David: John, it is an honor for me to interview you, to explore your
distinguished career in Nephrology, but quite frankly I see it as an exciting
and at times perplexing story, really a mystery story if I may say, which
demands answers. How does one stumble into a life of nephrology, do so much
pioneering work in renal transplantation, and then pursue relentlessly an
ever-widening commitment to higher ethical values in kidney disease and medicine
in general? So lets start with the beginning of your story and reveal the
events, which steered you from one chapter to the next. First question: What was
medical ethics to you as a medical student and junior physician?
John: Well when I was a student, which was in the 50’s, 40’s actually,
late 40’s and early 50’s, medical ethics as a subject really did not exist. It
was assumed that ethical behavior by physicians was one of the parts of the ‘art
of medicine’ that when learnt as an apprentice by walking the wards with seniors
who pontificated a little bit and who were very important, but from them one was
meant to learn what was needed for ethical behavior in the what was then the
centerpiece, ‘the doctor patient relationship’. So many things have changed
since then, but ethics was essentially a subject that was not talked about.
David: Now, as a young man you found yourself in the military in India.
John: Yes. After I’d graduated in London at Bart’s Hospital (St
Bartholomew’s H.), I was called up. The war was over actually, but military
service continued and I had the good fortune of two years in the army most of
which were spent as a medical officer in India. And there I was with the Gurkha
brigade and, at that time, Nepal was not an open country to Europeans so the
recruitment of Gurkhas was carried on the border. At each end of Nepal, there
was a British Army border post, and I was in both of them at different times.
David: You must have seen some real, raw medicine?
John: Broadly speaking the Gurkha troops were fairly healthy and well.
When we recruited them they had to walk out of the valleys, which involved
roughly 11,000 feet up, 11,000 feet down, every day for a few days. The ones
that got to the camp were fit and broadly speaking there was not a problem. The
area of India that we were in had no medical coverage at all for the local
people. Zero. So the other medical officer and myself would see every local
villager who was sitting under the shade of a certain tree at 9:00 in the
morning, after we had seen the ‘sick parade’of Gurkhas, and we’d see them for
free using the equipment provided by the Queen, or rather the military, and we
did actually have some extraordinary medical experiences there.
David: And then you became aware, I guess perhaps painfully, of humans
with absolutely no opportunity, no access to health care.
It was an extraordinary experience. We were the only people there. We were the
surgeons, the anesthetists, the physician, the lab person, the whole lot rolled
into two and we felt justified and this is where some of the sort of innate
hubris of medicine started to come through. We felt justified in doing things
for which we were not trained.
then from India soon thereafter you find yourself on the wards with Sheila
Sherlock and another test of your developing medical values I suppose.
Let me just lead to that by saying that I had the experience which I should
admit to, in India before leaving, of trying to do something for a woman who had
an enormous goiter, and she was having trouble breathing. We thought that she
would not live long with this so we actually operated on it and she died on the
operating table from hemorrhage.. And that was a very humbling experience. We
were trying to do good and we did a lot of harm. And that made me very cautious
about using the power that medicine unfortunately, or fortunately, gives to
physicians when they are in situations where people have nothing else. I then
formed the resolution that I wanted to go as far as I could in learning the art
of medicine and lead into a life in research. And with that in view, when I came
out of the army, I obtained a position as junior to Dr. Sheila Sherlock at the
Hammersmith Post-Grad. Medical School, in London. She was the queen of the
liver, both in Britain and indeed worldwide for many years. She told me when I
took the position that I was responsible for everything that happened on the
ward, on two wards while I was there, even if I wanted to take a day off I was
responsible for what happened when I was away, so in fact there was very little
much were you paid then?
John: One was given one’s keep, I mean one was fed and housed. The money was nothing. I’m not sure it was absolutely zero, but it was trivial. One didn’t look to it as an income.
as you look back were there some formative value experiences?
were and it’s a little difficult to describe it exactly because it was an
experimental unit. There were 50 beds, all people with liver disease and
gathered from all over the U.K. and so in addition to treating them for their
problems, there was also a very high level of research activity. And one of my
jobs I was told was to protect the patients from the researchers. How well I did
that is one of my problems. Some years later a paper was published in the New
England Journal -- in 1976 -- by a man called Beecher from Harvard. He had 20
examples, subsequently reduced somewhat to 17 I think, of unethical research
activity carried out in hospitals and to my horror I found -- not that my name
was on the paper -- but that I was resident at the Hammersmith Post-Graduate
School when a certain project, named by Beecher, was identified as being
unethical. At the time, and that’s the worrisome part, we really didn’t think it
was unethical. I mean it horrifies me to think how unethical it was without us
realizing it. Our research was to show the deleterious effect of dietary
protein in people whose liver is not working well. So patients, without
consent, were given increased protein intake that would make them more confused
and, in some cases, go into a coma and then the protein would be stopped and
they would come out of hepatic coma. It was then found if you sterilized the
bowel with an antibiotic and then fed the protein then they didn’t go into coma.
