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17 Apr 2009
By Khaw Boon Wan
1. Recently, I read an obituary in the Financial Times (Feb 23), noting the passing of a great doctor and a talented inventor: Dr Willem Kolff of the Netherlands. The nephrologists in this room will know him as the inventor of the first kidney dialysis machine. He built it under trying conditions, in 1941, when as a young doctor, he watched in horror as the Nazis invaded his country. He refused to let the occupation stop his pioneering work. In a cramped hospital room, he built the first dialysis machine, with the most extraordinary collection of raw materials gathered from a war-torn country side. The FT article listed some of them: parts from a downed fighter aircraft, radiator of an abandoned car, orange juice tins, a bathtub, a wooden drum and thin, artificial sausage skins!
2. After the war, Dr Kolff emigrated to the US where he would go on to become the driving force behind the first artificial heart, a man-made eye, an artificial ear and one of the first sophisticated prosthetic arms. He was an inventive genius who kept busy tinkering until shortly before his death at an age of 97.
3. Two points in the article caught my attention. First, he never patented his inventions because he felt they should benefit all mankind, not one individual. Second, his early dialysis machines failed and 16 patients died. The lucky 17th, just weeks after the end of the war, was a Nazi collaborator. "Most people wanted to wring her neck" said Dr Kolff later. He himself had supported the Dutch resistance and had helped save 800 of his countrymen from concentration camps by hiding them, or by helping them fake the symptoms of disease. Yet he still used his machine to save a dying Nazi sympathiser, who went on to live for another 7 years. Dr Kolff explained: "The moral is that we have to treat patients when they need help even if we don't like them."
4. Dr Kolff personified the highest standard of medical ethics and professional ethos. At a time when there is public uproar over Wall St bankers and excessive greed, I thought Dr Kolff's passing deserved more than a quiet obituary. It’s a pity that the values he stood for did not get wider publicity.
5. Last week, I attended NKF’s 40th Anniversary celebration during which we paid tribute to another great man in medicine: Prof Khoo Oon Teik, this time a fellow Singaporean. He is best known for founding the NKF, training up generations of nephrologists, and touching the hearts of thousands of Singaporeans who would otherwise have died waiting for kidney transplants. But those of us who know of his work, know him to have achieved much more, promoting medical excellence through sub-specialisation, promoting compassion among fellow human beings, passing on values to his trainees and medical students through personal example. Prof Khoo is also a humble man, full of love and compassion. He walks the talk of human kindness.
Incredible medical progress
6. Medicine is a noble calling and attracts its fair share of legends. Thanks to your profession, we have benefited from your research, dedication and the progress you have made. We now have better treatment for many common diseases, including diabetes, asthma, hypertension, heart diseases and some cancers. When I was born in 1952, life expectancy here was only 60 years; medical advancement has added 20 more years to it, within my lifetime.
7. And exciting possibilities are just around the corner. Stem cell, genomic, epigenetic, tissues and organ culture are just some of the many research areas that have promising possibilities. Singhealth and our research facilities here are active players in this field. For example: National Heart Centre has developed stem cells that can be transplanted into the heart to help patients with heart failure, while SGH is researching on the use of stem cells to develop skin substitutes for treating major burns.
Severe ethical challenges
8. But sometimes, these medical advancements bring with them severe ethical challenges. We are biological beings: our cells and organs will eventually fail and we will all die one day. When and how far should doctors step in to delay death is not always easy to decide. It goes way beyond technical capability or cost-benefit analysis.
9. What is right or wrong for a patient and his family depends on their philosophy, values, needs, desire and circumstances. What is right for an individual may be totally unacceptable to another. No one size can fit all. At the extremes, we can legislate relatively easily when it is black and white. But often time there is no black and white.
10. Take the example of the conjoined twins from India, contemplating separation surgery in Singapore. Conjoined twins at the head are rare, at one in 2 million live births. Majority of these twins do not survive. Those who survive present complex and challenging ethical, medical and legal issues to all those involved in their care.
11. To separate or not to separate? For those who are conjoined at the head, the operative mortality in separations attempted on about 40 twin pairs, was about 50%: one of the twins will not survive the operation. Surgeons, in some instances, have to pick one twin to die to save the other. Even those who survive the surgery were often left with brain damage.
12. We have had two such separations in Singapore. Their outcome reaffirmed these awful statistics. Although life as a conjoined twin would appear to be intolerable, there are conjoined twins who have progressed to adulthood. Thus, in some situations, it may be better not to operate on these patients. To change the course of nature may do more harm than good.
13. That is why we need wisdom to guide us through the ethical minefield. We have the National Medical Ethics Council, comprising wise persons like Dr Lee Suan Yew (who served until recently), Prof Roy Joseph, Prof Thirumoorthy and Prof Chng Jing Jih to help us address difficult ethical challenges. They are doing excellent work, advising my Ministry on important and contemporary ethical issues, such as the recent Human Organ Transplant Bill. I draw from their advice extensively and benefit from their vast experience and years of valuable insight.
Passing On Values
14. The current global recession is a time for reflection. The world economy will recover, sooner or later, but I hope that useful lessons would have been learnt and that humanity will emerge from the recession wiser. No doubt, the global financial community will bounce back, global regulations will be tinkered with, and there will be calls for more teaching on ethics in classrooms. But I believe more in the Chinese tradition of teaching through personal examples rather than precepts: “身教胜于言教”. Teachers are responsible for “transmitting morals, imparting knowledge and resolving doubts”: “师 者，传 道，授 业，解 惑”. The essence of teaching is thus not confined to professional knowledge, but hinges on moral cultivation of the students. Good teachers, in turn, command respect and exert lifelong influence on their students. Their achievement is measured by the number of accomplished students they inspire and train, “spawning good students like peaches and plums everywhere”: “桃 李 满 天 下”.
15. This is not an abstract idealistic construct. Our medical community has many such wonderful teachers. The many “peaches and plums” in this room testify to that. There are too many to name, but several names who have passed on come immediately to mind: Prof Seah Cheng Siang, Prof Chan Heng Leong, Mr N Balachandran, Prof SS Ratnam, Prof Wong Hock Boon. Many more are still active and in this room.
16. Our job is to continue to identify, recruit and retain good teachers and empower them to do their magic. The key to high medical ethics and professionalism is not crafting inspiring words but people, good people, leading the profession, setting personal examples, passing on values through daily interaction and osmosis.
17. What should those values be? I think we can take reference from Confucius: “What you do not want done to yourself, do not do to others”: “己所不欲，勿施于人”. It is not uniquely oriental but is equally emphasised in many western teachings and religions. Applying this principle to medicine, it means that when caring for a patient, a doctor should recommend what he would recommend to his own mother. The doctor will then need to go one step further and try to put himself in the shoes of the patient and the family and help the patient and the family arrive at the best decision for themselves. This is because we cannot assume that there is only one right decision for everyone.
18. Prof Foo Keong Tat has a piece of calligraphy at the SGH urology centre that reads:
一 切 为 了 病 人
为 了 病 人 一 切
为 了 一 切 病 人
This is a clever and meaningful rearrangement of three pair of double words to state the mission of a doctor, which is to always work in the best interests of his patients and to help meet their desire. Prof Foo does not need the calligraphy to remind him of what a good doctor should be, because he is a living role model himself. He must have meant that couplet to remind his trainees and the many medical students who train under him.
19. And just what is the desire of the patient? It will vary from person to person. Mine is to live a meaningful and healthy life and then die quickly, and not be a burden to anyone.