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Editorial Embryonic Stem Cell Research: Is It Merely the Means to an End? Cristina Pop*, B.Sc. and Jennifer Williams†, B.Sc., P.T. I. INTRODUCTION To some people, the promise of embryonic stem cell (ESC) research may seem a scientific messiah, one in its infant stage and currently under the threat of being killed by Herod-a political decree of its death before its potential may never be known. A religious metaphor is used here precisely because the arguments revolving around ESC research are so powerful as to evoke an opinion from all: religious leaders, politicians, the legal community, scientists, and ethicists. While the various views are intimately related, we will attempt to categorize them for the sake of simplicity. The goal of this paper is not to convince the reader of the opinion of its authors. Our purpose is to present an objective overview of all the relevant issues surrounding embryonic stem cell (ESC) research, including the anticipated benefits, religious, legal and ethical arguments. Although we recognize that other issues concerning reproduction technology, including human cloning as an alternative means of having a child, pre-implantation diagnosis, and abortion are all intimately linked to the question of ESC research, we have chosen to concentrate on the issues surrounding therapeutic cloning, and ESC research. II. WHAT IS CLONING? Reproductive cloning is the cloning of an entire organism (whether sheep, dog or human) to yield a fully developed fetus (24, 28). Reproductive cloning is a subset of cloning research that can be used to aid infertile couples as well as other applications discussed later. Another subset of cloning research is therapeutic cloning (17). This latter area studies how cloning of specific cells, such as embryonic stem (ES) cells, could be used to treat diseases (17). This type of cloning research does not involve the production of offspring, and is therefore considered ethically different from reproductive cloning (17). It is important to understand the difference between these two areas of scientific investigation, since they have altogether separate aims and therefore different results or consequences. III. TECHNIQUES CURRENTLY USED FORCLONING A) Splitting of the Morula During the cleavage period, each individual blastomere is totipotent, and can therefore generate an entire organism on its own. The fetuses arising from each blastomere would be clones of each other, but not clones of their parents, since each arose from one fertilized ovum (24, 5, 11). B) Somatic Cell Nuclear Transfer (SCNT) SCNT is a technique used to produce a clonal child that is effectively a delayed identical twin of its parent. The donor is first given oral contraceptives for approximately two weeks, providing a clean slate to begin from. The donor's pituitary gland is then pharmacologically prevented from secreting gonadotropins. Finally, the donor is injected with FSH and LH to promote follicular maturation. Once follicles have matured, a mature oocyte is aspirated from the donor's ovary using a needle. The genetic material of the oocyte is then removed via the insertion of a small needle through the zona pellucida, into the cell, removing all of the chromosomes and some of the surrounding cytoplasm (ovum enucleation) (5). In addition, a somatic cell from the "parent" is isolated via skin biopsy, which involves the removal of fibroblasts from the skin of the donor. A fibroblast nucleus is isolated and immediately injected into the enucleated ovum. The "fertilized cell" is then stimulated to begin mitosis. After several days, the cleaving embryo is a human clone of its donor parent. However, this embryo cannot be allowed to develop beyond 14 days according to ethics guidelines (5). The embryo is allowed to develop only up to day 14 because during the first two weeks of development, the embryo has not yet begun to construct its nervous system, and therefore cannot have a consciousness (11,28). Furthermore, in utero, the embryo would not normally implant before the second week and is therefore still independent of the mother. Spontaneous abortions are common in nature prior to implantation and thus some ethicists do not see the killing of an embryo up to the implantation stage as an immoral act (5). C) Cloning existing stem cell lines These stem cell lines have been previously isolated from embryos which were discarded during fertility procedures, such as IVF (in vitro fertilization), IUF (intra-uterine fertilization) etc (6). These cells are induced to replicate via morula separation, but it needs to be mentioned separately since, in some countries (e.g. the United States (U.S.) and Germany) it is theonly research technique approved for public research (6, 27, 16). IV. ANTICIPATED BENEFITS OF HUMANEMBRYONIC CLONING Human cloning in general, and the use of ES cells specifically, have been the sources of much recent public debate. If allowed to become widely used, these procedures would have serious ethical implications, precisely because they can have a significant impact on the development of the entire human race. Decreasing the genetic variation of future human populations can reduce our capability to adapt to environmental changes and thus severely endanger the future of our race (15). So why even consider such potentially hazardous research? Because all of the aspects of human cloning research which make it potentially dangerous also give it beneficial potential. Both therapeutic and reproductive human cloning can be tools for improving the lives of many sick or infertile people. A) Therapeutic cloning: Using ES cells to treat disease Researchers are desperately trying to discover methods of differentiating stem cells into specific types of cells, which can then be used to replace dysfunctional and/or damaged cells in diseased patients. If scientists manage to develop ways to produce mature nerve cells from ES cells, these healthy cells can be implanted into Alzheimer's, Parkinson's, Multiple Sclerosis or nerve-injured patients (31). The implanted cells would then take on the jobs of damaged neurons