Fascinating insights: The ‘art of doing nothing’ in medicine.
Perspective from The New England Journal of Medicine — The Art of Doing Nothing
Source: The Art of Doing Nothing — NEJM
Fascinating insights: The ‘art of doing nothing’ in medicine.
Perspective from The New England Journal of Medicine — The Art of Doing Nothing
Source: The Art of Doing Nothing — NEJM
I was often fascinated by the brilliant maverick doctor (Hugh Laurie), in the TV series “House”, dealing with patients with mysterious problems, and invariably ending up with an extraordinary diagnosis and saving the patient’s life. Today, I believe that seems to happen more on television than in the real world.
Increasingly the disease burden across the globe has veered massively towards long term conditions, and it almost seems as if medicine today is no longer about curing at all. What better example than the U.S. health care crisis, where the primary aim of health-care reform now appears to be cost-cutting rather than improving coverage. Indeed, spending on doctors, hospitals, drugs, etc. now reportedly accounts for more than one out of every six dollars that Americans earn. The point here is not to judge the vision of Obamacare, as the phenomenon is not just limited to America but is rather becoming a global reality.
Too much medicine
Ivan Ilich opens his book “Limits of Medicine’ (1973) with a scorn. “The medical establishment has become a major threat to health. The disabling impact of professional control over medicine has reached the proportions of an epidemic”.
While Ilich’s rhetoric is too hard to be missed, the undertones may actually be becoming relevant now, more than that at anytime in the past, and much faster than what we can appreciate at an individual level. According to a United States Department of Health and Human Services report, in a country of about three hundred million people, around fifteen million nuclear medicine scans, a hundred million CT and MRI scans, and almost ten billion laboratory tests are performed each year. Its no different in urban India and elsewhere, where the phenomenon of over-testing in clinical practice is disquieting. But does this represent an improved quality of care? Not sure!
Misdiagnosis or overdiagnosis
“Medicine is about ameliorating, palliating, listening, explaining, advising, and consoling. It’s not glamorous. It should also be about caring, but patients accept that doctors are “too busy” for that (sometimes, I fear, in pursuit of the mirage of diagnosing, treating, and curing).”
Atul Gawande, besides being an endocrine surgeon at the Brigham and Women’s hospital, and a professor of Health Policy and Management at the Harvard School of Public Health, is also the chairman of Lifebox, a nonprofit dedicated to reducing deaths in surgery globally. The celebrated author of the book “The Cost Conondrum” provides an interesting emic perspective on the US healthcare, from the eyes of an insider.
Perhaps more than the inherent risks associated with overzealous investigations (e.g., radiation hazards), excessive investigation affects the health care system in more ways than is commonly realized. Indeed, the value of an investigation often depends on the likelihood of the patient as having a significant problem in the first place. A crushing chest pain and dyspnea raises the spectre of a serious heart condition, that renders an ECG as an invaluable piece of evidence. But, in the absence of signs or symptoms, an ECG, more often than not, adds no useful information. How many times we see a heart tracing that doesn’t look quite right but usually ends up as noise. Millions of ECG are done each year in healthy people; chances are that a heart tracing which is not completely normal may prompt further investigation, e.g., a stress test, 24-hr holter monitoring and even cardiac catheterization. The collateral damage from this over-testing can be colossal; thousands of dollars in costs, denial of health care to genuinely needy, anxiety, work absenteeism and, indeed, physical risks.
Nearer home, a similar trend is becoming a norm. All too frequently, in my general practice, I encounter prescriptions which appear to be exotic shopping lists of investigations. While generalizing this impression would obviously be wrong, invariably, these turn out to be fishing expeditions; in any case, since no one is perfectly normal, there is likelihood of finding a lot of fish. Who doesn’t have a little nodule here that can’t be completely explained, a lab result that is a bit off or a heart tracing that doesn’t look quite right.
Overdiagnosis is certainly not the same as misdiagnosis—the erroneous diagnosis. This is the correct diagnosis of a disease; one that probably would have never bothered the patient in his lifetime. We’ve long assumed that if we screen a healthy population for diseases like cancer or coronary-artery disease, we can save lives in large numbers. While the rationale is compelling, it apparently, is not playing out that way in the real world. Cancer screening with mammography, ultrasound, and blood testing has dramatically increased cancer detection over the last 3 decades. Thousands of more people are being diagnosed with these diseases than ever before. Yet, there is no objective evidence of its benefit, as the fall in mortality is too tiny to be considered a major gain.
