I'm delighted to welcome you here today
to what I believe you will find a very

stimulating and
impact whole series of presentations

our first I'd like to thank
you organizers of this event.

Which I love back here and
many colleagues who have

put together a tremendous series
of I quest panel presentations and

discussions that we all all
of us have benefitted from.

Today's topic is bioethics we have
three speakers I'm going to really

introduce each and asked them to turn
around and weave to the crowd each for

then share research for
about fifteen minutes from the podium and

then we'll all get together as
a panel off for a few observations and

discussion point and then we'll open
it up to the entire i rew prairie

continuing kind of patients and
will conclude by one thirty P.M..

Will prove that you're with me.

Is an associate professor in
our School of Public Policy.

Towards the intersection among public
policy bioethics biomedical research and

he has a particular interest in Pocus
on ethically contentious technologies

such as stem cell research
nanotechnology in two thousand

well he received a five year
in a September your award.

It's on graduate science education and
the development of scientific careers

He's the author of a book calling
A Beginner's Guide which is an accessible

introduction to the science of cloning and
Brianna it's oneself as well as

the associated ethical and policy
controversies Aaron who did his Ph D.

work in public affairs at Princeton
who also has an extreme colossally

from the University of Cambridge
where he was a Churchill scholar and

study competition and
biology at the singer center developing.

Algorithms to help analyze
the human genome sequence so

we're pleased to have Dr will be here
to present on his continuing research.

And secondly Dr Jennifer saying.

Jennifer is assistant professor in
the school of history and sociology and

she did her Ph D. work in sociology at the
universe you helped point San Francisco.

Dr Singh specializes in medical
sociology and science and

technology studies investigating
social cultural and

political intersection
of genetics Health and

Society she worked in the budget industry
as a molecular biologist at Genentech

she's also been a public health
researcher at the C.D.C. Dr C.

also completed a book project multiple
autism spectrum of ever could see and

you know that science
University of Minnesota press.

Her current research is
investigating historical social and

political factors shaping
definitions consequences

of autism diagnosis she is also
looking at barriers to arches and

diagnosis and educational services
based on intersecting inequality

race ethnicity class and
gender so we have Dr Singh

on her research today and
just in general that is.

An associate professor in the School
of Public Policy his research interests

are introduces a primary drawing
on fields including philosophy of

science bioethics and environmental
ethics philosophy of food yet

thinks of emerging technologies and
science and technology policy he's focused

in particular on the role of values
in science and the other stomach and

ethical implications of the social
organization of research.

Dr Goodall received his him in history and
philosophy.

From the University of Notre Dame
he's been a distinguished fellow

at the Notre Dame Institute pretty
unsteady and he was a costar our

department classes at
Yale University in Germany so

very sad Dr little present here
today I'd like to call Dr Levine

to get him started I'm going to sit
back here take a few discussion says

each a very speaker's proceeds will then
form a panel have here and continue the

conversation.

We'll try to use your slides just to.

Well welcome and thank you to
Jennifer who really organized this

care all who organizes
the whole series and

Steve crosses office funds all the series
through the fire Grant also to stand by

the microphone please let me know if you
you can hear me it's a pleasure to be here

today to see a nice crowd to talk about
bioethics with in Georgia Tech broadly and

within the I know how to
liberal arts in particular.

And thanks also to reporter for the nice
introduction the people are going to talk

about today is on a second line of work
that's looking at medical practice

particularly in the field of assisted
reproduction so it's a reproduction is in

vitro part of the proliferation primarily
so medical practices that help infertile

parents try to have children in a
particular talk about conflict of interest

in the oversight of assisted reproduction
using donated eggs I'll explain

more about what all that
means as we're going forward.

But.

I should note that the talk today is based
on a paper that came out just a couple

months ago this summer in the journal on
medicine and ethics and also acknowledging

my co-authors probably from west to
West Virginia University School of Law and

Michelle gallant problem and
study part of the studies at Princeton.

And I know it's a particular because
I think it sort of exemplifies

the interdisciplinary nature of the sort
of some of our series this is very clearly

a paper I would not have written on my own
I'm OK You know my work this is actually

quite different there is no novel
empirical data or analysis here it's much

more of a sort of systemic review and
conceptual argument about

the possibility of conflict of interest in
the faculty the patients in this field and

I thought was a nice paper for
this conversation today.

So first of bit of background
what is a donation and

so here we're talking specifically about
a form of in vitro fertilization to get

in vitro fertilization is an approach to
medical probes that dates to about late

making seventy's that helps infertile
people have children this is a form of

people protection where a third party
typically a young woman aged twenty to

thirty or so contributes her eggs to
help the intended parents have children

in the first it's just like the nation
occurred in one nine hundred eighty three.

Originally and donations were
typically provided by no one donors so

that woman who was donated would know the
intended parents that has changed in nine

hundred eighty seven the first anonymous
and compensated donation occurred.

And today a nation accounts for
about twelve percent of all I.D.F.

cycles in the United States yet it's not
perfect in this industry but most of

these are almost certainly anonymous and
compensated no the term is a donation

even though the woman who provided
actually almost all cases are paid for

their donation lots of debates and an
interesting nuances of language going on

your brothers use the sort
of standard terms of people.

So given this is a discussion of bioethics
criteria I want to spend just a minute on

the sort of broader high level
bioethics questions that are relevant

to the practice of of education and
there's really two main questions that

have articulated in the thirty or so
years of this technology existed one

is technology even morally
acceptable is it ever.

For people to use this it's
a reproduction with eggs or

you could have sperm here as well
that are donated by a third party and

there's no set answer to this although I
think within the United States there's at

least a tacit agreement that this is
continuing and it's been ongoing for

quite a period of time is not the case
in other countries around the world

necessarily which we can discuss more
human a panel of people like but

the arguments have been
marshalled against.

Third party reproduction in this area have
to do with harms to family structure what

does it mean to bring it back to
material from a third party into

the existing family and
to you have that interview to a child.

Potential for harm to children that result
as to reproduction using these third party

material and both of these could
apply either to sperm or egg donation

This is actually a very contemporary
policy debate over the rights

of children who were going to be produced
through either egg or sperm donation

to know that they were going to conceive
and have access to the identifying

information of their genetic parents in
addition to the parents who were them.

