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resulting in a drug cost of US$23 066 (R106 101) per Medical Ethics 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 Ethical considerations with available evidence, we believe that abciximab is not affordable for use in patients undergoing PTCA in our regard to the sanctity of context, where the resources available for health care in the private and public sectors are finite. The ethical obligation of human life distributive justice demands careful consideration of the costs and benefits of health care to society. It is necessary 'Science tells us what we can know, but what we can know that home-based cost/benefit ratio studies of the use of new is little, and if we forget how much we cannot know we agents be undertaken before they are recommended for become insensitive to many things of great importance. routine use. Until then, the mainstay of antiplatelet therapy in Theology, on the other hand, induces a dogmatic belief that ischaemic heart disease remains aspirin, which celebrated we have knowledge where in fact we have ignorance, and its centenary as a registered drug in 1997." by doing so generates a kind of impertinent insolence towards the universe. Uncertainty, in the presence of vivid Bongani M Mayosi hopes and fears, is painful, but must be endured if we wish to live without the support of comforting fairy tales. To teach Sean E Latouf how to live without certainty, and yet without being Patrick J Commerford paralysed by hesitation, is perhaps the chief thing that Cardiac Clinic philosophy, in our age, can still do for those that stUdy it." Department of Medicine University of Cape Town and Medical ethics is used to guide physicians in choosing the Groote Schuur Hospital correct option when dealing with philosophical problems Cape Town encountered routinely in medical practice. Perhaps the most 1. Antiplatelet Trialists' Collaboration. Collaborative overview of randomised trials of important and contentious issues in medical bio-ethics are antiplatelet therapy I: prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. BMJ 1994; 308: those dealing with the sanctity of human life, which has 81-106. 1 2. Detre KM, Holmes OR jun, Holubkov A, et al. Incidence and consequences of been debated since the time of the early Greek civilisations. periprocedural occlusion: the 1985-1986 National Heart, Lung, and Blood However, while the idea of the sanctity of human life has Institute Percutaneous Transluminal Coronary Angioplasty Registry_ Circulation 1990; 82: 739-750. been controversial for thousands of years, it is difficult to 3. Uncoff AM, Popma JJ, Ellis SG, Hacker JA. Topal EJ. Abrupt vessel closure complicating coronary angioplasty: clinical, angiographic and therapeutic profile. assess the impact of medical ethics on the management of J Am Call Cardio/1992; 19: 926-935. these problems. 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 An example of this can be found in the abortion debate. Med 1994; 330: 956-961. 5. Simaans ML, Rutsch W, Vahanian A, et al. Randomised placebo controlled trial of After centuries of discussion, sometimes inflammatory, there abciximab befare and during coronary intervention in refractory unstable angina: has been no progress on whether the pro-abortion or anti­ the CAPTURE study. Lancet 1997; 349: 1429-1435. 6. The EPILOG Investigators. Platelet glycoprotein lib/ilia receptor blockade and abortion stance is correct. Despite increasing knowledge of low-dose heparin during percutaneous coronary revascularisation. N £ngl J Med 1997; 336: 1689-1696. early gene-induced somatic differentiation, we still have no 7. Lefkovits J, Ivanhoe RJ, Califf RM, et al. Effects of platelet glycoprotein lib/Ilia accurate knowledge of when the 'life-force' or soul is receptor blockade by a chimeric monoclonal antibody (Abciximab) on acute and six-month autcomes after percutaneous transluminal coronary angioplasty for activated, and the argument has therefore remained a simple acute myocardial infarction. Am J Cardiol 1996; 77: 1045-1051. clear-cut choice between agreeing or disagreeing with 8. Lincotf AM, Califf RM, Anderson KM, et al. Evidence for prevention of death and myocardial infarction with platelet membrane glycoprotein lib/ilia receptor abortion, with the rest being mere semantic intellectual blockade by abciximab (c7E3 Fab) among patients with unstable angina undergoing percutaneous coronary revascularisation. J Am Call Cardiol 1997; 30: debate. It seems somewhat pointless and didactic to 149-156. discuss whetller a fetus is a true member of the human 9. Topo! EJ, Califf RM, Weisman HF, et al. Randomised trial of coronary intervention 2 3 with antibody against platelet lib/ilia integrin for reduction of clinical restenosis: species • as a justification or defence of abortion. A similar results at six months. Lancet 1994; 343: 881-886. 10. Mark 08, Talley JD, Tapol EJ, et al. Economic assessment of platelet argument can be used when bio-ethical groups attempt to glycoprotein lib/ilia inhibition for prevention of ischemic complications of high­ define vegetative states, either to condone or condemn risk coronary angioplasty. Circulation 1996; 94: 629-635. 