Original Article Ethic of consensibility, subaltern ethicality: The clinical application of embryonic stem cells in India AdityaBharadwaj DepartmentofAnthropologyandSociology,TheGraduateInstituteofInternationalandDevelopmentStudies, POBOX136CH-1211Geneva21,Switzerland. Y Abstract The article interrogates clinical and subjective patient expePriences outside the institutionalizedconditionsofscientificcommunication.Drawingonthenotionofconsensibility– consensualandcircumscribedrulesofscientificengagement–thearticlOere-imaginesethicalityon themarginsofanethicofconsensibilityasinherentlysubaltern.Thearticleisbasedonamulti-sited ethnographyfocusedonasmallclinicalfacilityinIndiaofferinghuCmanembryonicstemcell(hESC) therapies for a spectrum of disorders to local and global patients. The emergence of subaltern ethicality, the article argues, is intimately linked to ‘soma tic ethics’ in the event that a somatic R ethical stance is operationalized outside the consensible space of science. The article draws on interviewmaterialwiththeclinicaldirectorandtherapeuticexperiencesofpatientsfromGermany, O United States and Australia undergoing hESC therapy for chronic spinal cord injuries and lyme disease. In so doing, the article shows how subaltern ethicality is an ironic, critical stance pitted H against demands for (bio)scientific and (bio)ethical consensibility while seeking to become incorporated andnormalizedwithin its folds. T BioSocieties(2013)8,25–40.doi:10.1057/biosoc.2012.41;publishedonline14January2013 U Keywords:stemcells; India;consensibility; subaltern;ethics A Introduction Theuseofhumanembryosforthegenerationofstemcellsisembroiledinprotractedethical, legalandreligiousdebatesinmuchoftheEuro-Americanlandscape(Morgan,2003;Krones etal,2006).Theconceptualizationofhumanembryosassentientbeingshasmobilizedand polarized public opinion for and against such research (Ganchoff, 2004). In many parts of theworld,theuseofembryonictissueintheserviceofgeneratingbiotechnologicalproducts such as stem cells is viewed less critically (Bharadwaj, 2005; Sleeboom-Faulkner, 2008). In particular, the global spread of research and clinical application of stem cell therapies havefurtherexacerbatedcriticism(Sperling,2004;Prainsack,2006;Bharadwaj,2009;Song, 2010).Thereisgrowingconcernsurroundingtheethicalviabilityandscientificreliabilityof these therapeutic interventions (Bharadwaj and Glasner, 2009). The bone of contention is r2013TheLondonSchoolofEconomicsandPoliticalScience1745-8552 BioSocieties Vol.8,1,25–40 www.palgrave-journals.com/biosoc/ Bharadwaj the perceived lack of scientific scrutiny of these developments (Bharadwaj, 2012). These objectionsgototheveryheartofwhatZiman(1996)describedasconsensibility.According to Ziman, consensibility is a necessary condition for scientific communication. He argued, ‘thegeneralbodyofscientificknowledgeshouldconsistofactsandprinciplesthatarefirmly establishedandacceptedwithoutseriousdoubt,byanoverwhelmingmajorityofcompetent, well-informed scientists’ (Ziman, 1996, p. 6). While ‘science’ and ‘scientific facts’ are inherently unstable, the search for consensus and consensibility illustrates the fine-grained adjudication and legitimation of scientific knowledge and practice; we can say science gestates in an ethic of consensibility. The article interrogates demarcations – clinical and subjective patient experiences – outsidetheconsensibilecircuitsofscience.Theethnographicfocusisasmallclinicalfacility inIndiaofferinghumanembryonicstemcell(hESC)therapiesforaspectrumofdisordersto Y localandglobalpatients.ThiscaseofclinicalapplicationofhESCisdeemedproblematic– both locally and globally – because it is seen as not conforming to the dominant and P normalized view of scientific practice and bioethical oversight. The article re-imagines ethicality on the margins of an ethic of consensibility as inheOrently subaltern. This subalternity is not rooted in oppression or exploitation. As the article will later argue, the subaltern cannot simply be relegated to a space of oppressionCand exploitation but rather better conceptualized as always occupying a space of difference. Ethicality in a space of difference, to borrow from Veena Das (2012), can be imagined as not oriented to R ‘transcendental, objectively agreed upon values but rather through the cultivation of sensibilities within the