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Saying Yes Is As Important as Saying No - Humanity and the Christian Faith

by Prof Alastair V Campbell

I am glad to have a chance to speak because I know how concerned and dedicated you are, not only to care for people here in Singapore, but also to care for people in need, wherever that may be.
But how can we make sure that these are the ideals that medicine is driven by? How can we be sure that we continue to care for those who really need our care? There is a bit of a joke that goes around in medical school, not just here in Singapore, which is that medicine students have two stages in their training: the pre-cynical and the cynical. And that is a worry isn’t it? It is the worry that somehow the idealism with which many people coming into medicine may have gradually been lost as they progress in their careers.
I, like a number of my colleagues from the Yong Loo Lin School of Medicine, take part in the admission interviews for medical students. I say to the first year students when I first see them, that I am really amazed that there are so many Mother Teresas and St Francis’ of Assisi in the room, because medical student entrants have learned to stress how concerned they are about other people, and not to seek money or fame. Well, is that a genuine commitment? And how can we ensure that that commitment continues?
Ethics and medicine
First of all, I want to describe what is now happening about teaching ethics in medical training here in the Yong Loo Lin School of Medicine in the National University Hospital in Singapore. We have also assisted the Dental School in introducing ethics and are in a lot of discussion with our colleagues in the Nursing School about the same thing. So I think we will find that the kind of attention to ethics that is coming now into medicine will spread across all the health professional training here.
Let me be a little realistic again and say that no amount of medical training in ethics can make us ethical doctors - it cannot itself achieve that. Perhaps, it can alert the coming generations to the issues, help them think about them, and try to relate them to practice. But eventually, it depends upon the commitment, beliefs and morals of that individual on whether or not they are actually or eventually ethical practitioners. We cannot make ethical doctors. Only the profession and the individuals themselves can make ethical doctors, dentists, nurses and other health professionals.
Nevertheless, I think quite a bit of change has come on in the past few years and certainly in the Yong Loo Lin School of Medicine. The shift is the idea that ethics is not just icing on the cake, just not something you add now and again, or occasionally, as though it were not totally central to everything that medicine is about.
The emphasis is on the idea that medical ethics is integral to medicine. Medicine itself is a moral endeavour. It is a moral profession. Those who care for others cannot just do ethics as a part-time thing; ethics is in the middle of it. Not just in a dramatic moment, like the moment that television series “ER” love to show, but in every encounter between a health professional and a person in need, there are ethical dimensions. It is from that point of view that we try, and indeed, because we had a curriculum revision in the medical school, we have been able to begin to integrate ethics into medical training from the very start. In fact, on the very first day of the first year of medicine, one of the first lectures is on ethics. It starts absolutely at the beginning of the course.
We are concerned with both vertical integration and horizontal integration in introducing ethics.
Vertical integration means what we call a longitudinal track in the curriculum. It means that we are tracking the students’ intellectual and experiential journey through the five years of medicine. What we are trying to do is to make sure that as they develop and begin to learn how to be a professional, the relevant ethical questions are being raised at that point. So we are looking at something, which is reinforcement through the five years but not repetition. And that reinforcement has more sense as the students move into clinical placements and begin to actually see the real dilemmas that will face them in practice itself. We can lay a foundation for that at the beginning, as indeed we do in the first two years of the course, and we build on it as the years go on. So that is vertical integration.
Secondly, horizontal integration means that we should be connected to what else is happening at that time. So it is not “oh, it is Friday afternoon, it is time for ethics”. Now, it is about what are the students thinking about? What questions might be raised at this point in their course, at this point in this year?
Let me give you a couple of examples. Many medical students when they first come in are afraid of going into the anatomy dissection room, as they are afraid of encountering the cadavers for the first time, and understandably so. Others are not. We know from research that some students feel OK about it, while some do not. So what we do is we have a session with our colleagues in anatomy. This session is held just before they go into the room, we talk about the human cadavers, about respect for the dead body and what that might mean; and then we talk about the students’ own fears, or potential fears, and uncertainties in encountering the cadavers for the first time. So we are trying to be where the students are.
Similarly, later in the course in the first year again, when the students are looking at the neurological system, it is at that point that we raise ethical questions relating to brain death and different forms of unconsciousness and the dilemmas which that can be created in terms of human intervention and so on. So while we are doing the science, we are doing the ethics. That is horizontal integration. So it has been a big change, which I think may allow doctors and the other health professionals in the future to see how ethics is not some abstract subject but is actually a subject that relates directly to what it is they are concerned about.
The other aspect of that integration that is important is that our teaching is essentially collegial. I am not a medical practitioner, I am a philosopher and theologian by training, but we never teach alone, we always teach with our clinical or biomedical or scientific colleagues. We have clinicians from all the hospitals around Singapore to run our tutorial groups. So we have the collegiality and the integration that are essential in order to achieve the sense that this is actually about medical practice. It is not some theoretical discussion of whether things are right or wrong.
Christian belief and Christian faith
I want to pick up the title of my talk, which is revisiting the whole question of Christian belief and Christian faith. The first thing I should say is that in my position as a university professor in the School of Medicine, it is not my role nor would it be right for me to think that I am there to preach or evangelise. I am there to teach students of all religions and no religion. I am in a multi-cultural, multi-religious society in which all viewpoints are respected and honoured as they should be. So what we are doing in our teaching is try to reach out to everybody, not to reach out to those with a particular set of beliefs.
