Carrying Humanity to Mars
Bioethics and Manned Space Travel
Dr. Wolpe’s article is a personal discussion about the issue of bioethics and manned space travel in his capacity as a professor at the University of Pennsylvania. This discussion does not necessarily reflect the policy or the opinion of NASA or the Office of the Chief Health and Medical Officer.
Bioethical Questions About Manned Space Travel
- What kinds of information do we tell crewmembers millions of miles from earth?
- What if a family member is injured or killed?
- What if there is a terrorist attack on America like 9/11?
- What would we do if a crewmember became violent because of a traumatic brain injury or mental illness?
- Do we include a straitjacket as standard issue on the craft?
- How much medical training is adequate for the crew as a whole?
- What if the designated physician gets sick?
- What level of treatment is enough?
- What kinds of injuries or illness are we comfortable not treating?
- What role should families of astronauts have in decision-making about whether a crewmember should go on such a mission?
- If a crewmember is disabled in space, who becomes their surrogate decision maker? Their spouse? NASA physicians? Other crewmembers on the craft?
- How much do we need to know about human physiology, illness, drug metabolism, and other basic biomedical and pathological processes in space before we feel it is acceptable to send people into space?
- What risk factors are acceptable in Exploration Class Missions?
- Almost certainly the level of radiation crewmembers will be exposed to on a mission to Mars will exceed currently allowable limits. Will we allow astronauts to volunteer to take on risk levels that the law would not allow a worker on earth, such as at a nuclear power plant?
- How do we balance the life and safety of crewmembers with mission success? How much sacrifice is allowable before we abort the mission?
- Do we require prophylactic surgery—removal of the appendix, tonsils, perhaps gall bladder—before a three-year mission to Mars, to minimize the possibility of common problems that would be difficult to treat on the craft?
- Do we screen potential astronauts genetically and disallow, for example, a female astronaut with BRCA1 or BRCA2 (breast cancer susceptibility genes) from ECMs?
- To what degree do we allow astronauts medical confidentiality?
- What are the criteria for determining if something a crewmember tells a flight surgeon (back in Houston) is important enough that the flight surgeon needs to break confidentiality and tell mission control? And what should be told to other crewmembers?
- Should psychiatric information be treated differently from other medical information?
When President Bush announced his “Vision for Space Exploration” almost four years ago in a state of the union address, he committed the United States to the exploration of the solar system. He instructed NASA to retire the shuttle and develop a new Crew Exploration Vehicle, with the goal of returning to the Moon by 2020 to establish an extended human presence there. With the experience and knowledge gained by the new lunar missions, the president directed the National Aeronautics and Space Administration to pursue the goal of human missions to Mars and eventually to worlds beyond.
The president’s ambitious timetable for NASA required it to immediately begin planning to implement the directive. NASA began its life as an exploration agency, culminating with the race to land on the moon, but after the Apollo era and the missions to the moon ended, NASA became primarily a science agency. The building of space platforms such as Mir or the International Space Station were intended to allow and encourage space-based scientific research. Exploration of the solar system was relegated to unmanned missions, which are considerably cheaper than sending people into space, and which freed up considerable resources for scientific research.
A fundamental social and ethical question that underlies this endeavor is, of course, the pros and cons of manned spaceflight itself.
The president’s “Vision for Space Exploration” has shifted NASA’s emphasis back to manned space exploration, which requires a review of the ways we safeguard the health of the men and women who will be our emissaries to the moon and Mars. Along with the shift has come new attention to the medical and bioethical issues of long-duration flight. For the past 35 years human beings have been restricted to low-earth orbit, about 220 miles above the earth. The moon, in contrast, is about 240,000 miles away, meaning that we have to begin planning for a mission 1000 times as distant from earth as the current missions. The goal of creating permanent lunar stations also means, for the first time, constructing human habitats on another planetary surface.
A fundamental social and ethical question that underlies this endeavor is, of course, the pros and cons of manned spaceflight itself. For the purposes of this discussion, we will not engage that question, which is an important one but one that society as a whole must debate and decide. NASA receives its directives from the president, who has instructed the agency to begin designing ways to explore our solar system. While each of us has the obligation to participate in the discussion about the value of manned flight and the expenditures that go along with it, within NASA the obligation is to do the work that elected representatives of the people charge to NASA. To that end, NASA has begun the process of designing medical care for missions to the moon and Mars.
