This week I am breaking the convention of choosing a health story from the week and examining the ethical issues that emerge from it. Instead, I will take a look back at the big Medical Ethics issues of the year, many of which were covered in the articles on this site.

It would be near impossible to pick out the most central Medical Ethics issue of the year because there have been so many that have made the news in the UK. Many of them may have been presented as Medical rather than Medical Ethics issues but at the heart of them lay difficult moral questions.

Self-image emerged as an important question this year as we found ourselves grappling with the problems surrounding size zero models. The problems of image were not confined to the catwalk; they pervaded the home and even prevented some people from going out to work. Reasons for claiming incapacity benefit included being overweight and suffering from acne. Such is the image-obsessed society we live in that people had made life-changing decisions because of a problem that should only have been skin deep but had in fact deeper mental scars.

With all our fears about anorexia and the fashion industry, it might be difficult to believe that the UK also found itself on the brink of an obesity epidemic. Obesity was on the news regularly. It appeared and reappeared in different contexts from the House of Lords debate about whether our bread was sliced too thickly, thereby encouraging us to eat bigger portion sizes, to whether there were enough opportunities for people to exercise. Children were not excluded from this debate. Manufacturers were blamed for using cartoon characters on the packaging of unhealthy foods that were targeted at children. There were even calls to blame parents and classify childhood obesity as a form of abuse. We argued that childhood obesity had many causes, not just parents, so to classify obesity as abuse would be wrong and single out the parents of obese children when they were in fact only one potential factor.

Food additives also featured with regard to children and revealed some of the inconsistencies with regard to the Government’s approach towards children’s health. Toys that contained high levels of lead were being withdrawn for fears that children who put them in their mouths might suffer from lead poisoning. Yet when the dangers of food additives were discussed, the Government took a softer approach by relying on the goodwill of manufacturers not to use the additives rather than regulating their use or banning them completely.

The impact of the Government on our health has come under scrutiny in other areas as well. On the 1st of July, it became illegal to smoke in any enclosed public area in England. All pubs and restaurants went smoke free as a result of this legislation. The new rules were met with a mixed response. Some thought that such a move smacked of a “nanny” state whereas others, mainly non-smokers, were relieved because they would no longer risk the ill effects of passive smoke. One of the central moral benefits of the legislation is that people can exercise free choice, i.e., they can make the choice to smoke without compromising the health of those around them by exposing them to passive smoke as they did before. But soon after this legislation, the Government took a step too far. It proposed the introduction of graphic images on cigarette packets that would frighten people to such an extent that they would either stop smoking or not begin at all. The basis of this proposal was that the verbal warnings were no longer effective. Such a drastic step controls free choice by frightening people and thereby defeats its very purpose. The State’s position that Champix, a drug that could help smokers stop smoking, should be funded on the NHS also sparked controversy. That Champix existed was beneficial but whether alterations to what are essentially lifestyle choices and not medical conditions should be paid for by the State was questionable. Perhaps the most unfortunate piece of health news in the context of smoking was that of pregnant women who smoke. For all the effort that the Government has made to discourage smoking and protect non-smokers from passive smoke, it is ironic that no legislation is capable of protecting our most vulnerable group of underage passive smokers, the foetuses, some of whose mothers smoke.

The foetus has been another widely discussed group this year. The abortion law was re-examined after forty years and proposals were put forward to lower the deadline for abortions from 24 weeks to 20 weeks. The proposals were based on the idea that the foetus can feel pain from 20 weeks and also on the fact that science and medicine has now progressed to a stage where babies as young as 23 weeks can survive. Although abortion was debated independent of euthanasia, it seems odd that the law allows a healthy 23 week old foetus to be aborted but would not allow a very ill 23 week old baby to undergo euthanasia. The abortion law has not been revised and regardless of one’s views on abortion, it is at the very least inconsistent that the moral status of a being is dependent on whether it is inside the womb or out in the world. It is also important to challenge the argument that claims about foetal pain are inconclusive. We argued that although it was important to establish the accuracy of scientific claims, it must be recognised that we may never know for sure as to whether or not a foetus at 23 weeks experiences pain. For this reason, we ought to err on the side of caution and assume that it does feel pain especially as we would probably assume that a baby of the same age experiences pain.

We also saw another example of the close relationship between abortion and religion. A young woman from Dublin was initially prevented from travelling to England to have her foetus aborted. She was under the care of the State who did not want to allow her to travel abroad for an abortion. Abortion is illegal in Ireland. Her reason for wanting an abortion was that her foetus suffered from anencephaly (part of the brain, scalp and skull missing), a condition that would almost certainly result in the baby’s death within three days of the baby’s birth. The abortion debate is a debate about whether or not life ought to be preserved but sadly, in this case, life would not be preserved regardless of whether or not the mother was allowed to undergo an abortion. The moral question shifted, therefore, to one that asked whether it was right to prolong life unnecessarily. Eventually, the mother was allowed to travel to England to undergo the abortion.

Abortion also came to light in another context. The General Medical Council published new guidelines that suggested that GPs were obliged to maintain confidentiality with regard to abortion, contraception and pregnancy even if their patients were as young as 13. Doctors were no longer allowed to tell the patient’s parents why their child had been to see them even though they were meant to encourage the children to share this information with their parents. These guidelines had some downfalls, particularly with regard to young girls undergoing abortions. Although patient confidentiality is often beneficial to the patient, it is difficult to see who would provide a young girl with the support she might need after undergoing an abortion if no adult was allowed to be told of her situation.

