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ROYAL COLLEGE OF GP'S 50TH ANNIVERSARY LECTURE
Author: Dr Indarjit Singh OBE, JP
Humanity and Spitituality of Medicine
A golden anniversary is very special, and I would like to offer my congratulations on this important celebration of the founding of the Royal College. Today also happens to be Vaisakhi, one of the most important days in the Sikh calendar; the day on which Sikhs pledge to be true to the principles of Sikhism. So I suppose, it's a bit of congratulations all round. Vaisakhi is also very much a reminder of our common humanity, and the need to look beyond self, to wider responsibility and the service of others; a theme I'll return to during the course of this talk.
The subject of my talk, 'humanity and spirituality in medicine', seems a bit intimidating; so let me set minds at rest. I'm not going to bore you with deep reflections on spirituality that ignore the real world around us. Having said that, I would like to start with the words of a popular hymn, which to my mind, encapsulate the challenge of ensuring new scientific advances proceed with due regard to ethical values in a rapidly changing world.
New occasions teach new duties
Time makes ancient good uncouth
They must upwards still and onwards
Who would keep abreast with truth?
The verse refers to our need to re-discover truth and moral direction, at times of social and cultural change. Nowhere are the words truer than in the changing world of the medical profession, which has had to adapt to new diagnostic techniques and new treatments that, perhaps more than any other profession, interface with major ethical and religious dilemmas.
Let me briefly outline the extent of this change from personal experience. At the start of the Health Service in 1948, my father was a GP, practising only a few miles from here. Prescriptions were free, and although, as today, there were waiting lists for hospital beds, and long delays in outpatients, hospitals seemed less crowded and free from the atmosphere of crisis and collapse that is a common feature today. Doctors were regarded with uniform awe and respect, and nurses held in great esteem. Visiting hours were much more restrictive than today. Prolonged exposure to relatives, was not considered a good thing, for either patient or hospital staff. At the time, the new miracle drug was penicillin, used, with little thought given to long term bacterial resistance. Polio, or infantile paralysis as it was then commonly referred to, existed in endemic proportions. A popular brand of cigarette was advertised as 'good for your throat'. Widespread spraying with newly discovered DDT almost helped eliminate malaria, but as we've learnt since, almost, is not good enough.
It's important to look to the recent past, to understand and appreciate the massive changes in scientific progress, and the huge advances in clinical techniques which medical practitioners patients and wider society have had to take in their stride since the start of the NHS: whole families of new drugs, scanners and new imaging techniques, transplants and lasers to name just a few. New aids to our continuing quest for a longer and healthier life.
Speaking from even more personal experience, until about a year or so ago, I served as a lay member of the BMA Medical Ethics Committee. I was amazed at the constant stream of complex, major ethical issues arising out of new discoveries and new procedures. Let me list just some of the issues that exercised our minds, to give an indication of the need for new thinking, new learning, and the constant questioning of ethical boundaries derived from religious or from social morality. They are in no particular order.
- Advance Directives, or Living Wills
- Genetic testing where there is a family history of genetic disorders, implications for insurance, genetic screening of populations.
- Making Decisions on Behalf of Mentally Incapacitated Adults
- The Ethics of Xenotransplantation.
- The Meaning of Informed Consent.
- Consent for the Collection, Storage and Use of Gametes
- Ethical Issues in ITU.
- BMA view on Abortion.
- Physician Assisted Suicide. --- And more recently, we've had news coverage of the dilemma of would be, spouse assisted suicide of a female patient suffering a major diminution in quality of life. Alongside major medical advances, there have also been huge changes in society itself, and it is impossible to understand the problems, challenges and opportunities of today's Health Service, without look at and understanding the nature and magnitude of these social changes, and building them into the equation of our quest for better health for all.
The start of the Health Service coincided with a post war baby boom that has now become a generation now nearing the end of economically active life. The labour shortage of the early 1950's, led to the arrival, by invitation, of then youthful immigrants, now in retirement. These factors combined with better medical techniques have resulted in a steady growth in the proportion of the elderly in the population; a growing segment of the population that is not only economically inactive, but also a larger than average consumer of NHS resources. Many of the new advances in treatment and care are enormously expensive, with the effect that the care of the elderly takes up a growing proportion of the Gross Domestic Product. In the past, the important nursing aspect of the care of the elderly would have been absorbed within the family unit. But here also, there have been major social changes, which impinge directly on national resources.
