Ethical Isues & Imaging Methods

Transplant surgery has been carried out since the 1960's but it is only since the development of anti-rejection drugs such as cyclosporin in the 1980's that it has significantly increased the patient's life expect. However, the supply of organs nowhere near meets the demand & is actually falling in Britain.

Reasons why the number of potential organ donors is falling in Britain:

• Many people used to be killed in car accidents. Safer cars & seatbelts have reduced the number of people dying.
• Better medical treatment in intensive care means less badly injured people die.

Information the consultant surgeon might give the patient before the operation:

• Element of risk attached to surgical procedure e.g. the anaesthetic may give an adverse reaction
• The transplant may be rejected
• Immunosuppressant drugs have to be taken everyday for the rest of their lives. These drugs have side effects e.g. cancer, hair growth and moon face
• There will be a long recovery time for such a major operation

Recombinant DNA technology has been used in pigs to create animals whose organs are less likely to be rejected by the human body.

Ethical & Scientific Problems

- Some people's religious beliefs may prohibit them from eating pork & hence they may be uncomfortable at the though of receiving an organ from a pig.

- If the patient is young, they may need a second operation at sometime in the future.

- There is a potential danger of transferring viruses from one species to another e.g. mad cow disease.

- Animal welfare issues i.e. not wanting the animal to die or suffer.

There seems to be a trend to withhold operations from people whose medical problems could be considered to be self inflicted. E.g. people who are obese.

Information the surgeon gives to an obese patient before surgery:

• There is an element of risk attached to any surgical procedure
• The chances of success are lower because of the obesity
• There are practical difficulties in surgery for severly obese patients

Ethical

• The chances of survival for obese people during or following the operation might be reduced.
• Some conditions prevent people from exercising resulting in their gaining weight. It is not their fault.

Not ethical

• NHS funding might be better used for people who are not obese & hence have a better chance of survival.
• Obese patients also contribute to the NHS – pay their taxes etc.

Example: Herceptin. The cost for one patient's annual treatment with Herceptin to the NHS is £19,500. The NHS is not a bottomless pit in terms of funding. Although the money spent on the NHS has doubled in recent years, many hospitals have overspent their budgets by several million pounds.

For

• There is no ‘blame’ involved with conditions e.g. breast cancer (smokers may get lung cancer or heart disease but that is self inflicted).
• The money spent on one cancer patient may keep several kidney patients alive for many more years.

Against

• Expensive drugs may not provide cure – they may only extend life for a few months. Is the money worth it?
• The money spent on one cancer patient may keep several kidney patients alive for many more years.

Pharmaceutical companies test drugs on animals when they are first developed. Then they test them on human volunteers to see if it is safe. They often chose young healthy people often students.

A placebo is a dummy drug e.g. sugar pill that looks just like the real drug so the patient doesn't know which drug he is getting.

Information given to subjects before taking part in the clinical trials:

• Level of rish from taking the drug
• Possible adverse reactions i.e. side effects
• Ingredients that certain religious groups would object to

Doctors have to consider the following points:

• Patients can't make good choices & participate intelligently in setting goals and making decisions unless they are reasonably well informed about their condition
• Almost all dying patients report that they want to be informed about their medical condition, although excess frankness or a presentation of information that is percieved as uncaring can be viewed as cruel or as taking away hope.
• Many patients seem to have unrealistically optimistic expectations about the value of treatments regardless of what they have been told

For:

• Patients want to say goodbye to friends and family
• Doctors should not 'play God' it is the patient's life

Against:

• Patients may give up if they know they are dying
• Patients may not wish to know that they are dying

If a patient suffers serious injuries, usually head, they can't breathe unaided. They will then be connected to a life support machine. If the patient is assessed as brain dead then it will be suggested to the relatives that the life support machine will be turned off.

Ethical issues to be discussed:

• Ensuring the death would instant and painless
• There is no prospect of recovery
• Patients may have signed a living will expressing their wishes
• Brain activity is not linked to the rest of the body activity

An x ray is a short wave ionising radiation equipment. The x rays work on hard tissues like bone which absorb a lot of x rays so they show up white

X rays are used to diagnose:

• Chest - detect pneumonia or TB
• Breast - detect tumours
• Dental - detect decay
• Foreign bodies - x rays are used to identify & locate objects that have been swallowed so they can be removed

Pros:

• Readily available
• Provides clear images of bones

Cons:

• Poor images of soft tissue with low density
• Health risk due to exposure to x rays because it uses ionising radiation

CAT = Computer Aided TomographyThe scanner rotates to pass x rays through the body at different angles. A CAT scan is better than an ordinary X ray because it is very good for scanning the brain e.g. diagnosing tumours or areas of damage following stroke.

Ultrasound uses high frequency sound waves (not like CAT and X rays)

Ultrasounding is used to diagnose gallstones, kidney stones and pregnancy to check the foetus. It can't be used to diagnose brain tumors because the sound waves will not pass through the bone. Pros:

• No hazard for patient, so it can be used in pregnancy
• More effective than x rays in producing images of soft tissues
• Doesn't need a specialist room - can move around
• Inexpensive

Cons:

• Bones absorbs ultrasound so it is hard to get images of the brain
• Images need skilful interpretation
• Radiographer has to be skilful at operating the probe to get a clear image

The patient lies inside a very strong magnet. This makes atoms inside the body move and produces radiowaves. 

MRI scans would be used rather than CAT scans because it doesn't use ionising radiation which makes it safer than a CAT scan. Also in a CAT scan bones can obscure the image but in a MRI it doesn't which makes it good for accurately positioning tumours. 

Pros

• Doesn't use ionising radiation - safer than x rays or CAT scans
• MRI can be used to give serial pictures to follow the progress of a therapy
• Can produce a 3D image 

Cons 

• Patient has to go into a scanner - not good for patients who are claustrophobic 
• Takes a long time - can be stressful
• Cannot be used with patients who have metal objects e.g. pins in bones as the magnet may move the metal, endangering the patient 

Gamma radiation is given off by radioactive isotopes because it needs to travel through the body and gamma radiation is very penetrating. It is detected outside the body and it needs to be able to get out. 

The radioactive isotope enters the body by being injected into a blood vessel in the arm. The isotopes attach to red blood cells and pass through the heart in the circulation. They can be traced using special cameras or scanners. The dark areas are where there is high metabolic activity e.g. rapid cell division like a tumour. This technique is used to diagnose tumours of the spinal column and fractures that don't show up on conventional x rays. 

Pros

• Can go directly to the organs to be investigated 
• Allows good/clear images of soft tissues
• Small amounts of tracers needed

Cons

• Ionising radiation causes cancer
• Patient remains radioactive for about 24 hours after which the isotope is excreted