Mathematician Marcus du Sautoy is becoming an increasingly regular front-man for the BBC science documentary Horizon and, to date, his contributions have always been satisfyingly informative. The recent episode The Secret You is no exception.

In his quest to discover the underlying biochemistry and physiology of consciousness, du Sautoy visits a number of laboratories around the world where self-awareness and the notion of “the inner me” are being investigated. In doing so, he frequently participates in experiments; at one point he quips “another day, another scanner”(50:49).

Marcus du Sautoy takes part in many experiments as part of his search for the basis of consciousness

There are a raft of ethical questions which arise from functional Magnetic Resonance Imaging (fMRI) and other neuroimaging methods, some of which I have written about elsewhere (see Disorders of consciousness: do state-of-the-art neuroimaging techniques shed new light on the brain-injured patient?).

For me, the most interesting ethical questions in the programme arise from the work of Professor Adrian Owen. du Sautoy and Owen discuss experiments conducted with patients in PVS, a Persistent Vegetative State (16:44 to 19:22, though the discussion makes most sense if you start at 15:30).

Prof Adrian Owen of Cambridge University has made exciting discoveries about the awareness of a patient in PVS

Previously our abililty to tell whether or not a PVS patient was genuinely conscious was constrained by the fact that they had no physical ability to demonstrate their awareness. In ground-breaking experiments, however, Owen and his colleagues have communicated with patients by asking them to imagine performing certain tasks, for example playing tennis, and using fMRI to show that the appropriate areas of their brains are activate. By developing this further, it is possible to get the patient to imagine two different activities which are clearly distinguishable from one another in terms of brain activity. These can then serve as proxy signals as “yes” and “no” answers to questions posed.

A patient could be trained to make certain areas of her brain active as a proxy answer to questions posed by researchers (e.g. by imaging she was playing tennis or walking around her house)

These experiments have revolutionised our understanding of brain-injured patients. In particular it brings into question the practice of withdrawing food and water from patients in PVS on the assumption that the are not aware.

Horizon: The Secret You (TRILT code 01210858) was first broadcast on BBC2 on 20th October 2009. It is available to watch on iPlayer until 28th November 2009 (UK only).

Simplistic analysis sometimes looks at the horrors of Nazi eugenics before and during the Second World War and wonders how they could ever have come up with such evil. The sad truth is that the philosophical roots of Auschwitz include in no small measure the influence of British polymath Francis Galton.

Francis Galton coined the term "eugenics" in 1883

The first episode of Andrew Marr’s The Making of Modern Britain A New Dawn includes a very helpful section (from 14:02 to 16:38) discussing the origins of Galton’s thinking on eugenics and the influence that they had on prominent figures in England and abroad.

Set by Marr in the context of paranoia about the crumbling Empire and embarrassment at the difficulties experienced in the Boer War, Galton’s ideas about the role of breeding in development of human attributes received a warm reception from influential politicans and thinkers of his day. Allowing the less desirable members of society to breed freely, whilst at the same time “better” members of society were having smaller families, was seen to be diluting the genetic pedigree of the race.

Although in no sense a details description of Galton’s views, this short clip could be a useful introduction to the origins of eugenics for a class in philosophy, bioethics, or indeed several other disciplines.

A New Dawn (TRILT code: 0123695A) was first broadcast on BBC2 on 28th October 2009. It is available on iPlayer until 10pm on Wednesday 9th December (UK only).

The BBC's ethical debate programme is broadcast regularly (10 AM, BBC1, Sundays)

As users of our Upcoming TV worth recording feature will know, the BBC’s Sunday morning studio debate show The Big Questions frequently includes bioethical topics amongst the three issues discussed each episode. It has not proven possible to add posts on each of the programmes, and unfortunately they are only maintained online for a week after transmission. However, with the current series now more than halfway through a 43 episode run, it felt like an appropriate time to document in one list the programmes that have featured the most overtly bioethical discussions, and to provide the TRILT code for each episode so that members of the BUFVC can order copies via the catch-up service.

The series is continuing and additional issues will be added to this list as and when they are discussed.

Amanda Blue’s excellent Cutting Edge documentary The World’s Oldest Mums (Channel 4, 23rd July 2009) examined the cases of four women who were all at or near the age of 70 when the film was made.

Jenny Brown: 72 year old Jenny is “bursting to be a mother” and is seeking a clinic willing to help her to do so. The film shows her applying to, and being turned down by, the Bridge Centre in London and later trying to contact fertility specialists in Eastern Europe to fulfil her dream.

72 year old Jenny is seeking a clinic in the former Soviet Union willing to help her to have a child

Rajo Devi: Currently, the oldest mother in the world is 70 year old Indian Rajo Devi. Partly due to the social stigma associated with childlessness, India is becoming a major centre for the fertility treatment of older women; more than half of the 200 patients at one IVF clinic featured in the documentary are aged over 50.