To a large extent, over-testing is a by-product of all the new technologies we have for peering into the human body. Why not take a look and see if anything is abnormal? The motivation for over-testing is not always pecuniary, it can become a habit, or even we may genuinely but incorrectly believe in it. With some exceptions, doctors are not scientists. The tenet of science involves posing a falsifiable hypotheses, designing experiments that are amenable to interpretation and measurement and to finally nullify the hypothesis. To me that’s not how doctors should work. And certainly not as scientists.
It is not uncommon for me to be asked by my patients as to which part of the body I treat. The super-specialism in medicine thrives on diagnosis. No wonder then that I go weeks without a diagnosis. But the patients seem to be happy and I find that gratifying. GPs I believe are supposed to make a physical, psychological and social diagnosis. But this was not really taught in the medical school. To me over-testing is driven by the quest for diagnosis; Its just that the concept of diagnosis today appears to have stretched to the point where, perhaps, it isn’t useful.
A study published recently in the New England Journal of Medicine evaluated the cost-effectiveness of treating hypertension based on the most recent JNC 8 guidelines. The study was interesting in that a previous similar analysis had found that screening for and treating hypertension does not save money. The upfront costs of the doctor’s fee, lab costs, and invariably life-long prescriptions, were greater than the projected savings down the road from fewer cases of heart disease and strokes. But this NEJM study is a bit different and claims that in some cases it does save money….. and it got me curious !
The study was based on the sophisticated Markov-based model. Much care has been taken to simulate various real-world scenarios, with separate results for each scenario. Phew! But let us just look at what it means for people in the age bracket of 34 to 59. For men in this group, screening and treating hypertension was found to be cost-saving, but for women it was not.
To cut a long story short; the data presented for this age-group implies that if the people in this age range were treated for hypertension, the vast majority of people will not be affected at all. For men, the cost savings was 2% ($600 million out of $33 billion!!!) and it yielded 25,000 (.05%) more quality adjusted life years (QALYs) out of 2.3 million patients. (More coming on the QALYs in my next post) For women the costs went up slightly (0.4%) and the number of quality-adjusted life years increased by 0.02%. Of course, the benefit had to be higher for older persons, diabetics, et al. and more so in stage 2 hypertension. But the overall finding that there were no dramatic differences in the treatment groups was rather unchanged.
Lets look at it from a different angle – the public health perspective: A recent report pegged the average cost of coronary artery bypass surgery in the US at $75,345. Compare this with the cost of the same surgery in, say, Netherlands [$15,742 (about 79% lower)], and you will know what we are talking about here. The cost of angiography alone is about $900 in U.S. versus $174 (down by 81%) in the Netherlands. That the other developed countries usually do much fewer procedures than in the U.S. is an aggravating factor.
For those advocating for more and better primary care in US (which is clearly required), they should be mindful of the fact that screening and treating a common disease such as hypertension alone does not explain the cost savings and better outcomes with primary care. Its not to suggest that screening for hypertension in primary care should stop. Actually, it does help a little. But should this issue not be articulated in the main policy agenda …and in the debates aimed at making US health care more affordable? But that part is clearly missing! Here’s a link to a related video on the effect of revised 2014 guidelines on hypertension in US.
Before closing, a cartoon from americanpowerblog.blogspot.com that went viral back in 2013, and hilariously sums up the bane of US health care. At that time much of Obamacare was still in the pipeline. And here’s another interesting take on the costs of health care in U.S.
… To be concluded
My relationship with this book started in the south Indian city of Hyderabad in Dec 2002, at the time of my enrollment in the ‘Health Systems Research’ program. Before long, my initial perplexity with the notion of reading history in a technical school soon gave way to a mesmeric realism of the massive import and relevance of the subject to my field of work. The Cambridge Illustrated History of Medicine is one of the many seminal works of the celebrated British historian, (Late) Roy Sydney Porter (1946–2002). Until a year prior to his death in 2002, Porter was serving as the Director of the Wellcome Institute for the History of Medicine at University College, London.
