MOTIONS’S INFORMATION social change, economic uncertainty, and lifestyle

clashes between diverse social groups. The ongoing

nature of the obesity epidemic has been exaggerated
and this has triggered a new moral panic.
NHPEO 2019 YOGYAKARTA obsession with obesity can now be added to the list.
In discussing blame and responsibility for the so-
PRELIM 1 Many now argue that health and lifestyles have
become an important repository for new kinds of
called obesity epidemic, scientists, journalists and
politicians alike tend to focus on individual
moralising in society. We don’t have to look too far to responsibility. And in doing so, they gloss over the
Some researches suggest that the links find evidence of this: consider UK Government ways in which body size is tightly controlled by
between body weight and health are healthy eating initiatives such as ‘The Responsibility genetic factors and shaped by social factor – such as
tenuous than people fought. The fear of Deal ’, and the Change4life campaign . Each implores socio-economic status and neighborhood limitations,
moral panic over fat will divert the individual, whether adult or child, to take personal including poor access to healthy food outlets, a high
responsibility for their weight and health or the nation density of fast food restaurants and a lack of open
government funds and energies from will experience a health catastrophe. space for exercise. In this perspective, obesity is
other health concern. This rising tide of social.
obesity, however, affects the interest of A whole range of institutions, and individuals
the whole nation. associated with those institutions, are provided with But once obesity was listed among risk factors for
the responsibility to identify who might be ‘at risk’ chronic diseases, such as heart disease and diabetes,
TH disapproves of movements that aim to further the and to regulate their behaviour. Doctors in the UK are statistical evidence accumulated about obesity’s
acceptation of obesity in society being encouraged to ‘nudge’ patients at risk of widespread occurrence, dramatic graphs appeared
overweight, counsel them about their risk and suggest linking it to wellbeing.
weight management treatment (whether or not there is
Is the UK in a moral panic about
obesity?
any other medical indication of risk).
Fattest towns
Three quarters of British men are predicted to be
Epidemic or panic? Wikipedia provides a snapshot of obesity levels in the
UK . If you live in Tamworth you might not wish to
obese by 2030. Have we become greedier and less In 1993, in England, 13% of men and 16% of women learn that your town is the fattest in England, with
active or are more complicating factors at work? We were obese – in 2011 this rose to 24% for men and over 30 per cent of its inhabitants classified as obese.
live in an age of moral panics. They are becoming so 26% for women, according to an NHS report . The
common that in 2012 The Guardian produced a blog report estimated that one in 10 English children was Our obsession with body image and weight loss has
on the ten best moral panics . It showed that successful clinically obese, a significant increase since the turn of exacerbated the issue. You cannot pick up a
moral panics owe their appeal to their ability to find the millennium. Health risks associated with obesity newspaper today without a story about body weight.
points of resonance with society's wider seem clear, but some argue that the true scale and There are hundreds of websites devoted to the issue.
anxieties, suggesting a far deeper anxiety such as rapid Just Google 'obesity time bomb' and you will find out
the extent of the concern. Governments offer advice Moral panic here? Certainly. Eat what you want? It is Body mass index (BMI) is a simple index of weight-
regularly on diet, health and fitness, and the up to you. Go ahead, but remember, the fat devils for-height that is commonly used to classify
Government's former Chief Medical officer, Sir Liam await you. overweight and obesity in adults. It is defined as a
Donaldson, has talked up the obesity time bomb . person's weight in kilograms divided by the square of
sources : the open university, open learn his height in meters (kg/m2).
Characterising obesity firstly as a disease, and then
one of epidemic proportions, requires immediate Adults
mobilisation of resources to bring about change. In the Obesity and overweight
context of the ‘obesity epidemic’ this is translated into For adults, WHO defines overweight and obesity as
a sense that anyone might ‘catch it’. (Here we go, can 16 February 2018 follows:
you feel the ‘fat anxiety’ yet?). People who are Key facts
overweight or obese have succumbed, and are thereby  overweight is a BMI greater than or equal to 25;
dangerous ‘carriers’ to be avoided. This permits the  Worldwide obesity has nearly tripled since 1975. and
creation of notions like the obese ‘folk-devil’ (fat  In 2016, more than 1.9 billion adults, 18 years and  obesity is a BMI greater than or equal to 30.
devil?), and permits actions to be taken because of the older, were overweight. Of these over 650 million
‘danger’ to them, and to society. were obese. BMI provides the most useful population-level
 39% of adults aged 18 years and over were measure of overweight and obesity as it is the same for
Spreading fat fear 
overweight in 2016, and 13% were obese.
Most of the world's population live in countries
both sexes and for all ages of adults. However, it
should be considered a rough guide because it may not
where overweight and obesity kills more people correspond to the same degree of fatness in different
Social policy and health strategies target individuals’ than underweight. individuals.
behaviors as though all were at risk. We are all  41 million children under the age of 5 were
involved in helping to defuse a health time bomb! This overweight or obese in 2016. For children, age needs to be considered when
feeds a media frenzy and is of course a gift for the  Over 340 million children and adolescents aged 5- defining overweight and obesity.
multi-billion dietary industry. The preoccupations of 19 were overweight or obese in 2016.
the powerful with the body’s appearance of a few are  Obesity is preventable. Children under 5 years of age
visited on the wider population, through a fear of fat.
The message is that anyone could get fat, everyone is What are obesity and overweight For children under 5 years of age:
at risk and that the risk begins very early in life. This
stimulates a constant, anxiety-driven, routine of self-  overweight is weight-for-height greater than 2
surveillance, and helps to produce a lifestyle for many Overweight and obesity are defined as abnormal or standard deviations above WHO Child Growth
that is riddled with needless anxiety and excessive fat accumulation that may impair health. Standards median; and
conspicuously short of fun.
  obesity is weight-for-height greater than 3  The worldwide prevalence of obesity nearly tripled What causes obesity and overweight?
standard deviations above the WHO Child Growth between 1975 and 2016.
Standards median. The fundamental cause of obesity and overweight is
In 2016, an estimated 41 million children under the an energy imbalance between calories consumed and
 Charts and tables: WHO child growth standards for age of 5 years were overweight or obese. Once calories expended. Globally, there has been:
children aged under 5 years considered a high-income country problem,
overweight and obesity are now on the rise in low- and  an increased intake of energy-dense foods that are
Children aged between 5–19 years middle-income countries, particularly in urban high in fat; and
settings. In Africa, the number of overweight children  an increase in physical inactivity due to the
Overweight and obesity are defined as follows for under 5 has increased by nearly 50 per cent since increasingly sedentary nature of many forms of
children aged between 5–19 years: 2000. Nearly half of the children under 5 who were work, changing modes of transportation, and
overweight or obese in 2016 lived in Asia. increasing urbanization.
 overweight is BMI-for-age greater than 1 standard
deviation above the WHO Growth Reference Over 340 million children and adolescents aged 5-19 Changes in dietary and physical activity patterns are
median; and were overweight or obese in 2016. often the result of environmental and societal changes
 obesity is greater than 2 standard deviations associated with development and lack of supportive
above the WHO Growth Reference median. The prevalence of overweight and obesity among policies in sectors such as health, agriculture,
children and adolescents aged 5-19 has risen transport, urban planning, environment, food
 Charts and tables: WHO growth reference for dramatically from just 4% in 1975 to just over 18% in processing, distribution, marketing, and education.
children aged between 5–19 years 2016. The rise has occurred similarly among both
boys and girls: in 2016 18% of girls and 19% of boys What are common health consequences of
Facts about overweight and obesity were overweight. overweight and obesity?
Some recent WHO global estimates follow. While just under 1% of children and adolescents aged Raised BMI is a major risk factor for
5-19 were obese in 1975, more 124 million children noncommunicable diseases such as:
 In 2016, more than 1.9 billion adults aged 18 years and adolescents (6% of girls and 8% of boys) were
and older were overweight. Of these over 650 obese in 2016.  cardiovascular diseases (mainly heart disease and
million adults were obese.
stroke), which were the leading cause of death in
 In 2016, 39% of adults aged 18 years and over Overweight and obesity are linked to more deaths 2012;
(39% of men and 40% of women) were worldwide than underweight. Globally there are more  diabetes;
overweight. people who are obese than underweight – this occurs  musculoskeletal disorders (especially
 Overall, about 13% of the world’s adult population in every region except parts of sub-Saharan Africa and osteoarthritis – a highly disabling degenerative
(11% of men and 15% of women) were obese in
Asia. disease of the joints);
2016.
  some cancers (including endometrial, breast, dense, and micronutrient-poor foods, which tend to be physical activity and healthier dietary choices
ovarian, prostate, liver, gallbladder, kidney, and lower in cost but also lower in nutrient quality. These available, affordable and easily accessible to everyone,
colon). dietary patterns, in conjunction with lower levels of particularly to the poorest individuals. An example of
physical activity, result in sharp increases in childhood such a policy is a tax on sugar sweetened beverages.
The risk for these noncommunicable diseases obesity while under nutrition issues remain unsolved.
increases, with increases in BMI. The food industry can play a significant role in
How can overweight and obesity be promoting healthy diets by:
Childhood obesity is associated with a higher chance reduced?
of obesity, premature death and disability in  reducing the fat, sugar and salt content of
adulthood. But in addition to increased future risks, Overweight and obesity, as well as their related processed foods;
obese children experience breathing difficulties, noncommunicable diseases, are largely preventable.  ensuring that healthy and nutritious choices are
increased risk of fractures, hypertension, early markers Supportive environments and communities are available and affordable to all consumers;
of cardiovascular disease, insulin resistance and fundamental in shaping people’s choices, by making  restricting marketing of foods high in sugars, salt
psychological effects. the choice of healthier foods and regular physical and fats, especially those foods aimed at children
activity the easiest choice (the choice that is the most and teenagers; and
Facing a double burden of disease  ensuring the availability of healthy food choices
accessible, available and affordable), and therefore
and supporting regular physical activity practice in
preventing overweight and obesity.
Many low- and middle-income countries are now the workplace.
facing a "double burden" of disease. At the individual level, people can:
WHO response
 While these countries continue to deal with the  limit energy intake from total fats and sugars;
problems of infectious diseases and under  increase consumption of fruit and vegetables, as Adopted by the World Health Assembly in 2004, the
nutrition, they are also experiencing a rapid well as legumes, whole grains and nuts; and "WHO Global Strategy on Diet, Physical Activity and
upsurge in no communicable disease risk factors  engage in regular physical activity (60 minutes a Health" describes the actions needed to support
such as obesity and overweight, particularly in day for children and 150 minutes spread through healthy diets and regular physical activity. The
urban settings. the week for adults). Strategy calls upon all stakeholders to take action at
 It is not uncommon to find under nutrition and global, regional and local levels to improve diets and
obesity co-existing within the same country, the Individual responsibility can only have its full effect physical activity patterns at the population level.
same community and the same household. where people have access to a healthy lifestyle.
Therefore, at the societal level it is important to The Political Declaration of the High Level Meeting
Children in low- and middle-income countries are support individuals in following the recommendations of the United Nations General Assembly on the
more vulnerable to inadequate pre-natal, infant, and above, through sustained implementation of evidence Prevention and Control of No communicable Diseases
young child nutrition. At the same time, these children based and population based policies that make regular of September 2011, recognizes the critical importance
are exposed to high-fat, high-sugar, high-salt, energy- of reducing unhealthy diet and physical inactivity. The
political declaration commits to advancing the The challenge death to serious chronic conditions that reduce the
implementation of the "WHO Global Strategy on Diet, overall quality of life.
Physical Activity and Health", including, where At the other end of the malnutrition scale, obesity is
appropriate, through the introduction of policies and one of today’s most blatantly visible – yet most The response: making healthy choices easy choices
actions aimed at promoting healthy diets and neglected – public health problems. Paradoxically
increasing physical activity in the entire population. coexisting with undernutrition, an escalating global WHO began sounding the alarm in the 1990s,
epidemic of overweight and obesity – “globesity” – is spearheading a series of expert and technical
WHO has also developed the "Global Action Plan for taking over many parts of the world. If immediate consultations. Public awareness campaigns were also
the Prevention and Control of No communicable action is not taken, millions will suffer from an array initiated to sensitize policy-makers, private sector
Diseases 2013-2020" which aims to achieve the of serious health disorders. partners, medical professionals and the public at large.
commitments of the UN Political Declaration on No Aware that obesity is predominantly a “social and
communicable diseases (NCDs) which was endorsed Obesity is a complex condition, one with serious environmental disease”, WHO is helping to develop
by Heads of State and Government in September social and psychological dimensions, that affects strategies that will make healthy choices easier to
2011. The “Global Action Plan” will contribute to virtually all age and socioeconomic groups and make.
progress on 9 global NCD targets to be attained by threatens to overwhelm both developed and
2025, including a 25% relative reduction in premature developing countries. In 1995, there were an estimated In collaboration with the University of Sydney
mortality from NCDs by 2025 and a halt in the rise of 200 million obese adults worldwide and another 18 (Australia), WHO is calculating the worldwide
global obesity to match the rates of 2010. million under-five children classified as overweight. economic impact of overweight and obesity. It is also
As of 2000, the number of obese adults has increased working with the University of Auckland (New
The World Health Assembly welcomed the report of to over 300 million. Contrary to conventional wisdom, Zealand) to analyse the impact that globalization and
the Commission on Ending Childhood Obesity (2016) the obesity epidemic is not restricted to industrialized rapid socioeconomic transition have on nutrition and
and its 6 recommendations to address the obesogenic societies; in developing countries, it is estimated that to identify the main political, socioeconomic, cultural
environment and critical periods in the life course to over 115 million people suffer from obesity-related and physical factors which promote obesogenic
tackle childhood obesity. The implementation plan to problems. environments.
guide countries in taking action to implement the
recommendations of the Commission was welcomed Generally, although men may have higher rates of DIFFERENTIAL SENSITIVITY TO OBESITY'S
by the World Health Assembly in 2017. overweight, women have higher rates of obesity. For COMORBIDITIES IN MANY GLOBAL REGIONS
both, obesity poses a major risk for serious diet-related
noncommunicable diseases, including diabetes It has long been known that some communities are far
Controlling the global mellitus, cardiovascular disease, hypertension and more susceptible to type 2 diabetes due to weight gain
stroke, and certain forms of cancer. Its health than others, with the first demonstration showing that
obesity epidemic consequences range from increased risk of premature South East Asians in the UK were 3 times more likely
to develop diabetes as they gained weight especially in
the abdominal area (18). Then, the International
Obesity Taskforce with the George Institute in Sydney impact of much early nutritional deprivation in fetal REDUCING THE NATIONAL BURDEN OF OBESITY
assessed about 750000 Asians and compared their data life and early childhood (27).
with Caucasians, predominantly Australasians, and Countering the problem of obesity and diabetes is
showed that both diabetes and hypertension increased Analyses of the effects of the Dutch (28) and Chinese proving difficult because most policy makers assume
at much lower BMI values in Asians and that the (29) famines demonstrate clear effects on the it is an individual's responsibility and is easy to
difference was more marked when either waist-for- offspring's increased susceptibility to diabetes if the reverse. But there is substantial evidence for an
height or waist-circumference values were compared mother had been semistarved in pregnancy. Yajnik's adaptive, presumably hypothalamic, response to
(19). extensive analyses (30, 31) in India have also shown weight gain that then biologically resists attempts to
the predilection of even newborn babies to insulin slim by increasing appetite and reducing basal
Since then it has become clear that Asians are more resistance if their mothers are poorly fed. Discrepant metabolism with thyroidal and sympathetic responses
prone to cardiovascular disease for a variety of reasons folate/B12 status is particularly important and akin to those seen in lean adults when semistarved
including possible genetic differences (20). Mexicans indicative of the crucial nature of the metabolic (38). These responses can be reversed by reinfusions
are also more susceptible to both diabetes and availability of one-carbon components for nucleic acid of leptin up to its previous higher concentration in the
hypertension at each increment of BMI or of waist synthesis (32). Further analyses show that food obese state (39). Thus, in practice the majority of
circumference (21), and the same seems to be true of deprivation in early childhood (33)—and also perhaps obese individuals regain their excess weight after a
African Americans and Hispanic Americans in the US in adolescence (34)—increases susceptibility to later slimming episode, but persistent weight loss can be
(22). Similar differences seem to be evident in the diabetes. There is also long-standing evidence that achieved if there are clear incentives, e.g., to avoid the
Caribbean and now in the Middle East where diabetes childhood malnutrition in Jamaica leads to what seems development of diabetes in susceptible individuals
rates are extraordinarily high, affecting up to 20% of to be a persistent impairment of insulin secretion in provided they have sustained family and medical
all of a country's adults aged ≥20 years. However, the response to a glucose challenge (35), and this concept support to overcome what may well be biochemical or
reasons for this have to be treated with caution; of early pancreatic susceptibility to impaired humeral signaling to eat more (40).
although there are clear ethnic differences in programing of islet capacity is reinforced by longer-
mitochondrial haplotypes between different societies term studies on the reduced insulin secretion Given that the obesity epidemic is recent, it follows
(23), much of the excess diabetes from these associated with the greater likelihood of diabetes in that a prevention strategy with policies to counter the
haplotypes may only affect the progression of the the offspring from the Dutch famine (36). So primary drivers of the epidemic is needed. The
complications of diabetes rather than the incidence of extensive is the evidence for the importance of epidemic follows the complete mechanization and
diabetes itself (24). Recently, the genetic control of women's nutritional status pre- and postconception on computerization of modern living, resulting in a
adipocyte cellular mass and any limited capacity to the child's future propensity to obesity and diabetes collapse in the routine demand for physical activity.
store fat has been proposed as enhancing individuals' that this has now entered official WHO policy This sedentary status is not only intrinsically harmful
propensities to insulin resistance and diabetes (25). approaches to the importance of epigenetic and but requires a diet with a much lower energy density
Individuals' poor economic status and stress (26) are pathophysiological programming of obesity and with fewer total calories consumed to preserve energy
important contributors, but so also is the long-standing diabetes with the need for major new programs to balance. This means we all need to eat far less dietary
counter these problems (37). total fat (contrary to many popular and some scientific
analyses) as well as less dietary sugar. The lower because it seems a simple consequence of eating too slimming find they have regained most if not all of
energy density of food is helped if substantial amounts much or doing too little. The remedy seems simple— their weight loss after 1–2 years.
of fiber-rich complex carbohydrates, fruits, and to reduce intake or increase exercise. However, soon
vegetables are consumed. after I started running obesity clinics it became Many of these features were recognized in the 1970s
obvious that the obesity problem was more complex when obesity began to emerge as a major medical
However, huge industrial interests promote motorized than that. A patient's failure to maintain any weight problem, and here I bring the analysis up to date and
transport, mechanized work, and home entertainment; loss required an understanding of the patient's energy consider obesity as a global problem.
these all counter the need for physical activity. The needs, and with more sophisticated analyses it soon
problem is then amplified by an even more powerful became clear that different individuals have markedly THE RECOGNITION OF OBESITY AS A GLOBAL
food industry that not only usually controls different energy requirements. An individual's average CONCERN
government policies but also does its utmost to sell needs, assessed over a month, may range from 1500
more food, usually with additional fats, sugars, and kcals/day to 3500 kcals/day or more. We then found, The recent Director General of WHO frequently cited
salt to appeal to the primitive taste buds that were so with whole body calorimetry, that individual energy obesity as the major new global epidemic (1). She
important for our survival during our early evolution expenditures at rest were astonishingly constant, with clearly identified this epidemic as industrially driven,
in Africa. <1% differences over 24 h, unless we were yet there have been only modest attempts so far to
considering young menstruating women who were tackle the problem. This in part relates to obesity
So the challenge for medical specialists as well as shown to have a monthly cyclical resting metabolic being seen as a fringe interest for most major medical
public health physicians is to accept the need not only rate. Interindividual differences depended on the societies and only in the past 2 decades has it become
for effective (and usually costly) therapy but also to patient's age, sex, size, and degree of physical activity. a frequent medical challenge in clinical practice. The
support those who battle to improve public health by Given also that their mean weight gain was usually interests from governments in public health are very
changing government policies relating to public 0.5–1 kg/year, this merely amounted to a mean excess limited unless driven by decades of intense lobbying
transport, urban planning, and an everyday daily intake of 10–20 kcals/day over the year, a and overwhelming medical data, e.g., on the hazards
environment conducive to spontaneous walking. This difference that could not be measured. But people, for relating to smoking or when there is an exceptionally
needs to be combined with a range of diet-inducing social and other reasons, may vary their day's intake dangerous epidemic such as SARS or Ebola. Yet, no
changes, including fiscal measures to progressively by perhaps 1000–1500 kcals during the week, health service in the world will be able to cope with
change the price of different foods and to limit and implying there must be an extraordinary degree of the fully developed impact of the huge burden of care
then ban the use of high-energy ingredients in all medium and long-term appetite control. It then induced by obesity and its complications.
public sectors and then general catering. Without these became clear that obese individuals adapted as they
drastic measures the epidemic of obesity and diabetes gain weight and changed what we crudely called their In the mid-1970s specialist groups in the UK and US
will continue. “energy set-point.” So on slimming, their behavioral, were established to consider the new phenomenon of
hormonal and autonomic nervous system responses obesity, which was then affecting only middle-aged
The problem of excess weight gain and obesity is resist weight loss, thereby helping to explain why adults, particularly women (2, 3). Both national groups
difficult for many scientists and doctors to understand most people, however intelligent and committed, after agreed to express the weight for height that was
optimum for health in terms of the body mass index More than 600 million people, or 13% of the world's Meanwhile, families in England and several US states
(BMI; kg/m2). The designated normal BMI of adult population, are obese. The rate more than are sent warning letters warning if tests in schools
approximately 20–25 was based on pre- and post- doubled between 1980 and 2014, according to the show children are overweight.
World War II US mortality statistics (2). It was soon World Health Organization. The estimated cost to the
recognized that smokers not only had a substantially global economy is $2tn (£1.3tn), including £47bn to So far, anti-obesity policy has focused largely on
increased risk of premature mortality but also tended the UK. taxation or providing information. But, on Friday,
to be thinner not only because they ate less but also politicians in Puerto Rico, a self-governing US
because their metabolic rate was stimulated by National and local governments have struggled to territory, start debating whether the government
smoking, with an additional small increase in their address obesity, defined as having a body mass index - should get more involved in one of the main perceived
basal metabolism (4). When analyzed separately, based on the ratio of height to weight - of more than reasons for the growth in childhood obesity -
smokers have an increased death rate at each 30. They often face accusations of nanny-statism and irresponsible parenting.
increment in BMI, and the mortality rate of a normal opposition from food and drink companies if they do
weight smoker is similar to that of a very obese so. Attempts have been patchy and experts are divided If the legislative assembly approves Senator Gilberto
nonsmoker (Fig. 1) (5). The 20–25 BMI range to on what, if anything, works. Rodriguez Valle's plans, teachers will be told to look
minimize mortality has recently been confirmed by an out for students they think are obese. They would refer
integrated international prospective analysis of BMI in In 2011, Denmark brought in a "fat tax" on foods those detected to a counsellor or, in severe examples,
relation to mortality in one million men and three containing more than 2.3% saturated fat, but the to a social worker. Health department officials would
million women (6) and by the latest Global Burden of inflated prices drove consumers over the border to meet parents and decide whether the obesity comes
Disease estimates (7). Both these analyses were Germany. The policy was dropped a year later and the from overeating or a medical condition.
confined to nonsmokers and included adults in both government cancelled plans for a tax on sugar.
lower income and affluent societies. If food is the problem, it would be up to parents to set
In 2012, France quadrupled the tax on saturated fat- a diet and exercise programme, with monthly visits by
THW FINE PARENTS WHOSE rich palm oil, dubbed the "Nutella tax" because the officials to make sure it's being kept up. After six
CHILDREN ARE OVER OBESE popular hazelnut spread contained the ingredient. months, they would examine the child again. Parents
would face fines of up to $800 (£525) if there was no
Could fining parents cut childhood obesity? Voters in Berkeley, California, backed calls for a one- improvement within a year.
cent-an-ounce tax on fizzy drinks, in a referendum last
Obesity is described as one of the biggest problems year. The beverages were banned from schools in New Opponents say that, in a society where thinness has
facing mankind. The small US territory of Puerto Rico South Wales, Australia, in 2007, but this has become a status symbol perpetuated by glossy
is debating whether to fine parents who fail to get their sometimes been ignored. magazines and media images, the idea of teachers
children to lose weight. But would this work acting as body police will further stigmatise the
elsewhere? overweight. There is also a large question mark over
whether this approach, very much "stick" rather than in Wales in 2012. In Northern Ireland in 2011-12, it Philadelphia - the most overweight of America's major
"carrot", can work. was 10%. So, does Puerto Rico's proposal appeal? cities - has cut the obesity rate among children. The
city authority has persuaded shops to stock more fruit
But Rodriguez Valle and his supporters insist families "Obesity isn't like smoking, the cutting of which has and vegetables in areas once described as "food
will be informed in confidence, meaning no been a public health success in recent years," says deserts" because of a lack of nutritious offerings. It
humiliation for children in front of classmates. Fines Andrew Hill, professor of medical psychology at has also banned full-fat milk from school canteens, as
are "necessary for society", argues a colleague, saying: Leeds University. "Smoking is a single behaviour well as deep-fat frying, while sugary drinks have
"The obese child is a health problem that can become that's really explicitly linked to a number of adverse disappeared from vending machines.
a financial burden because the child can develop health conditions, whereas obesity is a state of body,
diabetes, heart ailments and other diseases." "None of these efforts involved stigmatising or
"The causes are driven by environment. You live in an penalising parents," says Rebecca Puhl, deputy
In 2013, 27.9% of adults in Puerto Rico were environment which encourages you to eat lots of food director of the Connecticut-based Rudd Center for
described as obese, upper to middling by rates across and discourages physical activity. To then apply a Food Policy and Obesity. "In contrast, these changes
the US. However, the figure for children under the age penalty to punish something that people have varying exemplify ways to support and empower parents to
of four - 17.9% - is the highest of all US states and degrees of control over seems to be not just make it easier to improve the health of their children."
territories. If parents are failing to do their job from counterproductive but morally dubious."
the start, schools have to ensure standards instead, Puhl argues that a more integrated approach. involving
backed by financial penalties, it is argued. Obesity is more of a problem among poorer groups, schools encouraging better eating and more exercise,
who live in an "obesogenic" environment, according is needed.
There is a sense of helplessness in the face of the to Hill. He argues that exercise is less available and,
world's weight gain, largely attributed to rising food given the higher proportion of household income spent But the Puerto Rico obesity plan has echoes of the
intake and falling activity levels. "Not only is obesity on food, leads to the purchase of cheap, highly action taken in the UK and elsewhere to combat
increasing," a study funded by the Bill and Melinda calorific products, sugary or fatty, with limited persistent truancy from school. In March last year, it
Gates Foundation, published last year, said, "but no nutritional value. was revealed that a record number of truancy fines had
national success stories have been reported in the past been handed to parents but that persistent truancy was
33 years. Urgent global action and leadership is Hill dislikes the Puerto Rican proposal. "We need to falling. But there has been criticism that there is no
needed to help countries to more effectively move the argument away from saying it's all about link and that fines do not work. Some critics believe
intervene." individual responsibility and 'it's you to blame'. People fines disproportionately affect poor parents.
do have some responsibility but we must recognise the
The latest UK figures show 24.7% of adults are obese, power of environment and how difficult it is to change For a study published in 2000, the economists Uri
lower than Puerto Rico, but still the among the highest for the rest of your life." Gneezy and Aldo Rustichini tested the effects of fines
in western Europe. The rate was 14% for children on parents who consistently picked up children late
aged two to 15 in England, 17% in Scotland and 19% from daycare centres in Israel. Rather than deter the
behaviour, lateness increased because they started to "If after another six months the situation persists, the Should People With Unhealthy Lifestyles Pay Higher
regard the fine as a reasonable fee for extra childcare, parents can be assessed up to $500 in fines. Health Insurance Premiums?
rather than a punishment. "A powerful, intrinsic
motive was crowded out by a weaker, extrinsic one," "Six months after that, if the problem continues, the Ethical Justification for Different Rates
they concluded. parents can be fined an additional $800."
Dubois reviews three ethical grounds that have been
"That's unlikely to happen with obesity because there's The Associated Press reports that Sen. Gilberto used to justify charging unhealthy people more or
a stigma surrounding it," says Peter Ayton, professor Rodriguez, one of the bill's sponsors says the program charging healthy persons less. (Economists consider
of psychology at City University. "But there's aims to "improve children's wellbeing and help parents the respective approaches fungible, that is, equivalent
definitely room for thinking more about incentives, make healthier choices." and interchangeable, from a rational economic
maybe some sort of rewards for losing weight, perspective.) The first is based on the principle of
especially as obesity tends to affect the poor most. The wire service adds that "more than 28 percent of beneficence: Encouraging healthy behaviors reduces
children in Puerto Rico are considered obese, suffering, prevents social exclusion, promotes
"People respond to incentives and deterrents. There compared with some 18 percent in the U.S. mainland." autonomy, and reduces the threat to social solidarity
needs to be more discussion of what works." (in light of potential concerns about the "free-rider"
The Puerto Rican paper, El Nuevo Dia, spoke to legal problem, where someone is seen to benefit from a
Proposed Law In Puerto Rico Would Fine Parents Of and health experts who called the proposal "incorrect" system without contributing a fair share). Dubois notes
Obese Children and "superficial." that this line of justification suffers from the familiar
problems of paternalism, wherein the
Lawmakers in Puerto Rico have introduced a Ricardo Fontanet, the president of the local chapter of state/government or some third party (the insurance
controversial measure that could punish the parents of the American Academy of Pediatrics, said that this company) asserts that it knows what is in a person's
overweight children. kind of initiative will complicate things, because some best interests better than the person himself.
"kids are obese because of medical complications or Beneficence may not be sufficient to override the
