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Death by deference: The flying syringe

March 23, 2010 - 03:15 -- Mark Benedict

Objectors to applications in public health assert that because it is impossible to obtain informed consent that the technology is inadequate. What a remarkable conclusion!

In an article in press which appears in Insect Molecular Biology, a Jichi Medical University team has successfully demonstrated that they can raise antibodies to Phlebotomus papatasi SP15 antigen by transforming Anopheles stephensi mosquitoes with a DsRed-SP15 fusion protein expressed in salivary glands (Flying vaccinator; a transgenic mosquito delivers an anti Leishmania vaccine via blood feeding. 2010. D. S. Yamamoto, H. Nagumo and S. Yoshida). The outcome was that mice on which these mosquitoes fed raised antibody against (SP15 similarly to when bitten by the sand fly. SP15 antibodies confer protection against natural Leishmania infection.) While this study did not demonstrate that protective immunity was acquired, it is likely a matter of time until such a “flying syringe” system is developed for some insect-borne disease.

What do the authors propose to do with such technology? Use it as a laboratory experimental system. Of course one would never actually use such a technology to prevent disease transmission, what with the issues of informed consent and controlling the dosage. And of course everyone (including on this website “Breakthrough' of the week: Flying syringes”) who has been asked about this technology has immediately declared it dead on arrival for application.

The dose rate issue is formidable, but for the moment I would like to address the apparently insurmountable issue of informed consent. This situation appears particularly problematic because unlike vaccination by needle, flying syringes would not request consent, nor could an individual reasonably refuse exposure. The conclusion has been that the technology is useless for vaccination. You could not get informed consent!

Is it that simple? I acknowledge that we all have a general right to informed consent. We are after all humans whose wishes for our personal welfare should be respected. But clearly, there are occasions in which informed consent is not given by a patient. (Ideally, in the US and presumably other countries, a patient provides some blanket consent prior to a procedure or they create a living will which provides instructions about appropriate treatment for times when the individual is incapable of providing it.) Informed consent is not provided in many emergencies in order to provide life-saving treatment. The patient simply is not capable of providing it. At this point, the physician, hopefully in consultation with family, provides the care they deem best.

So informed consent is essential - to a point. One can rightly object that such emergencies are not comparable to release of a mosquito capable of delivering vaccines. I agree. But what it indicates is that informed consent is an ideal that is weighed against other goods for the benefit of the patient. Given the potential for good that a “flying syringe” might provide, perhaps we should reconsider whether the problem is the technology or whether it is an inadequate capacity of the conventional concept of informed consent to address this eventuality.

Perhaps ethicists have anticipated technologies capable of great good at little risk and how they can be ethically applied without informed consent. Is democratic assent sufficient? Or is informed consent a static rule that is not capable of adapting to novel technologies? If so, it will bind future generations to reliance on antiquated remedies. If we dismiss a potentially beneficial technology with, “You could not get informed consent!” it might be time to challenge the ethicists to think harder about how to adapt blind – and potentially deadly - deference to consent.