Thoughts on NUBC: Learning What It Means to "Do" Bioethics

By: Dr. Tiffany Cvrkel

A few weeks ago a group of my undergrad students and I returned from our very first National Undergraduate Bioethics Conference (NUBC). I thought I’d write down a few thoughts about our experiences, and (hopefully) make a case for why attending this conference is a uniquely worthwhile experience.

We have a pretty thriving group of undergraduate bioethicists at UCLA. Most are pre-med students who do independent research in bioethics as a compliment to their intensive lab work and hard science curriculum. They are a passionate (and inspiring!) bunch, and they are always looking for ways to connect with their peers at other institutions.

And that’s the story of how they – not me, their faculty mentor! – found out about NUBC. As they were browsing this “Bioethx Under 25” blog, they found a listing for a conference aimed especially at them. I got an email pitching a trip to Chicago.

It was fitting start. While faculty members are involved in the orchestration of NUBC, much of it is run by undergrads for undergrads. A few of my students decided to submit papers to the conference, and Jessica Kriksciun (one of our seniors) had her paper accepted. They also decided to form a Bioethics Bowl team and compete during the tournament. None of us had any idea what a “Bioethics Bowl” looked like, but it sounded like a decent way to spend a Saturday.

If you’ve never been to a NUBC before, you should know it is an odd marriage of two very different events. The first is the conference itself, run in a mostly traditional way -- paper presentations along with brief Q&As. The second is a tournament event called the “Bioethics Bowl,” where student teams compete by giving well developed/supported arguments and objections regarding bioethics cases. The team with the better arguments wins.

I’ll give you a few moments here to quip about competitive bioethics. Many of my colleagues found this whole set-up an endless source of hilarity. And to be honest, I was a little wary. Some of my colleagues were worried that this kind of thing just reinforces combative relationships between bioethicists – a problematic dynamic that already exists in some places of our discipline. It’s hard enough to work in a cross-discipline space. Shouldn’t we all be trying to get along, not score points against each other?

I had another, slightly different worry. When I paged through the cases that the Bioethics Bowl would be using, I noticed the “ripped from the headlines” format. But the fact that these are real cases involving real people adds an additional burden for our students. I am close with some of the ethicists who worked on one of the cases in this year’s packet. I saw first-hand the devastation and anguish that this case caused for everyone involved. I feared real people’s stories might be turned into nothing more than rhetoric-laden debate fodder, cheapened to score points.

I am not against debate as an intellectual exercise. I was on my school’s debate team as a student, and once upon a time, I coached it. But the goals of debate are not always to find the most subtle, respectful, and nuanced lines of reasoning. The people from these cases? They deserve nothing less.

And when the Bioethics Bowl came around, there was indeed some debate-style rhetoric and hyperbole. But happily, this was not the norm. Most of the teams we saw weren’t trying to be cut-throat in point scoring. They were trying to work through the issues in genuine and sincere ways. There was a lot of “we agree with our opponents on their position, but we’d like to raise an issue that might have been overlooked” kind of dialogue – the kind of dialogue that happens in professional ethics committee meetings. And with a few exceptions, my students left each round feeling like they both made new friends and got to practice articulating true, difficult positions.

But the Bioethics Bowl – by far – was not the highlight of the conference, which you would never know by looking at the attendance numbers. It quickly became clear that there are also two demographics at NUBC, the people who were there for the conference and the people who were there only for the Bioethics Bowl. And the vast majority of people fell into the second category.

This was such a shame. The conference part of the NUBC was amazing. Sitting around the breakfast table before a day of presentations, all of us huddled together, the following conversation happened. One of my students asked, “Um, Dr. Cvrkel? What kinds of questions should we ask the presenters? I’ve been to lots of conferences where I’m not really supposed to ask questions, and this is the first time I’ve been at a conference where I’m the intended audience! What does a good question look like?”

And that’s when we discussed the difference between being a student and being a colleague. We talked about the art of asking useful and supportive questions instead of “gotchas.” We talked about when follow-up questions are appropriate and when they’re not. We talked about how to approach someone to discuss related projects. We talked about how to do bioethics in the real world.

I teach two large lecture classes every quarter; that’s hundreds of students, multiple times a year. And while I try to teach each of my students some of the finer points of bioethics, the famous authors, the important arguments, I can never offer them the experience of doing bioethics with their peers. We always have a power differential in traditional learning environments, and this means students never get to practice wielding their knowledge as equals. But at NUBC, they present their ideas not as students looking for approval, but as scholars looking to advance an idea. And they sit in the audience not merely to learn, but to engage.

