[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]





               HUMAN SPACEFLIGHT ETHICS AND OBLIGATIONS: 
                  OPTIONS FOR MONITORING, DIAGNOSING,
                     AND TREATING FORMER ASTRONAUTS

=======================================================================

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON SPACE

              COMMITTEE ON SCIENCE, SPACE, AND TECHNOLOGY
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                             June 15, 2016

                               __________

                           Serial No. 114-83

                               __________

 Printed for the use of the Committee on Science, Space, and Technology




[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]






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              COMMITTEE ON SCIENCE, SPACE, AND TECHNOLOGY

                   HON. LAMAR S. SMITH, Texas, Chair
FRANK D. LUCAS, Oklahoma             EDDIE BERNICE JOHNSON, Texas
F. JAMES SENSENBRENNER, JR.,         ZOE LOFGREN, California
    Wisconsin                        DANIEL LIPINSKI, Illinois
DANA ROHRABACHER, California         DONNA F. EDWARDS, Maryland
RANDY NEUGEBAUER, Texas              SUZANNE BONAMICI, Oregon
MICHAEL T. McCAUL, Texas             ERIC SWALWELL, California
MO BROOKS, Alabama                   ALAN GRAYSON, Florida
RANDY HULTGREN, Illinois             AMI BERA, California
BILL POSEY, Florida                  ELIZABETH H. ESTY, Connecticut
THOMAS MASSIE, Kentucky              MARC A. VEASEY, Texas
JIM BRIDENSTINE, Oklahoma            KATHERINE M. CLARK, Massachusetts
RANDY K. WEBER, Texas                DONALD S. BEYER, JR., Virginia
JOHN R. MOOLENAAR, Michigan          ED PERLMUTTER, Colorado
STEPHEN KNIGHT, California           PAUL TONKO, New York
BRIAN BABIN, Texas                   MARK TAKANO, California
BRUCE WESTERMAN, Arkansas            BILL FOSTER, Illinois
BARBARA COMSTOCK, Virginia
GARY PALMER, Alabama
BARRY LOUDERMILK, Georgia
RALPH LEE ABRAHAM, Louisiana
DRAIN LAHOOD, Illinois
WARREN DAVIDSON, Ohio
                                 ------                                

                         Subcommittee on Space

                     HON. BRIAN BABIN, Texas, Chair
DANA ROHRABACHER, California         DONNA F. EDWARDS, Maryland
FRANK D. LUCAS, Oklahoma             AMI BERA, California
MICHAEL T. McCAUL, Texas             ZOE LOFGREN, California
MO BROOKS, Alabama                   ED PERLMUTTER, Colorado
BILL POSEY, Florida                  MARC A. VEASEY, Texas
JIM BRIDENSTINE, Oklahoma            DONALD S. BEYER, JR., Virginia
STEVE KNIGHT, California             EDDIE BERNICE JOHNSON, Texas
WARREN DAVIDSON, Ohio
LAMAR S. SMITH, Texas





















                            C O N T E N T S

                             June 15, 2016

                                                                   Page
Witness List.....................................................     2

Hearing Charter..................................................     3

                           Opening Statements

Statement by Representative Brian Babin, Chairman, Subcommittee 
  on Space, Committee on Science, Space, and Technology, U.S. 
  House of Representatives.......................................     4
    Written Statement............................................     6

Statement by Representative Donna F. Edwards, Ranking Minority 
  Member, Subcommittee on Space, Committee on Science, Space, and 
  Technology, U.S. House of Representatives......................     8
    Written Statement............................................    10

Statement by Representative Lamar S. Smith, Chairman, Committee 
  on Science, Space, and Technology, U.S. House of 
  Representatives................................................    12
    Written Statement............................................    14

Statement by Representative Eddie Bernice Johnson, Ranking 
  Member, Committee on Science, Space, and Technology, U.S. House 
  of Representatives.............................................    16
    Written Statement............................................    17

                               Witnesses:

Dr. Richard Williams, Chief Health and Medical Officer, NASA
    Oral Statement...............................................    19
    Written Statement............................................    22

Captain Chris Cassidy, United States Navy (USN); Chief, Astronaut 
  Office, NASA
    Oral Statement...............................................    28
    Written Statement............................................    30

Captain Scott Kelly (USN, Ret.), Former Astronaut, NASA
    Oral Statement...............................................    35
    Written Statement............................................    37

Captain Michael Lopez-Alegria (USN, Ret), President, Association 
  of Space Explorers-USA; Former Astronaut, NASA
    Oral Statement...............................................    41
    Written Statement............................................    44

Dr. Jeffrey Kahn, Professor of Bioethics and Public Policy, Johns 
  Hopkins Berman Institute of Bioethics; Chairman, Committee on 
  the Ethics Principles and Guidelines for Health Standards for 
  Long Duration and Exploration Spaceflights, Board on Health 
  Sciences Policy, National Academies of Sciences
    Oral Statement...............................................    54
    Written Statement............................................    57

Discussion.......................................................    62

             Appendix I: Answers to Post-Hearing Questions

Dr. Richard Williams, Chief Health and Medical Officer, NASA.....    78

Captain Chris Cassidy, United States Navy (USN); Chief, Astronaut 
  Office, NASA...................................................   100

Captain Scott Kelly (USN, Ret.), Former Astronaut, NASA..........   109

Dr. Jeffrey Kahn, Professor of Bioethics and Public Policy, Johns 
  Hopkins Berman Institute of Bioethics; Chairman, Committee on 
  the Ethics Principles and Guidelines for Health Standards for 
  Long Duration and Exploration Spaceflights, Board on Health 
  Sciences Policy, National Academies of Sciences................   114

 
                        HUMAN SPACEFLIGHT ETHICS
                            AND OBLIGATIONS:
                  OPTIONS FOR MONITORING, DIAGNOSING,
                    AND TREATING FORMER ASTRONAUTS

                              ----------                              


                        WEDNESDAY, JUNE 15, 2016

                  House of Representatives,
                              Subcommittee on Space
               Committee on Science, Space, and Technology,
                                                   Washington, D.C.

    The Subcommittee met, pursuant to call, at 2:43 p.m., in 
Room 2318 of the Rayburn House Office Building, Hon. Brian 
Babin [Chairman of the Subcommittee] presiding.


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    Chairman Babin. The Subcommittee on Space will now come to 
order.
    Without objection, the Chair is authorized to declare 
recesses of the Subcommittee at any time.
    Good morning. Welcome to today's hearing titled ``Human 
Spaceflight Ethics and Obligations: Options for Monitoring, 
Diagnosing, and Treating Former Astronauts.''
    I recognize myself for five minutes and an opening 
statement.
    As a Nation, we have obligations to those we put in harm's 
way. As a Congress, we have a responsibility to provide for the 
treatment of conditions caused by federal service. As a 
legislator that represents the Johnson Space Center and the 
Astronaut Corps, I have a duty to care for my constituents.
    Since the 1960s, the United States of America has asked its 
bravest to travel in space in service to their country. The 
government recognizes its obligation to care for those it puts 
in harm's way in other instances. For example, we provide for 
the care of our veterans and our federal employees when their 
injuries are caused by their federal service.
    NASA currently provides treatment for active NASA 
Astronauts, and management and former astronauts are eligible 
for treatment of injuries sustained in their service through 
existing programs at the Department of Labor and the Department 
of Veterans Affairs.
    Over the last 15 years, several reports have highlighted 
the potential hazards of human spaceflight and the ethical 
obligations that we have as a Nation, and the additional steps 
that we might take and need to take to address gaps in meeting 
those obligations.
    From the dynamic launch environment to the unforgiving 
vacuum of space, to the energetic reentry to Earth, human 
spaceflight has always placed astronauts in challenging 
environments. Even training for spaceflight carries significant 
risks.
    Up until recently, however, space travel was measured in 
days. Mercury, Gemini, Apollo, and the Space Shuttle program 
placed astronauts in space for relatively short periods of 
time. Now, with the completion of the International Space 
Station, our astronauts now spend months in space. The risks 
and potential impacts on our astronauts' health are not always 
seen immediately.
    Captain Scott Kelly recently returned from the ISS after 
spending 340 days in space on one mission. This put his 
cumulative time in space at 520 days. Extended missions like 
his are teaching us a lot about the long-term effects of human 
spaceflight.
    Weightlessness leads to osteoporosis and loss in bone 
density. Long-duration space missions also seem to impact 
vision, as 60 percent of ISS astronauts reported worsening 
eyesight. Furthermore, radiation exposure increases the 
likelihood of cancer. These are just some of the conditions we 
know about. Staying in space longer and pushing farther into 
deep space will likely present additional risks.
    And while NASA attempts to mitigate these risks with 
protocols and countermeasures such as exercise, drug 
treatments, and spacecraft shielding, there will probably 
always be a cost to our astronauts that they bear for traveling 
in space.
    This raises several fundamental questions. For instance, is 
the request for additional authority simply about treating 
former astronauts, or is it also about NASA getting better data 
on human spaceflight? Are these two issues related? Are there 
classes of astronauts such as payload specialists who were not 
government employees that aren't covered by existing 
authorities? How should NASA administer treatment? Should they 
do it in-house or simply reimburse patients for this treatment? 
If NASA decided to diagnose conditions in-house, does this pose 
a potential conflict of interest when NASA is financially 
obligated to compensate former astronauts for conditions caused 
by their federal service? How would additional authority affect 
existing rights and benefits under current statutes? How would 
creating a new program at NASA impact the causation standard 
set forth by the Departments of Labor and Veterans Affairs? In 
other words, will a new authority make it easier or harder for 
astronauts to receive treatment and compensation?
    In order to address these questions, Congress included a 
provision in the 2005 NASA Authorization Act that asked for a 
plan on how to best provide for former astronaut care. 
Similarly, the most recent Authorization Act that received 
unanimous support in the House and awaits consideration by the 
Senate contained a provision asking for a cost estimate for 
expanding treatment.
    I think everyone here wants to make sure that we are doing 
right by our astronauts. They put themselves in harm's way to 
advance our knowledge of the universe and by bringing great 
pride to our Nation.
    I'm also very proud to say that I represent a great number 
of these astronauts who call Houston their home. As a health 
care professional myself and as their representative, you could 
say it's my duty emphatically to make sure these folks are 
taken care of properly.
    But this isn't simply about addressing a moral and ethical 
obligation. There is also a great benefit that we receive from 
providing this care. The long-term health information gained by 
providing treatment to former astronauts will give us a greater 
understanding of radiation exposure, vision impairment, bone 
loss, and many other ailments. This in turn will assist us to 
develop better monitoring and treatment protocols here on Earth 
for everyone, not just astronauts.
    I thank today's witnesses for joining us as we discuss 
these very, very significant and important issues, and I look 
forward to hearing your testimony and your answers to our 
questions.
    [The prepared statement of Chairman Babin follows:]
    
    
    
