Indian Journal of Medical Ethics

FROM THE PRESS

From the medical council…
In directives issued after the high court case RG Raheja v/s Maharashtra Medical Council and others, the MMC issued the following press releases:

“It has come to the notice of Medical Council of India that it has become a common practice for institutions running high-tech and high cost investigations and treatment to offer inducement to the doctor who referred the patient to them. Similar matters have been brought to the notice of Maharashtra Medical Council. According to the Code of Medical Ethics approved by the Central Government as regulations under Sections 33 of the Indian Medical Council Act, 1956, physicians are restrained from giving, soliciting or receiving any gift, gratuity, commission or bonus in consideration or return for the referring, recommending or procuring for any patient of the treatment. Maharashtra Medical Council will take stern action against doctors indulging in such unethical practices. The medical associations are requested to provide wide publicity to this matter and in their respective publications. Similarly, all concerned individuals are requested to report such matter to the State Medical Council in confidence."

And:

“This is to bring it to the kind notice of the concerned authorities of the public, private hospitals, nursing homes that they are bound to provide information regarding the patient care, treatment and relevant case papers on request by the patient when they are required for further treatment at other centres in the country or abroad or for any other concerned matter. The authorities may provide (a) certified copy of such papers while retaining (the) original or the copy as the case may be. This is a part of the patient’s right to information. The council had received directives from the Mumbai high courting the writ petition. This is for the information of the people for the hospital authorities and people at large”.

With no consent
Ranchi-based nephrologist SS Prasad was arrested following allegations of his involvement with an international gang selling human organs. Nasir Ali, a Mumbai-based powerloom worker, alleged that two people posing as job recruiters took him to Dr Prasad’s nursing home in June 1997 on the pretext of getting tests done before his departure to Saudi Arabia and removed a kidney without his consent. Dr Prasad, former head of medicine, Rajendra Medical College and Hospital, Ranchi, runs a private nursing home which he claims is the only one of its kind with sophisticated equipment for kidney transplant in eastern India and Varanasi. He could not produce the admission register or other reports, saying they had been confiscated by the income tax authorities. However, the clinic's manager turned approver and stated that four legal and 12 illegal transplants took place at the nursing home since 1997.

Illegal trade in human organs unearthed; doctor held. Sonali Das,The Times of India, May 10, 1998.

Kidney transplant racket
The police arrested the owner, executive director and two doctors of the NOIDA Medicare Centre (NMC), a 100-bed hospital, near Delhi, following a complaint from ajhuggi dweller in east Delhi that his kidney had been removed without his consent. The man was reportedly promised a job in Singapore, for which he would have to undergo a medical examination at the NMC. He was made unconscious, and recovered to find a scar below his stomach and later came to know that his kidney had been removed. The police arrested a middleman, a constable, who revealed he bad sent 25 people to the hospital for this purpose. Police said NMC doctors would send relatives of patients seeking kidneys to a nearby public call booth operator who would fix up a meeting through the constable. The kidney cost between Rs.75,000 and Rs.1,00,000 of which less than half went to the donor. Shaukat Ali’s medical records list him as Sunil Kumar, and an affidavit under this name states that he had offered to donate a kidney on humanitarian grounds. However, the Transplantation of Human Organs Act, 1994, does not apply in Uttar Pradesh. The IMA has described the arrests as high-handed, and the Delhi Nephrology Society stated that the kidneys could not have been removed without the donor’s knowledge.

Kidney transplant racket busted in NOIDA; hospital owner held. Express News ServiceIndian Express. May 11, 1998. And: Kidneys and crimes. Kalyan Chaudhuri, T K Rajalakshmi.FrontlineJune 19, 1998.

No one to treat kidney transplant patients
An excruciating death awaits most of the hundred-odd patients who received kidney transplants at the NOIDA Medical Centre (NMC) because their doctors are in jail and no other specialist will treat them.

The condition of two of the patients is critical; they were operated just before the arrest of Dr Harsh Jauhri and Dr Sanjay Wadhwan following a raid on the NMC. Fearing arrest under the Human Organs Transplantation Act, 1994, no doctor wants to be involved with a kidney transplant patient. Kidney transplant patients must be kept on life-long medication and supervision, to prevent rejection as well as infection. Improper treatment could mean death.

Many patients have approached the Indian Medical Association to plead their cases. The IMA has demanded the release of three of the eight people arrested after a man complained that his kidney was stolen. IMA secretary-general Prem Aggarwal stated that it is scientifically impossible to steal a kidney from anyone; this must have been a commercial donor pressing for adequate compensation.

