Thanks to scientific and medical progress, the average life expectancy of a person in North America is 80 years and increasing. But in sub-Saharan Africa, the average lifespan is half that figure, and dropping. Technology is often said to have made the world a much smaller place, so how can those of us fortunate enough to be in the developed world help close that shocking life expectancy gap? That question, according to the University of Toronto’s Peter Singer, is “the mother of all ethical challenges.”

Singer, a professor of medicine and an internationally-renowned expert on bioethics, returned Wednesday to the University of Chicago, the school where he studied medical ethics 22 years ago. And boy did we put him to work, asking him to deliver the opening speeches for two separate but related launches: this year’s MacLean Center for Clinical Medical Ethics seminar series, and the school’s new Global Health Initiative. In both lectures, Singer drew from vast experience in facilitating efforts to improve health in Africa, India, China and other areas of the developing world, offering valuable advice for what doctors, scientists, and universities could do to help such efforts.

It’s nice to think that simply sending doctors and the fruits of scientific research to needy countries would solve these problems, but as Singer explained, there are several obstacles to merely hoping public health will spread around the globe by osmosis. Singer showed this Nature Review Immunology figure from 2002, which illustrates how developing countries lag behind in vaccinations given to children despite the development of vaccines for more diseases. Lack of scientific discovery relevant to the developing world, ethical and social barriers and a “brain drain” of scientific talent from Africa and Asia have all contributed to these inequalities, Singer said.

But Singer also gave reasons for optimism. In 2003, The Bill and Melinda Gates Foundation (for which Singer serves as an advisor), issued their Grand Challenges in Global Health, funding vaccine research and efforts to limit diseases spread by insects - scientific questions more pressing to to poor countries. Six years later, those projects are already bearing fruit, such as the effort to infuse staple crops of poor populations with nutrients, the creation of genetically modified mosquitos that don’t spread malaria or the combination of several vaccines into a single injection. 

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Last Friday the Obama administration published its new guidelines for federal funding of embryonic stem-cell research, ending the Bush-era restrictions on that work.

Except they didn’t end all of the restrictions. The new rules do not allow for work on cells made via research cloning (somatic cell nuclear transfer), and they require an informed consent process that may exclude some cell lines already derived with different consent procedures. Advocates at both antipodes of the stem-cell debate found something to criticize in the Obama rules. Researcher Irv Weissman of Stanford said the rules maintain an “ideological barrier” that will hinder progress, while Douglas Johnson of the National Right to Life Committee said the guidelines herald “an incremental strategy to desensitize the public to the concept of killing human embryos for research purposes.”

For now Obama seems to have struck an ideological balance, and some conservatives are giving him credit for it. Yuval Levin, a former Bush bioethics adviser who recently appeared on this blog, wrote on Friday that the new guidelines “certainly could have been worse” from a conservative’s perspective.

At the same time, the new rules mean that federally funded research can move beyond 2001-era technology. Bush’s guidelines, which restricted funds to lines derived before August 2001, allowed researchers to work with just 21 cell lines. Obama’s rules open the door to hundreds of additional lines created since 2001, many of them with genetic defects that can help scientists understand how diseases develop.

In moral terms this may even be a clearer approach than Bush’s policy, which claimed to protect nascent life but did allow some funding of research that required the destruction of human embryos. Those rules allowed fewer stem-cell lines to qualify for funding, yet the restriction was based on an arbitrary cut-off date. Why was it moral to allow funding of research on stem cells taken before August 8, 2001, but beyond the pale to allow funds for cells taken after that date?

Levin, who also served as executive director of the President’s Council on Bioethics, wrote that by keeping some limits on stem-cell research funding, Obama’s NIH has conceded “that the destruction of embryos for research is not an innocent and unproblematic practice, but must be constrained for ethical reasons.” So far, so good. As the bioethicist Art Caplan once told me in an interview, “A human embryo may not be a legally protected person, but it’s also not just any old stuff.” Levin then goes further: “These rules raise the question of why limits are necessary, and any serious answer to that question would lead us to conclude that these rules are inadequate. ”

That’s not at all clear to me. Under Bush’s old rules, an embryo’s fate might depend solely on the date when it was created. Under Obama’s new rules, the embryo’s fate is governed by something far less arbitrary - the parents’ intentions, informed by all the options available to them. It seems reasonable to trust that whatever parents decide, they will see their embryos as something more than raw material.