everyday’ (p. 3). Subaltern ethicality is inherently ironic and O conflicted.Itisavanishingethicalitythatdisappearswithoutatraceordisappearsintothe hegemonic. Its emergence is intimately linked to ‘somatic ethics’ (cf. Rose, 2006, 2008) in H the event that a somatic ethical stance is operationalized outside the consensible space of science.Theresultingambivalenceproducesbothacritiqueofanethicofconsensibilityand T a desire to be consumed by it. The article opens with a refUlection on the ethnographic context and goes on to examine theethicofconsensibilityasnormalizedwithinthepracticeof(bio)science.Itisarguedthat an ethic of consensibiliAty within bioscience seeks to bind together epistemological and bioethical processes in order to acheive somatic standardisation. This ethico-epistemic benchmarking is r elated to a notion of subaltern ethicality: an ironic, critical stance pitted against demands for (bio)scientific and (bio)ethical consensibility while seeking to become incorporate dandnormalizedwithinitsfolds.ExpandingSpivak’s(1993)provocativequery ‘can the subaltern speak?’, the article argues that this irony is at the core of a subaltern stance. The Research ThearticleemergesfromanongoingstudyfocusingontherapeuticapplicationofhESCfor two prominent conditions: chronic spinal cord injuries and lyme disease. The larger ethnographyrevolvesaroundaNewDelhiclinic:NuTechMediworld.Since2000,theclinic hasofferedhESCtherapiesforarangeofdisorderstopatientsfromover20countries.The article draws on data accumulated over a 7-year period in the above research site and 26 r2013TheLondonSchoolofEconomicsandPoliticalScience1745-8552 BioSocieties Vol.8,1,25–40 Ethicofconsensibility,subalternethicality anthropological engagement with the politics, economics and culture of hESC research in India.Theethnographyhasremainedembeddedintheclinicsince2003andthefirstphase of this study culminated in a research monograph examining the rise of hESC research in India (Bharadwaj and Glasner, 2009). Thecurrentphaseofresearchisstudyingtheterrainoccupiedbyscientificstructuresand patientagencyintheculturalproductionofhESCtreatmentsinIndia.Presently,theresearch is tracking 10 chronic spinal cord injury/paraplegic patients and 2 lyme disease sufferers. The aim is to understand in depth their emerging experience of hESC treatment and expressions of recovery. In total, the research will focus on 20 spinal cord injury and lyme diseasepatientbiographies,respectively,outof108spinalcordand38lymepatientstreatedat theclinic.Thetwolymediseasepatientsinterviewedandfollowedupforthisstudyregistered dramatic recovery post hESC insertions. The experience of spinal cord injury patients was Y more circumscribed than the lyme suffers given the intractable nature of the condition. However,expressionsofhealingandrecovery–suchasregainingbowl andbladdercontrol, P beingabletowalkwithcalipers–arehighlysignificantasallspinalcordinjurieswerechronic and ‘natural’recoveryhadplateaued(duration rangingfrom 2 to9Oyears). The decision to focus on a smaller convenience sample of patients was taken to allow narrative detail to emerge and to understand why these paCtients continue to seek hESC therapies. The sample size is also restricted to allow for patient follow-up at regular intervals. The resulting longitudinal data promises to offer unique insights into the ‘truth R claims’ of hESC efficacy as well as patient narratives of healing and recovery. All patients were recruited from within the clinic based on treatment cycle-related availability. This O convenience sampling strategy eliminated any clinical bias or interference in participant recruitment.Theclinic’sinstitutionalethicscommitteegrantedfullaccesstoallclinicalareas H including patients so long as they had no personal objection to being approached with requests for interviews. In addition, the empirical backdrop to the argument in this article T stemsfrom3monthsoffocusedparticipantobservation.Theexclusivefocusinthis3-month period was on narrative pUroduction of ethics, morality and experimentation in the accounts of patients and the clinical director. All patient interviews were tape-recorded. Although names wereAanonymized to preserve confidentiality, where interviewees asked to beidentifiedbytheirfirstnames,noanonymizationwasattempted.Similarly,noattemptis madetoanonym