With this issue of January 2012, the Indian Journal of Medical Ethics (IJME) is entering its 20th year of uninterrupted publication. In the last 19 years, the journal has never had to combine two issues, and has been published regularly in the first month of each quarter. This has been a remarkable feat for a journal on medical ethics and bioethics on a shoestring budget, with voluntary contributions of time and material resources from individuals. IJME has been able to afford some part-time staff support only for the last six years. More heartening than its survival has been the support, goodwill and enduring contribution of its readers and well wishers from India and abroad. Their number is so large that to mention every one of them is impossible. Many may not even like to be named as they have merely done what they considered right and relevant. Their support in the process of growth in quality and content allowed the journal to contribute meaningfully to the debate on improving the health system, medical care and the conduct of health professionals, and in the taking forward and strengthening of bioethics discourse in the country.

While the first issue of the journal was published in August 1993, the processes that led to its publication began in 1989, with the coming together of doctors and health activists to intervene in the healthcare system to improve ethical standards, and to bring the concerns of patients, particularly of the most vulnerable segments, to the centre of healthcare. None of these individuals had any formal training or qualifications in bioethics, but they were studying it in their practice, in research and in the discussion of bioethics and the literature. The journal, therefore, became, not just a medium to share views, conclusions and research, but also a platform to learn. Over the years, the sharing and learning aspects of the journal have only been strengthened, and that is what we intend to consolidate.

In the beginning, most of us did not harbour any illusion that the journal would be able to carry on for long. In fact, we suffered from insecurity and the fear that it would die in its infancy or in childhood. Its survival and growth was made possible through sustained collective effort. With such support, over the last 19 years, IJME was carefully nurtured by four editors. Its executive editor, who worked with exceptional dedication for 14 years (1998-2011) helped the journal to make the transition from an amateur activity to a professional publication. However, all this was in the spirit of voluntarism, without having any of the administrative and financial support that professionally produced journals normally enjoy.

The dedicated efforts of these individuals, with the support of members of the editorial and advisory boards, both national and international, and, indeed, of its writers and readers, have taken IJME from an 8-page newsletter in 1993 to a 64-page, peerreviewed, indexed journal. Increasing numbers of submissions, theme issues and special issues for activities like the National Bioethics Conferences (three so far, in 2005, 2007 and 2010) on the platform of the journal, have often pushed the number of pages to 80 and more than 100. In the year 2000, through voluntary contributions of time and resources by members, the website of the journal was established, scanned copies of past issues were made available, and IJME became an online open-access free journal. At present, the online edition is used substantially by interested readers. In 2010, the journal website received 4.9 million hits, had 330,090 unique visitors with 434,180 visits with over one million pages being viewed and 192 GB volume of material was downloaded.

The transition

The strength of IJME is its organic, gradual growth. It was not something that a commercial publisher with professional, highly paid staff brought forth one fine day for everybody to read and appreciate. It has grown along with the consciousness and commitment to ethics of health professionals and health activists. It has also grown alongside the development of bioethics as a discipline in the country and in the developing world. Perhaps by being both a platform for expressing critical views on ethical issues and a fully peer-reviewed indexed academic journal, it has been a part of bioethics activism as well as of the academic development of bioethics. In that sense, its feet are firmly planted on the reality of the developing world and in movements struggling to improve people’s health and uphold their rights.

In the future, as the journal builds on this strength, there are some changes in the offing. These changes have been necessitated for various reasons. Given the complexities and demands in terms of time and resources for ensuring effective and efficient peer review of an increasing volume of submissions for publication, copy editing and many other complex components of the production process, it is very difficult for only one or two individuals, despite their dedication, to do everything. We have to gradually put in place a more complex division of labour and adopt the appropriate technology, including an online submission management and production system. While this process started two years ago, we are now required to consolidate it by establishing an independent office of the journal with some full-time support staff, and pay more attention to fund raising. This will mean that some editors and members of the Forum for Medical Ethics (FMES) will have to commit more time to establishing physical structures and work systems for the journal, and also make efforts to raise funds. At the same time, those who have voluntarily shouldered the responsibility of work for the last several years needed a temporary break or respite from the heavy workload they have attended to.

