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Suggested Citation:"Front Matter." Institute of Medicine. 2014. Health Standards for Long Duration and Exploration Spaceflight: Ethics Principles, Responsibilities, and Decision Framework. Washington, DC: The National Academies Press. doi: 10.17226/18576.
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Suggested Citation:"Front Matter." Institute of Medicine. 2014. Health Standards for Long Duration and Exploration Spaceflight: Ethics Principles, Responsibilities, and Decision Framework. Washington, DC: The National Academies Press. doi: 10.17226/18576.
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Suggested Citation:"Front Matter." Institute of Medicine. 2014. Health Standards for Long Duration and Exploration Spaceflight: Ethics Principles, Responsibilities, and Decision Framework. Washington, DC: The National Academies Press. doi: 10.17226/18576.
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Suggested Citation:"Front Matter." Institute of Medicine. 2014. Health Standards for Long Duration and Exploration Spaceflight: Ethics Principles, Responsibilities, and Decision Framework. Washington, DC: The National Academies Press. doi: 10.17226/18576.
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Suggested Citation:"Front Matter." Institute of Medicine. 2014. Health Standards for Long Duration and Exploration Spaceflight: Ethics Principles, Responsibilities, and Decision Framework. Washington, DC: The National Academies Press. doi: 10.17226/18576.
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Suggested Citation:"Front Matter." Institute of Medicine. 2014. Health Standards for Long Duration and Exploration Spaceflight: Ethics Principles, Responsibilities, and Decision Framework. Washington, DC: The National Academies Press. doi: 10.17226/18576.
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Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2014. Health Standards for Long Duration and Exploration Spaceflight: Ethics Principles, Responsibilities, and Decision Framework. Washington, DC: The National Academies Press. doi: 10.17226/18576.
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Suggested Citation:"Front Matter." Institute of Medicine. 2014. Health Standards for Long Duration and Exploration Spaceflight: Ethics Principles, Responsibilities, and Decision Framework. Washington, DC: The National Academies Press. doi: 10.17226/18576.
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Page xiii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2014. Health Standards for Long Duration and Exploration Spaceflight: Ethics Principles, Responsibilities, and Decision Framework. Washington, DC: The National Academies Press. doi: 10.17226/18576.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

HEALTH STTANDA ARDS FFOR ONG DU LO URATION ANND EXPLO ON SP ORATIO PACEFLLIGHT Ethics Princip ples, Resp ponsibilitiies, and Deccision Framework Committee C on n Ethics Prin nciples and G Guidelines ffor Health Standards S forr Long Durattion and Expploration Spaaceflights Board B on Heealth Sciencees Policy Jefffrey Kahn, Catharyn C T. Liverman, and a Margareet A. McCoyy, Editors

THE NATIONAL ACADEMIES PRESS • 500 Fifth Street, NW • Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. This project was supported by Contract NNH13CK14D between the National Academy of Sciences and the National Aeronautics and Space Administration. The views presented in this publication are those of the editors and attributing authors and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-29657-1 International Standard Book Number-10: 0-309-29657-9 Additional copies of this report available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2014 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Cover credit: All photos courtesy of the National Aeronautics and Space Administration Suggested citation: IOM (Institute of Medicine). 2014. Health standards for long duration and exploration spaceflight: Ethics principles, responsibilities, and decision framework. Washington, DC: The National Academies Press.

The National Acadeemy of Sciencces is a privatte, nonprofit, self-perpetuatiing society y of distinguishhed scholars en ngaged in scienntific and enginneering researcch, dedicatted to the furth herance of scieence and technnology and to their use for tthe generall welfare. Upoon the authority y of the charteer granted to it by the Congreess in 1863, the Academ my has a man ndate that reqquires it to addvise the fedeeral governnment on scieentific and tecchnical matterrs. Dr. Ralphh J. Cicerone is presideent of the Natio onal Academy of Sciences. The National Acadeemy of Engin neering was eestablished in 1964, under tthe charter of the Natio onal Academy of Sciences, as a parallel organization of outstan nding engineerss. It is autonomoous in its adminnistration and iin the selectionn of its mem mbers, sharing with w the Nation nal Academy oof Sciences the responsibility ffor advisin ng the federal government. The T National Academy of E Engineering allso sponsorrs engineeringg programs aim med at meetinng national neeeds, encouragges educatiion and researcch, and recogn nizes the superrior achievemeents of engineeers. Dr. C. D. D Mote, Jr., is president of th he National Acaademy of Enginneering. The Institute of Med dicine was estaablished in 19770 by the Natioonal Academy of Sciencees to secure th he services of eminent membbers of approppriate professioons in the examination e of policy matterrs pertaining too the health off the public. T The Institutte acts under th he responsibilitty given to the National Acaddemy of Sciencces by its congressional c charter c to be an n adviser to thee federal goverrnment and, uppon its ownn initiative, to identify i issues of medical carre, research, annd education. D Dr. Harvey y V. Fineberg is president of thet Institute off Medicine. The Na ational Resea arch Council wasw organizedd by the Natioonal Academy of Sciencees in 1916 to associate the broad b communnity of sciencee and technoloogy with th he Academy’s purposes of fu urthering know wledge and advvising the fedeeral governnment. Function ning in accordance with geneeral policies determined by tthe Academ my, the Counccil has becomee the principall operating ageency of both tthe National Academy of o Sciences an nd the Nationaal Academy off Engineering in providiing services to t the govern nment, the puublic, and thee scientific aand engineeering communiities. The Coun ncil is administtered jointly byy both Academ mies and thee Institute of Medicine. M Dr. Ralph R J. Ciceroone and Dr. C. D. Mote, Jr., aare chair annd vice chair, respectively, r of the National Research Counncil. w www.nationall-academies.o org

