Euthanasia, counterfeit drugs – Holby City

January 20, 2007

(Warning, contains plot spoilers!) In this episode, If the heart lies (October 10th 2006,  BBC1, TRILT code 005C80FB), the autumn 2006 season of Holby City continues with its strong representation of bioethic themes.  The issues of both counterfeit medicines entering legitimate supply lines and Gina Hope’s bid for euthanasia in Switzerland continue from the previous episode Taking liberties (Gina’s story is completed in the next episode, Moondance).  There is also a short, but potentially useful, discussion about saving a premature foetus against the wishes of the mother (26:12 to 27:45).

The sections developing the euthanasia storyline are 5:44-6:58, 8:10-9:30, 20:32-22:05, 29:21-31:00, 32:06-33:49, 38:22-40:30, 43:15-44:56, 52:10-53:42 and 55:16-57:06.  Of these, the discussion between Gina and Connie at 8:10 is possibly the most useful in isolation.

The counterfeit medicines plot is shown at 2:51-4:43, 14:19-15:41, 27:45-29:20, 40:32-41:35 and 48:50-50:10.  The best ‘stand alone’ section is probably the first of these, in which Bradley Hume, the assistant hospital manager, discusses the substandard drugs with the pharmaceutical supplier.  She promises to compensate the hospital but, as we discover in the clip 49 minutes in, she flees – leaving her ‘office’ and pill production machinery behind.

Euthanasia – Holby City

January 20, 2007

(Warning, contains plot spoilers!) Moondance (17th October 2006, BBC1, TRILT code 005CBA8B) focuses almost entirely on the culmination of the euthanasia storyline developed in previous episodes (eg. If the heart lies) and sees Gina Hope take her struggle with motor neurone disease to its unnatural end at an assisted suicide clinic in Switzerland.  Much of the dialogue could be used to raise some of the issues.  The majority is clearly delivered from a pro-euthanasia perspective, including 10.04-11.25, 12:55-14:45, and 17:32-22:12 (especially to 19:50).  When Gina’s husband Elliott catches up with her, their conversation at the cafe, starting at 38:11, offers the most balanced introduction to the issues.  The closure of the episode is very moving and caution is required before showing this to school-age students.  At the time of writing there is an ‘episode catch-up’ on the BBC website which conveys some of the emotion, although it omits

On a different theme, a conversation between disgraced manager Bradley Hume and research registrar Reg Lund (27:40 to 30:00) gives different perspectives on the current state, values and future of the NHS  – might be an interesting clip to use with medical students to introduce issues of clinical governance and management (although the recent Open University series Can Gerry Robinson Fix the NHS? offers far more depth on the issue).

IVF – A Child Against All Odds (6)

January 6, 2007

In the final episode of Robert Winston’s fascinating series on IVF, the focus is on two couples who have spent several years trying for a baby.  Whatever it takes (BBC1, 18th December 2006) follows Dee & Tim, and Yasmina & Aldwyn as they have interventions which, in Winston’s own words, are at the “outer reaches of fertility treatment”. 

Dee and Tim elect to have their embryos tested using Preimplantation Genetic Screening (PGS), a variant of PGD, in which one cell is carefully rolled away from the embryo at the 8-cell stage.  This approach allows doctors to tell whether the embryo has aneuploidy, that is an incorrect number of chromosomes (although technogical constraints mean that only 5 chromosome pairs can be tested at any one time).  It is believed that checking the chromosome number at this stage may reduce the chance of a miscarriage at a later stage, although those involved in fertility treatment are not all convinced of the value of PGS.  Sadly, all of Dee’s embryos have aneuploidy and they elect not to have any transferred to her uterus.

At the start of the episode, Yasmina and Aldwyn are already veterans of seven rounds of IVF.  Desperate for a baby, they move on to the ARGC clinic run by Mohamed Taranissi, a leading UK fertility specialist.  Dr Taranissi has controversial views regarding immune difficulties being a major cause of implantation problems and embryo rejection.  He prescribes a batch of 17 blood tests for Yasmina and then puts her on a number of additional drugs, including steroids, and a transfusion of a human blood protein.  Despite these extra treatments, this eighth round of IVF also fails.  However, the news is not all bad; as the programme finishes Yasmina is expecting twins after further therapy.

