Should Plan B be available over the counter?

Plan B, also known as the “morning after pill”, is currently available over the counter in the U.S. to anyone over the age of 17. The Food and Drug Administration (FDA) gave their public support to the Center for Reproductive Rights’ motion to make the drug available to all women without a prescription, arguing that it does not terminate pregnancy the way other pills such as RU-486 (“the abortion pill” that can be taken up 9 weeks after conception) but merely provides a higher dosage of birth control hormones to prevent pregnancy within 72 hours of unprotected sex. It is considered safer than Advil. Two weeks ago, the motion to eliminate the age restriction on the morning after pill was contested by the secretary of Health and Human Services Kathleen Sebelius, who spoke up against it stating that young girls would not be capable of understanding how to use it correctly and should not have access to it without a physician’s consent.

President Obama had lowered the age of accessibility to Plan B without a prescription to 17 shortly after he took office but this time around sided against the FDA, agreeing with Sebelius that the age restriction is fundamental.

Judge Edward Korman of the Federal District Court ruled against Sebelius, and ordered that the drug be available to all Americans within the next month.

The question of accessibility to birth control has always been controversial, and this time around is no different. The risk associated with eliminating the need for a prescription is that extremely young girls (as young as 11) can purchase the pill without anyone knowing or explaining to them what exactly they are taking and how it works. Like all other drugs, although it is considered very safe by the FDA, Plan B can have negative side-effects if not used correctly - altering the hormone dosage of a child’s body is not a light decision to make. On the other hand, making every girl under the age of 17 have to acquire a prescription from a physician before taking the drug can lead to much worse scenarios: girls who are in a situation in which they might need Plan B are most of the time embarrassed and afraid. Being too scared to tell their parents or any other adult including a doctor could lead to waiting too long and having to get an abortion later on if that is the case. The issue about the morning after pill is precisely what its name entails: time is the key factor. Waiting more than 72 hours can lead to inefficiency and more invasive procedures at a later stage of the pregnancy.

Although the thought of young girls buying Plan B without fully understanding its use is heartbreaking, what should be addressed is the root of the problem. By educating women, we can empower them and help them make decisions that are safe and healthy. But as long as young girls are having unprotected sex, taking the morning after pill is still the safest and most reliable option, and should therefore be available to all.

Sources:

http://www.chicagotribune.com/videogallery/75333635/Plan-B-controversy-reignites-science-debate-in-Congress

http://www.cbs12.com/news/top-stories/stories/vid_6436.shtml

Male circumcision – HIV prevention in one simple tool?

For years researchers have observed that male circumcision dramatically reduces the risk of HIV infection. However, until now, the science behind this was a mystery. In a recent study published in mBio, researchers have stated that a change in the “quantity and diversity of bacteria” surrounding the circumcised penis explains why (Liu et al.). A genetic analysis of the microbes living around the penises of circumcised and uncircumcised men in Uganda revealed a dramatic reduction in the amount of anaerobic bacteria—those that can survive in the low oxygen conditions at the tip of the penis (Bakalar). How does this reduce HIV transmission? A higher bacterial load interferes with the ability of “specialized immune cells known as Langerhans to activate immune defenses” (Park).  Ordinarily, the function of Langerhans is to train immune cells by presenting them with pathogens. But the large amount of bacteria in the “uncircumcised penile environment” increases inflammation, causing the Langerhans to infect healthy immune cells with the virus (Park).

Does this mean that circumcision will become the next means of HIV/AIDS intervention? “We’re not trying to prove that everyone should be circumcised,” replies the senior author of the study, Lance B. Prince. “We’re trying to understand how it works and, by understanding, possibly establish alternative strategies to reduce people’s risk for HIV.” (qtd. In Bakalar). However, not everyone shares the same goal. Since 2007, health experts have known that circumcision reduces HIV transmission by at least 60%. While highly common in Western countries, the tool is used much less frequently in countries  suffering the most from AIDS. In 2011, only 13 million circumcisions had been performed in sub-Saharan Africa—far below the WHO’s target of 20 million by 2015 (Adams). Dr. Stefano Bertozzi, director of HIV for the Bill and Melinda Gates Foundation, stated in 2011 that “circumcision is “clearly the most obvious, most cost-effective intervention we could use to dramatically change the course of H.I.V. in the near future” (qtd. in Adams).  It has been calculated that financing circumcision in AIDS-burdened countries could prevent up to 2 million infections per year.