izetheidentityoftheclinicasthefacilityhasreceivedunprecedentedglobal media coverage for anonymization to succeed. In addition, individual names in the public domain – such as media accounts – are not anonymized. No clinical data or files were accessed ,retrievedorstoredforthisresearch.Theresearchwascarriedoutaccordingtothe University of Edinburgh institutional ethics audit and due informed consent was sought as detailed in the University’s research ethics protocol. Ethic of Consensibility The philosophical thread connecting the realms of bioethics, biology and bioscience while entangledintheageofreasonandtheenlightenmentproject(cf.ShapinandSchaffer,1989; Good,1997)remainsunencumberedbyhistoricalandphilosophicalspecificitiesasitweaves a universally applicable narrative. This narrative presupposes a universal bioscientific r2013TheLondonSchoolofEconomicsandPoliticalScience1745-8552 BioSocieties Vol.8,1,25–40 27 Bharadwaj episteme, biological corporeality and bioethical normativity as necessary preconditions for ontological and epistemological expression. Ethical consensibility is continually negotiated on the confluence of these three bio-dimensions. The ethical in the production of a consensible terrain of praxis and thought is fundamentally institutional, a codified body of abstract knowledge circumscribed by a set of rules and regulations. Social science scholar- ship has expertly traced the genealogy of this ever-emerging – universal – world of ‘(bio)science’.Andthehumanbiologicalformisagoodplacetobegintracingthecontours of ethical consensibility. TheriseofhumanbiologyhasrightlybeentracedbacktotheCartesiandichotomousview of the world (cf. Merchant, 1983). As feminist scholars have conclusively shown, this philosophical mediation produced gendered prototypes of the normative body where the masculine ideal type came to typify the biological norm (Rothman, 1982; Martin, 1987; Y Laqueur,1990;Oudshoorn,1999).Digressionsfromthisepistemicconstruct–mostnotably visible in the female anatomical form – became legitimate docile objects and pathological P subjects in need of active (bio)scientific management (Martin, 1987; Davis-Floyd, 1990). By the middle of twentieth century, this early biological prototyOpe and its concealed philosophical and ideological structure was further refined to enable an imagination of the universalized, biomedicalized body (cf. Lock and Nguyen, 20C10, p. 88). Thescientificobjectificationoftheuniversalbodyisachievedthroughanequallyfamiliar and fundamental ‘epistemological split that runs like a fault line through modern Western R medical thinking – epitomised by the dichotomous distinction between what is biomedical andwhatisnot’(Fox,1999,p.4).Foxdescribestheexcludedepistemeasfallingoutsidethe O physical and biological parameters of medicine, falling outside the medicine’s ‘hard, objective and authentically scientific, and essential core’ (ibid.).It isperhaps not surprising H that(bio)ethicalframingofauniversalbodyandepistemologywouldnecessitateauniversal subjective point of departure. In this philosophical schema, ontological complexities T resulting from bioscientific interventions into universal biological forms through standar- dized epistemological practiceUs would self-evidently demand a universal code of ethical principles (Beauchamp and Childress, 1994). Nikolas Rose (2008) lucidly describes this form of bioethical framAing as a ‘legitimation device within the regulatory technologies of government, as they deal with highly controversial issues of life and its manage- menty[but]yitc an[also]servetoisolateresearchersfromcriticism,andfromthedetailed examination of the nature and consequences of their activities, by bureaucratizing the process wh ereby they obtain “ethical clearance” for what they do’ (Rose, 2008, p. 46). Briefly, theconceptualcoreofethicalconsensibilityisrootedinEuro-Americanhistorical, philosophical and scientific experience. There is no denying the fact that despite culture- specific genealogy of these developments, the principles of autonomy, beneficence, non- maleficence and justice – to name a few bioethical tropes – are important conceptual contributions to the process of overseeing welfare and deliverance of the ‘good’. However, the(bio)ethicalprojectdilutestheabilitytodeliversuchanoutcomebecauseitislessableto adapttoethicalcontingenciesanduncertainties.Thesamestructuralfaultlinerunsthrough the bio-scientific project that construes the human biological expression and knowledge production in ways that exclude complementing ‘local’ biological and epistemological articulations. It is against this backdrop that the notion of subaltern ethicality – an ironic position flanked by resistance to and desire for ethical consensibility – needs examining. 