In Our Time - Medical Ethics

Episode Date: December 16, 1999

Melvyn Bragg examines the technological advances and ethics of modern medicine. On an average working day about three quarters of a million of us go to the doctor’s. About a hundred thousand are visited by nurses and other health professionals. Then there are the three hundred thousand that go to the dentist. Health is a central preoccupation. It is also big business, saving life, lengthening life and even promising a stab at eternal life. Yet while some technology is Space Age, the morality is often not far away from the Stone Age. Who decides who lives or dies? Insurance firms, for instance, want genetic information - should they have it? Stem cell research - hailed by many as an extraordinary advance - now runs into conflict with those who do not want the human embryo to be, as they see it, abused. In the 16th century Francis Bacon told us in his Advancement of Learning “Medicine is a science which hath been more professed than laboured, and yet more laboured than advanced: the labour having been, in my judgement, rather in a circle than in a progression”. Well, after a century that has brought us penicillin, the discovery of DNA, heart transplants and key-hole surgery, have we finally escaped the loop? Or does our ethical application of what we can technologically achieve mean we are marching in Bacon’s circle still? With Barry Jackson, consultant surgeon and President of the Royal College of Surgeons of England; Professor Sheila McLean, Director of the Institute of Law and Ethics in Medicine, Glasgow University.

This BBC podcast is supported by ads outside the UK. Thanks for downloading the In Our Time podcast. For more details about In Our Time and for our terms of use, please go to BBC.co.com.uk forward slash radio four. I hope you enjoy the programme. Hello, in the 16th century, Francis Bacon told us in his advancement of learning, medicine is a science which hath been more professed than laboured, and yet more laboured than advanced,

the labour having been, in my judgment, rather in a circle than in a progression. Well, after a century that's brought us penicillin, the discovery of DNA, heart transplants and keyhole surgery, have we finally escaped the loop? What does our ethical application of what we can technologically achieve mean we are still caught in Bacon's circle? With me to discuss the ethics of modern medicine is the president of the Royal College of Surgeons, Barry Jackson, and Professor Sheila McLean, Director of the Institute of Law and Ethics in Medicine at Glasgow University, and author of Old Law New Medicine. I'm sorry about this voice, by the way, I seem to have contracted my own millennium bug. Sheila McLean, Hippocrates called medicine and art.

2,000 years later as we've heard Bacon said it was a science. Now towards the end of the 20th century, it is some aspects of religion. Can you tell us how remarkable the 20th century has been in the advancements of medicine? Well, I think one of the things it's done apart from the kind of amazing discoveries in scientific breakthroughs that you've mentioned is also to challenge the individual of practitioners of medicine

in a way that I think would be unheard of, even up until the turn of the century. And that's partly because the notion of medicine as an art was one with which I think people were very comfortable for a long time. And of course the doctor in the community could actually probably do very little, I think it would be fair to see, but did achieve a great deal just through the sort of placebo effect. And then science as the newest discipline, oddly enough,

but also the one which really has taken over our thinking in this century, seemed to transform medicine into a science and almost distance clinicians from their clients or patients. and I think towards the end of the century what we're now seeing is a recognition that actually medicine is both a science and an art, but as to how the practitioners of medicine and their patients

actually deal with that, I think, is much more difficult because science seems to say, I mean if we see medicine as a science and of course most of its major breakthroughs or the ones at least that are much vaunted in the media are very scientific in essence and if the public expect medicine to have the kind of certainty

and value neutrality that we expect from science, then I suspect that we'll be disappointed. And if clinicians are seduced into thinking that all they're doing is also scientific and that the intuition or the art part of medicine has gone, then they'll be in trouble. So I think they face a real conundrum. Mary Jackson, advances in anaesthetics and antibiotics have increased what surgeons can do and the number of operations they can perform, certain operations which have killed people of shock before then.

