Human Nature: Science, Technology, and Life.

Organ Rewards in Singapore

Two days ago, I mentioned Frances Kissling's proposal to reward organ donors by offering them "comprehensive long-term health insurance" as well as "life and disability insurance." Kissling framed the offer not as an incentive but as "the basic safety net that a just and giving society should provide people who offer to risk their own lives to save the lives of others."

She's not alone. Singapore has just "passed a law allowing cash payments to organ donors," according to Agence France Presse. "Previously, it was illegal for a living donor to be financially compensated." But now "an organ recipient can voluntarily pay the donor if he wishes to help cover expenses like hospital and surgery fees."

And how did proponents of the legislation present it? "This is a bill about fairness, being fair to donors who do suffer financial consequences as a result of their act of donation," Singapore's health minister told parliament during the debate. "I know the controversial nature of paying donors. But we also realize that it is unfair to allow genuine donors to bear all the financial consequences of their altruistic acts."

Coverage of transplant-related medical expenses is already legal in the United States. But it'll be interesting to see whether the message from Singapore—fairness to altruists—becomes an effective argument, here and elsewhere, for more extensive compensation.

Organ Rewards

If financial incentives for donating a kidney are wrong, what about financial rewards?

Frances Kissling offers that idea in a beautiful piece at Salon. She writes:

Appropriate concern for the international organ trafficking problem ... has so distorted the concept of altruism and eroded the principle of mutual respect that potential kidney donors are denied the basic safety net that a just and giving society should provide people who offer to risk their own lives to save the lives of others. ... [W]e financially abandon the donor almost immediately after we take their kidney. There is no provision for comprehensive long-term health insurance for donors, or for life and disability insurance. Opponents of any form of compensation or benefit to donors beyond costs directly attributable to the transplant itself fight efforts to provide these benefits.

What worries compensation opponents is that such benefits, framed as incentives to increase the organ supply, will economically coerce poor people to surrender body parts. But what if we don't frame the benefits as incentives? What if we present them, in Kissling's words, as what "a just and giving society should provide [to] people who offer to risk their own lives to save the lives of others"? And could we make this difference real, not just a matter of spin, by designing the reward system without regard to its effect on the organ supply?

Kissling argues that we should

treat potential donors with the same generous spirit with which they have offered their kidneys. No donor should spend a single dollar in the process of giving an organ. And donors should have the safety net they need to stay healthy, to support their family if they cannot work and life insurance should they die. ... One member of Congress who gets it is Arlen Specter, who is circulating the Organ Trafficking Prohibition Act of 2009. The bill increases the penalties for really buying and selling organs, but makes clear that state and federal government can provide the kind of benefits donors deserve without going to jail. Anyone disagree?

Well? Do you?

Drill Babies, Drill

Two arguments have persuaded the United States to fund stem-cell research using destroyed embryos. One is that the research will save lives. The other is that the embryos, left over from fertility treatments, will otherwise be wasted.

Both arguments are now being applied to fetuses.

More here.

Creativity and Body Parts

Drawn by payments of up to $10,000, an increasing number of women are offering to sell their eggs at U.S. fertility clinics as a way to make money amid the financial crisis. ... The Center for Egg Options in Illinois has seen a 40 percent increase in egg donor inquiries since the start of 2008. New York City's Northeast Assisted Fertility Group said interest had doubled and the Colorado Center for Reproductive Medicine said it had received 10 percent more inquiries.

One clinic's egg donation manager explains that the bad economy "encourages women to find creative ways to make money." It's an interesting use of the word creative. In this case, two kinds of creativity seem to be involved. One is the invention of egg donation in the first place. Selling eggs was impossible until doctors learned how to extract, preserve, fertilize, and transfer them for successful implantation. These breakthroughs made eggs transferrable and commercially valuable.