As Fox Latino reports, the bill was introduced in genetic issues." principle of respect for autonomy, which holds that
Puerto Rico's senate and would have education people should decide for themselves how they want to
officials identify obese children and then tell their A law professor told the paper that it would be terribly live their lives (as long as it does not harm others, as
parents what they can do to help them. Fox Latino difficult to prove that having an obese child implies discussed below).
adds: that the parents have mistreated the kid.
Dubois devotes an entire section to challenging the
"If, after six months, education officials determine that claim of actuarial fairness, i.e., because it costs more
THW EXPEL PEOPLE WITH
the child's condition has not improved, a staffer can to treat people who smoke, are overweight, are
refer the case to child-family services authorities as
UNHEALTHY LIFESTYLES FROM sedentary, and drink too much, it seems only fair that
one involving abuse or mistreatment. STATE INSURANCE they should pay more for their coverage. Dubois
argues that this position is empirically disputable, and
if applied consistently, would raise thorny issues about This is relevant because, in the long-term, it would be issue. They argue about it in terms of a powerful
similar issues, like genetic disorders, which most in the financial interests of the collective insurance tension between a sense of reciprocity and mutual
people would find ethically unacceptable (e.g., should industry to ignore unhealthy behaviors because such obligation versus sympathy and understanding about
a family with a child born with cerebral palsy be behaviors would eventually save them money. the degree to which individual health status is beyond
charged more, following the same logic of actuarial However, due to relatively high turnover in one's personal control. People want to believe that
fairness?). In the US context, the question of actuarial employment and changes in health insurance plans in they can and do exercise some degree of control over
fairness raises three points that deserve further the US, individual companies cannot bank on these their own health. At the same time, it is a rare person
discussion. First, there is an important distinction to be potential savings, and hence, they see it in their who is not cognizant of the fragility of the human
made between public and private insurance schemes. interests to promote differentiated plans to attain condition and the capriciousness of being stricken by
In a competitive market system, private insurance short-term savings. That said, the idea that charging disease. Given that there will never be enough money
companies can offer differential plans, and in people more can be ethically justified strictly on the to pay for all possible medical procedures for
principle, potential buyers can decide whether they basis of financial calculations appears thin, everyone (the US already pays 2–3 times the
consider the contractual terms fair or not. The same is unappealing, and unconvincing to most people, as it percentage of its gross national product for health care
not true of government-run, single-payer plans, where seems to diminish the value of mutual caring and expenditures as other industrialized nations, with little
the issue of discrimination against poor and minority commitment to a cold cash nexus. to show for it), it is imperative to use limited resources
people would be inescapable (because it is an fairly. The major challenge then is coming to terms
empirically well-established fact that the health The third grounds that Dubois discusses as with how much individuals should be held
behaviors and indicators at stake are more prevalent in justification for charging people with unhealthy accountable for exercising control over various health
these groups). A variation of this concern arises with lifestyles more is founded on an implicit social behaviors and how much weight should be given to
respect to the difference between employers who offer contract. Dubois makes surprisingly short shrift of this the social determinants of health (where poor health
a number of insurance plan options versus those who approach, devoting only a single paragraph to this line can be explained as the result of brute bad luck due to
offer only a single employer-funded plan. In the latter of reasoning, and he casts it largely in terms of circumstances of birth, which a just society should
situation, the question of equal or differential plans individual responsibility to make productive strive to rectify). In addition, as Rawls reminds us,
should be an issue for bargaining, where the contributions to society or "cooperative schemes" finding an appropriate balance needs to be tempered
employees can decide how they want to represent their (about which he suggests that insurance schemes may with justice considerations that give precedence to
collective interests, as they deliberate about the or may not qualify). Dubois quickly dismisses these concern for those who are least well off
relative weight that should be given to different ethical grounds, asserting that such arguments would require
considerations. Finally, though there is increasingly a more comprehensive theory of justice or the good Ethical Considerations in Designing a Differentiated
convincing evidence that the total costs of treating society to be tenable. It may perhaps be because he is Plan
people with unhealthy lifestyles over a lifetime is less writing from a European perspective, where Rawls
than the total for healthy people (because unhealthy (1971) may not have as much influence, but I think The fact that covering the higher medical expenses of
people die younger), it is equally clear that, on annual that it is precisely in terms of a social contract that people with unhealthy lifestyles on an annual basis
basis, unhealthy people use more medical services. most Americans are struggling to make sense of this means that others in the same plan will have to forego
other possible plan benefits (e.g., eye care, dental care;
or higher pay raises) is the nagging rub that points to involved in seeking to assign or apportion blame.) He ways that benefit the collectivity as a whole.
the larger issue of honoring a social contract based on raises a couple of other issues that seem less Conversely, however, these same plans can be seen to
mutual obligation and mutual responsibility. There is a compelling. Is it a form of state coercion? It depends. undermine social solidarity because such meritocratic
general sense that, if everyone did not smoke, Whereas it is easy to imagine horribly intrusive elements may be viewed as primarily benefiting those
maintained a healthy weight, drank only in requirements, it is equally possible to identify terms who are already advantaged and by eroding traditional
moderation, and got some regular exercise, plans that may not be particularly bothersome. Is it a notions of giving without expectation of return. In
would cost less and/or be able to pay for procedures violation of an existing social contract or an short, the issue is whether plans can be devised that
that they cannot now afford. Is there an ethically infringement on a right to health care? There are a benefit the least well off and reinforce the sense of
acceptable means to achieve the goal of assuring that range of existing remedies that lessen the magnitude social solidarity.
all members of a collective cooperative scheme are of these concerns (such as switching insurance plans
making a comparable, honest effort at doing that or voting in the opposing political party). Ethical Specifications
which is within their power to use limited resources
prudently? What sorts of ethical considerations weigh For my purposes, an interesting point raised by Dubois A number of criteria have been proposed by Dubois
against using financial incentives to remind people to is the ambiguous effect of such plans on the issue of and other analysts, which offer reasonable grounds for
be mindful of their obligations to one another? social solidarity. Schmidt (2008) describes how striking an ethically appropriate balance between
German law pertaining to health insurance avers an completely ignoring unhealthy behaviors and
Dubois identifies several important ethical concerns. inextricable link between personal responsibility and appreciating the many barriers that make it difficult
The most significant is that charging people more will social solidarity. The relevant section of the act, titled for individuals to live a healthy lifestyle. Four
fall disproportionately on those who already have less. "Solidarity and Personal Responsibility," reads, proposed standards help to inform the discussion.
Without careful crafting, charging higher premiums
may further stigmatize those who are more likely to In the spirit of a mutually supportive community Feiring (2008) and Pearson and Lieber (2009) propose
feel bad about themselves already, and it may act as a [Solidargemeinschaft], the task of the statutory health that differentiated plans should be imposed only
further disincentive to obtaining medical insurance, insurance is to maintain, restore or improve health of the prospectively for voluntarily refusing to take any
thus, exacerbating existing health disparities. As insured. The insured have co-responsibility for their action to change one's unhealthy behaviors. With this
Dubois notes, its implementation may also harm third health; through a health conscious way of living, taking standard, people would not be charged more for
parties such as dependent children; due to the inherent part in appropriately timed preventative measures [and] coming into a plan being overweight or smoking but
opportunity costs, paying for a child's braces, for playing an active role in treatment and rehabilitation, they for stating that they are not willing to try to do
example, may no longer be affordable in families of should contribute to avoiding illness and disability and anything about them. Applying this standard would
less financial means. Finally, Dubois points out that overcoming the respective consequences. (p. 200) recognize that health status is patterned by social
monitoring and enforcing compliance in such schemes position while acknowledging that it is not
will inevitably prove costly. (Again, by analogy, both Here, the act of actively taking care of one's health is "determined," that is, that the majority of poor people
divorce settlements and car accidents reports have seen to be an expression of one's participation in do not smoke, are not obese, do not drink excessively,
moved towards no-fault claims, due to the high costs contributing to a collective common good. Such and have some physical activity in their lives
schemes incentivize and reward those who behave in
(arguably, with some quibbling at the margins), and of proscribing them would far outweigh the benefits to Blog | December 06, 2014 | Healthcare Reform, Patient
therefore, that it is reasonable to ask others in the same be gained by their reduction or elimination. Relations, Patients
position to do the same. This standard entails two
stipulations: first, that the proposed voluntary action Each of these standards needs further specification, so By James Bartley
that would demonstrate the good faith effort to be a the final recommendation is to leave these details to be
contributing member to the collective goal of using resolved through a procedural process, such as Daniels I recently had the opportunity to travel to Annapolis,
limited resources prudently is accessible, and second, and Sabin's (1997) accountability for reasonableness. Md., for a weekend trip. Annapolis is an old historic
that it is the effort, not the outcome, that counts. It is Insurance companies should be required to present a town on the Chesapeake Bay. It is the home of the
sufficient that the member enroll in a smoking public rationale for meeting these standards, an state capital, the U.S. Naval Academy, and, during the
cessation program or weight loss program and not accounting of the anticipated benefits, and an appeals winter of 1783 to 1784, it served as the temporary
necessary that they achieve abstinence or a BMI of 25 process for exempting individual cases, with a public capital of the United States. On my way back home,
to avoid being penalized. review and rating process. we decided to visit Fort McHenry in Baltimore, Md.,
which recently celebrated the 200 anniversary of the
Second, members should be offered a range of options Discussion Battle of Baltimore, waged in 1814 on September 13
to fulfill their obligation to contribute to the good of and September 14. That battle, part of the War of 1812
the collective enterprise. Unfortunately, there is a high As the contentious debates about health care reform at with Great Britain, is noted for the inspiration of our
correlation among the most common behaviors that the state and national levels in the US have shown, a national anthem, Frances Scott Key’s “The Star
are used to define an unhealthy lifestyle: smoking, significant proportion of the American public demands Spangled Banner” — “Gave proof through the night
drinking, overweight, and sedentary. Rather than that individuals be held accountable for the behaviors. that our flag was still there.” Yes, I like history.
asking people to take action to address each of these They do not accept the strong egalitarian position that
problems independently, allowing people to choose people are entitled to an equal share of the benefits In any event, on our way to Baltimore, we stopped at a
the issue that they would like to address first irrespective of level of effort. With conscientious typical strip mall diner for breakfast in the town of
demonstrates sympathy and solidarity with their development, policies can be written that achieve an Pasadena, Md. While eating breakfast, my friend and I
efforts to overcome hardships. The measure also acceptable balance of principles that are fair to all both observed and commented, that many of the
promotes the exercise of autonomy, which has also involved. As various plans are enacted, it will be patrons were — sorry to be frank — obese. I really do
been linked with better health. critical to examine the effects of such policies and not know anything about the town or the area — the
how much good they actually accomplish. demographics, schools, workforce, average age, etc.,
The third standard is setting limits on the range of but the patrons that were enjoying breakfast at the
behaviors that should be considered for inclusion as http://www.medscape.com/viewarticle/737955_5 diner in Pasadena were not very healthy looking. The
unhealthy. Members should not be required to change sad part was their children were eating the same food,
behaviors such as sexual behaviors, childbearing, Higher Health Insurance Rates for Unhealthy and many were already obese.
sexual orientation, and participation in sporting Lifestyles?
activities that elevate risk of injury because the harm
A discussion regarding diet or lifestyle issues on a Numerous studies have linked poor diet, cigarette Tens of thousands of overweight children –
national level should also include a discussion on smoking, lack of exercise to diabetes, coronary heart some as young as four – will be shipped off
insurance, premiums, high deductibles, and also disease, cancer, etc. Why should an individual who to fat camp, under a Government scheme to
Obamacare. It is also appropriate and timely to discuss has a healthy lifestyle, with no visits to the doctor, tackle obesity.
one’s individual responsibility when we all, hospital, clinic, pay the same insurance premium as
(government, businesses, individuals), pay a lot of someone who has a poor lifestyle, with multiple visits Primary school pupils identified as being overweight
money for healthcare. to the doctor, hospital, and clinic? When I purchased will automatically be offered a place on a state-funded
auto insurance for my daughter, her premium was diet and exercise scheme.
Last year, the former Mayor of New York City, greater than mine since “statistically” young adults
Michael Bloomberg, attempted to “implement” dietary have more accidents. When someone purchases life
Although parents will have the right to refuse to send
behavioral changes to the citizens by banning the sale insurance, premiums are higher for someone who is a
their children to the classes, ministers hope the
of “big gulp” sodas at New York City movie theaters. smoker.
majority will attend.
A local judge decided Mayor Bloomberg
“overreached” his legislative authority level and the I would suspect that if all those folks who were
Parents groups said the new NHS rules meant Labour
law was never enacted. Bloomberg did ban cigarette enjoying pancakes/syrup with sausage, danishes, and
had moved "beyond a nanny state, to a dictatorship."
smoking in bars earlier in his tenure. chocolate milk at the diner in Pasadena were asked to
defend Baltimore against Great Britain in 1814, the
Health experts warned that the public branding of
On a national level, the FDA recently announced it Union Jack would be flying over Annapolis and not
young children as fat could damage their confidence,
will require restaurants with at least 20 locations, to the Stars and Stripes.
expose them to bullying and trigger eating disorders.
display the calorie count of food items on their menus.
However, paediatricians welcomed the move.
“While no single action can fix the obesity problem, THIS HOUSE WOULD FORCE PARENTS OF
the step we’re taking today ... is a really important one
Under existing regulations, children are weighed when
for public health,” said FDA Commissioner Margaret OBESE CHILDREN TO SEND THEIR
they start primary school – aged four or five – and
Hamburg.
again as they leave, at 10 or 11. Parents of all children
CHILDREN TO FAT CAMP
receive a letter saying whether their children are
While one may argue that it is not the government’s
healthy, overweight, underweight or very overweight.
responsibility to dictate lifestyle, the question stills
Latest figures show that by the time they leave school,
remains, at what point should an individual take
responsibility for his health, and should there be a Labour's secret plan to one in three children is overweight.
financial incentive/disincentive to influence that
lifestyle? send overweight children When it was introduced three years ago, the weighing
programme was met with a backlash from parents. In
to NHS fat camps its first year, more than half withdrew their children
from the scheme, for fear they would be bullied after Margaret Morrissey, founder of family lobby group Dr David Vickers, from the Royal College of
the class weigh-in. Parents Outloud, said it was "unforgivable" to promote Paediatrics and Child Health, said: "It seems to me
schemes which would inevitably encourage that it is more outrageous to tell parents that their child
When families were advised that pupils would not be humiliation to be heaped on those children bused off is overweight then do nothing about it, than to send
told their weights, nor singled out and told to diet, but to fat camps. them a letter and then offer some support.
that data would simply be used by local health
planners to monitor the spread of obesity and to help She said: "This has gone beyond a nanny state, beyond "Children who are overweight are already far more
them set up the right services, participation rates Big Brother." likely to be being bullied, I don't think enrolling them
increased. Last year, nine out of ten children were on these schemes will make that any worse."
measured. "To label young children as overweight because they
are carrying a few extra pounds makes them so Tam Fry, from the National Obesity Forum, said
The new guidance, slipped out to NHS Primary Care vulnerable to bullying, and increases the risk of pupils should be weighed every year, and parents
Trusts in England during the school holidays, orders developing eating disorders, especially among the given detailed information about their body mass
an immediate change of approach. girls. index so they could monitor their child, not a "badly
written letter" filled with alarming warnings.
From this month, pupils whose weight is too high – or "Obviously it is unfortunate if parents feed their
too low – will automatically be offered a referral to children badly but this Government appears to have Even if a child is just one pound overweight, parents
"weight management services" in areas which already forgotten that we do not live in a dictatorship." receive a standard NHS letter alerting them of an
run such programmes or can set them up quickly. increased risk of cancer, diabetes and heart disease.
Susan Ringwood, chief executive of eating disorder
Existing NHS schemes range from 12-week weight charity Beat, said she was "deeply concerned" that Latest figures show that by the start of primary school,
loss courses taking place at weekends and on school sending children to weight loss classes would increase 23 per cent of children are overweight, rising to 33 per
nights, to six-week residential courses costing £3,000 the risk of bullying, which could trigger conditions cent by the time they leave.
a patient for the most obese. like anorexia in the most vulnerable.
If current trends continue, more than half the adult
All PCTs have been "strongly encouraged" to have She said: "Children can be cruel, they exploit the population will be obese by 2050, while spending on
children's weight management services in place by weaknesses they find and we know that those who are obesity will rise sevenfold, according to Government
next September, so that every overweight child in bullied about their weight are more likely to develop forecasts.
England can be referred for diet and exercise sessions. disorders".
Currently, just a handful of PCTs automatically offer
Those identified as obese may be sent to paediatricians But paediatricians said the scale of the obesity crisis pupils a place on slimming programme if the school
for specialist treatment, drugs or even surgery. facing Britain meant that the drastic action being weigh-in finds they are overweight.
introduced by the Government was necessary.
They include Nottingham City PCT, which runs a https://www.telegraph.co.uk/news/health/ne "I constantly asked myself 'what am I doing wrong?'"
scheme which offers overweight pupils a place on a
12-week "Go 4 It" course which children and parents ws/6142249/Labours-secret-plan-to-send- It's a good question. Just over 33% of 11-year-olds are
attend twice weekly, to take part in fitness sessions, now overweight or obese and among four and five-
and quizzes and games about nutrition, cooking and overweight-children-to-NHS-fat-camps.html year-olds it's 22%, according to the most recent
exercise. figures from the National Child Measurement
Programme, which assesses the height and weight of
Richard Warsop, from Nottingham, is one of the primary children in England. The figures are similar in
children who has benefited from the scheme. By the Child obesity: Why do Wales, Scotland and Northern Ireland.
age of 12, Richard weighed 10 and a half stone.
parents let their kids get New research published today by the University of
With a height of 5 foot 2, that made him obese, Oxford also suggests that obese children and
according to charts of Body Mass Index – a fat? adolescents have several risk factors for heart disease,
recognised way of measuring how healthy someone's including raised blood pressure and cholesterol,
weight is compared to their size. The health risks for obese children may be even compared with normal weight children.
greater than previously estimated, new research
For years he had been bullied about his weight, suggests. So why do parents let their children get fat? Obesity experts say parents are struggling with a
culminating in an incident in which his nose was multitude of problems when it comes to their child's
broken. The recent start of the new school year was greeted weight. They range from a lack of education about
with reports of a dramatic rise in demand for extra- food, limited cooking skills and limited money to buy
In the year since being referred to the Nottingham large uniforms for primary school pupils. healthier food to longer working hours and marketing
scheme, he has lost two stone, while he has grown to 5 campaigns for junk food aimed at kids.
foot 9. It came as no surprise to Carol. Her two nieces were
wearing size 14 skirts by the age of 11, the average But the more sedentary lives children now lead is also
His mother Alison says the boost to his self esteem size worn by a grown woman in the UK. creating huge problems. Last week a study suggested
from meeting other children in the same situation that up to 75% of junior school children preferred to
made the biggest difference to her son, who is now far Her son also struggled to find a uniform big enough at stay at home than go to their nearby park.
more active, while the lessons for parents about health secondary school as his weight crept up to nearly 20
and nutrition opened her eyes to the family's unhealthy stone (127kg) in his teens. My mum wasn't the problem
lifestyle.
"You do feel judged by other people when your child My problems started when I was between five and
gets to that size, but the harshest critic is yourself," seven. When I was younger everyone said I had puppy
says the mother-of-two from Birmingham.
fat and I would grow out of it - I didn't. By my teens I Katy's son weighed over 23 stone (147kg) by the age "complicated relationship" with food herself, she says
had a serious weight problem. of 15. She knew the reason - he ate too much and did she used it to bond with her daughter.
too little exercise. She says she tried to help him but
People blame parents but my mum did everything she things only changed after he decided to help himself. This starts with 'clean your plate' syndrome - my mother
could she could to control my weight. put down huge portions and made us carry on eating long
"A lot of his eating habits were out of my control," after we were fullClaire, Nottingham
I was very good at convincing myself and others that I says the mother-of-two from Buckinghamshire. "He
wasn't eating very much. I would skip breakfast and would eat too much when he was at school and then Childhood obesity: 10 of your stories
lunch but make up for it at dinner. Sometimes I would come home and eat whatever was around, even cook
secretly eat through the night. big meals for himself. He wouldn't wait for me to get "We would snack together in the evening while
home and make dinner. watching television and treat ourselves with sweets
My mum would give me a good dinner because I said and puddings. It was like our special time together,"
I hadn't eaten all day. She didn't want me to over eat "I know I am not completely innocent when it comes says the mother-of-one from Shrewsbury.
but she didn't want me go without either to his weight. I have always struggled myself and have
some bad eating habits, but I tried hard to change the "I could see she was carrying a few extra pounds but
Stacey, once over 25 stone (159kg) way we both ate." she seemed happy. I didn't want to mention it because
I didn't want her to feel negative about herself.
What are the health risks of obesity? The turning point came on a holiday last year to the
US. Her son was too big to go on certain rides at a "When she started secondary she was almost 14 stone
Is this the ultimate healthy meal? theme park. Upset and humiliated, he went on a six- (89kg) and by then her bad habits were hard to break. I
week weight-loss camp and lost nearly three stone know I am responsible and I feel awful about it."
Watching TV was one of the most popular activities, (18kg). The camp was run by Wellspring UK, one of a
with 89% saying it was how they liked best to spend number of firms offering camps in the UK. Despite the rise in child obesity, experts say it's wrong
their time away from school, according to researchers to just blame parents.
Lightspeed. In July, scientists from University of "He had always refused to go before but now he
Montreal claimed every extra hour of television that a wanted to. He is a different child now, so happy and "They definitely have a responsibility, but the issue is
toddler watches each week adds to their waist size by confident. Before he had no self esteem and would much broader than simply blaming them," says Paul
the time they turn 10. have temper tantrums. His whole attitude to food has Gately, professor of exercise and obesity at Leeds
also changed, he now picks the right stuff to eat." Metropolitan University. He also runs weight loss
While the problems parents face might be increasing camps for overweight children.
so is evidence about the dangers of obesity. So why do Some parents know they are a bigger part of the
they let their children get so fat? problem. Tracey says she allowed her daughter to pick Many parents don't realise their child is fat when it
up her own bad eating habits. Admitting to having a might be obvious to other people, he says. According
to studies, 75% of parents underestimated the size of same problems. She felt very isolated and alone in her Statistics about weight-loss camps are hard to come
an overweight child, while 50% underestimated the issues." by. Campers often do not keep in touch with camp
size of an obese child. directors, nor do they always respond honestly to
Alexis, who is known as Lexi, spent eight weeks at questionnaires.
http://www.bbc.com/news/magazine- Camp Shane, in Ferndale, N.Y., and lost 25 pounds.
She has kept off every ounce since. But of the 1,000 campers who will weave their way
19661085 this summer in and out of Tony Sparber's three New
Continue reading the main story Image camps in Florida, California and the Pocono
Mountains in Pennsylvania, more than half are repeat
This is a big deal. customers. The figure is about the same for the 800
For Overweight campers heading to Camp Shane in the Catskills.
It is easy, after all, to lose weight in a controlled
Children, Are 'Fat environment, but it is a different story when you are "Maybe they're not losing the weight specifically, but
back home and faced with temptations like pizza and instead they're learning something that they can use 20
Camps' a Solution? ice cream and get little to no exercise. So it's not years down the road and put into use when they're
surprising that many children who attend weight-loss ready," said Marla Coleman, a former president of the
Two summers ago, Alexis Werth Mason was 12 years camps regain the weight. American Camping Association.
old and weighed 133 pounds. Not huge, but at 4-foot-
11, she was heavier than she wanted to be. "Coming home from camp was hard," Lexi, now 14, Ms. Coleman added: "It's education. Knowledge. It
said. "I knew what I had to do, but I saw everyone goes to everything camp does, which is experiential
Shopping was painful. Classmates teased her. A eating at school. When you see all your friends learning."
neighbor told her that she was too big to pull on his pigging out and watching old movies and crying and
sled. After desperately trying -- and failing -- at diets, stuff, you want to join in. It's peer pressure. So I ate in Perhaps more important, Ms. Coleman said, camp
her mother, Bonnie Werth, asked if she wanted to go moderation." gives children a reprieve from weight gain and the
to a weight-loss camp. torment they often experience back in the real world.
Thousands of young people will be spending this Many play sports for the first time, and have social
"She said, 'I can't go to a fat camp, Mommy, all the summer at weight-loss camps, a popular option for lives.
kids will make fun of me,"' Ms. Werth, the president parents who have no idea how to inspire their children
of Team Services, a marketing firm in Woodbury, to shed pounds. It is a slowly growing industry. But that is not always the case. Danielle Rothman,
N.Y., recalled. "But I convinced her to go." Nationwide, there are about a dozen camps devoted now 17, spent three summers at Camp Shane.
strictly to weight loss, four of them opened in the last "Everyone at Shane was overweight, yet people were
"It wasn't so much the weight loss," Ms. Werth said, year. But whether they work remains unclear. still being made fun of about their weight," said Ms.
"but I wanted her to be around other kids with the Rothman, who lives in Dix Hills, N.Y.. "The more
overweight kids are still made fun of. I was one of the or the death of a parent. They could trace the weight "Self-control is a process in behavioral terms --
thinner kids, and people would say, 'Why are you gain back to that. It was a big responsibility for the keeping track of target behaviors and systematically
here?' It made me feel good, but after a while I wanted counselors, none of whom was really equipped to deal evaluating these behaviors and goal setting," said Dr.
to hit them." with it." Daniel Kirschenbaum, a professor of psychiatry and
behavioral sciences at Northwestern who helped
Weight-loss camps usually run for three weeks, six One of the more promising programs is offered by the design the program, but has no financial involvement
weeks or eight week sessions, and they cost about two-year-old Wellspring Camps, which operates in the camps.
$7,500 for the entire summer -- about $1,500 more Camp Wellspring, near Lake Placid, N.Y., for young
than nonspecialized camps. Campers get about 1,500 women ages 14 to 22; Wellspring Adventure Camp Dr. Kirschenbaum said self-control could be taught
calories a day, and campers generally spend three to near Asheville, N.C., for boys and girls 11 to 16; and like any other skill through instruction, modeling and
four hours a day doing some kind of physical activity, Western Wellspring Adventure Camp in California, encouragement.
as well other activities like drama or arts and crafts. for boys and girls 13 to 18.
There are weekly weigh-ins and regular classes in So far, the camps have had encouraging success. A
nutrition and cooking. Unlike traditional weight-loss camps, Wellspring uses recent study by Wellspring found that 91 percent of all
a cognitive behavioral approach. Campers set goals its campers had maintained the weight or continued to
Most camps offer sessions for campers to explore their and monitor themselves, techniques that are lose six months after camp ended; the weight loss
feelings about food and weight. But critics worry that components of behavior modification, one of the most afterward averaged 7.4 pounds. The camps plan to
the camps are not run by people who have the widely accepted approaches to long-term weight-loss continue tracking campers' long-term weight loss to
necessary credentials to handle children with serious success. try to persuade health insurers to cover the programs.
emotional baggage, and that the sessions are too short
to change a lifetime of bad habits. Each camper is responsible for her own eating and Still, those involved agree that the most significant
exercise habits. At meals, for example, campers get factor for success is the level of parental involvement
Teresa Guerrero worked at a camp in Southern "controlled" foods, like measured entrees and dessert, once camp ends. It is not enough for the child to return
California in 2003 and 2004, where she was a and "uncontrolled" foods: berries, melons or fat-free home from 30 pounds lighter if the household does not
guidance counselor. soups. They can eat as much of the uncontrolled foods change as well -- whether that means eliminating junk
as they want, but they have to jot down the calories foods or encouraging exercise.
"There were a lot of very messed-up kids," said Ms. and fat grams in a journal, with the goal of staying
Guerrero, 26, who is a doctoral candidate in clinical under 20 grams of fat and about 1,200 calories a day. "The people who are successful are the parents who go
and school psychology at Hofstra. "The majority of the extra mile and are observant and watch their kids,"
them were compulsive overeaters." They use pedometers and are told to aim for a said Tony Sparber, 48, who has been in the industry
minimum of 10,000 steps a day. The overall goal is to for 25 years.
"A lot were medicated, or ate out of boredom, or cut change eating habits and make new ones.
themselves," she said. "A lot had experienced divorce
Although all camps offer lectures for parents on discuss what Lexi can eat. The two shop together, read Most important for Lexi, nothing tastes as great as thin
visiting day, only a few show up, organizers say. labels, prepare menus and cook. feels. And that kind of motivation is something that no
diet or weight-loss camp can instill in a person.
After camp ends, a New Image nutritionist calls "People don't have time to sit down to home-cooked
families each month. Every two months they receive a meals, and they're so busy they get Big Macs," said "Last winter my friend couldn't pull me on the sled
newsletter with recipes. But Mr. Sparber Lexi. "At camp I learned that there's 590 calories in because I was too heavy, and I was really upset about
acknowledges that most people do not follow through. one, so we don't do that anymore. Now we cook it," Lexi said. "This year, I went to his house and he
"It starts out strong, and as time goes on it fades," he dinners because I'm conscious of what I'm eating. We pulled me, and that was one of the happiest days of my
said. This year, in an effort to reach more people, he is substitute light or fat-free for sour cream. Even if you life."
adding an online counseling program with a do have a cookie every once in a while, it's not that big
nutritionist, as well as a weight management and of a deal. You work it off." http://www.nytimes.com/2005/06/28/health/nutrition/f
fitness program at the Jewish Community Center in or-overweight-children-are-fat-camps-a-solution.html
Tenafly, N.J. Lexi's mother said, "My fear was that when she lost all

