LETTERS

Dr Sanjay Nagral has raised a pertinent point in his editorial on sponsored medical education. Sports and cultural events are most vulnerable to such sponsorship. Go-between entrepreneurs called ‘event managers’ organise such sponsorships as commercial ventures, managing beauty contest shows one day and dance shows or film festivals on another. There are gutka, cigarette or liquor companies to sponsor such events.

Forms of sponsorship or patronage have changed from the feudal ages till modern times, and so have values. In this era of liberalisation, nations of the developing world are perceived as markets of consumers and not states of citizens.

Such forms of sponsorship can be effectively resisted if delete the professional groups practice austerity, though there will always be ‘select’ doctors or others to fall prey to such techniques. But sponsored ‘fun’ is not as innocent as it seems. There is no such thing as a free lunch, as they say. Thank you, Dr Nagral.
Reference
Nagral S: Pharmaceutical companies and medical conferences: sponsored medical education? Issues in Medical Ethics, 1998;6 (1):3.
Amrit Gangar,H-156 Mohan Nagar, Dahanukar Wadi, Kandivli (W), Mumbai 400067

Response to the second opinion
I read with interest the article on the ‘second opinion’. Unfortunately I am at a disadvantage in that I am not aware of the questions presented to various doctors, on whose responses this article has been based. Even so, I would like to express my views on the subject.

In my opinion, the problem should be examined under the following heads: (1) the patient’s right to a second opinion; (2) a second opinion requested by the family physician; (3) a second opinion requested by a consultant; (4) a second opinion sought by the doctor or the patient, in a public hospital; (5) a second opinion sought by the doctor or the patient, in a private hospital; (6) doctors wishing to establish themselves as ‘second opinion’ consultants.

(1) In the first instance, one must state in no uncertain terms that it is the patient’s right to consult whomsoever he pleases. No one can deny him that right. How he goes about it is another question, as in whether he will derive full benefit by receiving various opinions regarding the nature of his complaint and his treatment.

In such cases it is usual for such a patient not to tell the doctor that he has visited other doctors previously. If he does inform the last doctor of his previous visits to other doctors, the doctor is now placed in a difficult position. What should be his line of action? Should he contact each of the previous doctors consulted? What if the patient does not want him to do so? What about maintaining patient confidentiality which prevents a doctor from discussing his condition with others without the patient’s permission?

On this respect, some guidelines from the Medical Council would be helpful. Failing that, I think that the best and easiest way out is to advise the patient according to what one feels is in his best interests even if it differs from the opinion of the doctors previously consulted.

(2)The next situation is when the family physician seeks a second opinion either as confirmation or because of genuine doubt regarding the advice of the first consultant, or at the insistence of the patient.

If the second consultant is not aware of the first consultation, he will automatically examine the patient and give his advice accordingly. However, what should be his stance if he has been made aware of the fact that the patient has already been examined by a consultant and that his opinions either the same or contradictory?

In this case, the second consultant is placed in a quandary, because it is natural that he would not like to spoil his relationship both with the family physician as well as his consultant colleague.

If the opinion he has formed of the case is the same as that of the previous consultant there is no problem, unless the family physician or the patient insists that the second consultant carries out the treatment, particularly if an operation has been indicated. In this case, the second consultant should tell the family physician that he will conduct the operation only after discussing the case with the first consultant. Unfortunately, in this case, he will have placed himself in a position of spoiling his relationship with both the family physician as well as his consultant colleague.

Again, suppose his opinion differs from that of the first consultant. He has no option but to tactfully suggest to the family physician that removesemicolon; they all discuss the problem with the first consultant. But this can only be done if the family physician agrees. If the latter refuses the end of the matter is that the second consultant gives his opinion and lets the matter rest. Of course, he will be more careful the next time the family physician wishes to bring a patient to him for consultation.

(3)The situation is much more straightforward when a consultant requests a second opinion. In this case the second consultant examines the patient and gives his opinion in writing and perhaps also on the telephone to the first consultant.