And then finally the third will hear hope
risks to donors we can talk more about

this unlike sperm donation which is
a relatively low risk low effort activity

egg donation is a fairly and they can base
of intense medical procedure that carries

a set of risks and some people worry
that given these risks it's never really

appropriate to ask women to participate in
that process when the up but not a top for

themselves but
they're really doing this to help someone.

The second hire a professional it's let's
put aside the ethics of the overall

practice it's happening as we saw on
what how about recruit men and women and

compensation of these donors and there's
a very robust debate around the world over

whether women should be paid to donate or
provide their eggs for

reproductive system reproduction and the
arguments here tend to worry about things

like qualification of joke material and
potentially exploitation of the donors.

I want to move from that high level into
the specifics topic of the paper today and

the talk and that's conflict of interest
so much of your public familiar

with the concept of a conflict of interest
I don't want to dwell on it too much but

just to highlight that this is a debate
pick a topic a lot of policy attention

this is a report here from
the Institute of Medicine

conflict of interest in medical
research education and practices and

they define a public interest as a set
of circumstances that creates a risk

the professional judgments are actions
regarding a primary interest will be

unduly influenced by a secondary interest
sort of up on verbose definition here but

basically what they're worried about if if
you were a physician your primary interest

is probably caring for
your patients in if that is compromised or

under only influenced by some other
secondary interest making a profit

when in a war professional recognition or
someone that could be accomplished and

that's the kind of thing this is
medicine is concerned about here.

So why would we be particularly concerned
about this in the context of a donation I

think Ari sort of hinted at this but
again education is in the sort of category

of practices that a person undertakes
undertakes risks for the benefit of others

so the woman who donates is not
doing this primarily to benefit or

so she might receive some payment for
it or she might receive

some personal satisfaction from it but the
primary benefit is to a third party and so

the fact that she's undertaking
these potentially very serious risks

somewhat to no one the potentially
serious I think it's fair to say.

Raises this concern but
the real conflict comes here and

the second point and
this is a key position.

Who is typically reproductive
endocrinologist working to protect

the clinic often serves both parties and
by both parties here I mean

the intended parents in the woman who
is the egg donor are put May Well

you treating the intended parents helping
in the parent of a baby that's his or

her primary interest and there's.

Good reasons for

this I'm not saying it's right but
the intended parents are the ones who.

Are quite are the ones who
come to the physician and

say I would like treatment they're the
ones who paid the physician often a quite

substantial payment out of
pocket the physician's success.

Ability as a physician is a value
weighted based on whether or

not her parents have a baby
successfully right so

outcomes evaluation payment all
depend on the intended parents and

what this does this leave to invite with
the donor may really be seen much more

as a supplier than a patient the woman
provides eggs that are critical to

the process which is often anonymous she
doesn't pay in any way actually does he or

her or her duty or her work and
so she may be mistreated or

not prioritized and in the prosecution and
that's really the heart of the concern

here I'm We also know that there is a
fairly limited formal oversight here this

is an industry that propriety of reasons
we have a merely on voluntary guidelines

the fertility doctors get together with
some outside guidance but make a set of

rules that they then say they should
follow but don't always follow.

The research think that's fact very
interesting a powerful point of view but

really raises risks if these fertility
doctors are complicit that because their

primary interest is their intended parents
they may well set up voluntary guidelines.

That institutionalize those conflicts and
put actual donors or actual doors and

a real disadvantage position.

Still in the paper and I'm not going
to go through this in great detail

we look through the Indonesian process and

then we review existing literature as well
as try to fight gaps in the literature to

understand whether conflict of
interest is a problem here and so

briefly you can think of the recruitment
of an egg donor How is it that up a woman

words about the possibility of becoming an
egg donor thinks about that engages with

clinics or donor agencies to make
that decision to to donate or

this could involve advertisements in
newspapers billboards word of mouth

all sorts of possibilities once that
process started how is the donor screen.

To make sure she is eligible
she understands them and so

on ultimately how does she give
her informed consent to donate.

And is that information sent that will
lead serving the purpose of that.

After those sort of preliminary steps
there's the actual medical treatment and

so here there is a what's called
hormone stimulation so typically every

month a healthy woman will
produce one mature AG.

In.

I be up when I view a donation the woman
is induced to what's called Super

obviously and instead of producing one
which are egg from one woman might produce

eight ten twenty thirty or more healthy
eggs and that's because of these

hormone injections those eggs are then
retrieved in a surgical procedure and

then fertilized outside of the body and
the test to a teenager of I.V.

affable it's really
a petri dish usually but

the hormone stimulation in the retrieval
process are medical procedures and

run the risk of conflict of interest
changing the way physicians act

towards the donors and then finally what
the medical procedure is over there is

sort of a question of how well that donor
is followed up with and why the herd and

so on or if you just ignored in the
aftermath and the physician turned his or

her attention to you and the parents.

Again I'm not going to some detail but
basically I would say we argue in

the paper that conflicts of interest may
quite possibly affect all four of these

components over there and
maybe more seriously in some areas others.

M L Just briefly give you three examples
of evidence out there in the field that

suggests conflict may be a problem in the
way of disclosure of this is a paper that

will be Alberto has a Ph D. student here
in the room is the lead author on in that

report and I are co-authors on the other
three papers that are read but

this is looking at Risk disclosure
in the recruitment process so

if you're right publishing an ad
after advertisement sorry trying to

convince a young woman to become an egg
donor Do you disclose risks and I should.

No it's not our idea that you should
disclose risks the self or the guidelines

say you should and in California statewide
actually says you have to disclose.

The short answer though where
you just imply they don't.

Is that people don't so you can see
here outside of California only thirteen

percent of adults who didn't procreate
risk disclosure the stilt regulation

doesn't work in this case and in fine in
California works actually state watcha

disclose only twenty seven percent
of ads including appropriate closure

turns out not only the Self relationship
work state law doesn't actually work

either which I think is a an interesting
finding as well we don't know for

sure this is a conflict of interest that's
causing this problem but you can imagine

a conflict where positions and clinics
really want to as many donors as possible

in their library in their database so
they can recruit intended parents and that

could lead to sort of this underplaying
of the risk of this point in the process.

