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Presentation at the Senate Chamber of
Bayero University Kano Nigeria on January 10, 2013 by Professor Omar Hasan
Kasule Sr. Department of Bioethics King Fahad Medical City Riyadh Saudi Arabia
EM: omarkasule@yahoo.com, WEB: www.omarkasule-tib.blogspot.com
ABSTRACT
This paper argues that biotechnology induces
social re-engineering by using 3 examples of biotechnological breakthroughs
that change society: one is current, the oral contraceptive pill, one is on the
door step, stem cell technology, and one is futuristic, vaccination against
addiction. Biotechnology can be used for good or for bad. The only way to
ensure good applications of biotechnology is to incorporate morality in the
university educational curricula of future scientists. The paper gives an
example of the Malaysian experience of training doctors.
Key
words: biotechnology, ethical education, social engineering, oral contraceptive
pill, sexual behavior, sex revolution, vaccination, child mortality, addiction.
1.0
INTRODUCTION
The
question whether technology is value-neutral cannot be answered easily. Theoretically
it should be value-neutral but the practice is different this is because the
developers of the technology have a value system that impacts on the way they
plan to use that technology. Some of the values of the developers are embedded
in the technology itself and cannot be seen by many people or cannot be
disentangled. We can use simplified scenarios to illustrate this. The
architecture of a house has an embedded value of a nuclear or extended family.
Hospital architecture may have an embedded value regarding mixing / separation
of genders.
2.0 THE
ORAL CONTRACEPTIVE PILL AND THE SEXUAL REVOLUTION
2.1
The oral contraceptive pill: an introduction
The
oral contraceptive pill was cited as the most important technological
innovation of the 20th century[1]. On its
introduction in 1960 it soon replaced sexual repression and other less
effective methods[2]
to become a mass phenomenon in fertility control. Its impact has been compared
to major discoveries such as discovery of fire, discovery of electricity, and
discovery of atomic energy[3]. The
present paper will explore the impact of the pill on social change and use it
as an example to illustrate the argument that biotechnology has a potentially
big impact on social change depending on the way it is used. The way biotechnology
is used is determined by the underlying moral or value system
2.2
Development of the pill
There
is some indicative evidence that the development of the pill was not an
accident but had a background agenda. There was a strong desire among family
planning agencies and the feminist movement to get an effective contraceptive
that would let the woman control her sexuality. Margaret Sanger of Planned
Parenthood spearheaded the campaign to produce a safe and effective
contraceptive. With funding provided by Katharine Dexter McCormick, Planned
Parenthood invited Dr Gregory Pincus (a biologist) to develop a safe pill, a
task achieved in 1950. This pioneering work set the stage for 2 sexual
revolutions that will be discussed below.
2.3
The first sexual revolution: 1960s and 1970s
The
US Federal Drug Administration (FDA) approved the oral contraceptive pill on
23rd June 1960. The oral contraceptive pill (OC) was the first effective
contraceptive that gave women a reliable and private control of fertility[4] that
could be used without any worries about pregnancy since its failure rate was
low being less than 1 percent[5]. The
launch of the pill triggered a sexual revolution[6] that
started in earnest in the early 1960s and laid the foundation for the second
sexual revolution of the 1990s that is still evolving[7]. The
first sexual revolution was a drastic change in sexual behavior of the masses
involving all social classes and eventually all countries of the world. This
revolution has had far-reaching effects on the fabric of society, the family,
disease patterns, gender roles etc.
The
major change brought by the pill was to not only to allow sexual intercourse at
any time, in any condition, and without any prior preparation but also to
separate sexual enjoyment from reproduction[8]. The
purpose of sex could become recreation only without the possibility of
procreation[9]. For the
first time in human history sexual enjoyment was decoupled from the social
responsibility of fatherhood and motherhood among potentially fertile couples.
What started as birth control among married women soon extended to unmarried
leading to promiscuity. It is now extending to teenagers and sex education
programs are becoming mandatory in many schools with the message being clear
that children can have sex but that it has to be safe sex using a contraceptive[10]. The
mass media have been very active players in the sexual revolution by
encouraging sexuality among youths while at the same time condemning teenage
birth or abortion[11] which leaves effective contraception as the
only option.
