Journal of Advanced Nursing, 1993,18,1172-1177
The ethical use of fetal tissue for
transplantation and research
M Terese Verklan MSN RN C
Doctoral Candidate, and Research Associate, Umoersify of Pennsylvania, 117 N 15th Street,
p5O3, Philadelphia, Pennsylvania 19102, USA
Accepted for pubbcahon 20 November 1992
VERKLAN M T (1993) ]oumal of Advanced Nursmg 1 8 , 1 1 7 2 - 1 1 7 7
The ethical use of fetal tissue for transplantation and research
The exercise of organ and tissue transplantation is a conunon occurrence m our
soaety Expectations of future advances in this arena are raising many ethical,
moral and public-policy questions The scientific data base supporhng the
usefulness of fetal tissue to repair or reverse disease is modest, and uses are
speculative Should fetal tissue transplantation research proceed and, if so, under
what conditions? This paper exarrunes the issues related to the use and
proQorement of fetal tissue for research and transplantation
A COMMON OCCURRENCE
Dunng the last decade, high-technology medical/biosaence
research and practice has made the exercise of organ and
tissue transplantation a common occurrence m our tertiary
health care centres As skill levels grow and the possibilities
appear to have ever-fewer linuts, the expectations of future
advances have raised many ethical, moral and public-pohcy
questions The saentific data base supportmg the usefulness of fetal tissues to repair or reverse disease in humans or
in animals is modest indeed and, for the vast majonty of the
conditions in which its use has been proposed, still largely
speculative (MacDonald 1990)
For many, the question being raised is although we can
do this, should we do this should fetal tissue transplantation research proceed and, if so, under what conditions
(Walters 1988)? This paper will examme the issues related to
the use and procuranent of fetal tissue for transplantation
and research
Phases of ethical concern
Three phases of ethical concern relating to the use of fetal
hssue for research can be delineated. The 6rst phase, lasting
qjproximately from 1970 to 1978, can be charactaized as
an era of response to liberalized abortion laws (Walters
1958) Concern revolved around the possibility that
1172
research may be performed upon intact previable fetuses,
either m utero or ex utero post-abortion The second phase,
approximately from 1978 to the early 1980s, focused upon
the new techniques developed for prenatal diagnosis
The third phase was signaled by the adoption, m
October 1983, of a committee report on "Ethics m Medical
Research Involving the Human Fetus and Human Fetal
Tissue' by the Australian National Health and Medical
Research Council (Walters 1988) The Australian report
broke new ground m discussing the transplantation of
human fetal tissue into already-born patients, the propagation of fetal cells m tissue culture, and recommending
that fetal tissue be able to be used for these purposes, but
only if harvested after the fetus had died and only with the
pnor consent of the pregnant woman (Australia, National
Health and Medical Research Council 1984)
In 1984, the French National Ethics Committee discussed
the use of 'tissues fi-om embryos or from dead human
fetuses for therapeutic, diagnostic, or saentific ends'
(Walters 1988) They specifically asserted that the use of
fetal tissue be transplanted into those patients who had no
other recourse through existing alternative treatments
The Counal of Europe's Parliamentary Assembly,
strongly influenced by the French report, adopted
Recommendation 1046 m 1986, which devoted much
attention to formulating rules for the therapeutic use of
tissue from dead, externalized human fetuses (Courtal of
Eurojw, Parliamentary Assembly 1986)
Ethical use of fetal tissue
The United States Congress became interested in fetal
research in the early 1970s when it was reported that
researchers, funded by monies from the National Institute
of Health, were engaging in transplanting fetal tissue to
aUeviate Parkinson's disease and diabetes The report,
which appeared dunng the vigorous debate over abortion
that preceded the Supreme Court's decision m Roe vs Wade
(1973), aroused suffiaent public attention that both Houses
of the US Congress enacted legislation on the subject and
eventually established the National Commission for
the Protection of Human Subjects of Biomedical and
Behavioural Research Gonsen 1989)
The Committee's first task was to investigate and study
research involving the living fetus, and to recommend
whether and under what circumstances such research
should be conducted or supported by the Department of
Health, Education and Welfare (1988) Four months later,
the 'Report and Recommendations on Research on the
Fetus' was completed The Department of Health and
Human Services also mstituted a moratonum on therapeutic transplants of tissue from aborted fetuses pendmg
the conclusions of a study of saentific, legal and ethical
issues raised by such transplants (Helierstem 1988)
Unresolved dilemma
The dilemma continues to be heated and unresolved
because it relates to human subjects It has always been
difi&cult to distinguish between what is moral and what is
considered immoral In traditional Catholic medical ethics,
under the pnnaple of totality, the removal of an organ
from a living person was spontaneously classified as
'mutilation of the body', smce physical hfe, and so the body
itself, was seen as a gift entrusted to the human person by a
