Indian Journal of Medical Ethics

FROM THE PRESS

HIV/AIDS programme mismanaged

Critics of India's ambitious World Bank- funded AIDS control programme feel vindicated by the revelation in Parliament that the number of HIV-infected people in the country has snowballed to eight million. Health activists and non-governmental organisations have long protested against alleged mismanagement of anti-AIDS funds. Anti-AIDS activist Purushottaman Mulloli thinks that current donor-promoted H1V/ AIDS programmes cannot work in India in the absence of an effective primary health care system. The government's AIDS control efforts have also come under fire for targeting "high-risk" groups, leading to social ostracism of the group. Efforts will not get far without a change in medical professionals' attitudes, say activists. "Doctors remain unwilling to work with HIV positive people while society reacts with paranoia as the epidemic unfolds," complains Siddharth Vatsyayan of the AIDS Awareness Group. According to John Roegner of the NAZ Foundation (India Trust), hospitals and doctors in the Indian capital regularly turn away AIDS patients.

HIV spreads despite World Bank project Ranjit Dev Raj Inter Press Service, May 2,1999

Government doctors banned from conference
Israel 's health minister banned 200 public JLsector doctors from attending a conference in Turkey, organised and paid for by Teva, Israel's leading pharmaceutical company. He argued that the trip was aimed at promoting sales of a new anti-hypertension drug, Cardura-XL, which Teva markets in Israel for Pfizer, and would have violated "public and ethical considerations." Teva said that it had acted within government guidelines. The company was forced to cancel the conference and is considering legal action against the ministry. The health ministry issued guidelines in 1993, but the director general. Professor Gabi Barabash, said: "There are loopholes that have to be closed.

Doctors banned from drug company trip Judy Siegel-Itzkovich, Jerusalem BMJ August 8,1998; 317: 370.

IMA acts against sex selective abortions
Tne Indian Medical Association and the Medical Council of India have asked doctors to stop participating in sex determination and selective abortion of female fetuses. The IMA will circulate a set of directives to all its 1,700 branches. It has said that it will launch independent investigations against doctors suspected of being involved in such practices. The medical council has promised to revoke licences of doctors found guilty. This is the first time since the Indian parliament outlawed prenatal sex determination that medical institutions are trying to step up pressure on doctors. Not a single doctor has been convicted under the 1994 act.

Non-government organisations such as the Voluntary Health Association of India estimate that hundreds of thousands of foetuses are aborted each year only because they are female. The practice has spread across urban and rural India through easy access to non-invasive sex determination based on ultrasonography. Social activists and legal experts, however, are sceptical. "This is a situation where there is social sanction to an outlawed practice," says Anita Roy, a federal police officer.

Indian medical authorities act on antenatal sex selection Ganapati Mudur, New Delhi BMJ August 14,1999; 319: 401

WMA opposes national health database
The World Medical Association (WMA) I council meeting in Santiago, Chile. affirmed its support of the Icelandic Medical Association in its fight against the implementation of a national health database in Iceland.

In December 1998 Iceland passed legislation providing for the creation of a national health sector database covering the country's population. Patients had untilJune 17 to opt out the database, which would allow a private company to link their medical records with genealogical and genetic data.

The WMA council said that it stood fully behind the position taken by the Icelandic Medical Association in opposing the legislation, and it especially wished to point to the need to protect the integrity of patient data and have open access to all scientific data. The council is urging all national medical associations and governments to ensure that science is furthered by continued research without breaching medical ethics and patient confidentiality.

The Icelandic government has defended the development of the database on the grounds that patients' rights of confidentiality are fully protected and that rights to develop new drugs or lest candidate drugs are not being given exclusively to one company. Icelandic health authorities will have access to the scientific information, provided that they comply with specific regulations.

