LETTERS

Ethics in medical education
This is in response to Ethical problems in medical education by Dr. F. E. Udwadia . I congratulate him on a well written article that summarises the ills besetting our medical education system.

In his last paragraph, he decries the sharp, progressive fall in values all over the world, more so in our country'. I submit that this has happened in our country, slowly and steadily over the years since Independence, due to a steadfast refusal of the educated middle-class to involve themselves in the public sphere, be it social or political.

Social values are not lifeless or abstract but are living entities that need to be nurtured and shaped with time. If abhorrent social behavior is tolerated, it gradually becomes the norm with a gradual, steady downward spiral. We have felt that it is enough to be virtuous while deliberately closing our eyes to the lack of virtue around us. Many more have been guilty of the sin of omission than the few who have actually committed unethical acts.

Even while I was an undergraduate student in a Bombay medical school in the sixties, there were flagrant violation of ethics in the form of favouritism during exams, deliberate flunking of candidates to settle scores among themselves by examiners, hazing of candidates due to rivalry among the medical schools, to name just a few. Training posts and jobs as honoraries or full-timers required 'pull'. Cronyism and nepotism were rampant. The power of money was obvious. The corridors of medical schools were agog with news of one scandal or another but though the doctors whispered about the wrong doing of their colleagues behind their backs, they rarely expressed disapproval to their face.

The reasons given varied from "How can I offend her/him, (s)he is a good friend, our families know each other?", to the straight forward "Well, one needs the help of these people in future, so I can't alienate her/him." to "I don't want to get involved in this muck." and "What can I, a lone person, do against a powerful system?"

That times have not changed this attitude was brought home to me recently when I overheard a conversation where a doctor was relating how he was offered a suitcase full of money to pass a candidate in a postgraduate exam and how he angrily refused the bribe. Unfortunately, his anger did not extend to taking a meaningful action against the person offering the bribe.

If we want to change the medical scene we,the bystanders, will have to express strong disapproval to the miscreants, unmindful of the result of our action on the miscreant or ourselves. If we can register a complaint with the responsible authorities, however spineless they may be, that would be even better. Even a verbal censure has the effect of modifying objectionable behavior. This has been shown by Dr. Erwin Staub whose study on the role of bystanders was inspired by his observation of the treatment of Jewish people in Eastern Europe during Nazi occupation. We can certainly change the medical system but before that we will have to change ourselves.

Meenal Mamdani, 811 N. Oak Park Avenue, Oak Park, Illinois 60302, USA

Reference:
1. Udwadia FE: Ethical problems in medical education. Issues in Medical Ethics 1997;5:37-39.

Ethics in India
There is so much of 'ethics' in the air, even among our political (frightened) class that there is a distinct fear of the rhetoric becoming hypocritical, imitative and demonstratively vulgar. We shall again elevate ambivalence into a mystique and refuse to see truths steadily.

I saw this dance of rhetoric divorced from meaning during an extended tour of Tamil Nadu, with many tall poppies mowed down and yet not seen as guilty by a significant minority! Most of them have bought the argument that for a politician a term in jail is almost the same as losing an election!! -meaning it will pass (- and soon).

R. Srinivasan, Former Secretary Ministry of Health and Family Welfare B-49 1, Sarita Vihar New Delhi 110044

Issues in Medical Ethics (1)
Thanks for sending me the January-March 97 issue of your very significant journal and the subscription slip - this kind of systematisation is good, especially because subscribers tend to forget renewing their subscription unless reminded for. I am enclosing a cheque

As a lay person (I'm not a medical doctor) and a concerned citizen, I find your journal of immense value as it so firmly contributes to humanity's health in a holistic sense. For your great work (and it's rare now-a-days) I congratulate you and the editorial board members.

Without any doubt, Issues in Medical Ethics is the only journal on medical ethics in India. I'm sure in days to come your family of subscribers (medical and non-medical) will be large enough to provide you further sense of its unique worth.

Amrit Gangar,H-l 56 Mohan Nagar, Dahanukar Wadi, Kandivali West, Mumbai 400067

Issues in Medical Ethics (2)
I congratulate you and your staff for publishing such a good journal when all around us scams are going on, morality is at the lowest level and (it is) hard to find doctors doing ethical practice.

Bipin Desai,Children Hospital 2/1933 Majura Gate Surat 395 002

Issues in Medical Ethics (3)
I am receiving your journal regularly and go through it with interest. I particularly appreciated the article on medical practitioners abetting politicians. One topic which hasn't been discussed so far in Issues in Medical Ethics is the unethical promotion of drugs by pharmaceutical companies. Although this may be an obviously unethical and undesirable activity to many of us, there are an equally large number of practitioners who don't see any wrong or even feel it is a legitimate activity. An article on the topic, may be at a 'lower' level than other articles appearing in the journal, may be necessary.