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    Chairman Babin. I now recognize the Ranking Member, the 
gentlewoman from Maryland, for an opening statement.
    Ms. Edwards. Good afternoon, and thank you, Mr. Chairman. I 
want to extend a welcome to our distinguished panel this 
afternoon, and thank you as well for your patience.
    Human space flight is inherently risky. That's why NASA 
exercises diligence and caution during all phases of a space 
mission, including training, vehicle flight testing, launch, 
mission operations, and landing.
    In addition to mission risks, astronauts bear significant 
personal risks, particularly as they relate to their health. 
Health risks during long-duration flights include both short-
term health consequences as well as potential long-term health 
conditions that may arise months and sometimes years after an 
astronaut's service.
    This is a problem. Because of the small number of U.S. 
astronauts who have flown in space, and the corresponding small 
data set currently available on astronaut exposure during long-
duration flights, characterizing those risks is a major 
challenge for NASA. However, if we are to go to Mars, as I have 
strongly advocated, mitigating these health risks is critical. 
But we also need to ensure that the risks NASA's astronauts 
take are recognized and addressed by the American people.
    While active astronauts receive comprehensive health care, 
former astronauts do not. This needs to change. We need to 
ensure that care is provided for all of our NASA astronauts, 
not just those who are on active status. Providing ongoing 
medical care for active and former astronauts will give NASA 
the needed insight to enable earlier detection and treatment of 
any potential medical problems that could result from human 
spaceflight. It will also provide NASA with the data that are 
necessary to help mitigate against health risks related to 
future human space exploration.
    This is also a recommendation of a 2014 National Academies 
report, which concluded that lifetime healthcare for astronauts 
is our ethical responsibility. The report's principle of 
fidelity recognizes that ``Given the risks that astronauts 
accept in participating in hazardous missions, NASA should 
respect the mutuality of obligations and ensure health care and 
protection for astronauts not only during the mission but after 
return, including provision of lifetime care for astronauts.''
    NASA responded to the National Academies report by 
proposing a legislative change that would give NASA the 
authority to provide medical monitoring, diagnosis and 
treatment for psychological and medical conditions that are 
deemed by NASA to be associated with human spaceflight.
    It's worth noting that, as the Chairman indicated, the 
bipartisan NASA Authorization Act of 2015, H.R. 810, that was 
passed by the House in February 2015, directs NASA to provide a 
formal response to the National Academies report. This 
response, as directed in the legislation, must include the 
budgetary resources required for implementation of the report's 
recommendations, as well as any options that might be 
considered as part of the response. Had that bill been enacted, 
it is likely that our discussion today would have been much 
better informed.
    That said, Mr. Chairman, it's clear to me that ensuring 
comprehensive care of our astronauts before, during, and after 
their active service is a high priority. NASA's legislative 
proposal provides one option for addressing this issue, and I 
hope that we can explore other options as well.
    However, the impact each option would have on existing 
authorities warrants careful consideration. For example, should 
Congress direct NASA to provide astronauts with lifetime 
healthcare in return for their service to the nation? Under 
this scenario, how would existing astronaut healthcare support 
systems be affected, including those provided by the Veterans 
Administration for former military astronauts? Or should 
Congress pattern astronaut care after NASA's legislative 
proposal by directing NASA to provide enhanced medical 
screening that would facilitate claims made by former 
astronauts for occupational health conditions under the FECA 
and VA processes and provide proactive diagnosis and treatment, 
if needed, while those FECA and VA processes are underway? In 
either scenario, how would such authority be implemented?
    In addition, we need to clarify on how NASA intends to 
establish the causality link between human spaceflight and any 
identified psychological and medical conditions astronauts may 
develop. The bottom line here is that we need to do the right 
thing.
    And so Mr. Chairman, if the Committee intends to address 
the issues contained in NASA's proposal, I would hope that we 
could craft legislation on a bipartisan basis, and I look 
forward to working with you.
    Thank you, and with that, I yield the balance of my time.
    [The prepared statement of Ms. Edwards follows:]
    
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    Chairman Babin. Thank you very much, Ms. Edwards.
    I now recognize the Chairman of our full Committee, Mr. 
Smith from Texas.
    Chairman Smith. Thank you, Mr. Chairman, and welcome to our 
all of our witnesses today including three astronauts. I often 
say publicly, and I'll say again now, that I consider 
astronauts to be our modern heroes for many, many reasons, and 
certainly appreciate their presence here today.
    Mr. Chairman, I also believe this is probably the first 
hearing we have had dedicated entirely to the subject of 
astronauts' health in space, and so it's most timely, and as 
you and the Ranking Member both mentioned, it might lead to 
legislation that can be helpful to them in the future.
    Since NASA selected the first group of astronauts in 1959, 
more than 300 of America's finest have ventured into the cosmos 
as explorers. Each one of these astronauts represented the 
compelling urge of humankind to explore and to discover and the 
lure of curiosity that leads us to try to go where no one has 
gone before. From Neil Armstrong's first step on the Moon to 
Captain Kelly's one-year voyage on the International Space 
Station, their peaceful exploration of outer space continues to 
inspire our nation and the world.
    In an age when spaceflight has come to seem almost routine, 
it is easy to overlook how dangerous it is and how little we 
know about the long-term health effects of spaceflight.
    For almost 20 years, astronauts have lived on the 
International Space Station. One of their primary missions has 
been to learn about the physiological and psychological effects 
of long-duration human spaceflight. Captain Kelly's one-year 
mission was in pursuit of a scientific understanding of how the 
human body responds to extended space flight.
    But even with our 20 years of experience on the ISS, we are 
only just beginning to understand the effects of long-duration 
missions. Our lack of knowledge becomes especially evident as 
NASA prepares for its journey to Mars.
    Only 24 individuals have journeyed beyond low-earth orbit. 
All of these astronauts flew during the Apollo era and never 
for more than a handful of days. Using our current propulsion 
technology, a successful mission to Mars will require 
astronauts to survive a roundtrip spaceflight of no less than 
several hundred days, and unlike our near-Earth environment, 
the trip to Mars will offer no natural protection from galactic 
cosmic rays and solar radiation.
    Today, through its Lifetime Surveillance of Astronaut 
Health program, NASA screens and monitors astronauts for 
occupational related injury or disease. This program 
contributes to our scientific knowledge of long-term health 
effects and assists participating astronauts in monitoring for 
spaceflight related illnesses and disease.
    But this program does not provide for diagnosis or 
treatment of those no longer serving, nor for management and 
retired astronauts because NASA is not explicitly authorized to 
provide such services. These astronauts can receive treatment 
from the Department of Labor or the Veterans Administration 
now, but this may not be the best process for the former 
astronauts or NASA's developing knowledge base.
    We as a nation have a responsibility to ensure that our 
astronauts, both active and retired, are provided with 
appropriate monitoring, diagnosis, and treatment of 
spaceflight-related injuries and disease. This is also the 
recommendation of the National Academy of Sciences in its 
review of NASA's study of astronaut health.
    For our nation, the question should not be whether we 
should provide these services to our astronauts, but rather how 
to do it in a way that best addresses the current and future 
needs of our space explorers in America's quest for discovery 
of new frontiers.
    Thank you Mr. Chairman, and I'll yield back.
    [The prepared statement of Chairman Smith follows:]
    
    
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    Chairman Babin. Thank you, Mr. Chairman. I appreciate you.
    I now recognize the Ranking Member of the full Committee 
for a statement, Ms. Johnson from Texas.
    Ms. Johnson. Thank you very much, and good afternoon. Let 
me welcome our distinguished witnesses.
    Mr. Chairman, I'd like to thank you for holding this 
hearing on ``Human Spaceflight Ethics and Obligations: Options 
for Monitoring, Diagnosing, and Treating Former Astronauts.''
    Our NASA astronauts are American heroes, and they are some 
of the most accomplished, highly trained, and courageous 
individuals who serve our nation in the pursuit of furthering 
our exploration of outer space.
    Astronauts and our human space program also inspire the 
next generation, with many of our youngest Americans dreaming 
of one day following in their footsteps and exploring outer 
space. And I might add that no child falls asleep when there's 
an astronaut speaking in high schools.
    It is no surprise that our astronauts are held in very, 
very high regard. They accept considerable risks in doing their 
jobs and serving our nation. And over the decades that we have 
been sending humans into outer space, more than a dozen NASA 
astronauts have paid the ultimate price as part of this 
service.
    That's why I'm pleased that we are examining the 
responsibility we have to care for our astronauts, even after 
they have left active status including looking at the risk of 
cancer, musculoskeletal conditions, and ocular disorders are 
just a few of the known health concerns related to human 
spaceflight. But there is still much that we are learning and 
need to learn about the potential effects of space on the human 
body and on human health.
    Congress has acted to ensure that others we have put in 
harm's way, such as those who have served in our military, 
receive lifetime healthcare. It is time we do the same for NASA 
astronauts.
    The practicalities of how we authorize the provision of 
such health care is very important, and I look forward to 
hearing from our witnesses on key questions and issues that 
Congress needs to consider before we legislate in this area.
    I thank you, Mr. Chairman, and yield back.
    [The prepared statement of Ms. Johnson follows:]
    