loving Creator, no one would have the nght to jeopardize
or mutilate the body without sufiEicient reason (Ulshafer
1988) Organ procurement was viewed as not being
beneficial for the donor The introduction of a second moral
pnnaple, that of love or Chnstian chanty, created an
alternative viewpoint The issue of tissue donation should
not only be viewed under the paradigm of mutilation but
should also be seen as a taking of nsks m order to help
another m need (Ulshafer 1988)
EARLIEST MENTION OF RESEARCH
ETHICS
The earliest mention of research ethics is found m the
wntings of a Roman physician Celsus commenting on the
practice of vivisection of condemrwd criminals Gonsen
1989) It IS not cruel to mflict on a few cnminals sufferings
which may benefit multitudes of lrmocent people throughout the ages' Obviously, pubhc sentiment is not aligned
with this mode of thinking, as evidenced by the level of
emotion preapitated by the Nuremberg trials of Nazi
physicians
Our sensibilities are not aroused by procedures utilizing
cadaverous tissue, provided that respect for the dead is
maintained Leonardo da Vma performed pioneer studies
of the fetus by dissecting the cadavers of pregnant women
and dead fetuses (Australia, National Health and Medical
Research Counal 1984) We accept removal of tissue from
a cadaver, either for pathological analysis, research or
transplantation as authonzed by the Anatomical Cift Act
Oonsen 1989) Similarly, the National Commission recommends that, 'Use of the dead fetus, fetal tissue and fetal
matenal for research purposes should be permitted, consistent with local law, the Anatomical Gift Act and commonly
held convictions about respect for the dead (1976)
Clinically, the fetus is defined as a post-embryonic
organism, from about 8 weeks' gestation to term, contained withm the body of a pregnant person (Pntchard et
al 1985) There is no doubt that the product of human
reproduction is not humcin, this is based on biology It is the
term person that raises controversy Genetic distmctness
can be delineated from the moment of conception, however, the moment that personhood exists continues to be
debated Regardless of personhood status, another facet
that needs to be addressed is the issue of whether the fetus
IS alive or dead and, if alive, whether the fetus is viable
or not
Fetal death
All major reports concerning the use of fetal tissue have
generally agreed on the concept of death, although they
may have different approaches m their defiruhons of fetal
death The United Kingdom's Peel Committee bnefly
deftned fetal death as the state in which the fetus shows
none of the signs of life (UK, Department of Health and
Soaal Secunty, Scottish Home and Health Department and
Welsh Office 1972) The National Commission adopted
death of the organism, rather than the death of all cells and
tissues (US Department of Health, Education and Welfare
1976)
Cessation of the heart beat is the usual sign of death
mentioned by the Australian Committee, while the mterruption of the blood's arculation constitutes the cntenon
of death according to the French Committee (Walters
1988) It IS noted that little consideration is actually
devoted to the viability-^ionviability distinction Viability
of the fetus is defined m Roe vs Wade (1973) as 'ability to
survive ex utero, albeit with artifiaal aid'
1173
MT Verklan
Those fetuses that are considered nonviable are alive
but dying The probability of success m transplantation
mcreases through use of tissue from a livmg fetus, and may
be greater when the fetus is viable rathw than nonviable
(Mahowald 1989) Thus far, social policy has excluded
donation of vital organs or tissue from hve donors, even
when death is imminent (US Department of Health and
Human Services 1986) A departure from the longstanding
precedent opposed to such retneval (even if requested by a
dying donor), such as by usmg viable or even nonviable
(hvmg) fetuses as transplant 'donors', could only be
justified on grounds that the human fetus is not a person
whose hfe should be supported until natural death occurs
(Mahowald 1989)
Another issue commonly raised with respect to utilizing
hve fetus tissue, regardless of the status of 'person', is that
of the possibility of fetal sentiency or capaaty to feel pam
Although relatively little is known regardmg development
of the nervous system and the capaaty for expenenang
pam, research has demonstrated that human and animal
neonates have the capaaty to feel pam It then becomes
morally relevant to consider the possibibty that the
younger fetus may also have this capaaty If retneval of
tissue from livmg fetuses were ever permissible, it would
be morally mcumbent on the 'retnevers' to conduct the
procedure m a manner that avoided pam on the part of the
fetus such as through the use of analgesics (Mahowald
1989)
What of the research that may be directed toward a fetus
that IS about to die? The fact that this fetus is about to be
aborted seems to provide an opportunity for us to learn
much about fetal physiology, the pharmacology of drugs,
etc Gonsen 1989) Jonsen feels that moral judgement in
these cases is not absolute and lies somewhere in the
middle of the spectrum between vivisection and autopsy
does the imminence of abortion make a morally relevant
difference with respect to fetuses m utero, is it permissible
for some fetuses to be subjects of research that would not
be done on fetuses that eventually will be bom?
