and Markman do not present any coun-terargument.
Second, they claim that we erred indescribing the randomized trial compar-ing St. Johns Wort, sertraline, andplacebo as contrary to clinical equipoise.Although there remains some theoreti-cal debate in the literature whether anti-depressants are superior to placebo, theFood and Drug Administration has ap-proved several antidepressant drugsbased on the results of placebo-con-trolled trials. To be sure, in particulartrials, standard antidepressants often failto beat placebo. However, a recentmeta-analysis of depression trials in theFDA database, encompassing thousandsof patients, indicated a significant differ-ence between standard drugs and place-bo (A. Khan et al., Symptom Reduc-tion and Suicide Risk in Patients Treatedwith Placebo in Antidepressant ClinicalTrials: An Analysis of the Food andDrug Administration Database,Archives of General Psychiatry 57 (2000):311-17). Therefore, we see the inclusionof placebo in the St. Johns Wort trial asviolating clinical equipoise, which pre-vents physician-investigators from ran-domizing patients to treatments known,on the basis of the preponderance of theevidence, to be inferior. As we indicatedin our article, Charles Weijer, a leadingadvocate of clinical equipoise, has criti-cized placebo-controlled trials in depres-sion as violating this standard.
Finally, DeMarco and Markman sug-gest that clinical equipoise should bemodified to include reference to assaysensitivity and to trials without signifi-cant risk. It is possible to do so, but it isunclear how such a revised doctrine ofclinical equipoise would be formulated.We doubt that the moral transparencyand integrity of clinical equipoise can bepreserved when exceptions relating toscientific methodology and the level ofrisk are built into its definition. If it isacceptable within the meaning of clini-cal equipoise to randomize patients toplacebo despite the existence of proveneffective treatment, provided that use of
placebo is required for producing validtrial results or the risks are not signifi-cant, then the moral force of clinicalequipoise appears vitiated. This effort tosave clinical equipoise reinforces our ar-gument that this standard is unnecessaryto provide adequate guidance for theethics of clinical trials.
More about More Life
TToo tthhee EEddiittoorr:: Fearing the worstupon seeing the title Is More Life Al-ways Better? (HCR, July-August,2003), I was glad to find that DavidGems offers a sophisticated critical dis-cussion rather than a paean to the won-ders of mortality. Still, I think he over-rates the dangers of anti-aging therapiesand greatly increased longevity. His fearof the chilling. . . prospect of powerconcentrated relentlessly into the handsof a few undying individualsand par-ticularly into the hands of tyrants in-vites objections. First, a similar fearcould have been used against any poten-tially life-extending medical advance, in-cluding chemotherapy and antibiotics.Surely, a tyrant who dies of an infectionat thirty will do less harm than one wholives vigorously into his eighties. But itseems cruel to deny medical advances toeveryone for fear that such advancesmight prolong the active lives of somedreadful people. Moreover, such denialwould hardly be an effective way tocombat tyranny, for one tyrant can re-place another and often does. Particular-ly inappropriate for his argument isGems admonition, Remember thewords of OBrien to Winston Smith inOrwells 1984: If you want a picture ofthe future, imagine a boot stamping ona human faceforever. No increasedlongevity was envisioned in 1984; tyran-ny arose from a totalitarian system.
Gems also worries that access to lifeextension technology might be consid-ered a fundamental human right, likethat of access to education, eventhough we might not want to offer lifeextension technology to murderers. But
(regardless of whether society shouldoffer life extension technology to mur-derers) it seems clear that consideringsomething a fundamental human rightdoes not preclude denying it to murder-ers. After all, we consider liberty a fun-damental human right but deny it tomurderers.
FFeelliicciiaa NNiimmuuee AAcckkeerrmmaannBrown University
GGeemmss rreepplliieess::Felicia Ackerman raises an interesting
point when she compares life extensiondue to conventional medicine (such asantibiotics) to that resulting from treat-ments for aging. I have heard it arguedthat ethically there is little difference be-tween these two forms of life extension.In my view, this is not correct, at leastwhere the possibility of large increases inlifespan are concerned (that is, on theorder of decades). Yes, life expectancyfrom birth has increased greatly duringthe last century; yet the ripe old age ofthree score and ten that most aspired toin former times has increased onlyslightly. By contrast, an increase in meanlifespan of, say, 50 percent (as seen inmany animal experiments) would repre-sent a major qualitative change inhuman existence.