Cohabiting and extra-marital relationships are nothing new, but the discovery of the contraceptive pill has made such relationships more common and no longer subject to general social or moral censure This has had a major effect on the family unit, with more transient and frequently, less dedicated relationships. It's not a moral judgement but a statement of fact, that both within and outside marriage, a sense of responsibility to partner, parent, grandparent or even children, has shown a marked sense of decline in the last half century. Obsession with personal happiness: my life, my right to do my own thing, has become central to the life of many.
I believe today's misplaced stress on the importance of the individual, or self, has a lot to answer for. I speak partly from a religious perspective. Guru Nanak, the founder of Sikhism taught that where God exists there is no self; where self exists there is no God. The same sentiment was echoed by a Christian theologian who said it's the 'I' in the middle of sin, that makes it sin. We have clearly become more selfish in our attitude to those around us.
It has also become more common today, for both parents to go out to work making it physically impossible to care for an infirm family member. Responsibility then passes to the state -at a monetary cost and reduction in the funding available, and there is a less tangible, but non-the-less important cost arising from a weakening of family ties and responsibility. Family care at minimal cost has now been widely replaced by state or private nursing homes and the trauma of means testing and or, selling one's home to meet the cost of care. For others, particularly the mentally sick, 'care in the community', becomes total social abandonment.
Another area of concern is the growing disparity between the health care available to the wealthier and the poorer extremes of society. Particular concern for the children of the poor is highlighted in the BMJ publication 'Growing up in Britain' It shows that poor families in Britain have some of the unhealthiest children in the developed world, destined to grow up as illness prone adults. Infant mortality in Britain is said to be worse than that in Singapore and, in Europe, only Albania has a similar proportion of dangerously underweight babies. In the Report, Dr James Appleyard consultant paediatrician and chairman of the BMA's child health working party, emphasising that prevention is better than cure, estimates that every pound spent on improving a child's health would save eight pounds in later health care. A cash- strapped Health Service cannot afford to ignore such costing.
While Britain may lag behind much of western Europe in certain areas of health provision, no such criticism can be made of our country's pioneering work in many areas of medical research such as IVF, cloning techniques and much else. To the layman, the advances in medical research have been truly breathtaking, bringing us to a point where we can now play with the very building blocks of life in attempts to eliminate many genetically inherited disorders We are now on the brink of spare parts farming within animals to provide spare parts for arteries, heart valves, skin grafts and other body parts.
But, to the layman and to many within the medical profession, there is also a growing sense of unease. It's a feeling that we may be being too clever for our own good and that we are moving too fast to understand the moral, ethical, social and even scientific implications of our discoveries. The case of Dolly, the prematurely arthritic, cloned sheep, is an obvious example of scientific uncertainty. There is a sense of unease that society is being led into uncharted waters by a powerful combination of scientific and market forces, beyond the shoreline and safety of ethical and moral understanding.
Some of the new medical advances now available, or on the horizon, are or will be enormously expensive, and by today's standards, clearly unethical. But at least for the more- wealthy, there is the increasing prospect of a considerably longer and disease free life span. But how far do we want to go down this road at the expense of basic health provision for the many? It may seem a bit fanciful, but I must confess that the prospect of the likes of the Bin Ladens of this world, perhaps more spare parts than original, spanning the centuries, doesn't fill me with enthusiasm.
While we would all like a normal healthy life span, and perhaps a little bit more, I feel most people would agree with the Sikh teaching that it's not the number of years we live, but what we do in them that is important. In India, during the Gurus' time, and even today, there were and are, ascetics and yogis who devote their entire life trying to live that bit longer, without contributing any added value to the world in which they live. As Sikh teachings remind us, a life lived pandering to our own desires, is a life wasted.
On the other hand, let's look at those who have given so much to us all. Jesus Christ, who exerted such a powerful uplifting influence on world society, was in his 30s when he was crucified. Guru Arjan, author of much of the Sikh Holy Scriptures and founder of the Golden Temple was martyred in his forties. Alexander the Great had conquered much of Asia and the Middle East by the time of his death at the age of 32. Getting away from age, Stephen Hawking, severely stricken with disability, is nearer than any of us in fathoming the mysteries of time and space.
Clearly the quality of life is important to us all, which brings me to the question of euthanasia and related living wills or advance directives. While it is in my view clearly wrong to artificially prolong the life of a person in a vegetative state with no chance of recovery, the argument that, 'its life and I should be free to decide when to end it', ignores the reality of no man being an island. We are all part of the mainland. Our actions have a ripple effect on others, particularly those close to us.