Rajo Devi became a mother at 70 and (at the time of writing) is the oldest mother in the world

Mary Shearing: Interviews with 16 year old twins Amy and Kelly, reinforce the fact that fertility treatment to allow postmenopausal women per se is not a new phenomenon. The fact that their mother Mary Shearing has only recently turned 70, however, emphasises that the boundaries of possibility (and acceptability?) are certainly shifting.

Mary Shearing gave birth to twin daughters in November 1992 at the age of 53

Maria del Carmen Bousada de Lara: The saddest story in the documentary, concerns Maria del Carmen – saddest both in terms of the circumstances under which she came to find herself seeking fertility treatment, and the fact that she died a few weeks after the filming of her interview (see here for news report).

Maria died from ovarian cancer when her twin boys were 2 years old

With three brothers but no sister, Maria faithfully fulfilled the expected role and devoted much of her adult life to caring for her widowed mother. It was to Maria’s great misfortune that her mother lived to be over 100. It was only after this time that Maria felt able to seek fertility treatment, covertly flying to the USA and lying about her age to do so.

Is it right to give elderly women help to get pregnant?
What insights do these case offer regarding the ethics of helping post-menopausal women to have children? These four examples illustrate some of the arguments presented both in favour and in opposition to allowing fertility treatment for older women.

Arguments in favour
Advocates of fertility treatment for older women may argue in terms of individual autonomy, or may speak of rights, either rights to have a family per se, or more specifically under Article 8 of the Human Rights Act/European Convention of Human Rights, for the right to privacy. It is also possible to frame arguments in terms of the suffering of childlessness. In the case of Rajo Devi, it is clear that the stigma is greater; in her culture it is considered bad luck to encounter a barren woman on the street before lunchtime and in consequence her recent pregnancy has brought additional relief from ostracism (against this, it might be argued, we ought to challenge prejudice, not pander to it).

Advocates of treatment for older mothers may also highlight the unfair way in which women (in western culture, in particular) are villified for having families in their advanced years, whilst men who father children at equivalent ages are not judged in the same way, and may even by celebrated for their virility. Eric Clapton, for example had three daughters in his late 50s, and Rod Stewart’s seventh child was born when he was 60.

Arguments against treatment
For many people there is an inherent ‘yuk’ factor regarding older mothers. How can this moral repugnance be substantiated? It has been argued that embarking on a family at extreme ages demonstrates gross selfishness. This, however, can be a misleading oversimplification. Whilst it may be the case that a woman has put career development before family (there is some evidence of this in the case of Jenny Brown, for example), there may be other reasons for the delay. As demonstrated in the case of Maria del Carmen, it was actually a lack of selfishness that resulted in her leaving it so late to start a family, since she had devoted her life to caring for her mother. Regardless of the motivation, Robert Winston is amongst several commentators warning women not to assume that IVF will routinely provide them with a family at a later stage (see Career women given ‘false optimism’ by fertility clinics).

Those opposed to fertility treatment for older women may argue that there are health risks for the mother, and risks that her children will likely lose their mum at a tender age. Taking each of these in turn; it is certainly true that becoming a mother late in one’s life can take a terrible toll on the body. Mary Shearing comes across as a remarkably active 70 year old – we see her in the film water-skiing and working out in the gym. She was, however, ‘only’ 53 when she had her twins. Rajo complains of ongoing stomach pains after the birth and, although it is not expressly suggested in the documentary, there may well be a connection between the fertility treatment received by Maria and her subsequent ovarian cancer.

Regarding the premature death of their mother, it is – of course – true that over the course of history mothers have generally died much earlier in the life of their children than is the norm today; indeed, many would have died during childbirth itself. Nevertheless, there does seem to be a qualitative difference between the possibility of a parent dying during your childhood and the likelihood that this will be the case. Maria’s case is a sad reminder of this reality.

Additionally, it may be stressed that donated oocytes are a relatively rare commodity within healthcare provision and since it is a biological truism that fertility treatment is less successful for older women than for younger, available eggs should be prioritised towards younger candidates.

If not age, what other criteria should be used to determine who gets the egg? Should priority be given to women who have not had children before? Several of the cited examples already had adult children, including Mary Shearing and Lynne Bezant. Should onset of the menopause be a cut-off point? If so, what about women who have early menopause (ie before 45) or even premature menopause (in women under 40) ?

Ability to pay is a likely factor, particularly since NICE (the UK National Institute for Clinical Excellence) has state that only women under 40 can receive fertility treatment paid for on the NHS, and some primary care trusts (e.g. Oxfordshire) have set a lower age threshhold for publicly funded treatment. Receipt of treatment on the basis of ability to pay is, of course, identified as a source of injustice against the poor.

Even private clinics may impose some age-related criteria. It is interesting to observe that both Liz Buttle and Maria del Carmen lied about their age to receive treatment, and other evidence suggests that they are not alone in this (see Thousands lie to IVF clinics in desperation to have baby). We must remember too that differences between one jurisdiction and another can lead to patients receiving treatment elsewhere, e.g. Maria going to America and Jenny’s attempt to follow Patricia Rashbrook and others in going to the former Soviet Union (see Older British women head abroad for IVF).

