Medical Technology - Ethical Issues
Item
- Title
- Medical Technology - Ethical Issues
- Creator
- Anil Pilgaokar
- Date
- 1989
- extracted text
-
<7 2
MEDICAL TECHNOLOGY
tyl,
ETHICAL ISSUES
- Anil Pilgaokar -
CCLt
56..
/ o-'d
The practice of medicine by its very nature (a) invades the privacy
of individuals (patients) and i.d) is vulnerable to what may be
best termed "rationalized rnisuse/illuse potential. " It is in this
context that ethical facets of Medical Practice become very
important.
"Technology" (described as the "science of industrial
arts" - Consise Oxford Dictionary) by its very genesis lends
itself to commercial exploitation.
It is in this light that - .
ethical issues of medical technology become of paramount importance
but alas this is a neglected °ubjecc in the medical circles.
It
is with this at the back of the mind that we felt that it would
be of pertinence that there is at least some sort of debate and
discussion on the subject and hence this paper.
It must be
clarified at the outset that we are alive to the rather dismal
prospects of putting before you a comprehensive paper before
you but then that is neither our claim nor our aim to do so.
There are limitations of data and mor s importantly our own limi
tations which prevent us from taking any firm position (s) in
respect of many topics covered in the paper, but then it is our
hope that vigourous (rigourous) deliberations at the MFC meeting
would be helpful in (a) clarifying the grey areas on the one
hand and (b) taking up some position (s) in respect of many aspects
discussed in the paper; (which primarily is concerned with
raising some questions for discussion).
*
Admittedly medical technology is a broad term and it would be
purposeless to dwelve on every technology concerned with the
practice of medicine; for that matter even commonplace 'injections'
could be concieved as 'technology, and it would be quite pointless
to discuss the ethical aspects of injections here. Rather it is
our intention to restrict ourselves to newer sophisticated and/
or pervasive medical technologies. In very crude terms, for the
purpose of this paper we shall ignore the "first generation
technologies" (to burrow the current 'in' expression) like say
X-ray machines, and devote the discussion to "higher generation
technologies" like CAT-scan or PET-scan.
Groupinq/Cataqorization of Techno1ogies:
In our surrvey of literature we have not come across any grouping
or catagorization of the various technologies harnessed in
medical practi’ee: but for the purposes of this paper it is
important to device one and so even at the risk of being challenged
we have resorted to the following classifications
(i) Fu:ction replacement medical technologies eg. Heart-Lung
machines or say renal dialysis units; cardiac pace-makers etc.
(ii) Investigational-aid medical technologies like CAT-scans
sonography; echo-cardiography; and its sub-class (ii-a)
"Investigational-aid extendable (in some cases) to curative- n
medical technologies like some endoscopic instruments.
(iii) "Control technologies" like contraceptives, vaccines, and
artificial life-support technologies, and of course genetic
engineering and sex_preselection technologies.
Each as a class would have its own ethical considerations in
addition to general ethical considerations. A priori, the above
classification suggests a need for increasing stringency in
ethical considerations with each class of the medical technology.
Whereas the benifit; risk as also the costs benefit evaluations
vis-a-vis respective populations must form a base for assessing
the relevence (in ethical terms) in all the three classes of
technologies but it is evident that in the first class, the
. . 2 ..
2
ethical considerations would mainly relate to 'operational' part
i.e. use; mis—use; denial of use as also the fees for services
etc. The ethical questions in this class mostly relate to the
individual patient and the institution (investigating centre)
policies.
In the next class (ii), the ethical questions - all
ethical questions relevent to the previous class are indeed
pertinent but in addition, because of the enormous costs of
some of the instruments involved ethical considerations in
National priorities also must form important facets as many of
the instruments lock up and siphon significant monetory
resources, and thereby quite often affect (adversely) other
medical facilities by depriving funds for these.
In the last
class, even more wider questions relating to demographic,
individual rights vs rights of societies, right (’’) to manipulate
human systems and forms etc. could figures
(i)
Function replacement technologies^
Admittedly most of
these technologies are indeed 'life-saving' in critical
conditions.