Britain is also determined to lower its teen pregnancies, currently the highest in Europe. Towards this end, a new system is being tested whereby the contraceptive pill could be available over the counter, eliminating the need for a visit to the GP for a prescription. Pharmacists will need extra training for this added responsibility but while fewer teenagers may get pregnant, we need to ensure that more teenagers are not infected with sexually transmitted diseases as a result of substituting the pill for condoms. We ought also to be mindful of the possibility that improving access to the pill may result in increased levels of peer pressure for young girls to become sexually active before they are ready to. We also looked outside of the UK when a debate emerged in India as to whether sex education was appropriate in the Indian classroom. How do discussions like that fit into that cultural context?

The pregnancy debate also included ways to become pregnant. The inconsistencies in the number of IVF cycles being offered by different Primary Care Trusts to couples undergoing this treatment was controversial and raised the question yet again of what NHS funds were meant for. Is there a truly objective way to rank treatments on the NHS or is our perception of the importance of certain treatments dependent on whether or not these treatments affect us? Related to the question of IVF was the issue of the lady who, after trying to have a baby for fourteen years, finally decided to use some London buses to advertise for an egg donor. To what lengths should people go to have a baby and is this even a question that anyone other than the couple can answer? Moreover, are London buses meant to carry medical advertisements and, if so, how will they prioritise whose medical need is worthy enough to deserve a space? Related to the question of having children was the case of a man who refused to give consent for the frozen embryos of his ex-girlfriend to be used for her to bear children. The law requires that the consent of both parties is required for the embryo to be implanted but the prospective mother wanted the courts to override her ex-boyfriend’s wishes. Unfortunately for her, her wishes were refused. This is a case where location does makes a moral and legal difference. An embryo that had already been implanted before the relationship ended would not have been aborted even if the man wished this but an embryo outside of the womb that has not yet been implanted can only be implanted with the consent of both parties.

Embryos also caused moral controversy in another context. Proposals were put forward for hybrid embryos. We argued that not only were they morally permissible but that they might even be morally necessary. It seemed problematic that the moral outrage related to this issue accorded a higher moral status to hybrid embryos by discouraging their use for medical research whereas human embryos which were currently legally used ought in fact to have a higher moral status.

Moral issues were not confined to the beginning of life. A TV documentary in the UK on Alzheimer’s disease followed the life and illness of one patient until two days before his death. Opinion was divided as to whether filming a patient under such personal circumstances was morally appropriate. The patient, his wife and family were aware and had consented, however, to having the film-maker present. The patient’s wife wanted to highlight the disturbing and debilitating effects of the illness, as well as the fact that Alzheimer’s disease can kill, and the documentary did just that. It did, however, put more than just Alzheimer’s in the spotlight. The media was subject to scrutiny as well and it came under heavy criticism for being too intrusive.

So what is the role of the media with regard to our health? Holby City, a popular medical drama, was criticised because one of its episodes showed a doctor drinking excessively without showing precisely what the effects of excessive alcohol can be. Is medical drama meant to educate or entertain?

The question of death also came up in the context of organ donation. At present, those who wish to donate their organs after death actively sign up or “opt in” for organ donation. The Government has proposed altering this system to one where the default position would be an “opt in” position and people who do not want to donate their organs would have to opt out. This move would dramatically alter the culture of informed consent as we know it. Informed Consent entails opting for or choosing a medical treatment or procedure, not opting out from other procedures. Although the idea behind the Government’s proposal to increase the number of organ donors is understandable, such a move will threaten our right to genuinely choose as to whether or not to donate our organs.

Various other stories made the medical and moral news. The “Cannabis Granny” who used small quantities of the drug to alleviate her pain re-opened the debate as to why the drug was illegal in small quantities for medical reasons. The issue of drugs emerged again soon after when we examined the moral basis of drug classification and asked why certain drugs were illegal when they were less harmful than other drugs that were legal.

The moral considerations surrounding the rights of people with disabilities and the role of their carers in medical decision-making also came to the fore. Decisions that may have appeared disturbing were often morally appropriate under the particular circumstances. A few months ago, the proposal to remove the uterus of a girl who had severe cerebral palsy was met with opposition but on a closer examination, was the best option for her.

You might be wondering why we chose not to discuss some of the biggest medical stories. This is because the biggest medical stories don’t always make the biggest moral ones. 2007 presented issues like MRSA, Clostridium Difficile, mixed sex wards, poor hospital food, shortage of midwives, dirty ambulances and so on, all of which were big stories and had moral issues contained within. However, where a moral “answer” or solution is obvious, there is limited value in discussing the rights or wrongs of that issue. For example, MRSA is problematic and should be eliminated. No one would disagree. Our discussions tend to lean towards the harder moral questions where arguments on both sides are compelling and therefore require more thought.

We have engaged in a discussion of several other moral issues as well during the course of this year. I have no doubt that 2008, like every other year, will present its own set of Medical Ethics problems. Thank you for your readership and comments over the past few months. It is always a pleasure to hear from you. We hope you will read our next article that will be up in February. Meanwhile, if you would like to contact us, we will still respond to emails and take bookings for our Spring Workshop. We hope you will return to our site to read and participate in more ethical analysis of topical health stories in the New Year. 

Season’s Greetings, and I hope to see some of you at our next workshop.