However, he must under no circumstances proceed to treat or operate upon the patient unless the first consultant specifically requests him to do so, even if the patient desires that he do so. In fact, the second consultant should make it clear to the patient at the outset that he is carrying out this examination at his colleague’s request and therefore he will send his findings and opinion to the first consultant who will then discuss the same with the patient.

Here again, the question arises as to whether the second consultant should reveal his findings and opinion to the patient, particularly if the patient desires that he do so. In my opinion, he should tactfully explain to the patient that the first consultant will reveal the same and if necessary the possibility of a joint meeting of both consultants with the patient and family physician may be considered.

(4)A patient admitted into a public hospital is in the unique position of being under the care not only of a junior doctor and registrar but also two specialists in the field (honorary, and honorary assistant of the unit). It is unusual for the patient or his family physician to ask for a second opinion. However it is possible that in a problematical case, the specialist himself may request a second opinion (usually informally) from a colleague in another unit or at times get the opinion of others when the case is presented at a clinical conference in or out of the hospital.

But suppose that the patient or family physician wishes to have a second opinion from a specialist in the same hospital, or from one not attached to the hospital. This again creates a problem.

In my opinion if the case is really problematical, the consultant-in-charge of the patient may well be advised to allow this second opinion even from one outside the institution. If the hospital rules do not permit outside consultation the patient and family physician can be informed politely of the fact and asked to decide if they wish to continue the treatment in the same hospital or take a discharge from the hospital. However, if the case is really problematical the institution should see its way to bend the rules even to allow outside consultation.

(5)With regard to a patient admitted in a private hospital the situation is somewhat different. Here one does not usually have a team of doctors treating the patient, but only a junior resident of experience, and as a senior specialist (the situation may well have changed since I left Bombay in 1969).

In this case, I only partly agree with Dr Desai as regards the procedure to be performed when the patient or his family physician requests a second opinion. In this case, only a consultant of the same speciality should be called in (unless the patient has developed a complication which requires a doctor specialised in that condition). In my opinion, this examination should not be taken independently but preferably in the presence of the treating docor unless it is not convenient. In any case the findings and opinions of the second consultant should first be made known to the treating doctor and after mutual discussion both doctors should present their findings and opinions to the patient and family physician.

(6)About the advisability and utility of a second-opinion clinic: If one has considered the various conditions under which a second opinion is sought, one may well come to the conclusion that a special second-opinion clinic is superfluous. To start with, doctors working in such a clinic will be laying themselves open to the charge of arrogating to themselves superior knowledge. Again, their field will be limited because as special second-opinion consultants they are now confined only to giving their opinions and suggesting treatment.

Further, such doctors will only be able to examine patients referred to them by a family physician or specialist colleague and that too with all detailed notes regarding the patient, and with the consent of the first consultant who examined the patient. No individual patient will be able to approach them directly. Lastly, the doctor will have to forgo the right to carry on the treatment or operate on such patients. Under such circumstances, the second-opinion doctor may find his practice becoming smaller as days pass by and thus not economically practicable.

Reference
1.Pandya S. K.:Some opinions on the second opinion.

Samuel J Aptekar,PO Box 1005, Nazareth Illit, 7110, Israel

Errata
The previous issue ofIMEwas Volume VI (1), January 1998. For subscription rates please refer to the current issue. The editorial collective includes Sanjay Nagral and Sanjay Pai. Hutokshi Rustomfram’s comment on the bill to control public interest litigation referred to allegations against Justice Punchchi. These were not made by the Supreme Court Bar Association.

Ethics of HIV
Modern medical systems thrive on their mythopoiesis. The January 1998 issue ofIssues in Medical Ethicshas two articles on the unethicality of denying multi-drug treatment to HIV-positive and AIDS patients. This is a classical example of the truism that the pathway to iatrogenic hell is paved with impeccable therapeutic intentions.

Sandhya Srinivasan’s lament (1) is that some mothers were denied anti-retroviral drugs in the name of clinical trials. Her espousal of the cause is in the teeth of the facts that (a) as yet no one can say whether HIV-positivity implies HIV carriership, (b) no one knows whether the drugs are genuinely anti-HIV, and (c) the drugs are well-known cytotoxic and cancerogenic agents. In fact the need for a controlled trial arises when the efficacy and worthwhileness of the (so-called) specific therapy are not above board. Hence the placebo-treated women who were denied AZT were indeed spared the assault from a positively dangerous drug.

