Reunions are times for reflection, and my medical school class reunion is soon. There has been much to reflect upon, as 60 years is a long period in one’s life even though it is a microdot in the history of mankind. There have been hundreds of thousands of personal experiences during that time, all of which have enriched my life, and indeed I have been blessed.
In addition to those times with patients, I have witnessed momentous changes in all aspects of medicine. Things that were undreamed of during our student days are now routine and taken for granted. Newly invented diagnostic procedures are more efficient and precise. Scans have replaced many previously unreliable and time consuming tests. Antibiotics were invented. Vaccines virtually eliminated many serious illnesses. Now, no mother would hold her child in her arms while watching it die of diphtheria as did my grandmother, and there are few doctors left who have ever seen diseases so common in our day that they were accepted as a normal part of life.
While we were still in medical school, anti-depressant and anti-psychotic drugs were marketed, and within two years, 70% of state hospital patients, many of whom would have otherwise spent the rest of their lives in institutions, were discharged. Cardiologists who were limited in their treatments by very few medications now actually are able to visualize occluded coronary arteries and unplug them by sticking a catheter through the heart and into the coronary arteries, much as your plumber opens a clogged drain. Even more unbelievable was the idea that organs, especially the heart, could be transplanted. If that isn’t ghoulish enough, now there is talk of manufacturing organs from stem cells. And we must not forget, like it or not, this is the digital age, and computers have become an indispensable tool in all aspects of medicine, with even robots now entering the picture.
One day many years ago, during my internship, I found myself assisting in surgery to repair an abdominal aortic aneurysm, the first such surgery to be performed in the state of Ohio. The body’s largest blood vessel was in the process of bursting, and the patient was brought into the OR literally screaming in pain for which massive doses of morphine had no effect. One of the nurses was kept busy wiping the sweat from the surgeon’s brow to prevent it from dripping into the abdominal cavity as he worked. After 6 hours and gallons of blood, the patient died on the table, and the surgeon was barely able to make it to the dressing room, totally exhausted. Today, that procedure is routine and can sometimes be done without even opening the abdomen.
IS IT ETHICAL?
As is the case with most major scientific achievements, there have been many unintended consequences, and we are confronted with ethical questions, most of which have no acceptable answers. There are all those end-of-life dilemmas such as when to “pull the plug.” In my day, death was the enemy, and we considered ourselves ethically-bound to preserve life at all costs. Death was defined as lack of a heart beat, but with life support systems now in general use, it is possible to keep a heart beating indefinitely. Today, families are faced with the heart rending chore of agreeing to the withdrawal of such support. I have seen family members whose grief is compounded by the irrational belief that they were complicit in their loved one’s death. This problem has found a solution through asking patients to sign notarized documents promising to die appropriately and in a timely manner.
On the other hand, our newly found technology may preserve a life of pain and suffering and leave the physician to question the preserve-life-at-any-cost dictum. This has contributed to a newfound focus on “quality of life.” As a consequence, there are now five states permitting physician assisted suicide. We old fashioned guys and gals were bound by oath and a code of ethics to always do our utmost to save lives and never, under any circumstances, to end them. Although, there were undoubtedly occasions when a physician may have been overly generous with his doses of morphine for a patient who was finding it difficult to die. I suspect a similar treatment plan is often used in the terminal stages of hospice care today.
It is not surprising that these changes have generated controversy. There are those who feel dying should remain in the hands of God, and to violate the sanctity of life, no matter the rationale, is a most grievous sin and should be illegal. Strangely, some of those same people may feel that capital punishment is justified. There is also the argument that to accept assisted suicide is to go down a slippery slope from which there may be no return. Proponents of that position are not impressed with the safeguards put in place to prevent it being misused e.g. for depressed mental patients or for those elderly infirm people who are made to feel they are a burden.
MO’ LIFE MO’ PROBLEMS
The successes of medicine have also been responsible for cultural and political problems. There have been remarkable increases in longevity. During my lifetime, life expectancy has increased nearly 20 years in spite of the adoption of unhealthy lifestyles by many of us. This longer lifespan has contributed much to the current problems with social security as the actuarial tables, used at its inception in 1935, grossly underestimated the increase in lifespans. A longer lifespan allows some to outlive their savings, resulting in the creation of “sandwich families” where parents find themselves caring for both their children and their parents.
It has been well documented that healthcare expenses increase drastically as a population ages. A Kaiser Foundation study reports that the average person’s medical expenses double at age 70, triple at 80 and increase five times at 90. It seems likely that the future will see the average person living even longer, and the problem will be compounded by all those baby boomers joining the ranks. It is little wonder that the bean counters are predicting a major crisis for Medicare. It is enough to make an old person like me apologize for living so long.
