Until recently, such patients did not receive transplants at all because doctors worried that their health was too compromised. Now they can get transplants, but organ-donor waiting lists are long. And for Mr. Aldridge, 45, and other H.I.V. patients, a potential source of kidneys and livers is off limits, because it is illegal to transplant organs from donors who test positive for the virus — even to others who test positive.

But federal health officials and other experts are calling for repeal of the provision that bans such transplants, a 23-year-old amendment to the National Organ Transplant Act.

“The clock is ticking more quickly for those who are H.I.V.-positive,” said Dr. Dorry Segev, transplant surgery director of clinical research at Johns Hopkins and a co-author of a new study indicating that 500 to 600 H.I.V.-infected livers and kidneys would become available each year if the law were changed. “We have a huge organ shortage. Every H.I.V.-infected one we use is a new organ that takes one more person off the list.”

The ban on transplanting organs from people with the virus that causes AIDS was passed at the height of the AIDS scare in 1988, when infection with the virus was considered a death sentence. But now many people with H.I.V. are living long enough to suffer kidney and liver problems, adding to the demand for organs.

This has led some health authorities to say that H.I.V.-infected organs should be available for transplant, primarily for patients infected with the virus but also potentially for some who are not.

The federal Centers for Disease Control and Prevention and other health agencies are about to issue new guidelines that will encourage a first step: research involving transplanting H.I.V.-positive organs into H.I.V.-positive people. That would require the transplant ban to be lifted.

“We would like to see as many safe transplants occurring as possible, and there’s no reason why H.I.V.-positive recipients shouldn’t get transplants and that H.I.V.-positive donors can’t be used,” said Dr. Matthew Kuehnert, who directs the C.D.C.’s Office of Blood, Organ and Other Tissue Safety.

“I could see someone saying: ‘That’s horrible. Why would you want to transplant H.I.V.?’ ”he said. “They don’t understand. Anyone who understands transplant today, in the current era, understands the need.”

The H.I.V. Medicine Association, a professional group, just issued a similar statement, calling for “changing federal law on H.I.V.-infected organ donation.” Its chairwoman, Dr. Kathleen Squires, said her organization and other medical groups would lobby Congress this year.

Until recent years, H.I.V.-positive patients were not given transplants because of concerns that the virus could destabilize transplanted organs or that the immunosuppressive drugs used in transplants might make the virus more dangerous.

But a large clinical trial found that results in H.I.V.-positive recipients are “just as good as H.I.V.-negative patients, more or less,” said the study’s leader, Dr. Peter Stock, a transplant surgeon at University of California, San Francisco. “Our kidney patients do slightly worse than the general population of transplant patients, but better than kidney transplant patients over 65.”

Last year, at least 179 H.I.V-positive people received kidneys or livers, up from 9 in 2000.

Allowing H.I.V.-positive organs to be used would create an additional supply when some 110,000 Americans are awaiting transplants. They often wait years, and sometimes are too sick when organs become available to benefit from them.

There are concerns, even among some supporters of changing the law.

“People I know in the gay community are very split on it,” said Michael Bauer, 45, of Iowa City, who became H.I.V.-positive two years ago and will probably need a liver transplant in coming years. “There’s the concept that having an H.I.V-positive donor could actually be more damaging. You could have a donor who has a tougher strain of H.I.V.”

Doctors say this and other risks could probably be managed by screening out the sickest donors and recipients. And for patients like Mr. Bauer, the risks may be worth it.

“I can get slapped on a list for a healthy liver, but there’s a whole slew of people ahead of me,” he said. “I don’t want to be excluded from options.”

Others fear that H.I.V.-infected organs could be transplanted by mistake. While extremely rare, such errors have occurred.

In Chicago in 2007, four recipients were infected by organs from a single dead donor; the body had tested negative, but the test was administered too early, before the virus could be detected. In 2009 a kidney recipient in New York was infected from a living donor, who tested negative, then had unprotected sex and became infected in the 79 days before the transplant. That case prompted the federal disease centers to issue stricter testing recommendations this year, and Dr. Kuehnert said the new guidelines would address ways to make transplants even safer.

