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Oncocytic change occasionally oc- chronic lymphocytic thyroiditis cancer sign dates 2014 purchase leukeran online from canada, renal insufficiency cancer and virgo venus compatibility generic leukeran 5 mg without prescription, and ag- curs in these tumors cancer research reproducibility purchase leukeran 5mg visa, further confounding the diagnosis cancer man gemini woman love horoscope cheap leukeran online american express. Considering all cases of medullary porting as a mechanism to ensure consistent and complete thyroid microcarcinoma, however, the incidence of distant documentation of cancer pathology. Grade C Recommendation tasize together as histologically separate tumors in the same target organ (162). Management of patients with a thyroid nodule and histological diagnosis of medullary thyroid carcinoma. The eccentric nuclei exhibit nuclei with coarse granular chromatin and amyloid (174). Patients with a palpable thyroid nodule have a eral lateral neck, the contralateral central neck, the contralateral high rate of lymph node metastases that often elude detection lateral neck, and the upper mediastinum. Tumors located in the upper thyroid pole postoperative normalization of serum Ctn levels (biochemical metastasize first to the upper portion of the ipsilateral lateral cure) (58%, 33%, 7%, and 0% [p = 0. The Task Force did not achieve con- N0 No regional lymph node metastasis sensus on this recommendation. The technique signals impending nerve injury, most medical team, including the patient. These data suggest that systematic lymph less aggressive surgery in the central and lateral neck may node dissection in patients who had an inadequate lympha- be appropriate to preserve speech, swallowing, parathy- denectomy at initial thyroidectomy is worthwhile, as long as roid function, and shoulder mobility. Metastases to regional nodes and large tumor size mL and five or fewer metastatic lymph nodes were removed were adversely related to biochemical cure (186). The three remaining patients with develops or while it is clinically unapparent and confined to elevated serum Ctn levels refused surgery. In one series of 46 children, five pediatricians have concern that potential detrimental effects of (9. The surgeon M918T mutation should have a thyroidectomy in the first should consider foregoing a central neck dissection if he year of life, perhaps even in the first months of life. Grade C Recommendation patients without adrenocortical tissue, some surgeons have focused on subtotal adrenalectomy (249). Glucocorticoid supplementation will and slivers of it grafted to a heterotopic site. Currently, cryopreservation is practiced infrequently at a few medical centers (266). At reoperation all enlarged para- roidectomy with autotransplantation of small slivers of para- thyroid glands should be removed, and parathyroids of thyroid tissue to a heterotopic site; or 3) resection of only normal size should be left in situ. If there is evidence of normal para- period to determine if thyroidectomy has been curative. If these studies are negative the patients 50% and 80%, but it is likely to be significantly lower in the should be followed with physical examinations, mea- setting of modestly elevated serum Ctn values (277,278). To calculate the doubling time of a tumor marker single of lymph node metastases, and postoperative serum Ctn exponentials are fitted to the tumor marker concentration by levels in predicting outcome and planning long-term nonlinear least square regression. The 5-year rate of local control was 100% in those the median (and range) of serum Ctn was 1510 pg/mL (21– without residual disease, 65% in those with microscopic resid- 6000 pg/mL) and 18,450 pg/mL (276–247,000 pg/mL), re- ual disease, and 24% in those with gross residual disease (305). Long-term outcomes in patients undergoing repeat survival, but to achieve local control in those at high risk of neck operations have been fairly good, with excellent preven- regional recurrence. Most asymptomatic patients with elevated compartments may also be encompassed within the target at serum Ctn levels and occult metastatic disease are not sur- the discretion of the radiation oncologist. Nor should systemic must be weighed against the acute and chronic toxicity as- therapy be administered to patients with stable low-volume sociated with the therapy. Treatment of brain metastases by surgical resection, with widespread metastases that are progressing. Patients with acute symptoms from spinal either chemoembolization or systemic therapy (326–329). It is ex- to the liver a partial radiological response occurred in 42% and tremely uncommon for patients with bone metastases to be disease stabilization occurred in 42%. In an- Side effects of these potent antiresorptives include osteone- other study of 11 patients hepatic metastases were treated from crosis of the jaw, atypical subtrochanteric fractures, and hy- one to nine times by chemoembolization. Therapeutic options include less than 30 mm in size involving less than a third of the surgery, thermoablation (radiofrequency or cryotherapy), liver. Seventeen patients had a partial response, and in 10 patients with stable disease, or in patients who have a of them a partial response was confirmed (344). However, the drugs have to be given daily and chronically to maintain tumor control. Diarrhea occurs most frequently in patients with advanced Short-term toxicity is significant, with dose reduction or disease and hepatic metastases. Currently, treatment with the drugs is indi- tating both in terms of quality of life and nutrition. The antimotility agents loperamide, diphenoxylate/ careful monitoring because they are at increased risk for atropine, or codeine have minimal side effects and should be developing hypothyroidism, characterized by elevated serum used as first-line therapy. Livinski, Biomedical [W-2] Ectopic Cushing’s syndrome Librarian, National Institutes of Health Library for assistance with the manuscript and bibliography; Dr. The Thyroid Cancer Survivors’ Association, ever, because the syndrome can be severe and debilitating, Inc. It is important to treat hypokalemia, hy- Thyroid Association Guidelines for the Management of pertension, diabetes, and gastritis in patients with ectopic Medullary Thyroid Carcinoma. In cases refractory to medical Exelixis); and Steve Waguespeck (Consultant: Novo Nor- treatment bilateral adrenalectomy is an option. J Clin Endocrinol oncogene associated with multiple endocrine neoplasia Metab 86:5658–5671. J Natl multiple endocrine neoplasia type 2B and related sporadic Compr Canc Netw 8:512–530. Eur J Endocrinol 155: kindred with pheochromocytoma, medullary thyroid car- 645–653. Kohno T, Ichikawa H, Totoki Y, Yasuda K, Hiramoto M, multiple endocrine neoplasia, type 2. Wermer P 1954 Genetic aspects of adenomatosis of en- Okayama H, Haugen A, Skaug V, Chiku S, Yamanaka I, docrine glands. J Pediatr Gastro- tyrosine kinase domain in a family with medullary thyroid enterol Nutr 1:603–607. Raue F, Frank-Raue K 2012 Genotype-phenotype corre- familial Hirschsprung’s disease: a new indication for ge- lation in multiple endocrine neoplasia type 2. Professional disclosure of familial Tanaka N, Kameya T, Shimosato Y 1977 Production genetic information. Committee on Bioethics, American receptor subtype gene expression in medullary thyroid Academy of Pediatrics. Endocr Pract 17(Suppl 3): tients with elevated calcitonin levels and their relationship to 28–32. Ann Surg Oncol progression-free survival in patients with medullary thy- 19:37–44. Am J Surg pentagastrin tests for the diagnosis and follow-up of med- Pathol 20:245– 250. Papotti M, Komminoth P, Sobrinho-Simoes M, Bussolati cium test for the diagnosis of medullary thyroid cancer: G 2000 Thyroid carcinoma with mixed follicular and cutoffs, procedures, and safety. Effect of age on the number of calcitonin immuno- noma by calcitonin measurement in fine-needle aspiration reactive cells in the thyroid gland. Machens A, Dralle H 2012 Biological relevance of med- for nonhereditary medullary thyroid carcinoma in pa- ullary thyroid microcarcinoma. Machens A, Hauptmann S, Dralle H 2007 Increased risk 1977 Microfollicular thyroid carcinoma with amyloid rich of lymph node metastasis in multifocal hereditary and stroma resembling the medullary carcinoma of the thyroid sporadic medullary thyroid cancer. Eur J Endocrinol 155:229– Dralle H 2000 Improved prediction of calcitonin nor- 236. Bihan H, Baudin E, Meas T, Leboulleux S, Al Ghuzlan A, quantitative lymph node analysis. Groupe D’etude calcitonin: comparison with genetic screening in heredi- des Tumeurs a Calcitonine.
In a cohort study of 152 children with type 1 diabetes cancerous moles on african american skin buy leukeran american express, a linear relationship between HbA1c and growth rate was observed cancer man break up discount leukeran generic, and patients with total HbA1c above 16% had the greatest growth deceleration (Wise et al 1992) cancer research fellowships 2mg leukeran overnight delivery. In a longitudinal study from Germany cancer sign chinese order 2mg leukeran with mastercard, growth reduction was more pronounced in patients diagnosed before the onset of puberty, and final height was significantly lower in patients with prepubertal onset of diabetes compared with later onset (Holl et al 1998). In a smaller Australian study, the mean nearfi final height Z score was significantly lower than the mean prepubertal height Z score in boys with type 1 diabetes, but not in girls (Kanumakala et al 2002). Obesity appears to be an emerging problem in young people with type 1 diabetes, particularly among children with young onset of diabetes (<5 years of age) and females (Libman et al 2003; Kordonouri and Hartmann 2005; Clarke et al 2006). Several studies in Australia and overseas have shown that rapid growth and weight gain precede the onset of type 1 diabetes, and children are taller than their peers at diagnosis (Clarke et al 2006), while overweight and obesity persist after diagnosis, particularly in older children. It is thought that overweight in early childhood may initiate islet autoimmunity (Couper et