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ETHICAL ISSUES
IN THE PROGRESS OF
MEDICAL SCIENCE
AND
TECHNOLOGY
Author:
Dr. A.K.Tharien
Christian Fellowship Hospital
Oddanchatram
Tamil Nadu
Tel (O) : (04553) 226
(R) : (04553) 219
Editor:
Indu Prakash Singh
Wordprocessing: Jubi Baruah
Virender Singh Rohilla
Laser Typeset:
Jubi Baruah
Production:
Communication Team
Published by:
^*^71 f a’
Voluntary Health Association
Of India (VHAI)
Tong Swasthya Bhawan
*>d0, Institutional Area
^uthofllT
x,Nel Delhi-110 016
/Tej? 668071, 668072, 665018, 6965871
i- <
/ Fax: 011-6853708
E-mail No : VHAI@UNV.ERNET.IN
1995
NB: The views expressed in this booklet belong to the
Author and it in no way reflects the views ofVHAI.
CONTENTS
FOREWORD
1
I.
INTRODUCTION
3
II.
GENETIC MANIPULATIONS
7
a) Discovery of DNA
7
b) Gene Therapy
7
c) Bioethics
8
10
III. IN VITRO FERTILIZATION
a) Definition
10
b) Ethical Issues
10
c) Prenatal Screening
12
a
IV. ORGAN TRANSPLANTATION.
.
. ’
a) The Procedure
13
13
b) Commercialisation of Human Organs
13
c) Bill on Transplantation of Human Organs 15.
V.
d) Commodification of Human Life - ;
16’
ABORTION
17
a) Profile Advocates
17
b) Pro-Abortionists
17
EUTHANASIA
19
a) The Debate
19
b) What is Euthanasia?
20
c) The Dilemma
20
d) Death and Dying
21
e) The Christian Concept
22
VI.
f)
Suffering
22
g) Our Guiding Principle
24
h) Some Practical Suggestions
24
VII. CONCLUSION
25
VIII. COMMENTARY
26
IX.
APPENDIX I:
Hippocrates Oath B.C 460
30
APPENDIX II:
Declaration of Geneva-1948
32
APPENDIX III:
Declaration of Helsinki-1964
36
APPENDIX IV:
Declaration of Tokyo-1990
40
FOREWORD
Medical Science knowledge and technology has
undergone tremendous change through constant ex
perimentation and innovations over the last few years.
In pure scientific and technological sense the strides
made by medical science is just flabbergasting. Add
the human, ethical and religious angles to it, the com
plexities start appearing.
Keeping this in mind we approached Dr. A.K. Tharien,
who has over five decades of experience of working
with a missionary zeal at the grass-roots, to dilate on
the ethical issues in the progress of medical science
and technology.
Dr. Tharien makes a fervent plea for ethics in the medi
cal profession to be based on spiritual values. The
views expressed by Dr. Tharien may be controversial.
The purpose of this book will be well served, if the
debate that it is going to raise could make medical
profession accountable to common people. Proferring
care and cure to everyone.
Alok Mukhopadhyay
Executive Director
Voluntary Health Association of India
New Delhi.
I
INTRODUCTION
We are at the threshold of a new era, planning and
equipping ourselves for aglorious entry into the twenty first
century. Science and technology have made spectacular
strides in the recent past. Rapid growth ofmedical science
in isolation raises question on many ethical issues. For
instance discoveries in genetic engineering and embryo
experiments question the sacredness of human life. At a
recent conference convened by the WHO in Tokyo, to
which I was also invited to represent India, the world’s top
scientists in embryo experiments and genetic engineering
shared their startling discoveries. Some of them tend to
violate the time honoured ethical values. What is right or
wrong in a concrete situation? Why should a person
choose the right and shun away from the wrong? Who
decides? From the beginnings ofhuman existence, there
were certain codes of behaviour however inadequate or
inhuman they may look, that set the pattern for personal
and social behaviour.
The earliest and the most popular standard was to accept
the natural law and was to be directed by one's conscience.
Wherever we go wrong, there is a still small voice that
always warns us. We may call it the early stage ofsense of
guilt. But individual conscience is something subjective,
depending entirely on one’s natural tendency, circum
stances and instincts. Also very often we can rationalise our
behaviour even if the conscience troubles us and ignore its
protest.
Medical ethics that takes inspiration from philosophical
values is a category by itself because the questions that
are raised are distinctively different. From time to time the
IntemationalConferenceoftheMedical Associationshave
tried to give detailed list of the duties of the medical
practitioners in terms of the sick, in terms of fellow
professionals and in terms of the society as a whole
(examples are Declarations of the General Assembly of
WM A Geneva, 1948 and London, 1949,see Appendix II).
There has been very rapid social, cultural, economic and
political changes in the world. Medical technology, has
advanced by leaps and bounds so that attempts at listing
right and wrong will become irrelevant and inappropriate at
a later period. Certain basic principles of ethical values
have tobe kept sacred irrespective of the changing times.
Li fe is a gi ft ofGod we cannot give it nor have we the right
to take it. Humanity has put in our hands such power that
we can manipulate, if we want, both birth and death. But
these are areas where we have no ultimate rights.This gives
us on the one hand, freedom and privilege as we need not
answer for any deaths that happen inspite ofour best efforts
and sometime against our calculations it also give us a
responsibility that we can neither play with life, nor even try
to play God.
Healing is not merely curing certain diseases. It is not like
repairing and removing the defects ofa machine. It deals
with person. As such, it goes beyond the techniques to
5
relationships. These relationships should include the
dimension ofsociety, specially the relationship in the family
and with the community. So, healing is defined as restoring
apersonto thepurposeforwhichheiscreated. Nothing
that we do, should hide purpose: whenever opportunity
comes we have to consciously encourage this awareness.
In the healing process it is essential that a team is moulded
together, this includes the doctor, the nurse, the allied
professionals, the ward aids,etc. Responsibility is on each
ofthem to keep the integrity and bear and support each
other. This should be the healing community that enables
the patients to get well.
