The following post summarizes a talk given by Dr. Hilary Bok at Krieger 205 at Johns Hopkins University on February 23, 2011.
Imagine that people come up with therapies for various diseases…what’s been promising about stem cells is that we can personalize therapies, bypassing problems like rejection of cells. Suppose you have a stroke and there’s a good stem cell therapy for strokes. It would be better to get that therapy for you now, and we might not have time to culture a therapy from your own stem cells. We would like to have “off the shelf” stem cell lines. This would require a stem cell bank. Because of limitations on resources, we have to choose which stem cell lines that would be included in a stem cell bank.
The most obvious answer is to include the lines that will give the greatest number of matches (a utilitarian view of equality). We wouldn’t want to bother with a line that is a match for merely two people on Earth; this would be a huge waste of our resources and not be very effective. Where this gets tricky is that your alleles in question tends to follow from your ancestry. There is not enough genetic diversity between the alleles of different racial groups to have better stem cell matches between groups. So if we have to choose for this country, we would end up picking the lines that cater to whites. Ethnic admixture doesn’t help as much as one might hope. We would still end up with a wildly disproportionate stem cell bank that would benefit mainly whites.
Offhand, this utilitarian formula seems to encourage inequality among healthcare for different ethnic groups.
Q: If someone was to design stem cells in China for Chinese people, could these lines be used for Chinese Americans?
You might with some plausibility hope that these lines would help (though a lending program or something) people with Asian ancestry who live in other areas of the world. Things look trickier when you think about Sub-Saharan Africans or Native Americans who, through no fault of their own, would not be capable of creating their own racial stem cell bank. In the case of small racial groups, it’s then a question of how far down the list you go, if you were to try to cover 20% of each group, for example.
The question is, which strategy do you think is right?
Dom: I would target the relevant population by looking at prevalence of diseases among the races.
Sure, if you’re looking at sickle cell anemia, you don’t want to procure treatment for whites in the United States. However, some of these diseases that could be cured by stem cells do not correlate to genetics. Anyone could get a spinal chord injury, for example.
Dom: You could privatize the banks, since there’s no argument that these treatments are going to be very expensive and not feasibly translated to treat the population on a large scale. Thus the banks will be market driven…it may come down to that practically, anyway.
Ishan: You also have to look at WHO’S privatizing, since the businesses will have their own agendas.
Dom: It partly comes down to who’s paying for it.
It could be that most of the diseases that afflict just whites. But what if that doesn’t pan out? Or if the private funding from people target ONLY white people? The privatization is just a wild card – we don’t know that they’re going to follow any kind of equality values.
Ishan: It could be therapy driven. If we had a good promise of a stem cell therapy for diabetes, we could bank it based on who was most susceptible. We could prioritize based on the therapies that are the most effective.
JD: So there’s a demand for treatment, but also a demand for quality of treatment. For reasons we might say are unjust, the quality of treatment for certain races are unequal.
Right. There already are health disparities in the US between whites and african americans. We ought not do anything that increases this disparity. The most cost effective way of reducing these disparities could be a stem cell bank, but that frankly strikes me as unlikely. Suppose that you adopt a save-the-most strategy, and use the money you saved between covering other, less lucrative stem cell lines, to reducing other health care disparities or by introducing other stem cell lines.
It’s a really interesting question because by using an imaginary situation, we see how without including past injustices, we automatically create disparities by trying to provide the most health care to the most number of people.
Q: How long does it take to make a stem cell bank? How long does it take to collect different lines?
I’m not sure. It would take finding people with homozygous lines, then culturing them. The problem is trying to collect enough to cover a large spectrum of people, and knowing when to stop given a certain amount of resources.
Q: Could we use the transplant model? Where we try to treat who needs it most? Or the drug model, in which it is privatized, but government regulates who receives the treatment?
It differs from organs in that these are cells. In this case, I can take some cells and keep growing new ones. So it is not like organs because there are an obviously limited number of organs, but a stem cell line, once in the bank, can treat a much much higher number of people.
And with drugs, this might illustrate why we want a stem cell bank to begin with. It is a new injustice to make the availability to rely on existing wealth.
The thing is, even a person of good will could look at the way that trying to create “equality” of treatment shakes out and think, “I come up short.” And it wouldn’t be irrational or paranoid. I mean, isn’t it funny how it always turns out that way, when we supposedly live in a democracy that protects the rights and interests of all the people. The past grievance is irrelevant in the way that the logic that we arrive at the arrangement of the stem cell bank is not actually based on racial biases. However, it is relevant in the way that it still falls along lines that continue to create health disparities that are pre-existing.
Stenographer: Amy Marco