The Boys in the Ban

by Sean Philpott-Jones, Director of the Center for Bioethics and Clinical Leadership

For over 30 years now, the United States Food and Drug Administration (FDA) has banned blood donations from gay and bisexual men. It is a lifetime ban. Currently, no man who has ever had sex with another man can donate blood in the US.

The same is true for tissue donations. Just last year, for example, the FDA refused to accept for donation the eyes of an Iowan teen after learning that the boy was gay. When 16-year-old Alexander Betts committed suicide after months of bullying at the hands of classmates because of his sexual orientation, just a few months after he signed up as an organ donor, his family honored one of his last wishes by donating his organs and tissues. But while his heart, lungs, kidneys and liver were used to save the lives of six other people, the donation of his eyes was rejected because “tissue from gay men carries an increased risk of sexually transmitted diseases, including HIV/AIDS.”

The ban on blood and tissue donation from gay men was put in place in 1983, shortly after HIV, the virus that causes AIDS, was first isolated. It made sense at that time. Along with other socially or economically marginalized groups like injection drug users and commercial sex workers, during the early years of the AIDS epidemic gay men were — and still are — at increased risk of acquiring HIV. Banning donations from groups who were more likely to be infected with the virus, particularly when there were no effective treatments, was a logical step to protect the blood supply from contamination with HIV.

This was in part because the first tests to detect the virus in the blood of infected individuals were notoriously inefficient. In fact, these first tests didn’t — and many modern HIV tests still don’t — test for the presence of the virus itself. Rather, they test for the presence of antibodies to HIV.

Antibodies are proteins produced after the immune system encounters a foreign body like a virus, a bacterium or an allergen. They specifically recognize and bind to these pathogens, hopefully neutralizing them before they can infect a person and cause disease. Most vaccines are designed to trigger an antibody response to common infectious agents, such as those cause measles, chicken pox or hepatitis, in order to protect people exposed to those diseases.

Unfortunately, the antibodies produced by the human body against HIV are not protective. But they are a marker that a person has been exposed to HIV, and likely been infected. But an antibody response to HIV can take days or even weeks to develop after infection. So tests that look only for the presence of antibodies to HIV can miss those individuals who are recently infected. If these people give blood in the interval between when they were infected and when they develop an antibody response to HIV, testing their blood will suggest that it is clean even though it may contain live virus that can be spread to transfusion recipients.

But as a team of researchers as Harvard Law School point out in a recent article in the Journal of the American Medical Association, times have changed. HIV testing technologies have dramatically improved in the three decades since the virus was found. Modern antibody tests are much more sensitive, detecting anti-HIV antibodies much earlier in the infection process. We also have inexpensive and reliable tests that look for the presence of the virus itself. Used in combination, these tests can determine if a person has been infected within just a couple of days of exposure. They are a quick, cost-effective and largely infallible way to screen the US blood supply.

Given this, it seems rather unconscionable that the FDA continues to maintain a lifetime ban on blood donations from gay men. This is particularly true when you consider that other groups at high risk for HIV do not face a similar ban. For example, the ban on blood donations from men who have had unprotected sex with women who are known to be HIV-positive is only one year in duration, not life. The same is true for women who have had sex with an HIV-positive male partner. So it’s not the gender of the infected partner that matters, only their sexual orientation.

Moreover, in countries that have lifted the lifetime ban on donations from men who have sex with men, no concomitant increase in the incidence of transfusion-acquired HIV has been seen.

Finally, in 2010 an FDA advisory committee concluded that the lifetime ban keeps many low-risk men from donating to the nation’s blood supply. But despite this, the committee voted to keep the ban in place.

So why does the lifetime ban on blood donations by gay and bisexual men? It is sexual behavior not sexual orientation that determines whether or not an individual is at increased risk of HIV. A promiscuous heterosexual college student is a far greater risk than a gay man who has been in a long-term monogamous relationship.

Quite simply, the ban is purely discriminatory in nature. It does little more than perpetuate outdated and homophobic stereotypes. It also contributes to widespread stigmatization of sexual minorities, leading to the open hostility and institutionalized violence that lead young men like Alexander Betts to end their lives.

