Instilling ethical values

PROSPECTIVE doctors in Singapore - at least undergraduates at the National University of Singapore's Yong Loo Lin School of Medicine - couldn't ask for a better "moral guardian" than bioethicist Alastair Campbell.

If medical undergraduates now get lessons in ethics as part of their curriculum, few would be as well suited - in terms of personality and credentials - to spell out the rights and wrongs as the genial British professor, a renowned authority in his field who also happens to have a particular interest in the area of virtue ethics.

As founding director of the School's Centre for Biomedical Ethics, Professor Campbell, 76, added ethics to the medical curriculum - not as an elective but a core subject that runs through all five years of training, starting from day one.

Indeed, the idea that ethics should be as integral to medical training as, say, anatomy or physiology, was fleshed out here only after 2006, when he arrived to take up appointment as NUS's first Chen Su Lan Centennial Professor in Medical Ethics. He had earlier started and led two other bioethical centres, in New Zealand and in Britain.

But that's not unusual, says Prof Campbell of the lack of a formal and sustained focus on ethics in Singapore's medical curriculum prior to the establishment of his Centre at NUS in 2006.

"The whole development of ethics as a serious discipline in medicine has been very slow to develop, so there were quite a few medical schools that assumed that somehow students could learn by the examples of senior clinicians about ethics and how to act rightly - the apprenticeship model, the idea that if you follow a clinician around and watch how she or he deals with things, you'd understand about ethics," he tells BT. "That was a very common view when I first started in this field back in 1970; that was normal in Britain."

In eight years, the Centre has become prominent globally and certainly the biggest in Asia, with a strong mission in ethics education for not only medical students but all healthcare professionals, as well as active research in areas such as end-of-life issues, transplantation ethics and the ethics of genomics, stem cell research and therapy.

The feather in the cap was its appointment in April this year by the World Health Organisation (WHO) as its first collaborating centre for bioethics in Asia - strong recognition of the Centre's authority and expertise in the field and its international status.

But its "main job will always be to make sure that our students are properly prepared to be ethical professional doctors", Prof Campbell makes clear. "That's always going to be our main mission, and we keep working on this." Perhaps one can't really "teach" professionalism "but you can encourage it, develop it", he says. And it's "hugely important" to produce medical graduates who will be "professional, ethically reflective practitioners" who will put patients' interests first and who understand the medical laws well because of rapid changes in medicine and society today.

"There's a lot of worry that these sorts of ideals of medicine are under threat, that it's become dominated by commercial rather than patient interests," he says. And medicine keeps changing, he adds. "Every month, it seems, there's something new to challenge - the whole new development of genetics, the possible prediction of disease; the development of things like telemedicine; threats from things like Ebola; so we need graduates who can be flexible and be open to changes in medical practice."

Sure, "there's a limit to what teaching can do in the area of morality", he concedes, given the "very complex set of influences" on moral attitudes and behaviour. "But I guess what we're trying to do all the time is to let people think beyond the notion of competitive advantage, which is pretty strong in Singapore, and the idea that 'the happy life is the successful life is high purchasing power'... that's the message that's coming across all the time to our young people."

There's "no doubt that the notion of commercial advantage is becoming more and more powerful, in Singapore and elsewhere", says Prof Campbell, citing the "very interesting" debates here on doctors' fees .

"So the idea of going into medicine 'because you'll make lots of money' is pretty strong. If that were the only thing that brings people into medicine, then heaven help us, because we're all going to get sick... and we need doctors and other health professionals we can trust, not people after a fast buck. So, yes, sometimes it looks pretty bad, I agree," he says, laughing, "and, of course, the famous Susan Lim case is a dramatic illustration of what can go terribly wrong in terms of saying, 'If I can make those amounts of money, why shouldn't I?' " Dr Lim, a surgeon, was found guilty in 2012 of overcharging a member of the Brunei royal family for medical treatment.

"But on the plus side of that case, the High Court's final statements about why this was not acceptable are really encouraging, in terms of saying - it doesn't matter whether this is a poor person or a rich person, you have to charge what can be seen as a fair or reasonable fee, not the amount of money you can possibly make. And it's because sickness makes us so vulnerable, and if we can't trust the people that are going to help us when we're sick, then something terrible has happened in society.