Porter deftly chronicles the evolution of medical profession from the pre historic era, through the 19th century ‘age of science’ and right up to the contemporary post-modern medical enterprise. The book scores high both in terms of insightful narratives and aesthetic use of visual imagery. The 4th century carvings of Athenian ‘God of healing –Asclepius’; the illustrations of the 113 A.D. Roman ‘Battlefield – School of Surgery’, and, the painter’s rendition of the first ever surgery performed under general anesthesia in 1846 at Harvard Medical School, are just a few examples of the visual ambience that add to the authenticity of the book.
The writer’s mastery of the subject is unmistakable, both in terms of comprehensiveness and lucidity of prose. He has tried to offer a balanced perspective on the inherent complexities of the health care ecosystem alongside its evolution over time. The chapters are logically organized, each capturing a key element of the medical discipline in its entirety (e.g., History of Disease; Primary Care; Hospitals and Surgery; Pharmacology).
In ‘Medicine, Society and the State’, the author questions the ‘altruistic’ imperative that has long come to be attributed to the medical profession. He argues that medicine has historically been an instrument of sociopolitical power and that medicine of its times has always aligned itself with the powers-that-be, for its own survival rather than anything else. Porter manages to hold his ground well throughout and profusely cites examples like the complicity of German doctors in the experiments and exterminations during the holocaust. However, coming from a sociological ‘conflict’ perspective, there is a discernible bias in Porter’s assertion on this account.
The author does well to reflect on the new ethical challenges brought about by the rampant use of technology and dehumanization of the doctor-patient relationship. The take home message from the book is as profound as it is pragmatic– ‘History can provide us valuable lessons for the future’. The book concludes on a positive note:
The book is a must-read for public health practitioners.
Review by: Sanjeev Verma
Much of medical training is based on understanding the disease. But, more often than not, in a primary care setting, the doctor deals with illnesses rather than diseases. And understanding illness is not quite the same as understanding the disease. Indeed, illness includes the feelings of regret, guilt, fear, betrayal, loneliness, and all the other emotions that turn the same disease into different illnesses in different people.
Donald Irvine puts it quite eloquently in a 2003 article published in British Medical Journal, “Success relies on winning hearts and minds”, “Evidence is abundant that the public want doctors who are technically competent; give them the best possible clinical outcome; are as safe as possible; are kind, courteous, and respectful; and involve them in decisions about their care.”
But I also feel something missing here. The question about how it should be done, doesn’t quite tell us what should be done? The difference could appear superficial yet its implications profound.
Back in 1890s, the illustrious James Mackenzie captured the world’s attention with his many path-breaking contributions to cardiology. The one that I remember clearly from college was the description of the ‘irregularly irregular heart beat’. Mackenzie’s biography ‘The Beloved Physician.’ is one book I keep coming back to. For it charts the travails of a petty physician assistant who moved on to become the patriarch of cardiology…. and Mackenzie was beloved because he cared. Quite true that the doctors in Mackenzie’s time were unable to make most of the diagnoses of the conditions that their patients were experiencing, simply because most of these conditions had not yet been discovered. The same could very well be applying to us, although we don’t realize it just yet.
It wont be a surprise that medical journals in 30 years could well be full of conditions that nobody has ever heard of, but exist today undiscovered. Doctors in the past had virtually no effective investigation or drugs. Nonetheless, the people and populations they served believed they were hugely valuable – a fascinating paradox. We do have powerful drugs, and clever diagnoses. But maybe the part of the consultation that ultimately matters the most to many patients is the part that is most downplayed in the search for scientific truths and recordable data.
Quoted below verbatim from the paper “The placebo effect” by Watkins P (2003) in the journal Clinical Medicine:
“The good consultation should always leave a patient with an increase in self-esteem and perhaps some alleviation of their symptoms as well. Our forebears knew that their clinical skill in the consultation was paramount, given that their medications were often ineffective and functioned solely as placebos. The skillful consultation itself often has a placebo effect, depending on the bedside manner.’ (Watkins P, 2003).
I tend to think that today we might just be creating a form of medical practice that will not permit the placebo effect to work. We only realize this when research shows us that many of the treatments we are using are ineffective. People probably trust us because of all those consultations where nothing much seemed to happen. Irrespective of what we did therapeutically, they got better.
And here’s Mackenzie again quoted from his biography:
Could it be possible that what he appears to have recognized then is something we still recognize today: the quite extraordinary mismatch between the medical textbooks and the ways in which our patients present to us. Apparently, it was his attempt at gaining some clarity into his professional life, that led Mackenzie on the track that was to become his destiny. From a GP he turned into a GP with a special interest (whatever that means), and his special interest was triggered by the death from heart failure of a young woman in childbirth…… and his special interest was what we refer to as cardiology.
