Human embryonic stem cell research: a case study in ethics

by Denise Cooper-Clarke 15.04.02

In 1981 Alasdair MacIntyre’s After Virtue claimed that contemporary ethical debate offers striking evidence for the theory of emotivism. That is, the doctrine that "all evaluative judgments and more specifically all moral judgments are nothing but expressions of preference, expressions of attitude or feeling." It follows that moral disputes can never be rationally settled, because moral judgments are non-rational. It also follows that much of what passes for moral argument is highly emotionally charged and manipulative, and frequently involves the vilification of one’s "opponents". These features may certainly be recognised on both sides of the recent public "arguments" about human embryonic stem cell research.

Many thinkers now regard shrillness and interminability as intrinsic features of ethical debate. But MacIntyre is not one of them. Instead he claims that our contemporary moral chaos has resulted from the failure of the Enlightenment Project to provide a basis for the justification of morality, to replace the moral tradition which it jettisoned. This is not to say that the Enlightenment did not produce any number of contenders for such a theory of moral justification, but none gained universal acceptance. So the voices of utilitarianism, of Kantianism, of Human Rights, of Natural Law, of Divine Command Theory, of Virtue Ethics and many others combine in what often seems an unintelligible cacophony.

Almost all public ethical discussion takes place at the level of applied ethics, without making explicit that this rests on so called normative theories of ethics, which themselves rest on the foundation of meta-ethics. Fundamental disagreement exists at all these levels. And so a great deal of the disagreement at the applied ethics level, such as the debate about the permissibility of active voluntary euthanasia, or the use of human embryonic stem cells, actually arises at a deeper level, at the level of which normative theory we use, and at the level of meta-ethics -what is the source of ethical authority? As long as we ignore these deeper levels we are unlikely to resolve the applied issues. Even if we do pay attention to the more fundamental questions, we may still disagree but at least understand better why we do, rather than simply calling each other names and accusing each other of being unethical or immoral.

Meta-ethics is concerned with ultimate justification. Is there any objective basis for calling something right or wrong, or is it purely subjective? Can anything be either right or wrong depending on your point of view, or more likely, your cultural point of view? Most people agree that such radical relativism is incompatible with the discipline of ethics- there’s simply nothing to talk about. (Or at least nothing to reason about — we can still make a lot of noise shouting at each other in accordance with emotivist theory). Ethics is about right and wrong, or at least better or worse decisions, and to use these terms meaningfully presupposes some standard. But what is this standard? Traditionally Christians have seen the will of God (revealed primarily in the scriptures) as the objective standard for morality, though recently doubts about whether we can actually access the will of God have been raised. Instead, it is argued, we need to rely on the mind of the church, the community of faith. This is not an objective, but an intersubjective standard.

Normative ethical theories are concerned with the precise nature of the source of objective moral authority: They offer an answer to the question, "What makes something right or wrong?" There are only three basic theories, only three forms of answer to the question. The dominant normative ethical theory in Australia, particularly in Melbourne, because of the influence of Peter Singer, says that x is wrong because it produces harm to someone. Or more subtly, it produces more harm overall than benefit. Conversely, an action must be right if it can be shown that its likely benefits outweigh any likely harms.

The consequentialist theory of ethics says that: An action is right if and only if it promotes good consequences. The most prevalent version of this theory is utilitarianism, which specifies that An action is right iff it promotes the best consequences. And the most popular and sophisticated version of utilitarianism today is that pioneered by Prof. Peter Singer, called subjective preference utilitarianism. This stipulates that the best consequences are in fact the maximization of individual subjective preferences.

Crudely speaking, this means that is overall, more people’s subjective preferences (what they want) are satisfied by action a than action b then a is the right thing to do. This seems to make " sense" in many situations, but it sometimes produces odd results, or conclusions which run counter to some of our deepest moral intuitions. What is being claimed here is that no action is right or wrong in itself, but is only made so by the consequences it promotes. Its morality is not intrinsic but extrinsic. So, in unusual circumstances, murder, lying, theft, torture, may not only be permissible but obligatory. There can be no such thing as individual "rights" because any one person’s preferences must be weighed against the preferences of others. There is no independent "umpire" to judge whether those preferences are good or bad- it’s simply a matter of doing the sums and doing what satisfies the most preferences.