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      Chairman Babin. Yes, ma'am. Thank you.
    Now I'd like to introduce our panel of distinguished 
witnesses.
    Our first witness today is Dr. Richard Williams, Chief 
Health and Medical Officer for NASA. In this role, Dr. Williams 
is responsible for the oversight of all health and medical 
activities at NASA including the medical aspects of all 
national and international NASA missions involving humans. He 
has extensive experience in the clinical practice of general 
surgery, aerospace medicine, and occupational medicine as well 
as in administrative medical management. During his 27-year Air 
Force career, Dr. Williams served in a wide variety of settings 
as a clinical practitioner and medical leader including service 
in the contingency deployments. Dr. Williams holds an M.D. 
degree from the Virginia Commonwealth University and completed 
residencies in general surgery at Wright State University and 
an aerospace medicine and occupational medicine at the United 
States Air Force School of Aerospace Medicine at Brooks Air 
Force Base in Texas. Thank you for being here.
    Second witness today Captain Chris Cassidy, a United States 
Navy SEAL and the 16th Chief of the Astronaut Office at NASA. 
As NASA's Chief Astronaut, he is responsible for flight 
assignments, mission preparation, and on-orbit support of U.S. 
crews as well as organizing astronaut office support for future 
launch vehicles. Captain Cassidy was selected as an astronaut 
by NASA in 2004, and he's a veteran of two space flights, STS-
127 and Expedition 35. During STS-127, Cassidy served as a 
Mission Specialist and was the 500th person in history to fly 
into space. Captain Cassidy has been deployed twice to the 
Mediterranean and twice to Afghanistan. He is the recipient of 
the Bronze Star with a Combat V and Presidential Unit Citation 
for leading a nine-day operation at the Zawar Kili Cave on the 
Afghanistan-Pakistani border. Captain Cassidy received a 
bachelor of science in mathematics from the U.S. Naval Academy 
and a master of science in ocean engineering from Massachusetts 
Institute of Technology. Thank for being here. I'm the proud 
father of a Navy SEAL myself.
    Our third witness today is Captain Scott Kelly, a retired 
U.S. Naval Officer and former NASA Astronaut, who is fresh off 
his one-year mission in space. Welcome home, Captain Kelly. 
I've had the distinct pleasure and honor of meeting and 
visiting with Captain Kelly on several occasions before and 
after his historic mission. In 1996, Captain Kelly was selected 
by NASA. He has logged more than 520 days in space on four 
space flights and served as Space Shuttle Pilot on STS-103 in 
1999 and was the Mission Commander on STS-118 in 2007. Captain 
Kelly also served as a Flight Engineering for ISS Expedition 
25, and as the Commander of ISS Expedition 26. In March of 
2015, Captain Kelly launched for a one-year mission to the ISS 
serving as a Flight Engineer for Increments 43 and 44 and 
Commander for Increments 45 and 56. Captain Kelly returned to 
Earth on March 2nd, 2016, after his historic 340-day mission 
aboard the ISS. Captain Kelly received a bachelor of science 
degree in electrical engineering from the State University of 
New York Maritime College and a master of science degree in 
aviation systems from the University of Tennessee in Knoxville. 
Thanks for being here, Captain Kelly.
    Our fourth witness today is Captain Michael Lopez-Alegria, 
President of the Association of Space Explorers-USA, a retired 
U.S. Naval Officer, and former NASA Astronaut. Captain Lopez-
Alegria has over 35 years of aviation and space experience with 
the U.S. Navy and NASA and a variety of roles including Naval 
Aviator, Engineering Test Pilot, and Program Manager, NASA 
Astronaut, and International Space Station Commander. He is a 
four-time astronaut, having flown on Space Shuttle Missions 
STS-73, STS-92, and STS-113, and serving as Commander of ISS 
Expedition 14, flying to and from the ISS aboard Soyuz-IMA-9. 
He holds NASA records for the most extravehicular activities, 
or spacewalks, or EVAs, 10 EVAs and cumulative EVA time of 67 
hours and 40 minutes. Captain Lopez-Alegria received a bachelor 
of science in systems engineering from the U.S. Naval Academy 
and master of science in aeronautical engineering from the U.S. 
Naval Postgraduate School. He is also a graduate of Harvard 
University's Kennedy School of Government Program for Senior 
Executives and National and International Security. Thank you 
for being here today, Captain.
    Our final witness today Dr. Jeffrey Kahn, Professor of 
Bioethics and Public Policy at Johns Hopkins Berman Institute 
of Bioethics, and Chairman of the Committee on Ethics, 
Principles and Guidelines for Health Standards for Long 
Duration and Exploration Spaceflights for the Board on Health 
Sciences Policy at the National Academies of Sciences. His 
research interests include the ethics of research, ethics in 
public health, and ethics in emerging biomedical technologies. 
Dr. Kahn speaks widely both in the United States and abroad and 
has published four books and over 125 articles in bioethics and 
medical literature. Dr. Kahn received his B.A. from the 
University of California-Los Angeles, Ph.D. from Georgetown 
University, and MPH from Johns Hopkins Bloomberg School of 
Public Health.
    The Committee also invited a representative from the 
Department of Labor to discuss how the Department of Labor 
currently provides for treatment of federal employees under the 
Federal Employee Claims Act, or FECA. The Committee sent 
Secretary Perez or anyone in the agency that he would like to 
designate an invitation to appear. Unfortunately, the 
Department of Labor could not find anyone to appear, which is 
very surprising since there are 17,000 employees at the 
Department of Labor.
    Furthermore, we only asked them to comment on what they 
already do. Executive Branch officials have a responsibility to 
Congress and to the taxpayers of the United States to provide 
testimony and inform the legislative process. I am disappointed 
that a federal agency was unable to assist Congress, failing to 
fulfill this fundamental responsibility. It is no wonder that 
NASA wants to handle these issues themselves.
    I would now like to recognize Dr. Williams for five minutes 
to present his testimony.

               TESTIMONY OF DR. RICHARD WILLIAMS,

             CHIEF HEALTH AND MEDICAL OFFICER, NASA

    Dr. Williams. Mr. Chairman and Members of the Committee, 
thank you for this opportunity to appear before you today to 
discuss the critical issue of astronaut healthcare. This is an 
issue that has consumed me in my role as Chief Health and 
Medical Officer for NASA, and I am very grateful that the 
Committee is using its limited time and resources to focus on 
this critical agency priority.
    Astronauts are exposed to unique hazards that no one else 
on Earth has experienced. Microgravity and space radiation are 
just two of the exposures that are only found when we venture 
into space. Some conditions such as reduced muscle mass caused 
by exposure to microgravity are somewhat foreseeable while 
others are complete surprises. Certainly, the visual problems 
and increased risk of cataracts astronauts experience was not 
expected or predicted.
    For active astronauts, NASA currently provides medical care 
and treatment. We also use data from the treatment of active 
astronauts to figure out ways to minimize negative impacts to 
astronaut health.
    Some of the things we do include monitoring for radiation 
exposure, using exercise to combat microgravity effects, and 
continued health monitoring. While these efforts can't entirely 
mitigate exposure to space, they are valuable.
    However, when it comes to former astronauts, the situation 
is different. We invite astronauts to participate in our 
voluntary Lifetime Surveillance of Astronaut Health program. 
This includes a limited health status evaluation on an annual 
basis at the Johnson Space Center Flight Medical Clinic.
    However, if there are questions or concerns from this 
evaluation, NASA can only encourage astronauts to follow up 
with their personal healthcare providers. This presents a 
number of problems. NASA cannot do all the tests it believes 
need to be done to effectively monitor former astronauts as 
some of these tests would be considered personal healthcare. If 
personal physicians do tests and evaluations, we often do not 
have access to the data unless the astronaut aggressively 
pursues getting this data to us. And healthcare providers often 
don't understand the need for some of the targeted tests that 
we require for occupational health surveillance and would not 
routinely order them.
    For example, some astronauts should probably be receiving 
yearly MRI scans of the area around their eyes. MRI scans are 
not normally used as preventive screening; they are usually 
ordered in response to illness or injury.
    I need to emphasize how small this population is. There are 
only 280 living astronauts that have flown in space--280. That 
isn't even enough to take a good consumer product survey, let 
alone try to predict what effects human spaceflight might have 
on the human body 10, 20 or 30 years down the road. An average 
doctor or nurse practitioner no matter how skilled they are has 
no exposure to or understanding of these issues.
    With only 280 people to collect data from, we need to get 
as much data as possible from every one of them. With only 60 
percent of our former astronauts participating in the current 
surveillance program, expanding our authority to provide for 
extensive testing would be a great incentive to increase this 
number. We believe 80 percent or more would participate if our 
authority to provide testing and monitoring was expanded.
    Being able to gather data on astronauts' medical conditions 
and understand the health impact of spaceflight exposures over 
time is essential to provide crew health and safety during 
long-term journeys beyond low-Earth orbit. If we're serious 
about going anywhere beyond low-Earth orbit, we'll need to 
understand these risks.
    Ethically, we will make sure all decisions astronauts make 
about their healthcare and personal information are completely 
voluntary. This brings me to an issue that may even be more 
important than our need for data, and that is our ethical 
obligation to our astronauts. When the United States government 
puts individuals in harm's way, our government has an 
obligation to care for them. Our military personnel are 
provided the care they need for the hazards and dangers they 
have faced in service to our country. The Institute of Medicine 
has in multiple studies pointed out that NASA has an ethical 
obligation to the astronauts who have dared exposures no other 
human beings in history has faced.
    To meet the health needs of our astronauts and to live up 
to our ethical obligations, I urge Congress to act to ensure we 
can safeguard the well-being of our former and future 
astronauts.
    Mr. Chairman, I would be glad to answer any question you or 
any other member might have.
    [The prepared statement of Dr. Williams follows:]
    
    
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    Chairman Babin. Thank you, Dr. Williams.
    I now recognize Captain Cassidy for five minutes to present 
his testimony.

              TESTIMONY OF CAPTAIN CHRIS CASSIDY,

                   UNITED STATES NAVY (USN);

                 CHIEF, ASTRONAUT OFFICE, NASA

    Captain Cassidy. Mr. Chairman and Members of the Committee, 
I sincerely appreciate the chance to appear before you today. 
Thank you very much.
    As the Chief Astronaut for NASA, this issue is not only 
critically important to the agency but also of great importance 
to myself, both professionally and personally. In my role as 
the Chief, I serve in the most senior leadership position for 
active astronauts. I am the principal adviser Administrator 
Bolden through NASA leadership and the chain of command on all 
aspects of astronaut operations. This covers a wide variety of 
tasks from astronaut training, operations, and safety to 
advising on spacecraft design and even finding astronauts to 
speak in order to inspire our nation's students and the public 
and to keep those high school students from falling asleep.
    We take healthcare very, very seriously. Other than our 
crew, the most precious resource on the International Space 
Station is time. We have an international mix of six crew 
members on the Space Station, and each of them has only 16 
hours of awake time per day. Every minute of this period is 
treated as a critical resource similar to that of air, water or 
food. This time is used to accomplish the hundreds of 
scientific experiments to execute the many tasks required to 
keep the ISS functioning yet we still schedule two hours of 
exercise every single day. This is done simply because it's the 
best way we have found to counteract the effects of 
microgravity exposure. Without a doubt, there are many other 
tasks that could be accomplished with those two hours. However, 
absolutely nothing is more important than keeping our 
astronauts as healthy as we possibly can.
    Our knowledge of the kinds of health changes associated 
with the exposure to space has increased as more astronauts fly 
on the Space Station. Conditions have surfaced after long-
duration spaceflight that were not apparent in short-term space 
exposure. For example, muscle atrophy and the associated bone 
loss have been experienced on longer-duration flights that were 
not a concern on shorter missions.
    There are other major risks to long-term exposure to space. 
There is far more radiation in space without the protection of 
Earth's magnetic field. There is also experimental evidence 
that radiation encountered in space as compared to gamma or X-
rays commonly encountered on Earth is more effective at causing 
the type of biological damage that ultimately leads to cancer. 
This means that astronauts need to be more closely monitored 
for cancer for the rest of their lives versus someone who has 
not flown in space.
    Right now, NASA only has limited authority to provide 
medical monitoring for former astronauts. Our current program, 
the Lifetime Surveillance of Astronaut Health, does basic 
health screening but can't provide for the advanced monitoring 
and testing that is needed. Expanding the tests and conditions 
NASA can proactively monitor would greatly assist in 
establishing the evidence base that we need. It would also 
increase the numbers of astronauts who participate. With only 
about 280 living people who have flown in space, and about 60 
percent of those former astronauts participating in a limited 
health evaluation, every additional astronaut who can be part 
of this population is vital.
    The other reason for doing this extensive monitoring is to 
catch medical conditions in the early stages before they become 
more serious. Proactive monitoring gives us a much better 
chance of treating diseases in the early stages with a greater 
likelihood for a positive outcome.
    The lack of advanced monitoring worries me for another 
reason. We are involved in helping to evaluate our new 
generation of spacecraft, and the lack of data hampers us in 
our efforts to go beyond low-Earth orbit. How do we design 
vehicles to protect against the long-term effects of 
microgravity and radiation exposure if we still aren't certain 
of what those effects entirely are?
    I work with our Astronaut Corps on a daily basis. This 
isn't just an abstract issue for me. I know these men and women 
and their families. Their dedication, enthusiasm, bravery and 
diligence while they voluntarily accept the risks and dangers 
of spaceflight, that should not be an excuse to not be thorough 
with their health. We need to do everything in our power to 
understand and minimize the hazards they face in order to 
further protect future generations of Americans who will one 
day live off of our planet.
    Mr. Chairman, I would be happy answer your questions, and I 
look forward to them. Thank you.
    [The prepared statement of Captain Cassidy follows:]
    
    
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    Chairman Babin. Thank you, Captain Cassidy. I really 
appreciate that.
    I now recognize Captain Kelly for five minutes to present 
his testimony.