So just two more quick examples this is
the cover here is a really fascinating

book that when I am a wing a sociologist
at Yale wrote Sex sells the medical market

for eggs and sperm she reports a lengthy
ethnographic study of egg donor agencies

and sperm banks and what's a fine and
there is two things I want to highlight

for our discussion today one she found
that the screening process really focused

not on the help or knowledge of the donor
of informing them about the process but

more on ensuring they were marketable so
the clinics are doing all the screening

but really using an opt in to all they're
going to in a way that they can later sell

them to intended parents and so that's get
into this conflict when yes the clinics

want donors so they can sell
I.V.'s services to patients and

even perhaps more problematic was
she noted increasing pressure

on clinic personnel to approve
a donor at each step in the process so

the screening goes on through the numerous
stages from question here is to

in person psychological evaluations
what you found is the further you got

in the process the harder it was for
the clinic to say no don't do this.

And it may be that there was more in the
screenings are really the case where you

can probably say you know this person
isn't a good donor candidate but

that wasn't what was happening.

And then finally the last example and this
goes to the actual medical treatment so

I talked about the hormone
stimulation earlier and

you see there's a clear your point where
the interest of birds among the physician

in the intended parents in the donor over
the number of eggs that are produced

the more eggs that are produced the better
for the physician in the intended parents

because it increases the chance of having
a successful baby it increases the chances

of having additional
embryos to free it and

have more children later on it that the
parents which is a little bit of a little

clip but what five embryos is much better
than two ten is probably better than five

fiftieth's you know irrelevant and I'm
not in better probably quite dangerous.

The downside for the donor is that
the more stimulation you get the more like

you are risk of what's called a wage X.X.
or a very hyper stimulation syndrome this

is the well documented side effect of
the drugs that people take to donate eggs

the best literature out there suggests
more than eighteen expert use

substantially increases your risk of only
just us without any corresponding benefit

in the like that at least having one
healthy baby there's not a great debt on

your donation but paper that came up from
some people the C.D.C. and Emory recently

found that forty percent of voters in
the United States produce twenty or

more eggs and this went up too high
at sixty plus ends and in some cases.

The told the cycle so intended mothers
have anything eggs on their own

on average for much lower and only
thirteen percent of cycles have twenty or

more eggs that's not actually a fair
comparison because the donor a younger and

healthier and not infertile.

But it suggests that there is certainly
some concern here that donors are being

overstimulated perhaps to help serve
the interest of intended parents.

Clint clinicians more so than their own
interests so I suspect I'm close to out of

time here so I'll just briefly conclude by
saying we think about difference tragic.

To mitigate this conflict of
interest in the paper and

these range from an outright ban this is
a very strict stringent approach we model

this on with all the stark a lot of the
ban on positions are also it's illegal in

United States for a physician to review
for a patient to a clinic that he or

she owns an interest in so if I was in an
M. D. orthotics surgeon and I owned an X.

ray Priscilla the I can't just start
referring patients to my own facility and

physical therapy lower the big problem
with this a number of years ago if

the essentially banned you could apply
this sort of model to a donation but

it would eliminate all
the benefits of regulation and so

we see reasons to be quite hesitant we
talk a lot about mediation model so

this is introducing a third party
to help mitigate the conflict and

I think this is a much better fit for

it to make sure that it can be modeled on
a living we're going donation so if any of

you ever chose to donate a kidney to
living organ donation you would have

a third party representative
that watch out for

your interests throughout
the entire medical procedure and

that is a model that could be adopted
education although without a lot of

cost to the system that we conclude
is not justified today but

perhaps in the future and we alternately
argue that improving the existing

suppository framework is both most sort of
these of all and you know most likely to

work at this point in time and have
some ideas in the paper on how to to do

that including development some specific
records onto a guideline on conflict or

interest just like highlighting the issue
adopting some disclosure requirements many

of you probably had to disclose
a conflict of interest or

at least got a form saying you have
no conflicts that at some point and

I think actually most important is
changing the reporting requirements such

that the only outcome of the measure is no
longer success but also some of the health

outcomes for people like Donors
who contribute to the process

I think that would then give multiple all
sorts of names that could be optimized and

help clinics understand that making
sure their daughter's health

important matters as well so
I will leave it there but

look forward to the discussion in the Q.
and A a while thank you.

Tonight.

I just want to thank for encouraging.

Think about the panel that we have.

In this great session and
of course the willingness of Aaron and

Justin and referred to participate and
thank you all for being here today.

So the work of a talk today about.

Article I read science technology
that really looks at the social.

Implications of participating
at its research so

this is part of a larger project
the book project that I'm working.

That looks at this current
activism around genetics research.

As I'm for finding a gene for autism
from scientists for a person factor.

And the cost.

That this research is having.

That.

I took on.

Whether or not it's.

A start I just wanted.

My background and where I'm coming from
in terms of my training in science.

Or sociology and.

You know my first career was in
biotechnology working with the common.

Despite or in fascination and.

Really began to ask questions
about ethical questions about

the work I was doing in the lab is really.

Asking these questions.

About the impact they have on people says
medical practices as well as you know

the inequalities that helped her system
that were going to make many of these very

rich molecules that we were designing.

To most patients so in need or

you know if the pool's to intellectually
these concerns I apply for

a master's degree in Public Health
the focus on the ethical legal

the social implications of integrating
genetics into public health and this was

this problem was developed
really in the flow of the.

Course there was a lot of potential
attentional sprinted upon.

Her being you know treatments.

And cures for.

Which many of you know
really happened to have.

Dissipated.

My training.

That's in bioethics is really rooted
in public health of course this.

Was based on the development of
the comet report in one nine hundred

seventy nine which many of
you know was a result of or

in response to the public disclosure
of the simple that study.

This from ports and
taken you know your ethics

training to do any research
know that it involves

three fundamental principles which
are uses guidelines to conduct

research human subjects these
include respect for person or

autonomy in application form sent to
her a little bit about the next and

so do you know application of the sets and
the risks and

benefits of participation and
then Justice or the.

Costs and benefits in the application here
is that there are procedures in homes in.

The selection of research subjects.

OK So
all this framework is really useful and

it's very important as a starting point
point much of its application has been

situated around issues of autonomy and
informed consent and lets So

around justice and
issues of their distribution and.

Furthermore it doesn't necessarily take
into consideration how historical social

cultural factors as well as the live
moral experience can shape by the core

problems alternative framework
spacetime data from a critical

social science perspectives really
challenge me to think about.

Think outside of the individual
tenets this principle based approach

to embrace what sociologists have referred
to as a more critical bioethics or

by affable imagine imagination so
the research I'm sharing with

you today.