The second kind of creativity goes hand in hand with the first. You don't normally think of selling your body's parts or products. But bad times can make you think hard. One reason you might not have thought of selling something from your body is that the idea felt unnatural or somehow made you uncomfortable. But for $5,000, with bills to pay and no other income prospects, you decide you can get over those feelings.

Economics clearly drives the donation market. Two years ago, Reuters notes, a study found that the average payment to an egg donor in the United States was $4,216. But the average sperm donor in New York City gets only $60 per deposit. And sperm banks, unlike egg donation programs, are reporting no recent increase in donations. The money's not good enough.

The next question is whether money can persuade you to donate not just a body product, but a body part. In principle, half the world's kidneys are expendable. People are already buying and selling them on the global market, regardless of laws. Some reformers are proposing to replace this black market with a regulated system of incentives ranging from $15,000 to $40,000. If $5,000 is enough to make people think creatively about donating their eggs, $15,000 might well be enough to do the same for kidneys.

A Kidney Stimulus Package

The other day, I was reading about a new procedure in which a kidney was extracted for transplant through the donor's vagina. And it got me thinking: If kidney donors deserve special surgical benefits—which is what doctors argued in this case—then what other benefits should they be offered? How about free medical care? How about cash?

The Johns Hopkins doctors who performed last week's vaginal kidney delivery describe several special benefits. "An organ donor, in particular, is most deserving of a scar-free, minimally invasive and pain-free procedure," says one Hopkins surgeon. The natural-orifice procedure supplies these benefits. According to Dr. Robert Montgomery, head of the Hopkins transplant division, "Removing the kidney through a natural opening should hasten the patient's recovery and provide a better cosmetic result."

The doctors see these benefits not just as a special reward but as an inducement. "This approach could have a tremendous impact on people's willingness to donate," argues Montgomery. The shorter recovery time "greatly reduces the inconvenience of donating and we're hoping that will encourage more people to donate."

I've written before about the horrors of the international black market in organs from living donors. Federal law goes further, banning the provision of any "valuable consideration" in exchange for an organ. But the law adds that this term doesn't apply to "the expenses of travel, housing, and lost wages incurred by the donor."

So it's OK to compensate donors for lost income opportunities. And it's OK to make sure that they, of all people, get the most pain-free procedure with the best "cosmetic result." What else?

Sally Satel, a friend of mine and a frequent Slate contributor, points out that other countries have taken further steps. In When Altruism Isn't Enough: The Case for Compensating Kidney Donors, she reports that last year, "the Dutch health minister directed health insurers to reduce annual fees by 10 percent for registered organ donors."

Sounds good, right? If you do a good deed for your fellows, don't you deserve a reward? You're supplying a medical benefit to the community. Doesn't the community owe you, at a minimum, a discount on your health insurance?

And why stop at 10 percent? Satel notes that Saudi Arabia's Cabinet recently "passed a law to compensate unrelated living donors with lifelong medical care."

Still onboard? Let's keep going. Satel proposes to amend the definition of "valuable consideration" in U.S. law so that states can offer "incentives" for organs. The incentives, she explains,

could take many forms, perhaps as simple as an offer of lifelong Medicare coverage or a credit on the federal income tax. States could, perhaps, implement their own creative incentive ideas, such as the utilization of tuition vouchers, state income tax credit, loan forgiveness, or contributions to retirement accounts.

After all, lifelong medical care, which we've already agreed is appropriate, is a quantifiable benefit. What if the reward you really need isn't medical? What if you need a college education or a professional degree? What if you're struggling with your student loans or your mortgage? Can't we do something for you?

Don't worry. We're not talking about cash. Under most of the proposals outlined by various authors in Satel's book, benefits would be "in-kind," with "a months-long cooling-off period prior to surgery" so that nobody rushes to donate out of financial desperation. The value of the incentives might range from $15,000 to $40,000. And according to surgeon David Cronin and economist Julio Elias, there would be one further payoff:

A smoothly functioning pilot period of in-kind rewards might, however, allow the public to adjust to the very idea of compensation so that actual payment became more socially acceptable over time ...