As for tyrants: I imagine that Alexan-der Fleming would have winced had hebeen present when, say, Adolf Hitlerslife was saved by penicillin after theStauffenberg bomb plot (if it was). Hemight see a hundred thousand corpsesin that pill bottle, but I doubt that hewould regret his discovery. Nor did Imean to suggest that the danger of long-lived tyrants was a reason to abjure anti-aging medicine. Yet this says nothingagainst the fact that totalitarianism andan effective treatment for aging could bea terrible combination.
My comment about whether CharlesManson should be given anti-agingtreatment was really just an aside. Iwonder to what extent convicts are actu-ally denied life-saving medical treat-ment? But given anti-aging therapies as
H A S T I N G S C E N T E R R E P O R T 5November-December 2003
6 H A S T I N G S C E N T E R R E P O R T November-December 2003
cheap as antibiotics, it might be difficultto deny them to convicts. One mightimagine mass murderers sentenced tothree life terms in prison having the op-tion of serving their full term.
Conflicts of Interest
TToo tthhee EEddiittoorr:: In Bioethics, Con-flicts of Interest, the Limits of Trans-parency, Lynn Jansen and Daniel Sul-masy mischaracterize bioethics experttestimony before juries. They describe itas an activity in which the only way toestimate the value of what is claimed isto consider the reliability of the source.Adversarial courtroom contexts arestructured to prevent juries from accept-ing arguments or evidence uncritically.Fostering critical thinking about thesubstance of testimony is as much thepurpose of cross-examination as is creat-ing skepticism about the source by ask-ing about conflicts of interest. The com-mitment to fostering juries criticalthinking is also the reason experts arepermitted to testify on both sides ofcases, and the reason one must questionJansen and Sulmasys assertion that theclaims of the bioethicist typically aretaken as authoritative. Your readers
should understand that juries that arepresented with expert bioethics testimo-ny are expected to assess both the valueof the claims being advanced and thetrustworthiness of the source, and thatthey are aided in these tasks by the rulesand structure of the legal system.
The no past crimes evidence rule towhich Jansen and Sulmasy refer in sup-port of their argument that more infor-mation is not always better is a rule thatconstrains the state in criminal proceed-ings. Any analogy to information aboutbioethicists conflicts of interest is, Ihope, inapt.
BBeetthhaannyy SSppiieellmmaannSouthern Illinois University
JJaannsseenn aanndd SSuullmmaassyy rreeppllyy::Bethany Spielmans letter is puzzling.
She contests neither the conclusion norany of the arguments in our paper. In-stead, she asserts that we mischaracter-ize bioethics expert testimony beforejuries. We claimed while it is possiblethat some members of a jury may beable to assess the claims of a bioethicistcritically, it is likely that many membersof a jury will not have the analytical skillor the motivation to reflect carefully onthe rational value of the claims being
presented. For this reason, we conceded,there is a need for members of a jury tobe informed of any relationships, finan-cial or otherwise, that might substantial-ly compromise the judgment of thebioethicist. We stand by this characteri-zation. It is, of course, fully compatiblewith Spielmans claim that juries shouldbe encouraged to assess the rationalvalue of the claims presented to them.Indeed, to the extent that we have goodreason to have confidence in the abilityof juries to do so, then the case for dis-closing conflicts of interest in this con-text collapses.
Spielman asserts that the no pastcrimes rule is inapt as an analogy tobioethicists conflict of interest. Whatwe said was that certain kinds of infor-mation about the background of defen-dants should be withheld from juries.This information, while accurate, candistort a jurys judgment. These claimsare plainly true, and they illustrate thegeneral point that having more informa-tion does not always improve our abilityto make good judgments. The failure toappreciate this important point helps ac-count for the current uncritical enthusi-asm for extending disclosure require-ments to all contexts in bioethics.
Letters to the editor may be sent by emailto firstname.lastname@example.org, or toEditor, Hastings Center Report, 21 Malcolm Gordon Road, Garrison, NY10524; (845) 424-4931 fax.