al 2009) and accelerate beta cell loss (Wilkin 2001). This contrasts with the weight loss that occurs in the weeks or months before diagnosis due to hyperglycaemia. Factors contributing to overweight in type 1 diabetes include the requirement for supraphysiological insulin doses to achieve glycaemic targets, excess energy from inappropriate snacks, and excess energy intake to avoid or treat hypoglycaemia. Obesity is an independent risk factor for macrovascular disease in type 1 diabetes (discussed in Chapter 18). Obesity is a also risk factor for microalbuminuria in adolescents with type 1 diabetes (Stone et al 2006). Plotting of anthropometric measurements on an appropriate centile chart is an integral component of diabetes care for children and adolescents. Changes in growth or significant changes in weight, or pubertal delay, may reflect changing glycaemic control. In such cases, comorbidities such as coeliac disease or thyroid dysfunction should also be considered. Dietary advice and meal planning should be revised regularly to meet changes in appetite and insulin regimens, and to ensure optimal growth. Prevention of overweight and obesity is a key strategy in the management of type 1 diabetes (see Chapter 10). Regular review and adjustment of insulin doses (and basal rates on pumps) are required in children and adolescents, because insulin requirements can change rapidly with growth and puberty. In particular, significant insulin resistance may occur during puberty, and insulin requirements typically increase (>1 unit/kg/day). The narrative provides background information only; no evidencefibased guidelines are referenced in this section. In these situations, care may be provided by a local paediatrician or physician with access to resources, support and advice from a tertiary centre diabetes team. It is not known whether a lack of multidisciplinary team care, or other factors related to living rural locations, influence glycaemic control. Three crossfisectional studies that examined glycaemic control in young people with type 1 diabetes living in rural areas were identified (Handelsman et al 2001; Cameron et al 2002; Goss et al 2010). One of these studies included a control group of urban youth (Cameron et al 2002). The largest study was an audit of about 1200 children with type 1 diabetes living in New South Wales and the Australia Capital Territory, in which glycaemic control did not differ between those from urban and those from rural areas (Handelsman et al 2001). A Victorian study on clinical and QoL outcomes demonstrated no differences in glycaemic control between youth with type 1 diabetes living in urban and rural locations, despite less reported access to teamfibased diabetes care in rural centres (Cameron et al 2002). However, rural youth had lower QoL and the greatest deficits were seen in areas of mental health, selffi esteem, parent impact (emotional) and family cohesion. Following implementation of a multidisciplinary paediatric diabetes clinic in rural Victoria, glycaemic control improved significantly from a median of 9. Although there was no urban comparison group, the level of glycaemic control was comparable with that achieved in patients managed in urban centres (Goss et al 2010). There are limited data regarding glycaemic control in adults with type 1 diabetes from regional areas. In an audit of 239 young adults (aged 18fi28 years)with type 1 diabetes from New South Wales, median HbA1c was 42 significantly higher for those from regional centres in the first year following transition to adult care (9. Routine uptake of diabetes care during the first year of contact with adult services was significantly higher in Sydney and Newcastle compared with the regional areas (Perry et al 2010). These findings suggest that the glycaemic control of young people with type 1 diabetes is not influenced by location of residence. Thus, care provided locally in urban centres, or in partnership with outreach services, is likely to be comparable to that in regional centres for young people with type 1 diabetes. The management of patients living in rural and remote areas using telemedicine is covered in Chapter 8. Summary All people with type 1 diabetes, including those from rural and remote areas, should have access to optimal medical management. In rural and geographically remote areas within the Australian healthficare system, people with diabetes may be successfully cared for by a local paediatrician or physician, and a multidisciplinary healthficare team experienced in diabetes, with access to resources, support and advice from a tertiary centre diabetes team. A recent review (DiabCo$t Type 1) was identified that described the cost of type 1 diabetes in direct healthfisystem costs, indirect costs and QoL (Colagiuri et al 2009). DiabCo$t Type 1 was a retrospective, crossfisectional, selffireported survey of people with type 1 diabetes, aged 5 years and older, in Australia. Parents, guardians or carers were asked to assist with completing the survey when it was sent to children. The survey comprised two structured, selffiadministered