World Medical Association opposes Icelandic gene database Nigel Duncan, Santiago, Chile BMJ April 24,1999; 318: 1096

Investigation into mental hospitals
The National Human Rights Commission (NHRC) has constituted a central advisory group to look into the functioning of the Ranchi, Agra and Gwalior mental hospitals. The hospital managements came under the scrutiny of the supreme court through a writ petition. In a November 1997 order, the apex court asked the NHRC to involve itself in the supervision of the functioning of these mental hospitals in the same manner in which the Commission was requested to undertake similar work in respect of the Agra Protective Home. The NHRC has set up a central advisory group headed by the NHRC's chairman, justice MN Ventatachalaiah. to advise the Commission on the duties and responsibilities envisaged by the supreme court's order, the various steps to be taken to achieve these objectives and to review the progress of work.

NHRC sets up advisory group to supervise mental hospitals. Man Mohan. The Times of India, June 15,1999.

WHO guidelines questioned
The May 1999 issue of the Bulletin on Drug and Health Information carries an open letter to the director of WHO, questioning WHO guidelines which specify normal blood pressure as below 130/85 mmHg, and optimal blood pressure as below 120/80 mmHg. It notes that the only trial looking at optimal blood pressure contains "no evidence to recommend aiming for a blood pressure below 140/90 in non-diabetics". The trial was co- sponsored by the WHO and Astra, a pharmaceutical company. The letter adds: "We fear that the new recommendations will be used to encourage an increased use of anti-hypertensive drugs, at great expense, and for little benefit." The letter, which was written by Therapeutics Initiative, a group of Canada- based family doctors, can be signed on the Internet athttp://www.uib.no/isf/letter/index, htm.

Open letter to Director-General Gro Harlem Brundtiand. BODHl 1999 May-June; VI (2): 33- 34.

Delinquent Maharashtra doctors face action
Over 250 medical officers in Maharashtra face civil and criminal proceedings for dereliction of duty following a state government directive to the director of health services. This followed a department survey revealing that many medical officers attached to the public health centres, rural and district hospitals had left the headquarters without their superiors' written permission. They were also found carrying out private practice in blatant violation of Maharashtra Civil Service rules.
Under section 168 of the Indian Penal Code, a public servant unlawfully engaged in a trade is liable to simple imprisonment for a term which may extend to one year or with a fine or both. Medical officers drawing non- private practicing allowance are barred from private practice. "We found that while the doctors were not reporting to the public health centres, they were actually seeing patients at their official residence and collecting money from poor patients. In some cases, a section of the medical officers were running full-fledged nursing homes in the names of their relatives," an officer said. The state is also considering the suspension of registration of the erring officers. Specific instructions have been issued to the director of health services that the salary bill of medical officers who leave the headquarters without permission should be withheld.

Doctors to face action for negligence.Prafulla Marpakwar, Indian Express, June 27,1999

SA doctors against unethical colleagues
A group of South African doctors from the University of Cape Town's Health and Human Rights project is considering forcing the Health Professions Council to investigate the doctor who headed the apartheid government's chemical and biological warfare programme. They are also asking the council to lake action against doctors implicated in unethical conduct before the Truth and Reconciliation Commission.

Dr Wouter Basson is being tried for crimes associated with his role at the head of the programme. At present, he retains his job in the public health sector as a cardiologist. The Health Professions Council says it will conduct an inquiry into his conduct after the criminal trial. The South African Medical Association, the voluntary professional association for doctors, has allowed Dr Basson to remain a member but has initiated an investigation into his membership.

Among those who have now complained to the council is Professor Joe Veriava, who was instrumental in compelling the council to inquire into the death of the political activist Sleven Biko. Up until that time the council had refused to take action against the doctors who attended to Mr Biko after he was fatally assaulted while in police custody.

South African doctors demand action on '"unethical" colleagues Pat Sidley BMj September 4,1999; 319: 594

Indian children die of hunger
Gross malnutrition accounts for 55 per cent of all deaths of Indian children under the age of five. according to a recent UNICEF study. Thirty-seven per cent of babies born in West Bengal weighed less than the threshold 2.5 kg; 56.8 per cent of children under the age of five were underweight, and all of them ran a high risk of infection and death.

Malnutrition kills 55 per cent of kids, says UN study. Press Trust of India. Indian Express, September 3, 1999.

