LETTERS

A morale- booster from an eminent ethicist
I just noticed that you have an email address. So I take this opportunity to express my sincere thanks to you and the Editorial Board for sending me the journal of medical ethics.

It is certainly getting better and better. You are all doing a wonderful job, and I feel it was high time that such a large country as India have its own journal on the moral dilemmas of medicine.

Congratulations! Keep up the good work. If by any chance my standard of living elevates to the level of a simple bank clerk then you may expect a financial contribution to the journal even from me!

Bela Blasszauer
Medical University of Pecs
Pecs, Szigeti u. 12.
7624 H u n g a r y
Email:bela@cortex.pote.hu

Hospital ethics committee
We have learnt of an hospital ethics committee that has been set up in our institute. I place my thoughts on this subject in the hope of stimulating discussion on the subject.

An ethics committee is easy to constitute but its functioning can appear very nebulous, especially in a multi- religious and multi- cultural institution such as ours. It is so much easier for such a committee to function in institutes run by religious organisations which already have clear-cut ethical principles which govern the thoughts and shape their actions. It is also relatively easy for it to function in the West where the Judaeo- Christian ethic has homogenised societal attitudes and behaviour.

Our own ethical norms in this country are confused. We have codified, or tried to codify, principles of ethical behaviour based, I believe, on Judaeo- Christian thought that was imbibed by Indians educated by Western minds and exposed to Western literature. I believe the time has come for our Medical Councils to face this issue head on and formulate ethical norms that will encourage practice in keeping with our traditional and modern Indian values.

Of course, there are underlying humane values that run like a common thread through all religious and cultural traditions, which should form the backbone of our code of ethics.

In spite of what I believe, I know that Medical Councils will not fulfil their legitimate role. It will be up to small groups (such as the ethics committee at Tata Memorial?) to show the way. This, I hope, will be a positive fallout of the exercise.

I also hope that the ethics committee will not be an exercise in cosmesis. (I am not so bothered by the witch- hunting problem. Far worse is to sweep evidence of malpractice under the ethics committee carpet.)

To this end I would suggest that the Committee be renamed the Ethics and Standards Committee. Members of all departments, including the staff from the nursing, administration, social service and other departments,constitute an extended group that could meet every alternate month to review existing non- technical patient care practices and suggest improvements that would contribute to overall healthy functioning of the institution.

The problem may be a small one (eg. dealing humanely with death in the hospital environment, including the nitty- gritty of handing over the body, reduction of bureaucratic procedures at this sensitive time etc.) or a major issue such as the lack of access that the general (non- paying) patients have to consultant level care on a day- to- day basis.

I feel that until there is a full- fledged quality management exercise instituted at the Tata Memorial Hospital which would include a formal medical audit, the Ethics and Standards Committee could fill this gap in keeping with their avowed objective of improving patient care in its technical aspects.

I think an ethics committee is a step in the right direction, but it will remain only a step if all it does is review projects and lay down codes of behaviour in a esoteric manner.

To be effective, ethics should not just be preached but practised. We live in a world where the motto seems to be, ‘Do what I say - don’t do what I do.)

Anita Borges
Department of Pathology Tata Memorial Hospital Parel, Mumbai 400 012

Objectivity in journals on medical ethics
Exhibiting your personal opinion without fear or favour is one of the most important principles in the review of medical ethics

While reading several editions ofIssues in Medical Ethics, I noticed that most articles are clearly written from a personal view. Most contributors do not seek shelter in objectivity or refer to authorities on the matter, which is common in the ‘scientific’ journals.

It seems to me that the main objective of a journal on medical ethics is to extend your own opinion by reading others, rather than to obtain objectivity. Of course one has to obtain objectivity concerning the factual situation, but, as a matter of fact, moral objectivity is not always realisable. Thus, argumentation may be your only tool to reach agreement and, as I noticed inIssues in Medical Ethics, this tool can be very thought- provoking.

Roland D. Thijs
Holland
e- mail:R.D.thijs@med.ruu.n

Corruption in medical care - is the market the cause?
One of the most striking features of medical care in India is the extreme inequality between what it offered to the rich and to the poor. The majority of patients living in villages do not have access to the most basic necessities such as immunisation. The metros are flush with the latest technological marvels several times over, the several magnetic resonance scanners being one example. It is, however, a mistake to think that this metropolitan plenitude necessarily translates into better medical care. Those with money to burn are often subjected to unnecessary and inappropriate investigations. Often, the results of such tests only complicate matters, cause unnecessary anxiety and convert hitherto healthy captains of industry into quivering bundles of neurosis. When such tests are followed by unjustified surgery, the horror is compounded.

Pressures of the market worsen the situation. Let me provide an example. In the town where I live, a few doctors acquired a computerised tomography scanner (CT). It was not long before the need to pay instalments began to worry them. The group cajoled colleagues in practice to refer patients for scanning by ‘extending the indications for a scan’. The ubiquitous practice of offering a financial incentive for such reference - disguised as ‘interpretation fee’ - was already in vogue’.

