Biomedically Enhancing Humanity

Human enhancement has many forms: medication, caffeine, braces, contact lenses, steroids... but also education and science -- a collective intellectual enhancement. According to philosophy and public policy professor Allen Buchanan, “human beings have been enhancing themselves as long as they have been humans.”

Buchanan kicked off the 2010 A. B. Duke lecture series last week with his thoughts about the ethics of biomedical enhancement. Biomedical enhancements (BEs) are interventions that act directly on the body, improving some particular capacity. But “getting an enhancement doesn’t necessarily make you better off,” Buchanan noted. For instance, a person might wish to enhance their hearing, but enhancing it too much might make life unpleasant.

BEs can be cognitive or affective (improving mood or moral sentiments), can increase one’s resistance to disease or increase life span and quality of life. Different modes of BE include drugs, tissue/organ replacements, computerized neural implants and germline genetic interventions (genetically engineered embryos or sperm).

According to Buchanan, it’s not true that biomedical enhancements differ from traditional enhancements. For instance, if a person is highly reliant on their computer, then how different would it be to make that computer accessible via their mind?

BE certainly raises some interesting ethical questions, and has some incredible applications. One example is the ability to spread adaptive genes laterally, from person to person rather than from parent to offspring. This could have been helpful when infectious diseases like smallpox and bubonic plague wreacked havoc on human populations. Genetic resistance to a disease was uncommon before an outbreak, but quite prevalent afterwards, as only disease-resistant individuals survived to bear children. These deadly diseases produced rapid genetic change across whole populations, but millions died in the process. Alternatively, intentional genetic modification (IGM) “could spread desirable mutations more quickly and without the human cost,” according to Buchanan.

Opponents are concerned that BE could destroy human nature, have unintended bad consequences and/or provide an unfair advantage if only made available to some. Furthermore, there is the possibility for malicious dual use (repressive social control à la Brave New World).

But according to Buchanan, “It’s not a matter of being for or against it... because it’s going to happen. It’s already here.” Biomedical research frequently produces discoveries relevant to human enhancement. The only way to stop this would be to cease all biomedical research... and that’s just not going to happen.

One common argument against BE is that it interferes with nature. But Buchanan thinks we're giving nature, and evolution, too much credit.

“Don’t think of evolution as a master engineer ... Suboptimal design is a pervasive and necessary feature in evolution.” Buchanan went on to list several less-than-intelligent attributes:

• The dual function of the human pharynx (breathing and swallowing); resultant choking
• Humans’ inability to biosynthesize Vitamin C (We have the genetic pieces for it to be possible, but one part is missing, probably due to a mutation long ago)
• The male urinary tract goes through the prostate, instead of around it, making it prone to infection. The primate sinus is also prone to infection.
• The human birth canal runs through the female pelvis. As humans evolved to walk on two feet, and as human cranium size increased, giving birth became increasingly risky for both mother and child.

“How reliable is evolution as a means for improving human life -- or even for sustaining it?” Buchanan said. “Evolution doesn’t care what happens to you after you reproduce.” This might explain the preponderance of later-life problems, such as cardiovascular degeneration and accumulated mutations that lead to cancer. “There’s no reason to believe that evolution will correct [these problems],” Buchanan said. “In fact, there’s every reason to believe it won’t.”

Buchanan emphasized that humans must look beyond evolution’s haphazard progression. “[Evolutionary success] depends on a fitness between the organism and the environment, and the environment is constantly changing.” Furthermore, “current organisms are not the apex of evolution,” Buchanan said. “We are not completed works. It’s not the end!”

Latest Weapons Against Brain Cancer

Hope is the single most important therapy against cancer, says Dr. Henry Friedman of the Preston Robert Tisch Brain Tumor Center at Duke. Viral therapies to "rev up the immune system" against microscopic metastases are promising too. See Dr. Friedman discuss these and other things in a 5-minute video from CBS News.

At Home Care, Is It In You?

Guest post from NCCU summer intern David L. Fitts Jr.--

Millions of Americans are providing at-home care for a loved one with cancer, yet few feel up to the task.