Studies
within the first 10 years of the use of the pill explored its impact on sexual
behavior[12][13]. The
evidence linking the pill to the sexual revolution is circumstantial but is
very convincing. It is unlikely that the sex revolution following on the heels
of the introduction of the pill could have an alternative explanation. It may
be true that the sex revolution was already on the way but the pill accelerated
it by providing a more effective contraceptive which removed the inhibitory
fear of pregnancy.
The
sexual revolution based on liberation of fear of pregnancy started with the
pill and was completed by two major later developments. The morning after pill
and legal abortion on demand (following the US Supreme Court ruling in Roe vs
Wade) ensured that even if contraception failed there were remedies. This
removed any lingering fear of unwanted pregnancy that had remained even with
the use of the pill.
2.4
The second sexual revolution: 1980s and 1990s
The
mass use of the pill and the major changes in sexual mores soon led to a second
sexual revolution that is also referred to as the neo-sexual revolution[14].
Whereas the first sexual revolution saw the separation of sexual enjoyment from
reproduction, the second sexual revolution saw the separation of sex from
reproduction altogether. Using technologies of assisted reproduction such as in
vivo insemination and in vitro fertilization with surrogate mothers or fathers,
it became possible to produce children without coitus. Such children could
identify either a surrogate father or mother so some element of parenthood
existed. This remaining sense of parenthood could soon be eroded by cloning.
Reproductive cloning is a further development that may usher in reproduction
without involvement of any gametes and will negate the traditional concept of
descent from a parent. It is conceivable that the brave new world of medical
technology will soon breach the reproductive barrier between humans and animals
with unimaginable consequences.
2.4
The social impact of the pill
The
impact of the pill was not limited to sexual freedom. Sex without reproduction
soon gave way to sex outside marriage. Devaluation of the family, divorce,
teenage pregnancy, fatherless families, and teenage problems such as teenage
suicides[15] and drug
addiction. Alongside the changes due to medical technology, the second sexual
revolution has seen the elevation of homosexuality from a closet secret to
social respectability with several jurisdictions legislating for same-sex
marriages. The gay or lesbian couples have also had the audacity to claim
parental rights by adopting children or trying to produce children using
artificial means. Kindergartners in New York City were taught that gay and
lesbian families are the same as heterosexual families[16]
2.5
Conclusion: Medical Technology leading to social change
This
paper presents the thesis that the oral contraceptive pill is a prime example
of a technology that leads to major social change and has with time led to an
ideological change by affecting the way people think about marriage,
reproduction, and family. I do not agree with the views of the developers of
the oral contraceptive pill, Gregory Pincus and John Rock, who argued that
technology does not determine behavior[17]. They
could have said this to avoid the guilt of having introduced a technology that
in essence could be good but was applied in a wrong way with profound negative
effects on society.
2.0
STEM CELL TECHNOLOGY
2.1
Description of stem cells
A
stem cell is able to divide and replicate itself almost indefinitely and can be
grown to produce a more specialized or differentiated cell. Some stem cells are
already differentiated or specialized and can be grown to produce only specific
specialized cells. Other stem cells are more specialized or differentiated and
can be grown into a wide range of specific cell types. These are called
multi-potent or pluripotent cells. The third type of stem cells is called
totipotent. These are completely undifferentiated and can be grown into any
cell type.
2.2
Sources of stem cells
Multipotent
cells can be found in adult blood, adult bone marrow, and umbilical blood. They
can also be derived from cancer tissues and from fetal cells and embryonic
cells (either pre-implantation or post-implantation). Embryonic stem cells are
totipotent. They are able to develop into any type of body cell or tissue. The
nucleus of the stem cell can be removed and can be replaced by the nucleus of a
patient who has a damaged tissue. The cell can grow into the desired tissue.
Embryonic stem cells are more efficient than adult stem cells.