Cutting Edge: The World’s Oldest Mums was first broadcast on Channel 4 at 9 pm on Thursday 23rd July 2009. At the time of writing it is available via 4OD their catch-up service. BUFVC members can obtain a copy via their institutional representative in the usual way (TRILT ID: 0109BBFE).

(CJRW)

[This is a first BioethicBytes post from guest reviewer, Robert Cane – welcome Rob]

(Warning: contains plot spoilers!) 2000 film The 6^th Day takes its name from the Book of Genesis  ‘God created man in His own image, and behold, it was very good… And the evening and the morning were the sixth day.’ (Genesis 1:27,31), which is quoted during the opening credits.  In the near future as depicted in the film, animal cloning is ubiquitous, but, following a disastrous failed experiment, human cloning (beyond the cloning of organs) is strictly forbidden.

Adam Gibson (played by Arnold Schwarzenegger) is a commercial pilot who, along with his business partner Hank Morgan, is hired to provide transport for tycoon Michael Drucker. Drucker is the money behind Replacement Technologies, the company which, with access to the genetic code of almost every biological being, provides everything from new super foods to the cloning of recently deceased family pets.

At the last minute, Adam switches places and lets Hank do the flying for their first assignment for Drucker. Instead, Adam goes to the mall where he briefly considers having his family’s dead dog cloned before buying his daughter a life-size doll. Upon returning home for his surprise birthday party, Adam discovers that his family and friends have already begun the celebrations with an exact replica of him (a clone) in attendance.

From this point on, Adam must run for his life as the people behind the illegal creation of his clone attempt to kill him in order to erase any evidence of their crime. As the film progresses, Adam discovers that Drucker is running an illicit human cloning operation alongside scientist Dr. Weir and must destroy it to save his own life. Amidst a slurry of repetitive but passable action sequences in which Drucker’s henchmen are killed and cloned again and again, there are sporadic, but important, references to the many ethical questions surrounding cloning.

Although most of the film fails to rise above the level of an average Schwarzenegger action adventure and its action scenes are certainly nothing out of the ordinary, the 6th Day does make frequent attempts to engage with interesting ethical issues, and, even if a solid, but ultimately uninspiring action film does not appeal to you, many sections of it may be useful for facilitating discussions regarding cloning.

The Science
The first thing to note when considering the portrayal of cloning in the 6^th Day is the significant disjuncture between the fictional science of the film’s ‘near future’ and the actual science relating to the potential therapeutic or reproductive cloning of human beings (00:18:11 to 00:19:06). The clone of Adam Gibson – and, indeed, all human and animal clone in the film – was created by the implantation of Adam’s DNA into an adult-size blank human before a recording (a ‘syncord’) of his mind is transferred into the brain of the clone to create an exact physical and psychological replica of the original Adam Gibson. This is very different to the techniques of somatic cell nuclear transfer (SCNT) or induced Pluripotent Stem cell (iPS cell) use that represent the best strategies to create a genetically identical clone (see Chinese researchers clone Tiny the mouse from skin cells for a recent example of genuine cloning). Using current cloning approaches, the clone would be neither the same age as the original organism nor would it be in possession of a copy of its mind. Similarly, any effects of environmental factors would not be brought into play. This disjuncture may well be useful in its own right as the beginning of a discussion, but, crucially, it must be held in consideration when using any clips from the film to stimulate discussion of ethical issues.

Replacement to Avoid Loss
Although, as one might expect, the use of human clones to replace deceased loved ones is mentioned throughout the film, the best discussion of these issues occurs at the beginning of the film regarding Adam’s dog, Oscar. Adam’s wife asks him to get the deceased dog cloned through the company RePet so that their daughter will not have to suffer from its loss. Adam, however, is not keen on doing so (the scene in which Adam’s wife asks him to get the dog cloned can be viewed between 00:09:07 and 00:10:15). Another good scene that can be used to illustrate this debate is one in which Hank is attempting to convince Adam that he ought to get the dog cloned (00:11:42 to 00:12:27). If allowances are made for the fact that in the world of the film such cloning is commonplace and creates an exact replica of the deceased animal, then these scenes can be used to stimulate discussion regarding the possibility that reproductive cloning may provide an avenue for grieving parents to assuage some of their sense of loss.

The Prevention of Progress?
In one scene (00:30:05 to 00:32:19), Drucker gives a speech calling for the ban on research into human cloning to be lifted. Surrounded by anti-cloning protestors, and despite the revelation elsewhere in the film of his nefarious purposes, Drucker defends cloning on the basis that it can bring great benefits. Whilst, within a world in which cloning means the creation of an exact replica, the main thrust of his speech revolves around the possibility of replacing terminally ill loved ones with clones that can continue their lives, this scene can be used during a discussion on the arguments for and against cloning (both in therapeutic terms and as a solution for couples incapable of natural reproduction). In particular, it may be useful to draw comparisons between the ban on human cloning castigated in Drucker’s speech and current legislation restricting the use of cloning techniques. For example, in the UK reproductive cloning is illegal, but therapeutic cloning is legal under strict licensing conditions.