We can do better. It’s time to end the lifetime ban on blood and tissue donation by gay and bisexual men.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on August 28, 2014, and is available on the WAMC website. The contents of this post are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

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The Early Bird Get the Ethics?

by Karen Solomon, Bioethics Program Student

Does early to bed and early to rise, make a man healthy, wealthy and more ethical? Earlier research suggested a “morning morality effect”: that people are more ethical early in the morning, becoming less so as they “wear out as a day wears on.”

Not so fast, researchers now say. New research casts doubt on conceptions that night owls are less ethical than their early rising lark counterparts. Instead, a better predictor for ethical behavior takes into account the “fit” between one’s chronotype — night owl or morning lark — and the time of day when ethical behavior is implicated.

Consider the night owls who have more energy as the day wears on, with peak energy levels in the evening. Researchers postulated if internal body clocks supply the energy for ethical behavior, then the body clocks of night owls, people who have more energy as the day wears on, should overcome the morning morality effect, and demonstrate more ethical behavior in the evening.

To test this hypothesis, researchers asked participants to complete a matrix task or a die role and report the outcome, for the opportunity to earn a nominal monetary reward or tickets toward a raffle. What researchers evaluated, however, was the participant’s honesty in reporting the actual task outcome. Researchers found morning larks more likely to report task outcome honestly in the morning, during the larks’ peak energy hours. Conversely, night owls were more likely to behave ethically in the evening, confirming researchers’ belief that the fit between chronotype and time of day are better predictors of ethical behavior than chronotype alone. (Gunia, Barnes, & Sah, 2014)

Future research is needed to uncover the underlying mechanisms involved in the “chronotype morality effect” and the impact of interventions that boost the match or aggravate the mismatch between chronotype and time of day. However, these results clearly have broad implications, particularly for shiftwork in the workplace.

For example, understanding how body clocks inform ethical decision-making by health care professionals, particularly those involved with hospital emergency rooms and critical care units, may become a valuable tool in responding to the intense and often unpredictable nature of ethical dilemmas that characterize medical ethics. Such decision-making encompasses a range of highly personal and emotional health care decisions, including end-of-life care, organ donation, starting and stopping life-sustaining treatment, and informed consent. Such medical ethics decision-making also reflects the untimely nature of accidents, illness, and other tragedies.

In the future, health care administrators and professionals who understand the importance of aligning those involved with ethical decision-making with processes that take into account optimal times for ethical decision-making may provide the best opportunity for ethical decisions that stand the test of time. For example, scheduling ethics consultations and professional staffing consistent with optimal times for sound ethical decision-making may confirm the conventional wisdom that timing is, in fact, everything.

[The contents of this blog are solely the responsibility of the author and do not represent the views of the Bioethics Program or Union Graduate College.]

Taking the Icy Plunge (Or Not)

by Sean Philpott-Jones, Director of the Center for Bioethics and Clinical Leadership

There’s an epidemic that is sweeping this country. It’s not Ebola, despite all of the hype and misinformation about that disease that has dominated the news in the past two weeks. Rather, I’m talking about the ice bucket challenge.

Anyone who has watched television in the last couple of weeks has seen this: newscasters, celebrities and athletes like Matt Lauer, Martha Stewart and Nick Swisher being doused with a bucket of ice water in the name of charity. The goal of the ice bucket challenge is to raise money and awareness about amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig’s disease).

ALS is a neurodegenerative disease that affects nearly 30,000 Americans. It primarily affects people in their mid-40s to mid-60s, and is characterized by an increasing loss of motor function. Initial symptoms include muscle weakness or slurred speech. As the disease progresses these symptoms become increasingly pronounced. Patients with ALS gradually lose the ability to walk, speak, eat and (eventually) breathe. They slowly become prisoners in their own bodies, fully aware but trapped in an increasingly uncooperative shell.