But do you think that surgery as a technique has advanced great to this century? Yes, I think there have been considerable advances in techniques. You mentioned anaesthetics. Strange to say, I don't agree with you, that anaesthetics made an enormous change in the practice of surgery. A far greater change was due to the introduction of antisepsis and then asexis, so as to prevent the bacterial infections

that inevitably took place after operations in the days before we understood bacteria and bacteriological science. But during the 20th century, as a result of the advances in antisepsis, huge advances in techniques occurred. With antibiotics came on stream, many of the complications has occurred

from operations disappeared and we got greater and greater advances. Recently, as I think you hinted in your introduction, that minimal access surgery, small incision surgery to prevent keyhole surgery in late terms, has become the focus of

technical interest. And I think that's continuing, and there's a greater and greater range of keyhole operations now being done. But there will be a limit to what can be done that way. And certainly in the field of trauma, there's still large-scale open operations will need to continue. I think we've probably reached the acme of what can be done in terms of removing organs, transplanting organs and such like on the macro scale, but on the microscale. And certainly when, if we move into the consequences of genetics and such,

like, which we might touch upon a bit later, I think this is a whole new field that the practitioner is going to face. Sheila, this keyhole surgery, minimum access surgery, takes us to parts of the body that have not been reached before. For instance, you can do operations on a pregnant mother's womb. Now that takes us straight to one of the things which concerns you, which is the ethics of this matter. Take that as an example. How does that affect your view of what surgery is doing? Well, that's actually probably the best example of the extent to which apparently value-free advances can actually have enormous social and personal consequences. I mean, the development of these techniques is miraculous in a sense.

It certainly allows a lot of patients a great deal of a lot less pain, a lot less short of stay in hospital and so on. But the capacity to use that to perform surgery or other therapy on a fetus in the womb has consequences which affect the woman, of course, and whether or not she's prepared to accept the kind of risk that's associated for her in allowing this therapy. And it's hand in hand, unfortunately, with a trend, which is particularly acute in the United States, but is happening here as well to police women's pregnancy, to police the behavior that they actually undertake in the course of their pregnancy,

everything from their drinking habits and their smoking habits to sex, to drinking caffeine, to whatever else might be dangerous for the embryo or fetus. And the pattern of policing has become a pattern of enforcement. enforcement more recently, which means that women are forced into having cesarean sections if it's thought that they're not going to have a healthy natural birth. And so the trouble is that what you've got is an apparently great technique, which is obviously going to work in any number of areas, but that when it's translated into a real-life situation, for example, in that situation, then it has consequences, both legal and ethical, that the clinicians won't have thought of

because they're moving down the path of simply making things better. And of course, the more that we know about, the more that we screen prenatally, the more that we know of the risk to fetuses and embryos, the more it's likely that these kind of techniques will be encouraged. And the more, I mean, like it or not, the more some women will say, no, I'm not prepared to do that. That's what I rather meant when I said in my first question to you

that it may have moved on from being a science to partake if something to do with religion. As Ivan Illich said, didn't it, doctors and a new priests? Yes. And we're deferring all sorts of moral judgments to doctors and surgeons. What's your view of that? Well, I think that many patients turn to the doctor for the advice on a particular problem.

And still, even in this day of great skepticism about what medicine can and cannot offer, still very often are prepared to take that doctor's advice without really very much further thought. I mean, a lot of patients do want to know all the ethical implications, all the complications, all the possibilities of what can go wrong and what might not go wrong, the various options.

But still in my experience as a practicing doctor, and I know this is shared by many areas, others that still huge numbers of the population come to the doctor and they say, I want your advice and if you say to them, as I've done so many times, and I'm sure Sheila McLean will know this, that you say, well,

there's this option and there's that option and you can do this and we can do that and we can do a third option, and they say, well, I've come to you for your advice, you're my doctor, you tell me what you think and I'll abide by it. Does that put you in a slightly in a God position, doesn't it? You make the judgment

or at least Solomon. Well, it does. And I think that arguably might have been responsible for some of the unfortunate image that some doctors have had in recent times as actually acting in that way, when clearly they shouldn't, because every individual, every patient's got to be treated as an individual. But it is somewhat unnerving to find yourself in that position sometimes. It's one of those things I think that it's kind of chicken and egg. Because I think actually there was a tendency perhaps over a period, of years for doctors who were acquiring

