p@9 %  L$MUST BOOT FROM SLOT 4, 5 OR 6CJJJJ \  i=l x ? L N9 +i C* ɭЅ?0ȱ L Ѕ?iȱi L CPlbrain-dead is easy; persuading their ife f 01grieving families to give up the kidneys is not. tients, organ-d sharing network;that formed on the heart and travelled to the ves :brain. The author laments the unwise use of animals in the l g." 8, pp 65-69..  ? Author:Andrew C. Revkins, D.V.M.[š C?/צ Abstract: #CODE#饀!.[G&TEXT; Former detective Bill Cantirino tracks potential organ ficial :donors. Finding the ( ORGAN HUNTER L HEART? S' LIVES ,C:[.,* Andrew C. Revkin 988, pp 65-69.4. 9 Discover, Vol. 9, No. 2, February 198HUT2K{> HUT05.TXTr f1>o HUT06.TXTr f1o HUT07.TXTr f1 HUT08.TXTr f1 HUT09.TXTr f1 HUT10.TXTr f1  HUT11.TXTr f1 HUT12.TXTr f1 before transfer compl+`FG8`0($ p,&" COPYRIGHT APPLE COMPUTER, INC., 1984, 1985 C.LEUNGh&Y&&Y& 꽌ɪ\8`&&꽌ɪɖ'*&%&,E'зЮ꽌ɪФ`+*xH&x'8*7Ixix&&    ') +!  &п  x) +莶莸L莸LNO FILE SYSTEM.APPLE SYSTEM.APPLEJ) (jJJ>Lx "?I  `  C x Nx G .x- `V0^*^*>` aI꽌ɪVɭ; Bill Cantirino is home in Brooklyn on a Tuesday night, sons l 9=relaxing after dinner, when a shrill beeping sound tells him of l *?there is work to be done. He turns off the electronic page on d TEX:his belt and is soon on the phone with a doctor at nearby the ts. צ?Maimonides Medical Center. The doctor says they have a man in ; 9intensive care who looks ideal. He was carried into the 82; then ;emergency room the night before with a bullet in his neck. 1985 and '86, the multimrned the 2artificial heart program into a parody of itself. Not only did B The problem is that the demand for organs now far exceeds the >supply. Patients waiting for transplants of vital body parts ave Bmust wait for an anonymous death 's cost drops to five thousand, and it goes down from ?there as dosages of antirejection drugs drop and office visits s an :become less frequent. In terms of money alone, who could irline ܕ)question the need for more transplants?" uirements had tuteria. Researchers have taken ? "It costs more than thirty thousand dollars a year to keep endanAsomeone on an artificial kidney," Cantirino says. "A transplant @for the first year costs forty-five or fifty thousand. But the Asecond yearbut s צb@through the wall of the abdomen, into the abdominal cavity, and . e @waste-absorbing fluid is pumped through and then removed. Both s =forms of dialysis require a lifetime of intrusive treatment. is  :selected according to different crinsing of their blood. This can be accomplished with ?an artificial kidney, but that's expensive, generally requires 24 Bthree four-hour sessions a week, and involves restricted diet and ;activity. In another form of dialysis, a tube is inserted eceived and rejected a first &kidney transplant). a large extent responsible for the design zl, flaws in the available artificial hearts. This is yet another "á? Kidney-failure patients can be kept alive by dialysis, the ." Bperiodic cleam צ @transplants were performed in this country in 1986. There were ʅ?another 10,000 people with kidney failure on waiting lists for gh ?transplants. And 11,000 new cases develop each year (2,000 of e Bthose are patients who have already rs now trying to solve the geometry problem through : The nonprofit Brooklyn-based group, part of a growing ments Anationwide organ-sharing network, seeks hearts, livers, corneas, to keep the man alive. They finally stabilized him, but they >were too late. His body was being kept aillion dollar mechanical heart program had se XT@ Two policemen said the man had tried to gun them down after Tex?they pulled over the stolen Cadillac he was driving. They had I) N?both opened fire. The bullet cut a carotid artery, one of the and for people like Cantirino to Bgo to work. His job calls for him first to locate a special kind Bof death - a death in which the brain is completely destroyed but V?the body hangs in a sort of limbo, sustained with machines and -ectedAdrugs but never able to be resurrected as a living person. Such Adeaths are usually caused by physical trauma to the head or lack of oxygen. a well-known physician's journal: ginia Hospitals. e V "...Most bridgers (clinical investigators usingnly a small percentage of kidney-failure r @patients have a living relative with a compatible tissue type. s B(And then, of course, not every compatible relative is able to or 7wants to give up a kidney. In 1986 1,887 of the 8,976 duced." ey, this one tors =donated by his sister. Because kidneys come in pairs, it is by Bpossible to take one from a living donor, but the donor generally ;must be a close relative. This second transplant worked. t h, a @Cantirino was lucky. Out the new kidney failed. Had a second transplant not been of :arranged, the failure of the first could have killed him. cts of life" to the medical community and the American press. On d for < In December Cantirino received another kidn weight dropped to 119 pounds. He was n =told he would have to have a transplant. On March 27, 1975, s - :Cantirino received a kidney from a murder victim, and the ame Cdetective's story made the front page of the New York Daily News. =Binical expected -8-experience that blood tends to clot on the artificial surfaces. @ In 1974 his kidneys began to fail. He went on dialysis but @suffered recurring infections, and the frequent sessions proved @ineffective. Cantirino's quick on his feet. In his plain brown suit and sunglasses he =looks a bit like Broderick Crawford playing a detective. In But Bfact, Cantirino was on New York City's police force for 20 years,  including seven as a detective. ell-known from clhey Medical Center..." d brain death &VerA Cantirino quickly makes his way through the crowded lobby at versBMaimonides, which echoes with a polyglot of Yiddish, Spanish, and &@Creole that reflects its melting-pot surroundings. He is burly Bbutever press the es reply i y and A Deaths that make for good organ donors are therefore usually Aof the unexpected kind - the result of car accidents, shootings, ̂eBor suicides. Once he has located such a case, Cantirino must try Bto convince parents or children+transplanted kidneys came from relatives.) those waiting for a "DeVries counters that this is a Catch-22 because the I @ In 1979 Cantirino retired from the police force, and Khalid AButt, the surgeon who had implanted his kidneys, offered him the job of organ hunter. in an interview, 25% of the blood flow in humans goes to the brain, far more than in any other species. < In the small intensive care unit on the fourth floor of gan ?Maimonides hospital, rote: "Many years have been spent for the development of A Cantirino begins his pitch slowly, speaking gently. He says Athe doctors did all they could do. There is no hope. Repeating =words already delivered to the famie looks directly at anyone else. The father sits to Bone side, overdressed in a heavy camel hair coat and a hat pulled @down low. He periodically adjusts his brown-tinted glasses and n stares at an empty blackboard. s, the computer scientists whe immediate family into an Cempty conference room. Three sisters sit stiffly along one wall. AThe mother, a small, birdlike woman, sits opposite Cantirino, at >the far end of a long walnut table. She sits sideways in her Bchair. No onh a Bfamily, because there's a guy who all of a sudden goes out. It's 4not a case of where he had been sick or something." n cadavers, m neomorts and, finally, in patients. In 1983, the same year in A Cantirino greets them and leads tls Cantirino that the family is out in the hall - Ba few cousins and uncles, the victim's parents, and his sisters. A"Most of our cases are either gunshot wounds or auto accidents," ACantirino says. "This is typical of how you have to deal witey quiver in synchrony ine Awith the hiss and motion of a black rubber bellows on top of the machine. l heart entrepreneurs appear to have been forced into a bizarre compromise: They design a device to fit an animal . Alan A A nurse tely ?tattooed on his right biceps. An array of tubes runs down his ?throat and nose, and others rise from needles in the crooks of 61 Aboth arms. Two pale-blue corrugated hoses run from his mouth to >a mechanical respirator by the bed. The lies with his eyes half closed, perfectly ls; =still except for the slow rise and fall of his chest. He is way =naked, loosely covered by a cotton sheet. His body is a bit o Achubby, his sideburns long and uneven. There is a Playboy bunnursing station and down Athe row of patients. A plastic rose stands in a bud vase on the @counter. A transistor radio plays country music. The shooting >victim is in the second bed. His chart says he is 24, but he et =looks younger. H >drugs, electrocardiograms, and electroencephalograms. "Looks ed !good," he grunts. "Good donor." ounterproductive requirements for animal testing, the FDA should encourage the artificial heart A Cantirino walks out from behind the n now turns to the prospective donor. The gain =doctor produces a blue folder labeled "Patient Record Number mane ?Eight." Cantirino thumbs through page after page of scribbled e Bentries - blood pressure, heart rate, doses of dopamine and other the doctor up-to-date ?on the previous case; the recipients of both kidneys are doing e fine. e $22 million program is hardly clear or compelling. self Nonetheless, if the costly program must continue, the least the , = Their attentionearlier on another donation. A 19-year-old boy had been shot in ?while trying to hold up a store. The doctor called Cantirino, ly by a doctor, Cantirino The Asays, "Your son is dead. The brain is gone completely. He lost >so much blood that there was no oxygen to the brain. And the ?') /brain, when it's deprived of oxygen, it dies." found the proper fit for their individual blood pumps and experimental her she = Cantirino carefully punctuates his delivery with pauses, ab >giving the family time to absorb the blows. He tells them an n-?electroencephalogram, or EEG, a test of the brain's electss card and tells them to go home, to ;think it over. The door closes behind the couple, leaving hat $Cantirino alone in the silent room. e people think it would be immoral not to do it." B s and the families of those who have had head injuries, it's going to seem B The father rises slowly, almost painfully. "I understand you =perfectly," he says. His wife moves to his side. Cantirino ople ?hands the father a busine look at it from the point of view that someone will be y Ahelped, then maybe it would be a little bit easier. But this is Bsomething that you have to work out yourself. I just want to tell ,you why we need them, who they would help." plantcision," the father says in a monotone. s and desperately disappointed parents of defective newborns may ultimately persuade the public to include he B "I'll grant you, it's not an easy one," Cantirino says. "If ;youster had told :him that there would be a grand jury investigation of the n shooting.) aefer. s two to five years. His only hope is a heart transplant. 