Review
Ageing
Assisted dying
Culture
5 min read

For love there is no charge

Out of mind old people are at the centre of Allelujah! Sian Brookes reviews the film adaptation of Alan Bennett’s play.

Sian Brookes is studying for a Doctorate at Aberdeen University. Her research focuses on developing a theological understanding of old age. She studied English and Theology at Cambridge University.

In a hall decorated for a celebration a person stands in front of a seated group, all have their arms raised in celebration.
Jazz hands at the hospital.
BBC Films.

Spoiler alert – this film review reveals significant elements of the plot. 

Allelujah! is not a film that shies away from the big issues. In fact, you would be hard pressed to find a big issue this comedy/political commentary/drama/part-thriller doesn’t at least make reference to (and yes, it spreads itself across all of these genres too). With such an eclectic approach it is difficult at times to keep up with the narrative, and the deeper meaning of the film. Based on the Alan Bennett play, the plot centres around The Bethlehem, a small northern hospital for geriatric patients, which is facing closure due to the Tory government’s efficiency drive. It focuses on two members of staff, Alma Gilpin, a stoic and matter-of-fact but seemingly excellent nurse who has served the hospital her entire career, and a younger Dr Valentine. Other protagonists include an ex-miner patient and his son, a management consultant who has “made it” to London and is currently advising the Health Secretary to close hospitals such as the one in question for the sake of government finances. 

Whether it’s politics or the personal, this film has it all. It deals with levelling up, the cultural and economic gap between the north and south, the challenges of budget cuts in the NHS, the problems of a national health service claiming to 'care' but with managers more preoccupied by Westminster’s economic priorities. It depicts families waiting for older relatives to die in order to grab their inheritance, the broken relationship between an ageing man and his son, and those all-important stories of the older patients’ lives well-lived. And yet as the story line develops, a plot twist emerges which comes to overshadow the entire film, and in the process speaks to what is perhaps the most poignant of the many discussions it raises. Nurse Gilpin, who, until now has appeared consistently caring and committed to her patients, has been quietly administering fatal beakers of milk and morphine to those who she deems to be on “her list” of those who most need relief from their situation. When confronted by the doctor she justifies her actions with a multifaceted answer based on the requirement to provide more beds to a broken healthcare system, but also insisting “I had ended someone’s suffering”.  

When Dr Valentine remarks, “I like old people” a visitor responds “not even old people like old people”.

The manner in which Nurse Gilpin goes about what is effectively enforced euthanasia, is deeply chilling. And yet her reasoning is not entirely foreign to us – to end suffering could be deemed a noble cause. In fact, the need to simply delete the reality of suffering, particularly the suffering of the old is one that perhaps is not so uncommon. Throughout Allelujah!,we are reminded of our tendency to run from, to detest, to reject the suffering of the elderly in our society. When Dr Valentine remarks, “I like old people” a visitor responds “not even old people like old people”. A teenage intern declares to a patient “I hope I never live to be your age”. At the same time, characters look back on the days “when the elderly weren’t farmed out”, and questions are asked of families “if they love them, why do they put them away?”. A very good question. Of course, care needs are often too great for families to endure, yet it is still important to ask why the suffering of the old has become a professionalised service, which most of us avoid at all costs. Perhaps the answer to this is that we don’t like to watch the old suffer, we don’t like to watch them die, because their suffering and their death remind us of our future selves, our future suffering, our future death. In our sanitised, anything-is-possible-with-medicine-and-science society, death and the suffering that comes with it, is something from which we flee at all costs. Instead of acknowledging and working with it, we would rather pretend it wasn’t there at all.  

And yet, even as we try to avoid it, suffering and death are both certain parts of all our futures. 100% of us will die. For Nurse Gilpin, the solution to this is to bring on death prematurely, to erase the pain, overcome the misery by offering a false hope – that it doesn’t need to exist at all. In direct contrast to this, in a film which is littered with Christian references (Allelujah, The Bethlehem), there is a different approach taken by a messiah-type figure who seems to get everything right. Dr Valentine is compassionate and understanding. He not only challenges the political systems which undermine those most at the margins of society, but also has the kind of bedside manner we would all hope for in a doctor. In a closing monologue Dr Valentine utters the words of the doctors in the NHS, “We will be here when you are old, and we would die for you, we are love itself and for love there is no charge”.  

It is this suffering with which is so compelling, this suffering with which is truly sacrificial.

Nurse Gilpin and Dr Valentine offer two fundamentally different approaches to end of life care. One hastens the end quickly, deletes the suffering as efficiently as possible in order to make way for those in less pain. The other sits with those who suffer, holds their hand, gently cares for the human person that is in front of them. Even more, and perhaps most significantly Dr Valentine does not only watch from afar, but is willing to suffer himself for the sake of those in pain - working tirelessly, giving himself over day after day, fighting on with little sleep for limited pay just to make things a little less painful. It is this suffering with which is so compelling, this suffering with which is truly sacrificial, this suffering with which speaks of something much greater than politics, efficiency or inheritance, this suffering with which is indeed “love itself”, completely free of charge.  This is the logic that Christians see in the ancient notion of the incarnation, celebrated every Christmas, of God with us. This is what our older people need, this is what we will all need when we grow old. Let us only hope that when we get there, we find the one who is willing to offer it.