Only about one-third of the campers at Camp

this weight that she would get so obsessive about it
that it would develop into an eating disorder."
PRELIM 2
Wellspring and Wellspring Adventure Camp adhered
to its after-care program, which includes keeping a Ms. Werth continued: "From the day she came home, I Many people want to put their best face
daily online journal for self-monitoring and setting said, 'It's not about leaving all this stuff behind.' The (and body) forward, believing that
goals, and chatting with a behavioral coach by phone minute you deprive yourself of everything you've appearance is the key to success in life,
or e-mail. loved and enjoyed, you will end up compulsively love and at work. This realization has led
overeating. I was trying to create a balance for her and
All of those who followed that regimen, sustained or proving to her that you could have your cookies every men and women to undergo cosmetic
continued their weight loss at the three-month mark, day but in moderation." surgery (or plastic surgery) procedures.
said Ryan Craig, president of Wellspring camps, who Yet, despite an estimated rise in people
is also director of the Academy of the Sierras, a She added, "I signed her right up for Curves, and she going under knife to improve their
boarding school for obese adolescents in Reedley, got on her bicycle and rode to the gym and watched
appearances, cosmetic surgery remains
Calif. everything she's eating."
highly stigmatized and its recipients are
Lexi Werth Mason attributes her weight-loss success Ms. Werth also locks up junk food in a kitchen often deemed “fake.” Many believe that
to two things: her goal of fitting into a two-piece cabinet, and only she has the key. Lexi said she found this is caused by the changing cultural
bathing suit, and her mother. When she first returned that helpful. norm in society in which entertainment,
home from camp, her mother had snack bags full of
pre-cut vegetables waiting for her. Every night they
fashion, and media tend to show cosmetic surgery market1. Proponents argue that the risks may request repeat procedures or experience
inherent in surgery that is not medically necessary are too depression and adjustment problems, social isolation,
particular type of beauty and body. great and that women are merely succumbing to the family problems, self-destructive behaviours and
pressures of men. Opponents, in contrast, argue women anger towards the surgeon and his or her staff2.
This house would fund cosmetic plastic surgery. have a right to choose both how they look and what 1
American Psychiatric Association. Diagnostic and
methods they choose to get to how they look. This debate
Statistical Manual of Mental Disorders (4th ed.).
TH, which is a woman, would not make any will examine whether cosmetic surgery should be banned.1
Cosmetic Surgery,(accessed 8/6/2011) Arlington, Va: American Psychiatric Association
cosmetic changes to her appearance, including but
Press; 2000. available at
not limited to makeup, shaving, and plastic
POINTS FOR http://www.breastimplantinfo.org/what_know/teencos
surgeries
urgery.html (accessed 11/6/2011)
2
Cosmetic surgery can be psychologically damaging. Plastic and Reconstructive Surgery (Vol. 113, No. 4,
THW ban cosmetic/plastic surgery aimed to change
pages 1,229-1,237) (accessed 11/6/2011)
racial features
Point
Counterpoint
THW Ban Plastic Surgery
The compulsion to change one's body is often a
symptom of a deeper mental instability. It should be However, the vast majority of people who have
The distinction between cosmetic surgery and other
types of surgery such as reconstructive surgery is that treated as a problem, not encouraged with surgery. cosmetic surgery have one procedure and never look
cosmetic surgery involves techniques intended for the Research indicating that breast augmentation patients back. They're made happier and more secure in
'enhancement' of appearance. Cosmetic surgery involves are four times more likely to commit suicide compared themselves because of it. In fact, the same study by
both surgical and medical techniques and it is specifically to other plastic surgery patients raises questions about social worker Roberta Honigman and psychiatrists
concerned with maintaining normal appearance, restoring the mental health of women who choose implants1. It's Katherine Phillips, MD, and David Castle, MD, also
it, or enhancing it beyond the average level toward some only a plaster patched over a much deeper problem. suggested positive outcomes in some patients,
aesthetic ideal. Cosmetic procedures have grown in There are also studies that show negative including improvements in body image and possibly a
popularity dramatically, in 2006, nearly 11 million psychological effects on patients after their surgery boost in their quality of life as well1. Therefore, it
cosmetic procedures were performed in the United States has been completed. For example, a recent analysis 37 would be wrong to say that cosmetic surgery can be
alone. The number of cosmetic procedures performed in the psychologically damaging as a rule. Many studies
studies on patients' psychological and psychosocial
United States has increased over 50 percent since the start
functioning before and after cosmetic surgery by have shown that patients have higher self-esteem after
of the century. Nearly 12 million cosmetic procedures were
performed in 2007. In Europe, the second largest market social worker Roberta Honigman and psychiatrists surgery. For example, in a recent study by Sarwer
for cosmetic procedures, cosmetic surgery is a $2.2 billion Katherine Phillips, MD, and David Castle, MD, found found that a year after receiving cosmetic surgery, 87
business. Cosmetic surgery is now very common in several predictors of poor outcomes, especially for per cent of patients reported satisfaction following
countries such as the United Kingdom, France, and those who hold unrealistic expectations or have a their surgery, including improvements in their overall
Germany. In Asia, cosmetic surgery has become an history of depression and anxiety. The researchers body image and the body feature altered. They also
accepted practice; currently most widely prevalent and found that patients who are dissatisfied with surgery experienced less negative body image emotions in
normal in China where it is currently Asia's biggest
social situations2. [1]What you need to know, available at Point
1 Plastic and Reconstructive Surgery (Vol. 113, No. 4, pages 1,229-1,237)
http://www.breastimplantinfo.org/what_know/having_
(accessed 11/6/2011) Only those that can pay for it get it. The most popular
problems.html (accessed 15/6/2011)
2 Dittman, Melissa,. Plastic Surgery: Beauty or Beast? (accessed 11/6/2011) surgeries include breast augmentation, liposuction,
Counterpoint nasal surgery, eyelid surgery and abdominoplasty.[1]
The dangers involved in elective surgery are not worth There surgeries cost between £3,000 and £5000,
the risk The risks of cosmetic surgery are negligible.In actual between £2,500 and £6,000, between £3,500 and
fact, the American Society of Plastic Surgery £4,000 and between £2,000 to £6,000 respectively.[2]
Point estimates that there is 1 death in 57,000 procedures, So if it has the advantages the opposition claims, the
while a study in the medical journal Plastic and rich will look good, and the poor will not.
Sometimes we must accept those dangers, as they Reconstructive Surgery put the mortality rate slightly
come in the course of necessary medical procedures. higher, at about one in 51,459 operations.[1] To put Counterpoint
But with elective surgery– procedures people don’t this in perspective, your chances of being injured in a
need, but rather merely want – the risks can’t be motor vehicle accident are about 1 in 1,000 in any You can spend your money how you like. Why
justified. These risks apply both to the surgery itself, given year and there is about 1 maternal death for shouldn't people be allowed to make the personal
and to the long term. For example, leaking silicone every 7692 live births.[2] Therefore cosmetic surgery choice to change their appearance with their own
breast implants have been a widespread problem and is a lot safer than people perceive. Furthermore, cash? Furthermore, the appearance division the
can lead to death. Silicone gel can leak from the cosmetic surgery is becoming safer and safer. It is proposition seeks to suggest between rich and poor is
implant into healthy breast tissue and go other parts of increasingly strictly policed and sky-high legal pay- much more dependent on quality of diet. Diet is a
your body, such as the lungs and lymph nodes, where outs by bad surgeons have ensured that practitioners universal factor that affects complexion, height, etc.1,
it could be impossible to remove. Studies published in take more and more care.[3] Technology in surgery while cosmetic surgery is a relatively insignificant
2001 by scientists at the National Cancer Institute and in implants and so forth is forever improving. For factor in statistical terms and one that only affects the
raised questions about the long-term safety of breast example, new non-invasive procedures are being particular thing on which surgery is conducted.
implants. One study found that women who had breast 1
developed such as Liposonix and UltraShape Contour. Physical benefits of a balanced diet (accessed
implants for at least eight years were twice as likely to These procedures use focused ultrasound devices 11/6/2011)
die from brain cancer, three times as likely to die from which aim to achieve targeted reduction of fat tissue
lung cancer or other respiratory diseases, and four by focusing ultrasound energy that causes permanent An outright ban would be easier than the partial bans
times as likely to commit suicide, compared to other disruption of fat cells without damage to the that have been enacted in some places.
plastic surgery patients A second study found that epidermis, dermis or underlying tissues and organs.[4]
women with breast implants for at least eight years Procedures such as this would decrease the risk of Point
were 21% more likely to be diagnosed with cancer infection.
compared to other women their age.[1] There is also The state of Queensland in Australia has a ban on
the risk that the person having the surgery will be Cosmetic surgery is unfair, for only those who can teenagers having plastic surgery. This prevents anyone
dissatisfied with the results. afford it have access to it under 18 having cosmetic surgery unless it is to
correct deformities or disfiguring injuries, as well as palate. But your quality of life – your self-esteem, need to look beautiful. For example, in 2003, Teen
allowing for procedures to improve medical, employability, acceptance in a traditional society, etc magazine reported that 35 per cent of girls 6 to 12
psychological or social well-being. This potentially – is much better without one. Following this principle, years old have been on at least one diet, and that 50 to
leaves difficulty drawing the line for what is allowed1. breast reduction or augmentation or the removal of 70 per cent of normal weight girls believe they are
A much more comprehensive ban would avoid this. acne scars can be just as important. For example, overweight.[3] Cosmetic surgery sends the message
Cosmetic surgery is already to some extent regulated. Carole Wrigglesworth's breasts shrank after that the prejudices some have about appearance are
In the UK it is regulated by the GMC and practising breastfeeding baby girls and as her breasts shrank so valid.
surgeons have to be enrolled on its specialist register. did her self-confidence. As a result she opted to have a
At the same time all invasive cosmetic surgery and breast enlargement surgery and reflecting on the POINTS AGAINTS
laser treatments are regulated. A healthcare experience, Carole has absolutely no regrets — “I feel
commission inspects all registered establishments and sexier, more confident and extremely proud of my Banning cosmetic surgery would not prevent it occurring,
can revoke licences. As such it would not be difficult body.[2] better for it to be legal and performed properly
to expand these regulating bodies to be making sure
that cosmetic surgery is only performed when as in The availability of cosmetic surgery increases pressures Point
Queensland it is to correct deformities and disfiguring on women that they must look beautiful.
injuries. If banned, cosmetic surgery will flourish on a black
1 Point market. Of course cosmetic surgery is already
http://abcnews.go.com/Health/BeautySecrets/story?id available on the black market but if banned then
=4694079&page=1 ">, Childs, Dan, Australian State There is considerable evidence that women's potentially all the customers who have legal cosmetic
Bans Cosmetic Surgery for Teens, (accessed attractiveness is judged more harshly than men's. For surgery will become customers for black market
25/8/2011) example, in a study by Adams and Huston, 1975, cosmetic surgery. This will drive the prices up and it
participants were asked to rate the attractiveness of will be much more dangerous as it will be done by
Counterpoint photographs of people of varying ages. They found unscrupulous doctors and outside all the safety
that although attractiveness ratings of both men and precautions the legal environment provides. Examples
The desire for cosmetic surgery is driven not by women declined with age, the rate of decline for such as that of 46 year old Maria Olivia Aguirre-
external pressure to seek the acceptance of men, but women was greater.[1] Researchers report that Castillo died as a result of a black market cosmetic
the internal desire to look and feel better about women’s magazines have ten and one-half times more procedure in which cooking oil was injected into her
oneself. There are many who find that their ads and articles promoting weight loss than men’s buttocks by an unlicensed practitioner who promised a
appearance truly troubles them and that improving it magazines do, and over three-quarters of the covers of cheap alternative to legitimate procedures. After
would greatly enhance their quality of life. Operation women’s magazines include at least one message spending a week in a coma following the procedure,
Smile, which fixes oral and facial deformities found in about how to change a woman’s bodily appearance— Ms. Aguirre-Castillo succumbed to multiple organ
poor children across the world, is doing "cosmetic by diet, exercise or cosmetic surgery.[2] These views failure due to fat embolization, as the oil injected into
surgery."[1] You can survive with a hare lip or a cleft about appearance are damaging because it leads to her buttocks attacked her body functions1. Examples
seriously unhealthy lifestyles that women think they such as this would become much more of a common
occurrence if cosmetic surgery was banned due to the Counterpoint
increase in black market surgeries.
1 The development of cosmetic surgery over the years has It could however be argued that commercialized
Cosmetic Surgery bargains, (accessed 12/6/2011)
been intertwined with that of reconstructive and more medicine will harm society, yet produce little in the
Counterpoint general medical surgery. way of benefits. Non-profit hospitals undertake costly,
but needed, research and maintain services which are
The black market argument applies to everything Point not economically viable but which provide doctors
illegal. Of course that risk exists, but the number of with the training experiences necessary to medical
those undertaking the activity will be smaller, as the Cosmetic surgery has greatly aided reconstructive education. Where profits rule, however, such
opposition suggests by saying that operations will surgery. For example, maxillofacial surgery, or necessary, but unprofitable, research and services
increase in price. Lack of legal safeguards and medical surgery of the jaw, has developed with insights from important to medical education will be neglected.
accountability, and the probability that only badly both plastic surgeons and oral surgeons. The roots of Furthermore, as for-profits come to dominate the
qualified doctors will offer illegal operations will deter oral and maxillofacial surgery lie in the World Wars, health care sector, society will suffer a severe shortage
almost everyone from risking black market surgery. when service personnel sustained devastating facial of unprofitable, but critical, services, such as
Fewer operations must be desirable if it is agreed that injuries1. These grave injuries necessitated new emergency rooms. Meanwhile, scarce resources will
the activity concerned should be banned. Since innovations in reconstructive surgical procedures. It be squandered to produce and aggressively market
discussing the effects of banning cosmetic surgery is was around this time that aesthetic surgery began to lucrative, but unnecessary, services, such as cosmetic
at the present time a hypothetical task, this argument take its place as a somewhat more respected aspect of surgery1.
will cite the prohibition of drugs as an example. A plastic surgery. This progress also brought with it a
2001 Australian study of 18-29 year olds by the NSW greater understanding of anaesthesia and infection
Bureau of Crime Statistics and Research suggests that prevention, allowing surgeons to perform a wider Women have the right and freedom to choose how they
prohibition deters illicit drug use. 29% of those who variety of increasingly complex procedures2. To shut look
had never used cannabis cited the illegality of the down cosmetic surgery would be to cut off a valuable
substance as their reason for never using the drug, outlet for research and discovery. The market can Point
while 19% of those who had ceased use of cannabis sometimes create great benefits: people work hard in
cited its illegality as their reason1. pursuit of profits and often their work can help us all. The freedom to change their body if they wish is
1
NSW Bureau of Crime statistics and research, Does Plenty of people make a good living from normal important to women who have historically been
prohibition deter cannabis use?, (accessed 12/6/2011) medicine and they are not criticised, the same should subjugated by men, their bodies regarded as owned
be true for privately provided medicine: there's and for the use of men. Cosmetic surgery– the ultimate
nothing wrong with turning a profit. control over one’s body, perhaps – is the latest stage in
the emancipation of women and their ability to decide
what happens to their bodies. The French performance
artist Orlan, for example, sees plastic surgery as a path
towards self-determination – a way for women to
regain control of their bodies. Instead of having her Given that the reality is that we're judged on our that something is terribly wrong with his physical
body rejuvenated or beautiful, she turns the tables and appearance all the time, it's perfectly rational to want to appearance and that it needs to be mended. The
uses surgery as a medium for a different project.[1] look good. growth in cosmetic surgery enhances people's
Orlan designs her body, orchestrates the operations perception that there is something wrong with their
and makes the final decision about when to stop and Point body if they don't conform to the ideal beautiful form.
when to go on. She is the creator, not just the creation; It could also be argued that the lengths that women go
the one who decides and not the passive object of Nobody's forcing anyone to have cosmetic surgery– to to try and look good are indeed not rational.
another's decisions that many people view recipients the market is driven by demand. Attractiveness is Cosmetic surgery with its high cost and risks certainly
of cosmetic surgery to be.[2] Feminists have often greatly affects first impressions and later interpersonal does not seem like a rational option3.
envisioned a future where technology has been seized relationships. In a classic study entitled 'What is
for women for their own ends. Take, for example, Beautiful is good', psychologists Kenneth Dion, Ellen Surgery is always a risk.
Shulamith Firestone's Dialectic of Sex (1970) in which Berscheid and Elaine Hatfield asked college students In 2013, Americans spent more than $7 billon on cosmetic
she fantasies a world in which reproductive to rate photographs of strangers on a variety of surgery. From breast augmentation to rhinoplasty,
technology frees women from the chores and personal characteristics. Those who were judged to be procedures to change our appearance are becoming
constraints of biological motherhood. attractive were also more likely to be rated intelligent, increasingly common. But these surgeries don’t come
Counterpoint kind, happy, flexible, interesting, confident, friendly, without risks.
modest, and successful than those judged unattractive
If anything, cosmetic surgery is the latest phenomenon [1]. Teachers rate attractive children more highly on a . If you’re thinking about plastic surgery, it is important
variety of positive characteristics including IQ and you are aware of both the benefits and the risks. Here are
in the long history of the objectification of women in
sociability, and attractive babies are cuddled and some of the most common and most talked about cosmetic
society. In actuality this technology is not empowering surgery complications.
because it is largely used by women who are driven to kissed more often than unattractive babies[2].
1. Hematoma
meet male standards of beauty, exaggerating their
shape and seeking to remain youthful lest their partner Counterpoint
Hematoma is a pocket of blood that resembles a large,
leave them for (often literally) a younger model. A painful bruise. It occurs in 1-6 percent of breast
preference for younger women (which is universally On the other hand, it could be argued that instead of augmentation procedures and is the most common
documented) evolved for men to narrow the range of giving into this reality we should be fighting against complication after a facelift. Hematoma is a risk in nearly
productive mates to those still young enough to bear the culture of unrealistic beauty ideals. Allen all surgeries, and treatment sometimes includes additional
children1. As women's reproductive capacity drops off Ginsburg, a radical writer of the 1960s, said, operations to drain the blood.
dramatically, so do men's ratings of 'attractiveness' for "Whoever controls the media- the images- controls the
her. culture"1. The media constantly conveys unrealistic
1
Goehring, Jennifer, Modern standards of beauty: images of the ideal female body. Every woman has a
Nature or Nurture? An evolutionary perspective unique build and make-up, yet the media always tries
(accessed 11/6/2011) to perpetuate what they believe the universal standard
of women should be2. These convince an individual
2. Nerve Damage 4. Deep Vein Thrombosis and Pulmonary Embolism 8. Anesthesia Complications

The potential for nerve damage is present in many different Deep vein thrombosis (DVT) is a condition where blood Anesthesia is the practice that allows patients to undergo
types of surgical procedures. Numbness and tingling are clots form in deep veins, usually in the leg. When these surgery without feeling the procedure. General anesthesia,
common after plastic surgery and can be signs of nerve clots break off and travel to the lungs, it’s known as where medication is used to make you unconscious, can
damage. Most women experience a change in sensitivity pulmonary embolism (PE). Though relatively uncommon, sometimes lead to complications. These include lung
following breast augmentation surgery and 15 percent these complications can be fatal. infections, stroke, heart attacks, and death. More common
permanently lose nipple sensation. anesthesia risks include waking up confused and
5. Scarring disoriented, and shivering. A less common complication is
3. Infection anesthesia awareness, or waking up in the middle of
Surgery typically results in some scarring. Since cosmetic surgery.
Though postoperative care includes steps to reduce the risk surgery seeks to improve the way you look, scars can be
of infection, it remains one of the more common particularly troubling. Hypertrophic scarring, for instance, 9. Seroma
complications of plastic surgery. In breast surgeries, for is an abnormally red and thick raised scar that occurs after
instance, cellulitis (a skin infection) occurs in 2-4 percent 2-5 percent of breast augmentation procedures. Seroma is a condition that occurs when serum from your
of people. In some cases, infections can be internal and blood pools beneath the surface of the skin, resulting in
severe, requiring IV antibiotics. 6. General Appearance Dissatisfaction swelling and pain. It looks like a large blister. This can
occur after any surgery, and is the most common
Although most people are satisfied with their postoperative complication of a tummy tuck. Because seromas can
outcomes, disappointment with the results is a real become infected, they are often drained with a needle,
possibility. People who undergo breast surgery may effectively removing them, although there is a chance of
experience contouring or asymmetry problems, while those recurrance.
undergoing facial surgeries could simply not like the result. 10. Blood Loss

7. Organ Damage As with any surgery, some blood loss is expected.

However, uncontrolled blood loss can lead to a drop in
Liposuction can be traumatic for internal organs. Visceral blood pressure with potentially deadly outcomes. Blood
perforations or punctures can occur when the surgical probe loss can happen while on the operating table, but also
comes into contact with internal organs. Repairing these internally, after surgery.
injuries can require additional surgery. The perforations The Takeaway
may also be fatal.
As with most surgeries, plastic surgery complications are
more common in certain people. For instance, people who
are obese and the elderly are more prone to complications.
You can reduce your risk of suffering these unwanted
effects by fully vetting your doctor’s credentials and
investigating the facility where your surgery will happen. Facilities: Published data show that accredited office-based appear to increase the risk of DVT. Both DVT and PE are
Educating yourself about the procedure and possible risks, facilities have a safety record comparable to that of hospital unpredictable and can occur outside the surgical setting, as
and discussing your concerns with your doctor will also ambulatory surgery settings. Ambulatory or office-based the result of certain medical conditions or from
help you manage your expectations and reduce the risk of facilities should be accredited by a nationally or state- immobilization; for example, individuals have developed
complications. recognized accrediting agency, or be state licensed or DVT following long airplane trips.
Medicare certified. Postoperative monitoring and home care: In the
RISKS WILL BE RARE IF … Health: Candidates for cosmetic surgery should be in immediate postoperative period, any patient undergoing
When cosmetic surgical procedures are performed by generally good physical health and must be candid with cosmetic surgery should be monitored by qualified medical
properly trained surgical specialists adhering to accepted their physician about any drugs they are taking. The personnel and discharged from the surgical facility only
standards of clinical practice, serious complications are medical history should include hormones (oral after evaluation by the surgeon. Usually, cosmetic surgery
extremely rare. However, no surgery is completely without contraceptives and estrogen replacement) and even aspirin, is performed as an outpatient procedure; occasionally, the
risk. Patient safety is always the most important vitamins, and herbal medications since these substances can surgeon may recommend an overnight stay. Patients should
consideration in cosmetic plastic surgery, and a number of interfere with blood clotting or interact with medications arrange to have someone available for assistance for the
factors contribute to increased safety. The American used during surgery and could increase surgical risk. first day or two following surgery.
Society for Aesthetic Plastic Surgery (ASAPS), the leading Patient education: Before surgery, patients should be BENEFITS
organization of plastic surgeons who are certified by the educated about all aspects of the planned surgery, including Cosmetic surgery or plastic surgery is gaining popularity
American Board of Plastic Surgery and who specialize in whether to discontinue certain medications and stop fast due to its so many benefits and advantages. There is no
cosmetic surgery, offers these safety guidelines for anyone smoking. Postoperative care should be thoroughly doubt about it that what make this kind of procedure
considering cosmetic surgery. discussed with the surgeon, as surgery is not truly over popular are its benefits, safer approach to correct many
Credentials: Selected surgeons should be certified by the until the patient is ambulatory and has returned to a deformities of the body, and faster results.
American Board of Plastic Surgery (ABPS). Any doctor relatively normal routine. Facelifts, breast augmentation, liposuction, etc, are among
(even one from a nonsurgical specialty) can legally perform Risks: Most cosmetic surgery is extremely safe in the the type of cosmetic surgeries that are widely been
surgery. On the other hand, certification by the ABPS hands of surgeons certified by the American Board of performed globally, especially in countries where people
ensures at least five years of surgical training, including Plastic Surgery. However, even with the highest level of can afford higher medical treatment cost. While cosmetic
two years of training specifically in plastic surgery. Patients care, every surgery carries risks as well as benefits, and surgery generously offers its help to correct many
undergoing a cosmetic procedure should select a member these should be discussed thoroughly before surgery is deformities of the body, it doesn’t come cheaply. This is
of the American Society for Aesthetic Plastic Surgery undertaken. For example, multiple procedures performed at something that makes many people just keep planning their
(ASAPS) to help ensure that their surgeon has extensive the same time may increase the risks of surgery. There are budget to undergo such a surgery.
cosmetic surgical experience and has met ASAPS risks associated with anesthesia, analgesics and antibiotics. Benefits of cosmetic surgery can be divided into two,
requirements for continuing cosmetic surgery education. Smokers are at greater risk of complications including physical and emotional. Physical benefits are, obviously,
Hospital privileges: Cosmetic plastic surgery is often delayed wound healing, skin loss, scarring, and poor re-shaping or correcting a deformed part of the body. You
performed outside the hospital in an office-based surgical surgical outcome Other risks include deep vein thrombosis can notice, soon after the surgery, how you get back the
facility. Wherever the surgery is to be performed, selected (DVT) [formulation of blood clots in the veins] and desired or normal shape of a deformed body part, say ear,
surgeons should have hospital privileges to perform the pulmonary embolism (PE) [a blood clot that goes to the nose, breast, etc. You don’t have to wait long to see the
specific procedure in an acute care hospital. lungs preventing the lungs from exchanging air]. Factors result, this is the beauty of cosmetic surgery. When a
such as general anesthesia and prolonged operating time woman undergoes a breast augmentation surgery, she can
soon notice her cup size change, which definitely improves has enough experience, certification and skill to do such THBT SCHOOLS SHOULD TEACH SEX
her body shape and makes her more attractive. The same jobs. Cosmetic surgery or cosmetic treatment done POSITIVE SEX EDUCATION (IE TECHNIQUES
goes with Rhinoplasty or other cosmetic surgery improperly usually results so negatively that makes the FOR SEXUAL GRATIFICATION) IN
procedures, as once the procedure is completed, get the condition still worse. Some people try to save few dollars SECONDARY SCHOOLS.
results immediately. and neglect the criteria of selecting the right surgeon, suffer
Benefits of cosmetic surgery or plastic surgery from the heavily.
THBT Sex Education Should Be Taught At Schools
emotional angle have their own significance. It is quite Moreover, in order to avail the benefits of cosmetic
obvious that once you find your deformed body part has treatments, the patient has another responsibility, to
been brought to its normal shape, or has been made more follow the post treatment instructions seriously. It is Sex education has been taught in schools in a range of
attractive (as it is the case in breast enhancement in essential for you to seriously follow what you would be countries around the world for nearly a century in
women), you start to feel the lost confidence and self- told to do after the surgery or after a cosmetic treatment. various forms[1] it has become a fixture in schools in
esteem coming back and you soon start to behave Taking care of such steps is a sure way to avail the most Western countries. The specifics of the education
differently. Actually, emotional benefits of cosmetic numerous benefits of cosmetic surgery. program vary between countries, but they all generally
surgery are more important than the physical. If you feel deal with the basics of reproduction, physiological
good and different from ‘inside’, the whole world seems to development, sexual health, practice, and safety. In
change around you. The joy, the confidence, and the self- PRELIM 3 recent decades many countries, such as Germany since
esteem, all such plus points very positively affect your
1992 and Sweden as far back as 1956, have made sex
behavior and the pattern of life in general.
Emotional wellness plays an important role in our life. If
Teenagers are already under a great education a mandatory part of schooling, a policy that
you are confident, with self-esteem, and feeling good about uncontrollable pressure due to the new has been met with extensive criticism, particularly
from religious groups. Their criticism is that sex
yourself, the rewards are numerous. This very positively hormones flowing through their bodies.
influences your whole life, which increases productivity education is permissive toward young people’s sexual
and social behavior. This is the most encouraging benefit of Although many believe intercourse relationships and thus morally corrosive.
cosmetic surgery that many people fail to realize until they should be avoided until finding a
experience themselves. significant other bound for life by Opposition also derives from an objection to an
As other benefits of cosmetic surgery, you can get rid of
marriage, it is still important for extension of the state’s involvement into the family
aging signs, a natural process through which everyone has and questions of sexuality.[2] In developing countries
to pass. You can get rid of the visible wrinkles, fine lines, adolescents to be informed about this sex education schemes have developed in part at least
blemishes, etc from your face or from other visible parts of new experience. Sex Education is a to attempt to stem the HIV/AIDS epidemic,
the body. Many such skin flaws make you appear
unsightly, tired or aged. After undergoing the relevant very important part of maturing from a
cosmetic treatment, your appearance will become younger, teenager to an adult. Its medium varies Although some religious groups have opposed these
developments. In western nations however
healthier and fresh. from off line teaching to on line
Benefits of cosmetic surgery or cosmetic treatments are
many but to avail them and also to avoid any undesirable interaction. sex education is not always mandatory, in England
results or complications, you have to find a surgeon who and Wales for example parents can refuse to let their
children take part in some although not in all lessons not talked about and kept behind closed doors, young Adults need to offer guidance about negotiating a way
which provide information about sex and people are forced often to grope around in the dark, so through the messages about sex which proliferate in
reproduction.[3] Proponents of mandatory sex to speak. This can result in unwanted pregnancies, and the mass media and consumer culture.[6] Underlying
education highlight the benefits it provides in delaying even STDs, some of which can be permanent, a threat this discussion is controversy about what sex
the age of first intercourse, preventing sexually to fertility or even life threatening. IT leaves young education should be. Sex education has become a
transmitted disease and teenage pregnancy and in people confused.[2] The state thus owes an obligation shorthand term for the broader subject of personal
providing useful information for life regarding to its citizens to prepare them adequately for their relationships , sexual health and education about
sexuality and sexual expression. Opponents contend interactions in society, including those of a sexual sexuality[7] it is clear that views about what sex
that sex education encourage early sexual relationships nature. education should be and what it should contain has
and the risks which attend that and should be the changed significantly over time.[8]
purview of parents, and that forcing it to be provided A mandatory sex education regime serves as a defence
in schools undermines trust in the education system against misinformation about sex. Religious High quality sex education should not only contain
and harms the individuals’ relationship with the state organizations, most notably in the United States, factual information about the physiological issues of
promote abstinence by lying about the effectiveness of sexual development and reproduction. It should also
Points for contraception and about the transmission of STDs.[3] offer safe spaces for young people to consider the
When such activity is not countered by a scientific social and emotional aspects of sexuality and the
Sex education provides “Immunization” against explanation of sex and sexual practices a culture of social and peer pressures that arise in youth cultures.
sexually transmitted diseases and prevents ignorance develops that can have serious negative
unwanted pregnancy social and health effects on those who are Counterpoint
misinformed. An example of the benefits of sex
Point education is highlighted in the case of the United Sex education is not necessary to protect children from
States. In primarily liberal states where sex education disease and unwanted pregnancy. Young people can
It was said at the beginning of the HIV/AIDS is mandatory, young people are statistically more be informed of the dangers of sex without sex
epidemic that the only vaccination against the virus likely to be sexually active. At the same time in states education. Besides, if enough people are versed
was knowledge. Knowledge about what is out there is where sex education is banned or deliberately extensively in sex education they should provide
essential to guarding the self. There are a several of misleading, teen pregnancy rates are much higher.[4] sufficient herd immunity that the minority who object
ways in which this knowledge is essential; finding out Clearly the trade-off between high promiscuity rates on ethical grounds can abstain from sex education
about the risks of sex is just one, having accurate on the one hand and much higher rates of teen without negatively effecting the overall amount of safe
information about the pleasures as well as the risks is pregnancy and STDs on the other stands in the favour sexual practices in a society.
another.[1] Knowledge also prevents misinformation. of sex education.

