LETTERS

Doctors and sexual assault
After seeing your story 'Sexual Assault: the role of the examining doctor', I have a suggestion to make. Would it be possible for your journal to also examine the issue of doctors who sexually violate their patients during physical examinations?

I speak from personal experience. My doctor misused his physical examination and completely destroyed my trust. He did this under the guise of an "examination technique" (I must make it clear that there was no sexual penetration), thereby confusing me further. I kept asking myself if I was being oversensitive / critical / paranoid.

I belong to a privileged and upperclass family. I developed tuberculosis some years ago and went to my family doctor who also happens to be my uncle.

On the second visit to my doctor I was assaulted in a manner which left me completely confused as to whether it was part of the examination or whether I was being sexually violated. On my third visit my initial reaction was just to get out of the clinic. My fears that I was being sexually assaulted were confirmed when I walked out of the examining room and found that I was the only one in the clinic and that the main door was locked.

In one respect your article did cover part of my experience. After the last assault I went immediately to a lady general practitioner in my neighbourhood to verify whether the 'method' chosen for examination by my doctor was really necessary. While telling her what happened I momentarily broke down. Her reaction was: "For God's sake stop all this crying." At the time her only interest was to know the name of the doctor. After I told her, she said, "I don't know him," and dismissed me. I had the feeling that it was a piece of gossip as far as she was concerned.

In retrospect I thank her for her attitude. Her reaction toughened me for the coming months which as I'm sure you know are terrible as the victim invariably replays the scene and the sense of anger coupled with frustration is as fresh as it was the first time. I still do not know what action I could have taken since the onus of proof is invariably on the woman and this means revealing details which make the emotional recovery that much longer.

I believe it is essential to investigate this trauma that I am sure many women undergo. It is made all the more unfortunate by the fact that even after an assault the patient often goes back to the same doctor because of 'faith' in his healing abilities or the belief that a patient's accusation will not hold much water against the doctors respectable position. Either way it is rare for the doctor to be exposed or for any action to be taken against him.

Is there some way in which your magazine could tackle a subject like this? Is there any way for a victim to approach medical authorities without the accompanying trauma that a police investigation ensures?

V K Ram,via the internet
Reference:
D'Souza,Lalitha. Sexual assault: the role of the examining doctor. Issues in Medical Ethics 1998;6:113-116

Doctors and human rights: many issues
Your editorial on the medical profession and human rights took a narrow view of the question of medical ethics. It tended to stress instances in which a doctor has abutted or been a party to human rights violations. It missed certain other ethical issues which deserve mention.

Euthanasia or mercy killing has long been the punching bag ofethicologists. The question of playing God to alleviate a patient's suffering continues to spark off debate. The ethics involved in letting a seriously injured 'medico-legal case' lie in the hospital's casualty department till police formalities are completed needs a rethink. Is it ethical to allow legal interference in patient care?

No debate on medical ethics can be complete without a mention of prenatal gender determination. While some believe that reporting of foetal sex is unethical on the grounds that it promotes foeticide, others lay great store by the patient's 'right to know', perhaps even 'to choose'.

The aforementioned instances are commonly encountered by medical professionals. Decisions in their regard should come from the application of common sense and concern for the individual patient, not from formal study of the subject.

Dr Puneet Madhok,3A Horizon, Pali Hill, Bandra (W). Mumbai 400 050
Reference:
Pai, Sanjay. The medical profession and human rights. Issues in Medical Ethics, 1998: (VI) 4: 105

Fighting medical negligence
I am writing this for the information of those who plan to file or who have just filed medical negligence cases. You have a chance of winning if there is direct evidence in your favour: if a forceps was left inside the operated patient, the wrong part removed, the wrong blood group given, and so on. In the absence of such direct evidence, you have to prove the doctors' negligence. This will be an uphill task with almost no chance of winning.

I filed a complaint with a medical council, the so-called body of medical experts. During the hearing of my case they did not allow me to have an advocate. They did not examine a single medical paper before deciding the case. Professional sympathy and contacts go against the complainant, here. Facts have no value. How will an ordinary man to argue a medical case against doctors? The accused doctors' statements and their image carry more weight than those of someone with no medical knowledge. So your chances of winning in a medical council are 'nil'. The (negative) opinion given by a medical council will harm any legal case that you file, as it carries the verdict of a body of medical experts. So never go to a medical council for justice. You will only lose.