The challenge ofcommercialisation ofall aspects oflife is
great, but in medical profession it is greater. Money is a
means, not an end. A sense ofcontentment and a sense of
stewardship are essential to keep us free from the slavery
to covetousness.
The essential point is to accept our work, not only as an
occupation or even as a profession, but as a calling— a
vocation.
In this paper some of the current issues, some of which
were debated even at the recent UN Forum in Cairo, in the
realm medical ethics, are discussed.
6
II
GENETIC MANIPULATIONS
a) Discovery of DNA
In 1953 Wastonand Crick, in Cambridgeunveiled, the
structure ofDNA, (Deoxy Ribo Nucleic Acid) the material
from which genes are made. Subsequent researches showed
that scientists have immense possibilities to manipulate the
genes, by using recombinant DNA techniques. The pur
pose of genetic engineering is to introduce or delete or
enhance a particular trait in the body. This is done by
inserting foreign genes or by altering the existing genetic
make up of the person. By genetic manipulation one can
control the formation and development ofa foetus, like the
choice of sex, complexion, height, quality ofbrain and so
on. In other words one can make a baby to order.
b) Gene Therapy
The first gene therapy experiment was successfully
done on a four year old girl in 1990 in the US A. She had
a defective gene. This prevented her body from producing
an enzyme ADA (Adenosine Teaming) hampering her
resistance to disease. The scientist used a deactivated virus
as a king offerry boat to transport normal ADA genes into
the child's white blood cells. These numerous genetically
engineered cells would begin to produce the crucial en
zyme. Science is now unlocking the most closely guarded
secrets of human biology, yielding insights into the preven
tion, diagnosis, treatment and healing ofsome ofthe most
devastating illness for which there was no remedy in the
past. This break through in medical science showed that,
genetically engineered cells would be able to produce
needed therapeutic drugs within the body.
Genes, direct body's growth and survival. Defective
genes causes susceptability to certain diseases like cystic
fibrosis, cancer, diabetes, coronary diseases, mental
retardation etc.
The other class of gene therapy is germ line gene
therapy. In this the gene is inserted into the germ line (sperm
or egg) or embryo and the offspring will have this inserted
gene also, instead of a defective allele. It is possible now
that treatment can be given to the foetus, iffound defective
by therapy or surgical procedure, within the uterus or out
side the uterus.
c) Bioethics
Bioethics is a composite term derived from Greek
words. Bio means life. Ethics has been described as the
science of morals and rules of conduct, recognised in
human life.The rules ofconduct must be essentially social,
religious and moral values. Our ethics must be more than
rationalisation. The new technique in genetic engineering
and such other application of medical knowledge can
relieve and prevent human suffering or protect and pro
mote human life. Genetic engineering encompasses those
techniques that manipulate genes especially those using
8
recombinant DNA techniques. There will be some risks
for individuals but it would benefit many.
One can replace natural procreation with extensive
genetic selection of foetuses. We are not yet sure of the
long term results. In bio technology we are dealing with the
complexity of life itself, by introducing newer gene se
quences. What effect this will haveon family life itself?
Ifwe introduce different gene combinations into the
environment, there could be irreversible consequences.
New organisms may replace existing organisms in the eco
system. Drug resistant pathogenic organism might emerge.
Another question is ,i n whose hands will the power be?
Will the commercial interest dominate the scientist. USA
alone is spending over two billion dollars annually backed
by commercial interests. People whose tests reveal a
defective gene couldbecome victims ofgenetic discrimina
tion. Man with his scientific curiosity, ifgiven a free hand
might even produce allophones between species like
human and monkey hybrids and play god in creating new
species. So it will be necessary to guard against potential
abuses and avoid human vivisection.
9
Ill
IN VITRO FERTILIZATION
a) Definition
In vitro fertilization (IVF) a process of fertilising the
egg cell, sucked out from the follicles of the ovary and
mixing it with sperms in a test tube in the lab. This is a great
break through in medical science and an alternative means
ofconception in many infertile women. About 10 per cent
of married couple are reported as infertile. In women
infertility may be due to defective ovulation or blocked
fallopian tubes or unhealthy endometrium and in men
absence ofhealthy sperms. The fertilised ovum (embryo)
is transferred into the uterus in about 10 to 14 days. 25 per
cent ofthese are successful and gives no extra complication
except increased number of multiple pregnancy. It is
estimated that over 20,000 babies have been born since
1985.
b) Ethical Issues
Some argue that laboratory production of human
beings is no longer human procreation, as it amounts to
degradation ofparenthood and deprives procreation ofits
human involvement and love. IVF might und ermi ne values
which biological parenthood give to marriage. But it is
argued by scientists that IVF is a dramatic extension ofthe
sort ofinterference found in delivery, by caesarean section
or in hormonal induction oflabour.
In these experiments, there are a few surplus fertilised
embryos which are kept frozen for future use, for further
experiments for researchers to study genetic and develop
mental abnormalities, intricacies oftissue and cell differen
tiation etc. ,or to be ultimately destroyed. Can we treat the
fertilised ovum asalumpofjelly orblop oftissue which can
bedestroyedjikeatumoror tonsil? Is it right to use human
materials for experiments and ifso how far? At present the
proposed law in the UK does not permit embryo experi
ments beyond 14 days (which is the implantation stage).
Then the question is raised, do human embryos have any
right at all? If they have rights, at what stage? Can such
embryos be the material possession of the donors when
they do not intend becoming the parents.The fundamental
issue is whether or not respect should be shown to human
embryo, in view of the potential for full humanness. If
embryos are produced with the expressed purpose of
providing scientific information, that information has
already taken precedence, over the significance of human
existence.
In the West, ovum is fertilised from sperm ofunknown
parentsand children are bom without identity ofbiological
parents. (This is now changing, as donors have to record
their identify). A chi Id conceived in a test tube can have as
many as five parents: the egg donor, the sperm donor, the
surrogate mother, (who bears the child), and the couple
who raise the child. The potential emotional and psycho
11
logical ramifications ofthis could be deep and disturbing.
c) Prenatal Screening
Prenatal screening of embryo foetus, amniotic fluid
etc., has nowbecome a routine in most ofthe industrialised
countries to discover any defects.