The NUBC has been the one environment where my students experienced what it is like to be bioethicists. And that’s not easy to teach. But of all the things I’ve tried to teach my students, I can’t think of any that are more valuable.

The folks at Loyola University of Chicago put on a wonderful conference, and though it was our first, it won’t be our last. We’ll be in Florida for NUBC 2015—you should join us.

Dr. Tiffany Cvrkel is a philosopher, bioethicist, and lecturer in UCLA’s Molecular, Cell, & Developmental Biology department. She is also the faculty adviser for UCLA’s Undergraduate Bioethics Club (aka: The Bioethics Brigade) and runs the UCLA Bioethics Lab, where students do advanced/independent bioethics research.

Timbre at Death: Fragments on End of Life Care

By: Mohini Banerjee

This post is a small collection of impressions and quotes, hopefully prompting us to ruminate and reflect on the end-of-life.

“Nothing that you do in science is guaranteed to result in benefits for mankind. Any discovery, I believe, is morally neutral and it can be turned wither to constructive ends or destructive ends. That’s not the fault of science.”—Arthur W. Galston Quoted in an obituary piece for the New York Times.

Last week I attended an informal lunch discussion around the circumstances of a “good” death. In full bioethics form, we discussed the voluntary stopping of eating and drinking and physician assisted suicide. However, within ten minutes the discussion turned to music—that is, what would you want to hear when you go? I’ve never considered that question. It seemed oddly specific, macabre, and perhaps a little too eager. The scholars I conversed with seemed more comfortable discussing various likes and dislikes (certainly no Vivaldi), and I suggested my own favorite, Holst’s “Jupiter”. We talked about music and how Pete Seeger died with his friends and family singing in his hospital room. Persons and lovely harmonies seemed to soothe the often painful experience of dying. Some around the table discussed personal experiences, family or others, and the decisions taken towards the end-- meant to provide for oneself, while trying hardest to protect ones left behind. Their understanding of loss was completely enveloped in an ethical discourse on agency and patients’ needs.

“In quixotically trying to conquer death doctors all too frequently do no good for their patients’ “ease” but at the same time they do harm instead by prolonging and even magnifying patients’ disease.” 

― Jack Kevorkian, Prescription: Medicide: The Goodness of Planned Death 

Which words we choose around hastening death are particularly important since “euthanasia”, “physician assisted suicide”, “death with dignity”, “aid in dying”, “suicide”, “voluntary stopping”, "palliation", and “no extraordinary measures” are only some of the terms that contain their own emotional valences and particular historical backgrounds. Often this language gets conflated, bringing about both confusion and some misunderstanding. Some, for instance, would object to my inclusion of a quote by Dr. Kevorkian given the potential harm in including his ideas into any “reasonable” discussion on aid in dying. I agree that the mistaken assumption that aid in dying means euthanasia is harmful to a movement towards choices at the end of life. However, if we’re considering values at the time of death then our discussion should consider the reasoning of those who advocate for marginal positions.

“With terminal illness, your fate is sealed. Morally, we’re more comfortable with a situation where you don’t cause death, but you hasten it. We think that’s a bright line.” –Arthur L. Caplan Quoted in “True Freedom” Time Magazine.   

As a society we may want to be thinking more about the music and people we want in the room than the particular medical intervention that would make us most comfortable. We may not want to think of this at all. A melody chosen in the midst of a hypothetical conversation only signals our hope for a certain mood, however distant and contrived. Death, on the other hand, is uncomfortable both in actuality and in how we refuse to acknowledge its reality. Discussing medical decision-making at the end forces a contemplation of physical and mental anguish, but considering our soundtrack does not. In that potential future we are free of pain. And, whatever fear of the unknown we began with is pacified. We simply surrender to the trumpets blaring, drowning out the likely beeping machines. 

Mohini graduated from Smith College in May 2013 and is a research assistant at The Hastings Center, an independent non-profit research institute in bioethics. She founded Bioethx Under 25 in January and acts as Editor in Chief. For interest in the blog please email her at bioethicsunder25@gmail.com.