Young people must be informed about sex, how it Young people live now in a society which is very
works and what the risks associated with it are, and sexualised[5] it has been described as a carnal jungle.
how to access the risks and the pleasures. When sex is
A safe framework for understanding sexuality and Understanding one’s sexual identity is an exploration STD treatment and teen mothers. People dropping out
sexual identity are essential to human existence that must be pursued at one’s own pace, not at the rate of school due to pregnancy, and individuals who are
mandated from the state or school. Children mature unable to work due to debilitating venereal disease
Point physically and emotionally at very different rates and impose a steep cost on society. It is thus the state’s
mandatory sex education which offers the information duty to provide what parents often cannot for the sake
Sex and sexual identity is fundamental part of human and the emotional guidance at the same rate to of society as a whole.[2]
life. Sexual desire, for both procreation and recreation, everyone is not well tailored to the different
forms one of the core human drives that shapes development rates.[1] Leaving sex education in the hands of parents has the
behaviour.[1] Young people want to explore their own, further negative impact of normalizing incorrect or
and one another’s, bodies from quite an early age, Parents cannot be guaranteed to provide a suitable bigoted views regarding sexuality. Homophobic
long before they would be likely to settle down and amount of sex education families, for example, will not be able to provide the
get married. Sex for almost everyone in Western necessary information to homosexual children, who
countries is not something exclusive to marriage, and Point will suffer not only from lack of education, but also
most people have multiple sexual partners in their from a lack of sexual self-worth.[3] Mandatory sex
lifetimes. In order to face this reality, young people Parents have a great deal of responsibility in raising education can right the wrongs of such misinformation
must be armed with the knowledge of what sexual children, but they are unsuited to teaching about and bias.
intercourse entails and the pleasures and the risks sexuality as the resulting education will not be
inherent in it.[2] Sexual identity itself can be very consistent, be biased and in some cases may not be Counterpoint
confusing, especially for young homosexual or carried out at all. Parents tend to view their children as
transgender people who may not understand their less sexualized; they want them to be innocent. Thus it Parents know their children better than anyone. They
sexuality. A safe, objective environment in which the is often the case that parents seek to shield their know what s/he is like, and in what environment s/he
objective physical facts and the emotional aspects of children from the realities of sex, and themselves from will grow up and often live. The state is not infallible
sexual involvement and activity is provided is the young person’s developing sexuality maintaining and its decisions are not purely objective. When
essential to facilitate young people to come to grips their innocence through enforced ignorance. This children are not adequately mature for sex education,
with sexual identity as it is essential for full tends to be particularly harmful to young women, as parents must have the ability to make the decision on
development as a person. culturally boys are often expected to be more sexually their behalf to withhold information that could be
active than girls, and such activity is usually potentially damaging to their future development. As
Counterpoint considered appropriate for boys, while not so for girls. to homophobic or bigoted families, such views are
A double standard undoubtedly continues to exist.[1] It considered to be socially acceptable insofar as people
Sexual identity is confusing in any situation. It is in the interest of the state, however, to produce well- have the right to express such views. This does not,
becomes even more confusing when one is exposed to rounded individuals who can interact with society however, give parents license to abuse their children if
sex education and the broad spectrum of sexual effectively on all levels, including the sexual level. they have alternative sexual preferences. Sex
preference and practice before one is emotionally When parents do not provide adequate sex education,
equipped to understand and appreciate it. it is the state that is forced to pick up the tab to pay for
education is not necessary to ensure against abuse, that intercourse and most certainly does not foster early Parents should have the final choice in sex education
is the purview of law enforcement. promiscuity.[3] The abstinence programmes that have for their children
been developed in the united states in particular have
Even religious and conservative communities will been spectacularly unsuccessful in reducing rates of Point
benefit from mandatory sex education sexual exploration and STD and unwanted pregnancy
rates.[4] Research has made it clear which kinds of sex Parents are the ones who are responsible for their
Point education are most effective.[5] children and they know what is best for their own.
Parents are the people who best know their children;
Communities and organizations that oppose sex Counterpoint they live with them, feed them, understand them, and
education can actually benefit from it. Unfortunately know how and when is best to broach the topic of sex
this is often not appreciated by the communities Sex education does not benefit conservative with their children. Parents are in a very real way the
involved. One argument is that shielding children from communities as sex education is not simply a provider shapers of children’s psyche and development, so their
knowledge of sex and sexual practice is disrespectful of information. Rather, it entails at best an input on a central moral and physical issue such as this
to religion. Religious and moral abstinence is defined acknowledgement that kids will have sex regardless of must be respected. It is a myth that somehow parents
by the decision not to have sex, not by the absence of what they are told, and at worst a positive lacks the capacity to deal with an issue like sex.
knowledge of the existence of sex itself. Sex education endorsement of sexual activity. It is a shameful Rather, they are the best suited to it. The fact is that
can even be beneficial to understanding the religious abrogation of responsibility on the part of adults to children generally listen to their parents, or at least
and ethical perspective toward sexuality when it essentially allow children to make bad decisions. Sex consider seriously what they are told by them.
provides necessary discussion of the emotional aspects education encourages students to make a choice, Furthermore, parents are more capable than teachers,
of sexuality.[1] Information simply allows people to meaning more will make the wrong one.[1] Teaching in light of their intimate relationship with their
make fuller, informed decisions.[2] Sex education does children about sex will necessarily make them more children, to discuss the emotional aspects of sex and
not serve to normalize sexual activity and lewd prone to experimentation, and will likely cause them relationships, topics that would become jokes in the
behavior, as religious groups fear, because everything to view their peers in school in a sexualized context, classroom and the subject of ribald humour.[1] It is
in life is already sexualized. One need only watch a leading to less focus in the classroom on study, and better to leave sex education in the hands of parents
typical perfume ad on television to know that sexuality more on sex. Conservative and religious households who can apply the delicate touch.
inculcates popular culture already. Sex education have every reason to fear such developments.
would not lift the scales from the eyes of children Counterpoint
entirely; they already have some idea of what is going Against for
on. The danger is when they know something about Parents do not always know best, particularly when it
sex, but not enough to be safe. That is why mandatory comes to sex education. Parents cannot be trusted to
sex education is essential to people’s wellbeing. instruct children effectively in sex education because
they themselves are often uneducated in the matter and
The research evidence from across the world is clear have personal biases regarding the subject.[1] Often
that sex education holds back the age of first they will not understand the finer points of
contraception and STDs, things that have each This will alienate the parents of these children who is lost. Furthermore, when people are forced to
changed substantially in the past few decades, with hold the view that discussion of sex in such a conform to the set sex education program, they cannot
things like the morning after pill becoming readily framework is morally repugnant. move at their own pace. This is particularly harmful to
available in many countries, and diseases like people who are physically or emotionally less mature
[1]
Chlamydia much more prevalent in populations than Pogany, Sex Smart, 1998 than their fellow students and who would be better
they were in past generations.[2] Parents’ ignorance served if they were allowed to pursue sexual
may thus misinform children to their detriment. The Counterpoint knowledge at their own pace. When other students are
parent may not understand their child best preventing involved in the classroom, there is necessarily a
their children from ever developing a meaningful A disagreement over sex education will not alienate degree of peer pressure, which places a further strain
understanding of their sexuality. Such is the problem someone, whether child or parent, from the entire on the later bloomers of the class to conform and
for gay children raised in homes that say being gay is education system. Students can differentiate between experiment sexually before they are ready.[1] Another
sinful and unnatural.[3] With the only authority figure contentious aspects of education like sex education example is the case of gay and gender dimorphic
on the subject he knows telling him he is defective, a and the general education over which parents, students who will be left isolated within the class,
gay child is left to suffer and wallow in self-loathing. teachers, and state do not disagree. Both parents and even singled out as different, in a way that may not be
teachers will be able to explain the reasons for the conducive toward the promotion of understanding and
Sex education damages the education system difference in teaching in cases where the student is acceptance. Teachers cannot cater their lessons to
taught different things at home and in school. Saying every single student, and thus students with less
Point that just because one issue is contentious all of conventional sexual preferences and identities are left
education is ruined is merely alarmist. without meaningful engagement in the classroom.
Sex education damages the education system by
confusing the children and by alienating some parents. Sexual development is a process of gradual discovery [1]
Pogany, Sex Smart, 1998
When children receive mixed signals from home and and cannot be effectively taught in a classroom
at school they can suffer real confusion. When parents Counterpoint
tell their children that the teacher is wrong about sex, Point
it causes the student to raise his mental defences While certainly there should always be room for self-
toward the school thereafter and become less engaged Having a one size fits all sex education system cannot exploration in sexuality, a set mandatory curriculum is
in the process of education.[1] Children will be told by effectively deal differences within classes. Sexual essential to understanding the basics of sex and
their parents, and will thus come to believe, that the experience is a gradual process and cannot be offering opportunity to consider the emotional and
school is promoting a liberal view that is meaningfully taught in the structured environment of social aspects of it in the cultures of young people.[1] It
fundamentally contrary to their own. For example, a the classroom. People must discover much about their is unfortunate that some students may feel unprepared
Muslim girl will find schooling a horrific and own sexuality, through experimentation and self- to undergo sex education, but the value of the
alienating experience if she is forced to attend a sex exploration. By trying to impose a strict curriculum information outweighs any potential discomfort.
education class that conflicts with her faith as this will that explains sexual processes and practices along set Certainly there is nothing so scarring about the nature
be clashing with what she has been taught at home. guidelines, much of the opportunity for self-discovery
of sex that someone who is a bit immature cannot sexuality in a way that is not seen as a joke by often- any normative judgment regarding sexual practices,
handle with some effort. We need also to have some immature students. Inevitably teachers’ personal but rather provides the necessary information and the
confidence in the abilities and sensitivities of our opinions on sexuality will bleed into their teaching, as space to consider the emotional and social issues
teaching professionals to be able to respond with will that of the state officials that set the teaching involved to make informed choices about sex.
effective sensitivity to the different needs of their standards for the subject. In this way there is always a
[1]
students in the classroom situation. This means that normative judgment in sex education that will be seen Plummer, Sexual Cultures, Communities, Values
we need properly trained teachers to be delivering sex as the state mandating certain sexual behaviour and and Intimacy, 1996
education and teachers themselves have asked for this practice. This fundamentally attacks the rights of
[2]
to be the case. individuals to develop their mode of sexual expression Foucault, Studies in governmentality, 1979.
independent of the nanny state’s instruction and can Throughgood, Sex Education as Social Control, 1992
The research evidence does make it clear that young irrevocably harm peoples’ sexual identity.
people are at varying stages of maturity when they are
at the same chronological age. Young men may lag [1]
Lord, Condom Nation, 2009 Should Sex Education Be
behind young women and act with considerable
immaturity in sex education lessons.[2] The effective Counterpoint Taught in Schools?
answer to this may be to offer single sex lessons in sex
education rather than removing the opportunity for sex This argument is based on a particular view of the By Peter DeWitt on June 4, 2015 6:52 AM
education from all young people. state and its role in society.it is a view of the state
which is particularly innocent of and which fails to Thinking about sex education conjures up all of those
The state has had no historical role in sex education acknowledge the range of cultural messages relating to uncomfortable moments as an adolescent when we
to no ill effect, so should it develop one now. society and sexuality[1] which are broadcast had to sit at our desks and listen to our health teachers
hegemonically although not entirely openly by the talk about things that we joked about with friends but
Point state.[2] The state does have a role in sex education. It never wanted to have a conversation about with adults.
has taken an ever more holistic view of young citizens, But things have changed a lot since then.
Sexuality should not be within the purview of the and this is reflected in schools whose remit stretches
state. The state maintains order and security and not just to the academic education of students, but to There has been an increase in the number of LGBT
provides essential services. Sex education does not fall the preparation of young people for the full spectrum students who have come out while in high school, or
within its responsibility. Sexuality is for many people of activities and responsibilities they will face in adult sometimes, even middle school. We are surrounded
deeply personal and should be respected as such; life. Sexual interaction is a fundamental part of that images that inspire conversations about sex education
young people should be allowed to explore their life. Schools have evolved far beyond the provision of and other images created by fashion that offer so much
sexuality independently and with the guidance of skill in reading, writing, and arithmetic, and this skin that there is nothing left to the imagination.
family, not under the watching eye of the state.[1] Sex should be reflected in such programs as sex education.
education programs reduce sexuality to biology and The state does not in mandating sex education make AVERT defines Sex Education as
fail to adequately address the emotional elements of
"the process of acquiring information and forming 7. teaches young people how to reject sexual education (20 of which mandate sex
attitudes and beliefs about sex, sexual identity, advances and how alcohol and drug use education and HIV education).
relationships and intimacy. Sex education is also increase vulnerability to sexual advances, and  33 states and the District of Columbia
about developing young people's skills so that they 8. teaches the importance of attaining self- require students receive instruction
make informed choices about their behaviour, and feel sufficiency before engaging in sexual activity." about HIV/AIDS.
confident and competent about acting on these  19 states require that if provided, sex
choices." Advocates for Youth also believe, education must be medically,
factually or technically accurate. State
First and foremost, there is a debate between the use "Accurate, balanced sex education - including definitions of "medically accurate"
of sexual education programs, where they openly information about contraception and condoms - is a vary, from requiring that the
teach about sex and prevention, and abstinence-only basic human right of youth. Such education helps department of health review curriculum
programs, which Advocates for Youth say, young people to reduce their risk of potentially for accuracy, to mandating
negative outcomes, such as unwanted pregnancies and that curriculum be based on
1. "has as its exclusive purpose teaching the sexually transmitted infections (STIs). Such education information from "published
social, psychological, and health gains to be can also help youth to enhance the quality of their authorities upon which medical
realized by abstaining from sexual activity; relationships and to develop decision-making skills professionals rely."
2. teaches abstinence from sexual activity outside that will prove invaluable over life. This basic human
of marriage is the expected standard for all right is also a core public health principle that Many states define parents' rights concerning sexual
school-age children; receives strong endorsement from mainstream medical education:
3. teaches that abstinence from sexual activity is associations, public health and educational
the only certain way to avoid out-of-wedlock organizations, and - most important - parents."  37 states and the District of Columbia
pregnancy, sexually transmitted diseases, and require school districts to allow
other associated health problems; But is it the job of teachers in schools to educate parental involvement in sexual
4. teaches that a mutually faithful monogamous students about sex or is it the job of the parents? education programs.
relationship in the context of marriage is the According to the National Conference of State  Three states require parental consent
expected standard of sexual activity; Legislatures, before a child can receive instruction.
5. teaches that sexual activity outside the context  35 states and the District of Columbia
of marriage is likely to have harmful All states are somehow involved in sex education for allow parents to opt-out on behalf of
psychological and physical side effects; public schoolchildren. their children.
6. teaches that bearing children out-of-wedlock is As of Jan. 1, 2015:
likely to have harmful consequences for the Of course, if it's taught in schools, how properly are
child, the child's parents, and society;  22 states and the District of Columbia the students being educated? This debate between
require public schools teach sex whether it's the school's job or a parent's job will last
for a very long time, and quite frankly it is an area that Listening to the story made me blush a little as I drove This House Would Promote Safe Sex through Education at
many parents and teachers may agree. There are alone in my car through Massachusetts, and made me Schools
parents who do not want their children to be taught sex laugh a bit when Solow said that when she was a
education in schools, just as there are some teachers student her sex education class was taught by the This discussion starts from the point of view that
who don't think it is their job to teach it. physical education teacher and revolved around sexual education classes should be given at schools.
spelling tests. But does this mean that so-called “safe sex” should
On the other side are parents and teachers who agree it also be promoted within these lessons? Safe sex is the
should be taught in schools and at home because it is a Yes, spelling tests. She said, practice of sexual activity in a manner that reduces the
topic that we all cannot escape. And I'm sure there are risk of infection with sexually transmitted diseases
a bunch of people in the middle who do not even want "I definitely had spelling tests as a big part of my sex- (STDs) such as Chlamydia and HIV/AIDS, typically
to discuss the topic at all and just hope for the best. ed when I was in middle school: 'Spell gonorrhea. by use of condoms. Safe sex also includes sexual
Spell gonococcus. Now you pass or don't pass health.' practices that do not involve penetration.
NPR Literally, that was what was prioritized."
Traditionally sexual education lessons have focused
The NPR story, called Beyond The Birds And The She wants her students to have a much more on covering the biological facts about human
Bees: Surviving Sex Ed Today (which can be heard knowledgeable experience, and she also explores reproduction, and warnings against unsafe sexual
here) inspired me to think about all of the places that topics that are unfortunately still controversial in practices. Often today sex education is combined with
the topic of sex comes up in conversation. Sometimes today's schools, which is the topic of LGBT students. relationships education, in an attempt to place sex in a
it's through jokes on television or social media, other In the NPR story, Garsd writes, broader emotional, social and family context. But now
times it's in stories on the news, and most times it's the every day more and more people talk about “safe sex”
center of the conversation on the back of a school bus. "Beyond the basics, Solow is delving into topics that and how teenagers should be more informed about
Whether it makes us uncomfortable or not, we can't many teachers would skirt. Things like tolerance. protection against STDs.
seem to escape the topic. Solow recently asked her students if they thought
LGBT people would feel comfortable at the school. A Despite the worries some people have about whether
In the NPR story, Lena Solow, a teacher of ten years, lot of the kids say they didn't think so." sex should ever be seen as entirely risk-free, every day
this so-called "safe sex" is promoted more and more as
"Covers the topics you'd expect: how to prevent STDs, It's definitely a complicated debate, which will last for a solution for the epidemic of sexually transmitted
pregnancy. But Solow talks about way more than a very long time. What are your thoughts? diseases amongst teenagers. But what if the promotion
going all the way. "One of my biggest goals as a sex of "safe sex" has the opposite effect for which it was
educator is to be sex-positive," she explains, "to talk THW INCLUDE SAFE SEX IN THE SCHOOL introduced in Sexual Education classes? In 2011 the
about pleasure and to talk about sex not just as SEXS’ EDUCATION proportion of British 16-19 year olds who had had
something that just makes babies." unprotected sex rose to 26% and 45% did not consider
themselves to be well informed about
contraception.[1] Opponents argue that today sexual
education and promoting safe sex are mostly message is invariably confused – on the one hand, by Counterpoint
considered the same thing, while it isn't and shouldn't saying ‘here are the perils of teen sex – so don’t do it,’
be. They say it is one thing to inform teenagers about and on the other hand, ‘here is how to have teen sex Our children are sexually active. They are making
sex and its risks, and quite another to promote and safely.’ decisions that can affect the rest of their lives. They
encourage them to use "safe sex" as prevention. should be able to choose responsibly and be well-
Less moral forms start by saying, ‘the best form of a informed about the likely outcomes. They should
Other issues include whether parents should have the relationship is a loving, constant relationship’ and then know about sources of free or cheap contraception,
ability to ‘opt-out’ of sex education for their children – say, here are the ways to use protection if you’re not in who to turn to when pregnant or if they suspect they
or indeed whether the children themselves should be such a relationship’ – a logic which presumes children have a venereal disease, how to use contraception to
able to opt-out; whether or not sex education should are in sexual relationships to begin with. The avoid both, and, contrary to the impression of
be done with a particular focus (such as promotion of justification for this is that ‘adolescents know all about abolitionists, they should be told the benefits of
abstinence); and whether or not faith schools should sex’ – an idea pushed in our permissive society so abstinence. How can you tell people about that if you
be compelled to teach elements of a sex-education much it’s almost a truism – but contrary to that bland refuse to discuss sex? How can you imagine they will
syllabus (such as on homosexual relationships) which generalisation, many children don’t do these things take you seriously if you turn a blind eye to something
run contrary to their beliefs. early, don’t think about these things – they actually so many of their peers are doing?
have childhoods, and these lessons stir up confusion,
[1]The Guardian. ‘More young people having unsafe misplaced embarrassment or even shame at slower They need an external source of support to resist peer
sex.’ 26th September 2011. development. They also encourage children to view pressure, and have sex later rather than sooner:
http://www.guardian.co.uk/education/2011/sep/26/you their peers in a sexualised context. lamentably, it is presumed amongst many young
ng-people-unsafe-sex-contraception people that having unprotected sex with many partners
The openness with which education tells students to at an early age is the norm and they encourage others
POINTS AGAINTS
treat sex encourages them to ask one another the most to do it (and attempt to humiliate those that don’t). We
Sex education leads to experimentation and early personal questions (have you lost your virginity? – need mechanisms to support those that want to resist
intercourse, and indirectly encourages promiscuity how embarrassing, how uncool, to have to say no), that pressure: sex education is such a mechanism. Sex
and to transgress personal boundaries – all with the education is part of a package of provisions needed to
Point teacher’s approval. Inhibitions are broken down not help our teenagers avoid the terrible pitfalls of
just by peer pressure, but by the classroom. As pro-sex unwanted pregnancy and venereal disease. This
Sex education leads to experimentation and early education people love to point out, children develop in problem is here – pretending that it isn’t won’t make it
intercourse, and indirectly encourages promiscuity. their own time – but that means that some are learning go away. How else do opponents of sex education
The most moral form of Sex Education says ‘you about this too early, as well as ‘too late.’ We in society propose to deal with the huge problems of STDs and
shouldn’t do this, but we know you are,’ thus pushing are guilty of breaking the innocence of childhood, teen pregnancy? Effective and widely supported sex
children to consider their sexual existence before they earlier and earlier – and these lessons are a weapon in education programs can achieve real results. For
need to or indeed should. Thus sex education’s the forefront of that awful attack on decent life. example, in the Netherlands, amongst people having
intercourse for the first time, 85% used contraception the society around them, children who die from drugs themselves undeserving of it. As for the tedious idea
– compared to 50% in the UK. overdoses and whose parents say (honestly), ‘I just that children somehow need the nanny state to look
had no idea.’ It’s time to talk to our young people after their sexuality – who knows children and their
Children are bad decision makers about what they do – honestly, frankly, without needs better than parents? Schools are responsible for
frightening them into dishonesty and deception. To do so much that is wrong with our children, and by giving
Point otherwise perpetuates the cycle of ignorance about them free licence to delve into students’ sexuality,
youth society, and perpetuates the status quo of being things become so much worse, blurring the line
Sex education informs children about sex, and then able to do nothing to change it. between teacher, adviser, confidante, and sometimes
invites them to make a choice. But as demonstrated all in extremes, between teacher and lover – an abuse of
the time, children are bad decision-makers, often Responsibility for children's moral and sexual power that bringing sex into the classroom makes so
choosing what is bad for them. That is why adult upbringing is not the responsibility of schools much easier.
society often needs to decide for them – what they
should eat, what they should watch on T.V., when Point Counterpoint
they are mature enough to be able to choose whether
or not to drink or smoke. Surely sex is just as This is none of the state’s business. Teaching this Parents often know nothing (or worse, are armed with
important as those things – just as dangerous, just as subject en masse in a classroom reduces it to dangerously naive delusions) of the sexual state of
potentially destructive. The abdication of our biological notions, group embarrassment and crude their children. The picture painted by abolitionists is
responsibility in the sexual arena is shameful; we jokes. Furthermore, children have never needed this inaccurate – the process of deciding what is taught in
should be unafraid to simply tell children this is from the state: left alone, they learn from their family schools involves parents’ groups and school governing
something they cannot do, aren’t mature enough to and surroundings and grow naturally into adults bodies on a school-by-school basis, so parents do have
consent to yet – a responsibility we seem to shrink without the state’s involvement. Few things are a role in deciding what is taught. But ultimately, the
from even though it is reflected by the stated aim of responsible for parental disaffection with education state should be involved in educating the whole child,
society enshrined in the law of the age of consent. more than the teaching of sex and sexuality in ways not just in doling out academic ideas – and should
Lessons implicitly lauding the pleasures of intercourse contrary to their wishes. work hard to safeguard sexual health of youngsters, a
are entirely contrary to that aim. field near-impossible to separate from sex education.
Parents have a right to determine the moral
Counterpoint environment in which their children develop and this This is a subject just as important for the development
is a huge intrusion into that right. That moral of young people as the conventional subjects such as
That logic might sound impressive – but it’s the same environment has been manipulated again and again maths and English. The role of ‘teacher’ has to change
one that fails to control underage drinking, underage over the last forty years by a liberal teaching with time. Once, teachers only instructed the children
smoking, the watching of rated movies by those establishment set on undermining traditional values of the well-off or acted as a branch of the church, now
forbidden to do so, the eating of bad food – and and beliefs. Sex education has been a prime weapon in they teach everyone in a secular society. As their role
underage sex. It’s the same poor parental logic that has that social engineering. That tool should be taken changes, they must remain responsible and obey the
seen a generation of children grow up divorced from away from teachers, who as a body have proven
law: thus, the scaremongering of suggesting teachers behaviour, and who may not understand the subtleties Ignorance about sex is the primary cause of the
will abuse their students or lure them into relationships appreciated by liberal educationalists. In any case, so spread of sexually transmitted diseases (STDs)
is irrelevant, as both sides believe that is wrong, and few teachers want to teach this subject that the quality
should be prosecuted. of teaching is awful. Those that do end up teaching it Point
are often the oddest characters in the teaching
Rules banning discussions of sex in schools can deny establishment. Many teachers happy to ‘cover’ other The spread of AIDS in the 80s and 90s showed that
teachers the ability to deal with real problems. When subjects are uniquely embarrassed by this one, or education and information is more important than ever
an individual student comes to a teacher with a object to it on moral grounds and will not do so, as exemplified by the slogan in the British 1980’s
problem, a rule against discussing such things in the leaving it to the most liberal members of staff. advertising campaign to prevent AIDS ‘AIDS: Don’t
classroom will probably mean that this outlet of help Die of Ignorance’. The campaigns were credited with
the troubled adolescent has sought out, often because Counterpoint credited with changing behaviour through warnings on
he feels the family isn’t the place to get help, will be adverts and informing through an information
denied to him, will turn its back on him. Like it or not, Well taught sex education does no such thing. Sex and leaflet.[1] This shows that education can work even
in today’s fractured society teachers have taken on the responsibility classes must tread a fine line, first when starting from scratch. Giving sex education in
role of counsellor, and this rule will indirectly curtail stressing the importance of waiting until ready before schools is crucial to the spread of information to each
their ability to fulfil it. The result of that will be having sex, and pointing to the physical benefits of successive generation, and may be supplemented by
appalling. fewer partners and starting sex later – but must then frank discussion at home.
move on to the reality of modern Britain’s sex-ridden
Sex education for underage children undermines the teen culture, without applauding it, and try to decrease [1] Kelly, Jon, ‘HIV/Aids: Why were the campaigns
law the very high levels of STDs and pregnancy. Yes, successful in the West?’, BBC News Magazine, 28
that’s hard to do – but that doesn’t mean we shouldn’t November 2011, http://www.bbc.co.uk/news/magazine-
Point do it. On the contrary – it’s one of the most important 15886670
duties society faces today. Arguments about poor
Sex education classes for those under the age of teaching apply equally to maths. We often have to try Counterpoint
consent undermines the law. It says, ‘don’t do this – to recruit teachers in unpopular fields – true, difficult,
but given that you are, do this, this and this.’ This but hardly unique. The answer is to improve teacher While a serious disease, AIDS transmission makes up
sends a terrible message about the law – that breaking training, both for new graduates and for practising only a tiny proportion of sexually transmitted
it isn’t serious, that authority (as represented by teachers, and to bring in outside consultants from the infections each year. [1]
teachers) tacitly approves of that illegality, will health and social welfare sectors, who have deep
tolerate it and even encourage it. experience in this area. Firstly the harm of these infections has always been
satisfactorily low before public Sex Education, and
Sex education fails to tell our children clearly what is POINTS FOR secondly even if mandatory public education did have
right and what is wrong. And remember that these are a substantive benefit it would not outweigh the
children, who need clear boundaries to guide their infringement on the moral freedom of the parents.
[1] Health Protection Agency, STI Annual Data Tables psychological and physical harm from having sex too Counterpoint
http://www.hpa.org.uk/web/HPAweb&Page&HPAwebAut young, and should be encouraged not to do so.
oListName/Page/1201094610372 Promoting ‘safe sex’ is implicitly encouraging sex by The problem with mandatory sex education is
implying that it is safe and a normal thing to be doing. precisely that it presents that information in an
Abstinence is an outdated view, based on religious This will encourage young people to believe that there organised fashion – by the state. In doing so the right
teaching, which may be a personal choice but is not is no risk when this is not the case even if they do of the parents to raise their children in accordance
to be expected as the norm for everyone follow the prescriptions they have been taught about with their structure of beliefs is usurped.
sex.
Point Restricting information to children is inconsistent
The information age makes attempting to hide with the age of consent
Young people express their sexuality as part of their information on sex impossible
development to adulthood. It is not having sex that is a Point
problem, but having unsafe sex or hurting people Point
through sexual choices. Refusing to promote safe sex With the age of consent being 16 and with young
would mean not moving with the times. Just because The internet provides a vast amount of easily people being able to vote at 18, it does not make sense
schools do not promote safe sex does not mean that accessible information about sex, of varying degrees for parents to have control over whether their children
adolescents will not experiment with sex. They will of quality. Most children in the west now have access attended sex education classes right up until the age of
already be exposed to sexual imagery and ideas of sex to the internet and are therefore likely to have access 19 or whenever they finish full time schooling.
so it is necessary that they are taught properly how to to this information on sex, or at least educational
remain safe. materials on sex even if the child’s access to the The age of consent means that there is clearly a need
internet is controlled. to be taught about sex from that age of consent. This is
Schools may also want to talk about abstinence at the something that cannot be guaranteed to happen in all
same time; it is a way of keeping sexually safe. Given that it is impossible to prevent children from individual households if left to the parents whereas it
However schools have to recognise that the majority accessing this information if they really want to, it can be ensured in schools.
of pupils are unlikely to stick to abstinence regardless makes sense to present it to them in an organised and
of how much the school promotes it. It is therefore accurate fashion. Rather than allowing children to find Counterpoint
necessary for the school to also promote and educate information on their own through what may well be
about safe sex. unreliable resources it is necessary that they should get True, but nor does it make sense to make the classes
good reliable information. That this information when mandatory once the child reaches an age where it is
Counterpoint there is safe sex education comes from the school legally able to decide whether it wants to partake of
means that the children know that they information is them. Nor does this mean that these classes need to be
To not promote abstinence is not a neutral position, it reliable. They can then use this information to help promoting safe sex rather than simply teaching the
is a position the implicitly encourages sexual them decide how reliable any further information they facts and encouraging abstinence.
promiscuity. Children are at risk of severe may find from other sources is.
PRELIM 4 public that it might work. The first is to weed out side-
effects but the other is that if you give most people a
the study considered by proposition, there are many
sufferers who decide that chemotherapy, a painful and
medicine they will, not unreasonably, expect it to protracted treatment, which rarely yields promising or
Medicine has become a business. New make them better. conclusive results, may well be worse than the disease.
illnesses are being invented. Doctors
are paid according to the number of An entire industry has grown out of alternative Of course there is a cost associated with alternative
their prescriptions and operations. As a medicines. No doubt many alternative practitioners are medicine, although it is as nothing compared with the
well meaning, but this does not change the fact that cost of many medical procedures, notably in the US
result, new illnesses are invented and people are making money out of something that, as far but also elsewhere. There are plenty of conventional
unnecessary surgeries are performed. as anyone can determine, is basically snake oil. practitioners willing to prescribe medications that may
The ultimate goal is no longer health; it not be necessary or, at the very least, select
is turnover. This is an impact of Although many people take both alternative and medications on the basis of financial inducements
established treatments, there are a growing number of from pharmaceutical companies.
pharmaceutical industry in which
patients who reject conventional medical wisdom
medicine is beginning to be bought and (there’s an account of one such case here[i]) in cases Despite legal rulings[i], such practices still take place;
sold in a market, where prices that prove fatal the availability of alternative it would be disingenuous not to explore the extent to
determine outcomes, and where the medicines raises serious ethical and legal concerns, which commercial dealings influence the practice of
not-for-profit, service orientation of and also undermines the stringent regimes of conventional medicine.
monitoring and supervision that qualified medical
health care providers is threatened. professionals are subjected to.. Clearly advice should always be given on the basis of
the needs of the patient. However, there are many
THBT ALTERNATIVE MEDICINE IS A [i] David Gorski. “Death by ‘Alternative Medicine”: Who’s circumstances in which conventional medicine fails to
THREAT FOR MODERN MEDICINE to blame?”. Science-Based Medicine 2008. adhere to this principle. Venality and petty negligence
are not behaviours that are exclusive to the world of
POINTS for alternative therapies.