The consensus statement of a panel of experts who
addressed the issues in 1986, as weU as that of a National
Institutes of Health (NIH) panel that considered it m 1988
to 1989, assumes that only tissue from dead fetuses shall be
used for transplantation (Mahowald 1989) As mentioned
above, a moratonum exists on the funding for fetal
research
USE OF HUMAN FETAL TISSUE
The use of human fetal is not in itself objechonable
Considered without regard to the cause of fetal death.
1174
tissue from a deceased human fetus is entitled to the same
treatment and respect as that from a dead child or adult,
neither more nor less (Greelye^ a/ 1989) Transplantation is
govemed by the Uniform Anatomical Gift Act wbch, in
the case of a fetus, provides that either parent may dorute
the fetal remams as long as the other parent does not object
(Uniform Anatomical Gift Act 1988)
The only relevant difference between fetal tissue from a
spontaneous abortion and tissue from the cadaver of an
adult IS that the fetus was never m a position to choose
whether its cadaver should be used (Greely et al 1989) The
deceased's relatives are often approached regardmg organ
donation. The fact that the deceased is a fetus that has been
sjx)ntaneously aborted should not alter the ethical considerations behind that deasion Applying the legal and
ethical constraints that govern the use of cadavers to the
use of human fetal tissue affirms that fetuses have moral
value, are at least a potential human life and should be
treated with dignity (Uniform Anatomical Gift Act 1988)
The means through which human fetal tissue becomes
available is polemic Fetal tissue from spontaneous
abortions may not be an optimum tissue source, owmg to
the increase in abnormalities often noted The amount of
viable tissue that is potentially recoverable is limited, as
most of these abortions occur outside the hospital under
poorly controllable situations Ectopic pregnanaes have
been proposed as a fetal tissue source because of the type of
surgical procedure performed and the lack of abnoimalities
associated with the condition From an ethical pomt of
view, surgical removal of an ectopic pregnancy is comparable to therapeutic abortion for maternal health, with the
added caveat that the arcumstances are already fatal for the
fetus (Mahowald 1989)
Abortion
Some who oppose the use of fetal tissue for research and
transplantation do so because of compbaty m abortion the
use of even dead fetal tissue for transplant as compliaty m
and co-operation with moral evil, 'a morally unacceptable collaboration with the abortion mdustry' (National
Conference of Catholic Bishops 1990) This position
presumes the need for proxy consent for donating the
aborted tissue, furthermore, it asserts that a woman who
intentionally aborts a pregnancy forfeits her role m determining the fate of the aborted fetus and, therefore, cannot
give proxy consent (Smith 1990)
Even if one accepts the premise that abortion is a moral
evil, it does not follow that use of fetal remams makes one
morally responsible for or an acccnnplice to abortions that
Ethical use of fetal tissue
occur independently of the need to obtam tissue for transplant (Robertson 1990) The key eirhical issue is whether
fetal remains from the 1 6 million abortions performed
annually m the United States to end unwanted pregnanaes
should be discarded or used for clirucal research or therapy
when medically appropnate (Robertson 1990)
From a simple utilitanan viewpoint, the potential good
that may be acbeved through transplantation or research
outweighs the harm that is possibly inflicted by an elective
abortion One may argue that a truly pro-life position
favours the affirmation of life that transplantation entails,
while adcnowledgmg the negation of hfe that abortion
implies (Mahowald 1989)
A small proportion of opponents argue that sanctioned
use of fetal tissue will lead to an mcrease in the amount of
induced abortions If endorsement of the procedure leads
to widespread increase in elective abortions, to a reduced
sense of the v2Jue of humain life, and to exploitation of
women, it is possible that such an array of undesirable
consequences would outweigh the potential benefit of the
techruque (Mahowald 1989) At this time the claim is
viewed as too speculative and has been regarded by the
NIH panel as highly unlikely (Consultants to the Advisory
Committee to the Director of the NIH 1988)
Justification
Does the end justify the means? The intention is crucial to
the moral relevance of the relationship (Mahowald 1989)
If a link IS established between the therapeutic use of fetal
tissue and matemal deasions to abort, the wider ethical
support for fetal tissue transplantation would be narrowed
