Thursday, August 30, 2007

Texas Set to Take on Cancer

The News of the Week piece in the latest issue of Science has the encouraging news that the state of Texas is gearing up to launch a war against cancer. Here is an excerpt from the article entitled "CANCER RESEARCH: Texas Voters Asked to Approve $3 Billion Cancer Initiative" (by Jocelyn Kaiser):

Texas is planning a biomedical research initiative fit for a state where everything is bigger: a $3 billion pot of money for its scientists to wage war against cancer. Legislation signed by Governor Rick Perry in June would create a cancer institute to manage the 10-year program, funded through state bonds. If voters approve the November ballot measure, the amount of money awarded annually will easily top the $226 million in grants that the state received last year from the National Cancer Institute (NCI).

...A friend of former governor Ann Richards, Austin business executive Cathy Bonner, came up with the idea of a cancer research initiative after the popular Democrat died last year from esophageal cancer. Bonner says she was aware of California's stem cell initiative and thought "now's the time" to do something similar for cancer research, which she felt needed a "big vision" in a time of flat federal funding. She joined with Armstrong's foundation and other groups and pitched it to Perry. By May, the legislature had voted to convert the state's cancer-prevention agency into the Cancer Prevention and Research Institute of Texas and to give it authority to fund scientific research on "all types of cancer in humans." Voters are being asked on 6 November to approve the sale of $3 billion in bonds to fund the institute, which would give priority to matching grants, those promising economic benefits, and collaborations. Up to 10% of the funds can be spent on prevention and 5% on facilities; the first grants would be awarded in 2010.


Wednesday, August 29, 2007

The Fascinating Interconnections of Biomedical Research

For a number of years now I have been investing a good deal of my intellectual energies into reflecting on the ethical, social and legal challenges of the genetic revolution. This revolution raises important and novel challenges for theories of distributive justice. And if we don't begin taking these challenges seriously now, we risk unfairly distributing the by-products of a revolution that could greatly influence important phenotypes (like health, disease, intelligence, etc.).

One important part of my work has been to make some headway on the issue of what prioritarians ought to say about the duty to directly mitigate genetic disadvantage (through, for example, gene therapy). Recall from earlier posts (here and here), The Priority View maintains "that benefiting people matters more the worse off these people are (Parfit, 2000, p. 101)".

If one moves directly from the prescriptions of the Priority View to real policy- which I think is a mistake, especially in a field as novel (and still speculative) as biomedical technology- one might be inclined to take the view that we should focus most of our energies (and resources) on treating severe, early-onset genetic disorders. For these conditions impose severe restrictions on an individual's expected life-time acquisition of the "natural primary goods".

Those who have been following my blog will know that another project of mine (which really developed as a result of my interests in genetics and justice) is the intersection between theory and practice. So I am keen on integrating normative theory with the real world. And when we reflect on the realities we currently face, in the "here and now", numerous constraints and considerations need to come into play before we can derive sage prescriptions concerning what justice demands in terms of directly mitigating genetic disadvantage.

So take the following prioritarian intuition- the greatest urgency should be placed on mitigating the most severe early-onset disorders. A number of real-world constraints complicate this prescription. For example- how rare these disorders often are, the existence of alternative interventions (which may be more cost-effective), the costs of intervention, the likelihood that intervention will be successful, concerns about informed consent, other forms of disadvantage (socio-economic disadvantage), etc.

Grappling with these kinds of issues has convinced me that prioritarians must be pluralistic prioritarians. In other words, the value of priority must be reasonably balanced against other values (like utility), and thus we should strive to achieve judgements that are informed by a "big picture" perspective of the moral landscape (or what I have called "justice-many-things-considered").

Once one integrates one's normative aspirations with real-world empirical insights, we are more likely to arrive at sage prescriptions that can help us transform the status quo into a more fair and humane arrangement.

One of the challenges for my research has been to examine what the prioritarian ought to say about the priority of different biomedical interventions (e.g. therapies, enhancements, etc.), as well as traditional environmental interventions (e.g. opportunities for education, employment, income, etc.). And what I have come to realise is that these issues are much more complex, and fascinating, than I could have ever imagined. And this makes it much harder to figure out what is the right and wrong course of action! (hence the reason why it is important for us to think long and hard about these issues before jumping to hasty conclusions!)

Working in this area has taught me many interesting things. One important thing I have learned is that we must appreciate the diverse and fascinating interconnections of biomedical research. And an article in the latest issue of Nature Genetics brought this point home to me again tonight. The piece is entitled "Cancer drugs to treat birth defects" and it shows how the effort to treat prevalent diseases like cancer can actually aid the development of therapies for serious pediatric syndromes. Here are the some of the details from this fascinating "News and Views" piece:

Cancer drugs to treat birth defects
Andrew O M Wilkie

Identical mutations of the same genes can lead either to congenital malformations or to cancer, depending on their cellular and temporal context. The demonstration of activated RAS-ERK signaling in a mouse model of Apert syndrome suggests that drugs designed to inhibit this pathway in cancer may also delay the progression of several serious pediatric syndromes.

