J7ournal ofmedical ethics, 1985, 11, 178-183

Baby Fae: a beastly business

Thomasine Kushner Committee for Protection ofHuman Subjects, University ofCalifornia, Berkeley andRaymond Belliotti Department ofPhilosophy, State University ofNew York

Authors' abstractThe Baby Fae experiment has highlighted the growingtrend in medicine ofusing animal parts in the treatment ofhumans. This paper raises the question ofthe logical andmoral justification for these current practices and theirproposed expansion. We argue that the Cognitive CapacityPrinciple establishes morally justified necessary andsufficient conditions for the use ofnon-human animals inmedical treatments and research. Some alternative sourcesfor medical uses are explored as well as some possibleprogrammes for their implementation.

Baby Fae, in her short life, highlighted a growing trendin medicine - the use of animal parts in the treatmentofhumans. While transplanting a baboon's heart into ababy girl is by far the most dramatic, it is only the latestof many occasions where animal organs have been putto work for our benefit. Surgeons already tap animalsfor so-called 'spare parts', using sheep intestine forsurgical sutures, cow tendons and bones to replacehuman ones damaged in accidents, and heart valvesfrom pigs to repair human hearts.Our technical capacity to turn the bodies of animals

into vehicles for growing replacement parts for humansappears limited only by the imagination of medicalresearchers who, in the wake of the Baby Faeexperiment are hailing her operation as facilitatingfurther animal experimentation. Their eagerness givesnew imagery to the Orwellian notion of 'Animal Farm'.Already there is movement to establish baboon farmswhere colonies of primates can be raised to supplyhearts for xenografts. Less modest mindsenthusiastically envision unlimited possibilities inharvesting a variety of organs for human use (1).

Despite a perfunctory nod to the importance ofrespecting moral restraints in our relationships toanimals, the prevailing sentiment overwhelminglyprefers human lives over those of animals. Asreportedly articulated by Dr Leonard Bailey, BabyFae's surgeon, we can either choose to let babies die orintervene and thereby sacrifice - regrettably - somelesser form of life (2).

Key wordsTransplants; spare part surgery; speciesism.

What should we think of these alternatives? If weagree with a Los Angeles Times editorial that.'Medicine's goal is to reduce suffering and preservelife' (3) are we being too picayune to inquire as to whosepain and what kind of life?

Consider the following purposefully extremefictional media report of the future. Examining itlogically may offer a way of developing some muchneeded principles to govern cross-speciestransplantation:

The National Bio-Research Foundation announces theircolony of mentally handicapped persons being bred tobecome transplant donors has reached 2,500. Each yearabout 200 individuals are supplied to some 25 scientificfacilities. Dr Homograft, a spokesmanfor thefoundation,explains that the use of home-bred mentally handicappedhumans rather than earlier simian candidates results inmany more lives being saved and returned to normalfunctioning because of the vastly more compatible tissuematching in human-to-human procedures. Besides beingmedically superior, the mentally handicapped are also moreplentiful since they procreate well in captivity. DrHomograft emphasised that the donors were treated withrespect at thefoundation.

This hypothetical report strikes us as unforgivablycruel and an abhorrent perversion of medicaltechnology. It should be noted, however, that thelanguage of the report is only slightly modified fromdescriptions of how baboons are presently raised forresearch in the United States. Is there a logical andmoral justification for our lack of squeamishnessregarding the use of primates and other non-humans;or, is our attitude simply a popular prejudice whichfavors 'us' as opposed to 'them'?

Equality and SpeciesismIn looking for fair treatment guidelines, moralitydemands that we presume equal treatment and thatunequal treatment must be justified. This moralrequirement is captured by the following Principle ofEquality:

The unequal treatment of X and Y, with respect to

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Baby Fae: a beastly business 179

distributions of benefits and burdens must be justified by a

morally relevant difference between X and Y.

We make use of this principle when, for example, weexcuse very young children and severely mentallydefective persons from the same legal and socialresponsibilities we demand of normal adults. ThePrinciple of Equality is instantiated in cases whereanimal organs are used as follows:

When X and Y are members of different species, theunequal treatment ofX and Y, with respect to distributionof burdens at least, must be justified by a morally relevantdifference betweenX and Y.