28 r2013TheLondonSchoolofEconomicsandPoliticalScience1745-8552 BioSocieties Vol.8,1,25–40 Ethicofconsensibility,subalternethicality Subaltern Ethicality Subaltern is a position without identity (Spivak, 1993, 1999). For Spivak, the subaltern is nota‘classywordforoppressed,forother,forsomebodywho’snotgettingapieceofthepie’ (Kock, 1992, p. 45). At its broadest, subalternity is difference. This difference, unlike in a segment of post-colonial thinking, is not always oppressed (cf. Guha, 1982). Spivak explicitly clarifies how ‘yeverything that has limited or no access to the cultural imperi- alismissubaltern–aspaceofdifference.Nowwhowouldsaythat’sjusttheoppressed?The workingclassisoppressed.It’snotsubaltern’(Kock,1992,p.45).Theunequalrelationsof powerinasubalternspacearerelatedtoissueofaccesstothehegemonicrepertoireandnot simply a mark of class inequality, oppression and discrimination. In framing her contro- versialandprovocativequestion,‘Canthesubalternspeak?’(Spivak,1993),shegesturesat Y the segregation of speech from an act of listening. The subaltern can speak, but the act of speakingseldomproducesaresponse.Thisabsenceofconversationisnotafailureofspeech P but rather a failure to enunciate from within the confines of hegemonic grammar. In this respect,thesubalterncanbeunderstoodasaninstanceofepistemicOmismatch.Scholarshave argued that the dominant Western episteme has privileged certain ways of knowing as the onlyvalidbasisforproductionofknowledge(cf.Sharp,2009C).Fromscienceandreligionto art and governance, in order to be heard, the other must embrace the dominant epistemic mode of expression (ibid.). The reason ‘subaltern ca nnot speak’ is largely because the subaltern is almost always captured in translationR, never expressing but rather always interpreted (cf. Spivak, 1993, 1999, p. 272). The only way subaltern can speak, invoke a O response, set a conversation in motion is by inserting into the circuit of hegemony. The subalterncravesnormativityandnormalization.ToinvokeSpivakagain,subalternityisnot H something to be protected or museumized; ‘no activist wants to keep the subaltern in the spaceofdifferenceytoworkforthesubaltern,meanstobringitintospeech’(Kock,1992, T p. 46). In other words, one works against the subaltern status and into the hegemonic discourse. That is, make subUaltern part of the hegemonic grammar; end the silence. Subalternethicalitycanbeconceptualizedasoneinstanceoffailedrecognition,anethical location on the marginAof bioethical and epistemic consensibility. Subaltern ethicality is a vanishingethicality.Iteithervanisheswithoutatraceorvanishesintothehegemonicethicof consensibility.W ithrestrictedornoaccesstorecognitioninaspaceofdifference,subaltern ethicality continually demands to be heard despite enunciating in a different grammatical register;it askstobeletinwithoutunderstandingthecriteriaforgroupmembership.Atthis juncture ,Rose’s(2008)conceptof‘somaticethic’becomesuseful.Somaticethicisanactof judging and acting on one’s ‘soma’ in order to make oneself not just physically better but also a better person (Rose, 2006, 2008). In the global realms of biotechnological development, application and patient circulation, somatic ethics are more than ever before prone to inhabiting spaces outside the consensible limits of science. This could include patients driven by compulsions of ‘somatic soteriology’ – a sense-making device for one’s suffering, its reasons and means of deliverance from it – in order to seek experimental therapies resulting in the production of experimental ethicality. As somatic ethic travels, it alsoencountersgloballydispersedresearchersandcliniciansproducingexperimental‘ethics ofthebio’–ethicalconsiderationsdeemedrelevantbypatients,cliniciansandregulators–as they conduct everyday operations on the margins of ‘bio-morality’, that is, principles and r2013TheLondonSchoolofEconomicsandPoliticalScience1745-8552 BioSocieties Vol.8,1,25–40 29 Bharadwaj codes framing