Many alternative remedies, such as homeopathy, offer Counterpoint Although there are many accounts of the efficacy of
nothing but a false hope and can discourage patients from alternative cancer treatments, not one has been
consulting a doctor with what may be serious symptoms The overwhelming majority of practitioners of demonstrated to work in a clinical trial
alternative therapies recommend that they be used in
Point conjunction with conventional medicine. However, the Point
rights and opinions of the patient are foremost and
There are good reasons why new therapies are tested should be respected. In the case of cancer, since that is The National Centre for Conventional and Alternative
in scientific trials first, rather than just released on the Medicines has spent over $2.5bn on research since
1992. The Dutch government funded research between It is also worth reiterating that there is a massive are many accounts of fatalities caused by alternatives
1996 and 2003. Alternative therapies have been tested financial interest in ignoring, sidelining or – both directly and indirectly through delaying
in mainstream medical journals and elsewhere. Not condemning therapies that pose a threat to the medical accurate diagnosis as seen above (Oh, the same
only have thousands of research exercises failed to establishment. applies to animals too[ii]).
prove the medical benefit ”alternative” treatments for
severe and terminal diseases, serious peer-reviewed It seems incredibly unlikely that people would come The food supplements industry alone is worth $250 a
studies have routinely disproved them. back for more than one dose of a treatment that was year worldwide, with little examination of the medical
having no effect, and yet they do. impact of merrily shoving things into your system that
It’s all well and good to pick at mistakes in individual were bought at WalMart or Tesco.
studies. Indeed, this tactic often forms the mainstay of Overwhelmingly alternative therapies are used in
pleas for legitimacy made by members of the conjunction with established remedies - oddly the Counterpoint
alternative medical community. However, the odds latter tends not to get the credit for the miracle cure
against such consistently negative results would be Statistics for alternatives are difficult to generate as
extraordinary. Point patients will often move between practitioners and
frequently self-medicate.
By contrast, conventional medicine only prescribes Thankfully only 4.4% of the 60million or so
medicines and treatments that are proven, and Americans who say they use alternative therapies rely Clearly there are also conditions that any responsible
vigorously proven, to work. on them exclusively. It is odd that in the cases of practitioner would refer to a specialist in that
anecdotal accounts of the success of alternative particular field.
Counterpoint medicines this statistic is rarely mentioned[i].
However, many people are mistrustful of so-called
Partly the problem here may well be that clinical Equally, the impact of other treatment which may conventional medicine and the alternative medicine
research is simply looking for the wrong things. There have been used by patients eager to credit sector has proven both popular and has often brought
is enough anecdotal evidence of success to at least complementary and alternative medicines with curing about changes in lifestyle as well as direct health
suggest further research – it is worth noting that their conditions, tend not to get a look in, neither do benefits, if anecdotal evidence is to be believed.
there’s no money in many of these treatments so they the relative successes of conventional medicine.
actually get relatively little academic discussion. Responsible practitioners have welcomed the actions
This is probably why in every trial alternative of those governments who have licensed and regulated
A meta-study of the available material on analyses of medicine has a success rate of between 0% and 0%. the Complementary and Alternative sector.
the effectiveness of complementary medicine by the By contrast there needs only be one instance of harm
Cochrane Library found positive or confirmatory caused to demonstrate that this motion must stand. Although science may struggle to explain the benefits
outcomes in 34 percent of those papers it reviewed on Interestingly, although conventional medicine of these therapeutic technics, as they do not lend
the subject. publishes its mistakes in an effort to correct them, themselves to the tools of commercial medicine.
nothing similar exists for alternatives. Moreover, there
Against for Of course it is painful to deny treatment to a patient on Counterpoint
the basis that the medication has yet to complete its
A huge number of fully accepted medical practices trial stage but there is a reason for doing that in that it Absolutely nobody questions that many remedies can
started being seen as something a bit off the wall, it’s allows doctors to be 100 percent sure of a product be drawn from nature- penicillin provides one
wrong to deny sick people access to a treatment that before they’re prescribed. example- but there is something of a jump that
may be mainstream in 20 years happens between chewing on a piece of bark and a
The pharmaceutical and medical industries are regulated dose of a chemical.
Point worth billions of dollars annually. They have an
interest in ignoring the efficacy of remedies that are, Let’s deal quickly with the cost of medications – the
There is a fine line between what is considered for the most part, free or considerably cheaper second pill may well ‘cost pennies’; the first one, by
alternative and what is thought of as mainstream. contrast, costs hundreds of millions of dollars in
Techniques do move across that line and when they do Point research. On the basis that there is probably more than
so, they are seen as mainstream. However, this process one medicine in the world that procedure will need to
of reform, refinement and acceptance takes time. It’s understandable that the medical establishment has be repeated.
an interest in ignoring treatments that are freely
In the meantime it is simply unfair to deny treatment available. Pharmaceutical companies make billions As for the idea that there are older or more traditional
to patients who want it because the medical each year selling drugs that cost pennies to remedies and that these are still frequently used in
establishment is beholden to a conservative academic manufacture. much of the world, that is, indeed true. They are the
orthodoxy and drug and treatment providers with same periods of history and parts of the planet were
vested interests in ensuring that particular cures and There is an enormous vested interest in insuring that the bulk of humankind died – or continues to die –
techniques will continue to be purchased and utilised. the world in general- and the West in particular- agonizing deaths from relatively commonplace
remain tied to the idea that the only solution to disease diseases that modern medicine is able to cure with ‘a
Counterpoint is to swallow a pill provided by a man in a white coat. pill from a man in a white coat’. It is admittedly
There are other solutions that have been used for regrettable that more of the world isn’t covered by the
This comes down to the ‘well it can’t hurt, can it’ thousands of years before anybody worked out how to protection science offers but that is scarcely the fault
approach to alternatives. There is simply no serious make a buck out of it. For much of the world these of science.
medic – or any other scientist for that matter who therapies continue to be the ones people rely on and
would suggest that it’s a good idea to ingest products the rush of pharmaceutical companies to issue patents
that are of dubious origin and purport medical benefits on genes of some of these traditional remedies
without having been tested. In many cases these have suggests that there must be at least some truth in them.
been shown to be at least irrelevant and at worst
actively harmful.
Alternative medical practitioners tend to spend more Unsurprisingly, such a luxury is rare in an A and E Yet despite the pervasiveness, power, and promise of
time with their patients and get a better ward or even in the average GP’s surgery. contemporary medical science, large segments of
understanding of them as a whole, as a result they humanity either cannot access its benefits or choose
are more likely to treat the person than the symptom THIS HOUSE BELIEVES THAT WE SHOULD not to do so. More than 80 percent of people in
developing nations can barely afford the most basic
Point PROHIBIT PUBLIC HOSPITALS TO medical procedures, drugs, and vaccines. In the
industrial nations, a surprisingly large proportion of
Modern medicine tends to treat an individual symptom PROSCRIBE ALTERNATIVE TREATMENT people opt for practices and products for which proof
without putting it in the context of the whole person as to their safety and efficacy is modest at best,
and so will often fail to see it as part of a wider (THE HOMEOPHATIC TREATMENTS, practices that in the aggregate are known as
pathology. complementary and alternative medicine (CAM) or as
ACUPUTURE OR BACH FLOWER REMEDIES) traditional medicine (TM).
Alternative practitioners tend to spend more time with
their patients and so are better placed to asses Much of this book considers the formidable challenges
individual symptoms as a part of the person as a whole to advancing human health through the further
Chapter 69 Complementary and
rather than just dealing with symptoms one as a time dispersion of effective and economical medical
as the crop up. practices. This chapter considers both proven and
Alternative Medicine unproven but popular CAM and TM approaches and
Counterpoint attempts to portray their current and potential place in
the overall practice of medicine.
his is of course an excellent argument for more and The objective of medicine is to address people's
better funded clinics, especially in parts of the world unavoidable needs for emotional and physical healing. With globalization, the pattern of disease in
(including much of the West) where access to The discipline has evolved over millennia by drawing developing countries is changing. Unlike in the past,
medicine is difficult. on the religious beliefs and social structures of when communicable diseases dominated, now 50
numerous indigenous peoples, by exploiting natural percent of the health burden in developing nations is
It is also evidence that when people are genuinely products in their environments, and more recently by due to noncommunicable diseases, such as
worried about their health they tend to consult developing and validating therapeutic and preventive cardiovascular diseases, diabetes, hypertension,
providers of conventional medicine who are, as a approaches using the scientific method. Public health depression, and use of tobacco and other addictive
result, extremely busy. and medical practices have now advanced to a point at substances. Because lifestyle, diet, obesity, lack of
which people can anticipate—and even feel entitled exercise, and stress are important contributing factors
It perhaps says more than anything else about many to—lives that are longer and of better quality than ever in the causation of these noncommunicable diseases,
practitioners of alternative medicines that they have before in human history. CAM and TM approaches to these factors in particular
time to sit around bonding with their patients.
will be increasingly important for the development of which is derived from bovine or shark cartilage; example of the former is Reiki therapy, which aims
future health care strategies for the developing world. herbals, such as ginkgo biloba and echinacea; and to realign and strengthen healthful energies
unconventional diets, such as the low- through the intervention of energies radiating
Definitions and Domains of Complementary carbohydrate approach to weight loss espoused by from the hands of a master healer.
and Alternative Medicine and Traditional the late Robert Atkins.
 Manipulative and body-based approaches. These Alternative systems of medicine use elements from
Medicine kinds of approaches, which include massage, have each of these CAM and TM domains. For example,
been used throughout history. In the 19th century, traditional Chinese medicine incorporates
We refer to medical practices that evolved with additional formal manipulative disciplines acupuncture, herbal medicines, special diets, and
indigenous peoples and that they have introduced to emerged in the United States: chiropractic meditative exercises such as tai chi. Ayurveda in India
other countries through emigration as traditional medicine and osteopathic medicine. Both similarly uses the meditative exercises of yoga,
medicine. We refer to approaches that emerged originated in an attempt to relieve structural purifying diets, and natural products. In the West,
primarily in Western, industrial countries during the forces on vertebrae and spinal nerve roots that homeopathic medicine and naturopathic medicine
past two centuries as scientific or Western medicine, practitioners perceived as evoking a panoply of each arose in the late 19th century as reactions to the
although we acknowledge that not all Western illnesses beyond mere musculoskeletal pain. largely ineffectual and toxic conventional approaches
medicine is based on scientifically proven knowledge.  Mind-body medicine. Many ancient cultures of the day: purging, bleeding, and treatments with
The terms complementary and alternative describe assumed that the mind exerts powerful influences heavy metals such as mercury and arsenicals.
practices and products that people choose as adjuncts on bodily functions and vice versa. Attempts to
to or as alternatives to Western medical approaches. reassert proper harmony between these bodily
Increasingly, the terms CAM and TM are being used systems led to the development of mind-body
Economics of Complementary and
interchangeably (Kaptchuk and Eisenberg 2001; medicine, an array of approaches that incorporate Alternative Medicine and Traditional
Straus 2004). spiritual, meditative, and relaxation techniques. Medicine
 Alternative medical systems. Whereas the ancient
Endless varieties of practices are scientifically Greeks postulated that health requires a balance Although social, medical, and cultural reasons may
unproven and poorly accepted by medical authorities. of vital humors, Asian cultures considered that account for why people in a given country prefer
For the sake of organizing an agenda for research into health depends on the balance and flow of vital CAM and TM to conventional (Western) medicine,
these approaches, the U.S. National Institutes of energies through the body. This latter theory economic forces are also at play. This section
Health has grouped them into five somewhat underlies the practice of acupuncture, for describes the socioeconomic determinants of seeking
overlapping domains example, which asserts that vital energy flow can treatment from traditional healers and providers of
(http://nccam.nih.gov/health/whatiscam) as follows: be restored by placing needles at critical body CAM; reviews the evidence on the cost-effectiveness
points. of CAM and TM; and discusses cost-effective
 Biologically based practices. These include use of a  Energy medicine. This approach uses therapies approaches to regulating, improving, and expanding
vast array of vitamins and mineral supplements, that involve the use of energy—either biofield- or the use of CAM and TM. Much of this evidence is
natural products such as chondroitin sulfate, bioelectromagnetic-based interventions. An from industrial countries; few studies have been
conducted in or are applicable to low- and middle- United States, the average cost of a single visit to a this may not be true. In Zimbabwe, the mean monthly
income countries. This caveat is important for two Navajo healer was US$388, and the average annual income of households visiting an herbalist, Z$877,
reasons. First, the CAM and TM modalities discussed cost of using a traditional healer represented roughly a was greater than the mean monthly income of
in this section may not be used in many developing fifth of the reported annual income of respondents in a households using government clinics, Z$718 (Winston
countries. Second, the limited data on cost- survey (Kim and Kwok 1998). The high cost of using and Patel 1995).
effectiveness may not be applicable in the case of a healer was cited as the most common barrier to
those countries. Nevertheless, the data give a rough seeking care from this source. In Kenya, the average Although some traditional healers charge more than
picture of the relative cost-effectiveness of a number charge per patient per visit to a TM practitioner was K conventional practitioners, their fees may be
of CAM and TM practices. Sh 46 (US$4 in 1981), which was significantly greater negotiable, the method of payment may be flexible
than the average charge per visit even in private health (often on credit or in exchange for labor), and payment
Economic Factors That Influence the Use of care facilities (Mwabu, Ainsworth and Nyamete may be contingent on outcome. The availability of an
Complementary and Alternative Medicine and 1993). Finally, a survey in Zimbabwe reported that the outcome-contingent contract favors TM over Western
Traditional Medicine median cost of consulting an herbalist was Z$23 per medicine when the disease condition requires
visit, compared with Z$1 for a government clinic and providers to both exert effort in curing patients and
Users of CAM and TM approaches choose health Z$29 for a private doctor (Winston and Patel 1995). induce patients to comply with their
practices that resonate with their beliefs about health The same survey found that outcomes tended to be recommendations. Nonetheless, this strategy may be
(Astin 1998). Although economic factors play a role in better when patients went to government clinics (67.3 difficult to apply to the larger health care system.
this choice, the underlying incentives are not always percent of visits resulted in a good outcome) than
predictable. For instance, a common misconception is when patients consulted herbalists (50 percent of visits Furthermore, patients tend to seek care from
that patients opt for CAM and TM services because resulted in a good outcome). traditional healers for conditions such as mental
they are cheaper alternatives to conventional medical illness, impotence, and chronic disorders, which they
care. Even though there are certainly instances when TM is not always more expensive than conventional perceive as requiring greater involvement by the
the cost of treatment using CAM or TM is much medicine, however. Survey respondents in Ghana extended family and kinship group. Accordingly, the
cheaper than the cost of accessing a conventional reported that the cost of malaria treatment at a health availability of financial support for seeking treatments
medical service, several studies have found that CAM clinic ranged from ¢1,900 to ¢3,000 (US$1.30 to for these disorders is greater than it is for illnesses
and TM cost the same or more than conventional US$2.00 in 1997), treatment at home using drugs such as malaria or diarrhea, for which patients more
treatments for the same conditions (see, for example, bought from pharmacies or health care workers ranged often seek conventional treatment.
Muela, Mushi, and Ribera 2000). between ¢200 and ¢1,000 (US$0.10 to US$0.70), and
treatment by an herbalist was virtually free (Ahorlu Few published data are available on the financial costs
At least one study has shown that financial and others 1997). of TM in low- and middle-income countries. The data
considerations are rarely the primary factor in presented here on the use of traditional healers are
choosing a traditional healer, ranking behind such Another common misconception is that the poor are extracted from the World Bank's living standards
reasons as confidence in the treatment, ease of access, more likely to use TM. At least one study shows that surveys in Vietnam to provide one nationally
and convenience (Winston and Patel 1995). In the
representative snapshot of the situation. Of 28,254 complementary and therefore added to overall health health care and found that it does not. A possible
individuals in the sample, 10,033 had consulted a care costs. reason is that few individuals who are offered access
health care provider in the four weeks preceding the to CAM use them, and those who do might access
survey. These consultations included both home visits Thomas and others (1991) observe that patients who those services in addition to, not in place of, more
and visits to a provider. Of the 10,033, 1,829 had been use CAM and TM also commonly access conventional conventional health services.
to a public provider, 1,431 to a private provider, 7,650 medical care. In industrial countries, most CAM usage
to a pharmacy, and 259 to a traditional healer. 1 The complements conventional care, but this is also Studies that compare the cost-effectiveness of
most common reasons for visiting a traditional common in developing nations. For instance, Mwabu different CAM and TM approaches using the same
provider were headache, followed by cough and fever. (1986) provides evidence from Kenya that patients are analytical framework are rare. One such study in Peru
The per visit drug cost for consulting a traditional likely to use more than one type of provider from the looked at the costs and cost-effectiveness of treatment
healer was D 46, and the total cost per visit was D 51, range of those available, such as government facilities, using conventional medicine and TM (EsSalud and
compared with drug costs of D 38 and total costs of D mission clinics, private clinics, pharmacies, and OPS 2000). Complementary medical practices
41 for going to a private clinic. traditional healers. Furthermore, the choice of provider evaluated included acupuncture, homeopathy, tai chi,
depends on patients' illness, condition, socioeconomic meditation, reflexology, hydrotherapy, naturopathy,
One commonly cited motivation for using CAM and status, and education. If an initial visit to one kind of and massage. Patients were enrolled in either the
TM is that their use might lower the incidence and provider did not resolve the disease satisfactorily, a Western medicine group or the CAM group. Patients
costs of side effects associated with conventional follow-up visit was made to a different kind of were not randomized between the two treatment
treatments, but the published evidence on this point provider. Finally, the quality of care—including groups, but they were matched by disease pathology
remains mixed. There is some evidence that CAM is efficiency of service and waiting time at government and severity, age, and sex. Furthermore, selected
used in addition to conventional treatments (Thomas and private clinics—is an important determinant of patients had completed at least one year in the health
and others 1991), but CAM may also have the effect whether patients choose to go to traditional healers. system, as the investigators reasoned that this would
of displacing conventional treatments. An outpatient Most traditional healers surveyed in a second study enable them to evaluate their follow-up. Overall, the
survey found that, of 246 patients who had been referred patients to Western practices for treatment investigators found that complementary medicine was
receiving conventional treatment from the Royal when necessary (Mwabu, Ainsworth, and Nyamete between 53 and 63 percent less expensive than
London Homeopathic Hospital since the onset of care, 1993). conventional medicine for achieving equivalent levels
a third had halted their conventional treatment and of effectiveness. Complementary medicine was
another third had reduced their intake of conventional Economic Evidence especially cost-effective for osteoarthritis,
medication (van Haselen 2000). 2 The extent to which hypertension, facial paralysis, and peptic ulcers.
homeopathic treatment displaced conventional Although most studies tend to focus on a specific
treatment varied by indication. The use of CAM or TM practice, Sommer, Burgi, and Theiss The rest of this section looks at the economic evidence
homeopathic treatment often replaced conventional (1999) looked more broadly at whether the provision on specific forms of CAM or TM.
treatments in patients with skin and respiratory of CAM and TM services through prepaid health plans
infections; in patients with cancer, its use was purely or government insurance reduces the overall costs of
Acupuncture BlueShield health insurance plan found that the these groups—who incurred costs of roughly US$430
expenditures for the ayurvedic group were 50 percent over the two-year period of the study—reported that
Lindall's (1999) study finds that an acupuncture lower per person (Orme-Johnson and Herron 1997). their outcome was either good or excellent, compared
referral for musculoskeletal conditions costs a mean of However, the study was not randomized and failed to with a third of those who were assigned booklets;
US$422, roughly 60 percent less than the cost of control for the inclination of only a subset of people to however, the mean cost of care for the booklet group
referral to a Western practitioner. However, this study accept and remain compliant with ayurvedic was only US$153 for the two-year period.
was not randomized, and patients had to have failed approaches.
first-line drug treatment before being offered the Mind-Body Treatments
choice of second line-treatment, either with Chiropractic
acupuncture or with Western medicine. Little evidence is available on the cost-effectiveness of
Some studies found that spinal manipulation is less practices such as meditation and yoga, but the cost of
Homeopathy expensive than conventional treatments for episodes of acquiring the skills required for these practices, as
back pain. One nonrandomized study found that the well as the time costs of practicing them, are so low
Evidence indicates that the cost of homeopathic cost of chiropractic treatment over a five-year period, relative to conventional medicine that evidence of
medication is lower than the average cost of allopathic including both provider costs and equipment costs their clinical effectiveness might suffice to justify their
products, which would be an economic factor in favor (US$28,902), was 24 percent less than the cost of use on economic grounds. Available evidence from
of its use if homeopathy were proven to be effective. Western pain therapy (US$38,029) (Kumar, Malik, clinical studies suggests that mind-body treatments
A study by the National Health Service in the United and Demeria 2002). Moreover, 15 percent of patients can be cost-effective (Caudill and others 1991;
Kingdom found that the drug costs associated with in the chiropractic group were able to return to work, Friedman and others 1995; Hellman and others 1990;
homeopathy were lower than those of allopathic compared with none in the control group. Sobel 1995). Blumenthal and others (2002) find
practitioners (Swayne 1992). A four-year study of 100 significant declines in coronary events and in
patients that compared homeopathic drug costs with However, other larger and better-controlled studies predicted costs of care for patients who were assigned
those of conventional drugs found an average cost failed to find a difference between chiropractic and to a one-and-a-half-hour long weekly class on stress
saving of US$96 during the study period for those physical therapy in terms of either outcomes or costs management, relative to usual care for each of the first
using homeopathic drugs (Jain 2003). 3 (Cherkin and others 1998; Skargren and others 1997; two years of follow-up and after five years.
Skargren, Carlsson, and Oberg 1998). A study of
Ayurveda adults with low back pain who were randomly Beyond Cost-Effectiveness: Ancillary Benefits and
assigned to physical therapy or chiropractic Costs of CAM and TM
A study that compared medical expenditures over a manipulation or were just given an educational
four-year period for participants in a comprehensive booklet found no significant differences in either the Although cost-effectiveness is one guiding rationale
program of ayurvedic-based natural medicine (which mean costs of care or the outcomes between the for determining resource allocations for expanding (or
included antioxidant strategies, mind-body medicine, physical therapy and chiropractic groups (Cherkin and restricting) access to CAM and TM, additional societal
and other techniques) with participants whose others 1998). Three-quarters of the participants in benefits and costs, such as effects on biodiversity,
expenditures were covered through a BlueCross must also be considered. CAM and TM could provide
a rationale for conserving species, but overharvesting Expanding the Beneficial Use of conventional health care system would facilitate
of endangered species for medicinal purposes is also a Complementary and Alternative Medicine access to multiple health services at one location.
concern. According to WHO, 85 percent of the world's and Traditional Medicine
population (principally those in developing countries) Comprehensive policy on CAM and TM is lacking in
depends on plants for medicine, and 25 percent of Despite the uncertainty about the clinical efficacy and most countries, including the United States. According
prescription drugs have an active ingredient derived cost-effectiveness of certain CAM and TM practices, to the 1994 Dietary Supplement, Health, and
from a flowering plant (Cox 2001). The possible expansion of their use in instances in which moderate Education Act, the U.S. Food and Drug
extinction of medicinal plants is of concern not only to evidence of their efficacy and good evidence of their Administration cannot require proof that dietary
developing countries but also to industrial countries, safety exists could yield health, social, and economic supplements and herbal products are safe and effective
as in the cases of poaching of American ginseng and benefits. A number of surveys show that local before they are sold, although it is charged with
overharvesting of native saw palmetto. Similarly, the pharmacies are the primary source of treatment for requiring good manufacturing practices. The quality of
reliance of Chinese TM on tiger genitals, bear many ailments, especially in rural areas where herbal products is not regulated, and herbal products
gallbladders, and black rhinoceros horns has played an government or private clinics are less accessible. In typically differ from source to source and from batch
important role in poaching and threatens to wipe out these situations, improving the quality of TM might to batch in terms of their component ingredients and
these mega fauna. serve as an effective substitute for allowing the respective amounts and in terms of whether they
unregulated use of conventional medical treatments. contain contaminants. In the United States, no single
Local knowledge and culture regarding the uses of Training traditional healers is substantially less entity is responsible for all aspects of CAM and TM
medicinal plants may be important determinants of expensive than training doctors or nurses. A study of control, education, information, and research, and no
whether a certain species will survive (Etkin 1998). In 52 traditional healers interviewed as part of a survey national, voluntary system of self-regulation exists.
addition to the biodiversity value of these saved in Kenya estimated that the average out-of-pocket National nongovernmental organizations, such as the
species, scientists may be able to analyze these plants (cash) costs of training to be a traditional healer were Accreditation Commission for Acupuncture and
for potential clinical application on a broader scale K Sh 418 (US$40 in 1981) (Mwabu, Ainsworth, and Oriental Medicine, the American Board of Medical
than TM permits. Although preserving traditional Nyamete 1993). Acupuncture, the Council of Chiropractic Education,
knowledge of healing practices helps preserve the the Council of Homeopathic Education, and the
culture and identity of indigenous populations, CAM Traditional healers can also be recruited into a more Commission on Massage Therapy Accreditation,
and TM may impose significant costs. In such broadly based system for delivering public health; for accredit education in some CAM and TM fields, but
instances, promoting conventional treatments that do example, with additional training, traditional healers such accreditation bodies do not exist in many
not depend on endangered species may bring can serve as primary health care workers (Hoff 1997) developing countries. Nearly all countries lack
important benefits to society. and provide advice on such matters as sexually rigorous research training programs in CAM and TM.
transmitted diseases and oral rehydration therapy
(Nations and de Souza 1997; Nations and others 1988; A common misperception is that in the developing
Ndubani and Hojer 1999). In addition, permitting world CAM and TM is used primarily by poorer,
access to CAM and TM within the context of the uneducated populations, while in industrial countries it
is used more by affluent and better-educated segments combined and how other interventions (regulations, Integrative Medicine Fellowship Program trains
of the population (Eisenberg and others 1998). In both tax policy, managerial changes) are likely to affect physicians in CAM and TM and strives to produce a
settings, relatively little evidence supports this view. equity need to be studied. Given that the majority of new delivery model whereby physicians, patients, and
Many investigators have failed to critically assess the indigenous populations in developing countries use nurses form a healing team for the care of the patient.
use of CAM and TM by minority and immigrant TM for their primary health care, the availability, However, this program needs to be critically evaluated
populations in Western nations. In Africa, nearly 85 safety, and affordability of TM, including herbal before its adoption by more institutions can be urged.
percent of the population uses TM, often as the only medicines, should be ensured as a matter of equity.
way to obtain primary health care, and wealthier One way to do this is by supporting local production Despite the complexity, diversity, and controversy
people in developing countries often use TM (WHO of safe and effective herbals such as artemisia at surrounding CAM/TM approaches, some notable
2002). Investments in improving the quality and affordable prices. In addition, rigorous research on success stories reveal the influence of globalization,
consistency of TM could reduce the cost of health care TM should be supported. WHO is currently whereby modalities discovered in the developing
delivery, especially for chronic conditions such conducting collaborative studies on herbal treatments world have been adopted in the West, with or without
arthritic pain and AIDS, where TM interventions may for HIV/AIDS, malaria, sickle cell anemia, and modifications, and vice versa.
improve patients' sense of well-being, appetite, and diabetes. Ineffective or unsafe herbal products
energy. At the same time, in the absence of resources identified by such studies should be removed from Artemisinin
to extend the public health infrastructure, a network of use, while those with proven efficacy and safety
certified CAM and TM providers could provide the should be made available for therapeutic use. Artemisinin is a recently developed, active metabolite
infrastructure for delivering other care, such as of artemisia, an herbal extract that has been used in
immunizations and maternal-child health programs. Lessons Learned and Implementation China for centuries to treat fever. Chinese scientists
determined the active ingredient of the herbal in the
Recognizing the redistributive nature of investment in The pervasiveness of different modalities of TM and 1970s, and Western pharmaceutical companies have
TM is important. Indigenous people will seek the help CAM varies greatly from country to country. For developed several derivatives as drugs for use against
of traditional healers because of proximity, familiarity, example, in China, where traditional Chinese medicine resistant Plasmodium malaria (Li and others 2000).
and trust. Investments in TM could therefore be used is well integrated into the health system, many Randomized clinical trials have shown that one such
strategically to increase access to conventional different modalities may be used to treat a given drug, dihydroartemisinin-piperaquine, is effective
preventive and therapeutic care. Including the condition. In the United States, by contrast, CAM against drug-resistant Plasmodium falciparum malaria
traditional healer as part of the health care team may programs are slowly being integrated with (Hien and Dolecek 2004). Another artemisinin
thus be an important strategy both to attract patients conventional medicine. Several medical schools have derivative, artesunate, was shown to increase parasite
and to upgrade the skills and training of traditional nascent CAM programs and have integrated them into clearance and reduce the gametocyte count when
healers. medical school curricula to differing degrees. One of added to existing drugs to combat malaria (Adjuik and
the more acclaimed programs of this kind in the others 2004).
How equity is affected by the proportions in which United States is that developed by Andrew Weil at the
different condition-specific interventions are University of Arizona Health Sciences Center. His
Acupuncture ostracized practitioners of chiropractic medicine in the Homeopathy claims that the acts of serial diluting and
late 19th century and the first half of the 20th century, vigorous shaking imprint information into water so
Another CAM and TM modality that has considerable it has gradually evolved into a viable healing that medicinal properties are retained even when no or
acceptance is acupuncture. Many pain management discipline that is increasingly accepted by the few molecules of the starting medicine are present.
clinics, hospitals, and academic centers in the West conventional medicine community. The evolution of
now provide acupuncture services, and some chiropractic can be compared with that of osteopathy. As implausible as this claim may seem, homeopathy is
insurance companies reimburse for acupuncture Osteopathy was developed in the United States in used worldwide with reported success (Jonas,
services. Rigorous clinical trials have demonstrative parallel with chiropractic, but the field elected to Kaptchuk, and Linda 2003). Randomized controlled
positive efficacy in two areas: (a) management of accommodate rather than reject allopathic techniques. trials have suggested that it might be effective for
postoperative nausea and emesis (Shen and others treating influenza (Vickers and Smith 2000), allergies
2000) and (b) amelioration of the pain of chronic The second success story is research showing that (Taylor and others 2000), and postoperative ileus
osteoarthritis (Ezzo and others 2001; Soeken 2004; chiropractic manipulation for low back pain is (Barnes, Resch, and Ernst 1997). However, critics
Tukmachi and others 2004). Studies providing rational superior to bed rest, physical therapy, or provision of have questioned the quality and analyses of these
explanations of the mechanisms whereby acupuncture an educational booklet (Cherkin and others 1998). trials. Some have questioned the validity of pooling
might be achieving its effects complement the Chiropractic manipulation has also shown results data from trials of different populations, interventions,
evidence about its efficacy; for example, one comparable to those achieved with nonsteroidal, anti- and outcome measures, as several reviews of
mechanism of action appears to involve opioid- inflammatory drugs in alleviating back pain (Straus homeopathy have done. Jonas, Kaptchuk, and Linda
dependent brain pathways. This kind of two-step 2004). (2003, 393) assert that "there is a lack of conclusive
process—that is, initial demonstration of clinical evidence on the effectiveness of homeopathy for most
efficacy followed by scientific research into the Homeopathy conditions. Homeopathy deserves an open-minded
mechanism of action—is one way that CAM and TM opportunity to demonstrate its value by using
will gain scientific acceptance and integration into Homeopathy is a success in terms of its broad appeal evidence-based principles, but it should not be
conventional medicine. and use, not because of the strength of evidence substituted for proven therapies."
supporting it. Indeed, few conventional scientists and
Chiropractic Medicine and Osteopathy physicians find homeopathy to be plausible. Mind-Body Intervention
According to the "principle of similars" underlying
Chiropractic medicine was invented in the American homeopathy, practitioners choose remedies that, when The work of David Spiegel at Stanford University on
heartland during the waning years of the 19th century. given in high concentrations, produce symptoms group support for breast cancer patients excited wide
It uses spinal manipulation to treat an array of similar to those that the patient presents with. The interest in the potential value of mind-body
conditions thought to arise because of abnormal substance is then put in solution and serially diluted by interventions (Spiegel and others 1989). The study
alignment of or stresses on vertebrae, most often in as much as 1060, well beyond the point defined by was a randomized controlled trial with a 10-year
patients with musculoskeletal complaints. Two aspects Avogadro's number (at which a single molecule of the follow-up involving 86 women with metastasized
of chiropractic medicine are success stories. First, original substance could remain in the solution). breast cancer. A one-year psychosocial intervention
even though practitioners of conventional medicine
consisting of weekly supportive group therapy with The global use and potential effect of CAM and TM universal. That is, the standards for research into CAM
self-hypnosis for pain showed that the mean survival practices, the lack of adequate data validating their and TM approaches should be no different from those
time in the treated group was 37 months, compared safety and efficacy, and the existence of highly used in conventional biomedical research.
with 19 months for the control group. Moreover, effective conventional alternatives for many of them
Spiegel (1994) notes that appropriate psychotherapy dictate that resources should be devoted to fuller Both CAM and TM and biomedical practitioners need
(both group and individual) not only reduced characterization and standardization of CAM and TM to understand the strengths, limitations, and
depression and anxiety and improved coping skills, approaches. Investing precious resources in integrating contributions of their particular approaches so that
but also saved money by reducing the number of such approaches further into health care infrastructures they can work together in ways that ensure the best
office visits, diagnostic tests, medical procedures, and can be justified only on the basis of compelling data. possible care for their patients and the achievement of
hospital admittances. Although Spiegel's findings have This point leads to the question of what constitutes a their shared goals of improved individual and public
not been replicated, they do illustrate the potential rational agenda for this work. health. Once these issues have been addressed,
benefits of mind-body intervention and have led to countries could devote additional resources to
studies of possible mechanisms through which such For resource-rich industrial nations, one model for studying those CAM and TM approaches that appear
interventions may operate. CAM and TM research is that being implemented by to be the most promising in relation to their most
the National Center for Complementary and pressing public health problems. Some priority areas
The Research and Development Agenda Alternative Medicine (NCCAM) of the U.S. National for CAM and TM research are widely applicable,
Institutes of Health (http://nccam.nih.gov). In 2004, including studies of approaches to palliate chronic
The lack of product quality and consistency and the NCCAM planned to invest US$117 million in pain and suffering, relieve depression, help release the
absence of compelling data on the safety and efficacy research and research training. It is supporting some grip of addictive substances, and slow the progression
of most CAM and TM approaches present major 800 individual projects at present, including studies of of degenerative disorders such as arthritis and
challenges to any effort to optimize the distribution of the composition of natural products and their dementia.
precious health resources. These difficulties also pose pharmacological effects, studies of the neurobiological
opportunities for research. Other formidable mechanisms of acupuncture and the placebo effect, https://www.ncbi.nlm.nih.gov/books/NBK11
challenges include the variability in training, and clinical trials with 30 to 30,000 participants.
credentialing, and licensing CAM and TM NCCAM now has a strategic plan for its international 796/
practitioners. Increasingly, efforts are being made in programs that emphasizes research, training, and
several countries to regulate both products and efforts to learn about the rich, indigenous TM heritage.
practitioners. Ultimately, stringent controls on Australia, through a government agency similar to
training, practices, and products must be NCCAM, is conducting research and training NHS stops funding for
complemented by rigorous research to ascertain which programs in collaboration with its indigenous people. homeopathy at UK's largest
approaches are safe and effective—and for which Although the scope of NCCAM's research agenda is
indications. larger than what most other nations could alternative medicine hospital
accommodate, its underlying philosophy should be
Policy change should save London £3m and leaves “This is in line with the funding policy of Camden NHS England wrote to Health Secretary Jeremy Hunt
Bristol and Glasgow as last vestiges of publicly- Clinical Commissioning Groups, the local NHS body calling for an outright ban on homeopathic remedies
funded complementary medicine, campaigners said A that plans and pays for healthcare services in this on the NHS and changed its guidance to make clear it
major taxpayer-funded centre for homeopathic, herbal area,” the statement added. should not be routinely funded.
and alternative medicines will no longer be providing
these remedies on the NHS after health service chiefs Non-evidence backed treatments can still be purchased Chief executive Simon Stevens, ahead of the health
said homeopathy was “at best, a placebo”. privately. service’s review of homeopathic, herbal and
alternative remedy funding, said: “At best,
The Royal London Hospital for Integrated Medicine The statement continued: “Should you choose, you homeopathy is a placebo and a misuse of scarce NHS
(RHLIM), formerly the Royal London Homeopathic will be able to purchase these medicines from the funds which could better be devoted to treatments that
Hospital, describes itself as the “largest public-sector RLHIM pharmacy, while other homeopathic work.”
provider of integrated medicine in Europe”. pharmacies may also be able to supply the medicines.
Michael Marshall, project director at the Good
Integrated medicine centres offer alternative remedies, “You can speak to your clinician or the RLHIM Thinking Society which has been tracking NHS
such as acupuncture and herbal medicines, alongside pharmacy at your next visit about this.” funding of homeopathy and campaigning against it,
more evidence-backed interventions such as cognitive told The Independent: “This now should mean that
behavioural therapy, for managing conditions like pain Critics of homeopathy welcomed the change, saying it homeopathy is finished in London, saving the NHS
and insomnia. left just Bristol and Glasgow funding homeopathy in £3m.
the UK.
Policy changes by NHS commissioners in London will “We’ve already tackled and ended funding across the
now end funding for those without robust evidence, in Remedies are made up of ingredients which cause that majority of the rest of the country, leaving just Bristol
line with national guidance. condition or replicate its symptoms, based on the and Glasgow as the last remaining pockets of NHS
premise that “like will cure like”, and are then diluted homeopathy spending”.
A patient leaflet from University College London to one part in a trillion.
Hospitals Foundation Trust, which RLHIM is part of, Humanists UK Director of Public Affairs and Policy
says: “From 3 April 2018, The Royal London Hospital According to the NHS: “Practitioners believe that the Richy Thompson, said: “We are delighted by the
for Integrated Medicine (RLHIM) will no longer be more a substance is diluted in this way, the greater its announcement by The Royal London Hospital for
providing NHS-funded homeopathic remedies for any power to treat symptoms.” Integrated Medicine that it will end public funding of
patients as part of their routine care.” a pseudo-scientific ‘medicine’ that for decades has
However, systematic reviews of the evidence found it failed to show any beneficial outcomes for patients.
A statement on the RLHIM website said it would also was no better than a placebo for 0 out of 68 illnesses. The Hospital has in recent years been responsible for
“no longer be providing NHS-funded Herbal Medicine the majority of state funding.
for any patients as part of their routine care”.
He added that some state-funded Steiner schools also sperm, or egg to influence the embryos would be kept for up to 14 days to harvest
still fund these services and this will be "increasingly characteristics of a future person could stem cells.
difficult to justify".
be morally permissible In the present state of science, hybrid embryos are
http://www.independent.co.uk/news/health/nhs- produced as research tools, and only kept alive for 14
homeopathy-uk-alternative-medicine-hospital- THIS HOUSE SUPPORTS HYBRID- days or fewer. The article below only deals with the
camden-royal-london-hospital-for-integrated- ethical issues of this case, and not with the ethics of
medicine-a8253061.html EMBRYONIC CLONING producing new creatures that are a combination of
animal and human.
PRELIM 5
Human-animal hybrid A hybrid embryo is a mixture of both human and
animal tissue. There are several types of hybrid
CRISPR is a biological system for embryo (listed below), but recent controversy has
altering DNA. Known as gene editing, focused on cytoplasmic embryos.
this technology has the potential to
embryos
change the lives of everyone and These are created by transferring nuclei containing
DNA from human cells into animal eggs that have had
everything on the planet. Some biotech A hybrid embryo is a mixture of both human and
almost all of their genetic information removed.
firms are working on the theory that animal tissue.
CRISPR might be used to boost the The resulting embryos are more than 99% human,
function of the body's T cells so that with a small animal component, making up around
The science 0.1% (more detail below).
the immune system is better at
recognizing and killing cancer. The embryos are grown in the lab for a few days, then
Bioethics: Human-animal hybrid embryos
Disorders of the blood and immune harvested for stem cells: immature cells that can
system are other potential targets. In May 2008 a cross-party attempt to ban hybrid become many types of tissue. The embryonic stem
However, gene editing could be used to human animal embryos was defeated on a free vote in cells are used in research into different diseases as a
way of addressing the shortage of human eggs
genetically engineer bacteria or viruses the House of Commons, by 336 to 176. MPs had been
available for research.
debating the Human Fertilisation and Embryology
to be used in biological attacks against
Bill, which would allow regulated research using
humans, or to cause widespread crop hybrid or 'admix' embryos, where the nuclei of human Scientists do not intend to actually create living
damage. Some experts claim that cells are inserted into animal eggs. The resulting animal-human hybrids. [Such beings are often referred
to as chimeras after a creature in Greek mythology
editing the DNA of a human embryo,
which had a lion's head, a goat's body, and a serpent's produce energy for the cell. Mitochondrial DNA is Public opinion
tail.] separate from nuclear DNA; it is not involved in
cellular division or reproduction. In 2007, a poll conducted by the HFEA found that
Some 200 medical charities have urged MPs to 61% of the public supported the research after having
support legislation allowing the creation of animal- So the main genetic material is 100% human. the process and goals explained to them, while a
human embryos. Embryos produced by this technique are considered quarter was opposed to the research.
fully human - a "live human embryo" - by the Human
Possible types of animal/human hybrid embryos Fertilisation and Embryology Act. The debate
 Cytoplasmic hybrid embryos: embryos created A combination of human nuclear DNA and animal Ethical issues
through cell nuclear replacement using animal mitochondria is likely to make a difference to the
eggs resulting cells, but not enough is known about We believe, too, that we are God's partners in the
 Hybrid embryos: embryos created by mixing mitochondrial disorders to predict what the effects work of creation, both as innovators and as protectors,
human sperm and animal eggs or human eggs and might be. The House of Commons Select Committee and that this partnership obliges us to be guided by
animal sperm report acknowledged this and viewed it as a positive ethical principles.
 Human chimera embryos: human embryos which point.
have animal cells added to them during early Office of the Chief Rabbi, Memorandum to Select
development However, rather than deem this a reason not to Committee on Science and Technology November
 Animal chimera embryos: animal embryos which conduct such research, [Dr Justin St John from 2004
have human cells added to them during early Birmingham University] believes that the creation of
development
human-animal chimera or hybrid embryos may There are strong arguments on both sides of the ethics
 Transgenic human embryos: human embryos
actually "offer us the opportunity to elucidate some of of creating human/animal embryos. We've listed some
which have animal genes inserted into them
the causes of mitochondrial DNA disease" and that of the arguments put forward below.
during early development
"not to allow this work to go ahead would
considerably disadvantage experimental work in these In some cases the arguments seem to be similar but
Source: Human Fertilisation and Embryology
fields". expressed in a different way.
Authority
House of Commons Select Committee on Science and In some cases arguments on the same side of the case
Proportions of human and animal DNA
Technology Fifth Report, June 2007 seem to conflict with each other.
In cytoplasmic hybrid embryos, all the DNA in the
Quotations on both sides of the argument can be found
cell nucleus is human. The remaining animal DNA is
at BBC News - In quotes: The ethics of embryos
found only in the mitochondria, which are small rod-
shaped organelles found outside the nucleus that
Arguments against creating human/animal  The research will be of little scientific value - no embryos up to 14 days, there is no reason to
embryos new treatments have been produced by oppose research on an embryo that is less than
embryonic stem cell research wholly human
...the creation of an animal-human being represents a  Mixing human and animal genetic material risks  Neither human nor animal rights are violated since
natural border that has been violated, the most grave creating new diseases the embryo will never be allowed to become a
of violations. human or an animal
Arguments in favour of creating human/animal
Bishop Elio Sgreccia, president of Pontifical Academy embryos http://www.bbc.co.uk/ethics/animals/using/hybridem
for Life, May 2007
We think there is nothing illegal, immoral or unethical bryos_1.shtml

