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Oct-Dec2002-10(4)
Workshop on medical ethics,
Nagpur
On September 7 and 8, 2001, the Academy of
Medical Sciences in Nagpur organised a workshop on medical ethics in
collaboration with the Forum for Medical Ethics Society. It was a pleasant
surprise to find that a meeting on ethics could draw so many doctors, get them
to pay registration fees covering the entire workshop's costs, and also to
attend the meetings on a weekend.
As many as 10 presentations were packed into just
one and a half days. The speakers were Dr Sunil K Pandya and Dr Sanjay Nagral
from Mumbai, Dr Sanjay A Pai and Dr Jagdish Chinappa from Bangalore, and Dr
Shuchita Mundle from Nagpur. The meeting was chaired by Dr Raju Khandelwal,
president of the Nagpur Academy of Sciences, and Dr SP Kalantri of the
Mahatma Gandhi Institute of Medical Sciences in Sewagram. The topics covered
were: principles of medical practice; the doctor-patient and the doctor-doctor
relationships; the need to extend discussion on ethics beyond one-on-one
relationships; medical law and ethics; some ethical dilemmas; common unethical
practices; issues concerning transplants, and the links between doctors, drugs
and drug manufacturers. Group discussions were held on case studies. The meeting
concluded with a talk on the Forum for Medical Ethics Society and a resolution
to set up a similar group in Nagpur.
Many of the topics provoked lengthy discussions,
worthy of reproduction for our readers. They will be carried as separate reports
over the next few issues of the journal.
One such discussion concerned the profession's
response to HIV. In his presentation on unethical practices, Dr Nagral included
the following: mandatory testing for HIV, making positive results public,
segregating HIV positive patients, and discriminating in their care, even
refusing it. In many hospitals, every patient gets HbsAg and HIV testing
on the theoretical possibility that the infection might be transmitted from one
patient to another. Patients needing surgery who are known to have HIV will be
asked to spend large amounts on disposable equipment. People with HIV and
hepatitis have been placed last in the operative list. Doctors protesting
against this practice have been overruled.
The next day, Dr Shuchita Mundle spoke on issues
medical professionals should remember concerning HIV. She noted that counseling
for HIV/AIDS is recognised as an integral part of patient management.
Counselling has two aims: to prevent transmission, and to support those
affected, indirectly and indirectly. Whenever the test is proposed to be done,
one should ask: is it being done for the patient's benefit? In India, mandatory
testing can be done only on donated blood. When people come in for testing
because they perceive themselves at risk, testing must be linked to counselling.
The second issue is confidentiality. Test results
should be kept confidential. The only time when confidentiality may be broken is
to notify the partner. The third issue is stigma. It is counter-productive
to speak of HIV in terms of morality. Public health is not a moral issue; the
purpose should be to protect people. A woman can get HIV from her husband,
mothers can pass it on to their children, and so on. Attaching stigma makes it
difficult to tackle the problem.
The discussion following Dr Mundle's presentation
illustrated the strong feelings that doctors have on this subject though no
resolution could be reached. Arguments were put forward in favour of - and
against - the current practices of routine testing without counselling the
patient or taking his/her consent, and differential treatment for patients
according to known HIV status. It was noted that many hospitals do the test for
all their patients, without their consent, or counselling. Some hospitals do the
test after giving the patient a booklet on hepatitis and HIV. A participant
suggested that the test is a screening device, as for sugar or urea, and in some
hospitals counselling is done whenever test results are positive. Why is such a
big deal made out of HIV testing? We don't do pre- and post-test counselling for
other tests.
However, it was pointed out, pre-test
counselling is as important as post-test counselling. The patient must
understand what the test is all about and what it could lead to. Also, post-test
counselling becomes easier if pre-test counselling is done. It was suggested
that HIV testing cannot be equated with other tests because of the stigma and
discrimination that can follow a positive result. Further, mandatory testing is
illegal.
Some participants suggested that doctors had the
right to know if their patients were HIV positive. A participant referred to a
report of some surgeons having acquired HIV from their patients. "My hospital
staff gets angry if I do not tell them the patient is HIV
positive."
In response, it was asked why doctors focus on
patients' HIV status. Why shouldn't doctors be tested for HIV and HbsAg and
their patients be informed of the results? The veracity of reports of
doctors getting HIV infection from patients was questioned; it was pointed
out that this can be proved only with tests comparing the two infections and
demonstrating that they are genetically the same.
Finally, such practices are both unscientific and
unethical. The viral load in HIV infection is maximum during the window period
when no commonly used test can detect the virus. It is therefore both scientific
and ethical to take universal precautions and do away with routine pre-operative
testing.
Such practices are also a comment on a hospital's
sterilisation techniques . HIV is a fragile virus and cannot survive common
precautions. By taking unnecessary precautions, and forcing HIV patients to pay
for new equipment, the message sent is that your sterilisation technique is not
proper. Again, by demanding new instruments for patients who test positive for
HIV, but reusing instruments on patients believed not to have HIV, the doctor
tells us that improperly sterilised instruments are used for the latter group.