Not all the consequences of transplants involving H.I.V. patients are understood yet. Dr. Stock’s patients, for example, were two to three times as likely as other recipients to begin rejecting their healthy donated kidneys. More immunosuppressive drugs helped them adjust, he said, but the donated kidneys may wear out sooner, necessitating additional transplants.

The only known transplants involving H.I.V-positive donors and recipients, conducted in South Africa, have so far been successful.

There, with H.I.V. widespread, Dr. Elmi Muller, a Cape Town surgeon, performed four transplants in 2008 — “instead of wasting these kidneys, throwing them literally in the bin,” she said. After word got around, she said, some people questioned “whether it was the right thing to do.”

Dr. Muller stopped while ethics committees reviewed the question, and she ultimately obtained approval. Of 10 patients she has transplanted, only one has experienced rejection problems. About 50 are on a waiting list.

In the United States, patients with hepatitis C, a disease many H.I.V-positive patients also have, are now living with organs from donors with hepatitis C.

In 2004, Illinois passed a law allowing transplant of H.I.V-positive organs, and “our hope was maybe other states will pick this up,” said Dr. Michael Abecassis of Northwestern Memorial Hospital in Chicago. But federal transplant law supersedes the state one.

If such transplants are allowed, they will most likely start with clinical trials, and most organs will come from deceased donors; living donors are at risk for liver and kidney problems themselves. Most recipients would probably be H.I.V-positive because “we don’t really know what would happen to someone with non-H.I.V. status,” Dr. Abecassis said.

But some experts, including Dr. Segev and Dr. Kuehnert, say they can foresee such transplants even for H.I.V.-negative patients because contracting H.I.V. would be preferable to kidney or liver failure.

“I don’t want to minimize living with H.I.V, but it is a medically treatable disease now,” said Charlie Alexander, president of the United Network for Organ Sharing, which manages the country’s organ transplant system. “In certain cases, I think it would be medically appropriate.”

Mr. Aldridge, the Los Angeles patient, who has been H.I.V.-positive for 25 years, says he would certainly consider an infected kidney.

“There’s a stigma about transplanting us to begin with, with some people saying why should an organ be quote unquote wasted on us,” he said. “So if we can help each other it would make things much better for us. If I need a kidney transplant to survive, then so be it.”

Kidney transplants, for example, have a greater chance of success when the donor and recipient are as genetically similar as possible. But historically, organ donations from minority groups lagged far behind the need. Surveys have identified a number of reasons — including lack of awareness of the need for donor organs, distrust of the medical establishment, and a belief that their religion disapproves of organ donation (although most religions have no rules against donation).

In the 1990s, the National Minority Organ Tissue Transplant Education Program (MOTTEP) was launched to raise awareness of the need for minority organ donors. And the effort seems to be paying off, according to the new study, led by MOTTEP founder Dr. Clive Callender, a transplant surgeon at Howard University in Washington, D.C.

Using data from the United Network for Organ Sharing (UNOS), Dr. Callender and colleagues found that between 1990 and 2008, minority donation percentages in the U.S. went from 15% to 30% percent.

The rate of African-American donors more than doubled during those same years — from 22 to 53 per million. Meanwhile, the rates among Hispanics rose from 23 to 50 per million, and those of Asians climbed from 10 to 35 per million.

The findings are published in the May issue of the Journal of the American College of Surgeons.

MOTTEP runs media campaigns and works with various local organizations, including schools and social, civic and religious groups, to raise awareness of the need for organ donors. It also educates minorities on how to lower their risk of developing kidney disease.

The current findings suggest that the programs are having an impact, according to Dr. Callender’s team.

Along with the UNOS data, the researchers studied survey data from nearly 6,800 12- to 18-year-olds who have taken part in MOTTEP programs. As a group, the teenagers showed significant shifts in their understanding of kidney failure, organ and tissue donation, and their plans for becoming donor in the future.