In the matter of heart transplants and otherxenografts, if we propose to treat humans in one wayand non-humans in another we must be able to point to

the differences between the two species that makeunequal treatment morally permissible. For example,we have a conviction that it is morally permissible tokill an innocent insect but that it is not permissible tokill an innocent man; surely this conviction rests on

something firmer than the mere fact that these livingcreatures happen to belong to different species. Butuntil we can articulate some rational principle to guideour behaviour toward non-humans in research andexperimentation we may simply be allowing our

technical ability to run blindly ahead of the necessarymoral reflection.Our task, then, is to identify relevant characteristics

that might morally justify treating animals in a mannerwe do not deem acceptable for humans. Some possiblecandidates must be discarded straightaway since theyare characteristics shared by humans and non-humansalike; for example, animation and sentience, thecapacity to suffer or experience enjoyment or

pleasure. However, what does become increasinglypronounced, the higher one goes up the phylogeneticscale, is an entity's capacity for complex cognitions.Cognitive complexity here refers to the way anindividual receives, stores, processes and transmitsinformation. These capacities include such things asrationalisation, self-awareness, social interaction and

the possession of consciousness.Normal adult humans paradigmatically exemplify

these traits; and it is their more advanced degree ofcognitive ability that justifies some differences intreatment. If faced with the choice of giving a copy ofWar and Peace to an ape or to an adult human, forexample, it would be reasonable to choose the lattersince we assume the human has the ability to enjoy andbenefit from the book, whereas the ape presumablydoes not. Suppose however, this ability was as lackingin the human as it was in the ape - a severely retardedperson would be a case in point - under thosecircumstances preferential treatment would not bejustified.

This raises the important point that where the usualdifference between human and non-human does notexist, we cannot justify different moral treatment in the

distribution of either benefits or burdens. Ifwe treat anindividual human who lacks the cognitive abilityhumans normally possess, or are capable ofdeveloping, as if the quality were present, andconsequently treat the human differently from an apeof the same level, then such an act would exemplifyspeciesism. That is, the act would allow unequaltreatment of equally cognitive beings by an appealsolely to a difference in species. In contrast, thePrinciple of Equality demands that where a morallyrelevant difference between human and primate isabsent, there is no moral justification, other thingsbeing equal, for treating the two with anything otherthan equal consideration.

The 'other things being equal' clause should not bedisregarded since not only is the development ofcognition a matter of gradation with respect to thephylogenetic scale, it is also a process in an individual'slife. In this respect, potentiality becomes an issue. Achild, incapable of discernment, possesses limitedcognitive ability, as does a mental incompetent. But incontrast to the mentally impaired, under normalconditions, the child is potentially a fully cognitivebeing and must therefore be regarded as having acertain importance, if not because ofwhat it is, at leastbecause of what it might become. It is the view herethat the stringency of our duty to preserve an entity isdirectly proportional to not only the individual's actualpossession ofcomplex cognitive skills, but its potentialto achieve them as well.How might what has been said so far apply to

admittedly imaginary transplant cases? Let ussuppose that there are three needy organ recipients.Each possible recipient needs a different organ (forexample, a heart, a kidney and a liver), whichaccording to all possible matching procedures, can bestbe supplied by either of the other two. Thus, in orderto save two lives, one must be sacrificed; and, if theorgans of one are not used for the remaining two, allthree will die (4).

In the first scenario the three would-be recipients aretwo humans with normal cognitive capacities, oneadult and the other a young child; the third is an adultbaboon with full primate capabilities. Which organsshould be used? Our duty to preserve the maturehuman is more stringent than our duty to preserve thelife of the young child, since the former has full actualpossession of value characteristics (5), whereas thelatter does not, and the child does not have thepotential to attain more value than the amount theadult already possesses (6). Our duty towards thehuman child is stronger than that towards the baboonbecause, although the latter may have more actualvalue than the former, the child has potentialities thatfar exceed those of the monkey. Thus, the baboon inthis case is the best donor from a moral perspective.The second situation consists of a normal human

adult, but in this case the human child is retarded to thedegree that its cognitive capacity is reduced to the samelevel as that of the baboon. As before, the adult human

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180 Thomasine Kushner and Raymond Belliotti

would not be the appropriate donor for the reasonsoutlined above. The situation between monkey andchild has significantly altered since, being ofcomparable cognitive capacities, both actual andpotential, they now share an equal claim to the neededorgans.