theconduct ofresearch andclinical work (Rose, 2008,pp.46–48).Asthese globalcirculationsgaintraction,actorscanfindthemselvesfailingtoworkaroundorwork into the consensible space of science. Rose observes that ‘biological and ethical are intertwined’ (ibid.). This intertwining is predicated on the entwining of another kind: ‘bio- morality’ and ‘somatic ethic’. However, in a global order characterized by increasing levels of proactive therapeutic mobility to contexts and demarcations outwith the ethic of consensibility, we can expect to witness conflict between purveyors of ‘bio-morality’ and agentsespousinga‘somaticethic’.Inthesefraughtglobalencounters,theirentwineddestiny is prone to unravel as they – personal differences and agendas notwithstanding – seek to ‘justifythedecisionstheymustmakewhenhumanvitalityisatstake’(Rose,2008,p.48).It isinthiszoneofconflictwhereaspaceopensbetween‘somaticethic’and‘bio-morality’we canexpecttofindsubalternethicalityexploringroutesintotheconsensiblespaceofscience, Y searching for the harmonious entwined world of ‘bio-morality’ and ‘somatic ethic’. Subaltern ethicality in other words is a transitional, vanishing ethical space that emerges P and disappears as ‘somatic ethic’ and ‘bio-morality’ entwine and unravel. This is not a (dis)positionopposedtoconsensiblehegemonyeventhoughitmayrilOeagainstitunrequited. Subaltern ethicality can seldom oppose that which it seeks in order to speak. C The Clinic R There is worldwide scientific and media interest in India’s stem cell research programmes O (Bharadwaj, 2005; Bharadwaj and Glasner, 2009). The Indian state, and both public and privateinitiativesaimto‘lead’theworldintheculture,productionandeventualapplication H of hESC entities (ibid.). Although the Indian state in particular is striving to combine its strategic investment in stem cell research with the prevailing global scientific norms and T ethicalprotocolsasaconsciousstrategy andsoundcommercial investmentin theemerging ‘global moral economy’ (cf. BUharadwaj, 2009), notable departures to this policy do exist. The ethnographic focus on NuTech Mediworld offers a compelling illustration of one such facility that haAs forged ahead with clinical application of hESC despite domestic and international regulatory unease at the rapid translation from bench to bedside (cf. Jayaraman, 20 05). Since2000,theclinichasofferedhESCtherapiesforarangeofdisorderstopatientsfrom over20cou ntries.Thestemcellsattheclinicwerederivedfromoneleftoverembryofroman IVFcycle .Withdueconsentfromthecouple,theembryowasputthroughaseries oftests, including medical and genetic history of the donors, to determine the viability of any resulting stem cell lines. The clinical director controversially claims that theoretically one human embryo can generate enough cell lines to treat the entire human population. This suggestionputsaverydifferentperspectiveontheprevailing‘panicsandethics’surrounding the use of human embryos for stem cell generation (Bharadwaj, 2012) and what Lawrence Cohen(2003,2010,pp.253–254)describesas‘supplementarity’,anabilityofindividualsor populations to constitute their longevity through access to the organic forms of other persons.Ifindeedasingleembryocandivideinperpetuitytosupplycellsfortherapeuticuse, a breakthrough of this magnitude could potentially rewrite the rules of ‘supplementarity’. However, the boldest clinical claim to date involves the suggestion that human embryonic 30 r2013TheLondonSchoolofEconomicsandPoliticalScience1745-8552 BioSocieties Vol.8,1,25–40 Ethicofconsensibility,subalternethicality stem lines do not show any immune rejection in the body nor do they have any antigenic proteinsnecessitatingimmunosuppressantdrugsorindeedanyissuesaroundcross-matching irrespectiveofage,ethnicityandgender.Thusfar,therearenoreportedsideeffectsinanyof the patients and the range of conditions currently treated at the clinic are as diverse as diabetes,multiplesclerosis,Parkinsonsdisease,cardiacconditions,lymediseaseandchronic 0 spinal cord injuries. The hESC therapy at the clinic was first introduced in 2000, in keeping with the Indian Council of Medical Research (ICMR) ethical guidelines for biomedical research on human subjects (ICMR, 2000).Intotal, fourpatients volunteered to undergo stemcell therapy.At this stage, the objective was to test for safety. In the second year, six