PEDIATRICS Vol. 109 No. 5 May 2002, pp. 990-991
Embryonic Stem Cell Research
To the Editor—I see that the American Academy of Pediatrics (AAP) has endorsed the destruction of human embryos for stem cell research. 1 Although the second paragraph of the position statement from the Committee on Pediatric Research and the Committee on Bioethics contains a brief but well-written summary of the objections of those who oppose embryonic stem cell research, these objections are not answered but merely ignored in the rest of the statement. But even if you accept human embryonic stem cell research, the statement is inconsistent.
The statement says, "The use of embryos may require special considerations to limit the research to important issues that cannot be addressed in other ways ... " 1(p813) What about research on stem cells from sources that do not require the killing of the donor such as umbilical cords/placentas and adult sources such as skin, fat, and bone marrow? Has research on these sources progressed to the point where we can say they are unable to provide treatments for "spinal cord and bone injuries, diabetes, primary or acquired immunodeficiencies, cancer, metabolic and genetic disorders, and a variety of birth defects ... toxicities of drug treatment and environmental pollutants ... fetal alcohol syndrome?" 1(p814) Not from the reports that I have read. We are nowhere near the limit of the benefits available from research on stem cells from nonethically controversial sources, and we cannot say that they cannot provide the above benefits. Although certain issues involving development and teratogenesis could be better studied using the whole embryo rather than cell lines of either embryonic or postnatal sources, I do not see how this can be studied without going beyond the 14-day limit that the National Institutes of Health proposes and with which the AAP refuses to specifically concur.
Do I understand condition 6 correctly? Are researchers to be given carte blanche by donors? Denying donors the right to place any limitations on what is done is both unprecedented and ethically problematic.
The statement raises the point of the lack of regulation on research done with private funds. This is a good point and those of us who oppose the killing of embryos for research have been very remiss in not addressing it, sitting by while fertility clinics create far more embryos that could ever be expected to be returned to their mother’s uterus, fail to make provisions for the donations of embryos, which cannot for whatever reason be returned to the mother’s uterus, so that these embryos will be placed in the uterus of an adoptive mother, and while private researchers do what they want with these embryos.
We physicians do not like government regulations, but this is one place, where protecting human life is at stake, that we should have sought state and, where applicable, federal regulations on the practices of fertility clinics and on research involving human subjects. We should do so now, however belatedly.
In the meantime, we call on government and other funding agencies to give priority to research involving stem cells derived from sources that we all agree are ethical and we call upon fertility clinics and parents to exercise self-restraint, creating no more embryos than are "clinically necessary":
- Before fertilization, we call on fertility clinics to have parents sign a legally binding informed-consent agreement that specifies
- a) The maximum number of embryos to be created (no more than this number of ova will be exposed to sperm)
- b) The maximum number of embryos to be returned to the mother’s uterus or fallopian tube at any one time
- c) Provisions for the adoptive placement of embryos should either parent be unable or unwilling for them to be returned to the mother’s uterus or fallopian tube.
- a) The maximum number of embryos to be created (no more than this number of ova will be exposed to sperm)
- For those embryos currently frozen, we call on fertility clinics to contact their parents and encourage them to make provision for their adoption should they be unable or unwilling in the future to have them returned to the mother’s uterus/fallopian tubes for attempted implantation.
Patricia L June, MD, FAAP
Medical Center
Moultrie, GA 31768, USA
REFERENCE
1.
American Academy of Pediatrics, Committee on Pediatric Research and Committee on Bioethics. Human embryo research.
Pediatrics.2001; 108
:813
–816
We thank Dr June for her letter concerning the recent AAP statement on embryonic stem cell research. Our committees appreciate your deeply held beliefs on this issue, which we recognize are shared by others and by many in the AAP. Given the fundamental disagreements over the moral status of embryos, it probably is impossible to develop a position on this subject that all would consider acceptable. Yet this topic is one of critical importance to contemporary research and public policy so it is appropriate, in our view, that the AAP take a stand.
The seeking of information concerning the utility of nonembryonic stem cells is an ongoing process. Both embryonic stem cells and adult stem cells are believed to have tremendous promise for the treatment of disease. However, it is possible that embryonic stem cells will prove to be substantially more useful than adult stem cells in understanding human development and in developing effective treatments. Therefore, at our current stage of knowledge, it is premature to foreclose all research on embryonic stem cells. The AAP policy supports both avenues of research to maximize the potential benefits for children.
The reasons for the 14-day limit are provided in the statement, and this limit does not preclude the use of umbilical cells/cord blood or adult tissue-derived stem cells.
Condition 6 states: "There are to be no restrictions placed by the donor on the type of research performed." Condition 6 is 1 of 8 conditions that will limit embryo research as promulgated by US Department of Health and Human Services guidelines. All of these safeguards, including the fact that the decision to donate is strictly voluntary, that the embryos are already frozen and no longer clinically needed, that the physician responsible for fertility treatments cannot be engaged in the embryo stem cell research, and that there are to be no personal identifiers associated with the embryos used for research. We also suggest that Dr June has missed the ethical justification for condition 6. The purpose is not to give investigators "carte blanche" with embryo research, but rather to eliminate inappropriate, manipulative, or coercive incentives for couples to donate embryos for research.
The final section of the letter, including recommendations, states the opinion of an individual and also reflects the opinions of "reasonable persons in many segments of society ‘who have’ different opinions on this topic based on strongly held beliefs and value systems," as our statement notes. We feel that an ongoing debate on these topics is meaningful, pertinent, appropriate, and a right of all American citizens.
We stand by our statement that:
"The American Academy of Pediatrics believes that, under certain conditions, research using human embryos and pluripotent stem cells is of sufficient scientific importance that the National Institutes of Health should fund it and that federal oversight is morally preferable to the currently unregulated private sector approach."Dr June’s letter calls for a new set of restrictions for fertility clinics as well as encouraging adoption of embryos. The AAP statement does not address these issues. Such a change in current practice would restrict the choices available for prospective parents in a way that would appear to require legislation.
The issue of the adoption of embryos is very complex and raises concerns about the practicality of this concept. Couples unable to have children because of uterine anatomic abnormalities, (eg, bicornuate uterus, endometriosis, etc) could and would not use such embryos. Other possibilities may include ongoing storage for extending periods of time by concerned individuals who would bear the cost of storage. This, however, is impractical and raises other issues when this support lapses. Concerns may arise over aged embryos by prospective parents. The main point is that encouraging embryo adoption will not solve the problem of the fate of the tens of thousands (hundreds of thousands?) of embryos that are frozen currently given the limited interest in this reproductive option. As well, it would be ethically inappropriate to force any couple to have an embryo implant. Many other issues are of practical concern.
In conclusion, the committees writing this statement considered many points of view and lengthy debate. The statement reflects a compromise position recognizing a special moral status for human embryos while permitting some promising research that seeks to address the critical needs of a number of children and adults who could benefit from stem cell technology.
Russell W. Chesney MD, Chairperson
AAP Committee on Pediatric Research
Jeffrey R. Botkin MD, MPH, Chairperson
AAP Committee on Bioethics
Robert M. Nelson MD, PhD, Former Chairperson
AAP Committee on Bioethics
PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics
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