Raising key questions about the embryo’s moral status

30 MINUTE READ

from Luke’s Journal 2018 | Hot Topics #1 | Vol. 23 No. 3

Stem cells¹ have captured much scientific and popular interest with hopes of ‘cures’ and prolonged life for many degenerative diseases using replacement cells and tissue regeneration.

The science

There are two main types of stem cells:

1. Adult/non-embryonic, used for decades in bone marrow transplants.
   
2. The more controversial embryonic first derived in 1998 from foetal gonadal tissue by John Gearhart of Johns Hopkins University and from donated surplus fertility clinic embryos by James Thomson of the University of Wisconsin who discovered how to create immortalised human embryonic stem cell (hESC) lines.²

Embryonic stem cells proliferate rapidly and indefinitely, and thus potentially produce large numbers of specialised cells to treat large numbers of patients. However, there are problems of tumorigenesis (teratomas³), and immunological rejection requiring either lifelong immunosuppressant drugs with attendant susceptibility to infections, or creating genetically identical stem cells which foster ‘therapeutic cloning’.

The process known as somatic cell nuclear transfer (SCNT) where DNA from the recipient’s body cell is transferred to an egg whose nucleus has been removed, creating an embryonic clone of the donor, which can go on to yield embryonic stem cells, is the basis for both therapeutic and reproductive cloning. To date, no therapies have been developed through this research, and human trials continue.⁴

The discovery of stem cells

In 2001 scientists discovered stem cells throughout the human body, with optimism that some types, notably placental tissue, amniotic fluid and/or germline cells from testes and mesenchymal cells will be able to produce the same broad range of specialised cell types for medical treatments but without teratomas; making them a safer alternative in the clinical setting. Where possible, cells will come from the patient being treated. Being genetically matched, it would be less likely to be rejected by the body’s immune system.

The health benefits of adult stem cell treatments are already significant, with at least seventy-three research beneficial treatments, including heart, autoimmune diseases and people with diabetes regaining the ability to produce vital insulin after receiving transfusions of stem cells from their own bodies.⁵ “Adult stem cells remain the gold standard for real patient treatments.”⁶

“Embryos, whether created for reproduction or research, deserve equal moral respect.”

A significant advance was the discovery (first in mice 2006, then humans in 2007) that fully differentiated cells, like skin cells, can be dedifferentiated. However, they are capable of forming teratomas when implanted directly into animals and at least one of the introduced genes increases cancer risk.⁷ Embryo biopsy, already used in fertilisation clinics to perform preimplantation genetic diagnosis is another possibility; as is transplantation from dead/non-viable embryos, though with the same compatibility problems and issues of defining ‘death.’⁸

The Ethical Issues

Currently, embryonic stem cells, as well as SCNT derived cells can only be obtained by destroying the embryo. This raises the key question of the embryo’s moral status and the broader question of personhood and who deserves protection.⁹

These topics revisit assisted reproduction and abortion debates where embryos are already destroyed. There are wide-ranging opinions from the same moral status ascribed to human beings after birth, differing only in their stage of development (many Christians argue personhood from fertilisation; ‘a single organism with a continuous history’)¹⁰ to not having their own moral status due to their rudimentary developmental state (varying points of personhood).

Many uphold something is added after the embryonic stage that gives protectable status as persons; most commonly related to location (womb versus laboratory), formation (of the primitive streak as evidence of a brain with future self-awareness and reasoning), individuation (when twinning is no longer possible), or intention (implantation versus research).

Legislation in USA, UK and Australia reflecting consequentialist ethics takes a ‘middle’ position view in which the embryo is afforded a certain level of moral protection (‘respect’), while allowing embryonic stem cell research to proceed in the hope of the promised benefits. The Warnock Committee report (1984) recommending the justification of destructive human embryo research up to fourteen days¹¹ has had wide reaching influence.

Those opposing embryonic stem cell research rightly point to adult stem cell therapy successes, highlighting important alternatives which don’t require harm and the limited successes of embryonic research, thus not stopping all stem cell research and exciting possibilities for regenerative medicine.¹²

“There are also moral questions in using donated surplus embryos from in vitro fertilisation compared with embryos specifically created for stem cell research and implicitly, therapeutic and reproductive cloning.”