Evidently, the promotion of male circumcision is not far from becoming our primary strategy for preventing the spread of HIV in Africa. On one hand, this tool in prevention has advantages in cost and efficiency. Increasing coverage of circumcision will be tremendously cheaper than financing anti-retroviral therapy in poor African countries. Moreover, the potential of reducing transmission by 60% seems promising. But the ethical considerations also bear weight. A factor to be considered is that there are various cultural meanings associated with circumcision. In some communities, circumcision is performed for religious reasons or as a rite of passage. But in other communities, circumcision is viewed as culturally unacceptable or “forbidden” by religion (WHO 24). It may not be ethically permissible to place medical recommendations above cultural beliefs and religious practices. While circumcision is being promoted in African countries, neonatal circumcision rates have been steadily dropping in most Western countries, due to changing cultural preferences. People are beginning to see neonatal circumcision as barbarous, useless mutilation, and in the United Kingdom it has ceased to become routine procedure (WHO 12). In this context, promoting male circumcision in areas of high HIV prevalence seems to devalue the cultural and religious traditions in non-Western countries.

Also, promoting circumcision may not have as great an impact as other interventions, such as sexual health education. The danger of using this intervention in areas of high HIV prevalence is that circumcision does not provide absolute protection. The public health message that circumcision “may reduce, but does not eliminate risk of infection” and does not rule out the need for “safer sex practices” has proven difficult to communicate (WHO 28). In fact, studies in Africa have shown that male circumcision often leads to a false sense of security, causing people to engage in more unprotected sex. Randomized controlled trials do not take risk compensation into account—a real life obstacle to the effectiveness of circumcision. A statistical analysis by Gray et al. estimates that “if newly circumcised men were to increase the number of sexual partners by an average of more than 25%, this would offset any beneficial effect of circumcision, even assuming a high efficacy of 60%” (WHO 28). Clearly, male circumcision alone is not enough to stem the AIDS epidemic in Africa. Without public education on safe sex, circumcision will have limited efficacy as an intervention.

While endorsing higher circumcision rates may seem like a pain-free, low-cost solution to the problem of AIDS, the answer is not as simple. The development of HIV treatment suitable for the health infrastructure of African countries is still critical. In terms of prevention, Africa is not an exception– the most effective strategies remain HIV testing, promotion of safer sex practices such as condom use, and proper hygiene. In essence, these findings on the effect of circumcision on HIV show how imperative it is that we step in to improve Africa's picture of overall health.

http://mbio.asm.org/content/4/2/e00076-13

http://whqlibdoc.who.int/publications/2007/9789241596169_eng.pdf
http://healthland.time.com/2013/04/17/why-circumcision-lowers-risk-of-hiv/
http://well.blogs.nytimes.com/2013/04/18/how-circumcision-may-stem-h-i-v/
http://opinionator.blogs.nytimes.com/2013/03/20/in-one-simple-tool-hope-for-h-i-v-prevention/

Thinking About Drug Bans

A new study published in the UK ranks drugs based on the harm they do to oneself and to others; the results are somewhat counterintuitive, and might lead to some controversial changes in the way we view drug policies. Alcohol, for example, is by far the most harmful drug to others, and quite high up in terms of damage caused to the self. To what degree should we re-think our legislation on drugs?

To answer this question it is important to determine what the role of drug policy is in the first place: is it to regulate the harm we do to ourselves, to others, or both? 

That we should control drugs in terms of the damage they cause others is relatively uncontroversial, at least in principle. When one of our actions causes damage to somebody else, we open ourselves up to regulation or punishment. All sorts of activities are controlled by the government in this way, to little controversy: drunk driving laws, smoking laws, and (more obviously) laws against directly harming others follow this rationale. 

The degree of harm to others caused by alcohol appears to be sufficient for heightened regulation, particularly considering that other drugs do not cause comparable damage when it comes to injury and economic cost (breakdown below). In terms of overall damage caused to others, no drug is even half as harmful on this analysis.

It is one thing to say that we should be stricter on alcohol, but what about our views on other drugs? Alcohol again ranks near the top of damage to ourselves, though it ranks lower on some specific areas of damage, like dependence or impairment of mental functioning (see below). 

To what degree, though, is the government supposed to step in to prevent us from harming ourselves? This clearly depends on the type of activity that is concerned. At least three different kinds of self-harming activities exist, and our attitudes toward them are different. 