Show you could today provide comparable
evidence of the social context in the more

reasoning and that is within the parent's
decision to participate in autism genetics

research so it's based on interviews
I conducted with twenty three sets of

parents who participated in
the science simplex collection so

this is an autism genetic specific
database that consists of over

three thousand families who have
one child diagnosed with autism.

Participation trough a very full
evaluation of the child and

their parents as well as one and
that sibling.

The participation parents get what is
called a research valuation child.

Stick sustenance.

For oxygen and that and
parents were encouraged to use for.

Education to to receive or call.

Piper educational services.

OK so and literature ask if politics
really taking up research on

the restrictions of applying abstract
biomedical principles in genetics

research however much of this research
is in the context of a population or

a national type genetic databases
such as you say this is

where everybody here participates.

In the U.K. these qualitative
investigations begin to rebuild a complex

and contingent ways the general population
donates to genetic databases and

how decisions are really embedded in
different situations circumstances and

histories of individuals
as well as community.

The experience of participating
in genetic epidemiology said that

collect samples as part of the process
offers a different set of purposes for

participation such as the hope for
personal gain.

And the desire to help their family or

themselves or
their families in the future.

And people who donate to disease
specific tissue registries also

participate help develop and maintain
a sense of social solidarity with unity.

So drawn from this research.

And within the framework of a more
critical bioethics the intention of

this said it was really to investigate
how people understand experience and

construct a process donating.

To a disease specific genetic database so

in other words having people
who are experiencing illness or

really closely associate
illness in this case parents.

Negotiating decisions to
participate in that it database and

what are the circumstances that limit and
are unable their involvement.

So to.
After this question I analyzed the various

and overlapping narratives of
participation from the perspective of

parents or rather than a bioethics
situated within the predominant

application of autonomy or respect for
persons the study really and

covers a more context for Bioethics
situated in live human experiences and

how moral reasoning to participate
is embedded institutional

structures as well as social
situations in my analysis identified

three narratives the alchemists
parents the obligated parents and

the diagnostic parents these narratives of
participation aren't necessarily mutually

exclusive in fact they overlap with one
another but they serve as a framework to

really rebuild how parents experiences and
their social situations shape

their decisions to participate in the
narratives of the altruistic parent viewed

participation as an opportunity to
help in the autism community so

parents in the script described their
willingness to help in any way regardless

of the direct benefit that they would
have for their family these narratives of

altruism also conveyed an understanding
that the S.O.C. The Simon simplex flexion.

Would benefit the families
in the future and

many were aware that many years before
anything genetic would be revealed much

less help their family doubts wristed
narrative was also tied to emotional

experiences of living day to
day with the child autism.

And the challenges that their children
face so for example as my mother describe

it it's all relative if you've experienced
this kind of situation with these kinds

of difficulties I think that you want
to do whatever you can make him and

I think you want to do whatever you can
to make the situation for someone else.

A second set of narratives
was the obligated

in these narratives
participation in the S.S.C.

was viewed as a responsibility held by
parents to help their child to anyway.

Possible.

Especially since there's
a limited consensus on the causes

of the treatments as well as the
trajectories of autism So for example one

parent doubt that participating in the
S.S.C. was the easiest way to be involved

she stated it helps alleviate some of
the guilt that you feel as a parent but

you're never doing enough
to help your kid so

at least in some small way I'm trying to
help this pressure obligation and sense

of guilt if not achieved is built the
discourse surrounding the urgency placed

on parents to get an early diagnosis to
get a diagnosis as soon as possible so

that treatment can be so that intensive
therapy its can start as early as

possible to alleviate symptoms of
autism this discourse is also rooted in

the current Neil liberal model of Medicine
of the individual responsibility.

So in these cases the moral obligation
of parents to help their child can

can somewhat obscure the risks and
benefits of participating

in this research the diagnostic parents or
the third set of narratives and

situated around the acquisition of
the diagnostic evaluation in exchange for

participation this was a significant
anti enticement her parents and

the price for a diagnostic evaluation
can cost two thousand dollars and for

parents who had didn't have a diagnosis
before participating they might

be in a wait list for that is at least
a year long so parents have to wait to get

a diagnosis parents were encouraged by the
study investigator to use this evaluation

to help all apply for new or
continued eg educational services that

are titled under the Individuals
with Disabilities and education.

So what set of parents and
this group participated

to get a definitive diagnosis for their
child so these particular parents were new

to the world of autism and
they were seeking answers and so

they saw this as an opportunity
to to help their kid as one man.

Stated this is what we wanted first and
foremost with someone to say OK but

he's autistic and then tell us what
level he's capable of operating and

you know evaluate him and kind of keep and
kind of help us figure out what to do

to get him the services needed early.

Diagnostic narrative was based on parents
whose children are ready to diagnosis and

before the study but wanted an update
on the progress of the child and

whether they would qualify for
additional services.

So these narratives really demonstrate
that there's various reasons parents

participated in this study and it's you
know it's a mixed it's a mixture of

discourse around altruism obligation and
the necessary The necessary for

a diagnosis and
within this context you know and

surprising that these parents didn't
have any concerns about the risks for

privacy and they.

Also at the same time didn't have very
much knowledge about what the study

pale when I asked them about what
the study entailed the spike

I think they signed like three
different types of documents one for

participating one for their blood donation
one of the clinical information so

there was a lot of exchange of them.

However the narrative.

Was placed here.

OK However the narratives also reveal a
contractual bioethics and moral reasoning

to participate based on structural limits
and social complexities in situations so

these include a range of responsibilities
parents to help their children and

the greater autism community their
hopes in genetic science and

to provide social and medical legitimacy
and their need for early diagnosis and

such and access to services and
treatments for ISIS.

So the negotiations of responsibility.

That parent compression and biomedical
research were really evident throughout

the narratives this responsibility with
her tied like I said earlier to their

emotional knowledge and experiences of
parenting a child with autism which is

which essentially reduced their
perception of risk to minimal

at the individual level parents negotiated
responsibilities they had to their child

by expecting that their participation
would really operate some kind of

practical help for example the diagnosis.

For many parents offered
half forward especially for

parents who were receiving it for
the first time at the family level parents

were anticipating that genetic
information would be helpful for

their other unaffected siblings because it
would offer some kind of information about

the risk of having a child in the future.