Robert Winston also goes to visit a couple who tried unsuccessfully to have a baby using IVF (44:30-47:00).  Before doing so, he poses the question “how many IVF failures do you allow a couple to go through before you advise them to stop?” (40:19-40:50).  In this case, his ex-patients have reached fulfilment by adopting two boys. “For some couples, infertility can be a beginning, it doesn’t have to be an end” comments Winston. 

There are a number of potentially useful clips within this episode.  In terms of the technology (and the personal tragedy of failure), there is a very useful section from 31:55-39:55 where Dee’s embryos are screened by PGS.  The wrong number of chromosomes is very clear to see; the fluorescent dots representing different chromosomes are not in regular pairs.  The effects, and side-effects, of hormone treatment are vividly described from 11:00 to 15:10.

Follow this link to the BBC website for this episode. Members can purchase copies from the Britsh Universities Film and Video Council (TRILT code 005E1B49).

IVF – A Child Against All Odds (5)

January 5, 2007

In Gift of life (BBC1, 13th December 2006, TRILT code 005DEE22), attention returns to the issue of egg donation.  Like Karen and Alex in the previous programme Cheating time, Susanna and John travel overseas to buy eggs, on this occasion to Spain.  Susanna has to take a course of hormones to prepare her uterus to receive any embryos.  They discuss the potential emotional difficulties of raising a child that is only genetically related to John (14:30 into episode, and revisited at 27:30).  As it turns out, the issue remains theoretical this time as the pregnancy is not sustained.

Nicola and Stephen need IVF but cannot afford the £3000 fee.  They enter into an agreement to get their treatment free in return for donating half of Nicola’s eggs to another couple, who pay for both procedures.  Nicola enters into the arrangement knowing that it is possible that the she will not get pregnant but that the recipient of her donated eggs may do so (discussed in commentary 13 minutes into programme).  As it is, Nicola successfully conceives and gives birth to a daughter.

Finally, the episode tells the remarkable story of Bonny. Childless after going through a premature menopause, Bonny takes part in a pioneering operation in which she receives an ovary from her fertile twin sister Crystal (tissue from any other woman would be rejected, so this is not a route open to most people).  The procedure is a wonderful success and Bonny subsequently conceives naturally with her husband and also gives birth to a daughter.

There are not many excepts from this episode that would be suitable for teaching in isolation from the whole programme.  however, there is an interesting section from 45:00 to 48:47 in which Robert Winston talks to artist Stuart about the psychological difficulties of being fathered by an unknown sperm donor.  A change in the law means that children born as a result of donated sperm or eggs will have the right to know the identity of the donor when they turn 18.

The BBC website for this episode can be reached from this link.  BioethicsBytes notes on the final episode in the series, Whatever it take, can be found here.

IVF – A Child Against All Odds (4)

January 4, 2007

In Cheating time, the fourth episode in the A child against all odds series, Robert Winston turns his attention to older women seeking to become pregnant by IVF.  The focus is on two couples from the UK, plus an interview with Adriana Iliescu who aged 66 was, at that time, the oldest mother in the world (A 67 year old Spanish woman gave birth to twins in December 2006).

Karen and her husband Alex already have one daughter as a result of regular IVF.  Despite Karen being only 35, a dramatic decline in her fertility has left them seeking an embryo donated by a younger woman in order to increase their family.  Their search takes them to Russia.  A donor, paid the equivalent of a month’s wages for her services, provides a remarkable 21 eggs which are fertilised using Alex’s sperm.  There are concerns because the lining of Karen’s uterus is not as thick and ready to receive an embryo as they had hoped.  Despite this, the doctor’s transfer two embryos and Karen achieves a pregnancy. She later discusses on camera her struggle as she comes to terms with the fact that her unborn baby is not genetically hers (c. 51 mins), although the 12 week scan helps her in the bonding process.  The episode finishes with her giving birth to a son.