(Smith 1990) The willingness of women to donate fetal
hssue after abortion does not mean that successful fetal
hssue transplants will lead to abortions that would not
otherwise have occurred (Robertson 1990) As the pnmary
incentive for obtaming an elective abortion is to terminate
an unwanted pregnancy, it would simply be conjecture to
presume that widespread practice conceming abortion
would change Furthermore, the persuasive analogy
between organ transplantation and fetal tissue transplant,
founded on the understanding that the cause of death is
irrelevant as long as the potential medial use of the
available organs or tissue did not contnbute to the death,
would be significantly weakened, if not destroyed (Smith
1990)
Part of the NIH panel's supporhng rationale for fetal
tissue transplantation is the fact that abortion is legal and
that these aborhons woidd occur regardless of their use m
researdi (Consultants to the Advisory Committee to the
Director of the NIH 1988) The pahent or researcher
utilizing the fetal tissue has not intended the abortion to
occur In the UK, the transplantation of fetal tissue from
mduced abortions has been permitted smce July 1989,
based on the perceived separation of abortion and the use
of fetal tissue (Dickson 1990) When the deasion to abort
has already been made by others, a deasion not to
trcinsplant seems less in keepmg with a pro-life position
than its opposite (Mahowald 1989)
Authorization
Although the assumption is that the fetal tissue obtained
for transplants and research will be obtained under legal
practices, it remains unclear as to who may actually
authorize this tissue for use The NIH panel concluded that
matemal consent is suffiaent for the use of the hssue and is
the most appropnate mode of transfer of fetal tissues, based
on the congruency of our society's traditions, laws, poliaes
and practices, includmg the Uniform Anatomical Gift Act
jind concurrent federcJ research regulations (Consultants to
the Advisory Committee to the Director of the NIH 1988)
The 'Statement of Dissent' by Bopp & Burchaell rejected
this position and maintamed matemal forfeiture of the
proxy role (Smith 1990) This view disregards any contmumg interest the mother may have m the disposition of
that fetus' tissue It also mistakenly assumes that a person
who disposes of cadavenc remains acts as a guardian or
proxy for the deceased, who has no mterests, rather than as
a protector of their own interests in what happens to those
remains (Robertson 1990)
A third elective for obtammg fetal tissue would be to
institute routine screerung and utilize all aborted fetuses
unless there were explicit matemal objections A fourth
ophon, which would preserve some of the intent of
informed consent and significantly reduce any conflict
of interest for parental deasions about donation, would
accord authonty for donation to independent third
parties, for example, medical examiners or coroners, while
allowing either parent the nght of veto (Caplan 1987)
ISSUE O F C O N S E N T
Although the issue of consent is unresolved, guidelmes for
the procurement of fetal tissue for transplantation and
research have been formally delineated The caregiver or
researcher interested m the fetal hssue is prohibited from
undertaking any role that involves participation m the
woman's deasion to abort or to donate the hssue Those
involved in perfoimmg the aborhon procedure are also not
allowed to benefit from the ensumg use of the fetal hssue
1175
MT Verklan
Permission to donate the hssue can cmly be obtained after
the woman has deaded to undergo an elechve aborhon
These rules will ensure that tissue donation is not a
prerequisite to havmg the aborhon performed, and they
will prevent the prospect of donating fetal remains from
tnfluencmg the deasion to abort, a clearly preferable pobcy
when an adequate supply of fetal hssue is available from
elechve family plannmg aborhons (Robertson 1990)
Although not an expbat law, the woman should not
benefitfromthe use of the fetal hssue This may encourage
exploitahon of pregn2inaes, with the end result that
women are paid to supply fetal hssue for research or
transplantahon Federal regiilations currently prohibit
federally funded research projects from offermg women
'inducements' to parhapate m fetal-hssue research (Greely
et al 1989) The Nahonal Organ Transplant Act now
makes payment of 'valuable considerahon' for the donahon
or distnbuhon of specified fetal organs and 'any subparts
thereof (which arguably mdudes tissue and ceUs) a federal
crime (Robertson 1990)
Although the Uniform Anatonucal Gift Act (1988)
allows organ donation to specific persons for medical
purposes, some feel the act should be amended to bar the