This was because the actual ammonia intoxication was due to bacterial
fermentation in the gut, rather that the absorption of food by normal
digestion. That may now sound very easy to explain, but the principal is still
used, I believe, in the management of hepatic pre-coma. But at that time the
concept of “informed consent” was totally……
there we are in England with Sheila Sherlock, deep in the liver and then somehow
or other you find yourself in Canada very much into kidneys. How does that
it sounds a bit strange but I came to Canada because, after Hammersmith, I went
back to Bart’s Hospital to work on the service of the then Chief of Medicine ,
Prof. Ronald Christie, who, the following year, went to McGill as the Chief of
Medicine at the Royal Victoria Hospital. And although he didn’t bring me in any
sense -- and he was very emphatic that I should not give that impression -- he
did tell me about a position, a Hosmer teaching fellowship at McGill and asked
me if I wanted it. He gave me 24 hours to make up my mind. I asked a few friends
who came from Canada and they all said it was a good place to be so I took it
for a year. Its now 45 years later, but I came for just one year, in 1955.
think you said somewhere in the notes I read that ‘every opportunity needs an
yes! And let me just answer your other question, which was "Why the kidney?"
Well when I’d finished being teaching fellow, and then Chief resident at the
Royal Victoria Hospital, Christie said, "Now what are you going to do now
to justify your continued presence around here?" And I said, "Well what about
the liver?" And he said, "Oh well, we’re not ready for the liver in a formal
specialized sense. What about the kidney?" And I said, "Well what do you mean?"
He said, "Well, we need somebody in this new area of the kidney and what we
planned to do, if you were willing, is to send you to Chicago to Drs. Kark and
Pirani where you have to learn kidney biopsy because that’s what we need. We
need someone who can do kidney biopsies around here." So I was sent off to
Chicago for a week and traveled by bus in order to save some money on the very
inadequate grant that they gave me and came back knowing how to do kidney
biopsies. From then on I was one of two people who would answer consultations
around the hospital at the Royal Vic on electrolyte and acid base and kidney
problems. And the liver sort of faded into the background and has remained there
you embraced your emphasis in kidney nephrology as in retrospect a lifelong
ambition from that point on.
from there on, but there was something that cemented it which I should tell you
about. It was in the late spring of 1958 that an extraordinary event occurred
which happen to control my life thereafter. A young teenage girl of 15 years was
admitted to the Montreal Neurological Institute with convulsions , hypertension
and was in a stupor. I was on call that weekend and she had a high potassium and
she was acidotic and she was in renal failure. The resident who was very sharp
in getting the history of this young girl from her mother came along quite
excitedly, saying, "You know that girl over there has an identical twin.” You
can probably guess the rest. We quickly established that the young girl had
shrunken kidneys and chronic kidney disease, and there had been five transplants
between identical twins in Boston. This was long before any other type had been
tried, so we said to the mother: “Would you like to go down there? We can
arrange a grant to cover it”. The mother said “No, we will take our chance with
whatever can be done at McGill.”. So we decided to do a kidney transplant, and
my role was to coordinate the medical-surgical team. This was in 1958. It was
the first kidney transplant carried out in the Commonwealth. You might be
interested to realize that, in 1958, dialysis was still a dangerous undertaking.
So dangerous was it that we elected not to dialyze this young person. She was in
bad shape, but she no longer convulsing. So she was actually submitted to major
surgery under conditions of advanced uremia. It was one of the things I’ll never
forget, the speed at which urine came out of the ureter when the vascular
anastomosis had been finished but the rest of surgical site hadn’t been tidied
up. Yet, already, there was a flow of clear, golden fluid into her abdominal
cavity which demanded suctioning.. That was an exhilarating moment for us all,
actually, for everybody there!
Perhaps the high urea stimulated an osmotic diuresis?
Exactly. She had eleven litres of urine in the first day and, of course, that
was where a lot of skill was needed. We were doing three hourly total
electrolyte balance with estimates for free body water and insensible loss and
the whole thing. It involved a team of people wielding slide rules working out
what the fluid intake should be for each succesive three-hour period.
there you were then with this marvelous success, committed for life to kidneys,
and was there any other formative, medical, ethical event at the Vic in the
1950’s at McGill?
we’ve discussed this and yes there was. While all these things were going on in
the kidney side, I was also one of the junior physicians. And when I had been
Chief Resident I was responsible for doing consultations at night in the Allen
Memorial Institute, the psychiatric wing of the Royal Victoria. The now
infamous, though then famous, Dr. Ewan Cameron was carrying out research on
psychiatric patients. Again I have to say, as with my experience in Hammersmith
Hospital, the lack of ethics in this research of Cameron was not appreciated by
anybody, myself very much included. The fact that he was giving people excessive
doses of electroconvulsive therapy (ECT) to try and ‘deprogram the brain’ hoping
thereafter, having got rid of the psychosis, to be able to reprogram the brain.
