BIOETHICS DILEMMAS FOR THE TWENTY FIRST CENTURY


If you were ever looking for a set of issues calculated to reveal modern dilemmas, genuine concerns and strong differences of opinion you might do worse than look to the developing field of bioethics. The old, widely accepted commandments like: Thou shalt not kill have served society well through the years but their proponents tend to falter when it comes to keeping the suffering artificially alive.

My father a medical doctor in Christchurch, had his first serious encounter with this situation when, years ago, a patient he had never met before turned up at his surgery at our house with a request. The man had been diagnosed with inoperable cancer of the throat. His request was straightforward. “I can cope with the pain now but when it gets too bad I want you to come round and put me out of my misery”. “Sorry I can’t do that” my father told him. “My Hippocratic oath and the law of this country forbid it.” “Well be that as it may”, the patient replied. “When the time comes I will send for you.” My father told me that six months later, in the middle of the night, this same patient’s house keeper rang with the message. “He says it is time. Come immediately!” When my father arrived he found the man sitting on a chair, his body wasted by the disease, a massive tumour in his throat – and his voice reduced to a barely audible hoarse whisper. “Please finish it!” he pleaded. Although I know what then happened, I ask the reader, what should my father have done? The Hippocratic Oath with its “First do no harm” seems somewhat inadequate.

These days with a plethora of means to keep a patient artificially alive long past the point at which recovery is a remotely possible outcome, the issue of death by medical intervention has not become any clearer for the medical profession. Regardless of what the law might say there are probably few families with relatives in intensive care where the hospital staff have not at some time asked the question: “if anything happens do you wish us to resuscitate?”

However questions relating to euthanasia are only a small part of the field of bioethics. Another area where much thinking is still to be done is to do with transplants. For example in this country, Maori and Pacific Island Polynesians are disproportionately represented mongst those with kidney disease requiring dialysis, yet when it comes to kidney transplants only about one percent of the kidneys go to people in these groups. Since the choice of who offers and get the transplants is influenced among other reasons by choices relating to donor and patient wishes, by expectations of the health system, by the affected people’s state of education about the surrounding issues, by religious beliefs, by issues relating to lifestyle and even the ability of the patient and patient’s family to become proactively involved, no one simple answer to rectifying the situation exists. Still less clear, is the question of who should take responsibility to address the issue.

That the problem is related to basic understanding and belief is not a question. For example, compared to the rest of the population, a much smaller proportion of Maori and other Polynesian people are prepared to have themselves registered as donors on their driver licences, and in the case of fatal accidents often the families of those registered as donors will intervene to block any move to allow transplants. As a high school science teacher some years ago, I remember a number of instances where Polynesian and Maori pupils expressed strong opposition to the concept of transplants, telling me that their bodies were sacred and even that it was against the teaching of their Church.

Many of the issues in modern medicine are new to the population simply because advances in technology open up more possibilities. In vitro fertilisation, genetic engineering, gene therapy, stem cell research using embryos, cloning, genetic screening (with the attendant decisions about what to do with known defective embryos) and the choice of parents about accessibility of medical help for seriously ill children are all issues where ethical decisions must be taken.

Every now and again society encounters situations where parental consent appears to many to be dangerously archaic. For example Jehovah’s Witness parents have been known to block blood transfusions for seriously ill children on the grounds that it contradicts a verse in the Book of Corinthians where Paul says abstain from blood.

My own personal encounter with what I interpreted as needless superstition was a five year old diabetic child in the Samoan congregation attached to my local Methodist Church. Although known to be diabetic, when she got sick she was offered an orange drink and prayers rather a doctor and an insulin injection. When she slipped into a coma, the parents’ reaction was to call a prayer meeting conducted by an uncle… and even when she died they called the minister rather than a doctor. To say the minister was not pleased would be an understatement. It seems to me that Church leadership need to be discussing such issues with the Church Bioethics council – always assuming such this Council is supported by the particular church.

There is another set of issues which relate to who should make decisions. The recent book entitled “Four Gods” suggests that the nature of ones beliefs affects judgement on ethical issues. We may for example remember that when a Commission led by Senator Ted Kennedy was set up in 1974 to come out with acceptable set of guide on Bioethics decisions their main report – The Belmont Report was seriously challenged, particularly by fundamentalists and Christian Scientists who argued that mentally handicapped parents or children had no rights of autonomy in decisions relating to right to life, euthanasia, abortion or acceptance of proposed life-saving medical treatment. They also challenged whether professional bioethicists had a right to arbitrate on issues previously the preserve of theologians. A similar reaction came in 1982 when the Presidential report on Gene Splicing, The Spicing of Life, was released.

One of the background difficulties for any informed debate is the speed at which scientific progress as been made. This leads to what a friend, Hillary Moss once described in his book the Technologic Trap. In essence Hillary argued that technology had moved so far and so fast that the only people in a position to understand the implications of the research were in fact the technologists. This seems particularly to be the case in the area of genetic engineering. It seems to me at the general impression of white coated nerds mucking about with life in a dangerous and uncontrolled fashion is very far from the truth. However as the research opens up more and more hitherto undreamed findings, the ethical issues are bound to impact on our future and show no signs of abating as the century unfolds.

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