Ravi D'Souza, C/o Gram Vikas Mohuda PO Via Behrampur (GM) Orissa 760 002.

Issues in Medical Ethics (4)
The journal appears good and most of the cartoons are wonderful. Keep it up. Recently the Tamil Nadu government enacted a legislation to regulate the the mushrooming private hospitals and clinics which are run at substandard levels by any standard, and basic ethics are thrown to the wind. Now the IMA and Dental Associations are up against this legislation.

I wish someone mkes a study of it and writes an article in the journal.

R. Venkataratnam, MIG 332/l Anna Nagar Madurai 625020.

Issues in Medical Ethics (5)
Your editing of the special issue of Humanscape was very nice! It will definitely help to carry the message of medical ethics to a wider section - an enlightened one - of our society. We can expect more activity in this field in future. It will be interesting to know the feed-back from the non-medical readers of that magazine,

D. S. Srotri,D 103 Bharat Nagar 104/l Erandawana Pune 411 038.

(Dr. Amar Jesani of our journal had served as guest editor of the issue of Humanscape dated March 1997. A free copy of this issue was kindly sent to all subscribers of our journal by the editor of Humanscape -Editor)

Modern medical practice
Abusive modem medical practice
Creates scares about allergies,
osteoporosis,
Cancer, high cholesterol and diabetes.
And blows diseases out of all proportion.

People are stampeded into check-ups and monthly tests,
Boosted by sales personnel and advertisers,
Who promote hospitals and 'services',
So that well or ill,
people are subjected to tests.

Tests often reveal 'disorders'
that cause no disease,
Causmg anxiety on the need for 'intervention',
Converting asymptomatic persons into patients
To whom the doctor now prescribes expensive treatment.
Care providers get commissions and bonus,
Good for specialists, laboratories
Pharmacies and lawyers.
Gut not for the patient whose woes worsen
Doctors' ineptitude arises,
as they treat trivial complaints by complex means,
Producing doctor-made diseases
cryptically termed iatrogenic.
As superfluous tests disturb health and peace of mind,
Superstitions, phobias and socio-cultural influences
Lead to change of physicians,
Pushing many to alternative medical systems.
Is there a cure?
Mushrooming nursing homes and diagnostic laboratories
Must be subject to quality control and national norms.
Health care delivery must be delinked from profiteering.
Professionals must bc made to apply medical ethics,
The public must acquire health awareness,
Seek education for healthy living,
And modify life-style to prevent and promote health.

A. Uma and P. Thirumalai, Kolundu Subramanian,Madurai Medical College, Madurai 625020

Prescription by remote control
I reproduce beiow two examples of medical advice prescribed by a surgeon through the columns of a newspaper without having obtained a detailed history, examined the patient and arrived at a scientific diagnosis. Both items are from the column entitled 'Bodywatch' by Dr. Vithal Kamat published in Navhind Times.

The first extract is dated 19 April 1997:
"Q.: I am a 11-year-old boy having some facial problems. They are:
(1) My face is full of pimples and blackheads
(2) There are very small black clots in my nose
A.: Keep your face clean... Take cap. tetracycline 250 mg. twice daily for one month, then once a day for one more month. Take vitamin A and vitamin B complex for two months..."

The second item is from the issue dated 17 May 1997:
"Q.: I am a 28-year-old unmarried girl, Since some years ago, I used some external
objects to arouse sexual pleasure. Now I have a foul-smelling discharge
A.: . ..Take a course of antibiotics - tablets ciprolloxin, 500 mg. twice a day for 8 days..."
Is this ethical'? If not, is there a remedy through the Medical Council of India?

A concerned surgeon,Panaji, Goa 403001

(We posed this question to a senior consultant experienced in writing for the media. This is his response:
"It is unscientific and unethical to treat patients through correspondence. Prescribing drugs, especially those with side effects - and there are precious few without these unwelcome attendant effects 'by long distance' is also hazardous and may land the patient into a sorry mess."

"The best that a medical columnist can do is to make general observations and guide the person requesting help to her family physician or a relevant specialist. When recommending a specialist it is important not to favour any specific individual. It is best to direct the patient to 'a reputed surgeon' or 'a reputed endocrinologist' rather than Dr. A.B.C. If a teaching hospital is available nearby - as it is in Panaji - the patient can be guided to the appropriate department there so that treatment is made available to her at minimal cost."

