Out-of-body experiences

A couple of days before the government announced that the Human Fertilisation and Embryology Authority (HFEA) will be axed, the journal Human Reproduction published a report on why, nearly 40 years ago, the UK Medical Research Council refused to fund Patrick Steptoe's and Robert Edwards's attempt to produce a test-tube baby.

One surprising factor was that they weren't part of the in-crowd: Steptoe "came from a minor northern hospital" and Edwards wasn't even a professor. Properly shocking, however, is the news that the refusal came in part because government research was focused on limiting fertility, rather than increasing it. If ever we questioned the need for an "arm's-length" body to distance government policy from reproductive science, surely that little bombshell is enough to make us think again.

No doubt fertility clinics are rejoicing at the HFEA news. Scientists, if they know what's good for them, won't be. The HFEA was designed not to deal with the minutiae of regulating clinics, but to facilitate a public appraisal of the dilemmas that science creates.

The regulation of fertility and embryology research will now be hidden within the remit of the Care Quality Commission (CQC). There will be repercussions. These are life-and-death issues, and people care far more about them than whether the Mid Staffordshire NHS Foundation Trust is reducing the incidence of bedsores (the subject of a recent CQC press release). Without a distinct, visible body to oversee reproductive ethics, scientists in the field stand to lose public trust.

The HFEA has tackled some daunting issues in its time. Remember Diane Blood, who wanted to be impregnated using her dead husband's frozen sperm? The child, now nearly 12, was conceived and born despite the HFEA's disapproval. Perhaps the HFEA didn't get that right, but
it has made some good calls, too.

In 2004, the UK became the first European nation to permit research on cloned human cells. In 2007, scientists breathed a sigh of relief when the HFEA permitted women to donate eggs for research projects under certain circumstances. Another sensible decision, transparently made.

What was right in every case was that a high-profile public debate took place; scientists were not given carte blanche. Will this continue when reproductive ethics is a minor part of the CQC's remit?

The questions are only going to get more difficult. The birth of Louise Brown, the first test-tube baby, was nowhere near as complicated an issue as others that came after. Those on the horizon now - such as the engineering of artificial sperm and growing babies in artificial wombs - look even worse.

So, farewell then, HFEA. Louise Brown has just turned 32. You, the world's first overseer of reproductive technology, a model for other nations, didn't even make it to 20. Shame.

Michael Brooks holds a PhD in quantum physics. He writes a weekly science column for the New Statesman, and his most recent book is At the Edge of Uncertainty: 11 Discoveries Taking Science by Surprise.

This article first appeared in the 09 August 2010 issue of the New Statesman, The first 100 days

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Want to know how you really behave as a doctor? Watch yourself on video

There is nothing quite like watching oneself at work to spur development – and videos can help us understand patients, too.

One of the most useful tools I have as a GP trainer is my video camera. Periodically, and always with patients’ permission, I place it in the corner of my registrar’s room. We then look through their consultations together during a tutorial.

There is nothing quite like watching oneself at work to spur development. One of my trainees – a lovely guy called Nick – was appalled to find that he wheeled his chair closer and closer to the patient as he narrowed down the diagnosis with a series of questions. It was entirely unconscious, but somewhat intimidating, and he never repeated it once he’d seen the recording. Whether it’s spending half the consultation staring at the computer screen, or slipping into baffling technospeak, or parroting “OK” after every comment a patient makes, we all have unhelpful mannerisms of which we are blithely unaware.

Videos are a great way of understanding how patients communicate, too. Another registrar, Anthony, had spent several years as a rheumatologist before switching to general practice, so when consulted by Yvette he felt on familiar ground. She began by saying she thought she had carpal tunnel syndrome. Anthony confirmed the diagnosis with some clinical tests, then went on to establish the impact it was having on Yvette’s life. Her sleep was disturbed every night, and she was no longer able to pick up and carry her young children. Her desperation for a swift cure came across loud and clear.

The consultation then ran into difficulty. There are three things that can help CTS: wrist splints, steroid injections and surgery to release the nerve. Splints are usually the preferred first option because they carry no risk of complications, and are inexpensive to the NHS. We watched as Anthony tried to explain this. Yvette kept raising objections, and even though Anthony did his best to address her concerns, it was clear she remained unconvinced.

The problem for Anthony, as for many doctors, is that much medical training still reflects an era when patients relied heavily on professionals for health information. Today, most will have consulted with Dr Google before presenting to their GP. Sometimes this will have stoked unfounded fears – pretty much any symptom just might be an indication of cancer – and our task then is to put things in proper context. But frequently, as with Yvette, patients have not only worked out what is wrong, they also have firm ideas what to do about it.

We played the video through again, and I highlighted the numerous subtle cues that Yvette had offered. Like many patients, she was reticent about stating outright what she wanted, but the information was there in what she did and didn’t say, and in how she responded to Anthony’s suggestions. By the time we’d finished analysing their exchanges, Anthony could see that Yvette had already decided against splints as being too cumbersome and taking too long to work. For her, a steroid injection was the quickest and surest way to obtain relief.

Competing considerations must be weighed in any “shared” decision between a doctor and patient. Autonomy – the ability for a patient to determine their own care – is of prime importance, but it isn’t unrestricted. The balance between doing good and doing harm, of which doctors sometimes have a far clearer appreciation, has to be factored in. Then there are questions of equity and fairness: within a finite NHS budget, doctors have a duty to prioritise the most cost-effective treatments. For the NHS and for Yvette, going straight for surgery wouldn’t have been right – nor did she want it – but a steroid injection is both low-cost and low-risk, and Anthony could see he’d missed the chance to maximise her autonomy.

The lessons he learned from the video had a powerful impact on him, and from that day on he became much more adept at achieving truly shared decisions with his patients.

This article first appeared in the 01 October 2015 issue of the New Statesman, The Tory tide