There are many critiques of utilitarianism, including the observation that we often cannot predict what the consequences, especially the long term ones, of any action will be. But the main critique from a Christian perspective is that it places the decision-maker in a God-like position of responsibility for the well being of the entire universe. Of course we should responsibly think through the consequences of our actions and exercise prudence. Much of the wisdom literature teaches that doing the right thing generally results in good consequences but when there is a conflict between maximizing good consequences and obeying God, generally Christians have rejected the idea that we should "do evil that good may come". (Romans 3:8)

Running counter to consequentialism, and absolutely incompatible with it, are the non-consequentialist normative ethical theories which claim that there are some actions which should never be done, no matter what good consequences they promote. There are some things, it is held, which it is simply unjust or indecent to do, and the end cannot justify the means.

This basic difference between consequentialist and non- consequentialist thinking lies behind much of the argument about the permissibility of the use of human embryonic stem cells. It explains why the participants in the argument talk past each other, and no amount of discussion, rational or otherwise, will resolve the differences. For a utilitarian, the possibility of great medical benefits, such as treatments for diabetes, Alzheimer’s, Parkinson’s disease, even the possibility of regeneration of damaged spinal cord tissue leading to recovery from paraplegia or quadriplegia, self- evidently justifies whatever it takes to achieve this, providing the benefits can reasonably expected to outweigh the harms. Since the harms in the case of extracting stem cells from existing frozen embryos which are due to be destroyed anyway are negligible, there is simply no contest. In fact, utilitarianism is a very robust theory, which could justify far greater harm, including the killing of foetuses, infants or even adult humans, if the projected benefits in terms of "the greater good" or the maximisation of preferences could be demonstrated. To speak of the intrinsic evil of destroying human life makes no sense at all in this framework.

On the other hand, from a non-consequentialist perspective, if an action is wrong then the whole list of projected benefits from it are strictly irrelevant. At this level it is clear why no amount of argument will change anyone’s mind. There are two types of non-consequentialist normative ethical theories: deontological, and virtue. Deontological theory says that: an action is right iff it is in accordance with a moral rule or principle Such moral rules or principles may be derived from divine law, natural law, or reason. One very important contemporary version of deontological theory is the Human Rights Movement. To proclaim a right, such as the right to life, or free speech, or the right to die with dignity and so on, is to invoke a moral rule, to claim that there is a duty to provide, or at least not to interfere with, these things. Rights language is very strong moral language and is inherently incompatible with utilitarianism. Rights must not be violated, no matter what the consequences. In Australia, powerful rights language coexists with a strong emphasis on utilitarianism, which may explain some of our ethical confusion.

When we consider the morality of human embryonic stem cell research, the critical question from a deontological perspective will be whether destroying an embryo comes under the rule "You shall do no murder" or the general principle of the sanctity of human life. Or to put it in rights language, does the embryo have a "right to life". The usual approach to these questions is to ask "When does the life of a human individual begin?"

Another approach is to consider "What is the moral status of the embryo?". These two questions are often assumed to be the same, but I believe they should be seen differently.

"When does the life of a human individual begin?"
The question "When does the life of a human individual begin?" has a range of possible answers. This range is possible, even among Christian ethicists, because the scriptures do not give a definitive answer. The proof texts which are commonly cited do not bear the weight which is sometimes assigned to them, namely that "the Bible teaches that human life begins at conception". Psalm 139 certainly suggests that the process of intrauterine development is the work of God, and that God knows us even before we are born (as does Jeremiah 1:5). But this latter text may prove too much, as it says that we were known by God even before we were formed in the womb. According to Ephesians 1:4 , we were chosen by God even before the foundation of the world" . Neither of these texts is concerned with a definition of the beginning of a new human life.

Similarly, the interpretation of Exodus 21:22-23 is by no means clear. But even if it were, it is dealing with accidental injury to a pregnant woman resulting in miscarriage, so that we are probably dealing with a foetus (after the eighth week of development) but certainly not with a blastocyst (within 14 days of conception). Again, the text offers no definition of when conception occurs.
The possible answers to the question "When does the life of a human individual begin?" include:
- at fertilisation
- at 14 days
- at viability
- at the development of consciousness

Fertilisation
This is the most conservative view, and the official view of the Roman Catholic Church. But it is important to note that, contrary to the impression created by the media, it is also shared by many secular humanist philosophers. There are actually two possibilities here. We now know that fertilisation is a process which takes place over several hours, beginning with the penetration of the egg by the sperm, and the entry of the sperm’s head into the egg cytoplasm (the material surrounding the nucleus). Some think that this point is the beginning of a new human individual. Others consider that fertilisation has not taken place until the fusion of the sperm and egg nuclei, with the formation from two sets of chromosomes of a new genome.