patients underwent hESC insertion to consolidate safety and ascertain efficacy. There was an increase to 24 in the thirdyear to determine further the safety and efficiencyof the intervention. Eventually, Y thefiguresnowballedintothecurrentcohortofover900patients.Theclinichasadoptedthe Helsinki Declaration, at least in essence, as the foundational ethical register governing its P everyday practice and its institutional ethics committee. In addition, the clinic is Good Manufacturing Practice (GMP), Good Clinical Practice (GCP)Oand Good Laboratory Practice (GLP) compliant. These practices can be read as visible attempt to co-opt standardized baseline operational structures on which coCnsensible scientific practice is predicated.However,prevailingregulationstructuringscientificpracticeinIndiaisproving to be a ‘soft touch’ given the rapid pace of developme nt in the red biotechnology sector in R India and beyond. In many respects the clinic, like the Indian state, is caught up in a ‘governance limbo’. The prevailing ethical guidelines on stem cell research are ‘snarled up’ O byslow paced, oftenexcessive, bureaucratic procedures.Thishas further delayedthe long- awaited transition from ‘guidelines’to ‘robust legislation’. H The clinic has taken out a global patent on its unique embryonic stem cell extraction technique,whichisavailableinthepublicdomain(internet)andopentoscientificscrutiny. T This is the clearest indication yet that the clinic and its scientific director are gearing up to participate in the emergingUglobal bio-economy. On legal advice, the clinic withheld all publications until such time as the patent is granted. At present, there is no independent verification available tAhat can ascertain the exact provenance of this legal advice save the clinic’s own submission on the issue. However, existing industry norms as well as some universities’guid elinesonpublishing(forexample,theGermanUniversitysystem)appearto suggest that withholding publications is not an uncommon strategy when patent applicatio ns are pending. The clinic has systematic data on stem cell extraction technique, treatme nt protocols together with a working paper on chronic spinal cord injury covering 108 patients (40 quadriplegics and 68 paraplegic patients) who have undergone hESC therapy between 1 January 2004 and 31 December 2009. However, the absence of publications in scientific journals is accentuating criticism, as lack of peer review is seen as furtherevidenceofdubiousscientificpractice.Inthisrespect,theclinicismissingoneofthe key ‘obligatory passage points’ (Epstein, 1996) as it attempts to navigate its way to the consensible core of stem cell science. There is accumulating evidence to suggest that this accentuating criticism – emanating from regulatory agencies and fellow scientists – is curiously being articulated through media channels (cf. Bharadwaj and Glasner, 2009). However, thisisnot entirelyunusualgivenmassmediaisplayinganever-increasingrolein determining the outcome of scientific controversies (ibid.). Following Cohen, these r2013TheLondonSchoolofEconomicsandPoliticalScience1745-8552 BioSocieties Vol.8,1,25–40 31 Bharadwaj developments canberecapitulatedas afineillustrationof‘ethicalpublicity’ (Cohen,2010) and a form of ‘scandal publicity’ (Cohen, 1998). Clearly, the prevailing scenario can be read as a straightforward show of clinical belligerence and resistance. However, upon closer inspection a lot more than a simple digressionfromthenormappearstobeatstake.Throughthecourseofaninterviewin2010, the conversation with the clinical director deviated to the upcoming Geron hESC stem cell trialsintheUnitedStates.Whiletheclinicaltrialeventuallyfailedandtheentireprojectwas scrapped,in2010theGerontrialgeneratedmuchexcitementandwashailedasalandmark step forward in treating spinal cord injury. Q:YoumusthaveheardthatthereisanewclinicaltrialintheUnitedStates,whatare your views? A: All the best to them. Y Q: It is just that first it was on and then it was off and now it’s back on again y P (interrupted). A: What happened, this, I don’t know too many details, what I read that Geron got O this clinical trial go ahead from the FDA which they withdrew when they saw that therewassomecystformation,IthinktheircelllineisGNROC1somethinglikethat. C Unfortunately, I think, this is the one that is derived on animal