That's a good bet. Satel opposes cash payments, and a bill awaiting introduction in Congress, the Organ Donor Clarification and Anti-Trafficking Law of 2009, would reassert the ban on cash transactions (in fact, it would increase penalties for them) even as it legalized state-provided in-kind incentives. The question is whether such legal distinctions would hold firm in the face of the increasing social acceptability of compensation.

So here's the dilemma: If we maintain the ban on "valuable consideration," Americans with sufficient wealth will keep going abroad to buy organs from living donors on the black market. Those without sufficient wealth will wait for freely donated organs, and some will die waiting. On the other hand, if we relax the ban, we might get used to the idea of compensation and end up buying and selling organs legally.

Which is worse?

Body Parts From Trash

We cover a lot of fancy technology in this blog. But sometimes the most ingenious and far-reaching gadgetry is the least fancy.

A few recent cases: First we looked at incubators made from car parts. Then we learned about ugly standardized glasses you can adjust to your eyesight with a pump. In both cases, engineers are improving life in the developing world by using cheap, available materials instead of cutting-edge technology. But why stop with external devices? Why not extend the low-tech, high-utility revolution into the human body?

That's what Thailand's Prostheses Foundation is doing for thousands of Thais who have lost their legs to land mines, diabetes, and birth defects. "In 17 years, the foundation says it has given away more than 30,000 legs," Agence France Presse reports. In the United States, prosthetic legs cost $10,000 to $50,000 or more. So how can the Prostheses Foundation afford to give them away?

Answer:

It is the recycled materials that make the project workable, Thamrongrat [the foundation's vice chairman] said, as they they keep costs down and allow the foundation to make and distribute more legs. The foundation asks people to donate materials that can be used in the limbs, such as beer cans and aluminum pots. A prosthetic for below the knee costs the foundation 1,000 baht (about 28 dollars) to make, Thamrongrat said. It would cost the government 10,000 baht to build a similar one.

Example:

Twelve-year-old Matoha Dosare was born with no right leg, but thanks to recycled soft drink cans and some old stockings, he now has a new limb and new-found independence. ... Matoha has had three new legs fitted in the last two years, with the metal in the joints coming from the donated bottle caps and tins. The nylon from the stockings is used in the sculpting process to help form the legs.

Three prosthetic legs in two years? That sounds bad. The downside of getting a leg made from soda cans is that aluminum doesn't last as long as steel. But if the upside is a 90 percent cut in production cost, the kid comes out ahead, because he can get those three legs for one-third the cost of a government-issued prosthesis. And since he's growing, each new leg can be adjusted to his increasing size.

But here's the really interesting twist:

One prosthetic offered is the "farmer's leg," which uses more steel and ends in a stump with tire treads on the bottom rather than a false foot. This was created because farmers complained the foot got stuck in the mud. ...

The prosthetic extension designed to mimic a human foot did what feet sometimes do: It got stuck. So the leg makers replaced it with an extension designed for performance in mud. They made a foot more like a tire. In fact, they made a foot from a tire. It lacks the mobility of a healthy human foot. But for farming in Thailand, it has a better shape.

Adjustable Glasses

Last month, we talked about the transition from George W. Bush to Barack Obama and what it might signify for biotech policy: a shift from a conservative interest in technological frontiers to a progressive interest in distributive justice. Less debate, for instance, about things like future artificial wombs, and more attention to things like incubators made from car parts. The point of car-parts incubators was that nobody cares about the latest million-dollar American baby born at 21 weeks when you live in a country where preemies die at 35 weeks. What most of the world needs is an affordable incubator that works for most preemies and can be reliably maintained.