There are also moral questions in using donated surplus embryos from in vitro fertilisation compared with embryos specifically created for stem cell research and implicitly, therapeutic and reproductive cloning. The huge numbers (hundreds of thousands) of stored embryos could potentially be used for research once the decision has been made that they are no longer needed for implantation. This is seen as bringing a measure of good (saving someone else’s life, though potential recipient risks of tumours and rejection should not be forgotten) out of an unfortunate situation (consequentialist) so not morally problematic.

For some, it is unethical not to do it. Aside from the personhood issue, another ethical question is the acceptability of purposely killing and/or using body parts of those who will inevitably die. In other cases of ‘inevitable’ dying, of nothing lost but possible gain through research, including death row prisoners, the Tuskegee syphilis experiment and Auschwitz.

This has been found to be an insufficient justification. Harming (especially killing) some to benefit others has been deemed unacceptable. The Nuremberg Code and Declaration of Helsinki raise issues of subjects’ informed voluntary consent and protection from harm, which in this situation is the parents’ proxy consent. Can parents of ‘spare’ embryos give legitimate consent? There is heightened concern if ‘spare’ embryos from fertility clinics are deliberately created for research and/or there were significant financial incentives (‘commodification’) to donate.¹³

Cloning adds other questions

The United Nations (2005) condemned all human cloning as incompatible with human dignity. Many countries have completely banned cloning while some allow therapeutic cloning, but not reproductive cloning.

The creation of embryos for applied medical research from human-induced pluripotent stem cells (hiPSCs), which have the ethical advantage of not requiring gamete donation, is legal in some countries, but also raises ethical questions. Embryos, whether created for reproduction or research, deserve equal moral respect. Limiting to therapeutic cloning is difficult to regulate since the technology is the same and creates ethical challenges.¹⁴

There are ethical considerations with adult stem cells (which equally apply for embryonic stem cells) including risks of harvesting cells from donors and potential risks to recipients, notably toxicity and tumours. As in all human research, participants’ informed voluntary consent avoiding ‘therapeutic misconception’, confidentiality (especially where cell lines are shared) and safety are paramount.

Stem cell ‘tourism’ and commercialism, the use of unproven methods by fraudulent operators, pressures of rapid clinical translation (need for good pre-clinical trials to justify progression) and hidden conflicts of interest (especially financial) pose significant medical and financial risks to patients and their families with scientific responsibility and medical professionalism at stake, demanding appropriate preventive regulation to ensure safety and efficacy.

“As in all human research, participants’ informed voluntary consent avoiding ‘therapeutic misconception’, confidentiality (especially where cell lines are shared) and safety are paramount.”

The International Society for Stem Cell Research (ISSCR) issued guidelines (2007, reiterated 2013)
for clinical translation condemning unproven uses except in exceptional circumstances (seriously ill patients with stringent requirements). Regulation has been difficult because it is often couched as ‘medical practice’ in Australia under the Australian Health Practitioner Regulatory Agency (APHRA), and not the Therapeutic Goods Administration (TGA) which sets stringent requirements for medicines and devices. Medical professionalism, as elucidated in the Physician Charter including commitment to competence, supporting and fostering scientific knowledge and avoiding financial conflicts of interest, should preclude proffering unproven therapies and free consumer choice.¹⁵

Issues of cost and potential access of all who could benefit from treatments also raise ethical issues. In general, the rich have better access to biotechnology. Society risks injustice and elitism based on the ability to purchase treatments. Large-scale public stem cell banking and standardised production hold potential for wider access and reduced costs. Wise use of research resources to maximise knowledge in areas of greatest promise and clinical need with sound practice in clinical translation and balance of scientific transparency and data sharing are justice issues
to be addressed especially in this commercialised and competitive field.¹⁶

Application of Biblical worldview and principles

Although the Bible says nothing specifically about stem cells, some key biblical principles address the ethical questions raised.

Creation affirms human value in the imago Dei (Gen 1:26-28, 5:1, 9:6 – linked to prohibition of murder). Jesus’ substitutionary atonement for all humanity in his incarnation and redemption affirms human dignity as unique recipients of God’s love.¹⁷

In considering the moral status of the embryo, the Scriptures affirm the human individual is a person from the earliest point of his or her existence in the womb (consistent with what we now know as conception¹⁸), to whom God relates (Ps 139:13-18, Jer 1:5, Job 10:8-12).

David considers the ‘me’ speaking as an adult to be the same ‘me’ (person) conceived in his mother’s womb (Ps 51). The unborn is given equivalent importance to one born and there is no biblical distinction between early and late stages of the foetus (Exodus 21:22-25)¹⁹.

