One cloudless day I sat cross-legged in front of an Indian village temple listening to an old man. When young he had once asked Mahatma Gandhi what he should do with his life. 'Teach the villagers hygiene - how to build simple toilets and clean the water supply,' Gandhi said. This he had done, earning no salary and asking only for enough to eat and somewhere to sleep in each village he visited. Now it was 40 years and thousands of villages later.
A month before, in Stockholm in the middle of winter, I had marvelled at an enormous exhibition of the latest medical equipment, some items costing more than GBP1,000,000 each.
I could not help reflecting that the old man was saving more lives than the sophisticated equipment could. It now costs a huge sum to improve the life expectancy of someone in the West by even a fraction and very little to greatly improve that of his brother or sister in the Third World.
This is one of the real dilemmas modern technology has unleashed. 90 per cent of Indians live in villages. 90 per cent of Indian doctors live in cities. 70 per cent of Indians are born, live and die without seeing a doctor. Sophisticated equipment and the interesting work it makes possible can only be afforded in the cities. So it takes a deep motivation to care for those who need it most.
Nandan and Kavery Bhatt are young surgeons who graduated from a medical college in South India. They came to Britain for higher surgical training and returned to work in a rural hospital in the northern state of Uttar Pradesh. After eight years there they have now moved to a similar hospital in South India.
Kavery Bhatt points out that equipment which is discarded in the West as out of date can be reconditioned and utilized. Even items we regard as 'disposable' - theatre caps, gauze, bandages - can be sterilized and used many times. In Britain Nandan was given a set of 'use once only' disposable endotracheal tubes, for giving anaesthetics. They had been taken by the theatre sister from the waste-bin and carefully cleaned. Nandan was able to use them every day for more than a year.
The Bhatts - and others like them - by husbanding their scarce resources have taken good health care to a poor area that needs their help very much. Care and commitment are often more needed than anything more complicated.
And now the richer countries are also beginning to feel the pinch. The British National Health Service, for example, is short of money. It started out with the civilized view that the best in health care should be available for everyone who needed it, regardless of their ability to pay. What had not been foreseen was the expansion in technology which pushed up the costs astronomically. These costs have become a major problem, wherever and 'however health is organized.
Infinite requests cannot be met from finite resources. The relentless demand for more sophisticated techniques is gradually starving the service of the basics. There are various economic remedies but the likely result of most of them is that what is available for poorer people will be less than the best.
This is a moral question as well as an economic one, for we must care adequately for the less fortunate. We have to decide how much money we will put into this. And how many new advances in technology we will forgo so that all may share. In fact people are not as insensitive as we are sometimes led to believe. 'When we show people photographs and slides of the working conditions in India, it sparks their generosity and goodwill,' says Kavery Bhatt. 'Nurses, doctors, teachers, farmers, taxi drivers and even schoolchildren have come forward with financial help. Why should they do it? One often hears of injustices, selfishness and greed. But I think it is natural for people to be generous. Can there be a more positive virtue than to help those in greater need than ourselves?'
Lilian Cingo comes from South Africa. She is a senior nursing sister and is now in charge of the neuro-surgical unit in a London teaching hospital. After her experiences in many parts of the world, she gets angry when Britons knock their health service. 'It is still something people in Britain should be proud of,' she says. 'Some things in life are missed and praised only when they are gone.
'Something unique which has nothing to do with funding has not disappeared. This is caring. It comes from the love God gave us all for each other, a striving to do one's best. I saw a porter run so hard with the resuscitation trolley that he broke his toe, and when I said how sorry I was that it had happened he said, "This is nothing - we have saved the patient's life".
'I have seen nurses, doctors, technicians, forgetting their off-duty roster and regardless of the time of day or night, working together to give the best care to the top people of the country - and to a drug addict.
'This spirit still exists. We must focus our attention on it and not ignore it.' Doctors and nurses are faced with doubts and questions and even fears. How to care? How to allow oneself to feel true compassion? How to find the right diagnosis and understand a person's real needs? How to make available the right kind of treatment? How to make sure one's own energy will last? Even in countries where the best in technology is readily available we still have to ask whether it is appropriate.
Tony Roodvoets is a kidney specialist who faces daily dilemmas as he runs a dialysis unit in Holland. 'Advances in the medical field have been stunning,' he says, 'bringing relief from suffering and prolonging human life. More and more, however, we encounter situations in which prolonging life is technically possible, but does not benefit the patient.
'Artificial kidney treatment, for instance, may add years to life, years that are fruitful in work and human relationships. At the same time it makes heavy demands on the patient, his or her family, and the trained staff of the dialysis unit. Sometimes life is so limited and fraught with complications that, in retrospect, both family and doctor may feel that it would have been merciful for the patient to have died without that treatment.'
I was reminded of a friend of mine whose wife lapsed into terminal kidney failure and coma. Though she was on the point of death for a variety of irreversible reasons, in spite of good care and treatment, the use of an artificial kidney might have prolonged her life for a short time. The kidney specialist knew that my friend had a Christian faith. Together they explored the thought that though it was technically feasible to prolong life a little longer, this might be the moment at which Jesus was calling her home. My friend recognized the reality of the situation and his wife died peacefully.
Illness touches the human psyche deeply. It reminds us of our own humanity and mortality. It can arouse deep fears of suffering and dying. It can lead people to despair - or to God, depending on the spirit with which it is met. Those who suffer may meet great care - or indifference. In a world in which many are unsure what they believe it is the issue that faces people with the deepest questions, which they would often rather avoid.