To be continued…..
Why do we have an obsession for numbers? Come to think of it, it’s actually inconceivable for anyone to think of a world without numbers. Indeed, numbers help us make sense of the world around us. But there’s a fundamental human tendency at work here. We all feel uncomfortable in the face of uncertainty. And numbers provide us with a sense of control. And numbers have that halo of certainty. The allusion to science. As long as a number can be assigned to a problem, we know how big or small it is. Yet that sense of certainty is often an illusion. And perhaps in no other field does this illusion manifests itself as starkly as it does in the business of medicine. It all comes down to who you are. Numbers can be played up or played down.
Here’s a question: Which disease would you prefer? Disease A that kills 25 out of 100 people; or Disease B that kills 250 out of 1000 people? Sounds like a stupid question ? It is. Both mean the same: a quarter of people will be killed. Although both diseases imply the same risk; yet it tends to affect our perception. Its the science of cognition at play here; the theory of cognitive psychology that is often brazenly misused for manipulating minds. Here’s another one: Which of the two diseases is more serious? Disease A kills 1286 people out of 10000; or Disease B that kills 24.1 people out of 100. In a study, people rated disease A more serious even though Disease B carries almost double the risk. Gerd Gigerenzer calls this innumeracy. It comes in various forms – ‘illusion of certainty’, ‘ignorance of risk’, ‘mis-communication of risk’ or ‘clouded thinking’.
Playing with data is not a new vocation in medical industry. Small tweaks fetch big dollars. Any talk on this subject would be incomplete without reference to the commercially driven manipulation of drug efficacy data. From Prozac to Pravastatin there is no dearth of examples. My interest in this particular issue stems from the time I worked on my ‘medical ethics’ dissertation. Here I quote just one example from my thesis – the case of the celebrated ‘statin’ group of drugs – the bad cholesterol busters. Back in 1995, a press release by the American Heart Association (AHA) read – “Wonder drug cuts risk of death by 22% in people with high cholesterol”. The blockbuster headline was referring to the clinical trial results of pravastatin. But what is 22% one might ask? An average educated person would probably take it as “22 deaths prevented out of every 100 people treated with pravastatin.” But a quick look at the data and the mischief is hard to miss. The official report was a mish-mash of statistical jargon & hyperbole mixed with some mind boggling calculations. But the above AHA headline could only have been made from the following basic figures. Data reported at the completion of 5 years:
Deaths per 1000 people treated with pravastatin for 5 years: 32
Deaths per 1000 people treated with a placebo for 5 years: 41
Its fascinating how simple tweaks can allow one to abuse the data, so to speak. It is common for the media to report clinical trial results in terms of relative risk reduction; which is what the AHA did. But there are two other ways of interpreting the same data.
The AHA version first. Relative Risk Reduction: 41 minus 32 = 9 ÷ 41 x 100 = 22%. The calculation for Absolute Risk Reduction is a bit different. Let’s see how – Deaths were reduced from 41 to 32 for every 1000 people taking the drug. Implies 9 deaths averted for every 1000 people treated. In other words, an absolute risk reduction of 0.9 %. Now lets talk about the less industry-friendly interpretation- ‘Number Needed to Treat’ (NNT). NNT refers to the number of people who must take the drug in order to save one life. In case of pravastatin, thrder urns out to be 111. Implies that 111 individuals need to be treated in order to save one life. How? Because 9 in 1000 deaths were prevented by the drug; it comes to about 1 in 111). The most impressive and the most misused statistic is the first one – ‘Relative Risk Reduction‘ that suggests higher benefit than what really exists. Simply put, NNT means that out of every 111 people who swallowed the tablet daily for five years, only 1 person benefited while the other 110 did not. The phenomenon of innumeracy is not just exclusive to non-medical people, even physicians unwaringly suffer from this form of clouded thinking. Take the case of mammography that is a much recommended screening tool for breast cancer.