Elizabeth and her unborn son, John the Baptist, rejoiced at the arrival of Mary and Jesus (soon after conception) within her womb (Luke 1:39-45); God in Jesus fully identifies with humanity (Heb
2:17) by becoming a human embryo. Thus, the human embryo should be afforded the status of full personhood. “Embryos are persons with potential rather than potential persons.“²⁰

Their moral significance is rooted in what they are (origins), not in what they have the potential to become (destiny). Therefore intentional destructive research on embryos is morally equivalent to killing an innocent life (seriously viewed by God: Gen 9:6, Ex 20:13, Num 35:33) and human exploitation treating them as a means rather than an end; both are an affront to human dignity.²¹

Some Christian ethicists see support for embryonic stem cell research as a means to fulfil the biblical command to “love your neighbour as yourself”, in the spirit of the neighbourly Good Samaritan (Luke 10:25-37), given the great potential for ministering to the sick. Their support is further justified by making a distinction based on location (embryo outside the womb is morally different from one inside) which renders the blastocyst not equal to a human person. It is human life but does not enjoy personhood because it is growing and developing.

Others argue for a long-standing Christian tradition that makes a distinction between the ‘formed’ and ‘unformed’ foetus (based on a different interpretation of Exodus 21 above and Augustine and Aquinas).

For some, the basis for human nature is our destiny, not our origins as the imago Dei. Thus, the overall good far outweighs any possible evil, with the sacrifice of embryos in the best interests of the wider good justified within Christian thinking.²²

“Location is not relevant to human identity. We must care both about human suffering and value the life of the embryo.”

Scripture’s inclusive ethic reflecting God’s special concern for all but especially the weak and oppressed needs to reject an idolatry of technology (just because we can do it we should) in favour of doing what is right – including assessing the impact of stem cell research and therapy on all stakeholders, including those who are most vulnerable. The very genuine needs of the potential beneficiaries must be balanced against the donors/sources and recipients/subjects which includes those who risk harm by providing eggs or somatic cells and specifically embryos, who with no voice of their own, are surely among the most vulnerable members of the human community and who pay the highest price (destruction).

These are all our neighbours, requiring our love, protection and respect. Just as any other human’s personhood is unchanged regardless of their location or destiny, an embryo’s personhood is not invalidated whether in or out of the womb. Location is not relevant to human identity. We must care both about human suffering and value the life of the embryo.

The dangers of not upholding God’s concern and protection for the weak and vulnerable are very evident in the history of medical research e.g. the Tuskegee Syphilis Study. Well-intentioned desire for producing medical treatments can conflict with an inclusive disposition not to mistreat some, especially the weak in order to benefit others.

The Scriptures do not support that the ends justify the means (Rom 3:8).²³ Another aspect of this inclusive ethic is the justice issue of equality of access (Is 5:5-10, Amos 8:4-10,Mic 6:1-8, Neh 5:1-11) to present and future treatments that fits good news to the poor and powerless. Provision of fair, compassionate, adequate healthcare reflects our interdependence in community.²⁴

Conclusion

Human motives and means in the appropriately noble goal of relieving suffering (notably of devastating genetic diseases and chronic degenerative conditions) through biotechnical means need to be evaluated. Do we seek to deify ourselves and keep control of ultimate things in our lives (what may be termed a theology of glory in contrast with the more appropriate theology of the cross)? Does it reflect our failure of practical empathetic caring, particularly by the Christian community? Desperate, unloved suffering people are more likely to consider unethical solutions. Being human is to deal with our imperfection, finitude, and loss.

“Thus, affirmation of human personhood and dignity from conception and an inclusive aspiration, appealing to consequentialism, should strengthen our resolve to benefit suffering patients without harming others in the process.”

Being Christian is also to demonstrate how dependence on Christ enables us to accept and bear suffering.²⁵ Thus, affirmation of human personhood and dignity from conception and an inclusive aspiration, appealing to consequentialism, should strengthen our resolve to benefit suffering patients without harming others in the process. It should not, however, add substantially to the suffering of one group, especially a vulnerable group like embryos, in order to lessen the suffering of another. The fundamental bioethical principle of beneficence should not automatically trump the bioethical principle of non-maleficence.²⁶

Ultimately, the ethical argument about the use of embryonic stem cells in medicine depends on one’s view of the embryo’s personhood. For the utilitarian there is no intrinsic human dignity, whether adult or embryonic, that demands respect. This is clearly different to the scriptural ethic and unlikely ever to converge.

