Barely two column inches caught my eye on the front page of Saturday’s Herald:
An investigation has been launched after a human foetus was discovered within a bag inside a disused hospital building.
Full story: page 3.
But the full story shed little light and left more questions unanswered. This was a disused hospital site that has not seen maternity services for 24 years. All we know is that some kids with nothing better to do had broken into the place and are now under arrest. So many obvious questions arise from this report that remain unanswered.
The derelict site in question was part of the old Glasgow hospital, Stobhill.
When I read about this, I immediately thought of a poem, Stobhill, by the late great Scottish makar, Edwin Morgan (Edwin Morgan, Collected Poems, Carcanet 1990). Stobhill is surely one of the most upsetting and disturbing poems I have ever read. I can hardly bring myself to outline its burden, other than to say it is concerned with a (late) termination of pregnancy. It is an account from five people: doctor, boiler man, mother, father, porter. The reproduction of vernacular speech from each of them is faultless. But to speak of the technicalities of composition in this context seems beside the point.
If this poem is extremely upsetting and disturbing to me, it is because as a junior doctor I had a cameo role in an event not dissimilar and indeed, in every conceivable way, worse. I wrote it up in 1991. It was – for obvious reasons – distorted and fictionalised; yet when I read it now, I realise that it is entirely devoid of fiction. Periodically I think to publish it. Sometime, maybe.
We weren’t taught ethics as a discipline when I was a medical student (or, if we were, I must have dogged off that afternoon). The trendy conceptual framework of the day with respect to medical education was “Knowledge, Skills, and Attitudes”. They were taught more or less in that order. At a time before the notion of an “integrated curriculum” had caught on, medical students spent two or three years in lecture rooms, dissection rooms, laboratories and libraries, acquiring “Knowledge”. They gave us a BSc Med Sci at that point just in case we’d had enough. Then we were let loose on the wards to acquire “Skills” – primarily diagnostic skills, with a few technical procedures thrown in.
The “Attitudes” bit was really something of an afterthought. You can tell it was that because of the clumsiness of the nomenclature. How on earth do you impose an attitude on somebody? Pragmatically, most of us thought: keep your head down, do as you are told, and above all don’t let anybody suspect you’ve got “Attitude”. I think the general idea was that if you paced the wards night and day for another three years you would somehow imbibe and osmose the “wisdom” of the consultants and know how to make sound and humane decisions.
Nowadays, medical students are actually taught medical ethics as part of the undergraduate medical course. Medical students – more now than ever – are like pedigree race horses. They are trained to jump hurdles. They are professional exam takers, bursting with Knowledge and Skills. Ethics – another week, another module. What’s medical ethics condensed on to one side of A4? It is the template of Beauchamp and Childress (it’s the modern way, to be armed with a crib, going forward), that every medical decision should be informed by consideration of its import with respect to the concepts of autonomy, beneficence, non-maleficence, and justice.
Patient autonomy is a swipe against medical paternalism which is not always welcomed by the patient. The doctor outlines the pros and cons of a proposed procedure and seeks the patient’s “informed consent” to proceed. More often than not, the patient shrugs and says, “You’re the doctor.”
If a procedure must be beneficent it may seem redundant to add that it also be non-maleficent, yet the inclusion of both ends of the spectrum is frank admission that no therapeutic modality on earth is devoid of adverse side effects. Not one. Risks and benefits – you’ve got to balance them up. Actually you’ve got to get the patient to balance them up – because of his autonomy.
“Justice” puts the patient into the context of the wider community. It may be beneficent to Patient A to spend £1,000,000 on him, but if this is at the expense of Patients B- Z, is it “cost effective”? This is the ethical dilemma NICE grapples with every day.
But to return to Stobhill – my own personal Stobhill. I cannot speak of this. Let the Morgan poem stand in for me. I do remember that, at the time it happened, the BBC were showing a series of films by the surrealist Spanish film director Luis Bunuel – films like “That Obscure Object of Desire” and “The Discrete Charm of the Bourgeoisie”, in which everything that happens seems perfectly rational and logical, except that it is all utterly mad. I was a bit player in a Bunuel movie. I think that if somebody at that point had introduced me to Beauchamp and Childress’ “practical framework” for medical ethical deliberation, I would have told them it was the biggest crock of cockamamie bull…
Yet what else have we got?