Examination of the amniotic fluid from the uterus by a
needle after 12 weeks of gestation is one of the easiest
procedures. Sex can also be decided. In India sex deter
mination lead to extensive femicide by abortion. This has
devastating effects on our social structure and consequent
ly legislation has come against sex diagnosis.
12
IV
ORGAN TRANSPLANTATION
a) The Procedure
Sparepart surgery is increasingly becoming popular.
Technical barriers like vascular anastomosis, immunologi
cal rejection problems etc., havebeen overcome.
Viability and suitability ofcertain organs depend on the
time lapsed after the organic death ofthe subject. So there
is a tendency to remove the organ from the donors as early
as possible. Law has regarded death as the apparent
extinction oflife as manifested by the absence ofheart beat
and respiration. Indian penal code section 46 says" death
denotes death ofhuman being unless the contrary appears
from the context”.
The medical community faced with the dilemma ofnot
able to "harvest organs” from patients who seemed to have
lost all brain functionsbut continued to be kept aliveby life
support systems which artificially maintains respiration and
circulation. AHarvard Medical School committee made a
proposal in 1968 recommending the criteria ofdeath based
on brain activity. This is now accepted in India also. To
avoid error in judgement of neurological death , the
certifying physician should not be a participant in any phase
ofthetransplant procedures.
b) Commercialisation of Human Organs
Commercialisation ofhuman organs has become a
flourishing market over the last few years. Theemergence
ofan ’’Organ bazar”, by networking ofmedical fraternity,
touts, agents and some private nursing homes, was a
serious blot on the ethical foundation ofmedical practice.
Investigations revealed the startlingtruth ofthe clandestine
kidney rackets, in Bangalore, Bombay and Madras. Most
ofthe donors were poor slum dwellers and rural folk, who
were enticed with easy money. They were given false or
inadequate information about its risksand complications.
Seventy to eighty per cent ofthe remuneration was netted
by agency involved in the nefarious trade. Some of the
donors unfortunately did not liveto receive the monetary
remuneration promised. The choice before the poverty
stricken people was whether to sell one kidney and live or
to keep both kidneys and die of starvation. The law also
was circumvented through certain dubious means like
"kidney marriage"; getting married before operation and
divorcing soon after the surgery. Another method was by
transboundary smuggling oforgans by livecarriers, where
trade can take place in a foreign country, where laws are
not so strict. The" kidney tour racket" also came to light.
The prospective sellers are taken in groups for pleasure
tour to a developed country which is often theirdream land.
Later they are taken to a neighbouring underdeveloped
country, where the laws are not observed. A rich buyer
from the developed country will also reach this place and
transplantation operations take place in a well equipped
pri vate hospital fora minimum remuneration to the donor.
14
There were other crimi nal ways ofstealing kidney, on the
pretext of other operations like appendicectomy, or
kidney stones.
Human organs and their products are sold over the
counter, as a commercial enterprise; organs like kidney,
liver, heart, foetus, skin, semen, egg, genes, embryo and
even children are traded. Babies are bought and sold
through surrogate mother contracts. Attempts were also
made to patent, parts and products originating from the
body.
c) Bill on Transplantation of Human Organs
Voluntary Health Association of India, took the
initiative to mobilize public opinion and promotethe con
cept ofa legislation through investigations, reports, repre
sentations, campaigns, lobbying and publications. This
resulted in bringing out a bill in the Parliament in 1994. But
the bill got trapped within the red tapes of bureaucracy.
Further efforts ofVnAI in unearthing, shocking stories of
organ rackets and highlighting this issues through media
campaign and press reports resulted finally in notifying the
act, in February 1995.
The act prohibits commercial dealings in human organs.
There are restrictions on removal, transplantation and
storage oforgans. There are regulations and set standards
for hospitals which are conducting the operations and
prohibits removal and transplantation of organs for any
15
flourishing market over the last few years. The emergence
ofan "Organ bazar", by networking ofmedical fraternity,
touts, agents and some private nursing homes, was a
serious blot on the ethical foundation ofmedical practice.
Investigations revealed the startling truth ofthe clandestine
kidney rackets, in Bangalore, Bombay and Madras. Most
ofthe donors were poor slum dwellers and rural folk, who
were enticed with easy money. They were given false or
inadequate information about its risksand complications.
Seventy to eighty per cent ofthe remuneration was netted
by agency involved in the nefarious trade. Some of the
donors unfortunately did not live to receive the monetary
remuneration promised. The choice before the poverty
stricken people was whether to sell one kidney and live or
to keep both kidneys and die of starvation. The law also
was circumvented through certain dubious means like
"kidney marriage"; getting married before operation and
divorcing soon after the surgery. Another method was by
transboundary smugglingoforgansby livecarriers, where
trade can take place in a foreign country, where laws are
not so strict. The" kidney tour racket" also came to light.
The prospective sellers are taken in groups for pleasure
tour to a developed country which is often theirdream land.
Later they are taken to a neighbouring underdeveloped
country, where the laws are not observed. A rich buyer
from the developed country will also reach this place and
transplantation operations take place in a well equipped
private hospital for a minimum remuneration to the donor.
14
There were other criminal ways of stealing kidney, on the
pretext of other operations like appendicectomy, or
kidney stones.
Human organs and their products are sold over the
counter, as a commercial enterprise; organs like kidney,
liver, heart, foetus, skin, semen, egg, genes, embryo and
even children are traded. Babies are bought and sold
through surrogate mother contracts. Attempts were also
made to patent, parts and products originating from the
body.
c) Bill on Transplantation of Hu man Organs
Voluntary Health Association of India, took the
initiative to mobilize public opinion and promote the con
cept ofa legislation through investigations, reports, repre
sentations, campaigns, lobbying and publications. This
resulted inbringingoutabill intheParliamentin 1994. But
the bill got trapped within the red tapes of bureaucracy.
Further efforts ofVH AT in unearthing, shocking stories of
organ rackets and highlighting this issues through media
campaign and press reports resulted finally in notifying the
act, in February 1995.