As Christians engage with the wider community without a Christian worldview, however, the lessons of history and principles of inclusiveness encourage the nearly universal support for adult stem cells. The less controversial ethical issues, coupled with the potential for autologous donation and less complications, warrant enthusiastic support for further careful methodical research, especially hiPSC development, with their great potential for disease research (understanding the disease first helps generate therapy) and drug development.

Even without a high view of embryo personhood, consequentialism accounting for all stakeholders should spare embryo destruction in stem cell research in our resolve not to harm the most vulnerable, even in pursuit of noble medical goals. With increasing opportunities, scientific progress and the high hopes and to date unmet expectations of patients and families, issues of informed consent, regulation, commercialisation, justice and conduct and safety in clinical translation will continue to be important ethical considerations.²⁷

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References

1. Justin Lowenthal and Jeremy Sugarman, “Ethics and Policy Issues for Stem Cell Research and Pulmonary Medicine” CHEST 147, no. 3 (2015): 825. The term broadly refers to cells that have the capability of differentiating into diverse cell types.
2. Best, Fearfully and Wonderfully Made, 423-424; Mattes, “Bioethics and honoring humanity: a Christian perspective,” 36; Ismail, “Stem Cell Research and Ethics: An Update “ 1; Reisman and Adams, “Stem Cell Therapy: a Look at Current Research, Regulations, and Remaining Hurdles “ 486-487. The term adult can be misleading, as they can be from any source other than the embryo and include placenta and umbilical cord blood. By late 2014, the only stem cell–based treatment approved by the FDA for use in USA was for bone marrow transplantation (first done in 1968).
3. A cancer with several different types of tissue.
4. Wyatt, Matters of Life & Death, 125-126.Wyatt records that SCNT could prevent the inheritance of rare disorders of the mitochondria as well as provide ‘saviour siblings’, possibilities for children after becoming sterile and allow lesbian couples to share biological parentage. ; Best, Fearfully and Wonderfully Made, 425-431. Best reports early human embryos have been created but human embryonic stem cells have not been derived from them. ; Verhey, Reading the Bible in the Strange World of Medicine, World of Medicine, 185-186.Verhey notes an early trial for Parkinson’s disease went badly with serious side effects. ; “http://www.stemcellresearch.org/”.The stem cell research website records 0 research treatments, though trials for retinal disease continue. ; Lawton, “The promises and pitfalls of embryonic cell research: navigating the ethical maze,” 316-317, 321, 332; Kilner, “An inclusive ethics for the twenty-first century: implications for stem cell research,” 692, 707; Reisman and Adams, “Stem Cell Therapy: a Look at Current Research, Regulations, and Remaining Hurdles “ 854-855; Nancy M.P. King and Jacob Perrin, “Ethical Issues in stem cell research and therapy,” Stem Cell Research and Therapy 5, no. 85 (2014): 3; Ana Sofia Carvalho and Joao Ramalho-Santos, “How can ethics relate to science? The case of stem cell research,” European Journal of Human Genetics, 21 (2013): 592-593. In 2014, a team of US scientists used SCNT to create the first disease-specific embryonic stem cell line from a patient with type-1 diabetes. The insulin-producing cells have two sets of chromosomes (the normal number in humans) and could potentially be used to develop personalized cell therapies. In 2014, University of Washington scientists reported that they had successfully regenerated damaged heart muscles in monkeys using heart cells created from hESCs (published in Nature); first to show that hESCs can fully integrate into normal heart tissue. The Geron trial in humans (2009) which was stopped for safety and cost reasons highlights the important balance of progress and caution in this research. Overall SCNT has many technical challenges and needs a high number of oocytes. Carvalho and Ramalho-Santos consider their therapeutic implications as null. 