Suzanne is a businesswoman in her early 40s.  She has only married Alan relatively recently and they find themselves wanting to start a family.  Unfortunately, as the commentary puts it, “Suzanne is ready to have children at exactly the age when the quantity and quality of her eggs is falling” (5:50 into episode).  Initially they try an experimental new procedure called “assisted hatching”.  Working on the premise that older women may have difficulty conceiving because the outer layer of their eggs has become tougher with time and hence less likely to implant when put back into the uterus, doctors soften the eggs by careful treatment with a laser.  Sadly on neither this occasion, nor a later round of IVF, are they able to achieve a pregnancy.

In terms of teaching about the science and bioethics of fertility treatment, there are fewer stand-out clips in this episode than some of the other programmes in the series.  The section starting about 5 minutes in where we are first introduced to Suzanne and Alan is perhaps the most self-contained section illustrating the sort of situations that lead women to be seeking IVF.  Robert Winston’s reflections on the upper age limit for fertility treatment following his conversation with Adriana Iliescu are also interesting (43 mins in). 

This programme was initially transmitted on BBC1 on December 5th 2006 (TRILT identifier = 005DCCC6). Clicking on this link will take you to the BBC website for this episode, which also includes a short video clip where Robert Winston discusses Adriana’s case with her fertility doctor.  This is perhaps more illuminating concerning the key ethical issues than the programme itself.  BioethicsBytes notes on the next episode in the series, Gift of life, can also be found via this link.

IVF – A Child Against All Odds (2)

January 4, 2007

In Ice Babies, the second episode of A Child Against All Odds, Robert Winston follows the progress of three women each of whom has at some stage been diagnosed with cancer.  The chemotherapy necessary to fight the cancer also makes a woman infertile and therefore the only chance to have their own children in the future rest with the storage of embryos in liquid nitrogen at minus 195 degrees.  The three couples featured are at different stages in the process. 

Caroline and Carl stored two embryos when Caroline was diagnosed with a brain tumour.  The programme follows their story as Caroline, now given the all clear from the cancer, go through the thawing and implantation of the embryos.  At each step problems can occur, but against the odds Caroline becomes pregnant and gives birth to twins.  Tragically, one of the babies then lost her battle with infection and died.

Hilary and Clive have one daughter, but had been waiting before having another.  Hilary was then diagnosed with breast cancer.  Despite the risks that fertility treatment might inadvertently stimulate the cancer, Hilary receives hormones to produce eggs.  6 are harvested and 5 successfully fertilised before freezing of the resultant embryos for future use.  She must now wait to implant the embryos for at least two years, after her chemotherapy has been completed.

The case of Natalie Evans and her former partner Howard has been widely reported in the media.  When Natalie was diagnosed with cancer several years previously, she and Howard stored some embryos for implantation once she had recovered.  Howard, however, later left Natalie and withdrew permission for her to use the embryos.  Natalie took the case to court, initially in the UK and then in Europe.  The programme follows Natalie as she await, and then receives, the ruling of the European Court.  The judges agree with the UK courts and decide in favour of Howard (see BBC News report Woman loses frozen embryos fight).

The whole programme (58 minutes) is an engaging and thought provoking.  In terms of clips that may be used to illustrate aspects of the fertility process, you may like to consider footage of the thawing process (starting at 2 minutes, but particularly 3:30-4:40.  There is a good quote about the moral questions raised at 13:13-14:48, followed by more coverage of the fertilisation and freezing techniques.  At 29 minutes, Caroline’s doctor explains the odds of success by comparison to rolling of dice.

This epsiode was first broadcast on 21st November 2006 (BBC1, TRILT code: 005D8967).  The series is supported by a BBC website. An account of the following episode Make me a dad is also available here on the BioethicsBytes site.