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Another organ donation story

Twenty-five-year-old Venkatesh, a patient of muscular dystrophy on a ventilator, died while fighting a legal battle. He had petitioned the Andhra Pradesh High Court to be taken off life support while alive in order to donate his organs. The Court rejected his plea but then later ordered the setting up of a new committee to reconsider it.

While rejecting his plea, the court said, “…though it can understand the anguish of the mother and the noble intentions of her son, the statute has no such provision which provides exemption from the (Human Organs Transplant) Act as a special case.”

PTI. Venkatesh’s wish fulfilled in death. Indian Express. December 18, 2004.

Vaccination scams?

The Indian Association of Paediatrics’ guidelines state that vaccination camps must get permission of the local health authorities; qualified medical personnel must be present; there should be no profit-driven measure; accurate and appropriate information should be given; vaccines should be subsidised and even free if parents cannot afford them, and proper medical practices should be followed including cold chain, appropriate dosages and use of quality disposable syringes.

However, many reports indicate that all these guidelines are violated. Distilled water has been injected instead of vaccines, and by unqualified people. Some pamphlets distributed contain dangerous misinformation.

Drimi Chaudhuri. Watch your back at a vaccination camp. The Asian Age, Mumbai Age, September 11, 2004.

Hey, that’s not my signature!

A complaint has been filed against the Federation of Obstetricians and Gynaecologists’ Societies of India (FOGSI) challenging postal ballot papers for the FOGSI presidential election. Many votes did not bear the voter’s name and other details; many had the same hand writing. Some doctors testified that though they did not vote, their votes were accounted for. FOGSI representatives have not commented.

Manju V. Forgery allegation hits medical body’s elections. The Times of India. October 4, 2004.

Manpower adjustments

The Medical Council of India (MCI) debarred 10 doctors in Tamil Nadu for claiming employment as teachers in more than one medical college at the same time, pointing out that students suffered because of this malpractice done to fulfil mandatory manpower requirements during MCI inspections.

The Tamil Nadu Government Doctors’ Association asked the government for protection. As its Madurai branch president, Dr S Somasundaram, put it, “It was only on the instruction of the Directorate of Medical Education that the doctors went on temporary deputation during inspections.”

This is apparently a routine practice. Reportedly, when the MCI inspected Kanyakumari, Tuticorin and Tirunelveli colleges early in 2004, doctors and medical equipment from almost all government colleges in the state were transferred there temporarily.

The Association’s president, Dr K Prakasam, said the state executive asked its members not to accept “deputation offers” in future.

S Vijay Kumar. Medical Council debars 10 doctors. Hindu. November 27, 2004. Staff reporter. Doctors seek `protection’ from MCI action. Hindu. November 28, 2004

Doctors’ acquittal challenged

In a case that might reverse an earlier verdict on negligence a division bench of the Supreme Court issued notices to three Kolkata doctors, asking them why their conviction in a patient’s death should not be upheld.

The Court was responding to a special leave petition challen-ging the acquittal of Sukumar Mukherjee, Baidyanath Haldar and Abani Roychowdhury by the Calcutta High Court.

The doctors were charged with criminal negligence for causing the death of US-based Anuradha during her visit to the city in 1998. In 2002, Mukherjee and Haldar were convicted and sentenced to rigorous imprisonment. Roychowdhury was acquitted. In March 2004, the high court acquitted all three on an appeal.

A Supreme Court bench recently held that doctors involved in medical negligence cases may be liable for civil compensation, but could not be held guilty of criminal negligence. Another division bench disagreed with the judgment and referred the case to a larger bench.

R Venkataraman. New twist in neglect case. Telegraph. October 12, 2004.

Not innocent till proven guilty

Another division bench of the Supreme Court said it would “consider” suggestions to suspend the licence of doctors convicted in medical negligence cases resulting in death.

It was reserving its order on a public interest petition asking for the Medical Council of India and its state counterparts to act on a complaint against a doctor within six months.

The petition, filed by People for Better Treatment, a non-government organisation, said, “The licence of a physician should be suspended immediately if prima facie evidence of flagrant medical violation is established.” The axiom “innocent till proven guilty” should not be followed as the lives of innocent patients are at stake.

R Venkataraman. Doctor licence debar case. Telegraph. October 13, 2004.