Hobby Lobby and its Hypocrisy: Religious Demands on Others and Investment in Contraception

By Naomi Scheinerman 

Last week, the US Supreme Court heard oral arguments from Hobby Lobby (a chain of craft stores) and Conestoga Wood (a cabinetry company) who both claim religious exemptions from the Patient Protection and Affordable Care Act (ACA) contraception coverage. A recent story from Mother Jones reveals that Hobby Lobby has actually “spent millions of dollars on an employee retirement plan that invested in the manufacturers of the same contraception products the firm’s owners cite in their law suit.” In addition, the company also provided insurance plans to its employees that covered the very contraception they now reject for years before the ACA mandate required it. Although this information may not be crucial for the Court in its decision making, these revealed factors call into question the veracity and legitimacy of Hobby Lobby’s religious objection alongside considerations of justice and ethics in potentially granting an exemption.

For example, one concern is whether the Court should consider arguments based on faulty scientific claims. Hobby Lobby argues that they have no moral objection to the use of the majority of the contraceptives required in the mandate and will continue to cover access to these. Rather, they object to the copper and hormonal intrauterine devices (IUDs) and Plan B and Ella, “emergency” contraception taken after intercourse. Hobby Lobby claims that because these prevent a fertilized egg from implanting in the uterus, they function as abortions. Hobby Lobby is sadly not alone in erroneously labeling Plan B and Ella as so-called “abortion pills,” when in fact they do not terminate pregnancy because they work before pregnancy begins. Even if Hobby Lobby has a valid religious objection to abortions, they are fallaciously applying it to this case.

Legally, the Court has also been asked whether corporations can even claim religious exemptions. Hobby Lobby has Christian owners, but its employees are not exclusively Christian and therefore it is hard to define it as a distinct Christian corporation. Although the Court has ruled that corporations operate as individuals in terms of campaign finance laws, it has yet to extend this argument to other realms. This brings me to one of the most pressing questions: Does claiming religious exemption actually impose a religious ruling on others? Though Hobby Lobby claims it does not want to be imposed upon, its attempts to deny coverage of IUDs, Plan B, and Ella impose on its employees because they may have no moral objection to accessing these forms of birth control.

Further, when do religious exemptions to health coverage end? At what point should we consider right of access to be absolute and religious exemptions as inferior claims because they overshadow a more pressing moral concern in society? Can Hobby Lobby claim objections to vaccinations? Cancer treatments? Kidney transplants? Some religious groups do, and the Court would be quite quick to throw out those cases as extreme and an overt denial of rights of access. Hobby Lobby’s claims against IUDs, Plan B, and Ella are not so different. Emergency contraception can be vital for a woman who was raped or just wants the freedom to live a life without a child imposed upon her. Research has shown that unintentional pregnancies are linked with delayed prenatal care, low birth weight, maternal depression, prevention of education and jobs otherwise accessible to the mother, and family violence. These are good health reasons to offer the access and claim any denial of access as an abuse of religious arguments and an imposition on others’ freedoms from religion.

Naomi Scheinerman is a Research Assistant at The Hastings Center. She graduated Phi Beta Kappa, with high honors and in distinction from the University of Michigan in Ann Arbor, where she received bachelor’s degrees in philosophy, political science, and Hebrew and Jewish Cultural Studies. She contributes a bi-weekly column on reproductive health.

@BioethxChat: Let Your Voice Be Heard

By: Jennifer Chevinsky

Bioethics is a field that should matter to everyone.  Whether you are a bioethicist, healthcare professional, student, patient, or member of the general public, you will encounter topics such as organ donation, body image, and end of life care. You will have decisions to make when you walk into your healthcare provider’s office, whether you choose to follow a treatment plan, or refuse traditional medicine.  Ethical questions are not always easy or straightforward, but having an opportunity to join with individuals from different fields and with varying levels of expertise can encourage a broader understanding of a multitude of aspects that alone, one may not have considered.

                               

BioethxChat is a live tweetchat account, started in October of 2013 by @jchevinsky to reach an interdisciplinary group of students, professionals, and members of the general public. Live chats are hosted every Monday at 8:30PM EST, and cover a large range of disciplines, but specifically focus on the intersection of science and ethics.  The chat has gained a reputation of asking ‘the hard questions,’ and encouraging open, honest, and respectful discourse.  The goal of each chat is to unpack the ethical aspects of a number of complicated topics within a particular theme, helping individuals to reach better-informed positions.