                TESTIMONY OF CAPTAIN SCOTT KELLY

                          (USN, RET.),

                     FORMER ASTRONAUT, NASA

    Captain Kelly. And Mr. Chairman, I have a short video, if 
you don't mind, an introduction video.
    [Video playback]
    Mr. Chairman and Members of the Subcommittee, thank you for 
the opportunity to appear before you today to discuss the 
importance of understanding the medical impacts of human 
spaceflight on astronauts and the proposed legislation on 
astronaut health. This issue is of critical importance to me 
and to our nation's future space exploration initiatives.
    I recently returned with my colleague, Russian Cosmonaut 
Mikhail Kornienko, from nearly a year in space aboard the Isa, 
which serves as our best asset for understanding how human 
physiology behaves in a microgravity environment. Until at 
least 2024, the Space Station will continue to provide a 
platform for research on astronaut health and many other 
scientific investigations.
    The major objective of this Year in Space mission was to 
expand the experience and knowledge base required to safely 
send humans deeper into our solar system. A Mars mission is no 
easy feat and could require astronauts to be in space for three 
years or more. During this mission, we conducted more than 400 
experiments in the fields of biology, material sciences, 
chemistry, and physics. Many of these experiments focus on how 
the human body responds to weightlessness and other effects of 
long-duration spaceflight.
    One of these experiments, which was dubbed the Twins Study, 
gave researchers the unique opportunity to study my physiology 
while I was in space compared to my twin brother, retired 
Astronauts and Navy Captain Mark Kelly, who was on Earth. Data 
acquired from this Year in Space Mission will help NASA make 
determinations that will directly affect decisions regarding 
crew safety in the years to come in areas from the design of 
future spacecraft to medical and psychological risk mitigation. 
Although I've been home for 100 days, much of the data is still 
being analyzed by researchers from around the world.
    You know, much attention is paid to the risks astronauts 
face while launching aboard rockets or returning to Earth in a 
giant fireball. Much less attention is given to the other risks 
we face, which are much more insidious but potentially just as 
fatal. The environment astronauts are exposed to while in space 
is unlike anything we experience here on Earth. Specifically, 
we're exposed to high levels of radiation and carbon dioxide, 
and a microgravity environment which causes loss of bone and 
muscle, vision impairment, and effects on our immune system, to 
name just a few. These are very real issues that need to be 
solved before the human race is able to reach destinations 
beyond the Earth and the Moon.
    When I returned after 340 days, I was surprised how 
differently I felt compared to my long-duration mission of 159 
days. My muscles more quickly stiffened, and because my skin 
hadn't touched anything for nearly a year, it was extremely 
sensitive and became inflamed. I developed a hive-like rash on 
every surface of my skin that came in contact with ordinary 
surfaces on Earth during normal activities like sitting or 
lying in bed. My legs were swollen due to the fluid shift 
imposed upon my body by gravity. I even had flu-like symptoms 
that appeared to have been a result from my extended time in 
space.
    Exposure to the space environment has permanent effects we 
simply do not fully understand. The Lifetime Surveillance of 
Astronaut Health program NASA has in place to study astronaut 
long-term health is too limited to provide the data needed to 
ensure the safety of our space explorers. If we are to go 
beyond low-Earth orbit, NASA needs the ability to proactively 
and aggressively monitor, diagnose and treat astronauts who 
serve our country in the name of science and exploration. 
Expanding healthcare coverage for our U.S. Astronaut Corps will 
enable NASA to more effectively and efficiently support it and 
collect the data necessary to push out further into our solar 
system.
    Furthermore, continued investigation of space-related 
ailments and mitigation steps will help in treating similar 
ailments on Earth such as osteoporosis, muscle wasting 
diseases, high blood pressure, glaucoma, and certain brain 
disease, to name just a few. There are already FDA-approved 
treatment modalities which are a result of space-based 
research.
    Although Mars and other long-term NASA objectives seem to 
be many years ahead of us, laying a secure foundation for 
astronaut health is imperative to the continuance of our 
nation's ability to explore. Healthcare for our astronauts is 
critically important. Our astronauts are exposed to numerous 
health risk factors while in space, and while we are aware of 
some of the impacts, we just need more data from astronauts in 
space and on the ground to better understand these negative 
effects of this harsh environment.
    The proposed legislation on astronauts health will not only 
help us learn more about the impacts of human spaceflight but 
also will serve to protect the health of those who push the 
boundaries in the name of exploration on behalf of our nation. 
We are on the cusp of a new Space Age, one in which greater 
numbers of Americans will travel to space and go further than 
ever before.
    I was honored to play a small role in paving the way for 
those future pioneers but want to make it clear, this Year in 
Space mission was not my achievement; it was the achievement of 
thousands of dedicated professionals that believe, like I do, 
that the benefit of human spaceflight is vital to the continued 
success and development of our nation and our species.
    Mr. Chairman, I'd be happy to respond to any questions you 
or other members of the Subcommittee may have. Thank you.
    [The prepared statement of Captain Kelly follows:]
    
    
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    Chairman Babin. Thank you, Captain Kelly. We really 
appreciate your testimony.
    And now I recognize Captain Lopez-Alegria for five minutes.

     TESTIMONY OF CAPTAIN MICHAEL LOPEZ-ALEGRIA (USN, RET),

         PRESIDENT, ASSOCIATION OF SPACE EXPLORERS-USA;

                     FORMER ASTRONAUT, NASA

    Captain Lopez-Alegria. That's all right. Thanks, Chairman 
Babin, Ranking Member Edwards, and Chairman Smith, and Ranking 
Member Johnson and all the Members of the Subcommittee. Thanks 
for organizing this hearing and for asking me to give you some 
comments on the proposed legislative language as the President 
of the USA Chapter of the Association of Space Explorers.
    ASE is an international nonprofit professional and 
educational organization that has only one prerequisite for 
membership: having made at least one orbit of the Earth in 
space. Our vision is a world where living, working and 
exploring in space will be as familiar to humanity as life on 
our home planet.
    We count among our members over 400 current and former 
astronauts and cosmonauts from 37 nations and are organized 
into four regional chapters: Russia, Europe, Asia, and ASE-USA, 
by far the largest with 214 living members.
    There's a standing joke at the NASA Johnson Space Center in 
Houston that if you ask five astronauts for their opinion on an 
issue, you'll get at least six answers. Nonetheless, the 
response I received from the membership of ASE-USA was absolute 
unanimity in support of the change that would allow NASA to 
provide enhanced monitoring, diagnosis, and treatment of the 
effects of health hazards that are associated with having flown 
in space.
    I heard from former astronauts who left the agency from 
several months to several decades ago, and many of the stories 
were strikingly similar. My written statement mentions some of 
the known health hazards that are unique to the spaceflight 
environment, and members of the ASE-USA convincingly confirmed 
that that list is real with many personal accounts of 
musculoskeletal, vision, bone density, and most grimly, cancer-
related medical issues.
    In some case, their maladies were flagged during annual 
exams that are offered by NASA as part of the Lifetime 
Surveillance of Astronaut Health but in all cases, further 
diagnosis and any treatment is at the expense of the astronaut. 
There is ample precedent for targeted surveillance and 
treatment for occupationally related medical conditions both 
within the government, for instance, healthcare for veterans as 
well as screening for DOE and DOD nuclear workers as well as by 
non-government employers for their workers in mines, foundries, 
and in civilian nuclear power industry.
    But as compelling as some of my former colleagues' medical 
situations are, the most persuasive argument for this type of 
legislation is that understanding the human physiological 
response to spaceflight is imperative to inform future policies 
and procedures for managing health risks in space.
    In the absence of methodical medical surveillance and care 
for those exposed to these health risks, we are irretrievably 
losing an invaluable source of data and severely hampering our 
plans to extend human exploration beyond low-Earth orbit.
    The current and former astronaut cadre is the only study 
population that can facilitate our understanding of past and 
future space-related health risks. It is unforgivable to not 
monitor their health and collect and analyze the relevant 
associated data.
    I'm a participant in a previously mentioned LSAH. Each year 
I travel to Houston and receive a medical check that includes 
collecting my vital signs, blood and urine samples, exams of my 
vision, hearing, and lung function, an EKG, and a brief 
physical exam by a flight surgeon. Every few years, it is 
recommended that I undergo a colonoscopy to look for polyps or 
tumors that may have appeared as a result of my exposure to 
ionizing radiation while on orbit. The procedure is completely 
voluntary, and if I do choose to have it done, the results are 
not a priori shared with NASA. This is just one example of the 
lack of monitoring that negatively affects our understanding of 
the epidemiology of spaceflight.
    Another valuable test that might be performed is high-
powered MRI of my eyes to look for anatomical changes. Like 
about 60 percent of long-duration astronauts, I suffer from 
microgravity ocular syndrome, sometimes called vision 
impairment and intracranial pressure. VIIP is emerging as one 
of the most significant and least understood health risks for 
human exploration beyond low-Earth orbit. It seems absurd that 
we do not actively study those who have suffered from it.
    During my seven months aboard the ISS, my bone mineral 
density decreased by over ten percent. While the density itself 
recovered after a couple of years, we don't fully understand if 
the structure of the bone and therefore its resistance to 
fracture has returned. A test like QCT, quantitative computed 
tomography, cannot only measure bone mineral density but also 
assess the geometry of the bone and the stress-strain index, a 
much better measure of fracture resistance. This test is also 
not performed as part of LSAH.
    What I found perhaps most startling in responses from the 
ASE-USA membership was how many reported that they have dropped 
out of the LSAH program. A relatively routine physical that 
lacks targeted surveillance of known space-related health 
hazards, let alone any kind of in-depth diagnosis or provision 
of treatment, is simply not compelling enough for many former 
astronauts who might live far from Houston to take time from 
work and family to make the trip. This means that not only is 
NASA deprived of any data related to spaceflight-specific 
health risks, even the routine surveillance that is part of 
today's LSAH is often being done by local medical providers and 
the associated information is lost to NASA.
    There is a moral and ethical obligation on the part of any 
employer to exercise due diligence to study all occupational 
hazards that its employees encounter in the workplace to 
understand the short- and long-term health effects of those 
dangers to use all reasonable methods to prevent these risks 
from negatively impacting the well-being of its current and 
future workers and to provide care for former employees who 
suffer health issues as a result of their service.
    There are a number of significant human health risks 
associated with flying in space. Many of these perils are 
unique to the spaceflight environment and most evade our full 
understanding. It's clear that we must do our utmost to 
mitigate these risks for the cadre of current and future 
American astronauts by assiduously monitoring the health and, 
where applicable, treatment of their predecessors. This 
information is absolutely imperative for the design of 
missions, vehicles, and countermeasures for the human 
exploration of space beyond low-Earth orbit.
    Thank you again for this opportunity, and I look forward to 
answering questions from the Subcommittee.
    [The prepared statement of Captain Lopez-Alegria follows:]
    
    
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    Chairman Babin. Thank you, Dr. Lopez-Alegria.
    And now I recognize Dr. Kahn for five minutes.