Equal claim would suggest that the matter could bedecided by lot; but deciding an issue ofsuch magnitudein some chance fashion seems radically counter-intuitive. Perhaps this appears so only because it is easyto imagine the child with a network of relationships allof which would suffer if the child dies, a fabric ofconcern assumed to be missing in the monkey's case. Ifthis is factually true, then the child does have a higherclaim based strictly on consequentialist groundsbecause of the adverse affect the child's use and deathwould have on others. But if it were possible to showthat the baboon had a similar network, comparable interms ofwarnith, interactions and attachments to thoseof the retarded human, then the balance would revertback to equal claim shared by monkey and child (7).And, if it could be demonstrated that the baboon had,in reality, a closer network of relations than the child(the latter being an orphan abandoned in an institution,for example), the shifting weight of the consequenceswould suggest the human child be sacrificed to benefitthe baboon (8).

Morally permissible alternativesIf we are correct that present transplant and researchpractices cannot rationally be defended, in what wayscan our attitudes be changed to blur the distinctionbetween valuing a human life while devaluing the lifeof a non-human with the same cognitive abilities?There are two possibilities that might be considered.

First, we could change our attitude towards our ownspecies so that we would think it is morally permissibleto use a human for research, experiment or operationonly if we presently feel morally justified in using anon-human of equal cognitive capacity, or equal value,for the same procedures. By adopting this attitude wewould not only condone the use ofthe baboon heart forBaby Fae, but we ought to be equally ready to take theheart of a mentally handicapped human of similarstanding for her benefit. Few of us, however, areprepared to embrace such a radical departure from ourpresent treatment of the mentally disadvantaged.The second possibility would be to hold constant our

present protective concern towards members of ourown species, but change our attitudes toward animalsso that we consider it morally permissible to use a non-human for research, experimentation or operation onlyifwe would presently find it morally permissible to usea human with equal cognitive capacity for the sameprocedures. Viewed in this way, our inclination is toconclude that the baboon's heart could not be used forxenografts since we would not condone the sacrifice ofa retarded human with equal cognitive capacity.

Thus, two conclusions can logically be drawn. Thefirst, considerably more radical than current practice,

allows the use of mentally retarded adults in medicalexperiments; while the second, more conservative thancurrent practice, prohibits the use of fully cognitiveprimates in such experiments.

Since prudence dictates that where there is doubt ona moral issue, it is best to take the more conservativeposition; and since there is a general inclination not touse innocent life wantonly, we presume that thestronger claim is towards changing our behaviourtowards non-humans more equally to reflect theconcern and protection which we currently feel iswarranted towards members of our own species ofcomparable cognitive level.By conjoining the alternatives described above, it is

possible to establish both necessary and sufficientconditions for the use of non-human animals. Such aprinciple would stipulate that:

It is morally permissible to use non-humans for research,experiment and operations if and only if we would feelmorally justified in using an adult human ofequal cognitivecapacity for the same research, experiment or operation.

In applying the above Cognitive Capacity Principle tothe question of Baby Fae and her transplanted baboonheart, we should have to ask if it would be morallypermissible in such circumstances to substitute theheart of a mental incompetent whose cognitions couldnot exceed those of the monkey. Ifwe are not preparedto use such humans as a means for our ends, to use theirorgans as if they were 'spare parts', we have no basis fortreating non-humans of like cognitive capacity in adifferent manner.

Animals: individuals or interchangeable?

Equal consideration results from theacknowledgement that certain characteristics arevaluable regardless of where they are found. These arethe characteristics that make it possible for a creatureto have an individual life as opposed to being merely areplaceable member of a species (9). It is not arbitraryto hold that beings which possess a cognitive level ofsufficient complexity to allow them to conceive ofthemselves as distinct individuals existing over time,with some appreciation ofevents as they happen to andaffect them, and the psychological attributes necessaryto desire to continue living, are more valuable thancreatures without these capacities.As opposed to self-aware entities, leading lives of

their own (for example, primates, whales, dolphins),there are vast numbers of species whose members arevirtually indistinguishable from one another (forexample, fish and reptiles). The members of suchspecies lack the conception of themselves as livingbeings with a future, and can thus be viewed asinterchangeable receptacles of pleasurable and painfulexperiences. Their sentience entails that they do haveinterests that count; but, if upon their death they arereplaced by another member of their species whose life

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Baby Fae: a beastly business 181

is equal in pleasure it would be difficult to see wherethere has been an overall loss.