 It blurs the distinction between human beings and about this.

other animals
 It's a repulsive thing to do While we understand the concerns, we think they are Researchers Claim Embryonic
 It's unnatural largely founded on misinformation. People think we Cell Mix Of Human and Cow
 It's playing God are generating some sort of hybrid animal. This is just
 It violates human dignity cells, just for science. No animal is ever going to be
Correction Appended
 Human embryos have a special (moral) status from created.
the moment of fertilisation that should be
Venturing deep into uncharted realms of ethics and
respected and this makes any research using Professor Chris Shaw, Kings College London, 2008
human embryos wrong and a violation of their
medicine, a small biotechnology company said
human rights yesterday that its scientists had for the first time made
 It may produce enormous benefits for human
 It's wrong to create beings (embryos) that are human cells revert to the primordial, embryonic state
beings
solely at the disposal of scientists; it says that it is from which all other cells develop, by fusing them
 It is a strictly limited procedure - creatures capable
acceptable to create motherless beings and could with cow eggs and creating a hybrid cell.
of independent life will not be created. These are
open the way to the creation of beings that are 'just cells', not actual beings
effectively owned by whoever controls the  It avoids the use of human eggs in research The research comes from biologists who are well
medium in which the embryo develops  The genetic contribution of the animal to the known in their field but has yet to be confirmed or
 Even if using human embryos for research is embryo is so small that it is essentially a human published in a scientific journal. Their company,
sometimes acceptable, creating animal/human embryo Advanced Cell Technology of Worcester, Mass., said
hybrid embryos is a step too far  Since the embryo was not produced by human the method could eventually be used to grow
 It's the start of a slippery slope that could lead to fertilisation, it can't be regarded as a human replacement body tissues of any kind from a patient's
creating hybrid human/animal creatures capable embryo cells, sidestepping the increasing scarcity of organs
of independent life  It's very similar to cell nuclear replacement available for transplant and the problems of immune
 It's wrong to use animals in this sort of research research, and if we accept research on human rejection.
The technique is likely to concern and perplex Another serious uncertainty is the preliminary nature university teams sponsored by Geron said they had
ethicists because it would involve the creation of an of Advanced Cell Technology's work. No article has isolated and cultivated human embryonic stem cells,
embryonic cell that is part human and part cow, yet been submitted for peer review and publication in the all-purpose cells from which the fetus develops.
consisting of a human cell's nucleus in a cow egg a scientific journal, an essential touchstone of Dr. West laid the foundations for these developments
whose own nucleus had been removed. The company credibility. Scientists asked about the company's work by sponsoring leading scientists in the two fields.
said the hybrid cell quickly became more humanlike said they would require much more proof before
as the human nucleus took control and displaced cow believing that human embryonic stemlike cells had Researcher Uses His Own Cells
proteins with human proteins. Creation of the been created as the company contends, and some were
embryonic cells is an important component of a skeptical that the technique would work. Advanced Cell Technology, which Dr. West joined in
strategy that in principle offers high medical benefits October, has focused on cloning and genetically
if it can overcome the high barrier to public Announcement Tests the Waters improving cows, a technology developed by James M.
acceptance. Robl and colleagues at the University of
The company said yesterday that it had achieved the Massachusetts at Amherst. Dr. West said he hoped to
The technique would involve creating an embryo of feat with one cell almost three years ago. Dr. Michael use the technology to further the idea on which he
uncertain moral status, and one that crosses the barrier D. West, Advanced Cell Technology's chief executive, founded Geron, that of delving into the mystery of
between humans and other species. Even though a said that he was announcing the work to test its public human aging and sidestepping some of its processes.
hybrid would be in the form of cells, not a whole acceptability He said the company, which is privately
organism, the concept of half-human creatures arouses held, was not planning to go public or raise money The company said the work with human cells was
deep-seated anxiety, as is evident from the unfriendly now but needed to decide whether to commit money performed in 1996 by a Jose Cibelli, a colleague of Dr.
powers ascribed to werewolves, centaurs, mermaids, to development of the technique. Robl's at the University of Massachusetts. Using 52 of
Minotaurs and other characters of myth and folklore. his own cells, some of them white blood cells and
Some scientists praised Dr. West's decision to make others scraped from the inside of his cheek, Dr. Cibelli
''Many people are going to be horrified by this his work public but others were critical, saying he has fused each one with a cow egg whose own nucleus
scenario, others will say 'So what?' '' said Thomas invited a possibly fraught public debate on a slender and DNA had been removed, the company said. Most
Murray, director of the center for biomedical ethics at basis of fact. failed to thrive but one embryo grew and divided five
Case Western Reserve University in Cleveland and a times, generating cells resembling embryonic stem
member of the National Bioethics Advisory Dr. West is the founder of Geron, a biotechnology cells. Dr. Cibelli and Dr. West say the method could
Commission. ''This is the sort of thing that makes me company in Menlo Park, Calif., that has had two be made more efficient with present technology. They
very uncomfortable,'' Mr. Murray said. ''I think we are spectacular successes this year in research on aging. In use cow eggs because these are far cheaper and more
likely to get a very powerful reaction to it, and I would January it developed a method for ''immortalizing'' available than human eggs and raise no ethical
like for all of us to have a breathing space here to human cells grown in the laboratory by making them problems.
articulate our moral concerns.'' leap the supposedly immutable barrier at which cells
usually lapse into senescence. Last week two
Considering this work was sufficient to describe an principle, potential twins of himself, he said: ''I never batteries. If the bovine mitochondria should prove
invention, Dr. Robl and Dr. Cibelli filed a patent thought about it, it's a good question. But if you use incompatible with their humanized environment, the
application and then set the research aside to focus on your own cells to treat a disease you may have, you cells will not be viable.
the more immediately practical field of cow cloning, are not taking cells from another person selfishly.''
they said. Only two others beside himself and Dr. Ethicists said the mixing of species was likely to
Robl knew what had been done, Dr. Cibelli said. The Dr. West and Dr. Cibelli said they had no intent of trouble the public severely, at least at first. Lawyers
patent has not yet been issued but Dr. West said he transferring the embryos to a uterus, a step considered who specialize in issues of human reproduction note
was confident of receiving ''important intellectual unethical and unsafe: the embryos would be created that the moral and legal status of the human embryo is
property'' in the field. He said he is making the hybrid solely for the purpose of tissue culture. ''Any undecided in American law, a fact pointed up by the
cell technique public now ''because I want to be very technology can be abused, but once the public isolation of the human embryonic stem cells
open and level with everyone. We need to get the understands how these cells can be used to treat any announced last week. The new entity adds further
ethicists to talk about it so as to encourage a rational disease caused by loss or malfunction of cells, from complexity.
response to these new technologies.'' Parkinson's to diabetes to heart disease, the concerns
will be overshadowed,'' Dr. West said. If Advanced Cell Technology can produce viable
Dr. Cibelli said he regarded any embryos obtained in hybrid cells, they would offer a new route to growing
this way as ''not a separate individual, just a de- Lack of Evidence Raises Doubts new tissues for transplant. This is the same goal held
differentiated cell from a patient.'' Differentiation is by the scientists who announced last week that they
the process whereby the all-purpose cells of the very Whether Dr. West's prediction will be borne out had grown human embryonic stem cells in the
early embryo, known as human embryonic stem cells, depends on two major sets of factors, the scientific laboratory. It is widely accepted in principle that
become committed to their roles as the various validity of the proposed method and the ethical and embryonic stem cells can be directed to develop into
specialized tissues of the body. The process is legal questions that related work has already raised. any desired tissue, with enormous potential for
irreversible in nature, but egg cells apparently have the medicine, though this has yet to be achieved in
ability to de-differentiate, or reset to default mode, the From discussions with scientists, ethicists and lawyers practice.
settings in a specialized cell's nucleus. This is in the past few days, these concerns have emerged.
presumably what happened in the experiment reported Dr. West said the advantage of the Advanced Cell
this July when mice were cloned by transferring the Scientists are particularly critical of the lack of Technology method is that embryonic cells derived
nucleus of an adult mouse cell into another mouse's supporting evidence accompanying Advanced Cell from the patient being treated would generate entirely
egg cell. Technology's announcement, saying in essence the compatible tissues. The two methods reported last
claim could be true but there is no compelling reason week, by Dr. James A. Thomson of the University of
Dr. Cibelli, who trained as a veterinarian in Argentina, to accept it. Even if the claim is valid, biologists note a Wisconsin and Dr. John Gearhart of the Johns
said he believed he and his colleagues ''were the first serious uncertainty relating to an important component Hopkins University, derive stem cells from human
to de-differentiate a human cell by nuclear transfer.'' of the cells known as the mitochondria, which produce embryos or fetuses. Tissues made from these cells
Asked if he was concerned about destroying, in the energy the cell needs and are, in essence, its
would be incompatible with the patient, a problem that well with a human nucleus, in Dr. Pedersen's view, ''Even if it's only to create tissue, the minute you start
has not been resolved. and as most of the mitochondria in the hybrid cells are mixing species you raise all kinds of red flags in
contributed by the cow egg, the cells would probably people's minds,'' said Barnie Steinboch, a moral
In support of its claim, Advanced Cell Technology not remain viable for long. ''It's hard to say this is a philosopher at the State University of New York in
supplied a patent application and a photograph taken total sham, but I smell a sham here,'' he said. Albany. But she noted that pig valves are now seen as
of its embryonic cells under a microscope. The patent acceptable replacements in human hearts.
application describes how the cells are made but Citing the same data, Dr. Gearhart said the
provides no proof that they possess the properties to mitochondria in the hybrid cell had clearly carried it Rebecca Dresser, a law professor at Washington
be expected of human embryonic stem cells. Dr. Robl through its first few divisions but might not sustain it University in St. Louis, noted, as did several
said his laboratory was not set up to perform the in further development, unless the few human biologists, that distinctions between humans and other
required tests at the time the hybrid cells were made. mitochondria that were also present somehow took animals are less clear in nature than they are in
over. people's minds. ''Biologically a lot of this research is
Shown the photograph of the purported hybrid cells, showing us similarities and the upshot in a hundred
Dr. John Gearhart of Johns Hopkins, author of one of Dr. Pedersen said Advanced Cell Technology should years may be that the lines between humans and
the two methods reported last week, said that ''they be held to a high standard of proof ''because of what nonhumans will be viewed as a little bit grayer,''
certainly could be embryonic stem cells'' but that no the implications are for upsetting people unnecessarily Professor Dresser said.
scientific journal would publish the result without -- if you cry fire in a crowded auditorium you may be
further proof. ''It's not that I don't believe this liable if it's a false alarm.'' A perplexing feature of the hybrid embryo would be
biologically, I just think they could have given a little that it would start mostly bovine, then become mostly
bit more assurance as to what was done here.'' New Frontiers For Medical Ethics yet not entirely human. But some legal experts have
no doubt that any hybrid should be regarded from the
Dr. Roger Pedersen of the University of California, The human embryonic stem cells announced last week start as a human embryo. ''It doesn't matter that the
San Francisco, who also works on human embryonic have already pushed against the frontiers of ethical mitochondria come from a cow, it also has human
stem cells, said he doubted any hybrid cells would last acceptance. Experts in biomedical ethics say the mitochondria and so has all the potentials of a human
long enough to develop into useful tissue because of public is likely to be alarmed by the new technique, embryo,'' said Lori Andrews, a professor at the
their cow-derived mitochondria. The mitochondria of particularly because of the mingling of species. Dr. Chicago-Kent College of Law in Chicago.
chimpanzees and gorillas work well enough in human Murray of Case Western Reserve University in
cells but those of primate species that diverged more Cleveland said that the hybrid embryo ''escapes our ''Once it's gone through that first division it has gone
than 10 million years ago from the human line, do not usual categories.'' When biologists first learned to from being a somatic cell to a thing with potential
work. transfer genes from one species to another, ''The idea life,'' Dr. Andrews said, referring by somatic to the
of human-animal hybrids was often raised as the kind ordinary specialized cells of the human body. If
Because cows and humans last shared an ancestor so of monstrosity that no morally perceptive person transferred to a woman's uterus the embryos might or
long ago, cow mitochondria are very unlikely to work would ever create,'' he said. might not come to term, ''but under state laws it
doesn't matter whether the fetus is going to be born or ''If someone wants to inoculate themselves they can do Embryology Authority (HFEA) to create the embryos,
not -- it doesn't make them less human.'' that,'' Dr. Weinberg said. known as "cytoplasmic hybrids".