The act prohibits commercial dealings in human organs.
There are restrictions on removal, transplantation and
storage oforgans. There are regulations and set standards
for hospitals which are conducting the operations and
prohibits removal and transplantation of organs for any
15
purpose other than therapeutic. Surgery can only be done
after explaining, effects, risks and completions both to the
donor and recipients. For violations of the rules, the act
prescribes punishment ofa minimum imprisonment for two
years extendible to seven years and a fine ofRs. 10,000 to
Rs.20,000 for the middle men.
The act also redefines death as cessation of brain stem
activity, facilitating the transplantation of singleorgans such
as heart and liver. In keeping with the WHO recommendationsthelaw incorporates WHO's guiding principles of
transplantation and has provisions to encourage donation
by near relatives like spouse besides genetic relatives.
d) Commodification ofHuman Life
Biotechnology has made great advances. As in other
technological endeavours, absence ofaccountability and
regulatory systems have virtually reduced the human body
as a lucrative commercial enterprise.
The emerging trends for commercialisation ofmedical
services has to be curbed by creating public opinion for a
social policy. The question is also raised whether it is
justifiable to spend enormous amount ofmoney and energy
for prolonging the life span of a few rich, when thousands
are denied even the elementary and basic health needs
which will only cost very little. Isn't it a cruel act, to extend
longevity oflifewithout improvingthequality oflife?
16
V
ABORTION
Abortion was a much debated subject in the recent
UN population conference at Cairo. It is a highly emotional
subject. It touches the mysteries of human sexuality and
reproduction.
a) Profile Advocates
Profileadvocates likethe Muslim fundamentalists and
Roman Catholics, emphasised the sanctity of life and the
right ofthe unborn child who needs protection from society
through his life. Till the law of Medical Termination of
Pregnancy Act was passed by Indian Parliament in 1971
abortion was a violation of law. Now it can be done on
demand.
b) Pro-Abortionists
The pro-abortion lobbies at the UN forum in Cairo
emphasised the reproductive rights ofwomen and pleaded
for legalising abortion.Their concern arose from the high
incidence of deaths due to unsafe abortions, which is
greater in countries where abortion is not legal. A study of
legal status ofabortion in 190 countries reveals the follow
ing facts:
Reasonsfor A bortion
T o save the life of mother
For physical health of mother
No. of Countries
173
119
No. of Countries
Reasonsfor A bortion
To protect mental health of
mother
95
Pregnancy caused by rape or
incest
81
Causes offoetal impairment
For economic and social reasons
On simple request
No permission needed
78
65
41
17
It was reported in Cairo that paradoxically abortion is
minimum in countries like Netherlands where laws of
abortions are very liberal, 5 per 1000 births and in Latin
American countries like Brazil where abortion is legally
restricted, the abortion is 40 to 60.
Pro-abortionists plea to legalise abortion for certain
humanitarian grounds like, stigma of pregnancy out of
wedlock (unmarried girl, adultery, incest, rape), orifthe
foetus is diagnosed as physically or mentally defective, or if
pregnancy is a serious threat to the mothers survival, or
extreme financial and social stress. Most of the people
rightly agree that abortion should not be resorted, as an easy
method offamily planning.
18
VI
EUTHANASIA
a) The Debate
Medical science and technology have made great
strides in recent years. The medical profession has today
more power over life and death than they would have
chosen to have. Doctors have power to prolong life where
life seems to have lost its meaning and have power to ter
minate life without suffering. There are several points of
view on euthanasia: legal, social and compassionate.
The debate on Euthanasia has again become a live
issue in India as the Supreme Court of India in 1994 passed
a verdict that attempted suicide is not a crime. According
to the Indian Penal code, which was mainly adopted from
British Penal Code, attempted suicide was a crime, pun
ishable with years ofimprisonment. With the recent medi
cal knowledge gained by researchers and the opinions
expressed by eminent psychiatrists all over the world, the
judges in their verdict were sympathetic to those who at
tempted suicide.The Supreme Court of India is the high
est court, authorised to interpret the Constitution ofIndia
for legal matters. They gave the verdict that attempting
suicide is a mental derangement and hence not to be con
sidered as a crime. This signifies social approval of suicide
and euthanasia which is assisted suicide.
b) What is Euthanasia?
Euthanasia is the deliberate bringing about a gentle
and easy death, making the last days of the patient as com
fortable as possible. This is to ensure a calm and peaceful
death, within the context ofrelieving incurable suffering in
terminal illness or disability. Euthanasia is voluntary., when
requested by the sufferer; involuntary or compulsory if
it is against the will of the patient; and passive when death
is hastened by deliberate withdrawal of effective therapy
or nourishment.
c) The Dilemma
While I was working in England, I was resuscitat
ing an elderly lady who was admitted in the hospital emer
gency ward with severe demonstrable cerebral damage.
My chief of surgery an Englishman and devout Christian
told me gently, “ I don’t want to interfere with your pro
cedures but if it were my mother I would not do all that
you are doing and would allow her to die peacefully”. This
is often our dilemma Should one prolong the act of dying
in a case of irreversible death or when life is effectively
over. One of the achievements of modem medical tech
nology is the use of artificial life support systems like
artificial feeding, dialysis, controlled respiration, pump
circulation, etc. In some cases it can be so dehumanising,
painful, hazardous or costly that other considerations out
weigh the aim to conserve life. Euthanasia supporters raise
20
weigh the aim to conserve life. Euthanasia supporters raise
the question, how long to sustain life? A patient might say
“I do not want a vegetative existence by drips, drugs and
dialysis. I want to die with dignity. I have a right to lay
down my life just as I have a right to live”.
In the well known Dr. Arthur trial, where Dr. Arthur
in UK had prescribed an overdose of codeine to a baby,
bom with Down syndrome with the object ofhastening
his death, Dr. Arthur was charged with murder. Many
eminent witnesses were called to the trial. Most ofthem
justified the procedure. Finally the court acquitted Dr.
