A GUT FEELING:
some ethical and theological issues in
by Professor Peter D Howdle, Consultant Gastroenterologist, St James’s University Hospital, Leeds
(Professor Howdle, a former Vice-President of the Methodist Conference, is a local preacher in the Leeds (North East) Circuit)
[Originally published in Epworth Review Vol 31 No 2 April 2004 . Reprinted with permission]
“It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm.” [Florence Nightingale, Notes on Hospitals, 1863]
As part of my role as Vice-President of the Methodist Conference (2002-3) I thought it was important to relate my everyday work as a consultant physician to my Christian faith. It was natural therefore, in visiting many places around the UK and beyond, to discuss issues of medical ethics. This article is a synopsis of many such conversations. Many questions were raised, and very few definitive answers produced!
I confess to being no professional ethicist, but I do have an everyday experience of the issues. Such issues concern us all at some time or other, as patients, parents, carers, friends, or interested observers. We can feel overwhelmed and frightened, or challenged and indeed excited by some of the developments about which we read or hear. The degree of interest or apprehension is perhaps related to our personal proximity to the issues involved.
Issues in medical ethics are quite rightly seen as going beyond matters of medical fact and knowledge and are seen to involve opinion, philosophy, morality and belief. It is often assumed that religious thought or experience will provide some guidance or even rules which provide universal answers to the profound questions which may arise. It is also often expected that people of faith will be supportive, wise and pastoral in times of crisis or challenge. For all of us, however, it is important to consider some of these issues before they are forced upon us by circumstances.
Even if we do not have a personal ethical dilemma at this time, the modern media certainly keep us constantly aware of such issues and it is hard to avoid thinking about these things. For example, I was arrested by a news item in The Lancet in April 2002 headed “Controversy over deliberate conception of a deaf child”. Here was a deaf couple who wanted a deaf child since deafness was normal for them. The question was made more ethically complicated by the fact that the child was conceived after artificial insemination with sperm from a deaf donor, and born to a lesbian couple.
Some principles of professional medical ethics
How health professionals behave is a subject of great public interest. Their code of behaviour is based on Hippocratic ideas promulgated around 450 BC, which still form the basis of medical practice today. Such precepts as “treating all people equally” and “not doing any harm” we regard as being as fundamental today as they were when enunciated by Hippocrates.
Over many years of consensus morality, some general principles have developed which can be used in our ethical thinking when considering specific situations.
Principles of medical ethics:
- Non-maleficence: “do no harm”
- Beneficence: “do good”
- Justice: “act fairly and justly”
- Utility: “do the best for as many as possible”
Such principles would no doubt command wide acceptance by people of all religious groups and none.
There is a further principle to be taken into account, and that is the concept of “autonomy”. The patient is regarded as an autonomous individual: free to decide, self-determining and self-governing. In practice, it probably means the right to say “no”, since actually it is very difficult to be totally autonomous – there are so many constraints upon us. But the right to say “no”, and therefore issues of consent, are very important.
Some specific areas in medicine where ethical dilemmas arise
I propose to consider three areas of medical practice where ethical questions frequently arise: organ transplantation; end of life issues; and issues surrounding the beginning of life. Clearly there are many areas one could consider, but these raise some general questions. It will become apparent that it is not easy to come up with definitive answers.
1. Organ transplantation
We have become used to organ transplantation in recent decades, following the first heart transplant in 1967 by Christian Barnard. One has to remember however that many people at that time found it unethical, and in some cultures today it would be unacceptable. However in Western medical practice, organ transplantation is well established and ethically acceptable to the vast majority of the general public.
My own expertise is in the area of liver transplantation, a well-established treatment for liver failure. The criteria for transplantation have been carefully worked out, and, with the correct selection of patients, the improvements in peri-operative care and immunosuppression, up to 80% ten year survival figures are now expected following the transplant operation.
Some ethical questions do arise however concerning the cause of the patient’s liver disease, the use of resources and the donation of organs.
How should we regard patients whose liver disease is due to a virus contracted whilst abusing illegal drugs intravenously, or to an overdose of paracetamol, or to an excessive intake of alcohol? If the disease is “self-induced” does that affect how we treat the patient?
When it comes to the use of resources, transplant operations are very expensive, perhaps £50-60,000, followed by years of follow-up and the use of expensive drugs. Is that the best use of health service resources? How do we decide?