"As regards the Medical Council of India, Dr. Mani's experience, published earlier in your journal', does not permit optimism. Even so, there is nothing to be lost by 'A Concerned Surgeon' bringing this matter to their notice." -Editor)

Reference
I Mani MK: Our watchdog sleeps and will not be awakened. issues in Medical Ethics 1997;1:105-107.

Medical ethics: patients and relatives
Medical ethics merits continued debate throughant the lifetimes of doctors, patients and their relatives. Sometimes this results in acrimony, throwing more heat than light on the subject. As of today, ethics are practised more in their breach than in their observance. Just as it is with sincerity, ethics cannot really be taught. Both must come from within.

Life is constantly changing and so do medical ethics. After all, medical ethics and the medical profession as a wbole are mere reflections of society at large. In India, we are not permitted to advertise ourselves. even so, we continue to do so on the sl and, in some cases, through whispers and whimpers.

I would like to quote a personally experienced ethical dilemma. Two decades or so ago, a senior gynaecologist, approximately of my age and standing, had discussed one of her indoor patients with me. We happened to be attached to the same institution. Subsequently, she went on leave, deputing me as her locum tenens. The next day, I first saw my own patients and then those being attended to by her. Her patient then asked me, "Does a patient have the right to change her doctor?" It was obvious that she was referring to her own specific case and implied that she wished me to look after her care for good. How was I to resolve the dilemma ethically? After some thought, I told her, "The patient has an absolute right to change your doctor. But then the patient must consider the fact that her current doctor, who has treated her for years, knows all about her illnesses and understands her system. A new doctor would be ignorant ,of several details.

Hence, if the patient has faith in her original doctor, it would be wise for her to continue to seek her help." She got the point and continued with her original consultant.

Arvind R. Kapadia, Consultant Obstetrician and Gynocologist Basement Clinic, Bhatia General Hospital Tardeo Road, Mumbai 400007

Conference Announcements
Public Responsibility in Medicine and Research has announced its schedule of meetings.

6 November 1997: Conference entitled Reviewing and revising the expedited categories of research. Among the topics for discussion are:
a) expedited review of routine m-approval applications'

b) disposition of growing number of adverse experience reports;

c) expedited review of compassionate or treatment USC of FDA-regulated 'test articles'.

7 December 1997: Applied Research Ethics National Association holds its annual human subject research conference on TUSKEGEE: Can past lessons guide researchers in the future? Among the topics for discussion are:
a) the impending challenges for institutional review boards

b) the Tuskegee syphilis study legacy

c) managing continuing review and adverse event reports

d) IRB liability issues

e) regulatory updates from FDA and OPRR.

8-9 December 1997: Annual human subject research conference on Ethical research in an ethical society. Among the topics for discussion are:
a) update on NIH/FDA guidelines for the inclusion of women and minorities and the new guidelines on the inclusion of children in clinical trials

b) a review of the 'headlines' in human subject research and an analysis of what constitutes a research 'scandal'

c) the model informed consent form designed for use in obtaining tissue for research

d) creative informed consent procedures.

For further information contact: Joan Rachlin, Executive Director, PRIM&R, 132 Boylston Street, Boston, MA 02116.
Fax: (617)423-l 185. c-mail:PRMR@AOL.COM

International Conference on Human rights, Bioethics and Health
11-l 3 September 1997, Paris, France.

Although broadly considered to be a fundamental human right, access to health care still raises many issues, notably as regards its implementation in practice. On the one hand the number of persons deprived of social protection is increasing, even in the industrialised countries. On the other hand, the emerging new biomedical technologies are influencing the control of vital human functions (notably in the fields of procreation, genetics and neuroscicnces). This has resulted in a challenge to human rights, encapsulated in the formula - 'Towards grcatcr freedom, OR, towards the acceptance of greater risks'.

Sessions:
(1) Achieving solidarity in the light of economic constraints,
(2) IIealth and medicine in situations of crisis: Medicine in wartime, disaster medicine,
(3) The history of the right to health as a human right,
(4) Human rights and bioethics: Some innovative developments, (5) The protection of the vulnerable and the risks of the betrayal of medicine,
(6) Conceptual, legal and ethical aspects of health as a human right,
(7) Role and limits of ethical committees and
(8)Concluding session: Ethics and law in the development of public health policy in confirmity with human rights.

This conference is directed to persons involved in the practice of medicine ethics, health law, policy making in the public health sector, human rights and international cooperation. The official languages of the conference arc English and French, and simultaneous interpretation will be assured. Organised by: Council of International Organisations of Medical Sciences (CIOMS) and International Association of Law, Ethics and Science (IALES), For more information, write to: BYK Christian, Secretary General, CIOMS, 62 Rd. Port Royal, 75005, Paris, France. Fax: (+33)(l) 43 37 47 10