Chaos & Caprice – The Changing Face & Ethics of Medicine

By Dr David KL Quek

"…In a world dominated by chaos, we are far removed from the securities of traditional practice. In many important cases, we do not know, and we cannot know, what will happen, or whether our system is safe.

" We confront issues where facts are uncertain, values in dispute, stakes high and decisions urgent. The only way forward is to recognize that this is where we are at. In relevant sciences, the style of discourse can no longer be demonstration, as from empirical data to true conclusions. Rather, it must be dialogue, recognizing uncertainty, value-commitments, and a plurality of legitimate perspectives. These are the basis for post-normal science.

"In post-normal science, Quality replaces Truth as the organizing principle."

-- Silvio Fontowicz & Jerry Ravetz (in Introducing Chaos, by Ziauddin Sardar, Iwona Abrams, Icon Books UK, 1998; p157-9)

At the risk of sounding tired and tried, I wish to re-emphasise some issues, which I find ethically challenging and problematic.

Recently, I have been reading (perhaps much too selectively!), the concerns of the new millennium and how its technological advances would impact on our society, particularly with regards to the amoral direction of the advances of medicine and healthcare. Undoubtedly, these concerns will become even more critically assailed as our new millennium of wonders continues to march on relentlessly.

Twenty-first century Medicine continues to bedazzle and yet bewilder us in its explosive all-encompassing reach and implications. We are truly at the cusp of a new era, where the final mysteries of the human body, its workings and failures, might become fully unravelled in the not too distant future. Such an accelerated rhythm of change, at such unprecedented rates, would almost certainly continue to stupefy us.

Soon with the fine-tuning of the Human Genome Project, we would stand poised to manipulate, even eradicate our genetic predisposition to all manners of illness and/or co-morbid tendencies. Genetic therapies could possibly replace many of our current pharmacologic approaches to health and healing. Moreover, with continually refined miniaturised even roboticized diagnostic and surgical techniques we are also at the verge of changing the way in which we can intervene on the human body, as never before.

Nanotechnological wonders could possibly employ micro-robotic devices, which can act at a distance, at the very cellular level to clear ageing debris or even mitotic malignant clones of cells, even to clip leaking or bursting blood vessels, or close-up ruptured gut. The pinpoint accuracy of such therapeutic advances may make the mechanical skills and expertise role of physicians/surgeons redundant, yet our supervisory roles as technical wizards might become that much more specially honed and demanded.

Replacement body parts – whether human, transgenic, genetically engineered or even mechanistic – may become de rigueur. Obsolescent and ageing tissues and organs would become readily replaceable, even enhanced, perhaps almost as easily as changing a component chip, an IT board or a burnt-out flash bulb.

Already French doctors have tried injecting genetically-modified skeletal muscular cells into scarred dying hearts so as to revert terminal heart failure, with initial success, hope and hype. Clearly mankind is replete with ingenuity and genius, sufficient enough to conjure up all forms of magic to prolong or even to second-guess health and dying.

Clones for whatever replacement or redundant purpose will almost surely become a reality. DNA-manipulated embryos from same sex parents or single parents might escape the dragnet of self-imposed or state-legislated controls. Fully in vitro generated humans might become a new super species for humankind, which if allowed its genetic manipulation and perfection could lead to a superhuman race, perhaps becoming even completely distinguishable from us the "naturals", by developing true interspecies incompatibility.

However, much as we marvel at the huge potential of such wondrous advances in science, medicine and health, we cannot help but become somewhat deflated when we daily encounter the less than picture-perfect inadequacies of our changing world. More importantly, another sphere of uncertainty rears its Medusa-like head i.e. moral dilemmas arising from these new medical possibilities.

Recently in Malaysia, a twin with a life-incompatible congenital defect was kept alive and preserved so that one of his arms could be used as a historic transplant for its identical twin who was born with a defective upper limb stump. Would future life-incompatible births be considered spare parts for other less than perfect babies? Could their foetal cells be used for other medical purposes or developing cell lines for research, for cloning or whatever? Another baby was recently conceived so that its umbilical cord blood could be used for bone marrow transplant of her ill sister dying of leukaemia – luckily for her there were no incompatibilities’ problems, and both are doing well.