OUR MOST COMPLICATED FIELD
Of all the accomplishments in medicine, none holds more potential for raising ethical, moral, and religious questions, while at the same time promising the elimination of some of our most terrible diseases as does the field of genetics. The sequencing of the human genome was completed in 2003 after a 13 year period of collaboration by scientists worldwide. It was made possible by the development of extremely powerful computers, which were able to compile the huge amounts of data needed to identify and catalog the billions of DNA connections present in our genes. This has been hailed by many as the greatest scientific achievement of all time with the promise to unlock many of the secrets of life.
This research has made it possible to identify the location of mutations responsible for many of the inheritable diseases, and now, even more remarkable, a procedure called CRISPR (an acronym for a string of big words that I couldn’t remember even if I tried) makes it possible to actually remove a portion of DNA from a gene and replace it with DNA which has not been corrupted by mutation. With the repair completed, the condition can no longer be passed on to the progeny. The unraveling of the make-up of the genome promises to result in discovery of many genetically influenced diseases and further our understanding and elimination of those illnesses that “run in the family.”It is also possible to use CRISPR to modify the genetic make-up of bacteria and trick them into becoming friends rather that attackers. There seems little doubt that these discoveries will revolutionize the practice of medicine and further increase human longevity.
MORE THAN MEDICINE
Genetic manipulation of this sort has been found to be useful in a variety of areas other than medicine, including chemistry, biotechnology, and the life sciences, but the development of genetically modified foods seems to have gained the most attention and criticism. Nineteen European countries have banned GMOs, apparently out of fear that some botanical Frankenstein monster might be created, thereby refuting scientists’ reassurances of their safety. Other experts insist no danger exists and point out that we have made changes to the nature of living things for a long time with a methodology both cumbersome and lengthy.
Since the Stone Age, man has used selective breeding to modify the genetic make-up of both plants and animals. Witness the number of breeds of dogs we have, all of whom are direct descendants of wolves. On the botanical side, it is said that corn evolved from a Mexican weed with a seed pod smaller than your finger, which, thanks to the selective breeding initiated by Aztec farmers 9,000 years ago, we now have a plant which is said to provide 21% of the world’s food. Production of desired changes by this process is time consuming, often requiring hundreds or even thousands of years. Now, there is the potential to produce those changes in a single generation. There are already instances in which resistance to drought, disease, and pests have been accomplished.
LOOK OUT SEX ED
Many say that the genome is a “blueprint of life,” and as such it does seem that caution is in order before beginning to tinker with it. It is theorized that it will soon be possible to have “designer babies,” who can be ordered with whatever characteristics that are important to the parents. Imagine what Hitler could have done with the help of CRISPR in his zeal to develop a master race. Since there is no aspect of a person that is not designed and controlled by genes, the changes which could be accomplished are limitless. An even spookier thought is the possibility that life could be created by man. After all, DNA has been synthesized and is readily available, and it is deemed possible to construct a synthetic gene. If the construction of one synthetic gene is possible, why not an entire genome?
As with almost everyone else, I have dived headlong into this “Brave New World” of digital bliss. In a previous blog, I commented on warnings about artificial intelligence by a few guys who know about that stuff, and I also wrote about the replacement of people by machines. There has been speculation as to the effect of prolonged viewing of violent video games on kids, and recently evidence has been collected that kids’ attachment to their cell phones has all the qualities of addiction. I have also witnessed the birth of satellites, the internet, social media, space travel, atom bombs, jet airplanes, GPS systems, robots, television, and computers, to name few of the awesome things developed in the relatively brief time I have taken up space on this planet. Those few years have produced more advances in science and technology than happened through all of history. I am impressed and a little scared.
The ability for society to take advantage of all the marvelous achievements of our day without destroying itself, in my opinion, should be job one. It appears to me that our young people are strongly encouraged to learn technical skills and seek an education focused on math and science. Granted, there is great need for such occupations. Consequently, they are lucrative, but there is an even greater need for those who can view these changes from a distance. In that vein, I believe there has never been a greater need for a liberal arts education, yet it seems few share that view. We need philosophers, theologians, historians, artists, poets, writers e.g. professions not directly immersed in high tech stuff. I believe it is more important to know where we are going than how to get there. This is especially true during this time when events are changing so rapidly that there is hardly time to contemplate unintended consequences.
In medicine, when a new procedure or treatment is prescribed, physicians are taught to do a risk-benefit assessment. That is based on the premise that body parts are all linked together, so any changes in one organ are apt to result in changes somewhere else. In the case of the burgeoning technology which threatens to overwhelm us, I believe that it is important for those knowledgeable, but not directly involved in the research, to do risk assessments, also, in order to predict some of the side effects of technology. These ideas should be debated and become “Breaking News,” and perhaps even receive as much coverage as the rescue of a dog who fell into a well. In medicine, we have the FDA, which regulates drug and equipment development, but all that digital stuff, which I don’t understand, garners no press until it is out there, undoubtedly doing both good and bad.
Perhaps the greatest challenges facing generations to follow lays not in developing new technologies, but in learning to control those from mine.
Note from the editor: In case you were wondering, CRISPR stands for Clustered Regularly Interspaced Short Palindromic Repeat.