all this new and exciting technology that they could use and really make people better, to do what I suppose people would now describe as be paternalistic. So in a sense, I feel doctors set themselves up to do this playing God, and my image or my impression of the doctors that I deal with

and have done over the last 20 years, is that they very deeply regret that that was what happened because there are too many life and death types of decisions, there's too many deeply personal decisions that they don't want to take. Can we turn to something which fascinates me? the idea of calculating genetic disposition. It can be calculated that people have genetic disposition towards certain diseases, and their operations

going on like preemptive radical mastectomies or hysterectomies that perform on the basis of that likelihood. That seems to me to get us into all sorts of trouble. What do you think, very jay? Well, I think that this is a field that the profession is going to have to grapple with increasingly because we're going to have a great deal more knowledge about this in the fairly near future

as we start mapping the human genome and we will identify more and more diseases where the genetic predisposition will be known. That's going to bring a whole range of ethical problems with it, actually. It's not quite a straightforward as you might imagine. Yes, putting it crudely and bringing everybody up to speed. It's actually cutting off a healthy part of you because that part of you're taking out a healthy part of you,

because the genetic reading is that this part may get a disease at a certain time. But you could die before then of other things. Yes, I mean, this is a serious. worry, I think, actually, because there's two things in there. One is, as Barry says, we will get to know more and more, but unfortunately, we're not any better at risk calculation. And one of the reasons why, for example, why the government is very keen that the insurance industry shouldn't be given too much access to genetic information is because even actuaries are struggling to work out how you, what level of predisposition represents a real threat

and what doesn't. And therefore, I think there is an ethical debate that went on when women first made it public that they'd had mastectomies and so on, because there was a debate about whether or not surgeons should actually be participating in that kind of radical surgery, particularly given that at least at the time, it wasn't at all clear that this would actually prevent breast cancer happening if it was going to happen because it can appear elsewhere. It doesn't have to be just in the soft tissue that was being removed. So there are, I think, profound problems with that.

On the other hand, you could say, well, if that makes the women themselves feel better and more comfortable with their lives and feel that they're at less risk, then should we deny it to them? It's much easier to talk about breast cancer because that's an operation that can be done relatively safely without any untoward consequences. But if you take the broader range of cancers and there will be genetic predisposition

for various other internal cancers that can be worked out really quite soon, that poses a far different problem because the operation then to remove that healthy organ is a much greater risk to the individual patient than, say, removing a breast, or even both breasts, and alternatively if you elect not to have that operation you then get a group which has been called colloquially

I think the worried well because knowing that they have that genetic predisposition of an internal malignancy say every time they get an acour of pain in their tummy every time they get a minor gastric upset they'll think they've developed the cancer they'll be dashing off to their doctor and they will have to live with the mental stress

of knowing that they have that genetic predisposition and at any time it might strike or it may not And of course, as you rightly say, Melvin, they might die of something quite unrelated before the cancer ever catches up with them. What interests me is the accuracy of this genetic predisposition.

If you have a genetic predisposition, does that mean you inevitably get it? No. No, you see, well, do we have figures that, do we have 10% that don't or 50% that... I mean, it seems to me from what I've read, but you both in a wonderful position to correct me, that we've got a probing in the dark here

and people are losing lumps of themselves, which are healthy, because of this wonderful Fry's genetic predisposition. I mean, is it accurate enough? Even single gene disorders, which are the ones that we can predict the likely onset of most, things like Huntington's and the BRAC 1 and 2. I mean, nonetheless, some people with the gene

that would predispose them to Huntington's will live quite a long time and will not in fact die because of their Huntington's, in fact, they may not even get it. The same with the BRAC 1 and 2 genes, the breast cancer genes, is actually an even bigger number of people who will never go on to develop the disease. So even with what looks like the most straightforward link between genetics and disease,

