Making of Modern Medicine

May 10, 2007

In a 30-part radio series (15 mins per episode), Andrew Cunningham from Cambridge University offered a fascinating insight into the history of modern medicine.  The series was first transmitted on BBC Radio 4 over a six-week period in February and March 2007 (see here for episode guide). I only managed to catch the final two episodes, The Crippler and Transplant, but both contained fascinating bioethical conundrums. 

The Crippler tells the story of polio, and more specifically, the development of vaccine against the virus.  Ethical dilemmas included whether to use a killed virus or a live-attenuated virus (in fact both were developed) and suitable timing to swap from animal testing to human testing of the vaccine.  There was a genuine risk that these early vaccines might have inadvertently led to infection with an active or reactivated form of the virus, so who to include in the human trials was also an issue.  The decision made in 1950s America was to innoculate the residents of a home for mentally handicapped children!  As subsequent history shows, the vaccine turned out to be effective and mass innoculation programmes followed.

Transplant begins with Christiaan Barnard’s pioneering work on heart transplantation in 1967-68 (see BBC News report at time of his death in Sept 2001 – requires realplayer).  Cunningham asks to what extent those early pioneering operations can be considered successful in a medical sense (as opposed to proof or principle about surgical techniques, for example) and to what extent present day success in transplantation is, in fact, dependent upon breakthroughs in immunosuppresive drugs made in the late 1970s.  He raises questions about the overall place of transplantation in modern medicine – it absorbs a large slice of the resources available to medicine, it captures the public imagination, but for all of that involves a very small percentage of patients.

The final episode closes with some more general reflections on the ethical and social implications of medicines increasing adoption of science and technology.  These include the shift from focusing on the individual and their personal symptoms, to emphasising the disease, with the patient reduced to the role of someone who has the disease.  Cunningham talks about medicine as an arena in which the division between rich and poor has been broken down – disease A is the same whatever our bank balance. Personally, I think that this is rather an oversimplification; our likelihood of being struck down by certain illnesses is definitely not evenly distributed across classes, and our subsequent ability to garner resources to challenge the disease is also proportional to our income.

Other bioethical conclusions are rather less controversial.  The programme highlights the increasing reliance on machines in medicine (there is a nice poem written by an unnamed dialysis patient which echoes the marriage vows, beginning “do you take this machine, in sickness and in health…”).   Transplant technology has also prompted a re-evaluation of what it means to be an individual in an age where we have exchangeable internal organs, and a change in the definition of death, from a focus on heartbeat pre-1968, to brain death or indication of irreversible coma.      

Sadly, as a joint Open University production, the Making of Modern Medicine series is not covered by the Educational Recording Act and as such copies cannot be purchased from the BUFVC (OU programmes require a separate licence).  The BBC has, however, released it as a Radio Collection for personal use.  It seems like the sort of series that is highly likely to be re-broadcast at a later stage, so it may be worth setting up a TRILT alert so that you can catch it when repeated.

Transgenic animals, gene patenting – Next (Crichton)

May 9, 2007

(Warning: contains plot spoilers!) In his 2006 novel Next, Michael Crichton manifests concerns about current development in genetic technologies which are extensions of arguments that surfaced in his dinosaur cloning classics Jurassic Park and The Lost World during the 1990s.

The story is told over a series of 95 short and punchy chapter.  I say ‘the’ story, but in fact there are a number of distinct narratives which briefly intersect in a way that is familiar in recent films such as the Oscar-winning Crash. The book is packed (overpacked?) with Bioethics-related plotlines.  These include: selling of body parts; an unauthorised gene therapy trial with human subjects; the role of genes in behaviour; paternity testing; payment to egg donors; research ethics (e.g. who has the right to be first author on a research paper?); and consideration of the patenting of both genes and of cell lines. 

The greatest repeat theme in Next, however, involves transgenic animals, that is animals which have deliberately been given one or more genes from a different organism.  So it is that we are introduced to Gerard, a parrot with linguistic skills well beyond repetition of ‘pretty polly’; Dave, a chimp-human hybrid; turtles that glow in the dark and an orangutang with the ability to swear in several European languages.

Does Next have any value as a resource for teaching about bioethics?  I think it does (see below), but there are a number of reasons why I cannot recommend it without significant reservations.  Firstly, as a scientist, I am uncomfortable with the juxtaposition of fictional scientific discoveries alongside factual news accounts about recent genetic developments (some of which may themselves be rather overstated).  It becomes difficult to distinguish genuine scientific breakthroughs from real scientific studies that have been sensationalised by the original authors from, in turn, those that Crichton has simply made up (although his excellent annotated bibliography implies that at least some of the fictional events in the book are based on real incidents). Crichton would, I’m sure, counter that he has set out to write a novel not a textbook, and this is of course the case.  At the beginning of the book we are told that “this novel is fiction, except for the parts that aren’t” but I would have felt more comfortable if there had been some ‘code’ in the presentation to flag up the fantasies. 

Secondly, as an educator, it is necessary to warn colleagues and their students that the novel contains significant use of swearing to add ‘authenticity’ and several descriptions of ‘adult’ activity which limit the appropriateness of the book for all audiences. 

Having given those caveats – what material from the book could be used to introduce debate?  The ownership of commercially-valuable cell lines developed from human tissues is an important and genuine concern with echoes, as the book acknowledges, of the case of John Moore v theRegents of the University of California.  In Next, the focus is on the Burnet cell line, an efficient means to produce cytokines established, but without his permission or knowledge, using material taken from Frank Burnet.  When the cell line becomes mysteriously contaminated, does the company that holds the patent have the right to extract additional cells from Mr Burnet, or indeed from his daughter or grandson, to restart the line?  The courtroom scene in Chapter 86 (starting, in my copy, on page 372) presents some of the contrasting arguments over ownership.

Several sections on transgenics combine both narrative and some explanation of the science.  These include Chapter 32 (specifically pages 167 to 170) where we are introduced to Gerard the parrot and his genesis is described, and Chapter 35 (specifically pages 182 to 186) where Henry meets Dave his chimp ‘son’ for the first time, and the explanation of how he came into existence (pp. 192-196). 

The book concludes with an Author’s note, in which Crichton lays out explicitly the five most important conclusions that he has reached following his research for the book.  These are: (1) stop patenting genes; (2) establish clear guidelines for the use of human tissues; (3) pass laws to ensure that data about gene testing is made public; (4) avoid bans on research; and (5) Rescind the Bayh-Dole Act (legislation from 1980 giving US universities and small companies certain intellectual property rights concerning discoveries, even if they were federally-funded).

Overall, Next is a thought-provoking read. Personally, I feel that the power of the book to put over concerns about the pace and direction of some genetic developments would have been all the greater if the author had actually focused on fewer of the targets and with less recourse to ‘gritty’ realism.