products. It is unfor- tunate, but I think the first phase is only for safety so they are doing it on I think a 2-week-old spinal cord injury which is in acute phRase so obviously they cannot talk aboutefficacy.Efficacycannotbeascertainedifyouaretransplantingcellsintoanacute injurybecausenatural recoveryoccursifyouOcanshowthestemcellsareworkingina chroniccasethatiswhatisrequired,IdonotbelievethatGeroncanshowefficacybut theywillbeabletoshowsafetyaspectHwhichIthinkhadFDAconcernedafewweeks, few monthsago, which iswhy theyhadwithdrawn the supporty T Theclinicaldirectorwasnotaloneinmakingthiscriticalobservation.AsearlyasNovember 2005,JerrySilver,aneuroscienUceprofessorandstem-cellresearcheratCaseWesternReserve University in Cleveland, criticized Geron for moving too fast (Ertelt, 2011). The Geron A clinical trial was finally given the go-ahead based on lab studies on eight rodents. The clinical director was further probed on the ethical viability of the Geron clinical trial compared to the clinic’s ongoing and seven year old therapeutic interventions in patients from around the globe: Q: Wh at makes this trial ethical and your clinical application of hESC unethical? A: It is not unethical! I am in a different country I am ethical, I practise under all international guidance with all good practice in place. Q:Iamreferringbacktothecriticismonehearsaboutyouinthemedia.Whattheyare saying is that it is unethical because there is no clinical-trial data so what makes the clinical trial itself ethical where they are putting untested embryonic stem line into humans? A: No they won’t call it untested, they [are] tested on mice. They are tested on mice and it makes it ethical for human trial. Q: What are your views on that? A: No comments (laughs). My comments arey 32 r2013TheLondonSchoolofEconomicsandPoliticalScience1745-8552 BioSocieties Vol.8,1,25–40 Ethicofconsensibility,subalternethicality Q: Is that all it takes to make it ethical, it has to be tried on an animal? A: Yes, and then you have to follow certain protocols which scientists have in place andyouhavetoconformtothosethingsandthenyouhavebepartoftheirlobbyand thenyouarealright.AsIamfromanothercountrythoughIamabsolutelyfollowing whateverthiscountryhastoofferandIhaveinternationalpatientswhospeakhighly of this therapy. Q: So the criticism is that you have not followed these protocols? A:No,Ihavefollowedeveryprotocol,thatiswhatIamtryingtosay,Ihavefollowed every protocol only thing is whatever you hear about me is from the media, if a journalist who comes across sits across or doesn’t even sit across and passes a judgement (sic) y it is scientists sitting in London, like Stephen Minger, I am not ashamedtousehisnamebecausehedidnotbehavelikeascientisthehadtheaudacity Y tochallengemeorcallme,Iforgetthewordshesaid(sic),somethingweird,Iquestion him as a scientist if he is so interested why doesn’t he come and see, and he meaning P thescientist,ifIamaquackcomeandshowme,Ihavegoneonairandinvitedpeople over why don’t they do it y. O Oneofthemosttrenchantandvocalcriticsoftheclinic,DrCStephenMinger,formerlyfrom King’sCollegeLondon,isoftenquotedinleadinginternationaldailypapers.Breakingnews on the dramatic recovery of a 45-year-old Australian woman, Sonya Smith, who crushed R both‘T11’and‘T12’bonesinherspineandhad,sincehertreatmentattheclinic,begunto regainsensationandwalkwithcalipers,thereportconcluded:DrStephenMinger,aleading O stem cell scientist at King’s College London, said: ‘I think it’s dubious to say the least. She might be Mother Teresa [taking a swipe at the clinical director], but I’m skeptical’ H (Telegraph, 2007). Personal criticisms such as these have become commonplace in media renditionsandexperttestimoniesembeddedinmediareports(cf.TheGuardian,2005;Sky T News,2006, 2007;Telegraph, 2007,2008).The mainsource ofexasperation expressedby the clinical director is not dUirected towards ‘trial by media’, but rather for being judged unethically while following ‘all international guidelines’ as currently practised and interpreted in India. WAhile the clinic claims to follow the guidelines laid down in the country,emergingmovesinIndia,especiallythosesponsoredbytheICMR,areproactively seekingintegratio nwithanormalizedviewofconsensiblescience(ICMR,2006).TheICMR in this respect remains unimpressed by the clinic introducing hESC into an ever-increasing