In a cramped curriculum of medical education, there is hardly enough room for anything not directly related to learning how the human body works and fails. Yet on occasion, I find us students, exasperated from discussions of arcana and enigma of diseases and dodging academic curve balls ceaselessly thrown at us by well-wishing faculty, pleasantly distracted and wondering in and through the matters of spiritual province.
One of the dilemmas crisscrossing the canvas of patient-doctor relationship is that of praying with patients. Should a physician fend off the patient's request and choose to distance with references to own precepts that do not allow him or her to join in with a plea that may be as meaningful as a medicine. Would professional boundaries of an encounter be overstepped? Is praying a private personal matter, or private to a relationship, just like the matters of sexuality, psychiatric, or legal concerns?
While the modern medicine segregates theology and science on the basis that the latter affords practical packages of knowledge that at hands of its practitioners often translate into objective improvement of organic health, Hippocrates, Maimonides, and Rene Laennec (inventor of stethoscope and a devout Catholic) practiced at God's behest and will, as messengers and deputies of God. Certainly, the environment these forebears lived and practiced was less secular than ours, but practitioners of medicine of the past and religious figures of the community -- rabbi, imams, and priests, have frequently embodied the same person
So what should a modern physician do? Does the white coat confer an obligation to evaluate every action from the perspective of the benefit to the patient? Or, citing atheistic viewpoint, refuse? Or launch into a discussion whether praying actually confers any health benefit. The conflict arises for physicians when the role of a sensitive human being conflicts with the boundaries of a medical persona. Sometimes these boundaries are too rigid and a physician should enact the role of the caring human even if it may feel uncomfortable or embarrassing not to maintain the professional veneer. On the other hand, the boundaries could protect both patients and physicians. May be we are asking a wrong question? Rather than to look at a prayer as a treatment of material afflictions, perhaps a better question would be whether a prayer can positively affect emotional state of mind. And if you don’t like the word prayer, substitute it with meditation.
Perhaps, there is no good single answer for everybody. But I will pray to have wisdom to find one for myself.
Tuesday, August 09, 2011
Sunday, May 22, 2011
Being in the center of medical education, in fact its object – a medical student – affords a unique freedom that often does not survive as we progress towards seniority – the freedom to choose one's path in medicine and to form one's opinion about tenets upon which medicine rests. And its gray zones. While meanings of some principles, such as primum non nocere, transcend inclinations and interpretation, a great majority of others are debatable inconclusive minefields of uncertainty. One of such areas currently attracting a lot of attention is the research involving embryonic stem cells.
While it is widely believed, by supporters and opponents of the ESC research, that stem cells indeed hold an enormous regenerative potential, how to unleash such a potential is a matter of gritty debate. The central place in this debate is taken by ethical concerns. Such concerns drove the former president George W. Bush to limit federal funding to ESC research, only allowing such spending for investigations with ESC lines existing prior to the ban. This was claimed as an approach that would preserve the balance between ethics and scientific progress, and was hoped to satisfy sensibilities of those who oppose the ESC work on the one hand and on the other, thirst for development of new therapies by those who believe that such research is the holy grain for the preservation of human health. Furthermore, it was argued that the ESC ban would itself serve as a catalyst-in-disguise, prompting the development of new technologies, in a fashion not dissimilar to a clever work-around for a problem that cannot be solved head on. Indeed, clever ideas were put forward, and the field of stem cells was advanced by the development of so called induced pluripotent stem cells (iPSCs). These are the cells that were coaxed into ESC-like cells by clever molecular trickery. The key word here is ESC-like, for it is not yet known for sure whether these iPSCs are indeed identical to ESCs in every way, or simply appear indistinguishable at the level of detail we are currently capable to look. While some studies showed that iPSCs and ESCs are indeed quite similar in many ways, differences are also beginning to be identified. For this reason among others, the use of iPSCs in therapeutic trials lies in a foreseeable but indeed remote future. In meantime only ESCs can serve as a gold standard to further characterize the fidelity, potential, and safety of iPSCs.
