Gibson, A St Clair

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E d tor a Iresulting in a drug cost of US$23 066 (R106 101) percomposite event prevented. Similar results were obtainedwhen the analysis was confined to the high-risk group ofpatients with unstable angina pectoris. On the basis of theavailable evidence, we believe that abciximab is notaffordable for use in patients undergoing PTCA in ourcontext, where the resources available for health care in theprivate and public sectors are finite. The ethical obligation ofdistributive justice demands careful consideration of thecosts and benefits of health care to society. It is necessarythat home-based cost/benefit ratio studies of the use of newagents be undertaken before they are recommended forroutine use. Until then, the mainstay of antiplatelet therapy inischaemic heart disease remains aspirin, which celebratedits centenary as a registered drug in 1997."Bongani M MayosiSean E LatoufPatrick J CommerfordCardiac ClinicDepartment of MedicineUniversity of Cape Town andGroote Schuur HospitalCape Town1. Antiplatelet Trialists' Collaboration. Collaborative overview of randomised trials ofantiplatelet therapy I: prevention of death, myocardial infarction, and stroke byprolonged antiplatelet therapy in various categories of patients. BMJ 1994; 308:81-106.2. Detre KM, Holmes OR jun, Holubkov A, et al. Incidence and consequences ofperiprocedural occlusion: the 1985-1986 National Heart, Lung, and BloodInstitute Percutaneous Transluminal Coronary Angioplasty Registry_ Circulation1990; 82: 739-750.3. Uncoff AM, Popma JJ, Ellis SG, Hacker JA. Topal EJ. Abrupt vessel closurecomplicating coronary angioplasty: clinical, angiographic and therapeutic profile.J Am Call Cardio/1992; 19: 926-935.4. The EPIC Investigators. Use of a manaclanal antibody directed against theplatelet glycoprotein lib/ilia receptor in high-risk coronary angiaplasty. N £ng/ JMed 1994; 330: 956-961.5. Simaans ML, Rutsch W, Vahanian A, et al. Randomised placebo controlled trial ofabciximab befare and during coronary intervention in refractory unstable angina:the CAPTURE study. Lancet 1997; 349: 1429-1435.6. The EPILOG Investigators. Platelet glycoprotein lib/ilia receptor blockade andlow-dose heparin during percutaneous coronary revascularisation. N £ngl J Med1997; 336: 1689-1696.7. Lefkovits J, Ivanhoe RJ, Califf RM, et al. Effects of platelet glycoprotein lib/Iliareceptor blockade by a chimeric monoclonal antibody (Abciximab) on acute andsix-month autcomes after percutaneous transluminal coronary angioplasty foracute myocardial infarction. Am J Cardiol 1996; 77: 1045-1051.8. Lincotf AM, Califf RM, Anderson KM, et al. Evidence for prevention of death andmyocardial infarction with platelet membrane glycoprotein lib/ilia receptorblockade by abciximab (c7E3 Fab) among patients with unstable anginaundergoing percutaneous coronary revascularisation. J Am Call Cardiol 1997; 30:149-156.9. Topo! EJ, Califf RM, Weisman HF, et al. Randomised trial of coronary interventionwith antibody against platelet lib/ilia integrin for reduction of clinical restenosis:results at six months. Lancet 1994; 343: 881-886.10. Mark 08, Talley JD, Tapol EJ, et al. Economic assessment of plateletglycoprotein lib/ilia inhibition for prevention of ischemic complications of high-risk coronary angioplasty. Circulation 1996; 94: 629-635.11. Verheugt FWA. In search of a super aspirin far the heart. Lancet 1997; 349: 1409-1410.Medical EthicsEthical considerations withregard to the sanctity ofhuman life'Science tells us what we can know, but what we can knowis little, and if we forget how much we cannot know webecome insensitive to many things of great importance.Theology, on the other hand, induces a dogmatic belief thatwe have knowledge where in fact we have ignorance, andby doing so generates a kind of impertinent insolencetowards the universe. Uncertainty, in the presence of vividhopes and fears, is painful, but must be endured if we wishto live without the support of comforting fairy tales. To teachhow to live without certainty, and yet without beingparalysed by hesitation, is perhaps the chief thing thatphilosophy, in our age, can still do for those that stUdy it."Medical ethics is used to guide physicians in choosing thecorrect option when dealing with philosophical problemsencountered routinely in medical practice. Perhaps the mostimportant and contentious issues in medical bio-ethics arethose dealing with the sanctity of human life, which hasbeen debated since the time of the early Greek civilisations. 1However, while the idea of the sanctity of human life hasbeen controversial for thousands of years, it is difficult toassess the impact of medical ethics on the management ofthese problems.An example of this can be found in the abortion debate.After centuries of discussion, sometimes inflammatory, therehas been no progress on whether the pro-abortion or anti-abortion stance is correct. Despite increasing knowledge ofearly gene-induced somatic differentiation, we still have noaccurate knowledge of when the 'life-force' or soul isactivated, and the argument has therefore remained a simpleclear-cut choice between agreeing or disagreeing withabortion, with the rest being mere semantic intellectualdebate. It seems somewhat pointless and didactic todiscuss whetller a fetus is a true member of the humanspecies2•3 as a justification or defence of abortion. A similarargument can be used when bio-ethical groups attempt todefine vegetative states, either to condone or condemneuthanasia.' This type of argument merely circumvents thecore issue, which is that one either believes or does notbelieve that it is ethical to perform abortion or euthanasia,whatever the circumstances.The problem inherent in discussing these core beliefs isthat almost all debate is based on the premise that thesanctity of human life is paramount, and that to kill a humanbeing, whether by abortion or euthanasia, is ethically wrong.It is impossible to substantiate this argument rationally, andmost ethical groups do not even attempt to rationalise orargue this point,> but merely state with certainty that theirstand on the right to life is inviolate. It is difficult to decidefrom where this innate standpoint, which appears to beinherent in most human beings, is derived: Perhaps thederivation is secular, as religions are almost unanimous thathuman life is sacrosanct.5 Unfortunately, religion is asubjective entity and implies faith above irrefutableSAMJ Volume 88 No.2 February 1998evidence, and to be gUided by faith in the decision ontermination of life is difficult. If these morals do not comefrom religion, it is difficult to decide where the idea of thesanctity of life comes from. Perhaps it is an intrinsic fear ofone's own death which creates the moral position thatcausing death, whether in a social system or medicalenvironment, is fundamentally wrong. However, there is norational argument to substantiate the idea that human life issacrosanct, other than a benevolent subconscious ideal. Asstated earlier, bio-ethical debates do not even attempt tosubstantiate this idea, perhaps because it is inherentlyimpossible to do so.Often when the idea of the sanctity of life is discussed,bioethical debaters bring up the 'slippery slope' concept:which essentially states that if one takes a pro-choicestance on abortion or euthanasia, one will eventually causea social system to morally disintegrate or spiral downwardsinto anarchy. It is paradoxical that the people who defineeuthanasia or abortion as evil use the above argument, asthey are stating that although an individual has a set ofmoral standpoints which should prevail, humans must alsohave an immoral side which will take over and destroy allmorality if any movement from the accepted norm isallowed. By using a 'slippery slope' argument, ethicaldebaters suggest that the ability to do evil is innate in everysoul, and that this basic instinct is wrong. It is difficult torationalise critically that one basic instinct is wrong and theother right without slipping into dogma and showing one'sown innate prejudice. Therefore, it is problematic to use a'slippery slope' argument.Similarly, it is problematic to use historical perspectives,theories or practices to substantiate current philosophicalstandpoints in ethical debates or to deter medicalpractitioners from straying from currently accepted moralboundaries.' This is because it is perhaps impossible to goback in time to an absolute historical truth, where all priorjudgements and empirically derived information do notimpinge on this absolute truth.3 Therefore, the use ofhistorical perspective in defining ethical policy isimmediately prejudiced because an argument will have beencreated from inferences from a time period in history sometime after the origin of thought and rational consciousness,which is an intangible entity. All ethical arguments based onprior historical input can therefore have no basic premise,and cannot be used with any confidence to substantiatecurrent ethical perspective.Finally, for any bioethical debate to take place, one needsa social structure in order to begin discussion. Variousbioethical groups, which are usually created by members ofthe medical profession to discuss ethical issues, reachcertain conclusions. These are then drafted as policystatements to be used by others in the medical professionwhen confronted by ethical dilemmas!,4,8 However, the ideaof a policy statement automatically implies collectivethought or collective empowerment of a certain ethic orviewpoint, and thus individualism and freedom of choice arenegated by the very creation of a bioethical committee orpolicy-making group. This immediately creates a paradoxicalentity.What, therefore, would best serve the interests of thecommunity or individual medical practitioners involved indecisions about life and death? Perhaps the only rightchoice is that of the individual involved in that decision,regardless of time and place, If a man chooses to end hislife, that is his choice and he must be allowed to do so. If adoctor decides to end the life of someone with no consciouscontrol of their own, that must be, If a woman decides tohave an abortion, it is her choice. To argue that mistakesmay be made is irrelevant. Countless people die as a resultof ignorance or prejudice, and for each one mistake madeby a rational, intelligent physician, more correct decisionswill be made. The idea that life is special and inviolatebasically boils down to religious or social dogma. AsNietzsche9 observed, one's own will to power and individualcourage should decide on all aspects of life and death,irrespective of social or religious viewpoints. Ethicalstandpoints are intensely personal and an individual's choiceand by attempting to persuade others to adopt one's ownphilosophical viewpoint, one moves from philosophy todogma. In other words, medical ethics should be debatedby the individual practitioner alone, and that individual'sviewpoint should be based on their own ethical code. Anyattempt to establish an ethical code to govern the actions ofmedical personnel creates rules in an area of life where norules are possible.W Hopkins, M Hislop, M I Lambert and K H Myburgh areacknowledged for their constructive criticism of this article.A St Clair GibsonSports Science UnitUniversity of Cape Town1. Aussell BE. History of Western Philosophy - and Its Connecnon with Politicaland Social Circumstances from the Earliest Times to the Present Day. London:Routledge, 1946.2. Brooks 0, Nash E, Abels C, et al. Abortions - some practical and ethicalconsiderations. S Afr Med J 1995; 85: 183-184.3. Harris J. The elimination 01 morality. J Med Ethics 1995; 21: 220-224.4. Benatar SR, Abels C, Abratt R, et al. Statement on withholding and Withdrawinglile-sustaining euthanasia. S Afr Med J 1994; 84: 254-256.5. Keown 0, Keown J. Killing, karma and caring: euthanasia in Buddhism andChristianity. J Med Ethics 1995; 21: 265-269.6. Benatar SA. Dying and 'euthanasia'. S Afr Med J 1992; 82: 35-38.7. Boyd K. What can medical ethics learn from history? J Med Ethics 1995; 21: 197-198.8. Benatar SA, Abels C, Abratt A, et al. Abortions - some practical and ethicalconsiderations (Reply to letter). S Afr Med J 1994; 84: 469-472.9. Nietzsche F. Thus Spoke Zarathustra. Harmondsworth, Middx: PengUin Books,1969.Volume 8 Xo. 2 February 1998 SAMJ

Ethical considerations with regard to the sanctity of human life

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Ethical considerations with regard to the sanctity of human life

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