The Rights of Clones?
Throughout the 6^th Day, the point is made that clones are not afforded the same respect as other human beings. In one scene (00:45:29 to 00:46:14), whilst Adam is observing his own clone, he remarks that the clone is ‘not real’ and ‘not even human’, and Hank, who is with him, ponders how you might differentiate between two people who are the same, and whether it would be possible to consider either of them individuals. Along similar lines, one character, Tripp, is an anti-cloning extremist who sets out to kill several individuals that he knows to be clones (54:51 to 55:31). Whilst human clones do not exist in the contemporary world, and therefore do not face such discrimination, these clips could provide the basis of a useful discussion regarding the hypothetical treatment of human clones in a world where many reject the concept of cloning on the grounds that it is unnatural. Particularly pertinent issues to consider are whether or not clones would be considered legal equals and fully independent human beings, and whether they may face discrimination in human societies, which have so often sought to victimise those that are different.

Unhealthy Clones?
One of the key scenes in the 6^th Day involves Drucker and Dr. Weir, a man who had his wife cloned after her death only to see her die five years later (01:17:06 to 1:20:30). In this scene Drucker explains how the clone of Weir’s wife had accidentally been created with a genetic flaw (she had Cystic Fibrosis). Such flaws were routinely added to the DNA of the clones by Drucker, in order to ensure that those being cloned would be tied to him in perpetuity as they returned every few years to be cloned again. Obviously, this is a dystopian and unrealistic vision relying upon the fictional science around which the film is based. However, this scene could be used to stimulate debate regarding both the likelihood that many early clones may suffer health problems, and issues surrounding the use (or abuse) of genetic information by organisations and individuals with motives that are not entirely altruistic.

Thus, the 6^th Day may, despite its flaws, provide a number of useful clips that can illuminate many issues of ethical concern, and, that can, if used in conjunction with other materials of a more factual nature, provide a colourful and dynamic base upon which to build a discussion. Useful summaries of many of the ethical issues described here can be found on the website of the Center for Genetics and Society, and, in particular, in both its ‘Research Cloning Arguments Pro and Con’ and ‘Reproductive Cloning Arguments Pro and Con’ pages.

The 6^th Day (TRILT ID: 004F8F4D) is frequently shown on UK television, particularly on Five and their digital daughter channel Five US. Members of the BUFVC can use their back-up service to obtain copies.

[RC]

(Warning – contains plot spoilers!) Private Practice is a spin-off from Seattle hospital drama Grey’s Anatomy in which Dr Addison Montgomery (Kate Walsh) moves from Seattle Grace to join the staff of the Ocean Wellness Center in Los Angeles.

I have to admit that I tired of Grey’s Anatomy during Season 1 and although I was aware it has spawned another series I had no desire to watch. All this changed, however, following an excellent talk on the programme, given by Dublin Doctor Audrey Dillon at the 4th Postgraduate Bioethics Conference (Belfast, June 2009).

The writers of Private Practice, headed by Shonda Rhimes, have made a conscious decision to incorporate ethical issues into the storylines (see ‘Private Practice’ explores bioethics questions). This means, therefore, that the series may well throw up some interesting case studies as discussion starters.

At the time of writing, Living TV (UK) has just started transmission of Season 2 (see here for Episode guide). A Family Thing, the first programme of the series, was aired on 25th June 2009 (TRILT code 00FC042B). True to promise, it contained two subplots featuring ethical dilemmas.

Saviour siblings – a donor by design?

In the first (starting 7 minutes in), Molly and Eric Madison present at the clinic demanding that the staff deliver their baby daughter that day, despite the fact that she is only 27 weeks gestation. The girl, it transpires, has been conceived following Pre-implantation Genetic Diagnosis, to be a ’saviour sibling’ for her older brother, Jason.  The boy has leukaemia and has had his own bone marrow wiped out in preparation for a transplant from a donor who has now fallen unwell with pneumonia. He is therefore immunocompromised and urgently needs umbilical stem cells courtesy of the new child.

After the main credits, Addison challenges her colleague Naomi about why she has chosen a genetic match (“selective IVF” as it is called here, or more formally Preimplantation genetic diagnosis, PGD) for the couple. Naomi defends the actions as “a back-up” which is “done all the time”. Addison counters that the mother considers the child to be “an organ donor… for her she’s growing organs for her sick son”.

The story is picked up again as Addison, Naomi and another colleague Violet discuss the rights and wrongs of Naomi’s actions whilst in the queue for the cash machine, with others present (an interesting ethical dilemma in its own right). “You gave them hope they shouldn’t have” says Addison.