Another argument often stated by opponents of embryonic stem cells research aims to question the very need for such science. They argue that instead of focusing on emotionally-loaded ESC research, we should escalate support for adult stem cells, which are considered ethically-safe. These are the cells that already found in human body, and are also capable of maturing into several types of cells, albeit with a potential restricted to fewer types of cells. If an ESC cell can become any mature cell in the body, the fate of an adult stem cells is restricted to a certain lineage or organ tissue. For instance, a hematopoietic stem cell can give rise to all cells found in blood, but it cannot mature into, say, a brain cell, at least based on the current knowledge. Proponents of adult stem cell research claim that adult stem cell research would not only leave embryos alone and alive, but also have been shown to have generated therapeutic strategies in treating and even curing many diseases. The ESCs have not been used to treat any disease, not to mention cure one.
At the first glance, this is a true statement. Indeed, the most well-known example of using adult stem cells in treatment is bone marrow transplant, which has been used for decades in treatment and even cure of cancers of blood. The argument, however, has two significant flaws. The adult stem cell research has been going on for more than five decades, during which the field had time to evolve, and research led to production of super-efficient drugs and treatment regimens. The ESC research is much younger, with the first human embryonic stem cell (hESC) line created from a fertilized egg in 1998; iPS cells were first created in 2006. To expect the ESC research to generate viable treatments in such a short period of time is unrealistic, and to suggest that that such research is less profound because of lack of therapeutic solutions is ignorant. It is ever more ignorant to argue that one avenue of research should not be pursued because a similar research has borne out viable treatment options. One who professes this point of view point of view should be asked if they would agree to be satisfied with penicillin as an only option to fight infection diseases rather than developing vaccines and other anti-microbial agents.
Scientific intricacies, however, are not the part of the ethical debate for the most part. Instead, in the epicenter lies the conflict of dogmas. The opponents of the ESC research state that in their view life begins at conception, and by destroying an embryo one destroys an individual. The activists and proponents of the ESC research follow a line of thought summarized by Harvard paleontologist and evolutionary biologist Stephen Jay Gould, "I do not grant the status of a human life to a clump of cells in a dish, produced by fertilization in vitro and explicitly destined for discard by the free decision of the man and woman who contributed the components."
An individual vs a clump of cells in a dish.
It is wishful thinking to suggests that this conundrum can be resolved based on definitions and clever logical sequences, for no dogma can be altered. Yet, there are examples when long-held believes and thinking yielded to innovations without quite leaving the scene and often without even having been invoked. In most of such examples, the benefit of action and innovation is usually recognized in hindsight. Consider the related concept of in-vitro fertilization. Roman Catholic Church (RCC) opposes the IVF on the grounds that it violates the rights of the child, and deprives conjugal fruitfulness of its unity and integrity. Yet, a number of Catholic women and families have undergone such a procedure and have been given an opportunity to have children, something that the RCC cherishes. A similarly divisive ethical issue of gay marriages has been under constant push-pull court battle; while only six states (CT, IA, MA, NH, NY, VT) and the District of Columbia have now recognized it, people aren't waiting -- they live and enjoy each other’s company. What seems to have happened is that the decision on where to draw the line has shifted from the government and other institutions to individuals. It might happen to the ESC research debacle. People for whom ethical concerns about the wholesomeness (and holiness) of an embryo is an unalienable principle might in the future consider the regenerative fruits of the ESC research, and perhaps even take advantage of them. When they do, we, physicians, must leave the dogmas behind, accept the wholesomeness of a patient and his or her decision, and help enable them to live meaningful lives.
While it is widely believed, by supporters and opponents of the ESC research, that stem cells indeed hold an enormous regenerative potential, how to unleash such a potential is a matter of gritty debate. The central place in this debate is taken by ethical concerns. Such concerns drove the former president George W. Bush to limit federal funding to ESC research, only allowing such spending for investigations with ESC lines existing prior to the ban. This was claimed as an approach that would preserve the balance between ethics and scientific progress, and was hoped to satisfy sensibilities of those who oppose the ESC work on the one hand and on the other, thirst for development of new therapies by those who believe that such research is the holy grain for the preservation of human health. Furthermore, it was argued that the ESC ban would itself serve as a catalyst-in-disguise, prompting the development of new technologies, in a fashion not dissimilar to a clever work-around for a problem that cannot be solved head on. Indeed, clever ideas were put forward, and the field of stem cells was advanced by the development of so called induced pluripotent stem cells (iPSCs). These are the cells that were coaxed into ESC-like cells by clever molecular trickery. The key word here is ESC-like, for it is not yet known for sure whether these iPSCs are indeed identical to ESCs in every way, or simply appear indistinguishable at the level of detail we are currently capable to look. While some studies showed that iPSCs and ESCs are indeed quite similar in many ways, differences are also beginning to be identified. For this reason among others, the use of iPSCs in therapeutic trials lies in a foreseeable but indeed remote future. In meantime only ESCs can serve as a gold standard to further characterize the fidelity, potential, and safety of iPSCs.