Cristina Hendrix, assistant professor in the school of nursing, conducted a study that examined how a one-to-one training might help family caregivers of cancer patients improve their confidence and preparedness in caregiving.

Having family caregivers at home allows patients to feel secure and safe. However, Hendrix said that home care is a complicated task that adds to family members' burdens.

In her surveys, Hendrix said many family caregivers reported that they did not feel competent to take on the task. Many reported being stressed and finding the care a significant burden.

“Most cancer caregivers do not feel confident and prepared,” said Hendrix who spoke at the School of Nursing last month.

If a caregiver is not up to the task, Hendrix said that there are consequences for both the caregiver and the cancer patient. Many family caregivers reported feelings of depression when they struggled with caregiving.

One-to-one training of family caregivers before hospital discharge of their loved ones is important to help caregivers, Hendrix said. However, as early as one week after the patient's return, many family caregivers’ sense of competence starts declining again.

Regular communication and training between professional caregivers and the family caregiver can give the family caregiver a continuing sense of competence in their work, she said. Training must be formalized and at home throughout the care-giving period.

With an aging population, this topic will become more important in the future. It’s likely that more people will rely on family caregivers.

Hendrix’s research points to a possible solution to finding the resources to help both caregivers and patients on an issue that we would do well to think about more.

Engineering Futuristic Medicine

Massachusetts Institute of Technology professor Robert Langer gave a National Academy of Engineering summit focused on addressing worldwide needs a primer on how engineers can aid medicine.

One big challenge is figuring how to get "drugs of the future" into the human body in a way that can do some good, said the chemical engineer who won the 800,000 Euro 2008 Millenium Technology Prize for some of his innovations. Langer himself has "found over 200 different ways to get that not to work," he said in an address on Monday, March 9 at the Durham Performance Art Center.

The problem is that such large molecular weight drugs -- such as hormones, proteins, peptides and forms of DNA -- must reach targets such as a pancreatic cell in diabetes treatment or a tumor cell in cancer therapy without being chewed up by the body's own biochemistry. One successful stratagem his group has pioneered is placing the drug inside a protective polymer coat.
Another idea is designing polymers that be threaded though tiny bodily passages and then shift their shapes at internal body temperatures.

Langer's team has also created polymer scaffolds that experiments show may be usable to nurture cells needed to repair burned tissue, grow new noses or ears, even repair damaged spinal chords.

3D Cancer Detection

Biomedical engineers and cancer specialists at Duke have long been collaborating to discover ways to detect and treat cancer at all its stages. One of the recent major breakthroughs is the ability to observe and examine a live body tissue in three dimensions using a technique called Multi-photon microscopy.

According to researchers, more than 50% of all detected cancers arise in squamous epithelium, and if detected in a pre-invasive or pre-cancerous state, it can be treated relatively well.

The team led by Dr. Nirmala Ramanujam, Associate Professor of BME at Duke, has been studying optical spectroscopy, optical sectioning microscopy and photon migration techniques, and attempting to use them for characterizing and detecting biochemical and structural properties of various human tissues. According to Dr.Ramanujam, the multi-photon fluorescence microscopy—a technique enables doctors to "peer into the individual cells in a very non-invasive way to see how things change as early cancer progresses."

A multiphoton fluorescence microscope uses pulsed long wavelength laser light to excite fluorophores within a specimen. The fluorophore absorbs the energy from two long-wavelength photons that must arrive simultaneously in order to excite an electron into a higher energy state, from which it can decay, emitting a signal.

Another technique being explored by Ramanujam's group is called Ultraviolet-visible optical spectroscopy (UV-VIS). It is similar to fluorescence spectroscopy, in a way that fluorescence involves transitions from the excited state to the ground state, while absorption deals with electron transitions from the ground state to the excited state.

Dr. Ramanujam's current focus is on further researching and developing broad and effective techniques for clinical detection of cancer.

The Stuff After Genes

Have a look at a very nicely done article on epigenetics in a thoughtful new magazine called Miller-McCune.

