Several patients are dying in India because of the lack of a world-class facility for liver transplant. There had been instances of Indian patients waiting for their turn to receive an organ abroad. Organs are allotted to foreigners only when resident nationals are not suitable. Hence, with the noble thought of helping Indians waiting for organs, Global Hospital put out an advertisement to benefit end-stage liver disease patients and then sought registration of patients. The Global Hospital is well equipped with state-of-the-art facilities. Global Hospital doctors involved in liver transplantations are well trained in the UK. The hospital follows the King’s College protocol for liver transplants. To enlighten the public and doctors about the availability of the facility, we advertised in newspapers. As a result we received several inquiries from patients and doctors. There is no need for the hospital to promote anything unethical. We will do everything in good faith.

Mr Jagannathan was a patient suffering from end-stage liver disease (due to alcoholic liver disease). He was in a very bad condition and terminally ill. He was under treatment with doctors in another hospital. He had been advised liver transplant by another doctor in 2002 itself. As mentioned by the other doctor, probably during that time the results were not so encouraging. Precisely for that reason we started the transplantation programme by taking the help of the world-renowned liver transplant team from King’s College Hospital, UK, which does about 200 liver transplants a year.

Mr Jagannathan approached Global Hospitals for further management in December 2002. He was put under the treatment of a hepatologist and other concerned doctors were closely monitoring the case. As he was deteriorating, the liver transplantation option was thought of.

Initially, cadaver liver transplantation was discussed with the patient and his family members. As the patient’s condition was fast deteriorating, the family members were also given the option of live liver transplantation, as a last resort. Mrs Prameela, wife of Mr Jagananthan, had come forward to offer part of her liver. She was counselled thoroughly, and all problems and implications were discussed with all family members. Meanwhile, a cadaver liver became available at a far-off place. We discussed, with family members the option of getting the liver by arranging a chartered flight. But as the family members were not interested, we could not do the cadaver liver transplantation.

The doctor’s team explained everything thoroughly and in detail to the patient and to all family members. We have a very good ‘transplant co-ordination’ department, which explains the process in detail to the family members including the patient. In transplantation surgeries, unlike other surgeries, we counsel the patient, spouse, close relatives and friends. Without counselling, we do not undertake even a small procedure.

Apart from that, Dr Mallikarjun, son-in-law of the patient and a general surgeon with an MS qualification working as assistant professor in a reputed government teaching hospital, is the main spokesperson of the family. How can a surgeon say that he is not aware of the risks and complications of a complex surgery like liver transplant? It is highly absurd to say that the family members were not informed about the high risks involved in adult-to-adult liver transplants. The internet-savvy family members had equipped themselves with all the information on liver transplants and in fact discussed the implications of liver transplants with us. The allegation is baseless. Feigning ignorance about the major and most complex surgery planned for their parents is an afterthought. Global Hospitals follows all rules and regulations very strictly and does things ethically only

The UK National Health Service (NHS) may not be doing live adult-to-adult liver transplants for its own reasons. Guidelines of the NHS dictate the King’s College Hospital policies, but adult-adult liver transplants are being done in the private sector, in the UK. Even in India, some procedures may not be done in the government sector but are done in the private sector. The private sector takes up challenges because of its expertise, facilities, technology, etc.

The main surgeon, Dr Nigel Heaton, is a world-renowned liver transplant surgeon and had done about 21 such live adult-adult transplants, and total of about 1,000 liver transplants, before doing it here. Dr Paolo, with good experience, assisted many cases.

Professor Roger Williams heads the unit in the private institute where these transplants are done by Dr Heaton’s team. He refers to the high calibre of Dr Nigel Heaton. This itself shows Professor William’s faith in the team as he is allowing them to operate on his patients.

We did not invite the BBC team to record the liver transplant. The BBC was engaged in producing a documentary on Dr Nigel Heaton. The team came here and shot the liver transplant programme with the permission of family members.

Once a patient is willing to undergo transplantation, as per hospital policy, the patient has to pay Rs 95,000 towards the pre-operative work-up. The work-up was done as all family members including the patient had given consent for it, after understanding the problems, complications, pros and cons, etc. In our usual practice, we cannot initiate the transplant process until the patient makes some financial commitment, as the liver transplant involves lots of activities/ commitments from the hospital side. As a cadaver liver may be available at any time, transplantation has to be done on an emergency basis. That is why we collect an advance from the patient. After all our vigorous, but unsuccessful efforts to get a cadaver liver organ, we discussed live related liver transplantation as a last option as the patient’s condition was deteriorating fast. All the pros and cons, complications to the patient and to the donor, were explained to the family. Only after a thorough explanation patient/family members gave consent. After obtaining valid consent the surgery was performed. We indeed waived the donor surgery charges, investigations etc on humanitarian grounds (but not the charges for complications, if any, that might arise)

We discussed adult-adult live liver transplant, in detail, with all the concerned family members. The patient’s son-in law is a general surgeon. He was the main person and represented the family. The allegation that we said the search for a cadaver liver would continue and if cadaver was found the live donor transplant would be cancelled reveals that the patient and his family had been explained about both options. This means they had been thoroughly counselled about all options.

Mrs Prameela, the donor, was not hesitant. Dr Anurag Shrivasthava, the psychiatrist who examined her during the pre-operative work-up, certified her fitness. It was very clearly mentioned that she was very strong in her decision to donate a part of her liver to the husband. This shows they are hiding the facts.