Despite the progress, however, donor-organ shortages remain the number-one problem in organ transplantation. According to UNOS, more than 107,000 Americans are on the national waiting list for organ transplants, with about 85,000 waiting for donor kidneys. As of late 2009, minority group members accounted for 61% percent of the renal transplant waiting list.

http://www.journalacs.org/article/S1072-7515(10)00122-5/abstract

Lockhart pointed out that the Centers for Disease Control and Prevention (CDC) lists criteria [1] for people with increased risk of infection that could be transmitted if their organs are transplanted and who should therefore be excluded from donating regardless of their HIV-antibody status, “unless the risk to the recipient of not performing the transplant is deemed to be greater than the risk of HIV transmission and disease.” In such exceptions, recipients should give informed consent.

The list includes IV-drug abusers, prostitutes of either sex, and anyone who has had sexual contact with either group or with anyone with “known or suspected HIV-infected blood” or “inmates of correctional systems,” among others, as being high-risk for organ donation. But it doesn’t include people who are homeless, Lockhart noted.

Yet there is evidence that “the homeless may be at increased risk for infection because of their general poor health, with lowered immunity and poor living conditions and hygiene,” she said. Many homeless people “may also be immigrants from other parts of the world with endemic diseases. Organ donation from homeless donors may pose a risk to transmit these infections,” according to Lockhart. “Further study with a larger number of patients is needed to confirm whether homelessness should be added to the CDC high-risk organ-donation category.”

Dr Duane Davis

As the featured discussant for Lockhart’s presentation, Dr Duane Davis (Duke University, Durham, NC) was skeptical of the conclusions, given the study’s retrospective nature, the small number of homeless donors, and other reasons: “I think we need to put this into a broader philosophical [perspective]. Currently we use only 25% of organ donors as heart donors, so looking for an excuse not to transplant probably isn’t the direction we really want to be going in. We want to figure out how we’re going to be able to use all hearts that could be beneficial to other patients.”

To that end, Davis said, and considering the study’s limited evidence that infections in the recipients came from the homeless donors, an analysis that looked for significant predictors of recipient mortality might have been better.

Lockhart responded to heartwire , “I agree that we shouldn’t decrease our donor population and we already have a shortage of donors. But we also have a lot of donors who come from endemic areas where [coccidioidomycosis] is prevalent, Chagas’ [disease] is prevalent, West Nile virus is prevalent. This may be an emerging phenomenon–that we’re starting to see these transmissions more and more. So we really want to make sure we monitor the donors very carefully.”

Currently we use only 25% of organ donors as heart donors, so looking for an excuse not to transplant probably isn’t the direction we really want to be going in.

She and her colleagues had looked at 295 adult heart recipients at her center over five years, of whom 10 received hearts from donors that had been classified as homeless by the organ-procurement organization (OPO). Those 10 were similar to the 285 others with respect to donor and recipient age, sex, ischemic time, and other factors that can influence graft survival.

Survival declined gradually and consistently among the nonhomeless-donor group over three years, but it dropped precipitously during the first six months for those who received homeless-donor hearts. All five deaths in the latter group, three from infection and two from rejection, occurred within nine months of transplantation (p<0.001).

Recipient mortality from infection was significantly increased among those getting homeless-donor hearts, 50% vs 16% for those getting nonhomeless-donor hearts; there were no significant differences in death from rejection, vasculopathy, or multisystem organ failure.

Outcomes of Transplant Recipients With Hearts From Homeless vs Nonhomeless Donors

Only one of the three fatal infections could be firmly attributed to donor-heart transmission. One heart recipient died of coccidioidomycosis within one month of transplantation, “which was retrospectively identified in the donor,” Lockhart said. In neither of the two other infection-related deaths, one from pneumonia associated with a vancomycin-resistant Enterococcus and the other from Escherichia coli urosepsis, could the infection be traced to the donor.

The two other recipients of homeless-donor hearts died from the consequences of rejection but showed no evidence of infection.

Since only one of the homeless-donor recipient deaths could be attributed to “donor consequences,” the analysis doesn’t really show that infections from homeless heart donors cause an increase in recipient mortality, according to Davis. “We really should be very cautious and try to identify whether this is a true relationship or if this just happens to be a statistical phenomenon.”

But he said the study does raise the question of whether more can be done at the OPO level to screen for such infections, “so you can initiate appropriate prophylactic therapies.”