2.3
Diseases likely to be treated using embryonic stem cells
The
following serious medical conditions are candidates for cure using stem cells
by producing replacements for damaged tissues: diabetes, stroke, spinal cord
injury, and neurodegenerative disorders such as Parkinson's disease. Stem cells
could be grafted at a site of spinal cord injury. Stem cells grafted in the
pancreas could produce insulin that is deficient or lacking in diabetics. As
technology develops it is envisaged that a whole organ can be developed from a
stem cell. This will initially solve the problem of shortage of organ for
transplantation. At a later stage it can lead to a brave new world of spare
organs like car spare parts. The difference between and old and young will be
blurred but not by much.
2.4
Advantages of stem cells
Stem
cells have two main advantages. They can be a source of tissue or organs thus
helping overcome the shortage of organs for transplantation. Stem cells generated
under the patient’s own genetic control will be fully immunologically
compatible unlike donated organs that can be rejected by the patient.
2.5
Ethical controversy about embryonic stem cells
The
use of adult stem cells or cells from the umbilical cord raises few ethical
controversies. Embryonic stem cells, unlike adult stem cells, are a source of
ethical controversy because they are obtained from embryonic tissue, either
pre-implantation or post-implantation. Use of such tissue involves violation of
the purpose of preserving life. Since the cell is a potential human life its
use in research or transplantation involves denial of that life.
3.0
VACCINES AGAINST ADDICTION
3.5
HOW VACCINES CAN WORK AGAINST ADDICTIVE SUBSTANCES
•
Vaccines reduce or eliminate neurological effect of
addictive substances
•
Vaccines generate specific immune resistance to an
addictive drug
•
Antibody binds to drug and prevents it from reaching
the neural sites
•
Slow release vaccines may have ti be used to eliminate
immune protection can be overcome by increasing the dose of the addictive
substance requiring repeat vaccination which has low acceptability. Slow
release vaccines may have to be used
3.6
NICOTINE VACCINE: REVIEW #1
·
In an attempt to improve long-term quit rates
and blunt the reinforcing effects of nicotine in the brain,
the nicotineconjugate vaccine was developed
·
Vaccine administration
produces nicotine-specific antibodies that bind to nicotine from
exogenous sources, creating a large unit that is not able to cross the
blood-brain barrier, which limits the rate and extent
of nicotine absorption into the brain.
·
Results of clinical trials indicate that
individuals achieving high nicotine-specific antibody levels with
the nicotine conjugate vaccine have greater success with
smoking cessation at 12 months compared with those with lower levels.
·
Adverse effects associated with
the nicotine conjugate vaccine have been primarily mild and
localized in nature, with minimal systemic effects: tenderness and ache at the
injection site, general discomfort, headache, and muscle ache.
·
Awaiting results of phase III trials
·
Ottney AR. Nicotine conjugate vaccine as a novel
approach to smoking cessation.Pharmacotherapy. 2011
Jul;31(7):703-13. Source Department of Pharmacy Practice, North Dakota
State University, Fargo, North Dakota 58108-6050, USA.
3.7 NICOTINE VACCINE: REVIEW #2
·
Nicotine vaccines are among newer products
seeking approval from the FDA. Antidrug vaccines are irreversible, provide
protection over years and need booster injections far beyond the critical phase
of acute withdrawal symptoms.
·
Interacting with the drug in the blood rather
than with a receptor in the brain, the vaccines are free of side effects due to
central interaction.
·
For drugs like nicotine, which interacts
with different types of receptors in many organs, this is a further advantage.
·
Three anti-nicotine vaccines are today in
an advanced stage of clinical evaluation.
·
Results show that the efficiency of the vaccines
is directly related to the antibody levels, a fact which will help to optimize
the vaccine effect.
·
Escobar-Chávez JJ, Domínguez-Delgado CL, Rodríguez-Cruz IM. Targeting nicotine addiction: the
possibility of a therapeutic vaccine.Drug
Des DevelTher. 2011;5:211-24. SourceUnidad de
InvestigaciónMultidisciplinaria, Facultad de
EstudiosSuperioresCuautitlán-Universidad NacionalAutónoma de México,
CuautitlánIzcalli, Estado de México, México.
HEROIN VACCINE: REVIEW #1
·
A vaccine capable of
blocking heroin's effects could provide an economical, long-lasting and
sustainable adjunct to heroin addiction therapy without the side
effects associated with available treatment options.