In the short time that BioethxChat has existed, ‘#Bioethx’ has been called “one of the ‘alwaystrending’ influential hashtags in healthcare on Twitter,” and was also included in George Washington University Masters in Health Administration’s list of “Top 5 Twitter Chats for Health Administrators.” With the verification of the ‘Bioethx’ hashtag and addition to Symplur’s Healthcare Hashtag project, individuals can access transcripts, analytics, and other data about the chat for free.

Additionally, the chat has been a great platform to join with experts and activists to discuss important ethical issues.  For example, BioethxChat joined with the Death with Dignity National Center to bring forth a discussion on ‘A Dignified Death.’ Other topics that have been covered include ‘Sexuality and Gender,’ ‘Disability Ethics: Autonomy, Rights, andDignity,’ and ‘Domestic Violence.’ The BioethxChat website includes a full list of topics that have been covered, along with their associated transcripts, and helpful resources.

Bioethxchat will consider hosting a chat on any topic related to the broad field of bioethics, and supports the submission of topic suggestions from anyone with a passion for open, respectful dialogue. One of our most recent chats focused on ‘Professionalismand Conflicts of Interest in Healthcare,’ a topic suggested by two of our followers, who served as guest co-hosts for the chat. Among the other questions on our list, we discussed the connection between professionalism and ethics, as well as the complications of financial associations between pharmaceutical companies and healthcare providers.  The chat encourages references to foundational cases, current situations in the media, as well as personal encounters or experiences.

Social media, and Twitter in particular, has the power to unite individuals from across the world for a live, spirited conversation. Bioethxchat uses this medium to further its goal of making bioethics more accessible and inclusive, recognizing that while everyone has a perspective, not everyone is given a voice.

Let your voice be heard and join the #bioethx community this Monday at 8:30PM EST!

Jennifer Chevinsky is a medical student at the University of South Florida Morsani College of Medicine SELECT, a collaborative program with the Lehigh Valley Health Network.  She is the Chair of the American Medical Association’s Medical Student Section (AMA-MSS) Committee on Bioethics and Humanities, as well as the Chair of the American Society for Bioethics and Humanities Student Affinity Group. She is the creator and moderator of @BioethxChat (#Bioethx).

Mitochondrial Donation: Why the Controversy?

By: Michelle Bayefsky

Late last month, the Cellular, Tissue, and Gene Therapies Advisory Committee of the Food and Drug Administration (FDA) met to consider whether research on mitochondrial donation, which could be used to prevent women from passing on mitochondrial disease to their children, was ready to begin testing in humans.  Instead of excitement at the prospect of eradicating mitochondrial disease, which can cause blindness, dementia, epilepsy, and many other conditions, much of the public reaction was characterized by fear, confusion, and hostility.  Headlines from “Genetically Modified Babies” to “Tinkering with Frankenstein: Obama Admin Considers Three-Parent Embryos” flooded the internet, and scientists and bioethicists struggled to refocus attention on the medical feat that is close to being achieved.[1]

Mitochondrial donation involves either transferring healthy mitochondria from a donor into the egg of an affected woman, or inserting the pronuclei of two prospective parents into an enucleated donor egg.[2]  Since mitochondria carry their own DNA and are maternally inherited, children born after mitochondrial donation will technically have DNA from three people – hence the nickname “three-parent IVF” given to the procedure by the press.  This nickname is misleading, however.  The degree to which genetic parentage should be considered synonymous with parentage has already been questioned in debates regarding egg and sperm donation, surrogacy, and adoption.  “Three-parent IVF” suggests a complicated family situation which would be not at all necessary; if social and legal norms have been successfully established for donating gametes containing nuclear DNA to couples with infertility, surely the same could be accomplished with donating mitochondrial DNA.  Furthermore, it seems highly unlikely that we would come to view the donor of mitochondria, an organelle about which most members of the public have little knowledge, as a parent on equal footing with the parents who contribute nuclear DNA and/or intend to raise the resulting child.

Aside from the question of parentage, the major source of controversy surrounding mitochondrial donation is the fact that the technique constitutes a germline modification; the donated mitochondrial DNA would be passed down from generation to generation.  Previously, a line has been drawn (in law, in some countries) between gene therapies that treat problems in somatic cells, like muscular disorders, and modifications that are heritable.  Though mitochondrial donation is aimed at preventing disease, some worry that it will open the door to other types of germline modifications and the creation of ‘designer babies.’  These concerns are misplaced for two reasons.

