Indian Journal of Medical Ethics

FROM THE PRESS

Back to school
The Medical Council of India has recommended compulsory renewal of the registration of allopathic doctors every five years. The doctor would be responsible for applying, with a certificate of attendance of at least 30 hours of Continuing Medical Education (CME) programmes each year.

The likes has been welcomed by the Maharashtra Medical Council president Dr Sudhakar Deshpande, but Indian Medical Association president Dr F S Desai feels that CMEs, which are already being held in larger cities, are not feasible in rural areas where there are hardly five allopaths per taluka.

Compulsory renewal for allopaths.Indian Express. November 18, 1997

One more patient for Doctor Death
An elderly Indian Canadian, who was part of India’s freedom struggle, was the latest patient of Dr Jack Kevorkian, the controversial US doctor who has helped many sick people commit suicide.

Natverlal Thakore, a land developer and former educator in British Columbia province, Canada, had been suffering from Parkinson’s disease for the last eight years, according to his son, Arvind Thakore, who said none of the family mebers knew that his father had been in touch with Dr. Jack Kevorkian.

Mr Thakore’s suicide note explains why he decided to die:

"I am grateful to the merciful hands of Dr. Kevorkian… for assisting me to bring about a happy deliverance -mahasamadhi- final embrace with the Divine. This kind of death is my choice, and I take full responsibility in arranging my final exit.”

India Abroad News Service/India-West October 18, 1997

“Crash” courses in allopathy
The state government-appointed Ganeriwal committee has recommended crash courses in allopathy for practicing homoeopaths in Maharashtra, since 90 per cent of doctors in rural Maharashtra, including those in the primary health centres, are trained in Indian systems of medicine (ISM) but must in life-threatening situations must resort t modern medicines. The course excludes practitioners of ayurveda and unani who are already allowed to practice allopathy.

The subject came up when, after the Supreme Court’s judgement against cross prescription, the state FD passed a circular asking retail chemists not to honour ISM practitioners’ prescriptions, putting physicians from rural areas in a dilemma. The Mumbai high court later intervened and granted an ad-interim stay for the petition filed against the FDA’s circular.

Government to provide short-term allopathic training to homoeopaths, Express Pharma Pulse

University provides organs to HIV-positive patients
As new therapies prolong the lives of those infected by the virus that causes AIDS, the University of California in San Francisco, USA, is offering organ transplants to HIV-positive people whose infection with the virus was under control and who are not dying from other diseases. Others consider it a questionable policy. “I am not quite sure it is the best way of using a precious organ,” said Dr Steven Rudich, a transplant surgeon at he University of California in Davis, Medical Center.

AP, San Francisco, in Express Pharma Pulse, September 18, 1997

67 crib deaths in Kalyani hospital
At least 67 newborn babies died at the 550-bed J N Nehru Memorial Hospital in Kalyani between October 24 and November 25, 1997, out of the total of 918 babies born in the hospital during this period. Some doctors blame the poor maintenance and unhygienic conditions in the maternity ward. Only one of the four sterilisation machines in the hospital is operations.

Hospital superintendent Aditi Kishore Sarkar found nothing aunusual: “The infant mortality rate in the country is 90 deaths per every 1,000 live births.” 48 were cases of still-born babies, and two babies died of septicaemia. And in only one case the exact cause of death could not be ascertained, he added.

Surajit Biswas. The Asian Age, November 27, 1997

Hospital locks woman in labour room
A woman in labour was locked up and left unattended at he Asansol sub-divisional government hospital. Geeta Mondol, who had fainted when the labour pains began, said she regained consciousness just in time to catch her new-born baby as it tottered precariously on the edge of the bed.

Around 9 pm on November 20, when her labour pains began, Ms Mondol was taken to the labour room where the staff left her locked in, leaving an anxious relative waiting outside as she screamed in pain. She gave birth around midnight, unassisted. The relative woke the nurses up when she heard a baby crying. The nurses opened the door, only to order the patient back to her ward - on foot.

There have been other similar complaints, of a woman patient admitted for an appendectomy who complained of molestation, and a severely burnt pregnant woman who died untreated. Complainants say the wrongdoers are not punished because they belong to the ruling party.

Debajyoti Chakroborty, Statesman News Service, November 27, 1997.

Licensing private nursing homes
Following a ban on private practice by government doctors in April 1997, the Madhya Pradesh government made registration and licensing compulsory for all private nursing homes in the state.