There is a shortage of all organ donors at present, and patients may wait a long time for a suitable organ to be available. In England in 2002-3 there were 6,025 people on the national waiting lists for organ transplants generally but 401 died before a new organ became available. Sadly, of course, most organs are available from people who will die in intensive care units, their relatives having agreed that their loved one’s organs can be donated for transplantation.
There is an ongoing debate about at what stage organs can be removed in relation to the diagnosis of death. Also there is a debate about who can, or should, give permission. Should it be relatives? Should we have to obtain permission, i.e. should there be a requirement to “opt in” to donation? Perhaps nationally we should assume that once a patient has died organs can be used without seeking consent, and that one’s relatives had to “opt out”. This could potentially make a big difference to the availability of organs for donation, but it infringes certain civil liberties we hold dear. This area of debate also raises the question of the validity and legality of donor cards and advanced directives (“living wills”): should these expressions of a patient’s wishes be paramount?
A final area regarding organ donation surrounds the question of live donors. This principally concerns the donation of one kidney. This is well established and we all probably know of a parent who has donated one of their kidneys to a child for the treatment of renal failure. There are of course obvious risks but benevolent donors take these into account when undertaking such procedures.
However, internationally an illegal trade is developing in human kidneys. A human kidney can be bought from a donor in a developing country and sold for ten times the amount in the West. The medical facilities available are often woefully inadequate and as practised it is to be condemned. However, theoretically, there is an ethical question about whether there should be a regulated trade in kidneys. Should a person be allowed to sell a kidney? It could certainly ease the waiting list problem for those in desperate need of an organ.
2. End of life issues
The techniques involved in organ transplantation illustrate to us the many medical advances that have been made. Many life-prolonging treatments are now possible: dialysis, ventilators, provision of nutrition, emergency resuscitation. It is easy to forget that dying is a natural process and that quality of life is probably more important than quantity. It is precisely in this area where many of the difficult choices and decisions have to be made.
In Margaret Edson’s Pulitzer Prize-winning play “Wit”, Vivian Bearing is a professor of 17th century poetry and is dying with ovarian cancer in a high-tech American hospital after attempts at heroic treatment. She says, “I thought being extremely smart would save me, but I’ve been found out. I want kindness now.”
This is the area around which there is debate. One question which arises is whether it is easier (?better) never to start a treatment, than to start it and then stop it because it is apparently not helping.
Another area of debate is about age. In children with terminal disease or severe disability whose are the decisions? In older people, is there an age limit to various life-prolonging treatments? Do we “give up” too soon with elderly people and persist for too long with the young?
The provision of nutrition and hydration in various ways is now possible – is that different from other treatments? There is something very basic about providing this - and repugnant about withdrawing it?
There has been recent publicity about “Do not attempt resuscitation” (DNAR) orders for patients in hospital. This means that there should be a policy for each patient in the event of a sudden collapse, principally due to failing heart or lungs. Normally the resuscitation team would be called and cardio-pulmonary resuscitation (CPR) (“the kiss of life” technique) attempted. This, at first glance, seems entirely appropriate. But in some patients with other serious or long-term illnesses, it may be inappropriate – who should decide what to do?
It helps to know some of the facts – how successful is CPR?
- When CPR is attempted in hospital:
- 19% patients survive; 13% are alive at one year;
- in the over 74 age group: 14% patients survive; 7% are alive at one year.
One survey of older people showed that requests for CPR if it became necessary fell from 41% to 22% when these facts were explained.
In another survey, medical staff considered they would attempt CPR in 87% of older people, but when the older people were asked, 40% of them said they would not want it.
There are other situations where actively ending life is a sharper question and where decisions and choices are more challenging. There was the case of Miss B in March 2002 who was given the legal right to have her ventilator turned off. Here was a patient totally dependent upon medical technology and care but fully conscious and alert. She decided to refuse medical treatment, knowing that she would not survive. This was legally upheld; her autonomy was preserved.
Perhaps one step further is the challenge of assisted suicide. There are those terminally ill people who go abroad for legally allowable medication in order to hasten their death: clearly an issue which raises fundamental questions about the ending of life.
The legally and ethically acceptable treatment of terminally ill patients often leaves us dealing with uncertainty. Perhaps things are best left in the hands of the wise practitioner who understands the uncertainty which surrounds the application of the doctrine of “double effect”?
