E d tor a I
resulting in a drug cost of US$23 066 (R106 101) per
composite event prevented. Similar results were obtained
when the analysis was confined to the high-risk group of
patients with unstable angina pectoris. On the basis of the
available evidence, we believe that abciximab is not
affordable for use in patients undergoing PTCA in our
context, where the resources available for health care in the
private and public sectors are finite. The ethical obligation of
distributive justice demands careful consideration of the
costs and benefits of health care to society. It is necessary
that home-based cost/benefit ratio studies of the use of new
agents be undertaken before they are recommended for
routine use. Until then, the mainstay of antiplatelet therapy in
ischaemic heart disease remains aspirin, which celebrated
its centenary as a registered drug in 1997."
Bongani M Mayosi
Sean E Latouf
Patrick J Commerford
Cardiac Clinic
Department of Medicine
University of Cape Town and
Groote Schuur Hospital
Cape Town
1. Antiplatelet Trialists' Collaboration. Collaborative overview of randomised trials of
antiplatelet therapy I: prevention of death, myocardial infarction, and stroke by
prolonged anti platelet therapy in various categories of patients. BMJ 1994; 308:
81-106.
2. Detre KM, Holmes OR jun, Holubkov A, et al. Incidence and consequences of
periprocedural occlusion: the 1985-1986 National Heart, Lung, and Blood
Institute Percutaneous Transluminal Coronary Angioplasty Registry_ Circulation
1990; 82: 739-750.
3. Uncoff AM, Popma JJ, Ellis SG, Hacker JA. Topal EJ. Abrupt vessel closure
complicating coronary angioplasty: clinical, angiographic and therapeutic profile.
J Am Call Cardio/1992; 19: 926-935.
4. The EPIC Investigators. Use of a manaclanal antibody directed against the
platelet glycoprotein lib/ilia receptor in high-risk coronary angiaplasty. N £ng/ J
Med 1994; 330: 956-961.
5. Simaans ML, Rutsch W, Vahanian A, et al. Randomised placebo controlled trial of
abciximab befare and during coronary intervention in refractory unstable angina:
the CAPTURE study. Lancet 1997; 349: 1429-1435.
6. The EPILOG Investigators. Platelet glycoprotein lib/ilia receptor blockade and
low-dose heparin during percutaneous coronary revascularisation. N £ngl J Med
1997; 336: 1689-1696.
7. Lefkovits J, Ivanhoe RJ, Califf RM, et al. Effects of platelet glycoprotein lib/Ilia
receptor blockade by a chimeric monoclonal antibody (Abciximab) on acute and
six-month autcomes after percutaneous transluminal coronary angioplasty for
acute myocardial infarction. Am J Cardiol 1996; 77: 1045-1051.
8. Lincotf AM, Califf RM, Anderson KM, et al. Evidence for prevention of death and
myocardial infarction with platelet membrane glycoprotein lib/ilia receptor
blockade by abciximab (c7E3 Fab) among patients with unstable angina
undergoing percutaneous coronary revascularisation. J Am Call Cardiol 1997; 30:
149-156.
9. Topo! EJ, Califf RM, Weisman HF, et al. Randomised trial of coronary intervention
with antibody against platelet lib/ilia integrin for reduction of clinical restenosis:
results at six months. Lancet 1994; 343: 881-886.
10. Mark 08, Talley JD, Tapol EJ, et al. Economic assessment of platelet
glycoprotein lib/ilia inhibition for prevention of ischemic complications of high-
risk coronary angioplasty. Circulation 1996; 94: 629-635.
11. Verheugt FWA. In search of a super aspirin far the heart. Lancet 1997; 349: 1409-
1410.
Medical Ethics
Ethical considerations with
regard to the sanctity of
human life
'Science tells us what we can know, but what we can know
is little, and if we forget how much we cannot know we
become insensitive to many things of great importance.
Theology, on the other hand, induces a dogmatic belief that
we have knowledge where in fact we have ignorance, and
by doing so generates a kind of impertinent insolence
towards the universe. Uncertainty, in the presence of vivid
hopes and fears, is painful, but must be endured if we wish
to live without the support of comforting fairy tales. To teach
how to live without certainty, and yet without being
paralysed by hesitation, is perhaps the chief thing that
philosophy, in our age, can still do for those that stUdy it."
Medical ethics is used to guide physicians in choosing the
correct option when dealing with philosophical problems
encountered routinely in medical practice. Perhaps the most
important and contentious issues in medical bio-ethics are
those dealing with the sanctity of human life, which has
been debated since the time of the early Greek civilisations. 1
However, while the idea of the sanctity of human life has
been controversial for thousands of years, it is difficult to
assess the impact of medical ethics on the management of
these problems.
An example of this can be found in the abortion debate.
After centuries of discussion, sometimes inflammatory, there
has been no progress on whether the pro-abortion or anti-
abortion stance is correct. Despite increasing knowledge of
early gene-induced somatic differentiation, we still have no
accurate knowledge of when the 'life-force' or soul is
activated, and the argument has therefore remained a simple
clear-cut choice between agreeing or disagreeing with
abortion, with the rest being mere semantic intellectual
debate. It seems somewhat pointless and didactic to
discuss whetller a fetus is a true member of the human
species2•3 as a justification or defence of abortion. A similar
argument can be used when bio-ethical groups attempt to
define vegetative states, either to condone or condemn
euthanasia.' This type of argument merely circumvents the
core issue, which is that one either believes or does not
believe that it is ethical to perform abortion or euthanasia,
whatever the circumstances.
The problem inherent in discussing these core beliefs is
that almost all debate is based on the premise that the
sanctity of human life is paramount, and that to kill a human
being, whether by abortion or euthanasia, is ethically wrong.