there are actually exceptions to the role. And the difficult, I think a reason a lot of people are concerned about the way in which genetic information is managed is that in all the other conditions, the actual predisposition could be very tenuous. I mean, it may just be never happen. And as Barry says, if you then start giving people this information, I mean, one of the big debates,

should people actually go for genetic testing, If you give them this information and people don't understand risk, if people understood risk, they wouldn't bet on horses, let's be honest, or buy a lottery ticket. If you ask people, there was some research done a few years ago on people who might be at risk of Huntington's, which is a truly horrible condition. When the population were asked, or the possible population were asked,

something like 84% of them said that they would want a test to be made available for Huntington's, less than 10% of them actually took the test once it was available because they didn't necessarily want to know that information. Well, I was going to just interrupt there. Huntingdon's a rather unusual. It's quite a rare condition. I mean, I'm thinking in terms of the much more common conditions, particularly the cancers, which have got so many emotive overtones.

I mean, we have no real information as far as I know how the general public would react to genetic testing for genetic predisposition to the common cancers, as far as I know. I just sort of be rather vernacular about it. We're all going to die of something. So we've got a genetic disposition to what's going to get us in the end. So if we all know about that, we can,

what do we walk around with, a bag full of worries, or say, well, at least I know what's going to happen. But then you walk in front of a bus. Patients don't expect, Melvin, that they're going to die. I mean, say, all the patients I see expect that when they come to me and my colleagues, and if they've got a problem, there's an increasing expectation that the doctor can put them right and can cure them.

The surgeon can do whatever's necessary, that they're going to recover without any complication, and they're going to go on and live and live, and we hear in the newspapers regularly that the average age expectancy is increasing, the number of centenarians are increasing, they're all going to live for 100, and nobody actually recognises, really,

that they're going to die now increasingly. It's quite remarkable. We're starting to see death as a disease which can be cured. Well, you do have your genetic preaches we soon to die. There's no question of that, but I mean, I think that's why the issue about whether or not we make these kinds of tests routinely available or whether or not we encourage people to take them is the big issue.

You know, there's a difference between knowing you're going to die and knowing what you're going to die of. Now, I think most people would say, if you can tell me that I've got the gene, that means I'm most likely to get, more likely to get lung cancer than somebody else, there may be things I can do about that. Maybe I don't smoke, or I can watch this,

I can perhaps get regular checks. But if you just simply say to people, well, we're going to tell you that you've got this genetic predisposition and there's nothing we can do about it. There is no way of avoiding this. there's a one in X percent chance that it happens, it's going to happen. That is where the Worried Well syndrome becomes particularly acute. Barry Jackson, can you say what further ethical complications this gives you and your fellow surgeons

when the predisposition factor is presented to you? And it will obviously, the more we know about the human genome, increase. Well, I think it's a matter of trying to explain to the patient if they know that they've got this genetic predisposition, the implications of that and also for their children as well. They very often, we haven't touched upon the risks to children. In my experience is that patients are very often far more concerned as to what they might transmit to their children

than they are regarding themselves and they say that, you know, it's my children that one concerns me more than me. I'm, you know, adult. I've had my life, particularly if they're towards the, you know, in the maturity of their life. So I think these are difficult problems. I don't think the profession,

as yet has really come, quite honestly, to grips with this. There are certain areas such as the cystic fibrosis in the Huntingdon's career and the doctors that look at those particular aspects of pets and I think are probably very well familiar with it. But the ordinary general practitioner, the ordinary surgeon in the clinic, the ordinary physician in the clinic, the implications of the genetic predisposition, genetic testing and so on, hasn't really imping to an enormous extent, I don't think.