·
Heroin, however, presents a particularly
challenging vaccine target as it is metabolized to multiple
psychoactive molecules of differing lipophilicity, with differing abilities to
cross the blood brain barrier.
·
In this review, we discuss the opiate
scaffolding and hapten design considerations to confer immunogenicity as well
as the specificity of the immune response towards structurally similar opiates.
·
In addition, we detail different strategies
employed in the design of immunoconjugates for a vaccine-based therapy
for heroinaddiction treatment.
·
Stowe GN, Schlosburg JE, Vendruscolo LF, Edwards S, Misra KK, Schulteis G, Zakhari JS, Koob GF, Janda KD. Developing a vaccine against multiple psychoactive targets: a
case study of heroin. CNS
NeurolDisord Drug Targets. 2011 Dec;10(8):865-75. Source
Departments of Chemistry and Immunology, The Skaggs Institute for Chemical
Biology and Worm Institute of Research and Medicine (WIRM), The Scripps
Research Institute, La Jolla, California 92037, USA.
COCAINE REVIEW #1
·
The challenge in developing an anti-cocaine vaccine is
that cocaine is a small molecule, invisible to the immune system.
·
Linking a cocaine hapten to a highly
immunoigenicAd capsid proteins would elicit high-affinity, high-titer
antibodies against cocaine, sufficient to sequester systemically
administered cocaine and prevent access to the brain, thus
suppressing cocaine-induced behaviors.
·
In pre-clinical studies, the product evoked
persistent, high titer, high affinity IgG anti-cocaineantibodies, and was
highly effective in blocking cocaine-induced hyperactivity
and cocaine self-administration behavior in rats.
·
Future studies will be designed to expand the
efficacy studies, carry out relevant toxicology studies, and test dAd5GNE in
human cocaine addicts.
·
Koob G, Hicks MJ, Wee S, Rosenberg JB, De BP, Kaminsky SM, Moreno A, Janda KD, Crystal RG. Anti-cocaine vaccine based on coupling a cocaine analog to a disrupted
adenovirus.CNSNeurolDisord
Drug Targets. 2011 Dec;10(8):899-904. Source Department
of Genetic Medicine, Weill Cornell Medical College, New York, NY 10065, USA.
PROBLEMS
WITH VACCINES
•
Vaccination will have to be compulsory to be effective
•
Vaccines will change human behavior and individual life
style and identity
•
High potential for misuse of the vaccines
•
Use of medicine to solve a non-medical problem
ETHICAL
ISSUES: BENEFITS
•
Compulsory vaccination justified by high benefit,
individual and public.
•
Vaccination of students improves educational
achievement and discipline.
•
Compulsory vaccination of people in sensitive
occupations like pilots.
•
Compulsory vaccination of criminals
ETHICAL
ISSUES: RISKS
•
Withdrawal effects.
•
Vaccines will stay in blood for ever: no
confidentiality.
•
Elimination of the possibility of therapeutic switching
ie future good uses for addictive substances.
•
Repeat injections and Immune resistance
ETHICAL
ISSUES: INFORMED CONSENT
•
Vaccination under coercion with an irreversible
vaccine.
•
Cultural issues: what drug to vaccinate against;
alcohol is accepted in many societies
•
Vaccination of detainees and prisoners
•
Drug addicts not competent to consent
•
Parents deciding for children
ETHICAL
ISSUES: JUSTICE
•
Research on vaccines takes resources away from
treatment because addiction is not a normal disease
•
Unjust distribution of the vaccines
4.0 THE
RATIONALE FOR A MORALLY- BASED MEDICAL EDUCATION
4.1
The physician and applications of medical technology
Physicians
are the main agents in the development and use of medical technology. Their
moral stands on the use of that technology will determine the social
consequences whether positive or negative. Therefore the values imbued in the
medical curriculum as well the moral values in the medical environment have a
major role in determining the pace and direction of social change. The profound
impact of just one medical technology (the contraceptive pill) on social
behavior should be a waking up signal for medical educators who must make the
effort to input values into the medical curricula to ensure that future
physicians will not apply powerful medical technologies in ways that degrade
the moral standards of society.