and restore partial or complete functioning to the individual. Furthermore, ES cells could replace heart muscle cells that are damaged or destroyed after a myocardial infarction (17). Damaged cartilage (e.g. osteoarthritis) or bone (e.g. trauma or surgery) could also be replaced by implanted ES cells (17). These stem cells could also be used as sources of pancreatic cells and replace dysfunctional pancreatic cells in Diabetes Mellitus patients (17). They may no longer require chronic insulin medication and may be at reduced risk for heart disease, pregnancy complications, and many other long-term effects of diabetes mellitus. Stem cells may even be capable of generating entire organs, which could be used for transplants in patients in dire need for these structures (17). ES cells could improve the conditions of cancer patients. Cancer treatments such as chemotherapy and radiation often cause damage to the bone marrow, resulting in an underproduction of blood and immune cells. This effect could be counteracted by injections of hematopoietic stem cells (pluripotent cells capable of giving rise to red blood cells as well as cells of the immune system) (17). Replacement of immune cells would also treat many diseases of the immune system, such as AIDS (17). If embryonic cells could be collected and frozen from each newborn, they could provide a non-depletable source of cells and/or organs for that individual should the need arise (17). Something similar has already been done in the U.S., where a Colorado couple screened 15 embryos for one whose tissue type matched those of their 6 year-old daughter suffering from Fanconi's Anemia (17). The resulting fetus would not only be the little girl's sibling, but her blood donor. Cloning one's own ES cells would provide a faster, easier and less ethically questionable way to derive the same benefit (17). B) Reproductive cloning: another tool to increase fertility The fertility of first world populations has been rapidly declining over the recent past1. More and more couples are looking to science to help them conceive and scientific research has made many births feasible where they would not have been otherwise. Human embryonic cloning can serve as an additional method of conception for homosexual couples as well as couples with one severely infertile person (15, 28). Furthermore, an increasing percentage of people in developed countries remain single but still desire to conceive a child on their own. This cohort of the population would also benefit from reproductive cloning procedures. PART II: THE RELIGIOUS, LEGAL, AND ETHICAL ARGUMENTS SURROUNDING CLONING AND EMBRYONIC RESEARCH Although beneficial, the cloning techniques mentioned above must be placed under ethical scrutiny before being clinically implemented. Even though they may increase the lifespan of many and the fertility of some, these outcomes do not come without a price. The consequences must therefore be considered in their entirety and have in fact been the source of much public debate. Some of the ethical concerns around human cloning are considered below. The arguments for and against stem cell (SC) research are numerous and diverse. Often it depends on the standpoint of the individual making them. A catholic scientist, for example, may have a great deal of internal conflict depending on which aspect of him- or herself is presenting the argument. However, no matter how we define ourselves and our views, whether by profession, religious background, or politically, eventually there must be some element of consensus to determine if, and how far we as individuals and as a human society are willing to permit this type of research to proceed. The following presents an overview of the current religious and legal arguments, followed by a longer discussion of the ethical debate on embryonic research. V. AN OVERVIEW OF THE RELIGIOUS ARGUMENTS The religious argument about ESC research tends to circle around a central question: when does life begin (4, 9)? For those who believe that life begins at the moment of conception there is little need for debate: any research involving the destruction of the embryo is tantamount to murder. For others the answer is not so uni-dimensional. In this section, we present the current thinking on ESC research of three major religious traditions: Christianity, Judaism, and Islam. Although none of these religions have uniform thinking across all their denominations, there are certain commonalities to their thinking that will be presented here. For a more thorough discussion of this subject, please refer to the reference list. In the Instruction Donum Vitae, issued in 1987 by the Vatican's Congregation for the Doctrine of the Faith, "The human being is to be respected and treated as a person from the moment of conception; and therefore from the same moment his rights as a person must be recognized, among which in the first place is the inviolable right of every innocent being in life…No objective can in any way justify experimentation on living human embryos or fetuses, whether viable or not, either inside or outside the mother's womb." (25) A) The Roman Catholic Church The Roman Catholic perspective may be considered the most dogmatic of religious positions. Its contention is that no form of contraception, reproductive technology or ESC manipulation, whether for research, therapeutic, or cloning purposes is permissible (25). Thus, from the Roman Catholic viewpoint that there is no debate: From the moment of conception, there is life; if there is life then destruction or manipulation of said life is murder-end of story. However, if one delves further into Catholic doctrine, one discovers that the current and popular view is not the only one available. Until Pope Pius IX's declaration in 1869, the belief remained, in accordance with Aristotle, that the conceptus was not considered to be animatus, or with a soul, until it had acquired formatus, an obvious human form. For boys this occurred at 40 days gestation; for girls at 80 days (25). Although the reason for this strange discrepancy between male and female fetuses is beyond the scope of this