Despite being taken to see the older brother in his isolation unit and heavy emotional appeal from the parents, Addison still refuses to deliver the baby prematurely. The mother, however, takes events into her own hands, breaking her waters with a knitting needle. Addison is forced to proceed with the delivery.

In a teaching context, I think the first two scenes (Molly and Eric showing up at the Clinic, then Addison and Naomi discussing the case) would make an excellent introduction to the ethics of PGD.  There would be no need to include the later scenes.

Confidentiality v responsibility in the consultation?

In the second, pediatrician Dr Cooper Freedman is faced with 14 year old patient Dean Miller, who is HIV positive, but his parents have said they do not want him to know – he thinks he has a kidney infection. Now Dean has indicated to Cooper that he and his girlfriend are about to embark on a sexual relationship.

Aware of this, Cooper calls in the parents and – without revealing Dean’s intentions – try to get the parents to accept it is time for him to be told. For his own protection, they are adamant that time has not yet come.

Torn between his responsibility to Dean and his responsibility to the parents, Cooper calls a conference with all of them and ultimately reveals Dean’s secret to the parents. With the latter having threatened litigation if Dean was told his HIV status without their permission, this must have seemed the more financially-astute way out of the conundrum. In one sense, iturns out to be too late –  Dean and his girlfriend had already had sex the previous day.

Again, for teaching it is probably not necessary to show all of the segments in order to get a flavour of the dilemma. Cooper’s initial conversation with Dean, with his parents and talking with his colleagues on the promenade (again, in public) would do a good job raising the issues for discussion.

Ethical issues are not the same as ethical practice

This episode certainly bore out two points made by Audrey in her analysis of the series as a whole. The first is the absence of any genuine ethical reasoning – no mention was made of frameworks being used in the decision-making which seemed more to be driven by gut feeling and convenience.

Secondly, the medical team do not act in ethical ways. They discuss confidential cases in public, and are sexually promiscuous – including in the office, during work time.

A Family Affair (TRILT code 00FC042B, 60 mins)  was shown on Living TV on Thursday 25th June at 21:00 and was repeated on Thursday 2nd July at 20:00.

The BBC has a four part series featuring Professor Lesley Regan (from the Dept of Obstetrics and Gynecology at St Mary’s Hospital) as she probes the scientific validity of various health and beauty products. At the time of writing, Prof Regan has investigated the diet industry and over the counter medicines (the subject of this post). Future episodes are to look at children’s products and tbc.

The second episode Prof essor Regan’s Medicine Cabinet (first transmitted on BBC2 at 9pm on Thursday 23rd April 2009, and available on iPlayer until 14th May) contained several valuable sections for use in teaching about the evaluation of pharmaceutical products, and about the scientific method in general.

Which remedies will make into Prof Regan's scientifically-tested Pharmacy?

In the programme on non-prescription medicines, Prof Regan examines the credentials of homeopathy (00:03:30-00:17:30), painkillers (00:17:30-27:00), herbal remedies (00:27:00-00:35:35), cold medication (00:35:30-00:43:10) and health checks (00:43:20-00:56:42).

The last section, on health checks, includes some interesting discussion on the ethics of genetic tests offered by companies such as deCODEme . For example, what is the merit of taking a test reporting to tell you that you are at a high risk of Alzheimer’s Disease if there is no treatment available? Genetic tests of this type have been discussed elsewhere on bioethicsbytes (e.g. Visions of the Future and The Killer in Me), so we will focus here on other aspects of the programme. 

In a classroom setting, the most useful take-home messages relate to the nature of scientific evidence. At 00:10:30 we are introduced to Prof Regan’s three golden rules for the scientific merit of a study: (1) is it published in a reputable scientific journal? (2) does it involve sufficiently large numbers of patients to achieve statistically significant data? (3) has it involved comparision of the treatment against another approved therapy or a placebo?

This series of rules is offered after she discusses homeopathy with Tony Pinkus of Ainsworths, a leading homeopath. He suggests that the lack of scientific evidence for such remedies is caused by inadequacies in science not homeopathy: “Science hasn’t caught up with homeopathy… we don’t have the wherewithall in science as it is today”. Prof Regan points out at the dilution levels (30 times through a sequence of  at 1 part active ingredient into 99 parts alcohol is standard) would mean that there is a very low possibility that there is even one molecule of the active compound in the bottle.

As part of the programme two small-scale scientific trials are undertaken. The first (00:13:30-00:17:30) involves giving a set of insomniacs sugar bills to trial. Regan’s pseudoscientific babble to add gravitas to the medicine is fantastic – she stresses the dire importance, for example, of not using toothpaste within 30 mins before taking the tablets. I did feel sorry for the patients who had reported the efficacy of the new drug in glowing terms before Prof Regan revealed that they were just cake decorations; are they now back to restless nights?