It's something we're going to have to grapple with as we turn this into the next century in a major way, I feel. I mean, it's actually, I think, the biggest challenge that medicine, that doctors in particular and also other healthcare preferred is actually going to face, because there is nothing,

within the principles of medical ethics that I was talking about earlier, there is a presumption that there is a paradigmatic one-on-one relationship between the doctor and his or her patient. And so respect for autonomy works and beneficence works and all the rest of it. But actually, if you then say

that the doctor has got responsibilities to other people, for example, the siblings of the person, and of course they may be treated by the same clinician. There is not a single part of the principles of medical ethics which allows the doctor to make an ethical decision as to whether or not to maintain confidentiality, let's say, which would be a prime ethical commitment

and or divulged to a relative, the risk that is confronted, presented by their genetic inheritance. And I think unless medicine really looks at that very carefully, doctors are going to be in serious difficulty trying to, if they want to try and work from an ethical platform, because there isn't an obvious way at the moment. Especially where the patients are increasingly interested and want to know more in certain countries.

And, of course, the litigation issue is not a small or an irrelevant matter. We see it on the rampage in certain parts of the States and over here too. But can we just talk about embryonic stem cells for a moment? I've read that the use of these and the discovery of these is like a light turned on. Somebody said, the next thousand years is going to be different because this is such an extraordinary advance. Now, Barry Jackson, could you just, is it possible briefly to say,

I mean, I could try to it, but sounding like I do, no, believe me anyway. Would you briefly say what stem cells are about and why they're important? These are the precursors of all human tissue. They're the embryonic cells that actually, from which your skin, your heart, your lungs, your intestines grow. and it's now possible to isolate these very early, undifferentiated cells that have got the potential to turn into any particular tissue. We can obtain them in adults from bone marrow at the present time, which has these very early cells and use them for some purposes.

But there's quite a lot of research going on into much earlier taking the fertilised egg, donated fertilized eggs, for the first week before they implant into the uterus, they have the capacity to turn into any particular tissue, any particular organ in the body. And grow? And grow. And you can now, I believe, take these early cells and grow them in the laboratory setting, and you can maybe able to affect the growth so that you could grow a particular organ, in theory, at any rate, or a particular tissue, and then use that to be transatlanticle.

and then use that to be transplanted into a patient at some later stage. And we're told that degenerative conditions like Alzheimer's and leukemia could be halted by the development of... Well, this has been postulated. I mean, a lot of this is highly speculative. There's a lot of work going on in research laboratories. It's not very much applicable at the moment to humans. There's a lot of enthusiasm, I believe, by the researchers.

My prediction, I have to say, is having read a little bit about this, but not a great deal. is that the enthusiasm of the researchers is probably rather excessive at the moment. And I think it's going to be some years before this becomes a feasible proposition. But I'd be interested to know what Sheila thinks about, but she knows more about that. I think many people listening would say, good. That's excellent. That's marvelous because these generative diseases, particularly the diseases of aging, can be attacked this way far.

It seems. Barry Jackson qualified it, so I must doubly qualify. can be tackled in this way, like in no other way, and so on. Yet you see, a lot of people see, and there's huge pressure being brought to bear on people doing this research now, they see a very serious moral and ethical problem at the century. Could you explain that problem and explain the concern? Yeah, I mean, the major concern, I think, is for those who believe that there is a kind of potential human being in every sperm or every egg or every fertilised egg. and of course that means that their objection would not just be to the use of stem cells

but would also be to the assisted reproduction in general to any research on the human embryo. So there is a large group in the population for whom any kind of research of this sort is just simply morally objectionable. I'd be surprised if that group represented the majority, however, because I think although this is very technical scientifically, it actually has a lovely simple layperson's appeal about it. You know, the lay person actually genuinely thinks, I could understand why that might work.

And once we got over, you know, once we recovered from the birth of Dolly, I think we all got quite good at genetics, you know, quite good at the way these things were done and speak quite fluently about them after dinner. So I'm not sure that it frightens people quite as much as it used to. But I think the other kind of part of the debate is that it's inevitably and clearly linked with the kind of mad antipathy to cloning. So the use of tissue of anything in that way is, I mean, is still obviously, something that, I mean, cloning, for example,

I mean, we had just about every country in the world banning it before they even understood what it was, and still a great deal of public concern about it. And it has got to do with respect for persons and respect for the things that make us persons, and there will be a lot of people who feel very strongly against it. But it does

sound like a fabulous theory. I think there'll be a lot of discussion about this over the next decade, I would think. I mean, I don't really see this as coming on on stream into the main line until at least a decade has passed. I think our views will clarify probably a great deal. I would be surprised if most of your listeners knew very much about this.