First, consider the 'sin taxes'. Cigarette taxation is a good example: though to some degree we limit the use of cigarettes out of concern for those around smokers, there is another important component. We discourage smoking because, although it is pleasurable in the short-term, it is a very poor health decision in the long-run. President Obama, for instance, recently upped the cigarette tax from around $1 to around $2 per pack. The rationale is clear: smoking causes people enormous harm; smoke taxation clearly reduces the number of smokers; smoke taxation thus reduces harm in the population. This policy is relatively uncontroversial, paternalistic though it is. It is clear, however, that a cigarette ban would not be so warmly received; we draw a line on state paternalism at some point.

Next, consider the recently invalidated soda legislation passed by mayor Bloomberg in New York City. The law prevented restaurants from serving sugary drinks above 16 ounces. It did not prevent people from purchasing several drinks or from getting refills, but simply limited serving size. Bloomberg was not even preventing individuals from partaking in an activity they found enjoyable in order to lead them  to a better long-run outcome. Instead he was making a basically neutral short-run change that would encourage a drastically different long-run outcome. People, however, place enough intrinsic value on their freedom – even to make bad choices – that 60 percent of NYC residents opposed it.

Last, consider highly risky sports. Perhaps counterintuitively, cheerleading leads to two-thirds of catastrophic injuries among high school students. A number of proposals, from better supervision to more training, have come out of the startling statistics, but bans have yet to be considered. Why is this? One explanation is that the potential harm that comes out of cheerleading, skydiving, car racing, or other potentially life-threatening sports is different: those participating, even before becoming involved in the sport, are fully aware of the long-run consequences and willing to live with them. The joy of the sport overrides the potential for disaster.

Which of these is most similar to engaging in the consumption of drugs? Even those causing harm almost exclusively to the user – consider methamphetamine, ecstasy, or LSD – are harshly regulated. It is telling that an outright ban is not popular in any of the above scenarios: what makes drugs so different? Perhaps the harm that comes to the user is more immediate than the harm from smoking or obesity; is this a real reason to legislate differently on it? 

Other countries – Portugal comes to mind – have successfully de-criminalized the use of drugs that carry heavier stigmas. Perhaps it is time for us to consider the same: if we consider the effects done to ourselves, alcohol is high on the list of drugs to be banned; if we take into account the damage to others, it is by far the worst. Whatever approach we take, it may be time to re-consider our relatively friendly stance on alcohol. 

Parts Versus Whole

People in the United States who want to have children have been able to purchase donated sperm and eggs separately for some time, but the relatively recent practice of selling embryos introduces new issues. Recently, a fertility clinic in Davis, CA began combining donor eggs and sperm to create embryos, which can then be used in fertility treatments for a price tag of $9,800 for a pregnancy, a much cheaper price than what it costs to become pregnant via traditional in vitro fertilization (IVF). The clinic is able to offer the treatment at a lower cost because it creates a batch of embryos from a single sperm and single egg donor together, and then sells the embryos to multiple patients. Couples who opt for this method of fertility treatment would have no genetic relation to their children.

For some time, couples have been able to adopt embryos left over from other couples' IVF treatments in a process known as "embryo donation." But in these cases, embryos are created with the initial intent of being used by a specific couple seeking fertility treatment, whereas, in the case of the Davis fertility-clinic, embryos are created for the explicit purpose of selling them. Andrew Vorzimer, a fertility lawyer in Los Angeles, has expressed his disapproval for this new practice, describing it as a commodification of children.

However, others, such as I. Glenn Cohen, an assistant professor and co-director of the Petrie-Flom Center for Health Law Policy, Biotechnology and Bioethics at Harvard Law School, contends that it is an open debate whether this new practice introduces new ethical ground. Cohen notes that because the purchase of sperm and egg is already, for the most part, socially accepted, it is not clear whether the ethical issues introduced here are all that different. To put it bluntly, if it is okay to buy the individual components, why should it be any different to buy the final product?

While my own personal opinions are mixed on this issue, I think that this statement that Cohen raises about the ambiguity of any difference existing between sperm and egg sales and embryo sales is wrong. The blunt question posed above will have different answers for different people depending on their beliefs.