"So that's the business we're in; what we're working on is this kind of basic humanitarian commitment, this altruism that's there in these young people, to hope it doesn't disappear. Sometimes, I wonder if I'm wasting my time," he laughs, and then adds: "I think we might make some difference."

Accidental bioethicist

A philosopher and theologian by training, Prof Campbell calls himself a "totally accidental biomedical ethicist".

After obtaining his first two degrees, in philosophy and in theology, at the University of Edinburgh, he got a fellowship to do postgraduate study in the United States. And when he told one of his theology professors that he was considering studying "the problem of the language about God", the professor said "Oh, that's a little waste of time" and suggested that he looked, instead, at the relationship between religion and medicine.

"I hadn't thought of that," says Prof Campbell. "So okay, I'll do that. So I did a doctorate in the States, it was very good training. And a lot of the focus was on the relationship between religion and psychiatry in particular. That began to spark my interest in ethics and medicine, particularly in relation to psychiatric patients."

Then when he was back at Edinburgh as the university chaplain while working on his PhD dissertation, he was, by chance, asked to give lectures on ethics to senior nurses at the Royal College of Nursing.

"Of course, it wasn't a job. I mean, they paid me a little but my job was still in the university. So I started doing this, and the nurses were terrified of the subject and they had to pass an exam in it. By 1968, I guess, or '69, I'd been doing this for a year or two, and I thought, they need a book, they don't have a book. So I wrote this book and took it to a publisher, and the publisher said: 'Aww, that's interesting, ethics for nurses... you'd better do it for doctors as well'. I said okay. So that was my first book, in 1972, and it was called Moral Dilemmas in Medicine." The book, which the publisher predicted "will never sell", went into three editions.

The "next accident" happened in 1975, when he was picked to be the editor of the new Journal of Medical Ethics because the publishers couldn't find a doctor "who knew anything about the ethics" for the job. A member of the panel appointing the editor had read his book and told the panel: "He's not a doctor... but it makes very much sense".

"And so I became the first editor of the journal. Again, I hadn't applied, and that really just began to define my career. I was still teaching Ethics and Divinity at that time. But with the Journal and some subsequent books, I became much better known in medical ethics, and so I took a decision to move that way. It's been a wonderful move. While Divinity is very important and I was happy to be involved in Theology, Medicine is much more exciting and, in a way, you can do more in a much wider field in medicine."

Given his background, Prof Campbell can't stress enough that in teaching medical ethics, he's "not here to promote a religion ... (but) here to promote ethics".

"I'm not trying to push a Christian message at my students. I believe that Christianity and other religions provide a lot of insights into ethical issues. But I think because I've been a pastor in a university setting, I think the doctors realise that I know how to deal with people in crisis.

"The other thing is that sometimes in the past, particularly back in New Zealand, they've asked me for help where a patient's very driven by religious values that sometimes get in the way of medical treatment."

So "I guess there is a kind of interplay (between religion and medicine)", he says, "but I always want to make it very clear that I'm not some sort of crypto-evangelist; I'm here to help everyone - whatever their beliefs or no belief - to confront the ethical issues, that's my job".

And ethical issues there are aplenty today in the biomedical sciences. Take the rise of genomics, with the cost of mapping one's genetic blueprint having plunged dramatically to a couple of hundred dollars in just several years. "Here's why this is an ethical issue," says Prof Campbell. "Because the science has run ahead of its clinical application, and also of the ethics. And lots of people have jumped on this, in terms of commercial interests; they're trying to persuade people - 'you surely want to know whether your baby's going to get heart disease?' So the whole risk of false positives, predictions; of genetic discrimination - where people's insurance possibilities, their employment possibilities, could all be hazarded - is going to be one of the big ethical issues of our time, and it's moving very, very fast.

"But on top of that, there's this other problem, what we call 'genetic essentialism', which is saying that - you can predict everything if you know the genes. That's wrong, it's wrong. There's hardly any disorder, illness, disease, that is purely pre-determined by genetic make-up. Nearly all of them are a complex interplay of factors; lifestyle and environment are hugely important."

