Indian Journal of Medical Ethics

I enjoyed reading the articles on changing trends in general practice (1, 2, 3, 4, 5, 6). I was disappointed that no one bothered to discuss the important role patients can play in improving the ethical standards of medical practice. Why do doctors assume that they are the center of the medical universe, and that patients cannot be trusted to make their own decisions ? If good doctors spend time and energy in educating their patients, standards of medical practice would improve, as patients would then have tools they could use to evaluate the quality of their medical care - and the quality of their doctor-patient education can help to weed out quacks and unethical doctors who make unrealistic promises.

Dr Bawaskar, in his two pieces in the last two issues of the journal, has briefly shared with us his principled, ethical conduct in his clinical professional work (1, 2). I am writing this to say that he is not alone. There is a small but significant section of doctors who have been keeping away from the lures of drug companies and other medical companies, and trying to do justice to their patients. What is needed is that such doctors should keep in touch with each other, share their experiences, and act together, whenever there is such a chance, to oppose unethical practices.

One blatantly unethical practice is being promoted currently by the NORMA company, which sells compression stockings for varicose veins etc. A flier by this company offers doctors one Parker pen for every 'client' brought by the doctor to the company. This flier announces

What can we do collectively to stop this practice? The first step is to appeal doctors through various professional journals not to be party to this 'trade-off'. Second, some of us can jointly write to the concerned company that it should stop this unethical marketing. If we can get some well-known doctors to sign this letter, it will have more impact.

In Dr BC Rao's essay on general practice, the sentence: "A well-informed patient will demand treatment after being informed, and explaining a problem spending lot of time," (Page 10, second column, second paragraph, fourth line) should read, "A well informed patient will demand treatment based on knowledge and explaining [meaning making him knowledgeable] a problem will mean spending lot more time."

The experience she had at the TMC was, to say the least, horrifying. She was pushed from pillar to post, sent up and down floors, between buildings and traversing long corridors. All this could have been obviated if there was even a semblance of planning on the part of the organisers.

Today, she went because she had been asked to 'collect' the reports. It was the same story of being pushed around interminably. And after collecting the reports and the signatures of the doctors, the counter clerk took the entire file and said she could leave. She asked for the reports for her records, for which she had been specifically called there. She was told that the file remained with the TMC; she doesn't get any report from the file.

First, what was the propriety in calling her there at all if she was not to be given the reports or the copies thereof? Surely, they could have themselves made arrangements by which all reports are sent to one central record section for filing and records? Second, what is the point of getting the examination done if patients can't have the reports or copies thereof for their records? There was no element of courtesy at any stage, leave aside any sense of service, in any of the staff or the doctors she had the misfortune to be pitted against.

Admittedly, this was a free camp. But, does it mean that the patients should be treated as beggars? Better not to have such free camps at all, in that case. And, it is not only in cases of free camps but even in cases of paying patients, the treatment meted out to them is no better.

In February 2000, the Government of India adopted the National Population Policy 2000. One undoubtedly positive feature of the policy is that it resolutely affirms the "commitment of the government towards voluntary and informed choice and consent of citizens while availing of reproductive health care services, and continuation of the target free approach in administering family planning services".

It is thus profoundly disturbing that several State governments have announced population policies, which, in very significant ways, violate the letter and the spirit of the National Population Policy. Annexure I provides a summary of these State Population Policies.

Press reports (Outlook, 29th April 2002, Hindustan , 23rd April 2002, Annexures III and IV) indicate that, instead of preventing these distortions, the Union cabinet is considering a "Strategy Paper"(Annexure V) to review the national family welfare programme and policy which also violates the spirit of the NPP.

We would also like to bring to your notice, a Bill that has been framed in Uttar Pradesh, the Uttar Pradesh Population Control Bill, 2002 (Annexure VI). This Bill codifies all the anti-human rights features of the State Population Policies that we have referred to. This Bill is clearly violative of the provisions of the NPP 2000.

You would notice that the State population policies contain a series of disincentives and incentives that are anti-women, anti-adivasis, anti-dalit and anti-poor in general. They also are profoundly violative of human and democratic rights.

1. The disincentives proposed, such as denying ration cards and education in government schools for the third child, withdrawal of a range of welfare programmes for the Scheduled Castes and Scheduled Tribes with more than two children, debarring such people from government jobs etc. are questionable on

various grounds. The National Family Health Survey for 1998-99 shows that the Total Fertility Rate (TFR) is 3.15 for S.Cs, 3.06 for S.Ts, 2.66 among O.B.Cs and 3.47 among illiterate women as a whole. It is, in contrast, 1.99 among better off women and those likely to be educated beyond the tenth grade. Imposition of the two-child norm, and the disincentives proposed, would thus mean that significant sections among those already deprived populations would bear the brunt of the state's withdrawal of ameliorative measures, as pitiably inadequate as they are.

2. The two-child norm bars large sections of dalits, adivasis and the poor in general from contesting elections to the PRIs and thus deprives them of their democratic rights. Further, in the States where they have been imposed, as in Haryana, Madhya Pradesh and Rajasthan, we are aware of substantial numbers of women who have been deserted, or forced to undergo sex selective abortions. In general, such a norm provides an impetus for an increase in sex-selective abortions, worsening an already terrible child sex ratio in the country.

3. As the NPP itself acknowledges, there is a large need for health and safe contraceptive services. To propose punitive measures in this context is clearly absurd. Reflecting deprivation, the dalits, adivasis and Other Backward Castes bear a significantly higher proportion of the mortality load in the country. The National Family Health Survey for 1998-99, notes that the Infant Mortality Rate among the S.Cs, S.T.s and Other Backward Castes is 83, 84 and 76 respectively, compared to 62 for Others. Similarly the Under Five Mortality Rate is 119 among the S.Cs, 126 among the S.T.s 103 among the O.B.Cs compared to 82 among the Others. Clearly, to impose a two-child norm under such circumstances is to widen the inequality gap among our people. Instead of dealing with the causes for these differentials, what the state population policies seek do is to punish victims for their poverty and deprivation.