Doctors at the IMA blame the continuing racket in kidneys on the government’s failure to set up a cadaver-based organ donation programme. Dialysis is temporary and painful, and often results in complications. One kidney recipient said he would not have agreed to buy a kidney but there seemed to be no other way he would ever live a normal life.

(NOIDA kidney recipients await death.The Times of India, Bangalore, May 25, 1998.)

Prenatal sex-detection: the government does it for you
A senior official of the health department responsible for monitoring the Prenatal Diagnostic Techniques Regulation and Prevention (Misuse) Act was found conducting sex-determination tests in violation of the regulation. Akola police arrested deputy director of health services Vasant Bagdi and his his gynaecologist wife, Vandana Bagdi, member of the Akola District Consumer Grievances’ Redressal Forum. Police seized Rs.1.02 lakh and 20 samples of amniotic fluids from their Suraj Sonography Clinic, after a pregnant woman went to the clinic accompanied by plainclothes policemen and paid Rs.1,500 for the test. The doctors were arrested along with two assistants, after the doctor declared the test results. Records revealed that patients came from Nanded, Parbhani, Chandrapur and even other states.

(Doctor couple held for conducting sex tests. Prafulla Marpakwar. Indian Express, Mumbai, May 24, 1998.)

Is it chance or clomiphene?
A 25-year-old woman from Bhiwandi was underweight and six-and-a-half months pregnant when she went into labour at Cama hospital, Mumbai, and delivered quintuplets. The babies died within 12 hours of their birth. In New Delhi, another woman delivered quadruplets. This mother and these babies were in good health at last report. What are the chances that ovulation-inducing drugs were responsible? And if they were, what were the prescribing doctor’s responsibilities after the women became pregnant? Did s/he monitor the pregnancies, inform the mothers of the risks, and offer selective abortion to increase the remaining foetuses’ chances?

(Based on Quintuplets die within 12 hours of birth. Express News Service. Indian Express, Mumbai. May 24, 1998.)

‘Testing’ for virginity
Leaders of the Jain community in Gujarat condemned the virginity test conducted on a Jain Sadhvi at Shree Bachutner Jinalay, a Jain shrine at Kutch district. The test was ordered by the shrine’s head, under the pressure of followers. Instead of opposing the idea of such tests – and explaining that such tests are useless- some doctors went ahead and examined her, before declaring that she was a virgin.

(Virginity test on Jain Sadhvi condemned. Sanjay Vora. Sunday Mid-day. May 24, 1998.)

Promises, promises
Seven years after the DY Patil medical college promised to upgrade facilities at Rajawadi hospital, the college trust stated construction would begin.

In 1991, the college management signed an agreement with the Mumbai Municipal Corporation to let its students use the hospital’s facilities for clinical training. In return the college would spend Rs.9.1 crore for additional housing for 200 beds (bringing the bed strength to the MCI requirement of seven beds per student), and OPD, emergency care units, lecture theatres, an AC unit, hostel equipment and a library. The work was to be done in four years, but had not started seven years after the agreement. Though the college insists it has now made plans to start, the municipal authorities insist they have received no relevant applications.

(DY Patil’s date with promise. Manjiri Kalghatgi.Indian Express. May 13, 1998.)

The thin end of the wedge?
The wonders of assisted reproductive technologies never cease. A menopausal woman, wife of a prosperous Punjabi farmer, and the mother of two, became pregnant after her gynaecologist administered hormones to induce ovulation. And sperm separation increased the chances of a male child.

Citing the example of this couple, a Chandigarh-based voluntary organisation has filed a writ petition with the Human Rights Commission, Punjab, seeking strict implementation of the Prenatal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994. The Act was passed in Punjab in 1994, yet hoardings advertising X-Y separation are plastered all along the highways and in the cities.

(Girls not wanted. Nirupama Dutt.Indian Express. June 3, 1998. And: 60 plus and the mother of all pregnancies. Kuldip Bhatia. Indian Express, Mumbai. May 1, 1998.)

Doctors and the press?
The Karnataka Medical Council (KMC) reprimanded Dr N K Bhagavan for releasing ‘paper advertisements’ after he wrote an article on vascular surgery in a local daily’s science and technology page in September 1997. The article concluded with a note mentioning the names of the hospitals where he worked as a consultant, which has been taken by KMC president Dr Chikkananjappa as either advertising for himself or acting as an agent for the hospitals.