Consumer court awards compensation

B Varalakshmi was admitted to the Seven Hills hospitals in Visakhapatnam for bypass surgery and died the same day but her children were not informed till the next day. They filed a consumer complaint against the hospital, the cardiac surgeon, the anaesthetist and two other doctors, and the insurance company for refusing to reimburse them. The complainant alleged that the surgeon’s incorrect practice injured the aorta and led to severe bleeding. Also, the patient’s relatives were not properly informed of the risks of the operation.

The District Consumer Forum ordered the hospital and surgeon to refund the medical expenses and pay compensation of Rs 2.5 lakh plus Rs 12,000 in travel expenses and costs. The claim against the others was dismissed.

B Prabhakara Sarma. Hospital directed to compensate for negligence. The Hindu. July 3, 2004.

Doctors under siege …

Doctors are the target of much public anger. A glance at the newspapers gives an idea of the extent of this anger:

In Bangalore, protestors damaged the windowpanes of a private hospital alleging that negligence had led to a patient’s death. (The police said the patient was unconscious when admitted to the hospital.) That same day, a protest was staged in front of an ESI Hospital in Rajajinagar where a woman died of excessive bleeding soon after giving birth to a baby – the baby died shortly afterward. (The hospital authorities said the deaths were due not to negligence but “pulmonary embolism and obstetric shock.”)

In Kolkata such stories are commonplace. When a woman died in the hospital after waiting for four hours for the doctor on duty to turn up, a mob gheraoed the hospital superintendent and forced him to write an apology letter. (The director of health services said the doctor on duty should not have left without handing over charge – and the superintendent shouldn’t have issued an apology without permission from higher authorities.) In another incident, police were called in when people ransacked a nursing home following the death of a woman in childbirth.

In Andhra Pradesh, municipal employees demonstrated outside a hospital in Rajahmundry following the death of the wife of a municipal employee during a medical termination of pregnancy. (The hospital spokesman told reporters that the woman did not heed doctors’ advice to have the MTP postponed and her pulse dropped drastically during the procedure. She had probably died of drug reaction.)

In Bihar, a mob attacked a private hospital following the death of an infant allegedly due to medical negligence. The child’s father said doctors had assured him that he would be fine after surgery but then kept finding complications requiring repeated operations. (The management said the child had a rare intestinal complication. About the later discovery of a decaying body of another newborn in a storeroom, they said it belonged to a family which had been unable to pay the bill in full.)

And sometimes doctors got upset. Outpatient services at government hospitals across Andhra Pradesh were paralysed as doctors responded to a strike call by the state government doctors’ association. They were protesting an attack on doctors at Gandhi Hospital, Hyderabad, by engineering students. The students believed the doctors’ negligence led to their classmate’s death after a road accident.

… and the health system’s response

‘Zebra commandos’ have been deployed round the clock to protect doctors at the Mumbai Municipal Corporation’s hospitals following a series of violent attacks by relatives of irate patients. They are currently stationed at two hospitals but the programme will be expanded. The commandos are martial arts experts and have been ordered not to open fire unless the situation warranted it.

Staff Reporter. Death of two patients triggers protests. Hindu. November 17, 2004. Staff Reporter. ESIC authorities deny charge. Hindu. November 18, 2004. Correspondent. Apology row after oxygen-delay death. Telegraph. November 27, 2004. Anonymous. Clinic rampage. Telegraph December 2, 2004. Special Correspondent. Woman’s death in hospital sparks tension. Hindu. October 16, 2004. Joy Sengupta. Child death rage singes hospital. Telegraph. November 27, 2004. Staff reporter. Doctors’ strike hits government hospitals Hindu. October 6, 2004. Vinod Kumar Menon. Now, armed commandos to protect BMC hospital docs. Mid-day, December 11, 2004.

Free lunches from the industry

In the UK, government officials told a parliamentary inquiry that there was no evidence that the drug industry had an unhealthy influence on doctors’ prescribing, medical education, scientific research, and drug evaluation.

The health department’s Dr Felicity Harvey argued that because of the government’s influence, drug company representatives were giving doctors good information, proof being the rising numbers of prescriptions for antidepressants and drugs for heart problems.

Committee members have received written submissions and evidence that indicate widespread drug industry influence over many aspects of the health system.

Ray Moynihan. Officials reject claims of drug industry’s influence. BMJ. September 18, 2004.

Injecting malpractices in Pakistan

It is estimated that 90% of the over 1·5 billion injections administered in Pakistan each year are unnecessary.

For private practitioners injections mean money and they routinely reuse syringes. Shortages in the public sector mean that as many as 72% therapeutic injections and 50% immunisation injections in public health-care facilities are unsafe.