                 TESTIMONY OF DR. JEFFREY KAHN,

           PROFESSOR OF BIOETHICS AND PUBLIC POLICY,

          JOHNS HOPKINS BERMAN INSTITUTE OF BIOETHICS;

                   CHAIRMAN, COMMITTEE ON THE

                ETHICS PRINCIPLES AND GUIDELINES

             FOR HEALTH STANDARDS FOR LONG DURATION

                 AND EXPLORATION SPACEFLIGHTS,

                BOARD ON HEALTH SCIENCES POLICY,

                 NATIONAL ACADEMIES OF SCIENCES

    Mr. Kahn. Thank you. Chairman Babin, Ranking Member 
Edwards, Committee Chairman Smith, and Ranking Member Johnson, 
thank you for the opportunity to present testimony on this 
timely and vitally important subject today. I am a Professor of 
Bioethics and Public Policy at the Johns Hopkins University 
Berman Institute of Bioethics in Baltimore, and I should say 
after the introduction of my fellow witnesses, a rank 
underachiever.
    I appear before you today in my capacity as Chair of the 
Institute of Medicine--now the National Academy of Medicine--
Committee on Ethics Principles and Guidelines for Health 
Standards for Long Duration and Exploration Spaceflights, which 
issued its report in April 2014, as Representative Edwards has 
already noted.
    In addition, I should note that I'm currently Chair of the 
Board on Health Sciences Policy for the Health and Medicine 
Division of the National Academies, and a member of the 
Division's standing Committee on Aerospace Medicine and 
Medicine of Extreme Environments.
    In those contexts, I will describe recommendations 
contained in the report of the committee I mentioned related to 
protecting and sustaining astronaut health.
    First, I want to say that my committee's report in 2014 was 
not the first to identify the ethical obligations to protect 
astronaut health, as has been noted by others. As outlined in 
the 2001 IOM report titled Safe Passage, and as noted in the my 
committee's report as well, the new challenges that will be 
faced in long-duration and exploration spaceflight necessitate 
a new look at the ethics principles for these missions, and I 
quote now from Safe Passage: ``Current ethical standards for 
clinical research and practice with astronauts were developed 
in an era of short space missions when repeat missions were the 
norm and a return to Earth within days was possible. In future 
missions beyond Earth orbit, however, a diverse group of 
astronauts will travel to unexplored destinations for prolonged 
periods of time. Contact with Earth will be delayed, and a 
rapid return will be impossible. Long-duration missions beyond 
Earth orbit, space colony habitation, or interplanetary travel 
will create special circumstances for which ethical standards 
developed for terrestrial medical care and research may be 
inadequate for astronauts. These ethical standards may require 
reevaluation.'' That again is from 2001.
    My committee in 2014 noted that NASA, as an employer, a 
federal agency responsible for innovation and exploration, a 
research sponsor, and an international partner, has moral 
obligations to formally recognize and act on responsibilities 
that logically flow from the ethics principles outlined in our 
report if long-duration and exploration spaceflights are to be 
ethically acceptable. Among the six principles we identified, 
two are particularly relevant for discussion in the context of 
health care for former astronauts. Those principles are (1) 
fairness, and (2) as already noted by Representative Edwards, 
fidelity. Let me quote from the report. ``Fairness is the 
principle that requires that equals be treated equally, that 
burdens and benefits be distributed fairly, and that fair 
processes be created and followed. NASA's decision making 
surrounding missions should explicitly address fairness, 
including the distribution of the risks and benefits of the 
mission, crew selection, and protections for astronauts after 
missions.''
    An important ethical challenge of exposing humans to the 
risks of long-duration and exploration spaceflight is that the 
burden of the health risks associated with these missions falls 
to a limited number of astronauts and their families as well 
while the benefits of the proposed missions accrue primarily to 
future astronauts and to society more broadly.
    In addition to being a concern of appropriate risk-benefit 
balance about going at all, the appropriate risk-benefit 
distribution must also be considered. Asking individuals to 
accept great risk, either in likelihood or magnitude of the 
harm to be caused, can be partially balanced by making a 
commitment to provide long-term health care and health 
monitoring.
    The second principle we identified is fidelity, and again I 
quote from the report. ``Fidelity is the principle that 
recognizes that individual sacrifices made for the benefit of 
society may give rise to societal duties in return. Given the 
risks that astronauts accept in participating in hazardous 
missions, NASA should respect the mutuality of obligations and 
ensure health care and protection for astronauts not only 
during the mission but after they return, including provision 
of lifetime health care for astronauts.''
    Those who consent to incur long-term health risks for 
society's benefit are entitled to fidelity, reflected in 
society's commitment to minimize any harms that emerge, 
whenever they emerge. The committee noted that this concept of 
fidelity or reciprocity resonates with the basic, widely shared 
understanding that it is unjust to allow some people alone to 
bear burdens which, in all fairness and justice, should be 
borne by the public as a whole. As a practical matter, the 
public cannot physically share the risks that astronauts will 
bear. It can, however, share the costs and burdens of ongoing 
risk mitigation efforts.
    An astronaut's consent becomes binding and irrevocable at 
the moment the mission launches. Astronauts are free to 
withdraw their agreement to participate prior to launch of 
course, but from the launch moment forward, it becomes nearly 
impossible to turn back, and astronauts likely will encounter 
uncertain and unquantifiable risk exposures and endure 
potential harms to health that will persist after the mission. 
The irrevocability of participation in spaceflight creates an 
ethical imperative to define long-term duties owed to the 
participating astronaut.
    In this context, the principles identified by our committee 
report support the minimization of risk of harm, the treatment 
of injuries or health conditions during the flight, and the 
ongoing monitoring and provision of health care after the 
flight. This binding duty to provide ongoing surveillance, 
monitoring, and health care during the lifetime of the 
astronaut is part of the continuum of risk management that 
begins with engineering and design efforts to minimize risk and 
continues through the flight and post flight. Our committee 
concluded that the ethics responsibilities that result from 
sanctioning high-risk activities include continuous learning 
and engagement in health-related activities that protect 
astronaut health, support ongoing evaluation of health 
standards, improve mission safety, and reduce risks for current 
and future astronauts.
    Employers that knowingly expose employees to risks have an 
ethical responsibility to provide protection to the extent 
possible and to address the harms that occur when protections 
fail or turns out to be inadequate. Robust research and health 
monitoring or surveillance programs that fully inform all who 
are involved, including astronauts and their families, are 
required.
    Furthermore, the committee maintained that the nation, 
through NASA, has the ethical duties to protect and sustain 
astronaut health based on the ethics principles of fairness and 
fidelity. Providing lifetime health care to astronauts respects 
the commitment that our astronauts have made and the risks they 
have taken on society's behalf.
    Thank you.
    [The prepared statement of Mr. Kahn follows:]
    