Just a few weeks ago the media were agog because theBMJturned down an AIIMS paper on the grounds that the trial involved denying curative surgery to women with cervical precancer. It needs to be emphasised that (a) precancer as yet remains undefined, (b) treatment of precancer or cancer precipitates cellular and metastatic crises worse than the original disease.

Dr Sanjay Pujari’s article (2) harps on the backbreaking cost of drugs against HIV and AIDS, taking for granted the efficiency and the advisability of the drugs, both of which are as yetsub-judice. The fancy price tags betray the profit potential of the drugs making anti-retrovirus against the drugs of the future for the drug pushers.

Suffice it to say that ethicists of the like of Srinivasan and Pujari should first check whether the therapy denial is in any way inferior to the therapy administration. In the absence of that, the mythopoiesis surrounding HIV/AIDS will tilt the world view in favour of must-treatism with obvious disastrous results. If the much-taken-for-granted Swan-Ganz catherter can reveal its adverse side many years after its usage, then what of dangerous drugs? The bottom line is that in all likelihood, HIV-positiveness implies antibody positiveness and therefore virus negativeness. One day we will compliment the person who tests HIV positive.

References
(1)Srinivasan S: Physician, do no harm. Issues in Medical Ethics 1998; 1: 22-23.
(2) Pujari S: Anti-retrovirals in India.

Manu Kothari, Lopa Mehta, Vatsal Kothari,department of anatomy, GS Medical College and KEM Hospital, Mumbai 400 054

Sanjay Pujarireplies:
The subject of HIV medicine is continuously evolving and so are the new treatments. Intensive research in the hope of a cure is in progress and it would be a great disservice to the tireless workers all around the world if we criticise the efficacy of currently available drugs. Drug development essentially is based on an increasing understanding of the life cycle of HIV and its immuno-pathogenesis. After recognising the various enzymes responsible for replication of the virus, drugs are developed to inhibit these enzymes. At present computer modeling is extensively used to do this and also to determine, beforehand, to which molecules the virus develops easy resistance. Only those molecules which satisfy anticipated efficacy and delayed resistance are put into in-vitro studies. After successful in-vitro studies, animal studies are performed to assess toxicities at doses many times more than what would be used in humans. After that Phase I trials are carried out to assess safety in humans and only then do they progress to efficacy studies viz. Phase II and Phase III. After completing Phase III studies, the drugs get approval to be used in practice. Hence there is no question that any of these drugs are being tried out on a trial and error basis. Rather, all combinations are extremely rational.

It is true that we do not know the long-term toxicities of these drugs but only extensive use in the coming years will resolve the issue. Till then it would be inhuman to withhold such efficacious drugs from infected individuals. At the same time as more and more efficacious drugs are developed current treatments may become obsolete in the recent future. However, based on current understanding a ‘current standard of care’ is developed and implemented. Let us accept also that there is no ideal drug in tis world (100% effective, no side effects etc.) for any disease, leave aside HIV.

For the first time in the history of the AIDS epidemic, the CDC reported a decline in AIDS related deaths by 13-20% in the US and also a decline in the hospital admission rates. Also, for the first time the number of children born with HIV infection declined last year. This has been possible because of antiretrovirals. Let us stop criticising the basic issues about efficacy of these drugs and look ahead as to how we can make them more accessible and affordable to our people and improve their quality of life.

Sandhya Srinivasanreplies:
It is not necessary to debate the efficacy of HIV drugs to examine the ethics of delete HIV drugs to examine the ethics of placebo-controlled trials. It is enough that the clinical trials, supported primarily by the US Centers for Disease Control and the National Institutes of Health, deprived the control group of a treatment that is recognised in the funding country, the US as standard treatment for pregnant HIV-infected women, and is believed to prevent a large proportion of vertical transmission. It is this action that is being challenged as unethical.