Another argument often stated by opponents of embryonic stem cells research aims to question the very need for such science. They argue that instead of focusing on emotionally-loaded ESC research, we should escalate support for adult stem cells, which are considered ethically-safe. These are the cells that already found in human body, and are also capable of maturing into several types of cells, albeit with a potential restricted to fewer types of cells. If an ESC cell can become any mature cell in the body, the fate of an adult stem cells is restricted to a certain lineage or organ tissue. For instance, a hematopoietic stem cell can give rise to all cells found in blood, but it cannot mature into, say, a brain cell, at least based on the current knowledge. Proponents of adult stem cell research claim that adult stem cell research would not only leave embryos alone and alive, but also have been shown to have generated therapeutic strategies in treating and even curing many diseases. The ESCs have not been used to treat any disease, not to mention cure one.
At the first glance, this is a true statement. Indeed, the most well-known example of using adult stem cells in treatment is bone marrow transplant, which has been used for decades in treatment and even cure of cancers of blood. The argument, however, has two significant flaws. The adult stem cell research has been going on for more than five decades, during which the field had time to evolve, and research led to production of super-efficient drugs and treatment regimens. The ESC research is much younger, with the first human embryonic stem cell (hESC) line created from a fertilized egg in 1998; iPS cells were first created in 2006. To expect the ESC research to generate viable treatments in such a short period of time is unrealistic, and to suggest that that such research is less profound because of lack of therapeutic solutions is ignorant. It is ever more ignorant to argue that one avenue of research should not be pursued because a similar research has borne out viable treatment options. One who professes this point of view point of view should be asked if they would agree to be satisfied with penicillin as an only option to fight infection diseases rather than developing vaccines and other anti-microbial agents.
Scientific intricacies, however, are not the part of the ethical debate for the most part. Instead, in the epicenter lies the conflict of dogmas. The opponents of the ESC research state that in their view life begins at conception, and by destroying an embryo one destroys an individual. The activists and proponents of the ESC research follow a line of thought summarized by Harvard paleontologist and evolutionary biologist Stephen Jay Gould, "I do not grant the status of a human life to a clump of cells in a dish, produced by fertilization in vitro and explicitly destined for discard by the free decision of the man and woman who contributed the components."
An individual vs a clump of cells in a dish.
It is wishful thinking to suggests that this conundrum can be resolved based on definitions and clever logical sequences, for no dogma can be altered. Yet, there are examples when long-held believes and thinking yielded to innovations without quite leaving the scene and often without even having been invoked. In most of such examples, the benefit of action and innovation is usually recognized in hindsight. Consider the related concept of in-vitro fertilization. Roman Catholic Church (RCC) opposes the IVF on the grounds that it violates the rights of the child, and deprives conjugal fruitfulness of its unity and integrity. Yet, a number of Catholic women and families have undergone such a procedure and have been given an opportunity to have children, something that the RCC cherishes. A similarly divisive ethical issue of gay marriages has been under constant push-pull court battle; while only six states (CT, IA, MA, NH, NY, VT) and the District of Columbia have now recognized it, people aren't waiting -- they live and enjoy each other’s company. What seems to have happened is that the decision on where to draw the line has shifted from the government and other institutions to individuals. It might happen to the ESC research debacle. People for whom ethical concerns about the wholesomeness (and holiness) of an embryo is an unalienable principle might in the future consider the regenerative fruits of the ESC research, and perhaps even take advantage of them. When they do, we, physicians, must leave the dogmas behind, accept the wholesomeness of a patient and his or her decision, and help enable them to live meaningful lives.
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