The root cause of the disease is still unknown, and there is no known cure. Treatments can slow the onset of symptoms, but most patients succumb to the disease rather quickly. The majority of people living with ALS die within 3-5 years of their initial diagnosis, although there are notable exceptions like famed physicist Stephen Hawking, who has lived with the disease for over 50 years

The federal government spends about $60 million on ALS research. Private organizations like the ALS Association also spend money, both to develop new treatments and to provide care for those affected by the disease. As a non-profit organization, however, the ALS Association depends on contributions from people like you and me, and that’s where the ice bucket challenge comes in.

The challenge is simple. A person either donates $100 to the ALS Association or agrees to post a video of them getting doused with ice water on a social media site like Facebook (usually with a hash tag like #IceBucketChallenge or #StrikeOutALS). That person then challenges three of their friends to do the same: donate or get doused.

The campaign has been remarkably successful. In the past month, the ALS Association has raised over $1.5 million. Donations are up nearly a hundredfold since the campaign began. That’s a good thing, so what I’m about to say is likely to be surprising and even a little upsetting to some.

I think the ice bucket challenge is a crock, and I want no part of it. To all my friends who have called me out on Facebook to participate, my answer is ‘no’.

This isn’t to say that I don’t believe that ALS is a terrible disease. It is. I have seen the effects first hand, when the brother of a close friend contracted the disease. I have also donated to the ALS Association in memory of a former student’s father, who died from complications related to ALS last year

I am opposed to the ice bucket challenge for a number of reasons. First, I don’t believe that it does anything to raise awareness of ALS in the long term. Most of the videos that I have seen posted on Facebook, Vine and other social media sites say little to nothing about the disease and its impact on the families affected by ALS. They also don’t discuss why monetary donations are desperately needed, where to donate to, or how the money will be used.

Second, I have a real problem with a fundraising campaign in which public humiliation or exhibitionism seems to be the primary goal, with donations to a charitable cause an afterthought. Consider the rules of the ice bucket challenge: you either film yourself getting doused with ice water or you donate $100 to a charity. Charitable donations are the consolation prize in this extortive game.

In fact, what most people don’t realize is that the ice bucket challenge predates the ALS Association campaign. It was actually started as a game among pro athletes like golfer Greg Norman, with those who refused asked to donate to a charity of the challenger’s choice. The original challenge was never about raising money or awareness of a charitable cause, and now we have thousands or millions of Americans who feel like they’ve contributed to ALS research without actually doing anything.

If you want to help those living with ALS, dunking a bucket of cold water over your head is not the way to do it. Rather, you should visit the websites of organizations like the ALS Association and learn more about the disease. You should donate money to the cause and encourage your friends and family to do the same (without subjecting them to hypothermia). You should write your Congressional representatives and encourage them to increase funding for ALS research. Finally, you should consider donating your time to help those with the disease and their families.

Save the ice for your drinks.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on August 14, 2014, and is available on the WAMC website. The contents of this post are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

Big Bad Ebola

by Theresa Spranger, Bioethics Program Alumna (MSBioethics 2012)

Last week Ebola came to the United States, it came on a specialized plane in the form of two medical missionaries. The conversation since has revolved around whether or not bringing them home for treatment was wise and/or just.

First, let’s talk about the risk of Ebola transmission, this seems to be the main concern for those who object to the patients being transferred to the U.S. As a nation we are at far greater risk from travelers not yet showing signs of the disease. The two missionaries are being well isolated and every precaution has been taken to ensure the virus does not escape the containment unit. The risk of contamination, transmission, etc. is very low from these patients. It is certainly not zero, a lie I have heard too many times from the media, but it is extremely low.

An argument I simply can’t stomach is: If the missionaries caught Ebola while using the appropriate personal protection equipment (PPE) isn’t the American medical staff at the same risk? Absolutely not. In Africa Ebola is rampant, patients are kept in large wards, the disease is in the communities, and there is no possible way the healthcare providers could have kept their guard up at all times. The risk of contracting the disease while in Africa is high, no matter the protection they used.

Argument 2: They knew the risks and went over anyway, just leave them in Africa to suffer the consequences of their decision. True, they knew the risks and this a viable, though not-so-compassionate response to the problem. Honestly, I think either decision could have been rationalized though I am sure the families of the missionaries appreciate the choice we made to bring their loved ones home and if it had been your family member you would have wanted them home too.