With autism at the community level
the participation provide the parents with

the opportunity to really help future
families or a chance to help advance

autism genetics research has also
negotiated their responsibility and

moral reasoning to participate based on
the book they placed in genetics research

so based on these narratives parents
anticipated that the study would help

determine the cause of autism
the genetic cause of autism and

create a better diagnosis for The Hobbit
parents knowing the cause of the believe

he'll experience by some parents
that they did something wrong and

would bring that sense of closure for the
diagnostic parent finding the genetic hive

uses a beautiful part of the process of
legitimization and acceptance of A.S.D..

Without knowing the causes parents were
at with some risk of being denied social

medical as well as state recognition

of the challenge of
the experience rather child.

Parents were also hoping that this
research would lead to a better diagnostic

tests to be used at an earlier age so
these responses.

Really underscore how involvement in
genetic study was intertwined with

somewhat unrealistic expectations and
hopes that research Afghans would address

major issues facing these families and
in comparison to what was

actually written in them or said document
it's their goals are very narrow and

you know I'm eighty what
might actually be discovered

in this process.

The dynastic currency associated with
autism really also brings up moral issues

of recruitment and the debate delivery of
a mental health diagnosis in biomedical

research so in this study the diagnostic
parrot really didn't think twice

about being part of the genetic database
in these parents that were most likely to

have left the least amount of knowledge
about what the research was about.

This flat knowledge is understandable
since such parents were

primarily concerned with getting
a proper guide says for their child.

And receiving information of the results
evaluation offered through the S.S.C.

was also like the gold standard they used
maybe twenty different instruments for

me it was a really pulled sander coach
because they wanted the basketball data

to match the genetic research and

so this could be construed as courses
especially since qualification for

educational services requires
an artisan diagnosis.

That's the also use the diagnostic
currency of autism as a recruiting mapping

as and so there's different ways to
recruit folks and in some cases families

who are on a wait list to get a diagnosis
were recruited a study that's parents

had to negotiate the risks of being in
a genetic database you know indefinitely

with the need for a diagnostic
evaluation Henschel a helpful game

the services this helps the tension to
parents structural issues such as time.

And they'll ability of clinicians
to actually give a diagnosis but

also a range of social factors that are
that create access are that's why access

to diagnosis treatment and
educational services

another troubling issue in this case
study was the length of time for

parents to actually get
the research evaluation.

After they participated some parents
had been waiting six months for

the work written report.

Travelling with the lack of follow up with
families once they received the report and

how to interpret the valuation any parents
even asked me how it's really hurt it

because they were they
were confused about it.

As well as the lack of a really guide on
how they cannot obtain services based

on this new knowledge of what they have.

OK so there is a participation in
the study teacher a variety of Discourses

parents really drawn to decide whether
to participate in genetics research

in the sense that it had to negotiate and
grapple with what matters most for

their family which often did
not coincide with predefined.

That's taking into account
alternative perspective

can really enhance our bioethical
imagination to recognize and

acknowledge meanings that are central to
people living and experiencing illness

as the number of disease specific
genetic databases continues to grow

these narratives can lend insight into
the development of more sensitive and

effective policies surrounding clinical
genetics research further in Perkel

research rooted in a specific site
of knowledge production allows for

a bottom up approach to uncovering
what constitutes moral issues

in this way I argue that
sociology of science and

technology studies can
really enrich the field by.

Taking into account social situations and.

Structural it's constraints
of living with illness and

employment this has on the scientific and
technological.

Thank you I'm going

to.

Come out.

Well.

Thank.

God.

OK everybody.

For.

Your part of it because I'm here
I'm not going to go pay her.

More going to.

Tell you some of my research interests and

to describe a project that I have thought
of going forward so I'm doing some more.

Promissory thing as opposed to things.

A little bit about the background and

I am trying to do here I
draw a lot in my research

in general and in this project in
the philosophy of science and science and

technology studies on the value of leaving
here for the research because if you

are if you're known as the argument
from inductive rest we know that

scientific research is not the sort
of neutral of error that it's

sometimes professionally made out to be
there are outliving decisions that must be

made throughout the research process and a
part of my research was well out where or

how or what the implications of because
they are going to be a little bit.

The way in which I'm applying and applying
the finds of discussions in this case and

what I'm doing this right
is to discuss the landscape

of arrests in the variety
of different risks and

value judgments that are made
by the Medical Reserve and

I think you are focusing on the risks
involved in defining diseases so

defining it is even in the first
place defining dition as being a.

Such as infertility for example as
Aaron mentioned Hillary is doing her.

Issues or patients on an office
is a decision involved and

I just think diagnostic.

Wander around.

Adjusting diagnostic criteria for

diseases there's lots of
discussion now and worries about.

Over diagnosis of disease so.

This is.

One of the things I'll be interested
in here and hopefully and

I have a question mark here but.

Where I would like to go for this is
to examine potential power policies for

management of epidemic risks generally and
in particular risks involved in the line.

From go.

So I mention this argument from inductive
reskin I'll just give you this real

quickly to give you a sort of play for
some of the arguments for

the claim that science is a is is and

in a limited Lee value laden
affair this is an argument

to the style of Richard Rudner who
was a philosopher of science and

operations researcher back in
the one nine hundred fifty S. So

the argument goes like best the scientist
quit scientist or the scientists and

her role capacity as a scientist
accepts or rejects hypotheses the.

There's a purple heart of hearts or
doing science but

no scientific hypothesis is ever
completely one hundred percent

certainty verified and there's always
some possibility that in the accepting or

rejecting hypothesis we might be wrong and
so the decision to accept or

reject a hypothesis depends upon whether
the evidence is sufficiently strong.

But whether the evidence is sufficiently
strong and this is Runner's

words as a function of the Importance
in a typically ethical sense of making

a mistake in accepting or rejecting the
hypothesis and therefore the scientific

quayside makes value judgement
has the same a little example of.

Suppose the hypothesis in
question that we're dealing with

is the hypothesis that a particular
pharmaceutical is not poxy.

If this is the hypothesis in question then
we are reasonably to demand a fairly high

standard of evidence before accepting
the hypothesis because the consequences

of wrongly accepting it would be severe
in this case given that large numbers

of people might be taking a pharmaceutical
on the other hand if the hypothesis in

question that I mean his example of
the machine stamped a lot of belt

buckles is not defective in that
case we need not apply such high

standards of evidence before accepting the
opposite because the consequences of wrong

are not nearly so severe in this case.

The general point here is that when
it is that the decision to accept or

reject the hypothesis is a decision that
is made in the face of uncertainty and

whenever one makes decisions in the face
of uncertainty one at the very least

presupposes a value judgment
value judgments concerning.