But when the question such as whose life?
become appearent (as in many cases in our setting do) then
ethical issues do arise and these need to be debated in
full measure. We shall take just two illustrations to
initiate the debate.
(a)
It is well-known that in a renal dialysis unit
priority for dialysis service is given to acute cases
rather than chronic renal failures. Again there is a
long ^'7aiting list for routine dialysis of chronic renal
failure patients (who have to be placed in a queue system
because of the paucity of dialysis units.
Even so when
"J.P." needed dialysis (Jaslog Hospital) he got precedence
over others. With all regards for the noble man, the
question of whether life of other citizen is worth anyless
needs to be taken up.
Again, the dialysis serves as a temparory respite until
the organ teransplant arrangements are available, and
it is at this juncture that further ethical issues arise.
Should kindney of a young person be transfered to older
person? The obvious answer is No.
Yet one finds that
kindney from a young woman (16) being transplanted on
to MGR - knowing that the leader was close to his grave.
The "organ trade" racket with the conivance of the medical
profession has been'highlighted in lay press and yet the
ethical questions have not been raised in relevant
bodies.
It must be conceled that the examples quoted above, are
not strictly ethical issues of medical technology,
rather they are issues related to 'medical practice1.
All the same these are so intimately connected with the
technology usage that the mention made here would not
be totally out of place.
(b)
Cardiac pace - makers are fairly widely used in
our country. And for harnessing this technology
Intensive Cardiac Care Units (ICCU) are essential.
The usefulness of these units is widely known and
acknowledged. What is not generally appreciated is
that in our settings is that a proliferation of such
units could actually impede the quality of service
(medical service) in other faculties of the hospital/
institution. A bed in ICCU could cost (to the institution)
..3..
4
3
some 100 times more than the bed in say a general ward
(of a public hospital). With relative crunches on the
budget of the hospital, the pinch for resources is felt
by other facilities. A y keen observer, who has observ
the "progress" of some of our premier public hospital
in last two decades, could not have failed to notice
that with the advent of super-specialities (like ICCU,
Artificial Kindly Units and the like), there is a steady
degradation in the facilities in other departments. So
we have a situation where the best of the facilities
would be available in these highly specialized units and
at the same time there would be acute dearth of common
requirements like cotton, lint and linen in the general
wards of the same hospital.
Even at the cost of increasing the length of the paper
let us labour over this point a little more.
It would
not require statistical figures to state that the
incedence of tuberculosis in the city of Bombay far, far
exceeds that of CVDs.: Dr. Amar Jesani ( Economic &
Political Weekly,Sept.24, 1988) has pointed out that the
deaths due to TB in the city have increased over the years
thus emphasising the increased requirement of hospital
beds for TB in the city, but these have in fact been
reduced by Bombay Municipal Corporation (paucity of funds)
in the only hospital for tuberculosis in the city of
Bombay; whereas there is a spurt in the ICCU beds in the
city.
(And mind you the ICCU beds cost some 100 times
more)
The number of ICCU beds in the city(in both public
and private hospitals together) are some 30 to 35% that
of the beds in the TB hospital.
Is this due to class biases ? CVD is a rich man's diseases and TB is a poor man's diseases.
Is it 'ethical'
to permit spurt in ICCU beds ?. At the cost of TB beds ?
(ii)
Investigational-aid medical technolocies ;- In this group
there are technologies that 'affordable' only to insti
tutions as for example CAT-scan instrument and there the
ones like sonography (ultrasound) which can be found with
individuals too. What is peculiar, atleast as far as
Bombay is considered is that none of the public hospitals
have these as of today.
And this brings out two possible
reasons for this viz(a) the aquisition of these instru
ments is primarily for 'marketing' reasons - marketing of
'image' of the institution and(b) the law of diminishing
returns impedes the aquisition of these instruments in
public hospital i.e. the additional benefit in investi
gations with the aquisition of these instruments is not
commensurate with the hugh cost of aquisition, operation
and maintenence of the instrument.
