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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
JAMA Forum

When the First Person With Quadriplegia Walks Again

On January 7, 2013, the US Supreme Court refused to reviewSherley v Sebelius, a 3-year-old legal challenge to the federal funding of human embryonic stem cell (hESC) research. In so doing, the Court ended a long-running legal feud while reempowering the National Institutes of Health (NIH) to fund peer-reviewed meritorious research using NIH-sanctioned hESC cell lines.

Eli Adashi, MD, MS

Although a legal battle over hESC research may have been settled, the same cannot be said for the attendant war. Indeed, the ethical debate surrounding hESC studies is all but guaranteed to continue. With no obvious end in sight, what it would take to put this divisive national exchange behind us? I would argue that medical breakthroughs combined with a dose of compassionate pragmatism are important arbitrators of such an ethical logjam.

The issues at hand in bioethical debates typically aren’t static. Instead, such debates have frequently been shown to evolve to a point of resolution. Although the nature of this self-sorting and conciliatory property of the public discourse remains enigmatic, against all odds, seemingly irreconcilable ethical quandaries ultimately have found clarity, even in the thorny arena of reproductive ethics.

Debate Over Oral Contraceptives

For example, the use of combination oral contraceptives was neither routine nor legal a meager 50 years ago. Indeed, although the US Food and Drug Administration approved the first combination (norethynodrel and mestranol) oral contraceptive preparation on June 23, 1960, contraceptives were not available to married women in all states until the Supreme Court ruled in Griswold v Connecticutin favor of plaintiffs who were challenging a Connecticut law that prohibited the use of contraceptives. Notwithstanding the central role of social justice, the growing recognition of reproductive rights, and the surging feminist movement in swaying opinion, there is no doubt that medical innovation replete with compassionate pragmatism were also instrumental in settling the debate.

The evolution of the ethical debate over in vitro fertilization (IVF), a feat recognized by the 2010 Nobel Prize in Physiology and Medicine, is an all-but-forgotten example of the allied power of medical innovation and compassionate pragmatism in resolving such a debate. Indeed, the pioneering efforts to develop this technology were the subject of intense ethical deliberations that pitted faith against secularism and orthodoxy against heterodoxy. The notion of a “test tube baby” was hardly welcome; even the British Medical Research Council saw fit to express “serious doubts” about the “implantation in women of oocytes fertilized in vitro.

All that changed with the birth of Louise Joy Brown on July 25, 1978, the first baby born as a result of IVF, an event seen as a turning point in the treatment of infertility. In offering hope to millions of couples who had been unable to have children, the approach could finally be seen as a family-building pro-life tool.

The acceptance of IVF, the conquest of the tangible over the ephemeral, compellingly illustrates the combined power of a key medical advance and compassionate pragmatism in ending an otherwise intractable ethical conflagration. Without this potent combination, the debate might still be raging.

Waiting for a Game Changer

By all accounts, the ethical challenges raised by the use of federal funds to support hESC research are following a similar trajectory. Absent a major therapeutic breakthrough, there is every reason to believe that the attendant controversy will continue unabated in the political and legal arenas. As the ideologically divergent executive orders by Presidents Bush (in 2001) and Obama (in 2009) over public funding of hESC research have demonstrated, such federal support of hESC research is likely to remain administration-dependent. And if past experience is any indication, future legal challenges are likely in the wings. That said, there is every reason to believe that the successful application of regenerative medicine would change all that.

Imagine, for example, the game-changing effect of the first successful repair of a severed spinal cord. When the first person with quadriplegia walks again, further debates on the ethics and public funding of hESC research would appear counterproductive, if not (for a large segment of the population) pointless. A similar outcome would likely follow the successful reversal of Parkinson disease by replenishing the brain with functional dopamine-producing neurons.

Whatever the precise nature of such a major therapeutic advance emerging from hESC research, recognition of its lifesaving and life-sustaining properties is bound to change the outlook on this field of investigation. To underestimate the potential of a breakthrough to end an ethical impasse is to misjudge the healing potential of compassionate pragmatism.

About the author: Eli Y. Adashi, MD, MS (Eli_Adashi@brown.edu) is Professor of Medical Science at the Warren Alpert Medical School of Brown University in Providence, RI. A member of the Institute of Medicine, the Council on Foreign Relations, the Association of American Physicians, and the American Association for the Advancement of Science, Dr Adashi has focused his writing on domestic and global health policy at the nexus of medicine, law, and ethics. A former Franklin fellow, Dr Adashi served as a senior advisor on Global Women’s Health to the Secretary of State office of Global Women’s Issues during the Obama Administration.