In April the council released the details of the inquiry to the press, stating that there was aprima faciecase of violation of the Code of Medical Ethics. Dr Bhagavan filed a writ petition in the high court which has stayed the KMC’s order. “By stopping doctors, you are taking away the public’s right to know (about medical developments),” says one surgeon.

The KMC reportedly will be writing to a leading cardiac surgeon for a cover story done on him in a Kannada magazine. Other doctors have been cautioned for appearing frequently in the press, and a senior surgeon from Kempegowda Institute of Medical Sciences was also served a notice following a newspaper article.

(KMC takes doctor-writer to task. Sriranjan Chaudhuri. The Times of India, Bangalore. May 24, 1998.)

Quack service
The Mumbai police arrested five men practising as doctors in the Deonar slums. They had certificates from Uttar Pradesh claiming they were Ayurvedic doctors but when police confiscated the certificates following complaints from doctors in the area, the Ayurvedic Council registrar replied that the doctors had no permission to practice in Maharashtra.

Several so-called experts with degrees from dubious institutions in Bihar, UP and AP, claim to have cures for virtually any disease including AIDS. However, municipal officials cannot take action against quackery; it is up to the police. The police planned to launch a drive against quacks, but added that the public should come forward to register complaints.

(Five ‘doctors’ practising in Deonar slums held. Crime reporter.The Times of India. May 15, 1998.)

Government doctors can go private…
Doctors serving in Maharashtra government hospitals may soon be able to earn a private income. The state government’s proposal is meant to prevent doctors from quitting government service for more lucrative private practice, while attracting more medical graduates to work in government hospitals. It will not apply to civic corporation hospitals. This will be applicable to doctors with a minimum of 10 years’ service, including three years in rural government hospitals.

The draft stipulates that they may not set up private nursing homes but lets them serve as consultants; they must also be present when slotted for duty.

(Private practice bait for government docs. Swati Deshpande-Aguiar.Indian Express. April 29, 1998.)

… but not in MP
Meanwhile the MP health minister Prem Narain Thakur ruled out the possibility of reconsidering the ban on private practice by government doctors. He said all resignations of doctors quitting government service in protest would be accepted. Twenty-six doctors resigned after the ban was imposed last year. The announcement is in contrast to the chief minister’s announcement that the government was reviewing the ban.

Mr Thakur added that doctors working in medical colleges would be transferred to rural areas, as would those posted in urban centres for 10 years or more; here they could get a non-practising allowance.

District panchayats had been asked to appoint 1,200 doctors on contract for Rs. 6,200 a month: so far 250 had been appointed.

(MP to continue ban on government doctors. Times of India news service.The Times of India. April 30, 1998.)

Government for sale
The Maharashtra government has invited tenders from the private sector to manage its renovated GT hospital as a super-specialityservice. Construction of the 300-bedded hospital started in 1974, but following legal wrangles, it was finally built free of cost by a private company in return for an adjacent plot where the company has built a shopping complex. Completed only in 1996, the building has been lying unused since.

A government official points out that existing services do not meet the needs of poor patients. It is ironical that the government launched Jeevandai Yojna to provide services to the poor, even as it takes away existing facilities meant for them.

The entire building would be given on a 99-year lease. The ground floor would be given to shops.

(Five-star government hospital up for sale. Narendra Pathak.The Times of India. April 24, 1998.)

A new forum for doctors?
More than 20,000 doctors in Mumbaiorganisedthemselves under the banner of the Forum of Medical Associations (FOMA). They were inspired by a March 27 Supreme Court judgement in a medico-legal case under the Consumer Protection Act in which the court ordered compensation of Rs.12.5 lakh to a minor patient, and Rs. 5 lakh to his parents for “the acute mental agony caused to them on account of their only son being reduced to a vegetative state …resulting from negligence of an unqualified nurse”. (Spring Meadows Hospitals and others v/s Harjot Alhuwalia.)

The quantum of compensation prompted FOMA to advise its members to up their insurance cover to indemnify themselves against potential malpractice suits.

FOMA was set up at the urging of the Mumbai-based Association of Medical Consultants to act as a pressure group to fight medico-legal cases, says Dr Lalit Kapoor, its co-convenor. The forum will approach various government and regulatory bodies to tackle medical infrastructural inadequacies.