One huge controversy that is still yet to be solved when discussing embryo ethics is the time at which the moral status of a person applies in one’s life. Some contend that it is when fertilization begins, others contend that it is when the first signs of a nervous system start to form, and still others argue for the stage of implantation, from which life will continue to develop on its own. The reason for this relevance is that, for example, when Vorzimer argues that this new practice is a commodification of children, he is indirectly stating that an embryo is a child, namely that life begins at fertilization. In contrast, Cohen would most likely hold a different opinion of when the moral status of a person applies during the pre-birth stages because he sees no difference in the individual components and the final product. And because this debate of when personhood starts is so controversial and absent of a clear answer, I expect the same stagnant deadlock in this debate of whether the fertility clinic is Davis is doing a morally permissible favor or abomination to society.

Source:

http://www.foxnews.com/health/2013/04/11/made-to-order-embryos-create-new-legal-issues/

Identity Crisis: The Challenges of Curing Mental Disabilities

Is it possible to reverse the cognitive disabilities associated with Down Syndrome? According to BioEdge, the Swiss pharmaceutical company Rouche began conducting human studies this week designed to answer precisely this question. Although the study so far is small and is being done primarily to test safety, the drug being tested, RG1662, might also be able to reverse the effects of the neurotransmitters that cause cognitive impairment in individuals with Down Syndrome.

While this study, if successful, could change the treatment of disabled individuals forever, it also raises the ethical question of such drugs could affect the personal identity of disabled individuals over time. If drugs like RG1662 were perfected such that they could almost perfectly reverse the symptoms associated with Down Syndrome, would the individuals after the treatment be the same as those before it? This might sound like a simple question, but it must be noted that the individuals who finish the treatment will have memories, intentions, habits, and personal characteristics that the individuals who entered the treatment would have lacked when starting the treatment. Would the pre-treatment and post-treatment individuals be the same persons who merely have a greater ability to express themselves after the treatment, or would they be different persons?

This occasions another related philosophical question: how much can a person’s psychological makeup change before that person ceases to exist? Many philosophers believe that rapid, irreversible psychological changes destroy one’s personal identity. (For instance, they might say that Phineas Gage was actually a different person after the accident than before it.) How slowly must one’s psychological makeup change in order for personal identity to be retained? I suspect that one's answers to these questions will strongly influence how such mental-enhancement treatments will be carried out and for how long they will last.

Of course, the difficulty will be finding an answer to these philosophical quandaries in the first place, and one of the challenges that will inevitably arise once drugs like RG1662 are refined is finding a way to make sense of personal identity in the light of modern science.

Reducing suffering

Philosopher Peter Singer supports the view of "infanticide," but he argues for the rights of animals. He believes that parents should be able to make the choice of whether a disabled child should live, or whether the child should be humanely killed. He bases his claims on some other philosophers such as John Locke, when Singer states that a person is a rational substance, and a disabled baby without a brain, who cannot smile, communicate, or feel anything, is not a person. To claim that the baby is still a human being and is entitled to protection is to be prejudice against other species. A chimpanzee might have more rational thought than the disabled baby, but if being born to human parent entitles it to more rights, then we are just favoring our own species.

Singer's conclusions follow a strong logical sense, and a lot of his ideas are based on reducing the suffering. In the case of animals rights, by limiting the amount of experimentations, or simply avoid eating meat, can reduce their sufferings. In the case of euthanasia of disabled children, one can reduce the suffering of both the family, or to the baby that might have to live through a painful life.

However, should we always let these logical conclusions guide us? We try hard to reduce the sufferings, of both animals and ourselves. However, there will always be suffering in life, and perhaps this is a part of nature that we should not change. Hundreds of years ago, when we do not have the medical knowledge of the disability, we do not interfere with the child's life with euthanasia. Now that we do know about these disabilities, do we have the rights to interfere, and do we have the obligation to interfere?

Singer brought up another way to reduce suffering. In the developing countries, there are many that are starving, or in need of some other necessities. If an average person gives away just a tiny portion of what they own, they can reduce suffering to many people. However, I don’t think we are obligated to help. It's a nice gesture to provide need to the developing countries, and many people do give to charities. By providing the aid, we are affecting the natural order of things, and if nature creates a world that has suffering, then we do not have a moral obligation to remove it.

http://www.youtube.com/watch?v=gMZvIZEO1E0

Donation Abomination

In many arguments surrounding the moral quagmire of organ sales, we often hear the needs of patients on organ transplant lists pitted against the welfare of organ donors/sellers. The refrain is common: 9 out of 10 people who need an organ transplant operation cannot obtain one, but if we legalize the selling of organs, supply will rise. On the other hand, such a drastic legal move would endanger millions of healthy humans around the world. By doing so, we could be exploiting their poverty; a man with a starving family may feel too much pressure to sell a kidney for a couple grand (I, for one, think he should be able to make that choice so that his family lives another day, but that’s another topic). Also, traders in today’s black market are known to forcibly cut out organs from others to sell them. If we created a legal market, this situation would only worsen.