questionnaires, one for people with diabetes and another for their carers. The questionnaires were designed to elicit information on costs incurred over the previous 3 months. The DiabCo$t Type 1 survey collected direct healthficare costs, nonfihealth care costs and indirect costs for people with type 1 diabetes, costs to carers, and an assessment of the impact of type 1 diabetes on the individual’s QoL. It was not intended or possible to separate healthficare costs attributable to diabetes and those incurred for nonfidiabetes related conditions. The mean age of respondents was 32 years, and time since diagnosis was just over 8 years. Mild hypoglycaemic episodes in the 3 months preceding the survey were reported by 88. About 19% reported experiencing a mean of almost three severe hypoglycaemic episodes requiring assistance. This figure comprised $3862 in direct costs ($3640 direct health costs and $222 direct nonfihealth costs) and $807 in indirect costs ($418 related to the person with type 1 diabetes and $389 related to carer costs). Consumables, blood glucose testing strips and insulinfiadministering equipment accounted for 4. The average total annual cost was $3468 for people without complications, $8122 for people with microvascular complications only, $12 105 for people with macrovascular complications only, and $16 698 for people with both macrovascular and microvascular complications. Nineteen percent of carers reported being retired or currently not working in order to care for the person with diabetes. Carers took an average of almost 3 days off work in the previous 3 months to care for the person with diabetes. The employment situation of 17% of carers had changed to care for the person with diabetes, with an accompanying reduction in income for nearly 70% of these carers, resulting in mean annual lost wages of $7413 per carer (Colagiuri et al 2009). People with type 1 diabetes reported an impact on healthfi related QoL, particularly for the ‘pain/discomfort’ and ‘anxiety/depression’ dimensions. This was the first individual level assessment of the financial and personal impact of type 1 diabetes on the person with diabetes and their carer in Australia. The minimum estimated cost to the nation of type 1 diabetes ranges from $430 to $570 million, depending on the data used to estimate the number of people with type 1 diabetes in Australia. These costs are substantially higher than previous estimates, which were based on administrative rather than patientfilevel data. The real cost is even higher, since the full impact of indirect costs associated with premature mortality could not be assessed because this was a selffireported questionnaire, and the survey did not evaluate the cost of disability (Colagiuri et al 2009). These findings have important implications for policy and service delivery for people with type 1 diabetes and their carers. The role of complications as a cost driver underlines the need to ensure access to appropriate standards of care, to prevent or delay the onset of complications.
Macroscopic appearance of Papillary carcinoma of thyroid showing focal greyish white tumor (215/12) Fig-18 Papillary carcinoma Photomicrograph shows psammoma bodies within the cores of papillae H&Ex100 (215/12) Fig-19 Papillary carcinoma:Photomicrograph shows branching papillae having a fibrovascular stalk covered by a single to how to cook cancer fighting foods order 5 mg leukeran with mastercard multiple layers of cuboidal epithelial cells cancer man driving me crazy generic 5 mg leukeran free shipping. Anaplastic carcinoma:Highly anaplastic spindle cells with nuclear atypia H&Ex400 (4113X11) Fig- 24 cancer zodiac sign of 2013 order leukeran mastercard. Ki-67 Immunohistochemical staining- Follicular adenoma Positive x 100 (853/12) Fig- 28 cancer and scorpio this month cheap 5mg leukeran visa. A feat which today can be accomplished by any competent operator without danger of mishap and which was conceived more than one thousand years ago. But is there any operative problem propounded so long ago and attacked by so manywhich has yielded results as bountiful and so adequatefi Halsted, 1920 1 Modern thyroid surgery, as we know it today, began in the 1860s in Vienna with the school of Billroth. Kocher, 3 a master thyroid surgeon who operated in the late nineteenth and early twentieth centuries in Bern, practiced meticulous surgical technique and greatly reduced the mortality and operative morbidity of thyroidectomy for goiter. Kocher received the Nobel Prize for his contributions to thyroid surgery and for this very important contribution, which proved beyond a doubt the physiologic importance of the thyroid gland. In the best of hands, however, thyroid surgery can be performed today with a mortality that varies little from the risk of general anesthesia alone, as well as with low morbidity. Each lobe resides in a bed between the trachea and larynx medially and the carotid sheath and sternocleidomastoid muscles laterally. This structure is a long, narrow projection of thyroid tissue extending upward from the isthmus and lying on the surface of the