When you go to the legal system the person hearing your case has no medical knowledge. The statements of the accused doctors and the opinion of the medical council carry more weight and form the basis of the verdict.

Many doctors will sympathise with you and even give you an opinion in your favour but will not sign it. An unsigned opinion has no value in law. The doctors will say that signing will cause professional enmity. Why should they damage their reputations for a person who is not related to them?

Those judging medical negligence cases should understand the problems faced by complainants and accept unsigned medical opinions, forwarding them if necessary to a public sector hospital for comment, before deciding the case.

R G Raheja,Mumbai

Ethics, human rights and polio eradication

From the time that India became signatory to the 1988 World Health Assembly resolution to commit the World Health Organization and all member nations to eradicate poliomyelitis worldwide by the year 2000, our efforts under the Universal Immunisation Program (UIP) have improved. This is evident from the steady downward trend in the annual reported number of children with polio from 1988.

In December 1995 the Ministry of Health and Family Welfare introduced nationwide annual pulse immunisation in which all children under a specified age are offered two doses of oral polio vaccine (OPV) one month apart. Currently all children under five are encouraged to get two pulse doses each year, irrespective of the number of doses previously taken. This is the main plank of immunisation for interrupting the transmission of natural (wild) polioviruses in the country.

The Ministry has also improved upon the disease reporting system used to monitor the programme's progress and guide immunisation activities. From the last quarter of 1997 a special project has been established to JtfR detect all children under 15 years with acute flaccid paralysis (AFP). J From each child with AFP two stool samples are collected on 2 consecutive days and sent to one of the nine poliovirus laboratories in the country. If poliovirus is cultured, it is typed and also sent to a reference laboratory for its molecular characterisation: whether wild or vaccine-derived. When no more wild viruses are detected in spite of diligent search, we will know that success has been achieved. If stool specimens were not collected within two weeks of onset of paralysis, but if paralysis persists for more than 60 days, the case is clinically diagnosed as polio. In fact the 60-day follow-up is encouraged for all children with AFP to monitor the concordance between virus isolation and clinical diagnosis.

Health care workersin the public and private sectors are required to report every child with AFP. A highly paid cadre of surveillance medical officers oversees the surveillance and stool collection. Two of the polio laboratories examining stool samples also function as reference laboratories.

Routine immunisation is given free by the public-sector and for a fee by the private sector (the vaccine may be purchased). Pulse immunisation involves the public and private sector health sectors, nongovernmental organisations, local volunteers and other sectors.

The executing agency of the national polio eradication programme is the Ministry of Health and Family Welfare. The participants in this programme are all children under five who receive OPV and all children under 15 who have developed AFP. They (and their parents) participate for the benefit of the entire community, not in order to get treatment for an illness, or purely in their self interest. The time and expenses of travel, and any risk involved in participating in it, are borne by the participants themselves.

It is necessary to acknowledge the ethical obligations of the programme implementors and the rights of participants, including the right to compensation for any harm. The ethical principles risk involved here are no greater from those for medical practice, research or clinical trials.

The basic tenets of ethics are autonomy (respect for the individual), beneficence, nonmaleficence and justice (fairness). By virtue of the fact that some children develop AFP as a consequence of their participation in the programme, it becomes ethically necessary, for the sake of justice, to offer the best possible treatment for the acute condition and rehabilitation as long as is reasonably necessary.

From 1987 to 1993, at the request of the Ministry, the Christian Medical College Hospital, Vellore, established a model project to control polio in the North Arcot District, under the guidance and support of the Indian Council of Medical Research. Every child with AFP was admitted to the hospital for a few days in the acute stage and offered rehabilitation services for two years, at no cost to the family. Transportation expenses and when necessary food expenses were reimbursed.

Under the national polio eradication programme it is imperative that every child with AFP be treated free of cost. This should be done to uphold the ethical principles of respect for the individual and justice, and also for the programme's success. The most effective incentive for a health worker to report each case ofAFP is the visible result of such reporting. If each case is treated with care and competence, which health worker will not report the next case? The families of all children identified with AFP (from the time surveillance was established in 1997) must be offered domiciliary counseling about their right to rehabilitative treatment.