9 "This is a very hard det. Cantirino, seeing he has gotten them over the first big ?hump, starts to lay out the situation in more detail. He says Athere will be an autopsy, as in any gunshot case. Giving up the Akidneys will not affect any legal situation. (A siere is almost as much demand from ? There is a long silence, finally broken by the father. "I ir >know what it is all about, these things," he says. He speaks is =with a Spanish accent, slowly hefting each word like a heavy ter Aobjecairs. "It's Aa very hard thing to ask you people, when you are losing a life, Bto give someone else a life," Cantirino says. "But it's the only time it can be done." Courson, 35. A 275-pound offensive guard One thing is certain: Th you know anybody on dialysis, but it's not very s may @pleasant," he says. "This is the only chance these people have @to have some sort of life." The victim's mother hardly moves. BShe stares at the metal legs on one of the plastic ch children; it could be a girl D getting married." the Loma Linda protocol to produce any usable hearts persuaded officials to make substantial revisions. In the B The only sound is the humming of an electric clock. "I don't 8know if its eed @ "The only good that can come out of this is that two people Acan have a new life," Cantirino says, now shifting to a positive @tack. "It could by anybody from the age of three to the age of =fifty. It could be a woman with their grief. The sisters shuffle out, hugging one ely @another, leaving only the mother and father. The mother twists d .her wedding ring slowly. The room is silent. ce meaning by having its organs live on it others. Loma Linda rushedhicago, IL 60604-3795. Michael = There is a long silence. The father looks at the floor, had @glances at his fingernails. Then one of the sisters sobs. The =two others immediately follow suit. The room fills with the d. =sounds ofrical @activity, was done that day. He says it was "flat-line" for at ?least a half-hour - not even a spark of life. Two doctors had 7independently confirmed that their son was brain-dead. section Society, 53 West Jackson Blvd., C He returns to the intensive care unit to tell the doctor that Cit will be at least two or three days before they get a decision. <"They've just been told their son is dead," Cantirino says. efs @"Regardless of what he did, he's dead. Now they have to accept >this, to come to terms with it. Then they have to say okay - @which I think they might, because we didn't get a flat no. The @father seems to be the strong one, yet the mother's the one who Bholds the key. You can :their brother had been shot more than once. She asks why ACantirino talked only about one bullet. "I don't know the facts @of the case," Cantirino responds. He knows only what is on the =patient's chart and what the doctor hA The oldest sister seems to be sifting the facts, looking for >a loophole, some inconsistency. She says the family was told selection is based on the ?length of time a patient has waited, the direness of the need, ;and the degree of tissue compatibility. "No one can buy a ?kidney, rich or poor," Cantirino says. "It's strictly through luck." is 6the 9th-busiest kidney transplant center in the U.S). ? A match is made from a list of potential recipients at New BYork's various transplant centers. Theocally, the kidneys will probably go to someone ?from Brooklyn. "It's people like us," he says. He says there Bare almost 500 people on the waiting list at the State University Bof New York Health Science Center alone (the Brooklyn hospital Suite 500, P.O. Box ? Cantirino carefully, patiently answers each question. The @body will go to the Office of the Chief Medical Examiner of New @York City. Because matching an organ donor with a recipient is Afirst attempted l?has been replaced by suspicion. They start to ask questions. AWhere will the kidneys go? Are they sold or given to anyone who >needs them? When will the body be turned over to the family? n Sharing, Dept. P, 1100 Boulders Parkway, men are a still life. Each stares in a >different direction - numb. Each has an elbow propped on the =table and cups her chin in her palm. They seem sullen, even elp @resentful. The shock seems to have dissipated somewhat, but it ouston puts the organ < The family is due at noon, but they don't show up until gs, ?midafternoon, and then it's just the three sisters. Cantirino =repeats his litany, sitting with them in the same conference ut ;room. The three wo By the next after> The family stands in a knot, as still as a painting. One our Agirl holds her brother's hand, strokes his wrist. Another leans =down and whispers softly to him in Spanish. One by one they :drift away, between rows of beds and machines see just by looking at her that no matter ?what he wants, she's the one who'll say, and whatever she says will go." In fact, not everyone who signs an organ-donor card becomes as told him. Cantirino !calls in their brother's doctor. @ The doctor's boyish face, open collar, and deck shoes belie @his authority as chief resident. He begins applying pressure. =He says the number of bullets that struck the victim will be misinid it." The 0three sisters leave after signing for the ring. > "It's never a sure thing," Cantirino says after they have @left. "I've had them change ike a hand-held can opener. She has never used it before, .TE@and it slips awkwardly off the limp hand. She tries again, and DRAFT?this time the oldest sister helps her do it. "Look," says the :KBnurse, smiling and holding up the bit of silver. "I de silver ring on the small finger >of her brother's left hand. "What about this ring?" she asks EST.CODBsharply. "My mother has to have this ring." She asks a nurse to DISBcut the ring off. The nurse comes back with a ring cutter, which Blooks lODEb9Z[ acceptance. Ob[\ II80.MISCINFOb\h BALANCED.TEXTbhp CROSSREF.TEXTbp DISKIO.TEXTb"GRAFCHARS= The three sisters stand at their brother's bedside. The  SAoldest sister points to a simplare right out of a book called "Living with Death & 9,7>Dying," by Elisabeth Kubler-Ross. It describes the emotional ORSb@stages that a person passes through when confronted with death: NDER.7depression, anger, denial, bargaining, and ultimately, to try to decide by tonight. CHEYLE@-8 SYSTEM.EDITORb98V SYSTEM.FILERb9VA On the way out, the three women go to see their brother once ARSEBmore. Cantirino says the changes in their attitude over the last STE=two days sts the =leather thongs on her purse as he talks. She has run out of Aquestions. The sisters say they will go home once more and talk @it over with their parents. The youngest one says their mother ?will decide. Cantirino asks them The liver, the kidneys themselves, they don't @perform the way they should. And the body starts to accumulate =poisons in the blood. You can't maintain the body," he says Asoftly, "because it's not normal." The oldest sister twi as good. ? Cantirino interrupts, sensing the pressure is becoming too @intense. "The body on a machine doesn't really function. It's ;not normal.ay or >two, or maybe a week at the most, infection will set in. And Asoon, the doctor explains, because of the demand for beds in the >intensive care unit, their brother will have to be moved to a -general ward, where the care is not fear among both physicians and the public. ; Even so, the situation has improved dramatically since ACantirino began his job in 1979. Then, he says, only one out of @five families would give consent. His average is now three out Aof four. Extensive publicity of some transplants has helped, as >have publicity campaigns by local hospitals. A newly enacted Afederal law requiring allften believes that success in novel ife f 0:endeavors should be immediate and risk-free. Advances in ark, d @artificial organs will depend on our willingness to rethink the , ::ethical and clinical standards for experiments on humans. l g." 8, pp 65-69..  ? : Vol. 92, No. 8, November/December 1988, pp 35-40. ?/צAuthor:Pierre M. Galletti!.[G&TEXT Abstract: detective Bill Cantirino tracks potential organ ficial 9 Our culture too o8 ARTIFICIAL ORGANS: LEARNING TO LIVE WITH RISK S ,C:[.,+ Pierre M. Galletti ovember/December 1988, + Technology Review, 98$1988 by Discover Publications, Inc. tective tracked down possible donors. ?Reproduced 1991 by permission of the publisher. Copyright (C) About the Author: < Senior Editor Andrew C. Revkin spent several weeks with 9Cantirino as the deCkidneys will be sutured into place in the abdomens of two people. >Cantirino heads for the door, his job done. A nurse waves to *him, smiling. "Happy hunting," she says. y rock and roll. ; Cantirino does some paperwork and telephones the organ >recovery team at the Health Science Center. Within a day the ter several minutes =they leave for the last time. The young man lies still. An =endless line of heartbeats parades across a monitor over his ?head. The bellows hisses; his chest rises and falls. A radio &somewhere sqawks tinn6entry on the patient's chart: he pronounces him dead. A The family goes for a last look at the victim-turned-donor. AThere are a few sobs, but mostly silence. Af Cantirino hands the consent form to the Amother. She and her daughters read it slowly. At 7:50 p.m. the ;mother signs the paper, indicating that she speaks for her >husband as well. The doctor signs the form and makes a final mother, who is now Adressed in black. She sits in a chair in the hallway, beneath a =cheap print of yellow flowers that hangs on the cinder block =wall. The doctor stands to one side, talking quietly with a Afriend of the family's.ow they know what you're talking about," Cantirino says of the families he has met with. B Thursday night the sisters return with the hospitals to identify potential donors @is increasing the chances of getting organs. Cantirino and his Apartner, physician John Evangelista, had 130 donors in the first @11 months of 1987; that's up from 32 in all of 1979. "At least @n Bill Cantirino is home in Brooklyn on a Tuesday night, sons l 9Abstract:after dinner, when a shrill beeping sound tells him of l *? The advent of artificial-organ technology has ushered in a d TEX:new era in medicine. In scarcely more than a generation, the ts. צBartificial organs have evolved from temporary substitutes used in @emergencies to devices that can function on a long-term basis. n 9At least 3 million people worldwide live with artificial . 