The various possible
outcomes of the decision.

So in this case what we have is
value judgements concerning.

The decision to its.

To reject the hypothesis and in many
of these cases it's worth pointing out

now come back to this
as we go forward that.

The risks involved in
being wrong either way

in many cases following different parties.

And this or
this will become important later on but

if you think about say the decision to.

To accept the hypothesis that.

That particular
pharmaceutical is safe right

wrongly accepting that hypothesis
would fall to the risks of

that fall largely on the public and
the consumers who would be taking that

drug right whereas the risk of
wrongly rejecting the hypothesis or

wrongly not affirming
the hypothesis is a risk that.

You could say falls more on
the side of it was producing and

have been having an interest in
selling the drug so in many cases.

It's not just that there are risks
involved in these decisions but

the risks fall on different parties.

OK.

Inductive risk is an important all right
type of risk it's an important place in

the research process where values play
a role but it's far from the only one and

a colleague of mine Rebecca Cooper and
I are using the term Sam

expressed as the risk of error that
arises anywhere in our epistemic

practices there are all kinds of decisions
made throughout the research process

that carry this kind of risk and one of
the things that were kind of it was sort

of spell out in the use of fairly precise
about where these decisions are and

what their what their outcomes are.

Just three examples here data
characterization choice of model organism

and concept formation clearly there are
risks involved in data characterization.

So in the past I've done some
research on on on the Vioxx

episode that a case study on
the by activists and that whole.

Mass and one of the many controversies
involved in that research

concerned how to classify deaths
that occurred in the context

of clinical research.

For example did this patient
die from a heart attack or

should we classify this as a cause of
death I mean there are many instances

in which it's unclear how
to characterize data.

And so there is risk involved here and

again the risks tend to fall in different
parties so it's not surprising that Merck

which was particularly
concerned about heart attacks.

Tended to err on the side of classifying
as a known cause of death opposed to heart

attack but there is risk
involved in a paraphrase ation.

Choice of model organism So
if you're doing.

A toxicological study on on animals for
the purpose of eventually knowing

what the effects of this particular
chemical or whatever is on a human being

there's you have to choose a model
organism choose an animal and there

are risks involved in this A colleague
of mine in Germany has done a study on.

Research on the carcinogen and

the facts of Bisphenol A is
a chemical used in lots of.

Industrial products and.

The research on this and
the question of whether or not and

that pill is a carcinogen it or not and

the outcome of this tends to
all largely on funding lines so

as of a couple years ago it was the case
that ninety percent of government studies

found in the sociate in
between this chemical and.

The camera which were
presented on the back

zero percent of industry funded studies.

And the supply.

I was that's well it turns out that.

This was due largely to
the choice of model organs.

So in the industry funded studies.

They chose a strand of rap that was
particularly insensitive to estrogen and

ask your dentist chemically very
similar to two to Bisphenol A right

whereas in the government study
government funded studies they chose.

A strand of route that was
much more sensitive to Africa.

There's no one right and so I got a pretty
good shout to use this particular strain

of rat right it's a decision that must
be made in the face of uncertainty but

there's risk involved again the risks
tend to fall on different parties.

And there are also risks
in concept formation.

Which it's because it is what I want to
talk about for the rest of the time and

in particular.

Concepts of disease so I mentioned earlier
there are these sort of general worries

about overdiagnosis of disease
there are sort of scary pictures on

the cover of The Lancet in
places like this recently.

There are many reasons.

Why.

There might be a general trend toward
over diagnosis of the those who are.

Diagnostic tools that we have
are much more sensitive now and so

we're able to catch you know smaller and
smaller prophecies going on by five.

One potential cause of this sort of reason
for this that people are worried about is

over diagnosis of disease due to
expanded disease definition or

worries of very sort of a general
trend of expanding disease definition

that there's some evidence for this is
just this one study done by morning and

and colleagues where they reviewed
publications between two thousand and

thirteen that made decisions on
disease definitions are good.

I know if they are curious because these
are common missions in the United States

they found sixteen publications on
fourteen common conditions that made such.

Decisions.

Ahead of them with widening
definitions one opposed narrowing at

five were unclear and they typically did
this on the basis of no new evidence so

it wasn't like OK with it we now
learn exactly what he H.D. is or

hypertension is and so we can adjust
diagnostic criteria accordingly or

typically in these cases expanding
diagnostic criteria on the basis of.

So why would this be
why would they do this.

For one very obvious and perfectly
reasonable and justifiable motivation

that when George Friedman for the second
round if we expand say our criteria for

hypertension then that will allow us to
catch more people with hypertension and

treat them before they experience
serious symptoms from this

perfectly understandable motivation for
doing this there's also of course

the perhaps more worrisome
motivation of increasing profits for

treatment because of course if you
expand diagnostic criteria your TRUE.

Click of a pen multiplying the number
of people who have a disease and

thereby multiplying.

Same number of potential customers for
the treatment and

there are some worries that
this is playing a role here so

in the same study by Moynihan
colleagues they looked at.

Conflicts of interest disclosures out of
the sixteen panels there were fourteen

that disclosed conflicts of interest
the average proportion of members.

Of.
These committees making these decisions

with money for ties.

And he was what seventy five percent.

Among members with ties
the median number of companies

which they reported ties with seven and
perhaps most worrisome twelve

out of the fourteen committees that
this close to one like her were chaired.

By five hundred people hired in history.

The point that I want to make
here is I don't want to act like.

You know there's some simple
way to deal with this these

are these are very complex decisions.

But they are decisions that involve
tradeoffs between rests and

the risks again to some extent
all in different parties so

there has been to expand these
definitions are diagnostic criteria

ready with an increased risk of
overtreatment that is increased risk of

treating people for conditions that they
were will never suffer symptoms from and

exposing them to the risks
of those treatments.

And narrowing got
conditions that definitions

are diagnostic criteria of course
increases the risk of under treatment.

Again there's no there's no obvious
way to balance these threats.

But they are risks and they do we do
need to have put some thought into

how they ought to be balanced and so
far this kind of goes off the page

ultimately and
this is again sort of a promise or

what I hope we do in the near
term is to look at policies that

could help us to manage these risks in
general I'm sort of interested in the and

the very big question of policies at
different levels of research that

will help us manage the whole the variety
of the landscape about the stem of risks

that scientists face but in his project
I want to look at this question

of setting diagnostic criteria for
diseases and looking at policy for.