paper, the relevance is in the discussion as to when life begins. For those Catholics who maintain this belief that a soul must be conferred upon a fetus before it is to be considered as a person, the question of ESC research is more open to debate. No longer dealing with the heinous crime of murder, the debate delves further into the realm of ethics, which will be dealt with in a subsequent section. B) Protestant Denominations Protestant beliefs are very diverse. Some traditions hold a similar view to that of the Roman Catholic Church: life begins at conception. Other views may hold that an embryo gradually acquires full human status, therefore research on ESC may be considered permissible. "It is, in fact, part of the Protestant ethos that moral questions are determined by the individual conscience, and there is therefore room for a variety of stances on this point. Protestant thought, therefore, may accept that this is an issue on which Christians may have very differing views, with these differing views being compatible with Christian beliefs." (22) C) Judaism Jewish law is set by the Torah. According to Jewish tradition, "… a person becomes a person, only upon birth." (10, 21) Other sources suggested that an embryo only acquires the status of personhood after forty days of gestation.10 It may at least be concluded, therefore, that Judaism does not grant full moral status to an embryo from the moment of conception (10). From our research, Judaism comes out as the religion strongly in favour of ESC research (10, 4) In the Torah, there are 613 commandments or good deeds that a person should follow. Among these "mitzvahs" is the command: "Thou shalt be fruitful and multiply…" This has been cited in favour of in vitro fertilization techniques (21). More important to the ESC debate is the clause indicating that almost any Jewish law may be broken in order to save a life. Those who are sick, or too young, or pregnant do not participate in fasts because it could bring them harm; and those stem cells from frozen embryos should be researched as they may prevent the death of those suffering from illness. Furthermore, "Never having been implanted into a woman's uterus, Jewish law does not even accord these embryos the limited status of an ordinary fetus. And yet, flushing them down the sink seems to dishonour their potential for human life…Even though the destruction of the embryo may be a sin, that act is massively overridden by the drive to save another life." (21) D) Islam Islamic tradition holds that ensoulment of the fetus does not occur until four months of gestation, according to the Qur'an and Sunnah (4). In a news release accompanying a recent poll held by the Islamic Institute, a political body in the U.S., the following statement was made, "Under the Islamic principle of the 'purposes and higher causes of the Shari'ah (Islamic law)', we believe it is a societal obligation to perform research on these extra embryos instead of discarding them." (4) However, there is still controversy surrounding the question of whether or not embryos should be created for the sole purpose of research." (4) VI. LEGISLATION Legislation on new technology often tends to lag behind its scientific development. However, the controversy surrounding cloning and other forms of embryo research, including therapeutic, has caused a great deal of public outcry. Politically speaking, the general view is that cloning is unacceptable. Nonetheless, there remains a much greater divide amongst both law makers and the public as to whether ESC research for therapeutic purposes should be legal. Canada On Dec 3, 2001, following the publication of a research paper reporting the first cloning of human embryos in the E-journal of Regenerative Medicine, the Canadian Medical Association (CMA) issued a statement suggesting the need for an independent regulatory agency. This statement suggests, on behalf of the Assisted Human Reproduction Health Care Providers Coalition, that there is concern that the proposed draft legislation as written would inadvertently prohibit some potentially beneficial research which Minister Rock is in favour of: "Research using human reproductive materials has the potential of bringing significant benefits to Canadians and, therefore, this research should be encouraged." (6) An independent coalition would have the ability to procure input from both the public and experts (6). Its proposed responsibilities include accrediting facilities, issuing licenses, and monitoring the physicians and scientists according to national standards of research on human subjects. At this time, there is no comprehensive legislation on ESC research. In May 2001, Health Minister Allan Rock presented draft legislation to the Standing Committee on Health. If accepted as a law, the cloning of human beings, the sale and purchase of human embryos, and paying women to act as surrogate mothers would be considered illegal. It would further act to regulate reproductive technologies and permit limited ESC research to those who obtain a license. The minister has requested a report on the legislation by the Committee in January 2002. Currently no research is permitted on any embryo beyond the age of 14 days (23). United States of America In August 2001, President George Bush approved federal funding of research conducted on pre-existing ES cells. Much controversy has stemmed from the number of reported existing lines. No federal funding would be given for research on embryos whether created for research purposes, or left-over from in vitro fertilization techniques. Aside from bans of federal funding, it would appear that all types of research are permissible within the United States as long as the finances are available from sources outside of the government. VII. THE ETHICS OF EMBRYONIC RESEARCH:IS IT MERELY THE MEANS TO AN END? It is incredible the number and nature of scientific discoveries and advancements the world has seen in the last quarter of a century. What was once merely the stuff of science fiction novels, movies, or cartoons is now a part of daily discoveries. A sheep was cloned, a test tube baby was born, the