4. The proposals violate several fundamental rights, the Directive Principles of the Constitution of India, as well as several international Covenants that India is signatory to, including the ICRC, CEDAW as well as the Beijing Platform of Action and the Cairo Declaration.

We are astonished to learn from the press reports referred to earlier, that the Union Cabinet could consider discussing the so called strategy paper which does not have the imprimatur of either the National Population Commission or the Ministry of Health and Family Welfare. The anonymous document thus does not carry the mandate of any statutory, advisory or decision-making body.

The document itself is poorly substantiated by data, deeply contradictory and shockingly at variance with the National Population Policy 2000. Although the NPP 2000 can be described as weak on many counts, it is firmly committed to respect for human rights, freedom and dignity of women, values that all of us cherish. These were translated into a non-target oriented family welfare programme, which rightly abjured incentives and disincentives. The NPP, as we noted earlier, recognises that there is a large and unmet need for quality health and reproductive and child health services; it also recognises that infant mortality rates are still unconscionably high and that there is an urgent need to strengthen health services, attending particularly to the needs of the poor and the marginalised. Above all, it recognises the need for quality services which respect the dignity of people, even as it emphasises equity.

The "Strategy Paper", on the other hand, is drafted in the a-historical and unscientific language of Malthusian scare-mongering. While it recognises that infrastructure is weak, and that the quality and coverage of health services are poor, it absurdly attributes these failures of the State primarily to population growth. While it recognises that there is an adverse sex ratio, it is not averse to calling for a two-child national norm when it is absolutely clear that such norms have indeed contributed to the adverse sex ratio. While it recognises that there is an unmet need for health and family welfare services, it contradictorily calls for a range of incentives and disincentives, holding up Andhra Pradesh as an example. Further, it argues, incorrectly, that China continues to have a one-child norm. In any case, comparisons between India and China are inapposite for a large number of reasons, including per-capita incomes, achievements in health, equity and education that India can unfortunately not boast of. Finally, the so-called strategy paper invidiously suggests that concern for rights and equity are current only in NGOs financially supported by UNFPA.

It needs to be put on record that we had, even before the ICPD, and indeed with no links to the UNFPA, critiqued the family planning policy as it then existed. The population policy in the country, it was noted, "has been one of fertility control, pursued relentlessly, and at times coercively, bringing disrepute to the family planning programme and compromising women's health and accelerating the declining sex ratio". It is possibly in the light of such critiques, along with the commitments made at the ICPD at Cairo, that the NPP 2000 abjures targets, incentives, disincentives and specifying a two-child norm.

Depriving children of their rights to survival and development is not only violative of the International Convention on the Rights of the Child, but also of successive directives of the Supreme Court to enhance their right to education. We request the NHRC to direct States to comply with these directives and not use population policies to deny these rights.

The 73rd and 74th Constitutional Amendments sought to strengthen and expand the base for India's democratic governance by providing Constitutional recognition to local self-government bodies. The States' legislations on Panchayati Raj providing disqualifications on the basis of the two-child norm, invariably cite the National Population Policy as the rationale for such restrictive and punitive measure for elected representatives of the Panchayats, when the National Population Policy does not provide such a norm. Moreover, similar disqualifications are absent for representatives elected to State Assemblies and Parliament. We request the NHRC to take cognisance of this violation of Constitutional rights, and direct States to strike down these provisions.

All India Democratic Women's Association, Centre of Social Medicine and Community Health, Jawaharlal Nehru University, Centre for Women's Development Studies, Centre for Enquiry into Health and Allied Themes, Delhi Science Forum, Forum for Creches and Child Care Services, Jagori, Jan Swasthya Abhiyan, Joint Women's Programme, Karnataka State Women's Information Resource Centre, Mahila Sarvangeen Utkarsh Mandal, Medico Friends Circle, National Federation of Indian Women, Nirantar, Saheli, Sama, Young Women's Christian Association of India

As a million soldiers face each other across the volatile line of control and the border between India and Pakistan, the arguments have shifted from no use of nuclear weapons to their potential use in the event of conventional war, to the current state of actual deployment…a nuclear first strike becomes a frighteningly real possibility…

In contrast to the nuclear disarmament appeals from a few years ago, most of the medical associations on both sides of the border have maintained an ominous silence… (One) explanation is that few among the health professionals are even remotely aware of the true meaning and consequences of a nuclear conflict.…

The current nuclear imbroglio in India and Pakistan is a direct consequence of a lack of human and social development in the region. Malnutrition rates in the region are among the highest in the world, and successive generations have been fed a daily gruel of intolerance, jingoism, and religious fervour by political and military governments. The current military standoff must also be viewed in the context of the growth of religious intolerance and lack of social development in both countries. A conservative estimate of the costs of nuclear weaponisation in India placed it at well over $10bn and although modest by comparison, it is sobering to note that Pakistan's recent ballistic missile tests alone could have funded the entire health budget of several districts…

With Hindu extremists tugging at its sleeves and Islamic militants attempting to trigger an all-out conflict, neither India nor Pakistan possesses stable command and control systems ensuring that an accidental conflict will not be triggered … The only prudent way ahead for the leadership of the two countries is to step back from the brink and start substantive discussions and political dialogue. The large cadre of health professionals and societies in both countries, as indeed globally, must assume responsibility for the promotion of peace, and eventual nuclear disarmament.