Open up an address to kill
him with her cell phone.

And an aunt.

Fifteen minutes

ago.

Well I.

Hope.

It's safe.

It's.

All right first and
over all absolutely just.

The motivation for this series and

also acknowledging that he has
put together a very fascinating.

Set of truth that evidence of.

All of this series there's a lot
of conversation about the role and

value of the liberal arts in education and
research couples many in economic and

higher education policy circles.

In this panel I think demonstrate here at
Georgia Tech certainly certainly you know

I've been out of college with the arts
that this kind of work delivers

fresh insects to our
community in our society

and through them my parents these
insights into the realm of design and

innovation and impact to advance
the human condition and as.

Yemen.
Street how could we know the liberal arts

as absolutely essential to
the education of future generations and

to the research mission
of the university so

congratulations once again to those who
organize it for opportunity there and

so there are make brief comments
on each of the papers and

then open up the conversation
these are just sort of time and.

I've described here noting that Dr Levine
is pushing certain assumptions.

About.

How we regulate you know very complex and

inches around this is the focus as
we noted as I noted mean action and

illustrate inductive marks the focus
of his work is on contentious ethically

contentious science and technology and
here it might be tempting to say

her pressure we know what the person with
sponsibility and if we have a problem

we have to watch and then we deal
with the powerful end of story but

as we see in this rich within
the fifteen minutes we had which.

Exploration of this study which brings
together this introduce a planetary

scholars there is much to be understood
here much to be investigated both

empirically and
also in terms of the concept.

Of the concept of the upgrade on the
ground we see in the blink of an eye and

hymns of human life and the early nineteen
eighties to the present the possibility to

engage in this egg donation
assisted assisted reproduction and

we see responses that are.

Given the time span relatively minimal and
way but.

As investigation shows
in affected worrisome

we now says of the potential
in this case focusing simply

on the question of conflicts of
interest and concern we have it

risks an area that's ethically
fraught in human experience and

in society that is procreation
an area also right that is the use of

parts of bodies for the benefit of other
people that of course is an ethically But

concept we see it throughout human
history explored in human society we have

the notion of professionalism which has
been the topic of executive writing and

but the properties to the present and
beyond and

we have all these intersecting
around this technology and

science that have been able this practice
to go forward in a very short period

of time and we have real human
beings who are being affected and

the temptation might be again to sort of
resort to that paradigm where we've got to

have a while but what I observe in
this research is a very nuanced

examination of just where
the risks arise just what their

character is just hope we know what
we don't know and what we need to.

Where they're investigating and then at.

These different models what would
work best not a claim that this will

work best for
ever as this sort of exploration I think.

Tells us these are dynamic problems
the change over time driven by science and

technology are the fundamental
questions about our community and

society being mean but
we're constantly probably to evaluate

what we can do that would be best know and
it's interesting and I think that

where these researchers and is in a
recommendation for increased professional

self-regulation I think that might be
a topic for questions as we proceed.

So no let's see how long did they take
a better period here really tempted to

talk out there that each will be
seeing similarly question assumptions

that in the theoretical ground of
bioethics we have seen in principle they

are not sort of invented out of nearly as
they are right from my past experience

human beings in society but
she investigates again and

holes in the US human beings and they
would experience and what they mean for

you in this very nuanced investigation
of the secular science and

technology that have advanced again very
rapidly and I believe in human history

that have tapped into what we now
see through her words are these

we held motivations of parents in this
situation to do what they can for

their children to honor their
obligation to others and

to attempt to find knowledge in

a circumstance in which it is so
cool not to understand.

When of course we have similarly
ethically rich circumstances of that

fundamental bond of parent and child so
once again we have an opportunity

to see that in our future.

Concept of how this research proceeds and
how we should understand

the experiences of those most affected
we need to expand our thinking

can text stories by working
with her with this slight

We need to expand our thinking he's taking
the richness of with more experience and

then proceed to think through what
principle Flo flying high flying and

with our sea and air are important to
the research and its future progress.

Moving on to Dr Bedell
again similar themes here.

Pushing past the idea that
we have in science and

technology the sort of headlines that
we all clear to see and you know

oftentimes in the professional journals as
well as particularly press that suggested

scientists have discovered something that
technologists have invented something and

here's the sort of bottom line instead
as Dr Biddle explains drawing and

has research in which stimulated
by these are sort of fundamental

questions about well how do we know
there and what extent we know that and

isn't it sort of baked into
the human condition and

social structures around it that certain
knowledge is something hard to claim and

hard to act on and in the circumstances
in which we rationally do so

we see the risks distributed and we hope
to avoid those sorts of circumstances so

Dr Goodall and
his colleagues have again diving deeper.

Insight into a problem.

That affects human beings in our society
and it's structured build up around it.

Invites them to take a broader we'll get
the whole process was hosing the breath

again a complex situation and allow us to.

More.

Situated in an exacting sort of.

Coding or where the best sly and
opens the door once again

thinking about it social structure
is the impacts on human beings.

And concepts we can use to help us
organize are thinking about what our

policy would punch be so again three
papers that wonderfully indicate this as.

Stimulating and.

Now we get to the other it's.

Not simply I mean directed
to whomever you wish

yes.

Thanks Peter interesting question.

Are there biological best practices and
I think there are attempts but

I think they're not as holistic as I think
big they divide the field in different

ways so there's a set of what you
might call clinical ethics and so

there's a part of ethics it's
really in the hospital setting.

The rise How should your set up
professionals interact with by

their patients in some ways this is
what I mean I think we're going to

have a lot of bioethics attention has
gone into the development here and

there are a lot of guidelines say there
is a set of clear best practices but

there is a closer sort of idea these are
things we should think about here this is

almost a set of practices
that could be accredited

we could pass help from
one program to another.

I think it's not as clear cut in the world
of research ethics where you're thinking

about biomedical research
rather than health care.

There's been progress but

I don't think I think it's go back to
the sociological here it depends a lot

on the politics of the specific case it's
not clear that the same thing applies to.

Difference.

You could make it

I.

Just.

Talked about how everything's happening.

Record.

Pace it's really hard to keep up with
the scientific technology and how their.

Research questions.

When I was working at Stanford.

They developed.

That could help researchers grapple with
some of the questions because they're so.

There you know it's just part of
territory in terms of thinking.