It is true that public hospitals have little access to
recovery of costs from the patients (even when these have
resorted to collecting partial fees from the patients (in
Maharashtra).
-.But in private hospitals fees are
levied for services, it would be unthinkable to operate
these instruments (CAT-scan) if these are to be used solely
used in well selected cases only. This is because the
capital investment (around Rs.30 lacs) and allocation for'
operation and maintenence (another Rs.30 lacs) would work
out in annual interest of Rs.10 to 12 lacs, which would
have to be acrued 'from the patients, (i.e.Rs.l lac per
month). And considering that the time required for 'proce
ssing' a patient is 2 hrs and an 8 hr working period, it
. .4
4
would mean to break even this Rs. 1 lac would have to
be recovered from 120 patients or Rs.833/- per patient.
The question that one needs to consider is that would
there be 120 truely well selected cases for such scan
in a month, every month, every year ? If the answer is
NO then it follows that patients who do not require such
an investigation would also be enlisted for such investi
gation - which seems to be the case indeed. How does
this stand on ethical grounds ? How does one ensure that
such trend is checked ? reversed ? Could there be a
well laid down norms for selecting cases ? Could there
be an audit of such investigations ? Who would conduct
such an audit ? These and many other questions will need
to be answered.
Sonography .i Ultrasound technology : This has been the
domain of obstetricians and many obstetricians perhaps
aquire this instrument for 'image' purposes. The pre
mise that the technology is ’safe' (is it conclusively
proved ?) has led to rampant ill-use or mis-use. Wides
pread (though unconfirmed) reports have indicated that
this technology is used to detect pregnancy when cheaper,
more accurate and non-invasive pregnancy tests are freely
available.
One reason behind this is to enable to charge
fees (ususally exhorbitant) for the investigation. How
ethical is this ? What does one do to prevent this ?
What are the situations when use of this technology is
rational ? Can there be an audit?
(iii)
Control technologies s- These are perhaps the most
'impactful' and controversial technologies, and ethical
as also philosophical must be discussed.
Contraceptives technology s There has been a shift:’, in
technology (ies) 'progressing' "tiser-safety" to "contrace
ptive duration of action" (from condoms & diapharms to
'implants');- there is a shift from "user-control"
(condoms & diaphrams) to "doctor-control" (implants).
The shift has been from birth control to population
control.
Is this ethical ?
In the case of doctor-control (and therefore state
control) contraceptive if there is a contraception
failure should it not merit compensation ? Is consent
necessary ? imminent ? Is it sought to ?
The question also arises of 'doctored' results of field
trials ? Should there be a third party audit of the
field trials, particularly since there is an obsession
to pushing these technologies.
Vaccines ; These technologies being a part of Preventive
Medicine are state mediated and at general population
level some questions need to be raised.
Is consent a
necessary pre-requisit before vaccination ? In the event
of vaccine failure should the patient not be compensated ?
Can vaccination be forced in epidemics ?
Sex-preselection / selecrtive foeticide s Sex-determination
and selective foeticide and Sex-preselection technologies
. . .5
T
5
I
are the ones which have discriminitory and demographic
upset potential of the worst kind and yet these techno
logies are vigourously persued.
In extremely small
number of cases where a particular sex foetus could
jeopardize the life of the pregnant woman can these be
justified if at all.
Even so there are no laid down
ethical codes in respect of these at all. Apart from
catering to individual passion for a particular sex of
spring, scientific ego of achieving control over life
processes, and a political handle to manipulate sex
composition of a population, these technologies have
little to offer to mankind.
The basic premise in medical
research is to improve the quality of human sustenance.
These technologies have very little to offer in that
direction (except perhaps cases mentioned above.) But
they do have an enormously large adverse potential.
Should such technologies be allowed to be harnessed in
the country ? Should not the medical comunity decrey
these technologies on ethical grounds ?
Genetic Engineering : These technologies can have extremely widespread manifestations and carry with them dich
otomous repurcussions.