Our growing ability to master our environment has come at a time when faith in God and the life that springs from it has been waning. No longer can we take the sanctity of life for granted. And yet the fear which such a loss of faith has produced has heightened the idea that 'my life' is sacred: we harness our technology to the ultimate goal of keeping 'me' alive as long as possible.
Some people regard economics as the only important criterion. If you can afford it you can have it; if you cannot afford it you cannot have it. But fortunately many realize that our very knowledge poses questions which go much deeper and which touch on good and evil.
We need to do more than just ask whether a technique is available, affordable and appropriate. We must also consider whether it is morally acceptable.
The best-known and most obvious of the moral issues raised by medicine is abortion the fact that today, for the first time in history, so many pregnancies are deliberately terminated at the hands of a doctor.
Doctors often keep their own feelings to themselves, but one New Zealand gynaecologist, Norman Maclean, has been willing to speak about the anguish the abortion issue has caused him. In 1974 he was a postgraduate, specializing in obstetrics and gynaecology in Scotland.
On his first morning there he offered to finish the operating list for the consultant. It was only as he scrubbed up that he realized that the next five cases were all terminations of pregnancy. 'I was confused and uneasy but uncertain of my convictions,' he says. 'For the sake of peace and popularity I kept my mouth closed. I tried not to let the situation trouble me and as time passed I did more and more.' He found that he could talk and joke as he worked. 'I functioned as a technician.'
Dilemma
Since his teenage years he had been utterly mystified by the enormous destruction of innocent life in the Jewish Holocaust. One night he woke up saying to himself that he was no different doing abortions in Scotland than a guard in a Nazi camp. 'With considerable distress I realized that I too had been part of that terrible destruction. I had a clearer understanding of the German guard's dilemma. He turned on a gas tap whilst I wielded a curette. He obeyed his orders. I obeyed mine. He kept his position in the army, I kept mine in the National Health Service. Like him I had lost my sense of the sanctity of individual human life. It is the first step away from the absolute standard that is the most dangerous.'
This experience changed his life.
A friend of mine gave birth recently to an eight-and-a-half pound boy. The child might never have been born at all had his parents followed the advice of their gynaecologist. Because the mother had a severe case of chickenpox in the early weeks of pregnancy, the gynaecologist advised termination.
Abortion was not an option they could countenance because of their beliefs. The suggestion was all the harder to contemplate as she had already had two miscarriages.
Distraught, the parents decided to seek the advice of another doctor who was a personal friend. It was a fortunate choice; the doctor's neighbour had just completed a study of chickenpox in early pregnancy. Of some 150 cases reviewed not one had revealed any damage. This reassured the parents - though throughout the pregnancy they could not be sure that their baby would be born without handicap. Fortunately he is perfectly healthy.
What alarmed the parents was the climate that encourages abortion so easily. How many other mothers in similar circumstances would have taken the gynaecologist's advice and had an abortion?
A Swiss mother who persuaded herself against her better judgment to have an abortion found that it seriously affected her love for her other four children and the atmosphere in the family. 'We no longer enjoyed talking at table and we rarely sang. We had to force ourselves to lighten the atmosphere.
'Twenty-five years later our children still have problems which began at that time.' She described this experience on TV at the time of a national referendum on abortion. 'The weight came off my heart. I felt God had forgiven me.'
Doctors and nurses have stood for the gentler virtues of caring and compassion in a somewhat carnal world. We have often been far from our own ideal - yet we have helped to develop some of the civilized values.
My father, who was a gynaecologist, kept a series of notebooks of all the interesting cases he had seen-from qualification to retirement. Many of the diseases he dwelt on in the first of the notebooks had dropped out of sight by the time I qualified. Of the drugs he used then, no more than about six remain in use. Almost all the powerful agents which we now take for granted have been developed since the Second World War. His only references to abortion featured the back-street abortionist who risked killing girls for gain.
As I write, the British Abortion Act, which produced the abortion explosion, is being challenged in Parliament in a way that may amend the law. For it is clear that people's sensibilities have altered - the rights of the child have surfaced. Conscience is once more active across party boundaries, and (with thanks due to those who have fought for this for years) we may be witnessing the beginning of a change.
The view has grown that those who favour abortion have compassion on their side, whilst those who hold to the view that abortion is wrong, do not - because some of those who hold strong views have at times sounded intolerant.
At the sharp end
This should never be so. When those of us who believe God's standards are absolute are honest about ourselves, we find more compassion not less. If we only love morality we end up with judgment of others and blindness to our own weaknesses. If we love God himself from whom springs true morality, he will teach us sensitivity.
One of my friends holds different views from me - but he has had to cope with the personal tragedy of the death of two of his children shortly before their teenage years through a genetic abnormality.
It is possible to understand the dilemmas people face and to suffer with them and yet to believe that a certain course of action, which might appear to offer a way out, is in fact wrong and would lead to other problems, which we hope individuals and society may be spared.
One can, for instance, recognize the potential value of genetic research as a means of combating genetic disease and yet feel that research on embryos is not the way forward; that another means of curing these diseases must and will be found.
Medicine is at the sharp end of the battle for values in the world. It can foster care, compassion, sensitivity, confidentiality, obedience to the Spirit of God, humility in the face of the unknown. It can work in partnership with the spiritual forces - believing in the miraculous as well as the scientific, knowing its own limitations, enabling those who have gone wrong or face death to know that they can be forgiven and start again.
Or it can be purely materialistic and mechanical and deprive people of the values and faith that have sustained us.
In this sense the medical profession has been entrusted not just with the well-being of our patients, but the soul of our nations.
By DR JOHN LESTER