It was really an extraordinary piece of medical hubris. This was being carried
on without any patient consent, without any review, they had no research
protocol rthics review -- it was based on trust. The patients trusted him to be
doing things in their interest.
let me ask you though, you say that you really weren’t aware that this wasn’t
optimal, but yet you are obviously a kindly, caring person, indeed the son of an
Anglican minister. Surely part of you sensed that there was something that
perhaps wasn’t the way it should be?
suppose, but no I have to stand condemned by a failure to be sensitive to what
was going on. The part that concerned me most was the insulin coma. He had
another program that was was keeping patients with psychiatric illness as a very
low blood sugar for a week at a time and I couldn’t believe that that was good
for the brain, that “depatterning the brain by hypoglycemia” seemed to me to be
outrageous. And I did say that. But you know, everyone said, "Look, I know this
man Cameron, he’s writing the new book on psychiatry. We’re going to look back
and say how proud we are that we were at the Royal Vic when Cameron was there!"
you did some experiments of your own didn’t you trying a new way of doing
Yes we did and that is an interesting story, which I must come clean on. This
was way back in about 1961, before dialysis was firmly established, I should
have mentioned that between 1958 and 1961, dialysis really came home. Belding
Scribner, in Seattle, found that if you did it frequently -- and particularly if
you started earlier -- that it was very effective treatment. By the way its
very expensive and it was envisioned that there were would never be enough money
for everybody with renal failure to have dialysis. It turns out that for Western
countries that is probably not the case. There probably is enough money for
everybody to get dialysis. But in those days it was not conceived that it would
be possible to raise the $35,000 a year to keep a person alive on dialysis so
one had to look for other things. The one we looked at was called “intestinal
perfusion”. Why not use the membranes that line our body cavities or our gut,
particularly the small intestine, as a means of trying to get the poisons out?
And we did this by constructing, with patients’ consent I might say, openings
into the small bowel, the first at the upper end just beyond the duodenum and
the second at its other end, just before its enters the colon. These two holes
into the bowel were then used for perfusion for six hours a day. During the rest
of the time the bowel was used for digestion. Intestineal perfusion could
control the urea, completely control the electrolyte and acid-base balance, but
still the patients died afte about 6 months.. They died unfortunately from uric
acid accumulation in the heart. Uric acid crystals were seen there in the
autopsy. Uric acid would not come out.. Moral of the story? Why wasn’t it done
in dogs first? It’s easy to say, "Well here are patients that are dying and we
know we can’t afford dialysis for them all. Why not try this and see if it
works?" And of course there’s the enthusiasm to go ahead and do it and of course
you know that patients, when desperate, will agree to things that perhaps one
shouldn’t have asked them. So the problem this time, was that it was research
that had not gone through rigorous animal testing. We would say that the
existences of the situation were so acute for these patient that there wasn’t
time to do the animal testing, but that’s not a valid argument. In retrospect I
consider that whole episode unethical.
the joust to position of dialysis versus transplantation reversed itself as you
said. You have noted that early on dialysis was dangerous and transplantation
was very experimental and then a few years later the reverse perhaps was true,
that dialysis was well established and safe. In view of that, what made you
continue to this big, full steam ahead thrust to make Canadian renal
transplantation so vibrant?
and your right in saying that there was a controversy going in medical circles
as to whether transplantation was justifiable if there was dialysis. The reason
for saying that transplantation should be persisted with, despite the fact that
dialysis was getting better and better, was two-fold. Firstly, in Montreal at
the time, the Montreal General and the Hotel Dieu and Notre Dame Hospital were
all doing long term dialysis and no other hospital was doing transplant. But
that by itself would not be a good enough reason. The other reason was that
there was very little going on in Eastern Canada at that time in treating renal
failure. I’m one of the nephrologists who, unfortunately, can remember when most
of the patients died in two to three months. We would be sent patients from
right the way down to St. John’s, Newfoundland, who were ‘in extremis’, and who
could not come and live in Montreal -- there being no dialysis down there. The
extraordinary success of the identical twin transplant made one realize that
there was a vision there. But, in 1962, Roy Calne, working with Joseph Murray
(who later shared a Nobel Prize) at the Peter Brigham Hospital in Boston ,
showed that “Imuran” combined with “Actinomycin C.” and radiation could cause
kidney transplants to persist in dogs. This soon then led to the same
medicaitons being used in patients, using non-identical kidney donors. When this
was published in the New England Journal of Medicine in 1963, we at the Royal
Vic then decided we would put emphasis on that mode of treatment for human
patients, using kidneys from deceased patients. Now, how well did it work? The
answer is not very well. So poorly, in fact, that there was a meeting in
Washington, I think, in 1965, put on by the Ciba Company where there were
serious questions as to whether kidney transplants were being used prematurely
on humans. There was some talk on a moratorium. That all changed when Tom Starzl
showed better transplant survival with kidneys from family members, (and from
some prisoners who received parital reduction of their sentances – another
serious ethical dilemma!).