It is with this at the back of
mind that there needs to be an extensive debate on the
merits and demerits of these technologies to work out a
rigid code of procedures.
l
The justifiable purpose of genetic engineering (we are
restricting ourselves only to medical aspects of genetic
engineering only) can be to rectify genetic aberrations
(note the avoidence of the word abnormality) which can
have disasterous or agonizing consequence and nothing
more.
However as things stand today the commonly per sued
(and commonly percieved) goal of the technology is to
rectify genetic abnormalities and improve the quality
( of genes ? ). Just what is abnormal? What is impro
vement in quality of genes ? On this there is no final
word. What is more it is unlikely that there could -be
any final word on this. Allow us to elaborate this
further.
Genetic aberrations like Down's syndrome; inborn errors
of metabolism; juvenile diabetes (?) can have disasterous consequences and genetic rectification could
possibly avoid these con-sequences and perhaps this
technology could have credence in these areas. But say,
if a person has six fingers on his/her hand, there is no
reason to label him/her as ABNORMAL just because he/she
does not conform to the commonly percieved frame of
reference, since there is no physiological/physical agony
or distress emanating. This line of argument can be
extended to ridiculous but effective extent thus.
Blond hair, blue eyes and fair skin is normal to certain
populations and a dark skinned, dark eyed and black haired
person in this population would be ABNORMAL would genetic
engineering experts like to 'improve' (?) this individual
to fair skin, blue eyed and blond haired person. Decades
. . .6
6
earlier an 'engineer' attempted to do a similar exercise.his name was Hitler and his goal was called Fascism.
Cun genetic engineering lead to camouflaged-Fascism ?
What are the ethical and philosophical positions one
takes on genetic engineering ?
Life support technologies employed in lengthing 'vegitative' forms of human (inhuman) existence ? Prolonging
'life' with total disregard to QUALITY of life is not
uncommon these days Is this ethical ? Is it ethical to
perpetuate incapacitation ? What is the position one
takes on this issue ?
Research What are (should be) the priorities in research for
developing technologies ? Who takes the decisions ? Whose
needs (what needs) are given importance 7 These are the crucial
questions that need to be answered. The situation existing today
is not one where 'independent' medical scientists engaged them
selves in research and lead to discoveries.
Today he or she is
either employed directly by commercial corporation or if not is
his research effort is heavily financed ( and therefore contro
lled) by commercial corporations (for profits) in the name of
'service to humanity'. The commercial priorities invariably
leed to secrecy, unethical conduct of research (witness the
contraceptive research) and 'doctored results' and when scien
tific expertise and commercial power combine (as it is today)
all this become ever so easy and free from challenge.
If there are strict laid down norms for drug research, why can
their not be similar rigidity of conditions in research for
developing technologies ? The question of consent in research
& in practice is a virtual farce.
Ethics of research and prac
tice is evident by its absence. Use of technologies to serve
defence medicine - whether right or otherwise - can be a matter
of debate in United States but in India (today) does it have any
place ?
Fears ;
There can be no conclusions to a paper of this sort only
FEARS. When one overviews the situations one distinctly gets
the impression that the entire persuit is one of concentration
of power, centralization of power - Medical Power; Contraceptive
technology is shifting from end-user control to doctor-institution
control. High priced instruments are phasing investigation patho
logy from individual doctor to institution.
Function replacement
technology vulnerably chains the patient to medical establishment.
Artificial Life Support systems virtually confines the patient to
institutions with .very little else. Through selective foeticide
and sex-preselection technology, medical establishment aquires a
manipulative potential and this is further compounded with the
emergence and proliferation of genetic engineering.
We have had
political leaders controlling populations, we have had religious
leaders controlling populations. Will the Medical man
Commerce
man combine also jump into the arena ?
NOTE
We appeal to your generosity and pardon us for stretching
the point to ridiculous extent but believe us the inten
tion is only to provoke discussion.
—0O0—
I
Position: 1535 (5 views)