Normal women after a particular age are encouraged to periodically undergo mammography even in the absence of any symptoms. Lets simulate a real world scenario and see how this works (or doesn’t work). Taking a simple approach, the risk of a woman between 40-50 years of age having breast cancer is about 0.8 percent. That’s the rough prevalence rate. Studies have shown that only 90% of women who actually have breast cancer will be diagnosed as such by mammography. Among women who do not have breast cancer, the probability of their being labelled as a case of breast cancer comes to about 7 %. Now it gets a bit complicated from here on. What is the actual probability of a woman whose mammogram is positive for breast cancer, will actually have a breast cancer? Its surprising how simple these equations become if we think in terms of numbers rather than percentages. Lets do this again with numbers:
8 out of every 1000 women have breast cancer. Out of 8 such women, 7 will turn out positive on mammography. Of the remaining 992 women who don’t have breast cancer, some 70 women will still have a positive mammogram. Imagine a group of women who have positive mammogram on screening. How many will actually have breast cancer? Its the same information as given earlier, but thinking in terms of numbers makes it a bit easy to calculate, which is: Only 7 out of the 77 women who tested positive on mammography (70+7) actually have breast cancer. This works out to about 1 in 11 women or, in other words, 9 %. Much lower than the estimate of 90% highlighted by the media. One incident widely reported in the media showed how clouded thinking may affect even physicians. A consultant in the erstwhile Clinton administration asked a group of American physicians the probability of a woman who tested positive on mammography, as actually having breast cancer. 95 % of physicians estimated the probability as 75% – almost 10 times more than that in reality.
That there were extraneous considerations motivating the aggressive industry-sponsored campaign promoting mammography, is a tale for another day. The point here is not to debate the merits and demerits of mammography. The relevance of the foregoing is more to acknowledge our deficiency when it comes to interpretation of research statistics. Acknowledging our innumeracy is the first step towards dealing with it. Modern medicine is gradually witnessing a transition towards patient-centred medicine, where patient and physician are poised to equally participate in deciding the course of treatment, guided by each individual’s unique circumstances. This paradigm change is already occuring, and the best start to it would be to grow out of our innumeracy. Referring to the risks and benefits of a particular medical intervention in terms of natural frequencies (numbers), rather than percentages, is a step towards warding off the illusion of certainty that envelopes scientific medicine. Let this aspect of science be diligently taught to take numbers for what they are- just numbers!
Medical system, like any other enterprise, happens to be run by humans. But why do mistakes by doctors seem so outrageous to other people? Are doctors supposed to be perfect? The usual refrain – Why not? People trust you with their lives! Wait a second, we are not the only ones dealing with lives. How about the airlines industry. With them it is more like 300 lives depending on 2 pilots. Why is there a double standard when it comes to medical error!
True, we all know how to deal with the mistakes in our personal lives. The universal remedy for mistake is communication. Acknowledge, talk about it, forgive and best of all learn from it. Can we say the same when it comes to medical practice? I’m afraid no. Institute of Medicine pegs the number of deaths attributed to medical errors in U.S. at just under 100,000 every year. And that number almost certainly is a conservative estimate given that its a taboo subject within the discipline. Imagine the corresponding number in the developing world. The thought is disturbing.
Does the problem lie in the social construct of medicine? Looks likely. We don’t come out of medical school thinking “ok I’ll try my best to avoid mistakes”. Its not allowed, even if implicitly. You need confidence to start and sustain the job and accept the psychological burden of taking another person’s life into your hands. It’s part of the prerogatives you earn in medical school.
“We send each one of them out into the world with the admonition, be perfect. Never ever, ever make a mistake, but you worry about the details, about how that’s going to happen.” That’s quoted from Brian Goldman’s thought-provoking TED Talk lecture titled, “Doctors make mistakes. Can we talk about it.” In this video, Brian talks about the culture of denial in medicine – the denial of errors and the toll it takes on the physician himself in addition to the patient. He does an excellent job of letting the audience peer inside a doctor’s emotional life with regards to mistakes and errors. “And we have this idea that if we drive the people who make mistakes out of medicine, what will we be left with, but a safe system.” (Here’s some unbelievable statistics from U.S. “Facts About Physician Depression and Suicide”)
In his fascinating book “The Youngest Science“, Lewis Thomas (1913-1993) provides a compelling narrative of “what medicine was, and what it has become; its evolution from hand-holding to scientific care; its complete transformation from an art of comforting to the hard core science of healing”. Healing at the cost of dehumanizing. This is a thought provoking must-read both for patients and doctors. “As a medical intern in 1937. Back then medicine was cheap but ineffective. The main benefits of hospitals were warmth, food, shelter and attention from nurses. Doctors and medicine made hardly any difference.”