Here's another target for the progressive ethic: eyeglasses. The man leading the charge is Joshua Silver, a physicist at Oxford. In Saturday's Washington Post, Mary Jordan explains the situation:

In the United States, Britain and other wealthy nations, 60 to 70 percent of people wear corrective glasses, Silver said. But in many developing countries, only about 5 percent have glasses because so many people, especially those in rural areas, have little or no access to eye-care professionals. Even if they could visit an eye doctor, the cost of glasses can be more than a month's wages. This means that many schoolchildren cannot see the blackboard, bus drivers can't see clearly and others can no longer fish, teach or do other jobs because of failing vision.

Silver's answer: Adjustable glasses.

[T]he more liquid pumped into a thin sac in the plastic lenses, the stronger the correction. Silver has attached plastic syringes filled with silicone oil on each bow of the glasses; the wearer adds or subtracts the clear liquid with a little dial on the pump until the focus is right. After that adjustment, the syringes are removed and the "adaptive glasses" are ready to go. Currently, Silver said, a pair costs about $19, but his hope is to cut that to a few dollars.

Silver has already distributed some 30,000 pairs, chiefly through the U.S. Department of Defense, which is giving away 20,000 (with U.S. public-relations inscriptions attached) in Africa and Eastern Europe. His next goal is to disseminate another million pairs in India. The ultimate target is 1 billion people who need glasses but don't have them.

Silver's glasses are ugly. They don't correct astigmatism or catch glaucoma. They're inferior to what the eye-care industry can sell you. But they're superior to what most people in need of vision correction can buy, which is nothing. I'm a congenital critic of utilitarianism (the idea of promoting the greatest welfare of the greatest number of people) when it threatens humanity. But when it serves us -- all of us -- I'm a big fan.

If you like Silver's vision, here's his Web site. Take a good look.

Organs, Haste, and Culpability

We have a verdict in the premature-organ-harvesting case.

Let's go to the Los Angeles Times for a summary of the case. Two years ago, the patient, Ruben Navarro, lay close to death after a heart attack.

His mother had given permission for organ donation, and a team that included [Dr. Hootan] Roozrokh flew in from San Francisco on behalf of a regional transplant network.  Roozrokh ... was to supervise a donation after cardiac death ... In most transplants, the removal of organs occurs only after a patient is declared brain-dead. In donations after cardiac death, a patient's brain is irreversibly damaged but still functioning minimally. With a family's consent, the patient is removed from life support and, once the heart has stopped, the patient is declared dead, and organs may be removed minutes later. Many experts say, however, that organs are usable only if they can be retrieved within 30 minutes after the machines are turned off.
According to prosecutors, Roozrokh ordered up excessive doses of the painkiller morphine and Ativan, an anti-anxiety drug, so that Navarro would die within that crucial half-hour. As it turned out, he died eight hours later and Roozrokh did not remove any organs.

So the basic problem was that Navarro's medical care was being directed by a guy sent to the hospital to get his organs—and that the doctor's actions may have helped the organs but not the patient. The doctor was looking at a felony charge, dependent adult abuse, with a possible sentence of four years.

Verdict: Not guilty. But the jury also issued this statement (handwritten PDF here):

Ruben's case has identified that Donation by Cardiac Death (DCD) is in desperate need for further identification of prescribed policy in order to continue successfully as a viable option for organ donation in this country. Refining the nationwide protocol of DCD organ procurements will be an important part of Ruben's legacy...

In other words, Roozrokh may have crossed the line, but the jury blames the system, or lack thereof, for failing to draw the line clearly in the first place. I think the jury did the right thing. Most of us are selectively pious. We like to single out villains when bad things are done. It's harder to admit that the bad things are extensions of good ideas and that the people behind those ideas include us. What happened to Navarro wasn't a bad doctor. It was a system that has increasingly pushed boundaries to get organs that save lives. As Art Caplan puts it in the Times story:

There's a growing waiting list; there are more centers competing for donors; and it's a very lucrative procedure for hospitals. It's against that backdrop that the story of a doctor being sent out to come back with organs unfolds.