COMMITTEE ON ETHICS PRINCIPLES AND GUIDELINES FOR HEALTH STANDARDS FOR LONG DURATION AND EXPLORATION SPACEFLIGHTS JEFFREY KAHN (Chair), Johns Hopkins University, Berman Institute of Bioethics, Baltimore, MD NANCY CONRAD, The Conrad Foundation, Washington, DC PETER F. DEMITRY, 4-D Enterprises, LLC, Haymarket, VA BONNIE J. DUNBAR, University of Houston, TX BARBARA J. EVANS, University of Houston Law Center, TX BERNARD A. HARRIS, JR., Vesalius Ventures, Houston, TX DAVID G. HOEL, Medical University of South Carolina JONATHAN KIMMELMAN, McGill University, Montreal, Canada ANNA C. MASTROIANNI, University of Washington School of Law, Seattle LAWRENCE PALINKAS, University of Southern California CAROL E. H. SCOTT-CONNER, University of Iowa Hospitals & Clinics MICHAEL A. SILVERSTEIN, University of Washington School of Public Health RONALD E. TURNER, ANSER (Analytic Services, Inc.), Falls Church, VA R. LEONARD VANCE, Virginia Commonwealth University, Richmond GREGORY R. WAGNER, National Institute for Occupational Safety and Health, Washington, DC IOM Staff CATHARYN T. LIVERMAN, Co-Study Director MARGARET A. MCCOY, Co-Study Director SARAH DOMNITZ, Associate Program Officer (since December 2013) CLAIRE F. GIAMMARIA, Research Associate JUDITH L. ESTEP, Program Associate ASHNA KIBRIA, Research Associate (since December 2013) R. BRIAN WOODBURY, Senior Program Assistant (since December 2013) ANDREW M. POPE, Director, Board on Health Sciences Policy v

Consultants TRISH LEADER, Technical Writer VICTORIA WEISFELD, Technical Writer vi

Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: John R. Ball, American College of Physicians Thomas F. Budinger, University of California, Berkeley Naomi L. Gerber, George Mason University Sven Ove Hansson, Royal Institute of Technology Mae C. Jemison, BioSentient Corporation Gloria Leon, University of Minnesota Melissa A. McDiarmid, University of Maryland School of Medicine Walter Schimmerling, East Carolina University David H. Wegman, University of Massachusetts at Lowell Laurie Zoloth, Northwestern University Although the reviewers listed above have provided many constructive comments and suggestions, they did not see the final draft of the report before its release. The review of this report was overseen by James F. Childress, University of Virginia, and Steve Fienberg, Harvard Univer- sity. Appointed by the Institute of Medicine, they were responsible for vii

viii REVIEWERS making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review com- ments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

Preface The prospect of long duration and exploration human spaceflight poses many significant challenges, not the least of which are the ethical issues raised by exposing astronauts to environments with uncertain and even unknown risks to their health, and excessive levels of known health risks. As a federally funded institution, National Aeronautics and Space Administration (NASA) recognizes that undertaking missions with such great risk and high levels of uncertainty raises challenges for decision making related to the health and safety of astronauts. In response to these concerns, the Institute of Medicine (IOM) convened a group with inter- disciplinary expertise and a range of backgrounds to analyze the ethical issues faced when existing health standards will be exceeded or when health risks are uncertain or unknown. This report represents the collective conclusions and recommenda- tions of a diverse group of experts, each of whom brought their expertise and perspectives. The charge to the committee was clear. However it did not lend itself to the typical approach of collection of data, but instead largely relied on conceptual considerations and analysis. The resulting recommendations take the form of a collection of ethics principles and a framework for their application when faced with decisions about exceed- ing existing health standards or when standards do not exist. In recom- mending this collection of principles, the committee sought to identify and articulate the relevant moral rules that must be followed in the con- text of health standards for long duration and exploration spaceflight. The committee’s considerations were informed by information from NASA, input from a range of stakeholders, and presentations from invit- ed experts at public workshops. These principles and decision-making framework are not a checklist or recipe, but rather are intended to pro- ix

x PREFACE vide the parameters that must be satisfied for ethically acceptable health standards in these contexts. We hope they perform that function as NASA plans for future space exploration. This report benefitted immensely from the dedicated, diligent, and skilled work of the IOM staff, including Meg McCoy, Cathy Liverman, Claire Giammaria, and Judy Estep; the committee gratefully acknowl- edges their tireless efforts. Lastly, I want to thank my colleagues on the committee for their hard work and unflagging patience as we considered, and often reconsidered the ethical issues and challenges relevant to health standards for long duration and exploration spaceflight. It was a privilege to work with such a dedicated and insightful group. Jeffrey Kahn, Chair Committee on Ethics Principles and Guidelines for Health Standards for Long Duration and Exploration Spaceflights