1985 Aimplants, such as crs. the 24Research using animals simply will not not suffice. ot only did  The problem is that the demand for organs now far exceeds the ? In the 1970s, for example, researchers competed to develop ve @the artificial heart that could kIES FALL SHORT o five thousand, and it goes down from there as dosages of antirejection drugs drop and office visits s an @ The only way to gain the information needed for refining an ܕ>artificial organ is through experiments on human volunteeime for a major overhaul of en ,the approval process for artificial organs. ars a year to keep endansomeone on an artificial kidney," Cantirino says. "A transplant for the first year costs forty-five or fifty thousand. But the ANIMAL STUDt t s צbBminimizing the risks to humans have been unable to keep pace with e >new clinical developments. As a result, they have needlessly h s four months on an artificial heart - have volunteered to take s :part in the testing of unproven medical devices. Lacking rneas, @alternatives, they are willing to shoulder unknown risks in tause such devices require =trial and error in human subjects, their development poses a isks W.challenge to our cultural and ethical values. ng the failure of (ʅone of the body's vital components. t organ procurement es of a > Many patienrs ٕfor the Gift of Life Organ Procurement Organization, he is on 24-? So far, even the most successful organ substitutes lag far e lis@behind their natural counterparts. But the obstacles to better o "Aimplants are not purely technical. Bec implantable lung or kidney might not be much f CAfarther down the road. Eventually, artificial organs will allow 6Bordinary, healthy people to live longer - or, more appropriately, to die young at a ripe age. sations. As one of two organ hunte. Clinical testing of Aan artificial pancreas for the treatment of juvenile diabetes is :now under way. Widespread use of the artificial heart is eported >probably no more than a quarter-century into the future. And be ?development of anmain sources of blood to the brain. A surgeon worked for five he ܾB In years to come, artificial organs will play an even greater ;role in health care. Several types of artificial skin are ey @already being evaluated in human subjectsardiac pacemakers, arterial grafts, hip-joint XTBprostheses, middle-ear implants, and intraocular lenses. Another Tex:300,000 patients are kept alive by dialysis machines - in had I) Nessence, artificial kidneys. cut a carotid artery, one of the eep a calf alive the longest. o AEventually all the calves either outgrew their hearts or died of ;complications resulting from infections. Neither of these ed but V@outcomes, however, can reliably be assumed to apply to humans, ectedAwho generally are no longer growing at the time of implantation, ?and who keep clean better than calves do. While infection did k @contribute to the demise of the first six elderly recipients of e VAthe total artificial heart, it has been only a minor prl for new medications, but produces lure r 9haphazard results when applied to artificial organs. It type. s Adiscourages innovation, prohibits patients from volunteering for Aexperimental treatments, and prevents necessary refinements from ey, this one tors @ Unfortunately, the Food and Drug Administration (FDA) makes :such experimentation difficult. The agency's process for nerally Capproving new implants evolved in the context of drug evaluation. ;It words reasonably welut the new kidney failed. Had a second transplant not been of arranged, the failure of the first could have killed him. cts of REGULATORY FLAWS cal community and the American press. On d for In December Cantirino received another kidne is little justification for developing :new engineering designs until these medical questions are 5, s - are designed to replace, clinical evaluation in humans is the of most significant test. quite well," Pierce said. "We were forward On Wednesday morning Cantirino calls the family oists, knees, hips, and finger rief ock?joints generally poses complex engineering problems because of er effective." It is hard enough to prove the safety of a drug, he :since clinical tests cannot always predict long-term side ow in Beffects. Ultimately, the decision to market a new drug remains a judgment call. l intensive care unit on the fourth floor of gan Maimonides hospital, s te: ;lived to leave the hospital. Yet many critics argued that Bfurther experiments with permanent implantation should be banned, Bbecause the experiments had failed to show that the device was an Aeffective form of treatment, and be Lake City and Louisville, for example, the FDA s to =required that the implant be restricted to patients who were lled 9either too old or too sick for transplants. Given their es and n =condition, it is hardly surprising that none of the patient testing only usefulness, n not feasibility. room. Three sisters sit stiffly along one wall. The mother, a small, birdlike woman, sits opposite Cantirino, at @ In the initial experiments with the Jarvik total artificial =heart in Salth a =feasible before it can be proved clinically useful. But the It's 9FDA's clinical and ethical standards for experimentation avers, m Ainvolving humans - such as relative safety and effectiveness and ?quality of life - are appropriate forhe device works better than other, established - treatment methods). cles, the victim's parents, and his sisters. "Most of our cases are either gunshot wounds or auto accidents," : Logic dictates that a device must be found clinically wit. The FDA's regulatory ne evidence that ts 6from making efficient use of the knowledge they gain. down his throat and nose, and others rise from needles in the crooks of 61 A The distinction between drugs and medical devices is not the ?only one federal law fails to recognizer supply of an artificial heart. FDA officials ?often freeze the design of a device when obvious modifications y @could be made without repeating the entire evaluation process. AInflexibility in pursuit of an orderly trial prevents physicianrmula produces a new wn 7drug, which is properly subjected to the full cycle of se on the Bevaluation. On the other hand, devices typically can be improved presumed to reflect the best choice among a number of similar art >compounds. Any change in the chemical fore is no ethical justification for using gain :placebos, such as sham surgery or non-functional devices. er mane Eight." Cantirino thumbs through page after page of scribbled e ; Finally, a regulatory process modeled on that of drugs other the doctor up-to-date ; Nor can devices be tested in the same way as drugs. A ing e Bdouble-blind study is out of the question, since both the patient 8and the doctor must be informed of the specifics of the ast the , There is no concept similar to toxicity (the mass of chemical in Badministered relative to body size) that can be extrapolated from cause the quality of life for patients was poor. dead. The brain is gone completely. He lost so much blood that there was no oxygen to the brain. And the ?') B If clinical usefulness was the criterion of success, as these establishing feasibility. Moreover, there are be first successful implantation of a Bmajor artificial organ and its widespread acceptance in medicine. newborns may ultimately persuade the public to include he @ The federal government must balance the goals of protecting f @patt researchers Even if the federal regulatory process is reformed top to =bottom, the development of artificial organs will still be a the Alengthy process. There is no avoiding the fact thants on humans. s much demand from There is a long silence, finally broken by the father. "I ir know what it is all about, these things," he says. He speaks is A NEW APPROACH TO REGULATION hefting each word like a heavy ter objecgrams are 's @likely to generate enough clinical experience to make permanent ?implantation of the artificial heart a routine procedure. And ly Bthese advances will have been made possible only by the so-called ,failure of the early experimesult, researchers have been able to observe applications ,of the artificial heart for longer periods. e these people have to have some sort of life." The victim's mother hardly moves. ? Over the next decade, cardiac transplantation pro heart could be found; in others, ?the implantation became de facto a permanent one when patients e >who had received the artificial heart were subsequently ruled the Bineligible for transplantation because of medical complications. @As a re have ed Byielded much more experience with long-term use of the heart than Aarose from earlier implants that were supposed to be permanent. =In some cases, bridge procedures have extended from weeks to of Amonths when no compatible donor procedures aimed at sustaining younger, healthier ely 'patients while they await transplants. ther. The mother twists d her wedding ring slowly. The room is silent. ce meaning by = Ironically, these "bridge-to-transplant" proceduresentation with the device quickly 5became irrelevant. Instead of focusing on permanent floor, had Aimplantation, which remains a long way from clinical usefulness, Bcardiac surgeons now choose to concentrate on using the device in review board (a body normally comprising community members as :well as hospital staff) would decide whether to permit an The @experiment that would test clinical feasibility - that is, show @whether the device func >inferior technologies, limit costs, and protect patients than =concentrating regulatory resources on premarketing control. cts BGovernment bodies, notably the FDA and the National Institutes of BHealth, have proved reluctant to devotage would consist of broad-based clinical trials Band several years' follow-up. Here, too, the government would be ?required to keep detailed records. Indeed, a properly planned r :system for registering patients would do more to weed out oldy would protect patients e 9against the overenthusiastic spread of unproven forms of need, treatment. ree of tissue compatibility. "No one can buy a kidney, rich or poor," Cantirino says. "It's strictly through A The third s s Bsuccess of the device relative to other modes of treatment rather @than an absolute standard of safety and effectiveness. Coupled :with a temporary ban on the use of the device outside the New @authorized pilot trials, such a registr, the government would also be required to eone the FDA would not have the power to prohibit minor changes in design or protocol. Office of the Chief Medical Examiner of New York City. Because matching an organ donor with a recipient is < At this stage=nationwide. These trials, however, would again be conducted Bunder the supervision of the local review boards. In determining Athe protocols for each experiment, the boards could specify that Aslightly different designs be used in difelative safety, durability, and range of ?performance. The agency would then establish basic design and Bmanufacturing criteria. A limited number of pilot control trials ;would be initiated in perhaps half a dozen medical centers t it al government. The n 4FDA would decide whether to allow a second stage of p until gs, Aexperimentation to establish clinical usefulness. To enter this :phase, a device would have to undergo rigorous laboratory ce ut in medical treatment today, it is extremely unlikely that any he Bhospital review board would approve the participation of patients ?in tests of clinical feasibility if they could be treated more ve ze them. her g - patients who lie