[Note: This post originally contained a quotation from a private classroom setting, which has been removed at the speaker's request.]

Neuroblastoma patients recently got some of the best research news they’ve had in a while - but the news wasn’t perfect for everyone.

Word of the advance came in an announcement last month from the national Children’s Oncology Group. A Phase III trial of an antibody-based treatment for neuroblastoma (protocol ANBL0032) had found that the treatment significantly increased patients’ chances of survival. The trial was immediately halted - standard procedure in cases where a trial is so successful that it would be unethical to deny patients the treatment.

The antibody treatment yielded a striking survival gain of about 20 percent for children with the deadly form of cancer. Neuroblastoma researchers such as Susan Cohn, M.D., were elated.

“This is as successful a story as we’ve had in neuroblastoma treatment in many, many years,” Cohn told me in a recent interview. “We hope to be able to incorporate this as part of our standard approach.”

The protocol is on hold to study toxicity issues that arose in some patients, but experts hope the treatment will be available soon for more patients. The March 19 statement from COG concluded, “We now expect that this immunotherapy may eventually become a standard part of high-risk neuroblastoma treatment after stem-cell transplant.”

So what’s the downside? It’s simply the nature of such clinical trials, in which not everyone can get the superior treatment.

Patients are randomized at the start of a trial like this one; some get the new treatment, some get the standard, established protocol. Some families opt out altogether. No one knows at the outset whether the new protocol will be better, the same or perhaps worse than the existing treatment.

But it’s clear now that in this case, patients who got the new protocol stood a markedly better chance of surviving their cancer than those who stayed with the old form of treatment. A 20 percent improvement is no guarantee, of course; some patients on the new protocol died, and many who got the existing treatment did fine. Yet an outcome like this can raise a tantalizing “what-if” question in the minds of some parents. Might a child have had a better chance at survival if randomization had placed him or her in the new treatment group? What about parents who may feel guilt over not taking part in a trial that could have improved their child’s outcome?

Such doubts may be impossible to resolve. It’s difficult to imagine replacing randomized trials as the gold standard for gathering scientific evidence that a treatment works.

“You just never know until you do the study,” Cohn said. “We are so grateful to the families who are willing to participate in these trials.”

The Washington Post reported this afternoon that President Obama plans to lift the Bush-era restrictions on stem-cell research funding via executive order on Monday. Now comes the hard part - implementing a stem-cell policy that’s meaningful, has full ethical protections and unlocks the scientific talent that’s been held back the last eight years.

One insider point to watch on Monday is whether someone from the National Institutes of Health will help explain the new funding channels for this research. It’s a question of some urgency. Just this week, the NIH released a set of “challenge grant” topics that are eligible for a pool of $200 million as part of the new federal economic stimulus act. The NIH site describes the qualifying projects as those which “address specific scientific and health research challenges in biomedical and behavioral research that will benefit from significant 2-year jumpstart funds.” Embryonic stem-cell research would seem a natural fit - especially since the Bush administration held it back for years - but it’s not clear yet that Obama’s rule change has come in time for stem-cell grant seekers to get a share of the stimulus money. That’s one reason why Obama’s delay in announcing changes to the stem-cell policy was a bit puzzling. Many observers - including me - expected him to lift the restrictions his first week in office.

Around research centers like the University of Chicago, stem-cell scientists are poring over such details. I just spoke with John Cunningham, M.D., a specialist in pediatric stem-cell transplantation, who directed me to the brand-new NIH list of “Highest Priority Challenge Topics.” (You can see a more researcher-oriented application guide here.) Stem-cell research is on the list, but not specifically the embryonic stem-cell research that’s been subject to Bush’s limits. I count five topics that relate to iPS cells - short for induced pluripotent stem cells - which were discovered in 2007 and seem to have many of the properties of embryonic stem cells but are derived from adult cells. That’s fantastic because iPS cells deserve more study. But embryonic stem-cell research never appears by name, except to say that “iPS cells act like embryonic stem cells.”