Dr Kapoor says doctors account for just 30 per cent of health care inputs, the supporting infrastructural services including blood banks, paramedical staff like nurses and ambulance services. The lack of qualified nurses is especially dire, with a paucity of recognised nursing colleges.

Doctors are becoming increasingly perturbed with the mounting pressure to become accountable to more than one beneficiary of their service, says Dr Kapoor. However, bringing doctors under the CPA will only benefit insurance and legal firms, he argues. The vast amounts awarded as compensation have doctors worried. If clients demand standard services and greater accountability they will have to pay for it.

Doctors in India have fought a four-year losing battle to exclude themselves from the purview of the Consumer Protection Act.

(Docs float new forum. Swati Deshpande-Aguiar.Indian Express. April 22, 1998.)

We don’t need no education…

The Maharashtra government’s Grant Medical College has not renewed journal subscriptions or bought books, saying it doesn’t have the money. The chairperson of the library committee and the chief librarian informed department heads that the hospital management failed to allocate for medical journals and internet connections, and may also find it difficult to buy new books. “The Library Committee regrets the non-availability of journals for 1997 and 1998 and books for 1998,” the letter says.

(GMC cuts costs: stops buying journals, books. Express News Service. Indian Express. May 6,1998.)

Embryosfor transatlantic sale
Advertising for surrogacy is banned in the UK. However, interested couples can get transatlantic embryos via the Internet. They can select an ovum donor from internet profiles posted by the California -based Center for Surrogate Parenting and Egg Donation, and mail frozen sperm for use with the designated egg. The Center will fertilise the donor egg with the posted sperm and post the resulting embryo back to the UK in deep-freeze packaging ready for implantation in the mother's womb.

The Human Fertilisation and Embryology Authority (HFEA) guidelines regulating fertility clinics in the UK do not permit payment to sperm or egg donors.

The HFEA had not been approached by the US organisation though each frozen embryo imported into Britain needs an individual license, and must be delivered to a licensed fertility clinic. This facility was used for recent entrants into the UK who wanted to receive embryos held in storage abroad.

(Made to order. Jenny Hope. Reprinted inMid-day. May 22, 1998.)

Buy a kidney from death row in China
US undercover agents arrested two men who offered to sell kidneys from executed Chinese prisoners and arrange for American patients to have the transplants in China. The men also offered to supply corneas, pancreases, livers, lungs and skin.

Harry Wu, a human rights activist who helped the FBI set up the ‘sting’ operation, said the men had guaranteed the organs of at least 50 of the 200 prisoners executed on China’s Hainan Island each year.

The Chinese government has always contended that such transplants occur on a limited basis, and only with the consent of the prisoners or their families. But the arrested men reportedly said that prisoners generally “have no political rights, so we don’t ask.” Prisoners’ relatives were reportedly sometimes paid “a little money” to get their consent.

The overt sale of organs is illegal, but the everyday use of executed prisoners as organ donors is legal in China. China kills more prisoners than the rest of the world combined. In 1996, 4,367 people were put to death, while more than 6,100 received death sentences, even for crimes like robbery and counterfeiting.

According to a Chinese expert, who broke the silence about this issue in a 1996 article in a Chinese medical ethics journal, a majority of all organs used in transplants in China come from executed prisoners. Roughly 2,000 kidney transplants are reported in Chinese medical journals each year, said Dr. Charlotte Ikels, who has studied organ procurement in Asia. Ten to 15 per cent of kidney transplants are believed to involve foreign patients. The practice is routine and acceptable; with costs relatively low, overseas Chinese come to China for many kinds of medical care, and many hospitals actually have separate wings devoted to foreign patients.

(From: FBI arrests two Chinese for selling organs of executed prisoners. Christopher Drew.New York Times. February 24, 1998. and: Arrests put focus on organ trafficking from China. Erik Eckholm. New York Times. February 25, 1998.)

Doctor-assisted suicide gets public finance in US
The US state of Oregon will include doctor-assisted suicide on the list of “treatments” covered for people on government health services. Following a vote by the Health Services Commission, doctor-assisted suicide was joined to other forms of “comfort care” for any “terminal illness”.

The decision challenges the assumption that allowing doctor-assisted suicide only declares the government’s neutrality on individuals’ private actions. If dying people with private insurance can pay for medical help in taking their own lives, why should poor people by deprived of the same opportunity?

By including doctor-assisted suicide in that category, which covers pain management, home nursing and other palliative care for the dying. Oregon avoided any comparisons between less and more expensive exits for the terminally ill, although suicide clearly has greater priority than some high-cost life-saving therapies. It has also clearly become an integrated part of a budget-stretching rationing system.