Very interesting because not only did you go from liver to kidney and pass the
early rocky stages of dialysis, but you were significantly committed to renal
transplantation to even get into basic immunology.
of course what happened was that we started doing kidney transplants between
unrelated people and we got into rejection and a whole lot of different
problems. And the immunologists, who were consulters, and they said, "Look, this
is not our type of immunology. We can’t really help you with this. You’re going
to have to work this out more or less for yourselves." And it’s a fact that the
allergists, who were basically the immunologists of the days, were not that
interested in getting involved in kidney transplant immunology.
then why didn’t you just rely on the exciting and successful immunology work,
which was taking place elsewhere? Why did you feel you had to do it?
John: Well, because even the places elsewhere weren’t doing transplant immunology at that time, so there was nobody to call virtually speaking. You had to figure out a way, along admittedly with others who were facing similar problems, and try and find your way through this. So we rapidly developed what expertise we could in studying the antibodies that developed after transplantation and after dialysis or after blood transfusion and tried to put together and one of the most exciting events of course was finding out the deleterious effect of antibodies directed against kidney tissue, tissue groups, the HLA antibody and question of acute rejection. For example, a transplant that carried out at the Montreal General Hospita caused yheir transplant program to drop in its tracks. Byill luck, the first transplant that was carried out there was between a wife who received a kidney from her husband. But, because of previous pregnancies, she already had developed antibodies against those factors in her husband’s tissue profile which were foreign to her. because of the fact that these factors were carried on the fetuses. So she was immunologically sensitized to her husband through pregnancy and when they did the transplant it went black on the table and had to be taken out within an hour. Now that is transplant immunology! No allergist will tell you that you couldn’t do that.
nothing seems to have intimidated you?
did what you thought you had to do.
think it was a feeling in those days, now we’re going back along way, that we
had gotten away from the fact that when you developed chronic kidney failure you
always died. Admittedly hemodialysis was establishing a better track record,
though still considered enormously expensive and it was just a persistence to
carry on with this and the fact that we were getting patients from elsewhere who
couldn’t be accommodated on long term hemidialysis.
you tell me briefly this remarkable story or chapter, an hour-long mystery
story…tell me about the circumstances that led you to do this human
In the early part of “dialysis with a view to transplantation”, which was the
program that the Royal Victoria adopted, we were using a lot of blood in
dialysis. Each dialysis patient would get four units of blood a week as the
dialyser (in those early days) had to be primed with two units of blood, each
time it was used. We found, once we started doing transplants on dialysis
patients, that those who had received over a 100 units of blood in the
preparatory period actually did better than the transplants that were carried
out on people who hadn’t been on dialysis long, and hadn’t been transfused very
much. So much that the paper that we presented to the Transplant Society in
1966, we claimed that our policy was, and indeed it was, that you didn’t get a
transplant until you had had a 100 units of blood!! Now you might say “Surely
they would be fully sensitized” This question has never been fully answered as
to why if you give blood directly into the vascular system it does not
sensitize, indeed it produces antibodies that may be beneficial. This was the
basis for thinking that blood transfusion was beneficial and indeed many people,
many units around the world prior to cyclosporin used to use blood transfusion
as a preparatory aspect to transplantation. Were we inducing “stem cell
proliferation?” Who knows! Then a doctor called me from St. John’s,
Newfoundland. He said, "I have this lady who lives at Burgeo on the south coast
of Newfoundland." At that time it was accessible certain times of the year only
by sea. She had kidney failure and I said, "You know we can’t do anything for
that really. That lady is…it’s a lack of access to medical facilities that is
limiting her opportunity." He was a deontologist, I’m happy to say, so he just
put her on a plane with a little note attached to her saying, "Please see and
advise", and she finished up on the ward in Montreal! We didn’t know what to do
with this lady. She had a number of kids and she was a mother of a family of
five I think and there she was. We had more or less decided that all we could do
was to give her peritoneal dialysis until she was feeling well and then
discharge her. There was no question of the family translocating to a dialysis
unit, to a part of the country where there was dialysis. And then another
resident, and I must say both stories I’ve told about this sharpness of
residents are striking! A resident said to me, "You know, that lady there who
has hepatic disease and is dying and this renal patient here – they bith have
the same blood group." He said to me, "You’ve been prattling on about blood
being good for transplants and things."