Certainly there are blood tests for infections, Lockhart said to heartwire , “but often they’re not back by the time we actually implant the organ; it may be a retrospective finding.”

Currently, potential heart recipients are told whether the donors were IV drug abusers or prostitutes, “but we do not have to disclose that they were homeless, living on the street,” she said. “I think the patients do have some rights to know what kind of donor [the heart is from].”

Neither Lockhart nor Davis had disclosures.

References

The scientists did not clone the pigs – instead they adapted a procedure used in mice and human stem cell researchand were able to grow a specific kind of cell, induced pluripotent stem cells, or IPS cells.

Pluripotent stem cells have the ability to turn into any cell in the body. IPS cells were first developed about five years ago by Shinya Yamanaka, who used four genes to coax a regular mouse cell into acting like an embryo. Creating stem cells with this method is less controversial than harvesting them from an embryo, which destroys the fertilized egg in the process.

According to Dr. Steve Stice, director of the University of Georgia Regenerative Bioscience Center, his team took a bone marrow cell from a pig and injected six new genes, which caused it turn into an embryo-like cell.  Pluripotent stem cells were harvested from this embryo-like cell and injected in another pig embryo. 

The first piglets carrying these new stem cells were born September 3, 2009. 

So far human embryonic stem cell research has not actually found its way into the human body.  Most of the research is still in mice.  But mice aren’t the best animal models to get more accurate data on how a treatment may affect a person.  For example, mice hearts beat four times faster than a human heart and mice don’t get atherosclerosis (clogged arteries) – but pigs do.  That’s why pigs are much better animal models says Stice. “Physiologically, pigs are much closer to a human,” he says.

The researchers also found that unlike mouse embryonic stem cells, which can turn into cancer cells, none of the pigs developed any signs of tumors.

But it has been very difficult to harvest embryonic pluripotent stem cells from pigs. Stice credits his research assistant Franklin West with finding a way to make the existing IPS technology work in pigs.  

Now researchers hope to find many different applications for these new pig stem cells and the pigs they can produce.  They are already working with scientists at Emory University to develop insulin-producing pancreatic islet cells, which might be transplanted into people with diabetes.

Stice thinks this new method can also be used to genetically engineer healthier livestock for other tissue transplants and food consumption. He suggests these stem cells may someday be used to make “artificial bacon,” which would eliminate the need to slaughter pigs.

The research will be published in the online journal “Stem Cell and Development.”

A consultation being run by the independent Nuffield Council on Bioethics is canvassing opinions from the public and professionals on different incentives which could be provided to potential donors. 

Ethicists will examine whether laws prohibiting the collection of eggs and organs from dead people should be eased.

Medical experts have suggested that organ donors might also have their funeral expenses paid or jump the queue if they need a transplant themselves.

Last year about 3,500 transplant operations were carried out in the UK, but 8,000 patients are waiting for organs.

The promotion, which has been described by some as a raffle, has sparked an ethical debate in Britain about whether women should be paid for their eggs — which is illegal in the European Union, but not in the United States.

The Genetics and IVF Institute held a free educational seminar for British couples on Wednesday. Of the participants, one will win a treatment cycle for donated in-vitro fertilization, to produce eggs. The prize is not based on a paid raffle.

In a statement, the clinic said its egg donors are college-educated women between 19 and 32. In the U.S., women are routinely paid from $10,000 to $35,000 or more for their eggs.

In Britain, women cannot be paid for their eggs and can only be compensated for their travel expenses and time off work; that cannot exceed more than 250 pounds (USD $384) per treatment cycle. To donate eggs, a woman must undergo a monthlong treatment that involves injecting herself with hormones and then undergoing a surgical procedure to retrieve the eggs.

Because the donated eggs — which may result from paying a woman for treatment — will happen in the U.S., the clinic is not technically breaking any British laws. But experts slammed the event as a publicity stunt.

“There’s something shocking in the association of a raffle and giving away a human product,” said Dr. Francoise Shenfield, a fertility and medical ethics expert at University College London. “In Europe, we have the general idea that altruism is a good thing and we don’t want to turn human body parts into a commodity.”