According to this view, the use of embryonic stem cells (which are actually obtained from the blastocyst, sometimes called the pre-embryo, within 14 days of fertilisation) is morally wrong since it destroys a human individual. The fact that the sacrificed blastocysts would be "spares" produced in the course of IVF, and would have been destroyed anyway, raises the question of complicity in evil. Is it possible or permissible to derive good from evil?

According to the theory of moral complicity, if the destruction of a blastocyst or embryo is considered a moral evil at all, any benefit deriving will be tainted with the original evil. However, a similar argument could be made in relation to the transplantation of organs from car accident or suicide victims. One is entitled to raise the question, however, whether so many "spare" embryos ought to be created. Various IVF programs create more or fewer "spares". Since they are created (and then destroyed) deliberately, the situation is not analogous to the use of organs from an accidental victim.

Against the view that a human individual begins at fertilisation is the observation that monozygotic twinning may occur at any time from the early blastocyst stage (around day 2 after fertilisation) up to (but rarely) around day 14. How can an individual be said to exist if it subsequently becomes two individuals? And when do twins come into existence as individuals? At fertilisation, or when division of the blastocyst or early embryo occurs? It is certainly possible, and indeed very plausible to regard the early stages of division of the fertilised egg as analogous to the division of an amoeba- one entity ceases to exist and is replaced by two identical entities. Julian Savelescu claims "There is nothing- no individual — that persists through these divisions. Only whenthe cells begin to be differentiated and to engage in coordinated activity do they together constitute an individual human being rather than human tissue."

However it should be noted that there is no distinct point at which differentiation may be said to occur definitively. The development of the blastocyst is gradual. Some degree of differentiation has already occurred in the blastocyst, with the formation of two different types of cells. These are the inner cell mass (from which embryonic stem cells are extracted) and which goes on to form the embryo (or more than one if there is twinning) and the outer cell layer, called the trophoblast, which goes on to form the placenta. Nevertheless, many people see the significant stage as 14 days.

14 days
In addition to the argument from twinning outlined above, 14 days is also often held to be significant because it marks the appearance of the primitive streak. The Melbourne Roman Catholic ethicist Norman Ford says "the appearance of the primitive streak marks the formation of a multicellular human individual with a craniocaudal body axis and bilateral symmetry… a human individual could not begin before cells of a rudimentary human organism from a distinct ongoing living body at this stage." At this point, the cells of the embryo are not only differentiated into those which will form the embryo proper and the placenta, but also differentiated into the three basic tissue types (ectoderm, mesoderm and entoderm). Thus Ford concludes, " Instead of viewing development in the first two weeks after fertilisation as development of the human individual, it seems preferable to interpret the process as cell multiplication and differentiation to form one or more human individuals" (his italics).

The other significance often attached to the 14 day stage is that implantation in the uterine wall is completed at around this time. Some see moral significance in the fact that at this point relationship with the mother is established. If implantation does not occur, the blastocyst is lost and so does not have the potential to develop into a human being. This observation has led to the idea that fertilisation ought to be distinguished from conception, which is not complete until implantation. Archbishop Peter Carnley in a recent article in the Bulletin made this point: "(W)hile fertilisation can happen in a laboratory, the conception of a human individual can only happen once the fertilised ovum is implanted in the womb of a potential mother. This is why we correctly speak of in vitro fertilisation, but not in vitro conception. IVF is a tried and tested procedure: IVC is impossibility". Leaving aside the claim that IVF is tried and tested (it actually has a fairly low success rate), this statement illustrates the dangers of attaching moral significance to the current state of scientific expertise. It is quite possible that in the future an artificial womb may be developed (so called ectogenesis). In this case, will we say that the new human individual has never come into existence because there is no implantation and hence conception?

Nevertheless, the view that a new human individual comes into being around the 14 day mark (it cannot be specified exactly) seems to me the most reasonable position, if we have to choose a discrete point. It lies behind the findings of the Warnock Committee in the United Kingdom, which concluded that embryo experimentation was justifiable until 14 days after conception. This position is also accepted in Western Australia and in South Australia.