well I don’t know whether she used those terms, but this resident said, "If one
was to use this patient…if these two patients were to come into some sort of
association, would there be any possibility?" The protocol rapidly formed that
given proper consent, and by now we were getting proper consent, could these two
people live in some sort of symbiosis, the liver of the uremic patient taking
care of the liver problem for the other lady and the kidney’s of the liver
patient taking care of the uremia of the first patient. We decided with Lloyd
McLean, Chief of Surgery at the Vic., who very much supported this, and both
families agreed to a trial of intermittent cross circulation. Both the patients
were stuporous. It was carried out in Intensive Care Unit. They were on bed
scales and arms were connected by silastic tubing. The volume of the two
patients’ were adjusted by just a simple screw clamp on one of the connecting
tubes. You could make the wight of one go up and the weight of the other go down
to get back into balance. The kidney of the liver patient was excreting urine
quite fast and the skin of the uremic patient became a bit yellow and they both
sort of woke up and said, "Where am I?" It was a remarkable experience. They
year was this now?
would be about 1966 – 67. Then we carried this on for a day or two…then we were
in the dilemma that this was working. We disconnected them and they lived their
separate lives for about three or four days and then it didn’t look so good so
we hooked them up again and again both improved. And the question was how long
could this go on? And we tentatively said well look we’ll do it for six months
and see how everything looks at the end of that time. Built into this agreement,
I should say, was that if one died then the organ that the other needed would be
provided by her cross-circulation partner. And that happened on Labor Day
weekend, 1966 I guess, when the surgeon was in Algonquin Park having a good
holiday. The liver lady died from variceal bleeding into the bowel and so there
was a considerable delay in putting her kidney into the uremic patient from
Newfoundland. But this did eventually take place and there was a 19-day period
of oliguria during which time, I must say, people were looking at me as if I was
a bit of a monster! Then the kidney started to work and she went home. She lived
for nine years and she had a baby called Victoria after the hospital!
here you are working on Labor Day, working many nights, we won’t even speculate
what the cost was to your family, but still you weren’t satisfied. You got
involved with helping the formation of the Canadian Society of Nephrology and
perhaps even more so the Kidney Foundation of Canada. Why would you have done
I think the Kidney Foundation one I can answer more directly because it was
clear that what one needed was research. I mean we were involved in things that
we barely understood that had vision of a future and yet was also fraught with
all sorts of dangers and mistakes. I was looking after a young Montreal
architect, called Morty Tarder, and he had Goodpasture’s syndrome and he was not
doing well. We tried to dialyze him but he was bleeding into the lungs and
generally speaking he had a very stormy course and he died. He was about 35 or
so. And his father said, "This is unspeakably tragic. Isn’t there anything that
someone can do about this? I mean why do we have to have this sort of thing?"
Not then, -- but a little later I got in touch with him and said, "You know,
what we need is research and is there any possible way in which you can think
how one might raise money to do research?" And he was enthusiastic. He saw this
as bringing closure in some way to his grief. He had a shop on St. Andre
district in Montreal. He was part of a group of people there. He got them all
together and one in particular took a lead and said he would get involved and
they formed a group, which was going to form a kidney foundation. Now there were
problems getting the kidney foundation started. We didn’t know how to do it. I
was working with Dr. Guy Lemieux from the Hôpital Hotel Dieu and we sounded out
opinion across the country, urologists and nephrologists, and they were all
keen, at least most of them were. Some of them said they thought it was
unnecessary believe it or not. And then this lay group got in touch with the
National Kidney Foundation in the States and there was some dialogue there. So
the conclusion was that we should form a society to raise money. In the first
three years they raised $3,000 a year. Last year, 1968, they raised 3 million
dollars and I understand that the figure has been comparable to that in the last
few years. It’s an extraordinary cause of quiet satisfaction to see how this
thing eventually grew. We had opposition. We had opposition from the heart
group. They said, "Why can’t you just be a part of the heart?"
why can’t you just be part of the heart group? Why does every disease have to
have it’s own patient advocacy group?
think the answer is that the problems are unique and expensive and the direction
of research is not the same. There was absolute agreement amongst those who were
supporting the Kidney Foundation in the early stages. And one of the strongest
supporters was Yves Fortier, subsequently Canada’s ambassador to the United
Nations. It was actually he that staved off that question as to why shouldn’t it
be part of something else.
you say a brief word about the Canadian Society of Nephrology?