The pressure has reached the point where doctors at one hospital, as noted here,

removed hearts from infants 75 seconds after their hearts stopped. The infants were declared dead of heart failure even as their hearts, in new bodies, resume ticking.

It's a discomfiting new trend of treating people as bags of organs. But the driving force behind this trend isn't Hootan Roozrokh. It's all of us.

Meat Wagons

If you're old enough to imagine your dead body being carted away, you're probably old enough to remember "Meat Wagon Action Set," the sidesplitting (oops—wrong metaphor!) parody ad that first aired on Saturday Night Live in 1977. It looked like an ordinary commercial for a kids' race-car set until one car crashed and burst into flames. That's when the flagship vehicle arrived: an ambulance that picked up the bodies and hauled them away. In the background, you could hear the manly jingle, "Meat Wagon ..."

Back then, "meat wagon" was just slang for ambulance. No more. It's about to become quite real. Here's the skinny (oops—bad metaphor again!) from Rob Stein of the Washington Post. Backed by a three-year federal grant,

New York City is working on a plan to deploy a special ambulance to collect the bodies of people who have died suddenly from heart attacks, accidents and other emergencies and try to preserve their organs. If the "rapid-organ-recovery ambulance" succeeds, officials would like to expand the unique pilot program citywide with a fleet of ambulances and eventually duplicate it in other cities.

Stein explains how the plan would work:

Once all hope for resuscitation was gone, and as long as no family members objected, the victims' bodies would be transferred to the organ ambulance team, even if the victims' willingness to be organ donors was unclear. The crew could then perform measures on the body to prevent the organs from deteriorating, including chest compressions with an automated device and pumping oxygen into the lungs through a tracheal tube to keep blood and oxygen flowing. The crew might also administer the blood-thinning drug heparin to prevent clots while speeding to Bellevue. At the hospital, doctors could take additional steps, such as inserting a plastic tube known as a cannula into an artery, usually in the groin, to infuse the body with fluids to cool and preserve the organs. Organ bank workers would then assess whether the person was a suitable donor, determine whether they had an organ donor card or were listed on an organ donor registry, and try to locate a family member to give consent.

As you can imagine, the plan is freaking some people out. One bioethicist calls it "disgusting." But let's step back and understand what's going on here: Medicine is becoming ever more efficient and rational. Thanks to improving technology, organs that were previously useful only to their owners are now useful to other people, too. This has created pressure on doctors to think about dying people as resources, not just as patients. This pressure, in turn, has driven a movement to loosen organ-collection rules so that people who aren't yet brain-dead can be prepped for harvesting.

Meat wagons are the next step. They advance the rationalization of organ harvesting from the hospital to the street. Instead of letting perfectly good innards go to waste, they go out and get them.

If this creeps you out, you're not alone. But remember Human Nature's first law: In technology, bad things don't happen because they're bad. They happen because they're good. Nearly 100,000 Americans are officially waiting for organ transplants. Just yesterday, a friend of mine disclosed that her kidneys are failing, and she needs a donor. When you think about all these people, it seems crazy that healthy organs are being routinely thrown away with their owners. Stein reports:

Currently, New York City paramedics try for about 30 minutes to revive patients whose hearts have stopped before declaring them dead, while a doctor monitors their efforts remotely. The bodies are then taken to a funeral home, morgue or medical examiner's office.

The meat-wagon plan would end this presumption of nondonation. But the shift of presumption wouldn't start at death. It would start beforehand. Things you would never do to a hopelessly dying loved one—automated chest compressions, oxygen pumping, and injections of blood thinners of preservatives—make perfect sense when you start to think of that person as a failing organ bank. Nature doesn't give you the luxury of waiting for total, irreversible death. She starts ruining organs well before that. If you want them, you have to move fast.