Viability
This is the view that a new human individual comes into existence when she is able to exist independently of her mother, or at least to do so with medical assistance. They problem with this view is that as medical technology advances, the point of viability is pushed earlier and earlier. It used to be 28 weeks, now it is (at least theoretically) 20 weeks.

The development of consciousness
According to this view, what is fundamentally human about us should not be identified with our body or physical organism. We are more than physical entities "we are minds, or conscious minds to be more precise." And so "we do not begin to exist at least until the structures are present which would support consciousness". This is most likely around 26 weeks. "Thus, the fetus does not achieve a moral status before 26 weeks". Clearly this view would allow destructive research not only on embryos, but also on foetuses, even past the point of viability, and long past the point at which even doctors routinely performing abortions would generally feel comfortable with the procedure (12 to 16 weeks).

"What is the moral status of the embryo?".
In considering the use of human embryonic stem cells from a deontological perspective, if we ask the question "When does the life of a human individual begin?" , the critical distinction to make will be between fertilisation and 14 days. But if we opt for 14 days (or later), is that the end of the discussion? I think not, because "When does the life of a human individual begin?" is not the appropriate question to ask. It forces us to make a more or less arbitrary choice, to nominate one point in what is actually a continuous process. It also means that we must regard the destruction of an embryo or foetus before that point as of no moral significance, but after that point as equivalent to murder. Yet most people sense intuitively that there is a moral difference between the destruction of blastocysts, such as occurs with the defrosting of spare frozen embryos produced in the course of IVF, and the termination of a pregnancy at 12 weeks. Further, many would regard the termination of a pregnancy at 28 weeks (it would have to be called foeticide) as more problematic than at 12 weeks. They might both be regarded as wrong, but the later one as more wrong.

This intuition accords with the notion that the moral significance of the embryo increases gradually over time, in parallel with its physical development. Thus we avoid the dualistic notions of either ensoulment occurring at a discrete point in time, or of "personhood" being conferred in an all or nothing way at the point where consciousness becomes possible (actually it would be difficult to identify this point precisely). A human being cannot be divided up in this way into body and soul or body and "person". As whole beings we develop gradually. "A human organism accrues value as it takes shape and appears among us so that our responsibilities to nurture and protect each other come into full play".

This means that, even if we accept that 14 days marks a significant point in the emergence of a human individual, we may not regard the human pre-embryo as of no moral significance, as just a piece of tissue with which we can do whatever we like. It could be argued that as long as there is doubt, and since the process of development is gradual, we ought to give the pre-embryo the "benefit of the doubt" wherever possible, since what is at stake is so important. "We are bound together by our common humanity and we are aware that the roots of that humanity are in small beings who come into existence in the midst of human communities. Embryos don’t change into human beings, they are human beings.. They are inherently on the path towards being the kind of individuals who can be cared for, responded to, wondered about, grieved for and so on."

Which brings us to the third normative ethical theory, the second type of non-consequentialist theory, which is virtue theory. According to this:
an action is right iff it is what an agent with a virtuous character would do in the circumstances.

Virtue theory was the dominant way of doing ethics in the classical Greek era and up to the enlightenment period in the 17th century. It has enjoyed something of a renaissance since the 1980’s largely due to the work of Alasdair MacIntyre, and to some dissatisfaction with the other theories. Put simply, it says that there is more to the moral life than what a person does or does not do. The kind of person that you are is also relevant. It focuses on the development of good character and the acquisition of virtues or character traits, which it is claimed will then flow on to right decisions. It turns the logic of the other two normative theories on their heads. Where they might say, "you can recognise a good person because they do the right thing", virtue theory says, "you can recognise the right thing because it is what a good person does".

The health care professions particularly lend themselves to this approach. Certain qualities in their carers seem to be important to patients: compassion, kindness, sincerity, humility, patience, respectfulness, wisdom and so on. In contrast there are also well recognised vices, at least among the medical profession: arrogance, thoughtlessness, rudeness, insensitivity.