The implementation of the Madhya Pradesh Nursing Homes and Clinical Establishments (Registration and License) Act comes almost 25 years after it was passed in 1973. Official sources said the private nursing home or clinical establishment would be registered and issued a license only after a supervising authority, inspected the premises intended ot be used for that purpose. Nursing homes and clinical establishments would be required to maintain detailed records about their patients, childbirths, and the examination and treatment provided to their patients.

Licensing for private nursing homes in MP PTI, Bhopal, Express Pharma Pulse, September 4, 1997

Regulating homoeopathy
A national convention of experts in the field of homoeopathy highlighted the need for strict enforcement of the Anti-Quackery Act to weed out self-trained homoeopaths and those who practiced without valid registration. It also called for a central technical advisory board exclusively for homoeopathy; at least four regional laboratories for testing drugs; drastic steps to improve the standards of homoeopathy education by enforcing minimum norms for the colleges; providing a better deal for the teachers and changing the pattern of education.

Quack homoeopaths must be weeded out. Special correspondent, The Hindu, November 26, 1997.

“Supplementary income”
Lecturers of government and municipal medical colleges are making that extra buck by offering tutorials to MBBS students, in gross violation of the rules. Apart from charging as much as Rs.30,000 per subject, the professors use government hospitals to conduct practicals for private college students. A Sion hospital lecturer admitted: “We tell our students the be number and the symptoms to look for. They then probe the patient’s history and we discuss the case later. If anyone objects and creates problems we take the students to private nursing homes”.

Students of Sion hospital allege that private college students are even issued reference books in the college library without an identity card.

Professors from Sion, KEM and Nair hospitals are involved. One lecturer from the medicine department of Sion Hospital promised to ‘arrange’ for teachers in other subjects as well. According to this lecturer, the teachers are often examiners in the final examination. He said his wife, a lecturer at the KEM hospital, conducts classes in his absence, and a former dean of Sion hospital had sent a relative and her friends to him; the dean’s spouse fixing up the amount at that time.”

Dr Kumud Nihalani, dean of Nair hospital, and Dr Snehalata Deshmukh, vice chancellor Mumbai University, condemned the practice, but maintained that no action could be taken without a compalint. Dr Pragnya Pai, dean of KEM hospital, refused to comment. Dr Rajendra Shirhatti, dean of Sion hospital, said he would act if he got proof, and that “So far, I have at least been successful in stopping them from conducting classes within the hospital premises”.

Government doctors make hay while tutorial bug bites. Manjari Kalghatgi, Express Newsline, December 1, 1997.

HIV-positive patient thrown out of hospital
A Nepali man admitted to the BUL Nair hospital was allegedly thrown out three days after he tested HIV positive. Doctors refused to treat him when he was readmitted by a passerby. Khim Bahadur Singh alleges that when doctors found him HIV positive they declared his treatment complete and physically threw him out. The doctors say he left on his own but he is unable to move around. Dean KD Nihalani said no complaint had been received.

Nair hospital throws out HIV patient Sandhya Nair Sunday Mid-day. January 18, 1998

UK experiments on prisoners
Doctors at the hospital attached to Boradmoor, a top-security UK prison, gave their male patients hormones through pills or implants, to control their aggression, without their proper consent. At least two of the men later had to have resulting breast tissue surgically removed.

The trials, conducted int eh last ‘70s and early ‘80s, were sanctioned by the department of health and social security. Trials stopped without explanation. One patient says he was told he had no chance of getting out if he did not have the treatment; he was subjected to electric shock treatment without anesthesia, kept in solitary confinement, and administered excessive drugs. A former consultant psychiatrist at the hospital’s research unit said it was stopped when the physical side-effects emerged.

A spokesman at Boradmoor said the trials had received official approval but had ceased: “Our knowledge and understanding about these treatments have moved on.”

Mark Austin Broadmoor used for drug tests Sunday Times. January 18, 1998

One year after the pigheart outrage
The family of Purna Saikia, victim of a ‘xenotransplantation’, observed his first death anniversary, even as the state government is yet to figure out exactly what happened to him.

On January 1, 1997, Dr Dhaniram Baruah along with Dr Jonathan Ho, a Hongkong cardiac surgeon, and James, a Hyderabad perfusionist, claimed to have conducted a ‘successful’ multiple pig organ transplant on Saikia.