There seems to be no reason to believe that leadingan individual life need be limited to a certain body-typeor linked to any particular appearance. Rather thanbeing species specific, this ability is a function ofstructure, predicated on a level of mental developmentwhich depends upon an intact nervous system of a

certain complexity. And while the mentallyhandicapped and some higher order animals share thequalities of individual value, albeit in a more

rudimentary way than normal human adults, this in noway mitigates against the fact that to the extent thatentities, despite their species, share a comparablecapacity for the self-awareness that makes individuallives possible, they have an equal right to have thoselives protected.Whether or not the proposed Cognitive Capacity

Principle is unrealistic is a serious question. It iscertainly not impossible to put into practice; but howlikely is it that it might actually be implemented?There are some signs for optimism. There is increasingchallenge to the prevailing view that non-humans, as

creatures ofinferior moral status, can be made to sufferextremely painful or lethal scientific experiments forno reason other than our own bare-faced preference forour own species (10).

Also, we do have a dramatic example of a conversionin thinking regarding the once accepted practice ofslavery where one group exploited another purely forits own advantage. Like researchers today, slaveowners empathised with their slaves to a certaindegree, agreeing that they should not be mistreated;and there was a certain code of ethics as to how slavesshould be treated, in much the same way thatexperimenters today have codes regarding thetreatment of animal research subjects.Some would say that our change in attitude towards

slavery was easier to come by since it is simpler forpeople to change their minds regarding members oftheir own species with whom they can more easilyidentify. History shows, however, that it is difficult tooverestimate the ability of people, particularly powergroups, to see differences between themselves andother humans.

Keeping in mind the growing debate, and how farwe have come in our moral thinking, it is possible thatat some future time, regarding animals as organ

incubators available for human use will be thought ofwith the same repugnance with which the readerundoubtedly responded to the hypothetical report atthe beginning of this paper, wherein some humans,because of a mental handicap were being bred as organ

donors - even though we had the assurance of theirkeepers they were treated with 'respect'.

Other sources for medical uses

It would seem, however, that if we restricted organ

donors and research subjects to volunteers plus thosecreatures without the capacity for individual lives,future transplants and experiments would have to begreatly curtailed. Most organisms that fall below thelevel of self-awareness are in fact so different from ourown species that they are essentially useless for thosepurposes.

There are some alternatives, however, which notonly eliminate some of the moral dilemmas discussedhere but at the same time actually enhance the practicalpossibilities for success. Specifically, why not useindividuals who have suffered brain death, patients inirreversible comas, and infants born with anencephaly(11)? None of these groups possess, either actually orpotentially, the cognitive capacities that would make itpossible for them to lead individual lives as they havebeen discussed above.

Currently those who meet the criteria for braindeath, which in the United States requires the entirebrain including the brain stem to be dysfunctional, areused as organ donors but not for invasive researchprocedures. If these cadavers are consideredappropriate sources for organs and other body tissue,there appears no logical difference in using them alsofor research in place of the conscious, rational, sentientbeings presently sacrificed for these purposes.

Permanently comatose individuals, while notmeeting the criteria for brain death either in the UnitedStates or in Britain, since they do have minimal brainstem activity, are maintained indefinitely onrespirators or, as Karen Ann Quinlan did for so long,breathe on their own but with no hope of recoveringconsciousness.

While there seems no defensible reason why in thecase of irreversible coma the individual could not beused for both organ donation and experimentalresearch, there are two caveats that need to beconsidered. First, because perception of pain mayinvolve the cerebral cortex and in irreversible comasthere may be some degree of cerebral function, thedegree to which this is an actuality in any particularcase would have to be taken into consideration toensure procedures would be painless. Secondly, whenchildren are involved the determination of irreversiblecoma is much more difficult to ascertain. What cancount as reasonable medical certainty in adults may notbe applicable in children. For this reason, childrenwho appear to be permanently comatose should not beincluded in either the organ donor or research subjectcategories.There are, however, children who would qualify as

both organ donors and research subjects: anencephalicinfants. Because the entire cerebral cortex is missing inthese children, there can be no perception of pain.Thus, the precautions that would apply to irreversiblycomatose adults used for research would serve nopurpose in these situations (12).The proposal advanced here regarding the brain

dead, irreversible comas and anencephalic infantscould be implemented under (i) a compulsory