This 20th year is, therefore, devoted to such consolidation and transition. We are in the process of establishing an independent office for the journal in Mumbai. In the coming year, we will strive to establish an on-line system for submission, review and production. George Thomas, who has borne the responsibility of editing the journal for the last six years, has stepped down as editor. Sandhya Srinivasan, who has done the back-breaking work of being executive editor for the last 14 years, will continue to provide her expertise and guidance in editing the journal as consulting editor. We are in the process of enlarging the IJME editorial and administrative teams to tackle the new challenges. Two new members have joined the editorial advisory board. We welcome Dhanwanti Nayak, who is an anthropologist with a deep interest in the medical humanities. She teaches at the Manipal Institute of Communication at Manipal University, Karnataka. We also welcome to the board Deepa Venkatachalam. Her key interests are women’s health, technologies and bioethics, and she works with the women’s group Sama in Delhi. Another new member has joined the international advisory board. We welcome Jacob Leveridge, who is school research facilitator at the University College London, London, UK. We are very happy that these three members have joined us in IJME, and that their support and individual contributions will enrich the journal. During the coming year, we also intend to invite other individuals to be guest editors of our theme-based and special issues, to garner national and international bioethics expertise for the development of the journal.

Changes are also occurring in the FMES, the owner and publisher of IJME. This is essential as the FMES, as a non-profit society and public trust, is actually a product of the medical ethics and bioethics movement, and is to some extent shaped by it. In 2011, it invited many individuals from the bioethics movement to be its members, and is thus, involved in a process of transformation from a small, primarily Mumbai-based group to a national level society. In addition, Vasantha Muthuswamy, the distinguished bioethicist, will be taking over as chairperson of the FMES in the latter part of 2012.

The broadening of horizons around bioethics

The primary focus of the journal continues to be medical ethics and bioethics. From within the healthcare system, the ethical concerns and issues of many healthcare professionals, such as nurses and AYUSH professionals, demand attention. In the pluralist healthcare system of India, the quest for healthcare ethics must be enriched and strengthened by including their specific issues and concerns.

At the heart of the medical ethics and bioethics movement are the patients, the people, and the more vulnerable they are, the greater the need to be ethical. Normative ethical guidelines, rules and regulations, therefore, find their rationale only in so far as they protect and empower the vulnerable in healthcare relationships. However, as our experiences in India and in many developing countries testify, the mere existence of guidelines and rules and, for that matter, even laws and the power of regulators are not, in themselves, sufficient to improve ethical standards and professional conduct. The high pressure of work in the closed environment of health institutions, the pursuit of excellence in technology instead of humane caring, the high status enjoyed by medical professionals in society, their increasing wealth in the unregulated market of healthcare, etc, have insulated many of them from the living reality of patients and the widening inequities in society. In such a context, those making efforts to achieve an equity-based, humane healthcare system with universal access, are contributing to the strengthening of healthcare ethics. To achieve this, systemic reforms, changes in the conduct of professionals, and greater involvement of patients, and the people in general, in healthcare decision making is necessary. This process could be greatly enriched by interaction with the perspectives of the social sciences, law, philosophy, art, literature, and the media. For the development of holistic and humanistic medicine, it is crucial to open it to public scrutiny and the gaze of other professions. Those perspectives may vary but their interaction with medicine will be mutually beneficial, leading to a better understanding and appreciation of each other’s contribution. More so for bioethics, as it is multi-disciplinary, with medicine being only one component. Such interactions could contribute positively in the acceptance and observance of ethics by healthcare professionals. They could also act to deepen and widen the processes of building ethical guidelines and rules, which are often dominated by medical professionals. Therefore, IJME will endeavour to expand its scope by including the field of humanities in addressing issues in medical ethics and bioethics. We hope that such an inclusive approach, will, without diluting our focus, enrich the journal as well as the concerns and disciplines it represents.