First, it is unclear why the somatic-germ cell distinction in gene therapy should be our primary criterion rather than a distinction between healing and enhancing.  If our problem with the creation of designer babies – which, given the current state of reproductive medicine, embryology, and genetics is a very long way off – has something to do with satisfying petty parental preferences, we should focus our efforts on preventing the use of powerful reproductive procedures for insufficiently serious purposes.  We should debate what counts as the prevention of a serious genetic condition and what counts as enhancement, not ban germline modifications that are aimed at eradicating disease and reducing suffering.

A second reason that the emphasis on germline modification is misplaced is that technology is already available to select, if not modify, embryo’s genes.  Pre-implantation genetic diagnosis (PGD) is a technique that is used to test embryo’s genes during in vitro fertilization, before deciding which embryos to transfer into the woman’s uterus.  PGD can be used to select against serious heritable diseases, but it can also be used to select for sex, milder disabilities such as deafness or dwarfism, and children who can serve as tissue donors for sick siblings.  The US has no laws or regulations on the acceptable usage of PGD, and elective sex selection is relatively common.[3]  It seems inconsistent to object to the use of mitochondrial donation to prevent serious diseases when a technique that uses selection, rather than modification, to choose non-medical characteristics of future generations is currently unregulated and in use.

Finally, if we decide that the germline criterion must continue to be respected, even when using genetic modification to prevent disease, we could require that mitochondrial donation only be used to create male embryos.  We could use sperm sorting to select male sperm which would be combined with a female pronuclei and an enucleated egg with healthy mitochondria.  Since mitochondria are inherited maternally, if only males are created, the mitochondrial DNA would not be passed on to the next generation.  Though many people find sex selection objectionable, there is precedent for performing sex selection for medical purposes.  For example, PGD is sometimes used to select female embryos to avoid passing on X-linked disorders.

It is understandable that new developments at the intersection of reproductive medicine and genetic technology raise concerns about our attitudes towards future generations, especially given the history of eugenics.  However, we should regard mitochondrial donation for what it is – a tool designed to allow mothers suffering from mitochondrial disorders to have children to whom they are genetically related – rather than focusing on potential future abuses in the general area of genetics and fertility.  Though it is important to exercise caution in the modification of heritable genes, the distinction between healing and enhancing should be our primary criterion for deciding what techniques are ethical and permissible.

Michelle Bayefsky is a senior at Yale University, where she was elected to Phi Beta Kappa and founded and serves as Editor-in-Chief of the Yale Bioethics Journal.  After working as a research assistant at the Yale Interdisciplinary Center for Bioethics for over two years, she will graduate in May with a B.A. in Ethics, Politics and Economics.

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[1] Last week, the UK’s Human Fertilisation and Embryology Authority, the governmental body responsible for regulating reproductive medical care, released draft guidelines that would permit mitochondrial donation in humans. Children of mitochondrial donation could be born in the UK as early as next year. See Telegraph article here.

[2] Lewis, Ricki. "FDA Considers Mitochondrial DNA Replacement." Medscape Medical News. Medscape, 26 Feb. 2014. Web. 09 Mar. 2014. <http://www.medscape.com/viewarticle/821115>.

[3] Ginsburg, Elizabeth S., Valerie L. Baker, Catherine Racowsky, Ethan Wantman, James Goldfarb, and Judy E. Stern. "Use of Preimplantation Genetic Diagnosis and Preimplantation Genetic Screening in the United States: A Society for Assisted Reproductive Technology Writing Group Paper." Fertility and Sterility 96.4 (2011): 865-68.

4 Months 3 Weeks and 2 Days

By: Ty Bourgoise

This is part of a series on films and other media relevant to bioethics. Like recommendations, these reviews are here to help you find intelligent media you may or may not have heard of. So anything I review here, you can assume, bears my endorsement--go see it, read it, enjoy, and think.

Ceausescu-era Romania is grey, blue, and lit everywhere by the special effect of halfway burnt out bulbs. In the dimness, women throughout Gabita and Otilia’s dorm are concerned with how they look; judging by the number of cosmetics trading hands, beauty is one of those few freedoms an oppressed Romanian woman is allowed. A sane abortion, however, is one they aren’t.