5. Kilner, “An inclusive ethics for the twenty-first century: implications for stem cell research,” 690-692; Lawton, “The promises and pitfalls of embryonic cell research: navigating the ethical maze,” 316, 333-334; Mattes, “Bioethics and honoring humanity: a Christian perspective,” 36; Dr Prentice, “More Embryonic Stem Cell Hype, Less Reality and Ethics”; , “http://www. stemcellresearch.org/”; Best, Fearfully and Wonderfully Made, 424; Ismail, “Stem Cell Research and Ethics: An Update “ 1-2; Wyatt, Matters of Life & Death, 127; Reisman and Adams, “Stem Cell Therapy:a Look at Current Research, Regulations, and Remaining Hurdles “ 846, 855. The usefulness of cord blood stem cells in regenerative medicine has led to the establishment of cord blood stem cell banks where parents of a newborn baby can store the cells harvested from the umbilical cord immediately after birth (including Oman). The stemcellresearch website records 73 research treatments. Kilner and Wyatt record hundreds of research reports published or analysed in the Journal of the American Medical Association documenting benefit. The first transplanted human organ (a trachea) grown from adult stem cells was successfully performed in 2008 by researchers in Italy. A 2013 report from the Pharmaceutical Research and Manufacturers of America lists 69 cell therapies as having clinical trials under review with the FDA, including 15 in phase 3 trials.
6. Prentice, He argues that studies show there is no need for embryonic stem cells.
7. Kilner, “An inclusive ethics for the twenty-first century: implications for stem cell research,” 708-709; Best, Fearfully and Wonderfully Made, 435-437; Lawton, “The promises and pitfalls of embryonic cell research: navigating the ethical maze,” 434-436; Reisman and Adams, “Stem Cell Therapy:a Look at Current Research, Regulations, and Remaining Hurdles “ 854; King and Perrin, “Ethical Issues in stem cell research and therapy,” 3; Timothy Caulfield and others, “Research ethics and stem cells,” EMBO reports 16, no. 1 (2015): 4; Carvalho and Ramalho-Santos, “How can ethics relate to science? The case of stem cell research,” 593. Many researchers have turned to this methodology as more reliable and less controversial including Ian Wilmut, the cloning pioneer famous for producing Dolly, quoted as abandoning cloning and embryonic stem cell research because iPS cell technology ‘represents the future for stem cell research.’ However, few are calling for an immediate end to harvesting embryonic stem cells, citing the need to continue research, as they remain the ‘gold standard’ among pluripotent cells.
8. Kilner, “An inclusive ethics for the twenty-first century: implications for stem cell research,” 704-707; Lawton, “The promises and pitfalls of embryonic cell research: navigating the ethical maze,” 332; Carvalho and Ramalho-Santos, “How can ethics relate to science? The case of stem cell research,” 593. More research will be needed before the totipotency of single cell can be firmly established or dismissed.
9. Best, Fearfully and Wonderfully Made, 34-35. Table 3 sets out the different Personhood theories.
10. Meilaender, BioEthics 112.
11. Best, Fearfully and Wonderfully Made, 36-37. Best notes that this time is the formation of the primitive streak and marks the beginning of individual development. Conveniently at the time when IVF was approved in the USA, it was the maximum amount of time embryos were grown in the laboratory. She argues that the science is out of date with research showing that the embryo is organised from the first day and this position satisfied few –unjustifiably exploited embryos and at the opposite end limited research.
12. Lawton, “The promises and pitfalls of embryonic cell research: navigating the ethical maze,” 314, 323-324; Best, Fearfully and Wonderfully Made, 32-39, 413, 422-423, 437-441; Kilner, “An inclusive ethics for the twenty-first century: implications for stem cell research,” 696-697; Ismail, “Stem Cell Research and Ethics: An Update “ 1; Meilaender, BioEthics 111-113; Reisman and Adams, “Stem Cell Therapy:a Look at Current Research, Regulations, and Remaining Hurdles “855; Tetsuya Ishii et al., “Ethical and Legal Issues Arising in Research on Inducing Human Germ Cells from Pluripotent Stem Cells,” Cell Stem Cell 13 (2013): 146. After community consultation, Embryonic Stem Cell research was approved by the UK parliament (1990) and by the Australian parliament (2002), despite a Senate committee recommendation that human embryos be protected from destructive experimentation, reflecting the Nuremberg Code (1947) and the World Medical Association Declaration of Helsinki (1964), a key secular document of human research ethics protecting research subjects. Obama (2009) lifted Bush’s restriction on public funding. It is permitted in Belgium, Britain, Denmark, Finland, Greece, the Netherlands, and Sweden; however, it is illegal in Austria, Germany, Ireland, Italy, and Portugal. Jordan was the first country in Arab/Islamic world to pass regulation in January, 2014 affirming research is permissible in Islam (life begins 40-120 days from conception) if carried out for improving human health though bans private companies using embryonic stem cells. Ischii outlines the regulations in a number of countries (most using the 14 day rule) including the Japanese situation.