Until now, the philosophy of space-based medicine has been to treat that which is treatable in space, but for major injuries or illnesses, evacuate the crewmember and return them to Earth as quickly as possible. Such restricted capabilities will not suffice for long-duration space flight beyond low earth orbit (that is, missions to the moon or Mars, which we will call Exploration Class Missions).
Who decides what medical resources are used for whom?
ECMs require significant medical capability for a number of reasons. First, a craft can be weeks or months from return to earth. The distance between Mars and earth, for example, varies between 36 to 150 million miles. A craft on the way to Mars, then, can be many millions of miles from earth, and as the earth is orbiting the sun, there are only certain windows of opportunity for the craft to turn around and be able to rendezvous with the earth. Second, even real-time consultation may not be possible; a one-way radio transmission from Mars can take 14 to 30 minutes, with an equal delay for the response. Finally, while restocking supplies would be common for a lunar station, for a Mars mission supplies would have to be anticipated and sent ahead to be met by the craft.
NASA is therefore beginning the long process of undertaking a thorough review of the medical policies that will maintain health and provide medical care to our astronauts as we move to ECMs. Bioethics advisors to the Chief Health and Medical Officer of NASA have emphasized the need to begin that work by exploring the underlying values and priorities that inform medical decision-making. The Chief Health and Medical Officer has been very receptive to that perspective, and NASA has already begun to discuss and hold meetings and conferences about the basic bioethical questions that underlie decision-making about ECMs.
Should we allow the crewmember to continue, to risk or even sacrifice his or her life for the mission?
Bioethical questions begin with decisions about how to equip a craft. Given that crafts will have severe weight restrictions—known as “upmass” in NASA parlance—every decision to include one piece of equipment is a decision to exclude something else. Is ultrasound sufficient for imaging needs in space, or must we include heavier x-ray capability? These questions become thornier when we remember that there will be need for a full range of medical, psychiatric, dental, ophthamalogic, and even surgical and rehabilitative resources. A formulary must also be developed that anticipates all likely pharmaceutical needs of all crewmembers for an extended mission.
How do we balance different likelihoods and needs? Given a calculus between three measures—severity of a condition, likelihood of occurrence, and effectiveness of countermeasures (prevention and/or treatment)—how do we decide which kinds of potential health events we will address? In the context of severely limited space and upmass limitations, should high severity, low likelihood, and medium effectiveness of countermeasures trump medium severity, medium likelihood, and high effectiveness of countermeasures? How should we think about pain and suffering in such a calculus?
Once a craft is equipped, decisions must be made about allocation. Who decides what medical resources are used for whom? In some instances, it may not be prudent to use up a scarce resource on an injured or ill crewmember early in a mission, under the assumption that the resource may be needed later and restocking is not possible. Principles of triage should be worked out in advance of a mission and be part of medical and bioethical policy.
Also, there are basic value principles to be worked out in advance of all decision making. What is the relative weight of mission success and the life and health of the crew? An early mission to Mars will include an investment of tens of billions of dollars and years of work. What level of severity of illness or injury will be considered grounds to abort a mission already underway?
Imagine a crewmember who discovers a life-threatening illness with two years left on a mission. Should we allow the crewmember to continue, to risk or even sacrifice his or her life for the mission? Do we give them that choice? What of a crew member with a severe head injury who is disabled? A disabled astronaut removes two crew members from their normal duties: the injured member and the crewmember caretaker. A mission may not be able to sacrifice the work of two of its members. And what if a crewmember does perish? Do we store the body for two years for return to earth, or give the member a “burial at space”?
Questions like these, and hundreds others, are all on the table both at NASA and with our international space partners. Science fiction has explored some of these questions for decades (see adjacent sidebar), but we are now at the point at which we need to begin turning opinions into policy. Many competing interests are part of the conversation, and no policies for bioethics or medical care on ECMs have yet been adopted by NASA.
The good news is that NASA is taking these questions very seriously, many years before they need to be implemented, and so has the time to explore and debate them thoroughly. But many of these questions are not restricted to NASA. They reflect the deeper values of our society—ones that the American people have to face if we decide to continue manned exploration of the planets near our home.
Paul Root Wolpe is on the faculty at the Department of Psychiatry and Center for Bioethics, University of Pennsylvania, and is a Bioethicst at the National Aeronautics and Space Administration.
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