Virtue theory allows, as neither deontology nor utilitarianism does, for some virtues to be role related. This means that moral judgments may be particular rather than universal. There may not be only one right course of action, one thing which any moral person would do in the circumstances, but the right thing may be determined by who is making the decision. Another way of saying this is that different roles carry different priorities and responsibilities. A lawyer’s responsibility to a client is different to a doctor’s responsibility to a patient, which is different to a parent’s responsibility to her child. Parent’s responsibilities to their children (at whatever age) are relevant in the discussion of embryos, which are not isolated entities but in relationship with others. Parents have particular responsibilities to protect and care for their children. And some would argue that doctors also have particular responsibilities to care for the weak and vulnerable.

Alasdair MacIntyre's work makes it clear that there can be no generic ethic of virtue, rather a particular moral community shapes the character of its individual members in accordance with a shared, contentful vision of the good, embodied in a particular tradition based on a shared narrative. The church is such a moral community, its shared narrative being the scriptures.

One can see the difference a particular narrative and vision of the good makes when one considers the difference between Christian virtues and those shaped by other moral communities. The Christian vision shapes relational virtues such as love, patience, humility, self-control, and hospitality to strangers; and communal virtues such as mutual accountability and discernment.

These virtues are not valued in the liberal, individualist vision of human flourishing. The virtues shaped by the narrative of Western liberalism (which actually claims that there is no shared narrative) include individual self-determination, independence, freedom and authenticity to one's own understanding of the good. In addition, Western societies now place high value on the Aristotelian virtues of intelligence, physical beauty, health and wealth. This is in contrast to the Christian attitude of paying special attention to those human lives, which are weak and vulnerable; the disfigured or disabled; the handicapped and the poor; infants and the aged. Such attitudes are shaped by the Christian narrative that each human is created in the image of God, and was died for by the Christ.

From a virtue perspective, the critical questions will be "What responsibilities do we have, in various roles, and as a society, to human embryos (including pre-embryos)?" and "What virtues or vices would be evidenced in the practice of human embryonic stem cell research?" To answer these questions, we need first to consider the purpose of such research.


Potential Uses for Embryonic Stem Cell Lines
Embryonic stem cells have two unique properties.
- First, they may be propagated in vitro indefinitely, forming immortal cell lines.
- Second, they are pluripotent, which means that under the right conditions they may be transformed into any type of cell eg heart muscle, all the different variety of nerve cells, blood cells, liver cells and so on.

Hence, embryonic stem cell lines have a number of potential applications. They could be used for in vitro studies of human embryogenesis, human gene discovery and drug and teratogen testing. In addition, they could be used as a renewable source of cells for tissue transplantation, cell replacement and gene therapies. Problems of immunological rejection after transplantation could be addressed by banking multiple lines representing the major histocompatibility groups; creating universal donor lines through genetic modification; and customising cells through transgenesis. But the major potential use for embryonic stem cell research is in the development of so- called therapeutic cloning techniques.

Therapeutic Cloning
Therapeutic cloning involves the use of two separate new technological possibilities. The first is somatic cell nuclear transfer (the technique used to create Dolly), in which the differentiated DNA of an adult cell is altered to 'undifferentiate' it, so that it can be transferred into another, enucleated cell, and then switched on to produce either (potentially) a whole new human being or a particular type of tissue. The second is the ability to produce and proliferate in vitro, embryonic stem cells.
Compatible tissue for transplantation to treat a wide variety of diseases could be obtained in one of two ways using therapeutic cloning.

Therapeutic Cloning (1)
The first way would be to create a blastocyst (from an enucleated ovum plus adult nuclear DNA) which would then be used to generate embryonic stem cells, which would then be differentiated into a specific cell type. The person requiring the tissue for transplantation would provide a skin cell from which the nucleus, containing their DNA would be extracted, and inserted into a human ovum, which could come from the patient if she were a woman, or a donor. The resulting blastocyst would be (virtually) genetically identical to the skin cell donor, and so its cells would be compatible with the donor and could be transplanted without risk of rejection. It would in effect be the "identical twin" of the donor.

In this case, we need to be clear that an early human embryo would be deliberately created in order to be destroyed to provide stem cells. It is different from the use of existing "spare" embryos which would be destroyed anyway. It has been described as "cannibalising one's twin", a colourful expression which nevertheless captures the relational aspect of what is being done. Virtue theory emphasises that moral acts do not occur in a vacuum, but in the context of relationships which entail responsibilities. Does a good, or virtuous, parent or sibling sacrifice their own child or twin in order to gain even their own life? The Christian narrative suggests just the opposite - that it is good to be prepared to at least risk one's own life in order to protect the life of a neighbour. If a neighbour, how much more a child or brother or sister, no matter how young they are?