13. Best, Fearfully and Wonderfully Made, 413-414, 420-421, 427, 433, 437-441; Lawton, “The promises and pitfalls of embryonic cell research: navigating the ethical maze,” 322-326; Meilaender, BioEthics 114-116; Kilner, “An inclusive ethics for the twenty-first century: implications for stem cell research,” 709-711; Verhey, Reading the Bible in the Strange World of Medicine,186-187; Lowenthal and Sugarman, “Ethics and Policy Issues for Stem Cell Research and Pulmonary Medicine “ 826; Reisman and Adams, “Stem Cell Therapy:a Look at Current Research, Regulations, and Remaining Hurdles “846. In 2008, voluntary guidelines prepared by the National Academy of Sciences and the ‘ Society for Stem Cell Research’ allow individuals donating embryos for stem cell research to be reimbursed for “reasonable costs” but not in excess of expenses but regulation is difficult. National Institutes of Health (NIH) approved embryonic stem cell lines if embryos donated by individuals who sought reproductive treatment and who gave voluntary written consent to be used for research purposes. Australia prohibits selling of tissue. Best notes that UK law allowed up to 250 pounds (and reviewing) and Lawton notes at least one UK fertility clinic has already begun offering discounts for the cost of IVF to customers who are willing to donate some of their eggs for research purposes that likely include the creation of embryos. In the USA, private organisations pay thousands of dollars for eggs. In late 2014, 283 eligible lines met the NIH’s ethical guidelines.
14. Meilaender, BioEthics 117-118; Best, Fearfully and Wonderfully Made, 429-435; Lowenthal and Sugarman, “Ethics and Policy Issues for Stem Cell Research and Pulmonary Medicine “ 826; Verhey, Reading the Bible in the Strange World of Medicine, 188-189; Mattes, “Bioethics and honoring humanity: a Christian perspective,” 36; Ishii, Reejo Pera and Greely, “Ethical and Legal Issues Arising in Research on Inducing Human Germ Cells from Pluripotent Stem Cells,” 146-147. The UN resolution specifically refers to the need to prevent exploitation of women. Kilner highlights ‘therapeutic misconception’, when donors have no prospect of personally benefiting from the experiment in which they are participating mistakenly thinking they will benefit. The result is a violation of informed consent. 
15. Lowenthal and Sugarman, “Ethics and Policy Issues for Stem Cell Research and Pulmonary Medicine “ 826-832; Verhey, Reading the Bible in the Strange World of Medicine, 186; Reisman and Adams, “Stem Cell Therapy:a Look at Current Research, Regulations, and Remaining Hurdles “ 855-856; King and Perrin, “Ethical Issues in stem cell research and therapy,” 1-5; Munsie and Hyun, “A Question of Ethics: Selling autologous stem cell therapies flaunts professional standards,” 648-650; Caulfield and others, “Research ethics and stem cells,” 2-3. The growth in unproven autologous stem cell treatments has been enabled by liposuction techniques deriving mesenchymal stem cells. Caulfield outlines the regulations in a number of countries. In February 2014, the U.S. Court of Appeals in Columbia upheld a 2012 ruling that a patient’s stem cells for therapeutic use fall under the aegis of the Food and Drug Administration (FDA).
16. Lowenthal and Sugarman, “Ethics and Policy Issues for Stem Cell Research and Pulmonary Medicine “ 832; Kilner, “An inclusive ethics for the twenty-first century: implications for stem cell research,” 189; Wyatt, Matters of Life & Death, 133; Mattes, “Bioethics and honoring humanity: a Christian perspective,” 38; King and Perrin, “Ethical Issues in stem cell research and therapy,” 4-5.
17. Lawton, “The promises and pitfalls of embryonic cell research: navigating the ethical maze,” 326-328; Mattes, “Bioethics and honoring humanity: a Christian perspective,” 37; Best, Fearfully and Wonderfully Made, 40. 