Arthur as his motive was compassion. There is an argu
ment that if a foetus is found to be abnormal and severely
handicapped it should be sought out and eliminated be
fore birth, as such children are socially valueless. Do not
the physically handicapped and mentally retarded have as
much right to life like others and deserve to get the needed
care?
d) Death and Dying
The concept of death in the light ofnew knowledge,
is changing. It may be obtained by redefining life. Descrip
tions of life are organised at many different levels ofcom
plexity like molecular, cellular, organ, system, corporal,
mental, spiritual etc. Human life may be described as the
ability, actual or potential to respond to
be
self-aware. This is based on ceretjf^£ftni^^n*Silv
and others in 1969 have estabH^^t^rf^jcten^p sjuQi
and confirming it by encephalogram findings. Once cere
bral death is confirmed there is no chance for survival
though heart and lung functions continue. So it would be
quite unnecessary to continue supportive measures after
cerebral death.
e) The Christian Concept
According to the Christian concept, Almighty God
has created man in his image. He is the giver and sustainer
of life. He alone has the right to withdraw life. Life is not a
right but a gift of God belonging to God and at all times in
His hand. So we have no right to take away deliberately a
human life, even one’s own.Other religions generally agree
with the same concept.
Euthanasia requests may come out of depression and
confusion or out of a feeling of worthlessness, or due to
persuasion of interested parties with ulterior motives. Re
spect for the person of the patient and concern for the
family should lead us to use our resources as best as we
can to promote life. The essence of our approach to a
dying patient is to give ourselves in loving care to meet his
needs. A patient is not merely a biological unit but a per
son before God with social and family connections.
f) Suffering
Suffering can sometimes be redemptive and purpose22
ful. It is God’s opportunity (as health and an opportunity)
for a creative outcome or a witness or an amendment of
life.
Let me share with you the experience of two of my
friends who faced the issue of caring for children with dis
ability. One was a hospital Chaplain. When a child with
disability was bom to him, he asked God why this hap
pened to him, but he could not get an immediate answer.
He loved that child but the child could not adequately re
spond to his love in the normal way. This helped the Pas
tor to realise how God loves us in spite of us not being
responsive to His love. The other was a colleague of mine
and a highly qualified paediatrician. When a child with
disability was born to him and his doctor wife, they did
their veiy best to sustain her life. The child became criti
cally ill immediately afterbirth, needing exchange blood
transfusions.Though their colleagues questioned the wis
dom oftaking such an extreme step for such a child, they
choose to have the exchange transfusions. The child re
covered and subsequently brought a new purpose to their
life before she finally died at four months of age. Through
this the parents realised that God had a purpose in bring
ing her to their home. This experience was an act of God
to make them aware of the need of caring for many ne
glected children with disability in our society. So they
resigned from their busy clinical work to start a centre for
children with mental handicaps and special needs. An ap
parent traumatic experience became the rallying point for
a new mission for compassion
23
g) Our Guiding Principle
Ever since the time of Hippocrates in the fifth century
BC, the medical profession has been guided by the con
cept ofthe worth ofeach individual human life, which was
reaffirmed by the Geneva code in 1948, which states," I
will show the utmost respect for human life from the time
of conception”. “ Suffering is evil and we should take ev
ery step to mitigate or relieve it.” In the extreme, Hitler
had a utilitarian philosophy of life. Any person who had a
utilitarian value he preserved, and others he eliminated.
But we respect the unique value of human life. Scriptures
say man is made in the image of God. This gives human
life, a unique dignity and value. Life should be cherished,
supported and cared.
h) Some Practical Suggestions
* Doctors should serve and care for their patients in love.
♦ Deliberate attempt to end or shorten life, whether by
omission or commission is unethical, in my personal
view, and should be restrained.
* Our society’s leaders should proclaim the way of
righteousness and truth, against taking innocent lives,
and provide compassionate care.
♦ Education ofmedical personnel and people with moral
and spiritual values should be done, which may lead
to sound legislation.
♦
Bring in the principle of love as the motive and
main- spring.
g) Our Guiding Principle
Ever since the time of Hippocrates in the fifth century
BC, the medical profession has been guided by the con
cept ofthe worth ofeach individual human life, which was
reaffirmed by the Geneva code in 1948, which states," I
will show the utmost respect for human life from the time
of conception”. “ Suffering is evil and we should take ev
ery step to mitigate or relieve it.” In the extreme, Hitler
had a utilitarian philosophy of life. Any person who had a
utilitarian value he preserved, and others he eliminated.
But we respect the unique value of human life. Scriptures
say man is made in the image of God. This gives human
life, a unique dignity and value. Life should be cherished,
supported and cared.
h) Some Practical Suggestions
♦ Doctors should serve and care for their patients in love.
♦ Deliberate attempt to end or shorten life, whether by
omission or commission is unethical, in my personal
view, and should be restrained.
4 Our society’s leaders should proclaim the way of
righteousness and truth, against taking innocent lives,
and provide compassionate care.
♦ Education ofmedical personnel and people with moral
and spiritual values should be done, which may lead
to sound legislation.
o
Bring in the principle of love as the motive and
main- spring.
g) Our Guiding Principle
Ever since the time ofHippocrates in the fifth century
BC, the medical profession has been guided by the con
cept ofthe worth ofeach individual human life, which was
reaffirmed by the Geneva code in 1948, which states," I
will show the utmost respect for human life from the time
of conception”. “ Suffering is evil and we should take ev
ery step to mitigate or relieve it.” In the extreme, Hitler
had a utilitarian philosophy of life. Any person who had a
utilitarian value he preserved, and others he eliminated.
But we respect the unique value of human life. Scriptures
say man is made in the image of God. This gives human
life, a unique dignity and value. Life should be cherished,
supported and cared.
h) Some Practical Suggestions
* Doctors should serve and care for their patients in love.
♦ Deliberate attempt to end or shorten life, whether by
omission or commission is unethical, in my personal
view, and should be restrained.
♦ Our society’s leaders should proclaim the way of
righteousness and truth, against taking innocent lives,
and provide compassionate care.