In Christian Mungiu’s Palme d’Or winning film, 4 Months 3 Weeks and 2 Days, we see the extent to which they aren’t, and more. Very much more. The basic premise, though, is that Gabita, who needs an abortion, recruits her smarter and more practical roommate, Otilia, to handle the logistics. What unfolds is focused less on Gabita than Otilia. The result is something more thrilling and horrific than the best thrillers and horrors.

Because abortion is highly illegal, Otilia and Gabita have to make the latter’s a secret. In fact, for the first 35 minutes of the film there isn’t a peep of it. Otilia runs around, paranoid, collects money, doesn’t book a hotel room, books one, sneaks into it, and there haggles with exactly whom you’d expect to sell illegal abortions in 80s Romania: burly, enterprising, and charmless, a one “Mr. Bebe”, with his tools in a briefcase he does not want touched. A hotel bedroom is both his surgical and trading floor. Though, from the look on his, Gabita, and Otilia’s faces, you’d think this was a contract kill. This comparison might even overplay the apparent legitimacy of the procedure.

To “contract kill”, however, is the right comparison. Ceausescu’s regime was notably Orwellian with its conviction that aborting a fetus and murdering a person are morally equivalent. The acts are both relegated to the black market. But, in an odd scene, Otilia buys (presumably taxless) cigarettes from a random black marketer loitering in a hotel lobby. No one complains. Generally, it seems, everyone must tacitly trade in the illegitimate, only no one is willing to discuss or sympathize over this common misfortune. Such is the world that’s unsympathetic to Gabita and Otilia: it is inconsistent, and thereby amplifies the sense of possibility (and terror) that can be used to exploit these women. We know that their and Mr. Bebe’s punishment, if caught, would be draconian and arbitrary. 

After a nightmarish compromise, the success of the Gabita’s procedure is not the end of anyone’s troubles. Foil #2, after Mr. Bebe, is Otilia’s boyfriend, Adi—kind of attractive, kind of a jerk. After the lengths of secrecy we’ve seen Otilia and Gabita go, we’re nervous to see how he’ll react to Otilia’s news (Unwittingly, he partially funded Gabita’s abortion.). What actually happens, while perhaps not insane—he’s plain-vanilla clueless—makes the movie more interesting. We take his misunderstanding as a relief: well at least he didn’t flip out. But what a low bar for a support system! It’s not that Adi wants to call the cops, like others in Romania we presume would. He wants to fix Otilia’s anxiety; he just barely knows how to. “What if you needed [an abortion],” he says parroting Otilia’s question, “but it won’t happen to us!”

His misguided support causes us to wonder at Otilia’s interior state. Just because the Ceacescu has a clear stance on abortions, that doesn’t mean women receiving them have the space to process what they mean. Gabita wants to finish college; Otilia wants Gabita to be able to do so. But when it comes to the fetus itself—what is it? How does the intelligent Otilia comprehend her friend’s situation? After it’s done, Gabita tells Otilia she “got rid of it […] It’s in the bathroom.” From Otilia’s eyes we see that hump of cellular mass, unceremoniously thrown onto a towel in a trash bag on the bathroom floor. The fuller the picture gets, the less Otilia seems to know what she’s seeing. Or she’s horrified by what she sees. Or both, we don’t know: she doesn’t get an opportunity to express her feelings with anyone. Just silence.

The need to be silent is a force in these women’s lives, complicating what’s already complicated. Of note is that the movie has no soundtrack. Silence prevents Otilia from expressing frustration at one of her boyfriend’s family’s bougie dinner party. At said offensively aloof dinner party, Otilia, silently, endures a barrage of classist slights at her background. Silence is even in the very last scene, as Otilia finds Gabita, no longer in shock, treating herself to a platter from a wedding party in the hotel lobby: breaded brains, marrow, liver, and other charcuterie that blurs the reality between offal and delicacy, mirroring the person/thing distinctions that befall a fetus. We can see Otilia wanting to say something, but she’s so misunderstood from all angles, why would she? Intimacy, compassion and understanding seem like such far off longings.

Mungiu is happy to employ twisted ironies to ask questions of law, women’s rights, and biology. You’ll have to watch his movie to find answers, which are bound to be controversial. Though he’s clearly aghast of totalitarianism and exploitation, Mungiu is not merely, I believe, depicting a fight between good and evil. In that way, 4M3W2D doesn’t tie a bow on the morality of abortion. It just views it through x-ray vision.