Mr Jagannathan was in end stage liver disease and terminally ill. He was prepared/ stabilised to the best possible condition for surgery. He was never in good shape. They opted for live related transplant because he was deteriorating fast. He survived the surgery. If the patient was unfit, he would have died on the operation table itself or during the immediate post-op period. Everybody knows that liver transplantation surgery is a most complex surgery. It is a false allegation that they heard the words ‘major surgery’ for ‘first time’ just before the operation. He lived for two weeks after surgery. The donated liver worked well; it was not rejected. He did not die of a surgical complication. Surgery was successful but later he died of sepsis, which is one of the commonest causes of death in post-liver transplant cases all over the world, as patients are kept on immunosuppressive drugs to prevent graft rejection.

We did explain that the donor’s liver would grow back to normal size within two weeks, that and she would be back to her normal self in 4-6 weeks. And it usually happens. Her liver after donor surgery attained optimum size and even today her liver is working normally. There is no failure of donor surgery.

The donor was kept in the Liver Intensive Care Unit, after surgery. This is a fully equipped, ultra-modern facility. Trained and highly skilled nursing professionals and intensivists are there round the clock to take care of any complications. The donor had a cardiac arrest, which may happen in some patients, especially in the post-operative period. Our doctors and other team members immediately attended on her and resuscitated her. Because of the immediate attention, she survived the cardiac arrest. But unfortunately, because of ischemic hypoxia of the brain, she slowly slipped into a persistent vegetative state. All the reasons for the cardiac arrest have been explored, but no conclusion could be made. This is quite unfortunate but there is no medical negligence as they allege.

The main UK doctors who performed the surgery were here to manage the immediate post-operative period. The second UK surgeon was here for about one month. It is all teamwork. The UK doctors were enquiring about her health status, even today and we are appraising them. We also consulted some very good neuro-physicians and others and continued the treatment as per their suggestions. Recently the complainants brought a renowned senior neuro-physician of their choice to examine their mother. He was highly satisfied with our treatment. She is receiving the best treatment, he pointed out. That much special care is being bestowed on her. Because of our best treatment, she is still surviving. It is one of the good examples of teamwork and untiring efforts in patient care.

It is a false allegation that they did not know there were different success rates and risks for partial liver transplants from live donors and total liver transplants from cadavers. There is nothing to hide. In transplantation surgery, there is no money to be made. It is a highly cost-intensive procedure. With the noble intention of giving a ‘second life’ to the needy, Global Hospitals started the programme. Many hospitals have not started the programme because of the cost implications.

Transplantation is not new to us and the results are good. We are doing different varieties of liver transplantation, such as cadaveric, live related (adult- to- adult and adult- to- child), split liver transplant, etc. Prior to this case we did two cases and both are doing well. So far, we have done 21 liver transplants of different kinds and 18 survived. Our success rates are on par with those of the best hospitals in the West.

The usual package is Rs 12 lakh and approximately Rs 3 lakh for blood products (at actuals), and extra costs at actuals, if any complicatioan occurs. They paid only Rs 10 lakh before surgery. We did not insist on their depositing the entire amount. We have not charged the donor’s surgery and investigation expenses. It is another false allegation that when the donor was being taken into the operating theatre we asked the relatives to sign a form committing to pay Rs 23 lakh, including donor expenses. Why would we undertake the surgery if they were supposed to pay another Rs 23 lakh? Regarding the allegation that we pressurised them for payment, this again is false. We never told them that we would bear the cost of treating their mother. Everything has been done ethically. We neither pressurised them to pay the bills nor threatened to stop medication. We are treating the case on humanitarian grounds. The fact that we issued the bill in January 2005, nearly 21 months after initiation of treatment itself, establishes that we never exerted any pressure. In fact, we issued the bill at their request, unaware of the fact that they had filed a case in the AP Consumer Forum.

The hospital has highly skilled and reputed doctors, many of them trained in world-renowned centres. The facility and infrastructure are on par with the best in the world. We have done liver transplants with success rates on par with those in the West. Some patients for liver transplantation have come from abroad, after enquiries in different parts of world. We did our first heart transplant on February 6, 2004, and the patient celebrated his ‘first re-birthday’. We are one of the major centres for kidney transplantations, both live and cadaver. We did our first bone marrow transplant. Now, a patient from the UAE is waiting here for her lung transplantation, which again will be the first of its kind. We are also planning to do the ‘first’ small bowel transplantation and the first pancreas transplantation. The hospital has a good reputation for transplantations. With mala fide intentions they are making false allegations to besmirch our reputation.

It is unethical to say that we advocated a complicated and expensive surgery without giving the family sufficient information. Can anybody believe this? Extensive counselling was done not only to the patients and also to all the family members. They are highly educated and knowledgeable. The main spokesperson of the family, the son-in-law, is a practising general surgeon who does a number of surgeries daily. These surgeries have to be performed after explaining to the patients all complications and after obtaining their consent.

Not only in the US, in India also a regulatory system exists. As they filed a case in the consumer forum, we have given all records to the court for scrutiny. They filed a case in the police station. A state government committee has scrutinised the records and taken statements from us. Mr Jagannathan’s body was subjected to post-mortem examination. We are ready for any ‘scientific scrutiny’. We are co-operating with all the appropriate agencies. We have submitted the medical records to the General Medical Council, UK, as per their request. They have made false allegations against Global Hospitals in the media to get public sympathy to exploit the situation and to damage our reputation. Ethics should be followed by all. In spite of this, we are still providing the best possible care to the patient.