designahon of a reapient of fetal hssue (Greely et al 1989)
Tradihonally, relahves have been encouraged to donate an
organ when a close family member is m need Simply
because of that relahonship there may be a moral
obligahon to do all that is possible to relieve the suffenng
or save the life of that loved one There have been several
mstances where a woman has conceived m order to supply
hssue for a parent or an ofiFsprmg
These situahoris mvolve conflicts related to consent,
the donor benefitmg from the use of the fetal hssue,
encouragmg an aborhon that would not have occurred,
queshons of viabibty and personhood, etc Advocates of
'pro-choice' maintam that the woman has an absolute nght
over her body, this may extend to her fetus as well The
legal system has persistently msisted that organs and hssue
be provided on a voluntary basis, even when the prospechve donor is a close relahve (US Department of Health and
Human Services 1986) Potenhally, tbs could also be used
to support the woman's desire to donate fetal hssue to a
speafic reapient
ETHICALLY PERMISSIBLE
It may be presumed that the demand for fetal tissue will
increase as the soenhfic/medical knowledge base escalates
and the profiaency of related techniques spirals It appears
that the use of fetal hssue for transplantahon purposes is
etbcally permissible wlwn (Counal on Saentific Affairs
1176
and Counal on Ethical and Judiaal Affairs 1990) (a) the
guidelmes of the Counal on Ethical and Judiaal Affairs on
clinical mveshgation and organ transplantation are followed as they pertain to the recipient of the fetal tissue
transplant, (b) fetal tissue is not provided in exchange for
finanaal remunerahon above what is necessary to cover
reasonable expenses, (c) the recipient of the tissue is not
designated by the donor, (d) a final decision regardmg
abortion is made before discussion of the transplantation
use of fetal tissue is initiated, (e) deasions regarding the
techruque used to mduce aborhon, as well as the timmg of
the abortion m relation to the pregnant woman, (f) health
care personnel involved m the termination of a parhcular
pregnancy do not parhapate in or receive any benefit from
the transplantation of hssue from the abortus of the same
pregnancy, and (g) informed consent on behalf of both the
donor and the recipient is obtamed m accordance with
appbcabie laws
Although surgery to obtain fetal hssue for transplantahon purposes is not presently being done, the bkebhood
of this occumng m the near future is high Nurses need to
be aware of the moral issues surrounding the procedure m
order to examine their own moral conflicts and dilemmas
It has been recommended that nurses providing abortion
counsellmg should not ask pahents about fetal donation,
and those with moral objechon to abortion should not be
required to assist at the operahons to transfer fetal cells
(Gero & Giordano 1990)
Once the patient has made a deasion to abort the fetus
and donate fetal hssue, the nurse still has an obligation to
care for the woman The Intemahonal Code of Nursing
Ethics emphasizes that nursmg service is 'unrestncted by
considerations of nationality, race, creed, colour, age, sex,
pobtics, or soaal status' and that 'the values, customs and
spintual bebefs of the mdividual are to be respected'
(Thompson & Thompson 1985) If the pahent has come to
terms with fetal tissue transplcintation, the nurse cannot
refuse to provide care because of personal disagreement
with the treatment modality (Gero & Giordano 1990)
CONCLUSION
Although there is a pauaty of information supportmg the
usefulness of human fetal tissue to repair damage in
humans, transplantation of organs and hssue is one of the
major contnbuhons of high-technology medicine, both
today and in the future The ethical objechons appear
insuffkient to contmue a moratonum on peer-reviewed
research and clinical tnals of transplants The issue of 'what
can be done with the fetal remams' needs to be completely
separated from the abortion issue Because the aborh<Hi
Bhtcal use offetal tissue
and subsequent research use occur mdependently, views
about the lmmorabty of aborhon do not necessarily
detemune views of the morality of research with tissue
from aborted fetuses (Robertson 1990)
By adhenng to the guidelines for the ethical use of tissue,
both the mother and the fetus will be protected from
unnecessary nsks or harm Nurses must become aware of
the ethical issues, and develop a firm resolution with
respect to any moral dilemmas As guidelines continue to
develop and pnshne issues evolve, nursing must play an
active, educated role to ensure that ethical practices and
patient nghts continue to be upheld
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1177