On September 7 and 8, 2001, the Academy of Medical Sciences in Nagpur organised a workshop on medical ethics in collaboration with the Forum for Medical Ethics Society. It was a pleasant surprise to find that a meeting on ethics could draw so many doctors, get them to pay registration fees covering the entire workshop’s costs, and also to attend the meetings on a weekend.

As many as 10 presentations were packed into just one and a half days. The speakers were Dr Sunil K Pandya and Dr Sanjay Nagral from Mumbai, Dr Sanjay A Pai and Dr Jagdish Chinappa from Bangalore, and Dr Shuchita Mundle from Nagpur. The meeting was chaired by Dr Raju Khandelwal, president of the Nagpur Academy of Sciences, and Dr SP Kalantri of the Mahatma Gandhi Institute of Medical Sciences in Sewagram. The topics covered were: principles of medical practice; the doctor-patient and the doctor-doctor relationships; the need to extend discussion on ethics beyond one-on-one relationships; medical law and ethics; some ethical dilemmas; common unethical practices; issues concerning transplants, and the links between doctors, drugs and drug manufacturers. Group discussions were held on case studies. The meeting concluded with a talk on the Forum for Medical Ethics Society and a resolution to set up a similar group in Nagpur.

Many of the topics provoked lengthy discussions, worthy of reproduction for our readers. They will be carried as separate reports over the next few issues of the journal.

One such discussion concerned the profession’s response to HIV. In his presentation on unethical practices, Dr Nagral included the following: mandatory testing for HIV, making positive results public, segregating HIV positive patients, and discriminating in their care, even refusing it. In many hospitals, every patient gets HbsAg and HIV testing on the theoretical possibility that the infection might be transmitted from one patient to another. Patients needing surgery who are known to have HIV will be asked to spend large amounts on disposable equipment. People with HIV and hepatitis have been placed last in the operative list. Doctors protesting against this practice have been overruled.

The next day, Dr Shuchita Mundle spoke on issues medical professionals should remember concerning HIV. She noted that counseling for HIV/AIDS is recognised as an integral part of patient management. Counselling has two aims: to prevent transmission, and to support those affected, indirectly and indirectly. Whenever the test is proposed to be done, one should ask: is it being done for the patient’s benefit? In India, mandatory testing can be done only on donated blood. (comment: the results are not made available to the donors). When people come in for testing because they perceive themselves at risk, testing must be linked to counselling.

The second issue is confidentiality. Test results should be kept confidential. The only time when confidentiality may be broken is to notify the partner. The third issue is stigma. It is counter-productive to speak of HIV in terms of morality. Public health is not a moral issue; the purpose should be to protect people. A woman can get HIV from her husband, mothers can pass it on to their children, and so on. Attaching stigma makes it difficult to tackle the problem.

The discussion following Dr Mundle’s presentation illustrated the strong feelings that doctors have on this subject though no resolution could be reached. Arguments were put forward in favour of – and against – the current practices of routine testing without counselling the patient or taking his/her consent, and differential treatment for patients according to known HIV status. It was noted that many hospitals do the test for all their patients, without their consent, or counselling. Some hospitals do the test after giving the patient a booklet on hepatitis and HIV. A participant suggested that the test is a screening device, as for sugar or urea, and in some hospitals counselling is done whenever test results are positive. Why is such a big deal made out of HIV testing? We don’t do pre- and post-test counselling for other tests.

However, it was pointed out, pre-test counselling is as important as post-test counselling. The patient must understand what the test is all about and what it could lead to. Also, post-test counselling becomes easier if pre-test counselling is done. It was suggested that HIV testing cannot be equated with other tests because of the stigma and discrimination that can follow a positive result. Further, mandatory testing is illegal.

Some participants suggested that doctors had the right to know if their patients were HIV positive. A participant referred to a report of some surgeons having acquired HIV from their patients. “My hospital staff gets angry if I do not tell them the patient is HIV positive.”

In response, it was asked why doctors focus on patients’ HIV status. Why shouldn’t doctors be tested for HIV and HbsAg and their patients be informed of the results? The veracity of reports of doctors getting HIV infection from patients was questioned; it was pointed out that this can be proved only with tests comparing the two infections and demonstrating that they are genetically the same.

Finally, such practices are both unscientific and unethical. The viral load in HIV infection is maximum during the window period when no commonly used test can detect the virus. It is therefore both scientific and ethical to take universal precautions and do away with routine pre-operative testing.

Such practices are also a comment on a hospital’s sterilisation techniques . HIV is a fragile virus and cannot survive common precautions. By taking unnecessary precautions, and forcing HIV patients to pay for new equipment, the message sent is that your sterilisation technique is not proper. Again, by demanding new instruments for patients who test positive for HIV, but reusing instruments on patients believed not to have HIV, the doctor tells us that improperly sterilised instruments are used for the latter group.