Biotechnology

Scanning the articles is like hopping a time machine to a better, smarter world — a medical “Futurama” where doctors use “electronic noses” to sniff out ear, nose and throat infections, where “smart” pacemakers monitor a patient’s blood oxygen levels and cardiac wall pressure, adjusting the heart’s pace from moment to moment. And there will be souped-up wheelchairs that can climb stairs and go barrelling through sand and gravel like Humvees.

And, in a bit of news guaranteed to prick up ears everywhere, doctors will grow artificial penises and vaginas and use them to replace worn-out or disfigured parts. Dr. Myron Murdock, director of the Impotence World Association recently told Reuters that within 25 years genetic research will make it possible for scientists to construct male and female genitalia by culturing human cells and growing them over a mold.

In other words, expect the bizarre in medicine’s brave new world. Hospitals are going to change drastically, according to Dr. Charles B. Wilson, a neurosurgery professor and director of the Institute for the Future at the University of California San Francisco. As part of the admission process, Wilson predicts in his BMJ article, patients will be implanted with sensors that automatically perform more than 40 laboratory tests.

Wilson predicts that ceiling vents in hospitals will be equipped with air monitors to scan incoming visitors and sniff out anyone who could transmit an infection to a patient. Intensive care units will disappear, and we’ll see the emergence of “transportable intensive care beds” complete with sensors to monitor patients’ vital signs and deliver ventilation.

And in a scene straight out of “Star Wars,” robots will go tooling around our hospitals like automated candy stripers, running supply services and filling pharmacy orders.

Gazing through the pages of this month’s medical journals, the future looks exciting. But, as Dr. David H. Mark writes in JAMA’s introduction to the global theme issue, “Technological progress, even when it is real progress, often leads to new problems, difficult choices, and unforeseen dilemmas. Clearly, technology is not an unequivocal savior. With it often come difficult social, ethical, and economic choices.”

A prime illustration of the progress-problem dichotomy — and the attendant ethical and economic issues — is the thorny debate over xenotransplantation. The chronic shortage of human organs has compelled some doctors to promote the use of animals — pigs and primates, mainly — as an alternative source for organ transplants. Research is now underway to determine the viability of cross-species transplantation, with scientists looking at the immunological barriers, physiological functions and the risk of infectious diseases.

But opponents are calling for a moratorium on the research, saying that xenotransplantation — “Frankenscience,” some call it — is expensive, unethical and ridiculously dangerous due to the high risk of transmitting animal viruses to humans.

This gulf of dispute has separated supporters and critics since the first animal-to-human experiments at the turn of the century. For a long time, though, the debate raged on a mostly hypothetical level. But with recent advances in genetic manipulation and the development of immunosuppressive drugs, xenotransplantation is looking less like science fiction and more like medicine’s next big thing.

One of the more radical prophecies put forth in Wilson’s article is the idea that animal-to-human transplants will become quite commonplace in the near future — so common, he says with tongue only partly in cheek, that pig farms will sit next to hospitals for easy access. Wilson says, “By 2010, xenotransplantation will be available.”

It shouldn’t be, says Alix Fano, director of the Coalition for Responsible Transplantation and author of the 1998 book “Lethal Laws: Animal Testing, Human Health, and Environmental Policy.” “The risks are way too great,” she says. The FDA has acknowledged the risk, and yet the research goes on. In Fano’s view, “it’s inconsistent for agencies to continue to invest in a technology that could spread disease.”

Dr. Harold Vanderpool, a professor in philosophy of medicine at the Institute for Medical Humanities at the University of Texas Medical Branch in Galveston, serves on the FDA subcommittee on xenotransplantation. Vanderpool, who authored a BMJ article on xenotransplantation for the global theme issue, doesn’t deny the risks.

“The possibility of passing on diseases — many of which we haven’t identified yet — is a real concern,” he says. “The risks are great enough to require vigilant oversight. We have to be somewhat paternalistic about saying when trials can go forward.”

Vanderpool says that scientists are nowhere near ready to begin clinical trials on humans, but he believes the genetic research should continue, with the hope that xenotransplantation can someday be proven safe and effective. He says, “The probable benefits outweigh the probable risks.”

For Fano, “probable” is the key word. “The benefits have never been proven,” she argues. “Since 1906, 83 people have received animal organs and they’ve all died — most within a few hours or days.”

Still, the push for progress goes on. Fano believes that, if you follow the money trail, you can trace that push to the biotech companies who stand to cash in if xenotransplantation develops into a full-fledged industry. It’s a simple case of misplaced priorities, she says. “Is it fair to commit $35 billion a year to xenotransplantation when 50 million American lack basic health care and 50 million more are uninsured?”

Maybe not fair, Wilson says, but medicine must continue its forward march regardless of money issues. “Cost concerns cannot prevent the advance of science,” he says. And if the wealthy have a better chance of reaping the rewards of expensive high-tech medicine, that’s just the inevitable consequence of a society divided into haves and have-nots. “Someone who’s poor is less likely to get a new heart — or a new car. In a perfect world, this wouldn’t be true.”

But the xenotransplantation debate raises questions that go beyond financial nitpicking to the very core of what it means to be a human being. We tend to view the human heart as the locus of personality and soul; of our humanness. And that doesn’t bode well for the spiritual well-being of cross-species transplant recipients.

“How will the recipient feel,” Vanderpool wonders, “when he realizes that inside him beats the heart of a pig? Is he not fully human? A chimera of some kind? The whole notion of humans walking around with animal organs is an idea that most people haven’t come to terms with.”

But for scientists at work at century’s end, Vanderpool says, playing God just comes with the territory. “On all levels of truly innovative scientific advances, human beings are manipulating nature in ways that are surprising and, for some people, alarming. Xenotransplantation will raise a new specter for people who feel it’s unwarranted to cross boundaries in nature with impunity.”

For Wilson, those boundaries fluctuate with the societal climate. “When I was in med school,” he says, “people would die before they’d take blood from a black person.” Our cultural qualms can’t interfere with progress, he says, and in the case of xenotransplantation, “We’ve been given the wisdom to do what is a step forward for humanity. There will always be people who talk about the immorality of progress,” he says. “To get full accord is an unattainable goal.”

The only thing as inevitable and obdurate as the advancement of science may be the debate over the advancement of science.

Vanderpool takes a historical view. When the idea of in vitro fertilization was first introduced to the public, he points out, “There was enormous outrage and controversy, a great wringing of hands. But when Louise Brown [the first test-tube baby] was born in 1978, and she was healthy and normal, the controversy died down. The controversy tends to settle when you see the wonderful human results right before your eyes.”

It’s too early to tell whether we’ll see wonderful human results from xenotransplantation — or smart toilets, or electronic noses, or artificial penises — or if these new technologies will instead strip away some of the mystery of living day to day in the sway of the natural world. Science marches forward now, history steps in later to judge.

“Only the future will tell if this is for the betterment of humankind,” Vanderpool says, “or if it’s destructive.”