Another more contentious incident arose in England when the courts forcibly told parents of a pair of conjoint twins that the twins had to be separated against their wishes and religious beliefs. And this was performed knowing full well that upon separation one of the more dependent twins would die instantly, while perhaps helping to preserve the life of the other. Can the right to offer hope for one person, be the denial of right for another perhaps less capable, less endowed, less complete, when assessed in human terms, to live? Does certain killing of one somewhat lesser individual, condone the action made to preserve the life of another considered more capable of surviving?

Indeed all these ethical dilemmas will increase exponentially in the times to come. Will we be prepared for such challenges? Do we have the mechanisms to help provide some well-thought out ethical answers or guidelines? Should we not have a National Medical Ethics Board to spearhead these considerations before these conundrums shock us with their wantonness and amorality? Or is it sufficient to let such issues crop out piecemeal, with only the delayed wisdom of hindsight to guide us into the uncertain future?

On a grander scale, another incongruous moral issue is already with us – that is, the great global disparity in the distribution and availability of healthcare, medical amenities, technical and professional-expertise, and other sophisticated advances. The wealthier first world enjoys most if not all of these technological life-prolonging and life-enhancing advances, while the dire third world remains mired in terrible unsanitary conditions of living with callous exposure to the elements – often leading to infectious communicable diseases, long eradicated or well-controlled by their richer counterparts.

Whither, the human race in this one world, one globalized community? Indeed we are far from being so ennobled that we behave as one united species, all tending towards a common good. We are too disparate and too individualistic for that single-minded purpose of kindly brotherhood. Our much aspired to comity of nations is still but a pipe-dream, perhaps never to be realised, unless we are forced to face with a global threat of extinction, whether from within or without.

Still, in spite of this dismal world-view, some isolated but sporadic glimmers of humanity, of tenderness and caring, cannot help but evoke some hope that all is not lost. In the deep recesses of man’s overt inhumanity toward one another, lie some obscure but not altogether hidden fluctuating bubbles of our innate propensity for love and benevolent humanitarianism.

Crass and unbridled consumerism, winner-take-all market economy and the impending mainly dehumanizing globalization appears ready to supersede all of mankind’s hitherto more limited and circumscribed wants and needs. Indeed, our human face and ideals have become so eroded and distorted that we have mindlessly parleyed and sold our souls to the mercenary devil, now so gratuitously and cravenly sanctioned as the New Age God of Mammon.

Worse still, will the coming age of globalization further entrench the worship of money and competition with no moral anchor to moderate its excesses? At the end of the year 2000, it is perhaps time to contemplate on our purpose and our souls. As physicians, can we not be the initiators or advocates for a better kinder world? Or should we be quiet contented-discontented nonentities, too engrossed with our own small circle of life? I believe we can certainly do better than that.

As a parting shot, consider the following quotation from Silvio Fontowicz & Jerry Ravetz (in Introducing Chaos, by Ziauddin Sardar, Iwona Abrams, Icon Books UK, 1998; p157-9):

"In the heuristic phase space of post-normal science, no particular partial view can encompass the whole. The task now is no longer one of accredited experts discovering ‘true facts’ for the determination of ‘good policies’. Post-normal science accepts the legitimacy of different perspectives and value-commitment from all those stakeholders around the table on a policy issue. Among those in the dialogue, there will be people with formal accreditation as scientists or experts. They are essential to the process, for their special experience is used in the quality control process as the input. The housewife, the patient, and the investigative journalist, can assess the quality of the scientific results in the context of real-life situation."

"We call these people an ‘extended peer community’. And they bring ‘extended facts’, including their own personal experience, surveys, and scientific information that otherwise might not have been in the public domain."

"Post-normal science does not replace good quality traditional science and technology. It reiterates, or feedbacks, their products in an integrating social process. In this way, the scientific system will become a useful input to novel forms of policy-making and governance."

As doctors and scientists, we can help nurture a better-informed ‘extended peer community’ and help generate better policies for a Brave New World.

October 2000

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