The second experiment is worthy of greater attention, and might make a nice clip to show regarding the “How Science Works” strand of new GCSEs and A level courses. As part of  a discussion on branded v generic painkillers (00:17:30-00:27:00), Regan conducts a standard pain-endurance test involving keeping a limb immersed in ice-cold water (starts 00:19:30). Several players from Chiswick Rugby club take name-brand painkillers such as Nurofen or Anadin and see how long they can keep their arm in the water.

Testing the ability of pain-killing medicines to boost the capability to keep an arm in icy water

They then repeat the process using pills from unlabelled brown bottles. Believing these are generic versions (own-label ibuprofen, etc), they can only keep their arms in the water for shorter periods of time. It is useful to stop the video at 00:24:29, before a twist is revealed, and ask whether this is an appropriate scientific investigation. Sharp students may observe that this is not a fair test because the men knew what they were taking. Running the clip on reveals the trick – the drugs in the unlabelled bottles were actually exactly the same as the pills they had taken previously. This is used as evidence that the appearance of branding can have an impact on the efficacy of medicine.

Now, although there is apparently some evidence that brand name medicines can be recorded as being better than generics (a study from Keele University is mentioned) – I would nevertheless want to get a class of students to consider why this is STILL not a good experiment. Here are some of my observations in this regard:
- the cohort is very small (maximum of about 8 players shown, but only 3 or 4 in the footage of the actual test and each only does one medicine).
- trial only done once
- in all cases the order was brand name then generic, whereas the order should have been varied. This is important since…
- in all cases the arm exposed to the iced water had already been submerged in icy water for a period only shortly beforehand
- there was no indication that the subjects had been given time for the original medication to clear from their system
- I’m sure there are plenty more

So, unfortunately the desire for a telly-visual experiment has actually left the programme model a semi-scientific study of exactly the type it has set out to debunk.

Professor Regan’s Medicine Cabinet was first shown on BBC2 at 9 pm on Thursday April 23rd. It is available on iPlayer until 14th May 2009. Members can obtain copies for educational use from the BUFVC quoting TRILT code (00F0BD8B).

(cjrw)

The most recent episode of Holby City is available to view of download on via the BBC iPlayer.

Following on from the recent BioethicsBytes post Holby City – “If you can’t look after yourself, then why should we?” (published on January 21 2009; updated February 4th 2009), which concerned ethical issues in NHS resource allocation as highlighted by two episodes of the BBC1 drama Holby City, this update post covers events in more recent episodes of Holby City – including the denouement to the storyline, as depicted in Feet of Clay.

The storyline concerns the “zero tolerance” policy implemented by Head of Surgery, Dr Ric Griffin (Hugh Quarshie), who is refusing to authorise surgical procedures for patients whose lifestyle choices may have contributed to their illness. Previous posts have covered the instigation of this policy in the episode Just (first broadcast on BBC1 on January 20 2009, at 20.00; TRILT Identifier: 00D15A4E),  and the events and debates this creates between the characters in Tough Love (first broadcast on BBC1 on February 3 2009, at 20.00; TRILT Identifier: 00D8E505). This post notes relevant events in the subsequent episodes Trust, Truth and Mercy, and Take Her Breath Away, and the closure of the storyline in Feet of Clay.

Trust

Frankie Moore is brought into Keller Ward with breathing difficulties

Following on from Ric Griffin’s refusal to authorise a hernia operation for an obese man in the episode Just, Trust features a storyline involving the man’s son, Frankie, who is brought in with breathing difficulties (00:10:03 to 00:11:14). Given that Frankie is also overweight, Griffin has to choose whether or not to treat him. He elects to perform the necessary surgery in this case, since the procedure is now an emergency rather than elective one (00:14:25 to 00:16:04). However, following the sucessful surgery, Griffin and colleague Connie Beauchamp (Amanda Mealing) discuss the implications of his weight with Frankie and persuade him to lose weight (00:47:54 to 00:48:31).

Trust was first broadcast on BBC1 on February 10 2009, at 20.00. (TRILT Identifier: 00DB41DD).

Truth and Mercy

Griffin presents Frankie with a draft of the leaflet

Following on from the events in the previous episode, Trust, Griffin involves Frankie in the production of a leaflet to accompany his zero tolerance programme. The leaflet initially causes controversy between Griffin and Connie Beauchamp over whether the leaflet is “advertising” or “public service information” (00:05:48 to 00:06:18). However when Frankie arrives at the hospital he expresses concerns about whether or not Griffin’s programme is really worthwhile (see 00:06:53 to 00:07:43, and 00:12:06 to 00:12:40). This escalates when Frankie’s father arrives on the ward (00:14:31 to 00:15:53, and 00:16:32 to 00:17:16) when he accuses Griffin of “exploiting” Frankie and “taking advantage” of their situation (00:20:10 to 00:20:34, and 00:27:09 to 00:27:52). The events of the episode culminate in Frankie becoming interested in gastric band surgery (00:29:43 to 00:30:13, and 00:32:12 to 00:33:16), and discussion over whether the operation is necessary, desirable and how it should be paid for (primarily 00:44:22 to 00:45:31, 00:49:27 to 00:50:00, 00:51:11 to 00:51:45, and 00:52:58 to 00:53:48).