The human body consists of 100 billion cells. Should orrection: November 14, 1998, Saturday An article on His team at Newcastle University produced the
embryos created from them by the cow egg method be Thursday about a biotech company's claim to have embryos by inserting human DNA from a skin cell
regarded as having special status when they can be converted human cells to their primordial state by into a hollowed-out cow egg. An electric shock then
made so easily and plentifully? Dr. Andrews said that fusing them with cow eggs misspelled the name of a induced the hybrid embryo to grow. The embryo,
human embryos are not so hard to make the usual philosophy professor who said the technique would 99.9% human and 0.1% other animal, grew for three
way, and the fact that an embryo is easily made, by raise red flags in people's minds. She is Bonnie days, until it had 32 cells.
whatever means, is irrelevant to arguments about its Steinbock, not Barnie Steinboch.
status. Eventually, scientists hope to grow such embryos for
http://www.nytimes.com/1998/11/12/us/researchers- six days, and then extract stem cells from them. The
The moral status of the human embryo ''is not clearly claim-embryonic-cell-mix-of-human-and-cow.html researchers insisted the embryos would never be
established in U.S. law,'' Dr. Dresser said. The embryo implanted into a woman and that the only reason they
can be regarded as mere property, as a person, or as used cow eggs was due to the scarcity of human eggs.
something in between but deserving of special respect. First British human-
Congress, in banning the use of Federal money for The team's success comes days after Gordon Brown
research on human embryos, has favored the view that animal hybrid embryos was forced to give MPs a free vote on the human
they are in the category of people. But in custody fertilisation and embryology bill, which has faced
battles over fertilized embryos, courts have favored created by scientists condemnation from Catholic bishops. Cardinal Keith
the special respect status. Dr. Dresser said the hybrid O'Brien used his Easter sermon to denounce what he
cells could be seen as between the property and · Breakthrough could pave way for stem cell supply called experiments of "Frankenstein proportion" and
special respect status. · Move will aid research into untreatable conditions called the bill a "monstrous attack on human rights,
human dignity and human life".
The company said the hybrid cells were made by Dr. Britain's first human-animal hybrid embryos have
Cibelli in Dr. Robl's laboratory in the University of been created, forming a crucial first step, scientists Catholics object to the idea of putting human and
Massachusetts at Amherst. Michael Weinberg, believe, towards a supply of stem cells that could be animal DNA in the same entity and to the notion of
executive secretary of the university's human subjects used to investigate debilitating and so far untreatable creating what they regard as a life for the purposes of
committee, said the experiment was given conditions such as Alzheimer's disease, Parkinson's research, a life that will then be destroyed.
administrative approval, without review by the and motor neurone disease.
committee or major discussion. Dr. Cibelli was using John Burn, head of the Institute of Human Genetics at
his own cells, not experimenting on other people, and Lyle Armstrong, who led the work, gained permission Newcastle University, said the embryos had been
self-experimentation does not require special consent. in January from the Human Fertilisation and created purely for research. He told the BBC's Six
O'Clock News last night: "If you look down the importance of the parliamentary scrutiny of this area Evan Harris, the Liberal Democrat MP who led a
microscope it looks like semolina and it stays like that. of research over the coming weeks." campaign to ensure that research on human-animal
It's never going to be anything other than a pile of hybrids was not banned by parliament said: "Creating
cells. What it does is give us the tools to find out the Peter Andrews, professor of biomedical science at the these sort of cytoplasmic hybrid embryos was deemed
simple questions: how can we better understand the University of Sheffield's Centre for Stem Cell legal and legitimate under the 1990 HFEA Act and the
disease processes by working with those cells in the Biology, said: "The production of embryos by 2001 Therapeutic Cloning Regulations by both the
body?" transferring the nucleus of an adult human cell to a HFEA and by the science select committee, and was
human egg ... has already proved very difficult, let approved on that basis by the HFEA after a public
The research has not yet been published, but the team alone combining a human nucleus with an animal egg. consultation and after approval by a further unanimous
plans to submit the work for peer review in the coming Apparently these researchers have achieved some select committee report. Therefore it is wrong to say
months. Other scientists welcomed the work but also success - but by using the nucleus from a very early that this is pre-empting parliamentary debate or votes
urged caution in interpreting the results. embryonic cell, which might be easier to reprogramme on the new legislation in this area - the statutory
than an adult cell. At the moment it is impossible to framework is being updated."
Colin Blakemore, a former head of the Medical assess the significance of this report until we know
Research Council, said: "The creation of hybrid more details of what has been achieved ... the results https://www.theguardian.com/science/2008/apr/02/me
embryos is not illegal and researchers in Newcastle have been repeated and, importantly, they have been dicalresearch.ethicsofscience
and London were granted provisional licences for such reviewed by independent researchers in the usual
research in January, after extensive consultation by the way."
HFEA ... This research is at a very early stage and no CRISPR goes wild, and
results have been peer-reviewed or published. Josephine Quintavalle, of the pressure group
Comment on Reproductive Ethics, said the research scientists debate its
"However, these preliminary reports give hope that should not worry those opposed to hybrid embryos
this approach is likely to provide stem cells for because the Newcastle work did not seem convincing. fidelity
research without the use of human eggs or normal "The embryos didn't survive, they were created from
human embryos. The new bill is intended to confirm embryonic stem cells rather than adult tissue, and by Hannah Furfaro / 30 April 2018
the arrangements for regulation of this important area there's a lot of question marks over the research."
of research." This article was originally published 5 July 2017,
But she added: "What it has done is wake up the based on a paper published in Nature Methods. The
Mark Walport, director of the Wellcome Trust, agreed public to this reality, that while parliament is getting in journal retracted this paper on 30 March 2018, citing
that it was too early to assess the significance of the a tizz about this, while the whole country is up in arms problems in the study design.
results. "The aim of the research is to advance human discussing it, the HFEA is already issuing licences."
health," he said. "This work emphasises the The researchers used the gene-editing tool CRISPR to
correct a mutation that causes blindness in mice. They
concluded that the editing caused thousands of off- of brain and cognitive sciences at the Massachusetts CRISPR-CAS9 introduced more than 100 unintended
target mutations. In its retraction, the journal stated Institute of Technology. He says another enzyme the mutations and more than 1,600 one-letter swaps in the
that the researchers’ methods leave open the team used may in fact have caused the errant code of DNA, the researchers found.
possibility that the edited and control mice had mutations.
different genomes before the researchers used None of these changes had any obvious consequences.
CRISPR. The researchers also didn’t publish data Two weeks after the paper’s publication, Nature “As far as we can tell, it hasn’t affected the mice,”
showing the mice were identical before they used Methods editors added a note to the paper, saying they says Bassuk, professor of pediatric neurology at the
CRISPR. As a result, the retraction reads, the are considering the criticism of the results and plan to University of Iowa in Iowa City. But the researchers
researchers didn’t prove that gene editing led to the respond soon. tested only the mice’s vision and do not know if the
unintended mutations. mutations affected the animals’ behavior or
Wandering scalpel: perception.
The gene-editing tool CRISPR may cause thousands
of unintended mutations, but critics say it’s way too CRISPR is a molecular scalpel that cuts DNA. It can This was not the first time that CRISPR had caused
soon to accuse it of infidelity1. home in on a specific spot on the molecule using a accidental mutations, though previous reports found
piece of RNA as a guide. The tool holds significant far fewer mutations3.
A two-page study, published 30 May in Nature medical promise because it could help modify or fix
Methods, put biology’s hottest technique in the genes that cause medical conditions. “It’s always been a concern for everyone in the field
crosshairs, questioning its ability to rewrite DNA with that this is not a completely clean method,” says Anis
the precision necessary for medicine. The paper’s In 2016, Alexander Bassuk’s team reported injecting Contractor, associate professor of physiology at
findings quickly dominated social media mouse embryos with CRISPR fused to its usual Northwestern University in Chicago. Contractor was
conversations on biology. And the stocks of biotech protein partner, CAS9, which binds to DNA. The not involved in the research but uses CRISPR to make
companies with CRISPR-based projects dipped by as researchers targeted a gene called PDE6B that is mouse models. “This is a big red flag.”
much as 15 percent. involved in vision. The experiment was designed to
correct a mutation that causes blindness in the mice2. Contractor and others say the findings may prompt a
But some researchers are loath to end their love affair It did. change in best practices when using the method.
with CRISPR. Reports of the method’s infidelity, they Scientists may need to sequence the genomes of their
say, are greatly exaggerated. One reason, they note, is For the new study, Bassuk and his collaborators models — an expensive task — to uncover any
that the study is small — just two mice for CRISPR looked for off-target effects of the treatment. They unexpected mutations.
and a single control mouse. sequenced the whole genomes of the two mice and the
control mouse. They compared the results from the Rushed job:
“I think it’s an important finding that we really need to edited mice against a database that includes genomes
follow up, but it’s really hard to judge why there are of 36 mouse strains. Others, however, are downplaying the results.
so many [mutations],” says Guoping Feng, professor
“I don’t think this paper has any merit for CRISPR Bassuk points out that the team did the editing work in Published: Aug 13, 2018 By Mark Terry
research,” says George Church, professor of genetics 2015, early in CRISPR’s use.
at Harvard University. “I think it’s a negative example CRISPR, the gene editing technique that promises
that we can use as a cautionary tale.” Church is co- “We used what was available at the time,” Bassuk designer babies, to end to all disease as we know it,
founder of Editas Medicine, a biotechnology company says. “It’s obviously not what people are using in and biohacking where individuals could change their
that is using the technique to develop gene-editing 2017.” He says he is not sure whether the editing own genome to include that of fluorescent jellyfish or
therapies. The company lost 12 percent of its value the system made a difference in the results. lobster claws, seems to have more problems than
day the study was published. (Its stock has since gone originally thought. It’s still an amazing technique, but
up, surpassing its previous value.) In the past three months, researchers have debuted the the further researchers push into it, the more
first two mouse models of autism created using controversy it seems to generate, and as far as is
Church and the company’s other executives wrote to CRISPR. No one has yet published work on using known, nobody’s trying to merge human DNA with
Nature Methods with a laundry list of concerns about CRISPR to correct genes in animal models of the that of lobsters—yet.
the paper. Their biggest beef, says Church: The condition.
study’s control mouse likely wasn’t genetically At least two studies in June linked CRISPR to cancer.
identical to the ones that had been edited with In the short term, the findings “will definitely temper This is because CRISPR, using the Cas9 enzyme
CRISPR, so it’s impossible to know whether the the enthusiasm for CRISPR models,” says J. Tiago (other enzymes are now appearing to be more precise
mutations resulted from the method. Gonçalves, assistant professor of neuroscience at than Cas9, the first discovered), sometimes makes
Albert Einstein College of Medicine in New York, mistakes in other parts of the genome, which could
Instead, Church argues, it’s possible that the mutations who was not involved in the research. “But in the end, result in cancer cells.
represent natural genetic variance between the I’m confident the problems will be solved and we’ll
animals. Church stops short of saying the paper should figure out what’s happening.” And at least as controversial, in August 2017,
be retracted but calls it a “rushed job.” Another gene- researchers at Oregon Health & Science
editing company, Intellia Therapeutics, voiced similar https://www.spectrumnews.org/ne University conducted work on human embryos, using
complaints. CRISPR to remove a mutated, heart-disease-causing
ws/crispr-goes-wild-scientists- gene, replacing it with a healthy gene. What
The team also used an unusual version of the editing debate-fidelity/ Shoukhrat Mitalipov, the biologist in the study,
system, says Feng, who is using CRISPR to create found was that every one of the 112 embryos ignored
animal models of autism. He says the use of extra the healthy gene replacement. “Instead,” STAT wrote
nickase, an enzyme that can cause breaks in a strand
of DNA, could have caused the mutations.
Researchers Debate on at the time, “they copied the healthy gene from their
mother and incorporated that into their genome to

“I couldn’t figure out what reason you’d need to do it

Whether CRISPR Works replace the father’s.”

this way,” he says. in Embryos

And then the controversy erupted. Although some of detect the presence of large deletions up to ±5 kb from It’s possible that the techniques will “stick” when used
the controversy was related to an ethical debate about the mutation site in CRISPR-Cas9-treated human in individual cells that are then transplanted back, as
so-called “designer babies,”—and isn’t likely to end embryos. Although the PCR primers used in this study compared to Mitalipov’s experiments on embryos. It’s
anytime soon—there was quite a bit of debate among did not identify much larger deletions, available also possible that the technique, as is the case with
scientists on exactly what the findings of the study had evidence suggests that most deletions induced by many immuno-therapies like CAR-T, is easier to do in
to say about using CRISPR for gene replacements. CRISPR-Cas9 should have been detected with our hematological diseases than in solid tissue diseases.
Which is good, that’s what science is all about. assays.” Time will tell.

STAT writes, “Recent studies have shown that In other words, Mitalipov stands by his original STAT writes, “For DNA not carried by either parent,
CRISPR can tear through a genome like a tornado interpretation and backs it up with further testing. including for supposedly desirable cosmetic or other
through Kansas, leaving swaths of nothingness. That traits, ‘that procedure doesn’t really work,’ Mitalipov
can make it impossible to tell what CRISPR actually If further work verifies Mitalipov’s findings, it said. ‘The external repair template has no chance’
did, as a study last month revealed, which could be suggests that using CRISPR as is won’t be enough to against the gene from mom or dad. That underlines
why Mitalipov didn’t detect the mutant paternal gene, start fixing genes in embryos, at least not yet. STAT something CRISPR experts agree on: The technique is
argued scientists led by Maria Jasin of Memorial noted, “In every case where CRISPR deleted the too unpredictable and unreliable for use in fertility
Sloan Kettering Cancer Center and, separately, Paul paternal, mutant gene as intended, the embryo’s clinics any time soon."
Thomas of Australia’s University of Adelaide. Both genome repaired it not with the healthy gene that
critiques and Mitalipov’s response were published in CRISPR carried but by copying the healthy gene on https://www.biospace.com/article/
Nature.” the maternal chromosome.”
researchers-debate-on-whether-
Dieter Egli of Columbia University, Jasin’s co- Currently, there are clinical trials ongoing in China, crispr-works-in-embryos/
author in the critique, told STAT, “Evidence for Europe and the United States using CRISPR. CRISPR
correction was not provided in the original article. Therapeutics is treating patients with beta Questions and Answers about CRISPR
[But] I’ve come to accept that some of the embryos thalassemia in Europe using its gene-editing tool. In
have been edited.” that trial, researchers harvest stem cells from the Q: What is “CRISPR”?
patients and use CRISPR to fix the cells, so they have
Mitalipov, however, defends the original conclusions, increased levels of fetal hemoglobin, then infuse them A: “CRISPR” (pronounced “crisper”) stands for
and in his response, published in Nature, wrote, “To back into the patients’ bodies via stem cell transplant. Clustered Regularly Interspaced Short Palindromic
rule out the possibility of large deletions, we decided As of February 2018, there were nine registered Repeats, which are the hallmark of a bacterial defense
to carry out a large-scale re-testing of all embryonic clinical trials of CRISPR-edited cells to treat cancer system that forms the basis for CRISPR-Cas9 genome
blastomere samples from our published study,” and and HIV infections in China. There is one at the editing technology. In the field of genome
detailed the different methods they used to re-analyze University of Pennsylvania for melanoma, sarcoma, engineering, the term “CRISPR” or “CRISPR-Cas9”
the embryos. “In summary, all these tests failed to and multiple myeloma. is often used loosely to refer to the various CRISPR-
Cas9 and -CPF1, (and other) systems that can be In January 2013, the Zhang lab published the first A: CRISPR-Cas9 is proving to be an efficient and
programmed to target specific stretches of genetic method to engineer CRISPR to edit the genome in customizable alternative to other existing genome
code and to edit DNA at precise locations, as well as mouse and human cells. editing tools. Since the CRISPR-Cas9 system itself is
for other purposes, such as for new diagnostic tools. capable of cutting DNA strands, CRISPRs do not need
With these systems, researchers can permanently For more on many of the scientists and teams who to be paired with separate cleaving enzymes as other
modify genes in living cells and organisms and, in the contributed to the understanding and development of tools do. They can also easily be matched with tailor-
future, may make it possible to correct mutations at the CRISPR system from the initial discovery to the made “guide” RNA (gRNA) sequences designed to
precise locations in the human genome in order to first demonstrations of CRISPR-mediated genome lead them to their DNA targets. Tens of thousands of
treat genetic causes of disease. Other systems are now editing, visit our CRISPR timeline. such gRNA sequences have already been created and
available, such as CRISPR-Cas13’s, that target RNA are available to the research community. CRISPR-
provide alternate avenues for use, and with unique Cas9 can also be used to target multiple genes
characteristics that have been leveraged for sensitive simultaneously, which is another advantage that sets it
diagnostic tools, such as SHERLOCK. Q: How does the system work? apart from other gene-editing tools.