Shenfield, who has studied how many Europeans go abroad for infertility treatment, said it was impossible to know how many Britons were going to the U.S., since they are not obliged to report it. Many Europeans commonly seek treatment elsewhere to get around loopholes in their own country, like the number of eggs that can be retrieved or implanted, how much donors can be paid, and who is eligible to be treated.

Britain’s Human Fertilisation and Embryology Authority, which regulates fertility treatment, said the U.S. clinic’s raffle was inappropriate. “It trivializes altruistic donation,” the agency said, and runs contrary to the regulations that exist “to protect the dignity of donors and recipients.”

Trina Leonard, a spokeswoman for the Genetics and IVF Institute in Fairfax, Virginia, said the U.S. clinic was simply offering a seminar in London commonly held in the U.S.

“They’re not raffling off a human egg,” she said. Leonard said one person who comes to the seminar who wants to pursue a donated egg is given a free treatment cycle. She said the giveaway was promotional to introduce “new options” for people hoping to start a family.

She said the winner would be picked randomly, not according to need because that would be too complicated. The clinic has been giving away donor cycles valued at more than $10,000 for about a year, she said. Far more egg donors are available in the U.S. than in Britain.

According to the European Union’s Tissues and Cells Directive, donors may only be paid for their inconvenience. But the figure varies across the continent. In Spain, women can receive up to about euro900 (about $1,200) for donating eggs.

Allan Pacey, a fertility expert at the University of Sheffield, said the British supply of donated eggs might be increased if women received more money for their time. “To donate an egg, you’re really inconvenienced, and 250 pounds barely scratches the surface,” he said.

Some women weren’t sure if offering more money for eggs was a good idea.

Rhiannon Prytherch, 28, an actress and theatre manager in Darby, England, said even if she was offered money, she would not sell her eggs. “It doesn’t feel like a commodity that should be profitable,” she said. “I could never charge someone for that.”

But Prytherch said she might feel differently if she were the one needing eggs. “If I were a woman who wanted to have a child, I would be willing to pay.”

Pacey said the U.S. clinic’s approach risked turning human eggs into a commercialized product. “Having a lottery (to get eggs) is not how we do things in this country,” Pacey said.

Associated Press Writers Brett Zongker in Washington, DC and Chonel LaPorte in London contributed to this report.

Copyright © 2010 The Associated Press. All rights reserved.

What if you got $10,000 for your trouble? $100,000? Or more?

With 106,131 Americans now on waiting lists for an organ – 83,754 of them for kidneys – researchers at the University of Pennsylvania and the Philadelphia VA Medical Center sought to find out whether financial incentives would increase living organ donation.

Their findings – that payments would draw more participants without relying disproportionately on poor people – are highly controversial. Several ethicists yesterday criticized the study.

Still, the issue is of huge interest locally. The Philadelphia region has nine transplant centers, including seven for adults, and Pennsylvania ranks second nationally in the number of organs transplanted, behind California.

The idea of paying donors for organs has long been taboo because of concerns that it would unduly influence some people – particularly the poorest – to donate without fully appreciating the risks.

Scott Halpern, a Penn doctor and senior fellow at the school’s Center for Bioethics, and colleagues surveyed 342 rail and trolley commuters in Philadelphia and its suburbs to see how money would change their willingness to donate.

“We were surprised to find that, contrary to what a lot of ethicists were concerned about, people were as able to discern risks in the face of a $100,000 payment as with no payment,” Halpern said.

And he said that while payments increased the number of participants who said they would give a kidney to a stranger, those increases were similar for those with high and low incomes.

“Theoretical concerns about paying persons for living kidney donation are not corroborated by empirical evidence,” the Penn team concluded in the study that appears today in the Annals of Internal Medicine.

They reported that participants’ willingness to give increased significantly as health risks to donors diminished, when payments rose, and if recipient and donor were related.

And they called for “a real-world test of regulated payments for kidney donation . . . to definitively show whether payment provides a viable and ethical method” to increase the supply of kidneys.

Last year, 6,453 people in the United States died waiting for an organ. Nearly 92 percent of them died waiting for organs that living donors could have supplied – 4,456 needed a new kidney and 1,452 a liver.