    
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    Chairman Babin. Thank you, Dr. Kahn. All fascinating 
testimony. I thank every one of you witnesses for your 
testimony, and now I recognize myself for five minutes for 
questions.
    The first one I'd like to direct to Dr. Williams. How would 
additional authority affect existing rights and benefits under 
current statutes? And would creating a new program at NASA 
impact the standards that are set forth by the Departments of 
Labor and Veterans Affairs for compensation and treatment? In 
other words, will a new authority make it easier or harder for 
astronauts to receive the treatment and compensation that they 
are due?
    Dr. Williams. Thank you for the question, sir. I don't 
think that there'll be a major impact to existing 
infrastructure. As a matter of fact, we envision using an 
existing claims infrastructure working very closely with our 
partners in the Department of Labor, and we're developing the 
same relationships with the Department of Veterans Affairs to 
approach this as a facilitated claims process, providing the 
expertise and space medicine and disease-specific experts as 
well as the evidence base that we've accrued so far to help 
determine the likelihood of association with occupational 
exposure as disease develops in our former and retired 
astronauts.
    With regard to your question about whether I think this 
will make it easier to advance the plausibility of association, 
I think it likely will, sir. I think endorsement by the 
Congress in recognition that these unusual exposures can cause 
disease in our astronauts, I think that will send a powerful 
message and will enable us to be more successful in taking care 
of them.
    Chairman Babin. Absolutely. Thank you very much, Doctor.
    The next question I'd like to direct to our three 
distinguished astronauts. If NASA is given authority to provide 
additional treatment for astronauts beyond existing programs at 
the Department of Labor and Department of Veterans Affairs, 
should NASA provide that treatment in-house at NASA or 
reimburse patients for private-sector treatment? Captain 
Cassidy, how about you first?
    Captain Cassidy. Mr. Chairman, that's an excellent 
question. I think that there's some degree of care that can be 
handled in-house at the Johnson Space Center but I also think 
that there should be some flexibility in order to take care of 
the former astronauts who potentially in their older age have a 
hard time getting back to Johnson Space Center, or because of 
their condition can't make that trip.
    Chairman Babin. Right. Okay.
    Captain Kelly?
    Captain Kelly. Sir, I don't really have anything to add 
other than what Chris said, but I think, you know, the emphasis 
on some of these guys, as we age and traveling back and forth 
to Houston could be problematic.
    Chairman Babin. Sure. Thank you.
    And Captain Lopez-Alegria?
    Captain Lopez-Alegria. Yes, Mr. Chairman, pretty similar. I 
think clearly there are some things that the clinic at Johnson 
Space Center could not do from a medical perspective. We 
couldn't, you know, treat somebody with chemotherapy, for 
instance, at JSC, but I think to the extent possible, we should 
try to keep it in-house just to facilitate the transfer of the 
data, which are very important to the discussion, but agree 
with my colleagues about that being impractical in some cases. 
I think that we should endeavor to make it happen when possible 
but realize that that won't always be the case.
    Chairman Babin. Sure, and then just to follow up, if NASA 
does decide to diagnose and treat conditions in-house, does 
this pose a potential conflict of interest when NASA is 
financially obligated to compensate former astronauts for 
conditions caused by their federal service? If one of you three 
would like to take a stab at that?
    Captain Cassidy. Well, let me start by saying--and Scott 
will back me up on this--as military aviators, we have an 
adversarial relationship with our flight surgeons generally. I 
was expecting that to be the case at NASA and could not have 
been more wrong about that. The relationship that we enjoy is 
very unique, and there's no doubt in my mind that our best 
interests are at heart when they give us treatment. So I would 
have a great level of confidence that the people with whom we 
all have personal relationships would be very disposed to help 
us to the extent possible, and I don't see there being a 
conflict of interest. I think that it if you're saying the 
conflict of interest would mean they would be reluctant, I 
don't see that as a likelihood.
    Chairman Babin. Right. Anybody else? Pretty much in 
agreement?
    It's an interesting comment you make, because I was an Air 
Force dentist, and occasionally we had to put DNIF on 
somebody's records, and they were not happy: duty not to 
include flying.
    Let's see. I think I'm out of time so I will yield back, 
and we will call on the next one, the Ranking Member from 
Maryland, Ms. Edwards.
    Ms. Edwards. Thank you, Mr. Chairman, and thank you again 
to the witnesses. Your testimony was really--was very thorough.
    One of the questions that I had as we came up, and 
particularly for Captain Lopez-Alegria, if you could tell me 
whether the care is provided in-house or out-of-house in terms 
of the surveillance data that are gathered, and Dr. Williams, 
please contribute as well, it seems to me that you all are 
already close to or you already have a tool that could--a 
screening tool that could easily be used more broadly, whether 
that's at Johnson or at some private care facility, and the 
question is whether we can authorize both the mechanism for 
surveillance but also separately the provision of health care, 
in which case you would be able to capture more than the 60 
percent, I think, of the Astronaut Corps, retired and active, 
who are currently participating. Would that be right?
    Captain Lopez-Alegria. Well, I think your last point would 
absolutely be right, that you would have far more participation 
than we have. I don't know enough about what the current limits 
of the authority on the screening that are in place right now, 
but I do know that some of the tests that I mentioned in my 
oral testimony, which could be done, which hare very 
specifically targeted to hazards that are known to be caused by 
flying in space, are not being done, and I think that if that 
authority does not exist, which I assume it doesn't, who would 
be doing them, then they should be.
    Ms. Edwards. Dr. Williams?
    Dr. Williams. Yes, ma'am. We--our current authority to 
provide that ongoing health monitoring to former and retired 
astronauts is limited. Our ability to spend appropriated funds 
in providing that diagnosis and much more so in providing 
treatment in that group, we don't feel like we have the 
authority to do that. So although we have the basic framework 
in place, which is the Lifetime Surveillance of Astronaut 
Health, we believe that that framework can be greatly enhanced 
and greatly expanded and become much more comprehensive with 
specific authority to provide diagnosis and treatment.
    Similarly, we think that our ability to engage and treat 
serious illness that arises in the Astronaut Corps will be 
greatly facilitated by the--for the lack of a better word, I'd 
say the facilitated claims process we envision with our 
partnerships with the Department of Veteran Affairs and the 
Department of Labor.
    Ms. Edwards. So, I mean, I want to get to this, because I 
think there's a separate question. If we give the authority 
that then allows for the provision of health care, we could do 
that either through those who are covered by VA, those who are 
covered under the FECA, or other kinds of private health care. 
The question then becomes, can we develop a tool that 
encompasses all of the kind of surveillance that you would need 
both to provide current health care but also to look down the 
line in terms of providing prevention or looking forward to the 
future Astronaut Corps, and you're saying that we would need--
you would require a separate legislative authority in order to 
be able to do that?
    Dr. Williams. Yes, ma'am. I think based on the very small 
number of cadre of the astronauts and the very unique exposures 
and the need for targeted surveillance and broad preventive 
surveillance in this group targeted toward those exposures that 
we know more about than anyone else on the planet, I think that 
NASA having that care--we do have within our agency a 
comprehensive healthcare delivery system that is aimed at the 
active Astronaut Corps, and leveraging our abilities along 
those lines on behalf of the retired and former astronauts 
including helping coordinate their care wherever they live I 
think would go a great way toward making sure that we take care 
of them and recovering as much data as possible to establish 
our evidence base.
    Ms. Edwards. And Captain Cassidy, I take it that you 
believe that we--that Congress has to provide a broader 
legislative authority to provide those services?
    Captain Cassidy. Yes, ma'am. I think that it's--my 
experience base is with the active astronauts, and like my two 
colleagues here, I don't have a whole lot of experience with 
what it's like as a former astronaut to go through that. I've 
talked to both of them, but where I think we can do--I know we 
can do a better job at pulling this data together, and the 
execution of how we do that, where it happens, what tests are 
done, and the mechanism for payment I think are things that can 
be further honed and discussed as we move forward and actually 
get this going, but those are things that I think we could 
collectively get a better story on.
    Ms. Edwards. And Dr. Kahn, can you tell me, is there any 
other sector that you can think of where there's an employer 
who has an employee who engages in risk for the purposes of 
completing their employment where there isn't a comparative 
ethical obligation for care?
    Mr. Kahn. Thank you, Representative Edwards. It's a really 
interesting question. In fact, part of the work of the 
committee that I had the privilege to chair, we tried to find 
parallel occupational examples, and in fact, it's quite unique 
is the short answer. And so when people leave occupational 
environment, they tend to have either a new job or they become 
retired and then they're covered by other means. So astronauts 
are really frankly in a unique category that way.
    Chairman Babin. Thank you, Ms. Edwards.
    I now call on the gentleman from Alabama, Mr. Brooks.
    Mr. Brooks. Thank you, Mr. Chairman.
    Captain Kelly, thank you, sir, for being here today and for 
your service to America's space program. As many are aware, you 
and your twin brother, Mark Kelly, are providing scientists 
with a wealth of information on the effect that human 
spaceflight has on the body. NASA is set to share the results 
of the study next year. Are you in a position where you can 
give us any previews of what they're finding so far by sharing 
with us the most surprising or interesting things that you have 
noticed so far?
    Captain Kelly. Well, I mentioned in my testimony the 
difference between my initial 159-day flight and 340, my 
symptoms immediately upon return. I have gotten some data back, 
my bone mass, muscle mass data, some of the data on my vision, 
that for me I was kind of surprised that it was relatively flat 
in comparison to the 159 days. In other words, being in space 
for twice as long didn't mean that I lost twice as much bone 
mass. It was pretty similar. So I think some of these we do 
have, a good understanding to how to mitigate the risks to bone 
and muscle loss so we can stay in space longer.
    The data with regards to my brother and the comparison with 
me, a lot of those samples just came back on SpaceX, my 
biological samples, so, you know, like most research, you 
collect the data, you analyze the data, you write the reports, 
have it peer-reviewed. I think that type of genetic data, the 
effects of the radiation environment, the effects on my immune 
system, things like that as it compares to my brother are just 
going to take much longer.
    But I was actually, you know, pleasantly surprised that my 
bone and muscle data was pretty much flat between the two 
flights, although, you know, how I felt when I got back was 
much different.
    Mr. Brooks. And this is a question for each of you, though 
I'd like to start with the astronauts, Captain Cassidy first 
and working our way around, and then on the two ends of the 
table, and whoever wants to follow them, feel free.
    With current technology, can NASA safely send an astronaut 
on a Mars mission without resulting significant adverse health 
risk, and if not, what should be done to safely protect 
astronauts on a Mars mission?
    Captain Cassidy. Sir, that's a fantastic question because 
that's where I think our nation should go, to Mars, and that's 
where our vision is, and so how do we do that effectively and 
safely is a fantastic thing to consider, and clearly, radiation 
monitoring and protection is critically important there. Do I 
think that we could do that mission safely right now? We could 
do it as safely as we think we can, and there are certain risks 
that we don't know, and that's where collecting this data 
between now and going to Mars will keep my future colleagues 
safer.
    Mr. Brooks. Captain Kelly?
    Captain Kelly. Yes, sir. You know, my time on the Space 
Station, I was really inspired that building and operating this 
vehicle was the most difficult thing we have ever done, and I 
think it's proven that if we decide to do something and we set 
our mind to it and put the resources behind it, we can be 
successful, whether that's going to Mars or curing cancer if we 
decide that that's what we're going to do, and we devote the 
appropriate resources to do it, we can do it.
    Now, there are challenges with going to Mars. Chris 
mentioned radiation, which I completely agree with. I think the 
physical challenges, that would be the number one concern I 
would have is protecting the crew members on that long trip 
away from the protection of Earth. I think there are also, you 
know, challenges in the systems that keep us alive onboard the 
Space Station. You know, these are designed to work for long 
periods of time in low-Earth orbit but having them that can, 
you know, operate consistently, reliably, get us to Mars and 
back, is a challenge, but I think it's clearly a challenge that 
if we decide that's what we want to do, then we can accomplish 
it.
    Mr. Brooks. Well, with respect to the number one concern 
that both of you have mentioned, radiation, do we have the 
technology now to protect our astronauts from the radiation of 
a long-term flight to Mars and back or do we need to develop 
new technology?
    Captain Kelly. You know, I think there's two ways to 
