“The Good Death,” a play about euthanasia, has brought the issue of “mercy killing” to Dutch theatres at a time when such deaths are falling. They dropped to 2,325, or 1.7 percent of all deaths in 2005, from 2.6 percent in 2001. Playing to packed houses throughout the Netherlands, which legalised euthanasia in 2002, the play shows the law has not removed the moral dilemma for many involved.

In fact, part of the reason for the drop in euthanasia deaths could be that agonised doctors are opting to give patients heavy sedation until they die, rather than putting an end to their lives. Even some patients who have asked for euthanasia are given continuous deep sedation instead. This feature by our Netherlands chief correspondent Emma Thomasson looks at the issues involved.

This raises the question of whether deep sedation, while being presented as palliative care that is ethically acceptable for many faiths, is not in fact “euthanasia lite.” Or at least whether it is being used as such. The British Medical Journal has suggested this in a report that prompted an editorial and a lively reader discussion. “Although the exact cause of this trend is unclear, there are indications that continuous deep sedation may in some cases be being used as a substitute for euthanasia,” a report in Science Daily said.

The fall in Dutch euthanasia deaths is sometimes cited by “death in dignity” campaigners in other European countries as a sign that legalisation is not a slippery slope towards the easy disposal of ailing patients. This suggests it might lead in another direction that could undermine the palliative care option often presented as the alternative to legalised euthanasia.

Where do you think the line should be drawn in end-of-life care?

Before it slips from the news, take a look at a scandal in India that illustrates one of the biggest bioethical challenges we face in a globalised world. Last weekend, Nepal handed over to Indian authorities an Indian man arrested on suspicion of running a huge illegal kidney transplant racket. It seems this ring duped poor Indians into selling kidneys that could be transplanted into rich Indians and foreigners at many times the fee that the unwitting donors received. At least five foreigners — two U.S. and three Greek citizens — were found in a luxury guesthouse run by the racket in a city of high-tech companies just outside New Delhi.

Demand for cheap kidneys has skyrocketed in recent years in rich countries, mostly because people there are becoming more obese and suffering from kidney failure. This has led to “transplant tourism” where patients from rich countries travel to the developing world to receive new kidneys. It has led to serious proposals to set up a global kidney market to meet the demand.

This black market in kidneys for transplants is widely denounced as illegal and immoral because it exploits poor people. But would creating a worldwide organ trade make the practice any more moral? Is the danger of exploitation of the poor so strong that lawmakers should ensure that money doesn’t end up deciding everything?

This is one of those bioethical challenges that are multiplying as science and technology create situations that were unthinkable not so long ago. Ethics councils, churches and philosophers develop guidelines to keep up, but reality has a way of pulling ahead of them. Globalisation means agents in one country can arrange for patients in a second country to have the transplant performed in a third. We will probably see more rather than fewer cases like this one in Nepal and India.

We’ve written on this issue from several datelines over the past year. Here are a few that give an idea of the problem:

Keen demand fuels global trade in body parts

The who, what, where and why of organ trafficking

Calls for kidney market as transplant demand soars

China, Pakistan bowing to pressure on organ trade

Beijing approves organ transplant hospitals

Human organ trafficking threatens donations schemes

Pakistani gang arrested for stealing kidneys

Here’s the video of the arrest of the Indian suspect in Nepal:

Science and religion are sometimes portrayed as adversaries, especially by the “new atheists“, but the real picture has always been more complex. The latest breakthrough in stem cell research shows how quickly opposing sides can become allies. On Nov. 20, two research teams announced they had transformed ordinary skin cells into stem cells without destroying human embryos in the process. That meant that scientists could solve an ethical dilemma they had effectively created when they began using human embryos to produce stem cells.

Religious groups critical of embryonic stem cell research immediately hailed the breakthrough as an advance that opened the door to ethnical use of these potential wonder cells. They have now begun to use it as a welcome argument to bolster their positions in disputes on the issue. This must be happening in quite a few places, but here are two examples that show how science is helping religion in this case.

In Germany, the Roman Catholic Church has severely criticised the governing Christian Democratic Union (CDU) party for agreeing to loosen tight restrictions on embryonic stem cell research there. The law bars German scientists from working on stem cell lines developed after January 1, 2002. Researchers say this is hampering their work and want the cut-off date to be moved up to 2007.

