In a variation of a "Whack-a-Mole" arcade game, visitors to a bioethics exhibit now at the Maryland Science Center can get a feel for the complexities of contemporary health care decisions.
Punch a lighted "problem" to solve it, and almost before your hand is off the button two or three more buttons will light up. Trust me, it's a game you can't win.
Complications from treatment, limited financial resources, hardships on families -- the inescapable repercussions of illness extend far beyond the patient's bedside. So do the ethical dilemmas created by medical technology:
* Seven people need a liver transplant to stay alive. One is available. Who should get it -- the executive who heads his own company? The migrant worker whose earnings support a large family in Mexico? A single mother? A young boy? Other worthy candidates?
* To encourage more organ donations and thus avoid such excruciating choices, should families be offered financial inducements to donate the organs of deceased relatives?
* A woman lies comatose with no prospect of regaining consciousness. With a feeding tube and diligent medical care, her body can be kept functioning indefinitely. Should it be?
* A young boy is passionate about basketball and extremely gifted for his age. But his growth is lagging and he may well turn out to be shorter than average. Should his parents be allowed to give him a growth hormone to increase his height?
Dilemmas like these form the basis for "Designer Genes: Sizing Up Bioethics," sponsored by Kaiser Permanente Health Care Program. The exhibit, which remains at the Science Center through the end of April, is traveling to 12 Kaiser regions around the country.
Because visitors are asked to register their choices or opinions in a variety of situations, vote tabulations later this year will give an intriguing view of regional variations in attitudes. Already, for instance, it's clear that visitors to the exhibit in Los Angeles took a much more favorable view of selling organs for transplant than have people in Baltimore.
Perhaps that's not surprising. Dr. John Golenski, a Jesuit priest and a panelist at a bioethics seminar held this week in conjunction with the exhibit, points out that medical attitudes and practices vary widely: from frequency of hospitalization and modes of reimbursement to approaches to ethical dilemmas and the importance placed on institutional ethics committees. So do approaches to such bioethical problems as terminating life support systems.
Sometimes these differences reflect local laws or legal precedents -- particularly in the area of terminating life support. Maryland law does not directly address this subject, but an opinion from the attorney general, which would carry weight in court, allows families this decision-making power only for
patients who are considered terminally ill -- not those who can live indefinitely in a comatose state. Some states, however, grant families this power even for people who can live indefinitely in a vegetative state and who never expressed explicit preferences about being kept alive on life support.
We think of these brave-new-world ethical choices as unprecedented, and in many cases they are. No society has faced the unknown potential -- for good or for disaster -- of gene therapy techniques now being pioneered. But every generation has faced its ethical challenges, and a historical perspective always helps in dealing with them.
In that light, it's worth noting that when the use of anesthesia during surgery was introduced in the 19th century, many physicians objected to the practice. After all, they argued, suffering was part of being human. Physicians and moralists alike saw virtue in enduring physical pain.
Unfortunately, too much of that attitude has persisted into this century. Until recently, surgical procedures on infants were routinely performed without anesthesia. Even now, in too many instances this ambivalence is evident in the lack of aggressive attention paid to the pain associated with many kinds of terminal illness -- or to the chronic pain many otherwise healthy people endure as part of daily life.
If in everyday practice American medicine hasn't yet come to a fully accepted consensus on pain, then coming to grips with the expanding choices created by medical technology is a major challenge indeed.
But it's not a challenge we can duck. Like that Whack-a-Mole, the problems keep lighting up, faster than we can put them out.
Sara Engram is deputy editor of the editorial pages of The Evening Sun.