3. Issues surrounding the beginning of life
This third area of discussion perhaps raises the most controversial questions and the most emotive.
Many of the questions arise because of the technique of in vitro fertilisation (IVF) – now an established technique for the treatment of infertility but still, at best, only approximately 25% successful. This technique allows the possibility of study and research on early embryos. And in the UK, within strict guidelines, this is legally possible.
Several possibilities arise, however, about which there has been extensive publicity. Creating embryos in vitro opens up the possibility of selecting or rejecting particular embryos based upon their genetic make-up. Perhaps the most reasonable choice would be the rejection of an embryo with a diagnosable defect such as a serious inherited disease; some would reject even that as being unethical. Questions have been raised about selection of male or female embryos, or compatible embryos for the possible therapeutic benefit of older siblings. We then arrive at the question of selection for positive features, “genetic enhancement”. That poses the philosophical question as to what is a positive feature.
The availability of embryos has also raised the ethical question of using stem cells from embryos to produce specific tissue cells for medical treatment. Is that a proper use of an embryo?
Such availability of in vitro techniques has also led to the possibility of human cloning. Of course this is theoretically possible, as shown by the reproductive cloning of “Dolly” the sheep, i.e. the ability to create a whole animal. The technical problems associated with this process are still vast, and some of them may be biologically impossible to overcome. It is probably unlikely that human reproductive cloning will be established for many years. Therapeutic cloning uses similar techniques but is proposed not for reproduction but simply as a method of producing compatible tissue or cells for the treatment of the individual.
Although cloning is surrounded by horror and suspicion, ethically it raises very similar questions to embryo selection or the use of in vitro techniques at all.
All these developments therefore raise some fundamental questions in embryology:
- is it ethical to study embryos and perform IVF?
- should we allow embryo selection?
- does the embryo have any autonomy?
- is an embryo a suitable source of stem cells?
- is human cloning ethical?
- is there procreative autonomy i.e. should we be free to reproduce by any technique possible?
The area of embryology which I think we have to take seriously from an ethical perspective and perhaps is of the most immediate concern is that of embryo selection. It does seem right to use IVF for the treatment of infertility, but selecting out and rejecting embryos with less favourable characteristics – perhaps those who would be disabled – raises serious questions.
A Christian perspective
Most of what I have written raises ethical questions in the context of medical practice which is based upon the moral and ethical principles of Western civilisation. Are there, I wonder, any distinctive Christian ideas which might affect the application of some of the ethical principles outlined?
For example, how does the eternal dimension affect the way we view life on earth? Does our belief in eternity affect how and when we should die?
Our Christian faith may require us to act sacrificially when we seek to do good; thus, should we put ourselves at risk for the benefit of others: should we, for example, give a kidney as the outworking of our Christian behaviour?
The concept of community is important, particularly for the Christian, and may militate against the autonomy of the individual; maybe the resources used for one could be used more beneficially for the many. However, the community also has to be prepared to care for the less able rather than selecting them out at the embryological stage.
How do we deal with the “absolutes” of Christian teaching? The point where life begins is an obvious area for argument and discussion.
And finally, we come to the enormous issues of creation and creating. To be accused of “playing God” is an amazing challenge and responsibility for all Christians. Jackie Leach Scully (2002) reminds us that to “play” properly means showing such qualities as trust, respect, enjoyment in our relationships. At its best we call it love. She believes a loving God is active in creation, “playing” in a proper way. For the medical scientist to be active in creation, playing in a proper way, is to show respect for creation, care in the relationships which might be produced, and enjoyment, since it is by such intuitive leaps that great advances are made. The Bible calls this Wisdom (Proverbs 8:30-31, REB).
If we are made “in the image of God”, what does that mean for the practice of the carer or for the status of the patient? For the creator calls us, having been made in his image, “to be co-creators with him and contributors to the untrammelled energy of God’s unending agenda of love. Thus we share in drawing out from the natural processes of an evolving universe the humane and loving purposes of the God who risks his being in order to share with human beings.” (Jenkins, 2002, p 172).
Downie, RS and Calman, KC. Healthy Respect. OUP, Oxford, 1994
Jenkins, D. The Calling of a Cuckoo. Continuum, London, 2002
Scully, JL. Playing in the Presence. Quaker Books, London, 2002
Schwartz, L, Preece, PE, Hendry RA. Medical Ethics. Saunders, London, 2002