When the CDU agreed to this last week, two outspoken Catholic cardinals, Joachim Meisner of Cologne and Karl Lehmann of Mainz, condemned this as a betrayal of the Christian principles the party’s name claimed to represent. Meisner was especially critical of Research Minister Annette Schavan, a Catholic. He said the CDU decision was baffling, coming as it did “when science is opening up perspectives that present no ethical problems.”

Lehmann issued a statement as head of the German Bishops’ Conference: “The notable new successes in adult stem cell research and the reprogramming of cells are an additional argument against expanding embryonic stem cell research … so we call for a significant restructuring of European and German research funding from embryonic to adult stem cell research.”

In Belgium, the Catholic University of Leuven (KUL) thinks the breakthrough will help it keep its official Catholic status endangered by its stem cell research. The Vatican has been quietly investigating the university’s fertility centre, which does embryonic stem cell research that is firmly opposed by Catholic teaching. The university, with the support of Brussels Cardinal Godfried Danneels, has been arguing it needed to continue that work until research into adult stem cells — which it also does — finds an ethical way to produce them. No steps have been taken, but no compromise seemed possible. If the Vatican stripped KUL of its Catholic status, it could lose many Catholic students who study theology there.

“This reduces the bones of contention with Rome,” said KUL Vice-rector Mark Waer. “If these insights are confirmed, at some point it shouldn’t be necessary anymore to experiment with embryos.”

Cardinal Danneels agreed: “This is joyous news that can bring a turnaround on an important ethical question, the manipulation of the embryo. I’m very happy about this.” He also told the weekly Tertio that he always thought “the embryo problem might solve itself. Hasn’t Leuven been working all this time researching how equally good results could be reached with adult stem cells?”

There have been articles reporting that Asian laboratories had an advantage over those in countries with Christian traditions because Eastern religions had fewer qualms about using human embryos. The New York Times had a feature on Japanese scientist Shinya Yamanaka, one of the researchers pioneering the new technique. He gave no religious or philosophical reason for wanting to avoid destroying human embryos and simply said his scientific career changed when he saw a human embryo through a microscope: “When I saw the embryo, I suddenly realised there was such a small difference between it and my daughters … I thought, we can’t keep destroying embryos for our research. There must be another way.”

We noted here just the other day the all-but-absent ethical angle in the Daily Telegraph story about the creator of Dolly the cloned sheep and a new technique for creating stem cells without embryos. Now, we have two reports from Maggie Fox, our Health and Science Editor in Washington, that address the scientific and ethical issues.

Our story length limits meant the two had to be broken up, but they should be read in tandem.

One deals with the science:

WASHINGTON (Reuters) - Two separate teams of researchers announced on Tuesday they had transformed ordinary skin cells into batches of cells that look and act like embryonic stem cells — but without using cloning technology and without making embryos.

The other deals with the ethics :

WASHINGTON (Reuters) - Scientists and ethicists alike welcomed the news on Tuesday that two groups had been able to reprogram ordinary skin cells to act like embryonic stem cells — the body’s ultimate master cell.

Now, that’s more like it.

Despite all the optimism, this doesn’t mean the ethical debate is over. As Maggie’s second story explains, scientists will still work on embryonic stem cells because they could prove more powerful in the end. My question in the last post was whether opponents of embryonic stem cell research would support public funding for the new technique. Now I’m wondering how the debate about funding will play out between these two techniques.

The Daily Telegraph had a fascinating scoop over the weekend — Professor Ian Wilmut, the creator of Dolly the cloned sheep, has abandoned the therapeutic cloning method for a new way to create stem cells without an embryo. In classic Fleet Street style, the London daily announced in the second paragraph that the decision “will send shockwaves through the scientific establishment.” It took another 16 paras to get to other constituencies for this story, who are mentioned in passing in the line that “there is an intense search for alternatives because of pressure from the pro-life lobby, the opposition of President George W Bush and ever present concerns about cloning babies.”

That doesn’t take away from their scoop in any way — it is primarily a science story, written by their science editor Roger Highfield, and it’s a good one. But this second angle is of enormous importance to many readers out there who have moral scruples about embryonic stem cell research.

I was intrigued by a line high up saying: “Most of his motivation is practical but he admits the Japanese approach is also “easier to accept socially.” If I read that correctly, it means that science — which helped create this moral dilemma by developing the embryonic stem cell technique — may solve it eventually with another breakthrough that looks equally (or more) interesting to the scientist. That could take care of this issue, but others are bound to pop up that cannot be solved with a technical fix. Wilmot discusses this on a linked page publishing an extract from a book that he and Highfield wrote called After Dolly: The Uses and Misuses of Human Cloning. He believes an embryo cannot be considered a person until it is about 14 days old because it has no nervous system. The Roman Catholic Church, for example, counts personhood from the moment of conception, since it considers the potential in the embryo just as important as the cells that are already there. It’s hard to see how a technical breakthrough can bridge that gap.