Explainer
Biology
Culture
Ethics
9 min read

Ethics needs to catch-up with genetic innovation

Are we morally obliged to genetically edit?

John is Professor Emeritus of Cell and Molecular Biology at the University of Exeter.

An artistic visualisation of a DNA strand growing flowers from it.
Artist Nidia Dias visualises how AI could assist genomic studies.
Google Deepmind via Unsplash.

It makes me feel very old when I realise that Louise Brown, the first baby to be born via in vitro fertilisation (IVF), will be 47 years old on July 25th this year. Since her birth in 1978, over 10 million IVF-conceived babies have been born worldwide, of whom about 400,000 have been in the UK. Over that period, success rates have increased such that in some clinics, about 50 per cent of IVF cycles lead to a live birth. At the same time, there have also been significant advances in genetics, genomics and stem cell biology all of which, in relation to human embryos, raise interesting and sometimes challenging ethical issues. 

I start with a question: what is the ‘moral status’ of the early human embryo? Whether the embryo arises by normal fertilisation after sexual intercourse or by IVF, there is a phase of a few days during which the embryo is undergoing the earliest stages of development but has not yet implanted into the wall of the uterus; the prospective mother is not yet pregnant. In UK law, based on the Human Fertilisation and Embryology Act (1990), these early embryos are not regarded as human persons but nevertheless should be treated with some respect. Nevertheless, there are some who oppose this view and believe that from the ‘moment of conception’ (there actually isn’t such a thing – fertilisation takes several hours) embryos should be treated as persons. In ‘conventional’ IVF this debate is especially relevant to the spare embryos that are generated during each IVF cycle and which are stored, deep-frozen, in increasing numbers for possible use in the future.  

A further dimension was added to this area of debate when it became possible to test IVF embryos for the presence of genetic mutations that cause disease. This process is called pre-implantation genetic diagnosis and enables prospective parents who are at known risk of passing on a deleterious mutation to avoid having a child who possesses that mutation. But what about the embryos that are rejected? They are usually discarded or destroyed but some are used in research. However, those who hold a very conservative view of the status of the early embryo will ask what right we have to discard/destroy an embryo because it has the ‘wrong genes’. And even for the many who hold a less conservative view, there are still several questions which remain, including ‘which genetic variants we should be allowed to select against?; should we allow positive selection for genes known to promote health in some way?’; should we allow selection for non-therapeutic reasons, for example, sporting prowess?’ These questions will not go away and there are already indications that non-therapeutic selection is being offered in a small number of countries. 

Genetic modification 

This leads us on to think about altering human genes. Initially, the issue was genetic modification (GM) which in general involves adding genes. GM techniques have been used very successfully in curing several conditions, including congenital severe immune deficiency and as part of treatment programmes for certain very difficult childhood cancers. One key feature of these examples is that the genetic change is not passed on to the next generation – it just involves the body of someone who has already been born. Thus, we call them somatic genetic changes (from the Greek, sōmatikos, meaning ‘of the body’).  

Genetic modification which is passed on to the next generation is called germline GM which means that the genetic change must get into the ‘germ cells’, i.e., the sperm or egg. Currently, the only feasible way of doing this is to carry out the genetic modification on the very early embryo. At present however, with just one very specific exception, GM of human embryos is forbidden in all the countries where it would be possible to do it. There is firstly the question of deciding whether it is right to change the genetic makeup of a future human being in such a way that the change is passed to succeeding generations. Secondly, there are concerns about the long-term safety of the procedure. Although it would involve adding specific genes with known effects, the complexity of genetic regulation and gene interactions during human development means that scientist are concerned about the risks of unforeseen effects. And thirdly, germline GM emphasises dramatically the possibility of using GM for enhancement rather than for medical reasons.  

Genome editing 

This leads us to think about genome editing. In 2011, it was shown that a bacterial system which edits the genomes of invading viruses could also work in other organisms This opened up a large array of applications in research, agriculture and medicine. However, the ethical issues raised by genome editing are, in essence, the same as raised by GM and so there is still a universal prohibition of using the technique with human embryos: germline genome editing is forbidden. Despite this, a Chinese medical scientist, He Jiankui, announced in 2018 that he had edited the genomes of several embryos, making them resistant to HIV; two babies with edited genomes had already been born while several more were on the way. The announcement caused outrage across the world, including in China itself. He Jiankui was removed from his job and then, after a trial, was imprisoned for three years; his two colleagues who collaborated in this work received shorter sentences. 