11. Verheugt FWA. In search of a super aspirin far the heart. Lancet 1997; 349: 1409­ euthanasia.' This type of argument merely circumvents the 1410. 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 choice is that of the individual involved in that decision, termination of life is difficult. If these morals do not come regardless of time and place, If a man chooses to end his from religion, it is difficult to decide where the idea of the life, that is his choice and he must be allowed to do so. If a sanctity of life comes from. Perhaps it is an intrinsic fear of doctor decides to end the life of someone with no conscious one's own death which creates the moral position that control of their own, that must be, If a woman decides to causing death, whether in a social system or medical have an abortion, it is her choice. To argue that mistakes environment, is fundamentally wrong. However, there is no may be made is irrelevant. Countless people die as a result rational argument to substantiate the idea that human life is of ignorance or prejudice, and for each one mistake made sacrosanct, other than a benevolent subconscious ideal. As by a rational, intelligent physician, more correct decisions stated earlier, bio-ethical debates do not even attempt to will be made. The idea that life is special and inviolate substantiate this idea, perhaps because it is inherently basically boils down to religious or social dogma. As impossible to do so. Nietzsche9 observed, one's own will to power and individual Often when the idea of the sanctity of life is discussed, courage should decide on all aspects of life and death, bioethical debaters bring up the 'slippery slope' concept: irrespective of social or religious viewpoints. Ethical which essentially states that if one takes a pro-choice standpoints are intensely personal and an individual's choice stance on abortion or euthanasia, one will eventually cause and by attempting to persuade others to adopt one's own a social system to morally disintegrate or spiral downwards philosophical viewpoint, one moves from philosophy to into anarchy. It is paradoxical that the people who define dogma. In other words, medical ethics should be debated euthanasia or abortion as evil use the above argument, as by the individual practitioner alone, and that individual's they are stating that although an individual has a set of viewpoint should be based on their own ethical code. Any moral standpoints which should prevail, humans must also attempt to establish an ethical code to govern the actions of have an immoral side which will take over and destroy all medical personnel creates rules in an area of life where no morality if any movement from the accepted norm is rules are possible. allowed. By using a 'slippery slope' argument, ethical debaters suggest that the ability to do evil is innate in every W Hopkins, M Hislop, MI Lambert and KH Myburgh are soul, and that this basic instinct is wrong. It is difficult to acknowledged for their constructive criticism of this article. rationalise critically that one basic instinct is wrong and the other right without slipping into dogma and showing one's A St Clair Gibson own innate prejudice. Therefore, it is problematic to use a Sports Science Unit 'slippery slope' argument. University of Cape Town

Similarly, it is problematic to use historical perspectives, 1. Aussell BE. History of Western Philosophy - and Its Connecnon with Political theories or practices to substantiate current philosophical and Social Circumstances from the Earliest Times to the Present Day. London: Routledge, 1946. standpoints in ethical debates or to deter medical 2. Brooks 0, Nash E, Abels C, et al. Abortions - some practical and ethical considerations. S Afr Med J 1995; 85: 183-184. practitioners from straying from currently accepted moral 3. Harris J. The elimination 01 morality. J Med Ethics 1995; 21: 220-224. boundaries.' This is because it is perhaps impossible to go 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. back in time to an absolute historical truth, where all prior 5. Keown 0, Keown J. Killing, karma and caring: euthanasia in Buddhism and Christianity. J Med Ethics 1995; 21: 265-269. judgements and empirically derived information do not 6. Benatar SA. Dying and 'euthanasia'. S Afr Med J 1992; 82: 35-38. impinge on this absolute truth.3 Therefore, the use of 7. Boyd K. What can medical ethics learn from history? J Med Ethics 1995; 21: 197­ 198. historical perspective in defining ethical policy is 8. Benatar SA, Abels C, Abratt A, et al. Abortions - some practical and ethical immediately prejudiced because an argument will have been considerations (Reply to letter). S Afr Med J 1994; 84: 469-472. 9. Nietzsche F. Thus Spoke Zarathustra. Harmondsworth, Middx: PengUin Books, created from inferences from a time period in history some 1969. 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