That actually formed three or four years after the Kidney Foundation. Originally
the urologists who were well organized, offered to have a medical branch of the
Canadian Urological called Canadian Nephrological and they invited us to join
with them, they gave us honorary membership, and six of us went to their meeting
at St. Andrew’s, New Brunswick in 1964 I think. But the six who were there had
various interests as you know. I mean people who go into nephrology at that time
came from all over the shop. Some were interested in calcium and bone metabolism
and then electrolytes and then kidney and some were coming from other
directions, endocrinology, hypertension into the kidney and they didn’t really
have that much in common with straight urology. So the decision was then made to
form a separate Canadian Society. The first meeting was at the Chateau Laurier
here in Ottawa I think in 1965 and the ultimate charter I think dates from 1967.
By that time there was about 60-70 people who called themselves nephrologists in
so we have now the picture of a minister’s son, experience in India, liver
experience in England, Montreal, pioneering kidney transplantation, undaunted by
being a self-taught immunologist, stimulating patient advocacy, and then why
would you want to move all across this big country to the Rockies?
Well, again I had to make a choice. Up to now it was opportunism. I grabbed at
opportunities. I was made a career investigator of the Medical Research Council
in 1966 and I think it was and 1967 or 1968 I was visited by a MRC’ team led by
Frank Dixon, a famous nephro-pathologist at La Jolla in California. He nailed me
and said, "Here you are. You’re fooling around with immunology and transplants
and you are also trying to be the big clinical doctor in nephrology. You can’t
go on doing these two things. You have to choose. You either stay with the MRC
and do research or let that slide a bit and continue to run a clinical service."
said this to you during a visit?
intimated it and in a little conversation we had and then I had emphasis on this
from the MRC.
his written report?
And I decided I would take the research route.
give up seeing patients?
not give them up altogether, but no longer be sort of prominent in that area.
And so I made certain demand of McGill, which they couldn’t meet or refused to
meet. I said, “You know, I need a proper lab, I need a quarter of a million
dollars for special equipment and stuff like that” and at that time Lionel
McCleod went from Edmonton to Calgary and Lionel had been fairly big in the
Canadian Society of Nephrology. Walter McKenzie, who was Dean of Medicine,
wanted kidney transplants in Edmonton at the University of Alberta. He had a lot
of influence. He’d been President of the Royal College, he’d been President of
the American College of Surgery I think, and he got the government of Alberta to
say that they would underwrite $300,000 for a lab in transplant immunology at
the University of Alberta if Walter knew the right person. It so happened that
Malcom Brown the President of the Medical Research Council also intimated to me
that if I made this move and started something in transplant immunology out in
Alberta that this would be a very suitable place for them to site a MRC group, a
research group, financed entirely by a Medical Research Council. And so he sort
of said if you make that move then you get on with putting in an application and
I should also mention that the University in Alberta also recruited Erwin Demer
from Melbourne, Australia, who was a basic immunologist at last! So the idea was
that there would be two directors of this unit, one more clinical but looking
toward basic, and one basic and hopefully looking a bit clinical. And the MRC
then funded that and we had it for ten years. It was very well funded and we
were very fortunate.
let me repeat if I may a question. Leaving your patients, leaving this close
contact in a large measure, didn’t that foster in you some discomfort? Was there
any sense of abandonment in the heart of this Anglican minister’s son?
there was. I think it was reflected by the fact that I didn’t actually take up
new patients in Alberta for a couple of years. I did entirely the research
thing. That difficulty in academic medicine between dedication to patients and
the problems of dedication to research, and you can’t do them both fully is a
dilemma for academic medicine. You may have experienced it too. And nearly
everybody who does research here in academic medicine as physicians finds this
are some of the highlights of your early years in Alberta with the MRC group?
focus was quite different now. I was not responsible for patients with clinical
problems. We started to look into the whole question of tissue typing,
histocompatibility is the fancy word, but it’s really tissue groups as distinct
from blood groups, and we were looking for special populations because one might
expect their different tissue groups to be simpler, and more restricted. So we
decided on the Arctic and went up to study histocompatibility amongst the Inuit
-- in several expeditions funded by MRC. The Inuit are in a sense an inbred
strain of human. They have been inbreeding or interbreeding in relatively
limited number of people for 20 thousand years and we found in fact that there
were a whole lot of families where they all typed the same. We were able to find
what at that time was important in histocompatibility, namely homozygous cells
for use in mixed lymphocyte culture, MLC. We found a number of people with
homozygous HLA antigens on their cells and we actually sent these frozen in
their liquid nitrogen ampules around the world to the histocompatibility labs
and workshops. That was very expensive of course, but it was worthwhile and we
did do skin grafting there. We were very much helped by somebody who could speak
the language, Dr. Otto Shafer. Then I did similar work with the Hutterites
in Alberta who had had close breeding for 2-3 hundred years since they went
from Germany out to this continent. They also had a limited number of tissue
antigens and were able to give certain insights into histocompatibility. Those
were two of the areas, but the main area I suppose was immunological monitoring
of the events going on in the blood of patients after transplant, both cells
that were trained to be killer cells to the transplant as well as antibodies.
nobody was immune from your inquisitiveness, in fact you yourself fell pray to
your own curiosity.