Truth and Mercy was first broadcast on BBC1 on February 17 2009, at 20.00. (TRILT Identifier: 00DD2ABD).

Take her Breath Away

HolbyCare surgeon Michael Spence fits Frankie Moore's gastric band (00:06:53).

This episode opens with surgeon Michael Spence, from HolbyCare (the hospital’s private branch), fitting Frankie Moore with a gastric band – a procedure which sparks discussion of the implications of zero tolerance among the staff (00:09:27 to 00:10:13). The financial implications are also debated when Frankie’s father receives a bill for £7000 for his son’s operation – a cost he had believed would be met by the NHS (00:10:13 to 00:11:06, and 00:12:14 to 00:13:31). Mr Moore blames the confusion on Ric Griffin and lodges a formal complaint (00:41:30 to 00:42:03). Meanwhile, despite Frankies’s operation initially appearing to be a success, he begins to experience complications (00:29:29 to 00:30:18) – a situation which leads his father to re-evaluate his position (00:44:09 to 00:44:53, and 00:47:20 to 00:48:56).

Take Her Breath Away was first broadcast on BBC1 on February 24 2009, at 20.00. (TRILT Identifier: 00DF59A1).

Feet of Clay

Ric Griffin prepares to present his zero tolerance policy to the hospital board of trustees.

This episode opens with Ric Griffin preparing a presentation on his zero tolerance policy. Meanwhile, Connie Beauchamp prepares to treat a longstanding Holby City patient despite his being overweight and a known smoker and drinker. Although this patient, Steve Hewitt, should be excluded from treatment under Griffin’s zero tolerance policy he is also an important financial supporter of the hospital. Thus a row ensues about whether or not he should be allowed to remain in the hospital  (00:07:26 to 00:08:34, 00:10:24 to 00:11:48, and – in particular – 00:14:03 to 00:15:05, and 00:18:25 to 00:21:56). Eventually – and despite some minor complications – Griffin decides Steve Hewitt should be discharged and return when he has lost weight and seen a dietician (00:33:15 to 00:35:47); a decision which does not appear to affect Hewitt’s donation to the hospital (00:41:25 to 00:42:01 an 00:42:36 to 00:43:23). Unfortunately, just as Griffin is giving his presentation to the trustees, Steve Hewitt collapses outside the hospital (00:49:05 to 00:50:45) and although he survives, this effectively spells the end of Griffin’s zero tolerance initiative (00:53:22 to 00:54:07).

Feet of Clay was first broadcast on BBC1 on March 10 2009, at 20.00. (TRILT Identifier: 00E24D98).

Although Feet of Clay can be considered the closure of this storyline, it is likely that echoes of it will continue throughout this series of Holby City. Overall, the bioethical issues discussed in these additional episodes are very similar to those identified in the previous post on this storyline. These episodes develop the themes and illustrate some of the implications of zero tolerance within healthcare. 

Additional issues centre on the experience of obesity and how is it perceived and dealt with within healthcare and family settings (most notably via Frankie and his father). Further, these episodes also provide a number of quotes which can be used to summarise pro- and anti- clinician perspectives, and also that of the patient.

(BJG)

This episode of Darwin's Dangerous Idea can be viewed online via the BBC iPlayer until April7 2009.

In the three-part series, Darwin’s Dangerous Idea, broadcast on BBC2 to mark the 200th anniversary of the birth of Charles Darwin and the 150th anniversary of the publication of On the Origin of Species, broadcaster Andrew Marr explores the impact of the theory of evolution by natural selection on science, politics and society.

While the first and third episodes, respectively entitled Body and Soul and Life and Death, explore the historical spread of Darwin’s theory and the way it can be employed within conservation and ecology, the second episode, Born Equal?, includes a short section (between 00:45:12 and 00:56:20) that could be used in bioethics teaching.

Andrew Marr and his DNA sample

In Born Equal? Andrew Marr highlights how Darwin’s theory has been used for political purposes, in particular as a justification for eugenics programmes (most notably in Nazi Germany during the Second World War). As a historical exploration the programme as a whole is fascinating and very informative, however, it is as the episode approaches more recent events – especially the advent of DNA technology and genetic testing – that some of the bioethical issues that currently appear on the UK GCSE and A-level curricula begin to be discussed. Beginning at 00:45:12, the last fifteen minutes of the programme introduces issues around genetic information and privacy, and the possible use of genetic test results by employers and insurers.