cohort of national and international patients (cf. LifeSiteNews.com, 2001). However, as argued earlier, the ICMR-sponsored proposals are mere guidelines and cannot be legally enforced. As and when these guidelines become law, they are highly likely to mirror the prevailing ‘hyperethicality’ (Sunder Rajan, 2008) that governs the clinical-trial industry in India. Despite one of the most robust and stringent laws overseeing clinical trials in the world,theclinical-trialsubjectsinIndiaremainvulnerableandanexploitableresource.This isnotbecauselegalandethicaloversightisinadequateornotproperlyenforced,butrather because the liberal contract between the clinical research organization (CRO) and the trial subject enables ethical appropriation of ‘merely risked’subjects (ibid.). There is another crucial implication in the clinical director’s assertions. The science and therapeutic interventions are unwittingly explained by the clinical director as lying within the‘geographyofblame’(Farmer,1993).Theassertionnotbeingpartof‘theirlobby’isfirst r2013TheLondonSchoolofEconomicsandPoliticalScience1745-8552 BioSocieties Vol.8,1,25–40 33 Bharadwaj a veiled admission that access to consensible science is all but blocked and second this exclusion further accentuates the stigma of otherness and breaching the ethic of consensibility. Thus far, the clinic’s attempts to engage with research laboratories and experts around the world have yielded little success. Obviously, this seems self-inflicted, as withholding publications and data – otherwise prime signifiers of adherence to good scientific practice – would inevitably produce such isolation. However, when asked to explain how the clinic engaged with peers and participated in a well-delineated scientific public sphere, in the notable absence of publications, the clinical director replied: I have tried to speak at the International Society of Stem Cell Research, once it was heldinBrisbaneorQueenslandandotheroneheldjustrecentlyintheStates.Iapplied forspeakingattheWorldStemCellSummitandsomanyotherconferencesandeach oneofthemcameoutwitharefusaltoallowmethespacetotalk(sic).Now,Ythatwas myattempttoget itout,nowifscientists don’twantto hearandwantto commentI P won’t call them scientists, I will call them politicians, I am not going to call them scientists,iftheywere,theywillbeouttherehelping,understanding,cominghereand O checkingout(sic)yiftomorrowsomeonesaidIwannacome,youaremostwelcome. C While deepening isolation and exclusion from a community of local and global peers continuesunabated,asteadystreamofpatientsisarrivingattheclinicfromaroundtheworld. As the clinic continues to withhold scientific papers, patient testimony and experience of R incremental recovery are beginning to have a supplementing effect. This contingent, stopgap measure, while an inadequate response to strucOtural and ethical demands embedded in the ethicof consensibility, providesaccess to the worldof patientsand their‘somatic’struggles. H The Patients T A growing number of spinal cUord injury and lyme disease patients from the United States, Australia and Germany are taking their somatic struggles to the clinic. These moves are strainingrelationsbetweAen‘somaticethics’and‘bio-morality’.Patientsinterviewedthusfar hadproactivelyspenttimeandeffortresearchingtreatmentoptionsaroundtheworld,kept abreastofongoingbreakthroughsinthelivesoffellowspinalcordinjuryandlymesufferers, aswellasface duptoalotofcriticismandwell-meaningadvicefromscientistsandclinicians in their ho me countries before opting for hESC treatment in India. Interviewing an Australianpatient,Andrew(pseudonym),whosustainedirreversiblespinal-corddamagein a bungee jumping accident in Thailand, clarified how professional validation of hESC treatment outcome was a difficult terrain to negotiate: y first week I had a procedure here and I could wriggle a toe I didn’t believe it was happening y I feel pretty great I have sensation in my legs and use of bowel and bladder y Q. There is a medical ethics debate going on, should people embrace experimental therapies, is it ethical to offer such therapies? A. The doctors back in Australia there is a lot of debate that this is dangerous, ‘you mightdieoftumours’andinmymindIratherdieoftumoursthansitaroundforthe 34 r2013TheLondonSchoolofEconomicsandPoliticalScience1745-8552 BioSocieties Vol.8,1,25–40