Most used syringes and needles are dumped in open rubbish tips where rag pickers collect and resell them, some for the plastic, some for reuse.

Pakistan’s parliament is to discuss legislation that calls for regulation of disposable medical devices, including syringes, along with introducing single-use injection devices to public health facilities.

Khabir Ahmad. Pakistan: a cirrhotic state?. The Lancet. November 20, 2004.

Curfew and health care in Nepal

Damanta Bhandari went into labour but suffered complications requiring that she go to the hospital. But night curfew because of the conflict situation meant she had to wait till the morning. By the time she reached the hospital, it was too late. On the eve of International Women’s Day, Damanta died of excessive bleeding at the hospital gates.

Sanjay Dhakal. Fighting Against All Odds. March 12-18 2004.

Nepal doctors for democracy

Hundreds of doctors and health workers demonstrated in Kathmandu expressing solidarity with the ongoing movement, demanding restoration of peace and democracy and human rights.

Himalayan News Service. Doctors join five-party protest. The Himalayan Times, April 25, 2004.

First law on AIDS in China

China’s parliament has passed a law that requires the government to provide funding for prevention and control of AIDS and bans the sale and purchase of human blood.

China passes its first AIDS related law. BMJ. September 11, 2004.

AIDS research stopped

A team of researchers from the US, Australia and Cambodia halted preparations for the double-blind, placebo-controlled trial of a drug for HIV prevention after the Cambodian prime minister said the trial violated human rights.

HIV-uninfected female sex workers in Phnom Penh were to receive either 300mg of tenofovir or placebo daily for 1 year. They refused to participate without medical

insurance for 30-40 years for any tenofovir-related adverse events. The drug has been used to treat people with HIV but its safety and effectiveness among HIV-uninfected people is unclear.

The trial protocol was approved by the National Ethics Committee for Health Research in Cambodia, and by ethics committees at the foreign institutions.

Khabir Ahmad. Trial of antiretroviral for HIV prevention on hold. The Lancet. October 1, 2004.

Made-to-order babies?

The UK Human Fertilisation and Embryology Authority now permits parents to select embryos to create babies as a tissue donor to an ill sibling, relaxing earlier regulations on preimplantation genetic diagnosis.

The British Medical Association stated that “if technology to help a dying or seriously ill child exists, without involving major risk for others, then it can only be right that it is used for this purpose.”

The chair of a pro-life charity said, “It is only a matter of time before children are created for other reasons-to “balance a family” or for a particular physical characteristic.”

Rebecca Coombes. Fertilisation authority rules in favour of embryo selection for tissue donation. BMJ. July 31, 2004.

World Medical Association guidelines

The World Medical Association (WMA) made some important decisions at its annual general assembly in October 2004.

An amendment to its 2003 policy on physicians’ behaviour in times of armed conflict emphasises that “medical ethics in times of armed conflict are identical to medical ethics in times of peace.” This statement was made in the context of revelations that US physicians were complicit in human rights abuses in Iraq.

On the question of participants’ access to treatment post-trial, the general assembly issued a note of clarification to paragraph 30 of the Declaration of Helsinki on medical research involving human participants. (The Declaration when amended in 2000 stated that participants should get access to the “best proven prophylactic, diagnostic and therapeutic methods identified by the study” at the end of a trial – following which the drug industry and some researchers have argued that this was an unrealistic obligation.) It stated: “The WMA hereby reaffirms its position that it is necessary during the study planning process to identify post-trial access by study participants to prophylactic, diagnostic and therapeutic procedures identified as beneficial in the study or access to other appropriate care. Post-trial access arrangements or other care must be described in the study protocol so the ethical review committee may consider such arrangements during its review.”

Effectively, this placed responsibility on those who conduct trials to state clearly what is to happen once the study is finished. That would then be used to judge if the trial should be approved.

The WMA also published its first guidelines on how doctors should handle their relationship with commercial enterprises, covering medical conferences, gifts, research, and affiliations.

The chairman of the WMA’s medical ethics committee, said: “This issue of the inappropriate influence of commercial enterprise on the autonomy of physicians is one that has been causing increasing concern in recent years.”

Jeanne Lenzer. World Medical Association amends its policy on doctors’ duty during armed conflict. BMJ. October 16, 2004. Bryan Christie. WMA says trial participants must have access to best treatment when a trial ends. BMJ. October 16, 2004. Zosia Kmietowicz. WMA sets rules on how doctors handle industry sponsorship. BMJ October 16, 2004. See
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