John: Yes, I
have to admit to that. We were looking for “enhancing antibody” -- antibodies
that would help grafts survive and we thought we’d found one. And it happenned
to react with my cells. It lead to a protocol that we thought was worth doing
and we didn’t want to go through all the rigmarole of an ethics board, so we
decided on human experimentation between the two investigators. Well, with the
other investigator, it went pretty well. I gave him some of my skin and some of
the serum. Unfortunately the lab had misread part of the test in my case so that
when the serum was run into my veins -- following his skin graft -- I developed
an anaphylactic reaction. I’ve said this a number of times. “If you ever want to
see the head of your department and the Dean of your faculty in short order,
this is one way of doing it” because I remember waking up in the emergency room
and there were these two faces looking at me somewhat anxiously! But it all went
off…nothing much…there was no residuum, but it did teach me about the ethics of
auto- or self-experimentation. It is a serious matter not to be undertaken
lightly and does require ethics review and that's the part that I think is very
you knew that before you started the experiment?
John: Yea I
then here you are at about the age of 60 when most people want to have a summer
boat and slow down and play golf and read and then you made another big move.
John: Yup. By this time, and we had been in Alberta for a period of nearly 20 years. I had moved more or less back into clinical work and some of the research had metamorphosed into other things and I was no longer primarily involved in that, though I was still supported by Medical Research Council. One day there was an article in the Edmonton Journal and subsequently in the Globe and Mail where one of the patients had said, "I will give anybody $5,000 if they will give me a kidney." He had been on dialysis or several years. He was a very intelligent businessman actually who just got fed up and said, "I want out of this!" and he developed this stratagem for doing so. He had 200 people from across the country offer to be tissue typed for giving a kidney for 5,000 bucks. Seems absurd. Then we pointed out to him that this was against the law!. So he said, "Fine, I’ll ask for a kidney out of sheer love!" And he did so and he had about six people who were very keen to give him a kidney ‘out of love’ whom he’d never seen. And he came along and said, "Now what are you going to do about it?" And I said, "You know this isn’t our policy." And he said, "Who made you the policy maker? By what right do you as a physician involved in this game, make social policy for Canadians?" And of course he was quite right. We do make these presumptions and it caused me to think very much just who does empower physicians and the medical world to make enormous decisions on strategy and policy. And the answer is nobody. There is obviously trust that the medical world will do the right thing in the long run, but it made me very interested in the interaction between public policy and medical practice. At the same time I was also concerned about the fact that I thought people were making difficult and wrong decisions, particularly older people, in going on dialysis and not being able to do anything about it when it didn’t go well. So we formed a Quality of Life committee that didn’t actually interview patients but did discuss their problems at length. On this committee were non-medical people, including clergy, and we tried to see how societal values could impact medical decision-making in such a difficult decision -- where one’s life was at stake and yet if you made a mistake your life becomes miserable. All these things combined with the fact that I felt my fire for research had burnt out pretty much; this made me determined to take a sabbatical and that’s where I must say the academic life is wonderful in being able to give you an opportunity to go off and do something quite different. I wanted to do medical ethics. . . .
old were you at that time?
would be 61.
So you went off to Hastings Institute for Ethics.
John: Yes, I
first went to David Roy at the Institute for Clinical Research in Montreal for a
short time and then to Al Johnson at the San Francisco for a month or so. He’d
been there for many years teaching medical ethics. And then, but by far the best
experience was the Hastings Center in New York and the Kennedy Institute course
in Georgetown University. During all that time I put together a proposal for a
bioethics initiative at the University of Alberta, which Dr. Doug Wilson
accepted. He, as you know, David, is a nephrologist. He was then Dean of the
Faculty of Medicine and Dentistry at the U. of A. He said that they wanted this
so I was sort of mandated to develop it and so on.
what is it called today?
today it is called the John Dossetor Health Ethics Centre. They gave me that
honor of renaming it when I left last year.
John, despite your kindliness and compassion, you’re rather feisty. You have
some strong views on purchasing or vending kidneys and you haven’t hesitated to
express them. Do you think people should be permitted to buy and sell kidneys?