thyroid cartilage. Injury to the external branch of the superior laryngeal nerve leads to difficulty in singing and projection of the voice. Injury to one recurrent laryngeal nerve may lead to hoarseness of the voice, aspiration, and difficulty breathing. Bilateral recurrent laryngeal nerve injury is much more serious and often leads to the need for a tracheostomy. It enters the larynx behind the cricothyroid muscle and the inferior cornu of the thyroid cartilage and innervates all the intrinsic laryngeal muscles except the cricothyroid. The left recurrent laryngeal nerve comes from the left vagus nerve, loops posteriorly around the arch of the aorta, and ascends in the tracheoesophageal groove posterior to the left lobe of the thyroid, where it enters the larynx and innervates the musculature in a similar fashion as the right nerve. Thus, the nerve is vulnerable to injury if it is not visualized and traced up to the larynx during thyroidectomy. Medial traction of the lobe often lifts the nerve anteriorly, thereby making it more vulnerable. Likewise, ligation of the inferior thyroid artery, practiced by many surgeons, may be dangerous if the nerve is not identified first. Once more, there is no substitute for identification of the nerve in a gentle and careful manner. In most cases, this nerve lies close to the vascular pedicle of the superior poles of the thyroid lobe, 7 which requires that the vessels be ligated with care to avoid injury to it (Fig. Usually, four glands are present, two on each side, but three to six glands have been found. A and B, Shifts in location of the thyroid, parafollicular, and parathyroid tissues. Note that what has been called the lateral thyroid is now commonly referred to as the ultimobranchial body, which contains both C cells and follicular elements. Usually, however, these glands are found on the lateral or posterior surface of the lower part of the thyroid gland or within several centimeters of the lower thyroid pole within the thymic tongue. With experience, one becomes much more adept at recognizing these very important structures and in differentiating them from either lymph nodes or fat. A chain of lymph nodes lies in the groove between the trachea and the esophagus (Level 6, Fig. Lymph can always be shown to drain toward the mediastinum and to the nodes intimately associated with the thymus (Level 7, Fig. One or more nodes lying above the isthmus, and therefore in front of the larynx, are sometimes involved. These nodes have been called the Delphian nodes (named for the oracle of Delphi) because it has been said that if palpable, they are diagnostic of carcinoma. Finally, it should not be forgotten that the thoracic duct on the left side of the neck, a lymph vessel of considerable size, arches up out of the mediastinum and passes forward and laterally to drain into the left subclavian vein or the internal jugular vein near their junction. A wound that discharges lymph postoperatively should always raise suspicion of damage to the thoracic duct or a major tributary. A lateral lymph node dissection encompasses removal of these lateral lymph nodes (Fig. Rarely, the submental nodes (Level 1) are involved by metastatic thyroid cancer as well. To alleviate pressure symptoms or respiratory difficulties associated with a benign or malignant process 5. However, patients who had this therapy in infancy or childhood are still seen and are still at a 15b greater risk of cancer. These patients should also be observed carefully for the development of hypothyroidism. It is thought to be the result of exposure to iodine isotopes that were inhaled or that entered the food chain. In the hands of a good thyroid cytologist, more than 90% of nodules can be categorized histologically. Fifteen to 30% demonstrate sheets of follicular cells with little or no colloid (an indeterminate lesion). Patients with the cytologic diagnosis of a follicular neoplasm or suspicion of a follicular neoplasm should also be operated upon for up to 30% of these tumors prove to be carcinoma. Using a diagnostic test that measures the expression of 167 genes, investigators were able to identify 78 of the 85 carcinomas as suspicious and to recognize most of 21b the other lesions as benign. Thus, in the future, perhaps these or similar tests will become routine and will reduce the number of operations currently performed for these indeterminate lesions which are ultimately found to be benign. Far fewer isotope scans are currently being done because carcinomas represent only 5% to 10% of all cold nodules. In the presence of severe hypothyroidism, both the morbidity and the mortality of surgery are increased as a result of the effects of both the anesthesia and the operation. In most cases, intravenous thyroxine can be started preoperatively and continued thereafter. In general, small doses of thyroxine are initially given to patients who are severely hypothyroid, and then the dose is gradually increased. Young patients, those with very large goiters, some pregnant women, and those with thyroid nodules or severe ophthalmopathy are commonly operated