Science writers like Highfield can explain the details of the procedure far better than I, so please look their way (here’s a quick Google News search) for more. What interests me is the impact this may have on opponents of embryonic stem cell research. Will they embrace this as the moral alternative, or oppose this as well as “playing God”? Would those who say they want the often-mentioned benefits of stem cell research but oppose public funds for the embryonic type on moral grounds now campaign to have this new method bankrolled with taxpayers’ money?

Bioethical dilemmas know no boundaries. France found that out this weekend when the daily Libération revealed that a French couple that had used a surrogate mother in the United States had won a long legal battle to be recognised as the parents of the twin girls who resulted from the arrangement. Surrogacy is illegal in France. French officials refused to register the twins as the couple’s daughters, leaving them in a legal limbo for seven years. But an appeals court finally granted their wish, arguing it was in the children’s best interests to recognise the U.S. birth certificates that listed Dominique and Sylvie (their surname was not published) as the parents.

France banned surrogacy in 1994 in the hope of preventing a “rent-a-womb” market from developing. But this option is expressly banned by law only in France, Germany and Italy, according to the association CLARA which campaigns to change the French law. It is legal in other places, including Britain, Canada, Greece, New Zealand and some U.S. states. According to the twins’ father Dominique, between 20 to 40 French couples cross the Atlantic every year to have a child with a surrogate American mother.

Since Sylvie and Dominique were recognised as the twins’ parents in a state where surrogacy is legal, they could not be brought to court for breaking the law there. French courts tried to try them for aiding and abetting a case of surrogacy or violating the civil status of the children, but neither charge led to a conviction, Le Monde reported.

Sylvie, who could not conceive because she has no uterus, had her eggs fertilised in vitro by Dominique’s semen to create embryos that were genetically their own and carried to term by the “gestational carrier.” She told Europe 1 radio that the surrogate mother in California did not profit from the arrangement. Already a mother of four, she bore the child voluntarily for Sylvie and was only reimbursed for lost wages during the pregnancy. Rather than being poor and doing this for money, the surrogate mother and her husband actually had a combined annual income three times that of the French couple, their lawyer Nathalie Boudjerada told the radio.

Le Figaro called the decision “the first step towards the legalisation of surrogate mothers” in France. Paris plans to review its bioethics law in 2009.

An interesting little detail — since the French consulate in Los Angeles refused to register the twins as French citizens, Libération said, the couple simply applied for and got American passports for them to travel to France.

Does Italy have its own “Terry Schiavo case“? Eluana Englaro has been in a persistent vegetative state (PVS) for the past 15 years and her father is trying to get legal permission to remove her feeding tube. Italy’s highest appeals court recently sent the case back to a lower court in Milan that had refused to let him do so. The local media have already dubbed Eluana “Italy’s Terry Schiavo” and the retrial (when it happens) looks set to spark off another major bioethics debate there.

Beppino Englaro has been caring for his daughter at home and says it’s time to free her from “the inhumane and degrading condition in which she is forced to exist”. The appeals court (Court of Cassation) said the lower court must determine whether her PVS is irreversible and whether she expressed the wish not to be kept alive if in a PVS. Her father said she had expressed that wish, but apparently has no living will or other tangible evidence to back that up.

Eluana’s case lacks the husband-vs-parents element that propelled the Schiavo case into the U.S. national headlines in 2005. But thorny cases of bioethics get into the national spotlight in Italy. A Roman judge is still investigating a doctor who last year removed the respirator of paralysed muscular dystrophy patient Piergiorgio Welby, 60, who had described his life as “torture” and asked for the right to die. Only Switzerland, the Netherlands, Belgium and the U.S. state of Oregon permit assisted suicide for the terminally ill.

One Italian angle to the story is the traditional influence of the Roman Catholic Church, which just last month repeated its stand that it is morally wrong to remove artificial nutrition and hydration tubes from PVS patients, even if they will never regain consciousness. The Vatican daily Osservatore Romano has already denounced the Court of Cassation’s decision in the Eluana case as unacceptable because it would “lead legislators fatally towards euthanasia”.

There’s not much written in English about this case yet, but — a sign of the times — Eluana already has a sub-entry (under “euthanasia”) in the Italian Wikipedia.