♦ Education ofmedical personnel and people with moral
and spiritual values should be done, which may lead
to sound legislation.
♦
Bring in the principle of love as the motive and
main- spring.
VII
CONCLUSION
Views and ideas and even concept of ethics are fast
changing in the context of the rapid progress of science
and technology. Ethics are not merely laws for enforce
ment by the state, but self regulatory principles to be
practiced voluntarily imbued with a sense ofhonour and
social responsibility. We need serious ethical evaluation
to check the domination of market forces over human
values. Corrupt trade practice have seeped into the
system. The guiding principle ofoptimum benefit to all
needy patients seems to have lost in the melee of
activities. The benefit of scientific and technological
developmenthas gone beyond the reach ofthe common
patient mainly due to reasons defying ethics. Care
should be taken not to prescribe costly drugs when less
expensive but equal ly effective substitutes are available.
One should confine to the minimum essential investiga
tions, resisting the temptation of monetary benefits.
A doctor serves his patients in love and from true
ethical principle. There must be sound education in
moral and ethical principle. There must be sound educa
tion in moral and ethical values through educational
institution and communication media. We should create
a public opinion on moral values so that appropriate
legislation can comeup in Parliament. Only ethics based
on spiritual values and love can lead our society to
lasting happiness, harmony and peace.
vm
COMMENTARY
In a world where we are taught to define the meaning
of life in terms ofmaterial pleasures and achievements and
the acquisition ofhigh-tech toys, it is not surprising that
people who no longer enjoy these things will find life no
longer worth living. Movements for active euthanasia and
physician assisted suicide have swept the West. And now
Dr Tharien has called our attention to the rise ofthis move
ment in India.1
We should not be so presumptuous as to think that we
know the meaning of our lives. We may be here for pur
poses of which we are not aware. For this reason there
really can be no “ informed consent” to end one’s life be
cause we have no way to become informed of the impli
cation of dying or what will happen to us after we leave
tliis life. So Tharien is right to discuss God’s purposes from
a Christian point ofview. His views ought to be examined
by bioethicists ofother faiths as well as secular and strictly
scientific bioethicists.
Tharien accepts the concept of“cerebral death”. But
really this concept is not well-defined. In the years since
the US President’s Commission’s 1981 attempt to define
death2, studies of patients clinically declared" brain dead"
have revealed that numbers ofthem "maintain hypothalmicendocrine function", "maintain cerebral electrical activity",
"retain central nervous system activity in the form ofspinal
reflexes3."
Some authors have proposed that we no longer wait
for total brain death or for "brain stem death" and sug
gested continuing to regard "brain dead" patients as alive
so long as the heart is beating.4 This raises serious ques
tions for heart, lung and liver transplants.
Tharien correctly emphasises love, which should be the
response to patient’s depression rather than even consid
ering euthanasia. It should be added that one of the best
ways to show love, when non-pharmaceutical methods
fail, is by giving antidepressant drugs. Not enough physi
cians are aware that antidepressants can be effective even
when the depression is an understandable reaction to some
life event.5 A patient’s request for euthanasia may also be
because of pain, and physicians may be insufficiently
aware of proper use of narcotic analgesics.6’8 And there
are many gradations between acceding to a patient’s re
fusal oftreatment letting him die, and imposing coercive
treatment. Sometimes a patient will refuse treatment
because he wants a second opinion from another
physician, or prefers complementary medicine, or chooses
to rely on faith and prayer. Often such decisions ought to
be respected. But when the patient’s refusal is clearly and
dangerously wrong it does not follow that forceful treat
ment is in order. The love ofwhich Dr. Tharien has written
may be the better w'ay to bring the patient around. And if
27
love can reduce somewhat the need for drugs against pain
and depression, what a blessing this will be!
Tharien’s Christian approach is extremely important.
But I hope ourjournal doesn’t become too heavily Jewish
and Christian. Teaching the Buddhist meditative concept
of life is another loving alternative to euthanasia.91 hope
we shall be hearing more from bioethicists with Hindu,
Shinto, Muslim, secular and other Asian approaches so
that our journal will serve as forum for a truly pan-Asian
multilogue.
References
1.
Tharien, A.K.(1995) “ Euthanasia in India”, EJAIB
1:33-35
2.
Halevy, A., Brody B (1993) “ Brain death: reconcil
ing definitions, criteria and tests”, Annals ofInternal
Medicine 119:519-525.
3.
Truog, R.D., Fackler J.C. (1992) “Rethinkingbrain
death”, Critical Care Medicine 20 : 1705-1713.
4.
Aurbach, S.Z., et al. (1994) “Brain death in Halacha”,
Assia: Halacha and Medicine 14:21-23 (in He
brew).
5.
White, P.D. (1994) “ Clinical depression can be
understandable and treatable”, BM/309:721.
28
6.
Marks, R.M., SacharE.J. (1973) “Undertreatment
of medical in patients with narcotic analgesics”.
7.
Annals Internal Medicine 78:173-181.
Angell, M.(l 982)" The quality ofmercy” (Editorial),
WEW306:98-99.
8.
Glick, S.M.(1993)" The empathic physician: nature
and nurture",pp. 85-102 in: SpiroH.Metal.eds.,
Empathy and the Practice ofMedicine (Yale Uni
versity Press, New Haven and London).
9.
Ratanakul, P.( 1986) Bioethics (Bangkok, Mahidol
University ).(Appendix TH: “TheBuddhist concept
of life, suffering and death and thei r meaning for health
policy").
Frank J. Leavitt, Ph.D.
Faculty of Health Sciences,
Ben Gurion University of the Negev,
P.O.B. 654, 84105 Beer -Sheva, ISRAEL.
29
APPENDIX I
HIPPOCRATES OATH B.C.460
“I Swear by all the gods and goddesses, making them
my witness, that I will carry out, according to my ability
and judgement, this oath and this indenture. To hold my
teacher in this art equal to my own parents; to make him
partner in my livelihood; when he is in need of money
to share mine with him; to consider his family as my own
brothers, and to teach them this art, if they want to learn
it, without fee or indenture; to impart precept, oral
instruction and all other instruction to my own sons, the
sons of my teacher, and to indentured pupils who have
taken thephysician’soath,butto nobody else. I will use
treatment to help the sick according to my ability and
judgement, but never with a view to injury and wrong
-doing. Neither will I administer poison to anybody
when asked to do so, nor will I suggest such a course.
