Witnesses Argue Government Has Ethical Obligation for Lifetime Astronaut Medical Care–And Needs Data, Too
Three current and former astronauts, NASA’s Chief Medical Officer and a medical ethicist told a congressional committee today that the U.S. Government has an ethical obligation to provide lifetime medical care to people who fly into space as part of a NASA program. In addition, the data NASA could obtain by following individuals after they leave the astronaut corps would be invaluable in determining how to protect the health of current and future astronauts.
Three men who have made multiple journeys into space provided the astronaut viewpoint: Chris Cassidy, current head of the NASA astronaut office at Johnson Space Center (JSC); Michael Lopez-Alegria, who until recently held the U.S. record for the longest continuous spaceflight (215 days) and still holds the record for the most spacewalks (10), currently President of the U.S. chapter of the Association of Space Explorers; and Scott Kelly, who just broke Lopez-Alegria’s continuous spaceflight record by remaining in space for 340 days. Lopez-Alegria and Kelly are both retired from NASA now. All three are current or retired military officers as well.
Military personnel have lifetime medical coverage under the TRICARE program through the Department of Veterans Affairs (VA) and civilian government retirees may have coverage through the Department of Labor’s Federal Employees’ Compensation Act (FECA). NASA also has a voluntary Lifetime Surveillance of Astronaut Health (LSAH) program for former astronauts.
Collectively they do not cover all former astronauts (such as those who leave NASA’s astronaut corps before retirement or payload specialists who were never government employees) nor do they systematically collect data about former astronauts as they access medical care. The LSAH program is voluntary and only about 60 percent of former astronauts take advantage of it. It provides health status evaluations and former astronauts must travel to JSC to take part. If a medical condition is uncovered, NASA currently is authorized just to encourage the former astronaut to follow up with his or her personal health care provider, not to provide diagnosis or treatment.
The hearing before the Space Subcommittee of the House Science, Space and Technology Committee on June 15 focused on two questions the situation presents: what obligation does the federal government have to individuals who fly into space on behalf of the government and society at large, and what data are not being collected that could inform the government as it designs spacecraft and missions to take astronauts further into space for longer periods of time.
The three astronauts, NASA Chief Medical Officer Richard Williams, and Professor of Bioethics and Public Policy Jeffrey Kahn, were in agreement that the government has an ethical obligation to provide lifetime medical care for astronauts who fly as part of a government program and that NASA also needs the long term data on the health effects of spaceflight to inform current and future programs.
Kahn chaired a 2014 Institute of Medicine (IOM) study on Ethics Principles and Guidelines for Health Standards for Long Duration and Exploration Spaceflights. His committee identified six principles, two of which he said were relevant to this discussion: fairness and fidelity (or reciprocity). Fairness “requires that equals be treated equally” — that there needs to be a risk-benefit balance between those who take the risks of spaceflight (astronauts) and those who benefit (society). Fidelity “recognizes that individual sacrifices made for the benefit of society may give rise to societal duties in return” — those who consent to take long term health risks for society’s benefit (astronauts) are entitled to “society’s commitment to minimize any harms that emerge, whenever they emerge.”
Other government and non-government employees similarly engage in activities that risk their health — the military and the nuclear industry among many others — but Kahn said his committee tried to find occupational parallels and concluded that astronauts are in a “unique category.”
Williams discussed legislation that has been drafted to provide NASA with the authority to perform not only the evaluations currently conducted through the LSAH program, but also diagnosis and treatment for former astronauts. There are 280 living former astronauts, Williams said, and the cost of monitoring and diagnosis would be about $800,000 a year. Costs for treatment are difficult to estimate, but he anticipates there would be on average only one or two cases of significant illness every 1-2 years that would be expensive (on the order of $500,000) to treat.
Lopez-Alegria, who made four spaceflights, the longest of which was 215 days, and Kelly, who made a 159-day spaceflight in addition to his record-setting 340-day mission, both discussed some of the health effects they have experienced. Lopez-Alegria said he suffers from changes in his eyesight — Microgravity Ocular Syndrome — a recently discovered medical condition for astronauts who make long-duration spaceflights that is not yet understood. He said about 60 percent of long duration flyers are afflicted with this condition. His written statement provides a brief, but comprehensive summary of health effects experienced by astronauts more broadly and asserts that statistically, astronauts who fly to and from the International Space Station (ISS) on Soyuz spacecraft and remain for 6 months “have a threat of mortality comparable to those of U.S. infantry combatants on D-Day and New York City firefighters on 9/11.”
Kelly said that he was “pleasantly surprised” that initial data on his bone and muscle mass show little difference between his two missions, but other data, including that from the “Twins Study” with his twin brother Mark Kelly, will not be available for some time. He stressed that although his bone and muscle mass might not have changed much based on flight duration, he felt quite different returning from the 340-day mission. One difference was his skin was extremely sensitive after almost a year without coming into contact with clothing or anything else. After returning to Earth he developed a hive-like rash on “every surface of my skin that came into contact with ordinary surfaces on Earth … like sitting or lying in bed.” He also experienced flu-like symptoms and swollen legs. Although NASA focuses attention on the high risk launch and reentry phases of spaceflight, Kelly stressed, “much less attention is given to other risks astronauts face which are much more insidious, but potentially just as fatal.” He cited exposure to high levels of radiation and carbon dioxide as well as the microgravity environment that causes loss of bone and muscle, vision impairment and effects on the immune system.
Lopez-Alegria polled the U.S. members of the Association of Space Explorers — members must have made at least one orbit of the Earth — and reported there was “unanimity” that NASA needs to be able to provide advanced monitoring, diagnosis and treatment for former astronauts. His focus, however, is on the need to gather data to inform future policies and procedures for managing health risk in space. It is “unforgivable” to not obtain these data from the only population — current and former astronauts — that can provide it.
Williams summarized what is in the proposed legislation, but the text was not released. He said it would give NASA the authority to provide lifetime medical monitoring and diagnosis for former astronauts for medical conditions that NASA determines are associated with human spaceflight. It would apply to all former NASA astronauts regardless if they later fly into space with private companies, for example.
The draft legislation would not, however, apply to “space tourists” who make the journey into space of their own accord and not as part of a NASA program. Lopez-Alegria, who previously served as President of the
Commercial Spaceflight Federation, a trade group that advocates for private human spaceflight, said he supports the
“democratization” of space where many more people will have an
opportunity to make spaceflights. Getting health data from them on a
voluntary basis would be beneficial, but he does not believe the
government has an ethical responsibility to them as it does for those
taking part in spaceflights paid for by tax dollars on behalf of the country.
Although the draft legislation applies only to medical conditions “deemed by NASA to be associated with human spaceflight,” Kahn said his committee considered the question of “causality” and determined it was “impossible to answer” and “not compelling” in determining whether lifetime medical care is provided. That is especially true since new information is obtained all the time and it may take years before the relationship between spaceflight and a particular medical condition is understood.
Kahn’s 2014 IOM study is only the most recent on this topic. The first, Safe Passage, was issued in 2001 and led to language in the 2005 NASA Authorization Act that directed NASA to consider a lifetime health care program for astronauts. The House-passed 2015 NASA Authorization Act (H.R. 810) would require NASA to respond to the 2014 IOM recommendations. That bill has not been taken up in the Senate, however. The draft legislation discussed today could be included in a revised version of that bill. Despite the short legislative schedule remaining for the year, there continue to be rumors that an attempt will be made to get a NASA authorization act passed before Congress adjourns.