mysteries of the human genome are well on their way to being catalogued and characterized, and now to the question of what to do with the very beginning of human life itself. How do we, the human race, proceed? The following is a discussion of the ethical issues and concerns surrounding embryo research: is ESC research merely a means to an end? Is it ethical to do research on embryos with the intent of finding the potential cures to human illnesses? First, let us define ethics. Ethics is the secular or human moral contemplation of good conduct. Thus, the question becomes, "Is it right, according to human morals and values, to conduct research on embryos?" The next obvious question follows, "What are embryos?" From a scientific standpoint, embryos are the result of the union of an ovum and sperm thus creating a zygote, which then divides to become an embryo. Arbitrarily, past three months of gestation, an embryo is termed a fetus. However, it is not the scientific definition we are interested in here. What we really should be asking ourselves is, "What is the moral status of an embryo?" (1) Or, "Is an embryo a person?" (1) There are those who feel that an embryo is no morethan a ball of cells. As such, it has no moral value at all. If a scientist is just mixing up gametes in a petri dish, and he or she is lucky or skillful enough to create an embryo, and even to encourage it to divide outside of a uterus, then what is the harm? The answer to that question is in another, "Would you care for some human caviar?" If this question does not give you any feeling of disgust, then clearly there is no problem with the harvesting of human eggs for any purpose. However, it is likely that there is a feeling a revulsion finishing the reading of that question for most readers. If that is the case, then surely there is at least some moral status to be given to human embryos. How is moral status defined? Mary Ann Warren has described moral status as having seven criteria: 1) Respect for life; one should not kill or harm another living creature without a just cause, 2) Anti-cruelty; harm or pain should only occur to another sentient being when there is no other way of furthering the goals of one with higher moral status, 3) Agent's rights, 4) Human rights, 5) Ecological importance, 6) Interspecific communities, and 7) Transitivity of respect; moral agents should respect another's moral attribution of moral status (1). According to these criteria, the embryo has a weak moral status for two reasons: It is alive and because of the respect, we must accord to others attribution of moral status on the embryo. It is not a sentient being. It cannot live without the support of a woman's uterus, but it does have the potential to become a human being and therefore it must be respected (1). Still, is there not an inherent conflict between the concepts of respect and destruction? Certainly, there is for those who believe that life begins at conception and that there is never any reason great enough to offset the devaluation of destroying life. Yet, this treats the concept of respect as a black and white issue. Preserving life equals respect. Destroying life equals murder. Black. White. No gray. Yet, human life itself presents us with its own shades of gray. A female fetus develops approximately 6 to 7 million oocytes, but by the time she is born, only a million or so remains. By the time she reaches puberty and begins menstruating, a mere 40% of what she had at birth remains. Nature has destroyed approximately 95% of the oocytes that the fetus once had. Furthermore, when a woman's ovaries are being prepared for ovulation, anywhere between 5 and 15 follicles begin to develop. Only one, or on a rare occasion two, is ovulated and available for fertilization. Then, should fertilization occur, there is a large possibility that the woman will never even know she was pregnant, since the majority of embryos never even implant. Thus, one could argue that nature itself does not revere life such that it cannot be destroyed. Ah, yes, but that is nature, and who are we, mere mortals, to interfere with nature then? We all have our choice as to how to live. There are certain cultures that attempt to respect our place in nature ignoring the advancement of science. But that is not the question here. The question still before us is, "Can we respect life and still destroy it?" We can respect life by how we choose to conduct research on it. The training of many health care professions requires the study of anatomy. This study is enhanced by the use of cadavers and prosections; those who have died and given their body for teaching. Students show their respect in the way the bodies are treated, and in many institutions, such as McGill University, there are ceremonies to commemorate the lives of those who have generously contributed to students' learning. If this is an acceptable practice, then why would we not be able to afford such respect to embryos that are being experimented upon? The decision each person must make for him or herself is whether experimentation on embryos that would lead to their destruction is inherently wrong? If it is then we need not go further. No benefit of this research could possibly outweigh the detriment that would be done to human society by the undertaking of this research. But if we maintain that we can respect human life at the same time as conducting this research, then we must move onto what are the reasons for undertaking this research in the first place? In other words, "What are the anticipated benefits of ESC research?" This topic was covered in scientific detail in a previous section. What we are concerned with here is whether the ends justify the means. Surely, one of the greatest human virtues is compassion. To want to help another who is suffering is often one of the most compelling reasons one has for going into health sciences or into a health care profession. That being said, how do we propose to alleviate suffering by ESC research? There is obvious potential to find cures for diseases such as Alzheimer's
and Parkinson's from ESC research. However, that is all it is: potential.