approach that. One is, you get there really fast so you're not 
exposed to the radiation environment for as long, and the other 
one is some means of, you know, insulating the crew members 
from it, and you know, I'm not an expert on this, but my 
understanding is, if you have a propulsion system that 
potentially has a magnetic field as part of it, that can act 
like the magnetic field of the Earth to protect us from certain 
types of radiation, but again, I'm not an expert in this area.
    Mr. Brooks. Captain Lopez-Alegria?
    Captain Lopez-Alegria. Thank you, Representative Brooks. 
You know, I think could we do it technically, technologically? 
Perhaps. It would be incredibly expensive the things that you 
mentioned and my colleagues have mentioned about radiation. You 
could shield. That takes mass. That makes the vehicle heavier. 
That makes the vehicle more expensive. The current propulsion 
technology, we've heard how long it would take the mission. 
We'd have to bring our food with us. There are so many things 
that it's possible to do. I think a breakthrough in technology 
would make a lot of those problems go away or at least become 
much more easy to solve.
    One thing that I do think is going to happen in almost any 
case, it's going to be very difficult to have any kind of a 
reasonable abort possibility once you're on your way, and so 
this country's going to have to have a different risk 
acceptance posture, not just for radiation exposure, which is 
right now three percent above the normal population is what we 
admit for a risk of exposure-induced death, that would probably 
have to change. But also just the notion that somebody could 
have an unforeseen medical problem on the way which today we 
could have the crew member on the ground in a matter of hours, 
it would take potentially months to get them back.
    So we could do it. I think we have to go through some 
evolutionary processes in the way we think both at NASA and as 
a country for it to happen.
    Mr. Brooks. Well, my time is expired, but if the Chair 
would permit for Dr. Kahn and Dr. Williams to answer, that'd be 
great, but if not----
    Chairman Babin. No, certainly, go ahead, if you have 
something to add to that.
    Mr. Brooks. Dr. Kahn or Dr. Williams, would either of you 
like to add anything to a Mars mission safety, technological 
advances we might need to ensure health safety.
    Dr. Williams. I think my colleagues covered it quite well. 
Physiologically, we believe that we could send people on a 
Mars-duration mission out and back, you know, all the other 
safety concerns notwithstanding. We believe we could do that. 
Physiologically, I think it's safe to say that those astronauts 
would be forever changed. In all likelihood, they'd have a 
greater risk of developing a fatal cancer during their lifetime 
and the associated changes in bone and muscle. I mean, they may 
have a greater fracture risk and the cataracts and all the 
things we've talked about.
    One of the great challenges are the unknowns, and there are 
unknowns and unknown unknowns with regard to the increased 
duration of spaceflight. So that's what makes it so imperative 
for us to continue our studies and to continue gathering as 
much data as we possibly can in support of an eventual Mars 
mission.
    Mr. Brooks. Dr. Kahn, do you have anything to add?
    Mr. Kahn. I would just add to what Dr. Williams just had to 
say, that the committee that I chaired actually understood that 
there were such great unknowns and unquantifiable risks, and 
rather than try to answer the question that you posed about 
what technological breakthroughs would be necessary, whether we 
could do it today, we gave them a framework to think about the 
ethics of exceeding existing standards and how to think about 
that since, as Captain Lopez-Alegria said, there are existing 
health standards and we have to evaluate those standards in 
light of the mission that is being proposed, and that's what 
the committee that I chaired had to say.
    Mr. Brooks. Mr. Chairman, thank you for your indulgence.
    Chairman Babin. Yes, sir. Thank you.
    I'd like to now call on the gentleman from Virginia, Mr. 
Beyer.
    Mr. Beyer. Thank you, Mr. Chairman. I thank all of you very 
much for being here.
    Dr. Kahn, given the difficulty of establishing causality 
for medical conditions that may have resulted from human 
spaceflight one of the options would be to have NASA take care 
of all the medical problems that astronauts would have in the 
years to come. What are the pros and cons of such an approach?
    Mr. Kahn. Thank you, Representative Beyer, for that 
question. I think that's actually a really important question, 
and I'll speak to it from the ethics perspective because that's 
what I know, and in fact, the committee that I chaired 
discussed that, and we came to the conclusion that the 
causality question is impossible to answer, and that we as a 
country and a society owe astronauts protection and provision 
of care throughout their lifetimes without asking the question 
about whether--what they might suffer from in terms of injury 
or health needs was a result of their time in space or not.
    Mr. Beyer. Thank you, Dr. Kahn.
    I met earlier today with the Fire Chief for the County of 
Arlington in Virginia and talked specifically about this issue 
with the presumption of heart-lung disease, the presumption 
that if they got heart disease or lung disease later, that it 
was presumed to be from rushing into burning buildings, and he 
said it actually expanded in Virginia over the law to things to 
do with the GI tract also. So this just extends it to all those 
who go into space for us.
    Mr. Kahn. And as you heard from others, there's new 
information coming out all the time, and so what we don't know 
today may be something we learn about in the future, and so the 
committee that I chaired really did not find the causation 
question a compelling one as a matter of limitation of 
provision of the--of lifetime healthcare benefits.
    Mr. Beyer. I am struck today by the two big reasons we have 
at this hearing. On the one hand is the ethical considerations, 
the responsibility to take care of people who are sacrificing 
for all humankind. On the other hand, there's the simple 
practical data reason that we want to learn as much as we can 
to be able to move forward.
    Dr. Williams, what about when Captain Kelly retires and 
goes to work for a private space person, you know, SpaceX or 
Orbital, how does that influence the government's 
responsibility to take care of him and his space things, the 
space-related conditions for years to come?
    Dr. Williams. Yes, sir, another great question. I think 
there's plenty of precedent in the U.S. government that we 
would consider that to have no impact at all on our ethical 
obligation to take care of Captain Kelly and on our desire to 
gather as much data as we can to inform our database and to 
help us protect crews in the future, so I think there's no 
accrual, no effect at all, sir.
    Mr. Beyer. I was very impressed, fascinated by reading, 
Captain Kelly, all the impacts of your 340 days in space, 
everything from the rash to the flu-like symptoms and all the 
things we don't know yet, the unknown unknowns.
    So Dr. Kahn, from an ethical standpoint, especially after 
the recent death of Muhammad Ali, I mean, my mother never 
wanted me to box, right? The concussion and what the NFL is 
trying to deal with, concussions right now we see, those are 
voluntary sports. At what point do the ethical considerations 
become so great that we become reluctant to send men and women 
into space for the long voyages?
    Mr. Kahn. At what point would they? Is that the--is that 
your question?
    Mr. Beyer. You know, we send young men and women to go 
fight for us overseas because they're defending the country and 
we know we're going to lose some. We don't ever want to lose 
anybody despite Elon Musk saying the other day, ``We're going 
to go to Mars and some people are going to die.'' Do we go into 
this knowing with certainty that some of these health effects, 
the long-term health effects, are going to be inevitable?
    Mr. Kahn. I think what we want to be sure of, as sure as we 
can be, that we can protect the men and women who go into long-
duration spaceflight to the greatest extent possible, and that 
we learn along the way, so among the things that hasn't come 
out yet today is this notion of long duration, so we're talking 
hundreds of days in transit until there's some new propulsion 
system, and so we can learn along the way. So data will come 
back to Earth from the experience of astronauts as they fly, 
and we should use that and learn and use that to decide about 
whether people should spend more time in protective cocoons in 
the--on the way or whether there should be some other means by 
which we should modify exposure along the way. So I think it's 
a notion of learning as we go but we don't go until we're 
sufficiently confident that it's safe enough, and then it's up 
to NASA to decide when and if it's safe enough.
    Mr. Beyer. Thank you very much.
    Mr. Chairman, I yield back.
    Chairman Babin. Yes, sir, thank you, and I'd like to 
recognize the gentleman from Colorado, Mr. Perlmutter.
    Mr. Perlmutter. Thank you, Mr. Chairman, and thank you for 
having this hearing. It's fascinating and it's important. 
Gentlemen, thank you for your service.
    Dr. Kahn, I want to start with you because I thought your 
two sort of pillars of fidelity and fairness really kind of lay 
out the thinking on this for me.
    You know, if somebody--these three gentlemen next to you 
are explorers and they put themselves at risk to explore in the 
name of the United States, in the name of science, in the name 
of adventure, in the name of I don't know what, lots of things, 
and they now have put themselves at risk. So it's my opinion, 
based on your two principles of fidelity and fairness, that we 
have a responsibility to provide both the medical care that 
they may need on into the future and the research that they 
provide us as to their health.
    So did your committee agree with you on this fidelity and 
fairness? It certainly resonates with me.
    Mr. Kahn. Yes. Sorry if I wasn't clear, Representative 
Perlmutter. The--my testimony represents the conclusions of the 
committee that I chaired, and everything I said actually is a 
summary of what's in our report, which was issued in 2014, and 
so that was the consensus of those 16 people who have a variety 
of expertise, some like mine but actually two former astronauts 
were members of this committee, along with scientists and 
physicians and occupational health specialists.
    Mr. Perlmutter. The reason I'm sort of thinking about this, 
and Dr. Williams, you can chime in if you choose, you know, in 
my district we have Rocky Flats, where we built the nuclear 
triggers for our bombs, and we had a lot of workers out there. 
They've developed a number of maladies as a result, some I 
guess anticipated some not anticipated, and we came up with a--
we the Congress--came up with the Energy Employees Occupational 
Illness Compensation Program, which has worked in some regards 
and hasn't worked very well in other regards because, you know, 
whether it's bone mass or some issue of radiation or something 
like cataracts, completely unexpected, we've seen maladies that 
were never expected. So in your analysis, Dr. Williams or Dr. 
Kahn, how do we be inclusive? Do we just--see, right now, the 
burden is on the worker to say that the illness came from 
working at Rocky Flats. I'd just like to say hey, if you worked 
at Rocky Flats and you're sick, we're going to take care of 
you. If you're an astronaut and you got up there, we're going 
to take care of you. But it gets expensive. We've got to be 
prepared for potential costs if we build our astronaut base. I 
mean, what was your committee considering? And Dr. Williams, 
have we estimated what costs we might see in the future?
    Mr. Kahn. So the committee that I chaired did not--was not 
asked and did not try to estimate the cost, so we identified 
what we thought were, as you articulated, the pillars--we 
called them principles of ethics that would support 
recommendations which included a recommendation for lifetime 
provision of health care for astronauts but we did not go past 
that into the practical question of how much it would cost for 
how many people or for how many years we're discussing.
    Mr. Perlmutter. Dr. Williams?
    Dr. Williams. Yes, sir. I think when you articulated the 
sentiment that if we send you in harm's way as astronauts, we 
want to take care of you, I think that's what NASA absolutely 
wants to do.
    The practicalities of doing that with this legislation, we 
can--we have to be aware of the problems, hopefully at the 
earliest stage possible in order to remediate them, and that's 
the monitoring portion of our--the health monitoring portion of 
our proposal, which is quite detailed and quite targeted and 
broadly preventive in nature. And then I think with this 
authority, work very closely--under the envision model, work 
very closely with folks in existing claims structures--the DOL 
and the VA, whoever we need to--to lean very forward and be 
very proactive in--with regard to working--providing evidence 
and best expert opinion to try to receive favorable 
consideration of claims and acceptance of diseases as they 
arise.
    Mr. Perlmutter. Well, for all of us on this Committee, you 
know, I think I showed you, Captain Kelly, when you were up on 
Space Station, you know, 2033 we can do this. I mean, we really 
want--I don't know, you know, exactly what the timing is going 
to be. That'll be for the technicians and the engineers and you 
astronauts and the scientists to figure it out, but we want to 
get there, but we want you not to put your lives at stake. I 
mean, there will be some level of risk. I know I as a Member of 
Congress on behalf of the 750,000 people that I represent want 
to make sure that when you do put your lives at risk that--and 
your health for who knows how long down the road, we as the 
United States of America help you with your health care. 
Hopefully there's no problems, but if there are, we help you.
    And so I just thank you for your service, gentlemen. Docs, 
thank you for looking at this. This is important stuff. Thank 
you.
    Chairman Babin. Thank you. Thank you very much. Thank you, 
Mr. Perlmutter.
    I think there's a little time left if we could go back 
through for another round of questioning if the witnesses are 
agreeable and the members. Why don't we this? Instead of 5 
minutes, we'll have a 2-minute question period, okay? And Mr. 
Perlmutter, we're going to keep you at 30 seconds.
    Okay. I'm going to start out with Dr. Williams. Similar to 
the question that Mr. Perlmutter asked, NASA has indicated that 
