LETTERS

On ethics (1)
I hope the Forum for Medical Ethics will be able to act on the minds of at least a few doctors for the betterment of society. Unfortunately, ethics is something that cannot be injected into persons.

I am 64 years old. I have been practising in India for over eighteen years and find rapid deterioration in both the quality of medical practice and its ethics. This, in my opinion, is because there is no punishment against any trespass of rules and codes.

In fact, these days there is no punishment (only harassment) for any infraction in any field in our society. Ethics have hit a low, be it in teachers, judges, lawyers, priests, businessmen, police, government servants and, of course, politicians” Lack of merit and ethics are associated with corruption in every field.

As Dr. Shivram Karanth says, there is no pramaniktha in the actions of most persons. How true!

Shedde Prabhakarrao, Ratnakrupa,Shivbagh Road Kadri, Mangalore 575002

On ethics (2)
I find the issues of MedicaZ Ethics full of thoughtprovoking ideas and information provided by experts. These issues should also be read by lay persons.

May I suggest that you publish this journal monthly?

It is necessary for branches of the Indian Medical Association located in the various districts of each state to discuss the different topics covered in your journal. Certainly, they should subscribe to the journal. It is only when we, as members of the medical profession, introspect on these matters that we can hope for improvement.

R. M. Ambulgekar,32 Bhagwati Colony Aurangabad 43 1005

Organ transplantation
I wish to react to the letter from Manu L. Kothari and Lopa A. Mehta on this subject. ’The authors have objected to organ transplantation on two counts. ’

i) Possibility of malpractice in the form of murder to obtain organs once cadaveric transplant program is started in our country. This fear is based on fiction (by Dr. Robin Cook) and therefore appears to be fictitious. Whilst I share the authors’ anxiety on the possible misuse this is, in reality, unlikely. Experience in western countries, where cadaveric organs have been used for transplantation for over two decades, has shown that there has been no misuse as depicted in Coma. Every law can be exploited by the unscrupulous. To prevent such abuse one needs an honest, conscientious person in authority. If those in charge turn a blind eye - as was done recently in Bombay and Bangalore, misuse is inevitable.

ii) Futility of organ transplantations due to poor bio- availability, post- transplant physical ill health and fiscal consequences. There is always the possibility of a transplant failing but the risk of such an event is 10% with kidneys and 15% with livers. Aren’t such failures seen with other therapeutic modalities as well? Will the authors disallow any treatment that cannot guarantee 100% success? If 85 of 100 patients with irreversibly damaged livers can return to work 2 isn’t this to be preferred to all of them dying or remaining bedridden, economic and psychological burdens to their families? Failure is nothing but success turned inside out.

Transplantation is expensive in the West. A liver transplant there would cost Rs. 40,00,000 to Rs. 70,00,000. By my estimate, and that of others, the cost in a public hospital in this country would be Rs. 1,50,000 to Rs. 2,00,000.

Bio- availability may improve and postimmuno- suppressant infection reduced with the development of gene therapy a dream that will come true one day.

Let us accept that organ transplantation is the only hope for thousands with end- stage organ failure whose life is otherwise endangered. This procedure has come to stay despite reservations on the part of some. In order to curb unethical trade in organs from live persons it is essential for us to develop our program for using organs from cadavers as envisaged in the Human Organ Transplantation Act (1994). It is the duty of all socially conscious persons - especially those with the benefit of training in medical science - to support it.

References
1. Kothari ML, Mehta LA: Organ transplantation. Medical Ethics 1995; 3: 30.
2. Starzl TE, Demetris AJ: Liver transplantation. A 31 year perspective. Current roblems in surgery 1990; 27: 225.
3.Mathur SK: Liver transplantation in India - are we ready? Indian Journal ofGastroenterology 1991; 10: 142- 143.

S. K. Mathur,Professor of Surgery K. E. M. Hospital, Parel, Bombay 400012

Force- feeding a prisoner
A sigh of relief was heaved when Sunderlal Bahugana, the eminent environmentalist, ended his forty- nine- day- old fast. His health was rapidly deteriorating by then, with falling blood pressure and acetone in the urine.

The authorities had arrested him and taken him to the All India Institute of Medical Sciences, New Delhi, ostensibly to save his life. Bahugana, an advocate of naturopathy, refused modern medical care. On the basis of his decision, the court ordered that he be shifted out of hospital.

What is the role of the doctor in such a situation? If the doctor in charge feels that the life of a fasting leader is in danger, can the latter be force- fed or given intravenous fluids and electrolytes against his wish? What should guide the action of the medical professional - the wishes of the patient or the threat to his life?

Many feel that the doctor’s action should be guided by the Geneva Declaration (the modified version of the Hippocratic oath) which says that the health of the patient should be the first consideration of the doctor. If this guideline be followed, the doctor is justified in force- feeding the fasting individual.

In fact, the doctor’s action should be guided by the Declaration of Tokyo adopted by the 29th World Medical Assembly in October 1975. Clause V reads: “Where a prisoner refuses nourishment and is considered by the doctor as capable of forming unimpaired and rational judgement concerning the consequences of such a voluntary refusal of nourishment, he or she shall not be fed artificially. The decision as to the capacity of the prisoner to form such a judgement should be confirmed by at least one other independent doctor. The consequences of the refusal of nourishment shall be explained by the doctor to the prisoner.”

Fortunately for the medical profession such a dilemma was avoided when Bahugana ended his fast but a similar situation can arise in the future.

B. Ekbal,Professor of Neurosurgery Medical College Hospital Kottayam, Kerala 686008