This is one of the better pieces you'll see on the complex interplay between environmental factors and genes. It turns out that you are what you eat. But you're also what your grandma ate. Scary to think about.

Duke's own Randy Jirtle is mentioned, as no article on the field would be complete without him. Dean Bill Chameides has blogged on Jirtle as well.

Chemo and Radiation Sometimes Make Tumor Stronger

Many of us who have watched a loved one suffer through cancer treatments sort of suspected this might be true: some solid tumor cells that avoid being killed by radiation or chemo actually become tougher and better able to survive the next round of treatment.

Unfortunately, it's a lot like what Friedrich Nietzsche said: whatever doesn't kill me makes me stronger.

A Duke team led by Mark Dewhirst in radiation oncology has figured out how and why this happens: The solid tumor cells' innate ability to signal surrounding tissues to give them more oxygen gets turned up a notch by the treatment assault. Next time around, they're that much better able to resist.

Dewhirst and colleagues are now working on ways to turn off this gimme-oxygen signal in conjunction with chemo and radiation to really root the @#$%@s out. They've also made a movie showing the constant flux of oxygen in tumors, rising and falling like the tides. It's something that's only recently been identified.

Swinging for the Fences

Imagine a relatively simple hand-held device that physicians can use to determine whether cancer patients undergoing surgery have any tumor cells left behind that might set off another assault.

That’s what David Kirsch (photo) of the Duke Comprehensive Cancer Center is trying to develop. With such a device, patients might be spared the radiation therapy now commonly used after surgery “just in case” cancer cells remain. Also, patients found to have residual cancer cells might be given more precisely targeted high-dose radiation.

There are skeptics. But Dr. Kirsch recently received a Damon Runyon-Rachleff Innovation Award that will let him use the latest in molecular imaging technology to turn his idea into medical reality. Given for the first time this year, the awards, which provide $450,000 over three years, are underwritten by veteran Silicon Valley venture capitalist Andrew Rachleff, who says more funders of cancer research should start placing bigger bets on ideas with a high risk of failure but a stunning potential payoff.

The innovation awards are described here, and Dr. Kirsch outlines his research here.

Some other private funders of biomedical research also have staked out a high-risk, high-reward route for some of their programs. Among them, the locally based Burroughs Wellcome Fund and the larger Howard Hughes Medical Institute have helped lead the way out of the proverbial thought box.

The value of taking the less-traveled path in other areas of science and technology is explored in a recent New York Times article titled “Innovative Minds Don’t Think Alike.” Its spirit is captured by Intel co-founder Andrew Grove, who famously has said: “When everybody knows that something is so, it means that nobody knows nothin’.”

Listen to Cancer Patients

Cancer.

For many people, this diagnosis is as scary as it gets. At once, their world -- their future -- shifts tectonically. Yet when cancer patients express their fears and other negative emotions, their doctors often don't listen closely enough.

A Duke study, published in the Dec. 20, 2007, issue of the Journal of Clinical Oncology, concludes that physicians need to learn to demonstrate greater empathy in communicating with cancer patients -- and medical training should be adjusted to provide the necessary skills.

This cautionary tale for physicians, detailed in a medical center news release, has been reported widely in the media. See New York Times story from Jan. 8, 2008.

Effective communication between oncologists and their patients, especially those with advanced cancer, is essential to good care, says James Tulsky, M.D., director of Duke's Center for Palliative Care and senior investigator on the study (photo above).

"However, many oncologists have never been trained to respond to patients' emotions and concerns in a matter that shows their empathy," he says. "By teaching physicians to use explicit emphatic language when communicating with distressed patients, we have a chance to improve patient quality of life."

Toward this goal, the researchers produced personalized CD-Roms for the doctors in their study that highlight examples of when the clinicians responded emphatically to their patients, as well as examples of areas for improvement.

This study seems to dovetail with other research I’ve read about which suggests that when people first hear their cancer diagnosis, they immediately stop hearing anything else their physicians are saying.

Clearly, communicating about cancer is hard for everyone -- and any clues about how to make matters better are sorely needed.