extending existing monitoring of former astronauts would 
increase the cost to NASA from approximately $400,000 a year to 
around $800,000 a year. A recent University of Nebraska Medical 
Center report indicated that providing medical care for all 367 
astronauts and their families would cost between $2.4 and $6.5 
million a year. How much money would NASA's current proposal 
cost per year? Do you know that?
    Dr. Williams. We think the direct portion, health 
monitoring portion, would be in the neighborhood of doubling 
our current cost to $800,000 a year. Right now, we spend 400 a 
year for that portion. We believe if we--including remediating 
providers in the community for testing and imaging and so on 
and so forth, we think that would drive that cost up, and 
anticipating increased participation rates, we think it would 
drive it to $800,000.
    With regard to the remediation of illness and injury, the 
astronauts do display a very strong, healthy worker effect. 
They pursue very healthy lifestyles. They're committed during 
their careers and after their careers to maintaining good 
fitness and making good lifestyle choices. So when you compare 
chronic diseases and malignancies and so on and so forth to 
almost any comparison groups at this point, the astronauts 
compare very favorably. After latent period of exposure passes 
in the next 10 to 20 years, that's an unknown quantity at that 
point.
    But right now, we would anticipate based on historical 
precedent no more than one case, maybe two cases every one or 
two years of significant illness that would be expensive, and 
by ``expensive,'' I mean that would be in the, you know, 
$500,000 range for a catastrophic case of cancer or something, 
and that's what we believe we would be dealing with in the 
short term, sir.
    Chairman Babin. And one quick question here for you, Dr. 
Williams, and Captain Cassidy. The Department of Labor and 
Department of Veterans Affairs both provide treatment for 
conditions derived from federal service. Are there classes of 
astronaut such as payload specialists who are not government 
employees and therefore would not be covered by existing 
authorities? Do you all know the answer to that?
    Captain Cassidy. Sir, currently at NASA we have active 
astronauts and management astronauts. Management astronauts are 
folks that still work at NASA but are no longer in the line for 
a space mission, and we used to have in the past payload 
specialists. We no longer have that designation. However, from 
our perspective, anybody that goes on a space mission on a NASA 
mission should be covered.
    Chairman Babin. Right. Dr. Williams?
    Dr. Williams. And sir, for classes of astronauts like 
payload specialists, we believe that no matter what method that 
they use to enter the agency as a detailee or what method of 
employment they have, that there would be a pathway forward 
under existing structure to treat them just like we would any 
astronaut in clearly military or civilian service and pursue 
helping them.
    Chairman Babin. Thank you. Thank you very much.
    And I now call on the gentlewoman from Maryland, Ms. 
Edwards.
    Ms. Edwards. Thank you very much, Mr. Chairman, and thanks 
for the second round.
    Dr. Williams, I want to go back to the VA system because I 
understand that about 60 percent of the astronauts that have 
flown in space are military or retired military--we have two 
here on this panel--and as such, any occupational injuries or 
conditions are currently handled by the VA. Have you actually 
directly addressed with the VA how occupational-related health 
conditions for former military astronauts as a result of 
spaceflight will be handled if this legislative proposal is 
enacted?
    Dr. Williams. We have reached out to our contacts in the 
Veterans Administration and we are initiating discussions with 
them similar to those that we have initiated with the 
Department of Labor, and we would envision in implementation of 
this legislation partnerships going forward on both fronts to 
build this facilitated claims process with NASA playing a key 
role in determining accepting the diseases.
    Ms. Edwards. I mean, it is a little bit problematic, you 
know, 60 percent of the astronauts are retired military, and we 
have--you haven't engaged the VA in this discussion before 
presenting legislative proposal, but I hope that that happens 
really soon and that you're able to share that information with 
us.
    Captain Kelly and Captain Lopez-Alegria, you both are 
retired military. Have you used the existing VA system?
    Captain Kelly. I think it's important--I think it's 
important to point out that there are--astronauts come from all 
different backgrounds. Some of us are retired military. I'm 
personally, as is Mike, covered under Tricare for life as a 
retired military member. If you were a member of the military 
and you didn't retire, I believe the VA would still cover you. 
There are members of the Astronaut Corps that are civil 
servants. Some of those civil servants retire from federal 
service, in which case they do have retired civil service 
health care, but then there are other people that may fly for 
one flight or more and then leave federal service without any 
kind of long-term health care benefits until they were 
potentially eligible for Medicare. So there are different 
categories, and I think this system, this legislation, if 
enacted, would benefit them and people in different ways 
considering the fact that, you know, we already have health 
care coverage that is pretty good.
    Ms. Edwards. And in effect, at least bring the payment 
within one house, if not the care within one house?
    Captain Kelly. Certainly, and I think that the important--
the other important factor, as previously mentioned, was the 
fact that we can collect all this data whereas if I'm, you 
know, living in another state and I'm being treated under the 
Tricare system, NASA doesn't directly benefit from any of that 
information, and also the fact that, you know, those health 
care providers may not even know what they should be looking 
for in these types of, you know, cancer or radiation-based 
illnesses.
    You know, it's interesting, Mike and I--I was going to 
point this out, and I don't think he would mind mentioning it, 
but we're going to meet with one of our colleagues tonight who 
lives in the area that has recently been diagnosed with stage 
IV pancreatic cancer, and he's, you know, flown in space on a 
number of occasions, and you know, we never know whether that's 
actually directly related to his spaceflight but it's possible 
that it is.
    Ms. Edwards. Thank you very much. I mean, a reminder, it 
took us 30 years after Vietnam to finally recognize the long-
term impacts of Agent Orange.
    Chairman Babin. Yeah, absolutely.
    The next one, Mr. Beyer, the gentleman from Virginia.
    Mr. Beyer. Yes. Thank you, Mr. Chairman.
    And Dr. Williams, I know you're not a statistician but I 
understand from reading lots of science magazines that 
essentially we need to get to 10,000 DNA complete 
disarticulations into the database before we're really going to 
be able to figure out what some of these DNA connections are.
    You know, we have 250 retired astronauts. Sixty percent are 
in--so 150 are in the LSAH program right now. If we move to 80 
percent, that gets us 200. What are the--what's the 
implications for us of the limited sample size, the limited 
size of the database?
    Dr. Williams. It's something we've always struggled with, 
sir, whether we're actually doing space-based research with a 
small population and trying to, you know, reach conclusions or 
whether we're trying to do epidemiology on this very small, 
very uniquely exposed group of folks. The only thing--the thing 
I think that is most important to note is that given the group 
is so small, the data from every single one of them is precious 
and the data from every single one of them is important, and 
anything we can do to maximize participation in our program, 
both for the surveillance and recovery of healthcare data in 
the event of injury and illness, is critical.
    Mr. Beyer. A question for any of the three captains but 
perhaps especially for Captain Kelly. We had a Mars hearing 
here a couple weeks ago, and with, you know, the big companies 
that are developing all the places to get there, and Andy Weir 
came, who wrote The Martian, and at the end he threw out the 
proposal that we should be thinking about using rotational 
energy to create artificial gravity on the way up. So how much 
of the consequences that you all have felt have been radiation 
related versus gravity-free-related, and I say that because I 
think for Ed and for me, the highlight of this Committee so far 
has been when you and Dr. Lindgren did your flips at the end of 
the flight.
    Captain Kelly. Well, you know, I believe all the symptoms 
that we have, the stuff that we can feel when we get back, is a 
result of the microgravity environment versus radiation. I 
think the radiation effects are, you know, more long term and 
unknown, you know, of someone that does develop a cancer, 
whether or not that was due to the radiation, I don't think we 
can ever say for sure because it may have--you know, we get 
radiation here on Earth as well. It just increases our risk of 
those type of cancers.
    So as far as, you know, having an artificial gravity to 
mitigate those risks, I think, you know, based on how I felt 
after being in space for a year, if I was going to travel to 
Europa, for instance, and it's going to take, you know, many, 
many years to get there, I think--and then you have to perform 
after being in space for multiple years and you had to perform 
away from Earth, I think that type of artificial gravity would 
be crucial. If we're going to fly around the Moon or fly around 
Mars, for instance, and it's going to take, you know, three 
years and you'd be in space for three years or if you're going 
to land and be on the surface for a few weeks, being in space 
for an extended period of time is going to have a negative 
effect but fortunately you're coming back to Earth where, you 
know, there's a big, you know, system to support you. So 
artificial gravity in that type of mission I think is less 
critical.
    Mr. Beyer. Great. Thank you very much.
    Mr. Chair, I yield back.
    Chairman Babin. Yes, sir. Thank you, Mr. Beyer.
    And now for the gentleman from Colorado, Mr. Perlmutter.
    Mr. Perlmutter. For my 30 seconds.
    Chairman Babin. No, we'll give you two.
    Mr. Perlmutter. So this is to all of you. So as things have 
developed and we've heard from Mr. Musk and SpaceX that, you 
know, their intentions to try to get astronauts to Mars in the 
2020 time frame or sometime, and we know that there's going to 
be more commercial endeavors in space. So we have a small pool 
to do research on. Should we consider those astronauts that are 
on a private capsule? Should they be covered by something like 
this? And I'll start with the three captains and then go to the 
ethicist, I guess.
    Captain Lopez-Alegria. Well, I've been in this room a lot 
wearing my hat as president of a commercial spaceflight 
federation, so your comments about democratization of access to 
space are near and dear to my heart. I think that we would love 
to have the data from those folks that are going to be going, 
you know, first on suborbital but at some point on orbital 
flights. I do not think it is the responsibility ethically but 
I will leave that to the ethicist, but it seems to me that it 
would have to be a voluntary program for them, but what is 
clear is that the data that we are gathering in LSAH and 
hopefully with this expanded authority, our flights and our 
careers have been paid for by taxpayer dollars and we owe those 
taxpayers those data to help them make informed decisions about 
spaceflight.
    Captain Kelly. I don't really have anything to add other 
than what Mike said. I think that makes a lot of sense.
    Captain Cassidy. And sir, I concur as well.
    Mr. Perlmutter. Okay. So to the doctors, do you want to 
have a bigger pool? Do you want them in there, or should we 
cover them? What do you think?
    Mr. Kahn. Well, so I'll start. I think in terms of coverage 
that if it's commercial spaceflight, then those companies ought 
to take on that obligation, so I do think there's an obligation 
but not on the part of the government to protect those people 
but on the part of Elon Musk or whomever.
    In terms of the data, that to me is something that ought to 
be encouraged but I think it's hard to obligate on the part of 
individuals. So, you know, I think as our astronaut colleagues 
here will say, there's very few of them, and every bit of the 
data that is precious, and with the proper protections, there 
should be, I think, a lot of willingness to participate, but I 
don't think you can force people to do that.
    Dr. Williams. And sir, I think our database and our 
experience base would form the risk assessment database that 
the commercial companies are going to have to use. That's going 
to inform their risk decisions when it comes to a health 
standpoint and undertaking some of these longer missions.
    I agree with my colleagues. From a practical perspective, 
our health care infrastructure, and I'm sure our research 
community too would pursue helping them as much as we could by 
sharing our experience and our data as much as we can, and also 
we would seek to facilitate their gathering of data. We have a 
lot of experience in doing that. And if there were 
opportunities to leverage their data on behalf of future human 
spaceflight, we would welcome the opportunity to do so.
    Mr. Perlmutter. Thank you very much.
    Thanks, Mr. Chairman. I yield back.
    Chairman Babin. Yes, sir. Thank you, Mr. Perlmutter.
    I want to thank the witnesses. It's been an extremely 
edifying hearing, and to be honored with the three astronauts 
and the two doctors, thank you all for your many years of 
service to your country, and really I want to thank you from 
the bottom of my heart.
    The record will remain open for two weeks for additional 
written comments and written questions from the Members.
    So without any further ado, this hearing is adjourned.
    [Whereupon, at 4:27 p.m., the Subcommittee was adjourned.]

                               Appendix I

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                   Answers to Post-Hearing Questions

Responses by Dr. Richard Williams


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Responses by Captain Chris Cassidy

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Responses by Captain Scott Kelly



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Responses by Captain Michael Lopez-Alegria




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Responses by Dr. Jeffrey Kahn


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