On January 7, Saikia’s decomposed body was recovered from the Dhaniram Bharuah Heart Institute. A postmortem found that the body’s organs did not resemble human ones, and the doctors were arrested. However, investigators were unable to determine whether the organs were harvested before Saikia died, or to which animal they belonged, s the specimens were sent for forensic analysis. One year later, the results are not still not back, stalling any further action.

The Transplantation of Human Organs Act, 1994, under which the doctors were charged on January 10, 1997, was notified in the Assam gazette on February 6, which allowed James and Ho to leave Guwahati.

Dr Baruah, who insists he transplanted pig organs on Saikia who lived for a week before dying, has been barred from further such ‘trails’ till the case in closed.

Monimoy Dasgupta Stalemate persists over pigheart transplants, Telegraph, January 8, 1998

Tubectomy death
The Bombay high court ordered Arun and Kiran Sarang of Panvel to pay Rs.25,000 as compensation to the husband of Lilavati who died on the operating theatre during a tubectomy operation in their nursing home on September 13, 1987.

The Raigad-Alibag sessions court had ruled that the Sarangs were guilty of attempted murder and sentenced them to five years'’ rigorous imprisonment and a Rs.50,000 fine. The high court set aside the sentence and reduced the fine.

Failed operation, docs asked to pay.Express News Service, January 8, 1998

Bad tooth story

The Consumer Disputes Redressal Forum, Mumbai, has held Dr Ajoy Agarwal liable for negligence in the orthodontic treatment he provided to Arthi Sharad Oturkar, and asked him to pay Rs.10,000 as compensation.

Dr Agarwal had promised Ms Oturkar successful treatment within one year but treated her for four years without taking any x-rays. Finally another orthodontist she went to took an x-ray revealing supernumary teeth behind the normal ones, which had to be death with before orthodontic treatment could work. As a result of the bad treatment, the complainant suffered permanent injury in the right upper jaw.

Tooth and fail. Geeta Handa Khanuja Mid-day. January 13, 1998

Srinagar hospitals
Five Srinagar children, between seven months and three years of age, died within hours of each other on January 4, sparking protests and forcing a government probe. The doctors said four were brought into the hospital with acute infections, after treatment elsewhere, and died a ‘natural death’ in the hospital. One was brought in dead. But the parents complained that doctors were absent, leaving a single nurse to do her best. The wards were reportedly dirty, badly ventilated and poorly heated. Most wards had five patients to a bed. Women sat on the floor holding their children on their laps. An attendant said rats crawled on the beds at night.

Mukhtar Ahmad Child deaths spark fury. Telegraph. January 6, 1998

Charity hospitals
Five years after they were caught escaping the customs net, 11 medical institutions, including two from Mumbai, are yet to pay Rs.2.2 crore on imported critical medical equipment which is gathering dust in the customs warehouse.

So far Rs.21 lakh has been recovered from these institutions who misused the customs clause on exemption on duty on critical medical equipment. The companies: Surlux Mediquip Ltd, Mumbai, Banshankari Medical and Oncological Centre, Bangalore, Kalparuksha Charitable Trust, Kolhapur, Manipal Hospital, Goa, Indore Cancer Foundation and Jaya Diagnostic and Research Centre, Hyderabad.

It was found that many medical institutes misuse the provision for duty-free imports of critical medical equipment. A 1993 customs audit found that a March 1988 clause exempting customs duty for essential medical equipment that is used extensively for free patients was being misused by hospitals. Thirty-eight medical institutions were charged, 24 cases were settled, four paid up, three have been stayed by high courts, and seven are due.

Manjiri Kalghatgi Equipped to beat Rs.2.2 crore tax. Indian Express, January 12, 1998

Medical equipment boom
The medical equipment industry is projected to grow at over 20 per cent annually, attracting multinationals, says a report of Royal and Sun Alliance of the UK. The boom in private clinics has made business attractive, as have the tax concessions in the last budget.

A dozen multinational companies are said to be eyeing the cardiovascular and MRI market. Other equipment: blood sugar monitoring kits, endoscopes, medical cameras, ENT products, pathology laboratory equipment, and other automated systems. However experts worry about the effect of escalating health costs on Indians. Technological advances reduce the average life of electro-medical equipment to five years, making it a replacement market.

Experts feel the products are designed for diseases affecting the upper middle class. Though 75% of India’s rural population lacks sufficient medical facilities, public health care budgets are cut to control the fiscal deficit and nearly 90 per cent of health care expenditure in India goes to the private sector.