If the virtues of self-sacrificing love, compassion and kindness are especially important for parents in relation to their children, Christians also share a narrative where the other, the stranger, the outcast and the marginalised are welcomed by God and his people. The community of the people of God has always been characterised by its care and protection of the weak and vulnerable, modelled on God's care for them (eg. Psalm 146:7-9).

This insight may also be formulated in terms of the virtue of justice, which "demands that the powerless and dependent are protected against the uses of power wielded unilaterally. No human can be treated as a means to an end without consent. The foetus is an immature, dependent form of human life which only needs time and protection to develop".

Therefore, while it may be admitted that there are some tragic circumstances in which an early human life may be sacrificed (incidental to terminating a pregnancy) in cases of serious danger to the life or health of a pregnant woman, it would seem to be always morally culpable for anyone to deliberately seek to create a clone of themselves for the express purpose of destroying it in order to obtain tissue for whatever therapeutic purpose. This seems to me to be far more morally problematic than to seek to create a living child using the same technology.

And this scenario is not the worst (or perhaps best, depending on one's perspective) that has been envisaged. The consequentialist philosopher Peter Singer has proposed that embryos cloned using nuclear transfer be allowed to develop into advanced foetuses, from whom whole organs could be harvested. Recognising that most people would find this morally repugnant, he suggests that such embryos be genetically modified to be without a head, or at least a brain, so that they need not be regarded as "persons", ie. morally significant.

Therapeutic Cloning (2)
The second way to use cloning to produce compatible tissue for transplantation seems to me to be morally preferable. This would involve somatic cell nuclear transfer, not into an enucleated ovum, but into the pluripotent immortal stem cell lines already in existence in a laboratory. These could then be proliferated and differentiated into the required tissue type. This does not involve the deliberate creation and subsequent destruction of a blastocyst, making it much less morally problematic. But not entirely unproblematic, since the original stem cells were derived from the destruction of blastocysts.

But there are at least two other ways in which compatible tissue for transplantation to treat a wide range of diseases might be obtained. These possibilities repudiate the claim that embryonic stem cell research must be allowed to go ahead in order to "save millions of lives".

The first is the possibility of using somatic stem cells, which has received some though limited (compared to the claims for embryonic stem cells) attention in the media recently. Recent evidence suggests that pluripotent or at least multipotent stem cells exist in many tissues in adults. Such cells are the basis of existing therapies, such as bone marrow and peripheral blood stem cell transplantation, autologous skin grafting, and neural stem cells for the treatment of Parkinson’s Disease. Recent evidence form experiments in mice also indicates that somatic stem cells may be more plastic than previously thought, with the ability for a stem cell from one type of tissue to differentiate into cells of a quite different type. So, stem cells obtained from a skin biopsy might be able to provide nerve or muscle or other cell types for transplantation without any type of cloning being necessary.

The second alternative to the use of embryonic stem cells is the possibility of taking mature cells and "setting the developmental clock back so that they are able to become pluripotent without seeing an egg". Martin Pera of Monash University, who is an advocate of embryonic stem cell research, says, "That might be in the long term a better route (than therapeutic cloning)". But he quickly adds, "We will only find the way forward through continued research in the complimentary areas of embryonic stem cells, adult stem cells, and cell reprogramming".

Conclusion
Using a utilitarian framework, almost anything can be justified if the projected benefits are seen to be great enough. And when there is strong scientific pressure to go forward with research, and pressure from certain groups who claim that a moratorium on research harms their interests, the burden of proof seems to fall on those who would limit inquiry.

In addition to reasserting that there are some things not decent to do, no matter how great the benefit, the church might also turn its attention to a critique of our society's idolatry of health, long life and genetic "perfection". The most important goods make the worst and most powerful idols. Even secular ethicists are beginning to question the project of Modern medicine. In the words of Daniel Callahan:

"Bioethics has badly neglected the aims and aspirations of research as an area worthy of moral exploration. It has not taken on, for careful examination, the implicit models of human life and welfare and the human future that lie behind the biomedical research enterprise. If it has not been utterly captured by that enterprise, it has mainly stood on the sidelines, wagging its finger now and then. That is no longer good enough".