Ethical dilemmas

Another medical breakthrough he has grave reservations about is stem cell therapy, sometimes termed regenerative medicine. "Obviously if we could do something with spinal fractures, for example; Superman's great hope that his spine could be healed," he quips. "So regenerative medicine is a wonderful prospect. The problem is the hype and the exploitation that is currently happening. Not in Singapore so much, although I think there could be more regulations in Singapore than there are, but elsewhere, certainly in China and other places, where the magic words 'stem cell' are put in, but actually there is no evidence whatsoever yet that it would be effective, except in a very, very narrow range of conditions, and even then it's still very experimental." That said, he believes there is a big future in stem cell therapy.

Questions have also arisen in the current Ebola outbreak about the use of experimental drugs.

In Prof Campbell's view, the WHO has been "very responsible" in having an expert panel look early on into whether it was ethical in these exceptional circumstances to use an untested drug.

"The committee advised that in these circumstances you could use it. It won't become standard use yet because you need the clinical trials and you need to do proper research in the cases where it was used. I think that was the right way to go. I think there are times when the choices are so terrible that, provided the person who's receiving the drug was fully informed, I think it's justified. But that's exceptional, you do it in a crisis but you don't make it standard, you have to go through the proper processes normally. We think we have to be prepared to be that flexible every now and again and just go beyond regulation to exceptional circumstances."

And having been here for eight years, "it's very interesting to see the debate developing in Singapore about provision of healthcare and whether it's adequate, whether it's meeting the needs, especially with an ageing population with chronic illnesses as a main feature... there are big ethical issues there", says Prof Campbell, who declares himself to be a "dyed in the wool socialist".

Also, practising medicine and bioethics "in an Asian context" means looking at things like the significance of the family in decisions about the care of a patient, for instance; "the sense of duty and responsibility that's very strong in the culture", compared to perhaps a Western bias towards individual rights and autonomy, he says.

This leads to a question he finds of particular interest : "Where do you put the emphasis in ethics? Do you put it on my rights or my duties? Why do I insist on my rights but do not think that I have an obligation, to my family, to my community, to my country? That is the other side of the equation."

The idea ties in with his specialist interest in virtue ethics - which looks "not just at what we ought to do but what sort of people we should be, what's our character, what does it mean to be virtuous?"

The trouble with the word "virtue" is "it sounds very elitist, like you're very special people", he laughs.

"But actually you can have a simple kind of virtue, which is, these are just the sort of people that I'd want to share a country, a society, with. These are the sort of people I'd want as my doctor, my nurse, and I can trust them, because they'll be conscientious, they'll be dutiful, they'll be supportive. And that notion of the Virtuous Society, I think it's a precious thing to hold onto and to nurture, and to nurture in young people especially."

PROFESSOR ALASTAIR V CAMPBELL

Chen Su Lan Centennial Professor of Medical Ethics, NUS Yong Loo Lin School of Medicine

Director, Centre for Biomedical Ethics, NUS

1938 Born in Motherwell, Scotland

Married, has seven children and nine grandchildren

1959 MA (1st Class Hons, Mental Philosophy), Univ of Edinburgh

1962 - BD (Distinction in Systematic Theology), Univ of Edinburgh

1967 - ThD (Summa cum laude), San Francisco Theological Seminary

1978-1990 Senior Lecturer, Dept of Christian Ethics and Practical Theology, Univ of Edinburgh

1986 Visiting Professor, Dartmouth College, United States

1986-1987 Visiting Professor, Otago Medical School, Dunedin, New Zealand

1987-1990 Associate Dean, Faculty of Divinity, Univ of Edinburgh

1990-1996 Professor of Biomedical Ethics, Otago Medical School

Director, Bioethics Research Centre, Univ of Otago, Dunedin, NZ

1996-2005 Professor of Ethics in Medicine and Director, Centre for Ethics in Medicine, Medical School, Univ of Bristol, UK

Since 2006 - Director, Centre for Biomedical Ethics, NUS

OTHER MILESTONES

1975-1980 Foundation Editor, Journal of Medical Ethics

1997-1999 President, International Association of Bioethics

1999 HK Beecher Award, The Hastings Center, New York

Fellow of The Hastings Center, New York

2008 Honorary Vice President, Institute of Medical Ethics

2011 Corresponding Fellow of the Royal Society of Edinburgh