You know I think we're going through
our research protocol you know what how

do we even begin to start thinking about
what can actually what is actually a.

Contentious here and so it was
a group that was helping researchers

really think about their research.

So that's

why.

We're not.

Right that it's a hybrid private industry.

It's very different than academic

research.

Or public.

Were doing or.

Think about educating the next generation.

And.

Certainly something.

Boy an important.

Question.

Right yeah.

Yeah right.

Well and fortunately the people I
interviewed a part of the process of

recruitment was that they participated and
so they were obviously.

They obviously qualified to be part
of the study so the kid was just.

OK Right right but you bring up
a very interesting question so

I was just talking with that clinician
who does lots of diagnosis and

this is my next project is I'm
very interested right here with.

My next project really is looking
at the process of diagnosis and

what is a part of our conversation was and
a question I had what happens.

Parents that are just trying
to get in here that get it and

she said it's that they are very angry and
mad she says she had to

learn how to bring it differently where
it's like it's you know what we're here

to do is just help you figure out what
it is your child needs that people get

this idea that the diagnosis is
going to give them something.

And so I think that's an area where.

I can because when you can travel as well
that your question is interesting in

definitions of matter a lot
of low fertility and there

are still debate over whether infertility
itself should be treated as a disease and

after all it's not a disease of one
person but it is ease of some sort.

Of people who want to have a child and so

there have been big debates the World
Health Organization declared it a busy

relatively recent year on top of my
head but that was seen as a big win for

the infertility community going back to
just an argument here really I don't.

Think in this case it was pushed by
disease advocates really hoping to.

Fund it or to research and reimbursement
in that sort of area so that's one area

where the definition matters I think your
second question is also quite interesting

which is I did I talk about evolution in
the concept of intended parents and sort

of heterosexual norms which is how it is
talked about in most of the literature but

that obscures of course you could manage
a growing chorus of women who are very

bright they're going to increasing
use in the United States around

the world that's really one factor in that
same sex couples trying to reproduce or

security reproduce in different settings
with yours or yours and others.

In the.

I'm not clear never thought through
all of the shifting affects the spill.

It's a big argument I was making about
public interest in the recruitment of

donors my sense is it's not
a huge issue in that specific

context it is a bigger issue in the.

Parliament or regulation at large and

I think it actually many cases
the strategic choice to focus on

the war just in the war policy
at least controversial subset of

A lot of tension hinted at this but
procreation is a very.

Good.

Area of policy making this
is touching on the U.S.

on abortion politics and real politics
all sorts of other issues and

I think focusing the policy debate on.

What in the world of.

Reproductive advocates are essentially
white upper middle class

suburban couples works quite well for
their attempt to go to Congress in and

push for now that might be shortsighted
in certain areas of the environment but I

think that's the reality of how it played
how that really affects the proper debate

how that leaves people who are really
relevant to the problem of the technology

think they should have really been fully
explored at least with my let's proper It

may actually get better attention to some
of these critical bioethics perspectives

and from other others but
I think there were considerations.

Just so with that.

We think that and I you know I'm
sort of looking at the effects of.

A disease class I think the concept of
treatment but of course much harder to

quantify but it also affects people's
conceptions of similar types of others so.

Instead of you know looking at a child's
behavioral issues as some kind of

relationship between a child and his or
her classroom setting or something like

that we don't look at it that way but
in terms of you know what's that like.

With the with the disease or
a condition like that you know that's how

the child thinks about himself or
herself how others think about.

This is very difficult.

To describe.

Very.

Yeah.

Yeah.

Yeah.

Yeah.

So I mean so part of this is
right it's a good question and.

Part of this comes out of my work and
philosophy of science where there's a lot

of people of us in science who argue
that science is about like and

there are Dr argument and one of
the points that I'm trying to make how do

I make my colleagues record.

Is that.

There are.

Many other decisions in the research
process of sides of decision to accept or

reject because on the basis
of evidence and these.

So it's not just inductive versus right
you know it's over carrying on with her.

From from that literature.

But I mean I struggle with this
a little bit in that we just think of

risk in something that you know
involves probabilities as are very.

There are really it's not unreasonable
to talk about these as for us I'm so

I was you know the choice
of a model organism that's.

A decision that has to be made in place
of uncertainty and it has so real.

Real consequences.

To the extent that.

The outcome of the study has
some bearing It's a policy.

So I think that it's not
unreasonable to use.

The right.

Objections to

the.

I mean we use the term so.

Instead of just ambiguities or uncertainty
I mean you could think about every.

Step of things if there is such a thing
as you have to do with our knowledge of.

Using the term risk goes I think one of.

Their real.

Real consequences of this.

You know just what we call.

Someone made a wrong answer.

He's.

Done so we don't know the answer but.

Not.

Really a.

Choice Yeah.

RIGHT RIGHT RIGHT RIGHT RIGHT RIGHT I mean
I think it does it does make sense in

context to say this so
if you're really interested in.

Learning about the facts of Bisphenol
A human being given to human beings

credibly and sensitive to estrogen
then that choice of a model.

So I think you can't say it's right or
are.

Given a particular context or
set of goals.

Well it's.

Any attempt to balance the presuppose.

That.
I was trying to make because I think

that a lot of decisions are made.

Consideration of what what these different
effects are that you're talking about and

what Which values are reflected
by particular decisions so

it has to be a lot more.

Conscious reflection of.

Neutral balance.

I mean.

This is a story.

Where you know people.

This sense of altruism.

Certainty.

But fifty years later what was the outcome
was that really something worth

the risk I don't know that
something that could be.

Said.

Because we can't predict the future right.

We can't study it sometime
yesterday sort of

perspective want to look at
things are very difficult.

And principle.

And study.

Your.

Years ago but it really.

Sort of thirty years ago started.

One of the strongest are actually in the.

Policy is that there's
a lot of potential risk.

Articulated part of the animal model.

Biology but there is really
very little long term study of.

Ten years ago.

That is that if someone is going
to have to talk about it and said.

It was really one of the risk exists or.

Are real problems.

The person.

Would be I was just going
to add to that and so.

The participation in this database as well
as other databases involves an entire

family parents effect the child and
could see.

And so.

There is that these parents
are consenting for their children and

so there might be potential
implications in the future for

these kids to say I don't really want to
be part of this research and other and so

this is something that's I mean.

It is and see this is very problematic
that these kids are being researched they.

Say.

It'll be interesting to see as.

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