There is also potential to do the same type of research with adult stem
cells. Here, there is much less cause for ethical alarms to sound. There
is little or no harm to the donor and it may be done with the donor's
fully informed consent. So why is this avenue of research not being pursued
as fiercely as that of ESC? Because, scientists claim, it is more difficult
to isolate the cells and it will take too long. Why is it that humans
have come to demand that everything be available to them today, and if
not today then tomorrow? The purpose of most reproductive technologies is to enable an individual or couple who cannot achieve pregnancy by natural means to become pregnant. For example, a single mother or lesbian couple who wish to have a baby may choose to be artificially inseminated. A gay couple may choose to have a child by a surrogate mother. A heterosexual couple that has fertility problems may choose to attempt in vitro fertilization. The same couple may also wish to have preimplantation diagnosis if either or both partners or their first child has a genetic disease. There are ethical questions inherent to all of these examples that are beyond the scope of this paper. What is relevant is when a couple chooses to undergo in vitro fertilization. In order to increase the chance of having a successful pregnancy, several ova are collected from the woman and fertilized. Some of the resulting embryos are implanted, and others are maintained in stasis by freezing them with liquid nitrogen. Should the woman become pregnant, she, or the couple, may choose to keep them for the chance to have another child later on, or they may be discarded. What if, instead of discarding them, the woman, or couple, consented to having them used for research? Is there a problem with this? It becomes a problem when one realizes that often the clinics that perform in vitro fertilization are also involved in research. Thus, there is a question as to whether there would be pressure to create a greater number of embryos than needed in order to ensure there would be some left over to do research on. Another possibility is that this could become a method of coercion for infertile individuals or couples who do not have the financial means to have a child by in vitro fertilization. The clinic will provide the treatment free in exchange for a couple of extra embryos. So, if there is a possibility that donating embryos for research could become a corrupt business, then why not just clone them? Of course, we are not suggesting that we permit reproductive cloning, as to most people, this notion is reprehensible. If the goal of therapeutic cloning is to alleviate human suffering, then what better way to accomplish that than by cloning a dead child? Here comes the slippery slope argument. There can be no doubt as to the emotional anguish that comes from losing a loved one, especially a child. If we permit the cloning of embryos as a source of material to create a new heart for someone who will otherwise die, then how can we justify not removing the suffering of a mother whose child has died? If we permit one type of cloning, aren't we just opening the door to all others? If so, have we succeeded in completely devaluing all forms of human life? And what, then, about the young girl who finds herself in trouble? She cannot have this baby, so she seeks out an abortion. Although her world has been turned upside down, can't at least some good come out of this by allowing the stem cells of her baby, or better yet, if a female, its ova? What would be the harm in that? Perhaps it may even become a way for those in unfortunate financial circumstances to earn a little extra money: get pregnant and have an abortion. So many questions remain unanswered in the minds of so many individuals. At heart in all of these is what the value of human life is in all its forms, from its earliest days to the time we die. More pertinent here is if we can find an acceptable balance in which human life maintains its value and allow scientific progress to continue. Dr. Margaret Somerville suggests there is such a thing as "ethics time" that is needed to determine how to proceed when science, law, and ethics do not keep pace with each other: "A minimum amount of time is also needed for the public to become familiar with the benefits, potential benefits, risks, and harms of a new scientific development, not only at the physical level, but also at the level of its potential impact on values, norms, traditions, customs, culture, beliefs, and attitudes." What seems clear is that we, both as individuals and as a society, have not had adequate ethics time to determine what role embryonic research should play in a human society. References Wilder Penfield and the Montreal Neurological Institute: Heralding the Modern Age of Neurology and Neurosurgery Alexandre Henri-Bhargava* B.Sc. The Montreal Neurological Institute (MNI) was founded in 1934 as an institute "dedicated to relief of sickness and pain and to the study of Neurology", as is inscribed on a plaque adorning its exterior (1). To its founder, Dr. Wilder Penfield, "The problem of neurology is to understand man himself" (2). Thus this institute was not only founded to treat and study human sickness through medicine, but to understand humankind and the human mind in health, through science. How did it come to be that an institute with such a seemingly lofty purpose came to be founded in Montreal? What was its place in the larger picture of medicine at the time? The MNI is now a well-known institute, but what were its initial contributions to science, medicine, and the general public? * * * * * To understand what shaped the founding of the MNI, one first must understand what shaped its founder, Wilder Graves Penfield (1891-1976). He is described by Dr. William Feindel, his friend and later the third director of the MNI, as "having a great vision in life" (3). He acquired this vision foremost from his mother, who was convinced that her son was destined for greatness. As a student, Wilder shared his mother's belief. While studying at Princeton University, he sat down one day to make a list of possible careers in the hopes of choosing one that would fit the following criterion: "Objective: to support myself and family and somehow make the world a better place in which to live" (4). Lofty as the latter objective might seem, the young Penfield was