The interventions for eradication consist of routine immunisation for the 'herd effect' (to reduce the incidence of polio) and pulse immunisation specifically to interrupt transmission. For the former purpose, though the Indian Academy of Paediatrics' stipulation of a five-dose primary immunisation appears to be the bare minimum for reasonable personal protection in India as long as virus circulation is unabated, only three doses of OPV are given in the government's UIP schedule.

A number of children are reported to have developed polio in spite of taking three doses of OPV. Beneficence and justice demand that such children (and their families) be compensated for the defective service they received. From 1997, as virological data are available, every child who developed polio despite participation in the immunisation programme, no matter how many doses were taken, must be compensated. Even if the illness is not polio, treatment and rehabilitation are essential.

Finally, current virological investigations are already detecting children with polio caused by vaccine viruses. Generally speaking, a rate of one vaccine-associated case of paralytic polio is expected per 500,000 infants given the first dose of OPV. Thus, among the over 25 million first- dose recipients annually in our country, we may anticipate over 50 such cases every year. Every child who has vaccine- induced polio must be compensated with an enhanced quantum compared to the child who develops polio due to wild virus despite immunisation as a result of the vaccine's failure. Vaccine failure is due to deficient services. Vaccine paralysis, on the other hand, is the direct consequence of participation in the programme and a more serious adverse effect deserving higher compensation. The actual expenditure for compensating victims of adverse events will be only a very small but essential fraction of the total cost of eradication.

Dr. T Jacob John,Emeritus Medical Scientist of the Indian Council of Medical Research Christian Medical College Hospital, Vellore, Tamil Nadu

The ICMR's ethical guidelines: no debate?
On September 24, I attended a public debate on a draft consultative document entitled 'Ethical Guidelines on Biomedical Research Involving Human Subjects.' produced by an ICMR-sponsored committee under the chairmanship of Justice MN Venkatachalaiah of the National Human Rights Commission. The public debate was organised for the Southern region by the National Institute of Nutrition and I believe there was a similar one in Mumbai and in Calcutta for the Western and Eastern regions and a Northern regional debate is planned in the next few weeks in Delhi. All these are being minuted and sent back to the committee for finalisation by the end of the year.

There was a sincere attempt by the organisers at NIN to elicit a broader dialogue and among others, various people-oriented, gender issue related and societal related issues were raised.

However, I did feel that the debate was not based on well-informed judgement and often personal prejudices or 'status quo' urges were overshadowing a deeper 'ethical issue' exploring process.

In discussions at length with Dr V. Muthuswamy, Deputy DG and Chief,Division of Basic Medical Sciences. ICMR, New Delhi, who is member secretary of the Commitee and coordinator for the whole process, 1 noted:

In spite of evidently circulating over 500 copies of the draft guidelines, they (ICMR) had not received the sort of interactive response they had hoped for.Of the 27-member committee, 19 were Delhi-based bigwigs and though they had five subcommittees (to produce ethical guidelines for Human Genetic Research, Transplantation Research, Clinical Evaluation of Drugs/ Diagnostics/Vaccines/Herbals, Epidemiological Research and Assisted Reproductive Technology research) which had a slightly broader representation, the people involved were either retired people or even senior practitioners and, quite surprisingly, mostly Mumbai doctors and seven Delhi ICMR and Ministry of Health and Family Welfare representatives. Do these represent a wide cross section of opinion?

On the whole, the guidelines are comprehensive and based on ethical issues and there are serious attempts to build in controls and checks, but all of you with your extensive experience in interactive dialogue could help 'fine tune' the emerging guidelines and detect those that have slipped in advertently or consciously to justify questionable research. So do not miss the opportunity to write to DrVasantha.

The last guidelines of ICMR in 1980 also mentioned the need for ethical committees, informed consent, etc. but was very brief. Eighteen years later, the recent document is definitely more comprehensive and live to the new developments, but there may be a long delay before the next update. So better engage now rather than debate or critique the guidelines later.

Dr. Ravi NarayanCommunity Health Cell, 367, Srinivasa Nilaya Jakkasandra, 1st Main, 1st Block, Koramangala, Bangalore 560 034.
The proposed ICMR guidelines can be viewed athttp://www/healthlibary.com