Acknowledgments The Institute of Medicine (IOM) Committee on Ethics Principles and Guidelines for Health Standards for Long Duration and Exploration Spaceflights would like to express its sincere gratitude to everyone who made this report possible. This report was informed by the contributions of many individuals who provided expertise, personal insights and perspectives, and data. First, the committee would like to thank National Aeronautics and Space Administration (NASA) for its support of the study. The committee especially appreciates the leadership of Richard Williams, Chief Health and Medical Officer, NASA, who was instrumental in the development of this study and in leading the responses to a number of committee requests for information throughout the study. The committee appreciates input and assistance from many other current and former NASA staff members, including John Allen, Francis Cucinotta, Jeff Davis, Homayoon Dezfuli, Donna Good, Michael Griffin, David Liskowsky, Vincent Michaud, Victor Schneider, Marc Shepanek, Ed Simones, and Paul Wolpe. The insights gained from the NASA Astronaut Office, particularly from Michael Barratt, Robert Behnken, Shannon Walker, and Peggy Whitson, provided important context for the committee’s work. The thorough and considered input provided to all of the committee’s queries was much appreciated. The committee held two public workshops in May and July 2013 and gained valuable insights from the substantive presentations provided by the speakers (see Appendix A) and participants. The committee greatly benefited from the work of the IOM study staff team: Cathy Liverman and Meg McCoy co-directed the study; Claire Giammaria provided research support; and Judy Estep skillfully xi

xii ACKNOWLEDGMENTS managed all logistical and administrative aspects of the study. Our thanks to Andrew Pope for his leadership. Additionally, Sarah Domnitz, Ashna Kibria, and Brian Woodbury were instrumental in finalizing the report. The committee is also grateful to Trish Leader and Vicki Weisfeld of NEW Associates, LLC, for their assistance in editing the report and to Laura Penny for copyediting the report. Finally, the committee would like to express its thanks to the IOM and the National Research Council staff members who worked behind the scenes to ensure a seamless study process and successful production and dissemination of this report: Anton Bandy, Clyde Behney, Daniel Bethea, Laura DeStefano, Chelsea Frakes, Molly Galvin, Janice Mehler, Donna Randall, Lora Taylor, Erika Vijh, and Jennifer Walsh.

Contents SUMMARY 1 1 INTRODUCTION 13 2 NASA RISK MANAGEMENT AND HEALTH STANDARDS 25 3 HEALTH RISKS 45 4 RISK ACCEPTANCE AND RESPONSIBILITIES IN HUMAN SPACEFLIGHT AND TERRESTRIAL ACTIVITIES 75 5 RECOMMENDATIONS FOR ETHICS PRINCIPLES 103 6 RECOMMENDATIONS FOR ETHICS RESPONSIBILITIES AND DECISION FRAMEWORK 133 APPENDIXES A Meeting Agendas 155 B Committee Biographical Sketches 163 xiii

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Since its inception, the U.S. human spaceflight program has grown from launching a single man into orbit to an ongoing space presence involving numerous crewmembers. As the U.S. space program evolves, propelled in part by increasing international and commercial collaborations, long duration or exploration spaceflights - such as extended stays on the International Space Station or missions to Mars - become more realistic. These types of missions will likely expose crews to levels of known risk that are beyond those allowed by current health standards, as well as to a range of risks that are poorly characterized, uncertain, and perhaps unforeseeable. As the National Aeronautics and Space Administration (NASA) and Congress discuss the next generation of NASA's missions and the U.S. role in international space efforts, it is important to understand the ethical factors that drive decision making about health standards and mission design for NASA activities.

NASA asked the Institute of Medicine to outline the ethics principles and practices that should guide the agency's decision making for future long duration or exploration missions that fail to meet existing health standards. Health Standards for Long Duration and Exploration Spaceflight identifies an ethics framework, which builds on the work of NASA and others, and presents a set of recommendations for ethically assessing and responding to the challenges associated with health standards for long duration and exploration spaceflight.As technologies improve and longer and more distant spaceflight becomes feasible, NASA and its international and commercial partners will continue to face complex decisions about risk acceptability. This report provides a roadmap for ethically assessing and responding to the challenges associated with NASA's health standards for long duration and exploration missions. Establishing and maintaining a firmly grounded ethics framework for this inherently risky activity is essential to guide NASA's decisions today and to create a strong foundation for decisions about future challenges and opportunities.

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