TV: Hypothetically speaking
Authors: A. Berger
Journal: BMJ (2000)

Hypotheticals, BBC2, 28, 29, and 30 August, 11 20 pm

  Jenny and Jack want to have a baby but have problems conceiving. After many months they are referred to an infertility clinic to be considered for in vitro fertilisation. So far so good. It then turns out that Jenny has already had a child by a previous partner, but the child is now in care because the father was violent.

Should this fact be brought to bear on the clinician's decision to offer assisted conception to Jenny and Jack? Why has Jenny left the child in care, and is she a competent mother? According to the law, the whole situation—including the past—should be assessed if a couple is seeking help with fertility. Yet none of these questions arises for a couple conceiving a child by conventional means.

This dilemma is explored in Hypotheticals, a thought provoking television series in which each programme starts with a group of real life experts being offered a simple clinical scenario to discuss. The scenario above was debated by doctors, a lawyer, a journalist, a member of the BMA's ethics committee, a representative of the Human Fertilisation and Embryology Authority, and a patient representative. Gradually, more information is added, and the layers of complexity increase. Straightforward, almost knee-jerk responses give way to more prolonged discussions.

The answers to some of the ethical questions posed in the series may at first seem black and white. Is it right, for example, to test a patient's serum alcohol levels without first obtaining consent? Surely not. But the answers soon turn a more subtle shade of grey. What if you then discover that the patient had injured a cyclist because he was driving while under the influence? It would still arguably be unethical to test the patient. What if the cyclist is subsequently diagnosed as brain stem dead and the family agrees to organ donation, provided that the liver does not go to an alcoholic patient? Although most around the table looked sympathetic to the family's request, the transplant coordinators firmly believed that this would be “conditional donation,” which is ethically unacceptable.

Occasionally the twists in each scenario resulted in total disagreement. Should a vital piece of hospital equipment—such as an intensive care unit ventilator—be paid for by and credited to a fictitious tobacco company called Puff-a-Lot? “Yes,” said the cardiologist. “Definitely not,” said the chief executive of the hospital. Pragmatism and idealism became rivals. The patient representative looked bemused, perhaps wondering why it was an issue at all.

The Hypotheticals format makes for good entertainment and surprisingly riveting television, given that it involves 50 minutes of watching about 15 people sit around a horseshoe shaped table talking to each other. It is also highly informative and educational. The scenarios are laid out by a moderator, whose job it is to inform, to sometimes challenge, and—perhaps most difficult of all—to maintain momentum without the team getting side tracked by detail.

Each programme is moderated by one of two lawyers, Clive Anderson or Anesta Weekes. Anderson is the more natural host, perhaps because of his experience as a stand up comedian and television presenter, and he injects a little playful humour into the proceedings. Weekes is adversarial, and the episode she chairs is like a courtroom drama. 

The three Hypotheticals episodes will be shown on consecutive nights, which may weaken the overall impact of the series. The novelty of the format rapidly wears off after you've seen the first one, and perhaps radio would have been a better medium for presenting such verbal programmes. I also question the usefulness of this approach in helping people participate in real life priority setting and resource allocation.

But all the issues raised are fascinating, more so perhaps to a non-medical audience unfamiliar with the many ethical issues faced daily by doctors. My non-medical friends were sometimes shocked and dismayed by the decisions made by the clinicians. It is valuable to be reminded that clinical decisions made by doctors are not always acceptable to those outside medicine.