Health care costs in India have been increasing at four times that of inflation. There is no regulatory body to control business malpractices. Apollo Hospitals has earmarked Rs.1,250 crore to build over 100 hospitals around the country in the next five years. Fifteen will be in metropoli providing superspeciality care, 32 will be speciality hospitals in other big cities and the rest in small towns.

For the medical equipment makers, no news could be better.

V M Sathish.In the pink of health.Indian Express, January 12, 1998

Somatostatin fever mounts in Italy
Propelled by hurried judicial rulings and unprecedented media fervour, somatostatin reached the top of the Italian pharmacological “hit parade” in January. The unsubstantiated claims by an 85-year-old retired physiologist, Luigi Di Bella, that the drug can cure cancer turned somatostatin into a best-seller overnight.

Silvio Garattini, head of the Mario Negri Institute, Milan, said that the Di Bella regimen is “a totally irrational association of drugs (somatostatin, melatonin, and vitamins) supported by absolutely no scientific evidence or data whatsoever”. Yet clinical trials of somatostatin for cancer were called for by health minister Rosy Bindi. These have turned out to be purely observational “open-label” phase II studies, since hypothesis generation is the only possibility in the absence of any preliminary data. Yet, the media said “clinical experiments” would yield results within 2-3 months. Volunteers for these studies are expected to be far in excess of the planned 2600.

Some doctors exhorted patients not be lured from accepted oncological treatment, others have boosted their incomes by claiming that they also apply the “Di Bella method”.

Garattini said “all limits had been exceeded” after Di Bella announced at the European Parliament that the successfully treats retinitis pigmentosa, multiple sclerosis, amyotrophic lateral sclerosis, and Alzheimer’s disease with somatostatin.

Bruno Simini, The Lancet, February 7, 1998

Quinacrine sterilisation goes on
The All-India Democratic Women’s Assoiation and the Centre for Social Medicine and Community Health, Jawaharlal Nehru University, have jointly filed a public interest litigation against a medically unapproved sterilisation procedure. Pellets of the malaria drug quinacrine are inserted into women’s uteruses, causing inflammation to block the fallopian tubes.

Both the World Health Organisation and the International Planned Parenthood Federation’s medical advisory panel have opposed the use of quinacrine before the completion of toxicological studies: “Until the toxicological situation has been clarified and further clinical trials have been conducted, the use of quinacrine pellets for female sterilisation… cannot be recommended.”

Yet quinacrine has been used on more than 70,000 women worldwide in 20 years. A west Bengal doctor, Biral Mullick inserted it in 10,000 women.

Scars.Lina Mathias.Sunday Mid-day January 1, 1998

Blood in the days after the professional donor ban
After the ban on professional blood donors came into effect on January 1, blood banks around the country have reported a severe shortage of blood, even during the ‘lean season’, and of even the most common blood groups such as B positive. This leads some to believe it is an artificial shortage created by private interests.

In the absence of a set-up to replace the professional donor supply, professional blood donation will go underground, says Dr J C Jolly, founder-president of the Indian Society of Blood Transfusion and Immunohaematology, blaming the apathy of the medical profession towards a moral issue: buying blood from the poor.

There is evidence that doctors pocket commissions for directing patients to particular bloodbanks. A study of 17 private bloodbanks in Delhi by the NGO Vatavaran conforms they have bad testing, storage facilities. Only three million units of blood are collected annually to supply a demand of six million units, says Dr V N Sardana, joint director in charge of blood safety. It is estimated that 10% of HIV infection in India comes from blood transfusion. VB Lal, president of the Indian association of blood banks, says it is not fair to target commercial banks, pointing to the Indian Red Cross scandal in Mumbai in which 12 HIV infections in thalassemics were traced to a blood sale racket conducted by employees.

Lal argues that with high HIV prevalence in the general population, only screening blood makes it safe. Dr Prasada Rao says buying blood is an abomination. “No system can be based on the blood of destitutes”.

Meanwhile Delhi’s 700-odd professional donors demand rehabilitation. Dr Sanjay Kapoor of the Voluntary Health Association of India says professional donors are like commercial sex workers: society needs them but refuses to recognise them.

From: A question of blood,Devraj Ranjit, UNI, also published in AIDS NEXUS, November 2997 to January 1998, And: Blood bank ‘anaemia’ takes girl’s life (Rahul Gupta, Pioneer, January 6, 1998)

The industry-medical profession nexus
Virtually all the doctors who defended a class of drugs widely used to treat heart disease have hidden links to the makers of the drugs, said the New England Journal of Medicine recently.