upon. Thyroid storm results in severe tachycardia or cardiac arrhythmias, fever, disorientation, coma, and even death. Now, with proper preoperative preparation, 23 operations on the thyroid gland in Graves’ disease can be performed with about the same degree of safety as operations for other thyroid conditions. In mild cases of Graves’ disease with thyrotoxicosis, iodine therapy alone has been used for preoperative preparation, although we do not recommend this approach routinely. Beta-adrenergic blockers such as propranolol (Inderal) have increased the safety of thyroidectomy for patients with Graves’ disease. Instances of fever and tachycardia have been reported in persons with Graves’ disease who were taking only propranolol. In such patients it is essential to continue the propranolol for several weeks postoperatively. Remember that they are still in a thyrotoxic state immediately after surgery, although the peripheral manifestations of their disease have been blocked. Especially in children and adolescents, one should consider a total thyroidectomy or leaving a very small amount of tissue because the incidence of recurrence of thyrotoxicosis appears to be greater in this young group. Finally, when operating for severe ophthalmopathy, we try to perform near-total or total thyroidectomy, for improvement in the eyes may occur after this procedure. Of course, when operating on the thyroid, and especially in young patients with a benign condition, the surgeon should be very careful to avoid permanent hypoparathyroidism and nerve injury. The major benefits of thyroidectomy appear to be the removal of nodules if they are present, the speed with which normalization of thyroid function is achieved, possible improvement in the eyes, and possibly a lower rate of hypothyroidism than is seen after radioiodine therapy. In near-total thyroidectomy, a small amount of thyroid tissue is left to protect the recurrent laryngeal nerve and upper parathyroid gland.
We believe that there are reasons to cancer love horoscope for nov generic leukeran 2mg on-line supplement these existing arrangements in certain ways cancer research florida buy leukeran 2mg overnight delivery. As we have already indicated cancer woman capricorn man linda goodman purchase 5 mg leukeran with visa, ‘broad’ in this context means a debate that is not framed as a question about particular technologies a cancer fighting food that every man should eat buy leukeran with a mastercard, but considers the full range of responses to an identified challenge. The reason for this is to avoid an artificially narrowed and possibly distorted consideration. This can happen, for example, when a societal challenge becomes associated with a potential technological solution where other potential approaches, both technological and non- technological, might exist. Alternatively, it can happen when the nature of the challenge is understood from only one perspective that does not admit alternative constructions. A broad debate of this kind allows questioning of what is at stake (including what might be given up) in authorising and pursuing particular technological pathways and an exploration of different visions of future states of affairs and the values associated with them. Ultimately, such a debate puts into question ideas of the kind of common life that public policy exists to bring about, bringing shared and competing values to the surface. In particular, it means attending to the voices of those who do not share the majority interest and who prospective technologies might place in positions of vulnerability, as well as creating opportunity to represent the interests of future generations, whose voices are necessarily absent. Nevertheless, any national decision to permit or prohibit heritable genome editing interventions will have implications beyond the jurisdiction in which it is taken (we address this below) but for reasons we have set out in the course of this report, we believe that it is permissible within a margin of appreciation for individual jurisdictions to decide these questions of principle. The Authority later developed guidance on preimplantation tissue typing, where an embryo is selected both to exclude a serious disorder and to include a tissue-type characteristic so that the resulting person can serve as a matched tissue donor for an affected family member. While it is hard to imagine that genome editing could proceed without widespread societal support, the contingent outcome of debate should not be seen as determinative – it is appropriate that the decision rests with a properly constituted authority subject to requirements of international human rights law – or as final. Nevertheless, the idea of debate requires genuine engagement between different positions rather than simply measuring unreflective opinion and the distribution of prejudices. Our idea of public debate is also distinct both in conception and orientation from that of consultation on a specific question of public policy, of the kind that is used instrumentally to inform certain policy and regulatory decisions, although this