It's generally agreed that we should adopt a more holistic approach to individual and community health. Religion and spirituality urge that we go further and adopt a more holistic approach to life. For the sake of clarity, in discussion let's take God out of religion for a moment. Sikhs, like Christians, believe there is a Creator of all that exists. But for the moment lets take Him or Her, out of the equation and think of religion purely as moral and ethical guidance, and ask ourselves if religious guidance has anything to offer the world of the 21st century.
Today, in the developed world, the developing world, the former communist block and other areas, we are all lured by the siren call of materialism which says that we can buy happiness, health and contentment, by, as I said earlier, pandering to self. We are told that we can do this by having a larger home or a bigger car, or other material goodies, because we're worth it. It doesn't work, and our different religions have long warned us about this. Christianity warns us about greed and half a dozen other deadly sins. Incidentally, Sikhs list only five!
As we all know rising affluence in the West has been paralleled, with remarkable correlation, by increasing family breakdown, alcoholism, crime, particularly violent crime, drug abuse, record teenage pregnancies and a general fracturing of social structures. There has been a vast increase in suicide rates and in problems of mental health. Today it's common to say we're stressed. It's worth reflecting that the phrase hadn't been invented when the Royal College came into being in the austere and difficult 50's. It's interesting to read this week, that some doctors want to remove what they term 'lifestyle problems', like alcoholism and stress, from the category of medical illness.
The lesson of all this is that while we all want to live comfortably, selfish pursuit of material comforts, or quick fix solutions through drugs or alcohol abuse do us no good, and cause society a great deal of harm. I know that a famous lady once belittled the notion of society, saying there was no such thing. In my view Mrs Thatcher could not have been more wrong. Society is very much like a ship on which we are all afloat; it's the environment in which we live, and its well-being is inextricably linked to our own. There is nothing wrong in living comfortably, but religion reminds us that it is balanced and responsible living is the key to true contentment and fuller health.
I have spoken at length about many aspects of life seemingly remote from health care, that do in fact, affect both individual health and the health of the community in which we live. To these I'd like to add two more. The first is a growing lack of respect for those in authority and the second is increasing expectations of what may be possible, arising from media obsession with new discoveries; with theory being misinterpreted as treatment, which in reality may be many years away
Let me then summarise some of the inter-twined medical, ethical, social, and I believe spiritual factors, affecting health care today: an ageing population with increasing costs of treatment and care, the availability of highly expensive new drugs, costly new techniques, a reduction in family support -for the reasons outlined earlier, an increase in health care needs of the poor and their families. Individually, all these factors increase the cost and complexity of health care provision, and in combination make for the continual funding crisis that characterises the National Health Service today. The reality of Health Service funding today is that there is nowhere near enough money available to meet the basic costs of health care, let alone heightened public expectations.
Today we live in socially more enlightened times While we must educate ourselves against unreasonable expectations, we must, at the same time, look to minimum standards of treatment and care for all, and be prepared to pay for these. Painful though it may be, the way to meet current shortfalls is through higher taxation, increasing efficiency, and where necessary, a system of rationing based on priorities.
A system of priorities, or priority categories or age groups, in some ways appears to cut across the ethos of health care being equally available to all. But it already exists and I believe it has become a necessity. What is important is that provision is equal throughout the country and that the poor are not disadvantaged. Rather, provision, particularly of public health measures, must be weighted in their favour to reduce an intolerable level of sickness and poor health. Of course it is also important that national policies work to reduce the extremes of wealth all too visible today. At the same time we need set boundaries to what is ethically acceptable in potentially new treatment. This to my mind is the greatest challenge of all. The use of human embryos, to produce stem cells for treating genetic disorders, is example of this ethical dilemma. The possible benefits are obvious; but so too is the fact that manipulation of potential life, decreases, at least marginally, our respect for life. Nothing is for nothing.
We are all aware of the slippery slope that can easily take us from promising new treatment, to a trivialising of life. The boundaries of what is acceptable are constantly being tested, and it is important that in defining them, and assessing their continuing validity, we use our spiritual heritage and the, surprisingly common, ethical values found in our different faiths, to give us a fuller perspective on life.
I believe a holistic approach to health is inseparable, from a holistic approach to life, which leads to an understanding that it's not health, but how we use it that is all-important.
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