Meat wagons won't be the last step in the movement toward efficient organ harvesting. The next steps are already underway. As Stein points out, the compressions and injections would begin on board the meat wagon "even if the victims' willingness to be organ donors was unclear," in order to keep open the harvesting option while organ collectors hustle to locate family members and lobby them for consent.

The next barrier to go will be the five-minute rule. Under the current plan, Stein reports, "The organ team would wait five minutes after EMTs give up on resuscitation, to create a clear demarcation between efforts to save lives and those to preserve organs." But in those five minutes, lots of organs will spoil. Once we've accepted the idea that dying people are also organ banks, it's hard to see why we'll tolerate this delay. We'll probably shorten it a minute at a time.

We'll also dispense with the distinction between ambulances and meat wagons. For now, officials are determined to keep these functions in separate vehicles, so families and neighbors don't freak out when the ambulance shows up. But in the long run, it makes no sense to have a vehicle on the scene that can do only half the job. I can't imagine cities assembling, staffing, and dispatching fleets of meat wagons when they already have fleets of ambulances ready to be dually equipped.

Until then, fear not the meat-wagon siren. As long as you can hear it, it wails not for thee. At least, not yet.

Marrow With Children

If you're tired of reading about how dead Hillary Clinton is or how long it'll take her to admit it, fly with me across the Atlantic for a couple of minutes. A monumental debate is going on in the British House of Commons over the Human Fertilisation and Embryology Bill, which will influence how governments around the world regulate family and reproductive issues in the next century.

Everything's on the table in this free-for-all: late-term abortions, human-animal hybrids, and IVF for lesbians and unmarried women.

The liberals are steamrolling the conservatives. None of the proposed restrictions has passed. But what's really intriguing is the difference in vote counts among the various issues. It tells us something about which values people care about most. Is it life? Sex? Human dignity?

Here's how many members of Parliament voted for each proposed restriction:

A. Ban abortions after 22 weeks instead of the current 24 weeks: 233.

B. Require clinics to consider the "need for a father" in approving women for IVF: 217.

C. Ban abortions after 20 weeks: 190.

D. Ban the use of gutted animal eggs to make human embryos for research: 176.

E. Ban genetic testing of embryos to choose (for implantation and birth) those that could grow tissue for transplant to an already-born sibling: 163.

F. Ban abortions after 16 weeks: 84.

So the most popular restriction was on late-term abortions. Chalk one up for life.

But wait: The number of votes to prevent lesbian parenthood beat out the number of votes to prevent abortions after 20 weeks. From this, you could make a pretty good argument that feminists are right: Some supporters of abortion restrictions care more about regulating sex and family structure than about protecting life.

Personally, I'm sure of this. The proof is that most people who support abortion bans also support exceptions for rape and incest, where the life considerations are the same, but the sex and family-structure considerations are different.

Now look at the vote count on banning human-animal hybrids. The hybrids in question aren't equal mixtures of human and animal. They're fully human cell nuclei cloned inside eviscerated animal eggs, for lack of available human eggs. In other words, the animal contribution is minimal, almost inconsequential. Furthermore, the embryos are just for research and cell derivation, not for procreation. I'm not saying this is unobjectionable. I'm just pointing out that the degree of mixture is trivial.

Nevertheless, the number of votes to ban it is more than double the number of votes to ban abortions after 16 weeks. To that extent, "human dignity" beats out life. It seems that keeping our DNA separate from that of animals is more important than saving those second-trimester babies.

But that's still not the headline, in my book. The headline is that restrictions on lesbian IVF and trivial species mixture outpolled restriction of genetic testing to choose embryos for tissue harvesting. The common term for this practice is "savior siblings." Here's the prototypical situation: Your daughter has a serious disease. She needs compatible bone marrow. The best way to get it is for you and your spouse to make another baby and transplant its bone marrow to her. But not all your offspring will have tissue that matches hers. To guarantee a match, you need to make a batch of embryos, implant one that matches, and forget about the rest.