has an important function. Debate, in the sense intended here, is about the mutual exploration of and engagement between values, interests and understandings, rather than about seeking answers to specific questions. We favour an approach that lies partly in creating ways to link up existing interests and partly in providing opportunities and stimulus for interests to form, develop and be expressed through both uninvited and invited engagements. Attempts to foster and to harness this kind of debate in the past have met with different levels of success (regardless of what one thinks of the specific outcomes and their consequences). This has been picked over at great length by commentators; the salient point that we wish to emphasise, however, is the need to understand the multidimensionality of policy questions. This experience demonstrated starkly how mistaken the expectation that simply explaining the science clearly enough would lead people who were not part of the scientific and political culture to accept the outcomes that were valued within that culture. In the second case, there was little genuine engagement between entrenched positions and the outcome was simply to reveal deep societal divisions without offering any process by which to bridge them. In neither case did the process nurture or consolidate the moral community, or help the members of this community engage with each other in trying to identify conditions under which they all should live. An important function of the debate 537 In recent work that refers to the calls for engagement in genome editing, bioethicist Francoise Baylis has explored the notion of societal consensus in relation to strategies for collective decision making; see: Baylis F (2017) Broad societal consensus on human germline genome editing Nature Human Behaviour 1: 0103; Baylis F (2016) ‘Broad societal consensus’ on human germline editing, Harvard Health Policy Review 15: 19–23. As we said above, it is important for the regulator to engage in consultation to inform regulatory decisions that raise issues of public interest. But this must be set against a background of debate that is significantly broader and capable of informing broader research and biomedical policy. Nevertheless, this is not a reason to shrink from pointing out the need to fill a significant vacuum or the reasons why it cannot be fulfilled by existing institutions. Consultation may even be part of what it means for certain policy decisions to be ‘properly made’ and to help to insulate the Authority from judicial review. It also maintained a number of monitoring groups, which kept in view and reported periodically on issues such as genetic discrimination, intellectual property, genetic databases and identity testing. It would have links to government, rather than a single ministry, so as to be able to inform the development of public policy. It would also offer help to relevant regulatory bodies to inform regulatory policy on new genomic technologies. Its independent presence should help to nurture and sustain confidence that the public interest is being understood to encompass a broad and diverse range of interests and concerns that exist in civil society and is defined independently of the fertility sector and of scientific research. Importantly, and unlike existing national institutions, it should aim to engage with other countries and international institutions in the development of international norms. Of course, this information is also potentially relevant, useful or exploitable for a range of other individuals, corporations and institutions. This possibility has led some countries to enact genetic anti-discrimination legislation. This should involve examination of whether more coherent, robust measures than the existing piecemeal, non-statutory mechanisms and arrangements are necessary or desirable. Such an examination might assess whether it is appropriate to treat genetic discrimination as a so-called ‘protected ground’ for the purposes of equality legislation or whether some other statutory prohibition supported by appropriate legal remedies might be preferable. Though we have said (in Chapter 3) that we do not consider such arguments to be convincing or the asserted link to be meaningful, we nevertheless believe that, for the avoidance of any doubt, the possible corollary of this argument should not be permitted to result in discrimination against anyone who may be born following a heritable genome editing intervention. In practice, this means that the application of such processes in animals can generate economic value, which might also inform the development of human interventions. Their first casualty is likely to be the research team: collaboration may be threatened by a breakdown in trust as faculty contacts are restricted and researchers avoid one another. It is highly doubtful that the outcome of such disputes will be to the benefit either of the public or of scientific knowledge, and the process may draw on resources that might otherwise contribute to supporting excellent research. The effect is to put “a large and lucrative