those questions come immediately. And immediately you are faced with ethical problems. But by themselves those issues don't really pose an ethical conflict. They raise ethical issues but don't pose an ethical conflict. The reason ethical conflict arises is that we have other ethical obligations which have been mentioned also in the introduction today. Namely, to try to do what we can to cure disease and relieve suffering both in current and future generations. That's also an ethical conflict that's imperative on us. So, if you think it's problematic ethically, to use an embryo in research, you have to balance that with, among others things, your other ethical imperative, namely to relieve disease and distress in current and future generations. That's obviously an issue in this area even though we are at the very, very beginning of understanding in what way these embryonic stem -cells could be used in the clinical setting. That is far away in my view, at least for the embryonic cells, but in any case, let others more competent than I speak to that. But nevertheless, it's quite clear that the scientific community feels, and justifiably so, that this is an important avenue for them to continue to look at in their ongoing effort to cure disease. That itself, is a great humanitarian effort. We cannot forget that. It's not just science. This is part of a much more complex and broader humanitarian effort as I said a few times already. To relieve distress and cure disease.

So you have a conflict at least at that level, or other conflicts which I won't talk about directly right now. And of course, you immediately have the issue of whether this is the only way to accomplish that. If destroying an embryo raises for some people some ethical problems. On the other hand you have this imperative to relieve distress and cure disease. And there is also the other issue that came up a lot in our debates, namely, are there other paths other than through the embryo to achieve the same result? Of course, at the time we did our report in 1999, the assertion, it wasn't any more than an assertion at that time, I think, was that adult stem-cells, that is stem-cells which don't quite have the potency of embryonic stem-cells might, in fact, do the trick. And would eliminate some of the ethical conflict. Well, at that stage in any case, and I think basically still pretty much the same, adult stem-cells are first of all, harder to find and second of all, harder to reproduce which is what is needed for research in this area. But at that time, it was only an assertion. I feel that it is more than an assertion now. People have isolated adult stem-cells, that is, more specialized stem-cells in a number of different areas and I am sure that they will also prove very valuable. However, I do not think, in my own judgement, right now it will not substitute completely with dealing with the issues of embryonic stem-cells so we are still facing that ethic problem and ethic conflict.

Well, it's a pretty obvious ethical conflict. Now, is this something that public policy should take an interest in? In this country, our cultural traditions are such that we're very cautious about things that federal policy ought to take an interest in. We are in the cultural tradition of Will Rogers who said he is only safe when Congress is out of session. And we have that general view here in this country. That government is likely to be part of the problem rather than a solution to the problem. So we are very hesitant about public policy getting involved in issues, much more so than other governments. And the question is: "Should the federal government in particular, get involved in this case"? Well, I think there are two obvious reasons why it is a public policy issue in this particular case. One is that the government is a very significant funder of basic medical research. Through the N.I.H. programs, whether the intramural program or the extramural program, government supports an enormous proportion of the basic biological research community in this country and that it therefore, has to be held accountable for what it does. So, that by itself, the pure fact that the government will be financing work in this area, means that it cannot avoid having public policy take a stand on this particular issue.

But I think that there' s even a more basic issue involved here. The debate you come down on is: if the embryo or the fertilized egg from its very first moments has the same moral status and therefore deserves the same protection as a born person, then of course, as we pointed out many, many times, using the embryo in research is somewhat equivalent to homicide. And homicide is something that the State has an interest in. It doesn't matter what else might be involved if you were on that side of the debate and you thought that this was the moral equivalent of murder. Then, of course, the State obviously has a direct interest in it. And so public policy cannot avoid getting involved in this particular ethical issue, at least in my judgement. Now it's an interesting issue here, I think, what has been often overlooked in much of the discussion. Namely, if this homicide is what is driving forward your views on this issue, it clearly would be rather ludicrous to distinguish between public and private efforts in this area. That whether homicide financed by public funds is no good but by private funds is quite all right. If you are on that side of the issue, you lose all possibility, it seems to me, to distinguish between publicly funded and privately funded stem-cell research.