Examples of unwarranted surgery abound. Recently I saw a patient with tuberculosis of the lumbar spine without neurological abnormality who had been subjected to an operation to fuse the diseased vertebrae. It is standard practice to treat such patients with anti- tuberculous drugs alone as there is seldom any instability. Two months after the operation, the plates and screws came off the bones they were supposed to fuse. She had to undergo another operation to remove the metallic implants. Examples such as these are numerous and each doctor sees only the tip of the iceberg.

lssues in Medical Ethicshas discussed this problem over the past three years. What is the solution ? I am not convinced that appealing to the better instincts of the medical personnel is likely to improve matters. The very organisations set up to ensure ethical practice - the Medical Council of India and the state medical councils - are themselves mired in corruption.

I believe the only answer is removal of the cause, namely the possibility of fleecing patients of huge sums. In other words, we must abolish the market in medicine. This is possible through a system that ensures universal medical coverage to all our citizens and registration, perhaps by the state, of incomes of doctors and other personnel in the health field. A socialised system will not easily lend itself to corruption.

Reference
1. Mani MK: Our watchdog sleeps. and will not be awakened. Issues in Medical Ethics1996; 4: 105- 107

Thomas George
G 9 Railway Colony Ponmalai Tiruchi 620004

Doctor pressurised
On July 12, 1996, a police party headed by ASI Sikandar Singh of Police Post (PP) Jagdev Kalan visited the house of an old handicapped man Ajit Singh whose wife is totally confined to bed, in village Kotla Gujjran, Jhander. The old man was beaten up and taken away. He was brought back in a seriously injured condition and left. People took him to the PP in the village. The police recorded a report under Section 323 IPC which is for a non- cognisable offence. People were advised orally to take him immediately to hospital. He was taken to the Guru Nanak Dev Hospital where injuries were recorded. Afraid that he might die, the culprits and their friends helped in efforts to save him by giving funds and by arranging for blood. Ajit Singh, however, died.

The police bosses of Majitha police district tried to pressurise the family and relations of the deceased to compromise. When this did not succeed, the SSP himself took the position that it was a case only under the Section 323 of IPC and there was nothing to be done by the police. When the leader of the Communist Party India (CPI), Satya Pal Dang ,took up the cast, the SSP gave an explanation that Ajit Singh's death was due to old age. To support this, he said that the doctor who did the post- mortem has given such an opinion. Apparently the doctor concerned gave such totally wrong opinion under the police pressure. The SSP however agreed to order a fresh inquiry.

ASI Sikander Singh and his party had no jurisdiction in PS Jhander. It visited Kotla Gujjaran because some altercation had taken place. between a son of Ajit Singh and a relative of the ASI. In this, the latter had received some injury. In this matter a case had already been registered and the son of Ajit Singh arrested. The ASI, however, chose to take the law in his own hand and took the revenge in the manner described above.

While the SSP has recommended a magisterial in enquiry, the activists of the CPI and some concerned people from the village have requested the DIG, Police, Border Range and the District Magistrate to order registration of case under Section 304 IPC. However, the law has yet not taken its course

The above account is based on the inquiries done by the activists of the CPI and some villagers and is also made public in my statement dated September 9, 1996.

Ms. Vimla Dang, MLA
Ekta Bhavan, Chheharta (Amritsar) Punjab 143105.

Flaunting our ‘honours ’
We, medicos, are known to be vain peacocks strutting around, spreading our qualifications and professional feathers. There was a time when a cardiologist in Mumbai sported degrees and honours totalling a record 65 alphabetical characters, topped by the then popular 'SEM'. In desperation, Bombay Telephones ruled that henceforth it would refrain from printing degrees and qualifications!

We often wonder to whose good such display is directed.

Alternative medicine is a movement geared towards weaning patients away from the glamour and glitter of allopathy. Alas! There too, overkill is achieved by prefixing and suffixing names of leading lights in a manner that, unhelpably, betrays vanity.

As an example in point, we quote fromHolistic Mediscan, July 1996. Therein, a dignitary is introduced as “Lord Pandit Professor Dr. Sir Anton Jayasuriya, Chancellor OICUM”. It may be that this has some rationale in our age, governed as it is by imports from Madison Avenue - not only should drugs sell, but so should doctors!

Manu V.L. Kothari
Lopa A. Mehta
Department of Anatomy
Seth G. S. Medical College Parel, Mumbai 400012

Irrational X- ray tests
Most companies, while recruiting employees, conduct x- ray tests as a regular protocol of health assessment of applicants. This is performed regardless of an identical recent x- ray examination of an individual and without checking previous records. A person changing jobs is thus exposed to frequent ionising radiation.

The personnel department also refuses to pass on the data on his health to the individual. Since earlier x- ray films are not available to the next agencyrepeat exposure to x- rays becomes inevitable.

The patient is told that the x- ray test involves ‘a small risk’. Should this justify repeated, routine x- irration of that person? Shouldn’t clinical examination be a guideline to prescribing the test?

Is the medical profession over- using this helpful but hazardous test? This is a question of great relevance to young persons who constantly seek better prospects.

N. G. Wagle
Chartered Chemist and Consultant Chemical Technologist
31 Radheshyam Apartments Juhu Lane, Andheri West Mumbai 400058