determined to fulfill it. As a student at Oxford University during World War I, he was to travel to the continent to work in a field hospital. His ship was torpedoed during the crossing, and he feared that he might drown. Yet, he refused to die because he simply believed that, "This cannot be the end. My work in the world has only just begun. This cannot be the end" (4). At this age, Wilder Penfield was not only obviously driven but also impressionable. Years later, his beliefs about students in general would reveal his own feelings about himself as a student; "[Students] are lonely and highly impressionable and they have almost always some hidden strength" (5). The young Penfield took his own first impressions from Edward Conklin, his biology professor during his undergraduate years at Princeton. Conklin's passionate teaching of the subject led to Penfield's initial interest in medicine. Next, he would be inspired and impressed by two very renowned professors he met at Oxford, Sir Charles Sherrington and Sir William Osler. Feindel states that "Charles Sherrington became his scientific hero and William Osler his life-long inspirational tool" (6). Penfield was immediately impressed with Sherrington, who had contributed a vast amount of scientific knowledge in his investigation of reflexes, and it was Sherrington who inspired Penfield to study neurology. Of this, Penfield wrote that:
After his studies at Oxford, Penfield obtained his medical degree in 1918 at the Johns Hopkins University in Baltimore, whose medical school had been founded in part by his other Oxford hero, Sir William Osler. After this, Dr. Penfield spent a year following his burgeoning interest in neurology, interning at the Peter Bent Brigham Hospital, Boston, where he had a chance to closely observe the operations of Dr. Harvey Cushing, arguably the best neurosurgeon in the world at the time, and one whose fame was bringing respectability to the still-young field (4). He went on to do further study at the National Hospital, Queen's Square, London, where Victor Horsley had essentially 'founded' British neurosurgery. There he studied with the neuropathologist Gordon Holmes (who would eventually be knighted for his discoveries) and it is there that Dr. Penfield realized that he was living in a time when "advance in knowledge of anatomy and physiology of the brain was rapid, and neurologists were beginning to apply the new understanding to brain disease" (5). With this in mind, Penfield returned to America, in 1922, and began work as a neurosurgeon at the Presbyterian Hospital of Columbia University in New York. By now he was ready to tackle an important question that came to him one day from a senior colleague, Prof. Bill Clarke; "What causes epilepsy?" Ignorant of, but wanting to know the answer to that fundamental question, he came to see how his broad education had moulded him. He realized that:
This led him on a new quest to try to study the brain and its healing process as a whole. Along the way, he 'acquired' an assistant, Dr. William Vernon Cone who was to become his life-long partner in the effort. Adopting a new method was difficult for Penfield because it required him to delve into all aspects of studying the brain: the basic sciences of pathology, physiology, cytology, and anatomy would be critical to his approach to clinical neurosurgery. He would have to become the type of neurosurgeon that his hero Osler had advocated when he had said that he:
This would require him to keep up to date in and integrate all of these fields. Yet this was an era before the internet and long distance phone plans. Keeping up to date with research that was taking place far away was not necessarily easy. Thus, by 1922, Dr. Penfield "was firmly of the opinion that 'the real future of neurology' called for a neurological institute in which neurology and neurosurgery were not to be divided" (5). Moreover, as William Feindel relates, "Penfield had the increasing conviction that it would be best to bring together under one roof neurology, neurosurgery, neuropathology and neurophysiology" (8). Thus, by 1928 Dr. Penfield's vision was established: He wished to study the human nervous system in order to learn how to treat it and in order to begin to understand the human mind. This vision was the result of the unique experience of having studied with a plethora of great teachers and scientists. Later, Penfield would acknowledge this by saying:
* * * * * Dr. Penfield, therefore, had a plan and he had ambition; but he needed a setting in which to execute this plan, and more importantly, he needed like-minded persons to share it with. One such person was Edward Archibald, the professor of surgery at McGill University in Montreal, Canada. Prof. Archibald had long had an interest in neurology and neurosurgery and he had studied at Queen's Square with Victor Horsley. By 1927, however, he had divided his research and work in other areas and he realized that Montreal needed a full-time neurosurgeon. Thus, he recruited Penfield to take over and expand his neurosurgical duties in Montreal at the Royal Victoria Hospital (RVH). He immediately recognized that Penfield "[had] very large plans, plans for much more than I had in mind" (5). Penfield had already established a Laboratory of Neurocytology in New York with Dr. Cone as his assistant, and thus, were he to move to Montreal, he would want to establish and expand a similar research laboratory to coincide with his practice there. Archibald was receptive to Penfield's plans because he was also a researcher, like Penfield. William Feindel writes that, "W.E. Gallie, Professor of Surgery at Toronto, credited Archibald with changing the character of surgical education in Canada from purely clinical to scientific" (9). Thus, Penfield transplanted his research and practice from New York to Montreal, where he now had some allies who began to share his idea - of working to advance medical knowledge, unhampered by any "artificial" division between basic and clinical science, or between medicine and surgery. Someone who obviously shared this vision was Dr. Cone, who came to Montreal with Penfield. Until the end of his life, Bill Cone would remain Penfield's friend and partner. Somewhat whimsically, Penfield realized, in retrospect, that Cone and he "…were the beginning of a team, something more considerable than any individual can be.… We had heard together, the everlasting whisper that experienced explorers hear… we were fellow explorers" (5). With additional partners sharing his dream in Montreal, Penfield decided to make this "everlasting whisper" into a concrete plan: a proposal to the Rockefeller Foundation, a philanthropic organization dedicated to the advancement of medical science, for the building of an institute such as the one he had first envisioned some seven years earlier. About this, William Feindel writes that:
However, Penfield did not take full advantage of this "excellent relationship" and five months after having arrived in Montreal, he went alone to Richard Pearce, in charge of medical grants at the Rockefeller Foundation, with his idea. Although it was supported in principle by Archibald and by Charles Martin, the Dean of McGill's Faculty of Medicine, the application was denied. The MNI was Dr. Penfield's brainchild. He sowed the "germinal idea" as he termed it*. But in order for it to become a reality, he had to wait for this germinal idea to sprout and take firm roots in other like-minded thinkers. A key person who also came to adopt the idea was Alan Gregg, the man who replaced Pearce at the Rockefeller Foundation. Gregg was himself a physician by training and had grown very interested in the nervous system as a result of having read Osler's Principles and Practice of Medicine. By the time Penfield went to Gregg to follow up on McGill's request, Gregg had already decided that the Rockefeller Foundation should support neurological research. In fact, he was also considering other proposals for funding a neurological institute. Luckily for Penfield, he made a great impression on Gregg and the two men realized that they had similar visions. Gregg said of Penfield's plan, "I think I understand what you want to do. You have a plan that gives real promise in a field that is calling desperately for exploration" (5). In April 1932, the Rockefeller Foundation awarded McGill University a grant of $1 232 000 for the creation of a neurological institute. Two hundred and thirty-two thousand dollars was to contribute to half the cost of building the institute, and $1 000 000 was to establish a permanent endowment for the scientific research to be carried out there. * * * * * Why Montreal? There were many factors that made McGill University and Montreal an ideal setting in which to build the institute. First was the support that McGill had shown to Penfield. This support extended equally to the neurologists of Montreal with whom Penfield had obviously made friends, including Colin Russel, McGill's Professor of Neurology who would become the first neurologist on staff at the MNI. The close association of McGill's new Department of Neurology and Neurosurgery with the RVH would ensure that the RVH, McGill, and the yet-to-be MNI could all function in close association with each other, sharing resources, and more importantly, ideas. To illustrate this point, Gordon Holmes made the following comment in his Foundation Lecture for the MNI:
In spite of this, it seemed remarkable to some that an American philanthropy would award such a large grant to create a Canadian institute; But this action was defended by many valid arguments. One was that the institute was to be a scientific institute that would perform research without boundaries. A second was the fact that both the Montreal public and the Montreal medical community were very enthusiastic about the prospects of building such an institute and were prepared to support it. The Americans recognized and appreciated these facts. An editorial in the New York Times of April 21, 1932 on "Illocality" aptly illustrates these and other arguments supporting the grant. It reads:
These events were taking place before the age of biotechnology companies and squabbles over intellectual property rights, and financial gain was no where mentioned as a desired outcome of the institute. Thus, the Americans believed that everyone, everywhere, could stand to benefit from the research that the institute would carry out. Dr. Penfield also believed this and he saw Montreal as the place where medical discoveries could be most rapidly disseminated, and where one could also be receptive to the greatest amount of beneficial external influences. He expressed this by writing that:
In this quotation, Penfield also alluded to the fact that one of Montreal's great strengths was its mix of two different, but equally vibrant cultures. The mix of French and English was an asset because it meant that while many institutions in Montreal were set up in parallel, they did not necessarily mimic each other. This was true of Montreal medical and educational institutions. From his very first days in Montreal, Penfield had striven to initiate a dialogue with the French-Canadian neurologists and by doing so he doubled the amount of information and personnel to which the English ones had access. Montreal was unique in providing such a setting and it would be of immense benefit to the prospects of a new institute if people and knowledge from both cultures were incorporated into the institution. There were further reasons why 1930's Montreal was an ideal city for such a venture as was being proposed. Depression or not, Montreal was a comparatively large and wealthy city. In such a city it would be possible to raise private funds for the institute. Many of the wealthy so-called 'Scottish merchant princes' were already benefactors of McGill University, and funds for the remainder of the building were solicited from them. As is recounted in the Foundation Volume of the Hospital, "The vestibule [of the institute] bears the plaque of acknowledgement to generous benefactors: Rockefeller Foundation, Province of Quebec, City of Montreal, Sir Herbert Holt, J.W. McConnell, Walter Stewart, Four anonymous donors" (1). The three named individual benefactors had assured sizable donations that would cover the costs of the half of the edifice not covered in the Rockefeller grant. J. W. McConnell should be singled out in, particular. He was a media baron who published the aforementioned Montreal Star. He was an ardent supporter of McGill University and the new MNI, and would continue to provide needed money even after his initial generous donation of $100 000†. Notable as well, was the support that the MNI received from the public sector. As the institute's research and hospital portions were