On the other hand, if it's the first of these reasons, namely, you are just concerned with the publicly funding of stem-cell research then, of course, you could distinguish between public and private. Because it's a perfectly respectable argument that government expenditures would have to cross over a higher or different moral hurdle than the private expenditures. I, myself, don't think much of that argument but it's a possible argument and it's an argument that is often used. But it is important, I think, for everyone to remember that not all bioethical issues that come up are really public policy issues. This one, I think, however, squarely is.

Now, what to do, therefore? You have this ethical conflict. As I've tried to describe and its well known to you, it's been in newspapers everyday before September 11^th and even once in a while after September 11^th. What's a way to solve this problem? Well, I'll tell you what N.B.A.C. did. N.B.A.C. is the National Bioethics Advisory Commission. We did this report, as was mentioned earlier, in 1999 before this got quite the current level of notoriety that it has since President Bush took office. Our position was that we would balance off these positions in the following way. Namely, that it would be quite all right for federal funds to be used for the creation and use of embryonic stem-cells. That is, unlike the President Clinton policy, which I'll talk about in a minute, we said it was all right under certain conditions, which I'll describe in a moment, to both create and use these cells.

What were the restrictions? The restrictions had to do with two things. Namely, the source of these cell lines, we did put some restrictions on the source. And also issues regarding consent to the use of these materials and so on, which I won't go into in any detail but were important. The consent issues, that is the consent of the parents and so on who had to agree to the use of the embryo had to be structured in a certain way and so on and so forth. Basically the idea being not only to get consent but to separate the decision not to use the embryos for reproductive purpose from the decision to actually donate them or allow them be used for research purposes.

But creation and use were all right as far as we were concerned. What was not all right as far as we were concerned, we put restrictions on the source. There are a number of different sources. You can imagine the number of different sources for embryonic stem-cells. We eliminated the possibility of using embryos that were expressly created for research. Whether the so-called recruited embryo, that is you get someone to donate the ova and someone the sperm, use I.V.F. to get an embryo and so on, that recruited embryo we said, was not appropriate. And we also said that creating an embryo by using schematic cell nuclear transfer techniques was also not appropriate. But the general class that was inappropriate was those embryos that were created solely for research. We recommended that we use only those embryos that were initially created as part of a reproductive process. And now, at least as we viewed it, what we were recommending had more to do with how an embryo was going to be destroyed rather than whether it was going to be destroyed. We were quite well-aware that there were others who feel that these embryos should never be destroyed, maybe these people would adopt them in some case and so on. We remained unconvinced of that particular line of reasoning.

So that was our position. President Clinton rejected that position as I think all of you know, because he said, "Okay for use. Not okay for creation." You could not use federal funds for the creation of these cell lines but you could use them. I never liked that policy. As a matter of fact I had more respect for more conservative policies than that. I didn't like it because it seemed to be an extension of the policy of "Don't ask, don't tell". That is, you don't ask where they come from, you don't tell where they come from. You just use them. As if you can ethically separate yourself from the process of manufacturing or creating these stem-cell lines. It also sort of seems like hiring a hit man to do something for you. Here we are creating this demand for stem-cells using federal funds but we can't do the actual destruction. We hire a private firm to do that for us, it's sort of like hiring a hit man to do something, if you have that particular point of view regarding the moral status of these embryos. But nevertheless, that was his position and I'll come back and say something more positive about that in a moment.

President Bush's position, of course, is even more restrictive than that. Namely, you can't breed any cell lines but you could certainly use them providing that they were created before August 9^th. Another, and I think, rather suspect way of going about it. I can't think of any ethical reason why August 9^th had any moral standing of any kind. But, in any case, that's the policy.

Now I want to conclude my remarks by saying something about moral pluralism. Because I think understanding what moral pluralism is and it's unavoidability, gives you some different way to interpret both N.B.A.C'.'s position, President Clinton's position and President Bush's position. Because N.B.A.C .itself, at least in my judgement, (there are other members of the National Bioethics Advisory Commission here) even N.B.A.C.'s position was a compromise. Because you could easily ask, "Why didn't we okay the use of embryos that were produced especially for research?" I can't speak for all the members of the commission but in my mind, my reason was, simply because I wanted to show some respect for quite different points of view from my own. And one way of doing it without getting in the way of other ethical obligations to allow science to proceed was to say you could only use certain sources, sources that were created by a reproductive project. And that was my reasoning. Other members of the commission may have had different reasons for coming down that way but the point I'm making, even in my mind, we were compromising. I was compromising. The recommendation I supported was, in my view, a compromise from the position if it had only been up to me to decide what to do.