Still, several medical ethicists said they were concerned that the study didn’t address the overarching question of whether it is ethical to pay for an irreplaceable body part.

Moreover, Lainie Ross of the University of Chicago’s MacLean Center for Clinical Medical Ethics said, answers to a hypothetical survey about organ donation could not mimic the real world.

“The actual number of living donors who make nondirected donations to strangers is about 100 a year,” she said.

So the fact that 30 percent of the participants in Halpern’s study said they would donate suggested that they were just providing what they thought was the appropriate answer.

“We are seeing a lot of socially desirable answering,” she said.

Another problem, Ross said, was that by asking a group of commuters – even a range of urban and suburban participants with high and low incomes – the study likely missed those most vulnerable to financial incentives, “the poorest of the poor, as we know from the data from” Iran, where payments are allowed.

Ultimately, Ross said, the Penn researchers didn’t ask: “Is this the right thing to do?”

The answer is no, said George J. Annas, chairman of the department of health law, bioethics, and human rights at Boston University School of Public Health.

“I think it is out of bounds,” Annas said. “We know we can live with the system we have now. We have no idea about what another system would do.”

For example, would the payment system for living donors cause families of deceased donors to seek compensation? Would such a payment system reduce or eliminate the donations from people who now serve as living donors?

Both Annas and Ross said that before experimenting with a paid system, better treatment for chronic illnesses such as diabetes and high blood pressure that can cause kidneys and other organs to fail is needed.

“We have to concentrate not just on the supply side, but on the demand side, too,” Annas said.

Last month in a commentary in the New York Times, Sander S. Florman of the Mount Sinai Medical Center wrote that the current transplant system is broken.

He said a thriving black market in human organs exists in the United States and across the globe. Moreover, he wrote, little is being done to enforce laws against selling organs.

Florman, director of the Mount Sinai transplant center, said that to save and improve many more lives, the supply of organs needs to be increased.

He suggests an opt-out system for deceased donation, where people are presumed to consent to organ donation at death unless they specifically decline to do so.

Currently, the United States has an opt-in system. People must indicate that they are willing to donate before they die, and their surviving family members are asked to make a final decision.

It is being hailed as a breakthrough for young women whose hope of one day becoming mothers could be wrecked by cancer therapy in their reproductive years.

Stinne Holm Bergholdt, from Odense, Denmark, was diagnosed with a cancer type known as Ewing’s sarcoma in 2004, when she was 27.  Before she began chemotherapy, part of her right ovary was removed and frozen. Her left ovary had already been removed some years earlier after doctors found a cyst that turned out to be benign.  The cancer treatment was a success but, as usually happens in such therapy, the drugs brought the onset of menopause.

In December 2005, six thin strips of ovarian tissue were transplanted back on to what remained of her right ovary, and began to function normally, according to the case reported by the European Society of Human Reproduction and Embryology (ESHRE) in its journal Human Reproduction.

After a brief corse of hormones to stimulate egg production, Bergholdt became pregnant again and gave birth to her first daughter, Aviaja, in February 2007.
In 2008, she returned to her fertility clinic, seeking in-vitro fertility (IVF) treatment in the hope of conceiving again.

But a pregnancy test showed that she was already pregnant through natural means, and in September 2008, she gave birth to another girl, Lucca.

Seven other children have been born around the world using the so-called cryopreservation technique, but this is the first time it has helped a woman to have two babies.

“These results support cryopreservation of ovarian tissue as a valid method of fertility preservation and should encourage the development of this technique as a clinical procedure for girls and young women facing treatment that could damage their ovaries,” said her physician, Claus Yding Andersen, a professor at the University Hospital of Copenhagen.

Bergholdt is even having to use “pregnancy-preventing measures” to avoid a pregnancy right now, said Andersen.

In a press release, Bergholdt described the experience as “a miracle.”

“When I found out I was pregnant for the first time I was of course very happy and excited — but also very afraid and sceptical since I found it very hard to believe that my body was really working again,” she said.

“The second time it was quite a surprise to find out I was pregnant since we hadn’t been working on it — we thought we needed assistance like the first time… It was a very nice surprise to find out that my body was now functioning normally and that we were having a baby without having to go through the fertility treatment.”