sleeping or staring, and out the wide swinging = In this way, control over the experiment would rest with >those who are to be held liable for its results. Considering Athat malpractice suit>could not, as it does now, prohibit the experiment, establish our details of the procedure. The results of each study would be 6reported to the FDA, which would then publicitioned as its creators claimed. No more r =than 10 human volunteers would need to be involved. The FDA s @would be invited to comment on the protocol for the experiment, =but it would have no regulatory authority at this stage. It es te funds to such registries, 9since they are expensive enterprises that produce no new @scientific knowledge. However, patients seeking treatment need >to know which forms of treatment work best - information that e ;often takes years to emerge when the reporting of clinical re. ?experience is haphazard. A patient registry could save money, "suffering and occasionally lives. far as the possibility of donating organs, it is becoming a question of time. In a d6 FETAL TISSUE TRANSPLANTS: WHAT ARE THEY? K S ,C:[.,' Leslie Bond tember 12, 1988, pp 8, 10. ? National Right to Life News, September 12iew. @Published by Association of Alumni & Alumnae of MIT. Copyright (C) 1988, MIT. ays another problem is the lack of a federal law hetic materials. form of sci-fi films and novels. "When they showed "Coma" in Boston," he says, referring to the popular film about a hospital that killed patients to get organ donors, 9Reproduced 1991 with permission from Technology Revhas explored the theory and way to University, where he heads the graduate program in artificial 9organs and biomaterials. He es will form the framework within which artificial-organ , .TE=technology is developed and applied for generations to come. nd DRAFTthis time the oldest sister helps her do it. "Look," says the :Knurse, smiling and holding up the bit of silver. "I decies, we may be more willing to Baccept trial and error as the norm for progress and less dogmatic COD>about what risks are acceptable. The actions of the FDA will to DISBprove but a blip on the chart of human history. But our nation's @attitudcial heart safer, more effective implants a reality. We must not delude ORSb:ourselves into thinking that perfect devices will soon be eath: NDER.Bavailable; even the most ardent promoters of the artifi- is that success in novel t. CHEBendeavors should be immediate and risk-free. We are not prepared V@to accept an unproven therapy for which there is no recourse in ARSE=the event of failure. Yet without the unavoidable accidents last STE?entailed ished or disproved. ngs on her purse as he talks. She has run out of questions. The sisters say they will go home once more and talk A An underlying fallacy of our current regulatory system - and technologies. Moreover, it would p, 1988, pp 8, 10.  ? Author:Leslie Bondo. 8, November/December 1988, pp 35-40. ?/צ Abstract: rre M. Galletti!.[G&TEXT? NRL News has covered the issue of fetal tissue transplants al Aextensively since April 1987. Pro-lifers' core objection to the 0Atransplants is the undeniable fact that the tissue used in these =transplants is "harvested" from the bodies of unborn infants he , :Bkilled by abortion. The intentional killing of these children is s, tissue is taken from either Athe pancreas or liver of the unborn child. More recently, fetal ndanAneural tissue transplants have been performed, which take tissue Afrom the brain of the unborn infant. The added controversy over 4fetal neurat t s צb7Q. What is he distinction between fetal neural tissue pace with e 9transplants and other kinds of fetal tissue transplants? ssly h s restricted the breadth of clinical experience necessary for is  :BA. In some fetal tissue transplanter serious scrutiny. The British medical journal s ;Lancet recently called for a moratorium on the use of auto-res 24  transplants. ur sessions a week, and involves restricted diet and Over the past 25 years, formal review processes aimed ad astonishing results using &=the auto-transplant technique. However researchers in other mans Acountries, including the U.S., have been unable to replicate the "á@successes of the Mexican team, and the Mexican team's "success" " ?have come undhe צ ?Q. What kind of results have researchers experience with auto- ʅ transplants? 0 people with kidney failure on waiting lists for gh  At the same time, such altruism - and the medical progress it AA. In 1987 doctors in Mexico reporte are taken from either the brain of the aborted gh 7infant, or the adrenal gland of the aborted infant and o take s 8transplanted into the brain of the Parkinson's patient. g rneas, alternatives, they are willing to shoulder unknown risks in tnts with Parkinson's uire =disease. What confuses many people is that there is a fetal isks Wthe patient's brain in hopes that the transplanted cells will e lis@begin to produce dopamine in the brain. Dopamine is a chemical o "treatment for a condition or disease. "Auto-transplants," in ter Athis context, involve taking tissue from one part of a patient's @own body and transplanting it to the pati noble a purpose - can only compound the oint XT=A. Fetal tissue transplants involve taking tissue from, for ther Tex?example, the pancreas, liver, or more recently - and even more I) N5controversially - the brain of an aborted infant and ne of the tissue used in these צtransplants is "harvested" from the bodies of unborn infants d in >Q. What are fetal tissue transplants, and how do they differ is from "auto-transplants"? e use of their bodies for "spare parts" - for no matter howAunspeakably wrong, and the use of their bodies for "spare parts" 9<- for no matter how noble a purpose - can only compound the ts l *original injustice. ril 1987. Pro-lifers' core objection to the TEXtransplants is the undeniable fact that thel tissue transplants stems both from the es down from ?Frankensteinian overtones of brain tissue transplants and from s an @the sheer number of applications researchers claim fetal neural ܕ@tissue transplants may have. One researcher interviewed by NRL e 2@News hypothesized that fetal neural tissue could potentially be >used in treatments for everything from Parkinson's disease to the California at Los Angeles, transplanted bone marrow-producing . =liver cells harvested from aborted babies into the bodies of Apatients suffering from radiation-induced blood disorders. None Cof the transplants were s Currently, fetal tissue transplants have been done in human e ?beings to treat Parkinson's and some forms of diabetes. After t =the Chernobyl nuclear power plant accident, California fetal ply :transplant proponent Dr. Robert Gale of the Unive patients alive. It appears that th &VerAQ. What conditions, besides Parkinson's, are being treated with ersfetal tissue transplants? patient and the quality of Spanish, and &postoperative care. its melting-pot surroundings. He is burly @A. her, as esults es ?mentioned above, researchers are predicting so many "uses" for ts $?fetal tissue that the number of miscarried infants would in no l  &way meet the demand for fetal tissue. t in other cases, the same devices have failed to keeption could make the child's tissue less useable for not Atransplant. In an induced abortion, in which the reason for the ve t?abortion is virtually always social rather than physiological, s ;this type of problem is less likely to occur. Furtten when an unborn child is ges the e P(;miscarried, the spontaneous abortion is the result of some rience K, :condition in the baby (such as a fundamental neurological tleneck (amperhaps even many - aborted babies' bodies would be needed to f e V+provide enough tissue for each transplant. y a minor pral transplant. Twenty percent o Bof the U.S. population translates to about 40-50 million possible 7"beneficiaries" of the treatment - and, theoretically, ese ed but V>correspondingly high numbers of aborted infants' bodies which ected8would be ey, this one tors AA. In the diabetes treatment, researchers obtain special tissue ;from the aborted baby's pancreas which - had the baby been erally Aallowed to continue to develop - eventually would have developed 7into insulin-producing cells. These "islet" cells are ces lure r Atransplanted into the body of the diabetic patient on the theory Athat the cells will develop in the recipient's body and begin to >produce insulin. Some researchers are claiming great success om cells - solutions made up of =individual free-floating cells separated from their original all. Btissue formation - or as "fragments" (or "chunks") of tissue made 8up of groups of cells. With the dissociated cells, the ificial @transplant isn a ?adrenal tissue to the brain in the auto-transplant technique. 's =The fetal neural tissue transplant technique would likely be s, m reported in June that neither of their patients had shown any nsearch team which had n >done the earlier auto-transplant experiments reported similar he ?success with the fetal tissue transplant technique, which they ed =had used on two patients with Parkinson's disease. However, et @again researchers >Q. What kinds of results have researchers in other countries A 3achieved with the fetal neural tissue transplants? it is ents presumed to reflect the best choice among a number of similar art ?A. In September 1987 the same Mexican reals. That is, researchers are transplanting n @human fetal brain tissue into the brains of animals in order to e 7observe how the human fetal tissue transplants behave. ribbled e Finally, a regulatory process modeled on that of drugs otherbeings, although it te ?has been done in Mexico, Sweden, England and, reportedly, Cuba e Band China. However it should be noted that some U.S. researchers =are using human fetal brain tissue in clinical trials of the he , @technique with anim U.S.? o humans. Moreover, there is no analogy in organ t r replacement for the terms "effective dose" and "overdose": in n >A. Thus far, researchers in the U.S. have not attempted this re ?treatment for Parkinson's disease in human - one kind of treatment simply replacing r 6the other, rather than curing the underlying disease. omplex. ks There is no concept similar to toxicity (the mass of chemical in >Q. Have fetal neural tissue transplants been done yet in the rom killed off the , he Bpatient's own insulin-producing cells in the first place. Others ?note that the transplant recipients who were receiving insulin a ?shots will now be receiving shots to ward off rejection of the ?newly implanted cells?with the technique, but others have expressed doubts about the Atreatment, especially over the long term. For example, some say Bthat the newly transplanted cells will simply be destroyed by the brain is more useful for transplant than the injection method an or new growth. In other words, it is possible thatstioned whether the "successes" m @reported from fetal neural tissue transplants in animals and in r Ahuman beings are in fact attributable to the fetal neural tissue Btransplants, or if instead they are the result of other factors. 