A: CRISPR “spacer” sequences are transcribed into

short RNA sequences (“CRISPR RNAs” or
Q: Where do CRISPRs come from? “crRNAs”) capable of guiding the system to matching Q: How does CRISPR-Cpf1 differ from CRISPR-
sequences of DNA. When the target DNA is found, Cas9?
A: CRISPRs were first discovered in archaea (and Cas9 – one of the enzymes produced by the CRISPR
later in bacteria) by Francisco Mojica, a scientist at the system – binds to the DNA and cuts it, shutting the CRISPR-Cpf1 differs in several important ways from
University of Alicante in Spain. He proposed that targeted gene off. Using modified versions of Cas9, the previously described Cas9, with significant
CRISPRs serve as part of the bacterial immune researchers can activate gene expression instead of implications for research and therapeutics.
system, defending against invading viruses. They cutting the DNA. These techniques allow researchers
consist of repeating sequences of genetic code, to study the gene’s function. First, in its natural form, the DNA-cutting enzyme
interrupted by “spacer” sequences – remnants of Cas9 forms a complex with two small RNAs, both of
genetic code from past invaders. The system serves as Research also suggests that CRISPR-Cas9 can be used which are required for the cutting activity. The Cpf1
a genetic memory that helps the cell detect and destroy to target and modify “typos” in the three-billion-letter system is simpler in that it requires only a single RNA.
invaders (called “bacteriophage”) when they return. sequence of the human genome in an effort to treat The Cpf1 enzyme is also smaller than the standard
Mojica’s theory was experimentally demonstrated in genetic disease. SpCas9, making it easier to deliver into cells and
2007 by a team of scientists led by Philippe Horvath. tissues.
Q: How does CRISPR-Cas9 compare to other
genome editing tools? Second, and perhaps most significantly, Cpf1 cuts
DNA in a different manner than Cas9. When the Cas9
complex cuts DNA, it cuts both strands at the same such as cancer and mental illness. In addition, The ensuing headlines were gleefully apocalyptic:
place, leaving ‘blunt ends’ that often undergo CRISPR is now being developed as a rapid diagnostic. “Crispr May Not Be Nearly as Precise as We
mutations as they are rejoined. With the Cpf1 complex To help encourage this type of research worldwide, Thought,” “Crack in Crispr Facade after Unanticipated
the cuts in the two strands are offset, leaving short Feng Zhang and his team have trained thousands of In Vivo Mutations Arise,” and my personal favorite,
overhangs on the exposed ends. This is expected to researchers in the use of CRISPR genome editing “Small Study Finds Fatal Flaw in Gene Editing Tool
help with precise insertion, allowing researchers to technology through direct education and by sharing Crispr.” And then the biotech stocks went into a
integrate a piece of DNA more efficiently and more than 40,000 CRISPR components with academic tailspin. The big three Crispr-based tech companies
accurately. laboratories around the world. got hit the hardest. By the close of trading Tuesday,
Editas Medicine was down nearly 12 percent, Crispr
Third, Cpf1 cuts far away from the recognition site, Crispr’s Next Big Debate: How Therapeutics fell more than 5 percent, and Intellia
meaning that even if the targeted gene becomes Therapeutics had plunged to just over 14 percent.
mutated at the cut site, it can likely still be re-cut, Messy Is Too Messy?
allowing multiple opportunities for correct editing to This was far from just a blip in the nerdy news cycle.
occur. When it comes to Crispr, the bacterial wünderenzyme A reaction to a single scientific publication on this
that allows scientists to precisely edit DNA, no news scale raises important questions about science’s
Fourth, the Cpf1 system provides new flexibility in is too small to stir up some drama. On Tuesday incentive structure, its processes for publicly
choosing target sites. Like Cas9, the Cpf1 complex morning, doctors from Columbia, Stanford, and the evaluating evidence, and what happens when those
must first attach to a short sequence known as a PAM, University of Iowa published a one-page letter to the butt up against the prevailing philosophies of other
and targets must be chosen that are adjacent to editor of Nature Methods—an obscure but high-profile professions—namely, medicine.
naturally occurring PAM sequences. The Cpf1 journal—describing something downright peculiar.
complex recognizes very different PAM sequences About a year ago, they used Crispr to edit out a A decade ago, most of the conversations about this
from those of Cas9. This could be an advantage in blindness-causing genetic defect in mice, curing two letter would have happened in laboratory hallways.
targeting, for example, the malaria parasite genome of their cohort. Later, they decided to go back and But this week, geneticists, microbiologists, and
and even the human genome. sequence their genomes, just to see what else Crispr molecular bioengineers took to Twitter to digest the
did while it was in there. paper in public. While some experts decried the paper
as unnewsworthy (everyone’s known about Crispr off-
A lot, it turned out. With their method, the researchers target mutations forever!) the majority of threads
Q: What other scientific uses might CRISPR have observed close to 2,000 unintended mutations ticked off the experiment’s flaws: Tiny sample size!
beyond genome editing? throughout each mouse’s genome, a rate more than 10 Insufficient controls! Weird Crispr delivery! Out of
times higher than anyone had previously reported. If date/inefficient version of Crispr! The list goes on.
A: CRISPR genome editing allows scientists to that holds up, Crispr-based therapies are in for some Many doubted if it had been peer-reviewed. (It had.)
quickly create cell and animal models, which serious trouble. No one wants to go in for a vision- The hashtag #fakenews even made a few appearances.
researchers can use to accelerate research into diseases restoring treatment, only to wind up with cancer
because of it.
To be sure, the results do not match up well with and then you validate your results. All the critiques of formulations and side effects. How long can you have
what’s already in the literature on this subject. And, as the Nature Methods paper assumed the authors were the enzyme floating around your cells before it cuts
the paper itself says, “The unpredictable generation of operating with that same premise. somewhere it shouldn’t? What’s the right enzyme for
these variants is of concern.” Which is to say, the the job?
authors have no idea why or how these mutations are But in this case, the authors weren’t just scientists:
happening. Derek Lowe, a longtime pharmaceutical They were also doctors. And in medicine, there’s a Matthew Taliaferro, who studies gene expression and
industry researcher who writes a blog on the subject different guiding principle that places a premium on gene editing at MIT, thinks the paper will get more
for Science, had enough doubt in the results that he sharing significant results at face value. scientists thinking about those kinds of questions.
bought up some Editas and Crispr Therapeutics stocks “Crispr definitely has off-targets. But a lot of people
while they were down. The history of the case study is long and celebrated in use it assuming no other mutations get introduced
medicine. The first recorded report of what would one during the process,” he says. “So getting people to talk
But most scientists, while skeptical of the results, were day be known as HIV/AIDS was published by the about the need for controls is a good outcome of this
more disappointed in the way the paper was blown out CDC as five strange cases of pneumonia in gay men in whole thing.” And while he was surprised by the lack
of proportion. “It’s critically important to look closely Los Angeles. Vinit Majahan, an opthamologist at of some straightforward controls, Taliaferro is
at genomes being edited with the Crispr system, Stanford and co-author of Tuesday’s Crispr paper, aware that his initial reactions were colored by some
ideally with a method sensitive enough to detect even says it was in that spirit that he and his collaborators of the Twitter threads he’d already absorbed before
rare off-target events,” says Stephen Floor, a submitted their results to the journal. “I don’t have any tracking down the paper himself. “I think the data is
biophysicist who worked in Crispr creator Jennifer money in Crispr, I only have patients,” he says. “The perfectly fine,” he says. “It’s just the interpretation of
Doudna’s lab at UC Berkeley before beginning his culture and pressures of science right now push people it that to me seems odd.” Namely, that every Crispr
own gene editing cancer research at UCSF. Saying to not share results that aren’t a splashy cure. But in application is deeply flawed.
Crispr is 100 percent accurate or grossly inaccurate medicine you can’t do that. If you make an
isn’t helpful. What scientists need to understand is observation that’s important enough to share with your Which was never Majahan’s intention in the first
which sites are being cut, what rules govern which community, you’re obligated to do that right away.” place. “We didn’t write the headlines,” he says. “We
sites get cut, and how to emphasize only cutting at don’t think Crispr is bad, we think it’s great.” But he
sites you want. “It will be interesting to watch Since Majahan’s team is working on turning its didn’t get the opportunity to tell people that, because
subsequent validation that gets to the bottom of why previous work into a human treatment, they saw it as for one thing, he’s not on Twitter. When asked how he
this report found such a surprisingly high rate of irresponsible to take their results, small as they were, was responding to the criticisms from the scientific
mutation,” he says. and sweep them under the rug. Crispr is most often community, he laughed and said, “Can you read some
described as molecular scissors, but doctors like to me? I’ve heard there’s some nasty stuff out there.”
The key word there, if you didn’t catch it, is Majahan tend to think of it more like a drug. And the
“validation.” It’s pretty much the foundational tenet of more successes Crispr has—like curing mouse The amplifications (and denigrations) of those
science. You have an idea, you test it, you test it again, blindness—the more doctors start asking the next interpretations around Science Twitter may not have
you eliminate confounding factors as best as you can logical questions about things like dosing and been as knee-jerk as all the “Crispr Is Terrible and
Broken Forever” headlines. But still, they were an embryos to create babies is premature and exposes the that the scientific community thinks that gene editing
overreaction—because after all, this was just a single children to unnecessary health risks. Opponents also is still not safe or appropriate for use in human
paper. No one should presume a standalone study can fear the creation of “designer babies,” children edited embryos. “You could even wonder whether they’re
predict the future of an entire technique. At most, it to enhance their intelligence, athleticism or other doing this for attention,” she says.
indicates that Crispr is entering its inevitable traits.
adolescence, when shiny silver bullet technologies get At least one prominent gene-editing researcher, Feng
banged up and battle worn by new data. That doesn’t He, on unpaid leave from the Southern University of Zhang of the Broad Institute of MIT and Harvard, has
mean it isn’t the real deal. Just that it should be looked Science and Technology of China in Shenzhen since now called for a moratorium on producing gene-edited
at real hard every step of the way. February, objects to the term designer baby. “Call babies until researchers can establish safety
them ‘gene surgery babies’ if one must or better yet requirements. Hundreds of Chinese scientists have
ordinary people who have had surgery to save their signed letters condemning the work and calling for
Chinese scientists raise life or prevent a disease,” He and colleagues wrote in greater oversight of gene-editing experiments.
a perspective published online November 26 in the
ethical questions with CRISPR Journal. But in the video, He said that he Chinese authorities are also questioning the research.
realizes his work will be controversial, and he’s Shenzhen City Medical Ethics Expert Board said in a
first gene-edited babies willing to take the criticism. Some families need the statement that it is investigating the case, and the
technology to have healthy children, He said, adding hospital cited in documents describing the experiment
A Chinese scientist’s surprise announcement on the that enhancing intelligence or changing hair or eye has denied that the work was done there. He’s
eve of an international human gene-editing summit color are “not things loving parents do” and should be university said in a statement November 26 that the
that he has already created the world’s first gene- banned. work “seriously violates academic ethics and
edited babies has led to swift condemnation. academic norms,” and announced that it will launch an
Yet many researchers and ethicists argue that He’s investigation.
Jiankui He is expected to discuss his work November editing of the twin’s DNA was not lifesaving nor does
28 in Hong Kong at the second International Summit it prevent disease. Although the girls’ father has HIV, He could not be reached for comment.
on Human Genome Editing. But in an interview with there are safer ways to protect someone from
the Associated Press, and in a video posted November contracting the virus, which makes the engineering Disabling a gene
25, He announced that twin girls with an edited gene both unnecessary and unethical.
that reduces the risk of contracting HIV “came crying In another video, He said that his group used the gene-
into this world as healthy as any other babies a few The scientists involved in the announcement “have editing tool CRISPR/Cas9 to disable the CCR5 gene in
weeks ago.” knowingly violated the ethical norms surrounding this the fertilized eggs that produced the babies, called
technology,” says Josephine Johnston, a lawyer and “Lulu” and “Nana” (not their real names). CCR5
That announcement sparked outrage from many bioethicist at the Hastings Center, a bioethics research produces a protein that allows the most common
researchers and ethicists who say implanting edited institute in Garrison, N.Y. The researchers are aware version of the HIV virus to enter cells. Some people
naturally have mutations in the gene that help protect Even if Lulu and Nana don’t end up with any health verification might be possible because the Chinese
them from HIV infection. Such “gene surgery” has problems as a result of He’s genetic tinkering, the researchers say that the embryos were sequenced
already proven safe in adults with HIV, He said in the experiment is still bad science, says Julian Savulescu, before being implanted into the mother’s uterus and
video. HIV infection is still a deadly disease and in the a bioethicist at the University of Oxford. “I liken it to again after birth. But it may be harder to determine
developing world, “discrimination increases the Russian roulette. You can pull the trigger and not kill, whether CRISPR/Cas9 has caused any mutations that
devastation,” He said. Gene editing could spare such but that doesn’t mean what you did was right.” may later harm the children, Beaudet says.
children from their parents’ fate, He claims.
If He’s claims are true, the work is “monstrous” and Children often naturally develop DNA changes that
But the chance that Lulu and Nana would get HIV could set back gene-editing research, says Savulescu, their parents don’t carry. Beaudet and colleagues are
from their father when their mother doesn’t have the a self-described fan of the technology. Savulescu has conducting experiments with mice to determine
virus is “almost zero. In fact, probably zero,” says argued that parents may one day have a moral whether gene editing leads to more of these new
Anthony Fauci, director of the U.S. National Institute obligation to edit their children’s genes (SN Online: mutations than usual, he says. Such animal research
of Allergy and Infectious Diseases in Bethesda, Md. 11/28/17). But this experiment gives no real advantage and work on human embryos that won’t be used to
The children could easily avoid HIV infection by other to the babies and puts them at significant risk of harm, create a pregnancy are necessary before researchers
means, so “to put them through the risk of editing their he says. “The risk just wasn’t reasonable in this case. should even consider making gene-edited babies, he
genes as embryos to protect them from infection they It’s a bad scientific study.” says.
can easily prevent themselves, in my mind, is
inappropriate at best and unethical at worst.” For now, it’s difficult for researchers to assess how Legal issues
successful the gene editing was.
Potential complications Laws governing gene editing vary, with some
Determining success countries banning it outright and others, including
Fauci and others are concerned that gene editing may China, having no or less clear policies. In the United
sometimes go astray, damaging other important genes, He’s work has not been published in a scientific States, the Food and Drug Administration cannot
which could lead to health problems such as cancer journal, and other researchers have not gotten access accept applications for research in which human
later in life. The babies aren’t even guaranteed to to any data or DNA samples that could confirm He’s embryos are made to have heritable DNA changes.
escape HIV either: People who have defective CCR5 claim. Previous claims of successful gene editing in That provision effectively bans the use of the
genes may still be infected with a less common form human embryos in lab dishes have also been met with technology to make gene-edited babies or “three-
of the virus. And people with missing or defective skepticism (SN Online: 8/8/18). parent babies” who have a small amount of DNA from
CCR5 genes are more susceptible to serious an egg donor (SN: 12/24/16, p. 22).
complications from West Nile virus infections, Fauci Verifying the editing would require thoroughly
says. examining, or sequencing, the DNA of the twins and Organizers of the first human gene editing summit,
their parents, says Arthur Beaudet, a geneticist at held in Washington, D.C., in 2015, said then that
Baylor College of Medicine in Houston. That gene-editing research on human embryos could go
ahead, but only if no babies resulted from the The most potent use of the new gene editing editing technique CRISPR-Cas9. This is the second
experiments (SN: 12/26/15, p. 12). Since then, other technique CRISPR is also the most time human embryos have been employed in such
ethics committees have softened that stance saying controversial: tweaking the genomes of research, and the first time their use has been
that if gene editing were shown to be safe, it would human embryos to eliminate genes that sanctioned by a national regulatory authority. The
ethical to use the technology to correct diseases, but scientists at the Institute hope to cast light on early
cause disease. We don’t allow it now. Should
not to enhance health, intelligence or other traits (SN: embryo development—work which may eventually
3/18/17, p. 7). Public opinion in the United States has we ever? lead to safer and more successful fertility treatments.
also been swinging in favor of gene editing to correct
diseases, but not to enhance intelligence (SN Online: On November 25, 2018, geneticist He Jiankui of China's
The embryos, provided by patients undergoing in vitro
Southern University of Science and Technology announced
7/26/18). fertilization, will not be allowed to develop beyond
that his lab had successfully used the Crispr-Cas9 gene-
seven days. But in theory—and eventually in
editing system to make the world's first genetically edited
People have worried for decades that the ability to practice—CRISPR could be used to modify disease-
human babies. Outside scientists haven't verified his
modify people’s genes could lead to disparities causing genes in embryos brought to term, removing
claims, and his home university is planning to investigate
between genetic haves and have-nots, says Marcy him for academic violations. But if the results hold, the
the faulty script from the genetic code of that person’s
Darnovsky, executive director of the Center for experiment would mark a scientific milestone— and raise future descendants as well. Proponents of such
Genetics and Society, a nonprofit social justice profound ethical issues. In the August 2016 issue of “human germline editing” argue that it could
organization in Berkeley, Calif. She argues that National Geographic magazine, we invited contributors to potentially decrease, or even eliminate, the incidence
countries should immediately take steps to ban the use weigh the ethics of making edits to the human genome of many serious genetic diseases, reducing human
of human embryo editing. “We’re living in a time that future generations would inherit. suffering worldwide. Opponents say that modifying
when racism and socioeconomic disparities are human embryos is dangerous and unnatural, and does
increasing dramatically,” Darnovsky says. “The last not take into account the consent of future generations.
Pro: Research on Gene Editing in Humans
thing we need is for some biological procedure to fuel Who is right?
Must Continue
the false idea that some groups are biologically
superior to others.” Let’s start with the objection that embryo modification
By John Harris
is unnatural, or amounts to playing God. This
argument rests on the premise that natural is inherently
Pro and Con: Should John Harris is professor emeritus in science ethics at
University of Manchester, U.K., and the author of How to
good. But diseases are natural, and humans by the
millions fall ill and die prematurely—all perfectly
Gene Editing Be be Good, Oxford University Press 2016.
naturally. If we protected natural creatures and natural
phenomena simply because they are natural, we would
Performed on Human In February of this year, the Human Fertilization and
Embryology Authority in the United Kingdom
not be able to use antibiotics to kill bacteria or
otherwise practice medicine, or combat drought,
Embryos? approved a request by the Francis Crick Institute in
London to modify human embryos using the new gene
famine, or pestilence. The health care systems
maintained by every developed nation can aptly be Needless to say, parents and scientists should think denied, so, too, therapy delayed is therapy denied.
characterized as a part of what I have previously responsibly, based on the best available combination That denial costs human lives, day after day.
called “a comprehensive attempt to frustrate the of evidence and argument, about how their decisions
course of nature.” What’s natural is neither good nor will affect future generations. However, their decision- Con: Do Not Open the Door to Editing Genes
bad. Natural substances or natural therapies are only making simply cannot include the consent of the in Future Humans
better that unnatural ones if the evidence supports such future children.
a conclusion. By Marcy Darnovsky
Finally, there’s the argument that modifying genomes
The matter of consent has been raised by Francis is inherently dangerous because we can’t know all the Marcy Darnovsky, Ph.D., is executive director of the Center
Collins, director of the National Institutes of Health. ways it will affect the individual. But those who fear for Genetics and Society. She speaks and writes on the
“Ethical issues presented by altering the germline in a the risks of gene editing don’t take into account the politics of human biotechnology.
way that affects the next generation without their inherent dangers in the “natural” way we reproduce.
consent,” he has said, constitute “strong arguments Two-thirds of human embryos fail to develop The gene editing tool known as CRISPR catapulted
against engaging in” gene editing. successfully, most of them within the first month of into scientific laboratories and headlines a few short
pregnancy. And every year, 7.9 million children—6 years ago. Fast on its heels came the reemergence of a
This makes no sense at all. We have literally no choice percent of total births worldwide—are born with a profoundly consequential controversy: Should these
but to make decisions for future people without serious defect of genetic or partially genetic origin. new techniques be used to engineer the traits of future
considering their consent. All parents do this all the Indeed so risky is unprotected sex that, had it been children, who would pass their altered genes to all the
time, either because the children are too young to invented as a reproductive technology rather than generations that follow?
consent, or because they do not yet exist. George found as part of our evolved biology, it is highly
Bernard Shaw and Isadora Duncan knew this. When, doubtful it would ever have been licensed for human This is not an entirely new question. The prospect of
allegedly, she said to him “why don’t we make a baby use. creating genetically modified humans was openly
together … with my looks and your brains it cannot debated back in the late 1990s, more than a decade
fail” she was proposing a deliberate germline and a half before CRISPR came on the scene and
determining decision in the hope of affecting their several years before the human genome had been fully
future child. Shaw’s more sober response—“Yes but Certainly we need to know as much as possible about mapped.
what if it has my looks and your brains!”—identifies a the risks of gene-editing human embryos before such
different possible, but from the child’s perspective research can proceed. But when the suffering and It wasn’t long before we saw provocative headlines
equally non-consensual, outcome. Rightly, neither death caused by such terrible single-gene disorders as about designer babies. Princeton mouse biologist Lee
Shaw nor his possible partner thought their decision cystic fibrosis and Huntington’s disease might be Silver, writing in Time magazine in 1999, imagined a
needed to wait for the consent of the resulting child. averted, the decision to delay such research should not fertility clinic of the near future that offered “Organic
be made lightly. Just as justice delayed is justice Enhancement” for everyone, including people with
DNA Hacking Tool Enables Shortcut to Evolution “no fertility problems at all.” He even wrote the ad
copy: “Keep in mind, you must act before you get experimentation. By all accounts, far too much is PGD itself raises social and ethical concerns about
pregnant. Don't be sorry after she's born. This really is unknown about issues including off-target mutations what kind of traits should be selected or de-selected.
a once-in-a-lifetime opportunity for your child-to-be.” (unintentional edits to the genome), persistent editing These questions are particularly important from a
effects, genetic mechanisms in embryonic and fetal disability rights perspective (which means they’re
During the same millennial shift, policymakers in development, and longer-term health and safety important for all of us). But screening embryos for
dozens of countries came to a very different consequences. disease is far safer for resulting children than
conclusion about the genetic possibilities on the engineering new traits with germline gene editing
horizon. They wholeheartedly supported gene Conversations about putting new gene editing tools would be. Yet this existing alternative is often omitted
therapies that scientists hoped (and are still hoping) into fertility clinics need to begin with an obvious but from accounts of the controversy about gene editing
can safely, effectively, and affordably target a wide a often overlooked point: By definition, germline gene for reproduction.
range of diseases. But they rejected human germline editing would not treat any existing person’s medical
modification—using genetically altered embryos or needs. At best, supporters can say that it might re- It is true that a few couples—a very small number—
gametes to produce a child—and in some 40 countries, weight the genetic lottery in favor of different would not be able to produce unaffected embryos, and
passed laws against it. outcomes for future people—but the unknown so could not use PGD to prevent disease inheritance.
mechanisms of both CRISPR and human biology Should we permit germline gene editing for their
The issue of human germline modification stayed on a suggest that unforeseeable outcomes are close to sake? If we did, could we limit its use to cases of
slow simmer during the first decade of the 21st inevitable. serious disease risk?
century. But it roared to a boil in April 2015, when
researchers at Sun Yat-sen University announced they Beyond technical issues are profound social and From a policy perspective, how would we draw the
had used CRISPR to edit the genomes of nonviable political questions. Would germline gene editing be distinction between a medical and enhancement
human embryos. Their experiment was not very justifiable, in spite of the risks, for parents who might purpose for germline modification? In which category
successful in technical terms, but it did focus the transmit an inherited disease? It’s certainly not would we put short stature, for example? We know
world’s attention. necessary. Parents can have children unaffected by the that taller people tend to earn more money. So do
disease they have or carry by using third-party eggs or people with paler skins. Should arranging for children
In December 2015, controversy about using CRISPR sperm, an increasingly common way to form families. with financially or socially “efficient” varieties of
to produce children was a key agenda item at the Some heterosexual couples may hesitate to use this height and complexion be considered medical
International Summit on Human Gene Editing option because they want a child who is not just intervention?
organized by the national science academies of the spared a deleterious gene in their lineage, but is also
United States, the United Kingdom, and China. Nearly genetically related to both of them. They can do that Think back to the hypothetical fertility clinic offering
every speaker agreed that at present, making too, with the embryo screening technique called pre- “Organic Enhancement” as a “once-in-a-lifetime
irreversible changes to every cell in the bodies of implantation genetic diagnosis (PGD), a widely opportunity for your child-to-be.” Think back to the
future children and all their descendants would available procedure used in conjunction with in vitro 1997 movie Gattaca, about a society in which the
constitute extraordinarily risky human fertilization. genetically enhanced—merely perceived to be
biologically superior—are born into the physical harnessed for mammalian genome editing by Feng CRISPR-Cpf1, which has the potential for even
reality of those whom we might now call the one Zhang of the Broad Institute and MIT. simpler and more precise genome engineering.
percent. These are fictional accounts, but they are also
warnings of a possible human (or not so human) The CRISPR system Engineering the CRISPR toolbox
future. The kinds of social changes they foresee, once
set in motion, could be as difficult to reverse as the Like zinc fingers and TALEs, CRISPR systems are In early 2011, Feng Zhang was just starting his own
genetic changes we’re talking about. natural products. However, CRISPR-Cas differs from research group at the Broad Institute and MIT, where
zinc fingers and TALEs in one crucial aspect that he is an investigator at the McGovern Institute for
In opening the door to one kind of germline makes it superior for genome editing applications: Brain Research and a faculty member in the
modification, we are likely opening it to all kinds. whereas zinc fingers and TALEs bind to DNA through departments of Brain and Cognitive Sciences and
Permitting human germline gene editing for any a direct protein-DNA interaction, requiring the protein Biological Engineering. After learning about existing
reason would likely lead to its escape from regulatory to be redesigned for each new target DNA site, CRISPR research at a scientific meeting at the Broad,
limits, to its adoption for enhancement purposes, and CRISPR-Cas achieves target specificity through a he quickly realized that the system, with a single
to the emergence of a market-based eugenics that small RNA that can easily be swapped for other RNAs RNA-guided protein, could be a game changer in
would exacerbate already existing discrimination, targeting new sites. genome editing technology. He was already working
inequality, and conflict. We need not and should not on DNA targeting methods, having helped to develop
risk these outcomes. In nature, CRISPR-Cas systems help bacteria defend the TALE system as a Junior Fellow at Harvard. This
against attacking viruses (known as bacteriophage or system could target and activate genes in mammalian
Research Highlights: just phage). They consist of two components, the genomes.
CRISPR CRISPR (clustered, regularly interspaced palindromic
repeats) array and Cas (CRISPR-associated) proteins. Zhang and his team focused on harnessing CRISPR-
The ability to precisely edit the genome of a living cell CRISPR sequences bookend short stretches of DNA Cas9 for use in human cells. In January 2013, he
holds enormous potential to accelerate life science that bacteria have copied from invading phages, reported the first successful demonstration of Cas9-
research, improve biotechnology, and even treat preserving a memory of the viruses that have attacked based genome editing in human cells in what has
human disease. them in the past. These sequences are then transcribed become the most-cited CRISPR paper (Cong et al.,
into short RNAs that guide Cas proteins to matching Science, 2013). Researchers from George Church’s
Methods for genome editing — primarily zinc finger viral sequences. The Cas proteins destroy the lab at Harvard University reported similar findings in
nucleases and Transcription Activator-Like Effector matching viral DNA by cutting it. There are a number the same issue of Science (Mali et al., Science, 2013).
(TALE) Nucleases — have existed for several years, of different types of CRISPR-Cas systems in nature, The Zhang and Church papers showed that Cas9 could
but in 2013 these were quickly eclipsed by the which vary in their components; the CRISPR-Cas9 be targeted to a specific location in the human genome
efficiency, effectiveness and precision of the system uses just a single protein, Cas9, to find and and cut the DNA there. The cut DNA was then
engineered CRISPR-Cas9 system that was first destroy target DNA. In 2015, Zhang and colleagues repaired by inserting a new stretch of DNA, supplied
successfully harnessed a second system, called
by the researchers, essentially achieving “find and Cas9, which has advantages for gene therapy (Ran et The creation of babies whose DNA has been altered to
replace” functionality in the human genome. al., Nature, 2015). give them what parents perceive to be the best chances
in life has received a cautious green light in a
In September, 2015, Zhang and partners described a The Zhang lab has trained thousands of researchers in landmark report from a leading UK ethics body.
different system, Cpf1, which appears to have the use of CRISPR-Cas9 genome editing technology
significant implications for research and through direct education and by sharing more than The Nuffield Council on Bioethics said that changing
therapeutics. The Cpf1 system is simpler in that it 40,000 CRISPR-Cas9 components with academic the DNA of a human embryo could be “morally
requires only a single RNA. The Cpf1 enzyme is also laboratories around the world to help accelerate global permissible” if it was in the future child’s interests and
smaller than the standard SpCas9, making it easier to research that will benefit human health. In September did not add to the kinds of inequalities that already
deliver into cells and tissues. 2015, the Zhang lab also began to share Cpf1 divide society.
components.
Refining and sharing CRISPR tools The report does not call for a change in UK law to
Users can obtain guide sequences for knock-outs and permit genetically altered babies, but instead urges
The CRISPR toolbox is continuing to expand rapidly, transcriptional activation as well as information about research into the safety and effectiveness of the
opening new avenues for biomedical research. Since genome-wide libraries for CRISPR-based screening. approach, its societal impact, and a widespread debate
the first publications in early 2013, the Zhang lab and The Zhang lab plasmids can be obtained via Addgene, of its implications.
other researchers have engineered a number of a non-profit plasmid repository dedicated to improving
improvements to the system. For example, Cas9 has life science research. Additional information about “It is our view that genome editing is not morally
been modified so that instead of cutting the target materials can be found on the Zhang unacceptable in itself,” said Karen Yeung, chair of the
DNA, it can turn gene expression on by recruiting laboratory website. Nuffield working group and professor of law, ethics
transcriptional activators to its genomic location and informatics at the University of Birmingham.
(Konermann, et al., Nature, 2014). “There is no reason to rule it out in principle.”
Genetically modified
At the Broad Institute, the system has also been used But the report drew immediate criticism from some
for genome-wide screens to identify genes involved in babies given go ahead by quarters, with one lobby group accusing the authors of
resistance to cancer drugs and dissect immune opening the door to the unrestricted use of heritable
regulatory networks. CRISPR has been used to rapidly UK ethics body genetic engineering, and an age of genetic haves and
create mouse models of cancer that arise from multiple have-nots.
gene alterations (Platt et al., Cell, 2014). In 2015, The Nuffield Council on Bioethics says changing the DNA of
Zhang and his team reported success with Cas9 a human embryo could be ‘morally permissible’ if it is in Recent advances in genetic technology have given
derived from a different bacterium, Staphylococcus the child’s best interests scientists the tools to rewrite the DNA bound up in
aureus (SaCas9). SaCas9 is smaller than the original living cells, letter by letter. With the procedures in
hand, scientists can in principle tweak the genetic code
in sperm, eggs and embryos, and change dramatically through standard IVF is rewritten so that children have George Church, a geneticist at Harvard University
how future children develop. traits the parents find desirable. The Nuffield report who was not involved in the report, said he agreed
does not rule out any specific uses of genome editing, with the report’s guiding principle that gene editing
While laws in the UK and some other countries but says that to be ethical, any applications must “should not be expected to increase disadvantage,
currently ban the creation of genetically altered babies, follow the principles of being in the child’s interests, discrimination, or division in society,” adding that this
a handful of experiments around the world have and have no ill-effects for society. would be aided by lower costs and better public
shown that DNA editing could, in principle, prevent dialogue and education. Making changes to common
children from inheriting serious diseases caused by Jackie Leach Scully, professor of social ethics and gene variants in sperm and eggs could save roughly
faulty genes. bioethics at Newcastle University, and a co-author on 5% of babies from painful diseases he said.
the report, said heritable genome editing may one day
/science/2016/jun/07/sign-up-for-lab-notes-the- become an option for parents “to try and secure what But Marcy Darnovsky at the Center for Genetics and
guardians-weekly-science-update they think is the best start in life” for their future Society in California said that the report recognised
children. that if reproductive gene editing was permitted, it
The prospect of modifying genes in human embryos would be used for enhancement and cosmetic
has long been controversial though. For a start, the But she warned that there could be unintended purposes. “They dispense with the usual pretence that
procedure has yet to be proven safe. In a study consequences if the law were changed to allow gene this could – or, in their estimation, should – be
published in Nature Biotechnology on Monday, editing of human embryos. While the technology prevented. They acknowledge that this may worsen
British researchers found that the most popular tool for could potentially reduce the number of people affected inequality and social division, but don’t believe that
genome editing, Crispr-Cas9, caused more damage to by certain genetic disorders, it could leave those with should stand in the way. In practical terms, they have
DNA than previously thought. If the scientists are the diseases feeling more marginalised and with less thrown down a red carpet for unrestricted use of
right, gene editing could disrupt healthy genes when it medical support. inheritable genetic engineering, and a gilded age in
is meant only to fix faulty ones. which some are treated as genetic ‘haves’ and the rest
The report urges government to set up a new body to of us as ‘have-nots’.”
Another consideration is that any changes made to an ensure that as many voices as possible are involved in
embryo’s DNA would affect all of its cells, including public discussions about what should and should not
the sperm or eggs, meaning that genetic modifications be permissible. “We are very clear that what we need Designer babies: Picking
would be passed down to all future generations. Also, to have is as wide a discussion about this issue as
in the vast majority of cases alternative procedures, possible,” Leach Scully said. In the event that the law traits for non-medical
such as preimplantation genetic testing, can be used to is changed, gene editing of human embryos should be
screen embryos for harmful DNA. considered on a case-by-case basis by the fertility reasons could be 'morally
regulator, the Human Fertilisation and Embryology
DNA editing also raises the possibility of “designer Authority, the report adds.
babies”, where the genetic code of embryos created
 The group, which appraises the ethical realities of new “There was an enormous range of views, including
permissible', says UK technology, called for the government to that we should not do this as to do this would be to
begin canvassing national opinion and said copies of take a step humanity should not take,” Prof Yeung
ethics group the report would be sent to ministers and civil said.
servants.
Letting parents choose preferred “We thought quite hard about this and came to the
UK law does not currently permit any editing of view that, in and of itself, intervening in the heritable
characteristics of offspring to heritable DNA – genetic information contained in an genome would not be morally objectionable.”
avoid disease or otherwise, could embryo, egg or sperm – though it is allowed for
strictly controlled research purposes. This means “it should not be ruled out on principle”
be acceptable if it doesn’t but for any gene-editing to be ethically acceptable two
entrench disadvantages, says Even this, however, is hugely controversial and could tests must be satisfied, the group said.
have implications for people with diseases or less
Nuffield Council on Bioethics “desirable” traits if they become less common. Any Firstly, changes must be made for the benefit of the
change to the law would have to be subject to a health or welfare of the future person whose DNA is
Letting parents use new gene-editing technology to national public debate and parliamentary legislation, being edited.
pick characteristics of their unborn child can be as well as extensive testing for the safety of gene
“morally acceptable” as long as it doesn’t increase editing, the NCB said.
social inequalities, an influential medical ethics group UK panel says human
embryo editing ‘morally
has said. But a change is needed as we continue to expand our
understanding of the human genome, and which gene
In a major report on the looming frontier of human
gene-editing, the Nuffield Council on Bioethics
instructions affect different diseases and traits. The
arrival of precision genetic editing techniques like permissible’
(NCB) said it did not believe there was an ethical red crispr has made correcting damaged or undesirable
line in tinkering with the genetic material that will be genes a real possibility. An independent ethics panel in the UK has concluded
passed to future generations. that genome editing to influence the characteristics of
Professor Karen Yeung, chair of the NCB report a future person could be “morally permissible”.
It also did not draw a distinction between using these group, a law and ethics expert at the University of
techniques to tackle genetic diseases and for Birmingham, said these advances could have However, there would need to be a number of
enhancing desirable physical or intellectual traits, so- “profound consequences [which] affect the genetic measures put in place to ensure that genetic editing
called “designer babies”, so long as it meets strict make-up of society". “proceeds in ways that are ethically acceptable,” the
ethical and regulatory tests. inquiry, by the Nuffield Council on Bioethics,
concluded.
Genome editing is not currently lawful in the UK approach that is likely to appeal to some prospective The technique of genome editing – the deliberate
(unless for research purposes), but the practice could parents,” Professor Dave Archard, chair of the alteration of a targeted DNA sequence in a living cell
theoretically be offered in future to parents wishing to Nuffield Council on Bioethics. – could theoretically be used in assisted reproduction
change the genetic characteristics of their future child, to alter the DNA of a human embryo, before it is
such as excluding an heritable disease or a “There may be good reasons for allowing some transferred to the womb. This is not currently lawful in
predisposition to cancer in later life. parental preferences to be met, but we need to be the UK, but could, in time, become available as an
careful that the use of genome editing to help parents option for parents who wish to influence the genetic
The Council stressed the possibilities this raises could to exercise these preferences doesn’t increase social characteristics of their future child (for example, to
have “significant implications for individuals and for disadvantage, discrimination or division and that close exclude a heritable disease or a predisposition to
all of society”, and before the law so there must be attention is paid to the welfare of those involved, cancer in later life). The Council says that the
action now “to support public debate and to put in especially any child born as a result.” possibilities raised by this radical new approach to
place appropriate governance”. reproductive choices could have significant
The field has long been surrounded by controversy, implications for individuals and for all of society, and
It recommends that two overarching principles should with critics fearing that gene-editing could be used to there must be action now to support public debate and
be adhered to when considering use of heritable create a generation of so-called ‘designer’ babies. to put in place appropriate governance.
genome editing interventions in order for them be
ethically acceptable: they must be intended to secure The new report, Genome editing and human
the welfare of the future person; and they should not Heritable genome reproduction: social and ethical issues, sets out the
increase disadvantage, discrimination or division in range of ethical issues that arise in relation to the
society. editing: action needed to prospect of genome editing becoming available as a
reproductive option for prospective parents.
The Council also said the practice should only be secure responsible way
permitted after a “broad and inclusive public debate” The Council recommends that two overarching
on its potential use and implications, further research forward principles should guide the use of ‘heritable genome
to establish standards of clinical safety, and an editing interventions’ for them be ethically acceptable:
assessment of the risks to individuals, groups and An independent inquiry by the Nuffield Council on
society as a whole. Bioethics has concluded that editing the DNA of a  they must be intended to secure, and be
human embryo, sperm, or egg to influence the consistent with, the welfare of the future person;
“Huge advances are happening in genomics research, characteristics of a future person (‘heritable genome and
and whilst we have to acknowledge that genes alone editing’) could be morally permissible. If that is to  they should not increase disadvantage,
do not shape a person, the possibility of using genome happen, a number of measures would need to be put in discrimination or division in society
editing in reproduction to secure or avoid a place first to ensure that genome editing proceeds in
characteristic in a child offers a radically new ways that are ethically acceptable.
The Council further recommends that heritable “There is potential for heritable genome editing are controversial is that changes may be passed on to
genome editing interventions should be permitted only interventions to be used at some point in the future in future generations.
when: assisted human reproduction, as a means for people to
secure certain characteristics in their children. Professor Dave Archard, Chair of the Nuffield
 there has been a sufficient opportunity for broad Initially, this might involve preventing the inheritance Council on Bioethics said:
and inclusive public debate about its use and of a specific genetic disorder. However, if the
possible implications technology develops it has potential to become an “Huge advances are happening in genomics research,
 further research has been carried out to establish alternative strategy available to parents for achieving and whilst we have to acknowledge that genes alone
standards of clinical safety a wider range of goals. do not shape a person, the possibility of using genome
 the risks of adverse effects for individuals, groups editing in reproduction to secure or avoid a
and society as a whole have been appropriately Other reproductive options that are currently available characteristic in a child offers a radically new
assessed and measures are in place to monitor to prospective parents who face the possibility of approach that is likely to appeal to some prospective
and review these passing on an inherited genetic disorder, which parents.
genome editing might be considered alongside,
It adds that, if it were to be permitted, it should be: include pre-implantation genetic diagnosis, which There may be good reasons for allowing some
involves testing embryos for genetic characteristics parental preferences to be met, but we need to be
 strictly regulated (by the HFEA in the UK) and selecting one/s with preferred characteristics. careful that the use of genome editing to help parents
 introduced only in the context of a clinical study, to exercise these preferences doesn’t increase social
with monitoring of the long-term effects on Although the UK is one of the countries that permits disadvantage, discrimination or division and that
individuals and groups research on human embryos, the law does not close attention is paid to the welfare of those involved,
 licensed on a case-by-case basis currently permit genome editing interventions on especially any child born as a result.”
embryos that are to be placed in a womb. The law
Further recommendations would therefore have to be changed in order to allow NOTES TO EDITORS
the use of genome editing embryos, sperm or eggs for
In addition to these measures, the Council reproduction. 1. Copies of the report are available in advance, on
recommends the establishment of an independent body request.
in the UK to promote broad and inclusive societal The Council’s report sets out the ethical
debate on heritable genome editing interventions and considerations raised by the prospect of heritable To request the report, or an advance interview, please
related scientific and medical developments. genome editing interventions in relation to the contact:
interests of the people who would be affected by its
Professor Karen Yeung, Chair of the working use, of others in society who may be indirectly Sarah Walker-Robson,
party and Professor of Law, Ethics, and affected, and of human beings in general. One of the Communications Manager
Informatics at the University of Birmingham, said: main reasons heritable genome editing interventions
Nuffield Council on Bioethics reproduction was one of the areas identified in that Julian Hitchcock, Partner, Marriott Harrison LLP
swalker-robson@nuffieldbioethics.org review as requiring further ethical scrutiny.
Jackie Leach Scully, Professor of Social Ethics and
(+44) 0207 681 9619 / (+44) 07551 159670 This inquiry was carried out by an Bioethics, PEALS (Policy, Ethics and Life Sciences)
interdisciplinary working party that included members Research Centre, Newcastle University
Genome editing and human reproduction: social and with expertise in biology, human reproduction,
ethical issues will be published on the Council’s genome editing, law, and ethics. Tony Perry, Professor of Mammalian Molecular
website on Tuesday 17 July 2018. Embryology, University of Bath
To inform its deliberations, the working party received
2. About genome editing contributions from a wide range of people, including Christine Watson, Professor of Cell and Cancer
through an open call for evidence, an online Biology, University of Cambridge and Member of the
Genome editing is the deliberate alteration of a questionnaire, and a series of fact-finding meetings Nuffield Council on Bioethics
selected DNA sequence in a living cell. Genome and panel interviews.
editing techniques can be used to alter how a gene 5. About the Nuffield Council on Bioethics
functions, for example, by changing a variant of a 4. About the working party
gene that may give rise to disease to one that does not. The Nuffield Council on Bioethics examines ethical
CRISPR-Cas9 is an example of a method of genome Members of the working party were appointed for issues raised by new developments in biology and
editing that is now widely used in research. their personal knowledge and expertise, and do not medicine. Established by the Nuffield Foundation in
necessarily represent the views of their organisations. 1991, the Council is an independent body, funded
Heritable genome editing interventions are jointly by the Foundation, the Medical Research
interventions made to sperm, egg or embryo cells (or Karen Yeung (Chair), Interdisciplinary Professorial Council and the Wellcome Trust. The Council has
their precursors). The ‘edited’ DNA sequence would Fellow in Law, Ethics and Informatics, University of achieved an international reputation for addressing
be present in all cells of any future person grown from Birmingham public concerns, and providing independent advice to
those cells – including their own sperm or eggs – so assist policy makers and stimulate debate in bioethics.
may be passed on, in turn, to future generations). Richard Ashcroft, Professor of Bioethics, Queen http://nuffieldbioethics.org/
Mary University of London
3. About the project
Neva Haites, Professor of Medical Genetics,
This inquiry was initiated following publication of the University of Aberdeen
Nuffield Council on Bioethics’ previous report
Genome editing: an ethical review, in 2016. The Joyce Harper, Professor in Human Genetics and
development of genome editing applications in human Embryology, University College London