Julian Sheather on once upon a time in the west

Audiences can be fickle things. Last week I clambered down from my ivory tower and emerged, blinking, onto a brilliantly-lit podium at the Cheltenham Science Festival. The theme of the evening: Playing God – Risk in Surgery. I was on a panel with two surgeons, but my job was to do the ethics. I figured the live issue would be about balancing paternalism and autonomy. Was there a limit to the amount of risk a patient could be asked to take on? Could illness and the possibility of death be coercive? Could an ambitious surgeon, keen to make a name, lead the desperate into taking impossible and mutilating risks?

 How rose-tinted must be the windows of the ivory tower. I could not have been more wrong. A charming cardiac surgeon took us on a walk down memory lane, a long, long walk back to the good old, bad old days, the days before the scandals at Alder Hey and Bristol Royal Infirmary had put the spook into medicine, back to the days when surgeons were surgeons and patients were grateful. Back then, apparently, if a surgeon had an idea about a new way of doing things he would run it by his – and I mean his – team and provided nobody thought it absolutely insane, they would give it a go. On
the whole it didn’t do to tell patients what you were up to – not a good idea to worry them overmuch – best just to have a stab at it and see what happened. When it came to looking at the results, the first thirty or so were discounted. These were your ‘learning curve’ – these are not my words – but once the technique had settled down, you could begin to assess outcomes.
As I listened my blood ran a little colder than usual. I felt the ghosts of ancient wrongs beginning to stir. I thought of the long ethical haul from the Tuskegee syphilis study: black American sharecroppers with the disease were systematically denied penicillin so that researchers could better understand its natural history. What about informed consent, I spluttered? Research equipoise? What about giving people a choice? So far as this audience was concerned, it all fell on deaf ears. Predominantly elderly, they were in nostalgic mood. Several of the surgeon’s early patients were present, and they clearly adored him. As a young doctor he had done his best according to the mores of the time. He had also saved their lives.

Their questions were not about ethics but about ‘what he got up to in their chests all those years ago.’ ‘We’re still here’, they chirruped. ‘In my line of work’, he quipped, ‘your mistakes don’t usually come back to complain’.
That night it wasn’t surgery that was in the firing line, it was ethics. A woman came up to me afterwards. It’s a pity, she said, you seem like a nice man, but don’t you see that you and your ethics are part of the problem. Nobody can move for bureaucracy. Innovation is dying on the vine, choked by
the red tape of ethics. There are no pioneers any more. The great surgeons of old have been bought to their knees by Lilliputian ethicists. Okay so a few may have died back then, but think of the thousands saved. You can’t make an omelette without breaking some eggs.
If there was a serious point then this was presumably it. In medicine, as in many other walks of life, many could be saved by the sacrifices of the few. Contemporary life however puts the one before the many. Treatments and techniques that could save thousands are inhibited out of a squeamish
regard for individual rights. A respect for patient autonomy has brought medicine to a standstill. There is a certain cold utilitarian plausibility about this. But we need to be cautious. Pluck a man at random once a week from a public place and redistribute all his organs: many could be saved for the loss of one. This is facetious of course, but it makes the opposing point. The public interest is all well and good, but which of us would want to be the sacrificial lamb?
I slunk back to my ivory tower. ‘Reality in our century’, as Graham Greene once said, ‘is not something to be faced’. But then his was the twentieth century. In my view medicine has changed incomparably for the better over the last thirty years, and the rise of ethical sensitivity has played a key part in that change. It has helped put the patient in the centre. But it seems that not everyone agrees with me. Even, to my continuing surprise, some of the patients.

Julian Sheather is ethics manager at the British Medical Association.  The views expressed are his own.