Now let me just conclude, as I said, with a remark about moral pluralism. The idea of moral pluralism holds that a number of good and important ethical values and principles are inherently incompatible. That's why there is ethical conflict and why it is inevitable. As long as people enjoy free association and the capacity to think and act for themselves, which is probably something we don't want to reject, there will be value conflicts that are not due to such motives as selfishness, prejudice, ignorance, poor reasoning and other motives of that kind. Mainly, there will be disagreements and conflicts that come from the best possible motives, in some sense, unimpeachable motives. The result is that individuals not always agree about complex moral and political issues and that complete agreement will be very, very rare. The result is that if we accept moral pluralism as a fact, compromise and accommodation must be accepted by all sides.

That's really the conclusion that I come to in this respect. That if we accept moral pluralism, at least I haven't come across anyone who does not accept that, it would be hard to know how an American does not accept that as a fact. Compromise and accommodation must be accepted by all sides. So, as I explained just a few moments ago, N.B.A.C.'s position and my judgement and at least for some members of the commission was a compromise. A compromise, for example, to take another kind of recommendation. We could have recommended the creation and use of stem-cell lines whether they came from cloning or whether they came from recruited embryos or whether they came from excess embryos or any other source that you may think about. It was, in my view, a compromise and a worthy one. I think President Clinton's position, although I was a little flip about it a few moment's ago, is a different kind of a compromise. It's just a further compromise. He moved over a little bit more and it's perfectly understandable in that context. Although, as I said, I made flip comments about it a few moments ago, I understood it from his own perspective and what he thought he had to balance and what kind of compromises he wished to make. And I would make the same comment with respect to President Bush's policy. It also reflected that he had further compromise on the issue.

I think the biggest trouble with the current policy is that I think it is much less stable than either the N.B.A.C . recommendation or Clinton's position because I think it's going to become clear very, very shortly that we have to revisit the issue. If a code called for 60 cell lines or 20 cell lines or 26 or 27 or 37 or whatever the number is to continue to be useful all of which mostly are made of a bit of mouse cells and so on. It's hard to know what clinical use could become of that but in any case, I think his policy will require us to revisit the issue. And whatever the decision is when it's revisited, I think that the logic of scientific agenda, the logic of trying to produce new clinical modalities will require the President to revisit this issue sooner rather than later. I think the Clinton policy was longer lasting. It will also require revisiting at some stage as I'm sure the N.B.A.C. policy will as well but I think of these three, Bush's is the least stable of them all. It all comes down to the fact that this is a complex world and, as if you didn't know that, there are no easy answers, therefore, to complex issues.

That said, I'll conclude with a moral. And it really comes from my experience as Chairman of the National Bioethics Advisory Commission more than any other part of my own experience. Namely, as we looked for guidance in dealing with these ethical issues, we looked at theological positions from which we got a lot of inspiration, not quite so much guidance. We looked at moral philosophy in which there has been a renaissance in the last 20 to 30 years in this country and elsewhere. And I have to say that we got, particularly for myself, an enormous amount of inspiration, some help, but very little guidance in how to form public policy. And the reason is with, of course, as you know, good moral theories, good moral approaches, one doesn't knock out the other. No single approach of moral philosophy is so compelling to so many people that it knocks out all the other approaches. Instead we have different approaches of moral philosophy existing side by side with each other, each having its own strengths and weaknesses from which we try to get some guide for individual or government action.

I think that the only way out of this dilemma is that we, all of us, like artists, we have to face a terrible dilemma. That our life has to be characterized by continued moral calculations and recalculations. That's my so-called moral. But you can't expect to deal with these issues in any once and final way. That everything involves continuous moral calculations and recalculations and regardless of which theory of moral philosophy or which theological framework you want to use for our discussions. We cannot escape the fact that as this world changes as quickly as it is, that continuous moral calculation and recalculation is just going to be a part of every thinking person's life. That if you want to think these moral issues, that if you care about them, you want to be a moral person, you will not be able to avoid this continuous moral calculations and recalculations. This is true for public policy, this is true for individuals, I think it is true for all of us who care about living what we might call a useful and valuable life.