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182 Thomasine Kushner and Raymond Belliotti

programme, (ii) a presumptive programme allowingexceptions, or (iii) a consent programme. Under acompulsory programme, the brain dead, the irreversiblycomatose, and anencephalic infants would be usedautomatically and irrebuttably as organ donors andresearch subjects where appropriate. Such aprogramme has the advantage of providing anabundant stock of donors and subjects which mightfacilitate important and useful medical advances.However, the programme's disadvantagesundoubtedly militate against its implementation:violation of religious freedom, denial of FirstAmendment rights and excessive State intrusion inindividuals' lives and deaths.Under a presumptive programme allowing exception,

the brain dead, the irreversibly comatose, andanencephalic infants would be presumed to beavailable for use as organ donors and research subjects,but the presumption would be rebuttable. That is,such subjects would be routinely available for theappropriate medical experimentation unless they hadpreviously registered their objection or, possibly,members of their immediate family had registered suchan objection. Such a programme mitigates thedisadvantages of a compulsory programme, whileproducing more subjects for medical transplant andexperimentation than those provided by a pure consentprogramme.Under a consent programme, the brain dead, the

irreversibly comatose and anencephalic infants wouldbe presumed not to be subjects for medicalexperimentation unless they had registered priorwillingness. (In the case of infants or young childrenthe consent ofimmediate family members would serveas a substitute.) Such a programme supports individualautonomy, but would probably result in far feweravailable subjects for medical experiments than thefirst two programmes.We have no vehement objections to the

implementation of a presumptive programme allowingexceptions provided that all potential subjects and theirfamilies have ample prior opportunity to register theirobjections to their potential use as subjects in medicaltransplants and experiments. However, we fear that inpractice the poor, the uneducated, and the politicallyand legally disenfranchised would bear adisproportionate burden under such a programme. Ineffect, it is likely that only the advantaged segments ofsociety would be aware of their options and the detailsof registering formal objections to a State programme.Accordingly, only the advantaged segments of societywould truly be in a position to exercise the autonomy schighly valued by advocates of this programme.A consent programme - the most conservative ofour

three possibilities - is our preferred selection. Contraryto our immediate intuition, such a programme mightwell produce an adequate number of subjects formedical transplants and experimentation if itsimplementation was supplemented by massive publiceducation and vigorous support on the part of themedical community. Taking what would seem to be

the most difficult case, the anencephalic infant, there isreason to believe that parents of children so afflictedmay be more willing to offer consent than commonlyassumed. Those physicians who discuss organdonation with grieving parents, whose child only hoursbefore was alive and healthy but who must now grapplewith a fatal accident, can only be enormously moved byparental willingness to give their child's organs tobenefit another child (13).While it is true that under this consent

programme the advantaged segments of society wouldprobably bear a disproportionate burden (14), theirmembers would have done so under conditionsfacilitating autonomous choice. However, if theoptimism we have lavished on consent programmesturns out to be misplaced and an inadequate number ofsubjects are produced under our prescribed strategy,then we advocate the implementation of a presumptiveprogramme allowing exceptions (providing that thesafeguards alluded to previously are alsoimplemented).

Returning to the case of Baby Fae, it might well beasked if receiving a heart from one of the thousand orso anencephalics born each year in the United Stateswould have been a better choice for her, not to mentionher monkey donor. Her case is illustrative of how arethinking of which bodies can truly be said to have'spare parts' may result not only in logical consistencyand moral clarity, but medical practicality as well (15).

Thomasine Kushner PhD is a philosopher whose areas ofspecialisation are bioethics and aesthetics.Raymond Belliotti PhD is a philosopher and attorneyspecialising in ethics, political philosophy andjurisprudence.