Now that we have unpacked the risk of Ebola spreading in the U.S. I want to talk about the experimental Ebola antiserum. It is reported in the media that the two American missionaries have received this experimental antiserum and I have heard calls to release the drug to all those suffering in Africa. Advocates for release of the drug are particularly intent that it be given to the medical staff who has become infected while treating Ebola patients, since they were infected in the same way as the Americans. I understand the desire and it “feels” compassionate to fight to send this antiserum to Africa. However, there are some very important reasons why this should not happen:

First of all, we don’t know that this drug even works, it’s experimentation in humans is extremely limited, and for all we know it could cause more harm than good. It may seem like the simple solution in an emergency to toss protocol out the window. However, for the safety of the trial participants studies need to be limited in scope and as controlled as possible. If released to the general public or even the medical staff of Africa there would be no way to appropriately monitor for side effects and safety issues. Furthermore, to get the drug to the population as quickly as “demanded” would necessarily violate all study regulations and proper procedure in Africa. This is a huge risk, and if anything were to go wrong with the drug or study who would be blamed? Certainly America and the scientists. It simply isn’t a wise move.

Secondly, the supply of antiserum is extremely limited, there would be no way to make an acceptable amount of antiserum to treat those infected, presuming of course that the drug does what it is intended to do without major side effects.

The scientists have been painted as the bad guys by many of those pushing for the drug’s release and this is simply not true. Those scientists have committed their lives to finding a cure for Ebola and just because they are bound to a process you don’t like right now doesn’t mean that they are evil. If the process is followed and the trial successful perhaps we can have a long term cure for Ebola. Pushing to exempt this project from the scientific process will not help long term progress and could result in short term disaster.

It is easy and feels right to act on emotion, but it is rarely the wise choice.

[The contents of this blog are solely the responsibility of the author and do not represent the views of the Bioethics Program or Union Graduate College.]

Media Sensationalism and Medical Practice: Doctors Are Examining Your Genitals for a Good Reason

by Patricia Mayer, MD, Bioethics Program Alumna (2009)

There have been so many stories about bad behavior by doctors, so perhaps I should not have been surprised by the recent and blaring headline on the American Journal of Bioethics’ website: Doctors Are Examining Your Genitals for No Reason!

Oh dear, I thought, not another doctor taking advantage of a patient. But when I opened the article (the original was published in Slate), I saw nothing of the sort. In fact, instead of doctors taking advantage of patients, doctors were being pilloried for taking good care, recommended care, and appropriate standard-of-care-kind of care of their patients.

Many professional organizations have, for years, recommended yearly pelvic exams for women. The American Cancer Society began recommending this schedule in 1980. The American Congress of Obstetricians and Gynecologists (ACOG) also did (and still does) recommend yearly pelvic exams. The majority of family practitioners, internists, and gynecologists have followed this schedule for years.

A recent study published in the Annals of Internal Medicine now concludes there is insufficient evidence to continue this recommendation. The study includes a new recommendation of the American College of Physicians (ACP): ACP recommends against performing screening pelvic examination in asymptomatic, nonpregnant, adult women. Interestingly, even after this study was released, ACOG reaffirmed its original recommendation for yearly exams in a new Practice Advisory Recommendation.

Perhaps doctors were doing too many yearly pelvic exams, if you believe the ACP. Perhaps they are not, if you believe ACOG. But whether you ascribe to the ACP’s recommendations or to those of ACOG, to say doctors were “examining your genitals for no reason” is inflammatory, sensationalistic and unfair. Doctors did yearly pelvic exams as standard of care, following guidelines released by prominent medical organizations.

We need new information discovered in studies, but we don’t need sensationalistic headlines with lurid implications about doctors. As Joe Friday might be quoted as saying, “Please. Just the facts, ma’am.”

Oh, and by the way, Joe Friday never actually said that.

[The contents of this blog are solely the responsibility of the author and do not represent the views of the Bioethics Program or Union Graduate College.]