Since the federal government bars federal support for assisted suicide or euthanasia, Oregon must segregate the services involved in assisting suicide and pay for them with the state’s own dollars. The Oregon law also allows health care providers to refuse cooperation in doctor-assisted suicide.

At the moment, pharmacists and doctors are wrangling about the pharmacist’s right to know when a prescription is meant to provide a lethal dose to a dying patient who has requested it. Physicians are worried about violating doctor-patient confidentiality; pharmacists are worried that without such information they will not be able to act accordingly to their consciences.

(Oregon Medicaid’s doctor-assisted suicide. Peter Steinfels.New York Times. March 7, 1998.)

Sperm after death
A US senator’s bill on an increasingly frequent request – that doctors remove and preserve the sperm from men who have just died – is part of a growing effort to impose standards on a largely unregulated technology. The bill would only allow sperm to be taken from a man who had given permission, in writing, before he died, and it could only be used to conceive a child by a wife or partner.

At present relatives can decide what to do with body parts based on what they believe would have been the dead person’s wishes. Some say the procedure is so rare that it does not make sense to crush the desires of a grieving widow unless there was evidence of problems with the current law. But the bill’s proponents claim to establish a fundamental difference between an organ, which can prolong or improve another life, and sperm, which can create a new one. “… No one should be placed in the position of involuntarily creating another human being”.

The procedure for retrieving sperm from a dead man has been available for 20 years. But the number of requests are increasing around the nation as technological advances in in-vitro fertilization make it more likely to produce a child.

(Bill would govern the use of sperm from deceased donors. Ian Fisher. New York Times. March 7, 1998.)

Transgenic and transnational transplants
A surgeon preparing to perform the world’s first pig-to-human heart transplant is seeking the help of a British company to undertake the operation in Israel.

A government advisory panel on animal transplants recommended last year that despite the world-wide shortage of human organs, such operations should not yet be permitted in Britain. It is feared that pig organs could carry unknown viruses which may jump species and infect their human recipients.

However, Jacob Lavee, director of the prestigious Tel Hashomet transplant centre near Tel Aviv, is meeting scientists from Imutran, a British company, to discuss the proposal.

Imutran has developed a breed of genetically engineered pigs which produce organs that are not immediately recognised as foreign by the human immune system. The company, owned by Novartis, the international drugs giant, is expected by the Israelis to co-operate in the supply of a heart.

Lavee said the cost of the so-called ‘transgenic’ hearts will be met by private health insurers in Israel, anxious to share in the kudos of being associated with the first operations. “We have about 100 cardiac patients waiting for transplants. I believe these pig hearts will definitely provide the long-term answer”, he said.

“We have very few problems with red tape here and often we get permission to use new technologies much earlier than other countries”.

Jewish heart disease sufferers have a liberal attitude to the idea of “absorbing” rather than eating a pig organ. Pig heart valves have been used in humans in Israel since the early 1980s.

Yoran Nophar, 39, a molecular biologist, has volunteered for the pig transplant operation. He has been waiting six years for a new human heart. “I would have a pig heart even if it is risky”, he said. “It is clear that I am deteriorating, but what’s important is my mind and I welcome whatever can keep it functioning.”

Senior clinicians in Britain are divided over the ethics of the surgery. Professor Sir Roy Calne, who pioneered liver transplant surgery in Britain and is an Imutran advisor, said that if he were on an ethical committee considering permission for such an operation, he would reject it. However, he added: “I wouldn’t be violently opposed to it and the results would be interesting, but I don’t think the science has advanced sufficiently to go into man.”

Steve Westaby, director of the Oxford Heart Centre, believes it would be unethical to allow the operation in Israel when the risk of rejection and of pig-bore infection are considered unacceptable in Britain. “I don’t think it is right for scientists to say, “We don’t want this here but you can take it to another country and experiment on it”, he said.

In a statement, Imutran acknowledged that there are a number of transplant centres world-wide keen to pioneer use of the organs in human transplants. It had not comment on the specific Israeli proposal but said it would not participate in human trials until it had ensured the pig hearts could function safely for prolonged periods. “Once these steps have been completed and reviewed, it is likely only a small clinical trial will take place”, the company said.

(Jewish patient first in line for pig heart. L Rogers and A Goldberg. The Sunday Times. April 12, 1998.)