And a brief sample:

Until a few years ago, the title above might have seemed to belong only in the headlines of the tabloid press. However, as the genes mutated in birth defects and cancer have been identified, and the details of how these mutations disturb the regulation of biochemical pathways have been explained, a remarkable convergence in their underlying cellular mechanisms has been uncovered. This is well illustrated in a study by Vivek Shukla, Xavier Coumoul and colleagues1 on page 1145 of this issue. In a mouse model of Apert syndrome in which affected pups normally die within a few weeks with craniofacial malformations, injection of the pregnant mother with a specific signaling inhibitor enables the mutant offspring to survive and even reproduce. Thus, the huge investments into the design of new anticancer drugs might have collateral benefits in the treatment of rare congenital malformations.

....In conclusion, the work of Shukla et al.1 is likely to stimulate considerable further interest in the use of new drug treatments to reduce the complications associated with several pediatric syndromes. Obvious barriers to the successful implementation of such treatments include the prenatal onset of many of the more severe features of these syndromes, the difficulty of identifying them prenatally (especially as they often result from new mutations) and, as illustrated by the present work, the likely need for long-term treatment. But without the cancer connection, even the possibility of therapy for these rare birth defects would be beyond reach owing to the high costs of drug development, safety monitoring and efficacy testing.


Saturday, August 25, 2007

Impact of Aging Populations

The latest issue of Nature has an interesting "News and Views" piece by Frances Cairncross which addresses the impact of aging populations. Here are a few excerpts:

Ageing populations raise the spectre of crippling healthcare costs. Extra spending on medical research might bring healthier, happier older people who work (and pay taxes) for longer. Is that a good investment?

Many of the changes that will dominate the first half of the coming century are uncertain, but one is not: the global population will grow older. Already those aged 65 or over, who have rarely accounted for more than 2–3% of the populations of most countries, make up 15% of the rich world's inhabitants. The proportion is also rising in poor countries, as women in many nations have fewer children, and life expectancy rises, not just in infancy but in late middle-age and even in old age.

....This matters not only for those with greying hair, but also for governments. A consequence of falling fertility rates is that there will be fewer young people relative to the number of old people. One result is an upward creep in the average age of the labour force; another is a fall in the proportion of workers to non-working old folk. The upshot is fewer taxpayers, but also more people who are not contributing to the economy and are likely to draw increasingly on health services. If the books are to balance, people will need to work for longer. But will their health be good enough for them to do so? And if it is, will they be as productive as younger folk, or will an older workforce in industrialized countries lose its competive edge against industrializing countries that still have youthful employees?


Monday, August 13, 2007

Libertarianism and Rectification

*Originally posted April 2006*

This is my first post (of what I hope will be many) on libertarianism. I myself am not a libertarian but I really do enjoy debating with libertarians. I am fortunate to have had two excellent colleagues who are libertarians. Before coming to Waterloo I taught at Manchester University with Hillel Steiner (a left-libertarian). And here at Waterloo I have Jan Narveson (a right-libertarian) just down the hallway in the philosophy department. I have profited immensely from the many discussions and debates I have had with them over the years.

By seriously entertaining the arguments of my theoretical opponents I open my mind to new considerations that I would have failed to seriously entertain if I only discussed issues of justice with like-minded scholars (NOTE: such openness also guards against “group polarization”, a topic I will blog about at a future time). Furthermore, as a professor one is constantly exposed to diverse viewpoints in the classroom (from the left, right and everything in-between!) and I have never viewed the classroom as a venue for me to “indoctrinate” students with my own viewpoints. In fact, my classroom experiences actually play a formative role in my own intellectual development. So I try to create an atmosphere of openness and invite students to engage in civil debate with me as well as their peers. I find this helps me fine-tune my own moral and political sensibilities.

I would like to briefly outline one line of argument I have been recently developing against libertarianism. The thrust of this criticism stems from a larger beef I have with theories of justice that function at the level of “ideal theory” but I won’t get into that (at least not yet! :)). There are of course many variants of libertarianism, each of which is subject to different kinds of concerns and objections. Here I wish to raise a challenge for libertarians of a particular ilk- those who support Robert Nozick’s “entitlement theory of justice". This account of justice maintains that “whatever arises from a just situation by just steps is itself just (Nozick, 1974: 151). An important (though much neglected) component of Nozick’s theory is the principle of rectification. To make a long story short, the principle of rectification maintains that victims of injustice are sufficiently compensated if they are no worse off (having received compensation) than they would have been had the injustice not taken place (what Gregory Kavka (1982) calls the No Net Harm Criterion). If one takes the principle of rectification seriously (as good libertarians ought to!), then I believe this will lead libertarians to endorse conclusions that will not sit well with them.

It is useful to begin by distinguishing between intragenerational rectification and intergenerational rectification. The former refers to compensation for victims who are alive to collect rectification awards while the latter encompasses all injustices and, in theory, ensures that the present distribution of entitlements be that which would have obtained had only the principles in acquisition and justice in transfer been observed throughout history (Robert Litan, 1977: 234). Both types of rectification pose formidable challenges to libertarians.