18. Best, Fearfully and Wonderfully Made, 44. The use of the Hebrew word golem in Ps 139:16 is used in Jewish literature for the first stage of human life.
19. Wyatt, Matters of Life & Death, 163-164; Best, Fearfully and Wonderfully Made, 45-47; R. Alan Cole, Exodus: An Introduction and Commentary (Downers Grove: IVP/ Accordance electronic ed, 1973), 141; John D. Hannah, Exodus (eds. J. F. Walvoord and R. B. Zuck; 2 vols.; vol. 1; Wheaton: Victor Books/Accordance electronic ed., 1985), 177. There is some debate about the ambiguity of this passage which Best and Wyatt helpfully elaborate. Overall it supports the personhood of the unborn and its injury and/or death is serious.
20. Kilner, “An inclusive ethics for the twenty-first century: implications for stem cell research,” 697.
21. Lawton, “The promises and pitfalls of embryonic cell research: navigating the ethical maze,” 326, 328-331; Kilner, “An inclusive ethics for the twenty-first century: implications for stem cell research,” 698; Mattes, “Bioethics and honoring humanity: a Christian perspective,” 36-37; Best, Fearfully and Wonderfully Made, 43-49; Wyatt, Matters of Life & Death, 158-167. Tertullian appealed to Jeremiah 1 and Luke 1 to support his argument that human life begins at conception, as part of his broader argument against the practice of abortion, which was common in Greco-Roman society at his time. The Roman Catholic encyclical Donum vitae acknowledges blastocysts as unique, “ensouled” individuals requiring our respect and just treatment.
22. Mattes, “Bioethics and honoring humanity: a Christian perspective,” 37-38; Kilner, “An inclusive ethics for the twenty-first century: implications for stem cell research,” 696; Lawton, “The promises and pitfalls of embryonic cell research: navigating the ethical maze,” 323-324; Mellon, “James Drane’s More Humane Medicine: A New Foundation for Twenty-first Century Bioethics?,” 307; Best, Fearfully and Wonderfully Made, 49-50; Wyatt, Matters of Life & Death, 163, 171. Mattes cites two Lutheran ethicists, Jersild and Peters and Drane is an example of a liberal Catholic ethicist who hold these views. Best cites Berry who argues continuity only applies to persons which seems to be a priori ruling out the personhood of Ps 139. Wyatt cites Berry and Dunstan who argue the distinction between formed and unformed foetus and Jones, the ‘just war’ support.
23. Kilner, “An inclusive ethics for the twenty-first century: implications for stem cell research,” 686-687, 696, 700-702; Lawton, “The promises and pitfalls of embryonic cell research: navigating the ethical maze,” 314, 324; Mattes, “Bioethics and honoring humanity: a Christian perspective,” 36-38; Best, Fearfully and Wonderfully Made, 50-52, 441. Kilner has a helpful detailed discussion of the Tuskegee Syphilis Study to illustrate non-inclusive thinking.
24. Verhey, Reading the Bible in the Strange World of Medicine, 192-193, 382-386. There are challenges to recognise and define what is adequate/ ‘a decent minimum’ in the face of scarce resources. 
25. Wyatt, Matters of Life & Death, 133; Mattes, “Bioethics and honoring humanity: a Christian perspective,” 39; Meilaender, BioEthics 118-119.
26. Lawton, “The promises and pitfalls of embryonic cell research: navigating the ethical maze,” 324; Kilner, “An inclusive ethics for the twenty-first century: implications for stem cell research,” 694.
27. Mattes, “Bioethics and honoring humanity: a Christian perspective,” 36; Kilner, “An inclusive ethics for the twenty-first century: implications for stem cell research,” 689, 703, 712; Lawton, “The promises and pitfalls of embryonic cell research: navigating the ethical maze,” 323; Reisman and Adams, “Stem Cell Therapy:a Look at Current Research, Regulations, and Remaining Hurdles “ 854; King and Perrin, “Ethical Issues in stem cell research and therapy,” 1; Munsie and Hyun, “A Question of Ethics: Selling autologous stem cell therapies flaunts professional standards,” 651; Carvalho and Ramalho-Santos, “How can ethics relate to science? The case of stem cell research,” 593. Kilner cites Shields in a feature article as concluding that proponents of embryonic stem cell research “have a serious intellectual problem.” Carvalho and J Ramalho-Santos quote Jamie Thomson, the creator of the first human embryonic stem cell lines: ‘If human embryonic stem cell research does not make you at least a little bit uncomfortable, you have not thought about it enough.’ In July 2013, Japan’s health minister approved the first use of iPS cells in human trials.

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