References and notes

(1) Time 1984 Nov 12: 72.(2) The Miami Herald 1984 Oct 28: 26A.(3) Newsweek 1984 Nov 12: 118.(4) The arguments against vitalism, the view that life per se

is not only valuable but sacred, have bccn presented toour satisfaction elsewhere and need not be reiteratedhere. See for example, Singer P. Practical Ethics.Cambridge University Press: Cambridge, 1979: 90-92and Animal Liberation. Random House: New York,1975: 21-24. Also Rachels J. Euthanasia. In: Regan T,ed. Matters of life and death. Temple University Press:Philadelphia, 1980: 45-50. Neither do we subscribe toone of the elements of vitalism that contends because alllife is sacred no decision can be made; and, in a dilemmaas the one described here, there can be no interventionsuch that one life is used for the sake of another.

(5) We are taking the possession and exercise of the relevantcognitive capacities as our criteria of value.

(6) Our conviction might change if the 'mature human' werein a condition so as to make it unlikely that he or shewould be able to exercise value characteristics for verymuch longer.

(7) We recognise the practical problem researchers wouldface in trying to assess whether in any given situation aprimate could be reasonably said to have complex social

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relationships. However, there is evidence to suggest thatat least some of the higher animals, like primates, doindeed have a network of social connections. Ethologistsand others who study animals in their naturalenvironments are far more likely, for just this reason,than laboratory researchers to support restrictions onanimal use. See, for example, Goodall J. In the shadow ofman: Boston, Ma: Houghton Mifflin, 1971. Because of thisdocumentation we urge researchers to assume a networkof animal inter-relationships in the calculus.

(8) Other kinds of consequences could also be postulated inorder to argue in favour of one or the other.

(9) See, for example, reference (4): Singer: 99-103.(10) In addition to the Singer and Rachels works already

cited, see also, Sechzer J A, ed. The role of animals inbiomedical research. Cornell Medical College: New York,1983.

(11) For discussions of related issues see Gaylin W.Harvesting the dead. Harper's magazine 1974 Sept andFeinberg J. Sentiment and sentimentality in practicalethics. Proceedings and addresses of the AmericanPhilosophical Association Sept 1982 56, 1: 3242.

(12) A very legitimate point could be raised as to whetheranencephalics might not be subject to thalmic pain suchas that experienced by individuals who have corticallesions, but with the thalamus intact. This has beenparticularly well known in individuals who have had acortical resection for the treatment of intractable painbut who unfortunately as a result suffer from pain evenmore diffuse and agonising. In response, WalterFreeman, MD, Professor of Physiology, University ofCalifornia, Berkeley, points out that in the case of

anencephalics, the neothalamus is as underdeveloped, ornonexistent, as is the neocortex; therefore, the 'paincentre' in the thalamus is no more likely to exist thanthose cortical centres which are responsible for painperception. Consequently, it is quite likely that the kindof pain experience that would be accessible toanencephalics is that ofthe decerebrate animal orhumanas distinct from the decorticate animal or human. In thedecerebrate state, it is very common to see reactions topainful stimuli which are in the nature of reflexresponses which can suggest to an uninformed observerthat there is an experiencing of pain but there is noevidence that such experiences actually exist.

(13) Donald Buckner, MD Chief of Pediatric Surgery,University of Miami School of Medicine. PersonalCommunication.

(14) This is likely because the advantaged segments ofsocietyundoubtedly would be more aware of the possibility andprocedure for registering consent to this Stateprogramme.

(15) No doubt slippery slope arguments will be broughtforward to charge that this suggestion opens the floodgates for physicians to commit all sorts of atrocities in theuse of infants and others not beyond the hope ofconsciousness. While all slippery slope argumentsshould be duly considered, they are extremelyspeculative and only illustrate that wrong decisions canbe made either intentionally or unintentionally. Itshould also be mentioned that the force of slippery slopearguments alone is almost never conclusive in rulingagainst the legitimacy of a moral principle.

(continuedfrom page 172)

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Engelhardt H T, Spicker S F, eds. Evaluation andexplanation in the biomedical sciences. Dordrecht: Reidel,1975; 125-141.

(7) Toon P D. Defining 'disease' - classification must bedistinguished from evaluation. Joumal of medical ethics1981; 7: 197-201.

(8) World Health Organisation. International classificationof diseases, vol 1. Geneva: World Health Organisation,1977; 204. (Available from Her Majesty's StationeryOffice, HMsO).

(9) Cited by Kennedy I. See reference (3): 1.(10) See reference (8): 196.

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