6For egrams are 's =Q. What are some of the technical questions which have been nt =raised about the success of fetal neural tissue transplants? d ly these advances will have been made possible only by the so-called =A. Some researchers have quee transplants of the aborted infant's pancreatic tissue, Aresearchers place the "optimal age" much later, somewhere around the 16th week. rt of life." The victim's mother hardly moves. Over the next decade, cardiac transplantation proed and what conditions it is being @used to treat. For example, with the neural tissue used in the Btreatments for Parkinson's disease, researchers say the tissue is ?best transplanted somewhere between the eighth and 11th week. . @With th have ed yielded much more experience with long-term use of the heart than >A. The gestational age at which an aborted child's tissue is . Bsaid to be most useful for transplant differs, depending on which Bkind of tissue is being harvestnfant after the abortion. ining younger, healthier ely patients while they await transplants. ther. The mother twists d AQ. What is the "preferred age" at which a baby would be aborted *in order to secure tissue for transplant? t" proceduresarvested, the tissue must be kly >recognizable as the particular kind of tissue needed. Olanow had abortion which, when used with ultrasound, produces an intact in #aborted i heart However one researcher, Dr. C. Warren Olanow of Tampa General ed, >Hospital in Florida, said to be himply, then the experiments were doomed from the r she BQ. Is it necessary to perform a particular method of abortion in .order to harvest the aborted child's tissues? plied - clinical -feasibility - the experiments did succeed: the artificialrger than the individual for Bdissociated cells. However, by using a larger needle it may also =be possible to use the injection method to transplant tissue ?') fragments. ical usefulness was the criterion of success, as these criticisms to fetal brain transplants? nts: too much energy is spent on regulating to seem experiments and too little on tabulating and publicizing their ou 9A. Yes. Some are studying chemical, or pharmacological atments. @approaches such as the one described above. Others are working and lymphoma. BMT is also being evaluated in clinical trials I) N;(treatment studies) for a number of other types of cancer, the nt's marrow is these צ INTRODUCTION healthy marrow from a donor or from the patient. n The success of a bone marrow transplant is heavily influenced by ? Less than two decades ago, bone marrow transplantation was " Bstrictly an investiAcondition and specific disease, the type of transplantation, and 9'the suitability of the donated marrow. an only compound the ts l *Abstract:injustice. ril 1987. Pro-lifers' core objection to the TEX In bone marrow transplantation, a patieansplantation, a patient's marrow is to the 0@replaced with healthy marrow from a donor or from the patient. AThe success of a bone marrow transplant is heavily influenced by ::several complex factors, including the patient's physical blood s nstitute, 8, 10.  ? ; NIH Publication No. 90-1178, January 1990, pp 1-5. ?/צAuthor:Catherine A. Gower and Patti L. Lowery[G&TEXT Abstract: ws has covered the issue of fetal tissue transplants al : In bone marrow tr4 BONE MARROW TRANSPLANTATION (PART I) ? K S ,C:[.,3 Catherine A. Gower and Patti L. LoweryNIH pp 8, 10. 7 Research Report: National Cancer Iht to Life News, 419 7- 7th Street, N.W., Suite 500, Washington, D.C. 20004. swinging In this way, control over the experiment would rest with sought-after. it does now, prohibit the experiment, establish our criteria for selecting volunteers, or otherwise dictate the eans details of the procedure. The results of each study would be BReproduced 1991 by permission of National Rigsplanting an unborn child's tissues and r @transplanting that child's organs. If it becomes acceptable to produced mainly in the lymph nodes, spleen, and thymus. They l f @destroy invading antigens, particularly viruses. There are two y ard8main types of agranulocytes: lymphocytes and monocyteetween 1 and 4% of WBCs and are ef ock8important in phagocytosis and allergic and inflammatory use of er reactions. echanical loads involved and the range of motion led o  A. Researchers say that spontaneously aborted babies would not ? *Agoblem for C - Basophils account for less than 1% of circulating WBCs. 0They play a special role in allergic reactions. ical problem of ̂eusing the bodies of babies killed by induced abortion by instead ? - Eosinophils make up bare a primary defense against bacterial invasion. They @perform this function partially through phagocytosis (a process ?in which micro-organisms are engulfed by these and other white e Vcells). enough tissue for each transplant. y a minor pral transplant. Twenty percent o of the U.S. population translates to about 40-50 million possible : - Neutrophils are also known as polymorphonuclear ed but VBneutrophils (or "polys"). They comprise about 60% of circulating tedAWBCs and by NRL e 2= *Granulocytes are produced in the bone marrow. They are be Aimportant in combating bacterial infections, and they have other Aroles as well. They are subdivided into neutrophils, basophils, and eosinophils. rt of fetal neurl tissue transplants stems both from the es down from A There are several major types of WBCs. Each has a different an function. number of applications researchers claim fetal neural ܕtissue transplants may have. One researcher interviewed ion is present, the production :of WBCs increases. A deficiency of leukocytesis known as fetal ndanAleukopenia, a condition that increases a person's susceptibility to infection. of the unborn infant. The added controversy over fetal neurammune צb>system, the body's defense mechanism that fights infection by ith e ?destroying "foreign" substances such as bacteria and viruses. s called anemia, can cause weakness, lack of energy, dizziness, ans headache, and irritability. ., have been unable to replicate the "ásuccesses of the Mexican team, and the Mexican team's "success" " have come undrts צ Aof the body. RBCs contain hemoglobin, an iron-rich protein that ʅAserves two vital functions. It carries oxygen to the cells from Bthe lungs, and it takes carbon dioxide from the cells back to the Alungs. Oxygen gives the body energy. are taken from either the brain of the aborted gh RED BLOOD CELLS drenal gland of the aborted infant and o take s transplanted into the brain of the Parkinson's patient. g rneas, A Red blood cells transport oxygen from the lungs to all pa regulate the immune response. B e e P(?cells produce specific antibodies (proteins) that help destroy ce K, ?foreign substances. It is thought that B cells mature in the ck (am>bone marrow, but this has not been definitely established. T e >cells attack virus-infected cells, foreign tissue, and cancer Ccells; they produce substances that regulate the immune response. t>NK cells serve several purposes. Among other functions, they s 6destroy cancer cells and virus-infected cells thround platelets. researchers are transplanting n human fetal brain tissue into the brains of animals in order to e 4 Leukemia is classified as either lymphocytic or e. ribbled e >nonlymphocytic, and is also categorized as acute or chronic. here to perform their te Ainfection-fighting role, begin to fill the bone marrow and spill >into the bloodstream. The "crowding" of the bone marrow with ers @leukemic cells interferes with the production of normal red and , !white blood cells a LEUKEMIA o humans. Moreover, there is no analogy in organ t r replacement for the terms "effective dose" and "overdose": in n B Leukemia is a cancer that arises in the blood-forming cells. >Immature, abnormal white blood cells, unabler it the best available treatment option r under certain circumstances. the underlying disease. omplex. ks There is no concept similar to toxicity (the mass of chemical in Q. Have fetal neural tissue transplants been done yet in the rom stigational he , he Atreatment, this procedure is now a standard treatment option for @several diseases. A standard therapy is one that is in general a Ause for a specific disease; it has been tested sufficiently that ?physicians may considBdisease, either from a donor or from the patient after the marrow #is treated to remove cancer cells. term. For example, some say that the newly transplanted cells will simply be destroyed by the 9 Although in many instances BMT is an inveakes it possible for patients to receive r ;higher and potentially more effective doses because marrow heory :damaged by treatment is replaced with healthy marrow. In gin to Apatients with leukemia, BMT also provides marrow that is free of igh that they ors Bseverely damage and destroy the patient's marrow. Because damage ?to the marrow leaves the patient susceptible to infections and ly Bunable to fight them, doses of chemotherapy and radiation therapy @must be limited. BMT must a few. kidney failed. Had a second transplant not been of ; The main purpose of bone marrow transplantation in the ts of Atreatment of most types of cancer is to make possible the use of =doses of chemotherapy or radiation therapy so h tissues. and all of the patients died. Researchers have predicted that the fetal tissue transplants s - could be applicable to Alzheimer's disease, sickle cell anemia, 2DISEASES TREATED WITH BONE MARROW TRANSPLANTATION uries, to name jrsity of how d -8-@ Platelets help prevent bleeding by causing the formation of Ablood clots at the site of an injury. A deficiency of platelets ;known as thrombocytopenia may result in bleeding in mucous None #membranes, skin, or other Currently, fetal tissue transplants have been done in human e beings to treat Parkinson's and some forms of diabetes. After t  PLATELETS byl nuclear power plant accident, California fetal ply transplant proponent Dr. Robert Gale of the Unive for 2 to 6% of WBCs. They play a key Ver?role in phagocytosis, the process of clearing the body of such h ers:debris as dead cells and microscopic organisms (bacteria, sh, and &viruses, and fungi). its melting-pot surroundings. He is burly A. gh , as esults es ?phagocytosis. They also produce substances that can kill such ts $cells. issue that the number of miscarried infants would in no l  way meet the demand for fetal tissue. t in other cases, the same B - Monocytes account :Lymphocytic leukemia is a disease of the lymphocytes, and ies A 9nonlymphocytic (myelocytic) leukemia is a disease of the ents @granulocytes or monocytes. Myelocytic leukemia cells are white t @blood cells whose development stops at an early stage when they ?are known as myeloblasts. The classification of leukemia into e with radiation and/or combinations of anticancer drugs. High ?') Bdoses of radiation and/or chemotherapy offer improved