field for the exploitation of the licensed technology” in the hands of entities driven by duties to shareholders rather than to the public. Again, this runs counter to the presumed function of patents as instruments of public benefit. A patent is a negative right that gives inventor patent holders a power to exclude others from exploitation of the patented technology as, for example, in connection with gene drives. During the life of the patent, its owner may use licences to promote access: for example, Monsanto’s licence from the Broad Institute in connection with various agricultural applications “requires Monsanto to allow its farmer customers to save and resow seed from one season to the next, in contrast to some of Monsanto’s past practices. The outcomes of such consideration might be that governments and public research and healthcare institutions could adopt a policy of non-enforcement within the home state of relevant patents (and rights in associated software and databases) arising as a result of research funded wholly or in the main by that state. They often also involve those working in related academic disciplines that study or reflect on research and biomedicine, such as the social sciences and medical ethics. Many have ethical initiatives that engage participants with backgrounds outside the most relevant scientific and clinical fields. Such organisations often establish and produce position papers that usually reflect the interests of the membership (albeit that those may include interests in ethical research and practice). This began as an initiative under the aegis of the French medical research institute, Inserm, reaching out to those involved in research governance in other parts of the world (notably 557 ibid. While it remains to be seen whether such an initiative could produce a consensus that is sufficiently broad or strong, for example, to secure an agreement “not to proceed with some research until a more equitable approach to setting the terms of debate is achieved,” it could nevertheless provide a much needed counterbalance to globally divisive technonationalism and help to orientate discussion of policy towards the human purposes and consequences of technological change and technology transfer. We therefore endorse the desirability of monitoring and promoting dialogue among nations in a way that recognises and attends to the diversity of voices within each nation and that may be furthered by support for and participation in a dedicated global observatory or international association, as well as through the work of international institutions. The workshop, under the rubric ‘Editorial aspirations: human integrity at the frontiers of biology’, was organised under the aegis of the Harvard Science and Technology Studies programme by Sheila Jasanoff, Ben Hurlbut and Krishanu Saha (see sts. In our view it is, however, also unnecessary and may be undesirable, particularly if it were to lead to the adoption of a ‘lowest common denominator’ approach. This risks making them unwilling or unwitting magnets for those who wish to evade national regulatory controls or, at the very least, makes it difficult to be certain of the conditions (including ethical conditions) under which research or (potentially) clinical interventions are carried out. Common standards also help to facilitate the transfer of knowledge, practices and technologies. Differences (including ethical differences), on the other hand, can result in gradients along which people and resources flow, as we have noted above. It is therefore natural that it should engage more closely in the discourse that provides globalisation’s moral conditions of possibility. These issues involve a large number of different policy areas which are covered by a mixture of United Kingdom legislation and common law and some of the relevant policy areas are within the competence of the devolved administrations. We have concluded that the societal challenges, priorities and acceptable practices should be determined at the level of national jurisdictions, but nevertheless within a margin of appreciation that is reasonable under developing international human rights law. The process of elaborating this requires international dialogue and collaboration at many levels and between these levels. The activities involved are already subject to obligatory licensing and regulation under the Human Fertilisation and Embryology Act 1990. In addition, many instruments of soft law and governance provide further definition and guidance, and these enjoy a high degree of compliance in what is, in most cases, a field with a cohesive academic and professional culture. These debates are not, therefore, about establishing governance of genome interventions from scratch, but about the controlled and reasoned modification of restrictions already in force. Though this system tolerates margins of appreciation, which permit the expression of differences in prevailing societal values, it maintains a measure of international coherence while respecting these differences.
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