She and her husband have not decided yet whether they wanted more children, she added.

“The girls are still so small and need a lot of attention, but maybe in a couple of years we might think about it again.”

So how might the new Bioethics Commission operate? Fortunately, we have some idea because its new chair, Amy Gutmann, outlined her views on how bioethics commissions should be run in an article, “Deliberating About Bioethics” in the Hastings Center Report back in 1997. Most of the 13 member panel hasn’t been appointed yet, but Gutmann is well-known for her scholarly work on deliberative democracy, which she defines “as a form of government in which free and equal citizens (and their representatives), justify decisions in process in which they give one another reasons that are mutually acceptable and generally accessible, with the aim of reaching conclusions that are binding in the present on all citizens but open to challenge in the future.”  

In her article (co-authored with political philosopher Dennis Thompson), Gutmann distinguishes deliberative democracy from proceduralism and constitutionalism. In proceduralism, once basic rules of the game have been hammered out, moral disagreements are resolved through political bargaining or by moving them out of politics into the private sphere. Constitutionalism tries to avoid moral disagreement by creating a sphere of protected rights that are shielded from ordinary politics.

In Gutmann’s conception, deliberative democracy is an ongoing, transparent, society-wide discussion of fundamental values. Deliberative democracy is supposed to serve four important social purposes by addressing four ineradicable sources of moral disagreement. She identifies the four sources of moral disagreement as arising from (1) the scarcity of resources; (2) limited generosity; (3) incompatible moral values; and (4) the incomplete understanding that characterizes almost all moral conflicts. The four social purposes that deliberative democracy is supposed to address are (1) the promotion of the legitimacy of collective decisions; (2) the encouragement of public-spirited perspectives on public issues; (3) the promotion of mutually respectful decisionmaking: and (4) the correction of inevitable collective action mistakes.

Gutmann offers some concrete examples of how she thinks deliberative democracy might work. Let’s take scarcity. She notes that far more people need organs than there are organs available for transplant. How do we decide who gets them? She suggests that “deliberation can help those who do not get what they want or even what they need come to accept the legitimacy of a collective decision.” As it happens in 1984, the U.S. Congress passed the National Organ Transplant Act which made organ sales illegal. Since then donated organs have been allocated by the United Network of Organ Sharing based on various medical criteria depending on the specific organ. Although some voices (including mine) have been arguing for compensating donors as a way to increase supplies, it is true that there has not been much public pressure to change the current system. However, one hopes that the deliberative process will someday correct this particular collective action mistake. On the other hand, we can expect a lot more bioethical deliberation if the U.S. adopts a more centralized and increasingly government-controlled health care system. In another article Gutmann favorably cites the United Kingdom’s National Institute for Health and Clinical Excellence (NICE) as an example of how democratic deliberation works in making decisions about what medicines and treatments will be made available to patients in that country’s National Health Service.

The next issue is limited generosity. Gutmann acknowledges, “Deliberation will not turn self-centered individualists suddenly into public-spirited citizens.” She argues that members of bioethics commissions should not be chosen just to represent specific interest groups; that would simply result in old-fashioned interest group bargaining. Gutmann asserts that the number and diversity of voices on a bioethics commission is not necessarily the most important factor in making deliberation work. Instead bioethics commissioners “must come to the forum open to changing their own minds as well as to changing the minds of their opponents.” Bioethics commissioners will be more amenable to changing their minds on such limited questions as when is it appropriate to include minors in medical research rather than issues like abortion and assisted suicide.

Which brings us to Gutmann’s third source of moral disagreement—incompatible moral values. Here she recommends that bioethics commissions isolate irresolvable conflicts and focus on areas where agreement might be possible, e.g., minors in medical research. As an example of how deliberation can “economize” on moral disagreements, she cites the fetal tissue research guidelines issued in 1975 by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The commission held extensive public hearings and consulted legal experts, scientists, ethicists, and philosophers before promulgating its regulations allowing fetal tissue research. Those regulations included the requirement that researchers seeking to harvest tissue not have any part in the timing, method, or procedures used to terminate a pregnancy; no inducements to terminate a pregnancy could be made; both parents must consent; and artificial life support for nonviable fetuses was prohibited. But this deliberative outcome did not hold. In 1988, arguing that the fetal tissue research could encourage abortion, the Reagan administration imposed and later the Bush administration maintained a federal funding moratorium on fetal tissue transplant research. The moratorium was lifted by President Bill Clinton in 1993.