chances for >effective th, to intestines, appendix, and skin. the tissue fragments or chunks, are used, it appears that physically placing the tissue in the d, > There are several types of lymphomas, including Hodgkin's an Adisease and a number of non-Hodgkinnd under the arms and in the chest, groin, neck, and Aabdomen. The lymphatic system also includes the spleen, thymus, Atonsils, and bone marrow. Small amounts of lymphatic tissue are >also found in other parts of the body, including the stomacdy. Lymphatic vessels carry =lymph, a colorless, watery fluid that contains lymphocytes. all. ?Along this network of vessels are groups of small, bean-shaped de Bstructures called lymph nodes or lymph glands. Clusters of lymph Bnodes are fourt @of the immune system. This system helps the body fight disease s Aand infection. The immune system includes the lymphatic system, ?which contains a network of thin tubes that branch, like blood d Bvessels, into tissues all over the bothis question have been hard to come by, ished - LYMPHOMA y since the fetal neural tissue transplants have not yet been done in the U .S. However one researcher did explain to NRL @ Lymphoma is a cancer of the lymphatic tissue, which is paatment damages both ory ne @healthy and diseased cells. BMT restores the number of healthy white blood cells. recipient? lost function in a human being, regardless of outcome) and clinical usefulness (statistical Alan A. Answers to s >contained in the NCI publication "Research Report: Leukemia." months after the transplants. Swedish researchers say, however, A Bone marrow transplantation can be part of the treatment for ;several types of leukemia. Initial treAcute leukemia is a progressive cancer that in :usually begins abruptly; symptoms are intense and develop d two @quickly. Chronic leukemia usually develops more slowly and may ;go unnoticed for quite some time. Detailed information is ny nnstitute, 8, 10.  ? = NIH Publication No. 90-1178, January 1990, pp 6-10, 19. /צAuthor:Catherine A. Gower and Patti L. Lowery[G&TEXT Abstract: ws has covered the issue of fetal tissue transplants al B Part two of this article discusses three types of bone marrow 0:transplantation: allogeneic, syngeneic and autologous. A ent. Bdetailed explanation of the bone marrow transplantation procedure :>includes patient selection, pretreatment, marrow infusion and c s ave an HLA-matched sibling or @parent, and the odds of obtaining HLA-compatible marrow from an ndan=unrelated donor are slim. The National Marrow Donor Program ity C(NMDP) estimates that they range from 1 in 10,000 to 1 in 20,000. AFor these rne ne צb>system. These drugs affect the lymphocytes, inhibiting their ith e 7normal tendency to fight against "foreign" substances. ruses. s WBCs are produced or found in the bone marrow, lymph nodes, is  :A Only about 30-40% of patients hncreases. scrutiny. The British medical journal s WHITE BLOOD CELLS lled for a moratorium on the use of auto-res 24 < To reduce the chance that the donated marrow will react t and >against the patient, drugs may be used to suppress the immu a condition called graft-n &@versus-host disease (GVHD). It also is important to reduce the s and the recipient share any of these antigens. The chance of a 7success increasrs ٕAmarrow. Matching bone marrow is a much more complicated process =than is matching blood types. Matching is based on antigens or lis=found on cells. Scientists look at six markers called human ls o "Aleukocyte antigens (HLA), located on whe the two techniques so often linked? be much f C> An allogeneic graft comes from a sibling, a parent, or an ies 6Bunrelated donor. The success of an allogeneic transplant depends the type of disease and the availability transplantation may come from one of three s, TAsources. For an allogeneic transplant, the source of the marrow TexBis another person - usually the patient's sibling or parent - but N?unrelated donors may sometimes be used. Syngeneic transplants e types of bone marrow צtransplantation: allogeneic, syngeneic and autologous. A ent. n TYPES OF TRANSPLANTS of the bone marrow transplantation procedure includes patient selection, pretreatment, marrow infusion and " ? Bone marrow forBsupportive care for the patient. As medical technology advances, 9;many more people will be able to benefit from this form of ts l * treatment. justice. ril 1987. Pro-lifers' core objection to the TEX Part two of this article discusses threeasons, NMDP was created to improve the chance that a :patient will find a suitable donor. The NMDP coordinates ferent an @searches among donor and transplant centers throughout the U.S. ܕBand other countries. It receives requests for bone marrow donors 2@from transplant centers, searches a central computer file for a marrow transplantation are discussed later in this Report and f appropriate treatment option. The complications for 2 to 6% of WBCs. They play a key Verrole in phagocytosis, the process of clearing the body of such h ersdebris as dead cells and microscopic organisms (bacteria, sh, and &PATIENT SELECTION AND CONSENT ng-pot surroundings. He is burly A. dvances, the s es 8procedure is changing. Generally, however, bone marrow l such ts $Atransplantation will include these four steps: patient selection  ;and consent, pretreatment procedures, supportive care, and same infusion of the marrow. untMARROW TRANSPLANTATION PROCEDURE eign tissue, and cancer cells; they produce substances that regulate the immune response. tB The steps involved in a bone marrow transplantation vary from @one medical center to another. Also, as research alls in the patient's marrow are B e e P(:destroyed, it may be treated in a process called purging. troy ce K, foreign substances. It is thought that B cells mature in the ck (ambone marrow, but this has not been definitely established. T e &BONE The ld be צ=purpose of harvesting is to collect enough specialized cells t  :?(called stem cells) for engraftment to occur: All blood cells A(RBCs, WBCs, and platelets) develop from stem cells. To be sure =that any undetected cancer ce HLA matching is not necessary for autologous transplants, Bbecause patients receive their own marrow. The marrow is usually Bremoved, or harvested, when the cancer patient is in remission or ard;when cancer cells cannot be detected microscopically.etween 1 and 4% of WBCs and are ef ockAUTOLOGOUS TRANSPLANTS is and allergic and inflammatory use of er reactions. echanical loads involved and the range of motion led o  < In autologous BMT, the patient serves as his or her own not Bdonor. ent only 90.3% of all births (1 birth out of every 270), syngeneic ng WBCs. transplants are rare. le in allergic reactions. ical problem of ̂eusing the bodies of babies killed by induced abortion by instead - Eosinophils make up b TRANSPLANTS defense against bacterial invasion. They perform this function partially through phagocytosis (a process B Syngeneic transplants use bone marrow from an identical twin, V@a perfect HLA match. Given that identical twins represlso be helpful in locating bone marrow donors. ulation translates to about 40-50 million possible - Neutrophils are also known as polymorphonuclear ed but Vneutrophils (or "polys"). They comprise about 60% of circulating tedSYNGENEICent has been given >enough information to understand what the treatment involves, age Bincluding the risks, benefits, costs, and treatment alternatives. unable to fight them, doses of chemotherapy and radiation therapy @ Some specific questions that patients may want to ask their r 7physicians before signing the consent form(s) include: row heory damaged by treatment is replaced with healthy marrow. In gin to . *What are the benefits of this treatment? ow that is free of erapy and/or radiation carry =therapy. Side effects of chemotherapy and radiation include all. Supportive care is needed mainly to manage and lessen the d leukemia patient who is receiving an autologous or allogeneic r, Bgraft might receive a high dose of cyclophosphamide (Cytoxan) and ;total-body irradiation (TBI) to kill le a hollow silicone tube (similar to regular in 8intravenous tubing) that is intended for long-term use. p d two quickly. Chronic leukemia usually develops more slowly and may < Patients receive high-dose chemotherapy with or without y nples, and its use they ;decreases the need for repeated injections. Although some nto e ?catheters may have to be removed due to infection, most can be ed =kept in place for many months. Many medical centers use the et =Hickman catheter, @secured into one of the large veins in the chest. The catheter Ais used for giving blood products, antibiotics, and other drugs; @for nutritional support; and for transplanting the new marrow. t ;It can also be used to withdraw blood samnd platelets. researchers are transplanting n A Before actual transplantation, the patient undergoes several 9days of laboratory and diagnostic tests as well as other bbled e =procedures. An intravenous catheter is usually inserted and here to perform their te infection-fighting role, begin to fill the bone marrow and spill into the bloodstream. The "crowding" of the bone marrow with ers PRETREATMENT PROCEDURES s with the production of normal red and , white blood cells aLEUKEMIA o humans. Moreover, there is no analogy in organ t r & *Will I have to be far from home? ose" and "overdose": in n Leukemia is a cancer that arises in the blood-forming cells. $ *How often are checkups needed? , unable treatment cost? ilable treatment option r under certain circumstances. the underlying disease. omplex. ks ; *Will my insurance pay for this treatment? If not, is al in  financial help available? ansplants been done yet in the rom nable to work? , he treatment, this procedure is now a standard treatment option for 9 *What changes in normal activities will be required? eneral a use for a specific disease; it has been tested sufficiently that ' *How much will thdisease, either from a donor or from the patient after the marrow * *What are the risks and side effects? For example, some say that the newly transplanted cells will simply be destroyed by the < *How long will I be in the hospital and u loss usually begins 5 to 10 days after n, neck, and =chemotherapy. Patients often experience a temporary loss of us, appetite. nd bone marrow. Small amounts of lymphatic tissue are also found in other parts of the body, including the stomach, to B Destruction of the bone marrow (immunosuppression) leaves the Bbody unable to defend itself against infection. For this reason, Bthe patient usually is placed in a hospital room where it is easy =to take precautions to keep the rooogeneic bone marrow transplants each year, and the number of >autologous transplants is increasing steadily. If compatible by Bdonors were available, the number of allogeneic transplants could =increase to serve the 11,000 persons who, expertsRANSPLANTATION transplant in many a cases could be avoided altogether if scientists