The happy ending is that your daughter is saved, and you've made another child to love. But you've also crossed a line. You've made a bunch of human embryos and then flushed them not because of anything wrong with them, but because they weren't useful. And if there's no tissue match, you've crossed that line for nothing.

In my view, the rise of this mentality -- the reconceptualization of human beings as medical tools and resources -- is way more dangerous than gender upheaval, species-mixing, or even abortion. Abortions, no matter what you think of them, are defensive. Tissue harvesting, on the other hand, carries an affirmative mandate. It entitles you, and arguably obliges you, to deliberately create new human life, which will then live or die based on its utility to others.

Contrary to pro-life rhetoric, there's no broad incentive to increase the number of abortions. But there's plenty of incentive to increase the number of sibling saviors. That's why sibling saviors scored so well in the House of Commons. This is one thing I've learned from covering biotechnology: Bad things don't happen because they're bad. They happen because they're good.

Keep an eye on this utilitarian mindset as we continue to take ourselves apart. As the British debate illustrates, it'll be hard to stop.

The Audacity of Health

Housekeeping note: If you haven't bookmarked the Human Nature home page, I recommend it. It always has the best and freshest news from around the Web in easy-to-click format. Everything I discuss here, plus the stuff I can't get to, is posted there first. So are links to all the latest Human Nature essays and blog items. If you don't have it bookmarked, and the Slate URL is too hard to remember, just type humannature.us.com.

Here's one story you'll find there and in this morning's news batch: U.S. surgeons have begun the long process of repairing a 15-year-old Filipino girl, Jingle Luis, whose feet are so clubbed that they've twisted upside down and backward. The AP story explains:

Jingle's case is more severe than those usually seen by doctors in industrialized countries. "Generally speaking, with modern technology, it doesn't get to this point," said Dr. Terry Amaral, a pediatric orthopedic surgeon who performed the surgery. ... Clubfoot is a relatively common deformity, occurring in about one in 1,000 births. Children are usually treated in infancy with casts or braces that gradually bring the feet into correct alignment. The condition becomes harder to treat if it is not corrected early on.

It sounds like Jingle wasn't treated as a baby because the Philippines lacked the necessary technology. But that's not what happened. Read further:

Amaral said Jingle's case was complicated by the fact that her clubfoot was associated with spina bifida. ... He said doctors who saw Jingle as a baby thought that her spina bifida would shorten her life span and prevent her from walking, so they did not treat the clubfoot. "They felt it wasn't worth managing because of the life expectancy, so they decided to leave it alone," Amaral said.

This is a major factor in treatment decisions around the world. Often, the problem isn't that doctors in less-developed countries can't fix you. It's that resources are limited and that in this context, life-expectancy projections come into play.

In Jingle's case, doctors misjudged the severity of her spina bifida. If she'd been born in the U.S., it's likely that her doctors would have recognized that the defect wasn't so bad. But it's also likely that they would have calculated her prospects differently altogether. That's because life expectancies differ significantly between rich and poor countries, and life expectancies for infants with significant health problems differ even more. Life expectancy isn't a purely biological calculation. It's a socioeconomic calculation.

The interplay of economic progress, life expectancy, and treatment decisions doesn't end in childhood, or with the case of one disabled girl. In fact, it's going to be one of the most powerful forces driving the world in this century and beyond. Thanks to economic and technological progress, life expectancies are rising around the world. Some of this is due to reductions in child mortality. But a lot of it, if not most, is due to increases in the length of old age. As we conquer diseases and improve public health, people in India, China, and elsewhere can expect to live many years longer. That, in turn, is transforming calculations about which conditions are worth treating. If the average woman in Shanghai is probably going to make it to 75 instead of 65, a disease that strikes her at 60 and would take five years to kill her becomes, in utilitarian terms, a disease worth treating.

What's happening, in short, is an increase not just in our technological ability, but in our moral expectations. It's a wonderful thing. But it's going to be incredibly expensive.