At the same time, we try to be practical and at this point, I must tell you that in an earlier position I had, when I actually taught in the Divinity School of the University of Edinburgh in New College, Edinburgh, I was in a department called Practical Theology. I think theology can be practical, so the question then is how can the understanding that we might have about the nature of God’s purposes for humanity, relate to medicine?
Saying “Yes” as well as “No”.
I just want to pick up one or two issues of debate of the current time and to explain my title that we should be saying “Yes” as well as “No”.
The problem here is that I think very often Christianity, and other religions as well, have been seen as largely negative. They have been seen as prohibitive only, as saying “You can’t do that”, “This should not have happened”, and often people fail to see how the “Yes” is as important as the “No”. Perhaps, we fail to see it; perhaps, we fail to communicate this as well.
Let us take as the first example the debate about organs, about kidneys and the shortage of kidneys. Well, we have to say “No” to organ trading. We have to say “No” for two very good reasons: first, it is exploitative inevitably. If I take a vote in this room now on how many of you will sell your kidneys, I do not think I will get very many hands up, but the people that sell their kidneys are the people who are desperate for money and are exploited by the market.
Second, there is another important reason for the “No” and that is this body, this hunk of flesh of ours, is not a possession, like our car or our stereo or our latest mobile phone. It is not a piece of property for sale. We have to say “No” to the treatment of the human body as though it were a material object.
But we also have to say “Yes” to the idea of the gift of life, that we have something that we can give to others, be it our blood, be it our kidney, to someone that needs it or who is close to us, perhaps our relative. And that is an entirely different thing, and actually the gift of life is one of the things that we are able to celebrate and support.
We can think about the amendments to the Human Organ Transplant Act (HOTA) legislation and the recent headlines in the Straits Times, saying the first reimbursed kidney donor had just left hospital. This particular example is one where the National Kidney Foundation was able to make sure that there was no financial loss as a result of this act of giving. Now, one can say “Yes” to that. Why not make sure that people are able to give and they are not prevented from giving?” And the “Yes” is as important and in fact, more important than the “No”.
That leads me to cosmetic medicine. Now here, I am going to offend some people because maybe, there are some people here who are involved in delivering cosmetic medicine, or even those who have received it. Yet, I think cosmetic medicine is another example where something has gone wrong. It came out of a real need to make sure that people, who are terribly damaged by war injuries or by burns, are able to return to some kind of life and get over their disfigurements. But it has become the whitening of skin for people who do not want their skin so dark, or indeed the tanning of skin for those who do not want them so light. The idea is that we can fashion body shapes to whatever happens to be the customary shape of the era in which we live.
Incidentally, these go out of fashion and other shapes take their place. But even more so is the idea that somehow, we can defeat ageing and death. We can look forever young, we do not need to show those wrinkles that came from laughing and crying any more. We can have a smooth expression disguising our advanced years. I think we have to say “No” to all this. I am not saying that the practitioners who do it are particularly unethical, I am not criticising that, but I am criticising the value that seems to lie behind that, the value that seems to think that youth is better than age, and that there is something called beauty, which is the same as what is portrayed as the current fashion.
Again, the “Yes” of Christianity is the “Yes” to the fact that we are loved whatever we are like, however we appear, however old or young we are, however wrinkled we are. There is no distinction here and if you want to think about Christmas, then think about the New Testament. Think about the song of Simeon: “Lord, now let me depart in peace, for I have seen the infant Jesus”. He is an old man and a key to be being fulfilled in old age - to have seen something that matters. The wisdom of ageing in fact is something that seems to have been denied by this whole desire to create us perpetually young.
Now again, there is a “No”. The “No” is absolutely a “No” to taking the power of ending another’s life even at their request. That is a “No” with which Christianity is often associated and will continue to be in opposition to euthanasia, whether voluntarily or even more so if it is imposed.
But there is also a huge “Yes” here and that is a “Yes” to dying in a way that actually is dignified, without pain and fear, death accepted as part of what it is to be human. It is a “Yes” to stopping meddlesome medicine if medicine is prolonging something that is no use for that person. It is a “Yes” to giving of pain relief when that is required, not asking or worrying whether that pain relief itself may shorten the life, provided what we want to do is to relieve the pain and we are doing our best to do it. But it is particularly a “Yes” to creating an atmosphere of respect and love round the bedside of the person who is dying. The whole hospice movement, which was inspired by such beliefs, has Christian roots. We hope these beliefs are going to increase in Singapore’s appropriate and adequate terminal care, spearheaded by the hospice movement. This is that huge “Yes” that we have to be able to say “Yes” to a death that is with dignity, death that is without fear and pain. It is rather bizarre actually that the organisation in Switzerland that puts people to death at their request is called Dignitas. Actually in my understanding of dignity, it does not instruct another person to end your life.
Conclusion
In conclusion, I am going to quote an American poet called Robert Shannon. It is a piece about the difference between a plastic flower and a living flower. He writes: “How exquisite is a living flower which knows both birds and dying, but a plastic flower, which can last a thousand years, is ever brutal in its changelessness”.
The second poem is from the English writer, T.S. Elliot, the “Journey of the Magi”, which is about the wise men following a star and finding the infant Jesus. A few lines from the poem say: “Were we led all that way for birth or for death? There was a birth certainly but this birth was hard and bitter agony for us. Like death, our death as we return to our places, but no longer at ease there with an alien people touching their gods”.
In other words, the reality of the birth of Christ is a reality, which challenges us all to the fundamental depth of our being and yet it offers us a real “Yes” to life even in the midst of death.

Professor Alastair V. Campbell is the Chen Su Lan Centennial Professor of Medical Ethics and the Director of the Centre for Biomedical Ethics in the Yong Loo Lin School of Medicine at the National University of Singapore.
(This talk was given by Professor Alastair V. Campbell at the Christian Medical and Dental Fellowship Annual Dinner on 13 November 2009 at the National University of Singapore Society Guild House)