These issues are initally discussed within the context of prevention of Tay-Sachs disease in the USA, specifically the compliation of a genetic database within the New York Jewish community which can be used in family planning (see 00:45:12 to 00:49:53). The programme highlights how this database has allowed the disease to be “almost eradicated” from the community, but also presents the more critical point of view which sees this uses of predictive genetic testing as a modern form of eugenics. Marr then goes on to discuss the wider uses of predictive genetic testing and the bioethical issues they raise (primarily between 00:49:53 and 00:52:19). The programme culminates highlighting some of the implications of ‘genes for’ intelligence, particularly when the genetic varients involved are identified with (socially identified) ‘races’ (00:52:19 to 00:56:20).

The series is supported by a range of resources provided in collaboration with the Open University. These are suitable for use by schools, colleges and universities, and can be found at the Darwin Open2.net website.

The second episode of Darwin’s Dangerous Idea (entitled Born Equal?) was first broadcast on BBC2 on March 12 2009 at 21:00. It is availble to view or download via the BBC iPlayer until April 7 2009. Unfortunately as an OU joint production, you will need an additional license above and beyond normal ERA license in order to obtain copis from the BUFVC (TRILT Identifier: 00E487F5)

(BJG)

In Make me… stay awake, the final part of an engaging series of three documentaries (following Make me… smart and Make me… live forever), Michael Mosley investigates the effects of sleep deprivation and ways in which these symptoms may be alleviated. As he puts it in the introduction to the film, he wants to know if there are ways of “conquering… my need and my urge for sleep” (01:40).

Several sections of the programme brought bioethical themes into sharp focus – including the use of model organisms in research (17:53-20:47) and the use of drugs to stay awake longer (26:42- end).

Mosley starts by seeing how long he can keep himself awake and the impact it will have his abilities. In New York, he meets Tony Wright who holds the world record for staying awake (11 days and nights without sleep, set in 2007) and sleep expert David Rappaport. The latter makes the rather alarming statement that when you have the sensation whilst driving that you are  fighting to stay awake, you have already had multiple microsleeps (04:30).

Moving on to Philadelphia (13:30), Mosely visits David Dinges who undertakes sleep deprivation research on human volunteers. Dinges, whose experiments are funded by both NASA and the American military, emphasises the question “What is sleep for and can we get by without it?” (13:55) as the fundamental challenge for work in the field. Volunteers in his research commit themselves to at least five days of tests, frequently longer, during which they undergo physical and mental testing. “Scientists have a hard time helping government and industry use what we know”, Dingle observes “because what we know is complicated and they want simple solutions” (15:40). Individuals, based presumably on their genes, have natural differences in both their sleep patterns and their ability to cope with sleep deprivation.

Having commented that ethical issues concerning the use of human subjects inevitably constrains the insights which Dinges is able to derive from his work, Mosely then considers the research of Professor Amita Sehgal at the University of Pennsylvania. Professor Sehgal, Mosely informs us, “not only pushes her subject to the very limit, but pushes them over the edge. Then she liquidises their brains” (18:03). This is permitted because her research is carried out on Drosophila fruit flies, not humans. In addition to being able to carry out highly invasive experiments, Sehgal can also carry out selective breeding of flies in order to characterise the effect of specific mutations. For example, she discusses a mutant they call sleepless which, they observe, is short-lived, staggers and may have difficulty reproducing.

This is a nice illustration of the research merit of studying lower organisms in biomedical research. Ethically, this is several steps removed from work on mammals, let alone humans – a point which seemed to evade Republican Vice-Presidential candidate Sarah Palin in her now notorious rant against spending research dollars on “pet projects”.

In the final section of the programme (from 26:42), Mosely considers the potential role of drugs in counteracting tiredness. Caffeine, he notes, is a popular stimulant but there is growing interest in other cognitive enhancing drugs, especially Modafinil. The alertness caused by Modafinil (Provigil) was discovered accidentally, but is now exploited both in the treatment of the sleep disorder narcolepsy and by the US Military to keep pilots awake on long flights. In the spirit of self-experimentation which marks much of Mosley’s work, he elects to try out the effects of Modafinil for himself (but not before he has a barrage of safety tests).

Mosley flies to Prince Edward Island, Canada, where he meets “Terry” (28:33), a graphic designer who has been taking Modafinil for about a year in order to allow him to work 100 hours a week, punctuated by occasional 20 minute power-naps. Terry’s motivation is financial – by working twice as many hours, he argues, he can earn twice the income.

Whilst visiting Terry, Mosley takes the opportunity to try the drug for himself. Initially he is very impressed by the effects; he stays mentally alert for 42 hours and then has a good night’s sleep unaffected by the “buzzy” side-effects associated with other stimulants.

In the morning, however, he has some concerns arising from widespread rashes on his body and lumps on his neck (36:10). Although he recognises that all drugs have side effects (37:03), these changes coupled with his knowledge that Modafinil can cause anaphylactic shock and ’scalding’ of the skin make him reticent to try it again.

Make me… stay awake (TRILT identifier 00DF9530) was first transmitted on BBC at 22:35 on 24th February 2009. It is available on BBCi Player until March 3rd.

(CJRW)