Babies to order in the US
British couples desperate for a family are spending tens of thousands of pounds on perfect babies-to-order. Faced with two- year waiting lists in the UK, they are selecting their ideal offspring from advertisements on the Internet and travelling to the US for treatment. The business is attracting those who fear that a shortage of egg donors in this country may force them to remain childless.

Fertility experts believe what the number of Britons using US facilities will rise dramatically because the Net has made information on donors so accessible. Parents are choosing the genes they want their child to inherit.

An Indian couple asked a clinic for an egg from a Caucasian mother; a dark-skinned woman asked specifically for a tall Nordic donor. The sale of eggs is big business in America. While the British system pays a donor only Ł15 plus expenses, market economics operates in the US and genes can fetch high prices. In Britain, doctors insist that the donor must be close to the would-be parents' own genetic backgrounds. If the couple ask for a donor very different from themselves, most doctors will question whether they will make suitable parents.

In the US, agencies advertise for eggs in student newspapers at Ivy League universities. Up to $50,000 is offered for preferred characteristics. Some US egg donor agencies advertise directly on the Internet with soft-focus photographs of their donors on the web.

The donation procedure itself is complicated and while the process does not deplete the donor's reserve, it can be painful and sometimes leads to hyper stimulation, and in rare cases, stroke.

James Yeandel of the UK's Human Fertilisation and Embryology Authority said, "The number of people searching the Internet for egg donors is alarming, but I think the cost will be prohibitive for most British couples." The 68 licensed clinics in Britain charge about Ł3000 per cycle; US clinics at least three times that.

In search of the perfect baby. Nicole Vcash, Observer News Service, Indian Express, August 18,1999.

Protest against ruling on HIV marriage
Lawyer Anand Grover called for public protest against the Supreme Court ruling suspending the AIDS-affected person's right to marry. He said the right to marry is a fundamental right and no court of law can 'suspend' it. The apex court did not take cognisance of the fact that HIV-positive people get married with full, free and informed consent of their partner who may or may not have HIV positive status. "The restriction on the marriages of HIV- infected persons can have serious repercussions. The isolation of such persons will drive the epidemic underground, as doctors and hospitals will not maintain confidentiality with regard to their HIV status," he said. He said the apex court was right in making it a moral and legal right for an HIV-positive person to disclose his/her status to the prospective spouse.

Lawyer calls for protest on SC ruling in HIV marriage case. Indian Express, September 5,1999.

HIV patient denied treatment
'The National Human Rights Commission -L (NHRC) has issued notices to the Ministry of Health and Delhi government on a complaint filed by the All India Lawyers Forum for Civil Liberty (AILFCL) about the alleged denial of treatment to an HIV patient in Safdarjung hospital, Delhi.
In a letter to the NHRC chairman MN Venkatachalaiah, AILFCL chairman KK Nigam and president OP Saxena asked the NHRC to issue guidelines to the Centre and state governments to provide medical facilities to AIDS patients.

Notices to government for denying treatment to HIV patient. Press Trust of India. Indian Express. August 31,1999.

Kidney on the net
Online bidding for a human kidney topped US $5.7 million before executives at the Internet auction house EBay yanked the illegal posting." Fully functional kidney for sale," read the posting. "You can choose either kidney. Buyer pays all transplant and medical costs. Of course, only one for sale, as I need the other to live. Serious bids only." Selling human organs is illegal in the United States, punishable by up to five years in prison or a $50,000 fine. Ebay said it shut down the auction as soon as the company heard of it. Nevertheless the auction appears to mark an uncomfortable intersection of the frenzied atmosphere of Internet bidding, a possible hoax and the desperate shortage of organ donors in the United States. There are 42,907 patients waiting for kidney transplants in the United Slates, according to the United Network of Organ Sharing. The average waif exceeds three years. But experts said both the kidney offering and the seven bids it fetched were probably hoaxes.

Kidney draws $5.7 million bid on Ebay. The Times of India (Bombay Times), September 4,1999.