Similarly I will not give to a woman a pessary to cause
abortion. But I will keep pure andholy both life and my
art. I will not use the knife, not even verily on sufferers
from stone, but I will give place to such as are craftsmen
therein. Into whatsoever house I enter I will enter to help
the sick, and I will abstain from all intentional wrong doing and harm, especially from abusing the bodies of
man or woman , bond or free. And whatsoever I shall
see or hear in the course of my profession, as well as
30
outside my profession in my intercourse with men, if it
be what should not be published abroad. I will never
divulge, holding such things to be holy secrets. Now, if
I carry out this oath and break it not, may I gain for ever
reputation among all men for my life and for my art; but
if I transgress it and forswear myself, may the opposite
befall me”.
31
APPENDIX II
DECLARATION OF GENEVA-1948
I solemnly pledge myself to consecrate my life to the
service of humanity;
I will give to my teachers the respect and gratitude
which is their due;
I will practice my profession with conscience and dig
nity;
The health of my patient will be my first consideration;
I will respect the secrets which are confided to me;
I will maintain by all the means in my power , the
honour and the noble traditions of the medical
profession;
My colleagues will be my brothers;
I will not permit considerations of religion, nationality,
race, party politics or social standing to intervene be
tween my duty and my patients;
I will maintain the utmost respect for human life, from
the time of conception; even under threat, I will not use
32
my medical knowledge contrary
humanity;
to
the
laws of
I make these promises solemnly, freely and upon my
honour.
(Adopted by the third General Assembly of the World
Medical Association atLondon, England, October 1949.
Duties of Doctors in General
A doctor must always maintain the highest standards of
professional conduct.
A doctor must not allow himself to be influenced
merely by motives of profit.
The following practices are deemed unethical:
a) Any self-advertisement except such as is expressly
authorised by the national code of medical ethics.
b) Taking part in any plan of medical care in which the
doctors do not have professional independence.
c) Receiving any money in connection with services
rendered to a patient other than the acceptance of a
proper professional fee, or to pay any money in the
same circumstances without the knowledge of the
patient.
33
Under no circumstances is a doctor permitted to do
anything that would weaken the physical or mental
resistance of a human being, except from strictly thera
peutic or prophylactic indications imposed in the inter
est of the patient.
The doctor is advised to usegreat caution in publishing
discoveries. The same applies to methods of treatment
whose value is not recognised by the profession.
When a doctor is called upon to give evidence or a
certificate he should only state which he can verify.
Duties of Doctors to the Sick
A doctor must always bear in mind the importance of
preserving human life from the time ofconception until
death.
A doctor owes his patient complete loyalty and all the
resources of his science. Whenever an examination or
treatment is beyond his capacity he should summon
another doctor who has the necessary ability.
A doctor owes his patient absolute secrecy on all which
has been confided to him or which he knows because of
the confidence entrusted to him.
A doctor must give the necessary treatment in
34
emergency, unless he is assured that it can and will be
given by others.
Duties of Doctors to Each Other
A doctor ought to behave to his colleagues as he would
have them behave to him.
A doctor must not entice patients from his colleagues.
A doctor must observe the principles of “The Declara
tion of Geneva” approved by the World Medical Asso
ciation.
35
APPENDIX III
DECLARATION OF HELSINKI - 1964
It is the mission of the doctor to safeguard the health of
the people. His knowledge and conscience are dedi
cated to the fulfilment of this mission.
The Declaration of Geneva of the World Medical
Association binds the doctor with the words, ‘The
health of my patient will be my first consideration ’, and
the International Code ofMedical Ethics which declares
that ‘ Any act or advice which could weaken physical or
mental resistance ofa human being may be used only in
his interest.’
Because it is essential that the results of laboratory
experiments be applied to human beings to further
scientific knowledge and to help suffering humanity,
the World Medical Association has prepared the fol
lowing recommendations as a guide to each doctor in
clinical research. It must be stressed that the standards
as drafted are only a guide to physicians all over the
world. Doctors are not relieved from criminal, civil and
ethical responsibilities under the laws of their own
countries.
In the field of clinical research a fundamental
distinction must be recognized between clinical
36
research, in which the aim is essentially therapeutic for
a patient, and clinical research, the essential object of
which ispurely scientific and without therapeutic value
to the person subjected to the research.
I.
Basic Principles
1. Clinical research must conform to the moral and
scientific principles that justify medical research,
and should be based on laboratory and animal ex
periments or other scientifically established facts.
2. Clinical research should be conducted only by
scientifically qualified persons and underthe super
vision of a qualified medical man.
3. Clinical research cannot legitimately be carried
out unless the importance of the objective is in
proportion to the inherent risk to the subject.
4. Every clinical research project should be pre
ceded by careful assessment of inherent risks in
comparison to foreseeable benefits to the subject or
to others.
5. Special caution should be exercised by the doctor
in performing clinical research in which the person
ality of the subject is liable to be altered by drugs or
experimental procedure.
37
n. Clinical Research Combined with Professional
Care
1. In the treatment of the sick person the doctor must be
free to use a new therapeutic measure if in his
judgement it offers hope ofsaving life, re-established
health, or alleviating suffering.
If at all possible, consistent with patient psychology,
the doctor should obtain the patients’ freely given
consent after the patient has been given a full expla
nation. In case of legal incapacity consent should
also be procured from the legal guardian; in case of
physical incapacity the permission of the legal
guardian replaces that of the patient.
2. The doctor can combine clinical research with pro
fessional care, the objective being the acquisition of
new medical knowledge, only to the extent that
clinical research is justified by its therapeutic value
for the patient.
HL Non-therapeutic Clinical Research
1. In the purely scientific application of clinical re
search carried out on a human being it is the duty of
the doctor to remain the protector of the life and
health of that person on whom clinical research is
being carried out.