to have independent budgets, both of which were not to draw on McGill's general budget, the hospital operations would also have to be funded. For this, Principal Currie and Dean Martin approached the provincial and city governments and obtained $20 000 per year from the Province of Quebec and $15 000 per year from the City of Montreal. * * * * * On September 9, 1934, the Montreal Neurological Institute was officially opened by Edward W. Beatty, K.C., Chancellor of McGill University. An article that appeared that day in the Montreal Gazette ran a headline that described the event as an "Epoch Making Function" and proceeded to state that the cornerstone was laid "in the presence of a distinguished gathering of leading figures in the educational, ecclesiastical, medical, business and civic life of Montreal" (11). Luckily for the MNI, 'good things' came from the beginning. Dr. Penfield, accompanied by Dr. Cone and those studying with them, achieved great success in neurosurgery. Penfield's knowledge of the anatomy, physiology, and pathology of the brain, in addition to his beginning to understand the ætiology of the diseases he was working on as a result of his research, led him to strike out in new directions, attempting procedures few others had before. In particular, he made remarkable improvements in curative surgery for epilepsy. Dr. Penfield's patients appreciated how his research was enabling his clinical work. In the early case of one William Ottmann, a private patient, Penfield had cured him of debilitating seizures. This had been a particularly difficult case and Penfield had called in many experts from near and far to assist him with a novel procedure, at Ottmann's mother's expense. A very grateful Mrs. Ottmann was overjoyed and before her death a short time later, she donated $50 000 to Penfield's research, which eventually went into building the MNI. Penfield's success in treating William Ottmann came to be repeated many times at the MNI. It is not surprising, then, that quite quickly, "the institute had become the number one center for neurology and neurosurgery in Canada" (12). In the new institute, Dr. Penfield's operations began to make headlines across the country. During his operations, he would map out the brain of his patients to locate the origin of their seizures. In doing so, Penfield was able to develop maps of the human brain, including his famous homunculus. Penfield compiled these early findings at the MNI into a monograph in 1941 (13) and another in 1954 (14). * * * * * 'Good things' also came to the hospital portion of the MNI. This was, in fact where the public could feel the direct impact of the MNI's foundation. Patients of the MNI in its early days were well attended to by a caring staff. A large part of this was due to the influence of Dr. Bill Cone, who had become the institute's first Neurosurgeon-in-Chief. Of Cone, Preston Robb writes that:
Cone's innovation is described by Mary Fitzgerald, a nurse at the MNI during the early years; "He brought back ideas for equipment from all of his experiences elsewhere. For instance, the headrest with its multiple uses was his invention and of course the Cone-Barton tongs" (15). She also echoes Robb in saying that the high quality of patient care at the MNI was due to Cone, writing that, "Dr. Cone was the surgeon that showed his interest in nursing care and ways to improve it" (15). Elizabeth Barrowman, another early nurse goes on to further discuss Cone's many inventions and innovations, including the rocking 'Neuro' bed, drill hole techniques for the relieving of intracranial pressure, a wrinkle-free lining for the Minerva jacket (a sort of half-body cast immobilizing the head and neck), an improved neck collar, and the 'Pancake Turner' for prevention of bed sores, amongst many others, such as the helicopter ambulance (which would land on the turf of the Molson Stadium adjacent to the MNI) (15). * * * * * In developing for himself the model of how medicine should be, Dr. Penfield
dreamed of creating the MNI. This happened not because Penfield was either
a genius or a visionary, but simply because he was a product of his environment,
and he was ambitious and observant enough that he 'caught on' to the fact
that neurology was entering what Robert Aird calls its expansive "flowering
phase," which would be heavily dependent upon the integration of
the clinical and basic sciences (16). * * * * * The early years of the MNI definitely resulted in an improvement "to relief of sickness and pain". For example, Head Nurse Eileen Flanagan did much to ensure a high calibre of nurses right at the onset of the MNI's existence. The significance of this, in the 'big picture,' is that:
Moreover, the scientific research at the hospital yielded some results that were directly applicable to patient care. For example, Herbert Jasper recounted the story of:
As exemplified by this anecdote, the founding of the MNI saw an increase in quality of life for neurological patients. The early years justified the foundation of the MNI with regards to improvement in patient care and quality of life. As far as "the study of neurology" is concerned, the MNI represented a microcosm of the modern paradigm of medicine, and as Aird states, "in the Penfield account, a noteworthy fact is that the studies on epilepsy, like the studies of [several others], strikingly exemplify the dependence of modern neurology on… scientific advances" (16). The significance of the early days of the MNI is that it used this dependence to its advantage and was thus able to help start an age of modern progress in neurology. * * * * * Preston Robb writes that "Wilder Penfield had a dream, and he saw his dream fulfilled" (18). Penfield was a driven and dedicated surgeon, scientist and philosopher. This helped him fulfill his dream of building the Montreal Neurological Institute. But this dream was shared by others. It has been argued here that the fulfillment of this dream was a sign of his times, of faith in "biomedicine" and in moving beyond the descriptive phase of neurology. It was also a confirmation of this faith that the dream bore the fruit which was anticipated -- that is, that the MNI had early medical and scientific successes. Thus, Wilder Penfield and the MNI helped to herald the modern age of neurology. Acknowledgements References General references
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