This is an important point because as Cunningham said, “One of the things that lifting the current ban should allow us to do is really test whether iPS cells and embryonic stem cells have similar properties.” In theory the current challenge grant list could include work with embryonic stem cells, since some of the topics are broad enough to encompass work with several different cell types. For example, Topic 11, “Regenerative Medicine,” contains a broad opportunity to “Develop cell-based therapies for cardiovascular, lung, and blood diseases.” That could cover some work with embryonic stem cells, as could some of the items under the general category of stem cells.

But none of this is set in stone. What the president says on Monday may signal whether broader embryonic stem-cell funding will begin with the stimulus package, or whether scientists - and patients - will have to wait longer to start seeing more progress. Stay tuned.

UPDATE: Here’s a take on the news in an e-mail from embryonic stem-cell researcher and friend of the blog George Q. Daley, M.D., of the Harvard Stem Cell Institute and Children’s Hospital Boston: “I am brimful of hope and excitement about the announcement on Monday. I’ll be there, and I expect Obama to lift the restrictions and usher in a whole new era of scientific openness and opportunity for stem cell research. The future looks bright indeed for stem cell research.”

Will Saletan of Slate gave this new blog a very gracious shout-out yesterday - many thanks. He also replied to my earlier post taking Will to task a bit about “designer dogs.” I’d suggested that dog breeding is a bad analogy to bring home the problems of genetic trait selection in humans, because the former is so familiar and non-threatening. Will replied that he used a familiar example on purpose, and wondered what other analogies might work better.

To answer that, it helps to think a bit about what’s troubling in the first place about genetic trait selection for people. Breeding dogs with 25-year-old frozen sperm from a former champion doesn’t quite get at what disturbs me about human trait selection. Some people already have done a version of the dog trick with the now-defunct “Nobel Prize sperm bank” - the moral equivalent of breeding a former dog show champion. The Nobel bank was creepy, but it remained something of a fringe practice, even though it offered an easy route to instant eugenics.

One reason it stayed a fringe phenomenon may have been the lack of control prospective parents had over the outcome. You couldn’t really be sure your Nobel offspring would be an Einstein, and the child might lack good looks and social graces altogether. The Nobel bank may have boosted the odds that your child would have the desired traits, but it still relied on old-fashioned, largely unsupervised egg-sperm unions.

Pre-implantation screening of traits gets you more control, and that kind of control is what worries me most. Babies should be a little surprising - as in, “Whoa, red hair! Where did that come from? Loves art - who knew?” Having a child has always meant opening yourself up to something new and unpredictable. But meticulously screening out the traits you don’t want would bring a level of control that the Nobel bank never offered.

Maybe gambling is a better analogy for the problem than designer dogs. Reproduction the old way amounted to an honest roll of the dice. Now the dice could be loaded to prevent novelty.

That idea doesn’t make me sick - sorry, Will - but it does violate my parental sense of fair play. And if children lose their power to surprise, it will drain a bit of wonder from the world.

William Saletan of Slate has a nice piece this week warning of recent developments that could bring genetically selected “designer babies” a step closer to reality. He begins by noting that the idea is so shopworn that he’d stopped taking it seriously - me, too. Then he goes on to list some studies and changing practices by certain fertility clinics that could be a prelude to selection for traits such as gender, eye color and hair color. None of the news items he mentions is scary on its own, but as a group they suggest something troubling is in the air.

Or that’s what I thought, until I read Will’s post the next day on “designer dogs.” Dogs are basically a designer species - living, drooling examples of eugenics in action. Without thousands of years of artificial selection by humans, dogs as we know them wouldn’t exist. To Will’s mind, dogs are “an ecologically reckless genetic experiment.”

He’s being a little facetious, but just a little. The piece goes on to lament the origins of this year’s winner of the Westminster Kennel Club dog show - a poodle conceived with frozen semen from a former champion dog. That use of standard reproductive technology to make the dead poodle a dad again proves too much - “I want to throw up,” Saletan writes.

Leon Kass has praised the “wisdom of repugnance” in thinking about bioethics, but in this case repugnance seems more silly than wise. Dog breeders have been using frozen sperm since the 1960s. As bioethical dilemmas go, it’s a Brave Old World.

Saletan wants to use dog breeding as an analogy for designer babies, but it may be hopelessly flawed for that purpose because it’s so familiar. Such comfortable examples are of little help in imagining how awful genetic trait selection in human babies would be.