either knew how . B Bone marrow transplantation has become an established therapy Bin treating certain cancers. Currently, about 3,000 persons have @all used to l rs 6determine how well new marrow components are forming. t that the stimulation the brain receives when it receives the transplant t triggers the release of the brain's own healing chemicals. Some *THE FUTURE OF BONE MARROW Tftment usually occurs within 14 to 30 days following st big ?transplantation. Physicians evaluate results of various blood @tests to confirm that the marrow is growing and that cancer has g new WBCs, RBCs, and platelets, a process called engraftment. s. :Engragrams are 's Q. What are some of the technical questions which have been nt : Shortly after chemotherapy (with or without radiation s? d ly ?therapy) is completed, the patient receives the donated marrow ed >through the intravenous catheand other elements. aborted infant's pancreatic tissue, researchers place the "optimal age" much later, somewhere around the 16th week. rt of life." The victim's mother hardly moves. INFUSION OF THE MARROW e, cardiac transplantation proiven nutrients through the s being :intravenous catheter, a procedure called total parenteral n the Bnutrition (TPN). TPN is the intravenous infusion of a mixture of Aamino acids, glucose, fluid, vitamins, minerals, essential fatty acids, al weeks. @In addition, some treatment plans require a period of time when n 5the patient is not permitted to eat; this allows the issue is . =gastrointestinal tract to heal following chemotherapy. When hich :necessary, the patient can be gnfant after the abortion. ining younger, healthier ely A Adequate nutrition is another important supportive measure. AChemotherapy and radiation therapy often cause eating problems. BNausea and vomiting may make eating difficult for severucts given to transplantation ly Bpatients are treated with radiation to destroy lymphocytes in the Bdonated blood and prevent the risk of GVHD, which could be caused by those cells. when used with ultrasound, produces an intact in aborted i heart B Because chemotherapy and radiation also damage other parts of @the bone marrow, such as those that produce RBCs and platelets, . @the patient will need periodic transfusions to treat anemia and , ?thrombocytopenia. All blood prodme the patient's own marrow is destroyed until the she ?transplanted marrow produces enough white blood cells to fight n +infection, usually between 14 and 30 days. with certain types or stages of non-Hodgkin's and Hodgkin's lymphoma. rtificialm as free from infectious es, ?agents as possible. This is called protective isolation. The ly :patient is also given antibiotics to prevent and/or treat igh ?') Binfections. Protective isolation and antibiotic therapy continue >from the ti say, could in benefit from the procedure. nergy is spent on regulating to seem experiments and too little on tabulating and publicizing their ou ? The National Marrow Donor Program creates significant hope s. @that the number of available donors will increase. At the same Btime, researchers are making rapid progress to improve autologous =grafts by refining the methods used to cleanse the marrow of e cancer cells. till others are looking into using certain w novel crchers gathered last w צ?month at the Society for Neuroscience's annual meeting, Health n 8and Human Services Secretary Louis W. Sullivan extended n across Aindefinitely a ban on federally funded fetal tissue transplants.  Bone marrow forthe country." e for the patient. As medical technology advances, 9 As the ban on federally funded fetal tissue transplants is l *extended, many neuroscientists are responding with irritation and TEX@ The timing was ironic. As 12,000 reseacientists are responding with irritation and 0>ingenuity. The ban was extended by Health and Human Services r, @Secretary Sullivan who decided that "permitting the human fetal e :Aresearch at issue will increase the incidence of abortion across 1989, pp 378-379.  ? NIH Publication No. 90-1178, January 1990, pp 6-10, 19. /צ Abstract: k WeissA. Gower and Patti L. Lowery[G&TEXT? As the ban on federally funded fetal tissue transplants is al Bextended, many neuros* BYPASSING THE BAN (PART II) K S ,C:[.,' Rick Weiss December 9, 1989, pp 378-. @ Science News, Vol. 136, No. 24, December 9,permission of the National Institutes of Health. nce. The agency would then establish basic design and manufacturing criteria. A limited number of pilot control trials which the immune he n 0system's ability to function has been affected. of p until gs, experimentation to establish clinical usefulness. To enter this phase, a device would have to undergo rigorous laboratory ce ut addressed in current cancer clinical trials; others are still r @under study in the laboratory. Marrow transplant technology is l substances normally are produced by the body to help the bone our ;marrow cells develop, but they also can be produced in the eans Blaboratory. CSFs improve bone marrow's ability to produce normal cells. ced 1991 by permission of National Rigproteins that stimulate the growth and r Adevelopment of cells in the bone marrow. They may help to speed Brecovery after marrow grafting and prevent graft failure. Colony @stimulating factors (CSF) are one type of growth factor. These esponse modifier s @(BRM), is being studied for use before or after marrow grafting $to stop the growth of cancer cells. whether to permit an The A. As one researcher told NRL News, he sees no ethical s, show > Growth factors are hemicals produced by animals to treat human beings. d-looking at : Interferon, growth factors, radioactive isotopes, and irst n. Amonoclonal antibodies are currently under study as possible aids @in the BMT process. Interferon, a biological r transplantation may come from one of three s, TA The moratorium, which predominantly affects neuroscientists, Tex?forbids federal support for experimental transplants of tissue ut NBfrom intentionally aborted fetuses into humans. Continuing a ban Binitiated in March 1988 by the Reagan administration, it does not ܾBapply to transplants of animal fetal cells. Nor does it preclude @federal funds for transplanting human fetal cells into animals. the type of disease and the availability ng relegated to the status of scientific renegades. hey perform this function partially through phagocytosis (a process = "We really stuck our necks out," says D. Eugene Redmond, win, V>director of the neurobehavior laboratory at Yale Univerther delaying any conclusions e thing," says Jean R. Wrathall, a neur doubt nonfetal cells will ever match the orted gh Atherapeutic potential of fetal cells, this work stirs excitement among many researchers. of course, the HLA match is perfect. , Close relatives, especially brothers and sisters, are the nexesearchers at the Phoenix, AAriz., conference shared a wealth of data from novel experiments W@in animals - many involving transplants of nonfetal nerve cells (ʅ9that may someday find application in humans. While most e of a 9neuroscientistsrs ٕmarrow. Matching bone marrow is a much more complicated process A Although Sullivan's decision irritated many neuroscientists, lis@no one at the annual meeting expressed surprise. Indeed, as if o "Banticipating the extended moratorium, rtion across the country." The extended ban h f CAleaves many neuroscientists complaining that the national debate 6@about the morality of abortion is having too great an impact on s (the course of scientific investigation. es" the recipient's ng of a suitable donor. o-A Sullivan, rejecting the conclusions of a National Institutes =of Health advisory committee convened last year decided that rted @"permitting the human fetal research at issue will increase the e =incidence of aborsity. y ;Nine months after the initial funding ban, Redmond and his WBCs. >colleagues transplanted human fetal cells into the brain of a f ̂epreliminary results. For example, many presentations at this the Byear's neuroscience meeting focused on transpesent the first time a transplant of eir r ?genetically engineered cells has induced behavioral changes in y animals. y treatment is replaced with healthy marrow. In gin to *What are the benefits of this treatment? ow that is free of rats' symptoms by hadn't been a ban on fetal tissues," says Fred H. Gage of the se. t@University of California, San Diego. In neuroscience as in all m @areas of science, he says, "we're expanding our horlls in the patient's marrow are B e e P(< Economic and political problems aren't the only factors oy ce K, >prompting neuroscientists to seek alternatives to human fetal ck (amBcells. "The [funding] problems have in part stimulated people to Alook having be צAbetter things to do than go scrambling for private contributions  :Bfor their next fetal transplant, Redmond already sees researchers ;avoiding such experiments to escape the attendant hassles. sure that any undetected cancer ceons, lack of federal support may prevent Redmond's team s, biochemical support for neurons. Reports at the neuroscience s. Ameeting indicate that transplanted astrocyt point, says Gage, no one really knows whether fetal e ?cells can live up to their exalted promise. Ban or no ban, he n ?thinks researchers need to conduct more fetal cell transplants or Ainto animals - a procedure allowed under the moratorium -e uncontrollably, like us es, Acancerous tumors. "Some of these alternatives are going to have extreme liabilities." antibiotics to prevent and/or treat igh ?') infections. Protective isolation and antibiotic therapy continue @ At thish, to Destruction of the bone marrow (immunosuppression) leaves the = In contrast, Redmond notes, gene-altered fibroblasts and son, ;other engineered cells "are going to be extremely suspect" s easy :because of their potential to divid John R. Sladek in a review article in the Nov. 10 d ASCIENCE. "The benefits of studying fetal cells are many and the Bclinical potential for their use as therapeutic tools is just now being realized," they conclude. body, including the stomac lower or absent ation carry ?antigenicity eliminates the requirement of tissue matching and l. 6immunosuppression; and they are adaptable to the host h and ed de Aenvironment," write University of Rochester neurobiologists John @T. Hansen andrt SUPPORTIVE CARE stem. This system helps the body fight disease s @ Indeed, fetal cells today seem awash in scientific praise. A"Their ability to survive and multiply necessitates the grafting 6of only small numbers of cells; theirn cancer cells and healthy cells are destroyed, - ; Adds Gage: "It certainly is clear that fetal neuronal ot yet @transplants are more effective than any of the other cell types L at present." is a cancer of the lymphatic tissue, which is pafibroblast and engineering unimpeded, their value will remain an open question, Gage and ly >others contend. And the decision on whether to go ahead with the not elapsed to determine what are the outcomes of fetal brain te 6>tissue transplants conducted in Colorado and Connecticut as a n s 9treatment for Parkinson's. Elsewhere in the world, when 's ng ue, or fetal pancreatic Atissue and then transplanting it into the brain of patients with AParkinson's or in the abdomen of patients with diabetes. In our >country, the results have been, at best, mixed in the area of e e @pancreatic tissue ;in order to understand the role of these recommendations. es not ܾACurrently, fetal tissue transplants are taking place in the U.S. Aand in various nations around the world. For the most part, the Apractice involves taking fetal brain tiss Medical Committee on Ethics offers its ree s, T?imprimatur to fetal transplants in one article, while ethicist , TexAGeorge Annas and geneticist Dr. Sherman Elias go even further in N@a second separate "Sounding Board" essay. A quick rehashing is n? This article last w צ> The April 24 issue of the New England Journal of Medicine n n B(NEJM) offers two more heavyweight endorsements of the abominable :practice of ravaging body parts from aborted babies: The lants. ;Stanford University@contends the last thing we need is further inducement for women , 9!to exercise the abortion option. ing to fund fetal tissue s is l *transplants at the old level, expand the amount dedicated to this TEXwork, or get out of the business altogetherousand (or million) dollar question right nd 0:now is, Is the U.S. government going to fund fetal tissue ces r, Btransplants at the old level, expand the amount dedicated to this :;work, or get out of the business altogether? This article cross s, 89, pp 378-379.  ? 6 Vol. 16, No. 8, April 27, 1989, pp 2, 15. 0, 19. /צAbstract: k WeissA. Gower and Patti L. Lowery[G&TEXT Abstract: ban on federally funded fetal tissue transplants is al ? The sixty-four th; TURNING UP THE PRESSURE - FETAL TISSUE TRANSPLANTS ,C:[.,( Dave Andrusko l 27, 1989, pp 2, 15.78-. 0 National Right to Life Newand other elements. aborted infant's pancreatic tissue, iven nutrients through the s being >Reproduced 1991 with permission from SCIENCE NEWS, the weekly e Anewsmagazine of Science. Copyright (C) 1989 by Science Service, Inc. acids, glucose, fluid, vitamins, minerals, essential fatty acids, can't s. ?believe that patients with degenerative diseases are not up in n 9arms. It doesn't seem real. But then, I'm a scientist." e is . gastrointestinal tract to heal following chemotherapy. When hich necessary, the patient can be gnfant after the abortion. ining younger, healthier ely A "None of the reasons for the ban had anything to do with bad =science or good science or whether or not it's reasonable to s. >pursue this work on scientific grounds," Gage says. "Irs ٕ?researchers must or choose to provide backup for their claims, s @the outcomes have been uniformly disappointing with fetal brain lis transplants. annual meeting expressed surprise. Indeed, as if o "anticipating the extended moratorium, researchers at the Phoenix, ? The sixty-four thousand (or million) dollar question right s W:now is, Is the U.S. government going to fund fetal tissue cells (ʅBtransplants at the old level, expand the amount dedicated to this have. "In general, the cause of pply even a tiny fraction of the demand. At issue are @the 99.9% of elective abortions done for reasons unrelated to a an @direct threat to the mother's life and whether it is acceptable ܕ:to transplant the body parts of these babies. The ethicsr from situations where the r @mother aborts the baby to save the mother's own life. But even ndan>if everyone accepted the latter case (which is not the case), ty Awe're still talking about a handful of abortions which could not Bbegin to suics d צbBreported in NEJM are couched in cautionary language but come down e >with the usual positive recommendation. The ethics committee s >argues that virtually no one takes exception to using tissues s  :?from babies spontaneously aborted oe various steps to overrule or negate any e who l s #recommendation coming out of DHHS. imental transplants of human 4 fetal nerve cells into the brains of animals - experiments many d ? The observations of Stanford's Medical Committee on Eth the Department of Health n &Aand Human Services (DHHS). Whatever his recommendation, it will :be reviewed by Louis Sullivan, DHHS Secretary. The final e the "á@disposition would then await action by pro-life President Bush, " 7who could takdy צ Bon record as in favor of the transplants or very unlikely to have ʅ>serious objections. Although there were four dissenters, the om @panel's recommendation to go ahead is now apparently sitting on e ?an assistant secretary's desk over att of the business altogether? Last fall the ed gh from their own babies as to allow them to be aborted intact? to ?But, then again, why not, if the only question is getting some f nt of who knows y Ahow many patients? That we would be creating a new "demand" for the remains of dead babies? hers. These experiments, described . in the November Proceedings of the National Academy of Sciences y > And what does it tencreased by the use of fetal tissue transplant technology, there ?is nothing else to complicate our moral calculus? Is it of no ?significance that we would be integrating the slaughter of God e. ?knows how many babies into the medical managemease, would be the aborted baby] allows d Asome good to be salvaged from a death." Won't that affect women Bwho are ambivalent about aborting? Or, once "abuses" are curbed, @is it really true that, provided the number of abortions is not Biledge would have -8-=any marked effect" on their decision to abort, as the ethics r dismiss pro-life objections. Is it really true, for example, t 9that when women know of the availability of fetal tissue on the Btransplants, "it seems implausible that this knowcts of interest for physicians y a key Ver(abortionists). d notes that scientists have continued to perform ersexperimental transplants of politically noncontentious adrenal nd &B A few comments. As much as I read of proponents' thinking on ;thian decides to es @abort but before the abortion; can't let that tissue get cold. s $BAnd, to give their position the semblance of even-handedness, the  @authors conclude with a stronger recommendation than the ethics :committee's to avoid confli Bthe notion that abortion is such a permanent part of our everyday Our children will literally become nothing more than consumer ed Agoods, indistinguishable from everything else we purchase at the to offer the poor material incentives for abortion. It could s W@lead physicians to manipulate the timing and method of abortion (ʅ9to suit the transplant recipient. It might also provide to this 1incentives to cf ٕ;of science fiction. We can expect that the profound moral ms, s @dilemmas inherent in the use of human organs may be exacerbated lis?by the potential large-scale therapeutic use of fetal tissue. o "ACommercialization of fetal tissue could treatments for diabetes. Sufficient time has CB Current state and federal regulations are enacted principally 6Ato prevent exploitation of the fetus in biomedical research. At Athe time, therapeutic transplants of fetal tissue were the stufssful. Present organ-ic =transplant activity, which helps about 11,500 Americans each ith ;year, is a cottage industry compared with the fetal-tissue n our .transplant industry that is likely to emerge. in the area of e e pancreatic tissue =disease (1 million), Alzheimer's disease (2.5 to 3 million), not ܾAHungtington's disease (25,000), type I diabetes (60,000), stroke B(400,000) and spinal-cord injuries (several hundred thousand) may >be helped if these treatments prove succe and clinical trials are taking place in which T>fetal pancreatic cells are transplanted into adult diabetics. , TexGeorge Annas and geneticist Dr. Sherman Elias go even further in N> As many as 5 million Americans suffering from Parkinson's s nfrom aborted human t w צBfetuses to alleviate, perhaps cure, several crippling diseases of :the brain and central nervous system, such as Parkinson's minable =disease. Physicians have already transplanted kidneys and a ts. Bheart from a fetus,Abstract:the last thing we need is further inducement for women , 9 By denying the donor the organ's economic value, Congress l *@ Doctors are fairly confident that within the next few years s TEX>we will be able to transplant brain tissue organs from the realm of the market. ht nd 06Lamentably, human beings have in many respects become ngton's r, @commodities, and Congress has not succeeded in removing notions ; :5of economic value from the organ-procurement system. ticle cross r 1988, pp 61-63.  ? Author:Emanuel D. Thorne 8, April 27, 1989, pp 2, 15. 0, 19. /צ Abstract: k WeissA. Gower and Patti L. Lowery[G&TEXT> By denying the donor the organ's economic value, Congress al opponents, who fear that the medical use of fetal tissue will om ?legitimate what to them is an abhorrent practice, and those in e >the prochoice community who oppose ano right to the value of his tissue since he did nothing to Bcreate or add to its value. This argument has been advanced in a t:case pending in California. A patient there is suing his all m Bphysician for the economic value of his spleen, whiation is the primary motivation for e P(Blimiting property rights to human tissue, but other moral reasons K, >have been offered. For example, commercial developers of the ck (amBhuman body, such as pharmaceutical companies, argue that a person @has nrgans, they צ=retain the right to donate; and nobody has the right to take some :their organs from them. eded, Annas and Elias opt for "careful rs research" in a "few centers of established excellence." s. sure A Revulsion at commercializad led all 50 states and Congress to adopt legislation s, Alimiting property rights to human tissue. The most important is Bthe 1984 National Organ Transplant Act, which barred all sales of ardAhuman organs. Thus, while people cannot sell their oaw for regulating fetal tissue f ock2from our attempts to regulate other human tissue? pontaneous f er abortions; they see such tissue as more likely to be abnormal d o  > Moral repugnance at commercial exploitation of human body h >parts hannot be tissue. What lessons can we drte trade in human tissue derives not from a failure of Bmarkets to provide the necessary tissue but, rather, from a moral ;revulsion at the commodification of human beings. However .." n, V@repugnant the idea, the human body now has value that ca death that makes organs or e ? The ethical and economic issues associated with regulating s @human tissue are inextricably enmeshed, yet the economic issues o VBdraw little attention. This is not surprising. The primary urge ted@to regularnment, 2Parkinson's disease and diabetes lobbies) weigh in with their y d =views, the politics of the debate will change significantlyy restraint on a woman's n &Brights regarding her body. Some prochoice supporters resist this