The Forum for Medical Ethics Society and Moral Re-armament (India) jointly organised an international conference on ethical values in health care, at Panchgani, India, on January 2, 3 and 4, 1998. Participants held in-depth discussions of several aspects of the principles and practice of health care ethics, with special reference to India, Pakistan and the Scandinavian countries, and referred to various international and Indian codes and concerns. Their recommendations follow:

Considerable and sustained effort is needed to improve the present unsatisfactory state of health care practices. It is especially necessary to include, foster and develop a keen sense of moral values in all personnel engaged in promoting health or treating disease.

The absence of effectivity and efficiency in our watchdogs and regulatory agencies within our professions is deeply felt and must be corrected. Failure to do so will force the creation of external agencies by society, the government or the judiciary.

Whilst the medical professions and the pharmaceutical and medical supplies industries are interdependent, both parties need to halt unethical practices aimed at benefiting selected individual doctors and the industry at increased costs to the patient. It is vital that meetings, seminars and conferences at five-star hotels, lavish expenditure on doctors and their families and gifts in cash or kind to them be stopped. Professional organisations should raise funds from their own members, government, grant-giving agencies, independent charitable trusts and other similar sources that do not create a conflict of interest.

There is need for discussion and debates within the health care professions and between them and the intelligentsia in society at large for the evolution of practical guidelines on the ethical care of seriously ill patients in the face of shortages of equipment, personnel and finance. Special attention should be paid to the needs of the disenfranchised; how expensive intensive care should be rationed, and when doctors and nurses should withhold or withdraw intensive care.

Humans form the most important resource of the health care system. Health care teams must demonstrate a commitment to the dignity and worth of human life. Although each member of the team is responsible for the individual’s actions, the team must take collective responsibility for all actions as has admirably been practised by SEWA RURAL, an NGO from Gujarat. All members of the team are equal and for the team to perform in the best interest of patients and the community it is essential that members demonstrate mutual respect.

Whilst it is recognised that each member of the health care team has a specialised role with limitations, the paramount consideration of the welfare of the patient demands that each member does all that is possible to care for and help the patient. In life-or-death situations, it may be necessary for a given member of the team to go well beyond the normal range of responsibilities to save life. The use of adefibrillator by a nurse is an example. Under such circumstances, the principle of collective responsibility of the entire health care team must support and protect the individual acting in the best interests of the patient.

The curriculum for all members of the health care team must include, in addition to relevant medical and paramedical training, instruction in psychology, sociology, health care economics, skill in communication, philosophy of medicine and ethics.

It is important to have common and periodic continuing education programmes where all members of the team interact.

The right to death in peace, without pain, is indisputable. Everything possible must be done to ensure that the dying person is in comfort, amidst loved ones as the end approaches.

Terminating life by medical means is not permitted by Indian law. Given the sorry state of medical practices in several countries and the danger of the slippery slope, society should not give health care workers the sanction to end life. Instead, we must give emphasis to care which preserves human dignity and the meaning of life.

Medical research must be primarily relevant to the needs of the country and must conform to the highest ethical standards. Researchers must make a special effort to avail of native wisdom born of tradition and experience. It is also necessary to document alternative medical practices through research, as is being done by the Foundation for Research into Community Health, and incorporate all that is useful in the formulation and achievement of their goals.

Every health care institution must have an ethics committee composed of representatives from each of the health care professions, the administration and the representatives of society, especially from the legal and teaching professions. This committee must encourage reporting – anonymously if necessary – of deficiencies and malpractices within the institution so that corrective action can be taken.

The solution to most environmental problems and the provision of a significant number of preventive, promotive and curative measures in rural areas can emerge from health workers selected from the local population. A social revolution can be brought about by strengthening and assisting local panchayats and empowering rural women through education and specialised training.

Health care professionals, co-operating responsibly with the media, must inform, instruct and educate society on all matters concerning health and disease. Concerted effort is needed to promote measures that prevent disease, overcome deep-rooted prejudices (as against autopsies) and facilitate beneficent measures such as the periodic donation of blood during life and corneas and organs after death.

Neglect of the health of women will have a deleterious, cascading effect on the nation. Empowering women through education, and engagement in economic activity, is the key to improving the health and productivity of their families. It is important that the nation invests in women. Health care professionals must do all that is possible to ensure adequate care and education of the girl child and woman.

There are categories of individuals who require special application of all our qualities of head, heart and hands: the poor, prisoners, and those facing ostracism by society on account of their illness (leprosy, HIV/AIDS, tuberculosis). It is incumbent on all members of the health care team to ensure that the principles of justice, beneficence non-maleficeance and confidentiality are especially respected in their cases. We must keep in mind at all times that our primary responsibility is towards our patients. We owe responsibility to law enforcement, prison and government agencies, but this must give way in priority to our primary responsibility.

All health care institutions need regular, periodic audit of prescription practices, morbidity and mortality, and of the quality of patient care (social audit). The findings of these audits must be open to public inspection. It is important to ensure minimal standards of care to all patients whilst attempting to provide an optimal mix of general and intensive care.

It is essential to set up and ensure minimal standards in nursing homes, intensive care units in the private sector, and investigation laboratories. The present, unsatisfactory, ad hoc proliferation of these institutions has resulted in a wide variation in the standard of facilities offered at considerable cost. A system of certification and periodic re-accreditation of these institutions is mandatory with unsatisfactory units being forced to shut down.

Workshop on human rights and medical ethics

The department of civics and politics, University of Mumbai, held a two-day workshop on human rights and medical ethics on February 7 and 8, 1998. Participants included health activists, health researchers, lawyers and doctors. The four sessions covered human rights and health, rights and responsibilities of doctors, rights and responsibilities of patients, and organ transplant.

Kannamma Raman of the university introduced the topic of human rights. Pritam Phatnani highlighted the importance of preserving-medical records, handing only signed photocopies to patients or the police. K A Dinshaw, director of Tata Memorial Centre, pointed out that patients often take away original records.

Arun Bal, medical activist, noted that nearly 90 per cent of complaints against doctors are instigated by other doctors. Due to a virtual failure in the doctor-patient relationship, confused patients often file complaints based on stray comments from other medical personnel in public hospitals.

Amar Jesani of the Centre for Enquiry into Health and Allied Themes spoke on the relevance, to the medical

profession, of various international conventions on human rights, with special reference to torture victims, HIVpositive people and prisoners. Doctors have been known to remain silent despite knowing that torture has taken place, sometimes falsifying medical information to this end, usually under compulsion. This will continue until prison medical services become independent of the prison.

Manu Kothari of KEM hospital attacked the needless use of technical and surgical interventions in medical treatment. VN Acharya described most ICCUs as mere status symbols. Anil Pilgaonkar suggested that private practitioners display a certificate listing unethical procedures that they would NOT do in their clinic.

The law permitting cadaver transplant was expected to increase the number of such transplant procedures, doing away with the unethical buying and selling of organs. Sanjay Nagral of KEM hospital noted that Indian reservations about cadaver transplants have restricted the use of this ethical procedure. Dr Subhash Salunke, Maharashtra director of health, stated that the government had permitted 780 live transplants after confirming that there were no financial deals between donor and recipient.

From Indian Express, February 9,1998