Libertarians who champion the entitlement theory of justice, in the “here and now”, face a dilemma. If they believe that the distant injustices of the past have not been rectified then they should advocate, as Nozick himself does, a stringent prioritarian principle (like Rawls’s difference principle) rather than complain that the current welfare state is an unjust violation of their property rights. So good libertarians should join the fight with egalitarians (at least for the foreseeable future) rather than raising principled objections to redistributive taxation (in the current, non-ideal setting). I suspect this conclusion will be unpalatable to many libertarians thus lending support to the hypothesis that they are not seriously committed to the principles of entitlement. In which case one could be forgiven for thinking that some libertarians use Nozick simply as a façade to mask the fact that they are simply making a self-interested (rather than principled) argument for lower taxation.

On the other hand, if libertarians believe that the requirements of intergenerational rectification have been satisfied, then intragenerational rectification for (what THEY [not me!] see as) the victims of the existing welfare state (i.e. the rich) will require compensation the extraction of which will mandate an extensive (rather than minimal) state. And this conclusion will strike most of us (including, I suspect, some libertarians) as calamitous. Let me expand on this second horn of the libertarian dilemma.

Suppose one believes that the requirements of the No Net Harm Criterion has in fact been satisfied (how one could actually determine this I profess not to know!). Suppose further that we had knowledge of the exact date when intergenerational rectification had been satisfied. That date was 20 years ago. In such a scenario we could characterise the history of this society as having the following three stages:

Stage #1: Colonialism/ Slavery, etc... This stage was one where severe and frequent violations of the principles of initial acquisition and just transfers occurred. These transgressions were not rectified for centuries and thus issues of intergenerational rectification arose.

Stage #2: (Just) Welfare (or Compensatory) State: This stage was one where redistributive taxation occurred and eventually compensated the ancestors of the victims of past injustices for the atrocities that occurred during Stage #1.

Stage #3: (Unjust) Welfare State for the past 20 years: The past 20 years has been a situation where redistributive taxation has been imposed on the affluent members of society but such redistribution is not warranted by the No Net Harm Criterion. So for the past 20 years the affluent members of society have been “forced to work” for the benefit of others and this is a severe infringement of their right to self-ownership. This injustice has gone on for twenty years and this generates a claim to intragenerational rectification.

*If* the history of one’s society looked something like this, then (and only then) could one make sense of why, in the “here and now”, libertarians object to redistributive taxation. Libertarians believe that such taxation is analogous to forced labour as it violates the self-ownership of tax payers who are forced, under threat of coercion, to pay for universal education, healthcare, and the other social provisions of the welfare state. According to the No Net Harm Criterion, justice requires us to compensate the victims of the welfare state so that they receive the distribution of holdings *that would have* obtained had the injustice (i.e. redistributive taxation for 20 years) not taken place.

In the case of intragenerational rectification (unlike intergenerational rectification) it will be much easier to identify who has profited and who has been harmed by the welfare state. The problem for the libertarian will be extracting this compensation from those who have profited from the injustice of the welfare state. It is not simply enough to eliminate redistributive taxation itself (though that will be seen as a necessary measure). Eliminating redistributive taxation would simply prevent future state-sanctioned violations of self-ownership from occurring but it will not redress the injustices of the past. So the affluent (and their descendants), in the “here and now”, can demand compensation from those who reaped the benefits of universal education, universal healthcare and the other social provisions of the welfare state (and did not pay an equal share of the costs of these provisions). The consequences of the principle of rectification, in this kind of scenario, would be deeply troubling. It would lead to exploiting the most vulnerable members of our society. Recipients of welfare would be expected to repay their debt to the affluent. Those who received medical treatment funded through universal healthcare would be expected to repay their debt to the affluent, etc…. If these individuals cannot afford to repay their debt, why not make them the servants of the affluent? If taxation truly is analogous to forced labour, as Nozick suggests, then the rich have already served 20 years as the indentured servants of the poor. It seems only fair that, if the poor cannot repay the rich, that they sacrifice some of their own time to help compensate for the time the affluent spent working for the poor. This would help us to compensate the affluent for their lost time.

No doubt many libertarians will want to resist the conclusion that rectification could legitimize slavery. But given the fact that they often invoke such language when they oppose redistributive taxation, it is not self-evident how they could avoid such conclusions if society actually decided to implement the libertarian account of distributive justice. Far from legitimizing the “minimal state”, the entitlement theory of justice, when applied to non-ideal societies, will either inspire an egalitarian redistributive state (to rectify intergenerational injustice) or a draconian libertarian state that seeks to extract compensation from the most vulnerable members of our society. Either conclusion is one that should raise serious concerns for libertarians who invoke the principles of entitlement.

I can anticipate a few possible responses libertarians might make to my challenge. But I won’t pursue those here as I have gone on for long enough for just one blog entry! But I hope libertarians think the question of what their theory prescribes in non-ideal theory (rather than the idyllic Lockean state of nature) is a question worth taking seriously.