They may have read just the odd paragraph here and there in the popular newspaper, but it's something that is going to have to face a profession, and I must say I think it's going to have profound ethical implications in the future. There's been a suggestion that the umbilical cord could be of the greatest use here, that each person's umbilical cord could be stored, and things could be read from that when needed a letter at life. I didn't know this. Is this right? This is Noel Lenoir, the head of the European Committee on Ethics and Science, suggested that.

I didn't know that. That's fascinating. There is, as far as I know some research going on, because I could be wrong. I think it's in Bristol because they actually contacted me when they were thinking of putting forward their research proposal to go through what the legal and ethical problems might be, which is when I first became aware of it. And I have to say that I hope they got their money because it was extraordinarily, well-conceived project. I thought, anyway, taken great account

of all the other problems. But I understand that that is a very real possibility which would, of course, in many ways solve some of the problems that people have about using fetuses or fetal material. I think if that were feasible, I mean, having heard about it for the first time, minute ago,

I'm very much interested in that. I thought that would solve a lot of the problems that might otherwise arise if it's possible. But of course it causes other problems because the fears are that poorer nations, poorer people

will not be able to store their umbilical cords properly or they'll sell them off or so and so forth. So the exploitative side rears up instantly. The trouble is I'm not sure,

Melvin, how you could avoid any of that in any of the advances in medicine. We've just mentioned things like assisted reproduction and genetics revolution and so on. And the simple truth is that these are, I think, are kind of fixations of the rich world.

You know, the people in the poor world, may occasionally want access to some of the technologies of assisted reproduction, but it's by no means at the top of their agenda, I would have thought. But we are fascinated by it. Can I bring this discussion, which I've enjoyed enormously, to an end on this sentence from Christian Barnard, who said, the prime goal is to alleviate suffering and not to prolong life. And if your treatment doesn't alleviate suffering but only prolongs life,

that treatment should be stopped. Now, he said that very forcefully, as we know, who's a pioneering heart surgery. it seems to be the opposite it seems to be the case now the prime motive for a lot of people is to prolong life I think that's true

I think members of the public provided they feel reasonably well and they're not in pain and their mental capacities are still full they want to live a long life and doctors are encouraging this and of course the life expectancy is increasing

all the time not owing to better health generally, but also owing to the techniques and therapies that are now available. But it's not beyond the bounds of possibility that the stem cell techniques could prolong

life dramatically. If we can grow inside ourselves, that which is degenerating, regrow it, that could be an enormous factor. Well, that might be quite interesting. Would you like to live to 120? I'm having difficulty getting through the day to tell you the truth. I mean to say, I would

love to live to 120, provided I had my mental capacities and physical capacities, even though I was rather frail. I think it was great... I'm curious to know what the next century has in front of us, really. I'd like to pop back every five years to say how everybody's getting on. Absolutely. I think the other problem, though,

and part of what Christian Bernard is referring to is that modern medicine also has the wherewithal to keep people alive in circumstances where they might not be happy, and we have a legal regime, which doesn't permit doctors to make certain kinds of decisions in conjunction with their patients to allow that life to end. So there's also the positive side of living longer,

but there's also the negative side, which, I mean, for example, there's some evidence that in the United States, the fastest-growing suicide rate is amongst the elderly because they are terrified that they'll be hospitalized and inappropriately as they would see it kept alive because doctors don't dare to terminate treatment in some circumstances, even when their patient wants them to. So there's two sides.

It's the great kind of living to your 120 and being quite fit, and then there's a being made to live when you don't want to. Well, that raises all sorts of ethical problems of itself. I mean to say the persistent vegetative state and such like and when do you switch off, if you switch off the lifeline, huge ethical dilemmas. Well, thank you both very much. Thank you, Sherlock MacLine, thank you Barry Jackson, and thank you for listening. We hope you've enjoyed this Radio 4 podcast.

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