Kabra, S G : Medicine Deranged; Typical Problems in Medical Ethics: balancing between law and medical ethics. Kabra SG, Panchsheel Prakashan, Jaipur, 1999

Given the range of ethical issues that surround medical practice, the books under review are timely additions to existing literature on the subject. In today’s context, some major debates centre around the ethical dimensions of compulsory testing for HIV and sexually transmitted diseases for some sections of the population, and around the right to marry for HIV positive men and women.

The issue of ethics and medicine is, however, somewhat difficult to raise, especially for a medical practitioner. Dr S G Kabra is unusual in that he has consistently looked at the anomalies in the medical profession. In Medicine Deranged, he looks at the process through which the public health system has been co-opted by the powerful, while the private sector is not accessible to the poor. He suggests that there is a parallel between the co-option of the medical profession by the State in India, and medical practice under the Nazis. The example given is that of the population control policy of the state and the role of doctors in the process. The focus on preventing pregnancies has resulted in unethical practices such as the promotion of non-therapeutic abortions and unsafe contraceptive methods by doctors. To quote, “Ethics are the first casualty when the State drafts medical men to counter social pathologies and to solve social problems.”

“Typical problems in Medical Ethics” expands on the theme of medical practice and ethical dilemmas. It poses real-life situations which raise several questions. Cases includes questions of confidentiality in sensitive areas such as HIV and pre-marital pregnancies; weighing the right to work against the risks of infection, in the case of a person with tuberculosis. The cases include the responsibility of doctors in a case of artificial insemination, when, following insemination and pregnancy, the woman is blackmailed by someone claiming to be the father of the child. Here, too the issue is that of confidentiality. Significantly, these cases violate ethical considerations due to social stigma attached to these areas, hence medical practitioners have a special responsibility to maintain records according to strict ethical norms.

Other areas touched upon are the sensitive ones of the right to will to die with dignity, and of indigent patients with serious illnesses in a private hospital. How do doctors reconcile humane considerations with the professional and material requirements. Examples are given of gross negligence by doctors, as in deaths in laparoscopic sterilisation camps in West Bengal in 1989. The deaths took place because there were a high number of patients attending the camps and clinical screening of the patients could not be done.

It also touches on the doctors involved in the Nuremberg trials and draws a parallel with doctors in India who took part in the forced sterilisation drive during the Emergency in the 1970s. Do doctors have a duty to refuse to participate in non therapeutic interventions at the dictates of the State? Are doctors exempted from their responsibilities towards their patients and the society at large because they have been directed to act in a certain manner by the authorities? In such cases, who bears the final moral responsibility for human loss and suffering — the State or the doctors conducting the Nuremberg trials and the sterilisation drive?

The format of the book includes a succinct presentation of the cases, followed by a series of questions posed to doctors, legal experts, researchers and journalists. Hence, none of the cases are ‘resolved’ by the author, leaving the reader with a range of opinions, sometimes diverse on the same issue. For instance, in the case of a woman who had donated blood, that was found to be HIV positive in the first test. The woman was contacted and asked to undergo a second test, since the screening method has a false positive rate of 3-5 %. Her second test was negative. The ethical questions posed by the author include: since the test was done for judging the safety of the blood for the recipient and not for disease surveillance, was it correct to inform her; should her identity have been disclosed to the health authorities; should the spouse of an HIV positive person be informed of his status?

In this case, it was suggested by the doctors interviewed that in the case of a single person, no one should be informed other than the patient. A journalist felt that the woman should not have been informed until the second confirmative tests were done. All the persons interviewed expressed the view that if married, the spouse of a HIV positive person should be informed.

Clearly, none of the cases cited in the book have a clear and unambiguous resolution. Significantly, the author’s views do not impose on the reader and she is free to make up her mind about the issue. That I feel is one of the strengths of the book. Simultaneously, in the annexures attached to the book, where the theories, principles and practical aspects of medical ethics are explained in some detail. He also explains concepts such as informed consent and the goals of health care.

The books are marred by poor editing, and indifferent writing. However, that does not necessarily detract from the positive aspects of these pieces of work. They are thus significant contributions to the field.