As an American, I am struck by how easy it is to see 80s Romania as being like where I live. Romanian communism has traces of metaphor for how the US turns a moral and cultural blindeye on women who need abortions. Even in liberal states where abortionists are not murdered, women who opt for the procedure are stigmatized to the point of emotional isolation. But things can be worse, right? In some states, it’s been the path of least political resistance to forfeit women’s rights through legislation, pushing them into other states or just away; out of sight, out of…. Such spaces for women in those states are ripe for, 4M3W2D shows, horrific exploitation. So, best be abstinent, the logic goes, or act like nothing’s wrong. After all, who’s to blame for an unwanted pregnancy but you? Certainly you have no right to be upset about it.

Ok. Well. Mungiu gives Mr. Bebe a great metaphor to condense this attitude. “If the probe comes out, we’re done,” he harps in his medical instructions to Gabita. “You cannot move under any circumstances”. Don’t move. Don’t squirm, don’t cry, don’t cope. Barely express, but preferably don’t at all. Gabita may wail and yelp and nearly fail on all counts, but Otilia “performs,” disturbingly well. 

Ty Bourgoise is a writer living in New York.

Occupy Womb

By Naomi Scheinerman

Sweden is the first and only country to complete not just one, but nine, uterine transplants. The women were either born without a uterus or had it removed because of cervical cancer and received wombs donated from relatives. The ultimate goal, of course, is to become pregnant and now four of those women have also had embryos transferred into their new wombs (through IVF). The womb transplants are meant to be temporary i.e. they will be removed after birth. The discussions surrounding these procedures invoke a number of important ethical and philosophical questions related to the goals of medicine, resource allocation, and procreation.

One of the main concerns surrounds the ethicality of purposeful risk to the wombs’ donors, recipients, and occupants (the fetuses). In other words, absent a valid medical reason, can risk ever be ethically permissible? Further, are these procedures legitimate uses of medical resources in light of the risks? The recipients must take drugs and be monitored closely throughout their pregnancy to ensure that their bodies do not reject the uterus. It is also relatively unknown how a fetus will fare in a transplanted womb and in its future life.

Calculations of risk entail weighing the relevant options. In the case of medicine, risky surgeries are usually only conducted if the alternative (not having the surgery) is even riskier (such as a bone marrow transplant for a cancer patient). Thus, in the case of a well-functioning, decently healthy individual (such as the women in Sweden), engaging in a significant surgery, and putting relatives through an intensive surgery as well, seems to carry avoidable risks.

Another way to frame this concern: are womb transplants medically necessary or enhancing? Medically necessary procedures are those that save the individual’s life, such as a heart transplant or a blood transfusion. Medical enhancements are not crucial to an individual’s life but make it better, such as a cochlear device for a deaf person or LASIK eye surgery to correct imperfect vision. However, the distinction between a medical necessity and enhancement is often difficult to defend and can crumble upon further scrutiny. Often, procedures we think of as enhancing dramatically “save” one’s emotional life which itself is morally significant enough to legitimize the procedure. For example, a face transplant for a burn victim is not medically necessary in the sense that the burn victim could survive without it, but can be socially necessary for future happiness and success. The implications of this distinction are important because we tend to allocate our scarce medical resources for medical necessities and view enhancements as illegitimate uses of these resources. And yet, we can concurrently make the case that enhancements do some significant medical good. For a woman who desperately wants to be pregnant the distinction between necessity and enhancement begins to collapse.

My final concern, which most powerfully objects to womb transplantation, is whether it is a healthy model of procreation in today’s society. In a world filled with opportunities for sperm and egg donation, surrogacy, and now womb transplants, I worry that there is an undo emphasis placed on the desire for a genetic connection with one’s offspring. I have no doubt that it is a miraculous thing to be pregnant and create a new life using one’s own genetic material, and perhaps also the genetic material of one’s partner. However, I worry when that is the most important desire for a family. Instead we should focus on building healthy relationships with one’s child and finding a home for children worldwide. I worry that womb transplants and IVF can and do detract from what’s important about procreation and place undo emphasis on carrying to term and having a genetic relationship with one’s child.

Naomi Scheinerman is a Research Assistant at The Hastings Center. She graduated Phi Beta Kappa, with high honors and in distinction from the University of Michigan in Ann Arbor, where she received bachelor’s degrees in philosophy, political science, and Hebrew and Jewish Cultural Studies. She contributes a bi-weekly column on reproductive health.