However, arguments for legalization that are based on the good of the donor are overlooked. Our patronizing attitude toward those who look to sell their organs is nonsensical. Have you ever heard anyone discussing making this illegal? Activities enjoyed by the wealthy like the one shown in the video (wingsuiting) are legal in most countries. Ironically, these luxury activities can be more far more dangerous than any organ removal surgery, and yet yield far less value to the participants. It seems indefensible to let the privileged hang their life by a thread for a little bit of fun, yet not allow the poor to undergo surgeries for life-changing profits.

The claims that a legal market for organs would encourage mistreatment of vulnerable people also don’t hold merit. With a legal market, organ sales would be much more closely monitored, eliminating the chance for abuse. A higher supply would also drive price down, removing the incentive for criminals to forcibly remove others’ organs.

What about those in countries where black markets are less common, like the United States? Some opponents of legalization make lofty talk about how all that is good and noble in this world hangs on money-free organ donations. They insist that letting organs be sold takes away the opportunity to give one sacrificially. One problem with this line of reasoning is that it assumes an action loses its goodness when money becomes involved. But when we consider the roles of doctors—highly paid workers who are nonetheless emotionally involved and appreciated by patients—it should become clear that altruism and payment are not exclusive (also, if money corrupts organ donations, then the involvement of paid doctors implies that the donation is already corrupted). Plus, donating an organ is a serious choice that could have heavy consequences in the future. It seems unfair to decide that someone can’t receive money when they are doing good for others at their own risk.

Sources:

http://plato.stanford.edu/entries/organs-sale/

http://books.google.com/books?hl=en&lr=&id=shSmG2-J7nAC&oi=fnd&pg=PA252&dq=V.%09Radcliffe-Richards,+J.,+et+al.+%E2%80%9CThe+Case+for+Allowing+Kidney+Sales.%E2%80%9D+Arguing+About+Bioethics&ots=FEkXprRPtq&sig=zEMSie9Q0QPfPJygc6R-Ur4Vy20#v=onepage&q=V.%09Radcliffe-Richards%2C%20J.%2C%20et%20al.%20%E2%80%9CThe%20Case%20for%20Allowing%20Kidney%20Sales.%E2%80%9D%20Arguing%20About%20Bioethics&f=false

For-Profit Embryo Clinics

            The act of embryo donation, or giving away excess embryos crated for in-vitro fertilization to infertile women, has recently brought up some controversy. Currently the act is approved by organizations such as the American Society for Reproductive Medicine, as long as the embryos are not sold, they are donated. Legally there is nothing against this practice either, as long as the embryos are generated for self-use, and the extras are donated. However some problems have recently come to light with the use of for profit embryo banks selling the excess embryos.

            First of all these for profit embryo banks cause ethical dilemmas in how they treat the embryos in order to maximize profit. In November of 2012 “the Los Angeles Times reported on one such clinic that ‘sharply cuts costs by creating a single batch of embryos from one oocyte donor and one sperm donor, then divvying it up among several patients’”. There seems to be something very ethically wrong with taking the excess embryos not used for in-vitro fertilization and making them into more and more embryos to give to mare and more infertile mothers. What is even more frightening is that this practice is, as of now, legal in all but two states.

            There are even more basic ethical dilemmas posed by the sale of these embryos. First of all selling the embryos could lead to the exploitation of the poor, selling their embryos in order to survive. Furthermore the sale of embryos is also extremely problematic if you consider life to start at conception. Then this practice is similar to selling a life, something ethically abhorrent.

            Finally this practice would lead to many legal dilemmas as well. The most interesting one brought up in this article is “What would happen to such embryos if a gamete provider objects to the sale after fertilization or demands that the embryos be returned or destroyed?” If there is a problem after fertilization occurs who legally is right? Is the donor allowed to force and abortion? Is the recipient now in control? These are all questions that will have to be answered if the for profit embryo clinics are allowed to continue to operate.

http://www.nejm.org/doi/full/10.1056/NEJMsb1215894