Fast-forward a few decades, we find ourselves immersed in a world of incredible complexity. 4000 surgical procedures, 6000 licensed drugs and cures for nearly all of the imaginable illnesses. Yet we are far from satisfied. Perhaps we can learn from a best practice in airlines industry. It has an inbuilt system where pilots voluntarily report critical incidents, be it a near-miss mid-air collision, a simple human error or just a machine failure. The reporting is anonymous; guaranteed against any penal action. Best of all, no one can trace back the error to the reporting pilot. That’s the first step in quality assurance. We cannot correct what we don’t know or are unwilling to admit..
There’s no doubting the admirable medical science. However, we still have to deal with the flaws. As humans we will make mistakes. Is it possible to make a back up for the inevitable errors that will occur? Can we just update our culture accordingly? Better still, can we move over from “too-much medicine” to “patient-centered medicine”? Only time will tell.
Swine flu is an example of nature’s ingenuity in remaining one step ahead of medical science. Its the classical Darwinian theory of evolution at play. Simply put, organisms develop variations that increase their probability of survival and its the differential survival of variants that fuel the epidemics.
They ceaselessly roam the blue earth, seeking red blood. They are among us, yet forever apart. They are legion, yet invisible. They are undead”
Historically, viruses have been perceived as enigmatic organisms transcending the boundary between living and non living, evoking fear and hysteria for its mysterious ways.
As a survival strategy, influenza virus undergoes random changes in genetic code producing newer variants every year. These antigenic changes means that the human body is no longer able to mount an adequate response to the newer variant. This is why a new flu vaccine is needed each year. This annual cycle of genetic change ensures that a critical mass of vulnerable population is readily available for sustenance of the virus. The vulnerable population, however, progressively reduces over successive years. Usually after several decades, the pressure on the virus escalates leading to bigger genetic changes, thus producing new sub type of the virus. Such an eventuality renders the entire population susceptible to the new variant within a relatively short window of time, thus triggering pandemics. The most recent genetic shift took place in 2009. In the intervening years, the new H1N1 virus has established itself as the regular circulating sub type of influenza. A detailed history of influenza epidemics can be accessed here.
Different viral strains capable of infecting different animal species, when present at the same time in a single species, undergo genetic re-assortment. Pigs are excellent reservoirs for this natural mixing of flu virus sub types. That is why the genetic shift leading to global pandemics are generally derived from pigs and are, therefore, colloquially referred to as swine flu.
Much can be learned from the history of pandemics. Historical data on influenza outbreaks have shown that by the time a type-specific vaccine comes on the ground it is often too late for it to have any benefit. Moreover, development of immunity after vaccination takes up to 3 weeks, by which time the peak of transmission is already over. (Related news on flu vaccine limitations below). Indiscriminate use of antiviral treatment is also not recommended owing to the risk of development of newer drug-resistant variants. Restricting unnecessary exposure and personal prophylaxis, then, is a practical way to prevent getting infected in the ongoing swine flu. epidemic. Indiscriminate vaccination and off the counter use of Tamiflu can do more harm than good. There is no substitute for medical consultation for assessing one’s risk and taking recourse to specific interventions. Compliance with the government guidelines is a key imperative if we are to ward off the ongoing threat of swine flu.
Link: National Health Portal (NHP) of India website for updated information on swine flu
Green light for mitochondrial donation in UK:
State-of-the-art IVF technique for preventing genetic diseases
After four hours of intense debate in the House of Lords, peers have voted to approve regulations that will allow mitochondrial donation to be licensed for use. The techniques, pioneered by scientists at the Wellcome Trust Centre for Mitochondrial Research at the University of Newcastle, give hope to families suffering from mitochondrial disease. Wellcome Trust Director, Dr Jeremy Farrar shares his thoughts on this momentous decision…
Families who know what it is like to care for a child with a devastating disease are the people best placed to decide whether mitochondrial donation is the right option for them.
Parliament is to be commended for a considered and compassionate decision to give these families that choice, with proper safeguards under the UK’s internationally-admired regulatory system.
Parliament’s decision is a credit to the patients, scientists, doctors and ethicists who have worked so hard over the past decade to explain this complex research to…
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