The history of the bioethical deliberation over fetal tissue research might be seen as an example of Gutmann’s fourth purpose of deliberation, the correction of mistakes. In the fetal tissue case, later experts did argue that political appointees under Reagan and Bush were mistaken in their belief that federal funding of fetal tissue research would lead to more abortions. On the other hand, given that a National Institutes of Health advisory panel in 1988 recommended after considerable deliberation that the moratorium be lifted, one suspects that the encourages-more-abortions argument for banning federal funding was a stand-in for a deeper philosophical repugnance toward all abortion. In any case, the fetal tissue case and President Obama’s decision last year to overturn President George W. Bush’s limits on federal funding of human embryonic stem cell research shows that bioethics decisions in the U.S. are already provisional and open to challenge.

I generally agree with the proceduralists and constitutionalists. In order to keep the social peace and allow various visions of the human to flourish along side of one another, certain big questions about birth, death, and the meaning of life must be isolated from politics, making them private concerns to be protected from majoritarian tyranny. But for her part, Gutmann concludes hopefully, “By making democracy more deliberative, we stand a better chance of resolving some of our moral disagreements, and living with those that will inevitably persist, on terms that all can accept.” Given the current stark polarization that characterizes our national political institutions (if not public opinion), Gutmann, as head of the new Presidential Commission for the Study of Bioethical Issues, has her work cut out. Good luck to her.

Ronald Bailey is Reason’s science correspondent. His book Liberation Biology: The Scientific and Moral Case for the Biotech Revolution is available from Prometheus Books.

The key: A gene that produces a substance called interleukin-10. Among IL-10’s many jobs is tamping down inflammation from the very molecules most prone to damage lungs. But when lungs are donated, they’re quickly put on ice to stop tissue deterioration, and that keeps whatever IL-10 remains from working. So Dr. Shaf Keshavjee, University Health Network’s lung transplant chief, devised a two-part fix:

First, create a body-temperature chamber that will keep the lungs alive outside the body. His team created a protective dome to house the lungs, where a solution of oxygen and nutrients is pumped into them, mimicking the body but minus the blood. Second, insert a gene into those lungs that will quickly produce high levels of IL-10 and reverse the inflammation. His team reports success in Wednesday’s journal Science Translational Medicine. They stuck the IL-10 gene into an adenovirus, from the family of cold viruses, so it would be taken up by lung cells, and snaked the virus inside the airways of the dome-preserved lung. Using lungs first from a handful of pigs and then from humans — 10 donor lungs that had been rejected for transplant — the team found that lungs receiving the gene therapy significantly improved their ability to take in fresh oxygen and get rid of carbon dioxide, they reported. When lungs are injured, fluid breaks barriers to leak where only air is supposed to be, and that damage was fixed. “The beauty of what we’re doing here, is we’re transducing the cells in the lung to become little IL-10 factories,” Keshavjee said. “It’s personalized medicine for the organ, if you will.” The human lungs weren’t transplanted into sick patients. That’s a much bigger step that Keshavjee hopes to try in an experiment sometime in the next year. But he transplanted a few pigs with repaired pig lungs, and found they were functioning significantly better four hours after transplant than lungs that didn’t get gene therapy. Moreover, if the IL-10 lasts long enough, it potentially could help protect against post-transplant inflammation, too, a question for future experiments. Specialists said those tests should track how long repaired lungs last in animals before they’re tried in people. Some gene therapy experiments have documented side effects from adenovirus, cautioned Indiana University lung specialist Dr. David Wilkes in an editorial published with the research. Keshavjee said the adenovirus disappears relatively soon after delivering the gene, lessening risk of body-wide side effects. “If effective, these approaches will truly be a breath of fresh air for prospective lung transplant recipients,” Wilkes concluded. Copyright © 2009 The Associated Press. All rights reserved.