38
2. The nature, the purpose and the risk of clinical
research must be explained to the subject by the
doctor.
3. a) Clinical research on a human being cannot be
undertaken without his free consent, after he has
been fully informed; if he is legally incompetent the
consent of then legal guardian should be procured.
b) The subject of clinical research should be in such
a mental, physical and legal state as to be able to
exercise fully his power of choice.
c) Consent should as a rule be obtained in writing.
However, the responsibility for clinical research
always remains with the research worker; it never
falls on the subject, even after consent is obtained.
4. a) The investigator must respect the right of each
individual to safeguard his integrity, especially if the
subject is in a dependent relationship to the investi
gator.
b) At any time during the course of clinical research
the subject or his guardian should be free to with
draw permission for research to be continued. The
investigator or the investigating team should discon
tinue the research if in his or theirjudgement it may,
if continued be harmful to the individual;
39
APPENDIX IV
DECLARATION OF TOKYO-1990
I. Discussion ofhuman genetics is dominated today by
the efforts now under way on an international basis to
map and sequence the human genome. Such attention is
warranted by the scale of the undertaking and its ex
pected contribution to knowledge about human biology
and disease. At the same time, the nature of the under
taking , concerned as it is with the basic elements of life,
and the potential for abuse ofthe new knowledge which
the project will generate are giving rise to anxiety. The
conference agrees that efforts to map the human genome
present no inherent ethical problems but are eminently
worthwhile,especially as the knowledge revealed will
be universally applicable to benefit human health. In
terms ofethics and human values, what must be assured
are that the manner in which gene mapping efforts are
implemented adheres to ethical standard ofresearch and
that the knowledge gained will be used appropriately,
including in genetic screening and gene therapy.
II. Public concern about growth of geneticknowledge
stems in part from the misconception that while the
knowledge reveals an essential aspect of humanness it
also diminishes human beings by reducing thereto mere
40
base pairs of deoxyribonucleic acid (DNA). This mis
conception can be corrected by education of the public
and open discussion, which should reassure the public
that plans for the medical use of genetic findings and
techniques will be made openly and responsibly.
HI. Some types of genetic testing or treatment not yet in
prospectcould raise novel issues forexample, whether
limits should be placed on DNA alterations in human
germ cells because such changes would affect future
generations, whose consent cannot be obtained and
whosebest interests would be difficult to calculate. The
conference concludes, however, that for the most part
present genetic research and services do not raise unique
or even novel issues, although their connection to pri
vate matters such as reproduction and personal health
and life prospects, and the rapidity of advances in
genetic knowledge and technology accentuate the need
for ethical sensitivity in policy making.
IV. It is primarily in regard to genetic testing that the
human genome project gives rise to concern about
ethics and human values. The identification cloning,
and sequencing of new genes without first needing to
knowtheirprotein products greatly expand thepossible
scope for screening and diagnostic tests. The central
objective of genetic screening and diagnosis should
always be to safeguard the welfare of the person tested:
test results must always beprotected against unconsented
disclosure, confidentiality must be ensured at all costs,
and adequate counselling must be provided. Physicians
and others who counsel should endeavour to ensure that
all those concerned understand the difference between
being the carrier of a defective gene and having the
corresponding genetic disease. In autosomal recessive
conditions, the health of carriers (heterozygotes) is
usually not affected by their having a single copy of the
disease gene; in dominant disorders, what is of concern
is the manifestation ofthe disease, not the mere presence
ofthe defective gene, especially when years may elapse
between the results of a genetic test and the manifesta
tion of the disease.
V. The genome project will produce knowledge of
relevance to human gene therapy, which will very soon
be clinically applicable to a few rare but very burden
some recessive disorders. Alterations in somatic cells,
which will affect only the DNA of the treated indi
vidual , should be evaluated like other innovati ves thera
pies. Particular attention by independent ethical review
committees is necessary, especially when gene therapy
involves children, as it will for many of the disorders in
question. Interventions should be limited to conditions
that cause significant disability and not employed
merely to enhance or suppress cosmetic, behavioural or
42
cognitive characteristics unrelated to any recognised
human disease.
VL The modification of germ cells for therapeutic or
preventive purposes would be technically much more
difficult than that ofsomatic cells and is not at present in
prospect. Such therapy might, however, be the only
means of treating certain conditions, so continued dis
cussion of both its technical and its ethical aspects is
therefore essential. Before germ-line therapy is under
taken, its safety must be very well established, for
changes in germ cells would affect the descendants of
patients.
VII. Genetic researchers and therapists have a strong
responsibility to ensure that the techniques they develop
are used ethically. By insisting on truly voluntary pro
grammes designed to benefit directly those involved,
they can ensure that no precedents are set for eugenic
programmes or other misuse of the techniques by the
stateor by the privateparties. Onemeans ofensuringthe
setting and observance of ethical standards is continuousmultidisciplinary and transcultural dialogue.
VHL The needs of developing countries should receive
special attention, to ensure that they receive their due
share of the benefits that ensue from thehuman genome
project. In particular, methods and techniques oftesting
43
and therapy that are affordable and easily accessible to
the populations of such countries should be developed
and disseminated whenever possible.
Declaration passed by the Council for International
Organisation of Medical Sciences under WHO, held
in Tokyo and Inuyama from 22-27 July 1990.
Dr.A.K. Tharien, the author ofthis book, participated
in this Council.
44
SOME ISSUES RAISED
Has a patient the right to be delivered from incurable
suffering?
If a person has a right to life has he not also a right to
take away his own life?
Abortion, though once considered to be a criminal act,
is now often considered to be a benevolent and obliga
tory act. Should we not go along with the times?
Is it wrong to find out and eliminate a retarded foetus?
Iftest tube baby is a break through in medical technol
ogy, why-impose restrictions?
Is it wrong to attempt to create super-humans through
genetic engineering?
Is it ethical to sell or buy organs?
What is our priority? To prolonglife of a few or
improve the quality of life of the masses.
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