John: To be
quite frank I think that people should be able to do with what they want with
their own bodies. I happen to not want to do that, but if someone felt that they
should I see no reason why just as I don’t see that somebody who wants to
prostitute themselves for money should be put in jail or somehow inhibited. The
question is, who has the right to get involved in such a transaction? I don’t
think the medical world should ever get involved in a monetary transaction
involving tissue or organs. I’m not saying that I don’t think that if someone is
convinced they should have the right to sell part of their body that is their
right. They own their own body. But I do think for society to get involved in
this, and particularly the medical society, they are betraying the trust that
the public has every expectation and right to have in the integrity of the
we’re coming to the end of this at least this spiritual and value inquiry into
your development and helping others. What effect do you think you have had and
your centre had on young physicians in Alberta and on others?
know that’s a difficult question.
That’s why I asked.
think the answer to the question is…”We’ll just have to wait and see.” I think
my initiative in bioethics is part of a wider of initiatives that are going on
elsewhere in bioethics. Bioethics or ethics in healthcare delivery is a growing
subject. It’s a rapidly growing area. The old authority, apprenticeship by young
physicians learning their ethical behavior from their paternalistic mentors, all
that’s going, or has gone, hopefully! There is now a new way of looking at
decision making, with patients participating, in fact even the word patient is a
bit of a problem I think. Its still widely used and I still use it, but its
people who have illnesses should participate with their physicians in a joint
development of a comprehensive treatment, which they comprehend. It’s more than
consent. I’m personally a believer in comprehended consent rather than informed
consent. And I think all that is part of a movement that is hopefully improving
and one might even say cleansing some of the paternalism and all that out of
there’s a practical contribution, which you have made. You’ve been called upon
to look at organ donation and organ retrieval in Canada. It’s not a coincidence
that you’re a nephrologist and an ethicist. Could you comment on that? They’re
useful things that come out of your work.
think that in a sense there is recognition that I have made certain commitments
in my life and why not use it? I think its natural that people should want to at
least have that viewpoint represented and I have been flattered actually by the
fact that people still are interested in having me participate in those things
even though my contact with the bedside problem is rapidly receding and my
knowledge of medicine has decreased considerably. It’s now nearly ten years
since I practiced medicine. I don’t have a license any more so I really am only
qualified to speak on values and that component of the process and I’m happy to
its decreased from a stunningly high level!
John: Well I
don’t know about that!
Members of the International Society of Nephrology might say that your career
would only have been possible as a nephrologist. That is to say your achievement
in medical ethics, your inquiry into medical values, into patient advocacy
really is inimically related to the fact that you had early experience watching
so many patients die. You are aware of rationalization of scarce resources and
we spoke of this question of organ vending. Do you think a non-nephrologist or
had you been a dermatologist or a neurosurgeon you would have had the same
trajectory in this story of your professional life?
John: I can
only speculate, but I think I agree with you that I believe that I have been
enormously privileged to live through a period of medical development that
happens to be most acute in the kidney field where I started from, 100% failure
and finished up with 95% success either in dialysis or transplant. All through
that period I think nephrologists have been very fortunate and their
experience…Whether this will happen in the future you know one hates to think
that the future for others cannot be as rosy as the past was for me. I think
it probably is, but one can’t foresee that at the moment. But I do believe that
nephrology has given a group of people considerable opportunity that would not
have necessarily come from neurosurgery or dermatology.
will carry on now in the future John?
don’t know. As far as ethics is concerned in medicine, I think that’s going to
carry on, that’s in a growth phase. It’s going to be partly with physicians and
I hope increasingly so, although there are problems financial in going to ethics
for physicians because its not as well paid. I think women in nursing should
fully share their experiences and their decision making with medical ethicists,
and although there are laws concerning who can write drug prescriptions, etc. --
all that is going to go or be modified. I think dialysis units are a very good
example of how there is shared decision-making between nurses and physicians. So
I think there are movements afoot that are going to go on developing and
perhaps as our last question, which of course we can edit out. If a young John
Dossetor of 24-years old could sit beside us and listen what might he comment on
your remarkable life?
John: Oh! I
think that the person should say to herself, well this is just one man’s
experience. This was just one phase of the development of medicine and of
healthcare and of health, creation of health, which is a lot different from
delivering healthcare. These guys can’t see the opportunities that are going to
come my way just as no one could foresee the opportunities that were going to
come to him! and I hope they’d come my way so I can 50 years later say, well
no-one me this past fifty years, but I hope that they will be as worthwhile!
John, Dr. Dossetor, on behalf of the International Society of Nephrology thank
you ever so much for sharing this insight into the mystery and the joy of a
distinguished career. Thank you so much!