“We wonder how the public would interpret the debate over calcium-channel antagonists if it knew that the authors participating in the debate had undisclosed financial ties with pharmaceutical manufacturers,” said the study team.

The authors of the new study, led by Henry Thomas Stelfox of the University of Toronto, tried to gauge the involvement of industry-supported doctors in the calcium channel controversy by identifying articles published between March 10, 1995 and September 30, 1996, and categorising them as supportive of the medicines, critical, or neutral.

They discovered that “96 per cent of the supportive authors had financial relationships with manufacturers of calcium-channel antagonists as compared with 60 per cent of the neutral authors and37 per cent of the critical authors”. The Stelfox group acknowledges that he supportive authors may have ties to drug companies because the companies seek relationships with doctors who already support their products.

Conflicts of interest plague US medical journals Reuters, in Medeivision. February 8, 1998

Private hospitals and free medical care
Court hearings on public interest petition asking the Delhi government to enforce the private limited Apollo Hospital to fulfill its obligation to reserve 30 per cent of its beds for poor patients to eb treated free (mentioned in January’s IME) expose the manner in which government colludes with the private sector to bypass laws meant to help the poor.

V J Chacko, managing director of Indraprastha Medical Coporation Ltd. which runs the hospital (the Delhi government has 26 per cent shares in the company) challenged the government’s contention that it had “finalised guidelines for providing free medical facilities”.

Kailash Rani was clearly able to pay her Rs.3 lakh bill before her discharge in April 1997. On May 7, U R Kapor, the officer on special duty (medical), wrote asking the hospital to reimburse the money and treat Ms Rani as a “sponsored, free patient”. The hospital refused, whereupon the government launched an enquiry into a complaint filed by Ms Rani’s husband that he was not satisfied with the treatment. They clearly could not find anything wrong, since the hospital has not heard from them since.

Delhi government misusing free hospital concept. PTI in the The Times Of India. March 2, 1998

Branding for STDs
Following protest, the Maharashtra government was forced to take back Memorandum 2541, a circular to orphanages and destitute women asking for all inmates to be tested for HIV and those testing positive to be sent to an institution.

Also, a proposed amendment to the Protection of Commercial Sex Workers (CSWs) Act 1994 seeks to brand CSWs testing positive for STDs. “All persons suffering from STDs shall be liable to be branded by indelible ink on their persons to indicate the presence of STD and the board shall have the authority to decide the manner of markings.” Doctors must report all STDs, and any person suffering from STD having commercial sexual activity shall be liable for a term of quarantine until cured, and a fine of Rs.5,000.

HIV/AIDS patients may be branded for life. Medivision, February 15, 1998, page 2. And: Positively inhuman. Maria Abraham. The Weke. February 1, 1998

The right to know your doctor
The US patients’ right group Public citizen has come out with Questionable Doctors, a report of 16,638 US doctors facing a total of 34,049 disciplinary actions by state and federal agencies.

Their wrong-doings: 393 disciplined for sexual abuse of, or sexual misconduct with, a patient; 1,861 for a criminal conviction; 1,309 for substance abuse; 2,391 for substandard care, inocmpetence, or negligence; and 1,521 for misprescribing or overprescribing drugs.

Michael Grodin, director of medical ethics at Boston University School of Medicine (USA) agrees that patients have a right to accurate statistics on settled matters, but the doctors involved should have a right to respond before publication. Also, “One malpractice suit does not necessarily make a bad doctor”. Two-tbirds of obstetricians encounter a malpractice suit.

But for some offences cited, he suggests, the issue for medical boards is whether this sort of person should practise medicine. “It is a privilege to practise medicine, not a right”.

Kelly Morris, The Lancet, March 14, 1998

Drug promotion
The last two years have seen an unprecedented rise in the quantum and range of gifts and free services doled out by the pharmaceutical industry to the medical profession. Even medical representatives are surprised by the trend. It is not uncommon for companies to spend upto Rs. One lakh per month on 10 or 20 doctors at each headquarter level in selected states.

The major beneficiaries are specialists like cardiologists, diabetologists, gynaecologists, paediatricians, psychiatrists, surgeons and orthopaedic surgeons. The increased competition among companies has been seen by doctors as an opportunity to benefit.

N V Ramamurthy. ‘Gifts’ increase drug promotional costs’ Express Pharma Pulse February 12, 1998