Hypnotism to increase sperm count
A doctor practicing hypnotism in Nashik recently created a flutter in medical circles by claiming that his therapy had increased the sperm count in a patient, who later fathered a child. The doctor's haste in going to town about his success invited criticism and the attention of the medical fraternity, which responded with scepticism. But the most practical response was from the Andhashraddha Nirmulan Samiti, which asked the doctor for a public debate on the issue. At the public meeting, the doctor cut a sorry figure and was not able to give a satisfactory scientific answer to the 'miracle'. He made a rather sheepish exit saying he would conduct the experiment on at least 200 patients and involve medical experts to establish his claim.

Miracle gone bust. Rakshit Sonawane, Indian Express, Nashik Diary, August 18, 1999.

Norplant case
American Home Products Corp., the parent ofNorplant maker Wyeth-Ayerst Laboratories, will pay a reported $54 million-plus to more than 36,000 women ($1,500 per woman) to settle claims that the implantable contraceptive device caused headaches, irregular menstrual bleeding, nausea and depression. The company called the move to end five years of litigation a "pure business decision ". It did not admit any wrongdoing. The settlement covers most of the thousands of lawsuits filed against the company but not the claims by hundreds of other women who had different types of injuries including scarring from having the implants removed. The company has prevailed in most of its Norplant lawsuits winning three verdicts, 20 summary judgments and the dismissal of almost 14,000 claims.

Drug firm offers to settle Norplant case. Amy Westfeldt, Associated Press, The Times of India, August 28,1999.

Hospital also liable
The Consumer Disputes Redressal Forum, Dadar, Mumbai, has ordered the Lilavati Hospital to pay S P Bhanushali Rs 1,25,489 as compensation in a case of post-operative medical negligence, and held that the hospital is liable for actions of its honorary doctors. If also defined what constitutes specialist or expert care. The complainant's father. Mr Padmakar Vaman Bhanushali. underwent coronary artery bypass grafting at the hospital on October 31, 1997. On November 3, he contacted Dr Panda because of a fever associated with rash and chills, but no quick remedial action was taken. On November 7, he was examined by one Dr D'Silva who asked him to undergo some investigations and stop the drug Augmentin. He was subsequently admitted to Lilavati on November 11 after liver function tests showed abnormal results, but died on November 12, 1997. The cause of death was given as 'terminal cardiorespiratory arrest with blood transfusion induced graft versus host reaction with ischaemic heart disease." The court ruled: "A reasonable prudent doctor who professes to be an expert in the field ought to have the patient immediately admitted, investigated and more importantly, kept under close observation." That this was not done "amounts to negligence." Although Dr D'Silva is not a party in the case, the court ruled that the relationship of Dr Panda and Lilavati hospital is "that of a principal and an agent and that of Dr D'Silva and Lilavati Hospital is that of an employee and employer. By the law of vicarious liability, therefore, for all acts of omission and commission of the agent... the principal will be liable"

'Honorary docs answerable'. Express News Service, Indian Express, August 7,1999.

NEJM editor steps down
In August 1999, Jerome P. Kassirer, editor-in-chief of the New England Journal of Medicine, stepped down after a highly successful tenure of eight years, Dr Kassirer's exit ended a long-standing struggle between him and the Massachusetts Medical Society, which owns and publishes the NEJM. DrMarciu Angel!, interim editor- in-chief of the NEJM, writes in the September 2. 1999 issue that the main bone of contention was the Society's "ambitious plans to expand its role as a medical publisher, both in print and on line, by launching and acquiring new publications, repackaging the Journal's content for consumers, and entering into joint arrangements ('co-branding') with various information-based commercial enterprises. Kassirer privately questioned the wisdom of many of these ventures, but what he strongly opposed in his capacity as editor- in-chief was the use of the Journal's name to promote products for which he and Ins staff had no responsibility. To him. these activities threatened the Journal's credibility. To the society's leadership and publishing staff, such leveraging not only was good business practice, but also furthered the society's educational mission."

For more details, read the September 2, 1999 editorial on the NEJM web site (http://www.nejm.org)