4.2
Physicians and taking a moral stand
Muslim
physicians dealing with technology that has profound impact on society cannot
pretend to be morally neutral and can neither hide under the thesis that
technology is morally neutral. They need to take a moral stand both regarding
development and application of new medical technologies. Medical educators will
have to provide educational curricula that will equip future physicians with
the ability to take informed and positive moral stands. These moral positions
should not be looked at only in a negative sense of rejecting or mitigating
morally negative consequences of medical technology. They must also be looked
at ways of improving, reforming, and even Islamizing society if used in ways
that promote morally high standards.
4.3
Physicians and influence on social opinions and practices
The
physician is a social leader whose influence could move society in certain
directions. This leadership role is likely to be enhanced as medical technology
puts into the hands of the physician interventions that can change social
behavior of individuals and societies. The physician has a bigger leadership
role than ordinary persons because of intimate contact with people as
individuals and as families. The medical curriculum should teach social responsibility
and leadership and make sure that it produces physicians who are ethical and
who have the courage to change and improve society.
4.4
Physicians as initiators of social change
The
physician gets the reward, thawab,
for any initiative that leads to introduction of something good in the
community be it medical or non-medical. The physician should be at the
forefront of social change and reform to lead society to a better moral
position. The physician is expected to give leadership to patients on ethical
issues that arise out of modern biotechnology. He must be prepared not as a mufti
who gives legal rulings but as a professional who understands the medical,
legal, and ethical issue involved and can explain them to the patients and
their families so that they can form an informed decision. In order to play
this role well, the future physician must have sufficient grounding in Islamic
law and other Islamic sciences.
5.0 THE
ISLAMIC INPUT INTO THE MEDICAL CURRICULUM (IIMC)
5.1 Vision
The vision of IIMC has two separate but closely
related components: Islamization and legal medicine. Islamization deals with
putting medicine in an Islamic context in terms of epistemology, values, and
attitudes. Legal medicine deals with issues of application of the Law from a
medical perspective including
5.2 Five main objectives, ahdaafasaasiyyat
The first objective is the introduction of Islamic
paradigms and concepts in general, mafahiimislamiyyat ‘aamat, and as
they relate to medicine, mafahiimIslamiyat
fi al Tibb. The Muslim physicians must have some general concepts deriving
from Islamic teachings that can guide their work and research. The second
objective is strengthening faith, iman,
through study of Allah’s sign in the human body. Medicine and medical knowledge
have been described as the altar of faith, al
tibbmihrab al iman. Study of medicine leads to the conclusion that there
must be a powerful and deliberate creator because such a sophisticated organism
could not arise by chance. The third objective is appreciating and
understanding the juridical, fiqh,
aspects of health and disease, al fiqh al tibbi. There is a close
interaction between injunctions of Islamic law, shariat, and medical
practice. The fourth objective is understanding the social issues in medical practice
and research, al qadhaya al ijtima’iyat
fi al tibb. Medicine is not taught or practised in a social or ethical
vacuum. The fifth objective is teaching professional etiquette, ,adab al
tabiib, from an Islamic moral perspective. The physician carries a heavy
trust, the amanat of being
professionally competent. He must be highly motivated. He must have personal,
professional, intellectual, and spiritual development programs. He must know
the proper etiquette of dealing with patients and colleagues. He also must know
and avoid professional malpractice. He needs to be equipped with leadership and
managerial skills to be able to function properly as a head of a medical team.
5.3
Application of IIMC
The
curriculum has been applied at the Kulliyah of Medicine of the International
Islamic University in Kuantan Malaysia and at the moment several other
universities are seeking to emulate it.
REFERENCES
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IS. Forty years of combined oral contraception: the evolution of a
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20;17310:541-4.
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accessed June 30, 2006
[8]
www.en.wikipedia.org/wiki/Oral_contraceptive#Social_and_cultural_impact–
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[9]
www.archives.tcm.ie/thekingdom/2003/01/29/story8124.asp– accessed June
30, 2006
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[12]
Black S, Sykes M. Promiscuity and oral contraception: the relationship
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[16]
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