At present the universal prohibition of human germline genome editing remains in place. However, the discussion has been re-opened in a paper by an Anglo-Australian group.  They suggest that we need to develop heritable (i.e. germline) polygenic genome editing in order to reduce significantly an individual's risk of developing degenerative diseases. These includecoronary artery disease, Alzheimer’s disease, major depressive disorder, diabetes and schizophrenia. I note in passing that one of the authors is Julian Savulescu at Oxford who is already well-known for his view that parents who are able to do so, are ‘morally obliged’ to seek to have genetically enhanced children, whether by PGD, GM or genome editing. The use of polygenic editing, which would, in all likelihood, be available only to the (wealthy) few, fits in well with his overall ethical position. Needless to say, the paper, published in the prestigious journal Nature, attracted a lot of attention in the world of medical genetics. It was not however, universally welcomed – far from it. Another international group of medical scientists and ethicists has stated that ‘Human embryo editing against disease is unsafe and unproven …’ and even go as far as to suggest that the technology is ‘… going to be taken up by people who are pushing a eugenics agenda …’ remain very pertinent. 

Harder still and harder 

I have no doubt that amongst different reader there will be a range of opinions about the topics discussed so far. For anyone who is Christian (or indeed an adherent of almost any religious faith), one of the difficulties is that modern science, technology and medicine have thrown up ethical questions that could not have even been dreamed of by the writers of the Bible (or of other religious texts). We just have to use our wisdom, knowledge and general moral compass (and for some, prayer) to try to reach a decision. And if what I have already written makes that difficult, some recent developments multiply that difficulty still more.  

In the early years of this century, scientists developed methods of transforming a range of human cells into ‘pluripotent’ stem cells, i.e., cells capable of growing into a wide range of cell types. It also became possible to get both induced stem cells and natural stem cells to develop into functional differentiated cells corresponding to specific body tissues. This has huge potential for repairing damaged organs. However, other applications are potentially much more controversial. In 2023, Cambridge scientists reported that they had used stem cells to create synthetic mouse embryos which progressed at least as far as brain and heart formation within the normal pattern of mouse embryo development. 

At about the same time, the Cambridge group used individual human embryonic stem cells (from the blastocyst stage of embryonic development), to ‘grow’ early human embryos in the lab. There is no intention to use these embryos to start a pregnancy – indeed, it would be illegal to do so – but instead to study a period of embryo development which is not permitted with ‘real’ human embryos (research must not continue past 14 days of development). But how should we regard synthetic embryos? What is their moral status? For those who hold a conservative view of the normal human embryo (see earlier), should we regard these synthetic embryos as persons? Neither does the law help us. The legal frameworks covering in vitro fertilisation and early embryos (Human Fertilisation and Embryology Acts, 1990, 2008) do not cover artificial embryos – they were unknown at the times the legislation was drawn up. Indeed, synthetic embryos/embryo models are, in law, not actually embryos, however much they look like/behave like early embryos. Earlier this month, the Human Fertilisation and Embryology Authority (HFEA) discussed these developments with a view to recommending new legislation, but this will not dispel an unease felt by some people, including the science correspondent of The Daily Telegraph, who wrote that this research is irresponsible.  

But there is more. In addition to synthetic embryos, the HFEA also discussed, the possible use of gametes – eggs and sperm – grown from somatic stem cells (e.g., from skin) in the lab. Some authors have suggested that the production of gametes in vitro is the ‘Holy Grail’ of fertility research. I am not so sure about that but it is clear that a lot of effort is going into this research. Success so far is limited to the birth of several baby mice, ‘conceived’ via lab-grown eggs and normal sperm. Nevertheless, it is predicted that lab-grown human eggs and sperm will be available within a decade. Indeed, several clinicians have suggested that these ‘IVGs’ (in vitro gametes) seem destined to become “a routine part of clinical practice”.  

The lab-grown gametes would be used in otherwise normal IVF procedures, the only novelty being the ‘history’ of the eggs and/or sperm. Clinicians have suggested that this could help couples in which one or both were unable to produce the relevant gamete, but who still wanted to have children. In this application, the use of IVGs poses no new ethical questions although we may be concerned about the possibility of the gametes carrying new genetic mutations. However, some of the more wide-ranging scenarios do at the least make us to stop and think. For example, it would be possible for a same-sex couple to have a child with both of them being a genetic parent (obviously for males, this would also involve a surrogate mother). More extremely, a person could have a child of which he or she was actually, in strictly genetic terms, both the ‘father’ and the ‘mother’. What are we to make of this? Where are our limits?  

Dr Christopher Wild, former director of International Agency for Research on Cancer, explores in depth many of the developments and issue I outlined above. His article on why a theology of embryos is needed, is clear, well-written, helpful and thought-provoking. 

 

This article is based on a longer blog post with full footnotes.  

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