It is impossible to substantiate this argument rationally, and
most ethical groups do not even attempt to rationalise or
argue this point,> but merely state with certainty that their
stand on the right to life is inviolate. It is difficult to decide
from where this innate standpoint, which appears to be
inherent in most human beings, is derived: Perhaps the
derivation is secular, as religions are almost unanimous that
human life is sacrosanct. 5 Unfortunately, religion is a
subjective entity and implies faith above irrefutable
SAMJ Volume 88 No.2 February 1998
 evidence, and to be gUided by faith in the decision on
termination of life is difficult. If these morals do not come
from religion, it is difficult to decide where the idea of the
sanctity of life comes from. Perhaps it is an intrinsic fear of
one's own death which creates the moral position that
causing death, whether in a social system or medical
environment, is fundamentally wrong. However, there is no
rational argument to substantiate the idea that human life is
sacrosanct, other than a benevolent subconscious ideal. As
stated earlier, bio-ethical debates do not even attempt to
substantiate this idea, perhaps because it is inherently
impossible to do so.
Often when the idea of the sanctity of life is discussed,
bioethical debaters bring up the 'slippery slope' concept:
which essentially states that if one takes a pro-choice
stance on abortion or euthanasia, one will eventually cause
a social system to morally disintegrate or spiral downwards
into anarchy. It is paradoxical that the people who define
euthanasia or abortion as evil use the above argument, as
they are stating that although an individual has a set of
moral standpoints which should prevail, humans must also
have an immoral side which will take over and destroy all
morality if any movement from the accepted norm is
allowed. By using a 'slippery slope' argument, ethical
debaters suggest that the ability to do evil is innate in every
soul, and that this basic instinct is wrong. It is difficult to
rationalise critically that one basic instinct is wrong and the
other right without slipping into dogma and showing one's
own innate prejudice. Therefore, it is problematic to use a
'slippery slope' argument.
Similarly, it is problematic to use historical perspectives,
theories or practices to substantiate current philosophical
standpoints in ethical debates or to deter medical
practitioners from straying from currently accepted moral
boundaries.' This is because it is perhaps impossible to go
back in time to an absolute historical truth, where all prior
judgements and empirically derived information do not
impinge on this absolute truth. 3 Therefore, the use of
historical perspective in defining ethical policy is
immediately prejudiced because an argument will have been
created from inferences from a time period in history some
time after the origin of thought and rational consciousness,
which is an intangible entity. All ethical arguments based on
prior historical input can therefore have no basic premise,
and cannot be used with any confidence to substantiate
current ethical perspective.
Finally, for any bioethical debate to take place, one needs
a social structure in order to begin discussion. Various
bioethical groups, which are usually created by members of
the medical profession to discuss ethical issues, reach
certain conclusions. These are then drafted as policy
statements to be used by others in the medical profession
when confronted by ethical dilemmas!,4,8 However, the idea
of a policy statement automatically implies collective
thought or collective empowerment of a certain ethic or
viewpoint, and thus individualism and freedom of choice are
negated by the very creation of a bioethical committee or
policy-making group. This immediately creates a paradoxical
entity.
What, therefore, would best serve the interests of the
community or individual medical practitioners involved in
decisions about life and death? Perhaps the only right
Volume 8 Xo. 2 February 1998 SAMJ
choice is that of the individual involved in that decision,
regardless of time and place, If a man chooses to end his
life, that is his choice and he must be allowed to do so. If a
doctor decides to end the life of someone with no conscious
control of their own, that must be, If a woman decides to
have an abortion, it is her choice. To argue that mistakes
may be made is irrelevant. Countless people die as a result
of ignorance or prejudice, and for each one mistake made
by a rational, intelligent physician, more correct decisions
will be made. The idea that life is special and inviolate
basically boils down to religious or social dogma. As
Nietzsche9 observed, one's own will to power and individual
courage should decide on all aspects of life and death,
irrespective of social or religious viewpoints. Ethical
standpoints are intensely personal and an individual's choice
and by attempting to persuade others to adopt one's own
philosophical viewpoint, one moves from philosophy to
dogma. In other words, medical ethics should be debated
by the individual practitioner alone, and that individual's
viewpoint should be based on their own ethical code. Any
attempt to establish an ethical code to govern the actions of
medical personnel creates rules in an area of life where no
rules are possible.
W Hopkins, M Hislop, M I Lambert and K H Myburgh are
acknowledged for their constructive criticism of this article.
A St Clair Gibson
Sports Science Unit
University of Cape Town
1. Aussell BE. History of Western Philosophy - and Its Connecnon with Political
and Social Circumstances from the Earliest Times to the Present Day. London:
Routledge, 1946.
2. Brooks 0, Nash E, Abels C, et al. Abortions - some practical and ethical
considerations. S Afr Med J 1995; 85: 183-184.
3. Harris J. The elimination 01 morality. J Med Ethics 1995; 21: 220-224.
4. Benatar SR, Abels C, Abratt R, et al. Statement on withholding and Withdrawing
lile-sustaining euthanasia. S Afr Med J 1994; 84: 254-256.
5. Keown 0, Keown J. Killing, karma and caring: euthanasia in Buddhism and
Christianity. J Med Ethics 1995; 21: 265-269.
6. Benatar SA. Dying and 'euthanasia'. S Afr Med J 1992; 82: 35-38.
7. Boyd K. What can medical ethics learn from history? J Med Ethics 1995; 21: 197-
198.
8. Benatar SA, Abels C, Abratt A, et al. Abortions - some practical and ethical
considerations (Reply to letter). S Afr Med J 1994; 84: 469-472.
9. Nietzsche F. Thus Spoke Zarathustra. Harmondsworth, Middx: PengUin Books,
1969.